Phenotypes of disease severity in a cohort of hospitalized COVID-19 patients: Results from the IMPACC study

BACKGROUND

Better understanding of the association between characteristics of patients hospitalized with coronavirus disease 2019 (COVID-19) and outcome is needed to further improve upon patient management.

METHODS

Immunophenotyping Assessment in a COVID-19 Cohort (IMPACC) is a prospective, observational study of 1164 patients from 20 hospitals across the United States. Disease severity was assessed using a 7-point ordinal scale based on degree of respiratory illness. Patients were prospectively surveyed for 1 year after discharge for post-acute sequalae of COVID-19 (PASC) through quarterly surveys. Demographics, comorbidities, radiographic findings, clinical laboratory values, SARS-CoV-2 PCR and serology were captured over a 28-day period. Multivariable logistic regression was performed.

FINDINGS

The median age was 59 years (interquartile range [IQR] 20); 711 (61%) were men; overall mortality was 14%, and 228 (20%) required invasive mechanical ventilation. Unsupervised clustering of ordinal score over time revealed distinct disease course trajectories. Risk factors associated with prolonged hospitalization or death by day 28 included age ≥ 65 years (odds ratio [OR], 2.01; 95% CI 1.28-3.17), Hispanic ethnicity (OR, 1.71; 95% CI 1.13-2.57), elevated baseline creatinine (OR 2.80; 95% CI 1.63- 4.80) or troponin (OR 1.89; 95% 1.03-3.47), baseline lymphopenia (OR 2.19; 95% CI 1.61-2.97), presence of infiltrate by chest imaging (OR 3.16; 95% CI 1.96-5.10), and high SARS-CoV2 viral load (OR 1.53; 95% CI 1.17-2.00). Fatal cases had the lowest ratio of SARS-CoV-2 antibody to viral load levels compared to other trajectories over time (p=0.001). 589 survivors (51%) completed at least one survey at follow-up with 305 (52%) having at least one symptom consistent with PASC, most commonly dyspnea (56% among symptomatic patients). Female sex was the only associated risk factor for PASC.

INTERPRETATION

Integration of PCR cycle threshold, and antibody values with demographics, comorbidities, and laboratory/radiographic findings identified risk factors for 28-day outcome severity, though only female sex was associated with PASC. Longitudinal clinical phenotyping offers important insights, and provides a framework for immunophenotyping for acute and long COVID-19.

FUNDING

NIH.

[A shortened form of the Spanish Boston naming test: a useful tool for the diagnosis of Alzheimer's disease]

INTRODUCTION

The Boston Naming Test (BNT) is the most frequently used test of confrontation naming. Due to its length, several abbreviated forms have been proposed.

OBJECTIVE

The aim of the study was to develop a short form for the Spanish version of the BNT that could detect early semantic changes in Alzheimer s disease (AD).

PATIENTS AND METHODS

One hundred and three patients with diagnosis of probable AD (NINCDS ADRDA criteria), with GDS< 5 and 143 normal subjects, matched for age and education, were studied. Subjects with <4 years of education were excluded. No subject had any history of neurological of psychiatric disorders or alcohol abuse. All participants underwent a comprehensive neuropsychological assessment which included the 60 item Spanish version of the BNT. The sensibility and specificity of each item and demographic effect s variability were calculated (ANOVA). Those 12 figures with the highest sensibility and specificity which showed no significant educational or age variation were administered to all participants. The Spearman correlation coefficient was used.

RESULTS

Mean score for the control group was 11 (standard deviation: 1.16). No significant effects for age (r= 0.14574) or education (r= 0.101293) were found. The sensibility and specificity for correctly diagnosing AD was 85% and 94% respectively, similar to the longest version.

CONCLUSION

This 12 item version of the BNT can be a useful instrument for a rapid screening of AD, as it is as sensible and specific as the 60 item version, and it is not influenced by age or education.

[Relation between patient's subjective complaints and family reports in patients with Alzheimer's type dementia]

INTRODUCTION

Reduced ability to remember facts and events of everyday life is a common complaint in the elderly and is also the first sign of Alzheimer's disease (AD). The present research was designed to study the interrelationship between severity of memory complaints (MC), informant report, and performance in memory tests.

MATERIAL AND METHODS

Seventy three (73) patients (41 age associated memory impairment (AAMI), and 32 Alzheimer's disease) and 30 normal controls were studied using the Subjective Memory Questionnaire (modified version), an objective memory battery and the Hamilton depression scale.

RESULTS

Age Associated Memory Impairment subjects reported more severe MC (p< 0.001). No relationship was found between severity of MC and age, sex or educational level. Patient's MC didn't correlate with objective memory battery. A strong correlation was found with Hamilton depression score. Caregiver memory reports correlated with objective memory performances.

CONCLUSION

Depressive features in AAMI and anosognosia in dementia patients would explain these results. These data suggest that informant report is the best predictor of patient's memory performance.

Uptake of Down syndrome screening in an Australian Vietnamese population

It has been previously shown that the uptake of prenatal diagnosis by Victorian women of a non-English speaking background is significantly lower than that of comparable English speaking women. To explore this further we have examined the uptake of Down syndrome screening and diagnosis by Vietnamese women attending a community-based antenatal clinic in metropolitan Melbourne over a two year period. Of the 207 women studied, 161 (78%) were offered screening or diagnosis and of these women 139 (86%, 95%CI 81-92%) accepted the offer, representing 67% (95%CI 61-74%) of the entire population. Of the 127 women who had screening, rather than diagnosis, 12 (9%) had an 'increased risk' result. Eleven of these women accepted diagnosis. We also explored the reasons why 45 (22%) of women were not offered screening. Almost half (44%) of these women first attended the clinic at a too advanced stage of gestation but in 25 women there were no obvious reasons. These results are discussed in the context of current prenatal screening and diagnostic practice in Victoria and simple recommendations made.

Effect of omitting regular ACE inhibitor medication before cardiac surgery on haemodynamic variables and vasoactive drug requirements

Adverse events during coronary artery bypass graft (CABG) surgery have been described in patients receiving angiotensin converting enzyme (ACE) inhibitors, including hypotension on induction of anaesthesia and an increase in vasoconstrictor requirements after cardiopulmonary bypass (CPB). Omitting regular ACE inhibitor medication before surgery may improve cardiovascular stability during anaesthesia. We evaluated prospectively the effect of omitting regular ACE inhibitor medication before CABG surgery on haemodynamic variables and use of vasoactive drugs. We studied 40 patients with good left ventricular function, allocated randomly to omit or continue ACE inhibitor medication before surgery. Arterial pressure, cardiac output, systemic vascular resistance and use of vasoactive drugs were recorded during anaesthesia and in the early postoperative period. Patients who omitted their ACE inhibitors had greater mean arterial pressure during the study and required less vasopressors during CPB. However, these patients required more vasodilators to control hypertension after CPB and in the early postoperative period. There was no difference in hypotension on induction of anaesthesia or in the use of vasoconstrictors after CPB. We conclude that omitting ACE inhibitors before surgery did not have sufficient advantage to be recommended routinely.

Comparison of the sensitivity to change of long and short form pain measures

Our objective was to assess the sensitivity to change over time of three methods of assessing pain. We conducted a comparison of the sensitivity to change of three pain assessment measures in a double blind, double dummy parallel group study evaluating the efficacy of one of two doses of oral bromfenac and one of two doses of sublingual buprenorphine. Our subject pool consisted of 75 patients following general surgical and orthopaedic procedures. Pain intensity was measured by the affective, sensory and evaluative dimensions of the McGill Pain Questionnaire together with total score and word score, a 10 cm Visual Analogue Scale and by a four word scale. Effect size calculations indicated considerable variation in the sensitivity of the instruments to change. However, despite variation in the size of effect indicated by different measures, there was consistent agreement as to the most effective treatment regimen. This study suggests that simple measures of pain are sensitive to change and are worthwhile indicators of the impact of an intervention upon acute pain, although some care is needed in interpreting results from such instruments. More complex forms of assessment, such as the calculation of the MPQ sub-scales may not add anything to such data.

Testicular steroidogenesis in the Cebus monkey throughout postnatal development

There is scant information on testicular steroidogenesis during postnatal development in monkeys, particularly in New World species. Our purpose was to study the in vitro steroidogenic capacity of the Cebus monkey testis from birth to advanced puberty. Fresh testicular tissue was incubated in Medium 199 with or without hCG (10 IU/ml); and levels of pregnenolone (P5), dehydroepiandrosterone (DHA), progesterone (P4), androstenedione (A), testosterone (T), dihydrotestosterone (DHT), and 3 alpha-androstanediol (3 alpha-DIOL) were measured in tissue and incubation media by RIA. To determine the predominant steroidogenic pathway, the ratio between the concentrations of the 5-ene and the 4-ene T precursors was determined, and the relative conversion of 3H-P5 and 14C-P4 to T was calculated. The number of Leydig cells per testis was determined in all experimental groups. The testes of the Cebus monkeys could produce T in vitro without the addition of gonadotropins at all ages. T and the 5-ene precursors (P5 and DHA) were the main steroids found within testicular tissue throughout postnatal development. T content per Leydig cell increased continuously with age, but testicular T concentration reached maximal levels at early puberty and did not change thereafter. The ratios between 5-ene and 4-ene T precursors ranged between 2.8 and 13.2, which suggested a predominance of the delta-5 pathway. This was confirmed by the finding that 3H-P5 was more efficiently converted to T than was 14C-P4. The T production relative to that of its d-ene precursors progressively increased to reach maximal values in late puberty.(ABSTRACT TRUNCATED AT 250 WORDS)

Indium-111 OncoScint CR/OV and F-18 FDG in colorectal and ovarian carcinoma recurrences. Early observations

Indium-111 satumomab pendetide (In-111 OncoScint) planar and SPECT imaging and F-18 FDG positron emission tomography (PET) have been found individually to be helpful in the detection of recurrent colorectal and ovarian cancer, but have not been compared. Twelve patients who were examined for recurrent colorectal or ovarian carcinoma underwent both In-111 OncoScint imaging and F-18 FDG PET imaging. All had normal or equivocal results of CT or MR studies. Tumor detection abilities were similar in most cases. However, Oncoscint demonstrated an advantage in the detection of carcinomatosis. PET demonstrated an advantage in detecting focal tumor recurrence in one case and, not unexpectedly, in detecting liver metastases. All positive nuclear studies for tumor were found to be true-positives at pathology (7 patients), or by diagnostic new CT changes (1 patient). Finally, unreported, bone marrow, bowel, and colostomy sites appear to be normal sites of localization of F-18 FDG 1 hour after injection.

P6 acupressure and nausea and vomiting after gynaecological surgery

We studied the effect of P6 acupressure on 46 women undergoing laparotomy for major gynaecological surgery who received patient-controlled analgesia. Half the patients received acupressure at the P6 site, the remainder received acupressure at a "sham" site. There was a reduction in the requests for anti-emetic therapy in the group receiving P6 acupressure but there was no difference in the incidence of nausea and vomiting. There was no difference in total morphine consumption between the two groups.

Oral bromfenac 10 and 25 mg compared with sublingual buprenorphine 0.2 and 0.4 mg for postoperative pain relief

The aim of this single-dose, randomized, positive control, double-dummy, double-blind, parallel group study was to compare oral bromfenac 10 and 25 mg with sublingual buprenorphine 0.2 and 0.4 mg for treatment of postoperative pain. We studied 91 patients with moderate or severe pain after general surgical or orthopaedic operations, using pain intensity, pain relief, adverse effect, mood and sedation outcomes. There was a significant analgesic dose-response for buprenorphine, showing study sensitivity, but not for bromfenac. The two bromfenac treatments were significantly superior to the two buprenorphine treatments. Significantly more patients reported nausea with buprenorphine. There was evidence of a ceiling effect for analgesia with bromfenac.

Unexpected pulmonary clumping of In-111 leukocytes attributable to indium oxine reagent

Five cases of artifactual In-111 leukocyte pulmonary activity were noted at three local hospitals in a 4-day period. Based on the differences in the preparation of the final indium leukocyte product, the problem could be attributed to the indium oxine reagent in a specific lot. This artifact of multiple small foci of marked increased activity in the lungs (clumping pattern), attributable to the In-111 oxine reagent, has not been described previously.

Testicular ischemia and infarction following herniorrhaphy or varicocelectomy: evaluation by radionuclide imaging

The postoperative use of testicular imaging to evaluate the preservation of testicular circulation has been reported after orchiopexy, excision of a hematocele, and repair of a traumatized tunica albuginea. The authors discuss the previously unreported use of testicular imaging in patients who have undergone recent herniorrhaphy or varicocelectomy. The scan of a patient with intact testicular perfusion following herniorrhaphy is compared to the scans of two patients with absence of perfusion of a testicle five to seven days following respective herniorrhaphy and varicocelectomy surgeries.

Intracerebral infection of Cebus apella with the XJ-Clone 3 strain of Junín virus

To assess the usefulness of the South American primate Cebus apella as a model for neurovirulence of Junín virus, eight monkeys were inoculated with 10(5) LD50 of the attenuated XJ-Clone 3 Junín virus strain by the intrathalamic route. After the second week, weight loss and polyadenopathies were observed in most animals, one-half of which had a transient leukothrombocytopenia. Moderate clinical central nervous system (CNS) involvement was present in four of eight monkeys, while the rest had only mild neurologic signs. All recovered except one, which developed a deep coma and was killed in a pre-mortem stage at 18 days post-infection (pi). Junín virus was isolated from the throat from five, from the blood from three, and from the brain from two monkeys. In the most severely ill animal, virus titers higher than viremia were detected in both inoculated and contralateral brain hemispheres, as well as in lung, lymph node, and small intestine. Junín antigens and "in vivo" bound immunoglobulins were detected by immunofluorescence (IF) in the brain of four animals at 18, 21, 40, and 155 days pi. Moderate lymphocytic parenchymal and meningeal infiltration were observed in the brain of four animals, and gliosis was also present in the most affected monkey. Although the clinical response to infection was not uniform, all infected monkeys developed high IF antibodies. Cebus apella cannot be used as a highly sensitive model for Argentine hemorrhagic fever (AHF). However, the results obtained show that the XJ-Clone 3 strain can replicate in the primate CNS and to induce lesions and immunoglobulin deposition. In addition, viral persistence is suggested by the late detection of viral antigens in brain at 40 and 155 days pi.

Hormonal monitoring of early pregnancy by a direct radioimmunoassay of steroid glucuronides in first morning urine

The usefulness of the direct 4-hour radioimmunoassay of estriol-16-glucuronide (E3G) and pregnanediol-3-glucuronide (P2G) in first morning urine (FMU) for establishing a prognosis of the early pregnancy outcome was evaluated in 106 patients that became pregnant. Microaliquots of FMU were serially assayed from day 3 of the conception cycle until day 80 of pregnancy. The E3G and P2G profiles of 19 pregnancies which terminated in spontaneous abortion with either a diagnosis of the blighted ovum syndrome (n = 11) or presumption of a corpus luteum/trophoblast failure (n = 8) have been compared with those of clinically normal pregnancies (n = 87). Normal pregnancies displayed typical patterns of E3G and P2G development, while variations were observed in abortive events that reflected changes of the fetoplacental unit.