Mortality and risk factors of vaccinated and unvaccinated COVID-19 frail patients treated with anti-SARS-CoV-2 monoclonal antibodies. A real-world study

BACKGROUND

There is a scarcity of data on outcomes and predictors of therapeutic failure of mAbs in frail COVID-19 patients.

METHODS

Prospective study including consecutive COVID-19 outpatients referred by primary care physicians for mAbs treatment. Outcomes evaluated were 60-day mortality, time to SARS-CoV-2 clearance, need for hospitalization, and O₂-therapy.

RESULTS

Among 1026 COVID-19 patients enrolled, 60.2% received casirivamab/imdevimab and 39.8% sotrivimab. Median age was 63 years, 52.4% were males and median time from positive nasopharyngeal swab to mAbs administration was 3 days [IQR, 2-5]. 78.1% were vaccinated. Overall, 60-day mortality was 2.14%. No differences in outcomes were observed between the two mAbs used. No difference was observed in mortality between vaccinated and unvaccinated patients (p=0.925), although lower rate of hospitalization (p<0.005), less need for O₂-therapy (p<0.0001) and reduced nasopharyngeal swab negativity time (p<0.0001) were observed in vaccinated. Early administration of mAbs was associated with lower mortality (p<0.007), while corticosteroid use worsened prognosis (p<0.004). Independent predictors associated with higher mortality were older age (p<0.0001), presence of active haematological malignancies (p<0.0001), renal failure (p<0.041) and need for O₂-therapy (p<0.001).

CONCLUSION

This study shows similar effectiveness among mAbs used regardless of vaccination status and identifies COVID-19 patients in whom mAbs have poor activity.

214 THE IMPACT OF ARRHYTHMIA ON PROGNOSIS IN HOSPITALIZED COVID-19 PATIENTS. A CARDIAC TELEMETRIC MONITORING STUDY

Background

Cardiovascular abnormalities have been largely reported in patients with COVID-19. Among these, myocardial injury and rhythm disorders represent one of the most important complications in patients affected by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection. Moreover, a poorer prognosis has been documented in COVID-19 patients when complicated by arrhythmias, independently by age and sex.

Objectives

The aims of the present study were to identify some of non-cardiac and cardiac comorbidities and some myocardial electrical features (including QT dispersion) associated with arrhythmia in hospitalized COVID-19 patients. Moreover, another objective was to contribute in analyzing the impact of arrhythmias on outcome in this setting of patients.

Methods

At admission, each patient underwent cardiac telemetry monitoring through entire hospitalization period. In all the subjects, laboratory analyses, standard 12-lead electrocardiogram (both at admission and on discharge), and lung imaging examination (by means of both ultrasound scans and computed tomography) were performed. Patients exhibiting arrhythmia during in-hospital period were divided into three groups: i, with brady-arrhythmias; ii, with tachy-arrhythmias; and, iii, with tachy- and brady-arrhythmias.

Results

Two-hundred patients completed the study (males, 123; mean age, 70.1 years); of these, 80 patients (40%) exhibited rhythm disorders on cardiac telemetry. Patients with arrhythmia resulted to be older (p&lt;0.0001) than patients without arrhythmia. Moreover, patients with arrhythmia showed: i, greater number of comorbidities (p&lt;0.0001); ii, higher values of creatinine (p=0.007), B-type natriuretic peptide (p&lt;0.0001), troponin (p&lt;0.0001), c-reactive protein (p=0.01), ferritin (p=0.001), d-dimer (p&lt;0.0001), and procalcitonin (p=0.0008); iii, QT interval (p=0.002), QTc interval (p=0.04), and QTc dispersion (p=0.01); and, iiii, lower values of sodium (p=0.03), magnesium (p=0.04), glomerular filtration rate (p&lt;0.0001), and hemoglobin (p=0.008) as compared to patients without arrhythmia. By comparing the three subgroups of patients, no significant differences were found. Multivariate analysis showed that age (OR=1.14 [95% CI: 1.07-1.22]; p=0.0004), coronary artery disease (OR=12.7 [95% CI: 2.38-68.01]; p=0.005), and circulating troponin (OR=1.05 [95% CI: 1.003-1.10]; p=0.04) represented risk factors independently associated with arrhythmia. By analyzing all-cause in-hospital mortality, it resulted a ∼forty-fold higher among patients with arrhythmia (OR=39.66 [95% CI: 5.20-302.51]; p=0.0004) when compared to patients without rhythm disorders.

Conclusion

In the present study, arrhythmias have been to be associated with ageing, coronary artery disease, subtle myocardial injury, hyperinflammatory status, coagulative unbalance, and abnormalities in myocardial electrical impulse propagation in patients affected by SARS-CoV-2 infection. In alignment with previous reports, the presence of arrhythmia seems to be associated with a worse in-hospital prognosis. Given its usefulness, routinary use of cardiac telemetric monitoring should be encouraged in COVID wards.

Platypnea-orthodeoxia syndrome in SARS-CoV-2 related ARDS: a case report

Platypnea-Orthodeoxia Syndrome (POS) is an often misdiagnosed clinical condition characterized by dyspnea and hypoxia in sitting or semi-sitting position, reversible in supine position. Although POS is typically associated with intracardiac shunts, it seems frequent also in SARS-CoV-2 related Acute Respiratory Distress Syndrome (ARDS). In fact, the prevalent involvement of the lung bases due to interstitial pneumonia can determine refractory positional hypoxemia, with marked desaturation in the sitting position and regression or improvement in the supine position, configuring the clinical picture of the POS. We present a clinical case of POS associated with acute respiratory distress from SARS-CoV-2 pneumonia in which refractory hypoxia would have required support by invasive mechanical ventilation if the syndrome had not been identified.

Knowledge and attitudes towards clinical trials among women with ovarian cancer: results of the ACTO study

Background

Despite several initiatives by research groups, regulatory authorities, and scientific associations to engage citizens/patients in clinical research, there are still obstacles to participation. Among the main discouraging aspects are incomplete understanding of the concepts related to a clinical trial, and the scant, sometimes confused, explanations given. This observational, cross-sectional multicenter study investigated knowledge, attitudes and trust in clinical research.

We conducted a survey among women with ovarian cancer at their first follow-up visit or first therapy session, treated in centers belonging to the Mario Negri Gynecologic Oncology (MaNGO) and Multicenter Italian Trials in Ovarian Cancer (MITO) groups. A questionnaire on knowledge, attitudes and experience was assembled ad hoc after a literature review and a validation process involving patients of the Alliance against Ovarian Cancer (ACTO).

Results

From 25 centers 348 questionnaire were collected; 73.5% of responders were 56 years or older, 54.8% had a high level of education, more than 80% had no experience of trial participation. Among participants 59% knew what clinical trials were and 71% what informed consent was. However, more than half did not know the meaning of the term randomization. More than half (56%) were in favor of participating in a clinical trial, but 35% were not certain. Almost all responders acknowledged the doctor’s importance in decision-making. Patients’ associations were recognized as having a powerful role in the design and planning of clinical trials.

Conclusions

This study helps depict the knowledge and attitudes of women with ovarian cancer in relation to clinical trials, suggesting measures aimed at improving trial “culture”, literacy and compliance, and fresh ways of communication between doctors and patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-022-00970-w.

Non-invasive respiratory support in SARS-CoV-2 related acute respiratory distress syndrome: when is it most appropriate to start treatment?

BACKGROUND

Acute respiratory distress syndrome (ARDS) is one of the most severe complications of SARS-CoV-2 infection. Non-Invasive Respiratory Support (NRS) as Continuous Positive Airway Pressure (CPAP) and/or Non-Invasive Ventilation (NIV) has been proven as effective in the management of SARS-CoV-2-related ARDS. However, the most appropriate timing for start NRS is unknown.

METHODS

We conducted a prospective pilot study including all consecutive patients who developed moderate SARS-CoV-2-related ARDS during hospitalization. Patients were randomly divided into two intervention groups according to ARDS severity (assessed by PaO₂/FiO₂-P/F) at NRS beginning: group A started CPAP/NIV when P/F was ≤ 200 and group B started CPAP/NIV when P/F was ≤ 150. Eligible patients who did not give their consent to CPAP/NIV until the severe stage of ARDS and started non-invasive treatment when P/F ≤ 100 (group C) was added. The considered outcomes were in-hospital mortality, oro-tracheal intubation (OTI) and days of hospitalization.

RESULTS

Among 146 eligible patients, 29 underwent CPAP/NIV when P/F was ≤ 200 (Group A), 68 when P/F was ≤ 150 (Group B) and 31 patients agreed to non-invasive treatment only when P/F was ≤ 100 (Group C). Starting NRS at P/F level between 151 and 200 did not results in significant differences in the outcomes as compared to treatment starting with P/F ranging 101-150. Conversely, patients undergone CPAP/NIV in a moderate stage (P/F 101-200) had a significantly lower in-hospital mortality rate (13.4 vs. 29.0%, p = 0.044) and hospitalization length (14 vs. 15 days, p = 0.038) than those in the severe stage (P/F ≤ 100). Age and need for continuous ventilation were independent predictors of CPAP/NIV failure.

CONCLUSIONS

Starting CPAP/NIV in patients with SARS-CoV-2-related ARDS in moderate stage (100 > P/F ≤ 200) is associated to a reduction of both in-hospital mortality and hospitalization length compared to the severe stage (P/F ≤ 100). Starting CPAP/NIV with a P/F > 150 does not appear to be of clinical utility.

EGFR and K-Ras mutations in women with lung adenocarcinoma: implications for treatment strategy definition

Background

We aimed at investigating the outcomes of female patients with stage IIIB-IV adenocarcinoma of the lung according to EGFR and K-Ras mutational status.

Methods

One hundred and three consecutive female patients genotyped at a single Italian Institution were analyzed. Patients were planned to receive first-line platinum-based chemotherapy (CT) and a salvage treatment with anti-EGFR tyrosine-kinase inhibitors (TKIs) was proposed irrespective of tumor mutational status. EGFR (exons 18–21) and K-Ras (exon 2, codons 12–13) mutations were evaluated by real-time PCR and pyrosequencing. The association of mutational status with clinical variables and treatment benefit was investigated by chi-square test and log-rank test.

Results

EGFR and K-Ras mutations were found in 31 (30%) and 13 (15%) cases, respectively. Sixty-six patients received platinum CT: no correlation was observed between EGFR or K-Ras mutational status and response rate (RR) (p > 0.05). However, patients treated with first-line CT harboring EGFR activating mutations experienced a significantly reduced progression-free survival (PFS) in comparison with wild-type ones (4.4 vs. 6.4 months, respectively; HR 0.597, 95% CI 0.287-0.975; p = 0.048). Thirty-nine patients received salvage treatment with erlotinib: EGFR activating mutations were significantly correlated with RR (60% vs. 12.5%; p = 0.004) and PFS (11.4 vs. 4.5 months; HR 0.491, 95% CI 0.216-0.936; p = 0.044). Responses to erlotinib were not reported among women with K-Ras mutant tumors, while 50% of those with wild-type K-Ras achieved an objective remission (p = 0.296). Median PFS (3.5 vs. 8.8 months; HR 0.284, 95% CI 0.015-0.510; p = 0.010) and OS (3.9 vs. 19.8 months; HR 0.158, 95% CI 0.001-0.075; p < 0.001) were significantly shorter among K-Ras mutant patients treated with TKI.

Conclusions

In our population of Caucasian women with advanced lung adenocarcinoma we observed that the presence of EGFR activating mutations correlates with a significant reduction in the benefit from first-line platinum-based CT, emphasizing the importance of an upfront use of anti-EGFR TKIs in this patient subset. K-Ras mutations seem to correlate with a detrimental effect from anti-EGFR TKI, but this finding deserves further investigation.

Polymyositis occurring during alpha-interferon treatment for malignant melanoma: a case report and review of the literature

Polymyositis is a systemic autoimmune disorder characterised by proximal muscle weakness which most frequently involves the limbs, neck and trunk. Alpha interferon is an antiviral molecule with well-known immunomodulatory and antiproliferative effects, but its use is often associated with a variety of side effects, in particular autoimmune phenomena. We report the occurrence of polymyositis during treatment with alpha-interferon in a patient affected by malignant melanoma. Indirect evidence suggests that in this case the patient's myositis was not linked to her neoplasia, since the melanoma was confirmed to be in remission both at the time of the diagnosis of the muscle disease and again after more than one year of follow-up.

[Microscopic polyangiitis. A case report]

We describe a 36 year old male patient affected by microscopic polyangiitis; he was treated with corticosteroic and cyclophosphamide pulses obtaining clinical improvement and remission and acute flogistic index normalization. The peculiar aspect is a stable remission during a four years follow up; the only relapse was controlled with low dose of corticosteroids.

Comparison of the effect of a single oral L-thyroxine dose (150 micrograms) in tablet and in solution on serum thyroxine and TSH concentrations

150 micrograms of L-thyroxine were administered to each of 14 euthyroid goitrous patients orally between 7:30 and 8:30 a.m. after fasting overnight. The L-T4 dose given was one and half tablets of the drug "Eutirox" (L-T4 tablet of 100 micrograms distributed by Bracco, Milan, Italy) or one and half ml of the solution "Tiroxen" (solution containing 100 micrograms/ml of L-T4 distributed by Laboratori Baldacci, Pisa, Italy). Two studies (one with tablet and one with solution) were performed on each patient. The tablet or the liquid form of L-T4 were administered in random order. In each study a blood sample for serum hormone determination was drawn immediately before L-T4 administration, then 30 minutes later and every hour up to the fifth hour after. The second study was performed in similar fashion later. The mean serum TT4 concentration value at any time was very similar in the two studies, thus showing the same time course after the administration of solution and the tablet formulation. The mean basal TT4 value (9.07 +/- 0.56 and 8.90 +/- 0.73 micrograms/dl respectively) increased significantly at the first and second hours. The highest value was reached at the second and at the third hour after the solution (11.15 +/- 0.58 micrograms/dl) and the tablet (11.81 +/- 0.78 micrograms/dl) respectively. Subsequently, the mean TT4 values remained significantly higher than basally over the entire 5 hours. The FT4 mean serum concentration at all times were very similar in the two studies and showed the same time course.(ABSTRACT TRUNCATED AT 250 WORDS)