Cardiovascular involvement during COVID-19 and clinical implications in elderly patients. A review

Vascular dysfunction in hemorrhagic viral fevers: opportunities for organotypic modeling

The hemorrhagic fever viruses (HFVs) cause severe or fatal infections in humans. Named after their common symptom hemorrhage, these viruses induce significant vascular dysfunction by affecting endothelial cells, altering immunity, and disrupting the clotting system. Despite advances in treatments, such as cytokine blocking therapies, disease modifying treatment for this class of pathogen remains elusive. Improved understanding of the pathogenesis of these infections could provide new avenues to treatment. While animal models and traditional 2D cell cultures have contributed insight into the mechanisms by which these pathogens affect the vasculature, these models fall short in replicatingin vivohuman vascular dynamics. The emergence of microphysiological systems (MPSs) offers promising avenues for modeling these complex interactions. These MPS or 'organ-on-chip' models present opportunities to better mimic human vascular responses and thus aid in treatment development. In this review, we explore the impact of HFV on the vasculature by causing endothelial dysfunction, blood clotting irregularities, and immune dysregulation. We highlight how existing MPS have elucidated features of HFV pathogenesis as well as discuss existing knowledge gaps and the challenges in modeling these interactions using MPS. Understanding the intricate mechanisms of vascular dysfunction caused by HFV is crucial in developing therapies not only for these infections, but also for other vasculotropic conditions like sepsis.

An evidence-based debate on epigenetics and immunosenescence in COVID-19

Immunosenescence contributes to the decline of immune function leading to a reduced ability to respond to severe coronavirus disease 2019 (COVID-19) in elderly patients. Clinical course of COVID-19 is widely heterogeneous and guided by the possible interplay between genetic background and epigenetic-sensitive mechanisms underlying the immunosenescence which could explain, at least in part, the higher percentage of disease severity in elderly individuals. The most convincing evidence regards the hypomethylation of the angiotensin-converting enzyme 2 (ACE2) promoter gene in lungs as well as the citrullination of histone H3 in neutrophils which have been associated with worsening of COVID-19 outcome in elderly patients. In contrast, centenarians who have showed milder symptoms have been associated to a younger "epigenetic age" based on DNA methylation profiles at specific genomic sites (epigenetic clock). Some large prospective studies showed that the acceleration of epigenetic aging as well as the shortening of telomeres were significantly associated with lymphopenia and poor outcome suggesting prognostic biomarkers in elderly COVID-19 patients. Furthermore, randomized clinical trials showed that statins, L-arginine, and resveratrol could mediate anti-inflammatory effects via indirect epigenetic interference and might improve COVID-19 outcome. Here, we discuss the epigenetic-sensitive events which might contribute to increase the risk of severity and mortality in older subjects and possible targeted therapies to counteract immunosenescence.

Frailty after COVID-19: The wave after?

The COVID-19 pandemic poses an ongoing public health challenge, with a focus on older adults. Given the large number of older persons who have recovered from COVID-19 and reports of long-lasting sequelae, there is reasonable concern that the COVID-19 pandemic may lead to a long-term deterioration in the health of older adults, i.e., a potential "wave of frailty." Therefore, it is critical to better understand the circumstances surrounding the development of frailty as a result of COVID-19, as well as the underlying mechanisms and factors contributing to this development. We conducted a narrative review of the most relevant articles published on the association between COVID-19 and frailty through January 2023. Although few studies to date have addressed the effects of COVID-19 on the onset and progression of frailty, the available data suggest that there is indeed an increase in frailty in the elderly as a result of COVID-19. Regarding the underlying mechanisms, a multicausal genesis can be assumed, involving both direct viral effects and indirect effects, particularly from the imposed lockdowns with devastating consequences for the elderly: decreased physical activity, altered diet, sarcopenia, fatigue, social isolation, neurological problems, inflammation, and cardiovascular morbidity are among the possible mediators. Since the COVID-19 pandemic is leading to an increase in frailty in the elderly, there is an urgent need to raise awareness of this still little-known problem of potentially great public health importance and to find appropriate prevention and treatment measures.

Cardiovascular Complications in Patients Hospitalized for COVID-19: A Cohort Study in Havana, Cuba

INTRODUCTION AND OBJECTIVE

At least one in ten patients infected with COVID develop cardiovascular complications during hospitalization, increasing the number of deaths from this cause. However, the determinants of risk are not clearly elucidated. This study aims to determine whether there is a relationship between in-hospital cardiac complications and cardiovascular history and hospital evolution.

METHODS

Prospective cohort study of 373 patients with a positive diagnosis of SARS-CoV-2 admitted to an Intensive Care Unit between March and October 2021.

RESULTS

Median age was 69 (IQR: 57-77), 29.2 % of patients presented cardiovascular complications: 21.2 % electrical, 5.9 % acute coronary syndrome and 1.9 % pulmonary thromboembolism. Age RR: 1.02 (95 % CI: 1.00-1.04; p = 0.020) and history of ischemic heart disease RR: 2.23 (95 % CI: 1.27-3.92; p = 0.005) were identified as independent predictors of in-hospital cardiac complications.

CONCLUSIONS

Age and history of ischemic heart disease were identified as independent predictor variables of cardiovascular complications in patients admitted with severe COVID-19 involvement; being significantly associated with lower survival.

Senotherapeutics: An emerging approach to the treatment of viral infectious diseases in the elderly

In the context of the global COVID-19 pandemic, the phenomenon that the elderly have higher morbidity and mortality is of great concern. Existing evidence suggests that senescence and viral infection interact with each other. Viral infection can lead to the aggravation of senescence through multiple pathways, while virus-induced senescence combined with existing senescence in the elderly aggravates the severity of viral infections and promotes excessive age-related inflammation and multiple organ damage or dysfunction, ultimately resulting in higher mortality. The underlying mechanisms may involve mitochondrial dysfunction, abnormal activation of the cGAS-STING pathway and NLRP3 inflammasome, the role of pre-activated macrophages and over-recruited immune cells, and accumulation of immune cells with trained immunity. Thus, senescence-targeted drugs were shown to have positive effects on the treatment of viral infectious diseases in the elderly, which has received great attention and extensive research. Therefore, this review focused on the relationship between senescence and viral infection, as well as the significance of senotherapeutics for the treatment of viral infectious diseases.

Beneficial effects of prehospital use of statins in a large United States cohort of hospitalized coronavirus disease 2019 patients

AIMS

This large cohort study aimed to assess the role of chronic statin use on COVID-19 disease severity.

METHODS

An observational retrospective study from electronic medical records of hospitalized patients (n = 43 950) with COVID-19 between January and September 2020 in 185 hospitals in the United States. A total of 38 875 patients met inclusion criteria; 23 066 were included in the propensity-matched sampling with replacement cohort; 11 533 were prehospital statin users. The primary outcome was all-cause death; secondary outcomes were death from COVID-19 and serious complications. Mean, standard deviation, chi-square test, Student's t-test, linear regression, and binary and multinomial logistic regressions were used for statistical analysis.

RESULTS

Among 38 875 patients, 30% were chronic statin users [mean age, 70.82 (±12.25); 47.1% women] and 70% were statin nonusers [mean age, 58.44 (±18.27); 48.5% women]. Key propensity-matched outcomes among 11 533 chronic statin users showed 20% lower risk of all-cause mortality (OR 0.80, 95% CI 0.74-0.86, P < 0.001), 23% lower risk of mortality from COVID-19 (OR 0.77, 95% CI 0.71-0.84, P < 0.001), 16% lower risk of ICU admission (OR 0.84, 95% CI 0.79-0.89, P < 0.001), 24% lower risk of critical acute respiratory distress syndrome with COVID-19 (OR 0.76, 95% CI 0.70-0.83, P < 0.001), 23% lower risk of mechanical ventilation (OR 0.77, 95% CI 0.71-0.82, P < 0.001), 20% lower risk of severe sepsis with septic shock (OR 0.80, 95% CI 0.67-0.93, P = 0.004), shorter hospital length of stay [9.87 (±8.94), P < 0.001] and brief duration of mechanical ventilation [8.90 (±8.94), P < 0.001].

CONCLUSION

Chronic use of statins is associated with reduced mortality and improved clinical outcomes in patients hospitalized for COVID-19.

COVID-19's immuno-pathology and cardiovascular diseases

The pandemic of COVID-19 in worldwide causes recent millions of morbidity and mortality in all countries and is the most important challenge in the world in recent years. Coronavirus is a single-stranded RNA virus and infection with COVID-19 leads to acute respiratory distress syndrome, lung inflammation, cytokine storm, and death. The other complications include endothelial dysfunction, activation of coagulation, thromboembolic events, and vascular disease. Cardiovascular complications such as myocardial and stroke ischemia, pulmonary thromboembolism, systemic arterial, and deep vein thrombosis were reported. In this review, we presented immuno-pathological mechanisms and the effects of COVID-19 on the cardiovascular system, heart, vessels, coagulation system, and molecular glance of immuno-inflammation to the COVID-19's pathology on the cardiovascular system.

Targeted genetic analysis unveils novel associations between ACE I/D and APO T158C polymorphisms with D-dimer levels in severe COVID-19 patients with pulmonary embolism

Only a percentage of COVID-19 patients develop thrombotic complications. We hypothesized that genetic profiles may explain part of the inter-individual differences. Our goal was to evaluate the genotypic distribution of targeted DNA polymorphisms in COVID-19 patients complicated (PE+) or not (PE-) by pulmonary embolism. We designed a retrospective observational study enrolling N = 94 consecutive patients suffering severe COVID-19 with pulmonary embolism (PE+, N = 47) or not (PE-, N = 47) during hospitalization. A panel of N = 13 prothrombotic DNA polymorphisms (FV R506Q and H1299R, FII G20210A, MTHFR C677T and A1298C, CBS 844ins68, PAI-1 4G/5G, GPIIIa HPA-1 a/b, ACE I/D, AGT T9543C, ATR-1 A1166C, FGB - 455G > A, FXIII103G > T) and N = 2 lipid metabolism-related DNA polymorphisms (APOE T 112C and T158C) were investigated using Reverse Dot Blot technique. Then, we investigated possible associations between genotypic subclasses and demographic, clinical, and laboratory parameters including age, obesity, smoking, pro-inflammatory cytokines, drug therapy, and biomarkers of thrombotic risk such as D-dimer (DD). We found that 58.7% of PE+ had homozygous mutant D/D genotype at ACE I/D locus vs. PE- (40.4%) and 87% of PE+ had homozygous mutant C/C genotype at APOE T158C locus vs. PE- (68.1%). In PE+ group, DD levels were significantly higher in D/D and I/D genotypes at ACE I/D locus (P = 0.00066 and P = 0.00023, respectively) and in C/C and T/C genotypes at APOE T158C locus (P = 1.6e-06 and P = 0.0012, respectively) than PE- group. For the first time, we showed significant associations between higher DD levels and ACE I/D and APOE T158C polymorphisms in PE+ vs. PE- patients suggesting potential useful biomarkers of poor clinical outcome.

Do selected lifestyle parameters affect the severity and symptoms of COVID-19 among elderly patients? The retrospective evaluation of individuals from the STOP-COVID registry of the PoLoCOV study

BACKGROUND

Older individuals tend to include less physical activity in their routine and are more prone to chronic diseases and severe medical complications, making them the most burdened group that is losing years of life due to pandemic-related premature mortality. This research aimed to assess the lifestyle factors that affect the COVID-19 course among patients ≥ 65 years old.

METHODS

The study included 568 convalescents (64.1% women and 35.9% men) with persistent clinical symptoms after isolation. The mean age was 70.41 ± 4.64 years (minimum: 65 years; maximum: 89 years). The patients completed the questionnaire during their in-person visit to the medical center. The survey included questions regarding their health status when suffering from COVID-19, basic sociodemographic data, and medical history concerning chronic conditions and lifestyle.

RESULTS

Physical inactivity (p < 0.001) and feeling nervous (p = 0.026) increased the risk of having a severe disease course. Coronary artery disease raised both the risk of a severe disease course (p = 0.002) and the number of present symptoms up to 4 weeks (p = 0.039). Sleep disturbances increased the number of symptoms during infection (p = 0.001). The occurrence of any symptoms was also associated with the female sex (p = 0.004). The severity of the course was associated with longer persistent symptoms (p < 0.001) and a greater number of symptoms (p = 0.004); those with a more severe course were also at a greater risk of persistent symptoms for up to 4 weeks (p = 0.006). Senior citizens in the third pandemic wave suffered with more severe disease (p = 0.004), while illness during the fourth (p = 0.001) and fifth (p < 0.001) waves was associated with a lower risk of persistent symptoms for up to 4 weeks. The disease duration was significantly shorter among vaccinated patients (p = 0.042).

CONCLUSIONS

Elderly COVID-19 patients should re-think their lifestyle habits to consider a physical activity level that is adjusted to their abilities, in order to decrease the risk of a severe disease course and to further limit both the number and duration of symptoms. The research was carried out in accordance with the Declaration of Helsinki, and approval from the Bioethics Committee of Lodz Regional Medical Chamber to conduct the study was obtained (approval number 0115/2021). The PoLoCOV-Study ClinicalTrials.gov identifier is NCT05018052.

Biological and Exploitable Crossroads for the Immune Response in Cancer and COVID-19

The outbreak of novel coronavirus disease 2019 (COVID-19) has exacted a disproportionate toll on cancer patients. The effects of anticancer treatments and cancer patients’ characteristics shared significant responsibilities for this dismal outcome; however, the underlying immunopathological mechanisms are far from being completely understood. Indeed, despite their different etiologies, SARS-CoV-2 infection and cancer unexpectedly share relevant immunobiological connections. In the pathogenesis and natural history of both conditions, there emerges the centrality of the immune response, orchestrating the timed appearance, functional and dysfunctional roles of multiple effectors in acute and chronic phases. A significant number (more than 600) of observational and interventional studies have explored the interconnections between COVID-19 and cancer, focusing on aspects as diverse as psychological implications and prognostic factors, with more than 4000 manuscripts published so far. In this review, we reported and discussed the dynamic behavior of the main cytokines and immune system signaling pathways involved in acute vs. early, and chronic vs. advanced stages of SARS-CoV-2 infection and cancer. We highlighted the biological similarities and active connections within these dynamic disease scenarios, exploring and speculating on possible therapeutic crossroads from one setting to the other.

Sequelae and Comorbidities of COVID-19 Manifestations on the Cardiac and the Vascular Systems

COVID-19 patients with pre-existing cardiovascular conditions are at greater risk of severe illness due to the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) virus. This review evaluates the highest risk factors for these patients, not limited to pre-existing hypertension, cardiac arrhythmias, hypercoagulation, ischemic heart disease, and a history of underlying heart conditions. SARS-CoV-2 may also precipitate de novo cardiac complications. The interplay between existing cardiac conditions and de novo cardiac complications is the focus of this review. In particular, SARS-CoV-2 patients present with hypercoagulation conditions, cardiac arrhythmias, as significant complications. Also, cardiac arrhythmias are another well-known cardiovascular-related complication seen in COVID-19 infections and merit discussion in this review. Amid the pandemic, myocardial infarction (MI) has been reported to a high degree in SARS-CoV-2 patients. Currently, the specific causative mechanism of the increased incidence of MI is unclear. However, studies suggest several links to high angiotensin-converting enzyme 2 (ACE2) expression in myocardial and endothelial cells, systemic hyper-inflammation, an imbalance between myocardial oxygen supply and demand, and loss of ACE2-mediated cardio-protection. Furthermore, hypertension and SARS-CoV-2 infection patients’ prognosis has shown mixed results across current studies. For this reason, an in-depth analysis of the interactions between SARS-CoV2 and the ACE2 cardio-protective mechanism is warranted. Similarly, ACE2 receptors are also expressed in the cerebral cortex tissue, both in neurons and glia. Therefore, it seems very possible for both cardiovascular and cerebrovascular systems to be damaged leading to further dysregulation and increased risk of mortality risk. This review aims to discuss the current literature related to potential complications of COVID-19 infection with hypertension and the vasculature, including the cervical one. Finally, age is a significant prognostic indicator among COVID-19 patients. For a mean age group of 70 years, the main presenting symptoms include fever, shortness of breath, and a persistent cough. Elderly patients with cardiovascular comorbidities, particularly hypertension and diabetes, represent a significant group of critical cases with increased case fatality rates. With the current understanding of COVID-19, it is essential to explore the mechanisms by which SARS-CoV-2 operates to improve clinical outcomes for patients suffering from underlying cardiovascular diseases and reduce the risk of such conditions de novo.

Feasibility of a COVID-19 Rapid Response Telehealth Group Addressing Older Adult Worry and Social Isolation

OBJECTIVES

During the early months of the COVID-19 pandemic, virtual and telephone visits rapidly replaced most in-person care within the Veterans Health Administration (VA) to reduce the virus spread. To address the emerging mental health needs of older Veterans (e.g., social isolation) in the context of chronic underlying mental health needs (e.g., trauma), we developed an 8-week virtual group treatment manual. This article describes the results from a survey of geriatric mental health clinicians who used the COVID group manual to determine its acceptability and feasibility in these settings.

METHODS

Clinicians across three VA integrated care settings (home-based primary care, community living centers, and geriatric primary care) were surveyed about their experiences implementing this treatment (n = 21).

RESULTS

Clinicians found this intervention to be effective with their patients and useful and adaptable beyond the early pandemic period.

CONCLUSIONS

This group teletherapy intervention was feasible and acceptable when treating Veterans in integrated geriatric healthcare settings. Despite technical challenges experienced by older Veterans, clinicians found this manual to be effective in addressing COVID-related worry and social isolation.

CLINICAL IMPLICATIONS

This rapid response manual has remained clinically useful in geriatric mental health care settings beyond the initial weeks of the pandemic.

Cardiovascular Surgical Emergencies in France, before, during and after the First Lockdown for COVID-19 in 2020: A Comparative Nationwide Retrospective Cohort Study

Background: There are still gaps regarding the impact of the nationwide lockdown on non-COVID-19 emergency hospitalizations. This study aims to describe the trends in hospitalizations for cardiovascular surgical emergencies in France, before, during and after the first lockdown. Materials and Methods: All adults admitted for mechanical complications of myocardial infarction (MI), aortic dissection, aortic aneurysm rupture, acute and critical limb ischemia, circulatory assistance, heart transplantation and major amputation were included. This retrospective cohort study used the French National Hospital Discharge database. The numbers of hospitalizations per month in 2020 were compared to the previous three years. Results: From January to September 2020, 94,408 cases of the studied conditions were reported versus 103,126 in the same period in 2019 (−8.5%). There was a deep drop in most conditions during the lockdown, except for circulatory assistance, which increased. After the lockdown, mechanical complications of MI and aortic aneurysm rupture increased, and cardiac transplantations declined compared with previous years. Conclusion: We confirmed a deep drop in most cardiovascular surgical emergencies during the lockdown. The post-lockdown period was characterized by a small over-recovery for mechanical complications of MI and aortic aneurysm rupture, suggesting that many patients were able to access surgery after the lockdown.

Safety and Outcomes of Intravenous Thrombolytic Therapy in Ischemic Stroke Patients with COVID-19: CASCADE Initiative

BACKGROUND

There is little information regarding the safety of intravenous tissue plasminogen activator (IV-tPA) in patients with stroke and COVID-19.

METHODS

This multicenter study included consecutive stroke patients with and without COVID-19 treated with IV-tPA between February 18, 2019, to December 31, 2020, at 9 centers participating in the CASCADE initiative. Clinical outcomes included modified Rankin Scale (mRS) at hospital discharge, in-hospital mortality, the rate of hemorrhagic transformation. Using Bayesian multiple regression and after adjusting for variables with significant value in univariable analysis, we reported the posterior adjusted odds ratio (OR, with 95% Credible Intervals [CrI]) of the main outcomes.

RESULTS

A total of 545 stroke patients, including 101 patients with COVID-19 were evaluated. Patients with COVID-19 had a more severe stroke at admission. In the study cohort, 85 (15.9%) patients had a hemorrhagic transformation, and 72 (13.1%) died in the hospital. After adjustment for confounding variables, discharge mRS score ≥2 (OR: 0.73, 95% CrI: 0.16, 3.05), in-hospital mortality (OR: 2.06, 95% CrI: 0.76, 5.53), and hemorrhagic transformation (OR: 1.514, 95% CrI: 0.66, 3.31) were similar in COVID-19 and non COVID-19 patients. High-sensitivity C reactive protein level was a predictor of hemorrhagic transformation in all cases (OR:1.01, 95%CI: 1.0026, 1.018), including those with COVID-19 (OR:1.024, 95%CI:1.002, 1.054).

CONCLUSION

IV-tPA treatment in patients with acute ischemic stroke and COVID-19 was not associated with an increased risk of disability, mortality, and hemorrhagic transformation compared to those without COVID-19. IV-tPA should continue to be considered as the standard of care in patients with hyper acute stroke and COVID-19.

Clinical manifestations and socio-demographic status of COVID-19 patients during the second-wave of pandemic: A Bangladeshi experience

BACKGROUND

Bangladesh is a densely populated country with a substandard healthcare system and a mediocre economic framework. Due to the enormous number of people who have been unaware until now, the development of COVID-19's second-wave infection has become a severe threat. The present investigation aimed to characterize the clinical and socio-demographic characteristics of COVID-19 in Bangladesh.

METHODS

A cross-sectional analysis was carried out from all the other COVID-19 patients and confirmed by RT-PCR undergoing a specialized COVID-19 hospital. From March 1 to April 15, 2021, a total of 1326 samples were collected. Samples were only obtained from non-critical COVID-19 patients as critically ill patients required emergency intensive care medications. Then, from April 17 to May 03, 2021, SARS-CoV-2 infection and clinical assessment was performed based on interim guidelines from the WHO. The diagnosis was conducted through RT-PCR. Later, identifying the symptomatic and asymptomatic patient based on checking the Clinical Observation Form (COF). The patients filled the COF form. Finally, statistical analyses were done using the SPSS 20 statistical program.

RESULTS

In this investigation, a total of 326 patients were diagnosed as COVID-19 positive. Among them, approximately 19.02% (n = 62) were asymptomatic, and 80.98% (n = 264) were symptomatic. Here, the finding shows that the occurrence of this infection was varied depending on age, sex, residence, occupation, smoking habit, comorbidities, etc. However, Males (60.12%) were more affected than females (39.88%), and, surprisingly, this pandemic infected both urban and rural residents almost equally (urban = 50.92%; rural = 49.08%). Approximately 19% of the asymptomatic and 62% of symptomatic cases had at least one comorbid disorder. Interestingly, an unexpected result was exhibited in the case of smokers, where non-smokers were more affected than smokers. The study indicates community transmission of COVID 19, where people were highly infected at their occupations (35.58%), at houses (23.93%) and by traveling (12.88%). Noteworthy, according to this report, a large number (19.33%) of individuals did not know exactly how they were contaminated with SARS-CoV-2. Patients were most commonly treated by an antibiotic 95.09%, followed in second by corticosteroid 46.01%. Anti-viral drugs, remdesivir, and oxygenation are also needed for other patients. Among those, who were being treated, approximately 69.33% were isolated at home, 27.91% were being treated at dedicated COVID-19 hospitals. Finally, 96.63% were discharged without complications, and 0.03% has died.

CONCLUSION

This investigation concludes that males became more infected than females. Interestingly, both urban and rural people became nearly equally infected. It noticed community transmission of SARS-CoV-2, where people were highly infected at their workplaces. A higher rate of silent transmission indicates that more caution is needed to identify asymptomatic patients. Most of the infected people were isolated at home whereas nearly one-fourth were treated at hospitals. Clinically, antibiotics were the most widely used treatment. However, the majority of the patients were discharged without complications. The current investigation would be helpful to understand the clinical manifestations and socio-demographic situations during the second wave of the COVID-19 pandemic in Bangladesh.

Association of echocardiographic parameters with chest computed tomography score in patients with COVID-19 disease

Purpose

Although coronavirus disease 2019 (COVID-19) primarily affects the pulmonary system, the involvement of the heart has become a well-known issue. Pulmonary CT plays an additive role in the diagnosis and prognosis of the disease. We aimed to investigate the association of echocardiographic indices with pulmonary CT scores and mortality in COVID-19 patients.

Materials and methods

A total of 123 patients diagnosed with COVID-19 were included in this study. The British Society of Thoracic Imaging (BSTI) score and echocardiographic parameters were calculated, and echocardiographic indices were compared between BSTI score grades.

Results

During in-hospital follow-up, 36 of 123 patients (29.3%) had died. BSTI score, IVS, LVPWd, RV mid-diameter, RV basal diameter, RV longitudinal diameter, sPAP, and RVMPI were higher, and RVFAC, TAPSE, and RVS were lower in the non-survivor group than in the survivor group. There were statistically significant changes between BSTI scores in terms of LVPWd, RV mid diameter, RV basal diameter, RV longitudinal diameter, sPAP, RVFAC, RVMPI, and TAPSE. BSTI score was positively correlated with sPAP and RV basal diameter and negatively correlated with TAPSE and RVFAC. Multivariate logistic regression analysis demonstrated that sPAP (OR ​= ​1.071, p ​= ​0.002) and RV basal diameter (OR ​= ​1.184, p ​= ​0.005) were independent predictors of high BSTI scores (grade 4 and 5). Furthermore, age, sPAP, and a high BSTI score (grade 5) were independent predictors of in-hospital mortality in COVID-19 patients.

Conclusion

Echocardiographic indices were correlated with BSTI scores, and patients with higher BSTI scores had more cardiac involvement in COVID-19.

Prevalence and Prognostic Value of Myocardial Injury in the Initial Presentation of SARS-CoV-2 Infection among Older Adults

Myocardial involvement during SARS-CoV-2 infection has been reported in many prior publications. We aim to study the prevalence and the clinical implications of acute myocardial injury (MIN) during SARS-CoV-2 infection, particularly in older patients. The method includes a longitudinal observational study with all consecutive adult patients admitted to a COVID-19 unit between March-April 2020. Those aged ≥65 were considered as older adult group. MIN was defined as at least 1 high-sensitive troponin (hs-TnT) concentration above the 99th percentile upper reference limit with different sex-cutoff. Results. Among the 634 patients admitted during the period of observation, 365 (58%) had evidence of MIN, and, of them, 224 (61%) were older adults. Among older adults, MIN was associated with longer time to recovery compared to those without MIN (13 days (IQR 6-21) versus 9 days (IQR 5-17); p < 0.001, respectively. In-hospital mortality was significantly higher in older adults with MIN at admission versus those without it (71 (31%) versus 11 (12%); p < 0.001). In a logistic regression model adjusting by age, sex, severity, and Charlson Comorbidity Index, the OR for in-hospital mortality was 2.1 (95% CI: 1.02-4.42; p = 0.043) among those older adults with MIN at admission. Older adults with acute myocardial injury had greater time to clinical recovery, as well as higher odds of in-hospital mortality.

Coronavirus disease 2019 morbid pulmonary pathology: What did we learn from autopsy examinations?

BACKGROUND

Despite the rapidly expanding data on clinical, epidemiological and radiological aspects of coronavirus disease 2019 (COVID-19), little is known about the disease's pathological aspects. The scarcity of pathological data on COVID-19 can be explained by the limited autopsy procedures performed on deceased patients.

AIM

This work aims to review and summarize the pulmonary pathological findings observed in COIVD-19 deceased individuals based on recent case series reports published in English up to September 2020.

METHODS

A search in Google Scholar, PubMed^Ò, MEDLINE^Ò, and Scopus was performed using the keywords "autopsy and COVID-19," "postmortem and COVID-19," and "pulmonary/lung pathology and COVID-19."

RESULTS

Pulmonary autopsy hallmark findings of COVID-19 cases demonstrate the presence of diffuse alveolar damage. The presence of pulmonary thrombi was reported in the majority of patients. Cellular alterations included type 2 pneumocyte hyperplasia, inflammatory cell infiltrates predominantly by lymphocytes, other mononuclear cells, and neutrophils as evident by their specific immunohistochemical markers. Electron microscopy confirmed the presence of virus particles in different cell types, including types 1 and 2 pneumocytes.

CONCLUSION

The few emerging autopsy reports have substantially contributed towards our understanding of COVID-19 pulmonary histopathological aspects. COVID-19 caused acute severe respiratory manifestations that are the leading cause of morbidity and mortality in infected patients. More studies and research are needed to understand the inflammatory processes and histopathological changes associated with COVID-19 in African populations.

RELEVANCE FOR PATIENTS

Postmortem investigations advance important mechanistic knowledge on COVID-19 pathophysiology and clinical outcomes and could facilitate provisions for targeted therapies.

Cardiovascular injuries and SARS-COV-2 infection: focus on elderly people

The novel coronavirus disease (COVID-19) has hit the healthcare system worldwide. The risk of severe infection and mortality increases with advancing age, especially in subjects with comorbidities such as cardiovascular disease, hypertension, diabetes, obesity and cancer. Moreover, cardiovascular complications such as myocardial injury, heart failure and thromboembolism are frequently observed in COVID-19 cases, and several biomarkers (troponin, NTproBNP and D-Dimer) have been identified as prognostic indicators of disease severity and worst outcome. Currently, there is no specific therapy against SARS-CoV-2, although many medications are under investigation. The aim of this review will be to explore the intertwined relationship between COVID-19 disease and the cardiovascular system, focusing on elderly population. The available supportive treatments along with the related concerns in elderly patients, due to their comorbidities and polypharmacotherapy, will be explored.

Clinico-pathological features in fatal COVID-19 infection: a preliminary experience of a tertiary care center in North India using postmortem minimally invasive tissue sampling

OBJECTIVES

To study the histopathology of patients dying of COVID-19 using post-mortem minimally invasive sampling techniques.

METHODS

This was a single-center observational study conducted at JPNATC, AIIMS. Thirty-seven patients who died of COVID-19 were enrolled. Post-mortem percutaneous biopsies were taken from lung, heart, liver, kidney and stained with hematoxylin and eosin. Immunohistochemistry was performed using CD61 and CD163. SARS-CoV-2 virus was detected using IHC with primary antibodies.

RESULTS

The mean age was 48.7 years and 59.5% were males. Lung histopathology showed diffuse alveolar damage in 78% patients. Associated bronchopneumonia was seen in 37.5% and scattered microthrombi in 21% patients. Immunopositivity for SARS-CoV-2 was observed in Type II pneumocytes. Acute tubular injury with epithelial vacuolization was seen in 46% of renal biopsies. Seventy-one percent of liver biopsies showed Kupffer cell hyperplasia and 27.5% showed submassive hepatic necrosis.

CONCLUSIONS

Predominant finding was diffuse alveolar damage with demonstration of SARS-CoV-2 protein in the acute phase. Microvascular thrombi were rarely identified in any organ. Substantial hepatocyte necrosis, Kupffer cell hypertrophy, microvesicular, and macrovesicular steatosis unrelated to microvascular thrombi suggested that liver might be a primary target of COVID-19.

Pulmonary arterial hypertension (PAH) from autopsy study: T-cells, B-cells and mastocytes detection as morphological evidence of immunologically mediated pathogenesis

BACKGROUND

Pulmonary arterial hypertension (PAH) is characterized by severe vascular remodelling, resulting in increased pulmonary vascular resistance with cardiac hypertrophy and heart failure. However, the diagnosis of PAH is often inaccurate. Many cases of PAH are incorrectly diagnosed or missed, and they are often associated with death. The aim of this study was to verify the morphological and histological criteria of fatal cases of PAH and evaluate the lymphocytic populations associated to lesions with reactive neo-angiogenesis.

METHODS

Pulmonary lung sections from 10 cases of sudden unexpected death (SUD) in the absence of previously diagnosed diseases and in an apparent state of well-being, with final histological post autopsy diagnosis of PAH were collected. The pathological findings were compared using ten controls from non-pathological lung from deaths from other causes. The autopsies included 4 males (40%) and 6 females (60%) with an average age of 52.1 ± 10.1 years. Sections stained with hematoxylin and eosin (H&E) were revised for a morphological diagnosis. Subsequently, serial sections were performed and stained with immunohistochemistry for anti-CD20 (B-lymphocytes), anti-CD3 (T-lymphocytes), anti-CD4 (T-helper lumphocytes), anti-CD8 (T-cytotoxic lymphocytes) and anti-CD117/C-Kit (mast cells/MCs) to detect inflammatory infiltrate and different ratios of cell-type. Statistical analysis was conducted using a paired t-test looking at 100 cells in 3 different tissue samples representative of vascular lesion and 3 different random normal lung parenchyma fields without lesion (from 10 normal control lungs), to identify specific lymphocyte subpopulations in inflammatory infiltrates.

RESULTS

There was a significant percentage increase of CD20 (p < 0.001), CD8 (p = 0.002), CD4 (p < 0.001), and CD117/C-Kit positive (C-Kit+; p < 0.001) cells mainly detected around wall vessels; while increased MCs positivity and C-Kit+ were observed especially in alveolar septa. In addition, reactive angiomatosis was observed.

CONCLUSIONS

The inflammatory infiltrate should be included for a correct diagnosis of PAH besides the vascular remodelling. The inflammatory infiltrate seems to be implicated as a main factor in the pathogenesis. This finding is important to rule out secondary pulmonary hypertension, to identify SUDs of unknown causes and to add new elements to the literature that can explain the immunologically related pathogenesis of PAH.

The Neurological Manifestations of Post-Acute Sequelae of SARS-CoV-2 infection

Purpose of Review

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health challenge. This review aims to summarize the incidence, risk factors, possible pathophysiology, and proposed management of neurological manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC) or neuro-PASC based on the published literature.

Recent Findings

The National Institutes of Health has noted that PASC is a multi-organ disorder ranging from mild symptoms to an incapacitating state that can last for weeks or longer following recovery from initial infection with SARS-CoV-2. Various pathophysiological mechanisms have been proposed as the culprit for the development of PASC. These include, but are not limited to, direct or indirect invasion of the virus into the brain, immune dysregulation, hormonal disturbances, elevated cytokine levels due to immune reaction leading to chronic inflammation, direct tissue damage to other organs, and persistent low-grade infection. A multidisciplinary approach for the treatment of neuro-PASC will be required to diagnose and address these symptoms. Tailored rehabilitation and novel cognitive therapy protocols are as important as pharmacological treatments to treat neuro-PASC effectively.

Summary

With recognizing the growing numbers of COVID-19 patients suffering from neuro-PASC, there is an urgent need to identify affected individuals early to provide the most appropriate and efficient treatments. Awareness among the general population and health care professionals about PASC is rising, and more efforts are needed to understand and treat this new emerging challenge. In this review, we summarize the relevant scientific literature about neuro-PASC.

Prognostic Factors in COVID-19 Patients With New Neurological Manifestations: A Retrospective Cohort Study in a Romanian Neurology Department

Introduction: The emerging Coronavirus Disease (COVID-19) pandemic caused by Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a serious public health issue due to its rapid spreading, high mortality rate and lack of specific treatment. Given its unpredictable clinical course, risk assessment, and stratification for severity of COVID-19 are required. Apart from serving as admission criteria, prognostic factors might guide future therapeutic strategies.

Aim: We aimed to compare clinical features and biological parameters between elderly (age ≥ 65 years) and non-elderly (age <65 years) patients with COVID-19 and new neurological symptoms/conditions. We also aimed to determine factors independently associated with all-cause in-hospital mortality.

Methods: All consecutive patients with COVID-19 and new neurological symptoms/conditions admitted in our Neurology Department between April 1 and August 23, 2020 were enrolled in this observational retrospective cohort study. Patient characteristics such as demographic data, comorbidities, biological parameters, imaging findings and clinical course were recorded. All-cause in-hospital mortality was the main outcome, whereas COVID-19 severity, hospitalization duration and the levels of supplemental oxygen were the secondary outcomes.

Results: One hundred forty-eight patients were included, out of which 54.1% were women. The average age was 59.84 ± 19.06 years and 47.3% were elderly, the majority having cardiovascular and metabolic comorbidities. In the elderly group, the most frequent neurological symptoms/manifestations responsible for hospitalization were stroke symptoms followed by confusion, whereas in the non-elderly, headache prevailed. The final neurological diagnosis significantly varied between the two groups, with acute cerebrovascular events and acute confusional state in dementia most commonly encountered in the elderly (65.71 and 14.28%, respectively) and secondary headache attributed to SARS-CoV-2 infection often experienced by the non-elderly (38.46%). The elderly had statistically significant higher median values of white blood cell (8,060 vs. 6,090/μL) and neutrophil count (6,060 vs. 4,125/μL), C-reactive protein (29.2 vs. 5.72 mg/L), ferritin (482 vs. 187 mg/dL), fibrinogen (477 vs. 374 mg/dL), D-dimer (1.16 vs. 0.42), prothrombin time (151.15 vs. 13.8/s), aspartate transaminase (26.8 vs. 20.8 U/l), creatinine (0.96 vs. 0.77 mg/dL), and blood urea nitrogen level (51.1 vs. 27.65 mg/dL), as well as lower median value of hemoglobin (13.05 vs. 13.9 g/dL) and lymphocyte count (1,245 vs. 1,670/μL). Moreover, advanced age was significantly associated with more extensive lung involvement (25 vs. 10%) and higher fatality rate (40 vs. 9%). Overall, the mortality rate was 23.6%. Age as well as neutrophil count, C-reactive protein, fibrinogen, and activated partial thromboplastin time levels were independently associated with mortality.

Conclusions: Older age, higher neutrophil count, C-reactive protein, fibrinogen, and activated partial thromboplastin time levels are independent predictors of mortality in COVID-19 patients with new neurological manifestations/conditions at admission.

Older adults: panoramic view on the COVID-19 vaccination

In December 2020, COVID-19 vaccination started in many countries, with which the world community hopes to stop the further spread of the current pandemic. More than 90% of sick and deceased patients belong to the category of older adults (65 years and older). This category of the population is most vulnerable to infectious diseases, so vaccination is the most effective preventive strategy, the need for which for older adults is indisputable. Here we briefly summarize information about age-related changes in the immune system and present current data on their impact on the formation of the immune response to vaccination. Older age is accompanied by the process of biological aging accompanied by involution of the immune system with increased susceptibility to infections and a decrease in the effect of immunization. Therefore, in the ongoing mass COVID-19 vaccination, the older adults are a growing public health concern. The authors provide an overview of the various types of COVID-19 vaccines approved for mass immunization of the population by the end of 2020, including older adults, as well as an overview of strategies and platforms to improve the effectiveness of vaccination of this population. In the final part, the authors propose for discussion a system for assessing the safety and monitoring the effectiveness of COVID-19 vaccines for the older adults.

SARS-CoV-2 colonization of maternal and fetal cells of the human placenta promotes alteration of local renin-angiotensin system

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection appears to increase the risk of adverse pregnancy outcomes, such as pre-eclampsia in pregnant women. The mechanism(s) by which this occurs remains unclear.

Methods

We investigated the pathophysiology of SARS-CoV-2 at maternal-fetal interface in pregnant women who tested positive for the virus using RNA in situ hybridization (viral RNA), immunohistochemistry, and hematoxylin and eosin staining. To investigate whether viral infection alters the renin angiotensin system (RAS) in placenta, which controls blood pressure, we treated human trophoblasts with recombinant spike protein or a live modified virus with a vesicular stomatitis viral backbone expressing spike protein (VSV-S).

Findings

Viral colonization was highest in maternal decidua, fetal trophoblasts, Hofbauer cells, and in placentas delivered prematurely. We localized SARS-CoV-2 to cells expressing angiotensin-converting enzyme 2 (ACE2) and demonstrate that infected placentas had significantly reduced ACE2. In response to both spike protein and VSV-S, cellular ACE2 decreased although angiotensin II receptor type 1 (AT₁R) increased with concomitant increase in soluble fms-like tyrosine kinase-1 (sFlt1). Viral infection decreased pro-angiogenic factors, AT₂R, and placental growth factor, which competitively binds to sFlt1. Sera from infected pregnant women had elevated levels of sFlt1 and angiotensin II type 1-receptor autoantibodies prior to delivery, both signatory markers of pre-eclampsia.

Conclusions

SARS-CoV-2 colonizes ACE2-expressing maternal and fetal cells in the placenta. Infection in pregnant women correlates with alteration of placental RAS. As RAS regulates blood pressure, SARS-CoV-2 infection may thus increase adverse hemodynamic outcomes, such as pre-eclampsia in pregnant women.

Funding

NIH/NICHD grants R01 HD091218 and 3R01HD091218-04S1 (RADx-UP Supplement).

Immune reactivity during COVID-19: Implications for treatment

Clinical symptoms of COVID-19 include fever, cough, and fatigue which may progress to acute respiratory distress syndrome (ARDS). The main hematological laboratory findings associated with the severe form of disease are represented by lymphopenia and eosinopenia which mostly occur in the elderly population characterized by cardiovascular comorbidities and immunosenescence. Besides, increased levels of D-dimer, procalcitonin, and C reactive protein (CRP) seem to be powerful prognostic biomarkers helping to predict the onset of coagulopathy. The host immune response to SARS-CoV-2 can lead to an aberrant inflammatory response or "cytokine storm" which contributes to the severity of illness. At immunological level, patients affected by a severe form of COVID-19 show poor clinical trajectories characterized by differential "immunotypes" for which T cell response seems to play a critical role in understanding pathogenic mechanisms of disease. Also, patients with mild to severe COVID-19 displayed macrophage activation syndrome (MAS), very low human leukocyte antigen D related (HLA-DR) expression with a parallel reduction of CD04+ lymphocytes, CD19 lymphocytes, and natural killer (NK) cells. Corticosteroids resulted the best therapy for the immune dysregulation whereas repurposing of tocilizumab (IL-6 receptor antagonist) appears to have mixed results in patients with COVID-19. Besides, anticoagulative therapy was associated with reduced in-hospital mortality and need of intubation among COVID-19 patients. Furthermore, the beneficial use of intravenous immunoglobulin (IVIG) and passive immunotherapy with convalescent plasma needs to be validated in large controlled clinical trials. In this review, we summarize the main hematological parameters with a prognostic value in COVID-19 and the basis of immunological reactivity during COVID-19, with a focus on ongoing clinical trials evaluating immune targets as possible therapeutic strategies.

Neurological Sequelae in Patients with COVID-19: A Histopathological Perspective

BACKGROUND

Neuroinvasive properties of SARS-CoV-2 have allowed the hypothesis of several pathogenic mechanisms related to acute and chronic neurological sequelae. However, neuropathological correlates have been poorly systematically investigated, being retrieved from reports of single case or limited case series still.

METHODS

A PubMed search was carried out to review all publications on autopsy in subjects with "COronaVIrus Disease-19" (COVID-19). Among them, we focused on histological findings of the brain, which were compared with those from the authors' autoptic studies performed in some COVID-19 patients.

RESULTS

Only seven studies reported histological evidence of brain pathology in patients deceased for COVID-19, including three with reverse transcription-quantitative polymerase chain reaction evidence of viral infection. All these studies, in line with our experience, showed vascular-related and infection-related secondary inflammatory tissue damage due to an abnormal immune response. It is still unclear, however, whether these findings are the effect of a direct viral pathology or rather reflect a non-specific consequence of cardiovascular and pulmonary disease on the brain.

CONCLUSIONS

Notwithstanding the limited evidence available and the heterogeneity of the studies, we provide a preliminary description of the relationship between SARS-CoV-2 and brain sequelae. Systematic autoptic investigations are needed for accurate detection and adequate management of these patients.

Neurological Sequelae in Patients with COVID-19: A Histopathological Perspective

BACKGROUND

Neuroinvasive properties of SARS-CoV-2 have allowed the hypothesis of several pathogenic mechanisms related to acute and chronic neurological sequelae. However, neuropathological correlates have been poorly systematically investigated, being retrieved from reports of single case or limited case series still.

METHODS

A PubMed search was carried out to review all publications on autopsy in subjects with "COronaVIrus Disease-19" (COVID-19). Among them, we focused on histological findings of the brain, which were compared with those from the authors' autoptic studies performed in some COVID-19 patients.

RESULTS

Only seven studies reported histological evidence of brain pathology in patients deceased for COVID-19, including three with reverse transcription-quantitative polymerase chain reaction evidence of viral infection. All these studies, in line with our experience, showed vascular-related and infection-related secondary inflammatory tissue damage due to an abnormal immune response. It is still unclear, however, whether these findings are the effect of a direct viral pathology or rather reflect a non-specific consequence of cardiovascular and pulmonary disease on the brain.

CONCLUSIONS

Notwithstanding the limited evidence available and the heterogeneity of the studies, we provide a preliminary description of the relationship between SARS-CoV-2 and brain sequelae. Systematic autoptic investigations are needed for accurate detection and adequate management of these patients.

Epigenetic susceptibility to severe respiratory viral infections and its therapeutic implications: a narrative review

The emergence of highly pathogenic strains of influenza virus and coronavirus (CoV) has been responsible for large epidemic and pandemic outbreaks characterised by severe pulmonary illness associated with high morbidity and mortality. One major challenge for critical care is to stratify and minimise the risk of multi-organ failure during the stay in the intensive care unit (ICU). Epigenetic-sensitive mechanisms, including deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) methylation, histone modifications, and non-coding RNAs may lead to perturbations of the host immune-related transcriptional programmes by regulating chromatin structure and gene expression patterns. Viruses causing severe pulmonary illness can use epigenetic-regulated mechanisms during host-pathogen interaction to interfere with innate and adaptive immunity, adequacy of inflammatory response, and overall outcome of viral infections. For example, Middle East respiratory syndrome-CoV and H5N1 can affect host antigen presentation through DNA methylation and histone modifications. The same mechanisms would presumably occur in patients with coronavirus disease 2019, in which tocilizumab may epigenetically reduce microvascular damage. Targeting epigenetic pathways by immune modulators (e.g. tocilizumab) or repurposed drugs (e.g. statins) may provide novel therapeutic opportunities to control viral-host interaction during critical illness. In this review, we provide an update on epigenetic-sensitive mechanisms and repurposed drugs interfering with epigenetic pathways which may be clinically suitable for risk stratification and beneficial for treatment of patients affected by severe viral respiratory infections.

Intricate interplay between Covid-19 and cardiovascular diseases

Covid-19 disease can involve any organ system leading to myriad manifestations and complications. Cardiovascular manifestations are being increasingly recognised with the improved understanding of the disease. Acute coronary syndrome, myocarditis, arrhythmias, cardiomyopathy; heart failure and thromboembolic disease have all been described. The elderly and those with prior cardiac diseases are at an increased risk of mortality. Overlapping symptomatology, ability of drugs to cause QTc interval (start of Q wave to the end of T wave) prolongation on electrocardiogram and arrhythmias, potential drug interactions, the need to recognise patients requiring urgent definitive management and provide necessary bedside interventions without increasing the risk of nosocomial spread have made the management challenging. In the background of a pandemic, non-Covid-19 cardiac patients are affected by delayed treatment and nosocomial exposure. Triaging using telemedicine and artificial intelligence along with utilization of bedside rapid diagnostic tests to detect Covid-19 could prove helpful in this aspect.

COVID-19: Brief check through the pathologist's eye (autopsy archive)

During the COVID-19 pandemic, many deaths occurred especially among the old patients with cardiovascular comorbidities. Many questions have been asked and few simple answers have been given. The autopsy data are few and the aspects often observed are pulmonary diffuse alveolar damage (DAD), myocarditis, acute myocardial infarction (AMI), and disseminated intravascular coagulation (DIC); these aspects are not only in COVID-19 but also in other viral infections and in sepsis. It should be considered that coronavirus with its pathological organ changes have already been described in the years preceding the pandemic.