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Falasca K, Vetrugno L, Borrelli P, Di Nicola M, Ucciferri C, Gambi A, Bazydlo M, Taraschi G, Vecchiet J, Maggiore SM. Antimicrobial resistance in intensive care patients hospitalized with SEPSIS: a comparison between the COVID-19 pandemic and pre-pandemic era. Front Med (Lausanne) 2024; 11:1355144. [PMID: 38813381 PMCID: PMC11133528 DOI: 10.3389/fmed.2024.1355144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/25/2024] [Indexed: 05/31/2024] Open
Abstract
Introduction Coronavirus disease 2019 (COVID-19) is a highly contagious viral illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It has had a dramatic effect on the world, resulting in millions of deaths worldwide and causing drastic changes in daily life. A study reported that septic complications were associated with high mortality in COVID-19 patients. This study aimed to evaluate how the COVID-19 pandemic changed the pre-pandemic and post-pandemic prevalence of sepsis in ICUs and to evaluate the different risk factors associated with mortality and the different diffusion of microorganisms and their resistance. Materials and methods We conducted a single-center retrospective observational clinical study, observing all patients in the ICU of the SS Annunziata Hospital in Chieti (Italy) who were diagnosed with sepsis and had a bacterial isolate from their blood culture. Sepsis was diagnosed by SEPSIIS III criteria. We enrolled all in-patients in the ICU from January 2018 to December 2021. We divided the patients into three groups: (1) non-pandemic period (Np) hospitalized in 2018-2019, (2) pandemic period (Pp)-COVID hospitalized in 2020-2021 with a diagnosis of COVID-19, and (3) Pp-non-COVID patients hospitalized in 2020-2021 without a diagnosis of COVID-19. Results From January 2018 to December 2021, 1,559 patients were admitted to the ICU, of which 211 patients [36 (17.1%) in 2018, 52 (24.6%) in 2019, 73 (34.6%) in 2020, and 50 (23.7%) in 2021, respectively] met the selection criteria: 88 patients in period Np, 67 patients in Pp without COVID-19, and 56 patients Pp with COVID-19. The overall mortality of these patients was high (65.9% at 30 days in Np), but decreased during the Pp (60.9%): Pp-non-COVID was 56.7% vs. Pp-COVID 66.1%, with a statistically significant association with APACHE III score (OR 1.08, 95%CI 1.04-1.12, p < 0.001), SOFA score (OR 1.12, 95%CI 1.03-1.22, p = 0.004), and age (OR 1.04, 95%CI 1.02-1.07, p < 0.0001). Between the Np vs. Pp periods, we observed an increase in a few Gram-positive bacteria such as S. capitis (1 pt. -0.9% vs. 14 pt. -7.65%- p = 0.008), S. epidermidis, Streptococcus spp., and E. faecalis, as well as a decrease in a case of blood culture positive for S. aureus, S. hominis, and E. faecium. In Gram-negative bacteria, we observed an increase in cases of Acinetobacter spp. (Np 6 pt. -5.1%- vs. Pp 20 pt. -10.9%, p = 0.082), and Serratia spp., while cases of sepsis decreased from E. faecium (Np 11 pt. -9.4%- vs. Pp 7 pt. -3.8%, p = 0.047), and Enterobacter spp., S. haemolyticus, S. maltophilia, Proteus spp., and P. aeruginosa have not changed. Finally, we found that resistance to OXA-48 (p = 0.040), ESBL (p = 0.002), carbapenems (p = 0.050), and colistin (p = 0.003) decreased with time from Np to Pp, particularly in Pp-COVID. Conclusion This study demonstrated how the COVID-19 pandemic changed the prevalence of sepsis in the ICU. It emerged that the risk factors associated with mortality were APACHE and SOFA scores, age, and, above all, the presence of ESBL-producing bacteria. Despite this, during the pandemic phase, we have observed a significant reduction in the emergence of resistant germs compared to the pre-pandemic phase.
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Affiliation(s)
- Katia Falasca
- Clinic of Infectious Diseases—Department of Medicine and Science of Aging, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency—Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Paola Borrelli
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Claudio Ucciferri
- Clinic of Infectious Diseases—Department of Medicine and Science of Aging, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Alessandra Gambi
- Laboratory of Clinical Pathology, SS Annunziata Hospital, Chieti, Italy
| | - Magdalena Bazydlo
- Department of Anesthesiology, Critical Care Medicine and Emergency—Department of Medical, Oral and Biotechnological Sciences, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Giorgia Taraschi
- Clinic of Infectious Diseases—Department of Medicine and Science of Aging, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Jacopo Vecchiet
- Clinic of Infectious Diseases—Department of Medicine and Science of Aging, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, Department of Innovative Technologies in Medicine and Dentistry, “G. d’Annunzio” University Chieti-Pescara, Chieti, Italy
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Ucciferri C, Moffa L, Moffa S, Vecchiet J, Falasca K. Are monoclonal antibodies effective in patients with severe obesity in SARS-CoV-2 infected? Immun Inflamm Dis 2023; 11:e771. [PMID: 36840489 PMCID: PMC9910163 DOI: 10.1002/iid3.771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/29/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023] Open
Abstract
It is important to block SARS-CoV-2 infection immediately with early therapies, such as monoclonal antibodies (MonoAbs). Also, several studies show that obesity is associated with a high risk of severe COVID-19 disease. We enrolled 32 SARS-CoV-2 infected patients who received MonoAbs, all patients were not vaccinated for SARS-CoV-2, and they received therapy after 7 ± 2 days from the onset of COVID-19 symptoms. In the days following administration, patients followed home therapy with Pidotimod 800 mg bid for 10 days and cholecalciferol 2000 UI for 20 days, prescribed the same day they received MonoAbs therapy. Our study found that there are no differences in the therapeutic response between obese and nonobese patients with SARS-CoV-2 infection undergoing MonoAbs therapy, in fact, none of them underwent hospitalization. Furthermore, the effect of the immunostimulant Pidotimod and cholecalciferol may have contributed to the resolution of COVID-19 symptoms in these patients.
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Affiliation(s)
- Claudio Ucciferri
- Department of Medicine and Science of Aging, Clinic of Infectious DiseasesUniversity “G. D'Annunzio”ChietiPescaraItaly
| | - Livia Moffa
- Department of Medicine and Science of Aging, Clinic of Infectious DiseasesUniversity “G. D'Annunzio”ChietiPescaraItaly
| | - Samanta Moffa
- Department of PharmacyUniversity “G. D'Annunzio”ChietiPescaraItaly
| | - Jacopo Vecchiet
- Department of Medicine and Science of Aging, Clinic of Infectious DiseasesUniversity “G. D'Annunzio”ChietiPescaraItaly
| | - Katia Falasca
- Department of Medicine and Science of Aging, Clinic of Infectious DiseasesUniversity “G. D'Annunzio”ChietiPescaraItaly
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Dufrusine B, Valentinuzzi S, Bibbò S, Damiani V, Lanuti P, Pieragostino D, Del Boccio P, D’Alessandro E, Rabottini A, Berghella A, Allocati N, Falasca K, Ucciferri C, Mucedola F, Di Perna M, Martino L, Vecchiet J, De Laurenzi V, Dainese E. Iron Dyshomeostasis in COVID-19: Biomarkers Reveal a Functional Link to 5-Lipoxygenase Activation. Int J Mol Sci 2022; 24:15. [PMID: 36613462 PMCID: PMC9819889 DOI: 10.3390/ijms24010015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/13/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is characterized by a broad spectrum of clinical symptoms. After acute infection, some subjects develop a post-COVID-19 syndrome known as long-COVID. This study aims to recognize the molecular and functional mechanisms that occur in COVID-19 and long-COVID patients and identify useful biomarkers for the management of patients with COVID-19 and long-COVID. Here, we profiled the response to COVID-19 by performing a proteomic analysis of lymphocytes isolated from patients. We identified significant changes in proteins involved in iron metabolism using different biochemical analyses, considering ceruloplasmin (Cp), transferrin (Tf), hemopexin (HPX), lipocalin 2 (LCN2), and superoxide dismutase 1 (SOD1). Moreover, our results show an activation of 5-lipoxygenase (5-LOX) in COVID-19 and in long-COVID possibly through an iron-dependent post-translational mechanism. Furthermore, this work defines leukotriene B4 (LTB4) and lipocalin 2 (LCN2) as possible markers of COVID-19 and long-COVID and suggests novel opportunities for prevention and treatment.
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Affiliation(s)
- Beatrice Dufrusine
- Department of Bioscience and Technology for Food Agriculture and Environment, University of Teramo, 64100 Teramo, Italy
- Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Silvia Valentinuzzi
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Sandra Bibbò
- Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Verena Damiani
- Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Paola Lanuti
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Damiana Pieragostino
- Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Piero Del Boccio
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Ersilia D’Alessandro
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Alberto Rabottini
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Alessandro Berghella
- Department of Bioscience and Technology for Food Agriculture and Environment, University of Teramo, 64100 Teramo, Italy
| | - Nerino Allocati
- Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Katia Falasca
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, 66100 Chieti, Italy
| | - Claudio Ucciferri
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, 66100 Chieti, Italy
| | - Francesco Mucedola
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, 66100 Chieti, Italy
| | - Marco Di Perna
- Pneumology Department, “SS Annunziata” Hospital, 66100 Chieti, Italy
| | - Laura Martino
- Pneumology Department, “SS Annunziata” Hospital, 66100 Chieti, Italy
| | - Jacopo Vecchiet
- Department of Medicine and Aging Science, “G. d’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, 66100 Chieti, Italy
| | - Vincenzo De Laurenzi
- Department of Innovative Technologies in Medicine and Dentistry, University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy
| | - Enrico Dainese
- Department of Bioscience and Technology for Food Agriculture and Environment, University of Teramo, 64100 Teramo, Italy
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New Therapeutic Options in Mild Moderate COVID-19 Outpatients. Microorganisms 2022; 10:microorganisms10112131. [PMID: 36363723 PMCID: PMC9697915 DOI: 10.3390/microorganisms10112131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/14/2022] [Accepted: 10/26/2022] [Indexed: 11/16/2022] Open
Abstract
Background: In recent years, the therapeutic options for COVID have significantly improved; however, the therapies are expensive with restricted access to drugs, and expeditious and difficult to manage at home. We investigated the effect of pidotimod in preventing hospitalization in patients with mild-moderate COVID-19. Methods: A total of 1231 patients between January and June 2021 were screened. A total of 184 patients with mild-moderate COVID-19 were enrolled and divided into two groups: group-A (97) had undergone therapy with pidotimod 800 mg bid for 7−10 days and group-B (87) had other therapies. We excluded those who had undergone complete vaccination course, monoclonal anti-spike/antivirals or the co-administration of pidotimod-steroid. The primary outcome chosen was the emergency room, hospitalization, and deaths for COVID-related causes; the secondary outcome chosen was the duration of COVID-19 illness. Results: A total of 34 patients (18.5%) required hospital treatment, 11 in group-A and 23 in group-B (11.3% vs. 26.4%, p = 0.008). The median disease duration in group-A was 21 days (IQR 17−27) vs. 23 (IQR 20−31) in group-B (p = 0.005). Patients in the pidotimod group had higher SpO2 in the walking test (IQR 96−99% vs. IQR 93−98%, p = 0.01) and a lower need for steroid rescue therapy (11.5% vs. 60.9%, p < 0.001). Conclusions: In the first phase of disease, pidotimod can represent an effective, low-cost, weapon, without restrictions of use, that is able to prevent a second aggressive phase and promote faster virological recovery.
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Pontolillo M, Ucciferri C, Borrelli P, Di Nicola M, Vecchiet J, Falasca K. Molnupiravir as an Early Treatment for COVID-19: A Real Life Study. Pathogens 2022; 11:pathogens11101121. [PMID: 36297178 PMCID: PMC9610792 DOI: 10.3390/pathogens11101121] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/22/2022] [Accepted: 09/27/2022] [Indexed: 11/16/2022] Open
Abstract
Objectives: Below we report our experience in the use of molnupiravir, the first antiviral drug against SARS-CoV-2 available to us, in the treatment of patients with COVID-19. Materials and Methods: We enrolled patients diagnosed with COVID-19 and comorbidities who were candidates for antiviral drug therapy. All patients received molnupiravir (800 mg twice daily). Blood chemistry checks were carried out at T0 and after 7/10 days after starting therapy (T1). Results: There were enrolled within the cohort 100 patients. There was 100.0% compliance with the antiviral treatment. No patient required hospitalization due to worsening of respiratory function or the appearance of serious side effects. The median downtime of viral load was ten days (IQR 8.0–13.0), regardless of the type of vaccination received. The patients who had a shorter distance from vaccination more frequently presented vomiting/diarrhea. During baseline and T1 we found significant differences in the median serum concentrations of the main parameters, in particular of platelets, RDW CV, neutrophils and lymphocytes, the eGFR, liver enzymes, as well as of the main inflammatory markers, CRP and Ferritin. Conclusion: Participants treated with molnupiravir, albeit in risk categories, demonstrated early clinical improvement, no need for hospitalization, and a low rate of adverse events.
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Affiliation(s)
- Michela Pontolillo
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University “G. d’Annunzio” Chieti, 66100 Pescara, Italy
| | - Claudio Ucciferri
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University “G. d’Annunzio” Chieti, 66100 Pescara, Italy
| | - Paola Borrelli
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” Chieti, 66100 Pescara, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Medical, Oral and Biotechnological Sciences, University “G. d’Annunzio” Chieti, 66100 Pescara, Italy
| | - Jacopo Vecchiet
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University “G. d’Annunzio” Chieti, 66100 Pescara, Italy
| | - Katia Falasca
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University “G. d’Annunzio” Chieti, 66100 Pescara, Italy
- Correspondence: ; Tel.: +39-0871-357582; Fax: +39-0871-358595
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Claudio U, Antonio A, Marcella R, Erica C, Jacopo V, Katia F. Association of inflammatory biomarkers and cardiovascular risk scores in an Italian cohort of HIV positive patient undergoing antiretroviral therapy. Curr HIV Res 2022; 20:CHR-EPUB-124764. [PMID: 35748553 DOI: 10.2174/1570162x2002220623163705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/28/2022] [Accepted: 04/14/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Several algorithms have been developed to predict cardiovascular risk (CVR) over time, however none of them seem to be accurate when applied to HIV patients. OBJECTIVE The aim of this study was to assess plasma inflammatory biomarkers in relation to multiple CVR scores (FRS, ASCVD, PROCAM and the DAD-5 Years-Estimated-Risk) in an Italian cohort of HIV patients undergoing a combined Antiretroviral Therapy (cART). METHODS We enrolled HIV patients undergoing cART without any change in the HIV-related pharmacological therapy over the last 48 weeks Demographic and anamnestic data were collected, and a biochemical panel including the following biomarkers was collected: CRP, Cystatin-C, microalbuminuria, IL-18, IL-2, IL-4, IL-6, IL-10, TNF-α and IFN- γ. CVR scores were obtained for each patient and compared to the biochemical panel to assess statistical correlation. RESULTS 90 Caucasian HIV patients were enrolled. Assessment of CVR scores showed FRS values of 6.98±6.11%, ASCVD 7.18±6.25%, PROCAM 6.7±7.4% and DAD-5 Years Estimated Risk 3.10±3.41%. We found correlations between the levels of circulating cytokines measured and the cardiovascular risk prediction scores. CONCLUSIONS Our data showed that the values of selected inflammatory biomarkers strongly correlate with the CVR scores, suggesting that they can be employed as reliable predictors of cardiovascular disease in HIV patients. The routine use of selected biomarkers associated with systemic inflammation could be a valid and readily available tool for clinicians to assess and monitor cardiovascular risk in HIV patients. .
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Affiliation(s)
- Ucciferri Claudio
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d' Annunzio", Chieti-Pescara, Italy
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Auricchio Antonio
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d' Annunzio", Chieti-Pescara, Italy
| | - Reale Marcella
- Unit of Immunodiagnostic and Molecular Pathology, Department of Medical, Oral and Biotechnological Sciences, University \'G. d\'Annunzio\', Chieti- Pescara, Italy
| | - Costantini Erica
- Unit of Immunodiagnostic and Molecular Pathology, Department of Medical, Oral and Biotechnological Sciences, University \'G. d\'Annunzio\', Chieti- Pescara, Italy
| | - Vecchiet Jacopo
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d' Annunzio", Chieti-Pescara, Italy
| | - Falasca Katia
- Clinic of Infectious Diseases Dept. of Medicine and Science of Aging University "G. d'Annunzio" Chieti-Pescara Via dei Vestini 31, Chieti, Italy
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Yin J, Li C, Ye C, Ruan Z, Liang Y, Li Y, Wu J, Luo Z. Advances in the development of therapeutic strategies against COVID-19 and perspectives in the drug design for emerging SARS-CoV-2 variants. Comput Struct Biotechnol J 2022; 20:824-837. [PMID: 35126885 PMCID: PMC8802458 DOI: 10.1016/j.csbj.2022.01.026] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/18/2022] [Accepted: 01/27/2022] [Indexed: 12/15/2022] Open
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Anti-Inflammatory Effects of Immunostimulation in Patients with COVID-19 Pneumonia. J Clin Med 2021; 10:jcm10245765. [PMID: 34945060 PMCID: PMC8706211 DOI: 10.3390/jcm10245765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 11/27/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The effects of immunomodulators in patients with Coronavirus Disease 2019 (COVID-19) pneumonia are still unknown. We investigated the cellular inflammatory and molecular changes in response to standard-of-care + pidotimod (PDT) and explored the possible association with blood biomarkers of disease severity. Methods: Clinical characteristics and outcomes, neutrophil-to-lymphocyte ratio (NLR), plasma and cell supernatant chemokines, and gene expression patterns after SARS-CoV-2 and influenza (FLU) virus in vitro stimulation were assessed in 16 patients with mild-moderate COVID-19 pneumonia, treated with standard of care and PDT 800 mg twice daily (PDT group), and measured at admission, 7 (T1), and 12 (T2) days after therapy initiation. Clinical outcomes and NLR were compared with age-matched historical controls not exposed to PDT. Results: Hospital stay, in-hospital mortality, and intubation rate did not differ between groups. At T1, NLR was 2.9 (1.7–4.6) in the PDT group and 5.5 (3.4–7.1) in controls (p = 0.037). In the PDT group, eotaxin and IL-4 plasma concentrations progressively increased (p < 0.05). Upon SARS-CoV-2 and FLU-specific stimulation, IFN-γ was upregulated (p < 0.05), while at genetic transcription level, Pathogen Recognition Receptors (TRLs) were upregulated, especially in FLU-stimulated conditions. Conclusions: Immunomodulation exerted by PDT and systemic corticosteroids may foster a restoration in the innate response to the viral infection. These results should be confirmed in larger RCTs.
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Han F, Liu Y, Mo M, Chen J, Wang C, Yang Y, Wu J. Current treatment strategies for COVID‑19 (Review). Mol Med Rep 2021; 24:858. [PMID: 34664677 PMCID: PMC8548951 DOI: 10.3892/mmr.2021.12498] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022] Open
Abstract
The spread of the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged suddenly at the end of 2019 and the disease came to be known as coronavirus disease 2019 (COVID-19). To date, there is no specific therapy established to treat COVID-19. Identifying effective treatments is urgently required to treat patients and stop the transmission of SARS-CoV-2 in humans. For the present review, >100 publications on therapeutic agents for COVID-19, including in vitro and in vivo animal studies, case reports, retrospective analyses and meta-analyses were retrieved from PubMed and analyzed, and promising therapeutic agents that may be used to combat SARS-CoV-2 infection were highlighted. Since the outbreak of COVID-19, different drugs have been repurposed for its treatment. Existing drugs, including chloroquine (CQ), its derivative hydroxychloroquine (HCQ), remdesivir and nucleoside analogues, monoclonal antibodies, convalescent plasma, Chinese herbal medicine and natural compounds for treating COVID-19 evaluated in experimental and clinical studies were discussed. Although early clinical studies suggested that CQ/HCQ produces antiviral action, later research indicated certain controversy regarding their use for treating COVID-19. The molecular mechanisms of these therapeutic agents against SARS-CoV2 have been investigated, including inhibition of viral interactions with angiotensin-converting enzyme 2 receptors in human cells, viral RNA-dependent RNA polymerase, RNA replication and the packaging of viral particles. Potent therapeutic options were reviewed and future challenges to accelerate the development of novel therapeutic agents to treat and prevent COVID-19 were acknowledged.
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Affiliation(s)
- Fabin Han
- The Translational Research Laboratory for Stem Cell and Traditional Chinese Medicine, Innovation Institute for Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
| | - Yanming Liu
- Laboratory for Stem Cell and Regenerative Medicine, Institute for Tissue Engineering and Regenerative Medicine, Liaocheng People's Hospital/Liaocheng University, Liaocheng, Shandong 252000, P.R. China
| | - Mei Mo
- The Translational Research Laboratory for Stem Cell and Traditional Chinese Medicine, Innovation Institute for Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
| | - Juanli Chen
- Laboratory for Stem Cell and Regenerative Medicine, Institute for Tissue Engineering and Regenerative Medicine, Liaocheng People's Hospital/Liaocheng University, Liaocheng, Shandong 252000, P.R. China
| | - Cheng Wang
- The Translational Research Laboratory for Stem Cell and Traditional Chinese Medicine, Innovation Institute for Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
| | - Yong Yang
- The Translational Research Laboratory for Stem Cell and Traditional Chinese Medicine, Innovation Institute for Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
| | - Jibiao Wu
- The Translational Research Laboratory for Stem Cell and Traditional Chinese Medicine, Innovation Institute for Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong 250355, P.R. China
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Attitudes and Intentions toward COVID-19 Vaccination among Spanish Adults: A Descriptive Cross-Sectional Study. Vaccines (Basel) 2021; 9:vaccines9101135. [PMID: 34696243 PMCID: PMC8538537 DOI: 10.3390/vaccines9101135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/26/2021] [Accepted: 10/01/2021] [Indexed: 11/17/2022] Open
Abstract
Vaccination against SARS-CoV-2 is postulated as the most effective measure to control the COVID-19 pandemic. However, the use of other protection measures is necessary to efficiently combat the spread of the virus. The aim of the present study was to determine the attitudes and intentions toward COVID-19 vaccination among non-regular social media users in Spain and to analyze how these factors could condition the acceptance of other personal protective measures once an individual has received the COVID-19 vaccine. A cross-sectional design was used in this work. In total, 719 subjects, ≥18 years old and of both sexes, were recruited from primary public healthcare centers to self-complete a questionnaire between March and April 2021. The majority of participants had a positive attitude toward vaccination and showed high levels of intention to be vaccinated. Likewise, except those participants who considered the vaccine to be the most effective measure to fight the COVID-19 pandemic, the rest of the participants highlighted the importance of continuing to limit social interactions and/or wearing masks even after being vaccinated. Since vaccination can create a perception of total immunity against SARS-CoV-2, it is necessary that healthcare staff organize effective awareness campaigns on the importance of maintaining personal protective measures until vaccination coverage is greater.
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Ucciferri C, Caiazzo L, Di Nicola M, Borrelli P, Pontolillo M, Auricchio A, Vecchiet J, Falasca K. Parameters associated with diagnosis of COVID-19 in emergency department. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:851-861. [PMID: 33960733 PMCID: PMC8239864 DOI: 10.1002/iid3.440] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/26/2021] [Accepted: 03/29/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVES We designed this study to identify laboratory and radiological parameters, which could be useful to guide the clinician, in the evaluation of a suspected case of coronavirus disease 19 (COVID-19). METHODS This retrospective, observational, single-center-study recruited patients with a suspect of COVID-19 data were extracted from electronic medical records using a standardized data collection form. RESULTS A total of 566 patients with suspect COVID-19 infection were enrolled (280 were COVID-19+). The COVID-19 population was characterized with bilateral-pneumonia, a lower count of neutrophil, lymphocyte and monocyte, a lower neutrophil to lymphocyte-ratio (NLR). Lower of platelet count, d-dimer, troponin I, and serum calcium were in COVID-19 patients. The occurrence of COVID-19 diagnosis increased, independently of other variables, with pneumonia (odds ratio [OR]: 3.60; p < .001), neutrophil below normal range (OR: 4.15; p < .05), lactate dehydrogenase (OR: 2.09; p < .01) and sodium above normal range (OR: 2.34; p < .01). In patients with possible respiratory acute affections we found a higher neutrophil, higher monocyte, a higher NLR and a more elevation in d-dimer. In the Sepsis group showed higher level of white blood cell, C-reactive protein, d-dimer, and procalcitonin. CONCLUSIONS Our study confirms that patients with COVID-19 have typical radiological and laboratory characteristics. The parameters highlighted in the study can help identify COVID-19 patients, also highlighting which are the main differential diagnoses to be made and the parameters that facilitate the differential diagnosis.
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Affiliation(s)
- Claudio Ucciferri
- Department of Medicine and Science of Aging, Clinic of Infectious Diseases, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Luca Caiazzo
- Department of Medicine and Science of Aging, Clinic of Infectious Diseases, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Marta Di Nicola
- Laboratory of Biostatistics, Department of Medical, Oral, and Biotechnological Sciences, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Paola Borrelli
- Laboratory of Biostatistics, Department of Medical, Oral, and Biotechnological Sciences, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Michela Pontolillo
- Department of Medicine and Science of Aging, Clinic of Infectious Diseases, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Antonio Auricchio
- Department of Medicine and Science of Aging, Clinic of Infectious Diseases, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Jacopo Vecchiet
- Department of Medicine and Science of Aging, Clinic of Infectious Diseases, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Katia Falasca
- Department of Medicine and Science of Aging, Clinic of Infectious Diseases, University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
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Ucciferri C, Falasca K, Reale M, Tamburro M, Auricchio A, Vignale F, Vecchiet J. Pidotimod and Immunological Activation in Individuals Infected with HIV. Curr HIV Res 2021; 19:260-268. [PMID: 33430735 DOI: 10.2174/1570162x18666210111102046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 11/18/2020] [Accepted: 11/28/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The improvements in HIV infection therapy and the large availability of antiretroviral drugs have led to an increased survival among HIV infected people, and simultaneously to a raised morbidity and mortality due to not-AIDS-related events in this group compared to the general population. An increased systemic inflammation and a persistent immune activation play a pivotal role in determining high rates of non-AIDS comorbidities. In the last years, many natural or synthetic immunomodulatory molecules acting by different mechanisms have been conceived. Pidotimod is a synthetic dipeptide molecule showing immunomodulatory properties. The aim of this pilot study was to evaluate the effects of Pidotimod supplementation on residual inflammation in HIV infected population. METHODS Forty HIV positive individuals under cART were enrolled: 30 were treated with Pidotimod supplementation (study group) and 10 served as control group (without Pidotimod supplementation). For all participants, Cystatin C, PCR, ESR, microalbuminuria, TNF-α, INF-γ, IL-4, IL-10, IL1β, IL-18 and IL-2 were measured at enrolment (T0), 4 weeks after of Pidotimod supplementation (T1), and 4 weeks after completing supplementation (T2). RESULTS In HIV positive participants treated with Pidotimod, the evaluation of cytokine levels showed that IL-10, IFN gamma, and IL-4 were significantly higher at enrolment compared to the control group. The increase under Pidotimod treatment persisted after supplementation suspension, while the pro-inflammatory cytokines levels were reduced. Salivary IgA also increased during 4 weeks of supplementation and persisted at 4 weeks after completing supplementation. On the other hand, the Cystatin C and microalbuminuria levels decreased over time, at a greater extent the Cystatin C serum levels. CONCLUSION The study findings showed that the HIV population receiving Pidotimod achieved a rebalancing of pro-inflammatory and anti-inflammatory cytokines as well as a significant reduction in cystatin C levels. The treatment further allowed for an increase in salivary IgA levels at all the analyzed times, as a secondary event to a remodulation of the immunological status obtained with pidotimod. This approach could represent a new way to design new intervention strategies aimed at improving the persistent immune activation status in the virologically suppressed HIV population.
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Affiliation(s)
- Claudio Ucciferri
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d'Annunzio" Chieti-Pescara, Italy
| | - Katia Falasca
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d'Annunzio" Chieti-Pescara, Italy
| | - Marcella Reale
- Unit of Immunodiagnostic and Molecular Pathology, Department of Medical, Oral and Biotechnological Sciences, University "G. d'Annunzio", Chieti- Pescara, Italy
| | - Manuela Tamburro
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
| | - Antonio Auricchio
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d'Annunzio" Chieti-Pescara, Italy
| | - Francesca Vignale
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d'Annunzio" Chieti-Pescara, Italy
| | - Jacopo Vecchiet
- Clinic of Infectious Diseases, Department of Medicine and Science of Aging, University "G. d'Annunzio" Chieti-Pescara, Italy
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Di Carlo P, Falasca K, Ucciferri C, Sinjari B, Aruffo E, Antonucci I, Di Serafino A, Pompilio A, Damiani V, Mandatori D, De Fabritiis S, Dufrusine B, Capone E, Chiacchiaretta P, Brune WH, Di Bonaventura G, Vecchiet J. Normal breathing releases SARS-CoV-2 into the air. J Med Microbiol 2021; 70:001328. [PMID: 33629949 PMCID: PMC8346733 DOI: 10.1099/jmm.0.001328] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/29/2021] [Indexed: 01/22/2023] Open
Abstract
This study tests the release of SARS-CoV-2 RNA into the air during normal breathing, without any sign of possible risk of contagion such as coughing, sneezing or talking. Five patients underwent oropharyngeal, nasopharyngeal and salivary swabs for real-time reverse transcriptase PCR (RT-PCR) detection of SARS-CoV-2 RNA. Direct SARS-CoV-2 release during normal breathing was also investigated by RT-PCR in air samples collected using a microbiological sampler. Viral RNA was detected in air at 1 cm from the mouth of patients whose oropharyngeal, nasopharyngeal and salivary swabs tested positive for SARS-CoV-2 RNA. In contrast, the viral RNA was not identified in the exhaled air from patients with oropharyngeal, nasopharyngeal and salivary swabs that tested negative. Contagion of SARS-CoV-2 is possible by being very close to the mouth of someone who is infected, asymptomatic and simply breathing.
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Affiliation(s)
- Piero Di Carlo
- University "G. d'Annunzio" of Chieti-Pescara, Department of Advanced Technologies in Medicine & Dentistry, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Katia Falasca
- University "G. d'Annunzio" of Chieti-Pescara, Department of Medicine and Aging Sciences, Chieti, Italy
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, Chieti, Italy
| | - Claudio Ucciferri
- University "G. d'Annunzio" of Chieti-Pescara, Department of Medicine and Aging Sciences, Chieti, Italy
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, Chieti, Italy
| | - Bruna Sinjari
- University "G. d'Annunzio" of Chieti-Pescara, Department of Advanced Technologies in Medicine & Dentistry, Chieti, Italy
| | - Eleonora Aruffo
- University "G. d'Annunzio" of Chieti-Pescara, Department of Advanced Technologies in Medicine & Dentistry, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Ivana Antonucci
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Psychological, Health and Territorial Sciences, University "G. d'Annunziio" of Chieti_Pescara, Chieti, Italy
| | - Alessandra Di Serafino
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- Department of Psychological, Health and Territorial Sciences, University "G. d'Annunziio" of Chieti_Pescara, Chieti, Italy
| | - Arianna Pompilio
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- University "G. d'Annunzio" of Chieti-Pescara, Department of Medical, Oral and Biotechnological Sciences, Chieti, Italy
| | - Verena Damiani
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Domitilla Mandatori
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Simone De Fabritiis
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Beatrice Dufrusine
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
| | - Emily Capone
- University "G. d'Annunzio" of Chieti-Pescara, Department of Neuroscience, Imaging and Clinical Sciences, Chieti, Italy
| | - Piero Chiacchiaretta
- University "G. d'Annunzio" of Chieti-Pescara, Department of Neuroscience, Imaging and Clinical Sciences, Chieti, Italy
| | - William H. Brune
- Pennsylvania State University, Department Meteorology and Atmospheric Science, University Park, PA, 16802, USA
| | - Giovanni Di Bonaventura
- Center for Advanced Studies and Technology (CAST), University "G. d'Annunzio" of Chieti-Pescara, Chieti, Italy
- University "G. d'Annunzio" of Chieti-Pescara, Department of Medical, Oral and Biotechnological Sciences, Chieti, Italy
| | - Jacopo Vecchiet
- University "G. d'Annunzio" of Chieti-Pescara, Department of Medicine and Aging Sciences, Chieti, Italy
- Clinic of Infectious Diseases, S.S. Annunziata Hospital, Chieti, Italy
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Ortega MA, Fraile-Martínez O, García-Montero C, García-Gallego S, Sánchez-Trujillo L, Torres-Carranza D, Álvarez-Mon MÁ, Pekarek L, García-Honduvilla N, Bujan J, Álvarez-Mon M, Asúnsolo Á, De La Torre B. An integrative look at SARS‑CoV‑2 (Review). Int J Mol Med 2021; 47:415-434. [PMID: 33416095 PMCID: PMC7797443 DOI: 10.3892/ijmm.2020.4828] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
SARS‑CoV‑2 is a newly discovered member of the betacoronaviruses and the etiological agent of the disease COVID‑19. SARS‑CoV‑2 is responsible for the worldwide pandemic which has been taking place in 2020, and is causing a markedly higher number of infections and deaths compared to previous coronaviruses, such as SARS‑CoV or MERS‑CoV. Based on updated scientific literature, the present review compiles the most relevant knowledge of SARS‑CoV‑2, COVID‑19 and the clinical and typical responses that patients have exhibited against this virus, discussing current and future therapies, and proposing strategies with which to combat the disease and prevent a further global threat. The aggressiveness of SARS‑CoV‑2 arises from its capacity to infect, and spread easily and rapidly through its tight interaction with the human angiotensin‑converting enzyme 2 (ACE‑2) receptor. While not all patients respond in a similar manner and may even be asymptomatic, a wide range of manifestations associated with COVID‑19 have been described, particularly in vulnerable population groups, such as the elderly or individuals with other underlying conditions. The proper function of the immune system plays a key role in an individual's favorable response to SARS‑CoV‑2 infection. A hyperactivated response, on the contrary, could account for the more severe cases of COVID‑19, and this may finally lead to respiratory insufficiency and other complications, such as thrombotic or thromboembolic events. The development of novel therapies and vaccines designed to control and regulate a proper immune system response will be key to clinical management, prevention measures and effective population screening to attenuate the transmission of this novel RNA virus.
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Affiliation(s)
- Miguel A. Ortega
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
- Tumor Registry, Pathological Anatomy Service, Prince of Asturias University Hospital, Alcalá de Henares, 28801 Madrid
| | - Oscar Fraile-Martínez
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
| | - Cielo García-Montero
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
| | - Sandra García-Gallego
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
- Department of Organic and Inorganic Chemistry, 'Andrés M. del Río' Institute of Chemistry (IQAR), University of Alcalá, CIBER-BBN, 28805 Madrid
| | - Lara Sánchez-Trujillo
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
- Tumor Registry, Pathological Anatomy Service, Prince of Asturias University Hospital, Alcalá de Henares, 28801 Madrid
| | | | - Miguel Ángel Álvarez-Mon
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
- Department of Psychiatry and Medical Psychology, Infanta Leonor University Hospital, 28031 Madrid
| | - Leonel Pekarek
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
| | - Natalio García-Honduvilla
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
| | - Julia Bujan
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
| | - Melchor Álvarez-Mon
- Department of Medicine and Medical Specialties, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
- Internal Medicine Service, Prince of Asturias University Hospital, CIBEREHD, Alcalá de Henares, 28805 Madrid
| | - Ángel Asúnsolo
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
- Preventive Medicine and Public Health Area, Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain
- Department of Epidemiology and Biostatistics, Graduate School of Public Health and Health Policy, New York University, New York, NY 10027, USA
| | - Basilio De La Torre
- Ramón y Cajal Health Research Institute (IRYCIS), 28034 Madrid
- Preventive Medicine and Public Health Area, Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain
- Traumatology Service, Ramón y Cajal University Hospital, 28034 Madrid, Spain
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