Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

Sperm preparation and in utero insemination in the management of subfertility

OBJECTIVE

To study the place of sperm preparation and in utero insemination in subfertile couples in whom ovulatory and tubal aetiological factors have been excluded or treated.

DESIGN

A retrospective cohort study.

SETTING

Diagnostic Seminology Laboratory, Galle.

SUBJECTS AND METHODS

Patients (n = 325) who had in utero insemination (IUI) from September 1990 to June 1994 were studied retrospectively. All had stimulation of ovaries with clomiphene and the Insler score was used to confirm ovulation before IUI. Swim up, spin down and glass wool filtration techniques, and the Earl's balanced salt solution with human serum albumin were used for sperm preparation.

MAIN OUTCOME MEASURES

Association between variables.

RESULTS

Of the subjects 97(30%) had male factor, 79(24%) abnormal sperm-cervical mucous interaction and 41(13%) idiopathic subfertility. In 114(35%) the cause was not documented. The number of IUI attempts per subject ranged from 1 to 19 with a mean of 4.2 and SD 3.2. There were no significant difference in conception rates in relation to the different methods of sperm preparation or the underlying aetiological factor.

CONCLUSION

Sperm preparation and in utero insemination are feasible in Galle and should be considered as an option in the treatment of subfertility.

Age-associated changes in mitogen-induced lymphoproliferation and lymphokine production in the long-lived brown-Norway rat: effect of caloric restriction

We have previously demonstrated that age-related declines in Concanavalin A (ConA), induced proliferation and lymphokine production, occur in ad-libitum fed Brown Norway (AL BN) rats. Since caloric restriction (CR) extends lifespan, we expected that the age related changes in immune parameters would be delayed by CR. CR does act to delay age-related changes in proliferation in response to ConA. In addition, CR postpones the plateau in ConA induced interferon (IFN) production seen after 23 months of age in AL rats. However, CR does not postpone the age-related decline in ConA induced interleukin-2 (IL-2) production. Therefore, ConA induced IFN production maybe a good candidate as an early marker of physiologic aging, while ConA induced proliferative response is a possible candidate for a marker of late stages of aging.

Monocyte culture and adherence modifies LPS-induced IL-6 production and inhibition by hydrocortisone

The effect of hydrocortisone (HC) on IL-6 production by monocytes (Mo) that were cultured under either adherent or limited-adherent culture conditions was determined. Although freshly isolated Mo produced more IL-6 in response to LPS than Mo cultured 24 hr, culture had little effect on inhibition of IL-6 by HC. In contrast, the conditions of Mo culture had a significant impact on the kinetics of IL-6 production and inhibition by HC. Adherent Mo produced significantly higher levels of IL-6 4 hr after LPS compared to limited-adherent Mo. By 12 hr of LPS stimulation, comparable quantities of IL-6 were produced by both cultures. HC inhibition was complete 4 hr after LPS stimulation of adherent Mo, while 12 hr was required for maximum inhibition of limited-adherent Mo. Production of an IL-6 inhibitor was not responsible for the increased inhibition by HC with adherence, because both IL-6 protein and bioactivity were comparably decreased. The kinetics of inhibition of TNF alpha and IL-1 beta production by HC were similarly affected by adherence. Phenotypic analysis of cultured vs freshly isolated Mo showed a decrease in Mo expressing CD14, but not CD11b, which paralleled a decrease in IL-6 production by the cultured Mo. However, there were no phenotypic differences between adherent and limited-adherent Mo. The results demonstrate that the time of Mo culture, as well as adherence, may serve to alter LPS-induced IL-6 production and its inhibition by HC.

Age associated changes in mitogen induced proliferation and cytokine production by lymphocytes of the long-lived brown Norway rat

The long-lived, inbred Brown Norway (BN) rat demonstrates an age associated decrease in lymphoproliferation in response to ConA; however, these declines only become apparent after the age of median survival, 31 months. Significant declines in IL-2 production after ConA stimulation also occur after median survival. In contrast, production of IFN after ConA stimulation increases with age in BN rats. This increase in IFN production begins about 12 months of age and plateaus at about median lifespan. The imbalance in IL-2 and IFN production may reflect a dysregulation that results in a decreased proliferative response of lymphocytes with increasing age.

Maintenance of normal T lymphocyte function after transfection with SV40 large T

Human T lymphocytes in culture undergo cellular senescence similar to that observed in fibroblasts. We recently demonstrated that senescence of T lymphocytes can be postponed by transfection with SV40 large T. In the current study, we examine the functional activity of SV40 large T transfected T lymphocytes. Transfected T cells of both young and elderly subjects appear to display normal T cell function: they cease doubling upon removal of IL-2; in the presence of autologous adherent mononuclear cells they respond to mitogen stimulation and produce IL-2 and IFN-gamma during proliferation; and they express both IL-2 and transferrin receptors similar to those observed in mitogen-stimulated nontransfected T cells. In addition, more than 90% of the transfected cells express both the CD4 and "naive" T cell marker, CD45RA. In order to investigate whether the lack of long-lived CD8+ cells reflects phenotypic restriction, separated CD4+ and CD8+ subpopulations were transfected with SV40 large T. All transfections resulted in extended life spans of CD4+, but not CD8+, cells. Therefore, although SV40 large T transfected T lymphocytes maintain normal function, while demonstrating an extended life span, the effect may be restricted to CD4+ cells.

Extension of lifespan of human T lymphocytes by transfection with SV40 large T antigen

Lymphocytes have a finite and predictable proliferative life span in culture similar to that observed in fibroblasts. In general, the senescence of human fibroblasts is inevitable and irreversible, but their proliferative life span can be extended by certain DNA tumor virus oncogenes, such as the large T antigen of the SV40 virus. Here, we show that human T lymphocytes (HTL) can be stably transfected with SV40 large T and that expression of T antigen extended the life span of T cell cultures. PHA-stimulated HTL were transfected with pSV3neo, an expression vector containing the SV40 early region and the neomycin resistance gene. Transfectants were selected for neomycin (G418) resistance. Control HTL, either mock transfected or transfected with pSV2neo (containing the neomycin resistance gene only), ceased proliferation after about 17 population doublings. In contrast, HTL transfected with pSV3neo underwent more than 170 doublings. pSV3neo-transfected cells expressed SV40 large T RNA, detectable by in situ hybridization, and SV40 T antigen, detectable by immunofluorescence. Greater than 95% of the transfected cells were CD4 positive. These results clearly show that SV40 large T enables HTL to escape senescence. Transfection with SV40 large T may be a valuable method for obtaining long term human T cell lines for studies of both aging and immunology.

T-cell function in aging: mechanisms of decline

The above sections have provided numerous facts, many of which are conflicting, regarding the changes that occur with increasing age in T lymphocytes. Although it is impossible to state with absolute certainty the alterations that are responsible for decreased proliferation of lymphocytes from elderly subjects, the following summarizes the current status of the data: 1. The interaction of T lymphocytes with foreign stimuli appears to be generally intact. 2. Changes in numbers of CD3+, CD4+, or CD8+ cells before interaction with foreign stimuli or in the density of these markers or of mitogen receptors on the surface of aged T cells have not been consistently observed. When reported to occur, the changes are not sufficient to account for the significant decrease in T-cell proliferation that occurs with increasing age. 3. A defect in the ability of the membrane interaction with foreign stimulus to signal subsequent internal events may occur, because stimulation with phorbol esters and calcium ionophore can result in increased proliferation in some elderly subjects. 4. Decreased accumulation of cytosolic calcium after stimulation of elderly T cells occurs in mice and may be a major component of the defective activation system. This defect appears to be most apparent in the "memory" T cells (T cells expressing high levels of Pgp-1), which increase in number with increasing age. Decreases in Ca++ accumulation have not been observed in humans, but this may be due to different stimuli used. Further, investigation of an increase in "memory" T cells and of their inability to mobilize Ca++ has not been done in humans and rats. 5. Decreases in mRNA for c-myc, IL-2 receptor, and IL-2 have been reported in some, but not all, species. Whether these decreases are the result of decreases in Ca++ mobilization or are independent events in unknown. 6. Decreases in membrane expression of the activation marker RL388 and of TfR have been reported. 7. Lymphokines: a. Decreases in IL-2 production occur in mice and humans, but not in rats. In individuals with decreased IL-2 production, addition of exogenous IL-2 totally restores proliferative ability in only some individuals. Changes in IL-2R expression (number or affinity) may be an additional defect. b. Decreases in IFN-gamma occur in humans, but not in mice or rats. c. No change in IL-1 occurs in any species. Genotypic effects must be considered when evaluating the preceding observations. The heterogeneity among individuals, even within an inbred strain, cannot be discounted.(ABSTRACT TRUNCATED AT 400 WORDS)

Heterogeneity of changes in lymphoproliferative ability with increasing age

Although mean mitogen-induced lymphoproliferation decreases with increased age, the response of individual subjects demonstrates great heterogeneity. Results of this study clearly illustrate that individual variation is apparent not only in the level of proliferation, but also in the amount of interleukin-2 (IL-2) detectable after mitogen stimulation. Further, addition of exogenous IL-2 significantly increases proliferation in only about one third of elderly subjects. Data from inbred strains of rats housed under identical environmental conditions indicate that although genetic factors greatly influence both the level of proliferation and the rate of decline with age, variation occurs even within one inbred strain of rat.

Vitamin A deficiency decreases natural killer cell activity and interferon production in rats

We examined the effect of vitamin A deficiency on natural killer (NK) cell activity and interferon (IFN) production. Rats were weaned at 16 or 21 d of age onto semisynthetic diets containing either 0 or 4 micrograms retinol/g diet. At the time of study, retinol-depleted rats had serum vitamin A concentrations less than 7% of those of pair-fed controls. In two studies, rats exhibited no external signs of retinol deficiency, but with further depletion some symptoms were observed. Splenic NK cell activity against chromium-51-labeled YAC-1 cells was significantly decreased in vitamin A-depleted rats (22-80% of values for control rats, depending on the degree of retinol deficiency), regardless of the ratio of effector to target cells used. When vitamin A-depleted rats were repleted orally with retinol, NK cell activity was consistently normalized. To understand the possible mechanisms involved in decreasing NK cell activity, we investigated IFN production by concanavalin A-stimulated spleen cells from vitamin A-depleted, from repleted and from control animals. IFN titers were significantly decreased (22-33% of values for control rats) in supernatants of spleen cell cultures of the vitamin A-depleted rats. Repletion with vitamin A resulted in IFN activities ranging from 80 to 130% of controls. Adding alpha/beta IFN in vitro to the spleen cells of vitamin A-depleted animals increased their NK cell activity. The number of spleen cells reacting with a monoclonal antibody specific for rat NK cells was slightly lower in retinol-depleted rats, but not enough to account for the differences in NK cell and IFN activities. These data suggest that vitamin A deficiency affect the nonspecific arm of the immune system, possibly by altering the functional capacity of cells to produce lymphokines needed for the generation of an appropriate cytolytic response.