Comorbidities such as obesity, hypertension, and diabetes are associated with COVID-19 development and severity, probably due to immune dysregulation; however, the mechanisms underlying these ...associations are not clear. The immune signatures of hypertensive patients with obesity with COVID-19 may provide new insight into the mechanisms of immune dysregulation and progression to severe disease in these patients.
Hypertensive patients were selected prospectively from a multicenter registry of adults hospitalized with COVID-19 and stratified according to obesity (BMI ≥ 30 kg/m²). Clinical data including baseline characteristics, complications, treatment, and 46 immune markers were compared between groups. Logistic regression was performed to identify variables associated with the risk of COVID-19 progression in each group.
The sample comprised 213 patients (89 with and 124 without obesity). The clinical profiles of patients with and without obesity differed, suggesting potential interactions with COVID-19 severity. Relative to patients without obesity, patients with obesity were younger and fewer had cardiac disease and myocardial injury. Patients with obesity had higher EGF, GCSF, GMCSF, interleukin (IL)-1ra, IL-5, IL-7, IL-8, IL-15, IL-1β, MCP 1, and VEGF levels, total lymphocyte counts, and CD8
CD38
mean fluorescence intensity (MFI), and lower NK-NKG2A MFI and percentage of CD8
CD38
T cells. Significant correlations between cytokine and immune cell expression were observed in both groups. Five variables best predicted progression to severe COVID-19 in patients with obesity: diabetes, the EGF, IL-10, and IL-13 levels, and the percentage of CD8
HLA-DR
CD38
cells. Three variables were predictive for patients without obesity: myocardial injury and the percentages of B lymphocytes and HLA-DR
CD38
cells.
Our findings suggest that clinical and immune variables and obesity interact synergistically to increase the COVID-19 progression risk. The immune signatures of hypertensive patients with and without obesity severe COVID-19 highlight differences in immune dysregulation mechanisms, with potential therapeutic applications.
Cyoablation is a ablation technique underutilized except in parahissian pathways and atrial fibrillation ablation. Ablation inside venous coronary sinus remains a dreaded incursion, and cryoablation ...is rarely used. We present the case of a 43 YO female who had a recurrent wolff parkinson white syndrome due to an epicardial pathway inside the coronary sinus successfully treated with a large bore(8mm) cryocatheter. We also review literature and describe the advantages and similar reports of use of cryo in low flow recesses inside the heart.
Myocardial injury (MI), defined by troponin elevation, has been associated with increased mortality and adverse outcomes in patients with coronavirus disease 2019 (COVID-19), but the role of this ...biomarker as a risk predictor remains unclear. Data from adult patients hospitalized with COVID-19 were recorded prospectively. A multiple logistic regression model was used to quantify associations of all variables with in-hospital mortality, including the calculation of odds ratios (ORs) and confidence intervals (CI). Troponin measurement was performed in 1476 of 4628 included patients, and MI was detected in 353 patients, with a prevalence of 23.9%; 95% CI, 21.8–26.1%. The total in-hospital mortality rate was 10.9% 95% CI, 9.8–12.0%. The mortality was much higher among patients with MI than among those without MI, with a prevalence of 22.7% 95% CI, 18.5–27.3% vs. 5.5% 95% CI, 4.3–7.0% and increased with each troponin level. After adjustment for age and comorbidities, the model revealed that the mortality risk was greater for patients with MI OR = 2.99; 95% CI, 2.06–4.36%, and for those who did not undergo troponin measurement OR = 2.2; 95% CI, 1.62–2.97%, compared to those without MI. Our data support the role of troponin as an important risk predictor for these patients, capable of discriminating between those with a low or increased mortality rate. In addition, our findings suggest that this biomarker has a remarkable negative predictive value in COVID-19.
It is unknown whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) have a positive, neutral, or negative effect on clinical outcomes in patients with ...coronavirus disease 2019 (COVID-19).
To determine whether discontinuation compared with continuation of ACEIs or ARBs changed the number of days alive and out of the hospital through 30 days.
A randomized clinical trial of 659 patients hospitalized in Brazil with mild to moderate COVID-19 who were taking ACEIs or ARBs prior to hospitalization (enrolled: April 9-June 26, 2020; final follow-up: July 26, 2020).
Discontinuation (n = 334) or continuation (n = 325) of ACEIs or ARBs.
The primary outcome was the number of days alive and out of the hospital through 30 days. Secondary outcomes included death, cardiovascular death, and COVID-19 progression.
Among 659 patients, the median age was 55.1 years (interquartile range IQR, 46.1-65.0 years), 14.7% were aged 70 years or older, 40.4% were women, and 100% completed the trial. The median time from symptom onset to hospital admission was 6 days (IQR, 4-9 days) and 27.2% of patients had an oxygen saturation of less than 94% of room air at baseline. In terms of clinical severity, 57.1% of patients were considered mild at hospital admission and 42.9% were considered moderate. There was no significant difference in the number of days alive and out of the hospital in patients in the discontinuation group (mean, 21.9 days SD, 8 days) vs patients in the continuation group (mean, 22.9 days SD, 7.1 days) and the mean ratio was 0.95 (95% CI, 0.90-1.01). There also was no statistically significant difference in death (2.7% for the discontinuation group vs 2.8% for the continuation group; odds ratio OR, 0.97 95% CI, 0.38-2.52), cardiovascular death (0.6% vs 0.3%, respectively; OR, 1.95 95% CI, 0.19-42.12), or COVID-19 progression (38.3% vs 32.3%; OR, 1.30 95% CI, 0.95-1.80). The most common adverse events were respiratory failure requiring invasive mechanical ventilation (9.6% in the discontinuation group vs 7.7% in the continuation group), shock requiring vasopressors (8.4% vs 7.1%, respectively), acute myocardial infarction (7.5% vs 4.6%), new or worsening heart failure (4.2% vs 4.9%), and acute kidney failure requiring hemodialysis (3.3% vs 2.8%).
Among patients hospitalized with mild to moderate COVID-19 and who were taking ACEIs or ARBs before hospital admission, there was no significant difference in the mean number of days alive and out of the hospital for those assigned to discontinue vs continue these medications. These findings do not support routinely discontinuing ACEIs or ARBs among patients hospitalized with mild to moderate COVID-19 if there is an indication for treatment.
ClinicalTrials.gov Identifier: NCT04364893.
The pressure to use sustainable materials and adopt practices reducing the carbon footprint of the construction industry has risen. Such materials include recycled concrete aggregates (RCA) made from ...waste concrete. However, concrete made with RCA often presents poor fresh and hardened properties along with a decrease in its durability performance, especially when using its fine fraction (i.e., FRCA). Most studies involving FRCA use direct replacement methods (DRM) to proportion concrete although other techniques are available such as the Equivalent Volume (EV) and Particle Packing Models (PPMs); yet their impact on the durability performance, especially its performance against freezing and thawing (F/T), remains unknown. This work, therefore, appraises the F/T resistance of FRCA mixtures proportioned through various mix proportioning techniques (i.e., DRM, EV and PPMs), produced with distinct crushing processes (i.e., crusher's fines vs. finely ground). The results show that the mix design technique has a significant influence on the FRCA mixture's F/T resistance where PPM-proportioned mixtures demonstrate the best overall performance, exceeding the specified requirements while DRM-proportioned mixtures failed F/T resistance requirements. Moreover, the crushing process plays an important role in the recycled mixtures' cracking behavior under F/T cycles, where less processing leads to fewer cracks while remaining the most sustainable option overall.
Most of the previous research on recycled concrete aggregates (RCA) has focused on coarse RCA (CRCA), while much less has been accomplished on the use of fine RCA particles (FRCA). Furthermore, most ...RCA research disregards its unique microstructure, and thus the inferior performance of concrete incorporating RCA is often reported in the fresh and hardened states. To improve the overall behaviour of RCA concrete advanced mix design techniques such as equivalent volume (EV) or particle packing models (PPMs) may be used. However, the efficiency of these procedures to proportion eco-efficient FRCA concrete still requires further investigation. This work evaluates the overall fresh (i.e., slump and rheological characterization) and hardened states (i.e., non-destructive tests, compressive strength and microscopy) performance of sustainable FRCA mixtures proportioned through distinct techniques (i.e., direct replacement, EV and PPMs) and incorporating different types of aggregates (i.e., natural and manufactured sand) and manufacturing processes (i.e., crusher fines and fully ground). Results demonstrate that the aggregate type and crushing process may influence the FRCA particles' features. Yet, the use of advanced mix design techniques, particularly PPMs, may provide FRCA mixes with quite suitable performance in the fresh (i.e., 49% lower yield stress) and hardened states (i.e., 53% higher compressive strength) along with a low carbon footprint.
Studies examining urban health and the environment must ensure comparability of measures across cities and countries. We describe a data platform and process that integrates health outcomes together ...with physical and social environment data to examine multilevel aspects of health across cities in 11 Latin American countries. We used two complementary sources to identify cities with ≥ 100,000 inhabitants as of 2010 in Argentina, Brazil, Chile, Colombia, Costa Rica, El Salvador, Guatemala, Mexico, Nicaragua, Panama, and Peru. We defined cities in three ways: administratively, quantitatively from satellite imagery, and based on country-defined metropolitan areas. In addition to “cities,” we identified sub-city units and smaller neighborhoods within them using census hierarchies. Selected physical environment (e.g., urban form, air pollution and transport) and social environment (e.g., income, education, safety) data were compiled for cities, sub-city units, and neighborhoods whenever possible using a range of sources. Harmonized mortality and health survey data were linked to city and sub-city units. Finer georeferencing is underway. We identified 371 cities and 1436 sub-city units in the 11 countries. The median city population was 234,553 inhabitants (IQR 141,942; 500,398). The systematic organization of cities, the initial task of this platform, was accomplished and further ongoing developments include the harmonization of mortality and survey measures using available sources for between country comparisons. A range of physical and social environment indicators can be created using available data. The flexible multilevel data structure accommodates heterogeneity in the data available and allows for varied multilevel research questions related to the associations of physical and social environment variables with variability in health outcomes within and across cities. The creation of such data platforms holds great promise to support researching with greater granularity the field of urban health in Latin America as well as serving as a resource for the evaluation of policies oriented to improve the health and environmental sustainability of cities.
Renal dysfunction is frequent in liver cirrhosis and is a strong prognostic predictor of orthotopic liver transplantation (OLT) outcome. Therefore, an accurate evaluation of the glomerular filtration ...rate (GFR) is crucial in pre‐OLT patients. However, in these patients plasma creatinine (Pcr) is inaccurate and the place of serum cystatine C (CystC) is still debated. New GFR‐predicting equations, based on standardized assays of Pcr and/or CystC, have been recently recommended in the general population but their performance in cirrhosis patients has been rarely studied. We evaluated the performance of the recently published Chronic Kidney Disease Epidemiology Collaboration equations (CKD‐EPI‐Pcr, CKD‐EPI‐CystC, and CKD‐EPI‐Pcr‐CystC) and the more classical ones (4‐ and 6‐variable MDRD and Hoek formulas) in cirrhosis patients referred for renal evaluation before OLT. Inulin clearance was performed in 202 consecutive patients together with the determination of Pcr and CystC with assays traceable to primary reference materials. The performance of the GFR‐predicting equations was evaluated according to ascites severity (no, moderate, or refractory) and to hepatic and renal dysfunctions (MELD score ≤ or >15 and KDOQI stages, respectively). In the whole population, CystC‐based equations showed a better performance than Pcr‐based ones (lower bias and higher 10% and 30% accuracies). CKD‐EPI‐CystC equation showed the best performance whatever the ascites severity and in presence of a significant renal dysfunction (GFR <60 mL/min/1.73 m2). Conclusion: Pcr‐based GFR predicting equations are not reliable in pre‐OLT patients even when an IDMS‐traceable enzymatic Pcr assay is used. Whenever a CystC‐assay traceable to primary reference materials is performed and when a true measurement of GFR is not possible, CystC‐based equations, especially CKD‐EPI‐CystC, may be recommended to evaluate renal function and for KDOQI staging. (Hepatology 2014;59:1522‐1531)
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