Premorbid echocardiography and risk of hospitalization in COVID-19

BACKGROUND

COVID-19 has caused a global pandemic unprecedented in a century. Though primarily a respiratory illness, cardiovascular risk factors predict adverse outcomes. We aimed to investigate the role of baseline echocardiographic abnormalities in further refining risk in addition to clinical risk factors.

METHODS

Adults with COVID-19 positive RT-PCR test across St Luke's University Health Network between March 1st 2020-October 31st 2020 were identified. Those with trans-thoracic echocardiography (TTE) within 15-180 days preceding COVID-19 positivity were selected, excluding severe valvular disease, acute cardiac event between TTE and COVID-19, or asymptomatic patients positive on screening. Demographic, clinical, and echocardiographic variables were manually extracted from patients' EHR and compared between groups stratified by disease severity. Logistic regression was used to identify independent predictors of hospitalization.

RESULTS

192 patients met inclusion criteria. 87 (45.3%) required hospitalization, 34 (17.7%) suffered severe disease (need for ICU care/mechanical ventilation/in-hospital death). Age, co-morbidities, and several echocardiographic abnormalities were more prevalent in those with moderate-severe disease than in mild disease, with notable exceptions of systolic/diastolic dysfunction. On multivariate analysis, age (OR 1.039, 95% CI 1.011-1.067), coronary artery disease (OR 4.184, 95% CI 1.451-12.063), COPD (OR 6.886, 95% CI 1.396-33.959) and left atrial diameter ≥ 4.0 cm (OR 2.379, 95% CI 1.031-5.493) predicted need for hospitalization. Model showed excellent discrimination (ROC AUC 0.809, 95% CI 0.746-0.873).

CONCLUSIONS

Baseline left atrial enlargement is an independent risk factor for risk of hospitalization among patients with COVID-19. When available, baseline LA enlargement may identify patients for (1) closer outpatient follow up, and (2) counseling vaccine-hesitancy.

Clinical and echocardiographic risk score predicts need for hospitalization among patients with COVID-19

Background

Age and medical co-morbidities are known predictors of disease severity in coronavirus disease-2019 (COVID-19). Whether baseline transthoracic echocardiographic (TTE) abnormalities could refine risk-stratification in this context remains unknown.

Purpose

To analyze performance of a risk score combining clinical and pre-morbid TTE features in predicting risk of hospitalization among patients with COVID-19.

Methods

Adult patients testing positive for COVID-19 between March 1st and October 31st, 2020 with pre-infection TTE (within 15–180 days) were selected. Those with severe valvular disease, acute cardiac events between TTE and COVID-19, or asymptomatic carriers of virus (on employment screening/nursing home placement) were excluded. Baseline demographic, clinical co-morbidities, and TTE findings were extracted from electronic health records and compared between groups stratified by hospital admission. Total sample was randomly split into training (≈70%) and validation (≈30%) sets. Age was transformed into ordered categories based on cubic spline regression. Regression model was developed on the training set. Variables found significant (at p<0.10) on univariate analysis were selected for multivariate analysis with hospital admission as outcome. β-coefficients were obtained from 5000 bootstrapped samples after forced entry of significant variables, and scores assigned using Schneeweiss's scoring system. Final risk score performance was compared between training/validation cohorts using receiver-operating curve (ROC) and calibration curve analyses.

Results

192 patients were included, 83 (43.2%) were admitted. Clinical/TTE characteristics stratified by hospitalization are in Table 1. Moderate or worse pulmonary hypertension and left atrial enlargement were only TTE parameters with coefficients deserving a score (Table 1). The risk score had excellent discrimination in training and validation sets (figure 1 left panel; AUC 0.785 versus 0.836, p=0.452). Calibration curves showed strong linear correlation between predicted and observed probabilities of hospitalization in both training and validation sets (Figure 1, middle and right panels, respectively). ROC analysis revealed a score ≥7 as having best overall quality with sensitivity and specificity of 70–75% in both training and validation sets. A score ≥12 had 98% and 97% specificity and ≥14 had 100% specificity.

Conclusion

A combined clinical and echocardiographic risk score shows promise in predicting risk of hospitalization among patients with COVID-19, and hence help anticipate resource utilization. External validation and comparison against clinical risk score alone is worth further investigation.

Funding Acknowledgement

Type of funding sources: None.

Impact of gastrointestinal hemorrhage on hospital outcomes of patients with hypertrophic cardiomyopathy

Background

Patients with hypertrophic cardiomyopathy (HCM) may be at relatively high risk of gastrointestinal hemorrhage (GIH) due to acquired von Willebrand disease (aVWD) and anticoagulation for atrial fibrillation among others factors.

Purpose

We aimed to evaluate impact of GIH on in-hospital outcomes of patients with HCM.

Methods

The National Inpatient Sample reported 45,305 admissions for adults with HCM during a two-year period (2016–2017). Among them, 1,490 patients (3.3%) also had GIH. Baseline characteristics and in-hospital outcomes of the two groups were compared. Multivariable logistic regression analysis was used to assess the independent impact of GIH on in-hospital outcomes of HCM patients.

Results

Out of 45,305 HCM patients, 1490 (3.2%) also had concomitant diagnosis of GIH. HCM patients with GIH were older (70±9 vs 66±23 years), were more often male (64% vs 61%), and had higher prevalence of prior myocardial infarction (12% vs 7%, p<0.001) and cirrhosis (7.1% vs 2.6%, p<0.001) while being less often obese (15% vs 22%, p=0.01) or having a history of congestive heart failure (30% vs 36%, p=0.03) [Table 1]. Hospital mortality was significantly higher among those with GIH (6.4% vs 3.5%, p<0.001). Multivariable logistic regression analysis identified GIH as an independent predictor of higher in-hospital mortality [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI)=1.02–2.63, p=0.001], hypovolemic shock (aOR=5.17, 95% CI=2.5–10.6, p<0.001), mean length of stay (Δ +2.4 days, p<0.001) and mean hospital cost (Δ +$21,162, p=0.004).

Conclusion

Adults with HCM and GIH are older, less often obese with higher prevalence of cirrhosis and prior myocardial infarction. Presence of GIH is an independent predictor of higher mortality, hypovolemic shock, length of stay and hospital cost in HCM adults admitted to hospital.

Funding Acknowledgement

Type of funding sources: None. Table 1

Impact of cardiac rhythm abnormality on hospital outcomes of patients with hypertrophic cardiomyopathy

Background

Serious cardiac arrhythmias [atrial fibrillation/flutter (AFF), and ventricular tachycardia/fibrillation (VTF)] are associated with adverse outcomes in general population of patients with hypertrophic cardiomyopathy (HCM).

Purpose

We aimed to evaluate the impact of such rhythm abnormalities on in-hospital outcomes of adults with HCM.

Methods

The National Inpatient Sample reported 45,305 admissions for adults with HCM during a two-year period (2016–2017). Among them, 21,220 patients (47%) also had AFF and/or VTF. Baseline characteristics and in-hospital outcomes of the two groups were compared. Multivariable logistic regression analysis was used to assess the independent impact of rhythm abnormalities on in-hospital outcomes of HCM patients.

Results

HCM patients with arrhythmias were older (68±26 vs 64±29 years), were more often male (43% vs 36%), and had higher prevalence of congestive heart failure (45% vs 28%), chronic kidney disease (27% vs 22%), hyperlipidemia (52% vs 48%), obstructive sleep apnea (17% vs 13%), chronic obstructive pulmonary disease (22% vs 18%) and thyroid disease (19% vs 16%) [Table 1, all p<0.001]. Hospital mortality was significantly higher among those with arrhythmias (4.7% vs 2.7%, p<0.05). Multivariate logistic regression analysis identified arrhythmias as an independent predictor of in-hospital mortality (adjusted odds ratio=1.51, 95% confidence interval=1.19–1.91, p=0.001), increased mean length of stay (Δ +0.75 days, p<0.001) and increased mean total hospital cost (Δ +$18,263, p<0.001).

Conclusion

Adults with HCM and AFF and/or VTF are older and have higher prevalence of comorbid conditions. Presence of such rhythm abnormalities is an independent predictor of higher mortality, length of stay and total cost in HCM adults admitted to hospital.

Funding Acknowledgement

Type of funding sources: None. Table 1

Genetic Polymorphisms Complicate COVID-19 Therapy: Pivotal Role of HO-1 in Cytokine Storm

Coronaviruses are very large RNA viruses that originate in animal reservoirs and include severe acute respiratory distress syndrome (SARS) and Middle East respiratory syndrome (MERS) and other inconsequential coronaviruses from human reservoirs like the common cold. SARS-CoV-2, the virus that causes COVID-19 and is believed to originate from bat, quickly spread into a global pandemic. This RNA virus has a special affinity for porphyrins. It invades the cell at the angiotensin converting enzyme-2 (ACE-2) receptor and binds to hemoproteins, resulting in a severe systemic inflammatory response, particularly in high ACE-2 organs like the lungs, heart, and kidney, resulting in systemic disease. The inflammatory response manifested by increased cytokine levels and reactive oxygen species results in inhibition of heme oxygenase (HO-1), with a subsequent loss of cytoprotection. This has been seen in other viral illness like human immunodeficiency virus (HIV), Ebola, and SARS/MERS. There are a number of medications that have been tried with some showing early clinical promise. This illness disproportionately affects patients with obesity, a chronic inflammatory disease with a baseline excess of cytokines. The majority of the medications used in the treatment of COVID-19 are metabolized by cytochrome P450 (CYP) enzymes, primarily CYP2D6. This is further complicated by genetic polymorphisms of CYP2D6, HO-1, ACE, and ACE-2. There is a potential role for HO-1 upregulation to treat/prevent cytokine storm. Current therapy must focus on antivirals and heme oxygenase upregulation. Vaccine development will be the only magic bullet.

The Effects of Heme Oxygenase Upregulation on Obesity and the Metabolic Syndrome

Significance: Obesity is a chronic condition that is characterized by inflammation and oxidative stress with consequent cardiovascular complications of hypertension, dyslipidemia, and vascular dysfunction. Obesity-induced metabolic syndrome remains an epidemic of global proportions. Recent Advances: Gene targeting of the endothelium with a retrovirus using an endothelium-specific promoter vascular endothelium cadherin (VECAD)-HO-1 offers a potential long-term solution to adiposity by targeting the endothelium. This has resulted in improvements of both vascular function and adiposity attenuation. Critical Issues: Heme oxygenase plays an ever-increasing role in the understanding of human biology in the complex conditions of obesity and the metabolic syndrome. The heme oxygenase 1 (HO-1) system creates biliverdin/bilirubin, which functions as an antioxidant, and carbon monoxide, which has antiapoptotic properties. Future Directions: Upregulation of HO-1 has been shown to improve adiposity as well as vascular function in both animal and human studies.

Correction: Long-term clinical outcomes in a cohort of patients with solitary plasmacytoma treated in the modern era

[This corrects the article DOI: 10.1371/journal.pone.0219857.].

Long-term clinical outcomes in a cohort of patients with solitary plasmacytoma treated in the modern era

BACKGROUND

The risk of recurrence of solitary plasmacytoma (SP)/progression to MM is well established, but patient, imaging and treatment factors influencing risk of progression require further evaluation.

METHODS

This is a retrospective analysis of 66 SP patients (23 UK, 43 Brazil) diagnosed 1989-2016. Patient baseline characteristics were recorded. The incidence of progression to MM was calculated, including biochemical and imaging findings and the treatment modality received. Survival estimates were determined by Kaplan-Meier analyses.

RESULTS

With a median follow-up of 53.6 months the 5 year overall survival (OS) was 90.7% (95%CI 79-96%). The median progression free survival (PFS) from diagnosis was 61 months. Cumulative incidence of progression to MM was 49.9% at 5 years (95% CI 35.6-62.6%) and was significantly higher with bone plasmacytoma (47.2%, 95%CI 31.9-61.1%), than an extramedullary location (8.3%, 95%CI 0.4-32.3%, Gray test p = 0.0095)). The majority of patients with solitary bony plasmacytoma (SBP) received radiotherapy (RT) (51/53, 96.2%) whereas most extramedullary cases were treated with surgical resection (7/13, 53.8%). A small proportion of SBP patients received additional upfront chemotherapy, with 5/6 in remission after a median follow-up (FU) of 10 years. The diagnostic yield of surveillance functional FU imaging without other indications of relapse/progression was low. The positive predictive value of functional FU imaging was high but with a low negative predictive value, especially in cases of suspected relapse/progression.

CONCLUSION

Our data suggests functional imaging should be used if clinical suspicion of relapse/progression, rather than a routine surveillance tool, and upfront adjuvant chemotherapy is worthy of prospective evaluation.

THE NEUROPATHY SPECTRUM IN WALDENSTRöM'S MACROGLOBULINAEMIA

Background

UK WM Guidelines recognise 2 mechanisms of nervous system involvement either direct tumour invasion of the CNS or antibody mediated damage to peripheral nerves. We present 5 cases illustrating an extended diversity of PNS involvement in WM with implications for treatment and outcome.

Cases

A 73 year-old man (IgMκ WM) developed progressively disabling tremor with stable WM. Neurophysiology was demyelinating with disproportionate DMLs; anti-MAG antibodies were strongly positive. He was treated with DRC with symptom stabilisation.

A 64 year-old woman (IgMκ) with typical anti-MAG neuropathy developed severe episodic foot pain and ulceration. Skin biopsy confirmed leucocytoclastic vasculitis. She was treated with DRC but died from sepsis.

A 43 year-old man (IgMκ WM) with rapidly progressive sensorimotor neuropathy had lymphplasmacytoid cellular infiltrate in sural nerve. He was successfully treated with IDARAM.

A 59 year-old man (IgMλ WM) developed small then large fibre axonal neuropathy with autonomic symptoms within 2 years. A SAP scan showed moderate kidney uptake. MRI neurography directed biopsy and confirmed amyloid. Palliative treatment was offered.

A 70 year-old woman (IgMλ WM) developed severe burning pains in her feet and became ataxic 2 months later. Sural nerve biopsy confirmed endoneurial amyloid. DRC was given.

Discussion

These cases highlight the importance of accurate diagnosis in WM-associated neuropathy. We propose a novel diagnostic algorithm.

Long-term belatacept exposure maintains efficacy and safety at 5 years: results from the long-term extension of the BENEFIT study

The Belatacept Evaluation of Nephroprotection and Efficacy as First-line Immunosuppression Trial randomized patients receiving a living or standard criteria deceased donor kidney transplant to a more (MI) or less intensive (LI) regimen of belatacept or cyclosporine A (CsA). The 5-year results of the long-term extension (LTE) cohort are reported. A total of 456 (68.5% of intent-to-treat) patients entered the LTE at 36 months; 406 patients (89%) completed 60 months. Between Months 36 and 60, death occurred in 2%, 1% and 5% of belatacept MI, belatacept LI and CsA patients, respectively; graft loss occurred in 0% belatacept and 2% of CsA patients. Acute rejection between Months 36 and 60 was rare: zero belatacept MI, one belatacept LI and one CsA. Rates for infections and malignancies for Months 36-60 were generally similar across belatacept groups and CsA, respectively: fungal infections (14%, 15%, 12%), viral infections (21%, 18%, 16%) and malignancies (6%, 6%, 9%). No new posttransplant lymphoproliferative disorder cases occurred after 36 months. Mean calculated GFR (MDRD, mL/min/1.73 m(2) ) at Month 60 was 74 for belatacept MI, 76 for belatacept LI and 53 for CsA. These results show that the renal function benefit and safety profile observed in belatacept-treated patients in the early posttransplant period was sustained through 5 years.

Anatomical and electrophysiological changes in striatal TH interneurons after loss of the nigrostriatal dopaminergic pathway

Using transgenic mice that express enhanced green fluorescent protein (EGFP) under the control of the tyrosine hydroxylase (TH) promoter, we have previously shown that there are approximately 3,000 striatal EGFP-TH interneurons per hemisphere in mice. Here, we report that striatal TH-EGFP interneurons exhibit a small, transient but significant increase in number after unilateral destruction of the nigrostriatal dopaminergic pathway. The increase in cell number is accompanied by electrophysiological and morphological changes. The intrinsic electrophysiological properties of EGFP-TH interneurons ipsilateral to 6-OHDA lesion were similar to those originally reported in intact mice except for a significant reduction in the duration of a characteristic depolarization induced plateau potential. There was a significant change in the distribution of the four previously described electrophysiologically distinct subtypes of striatal TH interneurons. There was a concomitant increase in the frequency of both spontaneous excitatory and inhibitory post-synaptic currents, while their amplitudes did not change. Nigrostriatal lesions did not affect somatic size or dendritic length or branching, but resulted in an increase in the density of proximal dendritic spines and spine-like appendages in EGFP-TH interneurons. The changes indicate that electrophysiology properties and morphology of striatal EGFP-TH interneurons depend on endogenous levels of dopamine arising from the nigrostriatal pathway. Furthermore, these changes may serve to help compensate for the changes in activity of spiny projection neurons that occur following loss of the nigrostriatal innervation in experimental or in early idiopathic Parkinson's disease by increasing feedforward GABAergic inhibition exerted by these interneurons.

Three-year outcomes from BENEFIT, a randomized, active-controlled, parallel-group study in adult kidney transplant recipients

The clinical profile of belatacept in kidney transplant recipients was evaluated to determine if earlier results in the BENEFIT study were sustained at 3 years. BENEFIT is a randomized 3 year, phase III study in adults receiving a kidney transplant from a living or standard criteria deceased donor. Patients were randomized to a more (MI) or less intensive (LI) regimen of belatacept, or cyclosporine. 471/666 patients completed ≥3 years of therapy. A total of 92% (MI), 92% (LI), and 89% (cyclosporine) of patients survived with a functioning graft. The mean calculated GFR (cGFR) was ∼21 mL/min/1.73 m(2) higher in the belatacept groups versus cyclosporine at year 3. From month 3 to month 36, the mean cGFR increased in the belatacept groups by +1.0 mL/min/1.73 m(2) /year (MI) and +1.2 mL/min/1.73 m(2) /year (LI) versus a decline of -2.0 mL/min/1.73 m(2) /year (cyclosporine). One cyclosporine-treated patient experienced acute rejection between year 2 and year 3. There were no new safety signals and no new posttransplant lymphoproliferative disorder (PTLD) cases after month 18. Belatacept-treated patients maintained a high rate of patient and graft survival that was comparable to cyclosporine-treated patients, despite an early increased occurrence of acute rejection and PTLD.

Diltiazem use in tacrolimus-treated renal transplant recipients

BACKGROUND

Calcium channel blockers are widely used in the treatment of post-transplant hypertension but have the potential for drug interaction with calcineurin inhibitors. Renal allograft outcomes when diltiazem is used with cyclosporine have been reported, but similar data with tacrolimus are not available.

METHODS

We performed a retrospective analysis of all our renal transplant recipients from March 1997 to March 2002 who were given tacrolimus, mycophenolate mofetil and prednisone. Patients were divided into two groups based on whether diltiazem was started in the first postoperative week. Outcome measures included renal function up to 2 years post-transplant, blood pressure (BP) control, tacrolimus exposure, and costs related to tacrolimus monitoring.

RESULTS

Sixty-four patients constituted the diltiazem group and 32 the control group. Their baseline characteristics were similar. The mean average daily dose of diltiazem used was 213.95 mg/day. There was no difference in renal function, graft survival, or patient survival over 2 years. BP control was similar although the diltiazem group required more medication. Diltiazem was discontinued in four patients due to side-effects. There was no difference in tacrolimus-related side-effects between the two groups. There was also no difference in tacrolimus exposure, cost related to tacrolimus monitoring, or combined costs when the expense of diltiazem was added.

CONCLUSION

Diltiazem use is acceptably safe and efficacious in renal transplant recipients treated with tacrolimus-based immunosuppressive therapy. It can be considered as a first-line antihypertensive in these patients and is cost neutral for tacrolimus use.

Cost-benefit analysis and prediction of 24-hour proteinuria from the spot urine protein-creatinine ratio

AIM

A prospective cross-sectional study was performed on 170 patients with various glomerular diseases to study the accuracy of predicting 24-hour proteinuria from the spot urine protein-creatinine ratio (Up/Uc). A cost-benefit analysis was performed for the New Zealand health economic system to obtain the best cut-off values for proteinuria.

SUBJECTS, METHODS AND RESULTS

Two spot urine samples (Up/Uc1 and Up/Uc2) were collected on the same day as the collection of a 24-hour urine. A randomly chosen subsample of 50 patients provided a second set of urine samples. The correlation and precision of agreement between the two methods were examined. The predictive intervals were calculated for derived 24-hour proteinuria. The level of agreement was evaluated by the Bland-Altman method and concordance analysis. The limits of agreement were evaluated against the clinical limits of agreement. A cost-benefit analysis (CBA) was performed to obtain the optimum operating points on receiver operating characteristic (ROC) curves for the best decision threshold. Correlations of r = 0.97 and 0.99 were observed between Up/Uc1, Up/Uc2 and 24-hour proteinuria, respectively. The 95% predictive intervals were wide. A high concordance correlation coefficient was obtained. The most of the differences between the two methods fell within the clinical limits of agreement. The Up/Uc1 of 0.26 and 3.20 represent the best thresholds to detect normal and nephrotic proteinuria, respectively.

CONCLUSIONS

Despite wide confidence intervals, a good correlation and precision of agreement were demonstrated between the two methods across the whole range of proteinuria, regardless of the level of renal function. The difference between the two methods was less than the biological variability in the protein excretion and its measurement, enabling the methods to be used interchangeably. The optimum thresholds for abnormal and nephrotic range proteinuria were obtained.

Acute renal failure in a renal transplant donor due to primary antiphospholipid syndrome

Primary antiphospholipid antibody (APA) syndrome, a common prothrombotic disorder, has been known in dialysis patients and renal transplant recipients. We report a case of primary APA syndrome presenting as a posttransplant complication in a renal transplant donor. A renal donor presented with acute, painless anuria due to renal artery thrombosis 6 years following renal transplant surgery, subsequent thrombosis of jugular catheter and arteriovenous fistula occurred, despite anticoagulation treatment, due to primary APA syndrome. This incident represents the most catastrophic complication reported in a renal donor due to primary APA syndrome. The validity of a prothrombotic assay in an organ donor workup to detect predilection to hypercoagulable disorders and to prevent such complications is open to question. The actual significance of APA in the blood is unclear; hence, the presence of APA in a potential renal donor would pose an ethical and practical dilemma.