Classic and genetic cardiovascular risk burden and case-fatality from SARS-CoV-2 virus infection. The CARGENCORS study

Background

The disease presentation of the severe acute respiratory syndrome coronavirus 2 infection (COVID-19) ranges from asymptomatic to fatal. COVID-19 patients with pre-existing coronary artery disease (CAD) risk factors or overt cardiovascular disease more often develop severe COVID-19, which are also related to thrombotic, inflammatory, and to viral infectivity response. We hypothesised that despite some genetic predisposition, especially in COVID-19 severity, the main determinants of fatal complications in COVID-19 patients are related to comorbidity.

Purpose

To determine the role of genetics and cardiovascular comorbidity in mortality from COVID-19.

Methods

We conducted a retrospective cohort study including 3,120 patients with positive COVID-19 test from several hospitals and primary care between February 2020 and June 2021. Among them 1,096 required hospitalization, and 121 died within 3 months after symptom onset. Standard parametric and non-parametric methods, as required, were used to compare patient characteristics by vital status. Individual genotypes for 32 CAD, 14 thrombosis, 19 inflammation, and 11 viral infectivity single nucleotide variants (SNV), as well as, 2 COVID-19 SNVs already published were tested for association with mortality with Cochran-Armitage statistics and p-values corrected for multiple comparisons. The mutually-adjusted odds ratio (OR) and 95% confidence interval (95% CI) of fatal COVID-19 was analysed for SNVs significantly associated to case-fatality, with their adverse alleles count (0, 1 or 2), and for comorbidity factors with logistic regression adjusted for age and sex. The discrimination of the models was also estimated by the area under the curve (AUC).

Results

Fatal and non-fatal cases' characteristics are compared in Table 1. Fatal cases had a more adverse cardiovascular and anthropometric risk profile. After correcting for multiple testing by Benjamini-Hochberg method, we observed the inflammation-related rs6993770 SNV to be significantly associated with COVID-19 fatality (p-value = 0.04). The CAD-related rs9982601 and rs2505083 SNVs, and the thrombosis-related rs7853989 SNV were moderately associated with COVID-19 fatality (p-value ≤0.1). On Figure 1 we show the adjusted OR for rs6993770 (OR: 1.02; 95% CI 1.01–1.03 per risk allele) and that for clinical factors related to COVID-19 case-fatality. The AUC of the model was 0.85 (95% CI 0.81–0.88), which not improved that of a model with clinical risk factors alone (AUC: 0.84; 95% CI 0.81–0.87).

Conclusion

The rs6993770 inflammation (interleukin measurement trait)-related SNV was independently associated to case fatality; however the outcome was mainly driven by age, male sex, diabetes, and glomerular filtration rate.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Carlos III Health Institute and the European Regional Development FundAgency for Management of University and Research GrantsCrue-CSIC-Santander FONDO SUPERA COVID-19

Genetic risk score for risk stratification of patients positive for SARS-CoV-2 virus. The CARGENCORS study

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Carlos III Health Institute and the European Regional Development Fund Government of Catalonia through the Agency for Management of University and Research Grants Crue-CSIC-Santander FONDO SUPERA COVID-19

Background

The disease presentation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ranges from asymptomatic to fatal. COVID-19 patients with pre-existing coronary artery disease (CAD) risk factors or overt cardiovascular disease are at particular risk of severe disease. We hypothesised that a specific genetic risk score (GRS) based on single nucleotide polymorphisms (SNPs) allele count to score COVID-19 severity might include SNPs counts related to CAD incidence and to thrombosis, inflammation, and viral infectivity determinants involved in the severity of SARS-CoV-2. Such GRS could improve the early risk stratification of COVID-19 patients and optimize treatment strategies.

Purpose

To evaluate the capacity of a genetic risk score (GRS) with candidate genes to predict COVID-19 severity.

Methods

We conducted an age- and sex-matched case-control study with 1:2 ratio recruitment involving 2454 patients from Catalan hospitals and primary care. Cases were hospitalized severe (requiring at least oxygen treatment) or fatal COVID-19 patients; and controls were moderate-symptom and asymptomatic patients treated at home. Standard parametric and non-parametric methods, as required, were used to compare patient characteristics by severity. Individual genotypes for 33 CAD, 14 thrombosis, 22 inflammation, 15 viral infectivity SNPs and 2 COVID-19 SNPs already published were tested for association with severity with Cochran-Armitage statistics and p-values corrected for multiple comparisons. GRS was computed as the unweighted count of adverse alleles (0, 1 or 2). The odds ratio of severe COVID-19 was analysed for GRS (and its component SNPs) with logistic regression models adjusted for potential confounding factors. Area under the curve (AUC) improvement and net reclassification index (NRI) for GRS was estimated from a basic model including CAD and COVID-19 severity risk factors. Models’ performance was measured with the Akaike information criterion.

Results

SNPs identifications are not shown to prevent patent conflict. Cases and control characteristics are compared in Table 1. Cases had a more adverse cardiovascular and anthropometric risk profile. After correcting for multiple testing by Benjamini-Hochberg criteria, we observed 13 SNPs to be significantly associated with severity. After excluding the close SNPs in linkage disequilibrium, 7 were retained in the GRS model, which yielded the discrimination and reclassification characteristics described in Table 2.

Conclusion

A GRS with 7 SNPs related to CAD, thrombosis and inflammation significantly improves the severe COVID-19 risk assessment done with age, sex, comorbidity, and anthropometry alone.

Excess of all-cause mortality after a fracture in type 2 diabetic patients: a population-based cohort study

Post-fracture mortality in type 2 diabetes mellitus (T2DM) patients has been poorly studied. We report an absolute and relative excess all-cause mortality following a fracture in these patients compared to non-diabetic patients.

INTRODUCTION

T2DM and osteoporotic fractures are independently associated with a reduced lifespan, but it is unknown if T2DM confers an excess post-fracture mortality compared to non-diabetic fracture patients. We report post-fracture all-cause mortality according to T2DM status.

METHODS

This is a population-based cohort study using data from the SIDIAP database. All ≥50 years old T2DM patients registered in SIDIAP in 2006-2013 and two diabetes-free controls matched on age, gender, and primary care center were selected. Study outcome was all-cause mortality following incident fractures. Participants were followed from date of any fracture (AF), hip fracture (HF), and clinical vertebral fracture (VF) until the earliest of death or censoring. Cox regression was used to calculate mortality according to T2DM status after adjustment for age, gender, body mass index, smoking, alcohol intake, and previous ischemic heart and cerebrovascular disease.

RESULTS

We identified 166,106 T2DM patients and 332,212 non-diabetic, of which 11,066 and 21,564, respectively, sustained a fracture and were then included. Post-fracture mortality rates (1000 person-years) were (in T2DM vs non-diabetics) 62.7 vs 49.5 after AF, 130.7 vs 112.7 after HF, and 54.9 vs 46.2 after VF. Adjusted HR (95% CI) for post-AF, post-HF, and post-VF mortality was 1.30 (1.23-1.37), 1.28 (1.20-1.38), and 1.20 (1.06-1.35), respectively, for T2DM compared to non-diabetics.

CONCLUSIONS

T2DM patients have a 30% increased post-fracture mortality compared to non-diabetics and a remarkable excess in absolute mortality risk. More research is needed on the causes underlying such excess risk, and on the effectiveness of measures to reduce post-fracture morbi-mortality in T2DM subjects.

Early (1-year) Discontinuation of Different Anti-osteoporosis Medications Compared: A Population-Based Cohort Study

Although a number of reports suggest very low persistence with oral bisphosphonates, there is limited data on persistence with other anti-osteoporosis medications. We compare rates of early discontinuation (in the first year) with all available outpatient anti-osteoporosis drugs in Catalonia, Spain. We conducted a population-based retrospective cohort study using data from the SIDIAP database. SIDIAP contains computerized primary care records and pharmacy dispensing data for >80 % of the population of Catalonia (>5 million people). All SIDIAP participants starting an anti-osteoporosis drug between 1/1/2007 and 30/06/2011 (with 2 years wash-out) were included. We modelled persistence as the time between first prescription and therapy discontinuation (refill gap of at least 6 months) using Fine and Gray survival models with competing risk for death. We identified 127,722 patients who started any anti-osteoporosis drug in the study period. The most commonly prescribed drug was weekly alendronate (N = 55,399). 1-Year persistence ranges from 40 % with monthly risedronate to 7.7 % with daily risedronate, and discontinuation was very common [from 49.5 % (monthly risedronate) to 84.4 % (daily risedronate)] as was also switching in the first year of therapy [from 2.8 % (weekly alendronate) to 10 % (daily alendronate)]. Multivariable-adjusted models showed that only monthly risedronate had better one-year persistence than weekly alendronate and teriparatide equivalent, whilst all other therapies had worse persistence. Early discontinuation with available anti-osteoporosis oral drugs is very common. Monthly risedronate, weekly alendronate, and daily teriparatide are the drugs with the best persistence, whilst daily oral drugs have 40-60 % higher first-year discontinuation rates compared to weekly alendronate.

Incident type 2 diabetes and hip fracture risk: a population-based matched cohort study

SUMMARY

There is scarce data on the association between early stages of type 2 diabetes and fracture risk. We report a 20% excess risk of hip fracture in the first years following disease onset compared to matched non-diabetic patients.

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a chronic disease that affects several target organs. Data on the association between T2DM and osteoporotic fractures is controversial. We estimated risk of hip fracture in newly diagnosed T2DM patients, compared to matched non-diabetic peers.

METHODS

We conducted a population-based parallel cohort study using data from the Sistema d'Informació per al Desenvolupament de la Investigació en Atenció Primària (SIDIAP) database. Participants were all newly diagnosed T2DM patients registered in SIDIAP in 2006-2011 (T2DM cohort). Up to two diabetes-free controls were matched to each T2DM participant on age, gender, and primary care practice. Main outcome was incident hip fracture in 2006-2011, ascertained using the tenth edition of the International Classification of Diseases (ICD-10) codes. We used Fine and Gray survival modelling to estimate risk of hip fracture according to T2DM status, accounting for competing risk of death. Multivariate models were adjusted for body mass index, previous fracture, and use of oral corticosteroids.

RESULTS

During the study period (median follow-up 2.63 years), 444/58,483 diabetic patients sustained a hip fracture (incidence rate 2.7/1,000 person-years) compared to 776/113,448 matched controls (2.4/1,000). This is equivalent to an unadjusted (age- and gender-matched) subhazard ratio (SHR) 1.11 [0.99-1.24], and adjusted SHR 1.20 [1.06-1.35]. The adjusted SHR for major osteoporotic and any osteoporotic fractures were 0.95 [0.89-1.01] and 0.97 [0.92-1.02].

CONCLUSIONS

Newly diagnosed T2DM patients are at a 20% increased risk of hip fracture even in early stages of disease, but no for all fractures. More data is needed on the causes for an increased fracture risk in T2DM patients as well as on the predictors of osteoporotic fractures among these patients.

Effects of age and spatial learning on adenylyl cyclase mRNA expression in the mouse hippocampus

Adenylyl cyclase (AC) subtypes have been implicated in memory processes and synaptic plasticity. In the present study, the effects of aging and learning on Ca2+/calmodulin-stimulable AC1, Ca2+-insensitive AC2 and Ca2+/calcineurin-inhibited AC9 mRNA level were compared in the dorsal hippocampus of young-adult and aged C57BL/6 mice using in situ hybridization. Both AC1 and AC9 mRNA expression were downregulated in aged hippocampus, whereas AC2 mRNA remained unchanged, suggesting differential sensitivities to the aging process. We next examined AC mRNA expression in the hippocampus after spatial learning in the Morris water maze. Acquisition of the spatial task was associated with an increase of AC1 and AC9 mRNA levels in both young-adult and aged groups, suggesting that Ca2+-sensitive ACs are oppositely regulated by aging and learning. However, aged-trained mice had reduced AC1 and AC9, but greater AC2, mRNA levels relative to young-trained mice and age-related learning impairments were correlated with reduced AC1 expression in area CA1. We suggest that reduced levels of hippocampal AC1 mRNA may greatly contribute to age-related defects in spatial memory.

Posttranscriptional regulation of gene expression in learning by the neuronal ELAV-like mRNA-stabilizing proteins

The view that memory is encoded by variations in the strength of synapses implies that long-term biochemical changes take place within subcellular microdomains of neurons. These changes are thought ultimately to be an effect of transcriptional regulation of specific genes. Localized changes, however, cannot be fully explained by a purely transcriptional control of gene expression. The neuron-specific ELAV-like HuB, HuC, and HuD RNA-binding proteins act posttranscriptionally by binding to adenine- and uridine-rich elements (AREs) in the 3' untranslated region of a set of target mRNAs, and by increasing mRNA cytoplasmic stability and/or rate of translation. Here we show that neuronal ELAV-like genes undergo a sustained up-regulation in hippocampal pyramidal cells only of mice and rats that have learned a spatial discrimination paradigm. This learning-specific increase of ELAV-like proteins was localized within cytoplasmic compartments of the somata and proximal dendrites and was associated with the cytoskeleton. This increase was also accompanied by enhanced expression of the GAP-43 gene, known to be regulated mainly posttranscriptionally and whose mRNA is demonstrated here to be an in vivo ELAV-like target. Antisense-mediated knockdown of HuC impaired spatial learning performance in mice and induced a concomitant down-regulation of GAP-43 expression. Neuronal ELAV-like proteins could exert learning-induced posttranscriptional control of an array of target genes uniquely suited to subserve substrates of memory storage.

Calpain-PKC inter-relations in mouse hippocampus: a biochemical approach

In previous studies, we isolated and identified a mu-calpain/PKCalpha complex from rabbit skeletal muscle. Here, we have used specific purification procedures in order to study the interactions between mu-calpain and PKC in mouse hippocampus, a brain structure implicated in memory processes. We observed that mu-calpain and conventional PKCs (alpha, betaII and gamma) are co-eluted after anion exchange chromatography. In contrast to our previous results obtained on skeletal muscle, mu-calpain and PKC isoenzymes were dissociated after gel filtration chromatography. Furthermore, mu-calpain induced the proteolytic conversion of PKCalpha, betaII, and gamma into PKMalpha, betaII, and gamma with a preferential hydrolysis of PKCgamma, a specific isoenzyme of the nervous system. Although the mu-calpain/PKC interactions in the hippocampus are quite different from skeletal muscle, our results however, point out the functional importance of these inter-relations. Moreover, as PKCgamma has been involved in the biochemical events underlying learning and memory, the preferential relationship between mu-calpain and PKCgamma promotes the importance of the role that mu-calpain could play in the cellular mechanisms of memory formation.

Long-standing remission after 25-OH D3 treatment in a case of chronic myelomonocytic leukaemia

This report describes a case of chronic myelomonocytic leukaemia (CMML) in whom a complete remission was achieved and sustained 15 months after treatment with 25-OH vitamin D3. No side-effects were observed. Although vitamin D1 has been used in the treatment of myelodysplastic syndromes, to our knowledge this is the first case of long-standing remission in a patient with CMML. This 'differentiation therapy' might be considered as a possible alternative in the management of this disease.