Identification of Distinct Long COVID Clinical Phenotypes Through Cluster Analysis of Self-Reported Symptoms

Background

We aimed to describe the clinical presentation of individuals presenting with prolonged recovery from coronavirus disease 2019 (COVID-19), known as long COVID.

Methods

This was an analysis within a multicenter, prospective cohort study of individuals with a confirmed diagnosis of COVID-19 and persistent symptoms >4 weeks from onset of acute symptoms. We performed a multiple correspondence analysis (MCA) on the most common self-reported symptoms and hierarchical clustering on the results of the MCA to identify symptom clusters.

Results

Two hundred thirty-three individuals were included in the analysis; the median age of the cohort was 43 (interquartile range [IQR], 36–54) years, 74% were women, and 77.3% reported a mild initial illness. MCA and hierarchical clustering revealed 3 clusters. Cluster 1 had predominantly pain symptoms with a higher proportion of joint pain, myalgia, and headache; cluster 2 had a preponderance of cardiovascular symptoms with prominent chest pain, shortness of breath, and palpitations; and cluster 3 had significantly fewer symptoms than the other clusters (2 [IQR, 2–3] symptoms per individual in cluster 3 vs 6 [IQR, 5–7] and 4 [IQR, 3–5] in clusters 1 and 2, respectively; P < .001). Clusters 1 and 2 had greater functional impairment, demonstrated by significantly longer work absence, higher dyspnea scores, and lower scores in SF-36 domains of general health, physical functioning, and role limitation due to physical functioning and social functioning.

Conclusions

Clusters of symptoms are evident in long COVID patients that are associated with functional impairments and may point to distinct underlying pathophysiologic mechanisms of disease.

ISG15 deficiency features a complex cellular phenotype that responds to treatment with itaconate and derivatives

Background

Congenital ISG15 deficiency is a rare autoinflammatory disorder that is driven by chronically elevated systemic interferon levels and predominantly affects central nervous system and skin.

Methods and results

We have developed induced pluripotent stem cell‐derived macrophages and endothelial cells as a model to study the cellular phenotype of ISG15 deficiency and identify novel treatments. ISG15^–/– macrophages exhibited the expected hyperinflammatory responses, but normal phagocytic function. In addition, they displayed a multifaceted pathological phenotype featuring increased apoptosis/pyroptosis, oxidative stress, glycolysis, and acylcarnitine levels, but decreased glutamine uptake, BCAT1 expression, branched chain amino acid catabolism, oxidative phosphorylation, β‐oxidation, and NAD(P)H‐dependent oxidoreductase activity. Furthermore, expression of genes involved in mitochondrial biogenesis and respiratory chain complexes II–V was diminished in ISG15^–/– cells. Defective mitochondrial respiration was restored by transduction with wild‐type ISG15, but only partially by a conjugation‐deficient variant, suggesting that some ISG15 functions in mitochondrial respiration require ISGylation to cellular targets. Treatment with itaconate, dimethyl‐itaconate, 4‐octyl‐itaconate, and the JAK1/2 inhibitor ruxolitinib ameliorated increased inflammation, propensity for cell death, and oxidative stress. Furthermore, the treatments greatly improved mitochondria‐related gene expression, BCAT1 levels, redox balance, and intracellular and extracellular ATP levels. However, efficacy differed among the compounds according to read‐out and cell type, suggesting that their effects on cellular targets are not identical. Indeed, only itaconates increased expression of anti‐oxidant genes NFE2L2, HMOX1, and GPX7, and dimethyl‐itaconate improved redox balance the most. Even though itaconate treatments normalized the elevated expression of interferon‐stimulated genes, ISG15^–/– macrophages maintained their reduced susceptibility to influenza virus infection.

Conclusions

These findings expand the cellular phenotype of human ISG15 deficiency and reveal the importance of ISG15 for regulating oxidative stress, branched chain amino acid metabolism, and mitochondrial function in humans. The results validate ruxolitinib as treatment for ISG15 deficiency and suggest itaconate‐based medications as additional therapeutics for this rare disorder.

Perceived Usefulness of Smartphone Medical Apps As Theoretical and Clinical Learning Aids Among Medical Students in Pakistan: A Cross-Sectional Study

Background Smartphone applications have become popular tools in clinical educational environments, particularly because they enhance learning in any setting through their accessibility. Despite students utilizing these apps in their daily learning, Pakistan's medical education system has yet to strongly endorse them. Given the rising usage of medical applications among clinical year medical students and the wide range of apps accessible on contemporary devices aimed specifically at the student population, there is a lack of literature addressing the use of these apps on clinical learning in low- and middle-income countries (LMIC) such as Pakistan. Objectives Our study aims to (1) assess the level of awareness among clinical-year medical students in Pakistan, of smartphone applications for academic purposes, (2) determine the usefulness of medical apps as educational tools for clinical-year medical students, in terms of enhancing overall patient-care skills and (3) identify barriers to the usage of apps among students who do not have them installed. Methods This online questionnaire-based study includes clinical year medical students across four medical colleges (two private and two public sectors) in Pakistan. Participant identity was kept anonymous and informed consent was required to participate. A sample size of 360 was used based on previous studies in the UK and student estimates from chosen medical colleges. The questionnaire tool used consists of three sections; demographics and medical school information, perceived usefulness of medical smartphone apps on a Likert Scale and barriers to usage among students who do not have them installed. Results 97.9% of the total study population chose to participate in the study. There was roughly an equal percentage of responses from each clinical year and 72% of students reported active use of medical apps of which the vast majority (48%) have one to two apps on their phones. Only 39% of students felt that their medical colleges encourage the use of smartphone apps for academic purposes. 54% of students use apps to look up medical criteria for disease processes and almost 42% use them to search medications. On a Likert scale of 1-5, improvement of clinical performance received highest average score among users (3.92, SD 1.1), followed by quick access to medical guidelines (3.83, SD 1.0). The most common reasons for nonuse of medical apps were medical colleges not offering subscriptions and not knowing how to utilize apps. Conclusion Smartphone apps are widely used by clinical year medical students for academic purposes in our study. Despite lack of endorsement from their respective medical colleges, these apps are still popularly utilized for revision and research on disease criteria during clinics and rounds. Encouragement from the university has been identified as a significant barrier, however. Students who use smartphone apps reported an improvement in clinical performance overall; they were able to retrieve information quicker during rounds and noticed enhancements in formulating diagnoses and reading radiological images. In contrast, those not using these apps faced challenges with interpreting imaging results, recalling pharmacological properties of medications and developing differential diagnoses. Through these findings, we highlight the benefits of incorporating technological media into the undergraduate curriculum and hope medical universities from Pakistan can take inspiration.

Teratogenic effects of lead acetate on kidney

BACKGROUND

Lead remains a considerable occupational and public health problem, which is known to cause a number of adverse effects in both men and women. Conflicting reports have appeared on lead induced nephrotoxicity in experimental studies in the past. There is hardly any work on its teratogenic effects on kidney. Present study was therefore designed to investigate the effects of lead acetate on developing kidney.

METHODS

Twelve mice were used as experimental model and were divided into two groups of six animals each; group A served as control group and B was used as an experimental group. Lead acetate (10 mg/kg) dissolved in 0.02 ml of distilled water was administered as a single daily dose orally to group B whereas weight related amount of distilled water was given to group A for the entire period of experiment. On 18th day of gestation foetuses were dissected free of uterine wall under the dissecting microscope and were sacrificed; kidneys were removed and fixed in 10% formalin, dehydrated in ascending grades of alcohol, cleared in xylene and infiltrated with filtered paraffin. The paraffin blocks were made and five micron thin sections were obtained using a rotary microtome. The sections were stained with Hematoxylin and eosin and, PAS; these were examined under light microscope.

RESULTS

Significant decrease in cortical thickness was observed which varied from 578.61 +/- 1.4 microm in group A to 515.6 +/- 5 microm in group B (p < 0.001). Diameter of renal corpuscles varied from 57.7 +/- 0.07 microm in group A to 50.5 +/- 0.07 microm in group B (p < 0.001). Moderate cortical tubular atrophy showing thickening of endothelial basement membrane in glomeruli, desquamated epithelium with degenerated nuclei in proximal and distal tubules were observed in group B in contrast to group A.

CONCLUSION

The results of the investigation indicated that lead acetate administration to the dams produced deleterious effects on the developing kidney in mice.

What Stops Doctors Switching from Intravenous to Oral Antibiotics?

Aims To explore doctors’ perceptions of the motivators and barriers to complying with intravenous to oral switch antibiotic guidelines in a Model 4 Irish hospital. Methods A cross-sectional study was carried out amongst doctors attending hospital-wide educational sessions in November 2018 via a validated paper-based survey post ethical approval. Data were independently analysed using SPSS. Results One hundred and seventy four doctors of all grades and a variety of specialties participated. Respondents felt they were aware of the local intravenous to oral switch criteria but expressed they required prompts to consider switching to oral agents when appropriate, inclusive of alert stickers in the Kardex and medical notes as well as reminders from nursing and pharmacy staff. Other interventions to assist with improved decision-making included further education to junior doctors on the benefits of an intravenous to oral switch, electronic prescribing, and better accessibility to laboratory results. Conclusion Results will assist in implementing quality improvement initiatives to increase the rate of guideline compliance.

HIV and Pneumocystis Jiroveci Pneumonia (PJP) Managed With Extracorporeal Membrane Oxygenation (ECMO)

Presentation A 40-year-old Irish female presented with a new diagnosis of HIV, advanced immunosuppression and severe respiratory failure. Diagnosis Patient was subsequently diagnosed with Pneumocystis jiroveci Pneumonia (PJP). Treatment The patient was treated for HIV and PJP and required mechanical ventilation. She continued to deteriorate and veno-venous Extracorporeal Membrane Oxygenation (V-V ECMO) was deployed in her management after 18 days of mechanical ventilation. Conclusion HIV presenting with extensive pneumonia secondary to PJP and advanced immunosuppression is still a treatable condition. All available respiratory support including ECMO should be considered for patients even if they have been on mechanical ventilation for more than 7 days.

A Unique Case of Concurrent Long Bone Osteomyelitis and Empyema Caused by Fusobacterium nucleatum

We describe a patient presenting with constitutional symptoms, poor oral hygiene and leg swelling who was diagnosed with Fusobacterium nucleatum osteomyelitis of femur and empyema. Long bone osteomyelitis is rarely caused by this microorganism. This unusual case was successfully managed with drainage and antimicrobial therapy.

Cyclosporin induced effects on foetal kidney in albino mice

BACKGROUND

Cyclosporin A (CsA) is an immunosuppressive agent which is used to prevent graft rejection and to treat autoimmune disorders. Its teratogenic effects remain unexplored despite its extensive use even during pregnancy. Current study was, therefore, undertaken to investigate the effects of CsA on the developing kidney.

METHODS

Twelve pregnant mice were divided into two groups, A and B, having six animals each. Cyclosporin was freshly prepared in normal saline daily and administered subcutaneously by a single dose of 50 mg/kg in the morning to experimental group B during pregnancy from day 0 to day 18. The control group A was given comparable volume of normal saline only. The pregnant mice were sacrificed at the end of experimental period. The foetal kidneys were dissected and fixed in 10% formalin for histological preparations.

RESULTS

The results showed that weight of the foetuses and their kidneys exposed to CsA was consistently reduced. The mean weight of the foetuses exposed to CsA was 1.34 +/- 0.08 g as compared to 1.48 +/- 0.18 g in the control group whereas the mean kidney weight from CsA treated group was 9.47 +/- 0.27 mg when compared to the control having 10.79 +/- 0.53 mg. Morphometric analysis revealed reduction in total number of glomeruli and hypertrophy of remaining glomeruli. The total number of glomeruli/mm2 in the kidneys from CsA treated group was 26.85 +/- 4.43 as compared to 41.33 +/- 3.66 from the control group and the mean diameter of glomeruli from the foetuses of groups A and B was 7.11 +/- 0.47 mm and 8.66 +/- 0.63 mm respectively; the differences between the groups A and B of the animals on all the parameters above were statistically significant (p < 0.000).

CONCLUSION

The results of the investigation indicated that CsA administration to the pregnant dams produced deleterious effects of on the developing kidney in mice. On the analogy of the results, comparable effects of CsA are expected in case of human; this, however, needs further investigations.