COVID-19 Critical Illness: A Data-Driven Review

Longitudinal Assessment of Nasopharyngeal Biomarkers Post-COVID-19: Unveiling Persistent Markers and Severity Correlations

SARS-CoV-19 infection provokes a variety of symptoms; most patients present mild/moderate symptoms, whereas a small proportion of patients progress to severe illness with multiorgan failure accompanied by metabolic disturbances requiring ICU-level care. Given the importance of the disease, researchers focused on identifying severity-associated biomarkers in infected patients as well as markers associated with patients suffering long-COVID. However, little is known about the presence of biomarkers that remain a few years after SARS-CoV-2 infection once the patients fully recover of the symptoms. In this study, we evaluated the presence of persistent biomarkers in the nasopharyngeal tract two years after SARS-Cov-2 infection in fully asymptomatic patients, taking into account the severity of their infection (mild/moderate and severe infections). In addition to the direct identification of several components of the Coronavirus Infection Pathway in those individuals that suffered severe infections, we describe herein 371 proteins and their associated canonical pathways that define the different adverse effects of SARS-CoV-2 infections. The persistence of these biomarkers for up to two years after infection, along with their ability to distinguish the severity of the infection endured, highlights the surprising presence of persistent nasopharyngeal exudate changes in fully recovered patients.

The Impact of Pentraxin 3 Serum Levels and Angiotensin-Converting Enzyme Polymorphism on Pulmonary Infiltrates and Mortality in COVID-19 Patients

OBJECTIVES

The aim of this study was to examine the impact of the pentraxin 3 (PTX3) serum level and angiotensin-converting enzyme (ACE) gene insertion/deletion (I/D) polymorphism on the severity of radiographic pulmonary infiltrates and the clinical outcomes of COVID-19.

METHODS

The severity of COVID-19 pulmonary infiltrates was evaluated within a week of admission by analyzing chest X-rays (CXR) using the modified Brixia (MBrixa) scoring system. The insertion (I)/deletion (D) polymorphism of the ACE gene and the serum levels of PTX3 were determined for all patients included in the study.

RESULTS

This study included 80 patients. Using a cut-off serum level of PTX3 ≥ 2.765 ng/mL, the ROC analysis (AUC 0.871, 95% CI 0.787-0.954, p < 0.001) showed a sensitivity of 85.7% and specificity of 78.8% in predicting severe MBrixa scores. Compared to ACE I/I polymorphism, D/D polymorphism significantly increased the risk of severe CXR infiltrates, OR 7.7 (95% CI: 1.9-30.1), and p = 0.002. Significant independent predictors of severe CXR infiltrates include hypertension (OR 7.71), PTX3 (OR 1.20), and ACE D/D polymorphism (OR 18.72). Hypertension (OR 6.91), PTX3 (OR 1.47), and ACE I/I polymorphism (OR 0.09) are significant predictors of poor outcomes.

CONCLUSION

PTX3 and ACE D/D polymorphism are significant predictors of the severity of COVID-19 pneumonia. PTX3 is a significant predictor of death.

Occurrence, co-occurrence and persistence of symptoms of depression and post-traumatic stress disorder in survivors of COVID-19 critical illness

Background: Intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) are associated with psychological distress and trauma. The COVID-19 pandemic brought with it a series of additional long-lasting stressful and traumatic experiences. However, little is known about comorbid depression and post-traumatic stress disorder (PTSD).Objective: To examine the occurrence, co-occurrence, and persistence of clinically significant symptoms of depression and PTSD, and their predictive factors, in COVID-19 critical illness survivors.Method: Single-centre prospective observational study in adult survivors of COVID-19 with ≥24 h of ICU admission. Patients were assessed one and 12 months after ICU discharge using the depression subscale of the Hospital Anxiety and Depression Scale and the Davidson Trauma Scale. Differences in isolated and comorbid symptoms of depression and PTSD between patients with and without IMV and predictors of the occurrence and persistence of symptoms of these mental disorders were analysed.Results: Eighty-nine patients (42 with IMV) completed the 1-month follow-up and 71 (34 with IMV) completed the 12-month follow-up. One month after discharge, 29.2% of patients had symptoms of depression and 36% had symptoms of PTSD; after one year, the respective figures were 32.4% and 31%. Coexistence of depressive and PTSD symptoms accounted for approximately half of all symptomatic cases. Isolated PTSD symptoms were more frequent in patients with IMV (p≤.014). The need for IMV was associated with the occurrence at one month (OR = 6.098, p = .005) and persistence at 12 months (OR = 3.271, p = .030) of symptoms of either of these two mental disorders.Conclusions: Comorbid depressive and PTSD symptoms were highly frequent in our cohort of COVID-19 critical illness survivors. The need for IMV predicted short-term occurrence and long-term persistence of symptoms of these mental disorders, especially PTSD symptoms. The specific role of dyspnea in the association between IMV and post-ICU mental disorders deserves further investigation.Trial registration: ClinicalTrials.gov identifier: NCT04422444.

Neutrophil proteases are protective against SARS-CoV-2 by degrading the spike protein and dampening virus-mediated inflammation

Studies on severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) have highlighted the crucial role of host proteases for viral replication and the immune response. The serine proteases furin and TMPRSS2 and lysosomal cysteine proteases facilitate viral entry by limited proteolytic processing of the spike (S) protein. While neutrophils are recruited to the lungs during COVID-19 pneumonia, little is known about the role of the neutrophil serine proteases (NSPs) cathepsin G (CatG), elastase (NE), and proteinase 3 (PR3) on SARS-CoV-2 entry and replication. Furthermore, the current paradigm is that NSPs may contribute to the pathogenesis of severe COVID-19. Here, we show that these proteases cleaved the S protein at multiple sites and abrogated viral entry and replication in vitro. In mouse models, CatG significantly inhibited viral replication in the lung. Importantly, lung inflammation and pathology were increased in mice deficient in NE and/or CatG. These results reveal that NSPs contribute to innate defenses against SARS-CoV-2 infection via proteolytic inactivation of the S protein and that NE and CatG limit lung inflammation in vivo. We conclude that therapeutic interventions aiming to reduce the activity of NSPs may interfere with viral clearance and inflammation in COVID-19 patients.

Nebulized pH-Responsive Nanospray Combined with Pentoxifylline and Edaravone to Lungs for Efficient Treatments of Acute Respiratory Distress Syndrome

The COVID-19 pandemic has become an unprecedented global medical emergency, resulting in more than 5 million deaths. Acute respiratory distress syndrome (ARDS) caused by COVID-19, characterized by the release of a large number of pro-inflammatory cytokines and the production of excessive toxic ROS, is the most common serious complication leading to death. To develop new strategies for treating ARDS caused by COVID-19, a mouse model of ARDS was established by using lipopolysaccharide (LPS). Subsequently, we have constructed a novel nanospray with anti-inflammatory and antioxidant capacity by loading pentoxifylline (PTX) and edaravone (Eda) on zeolite imidazolate frameworks-8 (ZIF-8). This nanospray was endowed with synergetic therapy, which could kill two birds with one stone: (1) the loaded PTX played a powerful anti-inflammatory role by inhibiting the activation of inflammatory cells and the synthesis of pro-inflammatory cytokines; (2) Eda served as a free radical scavenger in ARDS. Furthermore, compared with the traditional intravenous administration, nanosprays can be administered directly and inhaled efficiently and reduce the risk of systemic adverse reactions greatly. This nanospray could not only coload two drugs efficiently but also realize acid-responsive release on local lung tissue. Importantly, ZIF8-EP nanospray showed an excellent therapeutic effect on ARDS in vitro and in vivo, which provided a new direction for the treatment of ARDS.

CT-based Radiogenomics Framework for COVID-19 Using ACE2 Imaging Representations

Coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 which enters the body via the angiotensin-converting enzyme 2 (ACE2) and altering its gene expression. Altered ACE2 plays a crucial role in the pathogenesis of COVID-19. Gene expression profiling, however, is invasive and costly, and is not routinely performed. In contrast, medical imaging such as computed tomography (CT) captures imaging features that depict abnormalities, and it is widely available. Computerized quantification of image features has enabled 'radiogenomics', a research discipline that identifies image features that are associated with molecular characteristics. Radiogenomics between ACE2 and COVID-19 has yet to be done primarily due to the lack of ACE2 expression data among COVID-19 patients. Similar to COVID-19, patients with lung adenocarcinoma (LUAD) exhibit altered ACE2 expression and, LUAD data are abundant. We present a radiogenomics framework to derive image features (ACE2-RGF) associated with ACE2 expression data from LUAD. The ACE2-RGF was then used as a surrogate biomarker for ACE2 expression. We adopted conventional feature selection techniques including ElasticNet and LASSO. Our results show that: i) the ACE2-RGF encoded a distinct collection of image features when compared to conventional techniques, ii) the ACE2-RGF can classify COVID-19 from normal subjects with a comparable performance to conventional feature selection techniques with an AUC of 0.92, iii) ACE2-RGF can effectively identify patients with critical illness with an AUC of 0.85. These findings provide unique insights for automated COVID-19 analysis and future research.

An ABC approach to cardiothoracic complications and sequelae of COVID-19: a tertiary centre experience

The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused unprecedented challenges to healthcare professionals (HCPs) worldwide. HCPs faced an unknown disease causing many complications, including now well-established acute respiratory distress syndrome (ARDS) and pulmonary artery thromboembolic disease, and some not so well known, for instance, tracheobronchomalacia, tracheal tear or dehiscence, granulation tissue formation and pulmonary hypertension. Many of these complications require highly specialist care warranting early recognition of complications and involvement of appropriately trained professionals. Here, we review the complications and sequelae encountered at our tertiary care centre with follow-up data and potential management strategies using the A (Airway), B (Breathing), C (Circulation) approach. This will not only familiarise HCPs with the different complications of COVID-19, but also arm them with a systematic approach to these complications.

Mitochondrial dysfunction, lipids metabolism, and amino acid biosynthesis are key pathways for COVID-19 recovery

The metabolic alterations caused by SARS-CoV-2 infection reflect disease progression. To analyze molecules involved in these metabolic changes, a multiomics study was performed using plasma from 103 patients with different degrees of COVID-19 severity during the evolution of the infection. With the increased severity of COVID-19, changes in circulating proteomic, metabolomic, and lipidomic profiles increased. Notably, the group of severe and critical patients with high HRG and ChoE (20:3) and low alpha-ketoglutaric acid levels had a high chance of unfavorable disease evolution (AUC = 0.925). Consequently, patients with the worst prognosis presented alterations in the TCA cycle (mitochondrial dysfunction), lipid metabolism, amino acid biosynthesis, and coagulation. Our findings increase knowledge regarding how SARS-CoV-2 infection affects different metabolic pathways and help in understanding the future consequences of COVID-19 to identify potential therapeutic targets.

The experiences of patients, family caregivers, healthcare providers, and health service leaders with compassionate care following hospitalization with COVID-19: a qualitative study

PURPOSE

This study explored the experiences of patients, caregivers, healthcare providers, and health service leaders of compassion in the care of people hospitalized with COVID-19.

MATERIALS AND METHODS

This study is a secondary analysis of qualitative data deriving from primary research data on recommendations for healthcare organizations providing care to people hospitalized with COVID-19. Participants comprised patients with COVID-19 (n = 10), family caregivers (n = 5) and HCPs in COVID-19 units (n = 12). Primary research data were analyzed deductively under the "lens" of compassion, as defined by Goetz.

RESULTS

Four interacting themes were found: (1) COVID-19 - to care or not to care? The importance of feeling safe, (2) A lonely illness - suffering in isolation with COVID-19, (3) Compassionate care for people with COVID-19 across the hospital continuum, and (4) Sustaining compassionate care for people hospitalized with COVID-19 - healthcare provider compassion fatigue and burnout.

CONCLUSIONS

Compassionate care is not a given for people hospitalized with COVID-19. Healthcare providers must feel safe to provide care before responding compassionately. People hospitalized with COVID-19 experience additional suffering through isolation. Compassionate care for people hospitalized with COVID-19 is more readily identifiable in the rehabilitation setting. However, compassion fatigue and burnout in this context threaten healthcare sustainability.IMPLICATIONS FOR REHABILITATIONHealthcare providers need to feel physically and psychologically safe to provide compassionate care for people hospitalized with COVID-19.People hospitalized with COVID-19 infection experience added suffering through the socially isolating effects of physical distancing.Compassion and virtuous behaviours displayed by healthcare providers are expected and valued by patients and caregivers, including during the COVID-19 pandemic.High levels of compassion fatigue and burnout threaten the sustainability of hospital-based care for people with COVID-19.

An observational study on factors associated with ICU mortality in Covid-19 patients and critical review of the literature

The novel pandemic caused by SARS-CoV-2 has been associated with increased burden on healthcare system. Recognizing the variables that independently predict death in COVID-19 is of great importance. The study was carried out prospectively in a single ICU in northern Greece. It was based on the collection of data during clinical practice in 375 adult patients who were tested positive for SARS-CoV-2 between April 2020 and February 2022. All patients were intubated due to acute respiratory insufficiency and received Invasive Mechanical Ventilation. The primary outcome was ICU mortality. Secondary outcomes were 28-day mortality and independent predictors of mortality at 28 days and during ICU hospitalization. For continuous variables with normal distribution, t-test was used for means comparison between two groups and one-way ANOVA for multiple comparisons. When the distribution was not normal, comparisons were performed using the Mann-Whitney test. Comparisons between discrete variables were made using the x² test, whereas the binary logistic regression was employed for the definition of factors affecting survival inside the ICU and after 28 days. Of the total number of patients intubated due to COVID-19 during the study period, 239 (63.7%) were male. Overall, the ICU survival was 49.6%, whereas the 28-day survival reached 46.9%. The survival rates inside the ICU for the four main viral variants were 54.9%, 50.3%, 39.7% and 50% for the Alpha, Beta, Delta and Omicron variants, respectively. Logistic regressions for outcome revealed that the following parameters were independently associated with ICU survival: wave, SOFA @day1, Remdesivir use, AKI, Sepsis, Enteral Insufficiency, Duration of ICU stay and WBC. Similarly, the parameters affecting the 28-days survival were: duration of stay in ICU, SOFA @day1, WBC, Wave, AKI and Enteral Insufficiency. In this observational cohort study of critically ill COVID-19 patients we report an association between mortality and the wave sequence, SOFA score on admission, the use of Remdesivir, presence of AKI, presence of gastrointestinal failure, sepsis and WBC levels. Strengths of this study are the large number of critically ill COVID-19 patients included, and the comparison of the adjusted mortality rates between pandemic waves within a two year-study period.

Microbead-based extracorporeal immuno-affinity virus capture: a feasibility study to address the SARS-CoV-2 pandemic

In this paper, we report on the utilization of micro-technology based tools to fight viral infections. Inspired by various hemoperfusion and immune-affinity capture systems, a blood virus depletion device has been developed that offers highly efficient capture and removal of the targeted virus from the circulation, thus decreasing virus load. Single-domain antibodies against the Wuhan (VHH-72) virus strain produced by recombinant DNA technology were immobilized on the surface of glass micro-beads, which were then utilized as stationary phase. For feasibility testing, the virus suspension was flown through the prototype immune-affinity device that captured the viruses and the filtered media left the column. The feasibility test of the proposed technology was performed in a Biosafety Level 4 classified laboratory using the Wuhan SARS-CoV-2 strain. The laboratory scale device actually captured 120,000 virus particles from the culture media circulation proving the feasibility of the suggested technology. This performance has an estimated capture ability of 15 million virus particles by using the therapeutic size column design, representing three times over-engineering with the assumption of 5 million genomic virus copies in an average viremic patient. Our results suggested that this new therapeutic virus capture device could significantly lower virus load thus preventing the development of more severe COVID-19 cases and consequently reducing mortality rate.

Pleiotropic Functions of Nitric Oxide Produced by Ascorbate for the Prevention and Mitigation of COVID-19: A Revaluation of Pauling's Vitamin C Therapy

Linus Pauling, who was awarded the Nobel Prize in Chemistry, suggested that a high dose of vitamin C (l-ascorbic acid) might work as a prevention or treatment for the common cold. Vitamin C therapy was tested in clinical trials, but clear evidence was not found at that time. Although Pauling's proposal has been strongly criticized for a long time, vitamin C therapy has continued to be tested as a treatment for a variety of diseases, including coronavirus infectious disease 2019 (COVID-19). The pathogen of COVID-19, SARS-CoV-2, belongs to the β-coronavirus lineage, which includes human coronavirus, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS). This review intends to shed new light on vitamin C antiviral activity that may prevent SARS-CoV-2 infection through the chemical production of nitric oxide (NO). NO is a gaseous free radical that is largely produced by the enzyme NO synthase (NOS) in cells. NO produced by upper epidermal cells contributes to the inactivation of viruses and bacteria contained in air or aerosols. In addition to enzymatic production, NO can be generated by the chemical reduction of inorganic nitrite (NO2-), an alternative mechanism for NO production in living organisms. Dietary vitamin C, largely contained in fruits and vegetables, can reduce the nitrite in saliva to produce NO in the oral cavity when chewing foods. In the stomach, salivary nitrite can also be reduced to NO by vitamin C secreted from the epidermal cells of the stomach. The strong acidic pH of gastric juice facilitates the chemical reduction of salivary nitrite to produce NO. Vitamin C contributes in multiple ways to the host innate immune system as a first-line defense mechanism against pathogens. Highlighting chemical NO production by vitamin C, we suggest that controversies on the therapeutic effects of vitamin C in previous clinical trials may partly be due to less appreciation of the pleiotropic functions of vitamin C as a universal bioreductant.

2023 Resolutions: It's time to revamp your pressure injury prevention programs

The success of any quality improvement project begins with acknowledging problems, defining and addressing each issue in detail, and setting goals. In the case of pressure injuries, the answer is fairly simple. Reduce the number of pressure injuries. Yet, the process yielding a "means to the end" is quite complex. It not only requires a team of interdisciplinary healthcare providers and leaders to ensure success; it requires continuous effort. The intention of this article is to highlight the importance of a comprehensive Pressure Injury Prevention (PIP) program and offer guidance based on evidence. Utilizing an organized framework for planning will help healthcare providers ensure all critical steps are completed. The Standardized Pressure Injury Prevention Protocol (SPIPP) provides detail surrounding the necessary steps toward compliance with best practice guidelines. A comprehensive checklist provided within the SPIPP article is designed to discuss specific details of the PIP program. The author of this article offers a broader framework and checklist, The Pressure Injury Prevention Implementation Checklist (PIPIC) based on blending several quality improvement methodologies. Challenges associated with pressure injuries continue to affect the lives of both patients and caregivers. Entering a new year, new month, or even new day brings the opportunity for change and improvement. Revamping a PIP program requires careful thought, planning, and dedication, but it is not insurmountable. Organizing a team to address the issues and approach the task with an organized, evidence-based plan will improve the overall PIP program success.

Neutrophil infiltration and myocarditis in patients with severe COVID-19: A post-mortem study

Aims

To investigate cardiac pathology in critically ill patients with coronavirus disease 2019 (COVID-19) and identify associations between pathological changes and clinical characteristics.

Methods

The present autopsy cohort study included hearts from 26 deceased patients hospitalized in intensive care units due to COVID-19, and was conducted at four sites in Wuhan, China. Cases were divided into a neutrophil infiltration group and a no-neutrophil group based on the presence or absence of histopathologically identified neutrophilic infiltrates.

Results

Among the 26 patients, histopathological examination identified active myocarditis in four patients. All patients with myocarditis exhibited extensive accompanying neutrophil infiltration, and all patients without myocarditis did not. The neutrophil infiltration group exhibited significantly higher rates of detection of interleukin-6 (100 vs. 4.6%) and tumor necrosis factor-alpha (100 vs. 31.8%) than the no-neutrophil group (both p < 0.05). On admission, four patients with neutrophil infiltration in myocardium had significantly higher baseline levels of aspartate aminotransferase, D dimer, and high-sensitivity C reactive protein than the other 22 patients (all p < 0.05). During hospitalization, patients with neutrophil infiltration had significantly higher maximum creatine kinase-MB (median 280.0 IU/L vs. 38.7 IU/L, p = 0.04) and higher troponin I (median 1.112 ng/ml vs. 0.220 ng/ml, p = 0.56) than patients without neutrophil infiltration.

Conclusion

Active myocarditis was frequently associated with neutrophil infiltration in the hearts of deceased patients with severe COVID-19. Patients with neutrophil-infiltrated myocarditis had a series of severely abnormal laboratory test results on admission, and high maximum creatine kinase-MB during hospitalization. The role of neutrophils in severe heart injury and systemic conditions in patients with COVID-19 should be emphasized.

The Usefulness of the COVID-GRAM Score in Predicting the Outcomes of Study Population with COVID-19

BACKGROUND

The COVID-GRAM is a clinical risk rating score for predicting the prognosis of hospitalized COVID-19 infected patients.

AIM

Our study aimed to evaluate the use of the COVID-GRAM score in patients with COVID-19 based on the data from the COronavirus in the LOwer Silesia (COLOS) registry.

MATERIAL AND METHODS

The study group (834 patients of Caucasian patients) was retrospectively divided into three arms according to the risk achieved on the COVID-GRAM score calculated at the time of hospital admission (between February 2020 and July 2021): low, medium, and high risk. The Omnibus chi-square test, Fisher test, and Welch ANOVA were used in the statistical analysis. Post-hoc analysis for continuous variables was performed using Tukey's correction with the Games-Howell test. Additionally, the ROC analysis was performed over time using inverse probability of censorship (IPCW) estimation. The GRAM-COVID score was estimated from the time-dependent area under the curve (AUC).

RESULTS

Most patients (65%) had a low risk of complications on the COVID-GRAM scale. There were 113 patients in the high-risk group (13%). In the medium- and high-risk groups, comorbidities occurred statistically significantly more often, e.g., hypertension, diabetes, atrial fibrillation and flutter, heart failure, valvular disease, chronic kidney disease, and obstructive pulmonary disease (COPD), compared to low-risk tier subjects. These individuals were also patients with a higher incidence of neurological and cardiac complications in the past. Low saturation of oxygen values on admission, changes in C-reactive protein, leukocytosis, hyperglycemia, and procalcitonin level were associated with an increased risk of death during hospitalization. The troponin level was an independent mortality factor. A change from low to medium category reduced the overall survival probability by more than 8 times and from low to high by 25 times. The factor with the strongest impact on survival was the absence of other diseases. The medium-risk patient group was more likely to require dialysis during hospitalization. The need for antibiotics was more significant in the high-risk group on the GRAM score.

CONCLUSION

The COVID-GRAM score corresponds well with total mortality. The factor with the strongest impact on survival was the absence of other diseases. The worst prognosis was for patients who were unconscious during admission. Patients with higher COVID-GRAM score were significantly less likely to return to full health during follow-up. There is a continuing need to develop reliable, easy-to-adopt tools for stratifying the course of SARS-CoV-2 infection.

Ivermectin: A Controversial Focal Point during the COVID-19 Pandemic

The SARS-CoV-2 pandemic has confirmed the apocalyptic predictions that virologists have been making for several decades. The challenge the world is facing is that of trying to find a possible treatment, and a viable and expedient option for addressing this challenge is the repurposing of drugs. However, in some cases, although these drugs are approved for use in humans, the mechanisms of action involved are unknown. In this sense, to justify its therapeutic application to a new disease, it is ideal, but not necessary, to know the basic mechanisms of action involved in a drug's biological effects. This review compiled the available information regarding the various effects attributed to Ivermectin. The controversy over its use for the treatment of COVID-19 is demonstrated by this report that considers the proposal unfeasible because the therapeutic doses proposed to achieve this effect cannot be achieved. However, due to the urgent need to find a treatment, an exhaustive and impartial review is necessary in order to integrate the knowledge that exists, to date, of the possible mechanisms through which the treatment may be helpful in defining safe doses and schedules of Ivermectin.

Emergency hospitalization caused by non-COVID-19 respiratory diseases before and during the COVID-19 pandemic: A retrospective observational cohort study

Background

The coronavirus disease 2019 (COVID-19) pandemic as well as the subsequent prevention and control measures is like a quasi-experiment intervention that might have changed the features of emergency hospitalizations. Mortality is high in patient hospitalization due to emergency respiratory diseases (ERD). Therefore, we compared the characteristics of these patients before and during the pandemic. Exploring this issue might contribute to decision-making of emergency management when most of the resources and attention has been devoted to combat COVID-19.

Methods

This study was a retrospective observational cohort study. All emergency hospitalizations due to ERD from January 1, 2019 to December 31, 2020 in a tertiary hospital in China were included. Data including patients’ age, sex, and clinical outcomes were extracted. Air quality was collected from the official online platform. Clinical characteristics were compared and odds ratios were calculated.

Results

The ERD hospitalization rate was lower in 2020 than in 2019 (6.4 vs. 4.3%, χ² = 55.449, P = 0.000) with a 50.65% reduction; however, the patients were older in 2020 than in 2019 (P = 0.000) with a higher proportion of admission to the intensive care unit (ICU) (46 vs. 33.5%, χ² = 20.423, P = 0.000) and a longer ICU stay (P = 0.000). The overall intubation rate, hospital mortality, and rate of discharge due to ineffective treatment in 2020 were higher than those in 2019 (15.6 vs. 8%, χ² = 18.578, P = 0.000; 4.2 vs. 1.1%, χ² = 4.122, P = 0.000; 5.5 vs. 2.4%, χ² = 8.93, P = 0.000, respectively). The logistic regression analysis indicated hospitalizations due to ERD were mainly associated with PM2.5 and sulfur dioxide on the day, and on the 4th and 5th days before admission (P = 0.034 and 0.020, 0.021 and 0.000, 0.028, and 0.027, respectively) in 2019. However, in 2020, the relationship between parameters of air quality and hospitalization changed.

Conclusion

The COVID-19 pandemic has changed the characteristics of emergency hospitalization due to ERD with a larger proportion of severe patients and poorer prognosis. The effect of air quality on emergencies were weakened. During the COVID-19 pandemic, it is necessary to pay more attention to the non-COVID-19 emergency patients.

Inflammasome activation in infected macrophages drives COVID-19 pathology

Severe COVID-19 is characterized by persistent lung inflammation, inflammatory cytokine production, viral RNA and a sustained interferon (IFN) response, all of which are recapitulated and required for pathology in the SARS-CoV-2-infected MISTRG6-hACE2 humanized mouse model of COVID-19, which has a human immune system1-20. Blocking either viral replication with remdesivir21-23 or the downstream IFN-stimulated cascade with anti-IFNAR2 antibodies in vivo in the chronic stages of disease attenuates the overactive immune inflammatory response, especially inflammatory macrophages. Here we show that SARS-CoV-2 infection and replication in lung-resident human macrophages is a critical driver of disease. In response to infection mediated by CD16 and ACE2 receptors, human macrophages activate inflammasomes, release interleukin 1 (IL-1) and IL-18, and undergo pyroptosis, thereby contributing to the hyperinflammatory state of the lungs. Inflammasome activation and the accompanying inflammatory response are necessary for lung inflammation, as inhibition of the NLRP3 inflammasome pathway reverses chronic lung pathology. Notably, this blockade of inflammasome activation leads to the release of infectious virus by the infected macrophages. Thus, inflammasomes oppose host infection by SARS-CoV-2 through the production of inflammatory cytokines and suicide by pyroptosis to prevent a productive viral cycle.

Differential Functional Responses of Neutrophil Subsets in Severe COVID-19 Patients

Neutrophils play a significant role in determining disease severity following SARS-CoV-2 infection. Gene and protein expression defines several neutrophil clusters in COVID-19, including the emergence of low density neutrophils (LDN) that are associated with severe disease. The functional capabilities of these neutrophil clusters and correlation with gene and protein expression are unknown. To define host defense and immunosuppressive functions of normal density neutrophils (NDN) and LDN from COVID-19 patients, we recruited 64 patients with severe COVID-19 and 26 healthy donors (HD). Phagocytosis, respiratory burst activity, degranulation, neutrophil extracellular trap (NET) formation, and T-cell suppression in those neutrophil subsets were measured. NDN from severe/critical COVID-19 patients showed evidence of priming with enhanced phagocytosis, respiratory burst activity, and degranulation of secretory vesicles and gelatinase and specific granules, while NET formation was similar to HD NDN. COVID LDN response was impaired except for enhanced NET formation. A subset of COVID LDN with intermediate CD16 expression (CD16^Int LDN) promoted T cell proliferation to a level similar to HD NDN, while COVID NDN and the CD16^Hi LDN failed to stimulate T-cell activation. All 3 COVID-19 neutrophil populations suppressed stimulation of IFN-γ production, compared to HD NDN. We conclude that NDN and LDN from COVID-19 patients possess complementary functional capabilities that may act cooperatively to determine disease severity. We predict that global neutrophil responses that induce COVID-19 ARDS will vary depending on the proportion of neutrophil subsets.

Intensive Care-Related Cognitive Impairment: A Biopsychosocial Overview

Advancements in critical care medicine have improved survival rates for patients experiencing critical illness in intensive care units (ICUs). While mortality has declined, more than half of ICU survivors experience functional impairments that persist beyond discharge. Of particular concern is ICU-related cognitive impairment, which can extend across the care continuum, ranging from acute and transient presentations in the ICU (eg, delirium) to long-term impairments years after discharge. ICU-related cognitive impairment has received increased attention in the literature, particularly as it relates to ICU survivors who have received and survived critical care in the context of SARS-CoV-2 pandemic and are now experiencing post-acute sequelae of SARS-CoV-2 infection. The medical complexity and heterogeneity of ICU survivors, coupled with the multifactorial etiology of ICU-related cognitive impairments, lead to challenges in how to optimize care for ICU survivors at various stages of recovery. This review aims to provide an overview of cognitive outcomes associated with critical illness by integrating recent literature focused on etiology, assessment, and interventions in the context of ICU-related cognitive impairments. The narrative review employs a biopsychosocial framework to comprehensively evaluate the multifactorial nature of ICU-related cognitive outcomes. Authors also highlight multidisciplinary teams composed of key rehabilitation providers are likely best suited for optimizing recovery trajectories of ICU survivors. This article is protected by copyright. All rights reserved.

Viral replication in human macrophages enhances an inflammatory cascade and interferon driven chronic COVID-19 in humanized mice

Chronic COVID-19 is characterized by persistent viral RNA and sustained interferon (IFN) response which is recapitulated and required for pathology in SARS-CoV-2 infected MISTRG6-hACE2 humanized mice. As in the human disease, monocytes, and macrophages in SARS-CoV-2 infected MISTRG6-hACE2 are central to disease pathology. Here, we describe SARS-CoV-2 uptake in tissue resident human macrophages that is enhanced by virus specific antibodies. SARS-CoV-2 replicates in these human macrophages as evidenced by detection of double-stranded RNA, subgenomic viral RNA and expression of a virally encoded fluorescent reporter gene; and it is inhibited by Remdesivir, an inhibitor of viral replication. Although early IFN deficiency leads to enhanced disease, blocking either viral replication with Remdesivir or the downstream IFN stimulated cascade by injecting anti-IFNAR2 in vivo in the chronic stages of disease attenuates many aspects of the overactive immune-inflammatory response, especially the inflammatory macrophage response, and most consequentially, the chronic disease itself.