Statin Use in Hospitalized Patients with COVID-19: A Comprehensive Analysis of the New York City Public Hospital System

INTRODUCTION

Statins have been commonly used for primary and secondary cardiovascular prevention. We hypothesized that statins may improve in-hospital outcomes for hospitalized patients with Coronavirus disease 2019 (COVID-19) due to its known anti-inflammatory effects.

METHODS

We conducted a retrospective study at the largest municipal health care system in the United States, including adult patients who were hospitalized for COVID-19 between March 1 and December 1, 2020. The primary endpoint was in-hospital death. Propensity score matching was conducted to balance possible confounding variables between patients receiving statins during hospitalization (statin group) and those not receiving statins (non-statin group). Multivariate logistic regression was used to evaluate the association of statin use and other variables with in-hospital outcomes.

RESULTS

There were 8897 patients eligible for study enrollment, with 3359 patients in the statin group and 5538 patients in the non-statin group. After propensity score matching, both the statin and non-statin groups included 2817 patients. Multivariate logistic regression analysis showed that the statin group had a significantly lower risk of in-hospital mortality (odds ratio 0.71; 95% confidence interval, 0.63-0.80; P < .001) and mechanical ventilation (OR 0.80; 95% confidence interval, 0.71-0.90; P < .001) compared with the non-statin group.

CONCLUSION

Statin use was associated with lower likelihood of in-hospital mortality and invasive mechanical ventilation in hospitalized patients with COVID-19.

Eosinopenia and COVID-19

CONTEXT

Early diagnosis of coronavirus disease 2019 (COVID-19) and patient isolation are important for both individual patient care and disease containment. The diagnosis is confirmed by testing for the presence of nasopharyngeal viral RNA with a polymerase chain reaction assay, which has limited availability, variable turnaround time, and a high false-negative rate. The authors report that a rapid laboratory test, the eosinophil count, readily obtained from a routine complete blood cell count (CBC), may provide actionable clinical information to aid in the early recognition of COVID-19 in patients, as well as provide prognostic information.

OBJECTIVE

To investigate the diagnostic and prognostic value of eosinopenia in COVID-19-positive patients.

METHODS

The eosinophil results of routine CBC from the first 50 admitted COVID-19-positive patients were compared with the eosinophil results of 50 patients with confirmed influenza infection at the time of presentation to the emergency department at Coney Island Hospital in Brooklyn, New York. The number of patients with 0 eosinophils on the day of presentation was also compared between the 2 groups. Furthermore, the eosinophil counts in the 50 COVID-19 patients were reviewed for the first 5 days of their hospital stay and before discharge, along with the outcome (deceased vs discharged), and trends in eosinophil data were compared based on the outcome.

RESULTS

On the day of presentation, 30 patients in the COVID-19 group (60%) and 8 patients in the influenza group (16%) had an eosinophil count of 0. An additional 14 patients in the COVID-19 group had 0 eosinophils during the following 2 days; the total number of patients in the COVID-19 group who had 0 eosinophils on admission or during the ensuing 2 days was 44 (88%). In addition, 18 of 21 deceased patients in the COVID-19 group (86%) who initially presented with eosinopenia remained eosinopenic compared with 13 of 26 survivors (50%).

CONCLUSION

The absence of an eosinophil count in a CBC can aid in early diagnosis of COVID-19. It may be a useful tool in deciding whether to promptly isolate a patient and initiate specific therapies while waiting for confirmatory test results. Persistent eosinopenia after admission correlated with high disease severity and low rates of recovery.

AACE/ACE disease state commentary: molecular diagnostic testing of thyroid nodules with indeterminate cytopathology

• Approximately 10 to 25% of fine-needle aspiration (FNA) biopsies yield an indeterminate result often labeled as atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) or follicular neoplasm/suspicious for follicular neoplasm (FN/SFN). The risk of malignancy typically varies between 15 and 30% for these categories. • Although many markers are in development and have been studied in a research setting, 2 principal tests are currently marketed for use to improve the malignancy risk assessment of "indeterminate" thyroid nodules. "Rule In" and "Rule Out" tests attempt to confirm or exclude the presence of cancer within a thyroid nodule by means of robust positive (PPV) or negative predictive values (NPV), respectively. • The Rule In tests determine the presence of single gene point mutations (BRAFV600E or RAS) or gene rearrangements (RET/PTC, PAX8/PPARγ) that have been shown to increase the ability to predict cancer, while the Rule Out test (Afirma® gene expression classifier, GEC) utilizes a proprietary gene expression classifier (RNA expression) specifically designed to maximize the ability to define a process as benign. • Among the presently available tests, only the BRAFV600E and RET/PTC rearrangement are associated with a PPV that approaches 100%. • The category of cytologically "indeterminate" nodule (AUS/FLUS, FN/SFN), cytopathology practice patterns, and the prevalence of malignancy within the population being tested all impact the NPVs and PPVs for the tests in question. • At present, molecular testing is meant to complement and not replace clinical judgment, sonographic assessment, and visual cytopathology interpretation. • As molecular testing is new and advances in the field are regularly occurring, clinicians need to stay informed, as recommendations for use within practice are expected to evolve.

The clinical endocrinology workforce: current status and future projections of supply and demand

CONTEXT

Many changes in health care delivery, health legislation, and the physician workforce that affect the supply and demand for endocrinology services have occurred since the first published workforce study of adult endocrinologists in 2003.

OBJECTIVE

The objective of the study was to assess the current adult endocrinology workforce data and provide the first analysis of the pediatric endocrinology workforce and to project the supply of and demand for endocrinologists through 2025.

DESIGN

A workforce model was developed from an analysis of proprietary and publicly available databases, consultation with a technical expert panel, and the results of an online survey of board-certified endocrinologists.

PARTICIPANTS

The Endocrine Society commissioned The Lewin Group to estimate current supply and to project gaps between supply and demand for endocrinologists. A technical expert panel of senior endocrinologists provided context, clinical information, and direction.

MAIN OUTCOME MEASURES

The following were measured: 1) the current adult and pediatric endocrinology workforce and the supply of and demand for endocrinologists through 2025 and 2) the number of additional entrants into the endocrinology work pool that would be required to close the gap between supply and demand.

RESULTS

Currently there is a shortage of approximately 1500 adult and 100 pediatric full-time equivalent endocrinologists. The gap for adult endocrinologists will expand to 2700 without an increase in the number of fellows trained. An increase in the prevalence of diabetes mellitus further expands the demand for adult endocrinologists. The gap can be closed in 5 and 10 years by increasing the number of fellowship positions by 14.4% and 5.5% per year, respectively. The gap between supply and demand for pediatric endocrinologists will close by 2016, and thereafter an excess supply over demand will develop at the current rate of new entrants into the work force.

CONCLUSIONS

There are insufficient adult endocrinologists to satisfy current and future demand. A number of proactive strategies need to be instituted to mitigate this gap.

Potential benefit of hormonal therapy for non-uterine soft tissue sarcoma (STS) - a case report and literature review

The expression of hormone receptors (HR) is considered a good prognostic marker in uterine sarcoma. Hormonal therapy is widely employed in the therapy of HR positive breast and gynecologic cancers, however, there is little information concerning hormonal therapy in HR positive extrauterine sarcoma.

A 55-60 year age group female presented with an estrogen receptor positive metastatic retroperitoneal leiomyosarcoma (LMS). She was treated with four cycles of a combination of Gemcitabine and Paclitaxel. Her disease remained stable for 29 months when tamoxifen was initiated. The patient succumbed to an unrelated malignancy after a total of 44 months of treatment.

Despite emerging reports about the potential benefit of hormonal therapy, selective estrogen and progesterone receptor modulators and aromatase inhibitors, for uterine sarcoma, there is a paucity of information regarding the application of these therapies to sarcomas arising at other sites. Our patient survived significantly longer than expected with metastatic retroperitoneal sarcoma. In part this may be due to the survival benefit associated with HR positive tumors, but it may also indicate a role for hormonal therapy which has yet to be explored.

Effect of early referral to an endocrinologist on efficiency and cost of evaluation and development of treatment plan in patients with thyroid nodules

Radionuclide uptake and scan and sonogram, frequently ordered before referral to an endocrinologist, are expensive and poor predictors of thyroid nodule malignancy. We estimated costs of excessive imaging and other studies by reviewing the records of all patients (n = 70) referred to a single, consulting endocrinologist, for thyroid nodule evaluation in a 2-yr interval and subsequently, presenting only pertinent histories and results of physical examinations, thyroid function tests, and thyroid autoantibodies, to a second, reviewing endocrinologist (RE) who was blinded to diagnosis and management. Concordance in diagnosis and management between consulting endocrinologist and RE was 87.1% and 93.4%, respectively. Accuracy of diagnosis, loss of patient's time (8.7 h, average), and cost of unnecessary testing, defined as tests not required by the RE for diagnosis and management according to published guidelines, were determined. Unnecessary testing included 153 physician's office or diagnostic laboratory visits, 44 sets of thyroid function tests, 32 radionuclide uptake and scan, 39 thyroid sonograms, and 3 computed tomography scans. The total direct cost of unnecessary tests was estimated at $27,290 ($390/patient) in addition to costs of 30 unnecessary physician's office visits. Only 2 of 8 surgical referrals required surgery, whereas 6 other patients required surgery, including 3 with papillary carcinoma. We conclude that early referral to an endocrinologist of patients with suspected thyroid nodules results in significant savings in cost of evaluation, patient's time, and increased diagnostic precision. Six of the 8 patients referred for surgery before endocrine consultation had benign thyroid disease that did not require surgery. Six additional patients were referred to surgery, 3 of whom had papillary thyroid carcinoma. Early referral of patients with suspected thyroid nodules to an endocrinologist results in significant savings in both cost and patient's time as well as increased precision of diagnosis.

Endocrine-mediated mechanisms of fatigue during treatment with interferon-alpha

Fatigue occurs in more than 70% of patients treated with interferon-alpha (IFN-alpha) and is the most problematic toxicity associated with IFN-based immunotherapy. Abundant evidence suggests that immune-mediated endocrine disease occurs during IFN-alpha therapy, which may contribute to the etiology of fatigue. Autoimmune thyroid disease is a well-recognized consequence of IFN-alpha therapy and may be mediated by the induction of IFN-gamma production by lymphocytes. Administration of exogenous IFN-gamma has been associated with upregulation of class II major histocompatibility antigens in the thyroid and the development of thyroiditis. Interferon-alpha also stimulates the production of interleukin-6; both interleukin-6 and IFN-gamma have specific effects on thyrocyte function. There also is evidence suggesting that IFN-alpha initiates a cytokine cascade that effects the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes, thus affecting regulation of glucocorticoid and sex steroid hormone secretion, but the clinical significance of these observations has not been established. Although endocrine disease will not explain the occurrence of fatigue symptoms in all patients, there is clear evidence that hormonal deficiency syndromes occur in a relatively large portion of patients receiving systemic IFN-alpha therapy. Most importantly, the possibility of hypothyroidism must be considered; however, diagnosis of hypothyroidism in cancer patients is complicated by the occurrence of the "sick euthyroid syndrome." Clinical recommendations for assessment and treatment of IFN-alpha-induced fatigue are offered. Most importantly, measurements of thyroid-stimulating hormone and antithyroid autoantibodies should be used to evaluate thyroid status. Acknowledging the limitations of current clinical data, adrenal- and gonadal-axis dysfunction also must be considered in patients with IFN-alpha-induced fatigue.

c-erb-A mRNA correlates with T3-receptor levels in liver and pituitary of tumor rats

In the rat tumor model of the sick euthyroid syndrome, differential regulation of T3-induced cellular responses have been demonstrated in liver and anterior pituitary. These effects occur with a concomitant decrease in nuclear thyroid hormone receptor (TR) number as measured by the binding of 125I-labeled T3. To explore the possibility that these altered responses to T3 in tumor rats resulted from changes in the expression of different TR forms, we correlated the relative abundance of mRNAs encoding each receptor form with the concentration of TR measured by specific T3 binding. In anterior pituitary of tumor rats, TR beta-1 and beta-2 mRNA levels decreased to 51 and 45%, respectively, compared to controls; rat c-erb A alpha-2 mRNA, which encodes a TR-related DNA alpha-binding protein that does not bind T3, decreased to 46% of control. These findings correlate with a decrease in nuclear T3 binding capacity that has been shown to be 63% of control. The level of TR beta-1 mRNA, the only quantifiable TR form in liver, was decreased to 61% of control in the same hepatic tissue that revealed a 50% decrease in TR as measured by specific T3 binding. The coordinate down-regulation of all TR mRNA forms to a degree that parallels the decrease in TR number as measured by specific T3 binding suggests that the differential regulation of T3-mediated effects in illness is by a mechanism other than changing concentrations of specific receptor forms.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential response to L-triiodothyronine of anterior pituitary growth hormone messenger ribonucleic acid (mRNA) and beta-thyrotropin mRNA in a hypothyroid Walker 256 carcinoma-bearing rat model of nonthyroidal disease

To continue our studies on the influence of T3 on TSH regulation in the Walker 256 carcinoma-bearing rat model of nonthyroidal disease, we measured the effect of T3 on pituitary content of beta TSH mRNA and rat (r) TSH in hypothyroid control (C) and tumor-bearing (T) rats. The effect of T3 on TSH regulation was compared to effects on GH mRNA and rGH in the same animals. mRNA content was normalized to a pool of pituitaries from euthyroid rats (= 1.0). beta TSH mRNA increased 18-fold in both hypothyroid C and T rats and then decreased similarly with increasing T3 infusion to a value of 0.1. GH mRNA content decreased to 0.11 +/- 0.01 in hypothyroid C rats, but to only 0.38 +/- 0.02 in T rats (P less than 0.001). The pituitary contents of GH mRNA and rGH in hypothyroid T rats was significantly greater than those in C rats at all T3 infusion rates. These data together with our previous report of decreased nuclear T3 in T rats suggest that regulation of beta TSH mRNA by T3 is intact in T rats, but occurs at a lower concentration of nuclear T3. In contrast, the GH mRNA response is enhanced, displaying differential regulation of these two T3-responsive gene products in this model of nonthyroidal illness.

Decreased anterior pituitary T3 nuclear receptors in a Walker 256 carcinoma-bearing rat model of nonthyroidal disease

Rats bearing the Walker 256 carcinoma have decreased pituitary nuclear T3 but normal pituitary TSH content and response to experimental hypothyroidism. To elucidate further the role of T3 receptor occupancy and biological response in the tumor-bearing rat model of nonthyroidal disease, we measured the concentration of T3 nuclear receptors, rTSH and rGH and beta-TSH mRNA and GH mRNA in the anterior pituitary of euthyroid rats bearing the Walker 256 carcinoma. The abundance of T3 nuclear receptors was decreased in tumor-bearing rats and was associated with a decrease in mRNA content for beta-TSH and GH. alpha-tubulin mRNA was decreased to a comparable degree. The pituitary content of rTSH and rGH was, however, the same as in control animals. Since tumor rats have normal regulation of TSH secretion by thyroid hormone, the present findings suggest that TSH secretion in T rats is maintained by a lower T3 nuclear receptor occupancy than in controls. The decrease in beta-TSH mRNA may precede a decrease in TSH synthesis and changes in pituitary TSH stores. Since the decrease in GH mRNA was comparable to the decrease in alpha-tubulin mRNA, it does not appear to be specifically related to decreased T3 nuclear receptor occupancy. We conclude that, in the tumor-bearing rat model of nonthyroidal disease, decreases in beta-TSH mRNA occur despite a decreased T3 receptor occupancy. Both thyroid-dependent and thyroid-independent factors may be involved in regulating beta-TSH mRNA.

Normal free thyroxine in critical nonthyroidal illnesses measured by ultrafiltration of undiluted serum and equilibrium dialysis

Considerable controversy exists concerning the assessment of thyroidal state in critically ill patients with decreased serum T4 and T3 concentrations, in part because serum free T4 values are often low in such patients no matter what method of measurement is used. We developed an ultrafiltration method to measure free T4 and free T3 in undiluted serum and compared the results with those obtained using a standard equilibrium dialysis method to measure free T4 and T3. In 30 consecutive intensive care unit (ICU) patients, serum free T4 values were similar to or higher than those in 12 normal subjects by both methods in most patients and were clearly distinguishable from those in hypothyroid patients. The serum total T4 concentrations in these patients ranged from 12.9-131.3 nmol/L (mean, 68.2; normal mean, 115.8). Free T4 by equilibrium dialysis was highly correlated with free T4 by ultrafiltration in the ICU group (r = 0.91; P less than 0.001). Serum free T3 levels, however, whether measured by equilibrium dialysis or ultrafiltration, were decreased in the ICU patients, confirming other reports of lowered free T3 in critically ill clinically euthyroid patients. Our findings suggest that the use of equilibrium dialysis of undiluted serum or ultrafiltration to measure serum free T4 concentrations will distinguish euthyroid hypothyroxinemic ICU patients from those with hypothyroidism.