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Maenetje P, Baik Y, Schramm DB, Vangu MDTW, Wallis RS, Mlotshwa M, Tiemessen CT, Li Y, Kornfeld H, Churchyard G, Auld SC, Bisson GP. Circulating Biomarkers, Fraction of Exhaled Nitric Oxide, and Lung Function in Patients With Human Immunodeficiency Virus and Tuberculosis. J Infect Dis 2024; 229:824-832. [PMID: 37386883 PMCID: PMC10938205 DOI: 10.1093/infdis/jiad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/12/2023] [Accepted: 06/27/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Identification of proinflammatory factors responding to Mycobacterium tuberculosis is important to reduce long-term sequelae of pulmonary tuberculosis (TB). METHODS We examined the association between plasma biomarkers, the fraction of exhaled nitric oxide (FeNO), and lung function among a prospective cohort of 105 adults newly diagnosed with TB/human immunodeficiency virus (HIV) in South Africa. Participants were followed for 48 weeks from antiretroviral therapy (ART) initiation with serial assessments of plasma biomarkers, FeNO, lung function, and respiratory symptoms. Linear regression and generalized estimating equations were used to examine the associations at baseline and over the course of TB treatment, respectively. RESULTS At baseline, higher FeNO levels were associated with preserved lung function, whereas greater respiratory symptoms and higher interleukin (IL)-6 plasma levels were associated with worse lung function. After ART and TB treatment initiation, improvements in lung function were associated with increases in FeNO (rate ratio [RR] = 86 mL, 95% confidence interval [CI] = 34-139) and decreases in IL-6 (RR = -118 mL, 95% CI = -193 to -43) and vascular endothelial growth factor ([VEGF] RR = -178 mL, 95% CI = -314 to -43). CONCLUSIONS Circulating IL-6, VEGF, and FeNO are associated with lung function in adults being treated for TB/HIV. These biomarkers may help identify individuals at higher risk for post-TB lung disease and elucidate targetable pathways to modify the risk of chronic lung impairment among TB survivors.
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Affiliation(s)
- Pholo Maenetje
- The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diana B Schramm
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mboyo Di-Tamba Willy Vangu
- Department of Nuclear Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Caroline T Tiemessen
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, USA
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Sara C Auld
- Departments of Medicine and Epidemiology, Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia, USA
| | - Gregory P Bisson
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Salindri AD, Auld SC, Gujral UP, Urbina EM, Andrews JR, Huaman MA, Magee MJ. Tuberculosis infection and hypertension: prevalence estimates from the US National Health and Nutrition Examination Survey. BMJ Open 2024; 14:e075176. [PMID: 38479740 PMCID: PMC10936476 DOI: 10.1136/bmjopen-2023-075176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 12/20/2023] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES Tuberculosis infection (TBI) is marked by dynamic host-pathogen interactions with persistent low-grade inflammation and is associated with increased risk of cardiovascular diseases (CVD) including acute coronary syndrome, myocardial infarction and stroke. However, few studies assess the relationship between TBI and hypertension, an intermediate of CVD. We sought to determine the association between TBI and hypertension using data representative of the adult US population. METHODS We performed cross-sectional analyses using data from the 2011-2012 US National Health and Nutrition Examination Survey (NHANES). Eligible participants included adults with valid QuantiFERON-TB Gold In-Tube (QFT-GIT) test results who also had blood pressure measures and no history of TB disease. TBI was defined by a positive QFT-GIT. We defined hypertension by either elevated measured blood pressure levels (ie, systolic ≥130 mm Hg or diastolic ≥80 mm Hg) or known hypertension indications (ie, self-reported previous diagnosis or use of antihypertensive medications). Analyses were performed using robust quasi-Poisson regressions and accounted for the stratified probability sampling design of NHANES. RESULTS The overall prevalence of TBI was 5.7% (95% CI 4.7% to 6.7%) and hypertension was present among 48.9% (95% CI 45.2% to 52.7%) of participants. The prevalence of hypertension was higher among those with TBI (58.5%, 95% CI 52.4% to 64.5%) than those without TBI (48.3%, 95% CI 44.5% to 52.1%) (prevalence ratio (PR) 1.2, 95% CI 1.1 to 1.3). However, after adjusting for confounders, the prevalence of hypertension was similar for those with and without TBI (adjusted PR 1.0, 95% CI 1.0 to 1.1). The unadjusted prevalence of hypertension was higher among those with TBI versus no TBI, especially among individuals without CVD risk factors including those with normal body mass index (PR 1.6, 95% CI 1.2 to 2.0), euglycaemia (PR 1.3, 95% CI 1.1 to 1.5) or non-smokers (PR 1.2, 95% CI 1.1 to 1.4). CONCLUSIONS More than half of adults with TBI in the USA had hypertension. Importantly, we observed a relationship between TBI and hypertension among those without established CVD risk factors. SUMMARY The prevalence of hypertension was high (59%) among adults with TBI in the USA. In addition, we found that the prevalence of hypertension was significantly higher among adults with positive QFT without established hypertension risk factors.
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Affiliation(s)
- Argita D Salindri
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Unjali P Gujral
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Elaine M Urbina
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Moises A Huaman
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J Magee
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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3
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Ogongo P, Wassie L, Tran A, Columbus D, Sharling L, Ouma G, Ouma SG, Bobosha K, Lindestam Arlehamn CS, Gandhi NR, Auld SC, Rengarajan J, Day CL, Altman JD, Blumberg HM, Ernst JD. Rare Variable M. tuberculosis Antigens induce predominant Th17 responses in human infection. bioRxiv 2024:2024.03.05.583634. [PMID: 38496518 PMCID: PMC10942433 DOI: 10.1101/2024.03.05.583634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
CD4 T cells are essential for immunity to M. tuberculosis (Mtb), and emerging evidence indicates that IL-17-producing Th17 cells contribute to immunity to Mtb. While identifying protective T cell effector functions is important for TB vaccine design, T cell antigen specificity is also likely to be important. To identify antigens that induce protective immunity, we reasoned that as in other pathogens, effective immune recognition drives sequence diversity in individual Mtb antigens. We previously identified Mtb genes under evolutionary diversifying selection pressure whose products we term Rare Variable Mtb Antigens (RVMA). Here, in two distinct human cohorts with recent exposure to TB, we found that RVMA preferentially induce CD4 T cells that express RoRγt and produce IL-17, in contrast to 'classical' Mtb antigens that induce T cells that produce IFNγ. Our results suggest that RVMA can be valuable antigens in vaccines for those already infected with Mtb to amplify existing antigen-specific Th17 responses to prevent TB disease.
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Affiliation(s)
- Paul Ogongo
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
- Department of Tropical and Infectious Diseases, Institute of Primate Research, Nairobi, Kenya
| | - Liya Wassie
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Anthony Tran
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
| | - Devin Columbus
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
| | - Lisa Sharling
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Gregory Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Samuel Gurrion Ouma
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kidist Bobosha
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | - Neel R. Gandhi
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Sara C. Auld
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jyothi Rengarajan
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
| | - Cheryl L. Day
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
- Department of Microbiology and Immunology, Emory University School of Medicine, Atlanta, GA, USA
| | - John D. Altman
- Emory Vaccine Center, Emory University, Atlanta, GA, USA
| | - Henry M. Blumberg
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Joel D. Ernst
- Division of Experimental Medicine, University of California, San Francisco, CA, USA
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Smirnova N, Lowers J, Magee MJ, Auld SC, Hunt WR, Fitzpatrick A, Lama V, Kavalieratos D. Pulmonary Function and Quality of Life in Adults with Cystic Fibrosis. Lung 2023; 201:635-639. [PMID: 37973684 DOI: 10.1007/s00408-023-00658-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE People living with cystic fibrosis (CF) experience impaired quality of life, but the extent to which pulmonary function is associated with quality of life in CF remains unclear METHODS: Using baseline data from a trial of specialist palliative care in adults with CF, we examined the association between pulmonary obstruction and quality of life (measured with the Functional Assessment of Chronic Illness Therapy Total Score). RESULTS Among 262 participants, median age was 33, and 78% were on modulator therapy. The median quality of life score was higher in those with mild obstruction (135, IQR 110-156) compared to moderate (125, IQR 109-146) and severe obstruction (120, IQR 106-136). In an unadjusted model, we observed a non-significant trend toward lower quality of life with increased obstruction-compared to participants with mild obstruction, those with moderate obstruction had quality of life score 7.46 points lower (95% CI -15.03 to 0.10) and those with severe obstruction had a score 9.98 points lower (95% CI -21.76 to 1.80). However, this association was no longer statistically significant in the adjusted model, which may reflect confounding due to sex, age, BMI, and modulator therapy. Comorbidities (depression and anxiety) and social determinants of health (financial insecurity and education) were also associated with quality of life. CONCLUSION Advancing our understanding of patient-centered markers of quality of life, rather than focusing on pulmonary function alone, may help identify novel interventions to improve quality of life in this patient population.
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Affiliation(s)
- Natalia Smirnova
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, AllergyAtlanta, GA, USA
| | - Jane Lowers
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA
| | - Matthew J Magee
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sara C Auld
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, AllergyAtlanta, GA, USA
| | - William R Hunt
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, AllergyAtlanta, GA, USA
| | - Anne Fitzpatrick
- Department of Pediatrics, Emory University, Randall Rollins Building, #R544, 1516 Clifton Road, NE, Atlanta, GA, 30322, USA
| | - Vibha Lama
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Emory University, AllergyAtlanta, GA, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University, Atlanta, GA, USA.
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Pediatrics, Emory University, Randall Rollins Building, #R544, 1516 Clifton Road, NE, Atlanta, GA, 30322, USA.
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Staitieh BS, Hu X, Yeligar SM, Auld SC. Paired ATAC- and RNA-seq offer insight into the impact of HIV on alveolar macrophages: a pilot study. Sci Rep 2023; 13:15276. [PMID: 37714998 PMCID: PMC10504379 DOI: 10.1038/s41598-023-42644-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023] Open
Abstract
People with HIV remain at greater risk for both infectious and non-infectious pulmonary diseases even after antiretroviral therapy initiation and CD4 cell count recovery. These clinical risks reflect persistent HIV-mediated defects in innate and adaptive immunity, including in the alveolar macrophage, a key innate immune effector in the lungs. In this proof-of-concept pilot study, we leveraged paired RNA-seq and ATAC-seq analyses of human alveolar macrophages obtained with research bronchoscopy from people with and without HIV to highlight the potential for recent methodologic advances to generate novel hypotheses about biological pathways that may contribute to impaired pulmonary immune function in people with HIV. In addition to 35 genes that were differentially expressed in macrophages from people with HIV, gene set enrichment analysis identified six gene sets that were differentially regulated. ATAC-seq analysis revealed 115 genes that were differentially accessible for people with HIV. Data-driven integration of the findings from these complementary, high-throughput techniques using xMWAS identified distinct clusters involving lipoprotein lipase and inflammatory pathways. By bringing together transcriptional and epigenetic data, this analytic approach points to several mechanisms, including previously unreported pathways, that warrant further exploration as potential mediators of the increased risk of pulmonary disease in people with HIV.
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Affiliation(s)
- Bashar S Staitieh
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, Emory University, 615 Michael St NE, Ste 200, Atlanta, GA, 30322, USA
- Grady Health System, Atlanta, GA, USA
| | - Xin Hu
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, Emory University, 615 Michael St NE, Ste 200, Atlanta, GA, 30322, USA
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Samantha M Yeligar
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, Emory University, 615 Michael St NE, Ste 200, Atlanta, GA, 30322, USA
- Veterans Affairs Atlanta Healthcare System, Decatur, GA, USA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, School of Medicine, Emory University, 615 Michael St NE, Ste 200, Atlanta, GA, 30322, USA.
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Yang P, Dickert NW, Haczku A, Spainhour C, Auld SC. Trend in Clinical Trial Participation During COVID-19: A Secondary Analysis of the I-SPY COVID Clinical Trial. Crit Care Explor 2023; 5:e0930. [PMID: 37346229 PMCID: PMC10281328 DOI: 10.1097/cce.0000000000000930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
To analyze the temporal trend in enrollment rates in a COVID-19 platform trial during the first three waves of the pandemic in the United States. DESIGN Secondary analysis of data from the I-SPY COVID randomized controlled trial (RCT). SETTING Thirty-one hospitals throughout the United States. PATIENTS Patients who were approached, either directly or via a legally authorized representative, for consent and enrollment into the I-SPY COVID RCT. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 1,338 patients approached for the I-SPY COVID trial from July 30, 2020, to February 17, 2022, the number of patients who enrolled (n = 1,063) versus declined participation (n = 275) was used to calculate monthly enrollment rates. Overall, demographic and baseline clinical characteristics were similar between those who enrolled versus declined. Enrollment rates fluctuated over the course of the COVID-19 pandemic, but there were no significant trends over time (Mann-Kendall test, p = 0.21). Enrollment rates were also comparable between vaccinated and unvaccinated patients. In multivariable logistic regression analysis, age, sex, region of residence, COVID-19 severity of illness, and vaccination status were not significantly associated with the decision to decline consent. CONCLUSIONS In this secondary analysis of the I-SPY COVID clinical trial, there was no significant association between the enrollment rate and time period or vaccination status among all eligible patients approached for clinical trial participation. Additional studies are needed to better understand whether the COVID-19 pandemic has altered clinical trial participation and to develop strategies for encouraging participation in future COVID-19 and critical care clinical trials.
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Affiliation(s)
- Philip Yang
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, GA
| | - Neal W Dickert
- Division of Cardiology, Emory University, Atlanta, GA
- Emory Health Services Research Center, Departments of Medicine & Surgery, Emory University, Atlanta, GA
| | - Angela Haczku
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California Davis, Sacramento, CA
| | - Christine Spainhour
- Emory Critical Care Center, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University, Atlanta, GA
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
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Salindri AD, Auld SC, Gujral UP, Urbina EM, Andrews JR, Huaman MA, Magee MJ. Tuberculosis infection and hypertension: Prevalence estimates from the US National Health and Nutrition Examination Survey. medRxiv 2023:2023.05.12.23289899. [PMID: 37325781 PMCID: PMC10262262 DOI: 10.1101/2023.05.12.23289899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Objectives Latent Tuberculosis infection (LTBI) is marked by dynamic host-pathogen interactions with persistent low-grade inflammation and is associated with increased risk of cardiovascular diseases (CVD) including acute coronary syndrome, myocardial infarction, and stroke. However, few studies assess the relationship between LTBI and hypertension, an intermediate of CVD. We sought to determine the association between LTBI and hypertension using data representative of the adult US population. Methods We performed cross-sectional analyses using data from the 2011-2012 US National Health and Nutrition Examination Survey (NHANES). Eligible participants included adults with valid QuantiFERON-TB Gold In-Tube (QFT-GIT) test results who also had blood pressure measures and no history of TB disease. LTBI was defined by a positive QFT-GIT. We defined hypertension by either elevated measured blood pressure levels (i.e., systolic ≥130mmHg or diastolic ≥80mmHg) or known hypertension indications (i.e., self-reported previous diagnosis or use of antihypertensive medications). Analyses were performed using robust quasi-Poisson regressions and accounted for the stratified probability sampling design of NHANES. Results The overall prevalence of LTBI was 5.7% (95%CI 4.7-6.7) and hypertension was present among 48.9% (95%CI 45.2-52.7) of participants. The prevalence of hypertension was higher among those with LTBI (58.5%, 95%CI 52.4-64.5) than those without LTBI (48.3%, 95%CI 44.5-52.1) (prevalence ratio [PR]=1.2, 95%CI 1.1-1.3). However, after adjusting for confounders, the prevalence of hypertension was similar for those with and without LTBI (adjusted PR=1.0, 95%CI 0.9 -1.1). Among individuals without CVD risk factors of elevated BMI (PRnormal BMI=1.6, 95%CI 1.2-2.0), hyperglycemia (PReuglycemia=1.3, 95%CI 1.1-1.5), or cigarette smoking (PRnon-smokers=1.2, 95%CI 1.1-1.4), the unadjusted prevalence of hypertension was higher among those with LTBI vs. no LTBI. Conclusions More than half of adults with LTBI in the US had hypertension. Importantly, we observed a relationship between LTBI and hypertension among those without established CVD risk factors.
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Affiliation(s)
- Argita D Salindri
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Sara C Auld
- Division of Pulmonary and Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Unjali P Gujral
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Elaine M Urbina
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Moises A Huaman
- Department of Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Matthew J Magee
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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8
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Day CL, Willis F, Staitieh BS, Campbell A, Martinson N, Gandhi NR, Auld SC. Mycobacterium tuberculosis-specific cytokine responses according to HIV status among household contacts of people with TB. Tuberculosis (Edinb) 2023; 139:102328. [PMID: 36871409 PMCID: PMC10040086 DOI: 10.1016/j.tube.2023.102328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 02/21/2023] [Accepted: 02/28/2023] [Indexed: 03/05/2023]
Abstract
Following exposure to Mycobacterium tuberculosis (Mtb), a coordinated host response comprising both pro- and anti-inflammatory cytokines is critical for pathogen control. Although tuberculosis (TB) remains the leading cause of death among people with human immunodeficiency virus (HIV), the impact of HIV infection on Mtb-specific immune responses remains unclear. In this cross-sectional study of TB-exposed household contacts with and without HIV, we collected remaining supernatant from interferon-gamma release assay (IGRA) testing (QuantiFERON-TB Gold Plus [QFT-Plus]) and measured Mtb-specific pro-inflammatory, anti-inflammatory, and regulatory cytokine responses with a multiplex assay of 11 analytes. While people with HIV had lower responses to mitogen stimulation for some cytokines (granulocyte-macrophage colony-stimulating factor [GM-CSF], interleukin [IL]-2, IL-10, IL-17A, IL-22), there was no difference in cytokine levels for people with and without HIV following stimulation with Mtb-specific antigens. Future studies are necessary to explore whether changes in Mtb-specific cytokine responses over time are associated with distinct clinical outcomes following exposure to TB.
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Affiliation(s)
- Cheryl L Day
- Department of Microbiology and Immunology, School of Medicine, Emory University, Atlanta, USA
| | - Fay Willis
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Bashar S Staitieh
- Department of Medicine, School of Medicine, Emory University, Atlanta, USA
| | - Angela Campbell
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA
| | | | - Neel R Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA; Department of Medicine, School of Medicine, Emory University, Atlanta, USA; Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, USA
| | - Sara C Auld
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, USA; Department of Medicine, School of Medicine, Emory University, Atlanta, USA.
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9
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Staitieh BS, Malik S, Auld SC, Wigger GW, Fan X, Roth AT, Chatterjee T, Arora I, Raju SV, Heath S, Aggrawal S. HIV Increases the Risk of Cigarette Smoke-Induced Emphysema Through MMP-9. J Acquir Immune Defic Syndr 2023; 92:263-270. [PMID: 36331810 PMCID: PMC9911107 DOI: 10.1097/qai.0000000000003125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND HIV is associated with an increased risk for emphysema. Matrix metalloproteinase 9 (MMP-9) is a lung tissue remodeling enzyme associated with emphysema. We previously found MMP-9 activity increases with increases in oxidative stress and that HIV increases alveolar oxidative stress. We hypothesized that HIV proteins would increase the risk of cigarette smoke-induced emphysema due to MMP-9. METHODS HIV-1 transgenic rats and wild-type littermates were exposed to cigarette smoke or sham for 8 weeks. Lung compliance and histology were assessed. Bronchoalveolar lavage (BAL), primary alveolar macrophages (AM), and serum samples were obtained. A rat alveolar macrophage cell line was exposed to the HIV protein Tat, and MMP-9 levels were assessed by Western immunoblotting. MMP-9 protein expression and activity were assessed in AM from the HIV rat model by ELISA and cytoimmunofluoresence, respectively. Serum from human subjects with and without HIV and tobacco dependence was assessed for MMP-9 levels. RESULTS MMP-9 expression was significantly increased in rat alveolar macrophages after Tat exposure. HIV-1 transgenic rats developed emphysema while wild-type littermates did not. MMP-9 expression was also increased in the serum, BAL, and AM of HIV-1 transgenic rats after exposure to cigarette smoke compared with wild-type rats. In parallel, serum samples from HIV+ smokers had higher levels of MMP-9 than subjects without HIV and those who did not smoke. CONCLUSION The combination of HIV and cigarette smoke increases MMP-9 expression in experimental rat HIV models and human subjects. HIV and cigarette smoke both induce alveolar oxidative stress and thereby increase MMP-9 activity.
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Affiliation(s)
- Bashar S. Staitieh
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Simran Malik
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Sara C. Auld
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Gregory W. Wigger
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Xian Fan
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Andrew T. Roth
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Tanima Chatterjee
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Itika Arora
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - S. Vamsee Raju
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL; and
| | - Sonya Heath
- Department of Medicine, Division of Infectious Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Saurabh Aggrawal
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
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10
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Baik Y, Maenetje P, Schramm D, Tiemessen C, Ncube I, Churchyard G, Wallis R, Vangu MDT, Kornfeld H, Li Y, Auld SC, Bisson GP. Lung function and collagen 1a levels are associated with changes in 6 min walk test distance during treatment of TB among HIV-infected adults: a prospective cohort study. BMC Pulm Med 2023; 23:53. [PMID: 36737697 PMCID: PMC9896708 DOI: 10.1186/s12890-023-02325-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 01/13/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients with tuberculosis (TB) and HIV often present with impairments in lung function and exercise capacity after treatment. We evaluated clinical and immunologic variables associated with a minimum clinically important difference (MCID) in the change in the 6 min walk test distance during the first 24 weeks of antiretroviral (ART) and anti-tubercular therapy. METHODS Adults initiating ART and anti-TB treatment in the setting of newly-diagnosed HIV and pulmonary TB were enrolled in a prospective cohort study in South Africa. Patients underwent 6 min walk tests and spirometry at weeks 0, 4, 12, and 24 and biomarker level measurements early during treatment, at weeks 0, 4, and 12, when inflammation levels are typically elevated. Biomarkers included matrix metalloproteinases-1 (MMP-1), tissue inhibitor of MMP (TIMP)-1, collagen 1a, IL-6, IL-8, vascular cell adhesion molecule 1 (VCAM-1), C-X-C motif chemokine 10 (CXCL-10), CXCL-11, macrophage colony-stimulating factor (M-CSF), plasminogen activator, vascular endothelial growth factor, and chemokine (C-C) motif-2 (CCL-2). An MCID was derived statistically, and achievement of an MCID was modeled as the outcome using logistic regression model. RESULTS Eighty-nine patients walked an average of 393 (± standard deviation = 69) meters at baseline, which increased by an average of 9% (430 ± 70 m) at week 24. The MCID for change in walk distance was estimated as 41 m. Patients experiencing an MCID on treatment had worse lung function, lower 6 min walk test distance, higher levels of proinflammatory biomarkers including TIMP-1 and M-CSF, and lower levels of collagen 1a at baseline. Experiencing an MCID during treatment was associated with increases in forced expiratory volume in 1-s [odds ratio (OR) = 1.17, 95% confidence interval (CI) = 1.05-1.33] and increases in blood collagen 1a levels (OR = 1.31, 95%CI 1.06-1.62). CONCLUSIONS ART and TB treatment are associated with substantial improvements in 6 min walk test distance over time. Achievement of an MCID in the 6 min walk test in this study was associated with more severe disease at baseline and increases in collagen 1a levels and lung function during therapy.
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Affiliation(s)
- Yeonsoo Baik
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 832 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | | | - Diana Schramm
- Department of Virology, Faculty of Health Sciences, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Caroline Tiemessen
- Department of Virology, Faculty of Health Sciences, School of Pathology, University of the Witwatersrand, Johannesburg, South Africa
- Centre for HIV and STIs, National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Itai Ncube
- The Aurum Institute, Johannesburg, South Africa
| | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | | | - Mboyo-di-Tamba Vangu
- Department of Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, USA
| | - Yun Li
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 832 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | - Sara C Auld
- Department of Medicine, Emory University Rollins School of Public Health and School of Medicine, Atlanta, GA, USA
| | - Gregory P Bisson
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 832 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA.
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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11
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Wigger GW, Khani D, Auld SC, Fan X, Guidot D, Staitieh BS. Chronic alcohol exposure impairs alveolar macrophage phagocytosis of Mycobacterium tuberculosis. Am J Med Sci 2023. [DOI: 10.1016/s0002-9629(23)00615-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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12
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Wigger GW, Khani D, Ahmed M, Sayegh L, Auld SC, Fan X, Guidot DM, Staitieh BS. Alcohol impairs recognition and uptake of Mycobacterium tuberculosis by suppressing toll-like receptor 2 expression. Alcohol Clin Exp Res 2022; 46:2214-2224. [PMID: 36281822 PMCID: PMC9772112 DOI: 10.1111/acer.14960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 09/12/2022] [Accepted: 10/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Alcohol impairs pulmonary innate immune function and is associated with an increased risk of tuberculosis (TB). Toll-like receptor 2 (TLR2) is a pattern recognition receptor on alveolar macrophages that recognizes Mycobacterium tuberculosis (Mtb). The expression of TLR2 depends, in part, on granulocyte-macrophage colony-stimulating factor (GM-CSF) signaling. Given our prior work demonstrating the suppression of GM-CSF signaling following chronic alcohol ingestion, we hypothesized that alcohol impairs TLR2 expression via the suppression of GM-CSF and thereby reduces the ability of the macrophage to recognize and phagocytose Mtb. METHODS Primary alveolar macrophages were isolated from control-fed and alcohol-fed rats. Prior to cell isolation, some alcohol-fed rats were treated with intranasal GM-CSF and then endotracheally inoculated with an attenuated strain of Mtb. Primary macrophages were then isolated and immunofluorescence was used to determine phagocytic efficiency and TLR2 expression in the presence and absence of GM-CSF treatment and phagocytic efficiency in the presence and absence of TLR2 neutralization. RESULTS TLR2 expression and phagocytosis of Mtb were significantly lower in the alveolar macrophages of alcohol-fed rats than control-fed rats. In parallel, blocking TLR2 signaling recapitulated this decreased phagocytosis of Mtb. In contrast, intranasal GM-CSF treatment restored TLR2 expression and Mtb phagocytosis in the alveolar macrophages of alcohol-fed rats to levels comparable to those of control-fed rats. CONCLUSIONS Chronic alcohol ingestion reduces TLR2 protein expression and phagocytosis of Mtb, likely due to impaired GM-CSF signaling. GM-CSF restores membrane-bound TLR2 expression and phagocytic function.
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Affiliation(s)
- Gregory W Wigger
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Darya Khani
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mariam Ahmed
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Layal Sayegh
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Xian Fan
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David M Guidot
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Bashar S Staitieh
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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13
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Graciaa DS, Kipiani M, Magee MJ, Mikiashvili L, Barbakadze K, Bablishvili N, Auld SC, Alghamdi WA, Alshaer MH, Peloquin CA, Avaliani Z, Blumberg HM, Kempker RR. Linezolid Exposure Is Associated with Cytopenias in Patients Treated for Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2022; 66:e0040822. [PMID: 35916515 PMCID: PMC9487506 DOI: 10.1128/aac.00408-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/17/2022] [Indexed: 02/04/2023] Open
Abstract
Although linezolid is effective for multidrug-resistant TB (MDR-TB) tuberculosis treatment, it is associated with cytopenias after 4 weeks of administration. Data on toxicities with long-term use of linezolid and drug pharmacodynamics in MDR-TB treatment are limited, and concerns about toxicity present barriers to wider implementation. This was a secondary analysis of a prospective cohort study of patients treated for MDR-TB in the country of Georgia from 2015 to 2017. Intensive blood sampling 4 to 6 weeks after treatment initiation with linezolid 600 mg daily was performed for pharmacokinetic (PK) analysis, including linezolid trough concentration (Cmin) and area under the curve from 0 to 24 hours (AUC0-24). Linezolid exposure was defined using literature-reported thresholds. Cytopenias were defined using an NIH adverse event (AE) scale. Logistic regression was used to evaluate the relationship between linezolid exposure and cytopenias. Among 76 patients receiving linezolid in their baseline treatment regimen and who had PK data available, cytopenia AEs occurred in 30 (39.5%) for an incidence rate of 46 per 100 person-years. The median duration of linezolid therapy was 526 days. No patients required dose reduction or interruption due to cytopenias. Median linezolid Cmin was 0.235 mg/L (interquartile range [IQR], 0.069 to 0.529), and median AUC0-24 was 89.6 mg·h/L (IQR, 69.2 to 116.2). Cytopenias were associated with linezolid PK parameters (Cmin > 2 mg/L and AUC0-24 > 160 mg·h/L). Cytopenias occurred frequently with long-term use of linezolid 600 mg/day and were associated with PK parameters but did not result in the need for treatment interruption in the management of a cohort of patients with MDR-TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Matthew J. Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Ketevan Barbakadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Sara C. Auld
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wael A. Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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14
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Verkerke HP, Damhorst GL, Graciaa DS, McLendon K, O'Sick W, Robichaux C, Cheedarla N, Potlapalli S, Wu SC, Harrington KRV, Webster A, Kraft C, Rostad CA, Waggoner JJ, Gandhi NR, Guarner J, Auld SC, Neish A, Roback JD, Lam WA, Shah NS, Stowell SR. Nucleocapsid Antigenemia Is a Marker of Acute SARS-CoV-2 Infection. J Infect Dis 2022; 226:1577-1587. [PMID: 35877413 PMCID: PMC9384592 DOI: 10.1093/infdis/jiac225] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 06/08/2022] [Indexed: 01/07/2023] Open
Abstract
Detecting severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is essential for diagnosis, treatment, and infection control. Polymerase chain reaction (PCR) fails to distinguish acute from resolved infections, as RNA is frequently detected after infectiousness. We hypothesized that nucleocapsid in blood marks acute infection with the potential to enhance isolation and treatment strategies. In a retrospective serosurvey of inpatient and outpatient encounters, we categorized samples along an infection timeline using timing of SARS-CoV-2 testing and symptomatology. Among 1860 specimens from 1607 patients, the highest levels and frequency of antigenemia were observed in samples from acute SARS-CoV-2 infection. Antigenemia was higher in seronegative individuals and in those with severe disease. In our analysis, antigenemia exhibited 85.8% sensitivity and 98.6% specificity as a biomarker for acute coronavirus disease 2019 (COVID-19). Thus, antigenemia sensitively and specifically marks acute SARS-CoV-2 infection. Further study is warranted to determine whether antigenemia may aid individualized assessment of active COVID-19.
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Affiliation(s)
- Hans P Verkerke
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Damhorst
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, Georgia, USA
| | - Daniel S Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kaleb McLendon
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - William O'Sick
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Narayanaiah Cheedarla
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sindhu Potlapalli
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shang Chuen Wu
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristin R V Harrington
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Andrew Webster
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Colleen Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christina A Rostad
- Department of Pediatrics and Center for Childhood Infections and Vaccines, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jesse J Waggoner
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, Georgia, USA.,Emory Healthcare, Atlanta, Georgia, USA.,Department of Pediatrics and Center for Childhood Infections and Vaccines, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Neel R Gandhi
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sara C Auld
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.,Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew Neish
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - John D Roback
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wilbur A Lam
- The Atlanta Center for Microsystems-Engineered Point-of-Care Technologies, Atlanta, Georgia, USA.,Department of Pediatrics and Center for Childhood Infections and Vaccines, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - N Sarita Shah
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sean R Stowell
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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15
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Smith AGC, Kempker RR, Wassie L, Bobosha K, Nizam A, Gandhi NR, Auld SC, Magee MJ, Blumberg HM. The Impact of Diabetes and Prediabetes on Prevalence of Mycobacterium tuberculosis Infection Among Household Contacts of Active Tuberculosis Cases in Ethiopia. Open Forum Infect Dis 2022; 9:ofac323. [PMID: 36420425 PMCID: PMC9595051 DOI: 10.1093/ofid/ofac323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/28/2022] [Indexed: 02/03/2023] Open
Abstract
Background It is uncertain whether diabetes affects the risk of developing latent tuberculosis infection (LTBI) following exposure to Mycobacterium tuberculosis (Mtb). We assessed the relationship of diabetes or prediabetes and LTBI among close and household contacts (HHCs) of patients with active pulmonary tuberculosis (TB) disease in Addis Ababa, Ethiopia. Methods In this cross-sectional study, we performed interferon-γ release assays, TB symptom screening, and point-of-care glycolated hemoglobin (HbA1c) testing among HHCs of active TB cases. Diabetes status was classified into diabetes (HbA1c ≥6.5% or self-reported diagnosis), prediabetes (5.7%-6.4%), and euglycemia (≤5.6%). Multivariable logistic regression was used to determine the association of diabetes with LTBI. Results Among 597 study participants, 123 (21%) had dysglycemia including diabetes (n = 31) or prediabetes (n = 92); 423 (71%) participants were diagnosed with LTBI. Twelve of 31 (39%) HHCs with diabetes were previously undiagnosed with diabetes. The prevalence of LTBI among HHCs with diabetes, prediabetes, and euglycemia was 87% (27/31), 73% (67/92), and 69% (329/474), respectively. In multivariable analysis adjusted for age, sex, and HIV status, the odds of LTBI among HHCs with diabetes were 2.33 (95% confidence interval [CI], .76-7.08) times the odds of LTBI without diabetes. When assessing interaction with age, the association of diabetes and LTBI was robust among participants aged ≥40 years (adjusted odds ratio [aOR], 3.68 [95% CI, .77-17.6]) but not those <40 years (aOR, 1.15 [95% CI, .22-6.1]). Conclusions HHCs with diabetes may be more likely to have LTBI than those with euglycemia. Further investigations are needed to assess mechanisms by which diabetes may increase risk of LTBI after Mtb exposure.
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Affiliation(s)
- Alison G C Smith
- Correspondence: Alison G. C. Smith, MD, MSc, Emory University School of Medicine, 201 Dowman Drive, Atlanta, GA 30322, USA ()
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Liya Wassie
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Kidist Bobosha
- Mycobacterial Disease Research Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Azhar Nizam
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Neel R Gandhi
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Sara C Auld
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew J Magee
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
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16
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Lalonde CS, Zhuang TZ, Aldredge AA, Adelman MW, AbouYabis AN, McLemore ML, Auld SC. Abstract 444: COVID-IRIS: Immune reconstitution after G-CSF administration for neutropenia during acute COVID-19 infection. Cancer Res 2022. [DOI: 10.1158/1538-7445.am2022-444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Immune reconstitution inflammatory syndrome (IRIS) is a rapid inflammatory response with immune recovery, most commonly observed following antiretroviral therapy initiation in people with HIV and underlying opportunistic infections. To date there is one reported case of COVID-associated IRIS in a neutropenic patient treated with granulocyte colony-stimulating factor (G-CSF). Here we describe a second case of COVID-associated IRIS in a patient with history of follicular lymphoma who received G-CSF during acute COVID-19 infection.
Case: A 64-year-old woman with history of follicular lymphoma and autologous stem cell transplant one year prior presented with dyspnea, diarrhea, and fever, and tested positive for SARS-CoV-2. She had received three doses of the Pfizer BioNTech vaccine. She was admitted to the hospital for acute hypoxic respiratory failure and treated with remdesivir 100mg, dexamethasone 6mg, and 2 L/min supplemental oxygen via nasal cannula for five days. Twelve days after discharge, the patient returned with persistent diarrhea, fatigue, fever, and an oxygen saturation of 87% on room air. She again tested positive for SARS-CoV-2 by PCR. She was admitted to the intensive care unit for high-flow nasal cannula (HFNC) with oxygen at 30 L/min and 50% FiO2 and treated with methylprednisolone 1 mg/kg daily. On admission, her D-dimer was 3943 ng/mL, C-reactive protein 136 mg/L, absolute neutrophil count (ANC) 767/mcL, platelets 84/mcL. Her chest CT scan was negative for pulmonary embolism but demonstrated bilateral ground glass opacities characteristic of COVID-19 pneumonia. Her ANC reached a nadir of 186 on day 3 at which point G-CSF (filgrastim 300 mcg/day) was administered for three days with subsequent neutrophil recovery. On day 6, in light of a negative test for COVID antibodies, she received high-dose monoclonal antibodies through a compassionate use program. At that time, her oxygen requirements were stable and inflammatory markers had decreased to CRP 25 and D-Dimer 940. However, her oxygen requirements and inflammatory markers rapidly increased thereafter, with HFNC settings up to 60L/80%, D-dimer 27754, and CRP 135. After a repeat chest CT on day 8 showed worsened ground glass opacities throughout all lung fields, her steroid dose was increased to methylprednisolone 2 mg/kg daily out of concern for COVID-associated IRIS following G-CSF administration. Her oxygen requirement and inflammatory markers declined over the following 2-3 days and she was transferred out of the ICU.
Discussion: We present here an unusual case of COVID-associated IRIS after G-CSF administration in a transplant patient with COVID-19 pneumonia. Given the increased risk of infection and severe illness in immunosuppressed patients despite vaccination, it is important for providers to be aware of complications associated with adjunct therapies such as G-CSF in this vulnerable population.
Citation Format: Chloe S. Lalonde, Tony Z. Zhuang, Amalia A. Aldredge, Max W. Adelman, Abeer N. AbouYabis, Morgan L. McLemore, Sara C. Auld. COVID-IRIS: Immune reconstitution after G-CSF administration for neutropenia during acute COVID-19 infection [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 444.
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17
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Wigger GW, Bouton TC, Jacobson KR, Auld SC, Yeligar SM, Staitieh BS. The Impact of Alcohol Use Disorder on Tuberculosis: A Review of the Epidemiology and Potential Immunologic Mechanisms. Front Immunol 2022; 13:864817. [PMID: 35432348 PMCID: PMC9009367 DOI: 10.3389/fimmu.2022.864817] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
Globally, an estimated 107 million people have an alcohol use disorder (AUD) leading to 2.8 million premature deaths each year. Tuberculosis (TB) is one of the leading causes of death globally and over 8% of global TB cases are estimated to be attributable to AUD. Social determinants of health such as poverty and undernutrition are often shared among those with AUD and TB and could explain the epidemiologic association between them. However, recent studies suggest that these shared risk factors do not fully account for the increased risk of TB in people with AUD. In fact, AUD has been shown to be an independent risk factor for TB, with a linear increase in the risk for TB with increasing alcohol consumption. While few studies have focused on potential biological mechanisms underlying the link between AUD and TB, substantial overlap exists between the effects of alcohol on lung immunity and the mechanisms exploited by Mycobacterium tuberculosis (Mtb) to establish infection. Alcohol misuse impairs the immune functions of the alveolar macrophage, the resident innate immune effector in the lung and the first line of defense against Mtb in the lower respiratory tract. Chronic alcohol ingestion also increases oxidative stress in the alveolar space, which could in turn facilitate Mtb growth. In this manuscript, we review the epidemiologic data that links AUD to TB. We discuss the existing literature on the potential mechanisms by which alcohol increases the risk of TB and review the known effects of alcohol ingestion on lung immunity to elucidate other mechanisms that Mtb may exploit. A more in-depth understanding of the link between AUD and TB will facilitate the development of dual-disease interventions and host-directed therapies to improve lung health and long-term outcomes of TB.
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Affiliation(s)
- Gregory W Wigger
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Tara C Bouton
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Karen R Jacobson
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Samantha M Yeligar
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States.,Atlanta VA Medical Center, Atlanta, GA, United States
| | - Bashar S Staitieh
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
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18
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Auld SC. Lung Function After Coronavirus Disease 2019: Some Answers, More Questions. J Infect Dis 2022; 225:1305-1307. [PMID: 34979027 PMCID: PMC9016437 DOI: 10.1093/infdis/jiab637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sara C Auld
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Emory University School of Medicine, USA
- Department of Epidemiology, Emory Rollins School of Public Health, USA
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19
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Auld SC, Harrington KRV, Adelman MW, Robichaux CJ, Overton EC, Caridi-Scheible M, Coopersmith CM, Murphy DJ. Trends in ICU Mortality From Coronavirus Disease 2019: A Tale of Three Surges. Crit Care Med 2022; 50:245-255. [PMID: 34259667 PMCID: PMC8796834 DOI: 10.1097/ccm.0000000000005185] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine the association between time period of hospitalization and hospital mortality among critically ill adults with coronavirus disease 2019. DESIGN Observational cohort study from March 6, 2020, to January 31, 2021. SETTING ICUs at four hospitals within an academic health center network in Atlanta, GA. PATIENTS Adults greater than or equal to 18 years with coronavirus disease 2019 admitted to an ICU during the study period (i.e., Surge 1: March to April, Lull 1: May to June, Surge 2: July to August, Lull 2: September to November, Surge 3: December to January). MEASUREMENTS AND MAIN RESULTS Among 1,686 patients with coronavirus disease 2019 admitted to an ICU during the study period, all-cause hospital mortality was 29.7%. Mortality differed significantly over time: 28.7% in Surge 1, 21.3% in Lull 1, 25.2% in Surge 2, 30.2% in Lull 2, 34.7% in Surge 3 (p = 0.007). Mortality was significantly associated with 1) preexisting risk factors (older age, race, ethnicity, lower body mass index, higher Elixhauser Comorbidity Index, admission from a nursing home); 2) clinical status at ICU admission (higher Sequential Organ Failure Assessment score, higher d-dimer, higher C-reactive protein); and 3) ICU interventions (receipt of mechanical ventilation, vasopressors, renal replacement therapy, inhaled vasodilators). After adjusting for baseline and clinical variables, there was a significantly increased risk of mortality associated with admission during Lull 2 (relative risk, 1.37 [95% CI = 1.03-1.81]) and Surge 3 (relative risk, 1.35 [95% CI = 1.04-1.77]) as compared to Surge 1. CONCLUSIONS Despite increased experience and evidence-based treatments, the risk of death for patients admitted to the ICU with coronavirus disease 2019 was highest during the fall and winter of 2020. Reasons for this increased mortality are not clear.
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Affiliation(s)
- Sara C Auld
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Kristin R V Harrington
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
| | - Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Chad J Robichaux
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
| | | | - Mark Caridi-Scheible
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - Craig M Coopersmith
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David J Murphy
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
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20
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Matheny M, Maleque N, Channell N, Eisch AR, Auld SC, Banerji A, Druey KM. Severe Exacerbations of Systemic Capillary Leak Syndrome After COVID-19 Vaccination: A Case Series. Ann Intern Med 2021; 174:1476-1478. [PMID: 34125573 PMCID: PMC8252024 DOI: 10.7326/l21-0250] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Meghan Matheny
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Noble Maleque
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia
| | | | - A Robin Eisch
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | - Sara C Auld
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia
| | - Aleena Banerji
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kirk M Druey
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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21
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Cheung PC, Eisch AR, Maleque N, Polly DM, Auld SC, Druey KM. Fatal Exacerbations of Systemic Capillary Leak Syndrome Complicating Coronavirus Disease. Emerg Infect Dis 2021; 27:2529-2534. [PMID: 34314669 PMCID: PMC8462330 DOI: 10.3201/eid2710.211155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We report 2 fatal exacerbations of systemic capillary leak syndrome (SCLS), also known as Clarkson disease, associated with coronavirus disease (COVID-19) in the United States. One patient carried an established diagnosis of SCLS and the other sought treatment for new-onset hypotensive shock, hemoconcentration, and anasarca, classic symptoms indicative of an SCLS flare. Both patients had only mild-to-moderate symptoms of COVID-19. This clinical picture suggests that these patients succumbed to complications of SCLS induced by infection with severe acute respiratory syndrome coronavirus 2. Persons with known or suspected SCLS may be at increased risk for developing a disease flare in the setting of mild-to-moderate COVID-19 infection.
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22
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Harrington KR, Staitieh BS, Nguyen MLT, Colasanti JA, Sumitani J, Marconi VC, Auld SC. Diagnosis and Management of HIV-Associated Pulmonary Diseases in a Ryan White-Funded Primary Care Setting. AIDS Patient Care STDS 2021; 35:239-248. [PMID: 34242091 PMCID: PMC8418444 DOI: 10.1089/apc.2021.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Despite widespread use of antiretroviral therapy (ART), people with HIV (PWH) continue to suffer substantial morbidity and mortality from pulmonary diseases. We sought to evaluate the prevalence of pulmonary symptoms, evaluations, and diagnoses (both infectious and noninfectious) among PWH receiving care at one of the largest HIV clinics in the United States. All PWH seen at the Infectious Disease Program in Atlanta, Georgia, from July 2013 to June 2018 were included. Multivariable logistic regression was used to assess the odds of all-cause mortality. Among 8387 patients, median age was 48 years, 35% had documented smoking, 74% were male, and the 47% with ≥1 pulmonary symptom or diagnosis were older and had higher rates of smoking compared to those without any symptoms or diagnoses (p-values <0.0001). Percent on ART was 97% and 81% for individuals with and without symptoms or diagnoses, respectively (p-value <0.0001). Patients with an infectious diagnosis were more likely to have a diagnostic test ordered than those with a noninfectious diagnosis (p-value <0.0001). After adjustment for demographic and clinical risk factors, odds of death were 2.1 times greater [95% confidence interval (CI) = 1.3-3.5] among those with a pulmonary symptom or diagnosis compared to those without. Despite a high prevalence of pulmonary symptoms and diagnoses in this large cohort of PWH, many did not have a complete diagnostic evaluation, particularly those with noninfectious diagnoses. Greater awareness of evaluation and treatment of noninfectious pulmonary diseases among HIV care providers will be critical to improving long-term outcomes for PWH.
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Affiliation(s)
- Kristin R.V. Harrington
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.,Address correspondence to: Kristin R.V. Harrington, BS, Department of Epidemiology, Rollins School of Public Health, 3rd Floor, Claudia Nance Rollins Building, 1518 Clifton Road, Atlanta, GA 30322, USA
| | - Bashar S. Staitieh
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
| | - Minh Ly T. Nguyen
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jonathan A. Colasanti
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Jieri Sumitani
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA
| | - Vincent C. Marconi
- Infectious Diseases Program, Grady Health System, Atlanta, Georgia, USA.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.,Infectious Diseases Clinic, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA.,The Emory Vaccine Center, Atlanta, Georgia, USA
| | - Sara C. Auld
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA.,Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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23
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Shantha JG, Auld SC, Anthony C, Ward L, Adelman MW, Maier CL, Price KW, Jacob J, Fashina T, Randleman C, Xu LT, Barnett J, Sadan O, Kandiah PA, Varkey JB, Kraft CS, Rouphael N, Linderman S, Ahmed R, Drews-Botsch C, Waggoner JJ, Weinmann M, Murphy DJ, Yeh S. Retinopathy and Systemic Disease Morbidity in Severe COVID-19. Ocul Immunol Inflamm 2021; 29:743-750. [PMID: 34464544 PMCID: PMC8562588 DOI: 10.1080/09273948.2021.1952278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/17/2021] [Accepted: 06/30/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE To assess the prevalence of retinopathy and its association with systemic morbidity and laboratory indices of coagulation and inflammatory dysfunction in severe COVID-19. DESIGN Retrospective, observational cohort study. METHODS Adult patients hospitalized with severe COVID-19 who underwent ophthalmic examination from April to July 2020 were reviewed. Retinopathy was defined as one of the following: 1) Retinal hemorrhage; 2) Cotton wool spots; 3) Retinal vascular occlusion. We analyzed medical comorbidities, sequential organ failure assessment (SOFA) scores, clinical outcomes, and laboratory values for their association with retinopathy. RESULTS Thirty-seven patients with severe COVID-19 were reviewed, the majority of whom were female (n = 23, 62%), Black (n = 26, 69%), and admitted to the intensive care unit (n = 35, 95%). Fourteen patients had retinopathy (38%) with retinal hemorrhage in 7 (19%), cotton wool spots in 8 (22%), and a branch retinal artery occlusion in 1 (3%) patient. Patients with retinopathy had higher SOFA scores than those without retinopathy (8.0 vs. 5.3, p = .03), higher rates of respiratory failure requiring invasive mechanical ventilation and shock requiring vasopressors (p < .01). Peak D-dimer levels were 28,971 ng/mL in patients with retinopathy compared to 12,575 ng/mL in those without retinopathy (p = .03). Peak CRP was higher in patients with cotton wool spots versus those without cotton wool spots (354 mg/dL vs. 268 mg/dL, p = .03). Multivariate logistic regression modeling showed an increased risk of retinopathy with higher peak D-dimers (aOR 1.32, 95% CI 1.01-1.73, p = .04) and male sex (aOR 9.6, 95% CI 1.2-75.5, p = .04). CONCLUSION Retinopathy in severe COVID-19 was associated with greater systemic disease morbidity involving multiple organs. Given its association with coagulopathy and inflammation, retinopathy may offer insight into disease pathogenesis in patients with severe COVID-19.
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Affiliation(s)
| | - Sara C Auld
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Casey Anthony
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
| | - Laura Ward
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Max W. Adelman
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Cheryl L. Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Kenneth W. Price
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
| | - Jesse Jacob
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Tolu Fashina
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
| | - Casey Randleman
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
| | - Lucy T. Xu
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
| | - Joshua Barnett
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Prem A. Kandiah
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Jay B. Varkey
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Colleen S. Kraft
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Nadine Rouphael
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Susanne Linderman
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA
| | - Rafi Ahmed
- Emory Vaccine Center, Emory University School of Medicine, Atlanta, GA
| | - Carolyn Drews-Botsch
- Department of Global and Community Health, College of Health and Human Services, George Mason University, Fairfax, VA
| | - Jesse J. Waggoner
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - Max Weinmann
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - David J. Murphy
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Steven Yeh
- Emory Eye Center, Emory University School of Medicine, Atlanta, GA
- Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE
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24
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Alabyad D, Rangaraju S, Liu M, Imran R, Kempton CL, Sharifpour M, Auld SC, Gaddh M, Sniecinski R, Maier CL, Guarner J, Duncan A, Nahab F. Validation of an admission coagulation panel for risk stratification of COVID-19 patients. PLoS One 2021; 16:e0248230. [PMID: 33740793 PMCID: PMC7979266 DOI: 10.1371/journal.pone.0248230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/22/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND There is limited data on the markers of coagulation and hemostatic activation (MOCHA) profile in Coronavirus disease 2019 (COVID-19) and its ability to identify COVID-19 patients at risk for thrombotic events and other complications. METHODS Hospitalized patients with confirmed SARS-COV-2 from four Atlanta hospitals were included in this observational cohort study and underwent admission testing of MOCHA parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, fibrin monomer). Clinical outcomes included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke, access line thrombosis, ICU admission, intubation and mortality. MAIN RESULTS Of 276 patients (mean age 59 ± 6.4 years, 47% female, 62% African American), 45 (16%) had a thrombotic endpoint. Each MOCHA parameter was independently associated with a thrombotic event (p<0.05) and ≥ 2 abnormalities was associated with thrombotic endpoints (OR 3.3, 95% CI 1.2-8.8) as were admission D-dimer ≥ 2000 ng/mL (OR 3.1, 95% CI 1.5-6.6) and ≥ 3000 ng/mL (OR 3.6, 95% CI 1.6-7.9). However, only ≥ 2 MOCHA abnormalities were associated with ICU admission (OR 3.0, 95% CI 1.7-5.2) and intubation (OR 3.2, 95% CI 1.6-6.4). MOCHA and D-dimer cutoffs were not associated with mortality. MOCHA with <2 abnormalities (26% of the cohort) had 89% sensitivity and 93% negative predictive value for a thrombotic endpoint. CONCLUSIONS An admission MOCHA profile is useful to risk-stratify COVID-19 patients for thrombotic complications and more effective than isolated d-dimer for predicting risk of ICU admission and intubation.
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Affiliation(s)
- Darwish Alabyad
- Morehouse School of Medicine, Atlanta, Georgia, United States of America
| | - Srikant Rangaraju
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Michael Liu
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Rajeel Imran
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Christine L. Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Milad Sharifpour
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Sara C. Auld
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Roman Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Cheryl L. Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Alexander Duncan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Fadi Nahab
- Department of Neurology & Pediatrics, Emory University, Atlanta, Georgia, United States of America
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25
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Staitieh BS, Auld SC, Ahmed M, Fan X, Smirnova N, Yeligar SM. Granulocyte Macrophage-Colony Stimulating Factor Reverses HIV Protein-Induced Mitochondrial Derangements in Alveolar Macrophages. AIDS Res Hum Retroviruses 2021; 37:224-232. [PMID: 33059459 DOI: 10.1089/aid.2020.0176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Despite the advent of antiretroviral therapy, people living with HIV suffer from a range of infectious and noninfectious pulmonary complications. HIV impairs antioxidant defenses and innate immune function of the alveolar macrophage by diminishing granulocyte macrophage-colony stimulating factor (GM-CSF) signaling. Since GM-CSF may be linked to mitochondria, we sought to determine the effects of HIV on GM-CSF receptor expression and alveolar macrophage mitochondrial function. At an academic medical center, studies were completed on alveolar macrophages isolated from both wild-type and HIV transgenic (HIV Tg) rats and human subjects with and without HIV. Primary macrophages were plated and evaluated for expression of GM-CSF receptor beta, phagocytic index, and mitochondrial function in the presence and absence of GM-CSF treatment. GM-CSF receptor expression and mitochondrial function were impaired in macrophages isolated from HIV Tg rats, and treatment with GM-CSF restored GM-CSF receptor expression and mitochondrial function. GM-CSF treatment of HIV Tg rats also increased alveolar macrophage levels of the mitochondrial proteins voltage-dependent anion-selective channel 1 (VDAC) and glucose-regulated protein 75 (Grp75). Similar to the HIV Tg rat model, impairments in mitochondrial bioenergetics were confirmed in alveolar macrophages isolated from human subjects with HIV. HIV-associated impairments in alveolar macrophage mitochondrial bioenergetics likely contribute to innate immune dysfunction in HIV infection, and GM-CSF treatment may offer a novel therapeutic strategy for mitigating these deleterious effects.
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Affiliation(s)
- Bashar S. Staitieh
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sara C. Auld
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Mariam Ahmed
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Xian Fan
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Natalia Smirnova
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Samantha M. Yeligar
- Division of Pulmonary, Allergy, Critical Care & Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Atlanta VA Health Care System, Decatur, Georgia, USA
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26
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Creel-Bulos C, Auld SC, Caridi-Scheible M, Barker NA, Friend S, Gaddh M, Kempton CL, Maier CL, Nahab F, Sniecinski R. Fibrinolysis Shutdown and Thrombosis in a COVID-19 ICU. Shock 2021; 55:316-320. [PMID: 32769822 PMCID: PMC8858425 DOI: 10.1097/shk.0000000000001635] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
ABSTRACT The coronavirus disease (COVID-19) pandemic has threatened millions of lives worldwide with severe systemic inflammation, organ dysfunction, and thromboembolic disease. Within our institution, many critically ill COVID-19-positive patients suffered major thrombotic events, prompting our clinicians to evaluate hypercoagulability outside of traditional coagulation testing.We determined the prevalence of fibrinolysis shutdown via rotational thromboelastometry (ROTEM, Instrumentation Laboratories, Bedford, Mass) in patients admitted to the intensive care unit over a period of 3 weeks. In 25 patients who had a ROTEM test, we found that 11 (44%) met criteria for fibrinolysis shutdown. Eight of 9 (73%) of the VTE patients met criteria for fibrinolysis shutdown.Given the high rate of fibrinolysis shutdown in these patients, our data support using viscoelastic testing to evaluate for the presence of impaired fibrinolysis. This may help identify patient subsets who might benefit from the administration of fibrinolytics.
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Affiliation(s)
- Christina Creel-Bulos
- Emory Critical Care Center, Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Sara C. Auld
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia
| | - Mark Caridi-Scheible
- Emory Critical Care Center, Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Sarah Friend
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Christine L. Kempton
- Hemophilia of Georgia Center for Bleeding and Clotting Disorders of Emory and Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia
| | - Cheryl L. Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Fadi Nahab
- Division of Vascular Neurology, Department of Neurology and Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Roman Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
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Alabyad D, RANGARAJU S, Liu M, Imran R, Kempton CL, Sharifpour M, Auld SC, Gaddh M, Sniecinski R, Maier CL, Guarner J, Duncan A, NAHAB FB. Abstract P112: Markers of Coagulation and Hemostatic Activation Identify Covid-19 Patients at High Risk for Thrombotic Events. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
COVID-19 has been associated with venous and arterial thrombotic complications. The objective of our study was to determine whether markers of coagulation and hemostatic activation (MOCHA) on admission could identify COVID-19 patients at risk for thrombotic events.
Methods:
COVID-19 patients admitted to a tertiary academic healthcare system from April 3, 2020 to July 31, 2020 underwent admission testing of MOCHA profile parameters (plasma d-dimer, prothrombin fragment 1.2, thrombin-antithrombin complex, and fibrin monomer). For this analysis we excluded patients on outpatient anticoagulation therapy preceding admission. Prespecified endpoints monitored during hospitalization included deep vein thrombosis, pulmonary embolism, myocardial infarction, ischemic stroke and access line thrombosis.
Results:
During the study period, 276 patients were included in the analysis cohort (mean age 59 ± 6.3 years, 47% female, 83% non-white race). Arterial and venous thrombotic events occurred in 43 (16%) patients (see Table). Each coagulation marker was independently associated with the composite endpoint (p<0.05). Admission MOCHA with ≥ 2 abnormalities was associated with the composite endpoint (OR 3.1, 95% CI 1.2-8.3), ICU admission (OR 3.2, 95% CI 1.8-5.5) and intubation (OR 2.8, 95% CI 1.5-5.5). Admission MOCHA with < 2 abnormalities (26% of the cohort) had sensitivity of 88% and a negative predictive value of 93% for an in-hospital endpoint.
Conclusion:
Admission MOCHA with ≥ 2 abnormalities identified COVID-19 patients at risk for a thrombotic event, ICU admission and intubation while < 2 abnormalities identified a subgroup of patients who were at low risk for thrombotic events. Our results suggest that an admission MOCHA profile can be useful to risk stratify COVID-19 patients. Further studies are needed to determine whether an admission MOCHA profile can guide anticoagulation therapy and improve overall clinical outcomes.
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Marmarchi F, Liu M, Rangaraju S, Auld SC, Creel-Bulos MC, Kempton CL, Sharifpour M, Gaddh M, Sniecinski R, Maier CL, Nahab F. Clinical Outcomes of Critically III Patients with COVID-19 by Race. J Racial Ethn Health Disparities 2021; 9:385-389. [PMID: 33469873 PMCID: PMC7815200 DOI: 10.1007/s40615-021-00966-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/25/2020] [Accepted: 01/10/2021] [Indexed: 12/21/2022]
Abstract
Background Studies of COVID-19 have shown that African Americans have been affected by the virus at a higher rate compared to other races. This cohort study investigated comorbidities and clinical outcomes by race among COVID-19 patients admitted to the intensive care unit. Methods This is a case series of critically ill patients admitted with COVID-19 to an academic healthcare system in Atlanta, Georgia. The study included all critically ill hospitalized patients between March 6, 2020, and May 5, 2020. Clinical outcomes during hospitalization included mechanical ventilation, renal replacement therapy, and mortality stratified by race. Results Of 288 patients included (mean age, 63 ± 16 years; 45% female), 210 (73%) were African American. African Americans had significantly higher rates of comorbidities compared to other races, including hypertension (80% vs 59%, P = 0.001), diabetes (49% vs 34%, P = 0.026), and mean BMI (33 kg/m2 vs 28 kg/m2, P < 0.001). Despite African Americans requiring continuous renal replacement therapy during hospitalization at higher rates than other races (27% vs 13%, P = 0.011), rates of intubation, intensive care unit length of stay, and overall mortality (30% vs 24%, P = 0.307) were similar. Conclusion This racially diverse series of critically ill COVID-19 patients shows that despite higher rates of comorbidities at hospital admission in African Americans compared with other races, there was no significant difference in mortality. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-021-00966-0.
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Affiliation(s)
- Fahad Marmarchi
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Liu
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Srikant Rangaraju
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Sara C Auld
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Maria Christina Creel-Bulos
- Department of Anesthesiology, Division of Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Christine L Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Milad Sharifpour
- Department of Anesthesiology, Division of Critical Care Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, GA, USA
| | - Roman Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Fadi Nahab
- Department of Neurology & Pediatrics, Emory University, 1365 Clifton Road, Clinic B, Suite 2200, Atlanta, GA, 30322, USA.
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Auld SC, Kornfeld H, Maenetje P, Mlotshwa M, Chase W, Vangu MDT, Torigian DA, Wallis RS, Churchyard G, Bisson GP. Pulmonary restriction predicts long-term pulmonary impairment in people with HIV and tuberculosis. BMC Pulm Med 2021; 21:19. [PMID: 33413293 PMCID: PMC7791797 DOI: 10.1186/s12890-020-01368-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 11/24/2020] [Indexed: 01/26/2023] Open
Abstract
Background While tuberculosis is considered a risk factor for chronic obstructive pulmonary disease, a restrictive pattern of pulmonary impairment may actually be more common among tuberculosis survivors. We aimed to determine the nature of pulmonary impairment before and after treatment among people with HIV and tuberculosis and identify risk factors for long-term impairment.
Methods In this prospective cohort study conducted in South Africa, we enrolled adults newly diagnosed with HIV and tuberculosis who were initiating antiretroviral therapy and tuberculosis treatment. We measured lung function and symptoms at baseline, 6, and 12 months. We compared participants with and without pulmonary impairment and constructed logistic regression models to identify characteristics associated with pulmonary impairment.
Results Among 134 participants with a median CD4 count of 110 cells/μl, 112 (83%) completed baseline spirometry at which time 32 (29%) had restriction, 13 (12%) had obstruction, and 9 (7%) had a mixed pattern. Lung function was dynamic over time and 30 (33%) participants had impaired lung function at 12 months. Baseline restriction was associated with greater symptoms and with long-term pulmonary impairment (adjusted odds ratio 5.44, 95% confidence interval 1.16–25.45), while baseline obstruction was not (adjusted odds ratio 1.95, 95% confidence interval 0.28–13.78).
Conclusions In this cohort of people with HIV and tuberculosis, restriction was the most common, symptomatic, and persistent pattern of pulmonary impairment. These data can help to raise awareness among clinicians about the heterogeneity of post-tuberculosis pulmonary impairment, and highlight the need for further research into mediators of lung injury in this vulnerable population.
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Affiliation(s)
- Sara C Auld
- Departments of Medicine and Epidemiology, School of Medicine and Rollins School of Public Health, Emory University, Atlanta, GA, USA.
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester, USA
| | | | | | - William Chase
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Mboyo di-Tamba Vangu
- Department of Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | - Drew A Torigian
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa.,School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Gregory P Bisson
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Ravimohan S, Auld SC, Maenetje P, Ratsela N, Mlotshwa M, Ncube I, Smith JP, Vangu MDT, Sebe M, Kossenkov A, Weissman D, Wallis RS, Churchyard G, Kornfeld H, Bisson GP. Lung Injury on Antiretroviral Therapy in Adults With Human Immunodeficiency Virus/Tuberculosis. Clin Infect Dis 2021; 70:1845-1854. [PMID: 31242296 DOI: 10.1093/cid/ciz560] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/24/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Immune restoration on antiretroviral therapy (ART) can drive inflammation in people living with human immunodeficiency virus (HIV) who have pulmonary tuberculosis (TB), but its effects on the lungs have not been assessed. We evaluated associations between pulmonary inflammation, recovery of pathogen-specific CD4 T-cell function, and lung injury prior to and after ART initiation in adults with HIV and pulmonary TB. METHODS This was a prospective cohort study in South Africa, following adults with HIV and pulmonary TB prior to and up to 48 weeks after ART initiation. Pulmonary-specific inflammation was defined as total glycolytic activity (TGA) on [18]F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) at baseline and 4 weeks after ART initiation. Spirometry, respiratory symptom tests, and flow cytometry were performed at the same times to assess lung involvement and the frequency of mycobacteria-specific CD4 T-cells. In addition, we evaluated lung function longitudinally up to 48 weeks after ART initiation. RESULTS Greater lung TGA on FDG PET-CT was associated with worse lung function and respiratory symptoms prior to ART initiation, and nearly half of subjects experienced worsening lung inflammation and lung function at Week 4 of ART. Worsening Week 4 lung inflammation and pulmonary function were both associated with greater increases in pathogen-specific functional CD4 T-cell responses on ART, and early decreases in lung function were independently associated with persistently lower lung function months after TB treatment completion. CONCLUSIONS Increases in pulmonary inflammation and decreases in lung function are common on ART, relate to greater ART-mediated CD4 T-cell restoration, and are associated with the persistent impairment of lung function in individuals with HIV/TB.
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Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Sara C Auld
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Jonathan P Smith
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Mboyo-Di-Tamba Vangu
- Nuclear Medicine, Charlotte Maxeke Johannesburg Academic Hospital, University of the Witwatersrand, South Africa
| | | | | | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - Gavin Churchyard
- The Aurum Institute, Johannesburg.,Advancing Care and Treatment for Tuberculosis/Human Immuondeficiency Virus, A Collaborating Centre of The South African Medical Research Council.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Auld SC, Maenetje P, Ravimohan S, Weissman D, Ncube I, Mlotshwa M, Ratsela N, Chase W, Vangu MDT, Wallis R, Churchyard G, Kornfeld H, Bisson GP. Declines in Lung Function After Antiretroviral Therapy Initiation in Adults With Human Immunodeficiency Virus and Tuberculosis: A Potential Manifestation of Respiratory Immune Reconstitution Inflammatory Syndrome. Clin Infect Dis 2021; 70:1750-1753. [PMID: 31552412 PMCID: PMC7146005 DOI: 10.1093/cid/ciz733] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 08/27/2019] [Indexed: 12/20/2022] Open
Abstract
End-organ impairment has received relatively little research attention as a possible manifestation of tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS). In this prospective cohort study, one-half of adults with human immunodeficiency virus and pulmonary tuberculosis experienced meaningful declines in lung function on antiretroviral therapy, suggesting a role for lung function in TB-IRIS definitions.
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Affiliation(s)
- Sara C Auld
- School of Medicine and Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Itai Ncube
- Aurum Institute, Johannesburg, South Africa
| | | | | | - William Chase
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Mboyo-Di-Tamba Vangu
- Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Gavin Churchyard
- Aurum Institute, Johannesburg, South Africa.,Advancing Care and Treatment for TB/HIV, a Collaborating Centre of the South African Medical Research Council, Johannesburg, South Africa.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine, University of Pennsylvania, Philadelphia.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
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Truong AD, Auld SC, Barker NA, Friend S, Wynn AT, Cobb J, Sniecinski RM, Tanksley CL, Polly DM, Gaddh M, Connor M, Nakahara H, Sullivan HC, Kempton C, Guarner J, Duncan A, Josephson CD, Roback JD, Stowell SR, Maier CL. Therapeutic plasma exchange for COVID-19-associated hyperviscosity. Transfusion 2020; 61:1029-1034. [PMID: 33231313 PMCID: PMC7753437 DOI: 10.1111/trf.16218] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/21/2022]
Abstract
Background Recent data suggests an association between blood hyperviscosity and both propensity for thrombosis and disease severity in patients with COVID‐19. This raises the possibility that increased viscosity may contribute to endothelial damage and multiorgan failure in COVID‐19, and that therapeutic plasma exchange (TPE) to decrease viscosity may improve patient outcomes. Here we sought to share our experience using TPE in the first 6 patients treated for COVID‐19‐associated hyperviscosity. Study Design and Methods Six critically ill COVID‐19 patients with plasma viscosity levels ranging from 2.6 to 4.2 centipoise (cP; normal range, 1.4‐1.8 cP) underwent daily TPE for 2‐3 treatments. Results TPE decreased plasma viscosity in all six patients (Pre‐TPE median 3.75 cP, range 2.6‐4.2 cP; Post‐TPE median 1.6 cP, range 1.5‐1.9 cP). TPE also decreased fibrinogen levels in all five patients for whom results were available (Pre‐TPE median 739 mg/dL, range 601‐1188 mg/dL; Post‐TPE median 359 mg/dL, range 235‐461 mg/dL); D‐dimer levels in all six patients (Pre‐TPE median 5921 ng/mL, range 1134‐60 000 ng/mL; Post‐TPE median 4893 ng/mL, range 620‐7518 ng/mL); and CRP levels in five of six patients (Pre‐TPE median 292 mg/L, range 136‐329 mg/L; Post‐TPE median 84 mg/L, range 31‐211 mg/L). While the two sickest patients died, significant improvement in clinical status was observed in four of six patients shortly after TPE. Conclusions This series demonstrates the utility of TPE to rapidly correct increased blood viscosity in patients with COVID‐19‐associated hyperviscosity. Large randomized trials are needed to determine whether TPE may improve clinical outcomes for patients with COVID‐19.
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Affiliation(s)
- Alexander D Truong
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sara C Auld
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Nicholas A Barker
- Department of Pharmacy, Emory St. Joseph's Hospital, Atlanta, Georgia, USA
| | - Sarah Friend
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - A Thanushi Wynn
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jason Cobb
- Division of Renal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christin-Lauren Tanksley
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Derek M Polly
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Manila Gaddh
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael Connor
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory Critical Care Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hirotomo Nakahara
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - H Clifford Sullivan
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christine Kempton
- Department of Hematology and Medical Oncology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeannette Guarner
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alexander Duncan
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cassandra D Josephson
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - John D Roback
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sean R Stowell
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, Georgia, USA
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Creel-Bulos C, Liu M, Auld SC, Gaddh M, Kempton CL, Sharifpour M, Sniecinski RM, Maier CL, Nahab FB, Rangaraju S. Trends and diagnostic value of D-dimer levels in patients hospitalized with coronavirus disease 2019. Medicine (Baltimore) 2020; 99:e23186. [PMID: 33181697 PMCID: PMC7668476 DOI: 10.1097/md.0000000000023186] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has been associated with increased incidence of venous thromboembolic events (VTE) as well as mortality. D-dimer is a marker of fibrinolysis and has been used as a diagnostic and prognostic marker in VTE among other diseases. The purpose of our study is to describe outcomes from out center and to examine trends in D-dimer levels as it relates to VTE and mortality.Patients admitted with confirmed COVID-19 cases to Emory Healthcare from March 12, 2020 through April 6, 2020 with measured plasma D-dimer levels were included in our retrospective analysis. Relevant data about comorbidities, hospitalization course, laboratory results, and outcomes were analyzed.One hundred fifteen patients were included in our study. Mean age was 64 ± 15 years, 47 (41%) females and 84 (73%) African-American. Hypertension was present in 83 (72%) and diabetes in 60 (52%). Mean duration of hospitalization was 19 ± 11 days with 62 (54%) patients intubated (mean duration of 13 ± 8 days). VTE was diagnosed in 27 (23%) patients (mean time to diagnosis 14 ± 9 days). Median D-dimer within the first 7 days of hospitalization was higher (6450 vs. 1596 ng/mL, p < 0.001) in VTE cases compared to non-VTE cases, and was predictive of VTE (area under the curve [AUC] = 0.72, optimal threshold 2500 ng/mL) although not of mortality (AUC 0.55, P = .34). Change in D-dimer level (AUC = 0.72 P = .004) and rate of D-dimer rise (AUC = 0.75 P = .001) were also predictive of VTE, though neither predicted death (P > .05 for all). Within the first 7 days of hospitalization, peak D-dimer level of >2500 ng/mL and a rate of change exceeding 150 ng/mL/d were predictive of future diagnosis of VTE. Rise in D-dimer >2000 ng/mL within any 24 hour period through hospital day 10 had 75% sensitivity and 74% specificity for diagnosis of VTE.We found that both magnitude and rate of rise in d-dimer within the first 10 days of hospitalization are predictive of diagnosis of VTE but not mortality. These parameters may aid in identifying individuals with possible underlying VTE or at high risk for VTE, thereby guiding risk stratification and anticoagulation policies in COVID-19 patients.
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Affiliation(s)
| | - Michael Liu
- Department of Neurology, Emory University School of Medicine
| | - Sara C. Auld
- Emory Critical Care Center. Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Department of Epidemiology, Emory University Rollins School of Public Health
| | | | - Christine L. Kempton
- Department of Hematology and Medical Oncology, Director, Hemophilia of Georgia Center for Bleeding & Clotting Disorders of Emory, HoG Director's Chair in Hemostasis
| | - Milad Sharifpour
- Department of Anesthesiology, Division of Critical Care Medicine
| | | | | | - Fadi B. Nahab
- Division of Vascular Neurology, Department of Neurology and Pediatrics
| | - Srikant Rangaraju
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
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Hernandez-Romieu AC, Adelman MW, Hockstein MA, Robichaux CJ, Edwards JA, Fazio JC, Blum JM, Jabaley CS, Caridi-Scheible M, Martin GS, Murphy DJ, Auld SC. Timing of Intubation and Mortality Among Critically Ill Coronavirus Disease 2019 Patients: A Single-Center Cohort Study. Crit Care Med 2020; 48:e1045-e1053. [PMID: 32804790 PMCID: PMC7448713 DOI: 10.1097/ccm.0000000000004600] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVES Increasing time to mechanical ventilation and high-flow nasal cannula use may be associated with mortality in coronavirus disease 2019. We examined the impact of time to intubation and use of high-flow nasal cannula on clinical outcomes in patients with coronavirus disease 2019. DESIGN Retrospective cohort study. SETTING Six coronavirus disease 2019-specific ICUs across four university-affiliated hospitals in Atlanta, Georgia. PATIENTS Adults with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 infection who received high-flow nasal cannula or mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 231 patients admitted to the ICU, 109 (47.2%) were treated with high-flow nasal cannula and 97 (42.0%) were intubated without preceding high-flow nasal cannula use. Of those managed with high-flow nasal cannula, 78 (71.6%) ultimately received mechanical ventilation. In total, 175 patients received mechanical ventilation; 44.6% were female, 66.3% were Black, and the median age was 66 years (interquartile range, 56-75 yr). Seventy-six patients (43.4%) were intubated within 8 hours of ICU admission, 57 (32.6%) between 8 and 24 hours of admission, and 42 (24.0%) greater than or equal to 24 hours after admission. Patients intubated within 8 hours were more likely to have diabetes, chronic comorbidities, and higher admission Sequential Organ Failure Assessment scores. Mortality did not differ by time to intubation (≤ 8 hr: 38.2%; 8-24 hr: 31.6%; ≥ 24 hr: 38.1%; p = 0.7), and there was no association between time to intubation and mortality in adjusted analysis. Similarly, there was no difference in initial static compliance, duration of mechanical ventilation, or ICU length of stay by timing of intubation. High-flow nasal cannula use prior to intubation was not associated with mortality. CONCLUSIONS In this cohort of critically ill patients with coronavirus disease 2019, neither time from ICU admission to intubation nor high-flow nasal cannula use were associated with increased mortality. This study provides evidence that coronavirus disease 2019 respiratory failure can be managed similarly to hypoxic respiratory failure of other etiologies.
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Affiliation(s)
- Alfonso C Hernandez-Romieu
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Maxwell A Hockstein
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center (ECCC), Atlanta, GA
| | - Chad J Robichaux
- Department of Biomedical Informatics, Emory University, Atlanta, GA
- Georgia Clinical and Translational Science Alliance, Atlanta, GA
| | - Johnathan A Edwards
- Department of Biomedical Informatics, Emory University, Atlanta, GA
- Georgia Clinical and Translational Science Alliance, Atlanta, GA
| | - Jane C Fazio
- Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - James M Blum
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Biomedical Informatics, Emory University, Atlanta, GA
- Georgia Clinical and Translational Science Alliance, Atlanta, GA
| | - Craig S Jabaley
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center (ECCC), Atlanta, GA
| | - Mark Caridi-Scheible
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Emory Critical Care Center (ECCC), Atlanta, GA
| | - Greg S Martin
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - David J Murphy
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
| | - Sara C Auld
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
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Auld SC, Staitieh BS. HIV and the tuberculosis "set point": how HIV impairs alveolar macrophage responses to tuberculosis and sets the stage for progressive disease. Retrovirology 2020; 17:32. [PMID: 32967690 PMCID: PMC7509826 DOI: 10.1186/s12977-020-00540-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/15/2020] [Indexed: 11/16/2022] Open
Abstract
As HIV has fueled a global resurgence of tuberculosis over the last several decades, there is a growing awareness that HIV-mediated impairments in both innate and adaptive immunity contribute to the heightened risk of tuberculosis in people with HIV. Since early immune responses to Mycobacterium tuberculosis (Mtb) set the stage for subsequent control or progression to active tuberculosis disease, early host-pathogen interactions following Mtb infection can be thought of as establishing a mycobacterial "set point," which we define as the mycobacterial burden at the point of adaptive immune activation. This early immune response is impaired in the context of HIV coinfection, allowing for a higher mycobacterial set point and greater likelihood of progression to active disease with greater bacterial burden. Alveolar macrophages, as the first cells to encounter Mtb in the lungs, play a critical role in containing Mtb growth and establishing the mycobacterial set point. However, a number of key macrophage functions, ranging from pathogen recognition and uptake to phagocytosis and microbial killing, are blunted in HIV coinfection. To date, research evaluating the effects of HIV on the alveolar macrophage response to Mtb has been relatively limited, particularly with regard to the critical early events that help to dictate the mycobacterial set point. A greater understanding of alveolar macrophage functions impacted by HIV coinfection will improve our understanding of protective immunity to Mtb and may reveal novel pathways amenable to intervention to improve both early immune control of Mtb and clinical outcomes for the millions of people worldwide infected with HIV.
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Affiliation(s)
- Sara C Auld
- Emory University School of Medicine, Atlanta, GA, USA.
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.
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Auld SC, Caridi-Scheible M, Blum JM, Robichaux C, Kraft C, Jacob JT, Jabaley CS, Carpenter D, Kaplow R, Hernandez-Romieu AC, Adelman MW, Martin GS, Coopersmith CM, Murphy DJ. ICU and Ventilator Mortality Among Critically Ill Adults With Coronavirus Disease 2019. Crit Care Med 2020; 48:e799-e804. [PMID: 32452888 PMCID: PMC7255393 DOI: 10.1097/ccm.0000000000004457] [Citation(s) in RCA: 277] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine mortality rates among adults with critical illness from coronavirus disease 2019. DESIGN Observational cohort study of patients admitted from March 6, 2020, to April 17, 2020. SETTING Six coronavirus disease 2019 designated ICUs at three hospitals within an academic health center network in Atlanta, Georgia, United States. PATIENTS Adults greater than or equal to 18 years old with confirmed severe acute respiratory syndrome-CoV-2 disease who were admitted to an ICU during the study period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 217 critically ill patients, mortality for those who required mechanical ventilation was 35.7% (59/165), with 4.8% of patients (8/165) still on the ventilator at the time of this report. Overall mortality to date in this critically ill cohort is 30.9% (67/217) and 60.4% (131/217) patients have survived to hospital discharge. Mortality was significantly associated with older age, lower body mass index, chronic renal disease, higher Sequential Organ Failure Assessment score, lower PaO2/FIO2 ratio, higher D-dimer, higher C-reactive protein, and receipt of mechanical ventilation, vasopressors, renal replacement therapy, or vasodilator therapy. CONCLUSIONS Despite multiple reports of mortality rates exceeding 50% among critically ill adults with coronavirus disease 2019, particularly among those requiring mechanical ventilation, our early experience indicates that many patients survive their critical illness.
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Affiliation(s)
- Sara C Auld
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
- Emory University Hospital, Emory Healthcare, Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
| | - Mark Caridi-Scheible
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - James M Blum
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
| | - Chad Robichaux
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
| | - Colleen Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Department of Pathology, Emory University School of Medicine, Atlanta, GA
| | - Jesse T Jacob
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Craig S Jabaley
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | | | - Roberta Kaplow
- Emory University Hospital, Emory Healthcare, Atlanta, GA
| | - Alfonso C Hernandez-Romieu
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Max W Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Greg S Martin
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Georgia Clinical and Translational Science Alliance (CTSA), Atlanta, GA
| | - Craig M Coopersmith
- Emory Critical Care Center (ECCC), Atlanta, GA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - David J Murphy
- Emory Critical Care Center (ECCC), Atlanta, GA
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Office of Quality and Risk, Emory Healthcare, Atlanta, GA
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Ravimohan S, Maenetje P, Auld SC, Ncube I, Mlotshwa M, Chase W, Tiemessen CT, Vangu MDT, Wallis RS, Churchyard G, Weissman D, Kornfeld H, Bisson GP. A Common NLRC4 Gene Variant Associates With Inflammation and Pulmonary Function in Human Immunodeficiency Virus and Tuberculosis. Clin Infect Dis 2020; 71:924-932. [PMID: 31751447 PMCID: PMC7428399 DOI: 10.1093/cid/ciz898] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/27/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Inflammasomes mediate inflammation in adults living with both human immunodeficiency virus (HIV) and tuberculosis (TB), but the relevance of inflammasome gene polymorphisms in TB-associated pulmonary damage is unknown. We hypothesized that functional single-nucleotide polymorphisms (SNPs) in inflammasome pathway genes modify systemic and pulmonary inflammation, contributing to respiratory impairment in adults living with HIV/pulmonary TB. METHODS This was a prospective cohort study set in South Africa following individuals living with HIV/TB up to 48 weeks post-antiretroviral therapy (ART) initiation. Ten functional SNPs in 5 inflammasome pathway genes were related to circulating inflammatory biomarkers and lung function assessed by spirometry pre- and post-ART initiation. Analyses used 2-sided t tests, Wilcoxon rank sum tests, Spearman correlation coefficients, linear regression, and generalized estimating equation models. RESULTS Among 102 patients with baseline samples, the minor allele (T) in NLRC4 rs385076 was independently associated with lower levels of interleukin (IL)-18 and IL-6 before and up to 12 weeks post-ART initiation (Benjamini-Hochberg corrected P values < .02). Patients with the CT/TT genotypes also had improved lung function vs CC patients up to 48 weeks post-ART initiation (forced vital capacity, 206 mL higher; 95% confidence interval [CI], 67-345 mL; P = .004 and forced expiratory volume in 1 second, 143 mL higher; 95% CI, 11-274 mL; P = .034). CONCLUSIONS A common SNP in the NLRC4 inflammasome may modify TB-associated inflammation in clinically relevant ways. This SNP may identify high-risk groups for lung damage in TB. Inhibition of NLRC4 activity may be an important approach for TB host-directed therapy.
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Affiliation(s)
- Shruthi Ravimohan
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Sara C Auld
- Department of Medicine, Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia, USA, Johannesburg, South Africa
| | - Itai Ncube
- The Aurum Institute, Johannesburg, South Africa
| | | | - William Chase
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Caroline T Tiemessen
- Centre for HIV-1 and STIs, National Institute for Communicable Diseases, and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mboyo-Di-Tamba Vangu
- Nuclear Medicine, CM Johannesburg Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Gavin Churchyard
- The Aurum Institute, Johannesburg, South Africa
- School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Drew Weissman
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hardy Kornfeld
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Gregory P Bisson
- Department of Medicine, Division of Infectious Diseases, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Nelson KN, Gandhi NR, Mathema B, Lopman BA, Brust JCM, Auld SC, Ismail N, Omar SV, Brown TS, Allana S, Campbell A, Moodley P, Mlisana K, Shah NS, Jenness SM. Modeling Missing Cases and Transmission Links in Networks of Extensively Drug-Resistant Tuberculosis in KwaZulu-Natal, South Africa. Am J Epidemiol 2020; 189:735-745. [PMID: 32242216 PMCID: PMC7443195 DOI: 10.1093/aje/kwaa028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 02/26/2020] [Indexed: 11/14/2022] Open
Abstract
Patterns of transmission of drug-resistant tuberculosis (TB) remain poorly understood, despite over half a million incident cases worldwide in 2017. Modeling TB transmission networks can provide insight into drivers of transmission, but incomplete sampling of TB cases can pose challenges for inference from individual epidemiologic and molecular data. We assessed the effect of missing cases on a transmission network inferred from Mycobacterium tuberculosis sequencing data on extensively drug-resistant TB cases in KwaZulu-Natal, South Africa, diagnosed in 2011-2014. We tested scenarios in which cases were missing at random, missing differentially by clinical characteristics, or missing differentially by transmission (i.e., cases with many links were under- or oversampled). Under the assumption that cases were missing randomly, the mean number of transmissions per case in the complete network needed to be larger than 20, far higher than expected, to reproduce the observed network. Instead, the most likely scenario involved undersampling of high-transmitting cases, and models provided evidence for super-spreading. To our knowledge, this is the first analysis to have assessed support for different mechanisms of missingness in a TB transmission study, but our results are subject to the distributional assumptions of the network models we used. Transmission studies should consider the potential biases introduced by incomplete sampling and identify host, pathogen, or environmental factors driving super-spreading.
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Affiliation(s)
- Kristin N Nelson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Neel R Gandhi
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- School of Medicine, Emory University, Atlanta, Georgia
| | - Barun Mathema
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Benjamin A Lopman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - James C M Brust
- Albert Einstein College of Medicine and Montefiore Medical Center, New York, New York
| | - Sara C Auld
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
- School of Medicine, Emory University, Atlanta, Georgia
| | - Nazir Ismail
- National Institute for Communicable Diseases, Johannesburg, South Africa
- Department of Medical Microbiology, School of Medicine, University of Pretoria, Pretoria, South Africa
| | - Shaheed Vally Omar
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Tyler S Brown
- Infectious Diseases Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Salim Allana
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Angie Campbell
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Pravi Moodley
- National Health Laboratory Service, Johannesburg, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Koleka Mlisana
- National Health Laboratory Service, Johannesburg, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - N Sarita Shah
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Samuel M Jenness
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Maier CL, Truong AD, Auld SC, Polly DM, Tanksley CL, Duncan A. COVID-19-associated hyperviscosity: a link between inflammation and thrombophilia? Lancet 2020; 395:1758-1759. [PMID: 32464112 PMCID: PMC7247793 DOI: 10.1016/s0140-6736(20)31209-5] [Citation(s) in RCA: 166] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA30322, USA.
| | - Alexander D Truong
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA30322, USA
| | - Sara C Auld
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA30322, USA
| | - Derek M Polly
- Department of Pharmacy, Emory University Hospital Midtown, Atlanta, GA, USA
| | - Christin-Lauren Tanksley
- Emory Critical Care Center, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA30322, USA
| | - Alexander Duncan
- Department of Pathology and Laboratory Medicine, Center for Transfusion and Cellular Therapies, Emory University School of Medicine, Atlanta, GA30322, USA
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40
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Benameur K, Agarwal A, Auld SC, Butters MP, Webster AS, Ozturk T, Howell JC, Bassit LC, Velasquez A, Schinazi RF, Mullins ME, Hu WT. Encephalopathy and Encephalitis Associated with Cerebrospinal Fluid Cytokine Alterations and Coronavirus Disease, Atlanta, Georgia, USA, 2020. Emerg Infect Dis 2020; 26:2016-2021. [PMID: 32487282 PMCID: PMC7454059 DOI: 10.3201/eid2609.202122] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
There are few detailed investigations of neurologic complications in severe acute respiratory syndrome coronavirus 2 infection. We describe 3 patients with laboratory-confirmed coronavirus disease who had encephalopathy and encephalitis develop. Neuroimaging showed nonenhancing unilateral, bilateral, and midline changes not readily attributable to vascular causes. All 3 patients had increased cerebrospinal fluid (CSF) levels of anti-S1 IgM. One patient who died also had increased levels of anti-envelope protein IgM. CSF analysis also showed markedly increased levels of interleukin (IL)-6, IL-8, and IL-10, but severe acute respiratory syndrome coronavirus 2 was not identified in any CSF sample. These changes provide evidence of CSF periinfectious/postinfectious inflammatory changes during coronavirus disease with neurologic complications.
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Nelson KN, Jenness SM, Mathema B, Lopman BA, Auld SC, Shah NS, Brust JCM, Ismail N, Omar SV, Brown TS, Allana S, Campbell A, Moodley P, Mlisana K, Gandhi NR. Social Mixing and Clinical Features Linked With Transmission in a Network of Extensively Drug-resistant Tuberculosis Cases in KwaZulu-Natal, South Africa. Clin Infect Dis 2020; 70:2396-2402. [PMID: 31342067 PMCID: PMC7245156 DOI: 10.1093/cid/ciz636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 07/10/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Tuberculosis (TB) is the leading infectious cause of death globally, and drug-resistant TB strains pose a serious threat to controlling the global TB epidemic. The clinical features, locations, and social factors driving transmission in settings with high incidences of drug-resistant TB are poorly understood. METHODS We measured a network of genomic links using Mycobacterium tuberculosis whole-genome sequences. RESULTS Patients with 2-3 months of cough or who spent time in urban locations were more likely to be linked in the network, while patients with sputum smear-positive disease were less likely to be linked than those with smear-negative disease. Associations persisted using different thresholds to define genomic links and irrespective of assumptions about the direction of transmission. CONCLUSIONS Identifying factors that lead to many transmissions, including contact with urban areas, can suggest settings instrumental in transmission and indicate optimal locations and groups to target with interventions.
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Affiliation(s)
- Kristin N Nelson
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Samuel M Jenness
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York, New York
| | | | - Sara C Auld
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | - N Sarita Shah
- US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - James C M Brust
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Nazir Ismail
- National Institute for Communicable Diseases, Johannesburg, South Africa
- University of Pretoria, South Africa
| | - Shaheed Vally Omar
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | - Tyler S Brown
- Massachusetts General Hospital, Infectious Diseases Division, Boston
| | - Salim Allana
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Angie Campbell
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Pravi Moodley
- National Health Laboratory Service, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Koleka Mlisana
- National Health Laboratory Service, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Neel R Gandhi
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
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Auld SC, Caridi-Scheible M, Blum JM, Robichaux C, Kraft C, Jacob JT, Jabaley CS, Carpenter D, Kaplow R, Hernandez-Romieu AC, Adelman MW, Martin GS, Coopersmith CM, Murphy DJ. ICU and ventilator mortality among critically ill adults with COVID-19. medRxiv 2020:2020.04.23.20076737. [PMID: 32511599 PMCID: PMC7276026 DOI: 10.1101/2020.04.23.20076737] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We report preliminary data from a cohort of adults admitted to COVID-designated intensive care units from March 6 through April 17, 2020 across an academic healthcare system. Among 217 critically ill patients, mortality for those who required mechanical ventilation was 29.7% (49/165), with 8.5% (14/165) of patients still on the ventilator at the time of this report. Overall mortality to date in this critically ill cohort is 25.8% (56/217), and 40.1% (87/217) patients have survived to hospital discharge. Despite multiple reports of mortality rates exceeding 50% among critically ill adults with COVID-19, particularly among those requiring mechanical ventilation, our early experience indicates that many patients survive their critical illness.
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Affiliation(s)
- Sara C. Auld
- Emory Critical Care Center (ECCC)
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine
- Department of Epidemiology, Emory University Rollins School of Public Health
| | - Mark Caridi-Scheible
- Emory Critical Care Center (ECCC)
- Department of Anesthesiology, Emory University School of Medicine
| | - James M. Blum
- Emory Critical Care Center (ECCC)
- Department of Anesthesiology, Emory University School of Medicine
- Department of Biomedical Informatics, Emory University School of Medicine
- Georgia Clinical and Translational Science Alliance (CTSA)
| | - Chad Robichaux
- Department of Biomedical Informatics, Emory University School of Medicine
- Georgia Clinical and Translational Science Alliance (CTSA)
| | - Colleen Kraft
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine
- Department of Pathology, Emory University School of Medicine
| | - Jesse T. Jacob
- Department of Epidemiology, Emory University Rollins School of Public Health
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine
| | - Craig S. Jabaley
- Emory Critical Care Center (ECCC)
- Department of Anesthesiology, Emory University School of Medicine
| | | | | | | | - Max W. Adelman
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine
| | - Greg S. Martin
- Emory Critical Care Center (ECCC)
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine
- Georgia Clinical and Translational Science Alliance (CTSA)
| | - Craig M. Coopersmith
- Emory Critical Care Center (ECCC)
- Department of Surgery, Emory University School of Medicine
| | - David J. Murphy
- Emory Critical Care Center (ECCC)
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine, Emory University School of Medicine
- Office of Quality and Risk, Emory Healthcare
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Yeligar SM, Auld SC, Staitieh BS. The Metabolic Woes of the Alveolar Macrophage in HIV. FASEB J 2020. [DOI: 10.1096/fasebj.2020.34.s1.01828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Samantha M. Yeligar
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine Emory University Atlanta GA 30322
- Atlanta Veterans Affairs Health Care System Decatur GA 30033
| | - Sara C. Auld
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine Emory University Atlanta GA 30322
- Department of Epidemiology, Rollins School of Public Health Emory University Atlanta GA 30322
| | - Bashar S. Staitieh
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Department of Medicine Emory University Atlanta GA 30322
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Peterson ML, Gandhi NR, Clennon J, Nelson KN, Morris N, Ismail N, Allana S, Campbell A, Brust JCM, Auld SC, Mathema B, Mlisana K, Moodley P, Shah NS. Extensively drug-resistant tuberculosis 'hotspots' and sociodemographic associations in Durban, South Africa. Int J Tuberc Lung Dis 2020; 23:720-727. [PMID: 31315705 DOI: 10.5588/ijtld.18.0575] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
<sec> <title>BACKGROUND</title> In KwaZulu-Natal, South Africa, the incidence of extensively drug-resistant tuberculosis (XDR-TB) is driven by the transmission of resistant strains. As data suggest that cases may be spatially clustered, we sought to identify 'hotspots' and describe these communities. </sec> <sec> <title>METHODS</title> We enrolled XDR-TB patients diagnosed from 2011 to 2014 in eThekwini. Global positioning system (GPS) coordinates for participant homes were collected and hotspots were identified based on population-adjusted XDR-TB incidence. The sociodemographic features of hotspots were characterised using census data. For a subset of participants, we mapped non-home XDR-TB congregate locations and compared these with results including only homes. </sec> <sec> <title>RESULTS</title> Among 132 participants, 75 (57%) were female and 87 (66%) lived in urban or suburban locations. Fifteen of 197 census tracts were identified as XDR-TB hotspots with ≥95% confidence. Four spatial mapping methods identified one large hotspot in northeastern eThekwini. Hotspot communities had higher proportions of low educational attainment (12% vs. 9%) and unemployment (29.3% vs. 20.4%), and lower proportion of homes with flush toilets (36.4% vs. 68.9%). The case density shifted towards downtown Durban when congregate locations (e.g., workplaces) for 43 (33%) participants were mapped. </sec> <sec> <title>CONCLUSIONS</title> In eThekwini, XDR-TB case homes were clustered into hotspots with more poverty indicators than non-hotspots. Prevention efforts targeting hotspot communities and congregate settings may be effective in reducing community transmission. </sec>.
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Affiliation(s)
- M L Peterson
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - N R Gandhi
- Emory University Rollins School of Public Health, Atlanta, Georgia, Emory University School of Medicine, Atlanta, Georgia, USA
| | - J Clennon
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - K N Nelson
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - N Morris
- Environment and Health Research Unit, South African Medical Research Council, Johannesburg
| | - N Ismail
- National Institute for Communicable Diseases, Johannesburg, University of Pretoria, Pretoria, South Africa
| | - S Allana
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - A Campbell
- Emory University Rollins School of Public Health, Atlanta, Georgia
| | - J C M Brust
- Albert Einstein College of Medicine, Bronx, New York
| | - S C Auld
- Emory University Rollins School of Public Health, Atlanta, Georgia, Emory University School of Medicine, Atlanta, Georgia, USA
| | - B Mathema
- Columbia University Mailman School of Public Health, New York, New York, USA
| | - K Mlisana
- National Health Laboratory Service, Durban, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - P Moodley
- National Health Laboratory Service, Durban
| | - N S Shah
- Emory University Rollins School of Public Health, Atlanta, Georgia, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Nelson KN, Shah NS, Mathema B, Ismail N, Brust JCM, Brown TS, Auld SC, Omar SV, Morris N, Campbell A, Allana S, Moodley P, Mlisana K, Gandhi NR. Spatial Patterns of Extensively Drug-Resistant Tuberculosis Transmission in KwaZulu-Natal, South Africa. J Infect Dis 2018; 218:1964-1973. [PMID: 29961879 PMCID: PMC6217717 DOI: 10.1093/infdis/jiy394] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 06/26/2018] [Indexed: 12/29/2022] Open
Abstract
Background Transmission is driving the global drug-resistant tuberculosis (TB) epidemic; nearly three-quarters of drug-resistant TB cases are attributable to transmission. Geographic patterns of disease incidence, combined with information on probable transmission links, can define the spatial scale of transmission and generate hypotheses about factors driving transmission patterns. Methods We combined whole-genome sequencing data with home Global Positioning System coordinates from 344 participants with extensively drug-resistant (XDR) TB in KwaZulu-Natal, South Africa, diagnosed from 2011 to 2014. We aimed to determine if genomically linked (difference of ≤5 single-nucleotide polymorphisms) cases lived close to one another, which would suggest a role for local community settings in transmission. Results One hundred eighty-two study participants were genomically linked, comprising 1084 case-pairs. The median distance between case-pairs' homes was 108 km (interquartile range, 64-162 km). Between-district, as compared to within-district, links accounted for the majority (912/1084 [84%]) of genomic links. Half (526 [49%]) of genomic links involved a case from Durban, the urban center of KwaZulu-Natal. Conclusions The high proportions of between-district links with Durban provide insight into possible drivers of province-wide XDR-TB transmission, including urban-rural migration. Further research should focus on characterizing the contribution of these drivers to overall XDR-TB transmission in KwaZulu-Natal to inform design of targeted strategies to curb the drug-resistant TB epidemic.
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Affiliation(s)
- Kristin N Nelson
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - N Sarita Shah
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York, New York
| | - Nazir Ismail
- National Institute for Communicable Diseases, Johannesburg
- University of Pretoria, South Africa
| | - James C M Brust
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - Tyler S Brown
- Infectious Diseases Division, Massachusetts General Hospital, Boston
| | - Sara C Auld
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Natashia Morris
- Environment and Health Research Unit, South African Medical Research Council, Johannesburg
| | - Angie Campbell
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Salim Allana
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Pravi Moodley
- National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Koleka Mlisana
- National Health Laboratory Service, University of KwaZulu-Natal, Durban, South Africa
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Neel R Gandhi
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- Emory University School of Medicine, Atlanta, Georgia
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Magee MJ, Salindri AD, Gujral UP, Auld SC, Bao J, Haw JS, Lin HH, Kornfeld H. Convergence of non-communicable diseases and tuberculosis: a two-way street? Int J Tuberc Lung Dis 2018; 22:1258-1268. [PMID: 30355404 PMCID: PMC6281291 DOI: 10.5588/ijtld.18.0045] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The intersection of tuberculosis (TB) with non-communicable diseases (NCDs), including diabetes mellitus (DM), chronic lung disease (CLD), and cardiovascular disease (CVD), has emerged as a critical clinical and public health challenge. Rapidly expanding NCD epidemics threaten TB control in low- and middle-income countries, where the prevention and treatment of TB disease remain a great burden. However, to date, the notion that TB may adversely impact NCD risk and severity has not been well explored. This review summarizes biomedical hypotheses, findings from animal models, and emerging epidemiologic data related to the progression of DM, CLD and CVD during and after active TB disease. We conclude that there is sufficient empirical evidence to justify a greater research emphasis on the syndemic interaction between TB and NCD.
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Affiliation(s)
- Matthew J Magee
- Division of Epidemiology and Biostatistics, Georgia State University
| | - Argita D Salindri
- Division of Epidemiology and Biostatistics, Georgia State University
| | - Unjali P Gujral
- Global Diabetes Research Center, Rollins School of Public Health, Emory University
| | - Sara C Auld
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine
| | - Jing Bao
- National Institute of Allergy and Infectious Diseases, National Institutes of Health
| | - J Sonya Haw
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine
| | | | - H Kornfeld
- Department of Medicine, University of Massachusetts Medical School
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Auld SC, Shah NS, Mathema B, Brown TS, Ismail N, Omar SV, Brust JCM, Nelson KN, Allana S, Campbell A, Mlisana K, Moodley P, Gandhi NR. Extensively drug-resistant tuberculosis in South Africa: genomic evidence supporting transmission in communities. Eur Respir J 2018; 52:13993003.00246-2018. [PMID: 30115614 DOI: 10.1183/13993003.00246-2018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/08/2018] [Indexed: 11/05/2022]
Abstract
Despite evidence that transmission is driving an extensively drug-resistant TB (XDR-TB) epidemic, our understanding of where and between whom transmission occurs is limited. We sought to determine whether there was genomic evidence of transmission between individuals without an epidemiologic connection.We conducted a prospective study of XDR-TB patients in KwaZulu-Natal, South Africa, during the 2011-2014 period. We collected sociodemographic and clinical data, and identified epidemiologic links based on person-to-person or hospital-based connections. We performed whole-genome sequencing (WGS) on the Mycobacterium tuberculosis isolates and determined pairwise single nucleotide polymorphism (SNP) differences.Among 404 participants, 123 (30%) had person-to-person or hospital-based links, leaving 281 (70%) epidemiologically unlinked. The median SNP difference between participants with person-to-person and hospital-based links was 10 (interquartile range (IQR) 8-24) and 16 (IQR 10-23), respectively. The median SNP difference between unlinked participants and their closest genomic link was 5 (IQR 3-9) and half of unlinked participants were within 7 SNPs of at least five participants.The majority of epidemiologically-unlinked XDR-TB patients had low pairwise SNP differences with at least one other participant, consistent with transmission. These data suggest that much of transmission may result from casual contact in community settings between individuals not known to one another.
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Affiliation(s)
- Sara C Auld
- School of Medicine, Emory University, Atlanta, GA, USA.,Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Sarita Shah
- Rollins School of Public Health, Emory University, Atlanta, GA, USA.,Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Barun Mathema
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Tyler S Brown
- Mailman School of Public Health, Columbia University, New York, NY, USA.,Massachusetts General Hospital, Boston, MA, USA
| | - Nazir Ismail
- National Institute for Communicable Diseases, Johannesburg, South Africa.,Dept of Medical Microbiology, University of Pretoria, Pretoria, South Africa
| | - Shaheed Vally Omar
- National Institute for Communicable Diseases, Johannesburg, South Africa
| | | | - Kristin N Nelson
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Salim Allana
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Angela Campbell
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Koleka Mlisana
- School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa.,National Health Laboratory Service, Durban, South Africa
| | - Pravi Moodley
- National Health Laboratory Service, Durban, South Africa
| | - Neel R Gandhi
- School of Medicine, Emory University, Atlanta, GA, USA.,Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Auld SC, Gandhi NR, Shah NS. Closing the book on Category II: time for individualized regimens for patients with recurrent tuberculosis. Int J Tuberc Lung Dis 2018; 22:1113-1114. [PMID: 30236175 DOI: 10.5588/ijtld.18.0569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sara C Auld
- Emory University School of Medicine, Emory University Rollins School of Public Health
| | - Neel R Gandhi
- Emory University School of Medicine, Emory University Rollins School of Public Health
| | - N Sarita Shah
- Emory University Rollins School of Public Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Abstract
PURPOSE OF REVIEW The intersection of tuberculosis (TB) disease and type 2 diabetes mellitus is severely hindering global efforts to reduce TB burdens. Diabetes increases the risk of developing TB disease and negatively impacts TB treatment outcomes including culture conversion time, mortality risk, and TB relapse. Recent evidence also indicates plausible mechanisms by which TB disease may influence the pathogenesis and incidence of diabetes. We review the epidemiology of stress hyperglycemia in patients with TB and the pathophysiologic responses to TB disease that are related to established mechanisms of stress hyperglycemia. We also consider clinical implications of stress hyperglycemia on TB treatment, and the role of TB disease on risk of diabetes post-TB. RECENT FINDINGS Among patients with TB disease, the development of stress hyperglycemia may influence the clinical manifestation and treatment response of some patients and can complicate diabetes diagnosis. Research is needed to elucidate the relationship between TB disease and stress hyperglycemia and determine the extent to which stress hyperglycemia impacts TB treatment response. Currently, there is insufficient data to support clinical recommendations for glucose control among patients with TB disease, representing a major barrier for efforts to improve treatment outcomes for patients with TB and diabetes.
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Affiliation(s)
- Matthew J Magee
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, PO Box 3984, Atlanta, GA, 30302-3984, USA.
| | - Argita D Salindri
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, PO Box 3984, Atlanta, GA, 30302-3984, USA
| | - Nang Thu Thu Kyaw
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, PO Box 3984, Atlanta, GA, 30302-3984, USA
- Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union) Office, Mandalay, Myanmar
| | - Sara C Auld
- Division of Pulmonary, Allergy and Critical Care Medicine, Emory University School of Medicine and Rollins School of Public Health, 615 Michael St, NE Ste 205 , Atlanta, GA, 30322, USA
| | - J Sonya Haw
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Dr SE, Glenn Memorial Building, Atlanta, GA, 30303, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Dr SE, Glenn Memorial Building, Atlanta, GA, 30303, USA
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Auld SC, Shah NS, Cohen T, Martinson NA, Gandhi NR. Where is tuberculosis transmission happening? Insights from the literature, new tools to study transmission and implications for the elimination of tuberculosis. Respirology 2018; 23:10.1111/resp.13333. [PMID: 29869818 PMCID: PMC6281783 DOI: 10.1111/resp.13333] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/14/2018] [Accepted: 05/20/2018] [Indexed: 12/12/2022]
Abstract
More than 10 million new cases of tuberculosis (TB) are diagnosed worldwide each year. The majority of these cases occur in low- and middle-income countries where the TB epidemic is predominantly driven by transmission. Efforts to 'end TB' will depend upon our ability to halt ongoing transmission. However, recent studies of new approaches to interrupt transmission have demonstrated inconsistent effects on reducing population-level TB incidence. TB transmission occurs across a wide range of settings, that include households and hospitals, but also community-based settings. While home-based contact investigations and infection control programmes in hospitals and clinics have a successful track record as TB control activities, there is a gap in our knowledge of where, and between whom, community-based transmission of TB occurs. Novel tools, including molecular epidemiology, geospatial analyses and ventilation studies, provide hope for improving our understanding of transmission in countries where the burden of TB is greatest. By integrating these diverse and innovative tools, we can enhance our ability to identify transmission events by documenting the opportunity for transmission-through either an epidemiologic or geospatial connection-alongside genomic evidence for transmission, based upon genetically similar TB strains. A greater understanding of locations and patterns of transmission will translate into meaningful improvements in our current TB control activities by informing targeted, evidence-based public health interventions.
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Affiliation(s)
- Sara C Auld
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - N Sarita Shah
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Division of Global HIV and TB, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Neil A Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Center for TB Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Neel R Gandhi
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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