Cardiac index is associated with oxygenation in COVID-19 acute respiratory distress syndrome

Eleven participants with COVID-19 acute respiratory distress syndrome requiring mechanical ventilation underwent pulmonary artery catheterization for clinical indications. Clinical interventions or events concurrent with hemodynamic were recorded. Increased cardiac index was associated with worse hypoxemia. Modulation of cardiac index may improve hypoxemia in patients with COVID-19 acute respiratory distress syndrome.

COVID-19 critical illness pathophysiology driven by diffuse pulmonary thrombi and pulmonary endothelial dysfunction responsive to thrombolysis

Patients with severe COVID-19 disease have been characterized as having the acute respiratory distress syndrome (ARDS). Critically ill COVID-19 patients have relatively well-preserved lung mechanics despite severe gas exchange abnormalities, a feature not consistent with classical ARDS but more consistent with pulmonary vascular disease. Many patients with severe COVID-19 also demonstrate markedly abnormal coagulation, with elevated d-dimers and higher rates of venous thromboembolism. We present four cases of patients with severe COVID-19 pneumonia with severe respiratory failure and shock, with evidence of markedly elevated dead-space ventilation who received tPA. All showed post treatment immediate improvements in gas exchange and/or hemodynamics. We suspect that severe COVID-19 pneumonia causes respiratory failure via pulmonary microthrombi and endothelial dysfunction. Treatment for COVID-19 pneumonia may warrant anticoagulation for milder cases and thrombolysis for more severe disease.

COVID-19 Critical Illness Pathophysiology Driven by Diffuse Pulmonary Thrombi and Pulmonary Endothelial Dysfunction Responsive to Thrombolysis

Patients with severe COVID-19 disease have been characterized as having the acute respiratory distress syndrome (ARDS). Critically ill COVID-19 patients have relatively well-preserved lung mechanics despite severe gas exchange abnormalities, a feature not consistent with classical ARDS but more consistent with pulmonary vascular disease. Patients with severe COVID-19 also demonstrate markedly abnormal coagulation, with elevated D-dimers and higher rates of venous thromboembolism. We present five cases of patients with severe COVID-19 pneumonia with severe respiratory failure and shock, with evidence of markedly elevated dead-space ventilation who received tPA. All showed post treatment immediate improvements in gas exchange and/or hemodynamics. We suspect that severe COVID-19 pneumonia causes respiratory failure via pulmonary microthrombi and endothelial dysfunction. Treatment for COVID-19 pneumonia may warrant anticoagulation for milder cases and thrombolysis for more severe disease.

Atypical Pneumonia: Updates on Legionella, Chlamydophila, and Mycoplasma Pneumonia

Community-acquired pneumonia (CAP) has multiple causes and is associated with illness that requires admission to the hospital and mortality. The causes of atypical CAP include Legionella species, Chlamydophila, and Mycoplasma. Atypical CAP remains a diagnostic challenge and, therefore, likely is undertreated. This article reviews the advancements in the evaluation and treatment of patients and discusses current conflicts and controversies of atypical CAP.

Comparative Evaluation of the Chemical Stability of 4 Well-Defined Immunoglobulin G1-Fc Glycoforms

As part of a series of articles in this special issue evaluating model IgG1-Fc glycoforms for biosimilarity analysis, 3 well-defined IgG1-Fc glycoforms (high mannose-Fc, Man5-Fc, and N-acetylglucosamine-Fc) and a nonglycosylated Fc protein (N297Q-Fc) were examined in this work to elucidate chemical degradation pathways. The 4 proteins underwent a combination of accelerated thermal stability studies and 4 independent forced degradation studies (UV light, metal-catalyzed oxidation, peroxyl radicals, and hydrogen peroxide) at pH 6.0. Our results highlight chemical degradations at Asn315, Met428, Trp277, and Trp313. A cross-comparison of the different Fc glycoforms, stress conditions, and the observed chemical reactions revealed that both the deamidation of Asn315 and the transformation of Trp277 into glycine hydroperoxide were glycan dependent during incubation for 3 months at 40 °C. Our data will show that different glycans not only affect chemical degradation differently but also do lead to different impurity profiles, which can affect chemical degradation.

Campomelic dysplasia: case report and review

Initial ultrasound of a fetus in the third trimester demonstrated shortened and bent fetal extremities with a narrow and misshapen thorax. These findings were suggestive of a fetus affected with a possible lethal skeletal dysplasia. Decisions regarding antepartum, intrapartum and neonatal care were made in this context. A newborn with campomelic dysplasia was delivered and suffered a rapid downhill course.

Estrogen-induced vasoprotection is independent of inducible nitric oxide synthase expression: evidence from the mouse carotid artery ligation model

BACKGROUND

Estrogen is vasoprotective in animal models of vascular injury, yet the mechanisms involved are incompletely understood. The role of inducible nitric oxide synthase (iNOS) in vascular repair is controversial, but many lines of evidence indicate that it plays a role in neointima formation after arterial injury and that 17beta-estradiol (E(2)) modulates iNOS expression. This study tested the hypothesis that E(2) reduces neointima formation after vascular injury via a mechanism that is dependent on modulation of iNOS expression.

METHODS AND RESULTS

Male and female wild-type (iNOS(+/+)) mice and mice with homozygous deletion of the iNOS gene (iNOS(-/-)) were studied intact (INT) or after ovariectomy (OVX) and implantation of E(2) or vehicle (V) pellets. Mice were randomized to 8 groups based on sex, iNOS status, OVX, and treatment with E(2) or V. Twenty-eight days after carotid artery ligation, mice were euthanized, and occluded vessels were evaluated for neointima formation by morphometric analysis. There was a marked sexual dimorphism in neointima formation in both the iNOS(+/+) mice and the iNOS(-/-) mice. iNOS(+/+) INT females had a >90% reduction in neointima formation compared with iNOS(+/+) males, and iNOS(-/-) INT females had a 65% reduction in neointima formation compared with iNOS(-/-) males. The sexually dimorphic response was attenuated by OVX and restored by E(2) replacement in both iNOS(+/+) and iNOS(-/-) mice.

CONCLUSIONS

These results demonstrate that the vasoprotective effects of E(2) after ligation vascular injury are, at least in part, independent of iNOS expression.

Cardiovascular effects of estrogen

There is a strong link between menopause and increased cardiovascular disease incidence in women, and observational studies suggest that postmenopausal hormone replacement therapy (HRT) reduces cardiovascular disease risk. However, the only published prospective controlled trial of the effects of HRT on cardiovascular outcomes (Heart and Estrogen-Progestin Replacement Study, HERS) showed no net benefit of conventional HRT in women with established coronary disease. An angiograpic study of HRT in a similar patient population showed no regression of established coronary lesions in the active treatment group. Fundamental mechanistic studies of the cellular and molecular events by which hormones protect (or fail to protect) blood vessels are needed to define the role of postmenopausal HRT in cardiovascular disease. Herein, we review studies from our laboratory using the rat carotid injury model showing that estrogen inhibits neointima formation through an estrogen receptor (ER)-dependent mechanism operative in the early period after vascular injury. We have demonstrated that activation of vascular smooth muscle cells and subsequent release of soluble factors including osteopontin stimulate the migration of adventitial fibroblasts in a luminal direction to eventually take up residence in the neointima, and furthermore, that production, release, or posttranslational processing of these factors are inhibited by estrogen through an ER-dependent mechanism. The relevant observational and prospective data on HRT in cardiovascular disease prevention are reviewed, and the cardiovascular effects of estrogen are discussed.