Nebulized Recombinant Tissue Plasminogen Activator (rt-PA) for Acute COVID-19-Induced Respiratory Failure: An Exploratory Proof-of-Concept Trial

Acute lung injury in COVID-19 results in diffuse alveolar damage with disruption of the alveolar-capillary barrier, coagulation activation, alveolar fibrin deposition and pulmonary capillary thrombi. Nebulized recombinant tissue plasminogen activator (rt-PA) has the potential to facilitate localized thrombolysis in the alveolar compartment and improve oxygenation. In this proof-of-concept safety study, adults with COVID-19-induced respiratory failure and a <300 mmHg PaO2/FiO2 (P/F) ratio requiring invasive mechanical ventilation (IMV) or non-invasive respiratory support (NIRS) received nebulized rt-PA in two cohorts (C1 and C2), alongside standard of care, between 23 April-30 July 2020 and 21 January-19 February 2021, respectively. Matched historical controls (MHC; n = 18) were used in C1 to explore efficacy. Safety co-primary endpoints were treatment-related bleeds and <1.0-1.5 g/L fibrinogen reduction. A variable dosing strategy with clinical efficacy endpoint and minimal safety concerns was determined in C1 for use in C2; patients were stratified by ventilation type to receive 40-60 mg rt-PA daily for ≤14 days. Nine patients in C1 (IMV, 6/9; NIRS, 3/9) and 26 in C2 (IMV, 12/26; NIRS, 14/26) received nebulized rt-PA for a mean (SD) of 6.7 (4.6) and 9.1(4.6) days, respectively. Four bleeds (one severe, three mild) in three patients were considered treatment related. There were no significant fibrinogen reductions. Greater improvements in mean P/F ratio from baseline to study end were observed in C1 compared with MHC (C1; 154 to 299 vs. MHC; 154 to 212). In C2, there was no difference in the baseline P/F ratio of NIRS and IMV patients. However, a larger improvement in the P/F ratio occurred in NIRS patients (NIRS; 126 to 240 vs. IMV; 120 to 188) and fewer treatment days were required (NIRS; 7.86 vs. IMV; 10.5). Nebulized rt-PA appears to be well-tolerated, with a trend towards improved oxygenation, particularly in the NIRS group. Randomized clinical trials are required to demonstrate the clinical effect significance and magnitude.

Pfizer BNT 162b2 COVID-19 vaccine-induced fulminant myopericarditis: A case study

The use of mRNA COVID-19 vaccine can on rare occasions cause life-threatening, fulminant myopericarditis. This case report demonstrates previously reported benefit of early use of venoarterial extracorporeal membrane oxygenation mechanical assistance and supports the use of intravenous highly purified immunoglobulin pharmacotherapy to help achieve a good clinical outcome.

Prognostic indicators and outcomes of hospitalised COVID-19 patients with neurological disease: An individual patient data meta-analysis

Background

Neurological COVID-19 disease has been reported widely, but published studies often lack information on neurological outcomes and prognostic risk factors. We aimed to describe the spectrum of neurological disease in hospitalised COVID-19 patients; characterise clinical outcomes; and investigate factors associated with a poor outcome.

Methods

We conducted an individual patient data (IPD) meta-analysis of hospitalised patients with neurological COVID-19 disease, using standard case definitions. We invited authors of studies from the first pandemic wave, plus clinicians in the Global COVID-Neuro Network with unpublished data, to contribute. We analysed features associated with poor outcome (moderate to severe disability or death, 3 to 6 on the modified Rankin Scale) using multivariable models.

Results

We included 83 studies (31 unpublished) providing IPD for 1979 patients with COVID-19 and acute new-onset neurological disease. Encephalopathy (978 [49%] patients) and cerebrovascular events (506 [26%]) were the most common diagnoses. Respiratory and systemic symptoms preceded neurological features in 93% of patients; one third developed neurological disease after hospital admission. A poor outcome was more common in patients with cerebrovascular events (76% [95% CI 67–82]), than encephalopathy (54% [42–65]). Intensive care use was high (38% [35–41]) overall, and also greater in the cerebrovascular patients. In the cerebrovascular, but not encephalopathic patients, risk factors for poor outcome included breathlessness on admission and elevated D-dimer. Overall, 30-day mortality was 30% [27–32]. The hazard of death was comparatively lower for patients in the WHO European region.

Interpretation

Neurological COVID-19 disease poses a considerable burden in terms of disease outcomes and use of hospital resources from prolonged intensive care and inpatient admission; preliminary data suggest these may differ according to WHO regions and country income levels. The different risk factors for encephalopathy and stroke suggest different disease mechanisms which may be amenable to intervention, especially in those who develop neurological symptoms after hospital admission.

Muscle Protein Synthesis Following Protein Administration in Critical Illness

Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly understood. Objective To quantify protein digestion and amino acid absorption, and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods Fifteen mechanically ventilated adults (12M; age 50±17y, Body Mass Index (BMI) 27±5kg·m-2) and 10 healthy controls (6M; 54±23y, BMI 27±4kg·m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5h, and a duodenal bolus of intrinsically-labelled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20g protein) over 60min. Arterial blood and muscle samples were taken at baseline (fasting) and for 6h following duodenal protein administration. Data are mean±SD; analysed with 2-way repeated measures ANOVA and independent samples t-test. Measurements and main results Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy controls (0.023±0.013 vs 0.034±0.016%/h; P=0.077). Following protein administration, plasma amino acid availability did not differ between groups (ICU patients 54.2±9.1 vs healthy controls 61.8±13.1%; P=0.12), and myofibrillar protein synthesis rates increased in both groups (0.028±0.010 vs 0.043±0.018 %/h, main time effect P=0.046, P-interaction=0.584) with lower rates in ICU patients compared to healthy controls (main group effect P=0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ~60% lower in ICU patients (0.007±0.007 vs 0.017±0.009 mole % excess (MPE); P=0.007). Conclusion The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.

Plasma exchange for COVID-19 thrombo-inflammatory disease

Severe COVID‐19 disease is a hyperinflammatory, pro‐thrombotic state. We undertook plasma exchange (PEX) to determine its effects on organ function and thrombo‐inflammatory markers.

Seven critically ill adults with severe COVID‐19 respiratory failure (PaO₂:FiO₂ ratio < 200 mm Hg) requiring invasive or noninvasive ventilatory support and elevated thrombo‐inflammatory markers (LDH >800 IU/L and D‐dimer >1000 μg/L (or doubling from baseline) received PEX, daily, for a minimum of 5 days. No other immunomodulatory medications were initiated during this period. Seven patients matched for age and baseline biochemistry were a comparator group.

Coagulation screening revealed no evidence of coagulopathy. However, von Willebrand Factor (VWF) activity, antigen and VWF antigen: ADAMTS13 ratio, Factor VIII and D‐dimers were all elevated. Following 5 days of PEX, plasma levels of all the above, and ferritin levels, were significantly reduced (P < .05) while lymphocyte counts normalized (P < .05). The P_aO₂:FiO₂ ratio increased from a median interquartile range (IQR) of 11.6 (10.8‐19.7) kPa to 18.1 (16.0‐25.9) kPa (P < .05). Similar improvements were not observed in controls. Acute kidney injury (AKI) occurred among five patients in the control arm but not in patients receiving PEX.

PEX improved oxygenation, decreased the incidence of AKI, normalized lymphocyte counts and reduced circulating thrombo‐inflammatory markers including D‐Dimer and VWF Ag:ADAMTS13 ratio.

Severe meningococcal serogroup W sepsis presenting as myocarditis: A case report and review of literature

The global incidence of invasive meningococcal disease due to serogroup W (MenW) has risen over the last decade. The following case emphasises the atypical features of MenW meningococcaemia, which included myocarditis, a rare but important complication. It also highlights the potential novel role that cardiac magnetic resonance imaging can provide in the diagnosis of MenW myocarditis. Complications of these infections can be avoided with early recognition and susceptibility testing to prevent the use of inappropriate antibiotics and treatment failure.