Developing a multivariable risk prediction model to predict prolonged viral clearance in patients with COVID-19

Rapid emergence of a PB2 D701N substitution during adaptation of an H9N2 avian influenza virus in mice

H9N2 avian influenza viruses (AIVs) have been isolated frequently from multiple avian species and, occasionally, from humans. To explore the potential molecular basis of cross-species transmission of H9N2 AIVs, an H9N2 AIV (A/chicken/Zhejiang/221/2016) was serially passaged in mouse lung. The results showed that the mouse-adapted H9N2 virus exhibited higher virulence and replicated more efficiently in mouse lung and liver. Whole-genome sequencing showed an amino acid substitution, D701N, in the PB2 protein, which is likely associated with the increased replicative ability of H9N2 virus in mice. The rapid emergence of adaptive substitutions indicates the necessity of continuous monitoring of H9N2 virus in poultry.

A systematic review of pregnant women with COVID-19 and their neonates

BACKGROUND

In December 2019, a novel coronavirus disease (COVID-19) emerged in Wuhan, China, with an incredible contagion rate. However, the vertical transmission of COVID-19 is uncertain.

OBJECTIVES

This is a systematic review of published studies concerning pregnant women with confirmed COVID-19 and their neonates.

SEARCH STRATEGY

We carried out a systematic search in multiple databases, including PubMed, Web of Science, Google Scholar, Scopus, and WHO COVID-19 database using the following keywords: (Coronavirus) OR (novel coronavirus) OR (COVID-19) OR (COVID19) OR (COVID 19) OR (SARS-CoV2) OR (2019-nCoV)) and ((pregnancy) OR (pregnant) OR (vertical transmission) OR (neonate) OR (newborn) OR (placenta) OR (fetus) OR (Fetal)). The search took place in April 2020.

SELECTION CRITERIA

Original articles published in English were eligible if they included pregnant patients infected with COVID-19 and their newborns.

DATA COLLECTION AND ANALYSES

The outcomes of interest consisted of clinical manifestations of COVID-19 in pregnant patients with COVID-19 and also the effect of COVID-19 on neonatal and pregnancy outcomes.

MAIN RESULTS

37 articles involving 364 pregnant women with COVID-19 and 302 neonates were included. The vast majority of pregnant patients were in their third trimester of pregnancy, and only 45 cases were in the first or second trimester (12.4%). Most mothers described mild to moderate manifestations of COVID-19. Of 364 pregnant women, 25 were asymptomatic at the time of admission. The most common symptoms were fever (62.4%) and cough (45.3%). Two maternal deaths occurred. Some pregnant patients (12.1%) had a negative SARS-CoV-2 test but displayed clinical manifestations and abnormalities in computed tomography (CT) scan related to COVID-19. Twenty-two (6.0%) pregnant patients developed severe pneumonia. Two maternal deaths occurred from severe pneumonia and multiple organ dysfunction. Studies included a total of 302 neonates from mothers with COVID-19. Of the studies that provided data on the timing of birth, there were 65 (23.6%) preterm neonates. One baby was born dead from a mother who also died from COVID-19. Of the babies born alive from mothers with COVID-19, five newborns faced critical conditions, and two later died. A total of 219 neonates underwent nasopharyngeal specimen collection for SARS-CoV-2, of which 11 tested positive (5%). Seventeen studies examined samples of the placenta, breast milk, umbilical cord, and amniotic fluid, and all tested negative except one amniotic fluid sample.

CONCLUSIONS

A systematic review of published studies confirm that the course of COVID-19 in pregnant women resembles that of other populations. However, there is not sufficient evidence to establish an idea that COVID-19 would not complicate pregnancy.

Pregnant women with COVID-19: the placental involvement and consequences

SARS-CoV-2, the leading cause of COVID-19 pandemic, was detected for the first time in Wuhan. In this study, we investigated the potential undesirable maternal and feto-neonatal consequences of COVID-19, and the related pathophysiological alterations in mother, neonate, and especially in the placenta as a vital organ, were reviewed. Also, the possibility of vertical transmission of virus and placental abnormalities were evaluated. The pregnant women were a vulnerable population for COVID-19, and several obstetric consequences were reported following SARS-CoV-2 infection. The higher risk of abruption, preterm labor, maternal death, stillbirth, intrauterine growth restriction, and newborns with fetal distress were adverse pregnancy and perinatal outcomes of COVID-19. Despite the ACE2 expression on placental components was confirmed, there is no agreement on the mother-child vertical transmission of this virus. Therefore, feto-neonatal consequences might be associated with placental abnormalities. The placental abnormalities are characterized by feto-maternal vascular malperfusion. Additionally, these adverse consequences lead to early termination of pregnancy in some cases, mostly via cesarean section. The pregnant women screening, coordination between healthcare personnel and neonatal unit, and infected women quarantine may decrease the risk of maternal and neonatal death after delivery.

Comparison of Clinical Features and CT Temporal Changes Between Familial Clusters and Non-familial Patients With COVID-19 Pneumonia

Purpose: This study aimed to compare the clinical characteristics, laboratory findings, and chest computed tomography (CT) findings of familial cluster (FC) and non-familial (NF) patients with coronavirus disease 2019 (COVID-19) pneumonia.

Methods: This retrospective study included 178 symptomatic adult patients with laboratory-confirmed COVID-19. The 178 patients were divided into FC (n = 108) and NF (n = 70) groups. Patients with at least two confirmed COVID-19 cases in their household were classified into the FC group. The clinical and laboratory features between the two groups were compared and so were the chest CT findings on-admission and end-hospitalization.

Results: Compared with the NF group, the FC group had a longer period of exposure (13.1 vs. 8.9 days, p < 0.001), viral shedding (21.5 vs. 15.9 days, p < 0.001), and hospital stay (39.2 vs. 22.2 days, p < 0.001). The FC group showed a higher number of involved lung lobes on admission (3.0 vs. 2.3, p = 0.017) and at end-hospitalization (3.6 vs. 1.7, p < 0.001) as well as higher sum severity CT scores at end-hospitalization (4.6 vs. 2.7, p = 0.005) than did the NF group. Conversely, the FC group had a lower lymphocyte count level (p < 0.001) and a significantly lower difference in the number of involved lung lobes (Δnumber) between admission and discharge (p < 0.001). Notably, more cases of severe or critical illness were observed in the FC group than in the NF group (p = 0.036).

Conclusions: Patients in the FC group had a worse clinical course and outcome than those in the NF group; thus, close monitoring during treatment and follow-ups after discharge would be beneficial for patients with familial infections.

Evaluation the relationship of left ventricular global longitudinal strain and laboratory parameters in discharged patients with COVID-19: a follow-up study

Background: The novel coronavirus infection (COVID-19) disease has spread rapidly and posed a great threat to global public health. The laboratory parameters and clinical outcomes of the disease in discharged patients remain unknown. In this study, we aimed to investigate the laboratory and echocardiographic findings of patients with COVID-19 after discharge and the relation between left ventricular global longitudinal strain (LVGLS) and inflammatory parameters in discharged patients. Methods: A total of 75 patients recovering from COVID-19 as the study group were prospectively recruited from the COVID-19 outpatient clinic for their follow-up visits at a median 6 months after discharge. Patients were classified into groups according to pneumonia severity and impairment in LVGLS. Laboratory findings of patients both at admission and after discharge were evaluated and the relation with pneumonia severity at admission and LVGLS after discharge were analyzed. Results: Serum ferritin, lactate dehydrogenase (LDH) and prohormone B-type natriuretic peptide (pro-BNP) levels after discharge were significantly higher in the study group than the control group (n = 44). Ferritin was found to be related to pneumonia severity. Serum ferritin and LDH values after discharge were significantly higher in patients with impaired LVGLS than those with preserved. There was a significant correlation between LVGLS, serum ferritin and LDH values after discharge (r = −0.252, p = 0.012; r = −0.268, p = 0.005, respectively). Conclusions: Clinicians should pay close attention to the serum ferritin and LDH levels in discharged patients for predicting the severity of COVID-19 disease and early identification of subclinical left ventricular myocardial dysfunction.

The Quest for System-Theoretical Medicine in the COVID-19 Era

Precision medicine and molecular systems medicine (MSM) are highly utilized and successful approaches to improve understanding, diagnosis, and treatment of many diseases from bench-to-bedside. Especially in the COVID-19 pandemic, molecular techniques and biotechnological innovation have proven to be of utmost importance for rapid developments in disease diagnostics and treatment, including DNA and RNA sequencing technology, treatment with drugs and natural products and vaccine development. The COVID-19 crisis, however, has also demonstrated the need for systemic thinking and transdisciplinarity and the limits of MSM: the neglect of the bio-psycho-social systemic nature of humans and their context as the object of individual therapeutic and population-oriented interventions. COVID-19 illustrates how a medical problem requires a transdisciplinary approach in epidemiology, pathology, internal medicine, public health, environmental medicine, and socio-economic modeling. Regarding the need for conceptual integration of these different kinds of knowledge we suggest the application of general system theory (GST). This approach endorses an organism-centered view on health and disease, which according to Ludwig von Bertalanffy who was the founder of GST, we call Organismal Systems Medicine (OSM). We argue that systems science offers wider applications in the field of pathology and can contribute to an integrative systems medicine by (i) integration of evidence across functional and structural differentially scaled subsystems, (ii) conceptualization of complex multilevel systems, and (iii) suggesting mechanisms and non-linear relationships underlying the observed phenomena. We underline these points with a proposal on multi-level systems pathology including neurophysiology, endocrinology, immune system, genetics, and general metabolism. An integration of these areas is necessary to understand excess mortality rates and polypharmacological treatments. In the pandemic era this multi-level systems pathology is most important to assess potential vaccines, their effectiveness, short-, and long-time adverse effects. We further argue that these conceptual frameworks are not only valid in the COVID-19 era but also important to be integrated in a medicinal curriculum.

Association of history of cerebrovascular disease with severity of COVID-19

OBJECTIVE

To determine whether a history of cerebrovascular disease (CVD) increases risk of severe coronavirus disease 2019 (COVID-19).

METHODS

In a retrospective multicenter study, we retrieved individual data from in-patients treated March 1 to April 15, 2020 from COVID-19 registries of three hospitals in Saxony, Germany. We also performed a systematic review and meta-analysis following PRISMA recommendations using PubMed, EMBASE, Cochrane Library databases and bibliographies of identified papers (last search on April 11, 2020) and pooled data with those deriving from our multicenter study. Of 3762 records identified, 11 eligible observational studies of laboratory-confirmed COVID-19 patients were included in quantitative data synthesis. Risk ratios (RR) of severe COVID-19 according to history of CVD were pooled using DerSimonian and Laird random effects model. Between-study heterogeneity was assessed using Cochran's Q and I2-statistics. Severity of COVID-19 according to definitions applied in included studies was the main outcome. Sensitivity analyses were conducted for clusters of studies with equal definitions of severity.

RESULTS

Pooled analysis included data from 1906 laboratory-confirmed COVID-19 patients (43.9% females, median age ranging from 39 to 76 years). Patients with previous CVD had higher risk of severe COVID-19 than those without [RR 2.07, 95% confidence interval (CI) 1.52-2.81; p < 0.0001]. This association was also observed in clusters of studies that defined severe manifestation of the disease by clinical parameters (RR 1.44, 95% CI 1.22-1.71; p < 0.0001), necessity of intensive care (RR 2.79, 95% CI 1.83-4.24; p < 0.0001) and in-hospital death (RR 2.18, 95% CI 1.75-2.7; p < 0.0001).

CONCLUSION

A history of CVD might constitute an important risk factor of unfavorable clinical course of COVID-19  suggesting a need of tailored infection prevention and clinical management strategies for this population at risk.

Risk factors for Covid-19 severity and fatality: a structured literature review

PURPOSE

Covid-19 is a global threat that pushes health care to its limits. Since there is neither a vaccine nor a drug for Covid-19, people with an increased risk for severe and fatal courses of disease particularly need protection. Furthermore, factors increasing these risks are of interest in the search of potential treatments. A systematic literature review on the risk factors of severe and fatal Covid-19 courses is presented.

METHODS

The review is carried out on PubMed and a publicly available preprint dataset. For analysis, risk factors are categorized and information regarding the study such as study size and location are extracted. The results are compared to risk factors listed by four public authorities from different countries.

RESULTS

The 28 records included, eleven of which are preprints, indicate that conditions and comorbidities connected to a poor state of health such as high age, obesity, diabetes and hypertension are risk factors for severe and fatal disease courses. Furthermore, severe and fatal courses are associated with organ damages mainly affecting the heart, liver and kidneys. Coagulation dysfunctions could play a critical role in the organ damaging. Time to hospital admission, tuberculosis, inflammation disorders and coagulation dysfunctions are identified as risk factors found in the review but not mentioned by the public authorities.

CONCLUSION

Factors associated with increased risk of severe or fatal disease courses were identified, which include conditions connected with a poor state of health as well as organ damages and coagulation dysfunctions. The results may facilitate upcoming Covid-19 research.

Pre-existing cerebrovascular disease and poor outcomes of COVID-19 hospitalized patients: a meta-analysis

BACKGROUND

Due to pro-inflammatory and hypercoagulation states, COVID-19 infection is believed to increase the risk of stroke and worsen the outcomes of the patients having pre-existing cerebrovascular diseases (CeVD). There is limited literature on prevalence of pre-existing CeVD in COVID-19 patients, and outcomes are unknown. The objective of this meta-analysis is to evaluate the outcomes of COVID-19 patients with pre-existing CeVD.

METHODS

English full-text-observational studies having data on epidemiological characteristics of COVID-19 patients were identified searching PubMed, Web of Science, and Scopus using MeSH-terms COVID-19 OR coronavirus OR SARS-CoV-2 OR 2019-nCoV from December 1, 2019 to April 30, 2020. Studies having CeVD or stroke as one of the pre-existing comorbidities and described outcomes including intensive care unit (ICU) admission, mechanical ventilation utilization, and mortality were selected with consensus of three reviewers. Following MOOSE protocol, 11 studies were included. The pooled prevalence of CeVD and outcomes were calculated. Meta-regression was performed, and correlation coefficient (r) and odds ratio (OR) were estimated to evaluate the effects of pre-existing CeVD on outcomes of COVID-19 patients. Meta-analysis with random-effects model was used to calculate OR along with its 95% CI from the studies containing data on composite poor outcome.

RESULTS

Out of 8/11 studies showing data on mortality and mechanical ventilation, and 7/11 on ICU admission, pooled prevalence of pre-existing CeVD was 4.4% (244/4987). In age-adjusted meta-regression analysis, pre-existing CeVD was associated with ICU admission [r: 0.60; OR: 1.82 (1.25-2.69)], mechanical ventilation [r: 0.29; OR: 1.33 (1.09-1.63)], and mortality [r: 0.35; OR: 1.42 (1.14-1.77)] amongst COVID-19 hospitalizations. 9/11 studies reported data on binary composite outcomes, the pooled prevalence of pre-existing CeVD was 4.3% (155/3603) and 7.46% (83/1113) amongst COVID-19 hospitalizations and COVID-19 hospitalization-related poor outcomes, respectively. In meta-analysis, COVID-19 patient with pre-existing CeVD had 2.67-fold (1.75-4.06) higher odds of poor outcomes.

CONCLUSION

COVID-19 patients with pre-existing cerebrovascular disease have poor outcomes and extra precautions should be taken in managing such patients during the ongoing pandemic.

Clinical manifestations of COVID-19 in the general population: systematic review

Clinical manifestations of COVID-19 are varied in the general population. This study aimed to systematize the literature regarding clinical manifestations of patients with confirmed COVID-19. A systematic review of the literature was conducted. A total of 8070 scientific productions were found in the databases. Among the studies, 184 met the initial inclusion criteria, with a total of 114,046 patients. After complete reading, 32 studies that did not report clinical manifestations were excluded. The 152 publications finally included a total of 41,409 individuals from at least 23 countries and 26 different clinical manifestations were reported. In percentage terms, 6 symptoms had a general prevalence greater than or equal to 25%, namely, fever (58.66%), cough (54.52%), dyspnea (30.82%), malaise (29.75%), fatigue (28.16%) and sputum/secretion (25.33%). Neurological symptoms (20.82%), dermatological manifestations (20.45%), anorexia (20.26%), myalgia (16.9%), sneezing (14.71%), sore throat (14.41%), rhinitis (14.29%), goosebumps (13.49%), headache (12.17%), chest pain (11.49%) and diarrhea (9.59%) were other common symptoms. Only one study reported dermatological manifestations. The least frequent sign/symptom was hemoptysis (1.65%). In studies with more than 100 patients, the 3 main symptoms were fever (57.93%), cough (54.21%), and dyspnea (30.64%). Dermatological manifestations do not appear among the main symptoms. The identification of all clinical manifestations of COVID-19 is essential for an early diagnosis and the adoption of preventive measures.

The relation between left ventricular global longitudinal strain and troponin levels in patients hospitalized with COVID-19 pneumonia

Left ventricular global longitudinal strain (LVGLS) from two-dimensional speckle-tracking echocardiography (2D-STE) provides a more accurate estimation of subclinical myocardial dysfunction. In patients with COVID-19, elevated high sensitive troponin (hs-TnI) levels are frequent independent from the underlying cardiovascular disease. However, the relationship between high troponin levels and LVGLS in such patients remains unknown. We aimed to investigate the relation between troponin levels and LVGLS values in patients with COVID-19. A total of thirty-eight patients diagnosed with COVID-19 pneumonia who underwent echocardiography examination within the first week of hospital admission were enrolled in our study. Patients were divided into two groups according to their hs-TnI levels. Conventional left venticular (LV) function parameters, including ejection fraction, LV diastolic and systolic volumes were obtained and LVGLS was determined using 2D-STE. Frequency of hypertension, diabetes mellitus and current smoking were similar among groups. Compared with the patients in the negative troponin group, those in the positive troponin group were more likely to have a higher age; higher levels of D-dimer, C-reactive protein and ferritin; higher need for high-flow oxygen, invasive mechanical ventilation therapy or both; and a higher number of intensive care unit admissions. There was no statistically significant difference in LVGLS and ejection fraction values between the two groups.(− 18.5 ± 2.9, − 19.8 ± 2.8, p = 0.19; 55.2 ± 9.9, 59.5 ± 5.9, p = 0.11 respectively). Despite troponin increase is highly related to in-hospital adverse events; no relevance was found between troponin increase and LVGLS values of COVID-19 patients.

Spinal epidural abscess in COVID-19 patients

Objective

To report the peculiarity of spinal epidural abscess in COVID-19 patients, as we have observed an unusually high number of these patients following the outbreak of SARS-Corona Virus-2.

Methods

We reviewed the clinical documentation of six consecutive COVID-19 patients with primary spinal epidural abscess that we surgically managed over a 2-month period. These cases were analyzed for what concerns both the viral infection and the spinal abscess.

Results

The abscesses were primary in all cases indicating that no evident infective source was found. A primary abscess represents the rarest form of spinal epidural abscess, which is usually secondary to invasive procedures or spread from adjacent infective sites, such as spondylodiscitis, generally occurring in patients with diabetes, obesity, cancer, or other chronic diseases.

In all cases, there was mild lymphopenia but the spinal abscess occurred regardless of the severity of the viral disease, immunologic state, or presence of bacteremia. Obesity was the only risk factor and was reported in two patients. All patients but one were hypertensive. The preferred localizations were cervical and thoracic, whereas classic abscess generally occur at the lumbar level. No patient had a history of pyogenic infection, even though previous asymptomatic bacterial contaminations were reported in three cases.

Conclusion

We wonder about the concentration of this uncommon disease in such a short period. To our knowledge, cases of spinal epidural abscess in COVID-19 patients have not been reported to date. We hypothesize that, in our patients, the spinal infection could have depended on the coexistence of an initially asymptomatic bacterial contamination. The well-known COVID-19-related endotheliitis might have created the conditions for retrograde bacterial invasion to the correspondent spinal epidural space.

Furthermore, spinal epidural abscess carries a significantly high morbidity and mortality. It is difficult to diagnose, especially in compromised COVID-19 patients but should be kept in mind as early diagnosis and treatment are crucial.

Advances in research on ACE2 as a receptor for 2019-nCoV

Currently, a novel coronavirus (SARS-CoV-2, also called 2019-nCoV) has triggered pandemic Coronavirus Disease 2019 (COVID-19), an acute infectious respiratory disease that first became epidemic in Wuhan (China) and is now spreading worldwide. Although 2019-nCoV and SARS-CoV are very similar viruses genomically and structurally, the huge number of severe cases and deaths now being caused by 2019-nCoV infections has understandably prompted intense research on the receptor used by it to enter human cells. Angiotensin converting enzyme 2 (ACE2), a functional receptor for SARS-CoV, now appears likely to mediate 2019-nCoV entry into human cells. In this review, we describe the roles performed by ACE2 as an enzymatic catalyst and as a receptor for this novel coronavirus. We also summarize the latest research pertaining to the changes noted in ACE2 expression after viral binding, and the relationships relating to virus transmission and population susceptibility to it. Lastly, we speculate on the pathogenesis of COVID-19 and provide a useful reference for drug development against this aggressive virus.