251
|
Touyz RM, Boyd MO, Guzik T, Padmanabhan S, McCallum L, Delles C, Mark PB, Petrie JR, Rios F, Montezano AC, Sykes R, Berry C. Cardiovascular and Renal Risk Factors and Complications Associated With COVID-19. CJC Open 2021; 3:1257-1272. [PMID: 34151246 PMCID: PMC8205551 DOI: 10.1016/j.cjco.2021.05.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 05/28/2021] [Indexed: 01/08/2023] Open
Abstract
The current COVID-19 pandemic, caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus, represents the largest medical challenge in decades. It has exposed unexpected cardiovascular vulnerabilities at all stages of the disease (pre-infection, acute phase, and subsequent chronic phase). The major cardiometabolic drivers identified as having epidemiologic and mechanistic associations with COVID-19 are abnormal adiposity, dysglycemia, dyslipidemia, and hypertension. Hypertension is of particular interest, because components of the renin-angiotensin system (RAS), which are critically involved in the pathophysiology of hypertension, are also implicated in COVID-19. Specifically, angiotensin-converting enzyme-2 (ACE2), a multifunctional protein of the RAS, which is part of the protective axis of the RAS, is also the receptor through which SARS-CoV-2 enters host cells, causing viral infection. Cardiovascular and cardiometabolic comorbidities not only predispose people to COVID-19, but also are complications of SARS-CoV-2 infection. In addition, increasing evidence indicates that acute kidney injury is common in COVID-19, occurs early and in temporal association with respiratory failure, and is associated with poor prognosis, especially in the presence of cardiovascular risk factors. Here, we discuss cardiovascular and kidney disease in the context of COVID-19 and provide recent advances on putative pathophysiological mechanisms linking cardiovascular disease and COVID-19, focusing on the RAS and ACE2, as well as the immune system and inflammation. We provide up-to-date information on the relationships among hypertension, diabetes, and COVID-19 and emphasize the major cardiovascular diseases associated with COVID-19. We also briefly discuss emerging cardiovascular complications associated with long COVID-19, notably postural tachycardia syndrome (POTS).
Collapse
Affiliation(s)
- Rhian M. Touyz
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Marcus O.E. Boyd
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Tomasz Guzik
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Sandosh Padmanabhan
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Linsay McCallum
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Patrick B. Mark
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John R. Petrie
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Francisco Rios
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Augusto C. Montezano
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Robert Sykes
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Colin Berry
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation, Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| |
Collapse
|
252
|
Kakavas S, Karayiannis D, Mastora Z. The Complex Interplay between Immunonutrition, Mast Cells, and Histamine Signaling in COVID-19. Nutrients 2021; 13:nu13103458. [PMID: 34684460 PMCID: PMC8537261 DOI: 10.3390/nu13103458] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 09/17/2021] [Accepted: 09/27/2021] [Indexed: 12/23/2022] Open
Abstract
There is an ongoing need for new therapeutic modalities against SARS-CoV-2 infection. Mast cell histamine has been implicated in the pathophysiology of COVID-19 as a regulator of proinflammatory, fibrotic, and thrombogenic processes. Consequently, mast cell histamine and its receptors represent promising pharmacological targets. At the same time, nutritional modulation of immune system function has been proposed and is being investigated for the prevention of COVID-19 or as an adjunctive strategy combined with conventional therapy. Several studies indicate that several immunonutrients can regulate mast cell activity to reduce the de novo synthesis and/or release of histamine and other mediators that are considered to mediate, at least in part, the complex pathophysiology present in COVID-19. This review summarizes the effects on mast cell histamine of common immunonutrients that have been investigated for use in COVID-19.
Collapse
Affiliation(s)
- Sotirios Kakavas
- Critical Care Department, “Sotiria” General Hospital of Chest Diseases, 152 Mesogeion Avenue, 11527 Athens, Greece;
| | - Dimitrios Karayiannis
- Department of Clinical Nutrition, Evangelismos General Hospital of Athens, Ypsilantou 45-47, 10676 Athens, Greece
- Correspondence: ; Tel.: +30-213-2045035; Fax: +30-213-2041385
| | - Zafeiria Mastora
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos General Hospital, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| |
Collapse
|
253
|
McFadyen JD, Peter K. The known knowns and known unknowns of vaccine-induced thrombotic thrombocytopaenia. Cardiovasc Res 2021; 117:e147-e150. [PMID: 34472568 PMCID: PMC8499896 DOI: 10.1093/cvr/cvab275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- James D McFadyen
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004 Victoria, Australia.,Department of Clinical Hematology, The Alfred Hospital, Melbourne, 3004 Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, 3004 Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, 3010 Victoria, Australia
| | - Karlheinz Peter
- Atherothrombosis and Vascular Biology Laboratory, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004 Victoria, Australia.,Department of Medicine, Central Clinical School, Monash University, Melbourne, 3004 Victoria, Australia.,Baker Department of Cardiometabolic Health, University of Melbourne, Melbourne, 3010 Victoria, Australia.,Department of Cardiology, The Alfred Hospital, Melbourne, 3004 Victoria, Australia
| |
Collapse
|
254
|
Cotter AH, Yang SJT, Shafi H, Cotter TM, Palmer-Toy DE. Elevated von Willebrand Factor Antigen is an Early Predictor of Mortality and Prolonged Length of Stay for Coronavirus Disease 2019 (COVID-19) Inpatients. Arch Pathol Lab Med 2021; 146:34-37. [PMID: 34546331 DOI: 10.5858/arpa.2021-0255-sa] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT Coagulation factor and endothelial injury marker, von Willebrand factor antigen (vWF:Ag), is elevated in coronavirus disease 2019 (COVID-19). OBJECTIVE To assess prognostic value of vWF:Ag for COVID-19 inpatients. DESIGN Citrated plasma samples collected from COVID-19 inpatients for D-dimer measurement were tested for vWF:Ag. Measurements of vWF:Ag and common acute phase reactants (APRs) were correlated with clinical outcomes and length of stay (LOS). RESULTS We included 333 samples from a diverse group of 120 COVID-19 inpatients. There was a clear association of higher peak measurements of vWF:Ag and other APRs with adverse clinical outcomes. Peak vWF:Ag >300% was associated with a 5-fold increased risk of death (Odds Ratio 5.08, P<.001) and a 30-fold increased risk of prolonged (>4 days) LOS (OR 29.65, P =.001). Peak D-dimer >3.8 FEU mg/L was associated with a 15-fold increase in risk of death (OR 14.73, P <.001) and a 5-fold increased risk of prolonged LOS (OR 4.55, P=.02). Using the earliest paired measurements of vWF:Ag and D-dimer from each patient and the same cut-offs, vWF:Ag was associated with a 3.5-fold increase in risk of death (OR 3.54, P=.004) and a 20-fold risk of prolonged LOS (OR 20.19, P=.004). Yet D-dimer was not significantly associated with either death (OR 1.9, P=.29) or prolonged LOS (OR 1.02, P=.98). CONCLUSIONS Both peak and early post-admission vWF:Ag >300% were highly predictive of death and prolonged length of stay among COVID-19 inpatients. Measurement of vWF:Ag may prove a valuable tool to guide escalation of COVID-19 treatment, particularly anticoagulation.
Collapse
Affiliation(s)
- Alexander H Cotter
- Departments of Pathology (AH Cotter, Shafi, Palmer-Toy), Research & Evaluation (Yang), and Cardiology (TM Cotter), at Kaiser Permanente / Southern California Permanente Medical Group, Pasadena, CA
| | - Su-Jau T Yang
- Departments of Pathology (AH Cotter, Shafi, Palmer-Toy), Research & Evaluation (Yang), and Cardiology (TM Cotter), at Kaiser Permanente / Southern California Permanente Medical Group, Pasadena, CA
| | - Hedyeh Shafi
- Departments of Pathology (AH Cotter, Shafi, Palmer-Toy), Research & Evaluation (Yang), and Cardiology (TM Cotter), at Kaiser Permanente / Southern California Permanente Medical Group, Pasadena, CA
| | - Timothy M Cotter
- Departments of Pathology (AH Cotter, Shafi, Palmer-Toy), Research & Evaluation (Yang), and Cardiology (TM Cotter), at Kaiser Permanente / Southern California Permanente Medical Group, Pasadena, CA
| | - Darryl Erik Palmer-Toy
- Departments of Pathology (AH Cotter, Shafi, Palmer-Toy), Research & Evaluation (Yang), and Cardiology (TM Cotter), at Kaiser Permanente / Southern California Permanente Medical Group, Pasadena, CA
| |
Collapse
|
255
|
Introcaso G, Bonomi A, Salvini L, D'Errico T, Cattaneo A, Assanelli E, Barbieri SS, Biondi ML. High immature platelet fraction with reduced platelet count on hospital admission. Can it be useful for COVID-19 diagnosis? Int J Lab Hematol 2021; 43:1319-1324. [PMID: 34534407 PMCID: PMC8653292 DOI: 10.1111/ijlh.13701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 08/05/2021] [Accepted: 08/26/2021] [Indexed: 12/20/2022]
Abstract
Introduction Health professions are heavily engaged facing the current threat of SARS‐CoV‐2 (COVID‐19). Although there are many diagnostic tools, an accurate and rapid laboratory procedure for diagnosing COVID‐19 is recommended. We focused on platelet parameters as the additional biomarkers for clinical diagnosis in patients presenting to the emergency department (ED). Materials and Methods Five hundred and sixty‐one patients from February to April 2020 have been recruited. Patients were divided into three groups: (N = 50) COVID‐19 positive and (N = 21) COVID‐19 negative with molecular testing, (N = 490) as reference population without molecular testing. A Multiplex rRT‐PCR from samples collected by nasopharyngeal swabs was performed and the hematological data collected. Results We detected a mild anemia in COVID‐19 group and lymphopenia against reference population: hemoglobin (g/dL) 13.0 (11.5‐14.8) versus 13.9 (12.8‐15.0) (P = .0135); lymphocytes (109/L) 1.24 (0.94‐1.73) versus 1.99 (1.49‐2.64) (P < .0001). In addition, abnormal platelet parameters as follows (COVID group vs reference population): PLT (×109/L) 209 (160‐258) vs 236 (193‐279) (P = .0239). IPF (%) 4.05 (2.5‐5.9) versus 3.4 (2.2‐4.9) (P = .0576); H‐IPF (%) 1.25 (0.8‐2.2) versus 0.95 (0.6‐1.5) (P = .0171) were identified. In particular, COVID positive group had a high H‐IPF/IPF Ratio compared to reference population [0.32 (0.29‐0.36) versus 0.29 (0.26‐0.32), respectively, (P = .0003)]. Finally, a PLT difference of nearly 50 × 109/L between pre/postCOVID‐19 sampling for each patient was found (N = 42) (P = .0194). Conclusions COVID‐19 group results highlighted higher IPF and H‐IPF values, with increased H‐IPF/IPF Ratio, associated to PLT count reduction. These findings shall be adopted for a timely diagnosis of patients upon hospital admission.
Collapse
Affiliation(s)
- Giovanni Introcaso
- Unit of Laboratory Medicine, Centro Cardiologico IRCCS Monzino, Milan, Italy
| | - Alice Bonomi
- Unit of Biostatistics, Centro Cardiologico IRCCS Monzino, Milan, Italy
| | - Laura Salvini
- Emergency Department, Centro Cardiologico IRCCS Monzino, Milan, Italy
| | - Tiziana D'Errico
- Unit of Laboratory Medicine, Centro Cardiologico IRCCS Monzino, Milan, Italy
| | - Annalisa Cattaneo
- Unit of Laboratory Medicine, Centro Cardiologico IRCCS Monzino, Milan, Italy
| | - Emilio Assanelli
- Emergency Department, Centro Cardiologico IRCCS Monzino, Milan, Italy
| | | | - Maria Luisa Biondi
- Unit of Laboratory Medicine, Centro Cardiologico IRCCS Monzino, Milan, Italy
| |
Collapse
|
256
|
Synergistic Effect of Static Compliance and D-dimers to Predict Outcome of Patients with COVID-19-ARDS: A Prospective Multicenter Study. Biomedicines 2021; 9:biomedicines9091228. [PMID: 34572414 PMCID: PMC8467668 DOI: 10.3390/biomedicines9091228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/09/2021] [Indexed: 12/24/2022] Open
Abstract
The synergic combination of D-dimer (as proxy of thrombotic/vascular injury) and static compliance (as proxy of parenchymal injury) in predicting mortality in COVID-19-ARDS has not been systematically evaluated. The objective is to determine whether the combination of elevated D-dimer and low static compliance can predict mortality in patients with COVID-19-ARDS. A “training sample” (March–June 2020) and a “testing sample” (September 2020–January 2021) of adult patients invasively ventilated for COVID-19-ARDS were collected in nine hospitals. D-dimer and compliance in the first 24 h were recorded. Study outcome was all-cause mortality at 28-days. Cut-offs for D-dimer and compliance were identified by receiver operating characteristic curve analysis. Mutually exclusive groups were selected using classification tree analysis with chi-square automatic interaction detection. Time to death in the resulting groups was estimated with Cox regression adjusted for SOFA, sex, age, PaO2/FiO2 ratio, and sample (training/testing). “Training” and “testing” samples amounted to 347 and 296 patients, respectively. Three groups were identified: D-dimer ≤ 1880 ng/mL (LD); D-dimer > 1880 ng/mL and compliance > 41 mL/cmH2O (LD-HC); D-dimer > 1880 ng/mL and compliance ≤ 41 mL/cmH2O (HD-LC). 28-days mortality progressively increased in the three groups (from 24% to 35% and 57% (training) and from 27% to 39% and 60% (testing), respectively; p < 0.01). Adjusted mortality was significantly higher in HD-LC group compared with LD (HR = 0.479, p < 0.001) and HD-HC (HR = 0.542, p < 0.01); no difference was found between LD and HD-HC. In conclusion, combination of high D-dimer and low static compliance identifies a clinical phenotype with high mortality in COVID-19-ARDS.
Collapse
|
257
|
Nusshag C, Morath C, Speer C, Kaelble F, Zeier M, Boxberger M, Schulze-Schleithoff E, Fiedler MO, Weigand MA, Merle U. Plasma Exchange in Patients With Severe Coronavirus Disease 2019: A Single-Center Experience. Crit Care Explor 2021; 3:e0517. [PMID: 34476404 PMCID: PMC8382335 DOI: 10.1097/cce.0000000000000517] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Supplemental Digital Content is available in the text. IMPORTANCE: Recent evidence suggests a multilevel inflammatory syndrome as a driving factor in some of the most severely ill coronavirus disease 2019 patients with overlapping features to other hyperinflammatory or autoimmune diseases. Therefore, plasma exchange is considered as potential therapy in these patients. OBJECTIVES: We characterize the longitudinal therapeutic efficacy and safety profile of plasma exchange in critically ill patients with clinical and laboratory evidences of coronavirus disease 2019–related immunopathology. DESIGN, SETTING, AND PARTICIPANTS: A retropsective case-control study of critically ill coronavirus disease 2019 patients treated with plasma exchange at Heidelberg University Hospital between March and December 2020. Plasma exchange–treated patients were compared with coronavirus disease 2019 patients on standard therapy matched for age, gender, disease severity, and features of hyperinflammatory syndrome. MAIN OUTCOME AND MEASURES: Mortality rate and course of clinical and laboratory parameters in response to plasma exchange were assessed in coronavirus disease 2019 patients and in patients on standard care. A plasma volume of 50 mL per kg body weight or a maximum of 4 L was exchanged. RESULTS: In total, 28 critically ill coronavirus disease 2019 patients were treated with a median of three plasma exchange procedures per patient. No relevant complications occurred during plasma exchange therapy. Inflammatory and biochemical markers of end-organ damage and endothelial activation were significantly reduced following plasma exchange together with normalization of body temperature, improved pulmonary function, and reduced vasopressor demand. Most importantly, these improvements were maintained after the last plasma exchange. In contrast, no such effects were observed in the control group, although baseline clinical and laboratory parameters were comparable. Kaplan-Meier analysis showed improved 30-day survival in the plasma exchange group compared with the control group (67.9% vs 42.9%; p = 0.044). In a multivariable analysis, the hazard ratio for death was 0.27 (95% CI, 0.11–0.68; p = 0.005) with plasma exchange versus standard care. CONCLUSIONS AND RELEVANCE: Our data provide further evidence for plasma exchange as a novel therapeutic strategy in a subset of critically ill coronavirus disease 2019 patients by potentially reversing the complex coronavirus disease 2019 immunopathology. Randomized controlled trials are underway to confirm these positive results.
Collapse
Affiliation(s)
- Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Kaelble
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, Heidelberg, Germany
| | - Monica Boxberger
- Department of Gastroenterology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Mascha O Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
258
|
Francischetti IM, Toomer K, Zhang Y, Jani J, Siddiqui Z, Brotman DJ, Hooper JE, Kickler TS. Upregulation of pulmonary tissue factor, loss of thrombomodulin and immunothrombosis in SARS-CoV-2 infection. EClinicalMedicine 2021; 39:101069. [PMID: 34377969 PMCID: PMC8342934 DOI: 10.1016/j.eclinm.2021.101069] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND SARS-CoV-2 infection is associated with thrombotic and microvascular complications. The cause of coagulopathy in the disease is incompletely understood. METHODS A single-center cross-sectional study including 66 adult COVID-19 patients (40 moderate, 26 severe disease), and 9 controls, performed between 04/2020 and 10/2020. Markers of coagulation, endothelial cell function [angiopoietin-1,-2, P-selectin, von Willebrand Factor Antigen (WF:Ag), von Willebrand Factor Ristocetin Cofactor, ADAMTS13, thrombomodulin, soluble Endothelial cell Protein C Receptor (sEPCR), Tissue Factor Pathway Inhibitor], neutrophil activation (elastase, citrullinated histones) and fibrinolysis (tissue-type plasminogen activator, plasminogen activator inhibitor-1) were evaluated using ELISA. Tissue Factor (TF) was estimated by antithrombin-FVIIa complex (AT/FVIIa) and microparticles-TF (MP-TF). We correlated each marker and determined its association with severity. Expression of pulmonary TF, thrombomodulin and EPCR was determined by immunohistochemistry in 9 autopsies. FINDINGS Comorbidities were frequent in both groups, with older age associated with severe disease. All patients were on prophylactic anticoagulants. Three patients (4.5%) developed pulmonary embolism. Mortality was 7.5%. Patients presented with mild alterations in the coagulogram (compensated state). Biomarkers of endothelial cell, neutrophil activation and fibrinolysis were elevated in severe vs moderate disease; AT/FVIIa and MP-TF levels were higher in severe patients. Logistic regression revealed an association of D-dimers, angiopoietin-1, vWF:Ag, thrombomodulin, white blood cells, absolute neutrophil count (ANC) and hemoglobin levels with severity, with ANC and vWF:Ag identified as independent factors. Notably, postmortem specimens demonstrated epithelial expression of TF in the lung of fatal COVID-19 cases with loss of thrombomodulin staining, implying in a shift towards a procoagulant state. INTERPRETATION Coagulation dysregulation has multifactorial etiology in SARS-Cov-2 infection. Upregulation of pulmonary TF with loss of thrombomodulin emerge as a potential link to immunothrombosis, and therapeutic targets in the disease. FUNDING John Hopkins University School of Medicine.
Collapse
Key Words
- ADAMTS13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13
- ALC, absolute lymphocyte count
- ALI, Acute Lung Injury
- AMC, absolute monocyte count
- ANC, absolute neutrophil count
- AT/VIIa, antithrombin-FVIIa complex
- Coagulation
- ELISA, enzyme-linked immunosorbent assay
- Hb, hemoglobin
- Hemostasis
- ICU, intensive care unit
- Ixolaris
- LMWH, low molecular weight heparin
- MP-TF, Microparticles-Tissue Factor
- PAI-1, plasminogen activator inhibitor-1
- PAR, protease-activated receptor
- TF, Tissue Factor
- TFPI, Tissue Factor Pathway Inhibitor
- Thrombosis
- WBC, white blood cells
- sEPCR, soluble Endothelial cell Protein C Receptor
- t-PA, tissue-type plasminogen activator
- vWF, von Willebrand Factor
- vWF:Ag, von Willebrand Factor Antigen
- vWF:RCo, von Willebrand Factor Ristocetin Cofactor
Collapse
Affiliation(s)
- Ivo M.B. Francischetti
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Corresponding author.
| | - Kevin Toomer
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yifan Zhang
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jayesh Jani
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Zishan Siddiqui
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniel J. Brotman
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jody E. Hooper
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Thomas S. Kickler
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
259
|
Kaundal RK, Kalvala AK, Kumar A. Neurological Implications of COVID-19: Role of Redox Imbalance and Mitochondrial Dysfunction. Mol Neurobiol 2021; 58:4575-4587. [PMID: 34110602 PMCID: PMC8190166 DOI: 10.1007/s12035-021-02412-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/29/2021] [Indexed: 12/20/2022]
Abstract
Severe acute respiratory syndrome coronavirus (SARS-CoV)-2 or COVID-19 has been declared as a pandemic disease by the World Health Organization (WHO). Globally, this disease affected 159 million of the population and reported ~ 3.3 million deaths to the current date (May 2021). There is no definitive treatment strategy that has been identified, although this disease has prevailed in its current form for the past 18 months. The main challenges in the (SARS-CoV)-2 infections are in identifying the heterogeneity in viral strains and the plausible mechanisms of viral infection to human tissues. In parallel to the investigations into the patho-mechanism of SARS-CoV-2 infection, understanding the fundamental processes underlying the clinical manifestations of COVID-19 is very crucial for designing effective therapies. Since neurological symptoms are very apparent in COVID-19 infected patients, here, we tried to emphasize the involvement of redox imbalance and subsequent mitochondrial dysfunction in the progression of the COVID-19 infection. It has been articulated that mitochondrial dysfunction is very apparent and also interlinked to neurological symptoms in COVID-19 infection. Overall, this article provides an in-depth overview of redox imbalance and mitochondrial dysfunction involvement in aggravating COVID-19 infection and its probable contribution to the neurological manifestation of the disease.
Collapse
Affiliation(s)
- Ravinder K Kaundal
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Raebareli, Lucknow, India
- Icahn School of Medicine At Mount Sinai, 1470 Madison Ave, New York, NY, USA
| | - Anil K Kalvala
- College of Pharmacy and Pharmaceutical Sciences, Florida A&M University, Tallahassee, FL, North America, USA
| | - Ashutosh Kumar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Kolkata, Kolkata, India.
| |
Collapse
|
260
|
Kountz TS, Jairaman A, Kountz CD, Stauderman KA, Schleimer RP, Prakriya M. Differential Regulation of ATP- and UTP-Evoked Prostaglandin E 2 and IL-6 Production from Human Airway Epithelial Cells. JOURNAL OF IMMUNOLOGY (BALTIMORE, MD. : 1950) 2021; 207:1275-1287. [PMID: 34389624 PMCID: PMC8816324 DOI: 10.4049/jimmunol.2100127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/07/2021] [Indexed: 11/19/2022]
Abstract
The airway epithelial cells (AECs) lining the conducting passageways of the lung secrete a variety of immunomodulatory factors. Among these, PGE2 limits lung inflammation and promotes bronchodilation. By contrast, IL-6 drives intense airway inflammation, remodeling, and fibrosis. The signaling that differentiates the production of these opposing mediators is not understood. In this study, we find that the production of PGE2 and IL-6 following stimulation of human AECs by the damage-associated molecular pattern extracellular ATP shares a common requirement for Ca2+ release-activated Ca2+ (CRAC) channels. ATP-mediated synthesis of PGE2 required activation of metabotropic P2Y2 receptors and CRAC channel-mediated cytosolic phospholipase A2 signaling. By contrast, ATP-evoked synthesis of IL-6 occurred via activation of ionotropic P2X receptors and CRAC channel-mediated calcineurin/NFAT signaling. In contrast to ATP, which elicited the production of both PGE2 and IL-6, the uridine nucleotide, UTP, stimulated PGE2 but not IL-6 production. These results reveal that human AECs employ unique receptor-specific signaling mechanisms with CRAC channels as a signaling nexus to regulate release of opposing immunomodulatory mediators. Collectively, our results identify P2Y2 receptors, CRAC channels, and P2X receptors as potential intervention targets for airway diseases.
Collapse
Affiliation(s)
- Timothy S Kountz
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Amit Jairaman
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Candace D Kountz
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Robert P Schleimer
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Murali Prakriya
- Department of Pharmacology, Northwestern University Feinberg School of Medicine, Chicago, IL;
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
261
|
Abraham EH, Guidotti G, Rapaport E, Bower D, Brown J, Griffin RJ, Donnelly A, Waitzkin ED, Qamar K, Thompson MA, Ethirajan S, Robinson K. Cystic fibrosis improves COVID-19 survival and provides clues for treatment of SARS-CoV-2. Purinergic Signal 2021; 17:399-410. [PMID: 33970408 PMCID: PMC8107773 DOI: 10.1007/s11302-021-09771-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 01/26/2021] [Indexed: 12/11/2022] Open
Abstract
Systemic pools of ATP are elevated in individuals homozygous for cystic fibrosis (CF) as evidenced by elevated blood and plasma ATP levels. This elevated ATP level seems to provide benefit in the presence of advanced solid tumors (Abraham et al., Nature Medicine 2(5):593-596, 1996). We published in this journal a paper showing that IV ATP can elevate the depleted ATP pools of advanced cancer patients up to levels found in CF patients with subsequent clinical, biochemical, and quality of life (QOL) improvements (Rapaport et al., Purinergic Signalling 11(2): 251-262, 2015). We hypothesize that the elevated ATP levels seen in CF patients may be benefiting CF patients in another way: by improving their survival after contracting COVID-19. We discuss here the reasoning behind this hypothesis and suggest how these findings might be applied clinically in the general population.
Collapse
Affiliation(s)
- Edward H Abraham
- Saint Francis Health System, Tulsa, OK, USA.
- Kansas City Urology Care, Kansas City, KS, USA.
| | - Guido Guidotti
- Department of Molecular and Cell Biology, Harvard University, Cambridge, MA, USA
| | | | | | | | - Robert J Griffin
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | | | | | - Kenon Qamar
- Kansas City Urology Care, Kansas City, KS, USA
| | | | | | | |
Collapse
|
262
|
Salva O, Doreski PA, Giler CS, Quinodoz DC, Guzmán LG, Muñoz SE, Carrillo MN, Porta DJ, Ambasch G, Coscia E, Diaz JLT, Bueno GD, Fandi JO, Maldonado MA, Peña Chiappero LE, Fournier F, Pérez HA, Quiroga MA, Sala Mercado JA, Martínez Picco C, Beltrán MA, Argañarás LA, Ríos NM, Kalayan GI, Beltramo DM, García NH. Reversal of SARS-CoV2-Induced Hypoxia by Nebulized Sodium Ibuprofenate in a Compassionate Use Program. Infect Dis Ther 2021; 10:2511-2524. [PMID: 34460083 PMCID: PMC8404026 DOI: 10.1007/s40121-021-00527-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/12/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Sodium ibuprofenate in hypertonic saline (NaIHS) administered directly to the lungs by nebulization and inhalation has antibacterial and anti-inflammatory effects, with the potential to deliver these benefits to hypoxic patients. We describe a compassionate use program that offered this therapy to hospitalized COVID-19 patients. METHODS NaIHS (50 mg ibuprofen, tid) was provided in addition to standard of care (SOC) to hospitalized COVID-19 patients until oxygen saturation levels of > 94% were achieved on ambient air. Patients wore a containment hood to diminish aerosolization. Outcome data from participating patients treated at multiple hospitals in Argentina between April 4 and October 31, 2020, are summarized. Results were compared with a retrospective contemporaneous control (CC) group of hospitalized COVID-19 patients with SOC alone during the same time frame from a subset of participating hospitals from Córdoba and Buenos Aires. RESULTS The evolution of 383 patients treated with SOC + NaIHS [56 on mechanical ventilation (MV) at baseline] and 195 CC (21 on MV at baseline) are summarized. At baseline, NaIHS-treated patients had basal oxygen saturation of 90.7 ± 0.2% (74.3% were on supplemental oxygen at baseline) and a basal respiratory rate of 22.7 ± 0.3 breath/min. In the CC group, basal oxygen saturation was 92.6 ± 0.4% (52.1% were on oxygen supplementation at baseline) and respiratory rate was 19.3 ± 0.3 breath/min. Despite greater pulmonary compromise at baseline in the NaIHS-treated group, the length of treatment (LOT) was 9.1 ± 0.2 gs with an average length of stay (ALOS) of 11.5 ± 0.3 days, in comparison with an ALOS of 13.3 ± 0.9 days in the CC group. In patients on MV who received NaIHS, the ALOS was lower than in the CC group. In both NaIHS-treated groups, a rapid reversal of deterioration in oxygenation and NEWS2 scores was observed acutely after initiation of NaIHS therapy. No serious adverse events were considered related to ibuprofen therapy. Mortality was lower in both NaIHS groups compared with CC groups. CONCLUSIONS Treatment of COVID-19 pneumonitis with inhalational nebulized NaIHS was associated with rapid improvement in hypoxia and vital signs, with no serious adverse events attributed to therapy. Nebulized NaIHS s worthy of further study in randomized, placebo-controlled trials (ClinicalTrials.gov: NCT04382768).
Collapse
Affiliation(s)
- Oscar Salva
- Clínica Independencia, Munro, Buenos Aires, Argentina
| | | | - Celia S Giler
- Clínica Independencia, Munro, Buenos Aires, Argentina
| | | | | | - Sonia E Muñoz
- Instituto de Investigaciones en Ciencias de la Salud, Ciudad Universitaria, Córdoba, Argentina
| | - Mariana N Carrillo
- Instituto de Investigaciones en Ciencias de la Salud, Ciudad Universitaria, Córdoba, Argentina
| | - Daniela J Porta
- Instituto de Investigaciones en Ciencias de la Salud, Ciudad Universitaria, Córdoba, Argentina
| | - Germán Ambasch
- Sanatorio Mayo Privado SA, Ciudad de Córdoba, Córdoba, Argentina
| | - Esteban Coscia
- Sanatorio Mayo Privado SA, Ciudad de Córdoba, Córdoba, Argentina
| | | | - Germán D Bueno
- Sanatorio Mayo Privado SA, Ciudad de Córdoba, Córdoba, Argentina
| | - Jorge O Fandi
- Clínica Independencia, Munro, Buenos Aires, Argentina
| | | | | | | | - Hernán A Pérez
- Sanatorio Alive, Ciudad de Córdoba, Córdoba, Argentina.,Department of Diagnostic Radiology and Nuclear Medicine, Center for Advanced Imaging Research, Maryland University, Baltimore, MD, USA
| | - Mauro A Quiroga
- Instituto Modelo de Cardiología, Ciudad de Córdoba, Córdoba, Argentina
| | | | | | | | | | | | - Galia I Kalayan
- CEPROCOR, Ciudad de Santa María de Punilla, Córdoba, Argentina
| | - Dante M Beltramo
- CEPROCOR, Ciudad de Santa María de Punilla, Córdoba, Argentina.,CONICET, Ciudad de Santa María de Punilla, Córdoba, Argentina
| | - Néstor H García
- Instituto de Investigaciones en Ciencias de la Salud, Ciudad Universitaria, Córdoba, Argentina. .,CEPROCOR, Ciudad de Santa María de Punilla, Córdoba, Argentina.
| |
Collapse
|
263
|
P 2Y 12 receptor blockers are anti-inflammatory drugs inhibiting both circulating monocytes and macrophages including THP-1 cells. Sci Rep 2021; 11:17459. [PMID: 34465804 PMCID: PMC8408182 DOI: 10.1038/s41598-021-95710-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 07/22/2021] [Indexed: 01/11/2023] Open
Abstract
P2Y12 blockade improves patient outcomes after myocardial infarction. As well as antithrombotic effects, anti-inflammatory effects may contribute to this beneficial clinical outcome. Here we aimed to identify potential anti-inflammatory effects of P2Y12 receptor blockers on monocytes and macrophages. Using flow cytometry, migration assays, flow chambers and RNA microarrays, we investigated the effects of adenosine diphosphate (ADP) and P2Y12 receptor blockers on blood monocytes, THP-1 monocytes and THP-1 monocytes after differentiation to macrophages. P2Y12 -expressing platelets can form aggregates with monocytes in circulating blood. Mediated by platelets, ADP results in activation of the integrin receptor Mac-1 on blood monocytes, as detected by the conformation-specific single-chain antibody MAN-1. Via the same association with platelets, THP-1 monocyte adhesion to the endothelial intercellular adhesion molecule 1 (ICAM-1) is induced by ADP. P2Y12 receptor blockers prevent these ADP effects on monocytes. Interestingly, in contrast to THP-1 monocytes, THP-1 monocytes, after differentiation to macrophages, directly expressed the P2Y12 receptor and consequently ADP was found to be a potent chemoattractant. Again, P2Y12 receptor blockers antagonised this effect. Accordingly, stimulation of THP-1 macrophages with ADP caused a substantial change in gene expression pattern and upregulation of several genes associated with inflammation and atherogenesis. These data establish novel anti-inflammatory effects of P2Y12 receptor blockers on monocytes and macrophages, which are expected to contribute to cardiovascular risk reduction.
Collapse
|
264
|
The roles of platelets in COVID-19-associated coagulopathy and vaccine-induced immune thrombotic thrombocytopenia. Trends Cardiovasc Med 2021; 32:1-9. [PMID: 34455073 PMCID: PMC8390120 DOI: 10.1016/j.tcm.2021.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/06/2021] [Accepted: 08/23/2021] [Indexed: 02/07/2023]
Abstract
In coronavirus disease 2019 (COVID-19), multiple thromboinflammatory events contribute to the pathophysiology, including coagulation system activation, suppressed fibrinolysis, vascular endothelial cell injury, and prothrombotic alterations in immune cells such as macrophages and neutrophils. Although thrombocytopenia is not an initial presentation as an infectious coagulopathy, recent studies have demonstrated the vital role of platelets in COVID-19-associated coagulopathy SARS-CoV-2 and its spike protein have been known to directly or indirectly promote release of prothrombotic and inflammatory mediators that lead to COVID-19-associated coagulopathy. Although clinical features of vaccine-induced immune thrombotic thrombocytopenia include uncommon locations of thrombosis, including cerebral venous sinus, we speculate coronavirus spike-protein-initiated prothrombotic pathways are involved in the pathogenesis of vaccine-induced immune thrombotic thrombocytopenia, as current evidence suggests that the spike protein is the promotor and other cofactors such as perturbed immune response and inflammatory reaction enhance the production of anti-platelet factor 4 antibody.
Collapse
|
265
|
Reveals of candidate active ingredients in Justicia and its anti-thrombotic action of mechanism based on network pharmacology approach and experimental validation. Sci Rep 2021; 11:17187. [PMID: 34433871 PMCID: PMC8387432 DOI: 10.1038/s41598-021-96683-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 08/13/2021] [Indexed: 11/08/2022] Open
Abstract
Thrombotic diseases seriously threaten human life. Justicia, as a common Chinese medicine, is usually used for anti-inflammatory treatment, and further studies have found that it has an inhibitory effect on platelet aggregation. Therefore, it can be inferred that Justicia can be used as a therapeutic drug for thrombosis. This work aims to reveal the pharmacological mechanism of the anti-thrombotic effect of Justicia through network pharmacology combined with wet experimental verification. During the analysis, 461 compound targets were predicted from various databases and 881 thrombus-related targets were collected. Then, herb-compound-target network and protein-protein interaction network of disease and prediction targets were constructed and cluster analysis was applied to further explore the connection between the targets. In addition, Gene Ontology (GO) and pathway (KEGG) enrichment were used to further determine the association between target proteins and diseases. Finally, the expression of hub target proteins of the core component and the anti-thrombotic effect of Justicia's core compounds were verified by experiments. In conclusion, the core bioactive components, especially justicidin D, can reduce thrombosis by regulating F2, MMP9, CXCL12, MET, RAC1, PDE5A, and ABCB1. The combination of network pharmacology and the experimental research strategies proposed in this paper provides a comprehensive method for systematically exploring the therapeutic mechanism of multi-component medicine.
Collapse
|
266
|
Robinson DH, Wimaleswaran H, McDonald CF, Howard ME, Willcox A. Pulmonary embolus in patients with COVID-19: an Australian perspective. Intern Med J 2021; 51:1324-1327. [PMID: 34423548 PMCID: PMC8653313 DOI: 10.1111/imj.15405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/11/2021] [Accepted: 05/19/2021] [Indexed: 12/15/2022]
Abstract
Pulmonary embolus (PE) is a known complication of coronavirus disease 2019 (COVID‐19). The diagnosis of PE in our hospitalised patients with COVID‐19 correlated with more severe disease and occurred despite the use of routine thromboprophylaxis. Higher D‐dimers were seen on admission in patients who developed PE and rose at PE diagnosis, suggesting a role for D‐dimer in risk stratification.
Collapse
Affiliation(s)
- Danielle H Robinson
- Department of Clinical Haematology, Austin Health, Melbourne, Victoria, Australia
| | - Hari Wimaleswaran
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Mark E Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Abbey Willcox
- Department of Clinical Haematology, Austin Health, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| |
Collapse
|
267
|
Dutta M, Tareq AM, Rakib A, Mahmud S, Sami SA, Mallick J, Islam MN, Majumder M, Uddin MZ, Alsubaie A, Almalki ASA, Khandaker MU, Bradley D, Rana MS, Emran TB. Phytochemicals from Leucas zeylanica Targeting Main Protease of SARS-CoV-2: Chemical Profiles, Molecular Docking, and Molecular Dynamics Simulations. BIOLOGY 2021; 10:789. [PMID: 34440024 PMCID: PMC8389631 DOI: 10.3390/biology10080789] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/05/2021] [Accepted: 08/15/2021] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a contemporary coronavirus, has impacted global economic activity and has a high transmission rate. As a result of the virus's severe medical effects, developing effective vaccinations is vital. Plant-derived metabolites have been discovered as potential SARS-CoV-2 inhibitors. The SARS-CoV-2 main protease (Mpro) is a target for therapeutic research because of its highly conserved protein sequence. Gas chromatography-mass spectrometry (GC-MS) and molecular docking were used to screen 34 compounds identified from Leucas zeylanica for potential inhibitory activity against the SARS-CoV-2 Mpro. In addition, prime molecular mechanics-generalized Born surface area (MM-GBSA) was used to screen the compound dataset using a molecular dynamics simulation. From molecular docking analysis, 26 compounds were capable of interaction with the SARS-CoV-2 Mpro, while three compounds, namely 11-oxa-dispiro[4.0.4.1]undecan-1-ol (-5.755 kcal/mol), azetidin-2-one 3,3-dimethyl-4-(1-aminoethyl) (-5.39 kcal/mol), and lorazepam, 2TMS derivative (-5.246 kcal/mol), exhibited the highest docking scores. These three ligands were assessed by MM-GBSA, which revealed that they bind with the necessary Mpro amino acids in the catalytic groove to cause protein inhibition, including Ser144, Cys145, and His41. The molecular dynamics simulation confirmed the complex rigidity and stability of the docked ligand-Mpro complexes based on the analysis of mean radical variations, root-mean-square fluctuations, solvent-accessible surface area, radius of gyration, and hydrogen bond formation. The study of the postmolecular dynamics confirmation also confirmed that lorazepam, 11-oxa-dispiro[4.0.4.1]undecan-1-ol, and azetidin-2-one-3, 3-dimethyl-4-(1-aminoethyl) interact with similar Mpro binding pockets. The results of our computerized drug design approach may assist in the fight against SARS-CoV-2.
Collapse
Affiliation(s)
- Mycal Dutta
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh; (M.D.); (J.M.); (M.Z.U.)
- Department of Pharmacy, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Abu Montakim Tareq
- Department of Pharmacy, International Islamic University Chittagong, Chittagong 4318, Bangladesh; (A.M.T.); (M.N.I.)
| | - Ahmed Rakib
- Department of Pharmacy, Faculty of Biological Sciences, University of Chittagong, Chittagong 4331, Bangladesh; (A.R.); (S.A.S.)
| | - Shafi Mahmud
- Microbiology Laboratory, Department of Genetic Engineering and Biotechnology, University of Rajshahi, Rajshahi 6205, Bangladesh;
| | - Saad Ahmed Sami
- Department of Pharmacy, Faculty of Biological Sciences, University of Chittagong, Chittagong 4331, Bangladesh; (A.R.); (S.A.S.)
| | - Jewel Mallick
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh; (M.D.); (J.M.); (M.Z.U.)
- Department of Pharmacy, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Mohammad Nazmul Islam
- Department of Pharmacy, International Islamic University Chittagong, Chittagong 4318, Bangladesh; (A.M.T.); (M.N.I.)
| | - Mohuya Majumder
- Drug Discovery, GUSTO A Research Group, Chittagong 4203, Bangladesh;
| | - Md. Zia Uddin
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh; (M.D.); (J.M.); (M.Z.U.)
- Department of Pharmacy, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Abdullah Alsubaie
- Department of Physics, College of Khurma, Taif University, Taif 21944, Saudi Arabia;
| | | | - Mayeen Uddin Khandaker
- Centre for Applied Physics and Radiation Technologies, School of Engineering and Technology, Sunway University, Bandar Sunway 47500, Malaysia; (M.U.K.); (D.A.B.)
| | - D.A. Bradley
- Centre for Applied Physics and Radiation Technologies, School of Engineering and Technology, Sunway University, Bandar Sunway 47500, Malaysia; (M.U.K.); (D.A.B.)
- Department of Physics, University of Surrey, Guilford GU2 7XH, UK
| | - Md. Sohel Rana
- Department of Pharmacy, Jahangirnagar University, Savar, Dhaka 1342, Bangladesh
| | - Talha Bin Emran
- Department of Pharmacy, BGC Trust University Bangladesh, Chittagong 4381, Bangladesh; (M.D.); (J.M.); (M.Z.U.)
| |
Collapse
|
268
|
Jing H, Chen X, Zhang S, Liu H, Zhang C, Du J, Li Y, Wu X, Li M, Xiang M, Liu L, Shi J. Neutrophil extracellular traps (NETs): the role of inflammation and coagulation in COVID-19. Am J Transl Res 2021; 13:8575-8588. [PMID: 34539980 PMCID: PMC8430084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 06/03/2021] [Indexed: 06/13/2023]
Abstract
COVID-19 has swept quickly across the world with a worrisome death toll. SARS-CoV-2 infection induces cytokine storm, acute respiratory distress syndrome with progressive lung damage, multiple organ failure, and even death. In this review, we summarize the pathophysiologic mechanism of neutrophil extracellular traps (NETs) and hypoxia in three main phases, focused on lung inflammation and thrombosis. Furthermore, microparticle storm resulted from apoptotic blood cells are central contributors to the generation and propagation of thrombosis. We focus on microthrombi in the early stage and describe in detail combined antithrombotic with fibrinolytic therapies to suppress microthrombi evolving into clinical events of thrombosis. We further discuss pulmonary hypertension causing plasmin, fibrinogen and albumin, globulin extruding into alveolar lumens, which impedes gas exchange and induces severe hypoxia. Hypoxia in turn induces pulmonary hypertension, and amplifies ECs damage in this pathophysiologic process, which forms a positive feedback loop, aggravating disease progression. Understanding the mechanisms paves the way for current treatment of COVID-19 patients.
Collapse
Affiliation(s)
- Haijiao Jing
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Xiaojing Chen
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Shuoqi Zhang
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Huan Liu
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Cong Zhang
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Jingwen Du
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Yueyue Li
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Xiaoming Wu
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Mengdi Li
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Mengqi Xiang
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Langjiao Liu
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical UniversityHarbin, PR China
- Department of Medicine and Research, Brigham and Women’s Hospital, VA Boston Healthcare System, Harvard Medical SchoolBoston, Massachusetts, US
| |
Collapse
|
269
|
Karnaukhova E. C1-Inhibitor: Structure, Functional Diversity and Therapeutic Development. Curr Med Chem 2021; 29:467-488. [PMID: 34348603 DOI: 10.2174/0929867328666210804085636] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/24/2021] [Accepted: 05/13/2021] [Indexed: 11/22/2022]
Abstract
Human C1-Inhibitor (C1INH), also known as C1-esterase inhibitor, is an important multifunctional plasma glycoprotein that is uniquely involved in a regulatory network of complement, contact, coagulation, and fibrinolytic systems. C1INH belongs to a superfamily of serine proteinase inhibitor (serpins) and exhibits its inhibitory activities towards several target proteases of plasmatic cascades, operating as a major anti-inflammatory protein in the circulation. In addition to its inhibitory activities, C1INH is also involved in non-inhibitory interactions with some endogenous proteins, polyanions, cells and infectious agents. While C1INH is essential for multiple physiological processes, it is better known for its deficiency with regards to Hereditary Angioedema (HAE), a rare autosomal dominant disease clinically manifested by recurrent acute attacks of increased vascular permeability and edema. Since the link was first established between functional C1INH deficiency in plasma and HAE in the 1960s, tremendous progress has been made in the biochemical characterization of C1INH and its therapeutic development for replacement therapies in patients with C1INH-dependent HAE. Various C1INH biological activities, recent advances in the HAE-targeted therapies, and availability of C1INH commercial products have prompted intensive investigation of the C1INH potential for treatment of clinical conditions other than HAE. This article provides an updated overview of the structure and biological activities of C1INH, its role in HAE pathogenesis, and recent advances in the research and therapeutic development of C1INH; it also considers some trends for using C1INH therapeutic preparations for applications other than angioedema, from sepsis and endotoxin shock to severe thrombotic complications in COVID-19 patients.
Collapse
Affiliation(s)
- Elena Karnaukhova
- Laboratory of Biochemistry and Vascular Biology, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland 20993. United States
| |
Collapse
|
270
|
Hammad MO, Alseoudy MM. The sex-related discrepancy in laboratory parameters of severe COVID-19 patients with diabetes: A retrospective cohort study. Prim Care Diabetes 2021; 15:713-718. [PMID: 34006475 PMCID: PMC8114673 DOI: 10.1016/j.pcd.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 01/08/2023]
Abstract
AIM This study aimed at providing evidence to consider sex differences in interpretations of laboratory parameters of severe COVID-19 patients with diabetes. METHODS For 118 diabetic patients, laboratory measurements and clinical outcomes were compared between males and females. This study also compared inflammatory ratios obtained from combinations of six inflammatory markers between the two groups. The risk factors for mortality were identified through logistic regression. RESULTS Males were 54 (45.8%) and females were 64 (54.2%). Males showed a significant increase in ALT (P = 0.003), CRP (P = 0.03), mean platelet volume (MPV)-to-lymphocyte ratio (P = 0.001), and C-reactive protein-to-albumin ratio (P = 0.044), whereas females had a significant increase in lymphocytes (P < 0.005) and MPV (P = 0.01). In all participants, multivariate analysis illustrated that older age, male sex, increased serum total bilirubin, and decreased PO2 were significant independent predictors of mortality (P < 0.05). CONCLUSION In severe COVID-19 patients with diabetes, there were significant sex differences in many laboratory characteristics with a higher risk of mortality among males.
Collapse
Affiliation(s)
- Maha O Hammad
- Department of Medical Biochemistry, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
| | - Mahmoud M Alseoudy
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| |
Collapse
|
271
|
Che Mohd Nassir CMN, Hashim S, Wong KK, Abdul Halim S, Idris NS, Jayabalan N, Guo D, Mustapha M. COVID-19 Infection and Circulating Microparticles-Reviewing Evidence as Microthrombogenic Risk Factor for Cerebral Small Vessel Disease. Mol Neurobiol 2021; 58:4188-4215. [PMID: 34176095 PMCID: PMC8235918 DOI: 10.1007/s12035-021-02457-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/16/2021] [Indexed: 02/08/2023]
Abstract
Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) due to novel coronavirus disease 2019 (COVID-19) has affected the global society in numerous unprecedented ways, with considerable morbidity and mortality. Both direct and indirect consequences from COVID-19 infection are recognized to give rise to cardio- and cerebrovascular complications. Despite current limited knowledge on COVID-19 pathogenesis, inflammation, endothelial dysfunction, and coagulopathy appear to play critical roles in COVID-19-associated cerebrovascular disease (CVD). One of the major subtypes of CVD is cerebral small vessel disease (CSVD) which represents a spectrum of pathological processes of various etiologies affecting the brain microcirculation that can trigger subsequent neuroinflammation and neurodegeneration. Prevalent with aging, CSVD is a recognized risk factor for stroke, vascular dementia, and Alzheimer's disease. In the background of COVID-19 infection, the heightened cellular activations from inflammations and oxidative stress may result in elevated levels of microthrombogenic extracellular-derived circulating microparticles (MPs). Consequently, MPs could act as pro-coagulant risk factor that may serve as microthrombi for the vulnerable microcirculation in the brain leading to CSVD manifestations. This review aims to appraise the accumulating body of evidence on the plausible impact of COVID-19 infection on the formation of microthrombogenic MPs that could lead to microthrombosis in CSVD manifestations, including occult CSVD which may last well beyond the pandemic era.
Collapse
Affiliation(s)
- Che Mohd Nasril Che Mohd Nassir
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Sabarisah Hashim
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Kah Keng Wong
- Hospital Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
- Department of Immunology, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Sanihah Abdul Halim
- Hospital Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Nur Suhaila Idris
- Hospital Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia
| | - Nanthini Jayabalan
- Translational Neuroscience Lab, UQ Centre for Clinical Research, the University of Queensland, Herston, Brisbane, 4029, Australia
| | - Dazhi Guo
- Department of Hyperbaric Oxygen, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Rd, Beijing, 100048, China
| | - Muzaimi Mustapha
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Health Campus, 16150, Kubang Kerian, Kelantan, Malaysia.
- Hospital Universiti Sains Malaysia, 16150, Kubang Kerian, Kelantan, Malaysia.
| |
Collapse
|
272
|
Bissell BD, Gabbard T, Sheridan EA, Baz MA, Davis GA, Ather A. Evaluation of Bivalirudin as the Primary Anticoagulant in Patients Receiving Extracorporeal Membrane Oxygenation for SARS-CoV-2-Associated Acute Respiratory Failure. Ann Pharmacother 2021; 56:387-392. [PMID: 34323121 DOI: 10.1177/10600280211036151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is a potential option for the management of severe acute respiratory failure secondary to COVID-19. Conflicting the use of this therapy is the known coagulopathy within COVID-19, leading to an incidence of venous thrombotic events of 25% to 49%. To date, limited guidance is available on optimal anticoagulation strategies in this population. OBJECTIVE The purpose of this study was to evaluate the utilization of a pharmacist-driven bivalirudin dosing protocol for anticoagulation in the setting of ECMO for COVID-19-associated respiratory failure. METHODS This was a single-center retrospective chart review over a 9-month period of patients receiving bivalirudin while on ECMO. All patients with acute respiratory failure requiring ECMO with a positive SARS-CoV-2 polymerase chain reaction were included. Bivalirudin was dosed via aPTT monitoring after a starting dose of 0.2 or 0.3 mg/kg/h. RESULTS There were 33 patients included in this study, all receiving mechanical ventilation. The most common starting dose of bivalirudin was 0.2 mg/kg/h, with an average time to therapeutic range of 20 hours. Compared to previous reports, rates of bleeding were low at 15.1%, and 6.1% of patients developed a new venous thromboembolic event while on ECMO. ECMO survival was 51.5%, with an ICU mortality rate of 48.5%. CONCLUSION AND RELEVANCE In the first published report of its use within this population, bivalirudin was found to be a viable choice for anticoagulation in those patients on ECMO for severe respiratory failure secondary to COVID-19.
Collapse
Affiliation(s)
| | - Taylor Gabbard
- The University of Kansas Health System, Kansas City, KS, USA
| | | | | | | | | |
Collapse
|
273
|
Pyne JD, Brickman AM. The Impact of the COVID-19 Pandemic on Dementia Risk: Potential Pathways to Cognitive Decline. NEURODEGENER DIS 2021; 21:1-23. [PMID: 34348321 PMCID: PMC8678181 DOI: 10.1159/000518581] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/19/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19), the far-reaching pandemic, has infected approximately 185 million of the world's population to date. After infection, certain groups, including older adults, men, and people of color, are more likely to have adverse medical outcomes. COVID-19 can affect multiple organ systems, even among asymptomatic/mild severity individuals, with progressively worse damage for those with higher severity infections. SUMMARY The COVID-19 virus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily attaches to cells through the angiotensin-converting enzyme 2 (ACE2) receptor, a universal receptor present in most major organ systems. As SARS-CoV-2 binds to the ACE2 receptor, its bioavailability becomes limited, thus disrupting homeostatic organ function and inducing an injury cascade. Organ damage can then arise from multiple sources including direct cellular infection, overactive detrimental systemic immune response, and ischemia/hypoxia through thromboembolisms or disruption of perfusion. In the brain, SARS-CoV-2 has neuroinvasive and neurotropic characteristics with acute and chronic neurovirulent potential. In the cardiovascular system, COVID-19 can induce myocardial and systemic vascular damage along with thrombosis. Other organ systems such as the lungs, kidney, and liver are all at risk for infection damage. Key Messages: Our hypothesis is that each injury consequence has the independent potential to contribute to long-term cognitive deficits with the possibility of progressing to or worsening pre-existing dementia. Already, reports from recovered COVID-19 patients indicate that cognitive alterations and long-term symptoms are prevalent. This critical review highlights the injury pathways possible through SARS-CoV-2 infection that have the potential to increase and contribute to cognitive impairment and dementia.
Collapse
Affiliation(s)
- Jeffrey D. Pyne
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Adam M. Brickman
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| |
Collapse
|
274
|
Logette E, Lorin C, Favreau C, Oshurko E, Coggan JS, Casalegno F, Sy MF, Monney C, Bertschy M, Delattre E, Fonta PA, Krepl J, Schmidt S, Keller D, Kerrien S, Scantamburlo E, Kaufmann AK, Markram H. A Machine-Generated View of the Role of Blood Glucose Levels in the Severity of COVID-19. Front Public Health 2021; 9:695139. [PMID: 34395368 PMCID: PMC8356061 DOI: 10.3389/fpubh.2021.695139] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/30/2021] [Indexed: 01/08/2023] Open
Abstract
SARS-CoV-2 started spreading toward the end of 2019 causing COVID-19, a disease that reached pandemic proportions among the human population within months. The reasons for the spectrum of differences in the severity of the disease across the population, and in particular why the disease affects more severely the aging population and those with specific preconditions are unclear. We developed machine learning models to mine 240,000 scientific articles openly accessible in the CORD-19 database, and constructed knowledge graphs to synthesize the extracted information and navigate the collective knowledge in an attempt to search for a potential common underlying reason for disease severity. The machine-driven framework we developed repeatedly pointed to elevated blood glucose as a key facilitator in the progression of COVID-19. Indeed, when we systematically retraced the steps of the SARS-CoV-2 infection, we found evidence linking elevated glucose to each major step of the life-cycle of the virus, progression of the disease, and presentation of symptoms. Specifically, elevations of glucose provide ideal conditions for the virus to evade and weaken the first level of the immune defense system in the lungs, gain access to deep alveolar cells, bind to the ACE2 receptor and enter the pulmonary cells, accelerate replication of the virus within cells increasing cell death and inducing an pulmonary inflammatory response, which overwhelms an already weakened innate immune system to trigger an avalanche of systemic infections, inflammation and cell damage, a cytokine storm and thrombotic events. We tested the feasibility of the hypothesis by manually reviewing the literature referenced by the machine-generated synthesis, reconstructing atomistically the virus at the surface of the pulmonary airways, and performing quantitative computational modeling of the effects of glucose levels on the infection process. We conclude that elevation in glucose levels can facilitate the progression of the disease through multiple mechanisms and can explain much of the differences in disease severity seen across the population. The study provides diagnostic considerations, new areas of research and potential treatments, and cautions on treatment strategies and critical care conditions that induce elevations in blood glucose levels.
Collapse
Affiliation(s)
- Emmanuelle Logette
- Blue Brain Project, École polytechnique fédérale de Lausanne (EPFL), Geneva, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Henry Markram
- Blue Brain Project, École polytechnique fédérale de Lausanne (EPFL), Geneva, Switzerland
| |
Collapse
|
275
|
Dawra S, Shrivastava S, Kumar D, Asturkar V, Kumar A, Ahmad F, Nanda S. Clinical complications seen in patients after recovery from coronavirus disease 2019: Experience from a COVID care center. Med J Armed Forces India 2021; 77:S475-S478. [PMID: 34334914 PMCID: PMC8313073 DOI: 10.1016/j.mjafi.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/02/2021] [Indexed: 10/25/2022] Open
Abstract
We have had recent experience that patients who have recovered from coronavirus disease 2019 (COVID-19) infection are being readmitted with thromboembolic complications, and some have had sudden cardiac death. There is paucity of literature on such presentations after clinical and microbiological recovery. In the present case series, we present five such patients recently managed at our COVID-19 care facility. All the patients described were elderly (mean age: 66 years) with multiple comorbidities (mean Charlson Comorbidity Index score: 3.5). Two were initially managed at another COVID care facility and discharged. They were admitted at our center within one week of discharge. One patient who was managed at our center was discharged and then readmitted. The other two had recovered from their illness and were planned for discharge (mean duration of hospital stay in initial admission: 14.4 days). All presented within one week of clinical and microbiological recovery (mean: 4.2 days). All were on adequate anticoagulation during initial presentation. All these patients had raised D-dimer levels (three suffered sudden cardiac arrest, one had a confirmed pulmonary thromboembolism, and one had acute ST-elevation myocardial infarction). Thromboembolic complications should be considered an important differential diagnosis in all patients who present with any complication in the immediate follow-up period of recovery from COVID-19 disease. Repeat analysis of D-dimer levels at follow-up may be considered in those who recovered from severe disease. Extended period of anticoagulation and close follow-up may be considered in all patients with COVID-19 who are at high risk of developing thromboembolic complications.
Collapse
Affiliation(s)
- Saurabh Dawra
- Classified Specialist (Medicine) & Gastroenterologist, Command Hospital (SC), Pune, India
| | - Sharad Shrivastava
- Senior Adviser (Medicine) & Gastroenterologist, Command Hospital (SC), Pune, India
| | - Dharmendra Kumar
- Senior Adviser (Medicine) & Gastroenterologist, Command Hospital (SC), Pune, India
| | - Vikram Asturkar
- Classified Specialist (Medicine) & Neurologist, Command Hospital (SC), Pune, India
| | - Ankit Kumar
- Resident, Department of Internal Medicine, Armed Forces Medical College, Pune, India
| | - Faiz Ahmad
- Senior Adviser (Medicine) & Neurologist, Command Hospital (SC), Pune, India
| | - Subrat Nanda
- Senior Adviser (Medicine) & Neurologist, Command Hospital (SC), Pune, India
| |
Collapse
|
276
|
Vasuri F, Ciavarella C, Collura S, Mascoli C, Valente S, Degiovanni A, Gargiulo M, Capri M, Pasquinelli G. Adventitial Microcirculation Is a Major Target of SARS-CoV-2-Mediated Vascular Inflammation. Biomolecules 2021; 11:biom11071063. [PMID: 34356687 PMCID: PMC8301851 DOI: 10.3390/biom11071063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 11/21/2022] Open
Abstract
We report the case of a 77-year-old woman affected by coronavirus disease-19 (COVID-19) who developed an occlusive arterial disease of the lower limb requiring a left leg amputation. We studied the mechanisms of vascular damage by SARS-CoV-2 by means of a comprehensive multi-technique in situ analysis on the diseased popliteal arterial district, including immunohistochemistry (IHC), transmission electron microscopy (TEM) and miRNA analysis. At histological analyses, we observed a lymphocytic inflammatory infiltrate, oedema and endothelialitis of adventitial vasa vasorum while the media was normal and the intima had only minor changes. The vasa vasorum expressed the ACE2 receptor and factor VIII; compared with the controls, VEGFR2 staining was reduced. TEM analyses showed endothelial injury and numerous Weibel–Palade bodies in the cytoplasm. No coronavirus particle was seen. IL-6 protein and mRNA, together with miR-155-5p and miRs-27a-5p, which can target IL-6, were significantly increased compared with that in the controls. Our case report suggests an involvement of adventitial artery microcirculation by inflammation in the course of COVID-19. Without evident signs of current infection by SARS-CoV-2, endothelial cells show a spectrum of structural and functional alterations that can fuel the cardiovascular complications observed in people infected with SARS-CoV-2.
Collapse
Affiliation(s)
- Francesco Vasuri
- Pathology Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.V.); (A.D.); (G.P.)
| | - Carmen Ciavarella
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (S.C.); (S.V.); (M.C.)
- Correspondence: ; Tel.: +39-0512144520
| | - Salvatore Collura
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (S.C.); (S.V.); (M.C.)
| | - Chiara Mascoli
- Vascular Surgery Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.M.); (M.G.)
| | - Sabrina Valente
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (S.C.); (S.V.); (M.C.)
| | - Alessio Degiovanni
- Pathology Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.V.); (A.D.); (G.P.)
| | - Mauro Gargiulo
- Vascular Surgery Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.M.); (M.G.)
| | - Miriam Capri
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (S.C.); (S.V.); (M.C.)
- Interdepartmental Center “Alma Mater Research Institute on Global Challenges and Climate Change (Alma Climate)”, University of Bologna, 40126 Bologna, Italy
| | - Gianandrea Pasquinelli
- Pathology Unit, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (F.V.); (A.D.); (G.P.)
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, 40138 Bologna, Italy; (S.C.); (S.V.); (M.C.)
| |
Collapse
|
277
|
Incidence and Outcomes of Pulmonary Embolism among Hospitalized COVID-19 Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18147645. [PMID: 34300096 PMCID: PMC8307735 DOI: 10.3390/ijerph18147645] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/08/2021] [Accepted: 07/13/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Patients with COVID-19 may be at high risk for thrombotic complications due to excess inflammatory response and stasis of blood flow. This study aims to assess the incidence of pulmonary embolism among hospitalized patients with COVID-19, risk factors, and the impact on survival. METHODS A retrospective case-control study was conducted at Al-Noor Specialist Hospital in Saudi Arabia between 15 March 2020 and 15 June 2020. Patients with confirmed COVID-19 diagnosis by a real-time polymerase chain reaction (PCR) and confirmed diagnosis of pulmonary embolism by Computed Tomography pulmonary angiogram (CTPA) formed the case group. Patients with confirmed COVID-19 diagnosis by a real-time polymerase chain reaction (PCR) and without confirmed diagnose of pulmonary embolism formed the control group. Logistic regression analysis was used to identify predictors of pulmonary embolism and survival. RESULTS A total of 159 patients participated were included in the study, of which 51 were the cases (patients with pulmonary embolism) and 108 patients formed the control group (patients without pulmonary embolism). The incidence of PE among those hospitalized was around 32%. Smoking history, low level of oxygen saturation, and higher D-dimer values were important risk factors that were associated with a higher risk of developing PE (p < 0.05). Higher respiratory rate was associated with higher odds of death, and decreased the possibility of survival among hospitalized patients with PE. CONCLUSIONS Pulmonary embolism is common among hospitalized patients with COVID-19. Preventive measures should be considered for hospitalized patients with smoking history, low level of oxygen saturation, high D-dimer values, and high respiratory rate.
Collapse
|
278
|
Viurcos-Sanabria R, Escobedo G. Immunometabolic bases of type 2 diabetes in the severity of COVID-19. World J Diabetes 2021; 12:1026-1041. [PMID: 34326952 PMCID: PMC8311488 DOI: 10.4239/wjd.v12.i7.1026] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/16/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
The outbreak of coronavirus disease 2019 (COVID-19) is caused by the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). COVID-19 and type 2 diabetes (T2D) have now merged into an ongoing global syndemic that is threatening the lives of millions of people around the globe. For this reason, there is a deep need to understand the immunometabolic bases of the main etiological factors of T2D that affect the severity of COVID-19. Here, we discuss how hyperglycemia contributes to the cytokine storm commonly associated with COVID-19 by stimulating monocytes and macrophages to produce interleukin IL-1β, IL-6, and TNF-α in the airway epithelium. The main mechanisms through which hyperglycemia promotes reactive oxygen species release, inhibition of T cell activation, and neutrophil extracellular traps in the lungs of patients with severe SARS-CoV-2 infection are also studied. We further examine the molecular mechanisms by which proinflammatory cytokines induce insulin resistance, and their deleterious effects on pancreatic β-cell exhaustion in T2D patients critically ill with COVID-19. We address the effect of excess glucose on advanced glycation end product (AGE) formation and the role of AGEs in perpetuating pneumonia and acute respiratory distress syndrome. Finally, we discuss the contribution of preexisting endothelial dysfunction secondary to diabetes in the development of neutrophil trafficking, vascular leaking, and thrombotic events in patients with severe SARS-CoV-2 infection. As we outline here, T2D acts in synergy with SARS-CoV-2 infection to increase the progression, severity, and mortality of COVID-19. We think a better understanding of the T2D-related immunometabolic factors that contribute to exacerbate the severity of COVID-19 will improve our ability to identify patients with high mortality risk and prevent adverse outcomes.
Collapse
Affiliation(s)
| | - Galileo Escobedo
- Laboratorio de Proteómica, Dirección de Investigación, Hospital General de Mexico “Dr. Eduardo Liceaga”, Mexico City 06720, Mexico
| |
Collapse
|
279
|
Subramaniam S, Ogoti Y, Hernandez I, Zogg M, Botros F, Burns R, DeRousse JT, Dockendorff C, Mackman N, Antoniak S, Fletcher C, Weiler H. A thrombin-PAR1/2 feedback loop amplifies thromboinflammatory endothelial responses to the viral RNA analogue poly(I:C). Blood Adv 2021; 5:2760-2774. [PMID: 34242391 PMCID: PMC8288670 DOI: 10.1182/bloodadvances.2021004360] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/12/2021] [Indexed: 12/24/2022] Open
Abstract
Activation of blood coagulation and endothelial inflammation are hallmarks of respiratory infections with RNA viruses that contribute significantly to the morbidity and mortality of patients with severe disease. We investigated how signaling by coagulation proteases affects the quality and extent of the response to the TLR3-ligand poly(I:C) in human endothelial cells. Genome-wide RNA profiling documented additive and synergistic effects of thrombin and poly(I:C) on the expression level of many genes. The most significantly active genes exhibiting synergistic induction by costimulation with thrombin and poly(I:C) included the key mediators of 2 critical biological mechanisms known to promote endothelial thromboinflammatory functions: the initiation of blood coagulation by tissue factor and the control of leukocyte trafficking by the endothelial-leukocyte adhesion receptors E-selectin (gene symbol, SELE) and VCAM1, and the cytokines and chemokines CXCL8, IL-6, CXCL2, and CCL20. Mechanistic studies have indicated that synergistic costimulation with thrombin and poly(I:C) requires proteolytic activation of protease-activated receptor 1 (PAR1) by thrombin and transactivation of PAR2 by the PAR1-tethered ligand. Accordingly, a small-molecule PAR2 inhibitor suppressed poly(I:C)/thrombin-induced leukocyte-endothelial adhesion, cytokine production, and endothelial tissue factor expression. In summary, this study describes a positive feedback mechanism by which thrombin sustains and amplifies the prothrombotic and proinflammatory function of endothelial cells exposed to the viral RNA analogue, poly(I:C) via activation of PAR1/2.
Collapse
Affiliation(s)
| | - Yamini Ogoti
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI
| | - Irene Hernandez
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI
| | - Mark Zogg
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI
| | - Fady Botros
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI
| | - Robert Burns
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI
| | | | - Chris Dockendorff
- Department of Chemistry, Marquette University, Milwaukee, WI
- Function Therapeutics LLC, Milwaukee, WI; and
| | - Nigel Mackman
- Department of Medicine, Division of Hematology and Oncology, and
| | - Silvio Antoniak
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina, Chapel Hill, NC
| | - Craig Fletcher
- Department of Pathology and Laboratory Medicine, UNC Blood Research Center, University of North Carolina, Chapel Hill, NC
| | - Hartmut Weiler
- Blood Research Institute, Blood Center of Wisconsin, Versiti, Milwaukee, WI
| |
Collapse
|
280
|
Chua AMU, Jamora RDG, Jose ACE, Anlacan VMM. Cerebral Vasculitis in a COVID-19 Confirmed Postpartum Patient: A Case Report. Case Rep Neurol 2021; 13:324-328. [PMID: 34248564 PMCID: PMC8255701 DOI: 10.1159/000515815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/07/2021] [Indexed: 12/02/2022] Open
Abstract
COVID-19 has primarily been reported as a respiratory illness, but involvement of other organ systems has been reported. We describe a case of a postpartum with COVID-19 who had cerebral vasculitis. The patient presented with headache, blurring of vision, right-sided body weakness, and incoordination. Cranial magnetic resonance imaging (MRI) and angiography (MRA) showed a small acute hemorrhage on the left occipital lobe with associated acute subarachnoid hemorrhage along the parietal and occipital convexities and bilateral moderate to severe narrowing of the cerebral vessels. The patient was discharged asymptomatic. On follow-up, patient had no residual neurologic deficits, and repeat cranial MRI/MRA showed complete resolution of the vasculitis. This report was compatible with the pattern of viral-induced vasculitis and provides support to the mechanism of COVID-19-associated neurologic manifestation.
Collapse
Affiliation(s)
- Audrey Marie U Chua
- Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines.,Department of Clinical Neurosciences, University of the East Ramon Magsaysay Memorial Medical Center, Quezon City, Philippines
| | - Roland Dominic G Jamora
- Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines.,Division of Adult Neurology, Department of Neurosciences, College of Medicine - Philippine, General Hospital, University of the Philippines Manila, Manila, Philippines
| | | | - Veeda Michelle M Anlacan
- Section of Neurology, Department of Internal Medicine, Cardinal Santos Medical Center, San Juan City, Philippines.,Division of Adult Neurology, Department of Neurosciences, College of Medicine - Philippine, General Hospital, University of the Philippines Manila, Manila, Philippines
| |
Collapse
|
281
|
Neary M, Box H, Sharp J, Tatham L, Curley P, Herriott J, Kijak E, Arshad U, Hobson JJ, Rajoli R, Pertinez H, Valentijn A, Dhaliwal K, McCaughan F, Rannard SP, Kipar A, Stewart JP, Owen A. Evaluation of intranasal nafamostat or camostat for SARS-CoV-2 chemoprophylaxis in Syrian golden hamsters. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2021:2021.07.08.451654. [PMID: 34268511 PMCID: PMC8282100 DOI: 10.1101/2021.07.08.451654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Successful development of a chemoprophylaxis against SARS-CoV-2 could provide a tool for infection prevention implementable alongside vaccination programmes. Camostat and nafamostat are serine protease inhibitors that inhibit SARS-CoV-2 viral entry in vitro but have not been characterised for chemoprophylaxis in animal models. Clinically, nafamostat is limited to intravenous delivery and while camostat is orally available, both drugs have extremely short plasma half-lives. This study sought to determine whether intranasal dosing at 5 mg/kg twice daily was able to prevent airborne transmission of SARS-CoV-2 from infected to uninfected Syrian golden hamsters. SARS-CoV-2 viral RNA was above the limits of quantification in both saline- and camostat-treated hamsters 5 days after cohabitation with a SARS-CoV-2 inoculated hamster. However, intranasal nafamostat-treated hamsters remained RNA negative for the full 7 days of cohabitation. Changes in body weight over the course of the experiment were supportive of a lack of clinical symptomology in nafamostat-treated but not saline- or camostat-treated animals. These data are strongly supportive of the utility of intranasally delivered nafamostat for prevention of SARS-CoV-2 infection and further studies are underway to confirm absence of pulmonary infection and pathological changes.
Collapse
|
282
|
Dusan M, Milan S, Nikola D. COVID-19 caused hearing loss. Eur Arch Otorhinolaryngol 2021; 279:2363-2372. [PMID: 34235578 PMCID: PMC8263317 DOI: 10.1007/s00405-021-06951-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/17/2021] [Indexed: 12/23/2022]
Abstract
Purpose The objective of this cross-sectional study was to determine if there is a potential link between COVID-19 infection and hearing loss. Methods The prospective study was conducted in the COVID Hospital Clinical Centre Niš, Serbia. We performed tonal audiometry and used a custom questionnaire and medical histories to determine the incidence of hearing loss in COVID-19 positive patients. Results There were 74 patients with COVID-19 that met the inclusion criteria of this study and they composed our experimental group. Fifty-four (73%) were men and 20 (27%) women. There were 30 (40.5%) patients with hearing loss. Seventeen patients had unilateral and 13 had bilateral hearing loss. Significant differences between hearing loss groups and control group were found across all age groups, but not at all frequencies. No important differences were found when unilateral hearing loss and bilateral hearing loss groups were compared. There were no significant differences in distributions of comorbidities between the patients with hearing loss and normal hearing patients. Conclusions We found that 30 (40.5%) of the COVID-19 positive patients had sensorineural type of hearing loss. Across all age groups, there were statistically significant differences in frequencies between the COVID-19 positive patients and the control group. There were no significant differences in distributions of comorbidities between the patients with hearing loss and normal hearing patients. Distribution of unilateral and bilateral hearing loss and audiogram types was also not significantly different between the age groups.
Collapse
Affiliation(s)
- Milisavljevic Dusan
- Department of Otolaryngology, University Clinic Centre Nis, Bul. Zorana Đinđića 48, Nis, Serbia.
| | - Stankovic Milan
- Department of Otolaryngology, University Clinic Centre Nis, Bul. Zorana Đinđića 48, Nis, Serbia
| | - Dordevic Nikola
- Department of Otolaryngology, University Clinic Centre Nis, Bul. Zorana Đinđića 48, Nis, Serbia
| |
Collapse
|
283
|
Magdy Beshbishy A, Oti VB, Hussein DE, Rehan IF, Adeyemi OS, Rivero-Perez N, Zaragoza-Bastida A, Shah MA, Abouelezz K, Hetta HF, Cruz-Martins N, Batiha GES. Factors Behind the Higher COVID-19 Risk in Diabetes: A Critical Review. Front Public Health 2021; 9:591982. [PMID: 34307267 PMCID: PMC8292635 DOI: 10.3389/fpubh.2021.591982] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 04/29/2021] [Indexed: 01/08/2023] Open
Abstract
Diabetes mellitus (DM) and coronavirus disease 2019 (COVID-19) are public health issues worldwide, and their comorbidities trigger the progress to severe disease and even death in such patients. Globally, DM has affected an estimated 9.3% adults, and as of April 18, 2021, the World Health Organization (WHO) has confirmed 141,727,940 COVID-19 confirmed cases. The virus is spread via droplets, aerosols, and direct touch with others. Numerous predictive factors have been linked to COVID-19 severity, including impaired immune response and increased inflammatory response, among others. Angiotensin receptor blockers and angiotensin converting enzyme 2 have also been identified as playing a boosting role in both susceptibility and severity to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Specifically, in DM patients, both their control and management during this pandemic is herculean as the restriction periods have markedly hampered the maintenance of means to control glycemia, hypertension, and neuroendocrine and kidney diseases. In addition, as a result of the underlyin cardio-metabolic and immunological disorders, DM patients are at a higher risk of developing the severe form of COVID-19 despite other comorbidities, such as hypertension, also potentially boosting the development of higher COVID-19 severity. However, even in non-DM patients, SARS-CoV-2 may also cause transient hyperglycemia through induction of insulin resistance and/or pancreatic β-cell injury. Therefore, a strict glucose monitoring of DM patients with COVID-19 is mandatory to prevent life-threatening complications.
Collapse
Affiliation(s)
- Amany Magdy Beshbishy
- National Research Center for Protozoan Diseases, Obihiro University of Agriculture and Veterinary Medicine, Obihiro, Japan
| | - Victor B. Oti
- Department of Microbiology, Nasarawa State University, Keffi, Nigeria
| | - Diaa E. Hussein
- Researcher, Department of Food Hygiene, Agricultural Research Center, Animal Health Research Institute, Port of Alexandria, Egypt
| | - Ibrahim F. Rehan
- Department of Husbandry and Development of Animal Wealth, Faculty of Veterinary Medicine, Menofa University, Shebin Alkom, Egypt
| | - Oluyomi S. Adeyemi
- Medicinal Biochemistry, Infectious Diseases, Nanomedicine & Toxicology Laboratory, Department of Biochemistry, Landmark University, Omu-Aran, Nigeria
| | - Nallely Rivero-Perez
- Área Académica de Medicina Veterinaria y Zootecnia, Instituto de Ciencias Agropecuaria, Universidad Autónoma del Estado de Hidalgo, Tulancingo, Mexico
| | - Adrian Zaragoza-Bastida
- Área Académica de Medicina Veterinaria y Zootecnia, Instituto de Ciencias Agropecuaria, Universidad Autónoma del Estado de Hidalgo, Tulancingo, Mexico
| | - Muhammad Ajmal Shah
- Department of Pharmacognosy, Faculty of Pharmaceutical Sciences, Government College University, Faisalabad, Pakistan
| | - Khaled Abouelezz
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Helal F. Hetta
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Natália Cruz-Martins
- Faculty of Medicine, University of Porto, Porto, Portugal
- Institute for Research and Innovation in Health (i3S), University of Porto, Porto, Portugal
- Laboratory of Neuropsychophysiology, Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal
| | - Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour, Egypt
| |
Collapse
|
284
|
Brojakowska A, Eskandari A, Bisserier M, Bander J, Garikipati VNS, Hadri L, Goukassian DA, Fish KM. Comorbidities, sequelae, blood biomarkers and their associated clinical outcomes in the Mount Sinai Health System COVID-19 patients. PLoS One 2021; 16:e0253660. [PMID: 34228746 PMCID: PMC8260001 DOI: 10.1371/journal.pone.0253660] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/10/2021] [Indexed: 01/16/2023] Open
Abstract
With the continuing rise of SARS-CoV2 infection globally and the emergence of various waves in different countries, understanding characteristics of susceptibility to infection, clinical severity, and outcomes remain vital. In this retrospective study, data was extracted for 39,539 patients from the de-identified Mount Sinai Health System COVID-19 database. We assessed the risk of mortality based on the presence of comorbidities and organ-specific sequelae in 7,032 CoV2 positive (+) patients. Prevalence of cardiovascular and metabolic comorbidities was high among SARS-CoV2+ individuals. Diabetes, obesity, coronary artery disease, hypertension, atrial fibrillation, and heart failure all increased overall mortality risk, while asthma did not. Ethnicity modified the risk of mortality associated with these comorbidities. With regards to secondary complications in the setting of infection, individuals with acute kidney injury and acute myocardial injury showed an increase in mortality risk. Cerebral infarcts and acute venous thromboembolic events were not associated with increased risk of mortality. Biomarkers for cardiovascular injury, coagulation, and inflammation were compared between deceased and survived individuals. We found that cardiac and coagulation biomarkers were elevated and fell beyond normal range more often in deceased patients. Several, but not all, inflammatory markers evaluated were increased in deceased patients. In summary, we identified comorbidities and sequelae along with peripheral blood biomarkers that were associated with elevated clinical severity and poor outcomes in COVID-19 patients. Overall, these findings detail the granularity of previously reported factors which may impact susceptibility, clinical severity, and mortality during the course of COVID-19 disease.
Collapse
Affiliation(s)
- Agnieszka Brojakowska
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Abrisham Eskandari
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Malik Bisserier
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Jeffrey Bander
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | | | - Lahouaria Hadri
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - David A. Goukassian
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Kenneth M. Fish
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| |
Collapse
|
285
|
Dallan LAO, F Lisboa LA, Dallan LRP, Jatene FB. Impact of COVID-19 on coronary artery surgery: Hard lessons learned. J Card Surg 2021; 36:3294-3295. [PMID: 34216055 PMCID: PMC8446953 DOI: 10.1111/jocs.15769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Luis Alberto O Dallan
- Department of Cardiovascular Surgery, Heart Institute from University of São Paulo Medical School (InCor), São Paulo, São Paulo, Brazil
| | - Luiz Augusto F Lisboa
- Department of Cardiovascular Surgery, Heart Institute from University of São Paulo Medical School (InCor), São Paulo, São Paulo, Brazil
| | - Luis Roberto P Dallan
- Department of Cardiovascular Surgery, Heart Institute from University of São Paulo Medical School (InCor), São Paulo, São Paulo, Brazil
| | - Fabio B Jatene
- Department of Cardiovascular Surgery, Heart Institute from University of São Paulo Medical School (InCor), São Paulo, São Paulo, Brazil
| |
Collapse
|
286
|
Bozzani A, Arici V, Tavazzi G, Boschini S, Guglielmi A, Mazza G, Mojoli F, Bruno R, Ragni F, Sterpetti AV. A simple prognostic score for COVID-19 hospitalized patients developing deep vein thrombosis. Phlebology 2021; 36:835-840. [PMID: 34212790 DOI: 10.1177/02683555211030099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of our study was to analyze the specificity, accuracy and sensitivity of a simple, easy to calculate, prognostic score for hospitalized COVID19 patients developing deep vein thrombosis. METHODS From March 1st to April 28th, 942 COVID-19 patients with severe symptoms were admitted to the hospital San Matteo of Pavia-Italy. Thirty two patients (3.4%) developed deep vein thrombosis during hospitalization. In all patients hemostatic and inflammatory parameters were abnormal. A simple prognostic score was developed based on the presence of specific co morbidities and D-dimers levels (quick San Matthew Score-quick SMS). RESULTS Nine patients died in a condition of multiple organ failure, 23 patients (71.9%) survived and left the hospital in good general conditions. The developed score was based simply on two parameters: 1) presence of four specific co morbidities and 2)systemic levels of D-Dimers. The quick San Matthew Score resulted in a sensitivity, specificity and overall accuracy of more than 90% (94%, 92%,93% respectively) and compared favorably with other scores. The score was prospectively validated in 100 COVID19 patients who developed deep vein thrombosis collected from the literature and prospectively confirmed in our hospital. CONCLUSIONS The findings of our study underline the importance of an immediate aggressive therapeutic approach for moderate and high-risk patients with COVID19 infection. The quick SMS score may help to identify patients at high risk for mortality and to follow the clinical outcome of the patient. A simple, easy to calculate prognostic score may also facilitate communication among health workers.
Collapse
Affiliation(s)
- Antonio Bozzani
- Vascular and Endovascular Surgery Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vittorio Arici
- Vascular and Endovascular Surgery Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Guido Tavazzi
- Anesthesiology and Intensive Care Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Pediatric Science, 19001University of Pavia, University of Pavia, Pavia, Italy
| | - Stefano Boschini
- Vascular and Endovascular Surgery Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Angelo Guglielmi
- Anesthesiology and Intensive Care Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giovanni Mazza
- Anesthesiology and Intensive Care Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Mojoli
- Anesthesiology and Intensive Care Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Pediatric Science, 19001University of Pavia, University of Pavia, Pavia, Italy
| | - Raffaele Bruno
- Department of Medical, Surgical, Diagnostic and Pediatric Science, 19001University of Pavia, University of Pavia, Pavia, Italy.,Infectious Diseases Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Ragni
- Vascular and Endovascular Surgery Unit, 18631Fondazione IRCCS Policlinico San Matteo, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | |
Collapse
|
287
|
The Prothrombotic State Associated with SARS-CoV-2 Infection: Pathophysiological Aspects. Mediterr J Hematol Infect Dis 2021; 13:e2021045. [PMID: 34276914 PMCID: PMC8265369 DOI: 10.4084/mjhid.2021.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 06/08/2021] [Indexed: 01/08/2023] Open
Abstract
Severe coronavirus disease-2019 (COVID-19) is frequently associated with microvascular thrombosis, especially in the lung, or macrovascular thrombosis, mainly venous thromboembolism, which significantly contributes to the disease mortality burden. COVID-19 patients also exhibit distinctive laboratory abnormalities that are compatible with a prothrombotic state. The key event underlying COVID-19-associated thrombotic complications is an excessive host inflammatory response to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection generating multiple inflammatory mediators, mainly cytokines and complement activation products. The latter, along with the virus itself, the increased levels of angiotensin II and hypoxia, drive the major cellular changes promoting thrombosis, which include: (1) aberrant expression of tissue factor by activated alveolar epithelial cells, monocytes-macrophages and neutrophils, and production of other prothrombotic factors by activated endothelial cells (ECs) and platelets; (2) reduced expression of physiological anticoagulants by dysfunctional ECs, and (3) suppression of fibrinolysis by the endothelial overproduction of plasminogen activator inhibitor-1 and, likely, by heightened thrombin-mediated activation of thrombin-activatable fibrinolysis inhibitor. Moreover, upon activation or death, neutrophils and other cells release nuclear materials that are endowed with potent prothrombotic properties. The ensuing thrombosis significantly contributes to lung injury and, in most severe COVID-19 patients, to multiple organ dysfunction. Insights into the pathogenesis of COVID-19-associated thrombosis may have implications for the development of new diagnostic and therapeutic tools.
Collapse
|
288
|
Yuen KCJ, Mortensen MJ, Azadi A, Fonkem E, Findling JW. Rethinking the management of immune checkpoint inhibitor-related adrenal insufficiency in cancer patients during the COVID-19 pandemic. Endocrinol Diabetes Metab 2021; 4:e00246. [PMID: 34268454 PMCID: PMC8250331 DOI: 10.1002/edm2.246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) is currently a major pandemic challenge, and cancer patients are at a heightened risk of severity and mortality from this infection. In recent years, immune checkpoint inhibitor (ICI) use to treat multiple cancers has increased in oncology, but equally has raised the question of whether ICI therapy and its side-effects is harmful or beneficial during this pandemic. Methods A combination of published literature in PubMed between January 2010 and December 2020, recommended guidelines in non-cancer patients, and clinical experience was utilized to outline recommendations on glucocorticoid timing and dosing regimens in ICI-treated patients presenting with AI during this COVID-19 pandemic. Results The potential immune interaction between ICIs and COVID-19 require major consideration because these agents act at the intersection between effective cancer immunotherapy and increasing patient susceptibility, severity and complications from the SARS-CoV-2 sepsis. Furthermore, ICI use can induce autoimmune adrenal insufficiency (AI) that further increases infection susceptibility. Thus, ICI-treated cancer patients with AI may be at greater risk of COVID-19 infection. Glucocorticoids are the cornerstone for replacement therapy, and for treatment and mitigation of adrenal crisis and relief of mass effects in ICI-related hypophysitis. High-dose glucocorticoids have also been used with cytotoxic chemotherapy as part of cancer treatment, and iatrogenic AI may arise after glucocorticoid discontinuation that increases the risk of adrenal crisis. Furthermore, in patients who develop the "long COVID-19" syndrome, when to discontinue glucocorticoid therapy becomes crucial to avoid unnecessary prolongation of therapy and the development of iatrogenic hypercortisolemia. Conclusion During the COVID-19 pandemic, much of cancer care have been impacted and an important clinical question is how to optimally manage ICI-related AI during these unprecedented times. Herein, we suggest practical recommendations on the timing and dosing regimens of glucocorticoids in different clinical scenarios of ICI-treated cancer patients presenting with AI during this COVID-19 pandemic.
Collapse
Affiliation(s)
- Kevin C. J. Yuen
- Departments of Neuroendocrinology and NeurosurgeryBarrow Neurological InstituteUniversity of Arizona College of Medicine and Creighton School of MedicinePhoenixArizonaUSA
| | | | - Amir Azadi
- Departments of Neurology and Neuro‐OncologyBarrow Neurological Institute/Ivy Brain Center at PhoenixSt. Joseph’s Hospital and Medical CenterPhoenixArizonaUSA
| | - Ekokobe Fonkem
- Departments of Neurology and Neuro‐OncologyBarrow Neurological Institute/Ivy Brain Center at PhoenixSt. Joseph’s Hospital and Medical CenterPhoenixArizonaUSA
| | - James W. Findling
- Division of Endocrinology and Molecular MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| |
Collapse
|
289
|
Abstract
The current, global situation regarding the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic and its potentially devastating clinical manifestations, i.e. coronavirus disease 2019 (COVID-19), took the world by storm, as millions of people have been infected worldwide and more than 1,600,000 patients have succumbed. Infection induced by various respiratory viruses may lead to thrombotic complications. Infection-elicited thrombosis may involve a repertoire of distinct, yet interconnected pathophysiological mechanisms, implicating a hyperinflammatory response, platelet activation and triggering of the coagulation cascade. In the present review, we present current knowledge on the pathophysiological mechanisms that may underlie thrombotic complications in SARS-CoV-2 infection. Furthermore, we provide clinical data regarding the incidence rate of thrombotic events in several viral respiratory infections that cause acute respiratory distress syndrome, including SARS-CoV-2 infection and finally we summarize current recommendations concerning thromboprophylaxis and antithrombotic therapy in patients with thrombotic complications related to SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Iraklis C Moschonas
- Atherothrombosis Research Centre/Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, 45110, Ioannina, Greece
| | - Alexandros D Tselepis
- Atherothrombosis Research Centre/Laboratory of Biochemistry, Department of Chemistry, University of Ioannina, 45110, Ioannina, Greece.
| |
Collapse
|
290
|
Han B, Li C, Li H, Li Y, Luo X, Liu Y, Zhang J, Zhang Z, Yu X, Zhai Z, Xu X, Xiao F. Discovery of plasma biomarkers with data-independent acquisition mass spectrometry and antibody microarray for diagnosis and risk stratification of pulmonary embolism. J Thromb Haemost 2021; 19:1738-1751. [PMID: 33825327 DOI: 10.1111/jth.15324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/22/2021] [Accepted: 03/25/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a leading cause of cardiovascular mortality worldwide. Rapid and accurate diagnosis and risk stratification are crucial for timely treatment options, especially in high-risk PE. OBJECTIVES The study aims to profile the comprehensive changes of plasma proteomes in PE patients and identify the potential biomarkers for both diagnosis and risk stratification. PATIENTS/METHODS Based on the data-independent acquisition mass spectrometry and antibody array proteomic technology, we screened the plasma samples (13 and 32 proteomes, respectively) in two independent studies consisting of high-risk PE patients, non-high-risk PE patients, and healthy controls. Some significantly differentially expressed proteins were quantified by ELISA in a new study group with 50 PE patients and 26 healthy controls. RESULTS We identified 207 and 70 differentially expressed proteins in PE and high-risk PE. These proteins were involved in multiple thrombosis-associated biological processes including blood coagulation, inflammation, injury, repair, and chemokine-mediated cellular response. It was verified that five proteins including SAA1, S100A8, TNC, GSN, and HRG had significant change in PE and/or in high-risk PE. The receiver operating characteristic curve analysis based on binary logistic regression showed that the area under the curve (AUC) of SAA1, S100A8, and TNC in PE diagnosis were 0.882, 0.788, and 0.795, and AUC of S100A8 and TNC in high-risk PE diagnosis were 0.773 and 0.720. CONCLUSION As predictors of inflammation or injury repair, SAA1, S100A8, and TNC are potential plasma biomarkers for the diagnosis and risk stratification of PE.
Collapse
Affiliation(s)
- Bingqing Han
- Peking University Fifth School of Clinical Medicine, Beijing, China
- The Key Laboratory of Geriatrics, Beijing Institution of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Chuanbao Li
- Department of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hexin Li
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying Li
- The Key Laboratory of Geriatrics, Beijing Institution of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuanmei Luo
- The Key Laboratory of Geriatrics, Beijing Institution of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ye Liu
- The Key Laboratory of Geriatrics, Beijing Institution of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Junhua Zhang
- The Key Laboratory of Geriatrics, Beijing Institution of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhu Zhang
- Department of Respiratory and Clinical Care Medicine, China-Japan, Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaobo Yu
- State Key Laboratory of Proteomics, Beijing Proteome Research Center, National Center for Protein Sciences-Beijing (PHOENIX Center), Beijing Institute of Lifeomics, Beijing, China
| | - Zhenguo Zhai
- Department of Respiratory and Clinical Care Medicine, China-Japan, Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaomao Xu
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Fei Xiao
- Peking University Fifth School of Clinical Medicine, Beijing, China
- The Key Laboratory of Geriatrics, Beijing Institution of Geriatrics, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, National Health Commission, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
291
|
Afshar-Oromieh A, Prosch H, Schaefer-Prokop C, Bohn KP, Alberts I, Mingels C, Thurnher M, Cumming P, Shi K, Peters A, Geleff S, Lan X, Wang F, Huber A, Gräni C, Heverhagen JT, Rominger A, Fontanellaz M, Schöder H, Christe A, Mougiakakou S, Ebner L. A comprehensive review of imaging findings in COVID-19 - status in early 2021. Eur J Nucl Med Mol Imaging 2021; 48:2500-2524. [PMID: 33932183 PMCID: PMC8087891 DOI: 10.1007/s00259-021-05375-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023]
Abstract
Medical imaging methods are assuming a greater role in the workup of patients with COVID-19, mainly in relation to the primary manifestation of pulmonary disease and the tissue distribution of the angiotensin-converting-enzyme 2 (ACE 2) receptor. However, the field is so new that no consensus view has emerged guiding clinical decisions to employ imaging procedures such as radiography, computer tomography (CT), positron emission tomography (PET), and magnetic resonance imaging, and in what measure the risk of exposure of staff to possible infection could be justified by the knowledge gained. The insensitivity of current RT-PCR methods for positive diagnosis is part of the rationale for resorting to imaging procedures. While CT is more sensitive than genetic testing in hospitalized patients, positive findings of ground glass opacities depend on the disease stage. There is sparse reporting on PET/CT with [18F]-FDG in COVID-19, but available results are congruent with the earlier literature on viral pneumonias. There is a high incidence of cerebral findings in COVID-19, and likewise evidence of gastrointestinal involvement. Artificial intelligence, notably machine learning is emerging as an effective method for diagnostic image analysis, with performance in the discriminative diagnosis of diagnosis of COVID-19 pneumonia comparable to that of human practitioners.
Collapse
Affiliation(s)
- Ali Afshar-Oromieh
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland.
| | - Helmut Prosch
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Cornelia Schaefer-Prokop
- Department of Radiology, Meander Medical Center, Amersfoort, Netherlands
- Department of Medical Imaging, Radboud University, Nijmegen, Netherlands
| | - Karl Peter Bohn
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Ian Alberts
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Clemens Mingels
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Majda Thurnher
- Department of Biomedical Imaging and Image-guided Therapy, Medical University Vienna, Vienna, Austria
| | - Paul Cumming
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, Australia
| | - Kuangyu Shi
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Alan Peters
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Silvana Geleff
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Xiaoli Lan
- Department of Nuclear Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Wang
- Department of Nuclear Medicine, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Adrian Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes T Heverhagen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 18, CH-3010, Bern, Switzerland
| | - Matthias Fontanellaz
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko Schöder
- Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andreas Christe
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stavroula Mougiakakou
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Lukas Ebner
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
292
|
Ramos SG, Rattis BADC, Ottaviani G, Celes MRN, Dias EP. ACE2 Down-Regulation May Act as a Transient Molecular Disease Causing RAAS Dysregulation and Tissue Damage in the Microcirculatory Environment Among COVID-19 Patients. THE AMERICAN JOURNAL OF PATHOLOGY 2021; 191:1154-1164. [PMID: 33964216 PMCID: PMC8099789 DOI: 10.1016/j.ajpath.2021.04.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/05/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2, the etiologic agent of coronavirus disease 2019 (COVID-19) and the cause of the current pandemic, produces multiform manifestations throughout the body, causing indiscriminate damage to multiple organ systems, particularly the lungs, heart, brain, kidney, and vasculature. The aim of this review is to provide a new assessment of the data already available for COVID-19, exploring it as a transient molecular disease that causes negative regulation of angiotensin-converting enzyme 2, and consequently, deregulates the renin-angiotensin-aldosterone system, promoting important changes in the microcirculatory environment. Another goal of the article is to show how these microcirculatory changes may be responsible for the wide variety of injury mechanisms observed in different organs in this disease. The new concept of COVID-19 provides a unifying pathophysiological picture of this infection and offers fresh insights for a rational treatment strategy to combat this ongoing pandemic.
Collapse
Affiliation(s)
- Simone Gusmão Ramos
- Department of Pathology and Forensic Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
| | - Bruna Amanda da Cruz Rattis
- Department of Pathology and Forensic Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Giulia Ottaviani
- Centro di Ricerca Lino Rossi, Anatomic Pathology MED-08, Università degli Studi di Milano, Milan, Italy
| | - Mara Rubia Nunes Celes
- Department of Pathology and Forensic Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil,Department of Bioscience and Technology, Institute of Tropical Pathology and Public Health, Federal University of Goias, Goiania, Goias, Brazil
| | - Eliane Pedra Dias
- Department of Pathology, Faculty of Medicine, Fluminense Federal University, Niteroi, Rio de Janeiro, Brazil
| |
Collapse
|
293
|
Shih E, Squiers JJ, DiMaio JM, George T, Banwait J, Monday K, Blough B, Meyer D, Schwartz GS. Outcomes of Extracorporeal Membrane Oxygenation in Patients With Severe Acute Respiratory Distress Syndrome Caused by COVID-19 Versus Influenza. Ann Thorac Surg 2021; 113:1445-1451. [PMID: 34139189 PMCID: PMC8204847 DOI: 10.1016/j.athoracsur.2021.05.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/29/2021] [Accepted: 05/19/2021] [Indexed: 01/08/2023]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) can be effective for refractory acute respiratory distress syndrome (ARDS) in patients with influenza, but its utility in patients with coronavirus disease 2019 (COVID-19) is uncertain. We compared outcomes of patients with refractory ARDS from COVID-19 and influenza placed on ECMO. Methods We conducted a retrospective analysis of 120 patients with refractory ARDS due to COVID-19 or influenza placed on ECMO at 2 referral centers from January 2013 to October 2020. Patient characteristics and clinical outcomes were compared. The primary endpoint was survival to discharge. Results Baseline characteristics and comorbidities were similar. During the study period, 53 patients with COVID-19 and 67 patients with influenza were supported. Venovenous ECMO was the predominant initial cannulation strategy in both groups (COVID 92.5% vs influenza 95.5%; P = .5). Survival to hospital discharge was 62.3% (33 of 53 patients) in the COVID-19 group and 64.2% (43 of 67 patients) in the influenza group (P = .8). In patients successfully decannulated, median length of time on ECMO was longer in COVID-19 patients (14 [interquartile range (IQR), 9-30] days vs influenza 10.5 [IQR, 6.8-14.3] days; P = .004). Among patients discharged alive, COVID-19 patients had longer overall length of stay (COVID-19 37 [IQR, 27-62] days vs influenza 13.5 [IQR, 9.3-24] days; P = .007). Conclusions In patients with refractory ARDS from COVID-19 or influenza placed on ECMO, there was no significant difference in survival to hospital discharge. In patients surviving to decannulation, the duration of ECMO support and total length of stay were longer in COVID-19 patients.
Collapse
Affiliation(s)
- Emily Shih
- Department of Surgery, Baylor University Medical Center, Dallas, Texas.
| | - John J Squiers
- Department of Surgery, Baylor University Medical Center, Dallas, Texas; Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - J Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Timothy George
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Jasjit Banwait
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Kara Monday
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Britton Blough
- Department of Surgery, Baylor University Medical Center, Dallas, Texas
| | - Dan Meyer
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
| | - Gary S Schwartz
- Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas
| |
Collapse
|
294
|
Fang FC, Benson CA, del Rio C, Edwards KM, Fowler VG, Fredricks DN, Limaye AP, Murray BE, Naggie S, Pappas PG, Patel R, Paterson DL, Pegues DA, Petri WA, Schooley RT. COVID-19-Lessons Learned and Questions Remaining. Clin Infect Dis 2021; 72:2225-2240. [PMID: 33104186 PMCID: PMC7797746 DOI: 10.1093/cid/ciaa1654] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Indexed: 12/13/2022] Open
Abstract
In this article, the editors of Clinical Infectious Diseases review some of the most important lessons they have learned about the epidemiology, clinical features, diagnosis, treatment and prevention of SARS-CoV-2 infection and identify essential questions about COVID-19 that remain to be answered.
Collapse
Affiliation(s)
- Ferric C Fang
- Departments of Laboratory Medicine and Pathology, Microbiology, and Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Constance A Benson
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA USA
| | - Carlos del Rio
- Departments of Medicine and Global Health, Emory University School of Medicine, Atlanta, GA USA
| | - Kathryn M Edwards
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN USA
| | - Vance G Fowler
- Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - David N Fredricks
- Department of Medicine, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Ajit P Limaye
- Departments of Laboratory Medicine and Pathology, Microbiology, and Medicine, University of Washington School of Medicine, Seattle, WA USA
| | - Barbara E Murray
- Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Susanna Naggie
- Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - Peter G Pappas
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL USA
| | - Robin Patel
- Departments of Laboratory Medicine and Pathology, and Medicine, Mayo Clinic, Rochester, MN USA
| | - David L Paterson
- Department of Medicine, University of Queensland Centre for Clinical Research, Herston, QLD Australia
| | - David A Pegues
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - William A Petri
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA USA
| | - Robert T Schooley
- Department of Medicine, University of California, San Diego School of Medicine, San Diego, CA USA
| |
Collapse
|
295
|
Iffah R, Gavins FNE. Thromboinflammation in coronavirus disease 2019: The clot thickens. Br J Pharmacol 2021; 179:2100-2107. [PMID: 34128218 PMCID: PMC8444860 DOI: 10.1111/bph.15594] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/20/2021] [Accepted: 05/27/2021] [Indexed: 12/15/2022] Open
Abstract
Since the start of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic, a disease that has become one of the world's greatest global health challenges, the role of the immune system has been at the forefront of scientific studies. The pathophysiology of coronavirus disease 2019 (COVID‐19) is complex, which is evident in those at higher risk for poor outcome. Multiple systems contribute to thrombosis and inflammation seen in COVID‐19 patients, including neutrophil and platelet activation, and endothelial dysfunction. Understanding how the immune system functions in different patient cohorts (particularly given recent emerging events with the Oxford/AstraZeneca vaccine) is vital to understanding the pathophysiology of this devastating disease and for the subsequent development of novel therapeutic targets and to facilitate possible drug repurposing strategies that could benefit society on a global scale.
Collapse
Affiliation(s)
- Raayma Iffah
- Department of Life Sciences, Centre for Inflammation Research and Translational Medicine (CIRTM), Brunel University London, London, UK
| | - Felicity N E Gavins
- Department of Life Sciences, Centre for Inflammation Research and Translational Medicine (CIRTM), Brunel University London, London, UK
| |
Collapse
|
296
|
MRI negative myelopathy post mild SARS-CoV-2 infection: vasculopathy or inflammatory myelitis? J Neurovirol 2021; 27:650-655. [PMID: 34101085 PMCID: PMC8186350 DOI: 10.1007/s13365-021-00986-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/16/2021] [Accepted: 05/10/2021] [Indexed: 02/07/2023]
Abstract
Since the onset of the COVID-19 pandemic, there have been rare reports of spinal cord pathology diagnosed as inflammatory myelopathy and suspected spinal cord ischemia after SARS-CoV-2 infection. Herein, we report five cases of clinical myelopathy and myeloradiculopathy in the setting of post-COVID-19 disease, which were all radiographically negative. Unlike prior reports which typically characterized hospitalized patients with severe COVID-19 disease and critical illness, these patients typically had asymptomatic or mild-moderate COVID-19 disease and lacked radiologic evidence of structural spinal cord abnormality. This case series highlights that COVID-19 associated myelopathy is not rare, requires a high degree of clinical suspicion as imaging markers may be negative, and raises several possible pathophysiologic mechanisms.
Collapse
|
297
|
Siscel J, Short M, Flynn B. Understanding ST-Elevation Myocardial Infarction in COVID-19: The Marriage of Bench Work and Big Data. J Cardiothorac Vasc Anesth 2021; 35:3164-3166. [PMID: 34218995 PMCID: PMC8180361 DOI: 10.1053/j.jvca.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/01/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jordan Siscel
- Department of Anesthesiology, The University of Kansas Health System, Kansas City, KS
| | - Margo Short
- Department of Anesthesiology, The University of Kansas Health System, Kansas City, KS
| | - Brigid Flynn
- Department of Anesthesiology, The University of Kansas Health System, Kansas City, KS.
| |
Collapse
|
298
|
Wang Y, Pang SC, Yang Y. A potential association between immunosenescence and high COVID-19 related mortality among elderly patients with cardiovascular diseases. Immun Ageing 2021; 18:25. [PMID: 34074305 PMCID: PMC8166579 DOI: 10.1186/s12979-021-00234-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 04/13/2021] [Indexed: 12/15/2022]
Abstract
Elderly patients with cardiovascular diseases account for a large proportion of Corona virus Disease 2019(COVID-19)related deaths. COVID-19, as a new coronavirus, mainly targets the patient's lung triggering a cascade of innate and adaptive immune responses in the host. The principal causes of death among COVID-19 patients, especially elderly subjects with cardiovascular diseases, are acute respiratory distress syndrome(ARDS), multiple organ dysfunction syndrome (MODS), and microvascular thrombosis. All prompted by an excessive uncontrolled systemic inflammatory response. Immunosenescence, characterized by systemic and chronic inflammation as well as innate/adaptive immune imbalance, presents both in the elderly and cardiovascular patients. COVID-19 infection further aggravates the existing inflammatory process and lymphocyte depletion leading to uncontrollable systemic inflammatory responses, which is the primary cause of death. Based on the higher mortality, this study attempts to elucidate the pathophysiological mechanisms of COVID-19 in elderly subjects with cardiovascular diseases as well as the cause of the high mortality result from COVID-19.
Collapse
Affiliation(s)
- Yuanyuan Wang
- Department of Cardiology, Hangzhou Xiacheng Hospital of Integrated Traditional Chinese and Western Medicine, Hangzhou, 310004, Zhejiang, China
| | - Shu-Chao Pang
- The First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Ying Yang
- Department of Cardiology, SirRunRunShaw Hospital, College of Medicine, Zhejiang University, No.3 Qingchun East Road, Hangzhou, 310016, Zhejiang, China.
| |
Collapse
|
299
|
Topp G, Bouyea M, Cochran-Caggiano N, Ata A, Torres P, Jacob J, Wales D. Biomarkers Predictive of Extubation and Survival of COVID-19 Patients. Cureus 2021; 13:e15462. [PMID: 34258124 PMCID: PMC8256763 DOI: 10.7759/cureus.15462] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 01/08/2023] Open
Abstract
Purpose Many patients with COVID-19 who develop acute respiratory distress syndrome (ARDS) require prolonged periods of mechanical ventilation. Mechanical ventilation may amplify ventilator-associated complications and extend resource utilization. A better understanding of prognostic indicators could help in the planning and distribution of resources, particularly in resource-limited areas. We analyzed laboratory studies of intubated COVID-19 patients with the goal of identifying biomarkers that may predict extubation success and survival to discharge. Methods A retrospective chart review was performed on all COVID-19 patients requiring mechanical ventilation between January 3, 2020, and January 7, 2020, in a single academic tertiary care center in Northeastern New York State. The electronic medical record was used to collect 14 laboratory variables at three time points: admission, intubation, and extubation (including terminal extubation) for all intubated intensive care unit (ICU) patients treated for COVID-19. Mean laboratory values were analyzed with the Mann-Whitney U test. Categorical variables were analyzed with the two-sample Wilcoxon rank-sum test. Results Seventy-two patients met the inclusion criteria. Forty-three patients were male. The mean age was 61 years. The overall mortality was 50%. On admission, intubated patients who survived had significantly higher platelet counts (p=0.024), and absolute lymphocyte counts (ALC; p=0.047). Notably, ferritin (p=0.018) and aspartate transaminase (AST; p=0.0045) levels were lower in survivors. At the time of intubation, survivors again had a higher platelet count (p=0.024) and ALC (p=0.037) levels. They had a lower D-dimer (p=0.0014), ferritin (p=0.0015), lactate dehydrogenase (LDH; p=0.0145), and AST (p=0.018) compared to intubated patients who died. At extubation, survivors had higher platelet count (p=0.0002), ALC (p=0.0013), and neutrophil/lymphocyte ratio (NLR; p=0.0024). Survivors had lower d-dimer (p=0.035), ferritin (p=0.0012), CRP (p=0.045), LDH (p=0.002), AST (p<0.001), and ALK (p=0.0048). Conclusions Biomarkers associated with increased risk of mortality include platelet count, ALC, lymphocyte percentage, NLR, D-dimer, ferritin, C-reactive protein (CRP), AST, alanine transaminase (ALT), and alkaline phosphatase (ALK). This study provides additional evidence that these biomarkers have prognostic value in patients with severe COVID-19. The goal is to find objective surrogate markers of disease improvement or success of extubation. When considered within the larger body of data, it is our hope that a mortality risk calculator can be generated for intubated COVID-19 patients.
Collapse
Affiliation(s)
- Gregory Topp
- Department of Medicine, Albany Medical College, Albany, USA
| | - Megan Bouyea
- Department of Medicine, Albany Medical College, Albany, USA
| | | | - Ashar Ata
- Department of Surgery, Albany Medical Center, Albany, USA
| | - Pedro Torres
- Department of Surgery, Albany Medical Center, Albany, USA
| | - Jackcy Jacob
- Department of Medicine, Albany Medical Center, Albany, USA
| | - Danielle Wales
- Department of Medicine, Albany Medical Center, Albany, USA
- School of Public Health, State University of New York at Albany, Albany, USA
| |
Collapse
|
300
|
Knefati M, Ganim I, Schmidt J, Makkar A, Igtiben S, Landa E, Tarawneh A, Hicks C, Zimmerman S, Sukpraprut-Braaten S. COVID-19 With an Initial Presentation of Intraperitoneal Hemorrhage Secondary to Spontaneous Splenic Rupture. Cureus 2021; 13:e15310. [PMID: 34211811 PMCID: PMC8236337 DOI: 10.7759/cureus.15310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 01/08/2023] Open
Abstract
The WHO declared coronavirus disease 2019 (COVID-19) a global pandemic in early 2020. As the pandemic has continued to evolve over a period of several months, many cases of unusual presentations are now emerging, which pose a greater challenge for physicians in terms of quickly identifying COVID-19 patients based on initial signs and symptoms. In this report, we present one such unusual presentation in a patient with sudden intraperitoneal hemorrhage and spontaneous splenic rupture with COVID-19 as the likely etiology and contributing factor. The patient was a 75-year-old Caucasian woman who presented to the emergency department (ED) with complaints of severe left-sided abdominal pain for several days without any preceding trauma. A CT of the abdomen/pelvis revealed a large amount of fluid in the abdomen, which raised suspicion of bleeding. An exploratory laparotomy revealed splenic rupture with hemoperitoneum, and the patient subsequently underwent an emergent splenectomy. The patient's COVID-19 antigen test returned positive during the surgery and was subsequently confirmed with a polymerase chain reaction (PCR) test. COVID-19 has been found to result primarily in respiratory symptoms through its ability to invade endothelial cells via angiotensin-converting enzyme 2 affinity. It is speculated that this mechanism may cause a predisposition to micro-thromboses, which can eventually lead to manifestations such as large lymphoid organ thrombosis. Based on this case presentation and the evolving literature on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), spontaneous splenic rupture is an emergent differential diagnosis that should be considered in COVID-19 patients presenting with gastrointestinal complaints such as abdominal pain and nausea.
Collapse
Affiliation(s)
| | | | | | | | | | - Eric Landa
- Internal Medicine, Unity Health, Searcy, USA
| | - Ahmad Tarawneh
- Pulmonary and Critical Care Medicine, Unity Health, Searcy, USA
| | | | | | | |
Collapse
|