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Yilmaz M, He Q, Demir E, Teräsjärvi J, Gürsoy UK. Salivary IL-33 and sST2 levels in relation to TLR2 rs111200466 polymorphism and periodontitis. Oral Dis 2024; 30:2254-2261. [PMID: 37427857 DOI: 10.1111/odi.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/30/2023] [Accepted: 06/28/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES Toll-like receptor-2 (TLR2) signalling pathway is involved in the regulation of interleukin (IL)-33 and its receptor suppression of tumorigenicity-2 (ST2). This study aimed to compare salivary IL-33 and soluble ST2 (sST2) levels of periodontitis patients with those of periodontally healthy individuals in relation to their TLR2 rs111200466 23-bp insertion/deletion polymorphism within the promoter region. MATERIALS AND METHODS Unstimulated saliva samples were collected, and periodontal parameters were recorded from 35 periodontally healthy individuals and 44 periodontitis patients. Non-surgical treatments were applied to periodontitis patients, and sample collections and clinical measurements were repeated 3 months following therapy. Salivary IL-33 and sST2 levels were measured with enzyme-linked immunosorbent assay kits, and TLR2 rs111200466 polymorphism was detected by polymerase chain reaction. RESULTS Elevated salivary IL-33 (p = 0.007) and sST2 (p = 0.020) levels were observed in periodontitis patients, in comparison to controls. sST2 levels declined 3-months following treatment (p < 0.001). Increased salivary IL-33 and sST2 levels were found to be associated with periodontitis, with no significant relation to the TLR2 polymorphism. CONCLUSION Periodontitis, but not TLR2 rs111200466 polymorphism, is associated with elevated salivary sST2 and possibly IL-33 levels, and periodontal treatment is effective in reducing salivary sST2 levels.
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Affiliation(s)
- Mustafa Yilmaz
- Department of Periodontology, Institute of Dentistry, University of Turku, Turku, Finland
- Department of Periodontology, Faculty of Dentistry, Biruni University, Istanbul, Turkey
| | - Qiushui He
- Institute of Biomedicine, Research Centre for Infections and Immunity, University of Turku, Turku, Finland
- InFLAMES Research Flagship Centre, University of Turku, Turku, Finland
| | - Esra Demir
- Department of Periodontology, Faculty of Dentistry, Bezmialem Vakif University, Istanbul, Turkey
| | - Johanna Teräsjärvi
- Institute of Biomedicine, Research Centre for Infections and Immunity, University of Turku, Turku, Finland
| | - Ulvi Kahraman Gürsoy
- Department of Periodontology, Institute of Dentistry, University of Turku, Turku, Finland
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2
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Arnaldos-Carrillo M, Noguera-Velasco JA, Martínez-Ardil IM, Riquelme-Pérez A, Cebreiros-López I, Hernández-Vicente Á, Ros-Lucas JA, Khan A, Bayes-Genís A, Pascual-Figal D. Value of increased soluble suppressor tumorigenicity biomarker 2 (sST2) on admission as an indicator of severity in patients with COVID-19. Med Clin (Barc) 2023; 161:185-191. [PMID: 37137804 PMCID: PMC10086099 DOI: 10.1016/j.medcli.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Soluble suppressor of tumorigenicity-2 (sST2) is a biomarker for heart failure and pulmonary injury. We hypothesize that sST2 could help predict severity of SARS-CoV-2 infections. METHODS sST2 was analyzed in patients consecutively admitted for SARS-CoV-2 pneumonia. Other prognostic markers were also measured. In-hospital complications were registered, including death, ICU admission, and respiratory support requirements. RESULTS 495 patients were studied (53% male, age: 57.6±17.6). At admission, median sST2 concentrations was 48.5ng/mL [IQR, 30.6-83.1ng/mL] and correlated with male gender, older age, comorbidities, other severity biomarkers, and respiratory support requirements. sST2 levels were higher in patients who died (n=45, 9.1%) (45.6 [28.0, 75.9]ng/mL vs. 144 [82.6, 319] ng/mL, p<0.001) and those admitted to ICU (n=46, 9.3%) (44.7 [27.5, 71.3] ng/mL vs. 125 [69.0, 262]ng/mL, p<0.001). sST2 levels>210ng/mL were a strong predictor of complicated in-hospital courses, with higher risk of death (OR, 39.3, CI95% 15.9, 103) and death/ICU (OR 38.3, CI95% 16.3-97.5) after adjusting for all other risk factors. The addition of sST2 enhanced the predictive capacity of mortality risk models. CONCLUSIONS sST2 represents a robust severity predictor in COVID-19 and could be an important tool for identifying at-risk patients who may benefit from closer follow-up and specific therapies.
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Affiliation(s)
- María Arnaldos-Carrillo
- Clinical Laboratory Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Universidad de Murcia, Murcia, Spain
| | - José Antonio Noguera-Velasco
- Clinical Laboratory Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Universidad de Murcia, Murcia, Spain; IMIB Pascual Parrilla, Murcia, Spain
| | | | | | - Iria Cebreiros-López
- Clinical Laboratory Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Universidad de Murcia, Murcia, Spain; IMIB Pascual Parrilla, Murcia, Spain
| | | | - José Antonio Ros-Lucas
- Pneumology Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Universidad Católica de Murcia (UCAM), Murcia, Spain
| | - Amjad Khan
- Nuffield Division of Clinical Laboratory Sciences (NDCLS), Radcliffe Department of Medicine, John Radcliffe hospital, University of Oxford, Oxford, UK
| | - Antoni Bayes-Genís
- CIBER Cardiovascular, Madrid, Spain; Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Domingo Pascual-Figal
- Universidad de Murcia, Murcia, Spain; IMIB Pascual Parrilla, Murcia, Spain; Cardiology Service, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; CIBER Cardiovascular, Madrid, Spain.
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3
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Wilkinson T, De Soyza A, Carroll M, Chalmers JD, Crooks MG, Griffiths G, Shankar-Hari M, Ho LP, Horsley A, Kell C, Lara B, Mishra B, Moate R, Page C, Pandya H, Raw J, Reid F, Saralaya D, Scott IC, Siddiqui S, Ustianowski A, van Zuydam N, Woodcock A, Singh D. A randomised phase 2a study to investigate the effects of blocking interleukin-33 with tozorakimab in patients hospitalised with COVID-19: ACCORD-2. ERJ Open Res 2023; 9:00249-2023. [PMID: 37868151 PMCID: PMC10588785 DOI: 10.1183/23120541.00249-2023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 07/25/2023] [Indexed: 10/24/2023] Open
Abstract
Background Increased serum interleukin (IL)-33 predicts poor outcomes in patients hospitalised with coronavirus disease 2019 (COVID-19). We examined the efficacy and safety of tozorakimab, a monoclonal antibody that neutralises IL-33, in improving outcomes in ACCORD-2 (EudraCT: 2020-001736-95). Methods ACCORD-2 was an open-label, phase 2a study in adults hospitalised with COVID-19. Patients were randomised 1:1 to tozorakimab 300 mg plus standard of care (SoC) or SoC alone. The primary end-point was time to clinical response (sustained clinical improvement of ≥2 points on the World Health Organization ordinal scale, discharge from hospital or fit for discharge) by day 29. Other end-points included death or respiratory failure, mortality and intensive care unit admission by day 29, and safety. Serum IL-33/soluble stimulated-2 (sST2) complex levels were measured by high-sensitivity immunoassay. Results Efficacy analyses included 97 patients (tozorakimab+SoC, n=53; SoC, n=44). Median time to clinical response did not differ between the tozorakimab and SoC arms (8.0 and 9.5 days, respectively; HR 0.96, 80% CI 0.70-1.31; one-sided p=0.33). Tozorakimab was well tolerated and the OR for risk of death or respiratory failure with treatment versus SoC was 0.55 (80% CI 0.27-1.12; p=0.26), while the OR was 0.31 (80% CI 0.09-1.06) in patents with high baseline serum IL-33/sST2 complex levels. Conclusions Overall, ACCORD-2 results suggest that tozorakimab could be a novel therapy for patients hospitalised with COVID-19, warranting further investigation in confirmatory phase 3 studies.
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Affiliation(s)
- Tom Wilkinson
- NIHR Southampton Biomedical Research Centre and University of Southampton, Southampton, UK
| | - Anthony De Soyza
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Miles Carroll
- Pandemic Sciences Institute, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - James D. Chalmers
- Division of Molecular and Clinical Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Ling-Pei Ho
- Medical Research Council Human Immunology Unit, University of Oxford, Oxford, UK
| | - Alex Horsley
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
| | - Chris Kell
- Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Beatriz Lara
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, London, UK
| | - Hitesh Pandya
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | | | - Fred Reid
- Clinical Development, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Dinesh Saralaya
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ian C. Scott
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory and Immunology, BioPharmaceuticals R&D, AstraZeneca, Cambridge, UK
| | - Salman Siddiqui
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Andy Ustianowski
- Regional Infection Unit, North Manchester General Hospital, Manchester, UK
| | | | - Ashley Woodcock
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
| | - Dave Singh
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, Manchester, UK
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4
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Kanaeva TV, Karoli NA. Prognostic biomarkers for cardiovascular injury in patients with COVID-19: a review. SECHENOV MEDICAL JOURNAL 2023. [DOI: 10.47093/2218-7332.2022.13.3.14-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Investigations into the causes of adverse outcomes of the novel coronavirus infection (COVID-19) have been ongoing since the beginning of the pandemic. There is evidence that coronavirus-induced cardiovascular injury is as important to a risk of adverse outcome as respiratory injury. Many studies have shown that concomitant cardiovascular disease aggravates the course of COVID-19. However, in some patients who did not have cardiovascular diseases before COVID-19, they are detected during hospitalization or after discharge from the hospital. The review examines data on the effect of serum biomarkers of cardiovascular disease determined during COVID-19 on the risk of adverse outcomes in the near and long-term follow-up periods. Among such biomarkers are considered: troponins, N-terminal pro B-type natriuretic peptide, creatine phosphokinase-MB, lactate dehydrogenase, myoglobin, growth stimulation expressed gene 2, pentraxin 3, angiotensin II, as well as D-dimer and homocysteine. Threshold values have been set for some of these biomarkers, which allow predicting the risk of an unfavorable outcome. At the same time, in most prognostic models, these markers are considered in association with cytokine storm indicators and other risk factors.
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Affiliation(s)
- T. V. Kanaeva
- Saratov State Medical University named after V.I. Razumovsky
| | - N. A. Karoli
- Saratov State Medical University named after V.I. Razumovsky
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Astegolimab or Efmarodocokin Alfa in Patients With Severe COVID-19 Pneumonia: A Randomized, Phase 2 Trial. Crit Care Med 2023; 51:103-116. [PMID: 36519984 PMCID: PMC9749945 DOI: 10.1097/ccm.0000000000005716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Severe cases of COVID-19 pneumonia can lead to acute respiratory distress syndrome (ARDS). Release of interleukin (IL)-33, an epithelial-derived alarmin, and IL-33/ST2 pathway activation are linked with ARDS development in other viral infections. IL-22, a cytokine that modulates innate immunity through multiple regenerative and protective mechanisms in lung epithelial cells, is reduced in patients with ARDS. This study aimed to evaluate safety and efficacy of astegolimab, a human immunoglobulin G2 monoclonal antibody that selectively inhibits the IL-33 receptor, ST2, or efmarodocokin alfa, a human IL-22 fusion protein that activates IL-22 signaling, for treatment of severe COVID-19 pneumonia. DESIGN Phase 2, double-blind, placebo-controlled study (COVID-astegolimab-IL). SETTING Hospitals. PATIENTS Hospitalized adults with severe COVID-19 pneumonia. INTERVENTIONS Patients were randomized to receive IV astegolimab, efmarodocokin alfa, or placebo, plus standard of care. The primary endpoint was time to recovery, defined as time to a score of 1 or 2 on a 7-category ordinal scale by day 28. MEASUREMENTS AND MAIN RESULTS The study randomized 396 patients. Median time to recovery was 11 days (hazard ratio [HR], 1.01 d; p = 0.93) and 10 days (HR, 1.15 d; p = 0.38) for astegolimab and efmarodocokin alfa, respectively, versus 10 days for placebo. Key secondary endpoints (improved recovery, mortality, or prevention of worsening) showed no treatment benefits. No new safety signals were observed and adverse events were similar across treatment arms. Biomarkers demonstrated that both drugs were pharmacologically active. CONCLUSIONS Treatment with astegolimab or efmarodocokin alfa did not improve time to recovery in patients with severe COVID-19 pneumonia.
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Rubio-Gracia J, Ibáñez-Muñoz D, Giménez-López I, Garcés-Horna V, López-Delgado D, Sierra-Monzón JL, Crespo-Aznarez S, Peña-Fresneda N, Pérez-Calvo JI, Sánchez-Marteles M. Comparative analysis of chest radiography and lung ultrasound to predict intra-hospital prognosis of patients admitted for acute SARS-CoV-2 pneumonia (COVID-19). MEDICINA CLINICA (ENGLISH ED.) 2022; 159:515-521. [PMID: 36337157 PMCID: PMC9618450 DOI: 10.1016/j.medcle.2022.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/27/2022] [Indexed: 11/06/2022]
Abstract
Background Point of care lung ultrasound (POCUS) has been recently used to assess prognosis in COVID-19 patients. However, there are no data comparing POCUS and chest-X ray, a technique widely used. Patients and methods Retrospective analysis in stable COVID-19 patients. Schalekamp radiological lung scale and LUZ-Score ultrasound scale were compared. Primary end-point was in-hospital death and/or need for Intensive Care Unit admission. Results A total of 138 patients were included. Median Schalekamp scale was 2 (2) and median LUZ-Score scale was 21 (10). No significant correlation was observed between both techniques. Patients with a LUZ-Score ≥ 21 points at admission had worse lung function and higher concentrations of LDH, CRP and Interleuquine-6. Schalekamp scale failed to identify patients at a higher risk at admission for the primary end-point. Addition of POCUS to a previous clinical model, improved risk prediction (AUC 0.805 [95% CI: 0.662-0.948]; P = <0.001). Conclusions Chest X-ray and POCUS showed no correlation at admission in this analysis. Only POCUS identified a group of patients with greater clinical and analytical involvement. POCUS improved, previous clinical model, while chest X-ray did not add relevant predictive information for the primary endpoint.
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Affiliation(s)
- Jorge Rubio-Gracia
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
| | - David Ibáñez-Muñoz
- Servicio de Radiodiagnóstico, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
| | - Ignacio Giménez-López
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
- Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain
| | - Vanesa Garcés-Horna
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
| | - Daniel López-Delgado
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
| | - José Luis Sierra-Monzón
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
| | - Silvia Crespo-Aznarez
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
| | | | - Juan Ignacio Pérez-Calvo
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
- Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain
| | - Marta Sánchez-Marteles
- Servicio de Medicina Interna, Hospital Clínico Universitario «Lozano Blesa», Zaragoza, Spain
- Instituto de Investigación Sanitaria Aragón (IIS Aragón), Zaragoza, Spain
- Facultad de Medicina, Universidad de Zaragoza, Zaragoza, Spain
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Investigation of hs-TnI and sST-2 as Potential Predictors of Long-Term Cardiovascular Risk in Patients with Survived Hospitalization for COVID-19 Pneumonia. Biomedicines 2022; 10:biomedicines10112889. [PMID: 36359409 PMCID: PMC9687975 DOI: 10.3390/biomedicines10112889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/01/2022] [Accepted: 11/05/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction: COVID-19 survivors reveal an increased long-term risk for cardiovascular disease. Biomarkers like troponins and sST-2 improve stratification of cardiovascular risk. Nevertheless, their prognostic value for identifying long-term cardiovascular risk after having survived COVID-19 has yet to be evaluated. Methods: In this single-center study, admission serum biomarkers of sST-2 and hs-TnI in a single cohort of 251 hospitalized COVID-19 survivors were evaluated. Concentrations were correlated with major cardiovascular events (MACE) defined as cardiovascular death and/or need for cardiovascular hospitalization during follow-up after hospital discharge [FU: 415 days (403; 422)]. Results: MACE was a frequent finding during FU with an incidence of 8.4% (cardiovascular death: 2.8% and/or need for cardiovascular hospitalization: 7.2%). Both biomarkers were reliable indicators of MACE (hs-TnI: sensitivity = 66.7% & specificity = 65.7%; sST-2: sensitivity = 33.3% & specificity = 97.4%). This was confirmed in a multivariate proportional-hazards analysis: besides age (HR = 1.047, 95% CI = 1.012−1.084, p = 0.009), hs-TnI (HR = 4.940, 95% CI = 1.904−12.816, p = 0.001) and sST-2 (HR = 10.901, 95% CI = 4.509−29.271, p < 0.001) were strong predictors of MACE. The predictive value of the model was further improved by combining both biomarkers with the factor age (concordance index hs-TnI + sST2 + age = 0.812). Conclusion: During long-term FU, hospitalized COVID-19 survivors, hs-TnI and sST-2 at admission, were strong predictors of MACE, indicating both proteins to be involved in post-acute sequelae of COVID-19.
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Prognostic Role of sST2 in Acute Heart Failure and COVID-19 Infection-A Narrative Review on Pathophysiology and Clinical Prospective. Int J Mol Sci 2022; 23:ijms23158230. [PMID: 35897800 PMCID: PMC9331735 DOI: 10.3390/ijms23158230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/14/2022] [Accepted: 06/19/2022] [Indexed: 12/04/2022] Open
Abstract
The importance of cardiovascular biomarkers in clinical practice increased dramatically in the last years, and the interest extends from the diagnosis purpose to prognostic applications and response to specific treatment. Acute heart failure, ischemic heart failure, and COVID-19 infection represent different clinical settings that are challenging in terms of the proper prognostic establishment. The aim of the present review is to establish the useful role of sST2, the soluble form of the interleukin-1 receptor superfamily (ST2), physiologically involved in the signaling of interleukin-33 (IL-33)-ST2 axis, in the clinical setting of acute heart failure (HF), ischemic heart disease, and SARS-CoV-2 acute infection. Molecular mechanisms associated with the IL33/ST2 signaling pathways are discussed in view of the clinical usefulness of biomarkers to early diagnosis, evaluation therapy to response, and prediction of adverse outcomes in cardiovascular diseases.
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9
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Motloch LJ, Jirak P, Gareeva D, Davtyan P, Gumerov R, Lakman I, Tataurov A, Zulkarneev R, Kabirov I, Cai B, Valeev B, Pavlov V, Kopp K, Hoppe UC, Lichtenauer M, Fiedler L, Pistulli R, Zagidullin N. Cardiovascular Biomarkers for Prediction of in-hospital and 1-Year Post-discharge Mortality in Patients With COVID-19 Pneumonia. Front Med (Lausanne) 2022; 9:906665. [PMID: 35836945 PMCID: PMC9273888 DOI: 10.3389/fmed.2022.906665] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 05/30/2022] [Indexed: 01/08/2023] Open
Abstract
Aims While COVID-19 affects the cardiovascular system, the potential clinical impact of cardiovascular biomarkers on predicting outcomes in COVID-19 patients is still unknown. Therefore, to investigate this issue we analyzed the prognostic potential of cardiac biomarkers on in-hospital and long-term post-discharge mortality of patients with COVID-19 pneumonia. Methods Serum soluble ST2, VCAM-1, and hs-TnI were evaluated upon admission in 280 consecutive patients hospitalized with COVID-19-associated pneumonia in a single, tertiary care center. Patient clinical and laboratory characteristics and the concentration of biomarkers were correlated with in-hospital [Hospital stay: 11 days (10; 14)] and post-discharge all-cause mortality at 1 year follow-up [FU: 354 days (342; 361)]. Results 11 patients died while hospitalized for COVID-19 (3.9%), and 11 patients died during the 1-year post-discharge follow-up period (n = 11, 4.1%). Using multivariate analysis, VCAM-1 was shown to predict mortality during the hospital period (HR 1.081, CI 95% 1.035;1.129, p = 0.017), but not ST2 or hs-TnI. In contrast, during one-year FU post hospital discharge, ST2 (HR 1.006, 95% CI 1.002;1.009, p < 0.001) and hs-TnI (HR 1.362, 95% CI 1.050;1.766, p = 0.024) predicted mortality, although not VCAM-1. Conclusion In patients hospitalized with Covid-19 pneumonia, elevated levels of VCAM-1 at admission were associated with in-hospital mortality, while ST2 and hs-TnI might predict post-discharge mortality in long term follow-up.
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Affiliation(s)
- Lukas J. Motloch
- University Clinic for Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
- *Correspondence: Lukas J. Motloch
| | - Peter Jirak
- University Clinic for Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Diana Gareeva
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Paruir Davtyan
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Ruslan Gumerov
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Irina Lakman
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
- Department of Biomedical Engineering, Ufa State Aviation Technical University, Ufa, Russia
- Scientific Laboratory for the Socio-Economic Region Problems Investigation, Bashkir State University, Ufa, Russia
| | - Aleksandr Tataurov
- Scientific Laboratory for the Socio-Economic Region Problems Investigation, Bashkir State University, Ufa, Russia
| | - Rustem Zulkarneev
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Ildar Kabirov
- Department of Urology, Bashkir State Medical University, Ufa, Russia
| | - Benzhi Cai
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- The Key Laboratory of Cardiovascular Medicine Research, Ministry of Education, Department of Pharmacy at the Second Affiliated Hospital, and Department of Pharmacology at College of Pharmacy, Harbin Medical University, Harbin, China
| | - Bairas Valeev
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
| | - Valentin Pavlov
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- Department of Urology, Bashkir State Medical University, Ufa, Russia
| | - Kristen Kopp
- University Clinic for Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Uta C. Hoppe
- University Clinic for Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Michael Lichtenauer
- University Clinic for Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
| | - Lukas Fiedler
- University Clinic for Internal Medicine II, Paracelsus Medical University, Salzburg, Austria
- Department of Internal Medicine, Cardiology, Nephrology and Intensive Care Medicine, Hospital Wiener Neustadt, Wiener Neustadt, Austria
| | - Rudin Pistulli
- Department of Cardiology I, Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Munster, Munster, Germany
| | - Naufal Zagidullin
- Cardiovascular Disease in COVID-19, International Research Network, Ufa, Russia
- Department of Internal Diseases, Bashkir State Medical University, Ufa, Russia
- Department of Biomedical Engineering, Ufa State Aviation Technical University, Ufa, Russia
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Fernander EM, Adogamhe P, Datta D, Bond C, Zhao Y, Bangirana P, Conroy AL, Opoka RO, John CC. Elevated Plasma Soluble ST2 Levels are Associated With Neuronal Injury and Neurocognitive Impairment in Children With Cerebral Malaria. Pathog Immun 2022; 7:60-80. [PMID: 35800259 PMCID: PMC9254869 DOI: 10.20411/pai.v7i1.499] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Murine experimental cerebral malaria studies suggest both protective and deleterious central nervous system effects from alterations in the interleukin-33 (IL-33)/ST2 pathway. Methods We assessed whether soluble ST2 (sST2) was associated with neuronal injury or cognitive impairment in a cohort of Ugandan children with cerebral malaria (CM, n=224) or severe malarial anemia (SMA, n=193). Results Plasma concentrations of sST2 were higher in children with CM than in children with SMA or in asymptomatic community children. Cerebrospinal fluid (CSF) sST2 levels were elevated in children with CM compared with North American children. Elevated plasma and CSF ST2 levels in children with CM correlated with increased endothelial activation and increased plasma and CSF levels of tau, a marker of neuronal injury. In children with CM who were ≥5 years of age at the time of their malaria episode, but not in children <5 years of age, elevated risk factor-adjusted plasma levels of sST2 were associated with worse scores for overall cognitive ability and attention over a 2-year follow-up. Conclusions The study findings suggest that sST2 may contribute to neuronal injury and long-term neurocognitive impairment in older children with CM.
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Affiliation(s)
- Elizabeth M. Fernander
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pontian Adogamhe
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dibyadyuti Datta
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Caitlin Bond
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Yi Zhao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN
| | - Paul Bangirana
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Andrea L. Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Robert O. Opoka
- Department of Paediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Chandy C. John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
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Biomarkers Associated with Cardiovascular Disease in COVID-19. Cells 2022; 11:cells11060922. [PMID: 35326373 PMCID: PMC8946710 DOI: 10.3390/cells11060922] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/20/2022] [Accepted: 03/05/2022] [Indexed: 02/08/2023] Open
Abstract
Coronavirus disease-19 (COVID-19) emerged late December 2019 in the city of Wuhan, China and has since spread rapidly all over the world causing a global pandemic. While the respiratory system is the primary target of disease manifestation, COVID-19 has been shown to also affect several other organs, making it a rather complex, multi-system disease. As such, cardiovascular involvement has been a topic of discussion since the beginning of the COVID-19 pandemic, primarily due to early reports of excessive myocardial injury in these patients. Treating physicians are faced with multiple challenges in the management and early triage of patients with COVID-19, as disease severity is highly variable ranging from an asymptomatic infection to critical cases rapidly deteriorating to intensive care treatment or even fatality. Laboratory biomarkers provide important prognostic information which can guide decision making in the emergency department, especially in patients with atypical presentations. Several cardiac biomarkers, most notably high-sensitive cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), have emerged as valuable predictors of prognosis in patients with COVID-19. The purpose of this review was to offer a concise summary on prognostic cardiac biomarkers in COVID-19 and discuss whether routine measurements of these biomarkers are warranted upon hospital admission.
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Análisis comparativo de la radiografía de tórax y la ecografía pulmonar para predecir el pronóstico intra-hospitalario de pacientes ingresados por neumonía secundaria a SARS-COV2 (COVID-19). Med Clin (Barc) 2022; 159:515-521. [PMID: 35428513 PMCID: PMC8890970 DOI: 10.1016/j.medcli.2022.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 01/08/2023]
Abstract
Antecedentes La ecografía torácica es una técnica novedosa para estratificar el riesgo de los pacientes COVID-19. Sin embargo, no existen datos que comparen dicha técnica con la radiografía de tórax, una técnica ampliamente utilizada en esta enfermedad. Pacientes y métodos Análisis retrospectivo en pacientes estables COVID-19. Se compararon la escala de daño pulmonar radiológica de Schalekamp y ecográfica de LUZ-Score. El objetivo primario fue la muerte intrahospitalaria o la necesidad de ingreso en la UCI para tratamiento con ventilación mecánica. Resultados Se reclutaron 138 pacientes. La mediana de la escala de Schalekamp fue de 2 (2) y la del LUZ-Score de 21 (10). No se objetivó una correlación significativa entre ambas escalas. Los pacientes con un LUZ-Score ≥ 21 puntos al ingreso presentaron peor función pulmonar y mayores concentraciones de LDH, PCR e interleucina-6. La escala radiológica de Schalekamp no logró identificar a una población de mayor riesgo. Únicamente la adición de la ecografía pulmonar a un modelo de valoración clínica mejoró de manera significativa el área bajo la curva para el objetivo primario (ABC 0,805 [IC 95%: 0,662-0,948]; p ≤ 0,001). Conclusiones No se objetivó una correlación entre la afectación radiológica y la ecográfica. Únicamente la ecografía pulmonar identificó un subgrupo de pacientes con una mayor afectación clínico-analítica. La ecografía pulmonar mejoró el modelo de predicción clínico, mientras que la radiografía de tórax no añadió información relevante.
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Jorge RG, Marta SM, Vanesa GH, Luis ML, Fernando RL, Silvia CA, Natacha PF, Borja GT, Alberto C, Patricia CL, Ignacio PCJ, Ignacio GL. Multiple Approaches at Admission Based on Lung Ultrasound and Biomarkers Improves Risk Identification in COVID-19 Patients. J Clin Med 2021; 10:5478. [PMID: 34884180 PMCID: PMC8658110 DOI: 10.3390/jcm10235478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/18/2021] [Accepted: 11/18/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Risk stratification of COVID-19 patients is fundamental to improving prognosis and selecting the right treatment. We hypothesized that a combination of lung ultrasound (LUZ-score), biomarkers (sST2), and clinical models (PANDEMYC score) could be useful to improve risk stratification. METHODS This was a prospective cohort study designed to analyze the prognostic value of lung ultrasound, sST2, and PANDEMYC score in COVID-19 patients. The primary endpoint was in-hospital death and/or admission to the intensive care unit. The total length of hospital stay, increase of oxygen flow, or escalated medical treatment during the first 72 h were secondary endpoints. RESULTS a total of 144 patients were included; the mean age was 57.5 ± 12.78 years. The median PANDEMYC score was 243 (52), the median LUZ-score was 21 (10), and the median sST2 was 53.1 ng/mL (30.9). Soluble ST2 showed the best predictive capacity for the primary endpoint (AUC = 0.764 (0.658-0.871); p = 0.001), towards the PANDEMYC score (AUC = 0.762 (0.655-0.870); p = 0.001) and LUZ-score (AUC = 0.749 (0.596-0.901); p = 0.002). Taken together, these three tools significantly improved the risk capacity (AUC = 0.840 (0.727-0.953); p ≤ 0.001). CONCLUSIONS The PANDEMYC score, lung ultrasound, and sST2 concentrations upon admission for COVID-19 are independent predictors of intra-hospital death and/or the need for admission to the ICU for mechanical ventilation. The combination of these predictive tools improves the predictive power compared to each one separately. The use of decision trees, based on multivariate models, could be useful in clinical practice.
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Affiliation(s)
- Rubio-Gracia Jorge
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
| | - Sánchez-Marteles Marta
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
| | - Garcés-Horna Vanesa
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
| | - Martínez-Lostao Luis
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Immunology Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain
- Center for Biomedical Research of Aragon, 50009 Zaragoza, Spain
| | - Ruiz-Laiglesia Fernando
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
| | - Crespo-Aznarez Silvia
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
| | - Peña-Fresneda Natacha
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Center for Biomedical Research of Aragon, 50009 Zaragoza, Spain
| | - Gracia-Tello Borja
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Immunology Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain
| | - Cebollada Alberto
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Biocomputation Unit, Center for Biomedical Research of Aragon, 50009 Zaragoza, Spain
| | - Carrera-Lasfuentes Patricia
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28005 Madrid, Spain
| | - Pérez-Calvo Juan Ignacio
- Internal Medicine Department, Clinical Hospital “Lozano Blesa”, 50009 Zaragoza, Spain; (S.-M.M.); (G.-H.V.); (R.-L.F.); (C.-A.S.); (G.-T.B.); (P.-C.J.I.)
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Center for Biomedical Research of Aragon, 50009 Zaragoza, Spain
- School Medicine, Zaragoza University, 50009 Zaragoza, Spain
| | - Giménez-López Ignacio
- Aragon Health Research Institute, 50009 Zaragoza, Spain; (M.-L.L.); (P.-F.N.); (C.A.); (C.-L.P.); (G.-L.I.)
- Center for Biomedical Research of Aragon, 50009 Zaragoza, Spain
- School Medicine, Zaragoza University, 50009 Zaragoza, Spain
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14
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Sánchez-Marteles M, Rubio-Gracia J, Peña-Fresneda N, Garcés-Horna V, Gracia-Tello B, Martínez-Lostao L, Crespo-Aznárez S, Pérez-Calvo JI, Giménez-López I. Early Measurement of Blood sST2 Is a Good Predictor of Death and Poor Outcomes in Patients Admitted for COVID-19 Infection. J Clin Med 2021; 10:3534. [PMID: 34441830 PMCID: PMC8396994 DOI: 10.3390/jcm10163534] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/08/2021] [Accepted: 08/08/2021] [Indexed: 01/08/2023] Open
Abstract
Although several biomarkers have shown correlation to prognosis in COVID-19 patients, their clinical value is limited because of lack of specificity, suboptimal sensibility or poor dynamic behavior. We hypothesized that circulating soluble ST2 (sST2) could be associated to a worse outcome in COVID-19. In total, 152 patients admitted for confirmed COVID-19 were included in a prospective non-interventional, observational study. Blood samples were drawn at admission, 48-72 h later and at discharge. sST2 concentrations and routine blood laboratory were analyzed. Primary endpoints were admission at intensive care unit (ICU) and mortality. Median age was 57.5 years [Standard Deviation (SD: 12.8)], 60.4% males. 10% of patients (n = 15) were derived to ICU and/or died during admission. Median (IQR) sST2 serum concentration (ng/mL) rose to 53.1 (30.9) at admission, peaked at 48-72 h (79.5(64)) and returned to admission levels at discharge (44.9[36.7]). A concentration of sST2 above 58.9 ng/mL was identified patients progressing to ICU admission or death. Results remained significant after multivariable analysis. The area under the receiver operating characteristics curve (AUC) of sST2 for endpoints was 0.776 (p = 0.001). In patients admitted for COVID-19 infection, early measurement of sST2 was able to identify patients at risk of severe complications or death.
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Affiliation(s)
- Marta Sánchez-Marteles
- Department of Internal Medicine, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain; (J.R.-G.); (V.G.-H.); (B.G.-T.); (S.C.-A.); (J.I.P.-C.)
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
| | - Jorge Rubio-Gracia
- Department of Internal Medicine, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain; (J.R.-G.); (V.G.-H.); (B.G.-T.); (S.C.-A.); (J.I.P.-C.)
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
| | - Natacha Peña-Fresneda
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
- Facultad de Medicina, University of Zaragoza, 50009 Zaragoza, Spain
| | - Vanesa Garcés-Horna
- Department of Internal Medicine, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain; (J.R.-G.); (V.G.-H.); (B.G.-T.); (S.C.-A.); (J.I.P.-C.)
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
| | - Borja Gracia-Tello
- Department of Internal Medicine, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain; (J.R.-G.); (V.G.-H.); (B.G.-T.); (S.C.-A.); (J.I.P.-C.)
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
| | - Luis Martínez-Lostao
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
- Facultad de Medicina, University of Zaragoza, 50009 Zaragoza, Spain
- Department of Immunology, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain
| | - Silvia Crespo-Aznárez
- Department of Internal Medicine, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain; (J.R.-G.); (V.G.-H.); (B.G.-T.); (S.C.-A.); (J.I.P.-C.)
| | - Juan Ignacio Pérez-Calvo
- Department of Internal Medicine, Hospital Clínico Universitario, Lozano Blesa, 50009 Zaragoza, Spain; (J.R.-G.); (V.G.-H.); (B.G.-T.); (S.C.-A.); (J.I.P.-C.)
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
- Facultad de Medicina, University of Zaragoza, 50009 Zaragoza, Spain
| | - Ignacio Giménez-López
- Aragon Health Research Institute (IIS Aragón), 50009 Zaragoza, Spain; (N.P.-F.); (L.M.-L.); (I.G.-L.)
- Facultad de Medicina, University of Zaragoza, 50009 Zaragoza, Spain
- Instituto Aragonés de Ciencias de la Salud (IACS), 50009 Zaragoza, Spain
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