Prolonged viral pneumonia and high mortality in COVID-19 patients on anti-CD20 monoclonal antibody therapy

PURPOSE

In clinical practice, we observed an apparent overrepresentation of COVID-19 patients on anti-CD20 monoclonal antibody therapy. The aim of this study was to characterize the clinical picture of COVID-19 in these patients.

METHODS

All adult patients from Turku University Hospital, Turku, Finland, with COVID-19 diagnosis and/or positive SARS-CoV-2 PCR test result up to March 2023, and with anti-CD20 therapy within 12 months before COVID-19 were included. Data was retrospectively obtained from electronic patient records.

RESULTS

Ninety-eight patients were identified. 44/93 patients (47.3%) were hospitalized due to COVID-19. Patients with demyelinating disorder (n = 20) were youngest (median age 36.5 years, interquartile range 33-45 years), had less comorbidities, and were least likely to be hospitalized (2/20; 10.0%) or die (n = 0). COVID-19 mortality was 13.3% in the whole group, with age and male sex as independent risk factors. Persistent symptoms were documented in 33/94 patients (35.1%) alive by day 30, in 21/89 patients (23.6%) after 60 days, and in 15/85 after 90 days (17.6%), mostly in patients with haematological malignancy or connective tissue disease. Prolonged symptoms after 60 days predisposed to persistent radiological findings (odds ratio 64.0; 95% confidence interval 6.3-711; p < 0.0001) and persistently positive PCR (odds ratio 45.5, 95% confidence interval 4.0-535; p < 0.0001). Several patients displayed rapid response to late antiviral therapy.

CONCLUSION

Anti-CD20 monoclonal antibody therapy is associated with high COVID-19 mortality and with a phenotype consistent with prolonged viral pneumonia. Our study provides rationale for retesting of immunocompromised patients with prolonged COVID-19 symptoms and considering antiviral therapy.

Differential interactions of age and sleep deprivation in driving and spatial perception by male drivers in a virtual reality environment

We determined the effects of age and sleep deprivation on driving and spatial perception in a virtual reality environment. Twenty-two young (mean age: 22 years, range: 18-35) and 23 old (mean age: 71 years, range: 65-79) participants were tested after a normal night of sleep and a night of sleep deprivation. The participants drove a virtual car while responding to uni- and bilateral visual and auditory stimuli. Driving errors (crossing the lane borders), reaction times and accuracy to visual and auditory stimuli, performance in psychological tests, and subjective driving ability and tiredness were measured. Age had no effect on the number of driving errors, whereas sleep deprivation increased significantly especially the number of left lane border crossings. Age increased the number of stimulus detection errors, while sleep deprivation increased the number of errors particularly in the young and in the auditory modality as response omissions. Age and sleep deprivation together increased the number of response omissions in both modalities. Left side stimulus omissions suggest a bias to the right hemispace. The subjective evaluations were consistent with the objective measures. The psychological tests were more sensitive to the effects of age than to those of sleep deprivation. Driving simulation in a virtual reality setting is sensitive in detecting the effects of deteriorating factors on both driving and simultaneous spatial perception.

Estimation of various mechanical characteristics of human bones using dual energy X-ray absorptiometry: methodology and precision

The mechanical competence of bone is determined by its macroscopic geometric characteristics [size, shape, apparent density (BMAD), cortical thickness (CWT), cross-sectional area, trabecular architecture], intrinsic material properties (stiffness, strength), and loading conditions (mode, direction, rate) at a given skeletal site. The main objective of this study was to introduce precise methods for further analysis of dual energy X-ray absorptiometric (DXA) data and for estimating macroscopic mechanical characteristics of bone at several skeletal sites representing both the axial and appendicular skeleton. This study showed that using computational BMAD, CWT and dimensional parameters, different site-specific mechanical characteristics (stiffness and strength indices) of a typical long bone (a bone consisting of both the cortical shaft and trabecular metaphyses and epiphyses at both ends) can be approximated with a low precision error (generally < 2%). The efficacy of a study applying DXA may be further enhanced by applying relevant site-specific parameters (different parameters for bone ends and shafts) for evaluation, the parameters based on the anatomic ROIs. Evidently high-quality operator performance is a prerequisite for effective accomplishment of longitudinal studies, especially when small changes in bone characteristics are expected. It should be kept in mind that to some extent the inherent two-dimensional nature of the DXA measurement compromizes the potential efficacy of the presented methods since some simple assumptions had to be made regarding the geometry and structure of bone. Nevertheless, in this study the observed values were consistent with those found by other investigators. Further experimental studies are needed for direct site-specific validation of the proposed analytic methods.

Enalapril premedication attenuates the blood pressure response to tracheal intubation and stabilizes postoperative blood pressure after controlled hypotension with sodium nitroprusside in neurovascular patients

Oral premedication with enalapril, 0.1 mg/kg was compared with placebo in 22 patients subjected to craniotomy and ligation of an intracranial aneurysm or extirpation of an arteriovenous malformation. Balanced hypotensive anesthesia was used with sodium nitroprusside (SNP) as the main hypotensive agent. The hypertensive response to laryngoscopy and tracheal intubation was significantly attenuated by enalapril (p = 0.020). The mean blood pressure was lower and more stable in the intensive care unit after enalapril than after placebo (p = 0.044). The median SNP dose rate tended to be lower in the enalapril-pretreated patients [0.6 (range of 0-3.5) micrograms/kg/min] compared to the placebo group [1.4 (0.4-5.8) micrograms/kg/min] (p = 0.12). Concentrations of plasma catecholamines, vasopressin, and endothelin as well as serum osmolality, arterial blood gases, and plasma electrolytes and level of consciousness were repeatedly measured. Enalapril had no significant effects on these variables. Plasma renin activity was increased and serum angiotensin converting enzyme (ACE) activity was reduced in the expected manner by enalapril. We found premedication with an ACE inhibitor favorable for hypotensive anesthesia in neurovascular patients as assessed by the circulatory responses.

Plasma concentrations of lidocaine (lignocaine) after cranial subcutaneous injection during neurosurgical operations

After cranial subcutaneous injection of lidocaine 0.8-3.7 mg/kg+adrenaline (epinephrine) 1:200,000 in neurosurgical patients, fast drug absorption was found with peak plasma concentrations of 0.6-1 microgram/ml in 5-10 min. However, the concentrations remained above the lowest effective antiarrhythmic level of 0.6 microgram/ml for only about 10 min. In one patient, simultaneously administered intravenous lidocaine had an additive effect on those levels. Induced hypotension (sodium nitroprusside) during aneurysm operations decreased the arterial plasma level of lidocaine and was followed by a new peak after discontinuation. Thus the absorption of a drug during induced hypotension from subcutaneous tissue is often erratic.

Brain monoamine metabolites and tryptophan in ventricular CSF of patients with spasm after aneurysm surgery

✓ Intraventricular pressure was followed continuously after operation for intracranial arterial aneurysm in 20 patients. Ventricular cerebrospinal fluid (CSF), homovanillic acid (HVA), tryptophan, and 5-hydroxyindole acetic acid (5-HIAA) were analyzed daily for 5 days, beginning before the clipping of the aneurysm. Postoperatively, seven patients had spasm, verified clinically and angiographically. Seven other patients with no clinical or angiographic signs of spasm, hydrocephalus, or increased intracranial pressure (ICP) served as controls. Nine of the 20 patients were hydrocephalic.

The mean ± SE values of HVA, tryptophan, and 5-HIAA in the controls were 264 ± 40, 1116 ± 85, and 88 ± 8 ng/ml, respectively, in the controls, and 182 ± 20, 982 ± 89, and 78 ± 3 ng/ml, respectively, in the patients with spasm. The differences are not statistically significant. However, the low values of HVA may have been produced by ischemic changes caused by the spasm. In hydrocephalic patients ventricular CSF tryptophan levels were statistically significantly higher, and 5-HIAA levels lower than in controls. In patients with increased ICP, neither alterations nor intercorrelations of monoamine metabolites and tryptophan were found. The results do not give direct support to prophylactic neuropharmacological treatment of postoperative arterial cerebral spasm. However, ventricular HVA, tryptophan, and 5-HIAA measurements can be used for prognostic purposes during the first few days after the operation.