Understanding the burden of interstitial lung disease post-COVID-19: the UK Interstitial Lung Disease-Long COVID Study (UKILD-Long COVID)

INTRODUCTION

The COVID-19 pandemic has led to over 100 million cases worldwide. The UK has had over 4 million cases, 400 000 hospital admissions and 100 000 deaths. Many patients with COVID-19 suffer long-term symptoms, predominantly breathlessness and fatigue whether hospitalised or not. Early data suggest potentially severe long-term consequence of COVID-19 is development of long COVID-19-related interstitial lung disease (LC-ILD).

METHODS AND ANALYSIS

The UK Interstitial Lung Disease Consortium (UKILD) will undertake longitudinal observational studies of patients with suspected ILD following COVID-19. The primary objective is to determine ILD prevalence at 12 months following infection and whether clinically severe infection correlates with severity of ILD. Secondary objectives will determine the clinical, genetic, epigenetic and biochemical factors that determine the trajectory of recovery or progression of ILD. Data will be obtained through linkage to the Post-Hospitalisation COVID platform study and community studies. Additional substudies will conduct deep phenotyping. The Xenon MRI investigation of Alveolar dysfunction Substudy will conduct longitudinal xenon alveolar gas transfer and proton perfusion MRI. The POST COVID-19 interstitial lung DiseasE substudy will conduct clinically indicated bronchoalveolar lavage with matched whole blood sampling. Assessments include exploratory single cell RNA and lung microbiomics analysis, gene expression and epigenetic assessment.

ETHICS AND DISSEMINATION

All contributing studies have been granted appropriate ethical approvals. Results from this study will be disseminated through peer-reviewed journals.

CONCLUSION

This study will ensure the extent and consequences of LC-ILD are established and enable strategies to mitigate progression of LC-ILD.

A systematic review and meta-analysis of incidence, prognosis, and laboratory indicators of venous thromboembolism in hospitalized patients with coronavirus disease 2019

OBJECTIVE

We have summarized the incidence, anticoagulation panels, laboratory characteristics, and mortality of venous thromboembolism (VTE) in hospitalized patients with coronavirus disease 2019 (COVID-19).

METHODS

After systematically searching PubMed, Embase, the Cochrane Library, MedRxiv, and BioRxiv, a systematic review and meta-analysis of 18 retrospective, 6 prospective observational, and 2 cross-sectional studies was performed according to the guidelines of the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement.

RESULTS

Overall, 4382 hospitalized patients with COVID-19 were included. Men accounted for significantly more patients than did women (odds ratio [OR], 1.59; 95% confidence interval [CI], 1.25-2.02; P < .001). The total incidence of VTE among the patients with COVID-19 was 28.3% (95% CI, 21.6%-35.4%), with an incidence of 38.0% (95% CI, 29.1%-47.4%) and 17.2% (95% CI, 11.4%-23.8%) among those with severe and general COVID-19, respectively. The total incidence of deep vein thrombosis (DVT) of the lower extremities was 18.3% (95% CI, 10.8%-27.2%). The incidence of DVT was 22.1% (95% CI, 11.0%-35.5%) and 12.8% (95% CI, 5.0%-23.3%) in those with severe and general COVID-19, respectively. The total incidence of pulmonary embolism was 17.6% (95% CI, 12.3%-23.5%), with a rate of 21.7% (95% CI, 14.8%-29.3%) in severe cases and 12.5% (95% CI, 6.1%-23.5%) in general cases. When COVID-19 severity was unclassified, the mortality for the patients with VTE was not significantly greater (25.2%; 95% CI, 12.2%-40.5%) than that for those without VTE (10.2%; 95% CI, 3.4%-19.5%; OR, 1.88; 95% CI, 0.46-7.64; P = .377). However, among the patients with severe COVID-19, those who had developed VTE had significantly greater mortality compared with those without VTE (OR, 2.02; 95% CI, 1.15-3.53; P = .014). The patients with COVID-19 and VTE had significantly higher D-dimer levels than did similar patients without VTE in multiple studies.

CONCLUSIONS

The occurrence of VTE, DVT, and pulmonary embolism has been substantial among hospitalized patients with COVID-19, especially among those with severe COVID-19. Patients with severe COVID-19 and VTE had significantly greater mortality compared with similar patients without VTE. An increased D-dimer level might be an indicator of the occurrence of VTE in patients with COVID-19.

Expression of Matrix Metalloproteinases and Their Tissue Inhibitors in Chronic Rhinosinusitis With Nasal Polyps: Etiopathogenesis and Recurrence

Chronic rhinosinusitis with nasal polyps is a multifactorial disease of the nasal and paranasal sinus mucosa and it includes, as comorbidities, anatomic and morphologic alterations, allergic rhinitis, and immunologic diseases. We investigated matrix metalloproteinases (MMP-2, MMP-7, and MMP-9) and their tissue inhibitors (TIMP-1 and TIMP-2) concentration in different etiopathogenetical groups of patients with nasal polyposis (NP) in relation to recurrence after sinonasal surgery. The study group consisted of 45 patients with NP (those with allergic rhinitis, nonallergic rhinitis and asthma or nonallergic rhinitis, and obstruction of osteomeatal complex [OMC]) who underwent endonasal sinus surgery. We also collected 10 patients who underwent septoplasty as control. Immunohistochemistry of nasal mucosa fragments, Western blotting, and polymerase chain reaction analysis showed increased MMPs levels (MMP-9 more than MMP-2 and MMP-7) and decreased tissue inhibitors of MMPs levels (TIMP-1 less than TIMP-2), in patients with chronic rhinosinusitis with nasal polyps compared with control group, in particular in patients with nonallergic rhinitis and asthma compared to those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC. We observed a higher risk of recurrence in patients with nonallergic rhinitis and asthma than in those with allergic rhinitis and nonallergic rhinitis and obstruction of OMC after 36 months from surgery. In this research, we evaluated pathogenesis of NP related to MMPs and their inhibitors concentrations in polypoid tissue.

Glycogen Synthase Kinase-3: A Focal Point for Advancing Pathogenic Inflammation in Depression

Increasing evidence indicates that the host immune response has a monumental role in the etiology of major depressive disorder (MDD), motivating the development of the inflammatory hypothesis of depression. Central to the involvement of chronic inflammation in MDD is a wide range of signaling deficits induced by the excessive secretion of pro-inflammatory cytokines and imbalanced T cell differentiation. Such signaling deficits include the glutamatergic, cholinergic, insulin, and neurotrophin systems, which work in concert to initiate and advance the neuropathology. Fundamental to the communication between such systems is the protein kinase glycogen synthase kinase-3 (GSK-3), a multifaceted protein critically linked to the etiology of MDD and an emerging target to treat pathogenic inflammation. Here, a consolidated overview of the widespread multi-system involvement of GSK-3 in contributing to the neuropathology of MDD will be discussed, with the feed-forward mechanistic links between all major neuronal signaling pathways highlighted.

Selexipag use for paediatric pulmonary hypertension: a single centre report focussed on congenital heart disease patients

Pulmonary hypertension is a rare and complex disease with poor prognosis. Paediatric cases are infrequent and usually associated with congenital heart disease. Management is problematical due to the limited therapy available and poor evidence of efficacy. Recently a new medication, selexipag (UptraviR), a prostacyclin receptor agonist, has been approved for the treatment of pulmonary artery hypertension in adults. We report our experience using selexipag in four paediatric patients with pulmonary hypertension associated with congenital heart disease.

Effects of CRRT on renal function and toxin clearance in patients with sepsis: a case-control study

OBJECTIVE

To explore the effects of continuous renal replacement therapy (CRRT) on renal function and toxin clearance in patients with sepsis and concurrent acute kidney injury (AKI).

METHOD

A retrospective analysis was performed using the medical records of 115 patients with sepsis and AKI. Among them, 60 patients received routine treatment (group A) and 55 patients received CRRT plus routine treatment (group B).

RESULT

After treatment, the clearance rates of serum creatinine, lactic acid, and urea nitrogen were significantly lower in group A than in group B. The decrease in high-sensitivity C-reactive protein and tumor necrosis factor-α levels after treatment was significantly higher in group B than in group A. For the Acute Physiology Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores from the two groups, the scores were significantly lower in group B than in group A. The mortality rate within 28 days was significantly higher in group A than in group B.

CONCLUSION

CRRT can effectively improve the condition of patients with sepsis and AKI, promote elimination of toxins (serum creatinine, lactic acid, and urea nitrogen) from the body, and reduce the mortality rate.

Association of short-term fine particulate matter exposure with pulmonary function in populations at intermediate to high-risk of cardiovascular disease: A panel study in three Chinese cities

BACKGROUND

Decline in pulmonary function contributes to increasing cardiovascular disease (CVD) risk. Although adverse effects of short-term exposure to fine particulate matter (PM_2.5) on pulmonary function have been recognized in healthy people or patients with respiratory disease, these results were not well illustrated among people with elevated CVD risk.

MATERIALS AND METHODS

A panel study was conducted in three Chinese cities with three repeated visits among populations at intermediate to high-risk of CVD, defined as treated hypertension patients or those with blood pressure ≥ 130/80 mmHg, who met any of the three conditions including abdominal obesity, dyslipidemia, and diabetes mellitus. Individualized PM_2.5 exposure and pulmonary function were measured during each seasonal visit. Linear mixed-effect models were applied to analyze the associations of PM_2.5 concentrations with pulmonary function indicators, including forced expiratory volume in 1 s (FEV₁), FEV₁/forced vital capacity (FVC), maximal mid-expiratory flow (MMF), and peak expiratory flow (PEF).

RESULTS

Short-term PM_2.5 exposure was significantly associated with decreased pulmonary function and an increment of 10 μg/m³ in PM_2.5 concentrations during lag 12-24 hour was associated with declines of 41.7 ml/s (95% confidence interval [CI]: 7.7-75.7), 0.35% (95% CI: 0.01, 0.69), and 20.9 ml/s (95% CI: 0.5-41.3) for PEF, FEV₁/FVC, and MMF, respectively. Results from stratified and sensitivity analyses were generally similar with the overall findings, while the adverse effects of PM_2.5 on pulmonary functions were more pronounced in those who were physically inactive.

CONCLUSIONS

This study first identified short-term exposure to PM_2.5 was associated with impaired pulmonary function and physical activity might attenuate the adverse effects of PM_2.5 among populations at intermediate to high-risk of CVD. These findings provide new robust evidence on health effects of air pollution and call for effective prevention measures among people at CVD risk.

Lung perfusion changes in COVID-19 pneumonia: a dual energy computerized tomography study

OBJECTIVE

There is limited and contradictory information about pulmonary perfusion changes detected with dual energy computed tomography (DECT) in COVID-19 cases. The purpose of this study was to define lung perfusion changes in COVID-19 cases with DECT, as well as to reveal any possible links between perfusion changes and laboratory findings.

METHODS

Patients who had a positive RT-PCR for SARS-CoV-2 and a contrast-enhanced chest DECT examination were included in the study. The pattern and severity of perfusion deficits were evaluated, as well as the relationships between perfusion deficit severity and laboratory results and CT severity ratings. The paired t-test, Wilcoxon test, and Student's t-test were used to examine the changes in variables and perfusion deficits. p < 0.05 was regarded as statistically significant.

RESULTS

Study population consisted of 40 patients. Mean age was 60.73 ± 14.73 years. All of the patients had perfusion deficits at DECT images. Mean perfusion deficit severity score of the population was 8.45 ± 4.66 (min.-max, 1-19). In 24 patients (60%), perfusion deficits and parenchymal lesions matched completely. In 15 patients (37.5%), there was partial match. D dimer, CRP levels, CT severity score, and perfusion deficit severity score all had a positive correlation.

CONCLUSIONS

Perfusion deficits are seen not only in opacification areas but also in parenchyma of normal appearance. The CT severity score, CRP, D-dimer, and SpO2 levels of the patients were determined to be related with perfusion deficit severity.

ADVANCES IN KNOWLEDGE

Findings of the current study may confirm the presence of micro-thrombosis in COVID-19 pneumonia.

Erste Evaluation eines Programms zur Frührehabilitation von Langzeitintensivpatient_innen

First evaluation of an early rehabilitation programm for chronically critically ill patients Abstract. Introduction: Chronically critically ill patients are an increasing challenge for teams in intensive care units due to the burden of symptoms and the consumption of resources. Structured multimodal concepts are recommended for nursing care and treatment. A local, interprofessional program for early rehabilitation aims to provide optimal care for patients through a systematic, proactive and holistic treatment process with a rehabilitative focus. The program consists of specific assessments and systematic coordination of interprofessional early rehabilitation. Problem and objective: Interprofessional collaboration requires mutual acceptance and good communication from those involved. The functioning of selected processes as well as the satisfaction of the professionals are topics of a first formative evaluation. Methods: The team evaluated descriptive quality data as well as self-generated structured questionnaires. Results: Specific adjustments were made to the treatment plan for 52 of 112 patients in the program. The assessments are easy to carry out and support systematic early rehabilitation. From the perspective of the professionals involved, both the interprofessional collaboration and their understanding for the patients improved. Discussion and transfer: The program optimizes treatment and promotes good interprofessional collaboration. The formative evaluation provides valuable information for future process changes such as the inclusion of patients as well as further disciplines and program development beyond the boundaries of the intensive care unit.

Virus Infection Induces Keap1 Binding to Cytokine Genes, Which Recruits NF-κB p50 and G9a-GLP and Represses Cytokine Transcription

Proinflammatory cytokine gene transcription must be moderated to avoid the pathological consequences of excess cytokine production. The relationships between virus infection and the mechanisms that moderate cytokine transcription are incompletely understood. We investigated the influence of Keap1 on cytokine gene induction by Sendai virus infection in mouse embryo fibroblasts. Virus infection induced Keap1 binding to the Ifnb1, Tnf, and Il6 genes. Keap1 moderated viral induction of their transcription by mechanisms that did not require Nrf2. Keap1 was required for NF-κB p50 recruitment, but not for NF-κB p65 or IRF3 recruitment, to these genes. Keap1 formed complexes with NF-κB p50 and NF-κB p65, which were visualized using bimolecular fluorescence complementation analysis. These bimolecular fluorescence complementation complexes bound chromosomes in live cells, suggesting that Keap1 could bind chromatin in association with NF-κB proteins. Keap1 was required for viral induction of G9a-GLP lysine methyltransferase binding and H3K9me2 modification at cytokine genes. G9a-GLP inhibitors counteracted transcription repression by Keap1 and enhanced Keap1 and NF-κB recruitment to cytokine genes. The interrelationships among Keap1, NF-κB, and G9a-GLP recruitment, activities, and transcriptional effects suggest that they form a feedback circuit, which moderates viral induction of cytokine transcription. Nrf2 counteracted Keap1 binding to cytokine genes and the recruitment of NF-κB p50 and G9a-GLP by Keap1. Whereas Keap1 has been reported to influence cytokine expression indirectly through its functions in the cytoplasm, these findings provide evidence that Keap1 regulates cytokine transcription directly in the nucleus. Keap1 binds to cytokines genes upon virus infection and moderates their induction by recruiting NF-κB p50 and G9a-GLP.

Sarcoidosis of the ear, nose and throat: A review of the literature

OBJECTIVES

Sarcoidosis is a multisystemic inflammatory disease with extrathoracic manifestations, most commonly affecting the young and middle-aged, female and Black populations. Diagnosis usually requires evidence of non-caseating granulomata and, when treated, prognosis is usually favourable. We aim to establish the incidence, clinical features and optimal treatment of ENT manifestations of this disease.

DESIGN

We performed a PubMed literature review to determine the evidence base supporting this.

RESULTS

ENT manifestations are present in 5%-15% of patients with sarcoidosis, often as a presenting feature, and require vigilance for swift recognition and coordinated additional treatment specific to the organ. Laryngeal sarcoidosis presents with difficulty in breathing, dysphonia and cough, and may be treated by speech and language therapy (SLT) or intralesional injection, dilatation or tissue reduction. Nasal disease presents with crusting, rhinitis, nasal obstruction and anosmia, usually without sinus involvement. It is treated by topical nasal or intralesional treatments but may also require endoscopic sinus surgery, laser treatment or even nasal reconstruction. Otological disease is uncommon but includes audiovestibular symptoms, both sensorineural and conductive hearing loss, and skin lesions.

CONCLUSIONS

The consequences of ENT manifestations of sarcoidosis can be uncomfortable, disabling and even life-threatening. Effective management strategies require good diagnostic skills and use of specific therapies combined with established treatments such as corticosteroids. Comparisons of treatment outcomes are needed to establish best practice in this area.

Principles of Resuscitation

Shock from all causes carries a high mortality. Rapid and intentional intervention to resuscitate can reduce mortality and organ injury. Approaches to fluid resuscitation, vasopressor use as well as commonly assessed laboratory values are reviewed in this paper.

Weight gain in the first week of life and its association with morbidity and mortality in extremely low birthweight (ELBW) infants

BACKGROUND

Weight gain in the first week of life is indicative of fluid excess in preterm neonates.

AIMS

To determine if morbidity and/or mortality of extremely low birthweight (ELBW) infants was lower in those who did not have excess weight gain in the first week of life, compared with those who did.

STUDY DESIGN

Retrospective cohort study.

SUBJECTS

ELBW infants born from 1st May 2014 - 31st May 2019.

EXCLUSIONS

major congenital abnormalities (including hydrops), died within the first 7 days, no recorded weight on day 6, 7 or 8.

OUTCOME MEASURES

We compared infants whose weight was greater than birthweight by day 7 and infants whose weight remained at, or below, birthweight by day 7.

RESULTS

There were 312 ELBW infants in the study population: 15 (5%) died before discharge from hospital. Holding birthweight and gestational age (GA) constant, the odds of death in neonates with day 7 weight >birthweight was about 3 times the odds of death in neonates with day 7 weight ≤birthweight (adjusted odds ratio 3.18, 95% confidence interval 0.66-15.26, p = 0.15). Neonates with day 7 weight >birthweight were more likely to have had a PDA that required treatment than those with day 7 weight ≤birthweight (65% versus 43% respectively; p <0.001).

CONCLUSIONS

ELBW infants who gain weight in the first week of postnatal life, have a greater risk of PDA requiring treatment and may have a higher risk of mortality than infants who lose weight in the first week of life.

Sleep, Classroom Behavior, and Achievement Among Children of Color in Historically Disinvested Neighborhoods

Children of color are more likely to have poor sleep health than White children, placing them at risk for behavioral problems in the classroom and lower academic performance. Few studies, however, have utilized standardized measures of both classroom behavior and achievement. This study examined whether children's sleep (parent and teacher report) in first grade concurrently related to independent observations of classroom behavior and longitudinally predicted achievement test scores in second grade in a sample of primarily Black (86%) children (n = 572; age = 6.8) living in historically disinvested neighborhoods. Higher teacher-reported child sleepiness was associated with lower adaptive behaviors and higher problem behaviors in the classroom, and predicted lower achievement. Parent-reported bedtime resistance and disordered breathing also predicted lower achievement.

Impact of COVID-19 on pediatric pulmonology healthcare practice

INTRODUCTION

Coronavirus 2019 (COVID-19) is typically spread by droplets and has had a remarkable effect on pediatric pulmonology healthcare practice. Here, we aimed to evaluate the effect of the COVID-19 pandemic on the clinical follow-up and hospital visits of patients followed up at a pediatric pulmonology unit at a tertiary care center.

METHODS

This study was an observational descriptive study performed at a tertiary care center pediatric pulmonology unit between January 2019 and December 2020. We analyzed the outpatient visits, laboratory procedures which including pulmonary function tests (PFTs), diffusion capacity assessment, plethysmography, and lung clearance index (LCI), high-speed video microscopy, gastric aspirate sampling, and Flexible fiberoptic bronchoscopy (FFB) during clinical follow-up, and hospitalization numbers of patients with chronic lung diseases during the COVID-19 pandemic and compared them with the previous year before the pandemic started.

RESULTS

In 2020, compared with 2019, outpatient visits decreased by 42.2%; from 8324 patients to 4804 patients and other laboratory procedures decreased after the pandemic started; PFTs including spirometry by 87.2%; from 2990 to 380 tests, diffusion capacity assessment from 172 to 55 tests, plethysmography from 172 to 53 and LCI from 70 to 9 tests, also high-speed video microscopy analyses by 64.3% from 300 to 107 patients, and gastric aspirate sampling by 75.5% from 42 to 9 patients. FFB procedures also decreased by 59.1%, from 142 to 58 patients, and only 15 were after the first reported case of COVID-19 in our country, and they were all for urgent indications. None of these patients was positive pretesting for COVID-19 who underwent the FFB. There was no significant decrease in patients' hospitalization due to pulmonary exacerbation in cystic fibrosis, interstitial lung disease, and primary ciliary dyskinesia.

Acute Stroke Patients with Sleep Apnea Acording to the Disability and Incidence of Relapse

BACKGROUND

Sleep is a complex process involving the interactions of several brain regions, which play a key role in regulating the sleep process, particularly the brainstem, thalamus, and anterior basal brain regions. The process of sleep is accompanied by a change in body functions, as well as a change in cerebral electrical activity, which is under the control of the autonomic nervous system.

OBJECTIVE

The aim of the study was to analyze the frequency of stroke recurrence and disability of patients with stroke and apnea.

METHODS

It was analyzed 110 acute stroke patients with sleep apnea. All patients were evaluated with: Glasgow scale, The American National Institutes of Health Scale Assessment, Mini Mental Test, The Sleep and snoring Questionnaire Test, The Berlin Questionnaire Test, The Epworth Sleepiness Scale, The Stanford Sleepiness Scale, and The general sleep questionnaire.

RESULTS

The largest number of patients with apnea on admission had a degree of disability of 4, and on discharge of 1. There was a statistically significant difference between the mean values of incapacity for admission and discharge. The student's t - test did not determine a statistically significant difference in disability according to the Rankin scale between patients with and without apnea at admission (t = 0.059, p = 0.95) and discharge (t = 0.71, p = 0.48). According to the NIHS scale, patients of both sexes with apnea had a neurological deficit of 7.55 ± 5.22 on admission and 7.1 ± 4.3 without apnea. Statistically significant difference was not found on the neurological deficit of both sexes, with and without apnea, at admission and discharge. With apnea, there were 13 relapses of stroke during one year, and without apnea in only 3 patients.

CONCLUSION

Patients with acute stroke have a significantly higher correlation rate according to sleep apnea. There is no significant correlation in the degree of disability between patients with and without apnea.

High conversion of tuberculin skin tests during the first year of antiretroviral treatment among South African adults in primary care

OBJECTIVES

Anergy reduces the sensitivity of the tuberculin skin test (TST) to detect Mycobacterium tuberculosis infection in people living with HIV. Antiretroviral treatment (ART) can reverse TST anergy, but data is scarce.

METHODS

To estimate TST conversion rates and factors associated with TST conversion, TST was placed at ART initiation, and 6 and 12 months thereafter (if TST negative at prior assessment).

RESULTS

Of 328 ART-eligible participants, 70% (231/328) had a valid TST result of whom 78% (180/231) were TST negative. At 6-month follow-up, 22% (24/109, 95% confidence interval [CI] 15%, 31%) of participants on ART, without incident tuberculosis (TB), and with a valid TST result converted to a positive TST. Of these 109 individuals, those with baseline CD4+ cell count >250 cells/μl were more likely to TST convert compared to those with baseline CD4+ cell count ≤250 cells/μl (odds ratio [OR] 3.54, 95% CI 1.29, 11.47). At 12 months post-ART initiation, an additional 12% (9/78, 95% CI 6, 20) of participants on ART, without incident TB and with a valid TST result experienced TST conversion. After 1 year on ART, TST conversion rate was 38 per 100 person-years (95% CI 26, 52), and lower in individuals with baseline CD4+ cell count ≤250 cells/μl (23/100 person-years, 95% CI 11, 41) compared to those with baseline CD4+ cell count >250 cells/μl (50/100 person-years, 95% CI 32, 73).

CONCLUSIONS

TST conversion rate in the first year of ART is high, especially among people with CD4+ cell count >250 cells/μl. A TST-based eligibility strategy at ART initiation may underestimate eligibility for preventive therapy for tuberculosis.

Predictive ability of the International Classification of Sleep Disorders-3 in identifying risk of obstructive sleep apnea among recently unemployed adults

BACKGROUND

The International Classification of Sleep Disorders (ICSD)-3 was developed to aid in the identification of these disorders. The core criterion A (ICSD-3A) to identify obstructive sleep apnea (OSA) requires the presentence of specific signs and symptoms. This study explores the predictive ability of the ICSD-3A for OSA as compared with objective measures of respiratory event index (REI).

PARTICIPANTS

A total of 291 participants who completed a home sleep apnea test (HSAT) during the screening evaluation of the Assessing Daily Activity Patterns through occupational Transitions (ADAPT) study were included.

METHODS

Participants were classified as having mild OSA (REI ≥ 5 and < 15), moderate (≥ 15 to < 30), or severe OSA (> 30). Predictive parameters identifying participants as having OSA by the ICSD-3A criteria were assessed using REI classifications as the reference standard and further compared with a subsample using the STOP-Bang questionnaire.

RESULTS

The ICSD-3A had a sensitivity of 19.2% for identifying participants as having moderate to severe OSA and specificity of 84.4%. The ICSD-3A had a receiver operating characteristics (ROC) = 0.53. On the subsample of participants, the STOP-Bang questionnaire's ROC is 0.61. Results were similar when examining the classification of participants with mild compared with no OSA.

CONCLUSION

In this population, the ability of the ICSD-3A in detecting moderate to severe OSA as well as mild OSA was low. The ROC for the ICSD-3 did not differ significantly from the STOP-Bang questionnaire's ROC in this research population.

Residual Lung Injury in Patients Recovering From COVID-19 Critical Illness: A Prospective Longitudinal Point-of-Care Lung Ultrasound Study

Scarce data exist regarding the natural history of lung lesions detected on ultrasound in those who survive severe COVID-19 pneumonia.

OBJECTIVE

We performed a prospective analysis of point-of-care ultrasound (POCUS) findings in critically ill COVID-19 patients during and after hospitalization.

METHODS

We enrolled 171 COVID-19 intensive care unit patients. POCUS of the lungs was performed with phased array (2-4 MHz), convex (2-6 MHz) and linear (10-15 MHz) transducers, scanning 12 lung areas. Chest computed tomography angiography was performed to exclude suspected pulmonary embolism. Survivors were clinically and sonographically evaluated during a 4 month period for evidence of residual lung injury. Chest computed tomography angiography and echocardiography were used to exclude pulmonary hypertension (PH) and chest high-resolution-computed-tomography to exclude interstitial lung disease (ILD) in symptomatic survivors.

RESULTS

Cox regression analysis showed that lymphocytopenia (hazard ratio [HR]: 0.88, 95% confidence intervals [CI]: 0.68-0.96, p = .048), increased lactate (HR: 1.17, 95% CI: 0.94-1.46, p = 0.049), and D-dimers (HR: 1.21, 95% CI: 1.03-1.44, p = .03) were mortality predictors. Non-survivors had increased incidence of pulmonary abnormalities (B-lines, pleural line irregularities, and consolidations) compared to survivors (p < .05). During follow-up, POCUS with clinical and laboratory parameters integrated in the semi-quantitative Riyadh-Residual-Lung-Injury scale had sensitivity of 0.82 (95% CI: 0.76-0.89) and specificity of 0.91 (95% CI: 0.94-0.95) in predicting ILD. The prevalence of PH and ILD (non-specific-interstitial-pneumonia) was 7% and 11.8%, respectively.

CONCLUSION

POCUS showed ability to monitor the evolution of severe COVID-19 pneumonia after hospital discharge, supporting its integration in clinical predictive models of residual lung injury.

Inflammatory cytokines and sleep parameters response to life style intervention in subjects with obese chronic insomnia syndrome

Background

Chronic primary insomnia is a prevalent sleep disorder that is associated with adverse effects on health outcomes. Sleep disturbance is usually associated with abnormal level of systemic inflammation biomarkers.

Objective

The aim of this study was to detect changes in sleep quality and inflammatory markers following weight loss among subjects with chronic primary insomnia.

Material and methods

Eighty previously sedentary subjects with chronic primary insomnia subjects enrolled in this study, their age ranged from 32–51 year were randomly assigned to life style intervention group (group A, n=40) or control group (group B, n=40). Polysomnographic recordings for sleep quality assessment, IL-6, IL-10 and TNF-α were measured before and at the end of the study after six months.

Results

There was a significant increase in the total sleep duration, sleep efficiency, sleep onset latency and IL-10 in addition to significant reduction in awake time after sleep onset, REM latency, IL-6 and TNF-α after 6 months of in group(A) as a result of weight loss program; while the results of the control group (group B) were not significant. Also, there were significant differences between both groups at the end of the study.

Conclusion

Life style intervention modulates systemic inflammatory parameters and sleep quality among subjects with chronic primary insomnia.

TRIM28 regulates SARS-CoV-2 cell entry by targeting ACE2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of coronavirus disease 2019, it binds to angiotensin-converting enzyme 2 (ACE2) to enter into human cells. The expression level of ACE2 potentially determine the susceptibility and severity of COVID-19, it is thus of importance to understand the regulatory mechanism of ACE2 expression. Tripartite motif containing 28 (TRIM28) is known to be involved in multiple processes including antiviral restriction, endogenous retrovirus latency and immune response, it is recently reported to be co-expressed with SARS-CoV-2 receptor in type II pneumocytes; however, the roles of TRIM28 in ACE2 expression and SARS-CoV-2 cell entry remain unclear. This study showed that knockdown of TRIM28 induces ACE2 expression and increases pseudotyped SARS-CoV-2 cell entry of A549 cells and primary pulmonary alveolar epithelial cells (PAEpiCs). In a co-culture model of NK cells and lung epithelial cells, our results demonstrated that NK cells inhibit TRIM28 and promote ACE2 expression in lung epithelial cells, which was partially reversed by depletion of interleukin-2 and blocking of granzyme B in the co-culture medium. Furthermore, TRIM28 knockdown enhanced interferon-γ (IFN-γ)- induced ACE2 expression through a mechanism involving upregulating IFN-γ receptor 2 (IFNGR2) in both A549 and PAEpiCs. The upregulated ACE2 induced by TRIM28 knockdown and co-culture of NK cells was partially reversed by dexamethasone in A549 cells. Our study identified TRIM28 as a novel regulator of ACE2 expression and SARS-CoV-2 cell entry.

Feasibility of Contrasting Brain Connectivity Patterns in Cognitive and Motor Cerebral Networks to Clinical Outcomes in Patients Surviving Acute Respiratory Failure: A Pilot Study

BACKGROUND

There is a paucity of research regarding the feasibility and association of cerebral cortex function to patient outcomes after acute respiratory failure (ARF).

PURPOSE

To determine the feasibility of functional connectivity measures and examine the association of functional connectivity to a multifaceted battery of outcomes in survivors of ARF.

METHODS

Eight ARF patients (age:58±3.7, ICU days:10.4±8.6) completed functional magnetic resonance imaging (fMRI), cognitive, physical-function, anxiety, depression, and driving simulator tests at one month post-hospital discharge. Pearson's correlations assessed the relationship between functional connectivity within the default mode network (FPN), sensorimotor network (SMN), and frontoparietal network (FPN) to outcomes.

RESULTS

Low physical-function (r=0.75, p=0.03) and divided-attention (r=-0.86, p=0.03) during the driving simulator task correlated with low FPN connectivity. Low SMN connectivity demonstrated relationships to slower gait speed (r=0.82, p=0.01) and low short physical performance battery (SPPB) scores (r=0.81, p=0.01).

CONCLUSIONS

fMRI is feasible to assess ARF patients' post-ICU limitations, as low post-ARF brain connectivity may be linked to low physical function, providing potential development of therapeutic interventions.

JTE-013 Alleviates Inflammatory Injury and Endothelial Dysfunction Induced by Sepsis In Vivo and In Vitro

BACKGROUND

Nowadays, there is no approved targeted agent for lung injury induced by sepsis. S1PR2 is confirmed to be a promising diagnosis and treatment target. JTE-013 as S1PR2 antagonists may be an agent of great potential. In this research, we sought to determine the functional role of JTE-013 in lung injury induced by sepsis.

MATERIALS AND METHODS

Seventy-two rats were assigned into normal group, sepsis model group and JTE-013 group. The animal model of lung injury induced by sepsis was constructed by cecal ligation and puncture. The human pulmonary microvascular endothelial cells (HPMECs) were divided into control, LPS and LPS + JTE-013 group. HPMECs induced by LPS served as the cell model of lung injury induced by sepsis. HE staining assay was performed for assessment of the pathological condition and Evans blue was applied for assessment of pulmonary tissue permeability. Wet/dry ratio was measured as indicators of pulmonary edema degree and neutrophil count was measured as indicators of infection status. The levels of inflammatory factors were detected by corresponding kits, cell survival by CCK-8 assay and protein expression level by western blot.

RESULTS

S1PR2 was highly expressed in vivo model of lung injury induced by sepsis. It was observed that JTE-013 as antagonist of S1PR2 alleviated the lung tissue injury, endothelial dysfunction and pulmonary edema induced by sepsis. In addition, JTE-013 reduced neutrophil count and levels of inflammatory factors. Moreover, results confirmed that JTE-013 enhanced cell viability and mitigated inflammatory response in cell model of sepsis.

CONCLUSIONS

Overall, JTE-013 as an antagonist of S1PR2 could relieve inflammatory injury and endothelial dysfunction induced by sepsis in vivo and vitro, resulting in attenuation of lung injury. These findings elucidated that JTE-013 may be a promising targeted agent for lung injury induced by sepsis.

Molecular Communications in Viral Infections Research: Modeling, Experimental Data, and Future Directions

Hundreds of millions of people worldwide are affected by viral infections each year, and yet, several of them neither have vaccines nor effective treatment during and post-infection. This challenge has been highlighted by the COVID-19 pandemic, showing how viruses can quickly spread and impact society as a whole. Novel interdisciplinary techniques must emerge to provide forward-looking strategies to combat viral infections, as well as possible future pandemics. In the past decade, an interdisciplinary area involving bioengineering, nanotechnology and information and communication technology (ICT) has been developed, known as Molecular Communications. This new emerging area uses elements of classical communication systems to molecular signalling and communication found inside and outside biological systems, characterizing the signalling processes between cells and viruses. In this paper, we provide an extensive and detailed discussion on how molecular communications can be integrated into the viral infectious diseases research, and how possible treatment and vaccines can be developed considering molecules as information carriers. We provide a literature review on molecular communications models for viral infection (intra-body and extra-body), a deep analysis on their effects on immune response, how experimental can be used by the molecular communications community, as well as open issues and future directions.

A clinician survey of use assessment, documentation, and education about cannabis in persons with cystic fibrosis

INTRODUCTION

To help open the clinician dialogue regarding cannabis use in persons with cystic fibrosis (CF) in the United States, we aimed to describe current practices of use assessment and documentation processes related to cannabis.

METHODS

A cross-sectional, anonymous survey study was distributed via email to CF directors and coordinators and to the Cystic Fibrosis Foundation (CFF) listservs of nurse, pharmacist, dietitian, social worker, and psychology care team members. The survey tool included multiple choice, scaled, and open-ended items, which assessed participants' awareness of current cannabis laws in their state, prescribing practices for medical marijuana, screening and documentation practices, knowledge of and what indications participants believe cannabis and cannabidiol (CBD) could be beneficial. Data were analyzed using descriptive statistics.

RESULTS

There were 282 survey participants, with majority as providers (28%) and social workers (29%), representing all US regions. Participants varied in terms of frequency of evaluating cannabis use, with 15.4% "always," 48.4% "sometimes," and 41% "rarely," or "never" asking about it. Regarding recreational versus medical cannabis use, 55.4% and 62.5% reported documentation of each type in the medical record, respectively. Participants reported appetite, pain, and nausea as the top three advocated indications for use. About 35% and 72% of participants felt "slightly" or "not at all" prepared to answer patient/family questions about cannabis and CBD, respectively.

CONCLUSIONS

The approach to cannabis use assessment, documentation, and education across CF care centers is variable. There is a need for care team and patient/caregiver education materials about cannabis/CBD and CF.

DUDA-Net: a double U-shaped dilated attention network for automatic infection area segmentation in COVID-19 lung CT images

PURPOSE

The global health crisis caused by coronavirus disease 2019 (COVID-19) is a common threat facing all humankind. In the process of diagnosing COVID-19 and treating patients, automatic COVID-19 lesion segmentation from computed tomography images helps doctors and patients intuitively understand lung infection. To effectively quantify lung infections, a convolutional neural network for automatic lung infection segmentation based on deep learning is proposed.

METHOD

This new type of COVID-19 lesion segmentation network is based on a U-Net backbone. First, a coarse segmentation network is constructed to extract the lung areas. Second, in the encoding and decoding process of the fine segmentation network, a new soft attention mechanism, namely the dilated convolutional attention (DCA) mechanism, is introduced to enable the network to focus on better quantitative information to strengthen the network's segmentation ability in the subtle areas of the lesions.

RESULTS

The experimental results show that the average Dice similarity coefficient (DSC), sensitivity (SEN), specificity (SPE) and area under the curve of DUDA-Net are 87.06%, 90.85%, 99.59% and 0.965, respectively. In addition, the introduction of a cascade U-shaped network scheme and DCA mechanism can improve the DSC by 24.46% and 14.33%, respectively.

CONCLUSION

The proposed DUDA-Net approach can automatically segment COVID-19 lesions with excellent performance, which indicates that the proposed method is of great clinical significance. In addition, the introduction of a coarse segmentation network and DCA mechanism can improve the COVID-19 segmentation performance.

Systemic sclerosis-associated interstitial lung disease in a Vietnamese adult female: Case report and literature review

Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is a rare disease in the Asian population and might be overlooked in clinical practice. Early diagnosis is crucial to initiate treatment and to prevent disease progression. Chest high-resolution computed tomography (HRCT) is the modality of choice for diagnosing and assessing this disorder. SSc-ILD should be included in the list of differential diagnoses of ILD. Familiarity with HRCT findings and thorough clinical examination are crucial for diagnosis and treatment.

Ghrelin protects against lipopolysaccharide-induced acute respiratory distress syndrome through the PI3K/AKT pathway

Pulmonary endothelial barrier dysfunction is a major pathophysiology observed in acute respiratory distress syndrome (ARDS). Ghrelin, a key regulator of metabolism, has been shown to play protective roles in the respiratory system. However, its effects on lipopolysaccharide (LPS)-induced pulmonary endothelial barrier injury are unknown. In this study, the effects of ghrelin on LPS-induced ARDS and endothelial cell injury were evaluated in vivo and in vitro. In vivo, mice treated with LPS (3 mg/kg intranasal application) were used to establish the ARDS model. Annexin V/propidium iodide apoptosis assay, scratch-wound assay, tube formation assay, transwell permeability assay, and Western blotting experiment were performed to reveal in vitro effects and underlying mechanisms of ghrelin on endothelial barrier function. Our results showed that ghrelin had protective effects on LPS-induced ARDS and endothelial barrier disruption by inhibiting apoptosis, promoting cell migration and tube formation, and activating the PI3K/AKT signaling pathway. Furthermore, ghrelin stabilized LPS-induced endothelial barrier function by decreasing endothelial permeability and increasing the expression of the intercellular junction protein vascular endothelial cadherin. LY294002, a specific inhibitor of the PI3K pathway, reversed the protective effects of ghrelin on the endothelial cell barrier. In conclusion, our findings indicated that ghrelin protected against LPS-induced ARDS by impairing the pulmonary endothelial barrier partly through activating the PI3K/AKT pathway. Thus, ghrelin may be a valuable therapeutic strategy for the prevention or treatment of ARDS.

Mortality in critically ill patients with coronavirus disease 2019-associated pulmonary aspergillosis: A systematic review and meta-analysis

Reports of COVID-19 associated pulmonary aspergillosis (CAPA) are rising, but the associated mortality and factors affecting it are not well-characterised. We performed a systematic review including 20 peer-reviewed English language studies reporting mortality in CAPA published till 18 February 2021from PubMed, Ovid SP, Web of Science, Embase and CINHAL. The pooled mortality in CAPA was 51.2% (95% CI: 43.1-61.1, I2  = 38%). The leave one out sensitivity analysis and influential case diagnostics revealed one outlier and its exclusion resulted in a mortality estimate of 54% (95% CI: 45-62). Higher odds of mortality: 2.83 (95% CI: 1.8-4.5) were seen in CAPA compared to controls. No significant difference in various subgroups according to the country of study, the continent of study, income category of country and quality of the included study was seen. None of the host risk factors, mycological test results, therapy for COVID-19 and antifungal therapy affected mortality. Thus, patients with CAPA have a high probability of mortality and early diagnosis with prompt therapy must be ensured to optimally manage these patients. However, more prospective studies with global and multi-centre coordination may help to address CAPA in a better way.

Molecular and clinical insights of matrix metalloproteinases into cancer spread and potential therapeutic interventions

Matrix metalloproteinases (MMPs) are the group of enzymes that belong to the family of zinc dependent endopeptidases. These proteases degrade collagen and other important proteins in extracellular matrix (ECM) and regulate cytoskeletal proteins, growth factors, chemokines and cytokines, thereby play significant role during organogenesis and normal tissue turnover. Recent studies highlight the tumorigenic functions of MMPs by modulating tumor microenvironment. Dysregulated MMPs/TIMPs cause an imbalance in crucial cell signals, and lead to serious pathological conditions related to inflammation, uncontrolled cell growth, ECM degradation, increased cell migration, cell death resistance, replicative immortality and the establishment of metastatic niche at secondary sites. Recently established correlation between the higher expression of active MMPs and cancer aggressiveness makes them probable target candidate of cancer diagnosis, prognosis and therapy. The present review focuses on the tumourigenic functions of MMPs and recent advancements in the development of MMP inhibitors of therapeutic potential in cancer treatment.

Normative reference equations of airway dynamics assessed by whole-body plethysmography during spontaneous breathing evaluated in infants, children, and adults

Effective specific airway resistance (sReff ), its reciprocal the effective specific airway conductance (sGeff ) are computed as ratios between the integral of the resistive aerodynamic work of breathing (sWOB) and the integral of the tidal flow/volume loop, the reciprocal, respectively. Unfortunately, reference equations to obtain normative values for sReff , sGeff , and sWOB are not yet available. To assess reference equations for sWOB, sReff , and sGeff during tidal breathing at resting level in healthy infants, children, and adults by a multidimensional model. Retrospectively exported data were collected from databases of five Swiss lung function centers, in which plethysmography (Jaeger Würzburg, Germany) was performed for the assessment of airway dynamics, static lung volumes, and forced breathing flow-volume loops, in a collective of 28 healthy infants, 47 children, and 273 adults. From this cohort, reference equations were computed based on anthropometric measures, lung volumes, indices of the breathing pattern, and timing of breathing. By multi-linear modeling reference equations of sReff , sGeff , and sWOB could be defined taking as independent parameters apart from anthropometric parameters, also parameters given by the ratio between the tidal volume and functional residual capacity (FRCpleth /VT ), and the ratio between VT and inspiratory time (VT /TI ). An alternative statistical approach to define reference equations of airway dynamics reveals that apart from the subject's anthropometric measurements, parameters of the magnitude of static lung volumes, the breathing pattern, and the timing of breathing are co-variants of reference equations of airway dynamics over a large age range.

Prediction of cardiovascular risk in patients with chronic obstructive pulmonary disease: a study of the National Health and Nutrition Examination Survey database

BACKGROUND

Cardiovascular disease (CVD) is a common comorbidity associated with chronic obstructive pulmonary disease (COPD), but few studies have been conducted to identify CVD risk in COPD patients. This study was to develop a predictive model of CVD in COPD patients based on the National Health and Nutrition Examination Survey (NHANES) database.

METHODS

A total of 3,226 COPD patients were retrieved from NHANES 2007-2012, dividing into the training (n = 2351) and testing (n = 895) sets. The prediction models were conducted using the multivariable logistic regression and random forest analyses, respectively. Receiver operating characteristic (ROC) curves, area under the curves (AUC) and internal validation were used to assess the predictive performance of models.

RESULTS

The logistic regression model for predicting the risk of CVD was developed regarding age, gender, body mass index (BMI), high-density lipoprotein (HDL), glycosylated hemoglobin (HbA1c), family history of heart disease, and stayed overnight in the hospital due to illness last year, which the AUC of the internal validation was 0.741. According to the random forest analysis, the important variables-associated with CVD risk were screened including smoking (NNAL and cotinine), HbA1c, HDL, age, gender, diastolic blood pressure, poverty income ratio, BMI, systolic blood pressure, and sedentary activity per day. The AUC of the internal validation was 0.984, indicating the random forest model for predicting the CVD risk in COPD cases was superior to the logistic regression model.

CONCLUSION

The random forest model performed better predictive effectiveness for the cardiovascular risk among COPD patients, which may be useful for clinicians to guide the clinical practice.

Mesenchymal stem cell exosomal tsRNA-21109 alleviate systemic lupus erythematosus by inhibiting macrophage M1 polarization

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with M1-type macrophage activation. Mesenchymal stem cells (MSCs) therapies have shown promise in models of pathologies relevant to SLE, while the function and mechanism of MSC-derived exosomes (MSC-exo) were still unclear. We aimed to interrogate the effect of MSC-exo on M1-type polarization of macrophage and investigate mechanisms underlying MSC-exo. Exosomes were isolated from MSC and the effect of MSC-exo on macrophage polarization was evaluated. The key tRNA-derived fragments (tRFs) carried by exosomes were identified by small RNA sequencing and verified in clinical samples. The effect of exosomal-tRFs on macrophage polarization was examined. In this study, MSC-exo dramatically suppressed expression of M1 markers, and reduced the levels of TNF-α and IL-1β, while increased M2 markers in macrophages. A total of 243 differently expressed tRFs (DEtRFs) were identified between MSC-exo treated and untreated macrophage, among which 103 DEtRFs were up-regulated in response to MSC-exo treatment, including tsRNA-21109. The target genes of tsRNA-21109 were mainly enriched in DNA transcription-related GO function, and mainly involved in inflammatory-related pathways, including Rap1, Ras, Hippo, Wnt, MAPK, TGF-beta signaling pathway. The tsRNA-21109 was lowly expressed in clinical samples and was associated with the patient data in SLE. Compared to the normal MSC-exo, the tsRNA-21109-privative MSC-exo up-regulated M1 marker (CD80, NOS2, MCP1) and down-regulated M2 marker (CD206, ARG1, MRC2), also increased the levels of TNF-α and IL-1β in macrophages. Western blot and immunofluorescence confirmed that the proportion of CD80/ARG-1 was increased in macrophages treated with tsRNA-21109-privatived MSC-exo compared to that with control MSC-exo. In conclusion, MSC-exo inhibited the M1-type polarization of macrophages, possibly through transferring tsRNA-21109, which may develop as a novel therapeutic target for SLE.

Lung ultrasound predicts non-invasive ventilation outcome in COVID-19 acute respiratory failure: a pilot study

BACKGROUND

The aim of this study is to determine relationships between lung aeration assessed by lung ultrasound (LUS) with non-invasive ventilation (NIMV) outcome, intensive care unit (ICU) admission and mechanical ventilation (MV) needs in COVID-19 respiratory failure.

METHODS

A cohort of adult patients with COVID-19 respiratory failure underwent LUS during initial assessment. A simplified LUS protocol consisting in scanning six areas, three for each side, was adopted. A score from 0 to 3 was assigned to each area. Comprehensive LUS score (LUSsc) was calculated as the sum of the score in all areas. LUSsc, the amount of involved sonographic lung areas (LUSq), the number of lung quadrants radiographically infiltrated and the degree of oxygenation impairment at admission (SpO<inf>2</inf>/FiO2 ratio) were compared to NIMV Outcome, MV needs and ICU admission.

RESULTS

Among 85 patients prospectively included in the analysis, 49 of 61 needed MV. LUSsc and LUSq were higher in patients who required MV (median 12 [IQR 8-14] and median 6 [IQR 4-6], respectively) than in those who did not (6 [IQR 2-9] and 3 [IQR 1-5], respectively), both P<0.001. NIMV trial failed in 26 patients out 36. LUSsc and LUSq were significantly higher in patients who failed NIMV than in those who did not. From ROC analysis, LUSsc ≥12 and LUSq ≥5 gave the best cut-off values for NIMV failure prediction (AUC=0.95, 95%CI 0.83-0.99 and AUC=0.81, 95% CI 0.65-0.91, respectively).

CONCLUSIONS

Our data suggest LUS as a possible tool for identifying patients who are likely to require MV and ICU admission or to fail a NIMV trial.

Inter-cellular CRISPR screens reveal regulators of cancer cell phagocytosis

Monoclonal antibody therapies targeting tumour antigens drive cancer cell elimination in large part by triggering macrophage phagocytosis of cancer cells^1-7. However, cancer cells evade phagocytosis using mechanisms that are incompletely understood. Here we develop a platform for unbiased identification of factors that impede antibody-dependent cellular phagocytosis (ADCP) using complementary genome-wide CRISPR knockout and overexpression screens in both cancer cells and macrophages. In cancer cells, beyond known factors such as CD47, we identify many regulators of susceptibility to ADCP, including the poorly characterized enzyme adipocyte plasma membrane-associated protein (APMAP). We find that loss of APMAP synergizes with tumour antigen-targeting monoclonal antibodies and/or CD47-blocking monoclonal antibodies to drive markedly increased phagocytosis across a wide range of cancer cell types, including those that are otherwise resistant to ADCP. Additionally, we show that APMAP loss synergizes with several different tumour-targeting monoclonal antibodies to inhibit tumour growth in mice. Using genome-wide counterscreens in macrophages, we find that the G-protein-coupled receptor GPR84 mediates enhanced phagocytosis of APMAP-deficient cancer cells. This work reveals a cancer-intrinsic regulator of susceptibility to antibody-driven phagocytosis and, more broadly, expands our knowledge of the mechanisms governing cancer resistance to macrophage phagocytosis.

ATS Core Curriculum 2021. Adult Pulmonary Medicine: Thoracic Oncology

The American Thoracic Society Core Curriculum updates clinicians annually in adult and pediatric pulmonary disease, medical critical care, and sleep medicine at the annual international conference. The 2021 Pulmonary Core Curriculum focuses on lung cancer and include risks and prevention, screening, nodules, therapeutics and associated pulmonary toxicities, and malignant pleural effusions. Although tobacco smoking remains the primary risk factor for developing lung cancer, exposure to other environmental and occupational substances, including asbestos, radon, and burned biomass, contribute to the global burden of disease. Randomized studies have demonstrated that routine screening of high-risk smokers with low-dose chest computed tomography results in detection at an earlier stage and reduction in lung cancer mortality. On the basis of these trials and other lung cancer risk tools, screening recommendations have been developed. When evaluating lung nodules, clinical and radiographic features are used to estimate the probability of cancer. Management guidelines take into account the nodule size and cancer risk estimates to provide recommendations at evaluation. Newer lung cancer therapies, including immune checkpoint inhibitors and molecular therapies, cause pulmonary toxicity more frequently than conventional chemotherapy. Treatment-related toxicity should be suspected in patients receiving these medications who present with respiratory symptoms. Evaluation is aimed at excluding other etiologies, and treatment is based on the severity of symptoms. Malignant pleural effusions can be debilitating. The diagnosis is made by using simple pleural drainage and/or pleural biopsies. Management depends on the clinical scenario and the patient's preferences and includes the use of serial thoracentesis, a tunneled pleural catheter, or pleurodesis.

Simultaneous pancreas and kidney transplant after bilateral lung transplant for a recipient with cystic fibrosis

Cystic fibrosis (CF) is an inherited autosomal recessive disorder. Despite optimized therapy, the majority of affected individuals ultimately die of respiratory failure. Lung transplantation is the only available therapy that deals definitively with the end-stage pulmonary disease and has become the treatment of choice for some of these patients. As patients with CF are living longer, extrapulmonary manifestations may develop including pancreatic failure, which manifests as exocrine insufficiency and CF-related diabetes (CFRD). Both of these can be managed through pancreas transplantation. We have previously reported our series of three simultaneous lung and pancreas transplants in patients with CF, which were complicated by surgical issues for both the thoracic and abdominal portions, rejection and resistant infections with disappointing long-term survival. Based on these results, a sequential approach was adopted: first, the thoracic transplant; and second, once the patient has recovered, the abdominal transplants. This is the first reported case of pancreas and kidney transplantation performed after a lung transplant in a patient with CF. It demonstrates a successful approach to treating CF with a lung transplant, and in an effort to improve the patient's long-term outcome, treating CFRD and pancreatic enzyme insufficiency, with a subsequent pancreas transplant.

Associations between ambient air pollutants and blood pressure among children and adolescents: A systemic review and meta-analysis

OBJECTIVE

Numerous epidemiological studies have investigated the effects of short-term and long-term exposure to ambient air pollution on hypertension and blood pressure among children and adolescents. However, the results were controversial. To provide researchers reliable evidence, this meta-analysis was performed.

METHODS

We searched all published studies in four databases examining the effects of particulate matter (PM₁₀, PM_2.5 and PM_1.0), nitrogen oxide (NO₂), sulfur dioxide (SO₂), ozone (O₃) and carbon monoxide (CO) on hypertension and blood pressure in children and adolescents. Overall risk estimates associated with per 10 μg/m³ increase of air pollution were analyzed by a random-effect model for articles with significant heterogeneity, otherwise, a fixed-effect model was applied. Subgroup analysis was conducted for studies with significant heterogeneity.

RESULTS

Of 3918 identified literatures, 154 were evaluated in-depth with 15 satisfying inclusion criteria. Increased risk of hypertension was associated with long-term PM₁₀ exposure (OR = 1.17, 95% confidence interval [CI]:1.13, 1.21). For systolic blood pressure (SBP), significant results were found for short-term PM₁₀ (β = 0.26, 95% CI: -0.00, 0.53) exposure, long-term PM_2.5 (β = 1.80, 95% CI: 0.94, 2.65) and PM₁₀ (β = 0.50, 95% CI: 0.19, 0.81) exposure. The corresponding estimates of diastolic blood pressure (DBP) were 0.32 mmHg (95% CI: 0.19, 0.45) for short-term PM₁₀ exposure, 1.06 mmHg (95% CI: 0.32, 1.80), 0.34 mmHg (95% CI: 0.11, 0.57) and 0.44 mmHg (95% CI: 0.25, 0.63) for long-term PM_2.5, PM₁₀ and NO₂ exposure, respectively. Stratified analyses showed stronger effects of PM₁₀ on blood pressure among studies with ≥50% boys' percentage (0.57 mmHg [95% CI: 0.44, 0.70] for SBP, 0.44 mmHg, [95% CI: 0.34, 0.54] for DBP, respectively) and articles using models to estimate exposure (0.90 mmHg [95% CI: 0.20 1.59] for SBP).

CONCLUSION

Ambient air pollution was associated with higher hypertension prevalence and elevated blood pressure in children and adolescents.

Machine Learning, Deep Learning, and Closed Loop Devices-Anesthesia Delivery

With the tremendous volume of data captured during surgeries and procedures, critical care, and pain management, the field of anesthesiology is uniquely suited for the application of machine learning, neural networks, and closed loop technologies. In the past several years, this area has expanded immensely in both interest and clinical applications. This article provides an overview of the basic tenets of machine learning, neural networks, and closed loop devices, with emphasis on the clinical applications of these technologies.

Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial

INTRODUCTION

Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care.

INTERVENTION

The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC.

OBJECTIVES

The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care.

METHODS

Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days.

CONCLUSION

This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.

Out-of-Pocket Spending for Asthma-Related Care Among Commercially Insured Patients, 2004-2016

BACKGROUND

Out-of-pocket (OOP) health care costs can cause financial burden and deferred care for many Americans. Little is known about OOP spending for asthma-related care among the commercially insured.

OBJECTIVES

To analyze OOP spending for asthma-related care overall, across types of care, and by income.

METHODS

Using enrollment, claims, and geocoded census tract data on income from a large US commercial health plan from 2004 to 2016, we measured inflation-adjusted OOP spending for individuals with asthma ages 4 to 64 years (n = 1,986,769). We estimated annual asthma-related OOP spending over time, and average total, asthma-related, asthma type of care, and asthma medication spending by income. We measured trends in median OOP cost per medication. Linear regression models were adjusted for patient covariates and deductible level.

RESULTS

Asthma-related OOP spending decreased over time both for patients enrolled in high-deductible health plans and for those in traditional plans. High-deductible plan enrollment increased from 7% to 54%. Compared with patients living in high-income areas, patients in the lowest-income areas had similar annual total and asthma-related OOP spending, but spent 30% less on controller medications and a higher proportion of their asthma-related OOP spending on inpatient and emergency care (10% vs 3%; P < .001). Asthma-related OOP spending represented a higher proportion of household income for patients in lower-income areas.

CONCLUSIONS

Patients with asthma living in the lowest-income areas have greater cost burden, lower spending on controller medications, and greater spending on high-acuity care than higher-income counterparts.