Physical and psychological sequelae at three months after acute illness in COVID-19 survivors

BACKGROUND

Coronavirus disease 2019 (COVID-19) may leave behind an altered health status early after recovery. We evaluated the clinical status of COVID-19 survivors at three months after hospital discharge.

METHODS

In this prospective observational cohort study, hospitalized patients aged ≥18 years, evaluated at one (M1) and three (M3) months post-discharge were enrolled. 251 patients (71.3% males, median [IQR] age 61.8 [53.5-70.7] years) were included. Median (IQR) time from discharge to M3 was 89 (79.5-101) days. Primary outcome was residual respiratory dysfunction (RRD), defined by tachypnea, moderate to very severe dyspnea, or peripheral oxygen saturation ≤95% on room air at M3.

RESULTS

RRD was found in 30.4% of patients, with no significant difference compared with M1. Chronic obstructive pulmonary disease and length of stay were independent predictors of RRD at multivariable logistic regression (OR [95% CI]: 4.13 [1.17-16.88], P=0.033; OR [95% CI]: 1.02 [1.00-1.04], P=0.047, respectively). Obesity and C-reactive protein levels upon admission were additional predictors at regression tree analysis. Impaired quality of life (QoL) was reported by 53.2% of patients. Anxiety and insomnia were each present in 25.5% of patients, and PTSD in 22.4%. No difference was found between M1 and M3 in QoL, anxiety or PTSD. Insomnia decreased at M3. Current major psychiatric disorder as well as anxiety, insomnia and PSTD at M1 independently predicted PTSD at M3.

CONCLUSIONS

Clinical damage may persist at three months after discharge in COVID-19 survivors. Post-recovery follow-up is an essential component of patient management.

Vertebral fractures at hospitalization predict impaired respiratory function during follow-up of COVID-19 survivors

PURPOSE

Morphometric vertebral fractures (VFs) have been recently reported as an important component of the endocrine phenotype of COVID-19 and emerging data show negative respiratory sequelae at long-term follow-up in COVID-19 survivors. The aim of this study was to evaluate the impact of VFs on respiratory function in COVID-19 survivors.

METHODS

We included patients referred to our Hospital Emergency Department and re-evaluated during follow-up. VFs were detected on lateral chest X-rays on admission using a qualitative and semiquantitative assessment and pulmonary function tests were obtained by Jaeger-MasterScreen-Analyzer Unit 6 months after discharge.

RESULTS

Fifty patients were included. Median age was 66 years and 66% were males. No respiratory function data were available at COVID-19 diagnosis. VFs were detected in 16 (32%) patients. No differences between fractured and non-fractured patients regarding age and sex were observed. Although no difference was observed between VF and non-VF patient groups in the severity of pneumonia as assessed by Radiological-Assessment-of-Lung-Edema score at admission, (5 vs. 6, p = 0.69), patients with VFs were characterized as compared to those without VFs by lower Forced Vital Capacity (FVC, 2.9 vs. 3.6 L, p = 0.006; 85% vs. 110% of predicted, respectively, p = 0.001), Forced Expiratory Volume 1st s (FEV1, 2.2 vs. 2.8 L, p = 0.005; 92% vs. 110% of predicted, respectively, p = 0.001) and Diffusing Capacity of the Lungs for Carbon Monoxide (DLCO 5.83 vs. 6.98 mmol/min/kPa, p = 0.036, 59% vs. 86.3% of predicted, respectively, p = 0.043) at 6-month follow up.

CONCLUSIONS

VFs, expression of the endocrine phenotype of the disease, appear to influence medium-term impaired respiratory function of COVID-19 survivors which may significantly influence their recovery. Therefore, our findings suggest that a VFs assessment at baseline may help in identifying patients needing a more intensive respiratory follow-up and patients showing persistent respiratory impairment without evidence of pulmonary disease may benefit from VFs assessment to preventing the vicious circle of further fractures and respiratory deterioration.

A Nomogram-Based Model to Predict Respiratory Dysfunction at 6 Months in Non-Critical COVID-19 Survivors

Objective

To assess the prevalence of respiratory sequelae of Coronavirus disease 2019 (COVID-19) survivors at 6 months after hospital discharge and develop a model to identify at-risk patients.

Patients and Methods

In this prospective cohort study, hospitalized, non-critical COVID-19 patients evaluated at 6-month follow-up between 26 August, 2020 and 16 December, 2020 were included. Primary outcome was respiratory dysfunction at 6 months, defined as at least one among tachypnea at rest, percent predicted 6-min walking distance at 6-min walking test (6MWT) ≤ 70%, pre-post 6MWT difference in Borg score ≥ 1 or a difference between pre- and post-6MWT oxygen saturation ≥ 5%. A nomogram-based multivariable logistic regression model was built to predict primary outcome. Validation relied on 2000-resample bootstrap. The model was compared to one based uniquely on degree of hypoxemia at admission.

Results

Overall, 316 patients were included, of whom 118 (37.3%) showed respiratory dysfunction at 6 months. The nomogram relied on sex, obesity, chronic obstructive pulmonary disease, degree of hypoxemia at admission, and non-invasive ventilation. It was 73.0% (95% confidence interval 67.3–78.4%) accurate in predicting primary outcome and exhibited minimal departure from ideal prediction. Compared to the model including only hypoxemia at admission, the nomogram showed higher accuracy (73.0 vs 59.1%, P < 0.001) and greater net-benefit in decision curve analyses. When the model included also respiratory data at 1 month, it yielded better accuracy (78.2 vs. 73.2%) and more favorable net-benefit than the original model.

Conclusion

The newly developed nomograms accurately identify patients at risk of persistent respiratory dysfunction and may help inform clinical priorities.

Residual lung damage following ARDS in COVID-19 ICU survivors

BACKGROUND

Coronavirus disease 2019 acute respiratory distress syndrome (COVID-19 ARDS) is a disease that often requires invasive ventilation. Little is known about COVID-19 ARDS sequelae. We assessed the mid-term lung status of COVID-19 survivors and investigated factors associated with pulmonary sequelae.

METHODS

All adult COVID-19 patients admitted to the intensive care unit from 25th February to 27th April 2020 were included. Lung function was evaluated through chest CT scan and pulmonary function tests (PFT). Logistic regression was used to identify predictors of persisting lung alterations.

RESULTS

Forty-nine patients (75%) completed lung assessment. Chest CT scan was performed after a median (interquartile range) time of 97 (89-105) days, whilst PFT after 142 (133-160) days. The median age was 58 (52-65) years and most patients were male (90%). The median duration of mechanical ventilation was 11 (6-16) days. Median tidal volume/ideal body weight (TV/IBW) was 6.8 (5.71-7.67) ml/Kg. 59% and 63% of patients showed radiological and functional lung sequelae, respectively. The diffusion capacity of carbon monoxide (DL_CO ) was reduced by 59%, with a median per cent of predicted DL_CO of 72.1 (57.9-93.9) %. Mean TV/IBW during invasive ventilation emerged as an independent predictor of persistent CT scan abnormalities, whilst the duration of mechanical ventilation was an independent predictor of both CT and PFT abnormalities. The extension of lung involvement at hospital admission (evaluated through Radiographic Assessment of Lung Edema, RALE score) independently predicted the risk of persistent alterations in PFTs.

CONCLUSIONS

Both the extent of lung parenchymal involvement and mechanical ventilation protocols predict morphological and functional lung abnormalities months after COVID-19.

6-Month Respiratory Outcomes and Exercise Capacity of COVID-19 Acute Respiratory Failure Patients Treated With CPAP

Background

COVID‐19 long‐term sequelae are ill‐defined since only a few studies have explored the long‐term consequences of this disease so far.

Aims

To evaluate the 6‐month respiratory outcome and exercise capacity of COVID‐19 acute respiratory failure (ARF) patients treated with continuous positive airway pressure (CPAP) during the first wave of the ongoing COVID‐19 pandemic.

Methods

A retrospective observational study included COVID‐19 patients with ARF. Interventions included CPAP during hospitalisation and 6‐month follow up. Frailty assessment was carried out through frailty index (FI), pO₂/FiO₂ during hospitalisation and at follow up, respiratory parameters, 6‐min walking test (6MWT) and the modified British Medical Research Council (mMRC) and Borg scale at follow up.

Results

More than half of the patients had no dyspnoea according to the mMRC scale. Lower in‐hospital pO₂/FiO₂ correlated with higher Borg scale levels after 6MWT (ρ 0.27; P 0.04) at the follow‐up visit. FI was positively correlated with length of hospitalisation (ρ 0.3; P 0.03) and negatively with the 6MWT distance walked (ρ −0.36; P 0.004).

Conclusions

Robust and frail patients with COVID‐19 ARF treated with CPAP outside the intensive care unit setting had good respiratory parameters and exercise capacity at 6‐month follow up, although more severe patients had slightly poorer respiratory performance compared with patients with higher PaO₂/FiO₂ and lower FI.

Prenatal diagnosis of congenital lipoid adrenal hyperplasia

Congenital lipoid adrenal hyperplasia (lipoid CAH) is a rare genetic disorder of adrenal and gonadal steroidogenesis of unknown cause in which cholesterol cannot be converted to pregnenolone. As a result, affected individuals can make no steroid hormones, so that all affected newborns are phenotypic females, irrespective of karyotype. We studied two pregnancies in a family with two previously affected children by examining fetal karyotype, genital ultrasonography, and amniotic fluid steroid concentrations and by performing ACTH tests on family members. Prenatal diagnosis correctly identified both an unaffected XX fetus and an affected XY fetus. In the affected pregnancy, amniotic fluid concentrations of progesterone and pregnenolone were 30% and 50% of normal, respectively, but concentrations of 17 alpha-hydroxypregnenolone, 17 alpha-hydroxyprogesterone, cortisol, dehydroepiandrosterone, androstenedione, and estriol were either extremely low or undetectable, suggesting that these detected steroids were donated by maternal steroidogenesis. Fetal cord blood obtained at the termination of pregnancy showed very low concentrations of estrogens donated by the mother's circulation. Absent fetal steroidogenesis was confirmed by gas chromatography and mass spectrometry of both fetal and maternal serum. The responses of 10 different steroids to adrenal stimulation with ACTH in the obligately heterozygous parents were normal. Thus, unlike the case with other forms of CAH, heterozygosity cannot be determined by hormonal responses to provocative testing with ACTH. Immunocytochemistry and Western blotting showed that the affected placental tissue contained P450scc protein, confirming that P450scc is intact in these patients.

Rodent models for studying steroids and hypertension: from fetal development to cells in culture

We have used several different approaches to study the role of steroids in hypertension, including rodent in vivo models, transgenic animals, and cell culture systems. Using the developing rodent fetus as a model for the ontogeny of regulation of glucocorticoid and mineralocorticoid synthesis, we found that in the developing rodent fetus, expression of both P450scc (cholesterol side chain cleavage) and P450c11 beta (11 beta-hydroxylase) mRNAs occur early, before there is complete organization of the fetal adrenal. Even after the zones of the adrenal are evident, the fetal adrenal still does not express the glomerulosa-specific P450c11AS (aldosterone synthase) mRNA. Stimulating maternal adrenal mineralocorticoid or glucocorticoid synthesis does not affect accumulation of fetal adrenal steroidogenic mRNAs, suggesting that the rodent fetal adrenal may be somewhat transcriptionally quiescent in vivo. We also used two different transgenic rodent systems to study the roles of steroids in hypertension. Using promoter-directed tumorigenesis in transgenic mice, we created transgenic mice that expressed SV40 T antigen under control of the P450scc promoter. Massive adrenal tumors, but not gonadal tumors, developed in all transgenic mice, and cells from these tumors were easily cultured. Using a novel selection tactic, we obtained several adrenocortical cell lines which have distinct characteristics, suggesting they were locked into various stages of differentiation; both expression of steroidogenic mRNAs and the steroids synthesized differ among the lines. Regulation of steroid synthesis and mRNA abundance also varies among cell lines. Several cell lines also express mouse renin, and its synthesis, secretion, and mRNA abundance is also hormonally regulated.(ABSTRACT TRUNCATED AT 250 WORDS)

Implication of NMDA receptors in glutamate-induced MCH secretion

The action of glutamate and N-methyl-D-aspartate (NMDA) on melanin-concentrating hormone (MCH) release was examined in primary cultures of rat hypothalamic neurons. Increasing concentrations of both glutamate and NMDA stimulated MCH release in a dose-dependent manner. We report here a specific toxic effect of 10(-4) M glutamate not observed after NMDA-induced MCH release. The involvement of the NMDA receptor in the MCH-evoked secretion was confirmed using MK-801 a specific NMDA non-competitive inhibitor. MK-801 inhibited NMDA-induced MCH release in a dose dependent manner. At 10(-6) M, this drug significantly inhibited MCH release suggesting an endogenous glutamatergic stimulation of MCH secretion. This study established that MCH neurons are sensitive to glutamate stimulation and that the evoked MCH secretion is mediated via NMDA receptor activation.

Diffusible factors from rat arcuate nucleus and Broca's diagonal band nucleus increase size and neurite outgrowth, respectively, of cultured melanin-concentrating hormone containing neurons

Using a co-culture model, we showed that diffusible factors from arcuate nucleus (AN) specifically increased the number and the size of hypothalamic neurons producing melanin-concentrating hormone (MCH). In this model neurite outgrowth and contacts between MCH neurons and dopaminergic neurons were also prominently increased, as compared to control lateral areas of the posterior hypothalamus (LH) primary cultures. These effects were mediated in part by AN glia but also by neurons of both fetal and adult AN. AN glia produced diffusible factor(s) mainly responsible for an important MCH neurite outgrowth and expressed inhibiting factors, preventing the adhesion of LH cells on AN glial cells. Furthermore, we report here a nerve growth factor-like effect from Broca's diagonal band on MCH hypothalamic neurons.

Expression of peptides derived from the melanin-concentrating hormone precursor in serum-free culture of rat fetal hypothalamic neurons: role of attachment factors

A serum-free medium culture was developed in order to study the secretory behavior of neurons producing the melanin-concentrating hormone (MCH) precursor. The present results show that our culture conditions (supplemented RPMI 1640, poly-D-lysine substrate) are efficient in promoting attachment and growth of MCH neurons dissociated from rat fetal hypothalamus. These neurons acquire a differentiation stage in which neuropeptides of interest to us are expressed in a pattern similar to that observed on tissue sections: (1) coexpression of salmon MCH, growth-hormone-releasing factor (GRF37), alpha-melanocyte-stimulating hormone and acetylcholinesterase immunoreactivities, and (2) different intracellular distribution of salmon MCH and 1-37 sequence of GRF37 staining. Neurite growth was rapid and interneuronal connections were observed early. These observations suggest that our model of defined medium culture is suitable for functional investigations on MCH neurons.