Throughout the SARS-CoV2 pandemic, multiple reports show higher percentages of hospitalization, morbidity, and mortality among men than women, indicating that men are more affected by COVID-19. The pathophysiology of this difference is yet not established, but recent studies suggest that sex hormones may influence the viral infectivity process. Here, we review the current evidence of androgen sensitivity as a decisive factor for COVID-19 disease severity.Relevant literature investigating the role of androgens in COVID-19 was assessed. Further, we describe several drugs suggested as beneficial for COVID-19 treatment related to androgen pathways. Lastly, we looked at androgen sensitivity as a predictor for COVID-19 progression and ongoing clinical trials on androgen suppression therapies as a line of treatment.SARS-COV2 virus spike proteins utilize Transmembrane protease serine 2 (TMPRSS2) for host entry. Androgen receptors are transcription promoters for TMPRSS2 and can, therefore, facilitate SARS-COV2 entry. Variants in the androgen receptor gene correlate with androgen sensitivity and are implicated in diseases like androgenetic alopecia and prostate cancer, conditions that have been associated with worse COVID-19 outcomes and hospitalization.Androgen’s TMPRSS2-mediated actions might explain both the low fatalities observed in prepubertal children and the differences between sexes regarding SARS-COV2 infection. Androgen sensitivity may be a critical factor in determining COVID-19 disease severity, and sensitivity tests can, therefore, help in predicting patient outcomes. The novel coronavirus disease COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV2) has evolved into a global pandemic and has affected millions of people worldwide. Two notably consistent findings are the low rates of prepubertal mortality 9 caused . AndrogeThe spike proteins of SARS-COV2 intermediate the entry to host cells by undergoing spike protein priming by the transmembrane protease serine 2 (TMPSS2) and by binding to Angiotensin-converting enzyme 2 (ACE2) receptors . Data frMoreover, androgen deprivation therapy (ADT), a commonly-used treatment for prostate cancer patients, has been shown to lower TMPRSS2 expression . The proAll androgens act through the androgen receptor, which is encoded by a single-copy gene on the X chromosome Fig. , and varHowever, the relationship between circulating androgen levels, androgen sensitivity, and COVID-19 severity is not straightforward. As androgens promote androgen receptor transcriptional activity, it would be expected that androgen-deprived patients would have a reduced number of activated androgen receptors to promote TMPRSS2 transcription and, thus, a decreased risk for SARS-CoV2 entry. Nevertheless, reported data from Italy and Germany suggest a contradictory outcome. Low testosterone levels can be observed in the majority of COVID-19 intensive care patients  and can The androgen receptor has three main functional domains: the transactivation domain, the DNA-binding domain, and the ligand-binding domain. The N-terminal transactivation domain harbors a polymorphic CAG nucleotide repeat segment. Interestingly, the length of polymorphic CAG nucleotides repeats is associated with the prostate cancer pathophysiology, as shorter CAG repeats inversely correlate to androgen receptor expression and subsequently increase the risk of prostate cancer . IncreasSince the start of the COVID-19 pandemic, various drugs have been proposed for treatment –26, but Similarly, NO affects androgen receptor activity. NO production and actions are dependent to some extent on androgen receptors and blocking androgen receptors reduces NO production . MoreoveRecently, preliminary results from the Randomized Evaluation of COVID-19 therapy (RECOVERY) trial have been labeled as a scientific breakthrough and received international praise due to its promising results. Dexamethasone, a glucocorticosteroid drug, reduced the mortality rate by one-third in mechanically ventilated patients and by one-fifth for those receiving oxygen without ventilation . NotablyFinally, high-throughput screening to identify compounds able to reduce ACE-2 levels revealed screening hits commonly can target androgen signalling pathway. Moreover, androgen inhibitors were able to reduce ACE2 levels suggesting beneficial effects of this approach . OngoingIn summary, androgen’s TMPRSS2-mediated actions can explain both the low fatalities observed in prepubertal children and the differences between sexes regarding SARS-COV2 infection. Androgen sensitivity might be a critical factor in determining COVID-19 disease severity, and sensitivity tests can, therefore, help in predicting patient outcomes. There is still a large potential for development of androgen suppression-based treatments for COVID-19, but ongoing trials will provide valuable knowledge that can lead to improved therapies.


Scientific Reports 10.1038/s41598-017-03598-9, published online 27 June 2017Correction to: In the Supplementary Information file originally published with this Article, additional datasets detailing the fungal strains and genetic primers used in this study were unintentionally omitted. These errors have been corrected in the Supplementary Information that now accompanies the Article.


Up to 20% of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) patients develop severe inflammatory complications with diffuse pulmonary inflammation, reflecting acute respiratory distress syndrome (ARDS). A similar clinical profile occurs in severe trauma cases. This review compares pathophysiological and therapeutic principles of severely injured trauma patients and severe coronavirus disease 2019 (COVID-19).The development of sequential organ failure in trauma parallels deterioration seen in severe COVID-19. Based on established pathophysiological models in the field of trauma, two complementary pathways of disease progression into severe COVID-19 have been identified. Furthermore, the transition from local contained disease into systemic and remote inflammation has been addressed. More specifically, the traumatology concept of sequential insults (‘hits’) resulting in immune dysregulation, is applied to COVID-19 disease progression modelling. Finally, similarities in post-insult humoral and cellular immune responses to severe trauma and severe COVID-19 are described.To minimize additional ‘hits’ to COVID-19 patients, we suggest postponing all elective surgery in endemic areas. Based on traumatology experience, we propose that immunoprotective protocols including lung protective ventilation, optimal thrombosis prophylaxis, secondary infection prevention and calculated antibiotic therapy are likely also beneficial in the treatment of SARS-CoV-2 infections. Finally, rising SARS-CoV-2 infection and mortality rates mandate exploration of out-of-the box treatment concepts, including experimental therapies designed for trauma care. Originating from the Wuhan Province in China, the novel member of the coronoviridae family named Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has rapidly developed into a global pandemic , 2. Give.Given their similar clinical profiles, there may be more similarities between severe trauma and severe cases of SARS-CoV-2 than might initially be assumed. In this review, we will consider the notion that severe disease progression in SARS-CoV-2/Corona Virus Disease 2019 (COVID-19) patients mimics disease mechanisms that occur in complicated courses of severe traumaThere is a broad spectrum in clinical courses of both severe trauma and severe illness caused by SARS-CoV-2 infection , 9–12. MIt is tempting to speculate that proven approaches and even promising experimental therapies for severely injured trauma patients can also play a role in the management of critically ill COVID-19 patients. This review will compare pathophysiology and treatment strategies between severe trauma and life-threatening SARS-CoV-2 infections.In trauma, tissue damage activates the immune response, with extensive tissue damage invoking systemic inflammation , 15, 16.Necrotic cells rapidly release alarmins (Damage Associated Molecular Patterns (DAMPs)), which are endogenous molecules and are equivalent in function to pathogen associated molecular patterns . As their name suggests, alarmins alert the immune system and their ultimate function is to restore homeostasis by promoting regeneration of damaged tissue , 20, 21.In trauma, various relevant alarmins have been identified and characterized. One such alarmin, High Mobility Group Box 1 (HMGB1), has shown chemotactic effects on monocytes, macrophages, and neutrophils, and is a very potent stimulator of immune cell maturation . In addiThe balance and interplay of these different endogenous molecules dictates the clinical course in trauma patients. Overexpression of either pro-inflammatory or anti-inflammatory mediators may induce organ dysfunction. Whereas a predominantly pro-inflammatory response leads to the systemic inflammatory response syndrome (SIRS), a predominantly anti-inflammatory reaction leads to the compensatory anti-inflammatory response syndrome (CARS). In the absence of inflammatory complications, concurrent SIRS/CARS responses should be considered a physiological process and balance each other out. However, excessive SIRS can result in immune overreaction, while CARS may lead to immune suppression or paralysis, with a subsequent increased risk of infectious complications , 20, 21.Extrapulmonary inflammatory processes affect the pulmonary compartment via the circulatory uptake of these cytokines , 28. OneThese pathophysiological inflammatory cascades result in significant changes in the anatomy, mechanics and function of the lung . An initThe exact pathophysiology of SARS-CoV-2 infection, and more specifically its considerable capacity to extensively disturb physiological homeostasis, is currently unclear. However, based on recent clinical and experimental findings and related viral diseases such as Severe Acute Respiratory Syndrome Coronavirus 1 (SARS-CoV-1), basic understanding has rapidly increased. The current SARS-CoV-2 virus, as well as the SARS-CoV-1 and the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) are related pathological human coronaviruses (CoVs) –36 PhyloIn line with SARS-CoV-1, the angiotensin-converting enzyme 2 (ACE2), a type I membrane protein, is considered the host cell surface-receptor for the SARS-Cov-2 spike receptors , 40. KubACE2 plays an important physiological role in regulating blood pressure via the renin-angiotensin-aldosterone system (RAAS). It is therefore tempting to hypothesize that there is an interplay between clinical observations linking hypertension with impaired outcome in SARS-Cov-2 infection , 47. UpoIn addition to these direct pathophysiological processes of SARS, it is likely that other indirect processes also play a critical role in the rapid progression of severe COVID-19. The SARS-CoV-1 epidemic emphasized this with the observation that disease progression into critical stages was commonly associated with diminishing viral titers , 49. StuFrom an immunological perspective, a prominent neutrophil and macrophage presence was observed in the pulmonary interstitium and alveoli in SARS-CoV-1 fatalities . The abeIn SARS-CoV-2, lymphopenia is common , 12 and In addition to an altered cellular immune response in fatal SARS-CoV-1/2 infections, transient humoral dysregulation has also been described. Whereas minimal cytokine level alterations are seen in mild COVID-19 infection , severe Although experimental clinical data on COVID-19 infection is scarce, the presence of an aberrant humoral immune response is further suggested by significantly increased serum IL-6 levels found in COVID-19 fatalities , 60. MorBased on these findings, it is tempting to hypothesize that rather than direct cytotoxic effects of virus-infected cells alone, severe SARS-CoV-2 infection triggers both the humoral and cellular immune system. Consequent life-threatening complications therefore primarily relate to an aberrant immune response. A similar aberrant immune response after severe trauma has been well established. The pathophysiological mechanisms observed in trauma may be universal and are therefore likely also involved in COVID-19 disease progression. Insights in the pathophysiology of severe trauma may therefore form the basis for novel therapeutic concepts for SARS-CoV-2 and we propose the pathophysiological model of COVID-19 disease progression as being displayed as Fig. insult , into the development of end-organ inflammation and dysfunction. The initial insult evokes a local systemic response including involvement of natural killer cell/dendritic cells, lymphocytes, neutrophils and macrophages. Adequate responses result in viral clearance and in the case of contained local infection, minimal collateral damage to parenchymal organ cells and consequent recovery. However, in case the immune response is unable to stop ongoing viral replication, disease progression may occur. Based on the pathophysiological concepts in SARS-CoV-1, SARS-CoV-2 and trauma summarized above, it is tempting to hypothesize that COVID-19 disease progression is based on two primary mechanistic pathways. These pathways are a direct (PAMP-driven) pathway and an indirect (DAMP-driven) pathway, either of which can lead to COVID-19 disease progression:(i)direct (‘PAMP’)-driven pathway. This is characterized by increased local spread of the virus and eventually dissemination of viral infection . Vital organ involvement may occur, even in the absence of initial systemic inflammation, leading to (multiple) organ dysfunction.A (ii)indirect (‘DAMP’)-driven pathway. Upon contained local inflammation, a secondary massive immune response may be initiated . These processes lead to extensive systemic inflammation and subsequent altered homeostasis of vital organs. Finally, organ failure may occur due to inflammation-induced collateral damage in end-organs. Progression according to this pathway is independent of viral load.An This figure summarizes the process of ongoing inflammation, starting from These are not mutually exclusive pathways, and interplay between these may potentially play a role in the progression of COVID-19. At all phases of both pathways, improvement and restoration of homeostasis is possible and will lead to recovery. In traumatology, the term ‘first hit’ is used to describe the initial insult condition, or trauma, the patient faces. The intensity of the first hit is based on the trauma load: the degree of initial tissue damage, including organ injury, fractures, burn injury, soft tissue injury, and hypovolemic shock. Consequently, local and systemic release of both pro-inflammatory and anti-inflammatory mediators is dependent on the severity of the first hit of the trauma itself . These iSimilarly, with COVID-19, the first hit is the initial viral infection itself, centred primarily on respiratory tissue. The magnitude of the first hit is associated with predisposing factors  and viral load. Existing comorbidities may also affect the severity of the initial insult and determine the overall impact of the first hit on homeostasis. Patients with diabetes, cardiovascular disease, hypertension and lung disease are especially prone to decompensation in SARS-CoV-2 infection , 12.In trauma cases, the secondary activation of various molecular cascades due to an additional insult are known as second hit- phenomena. This secondary immune cell activation, or priming, is stimulated by a variety of triggers , 16, 31.Similarly, in severe COVID-19 infection, secondary insults or complications may stimulate an exaggerated immune response, amplify systemic inflammation, or at a later stage induce immune paralysis. Respiratory distress and systemic hypoxemia may stimulate further tissue injury and abruptly require intensive care and monitoring. In addition, metabolic decompensation and systemic hypoperfusion are further risk factors associated with remote tissue damage. Secondary pulmonary bacterial infections or catheter-associated infections are further potential second hit events, all of which are capable of aggravating the clinical course of the disease. Figure red curves in Fig. blue curves in Fig. In some patients, however, immune dysregulation occurs. Excessive immune activation  stimulate the expression of prothrombotic mediators. Dampening the proinflammatory immune response may further minimize the risk of thromboembolic complications . Increastransfusion of blood products should be minimized to avoid transfusion induced immune activation and more specifically transfusion-related acute injury (TRALI)-like conditions .prevent and treat secondary infections adequately to prevent additional infectious insults and inflammatory exaggeration. We suggest actively searching for secondary infections by serial clinical examination and routine laboratory analysis of infection parameters. Additionally, catheter associated infections can be minimized with regular renewal schedules of catheters .Based on experience treating ARDS in trauma, trying to do more may in fact be less. The majority of these experimental treatments may be focusing on the wrong enemy: the virus, instead of the hosts’ uncontrolled immune response. Alternatively, as in trauma, anti-inflammatory interventions to modulate the hyperactive immune response in COVID-19 may be promising. Most modern treatment modalities for trauma are aimed at the indirect DAMP-driven pathway, and to dampen second hit events. Applying these concepts to COVID-19 treatment, the following measures complementary to current treatment guidelines for COVID-19 disease should be considered:Table This review attempts to draw analogies to pathophysiological and therapeutic principles between severely injured trauma patients and COVID-19. Many similarities between both conditions have been identified, supporting the hypothesis that treatment concepts for ARDS in trauma may potentially be of use in the management of COVID-19. Two complementary pathways of disease progression into severe COVID-19 have been identified and described. Based on established pathophysiological concepts in the field of trauma, we strongly suggest postponing all elective surgery in endemic areas. Immunoprotective protocols such as lung protective ventilation, adequate thrombosis prophylaxis, prevention of secondary infection, and calculated antibiotic therapies used to minimize inflammatory complications in trauma patients are likely beneficial in the management of SARS-CoV-2 infections, and should be universally applied whenever possible. Finally, experimental immunomodulatory interventions currently being investigated in the setting of severe trauma may play a role in the management of COVID-19 patients and should be investigated.


Information regarding the clinical features and outcomes of pneumonia due to an infection with human coronavirus (HCoV)-OC43 in children with cancer is rare. This report presents the clinical features in terms of chest CT scan images which may be used to identify cases of HCoV-OC43 infection induced pneumonia in immunocompromised children.We report here a girl with acute lymphoblastic leukemia who developed respiratory symptoms during febrile neutropenia. Rapid clinical progression and nodular lesions on her chest X-ray and computed tomography scans were suggestive of a pulmonary fungal infection.A series of tests eventually confirmed the exclusive presence of HCoV-OC43 by the FilmArray Respiratory Panel from a throat swab sample.After the diagnosis was confirmed, the antimicrobial agents initially administered were discontinued.Although the chest CT scan images looked severe, the clinical course of the infection induced pneumonia was benign. The respiratory status of the patient was completely resolved in 2 weeks.This report highlights the importance of early identification of respiratory viruses, via the realization of their clinical characteristics, which helps reduce the duration of administration of antimicrobial agents in this setting. In this report, we present a young girl with acute lymphoblastic leukemia (ALL) who developed pneumonia resulting from an HCoV-OC43 infection, which was characterized by severe chest CT scan images but a benign clinical course.The human coronavirus (HCoV)-OC43 is one of the common coronaviruses to cause an infection in healthy children, and usually induces only mild upper respiratory diseases. Approximately 30% to 33% of children with HCoV-OC43 infection have been diagnosed with lower respiratory tract infection.1.19 cells/L with 49% blasts, hemoglobin 7.9 g/dl, and platelet count 231 × 109 cells/L). She had been diagnosed with B cell precursor ALL on December 24th, 2019. Cytogenetic analysis disclosed the presence of the karyotype 46,XX,del(9)(q34),t, while molecular analysis was negative for ETV6-RUNX1, TCF3-PBX1, and BCR-ABL1. The girl received chemotherapy according to the Taiwan Pediatric Oncology Group (TPOG) 2013-ALL-SR protocol, and spinal tap and triple intrathecal therapy was performed 7 to 10 days after chemotherapy. No leukemic cells were found in the cerebral spinal fluid and the patient commenced prophylactic antibiotic and antifungal therapies with levofloxacin and micafungin on January 14th, when her leukocyte count was less than 1 × 109 cells/μl. She later developed febrile neutropenia on January 20th, and was administered teicoplanin and meropenem post collection of her blood for culture. Her blood culture yielded Streptococcus mitis which is sensitive to teicoplanin. However, she gradually developed a cough in parallel with a respiratory tract infection from her mother who was taking care of her in the hospital. A chest X-ray on January 22nd showed increased infiltration in the right lower lobe . She had increased difficulty in breathing requiring low-flow nasal cannula support and auscultation yielded a coarse breathing sound without wheezing or rales. A second chest X-ray revealed patchy nodular opacities in the right middle lobe and bilateral lower lobes  fluid 1 week later. The BAL samples were subjected to multiple staining and culture, including Gram staining and special stains in cytology, which later revealed the samples to be negative for fungi, acid-fast bacilli, and viruses. Thus, antimicrobial agents were discontinued. Her respiratory status became asymptomatic in the following week, and a chest X-ray 1 month later showed complete resolution of the pulmonary infiltrates.An 8-year-old girl presented with fever and an abnormal hemogram , 6 types of human coronaviruse (HCoV) have been known to cause infections, namely HCoV-OC43, HCoV-299E, HCoV-HKU1, HCoV-NL63, severe acute respiratory syndrome (SARS)-CoV, and middle east respiratory syndrome (MERS)-CoV. It has been reported that the HCoV-OC43 infection occurs frequently in early childhood and largely presents symptoms of upper respiratory tract infection. Real-time polymerase chain reaction assay of the nasopharyngeal aspirate sample confirmed an HCoV-OC43 infection, and after the leukocyte count increased, the respiratory condition of the young boy reportedly improved. In another study, Morfopoulou et al reported an 11-month-old boy with severe combined immunodeficiency who contracted HCoV-OC43-associated encephalitis after he underwent cord blood transplantation and died 1.5 months after the transplantation. In yet another study, Nilsson et al reported a 9-month-old infant with ALL who had persistent HCoV-OC43-associated respiratory infection and developed fatal encephalitis. Therefore, it is of paramount importance that physicians be aware of the risk of the serious complications associated with the HCoV-OC43 infection during the treatment of immunocompromised children.Although HCoV-OC43 is predominantly associated with upper respiratory tract infections, there have been cases where it has been associated with a serious infection in immunocompromised children. Simon et al reported a 5-year-old boy with ALL who presented with febrile neutropenia and pneumonia.,9 However, little is known about the radiographic findings of pneumonia caused by the other coronaviruses, which generally cause self-limited upper respiratory tract infections in immunocompetent patients. Pene et al reported 2 immunocompromised patients with pneumonia caused by HCoV-299E infection, of whom one had chest CT images that showed multiple micronodular opacities. In this report, our patients chest CT scan revealed multiple nodular and wedge-shape opacities, predominantly in the bilateral lower lobes and the right upper lobe, which were similar to those reported by Pene et al To the best of our knowledge, our report is the first to describe the specific features of a chest CT scan in pediatric cancer patients with HCoV-OC43 pneumonia.Extensive or multifocal ground glass opacification with consolidations is a common sign in chest radiography, which is suggestive of pneumonia caused by the highly pathogenic coronaviruses, SARS-CoV, MERS-CoV, or COVID-19. Recently, there has been a growing emphasis on the identification of viral infections to enable the application of individualized treatments and reduce the antibiotic burden in children with cancer and febrile neutropenia.–14 Although we identified HCoV-OC43 from the throat swab sample, we modified and continued the administration of antimicrobial agents to our patient due to the severe chest images we obtained that were mimicking serious pulmonary infections. Nonetheless, rapid improvement of the respiratory status and negative microbiological results on the BAL fluid sample were suggestive of a benign course of the HCoV-OC43 infection-associated pneumonia. Therefore, it is important for physicians to recognize the clinical characteristics of such an infection so that the duration of the antimicrobial therapy may be reduced.Febrile neutropenia is a common complication of cancer treatment in children. Because of the decreased inflammatory response, bacterial and fungal infections in neutropenic patients are the major causes of morbidity and mortality. As a result, there is an updated guideline, which focuses on strategies for antibacterial and antifungal therapies for the management of febrile neutropenia in children with cancer or hematopoietic stem cell transplantation.In conclusion, our report describes the case of pneumonia caused due to an HCoV-OC43 infection during the induction therapy of a girl with ALL. Although HCoV-OC43 infection occasionally causes serious lower respiratory infection in immunocompromised children, as presented by severe chest images, its clinical course may be benign as is the case with our patient.Conceptualization: Shih-Hsiang Chen, Tsung-Yen Chang, Chia-Jui Du.Data curation: Shih-Hsiang Chen, Tsung-Yen Chang, Chia-Jui Du.Formal analysis: Shih-Hsiang Chen.Investigation: Chih-Chen Chang, Chih-Jung Chen, Chih-Yung Chiu.Supervision: Cheng-Hsun Chiu.Validation: Chih-Chen Chang, Chih-Jung Chen, Chih-Yung Chiu.Visualization: Chih-Chen Chang, Chih-Jung Chen, Chih-Yung Chiu.Writing – original draft: Tsung-Yen Chang, Chia-Jui Du, Shih-Hsiang ChenWriting – review & editing: Shih-Hsiang Chen, Cheng-Hsun Chiu.


To the Editor—Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is highly infectious in healthcare-related settings, both among patients and healthcare workers (HCWs).1 Hospital personnel have shown an increased risk of coronavirus disease 2019 (COVID-19) compared to the general population, possibly associated with repeated exposures and, in the current emergency context, frequent lack of adequate personal protective equipment (PPE). The spread of SARS-CoV-2 has also been dramatically efficient in long-term care facilities (LTCFs), where the combination of asymptomatic or paucisymptomatic occupational carriers and a highly fragile elderly population have produced numerous outbreaks, greatly contributing to the total burden of COVID-19–related deaths.23 Current recommendations4 include the adoption of general IPC measures , environmental measures , administrative measures , and patient management measures .An integrated COVID-19 infection and prevention control (IPC) strategy must be promptly adopted by healthcare facilities to prevent further outbreaks. This strategy should involve HCWs, patients, visitors, and support personnel  due to their reported role in nosocomial outbreaks.5 have shown promising results. A limitation of this approach is the short-term RT-PCR positivity, with consequent need of repeated testing, sustained usage of intensive laboratory resources, exposure risks for the operators involved in screening, and possibly reduced compliance with repeated swab testing. To overcome some defects of traditional PCR-based testing, novel kits for point-of-care rapid PCR testing are currently being developed, with as yet uncertain yield.Systematic screening of HCWs and support personnel plays a key role in limiting the intrahospital spread of SARS-CoV-2. The most described approach is screening with viral genome real-time polymerase chain reaction (RT-PCR) on nasopharyngeal swabs. RT-PCR tests should be offered whenever an HCW presents with any symptom suggestive of COVID-19; initial screening is warranted for all new employees. Universal RT-PCR screening protocols6 it appears that the detection of serum anti-SARS-CoV-2 IgG antibodies with appropriate methods  is observable in almost all infected subjects within 20 days from symptom onset. Data on IgM appear less conclusive, and currently, these data do not support the classic sequential IgM–IgG transition; therefore IgM should not be the only target of antibody search.Antibody response to SARS-CoV-2 has not been completely characterized; however, from the best available data,7Many regulatory institutes have assessed rapid, point-of-care antibody tests based on lateral flow immunoassay (LFIA), produced by multiple manufacturers. Although tempting for practical reasons, these tests have not met expectations for use in clinical settings due to unsatisfactory sensitivity and specificity.Serial serological screening with a validated technique, such as CLIA, could provide a significant contribution to IPC in hospitals and LTCFs, considering its lower cost, easier repeatability, and sustainability in the medium term, compared with swab-based molecular assays. Although serological tests have limited utility in diagnosing individual acute infections, they can inform actions to protect the hospital community. A serum antibody screening approach is indeed already used in surveillance campaigns among HCWs for other communicable diseases .8A possible protocol Fig.  could inWith the preliminary application of this protocol, starting in April 2020, we performed screening of ~800 HCWs in 3 non-COVID hospital centers in Tuscany, Italy. Thanks to serological screening and confirmatory RT-PCR swab tests at seroconversion, we detected 3 asymptomatic SARS-CoV-2 carriers with ongoing viral spread. Consequent epidemiological analyses documented probable nonoccupational origin of the 3 cases. In the context of an integrated IPC strategy, no secondary cases were detected among hospital strict contacts.We believe that periodic serum antibody screening with validated techniques may be used to guide RT-PCR testing to detect asymptomatic or pauci-symptomatic infections and help stop nosocomial transmission chains. Further studies on effectiveness, acceptability, sustainability of this approach are warranted.


Coronavirus disease 2019 (COVID-19) caused by coronavirus SARS-CoV-2 infection has now evolved into a worldwide crisis that triggers substantial morbidity and mortality. COVID-19 occurs more frequently and has more serious complications in patients with diabetes mellitus, but the underlying mechanisms remain largely elusive. Here, we summarize current and evolving concepts on the detrimental effect of hyperglycemia on SARS-CoV-2 infection and consequences, focusing on several key mechanisms underlying the link between diabetes and COVID-19. A better understanding of the mechanisms by which hyperglycemia worsens the prognosis of COVID-19 is critical for reducing the risk of SARS-CoV-2 infection and its associated mortality.COVID-19 caused by coronavirus SARS-CoV-2 infection was declared by the World Health Organization on March 11, 2020 as a global pandemic. Clinical data show that the severe cases can rapidly progress to acute respiratory distress syndrome (ARDS), septic shock, and multiple organ dysfunction syndrome (MODS) . ImportaEpidemiologic evidences show that type 2 diabetes mellitus (T2DM) is the second most common comorbidity of COVID-19, and that people with T2DM are more susceptible to SARS-CoV-2 infection . It is rP = 0.01) and more fatal cases  were identified in COVID-19 patients with diabetes  admission  receptor, a plasma membrane protein expressed largely in lungs, leading to COVID-19-related interstitial pneumonitis and ARDS . IncreasACE2 is also expressed in many other tissues with endothelial cells including the heart and kidneys and, importantly, in insulin producing β-cells . SARS-CoGlycated hemoglobin level is higher in diabetic individuals due to increased circulating glucose level, which could be an important factor for COVID-19 infection and mortality . The surSARS-CoV-2 mainly invades the respiratory tract and lungs, and pulmonary cells represent one of the major cellular sites for coronavirus entry . Previou+ T cells, and CD8+ T cells are all greatly decreased in nearly all COVID-19 severe patients compared with non-severe cases  population. Dysregulation of T cells and macrophages leads to increased secretion of inflammatory cytokines and chemokines, triggering cytokine storm . PatientRecent researches reveal that cytokine storm emerges in COVID-19 patients with hyperglycemia or T2DM, leading to dysregulation of immune response and ARDS . IncreasLactate is previously considered as a metabolic by-product, while cumulative evidence suggests that lactate regulates diverse biological processes such as modulation of the inflammatory immune response , suppresThe outbreak of the COVID-19 pandemic has caused a global health crisis of our time. A growing body of clinical evidence shows that patients with pre-existing diabetes are highly susceptible to SARS-CoV-2 infection and its associated mortality. The exact mechanisms linking diabetes and COVID-19 remain to be further elucidated, but available clinical/laboratory observations suggest that hyperglycemia-induced immune dysfunction, cytokines storm, and elevated lactate levels may play critical roles in the severity of COVID-19 in patients with pre-existing diabetes. A large body of evidence shows that hyperglycemia or diabetes may impair immune response mediated by macrophages, monocytes, and DCs, weaken T-cell function, and promote cytokine storm, ultimately resulting in increased susceptibility of SARS-CoV-2 infection and COVID-19-associated mortality. Thus, medications for lowering blood glucose levels, blunting immune suppression and cytokines storm, or suppressing lactate levels would be beneficial for effective therapeutic treatments for COVID-19 in patients with obesity and diabetes.In addition to common anti-diabetic drugs, some other medicines, such as the traditional Chinese medicine Lianhuaqingwen (LH) and Artemisinine (Qinghao), can or may improve the prognosis of COVID-19 patients with pre-existing diabetes. LH has been exerted broad-spectrum antiviral effects on a series of influenza viruses and immune regulatory effects . It is a


Nonfunctioning gonadotropic pituitary neuroendocrine tumors (PitNETs) are among the most frequent neoplasms of pituitary gland. Although PitNETs are commonly considered benign, a notable part of patients suffer from tumor recurrence after treatment. Invasive growth of pituitary tumor is among the most important prognostic factors. Since molecular features of invasiveness are of potential clinical usefulness, this study was aimed to verify whether invasive and noninvasive nonfunctioning gonadotropic PitNETs differ in the miRNA expression profile and whether the differences could provide a possible molecular classifier.  miRNA profiles were determined in 20 patients (11 invasive and 9 noninvasive tumors) using next-generation sequencing. The expression of selected miRNAs was assessed in the independent cohort of 80 patients with qRT-PCR.  When miRNA profiles of invasive and noninvasive tumors were compared, 29 miRNAs were found differentially expressed. Hsa-miR-184, hsa-miR-181a-2-3p, hsa-miR-93-3p, hsa-miR-574-5p, hsa-miR-185-5p, and hsa-miR-3200-5p showed a potential clinical value according to ROC curve analysis. Unfortunately, differential expression of only hsa-miR-185-5p was confirmed in the validation cohort, with AUG at 0.654.  Differences in miRNAs expression profiles in invasive and noninvasive gonadotropic PitNETs are slight and the level of miRNA expression seems not to be applicable as useful classifier of tumor invasiveness. Pituitary neuroendocrine tumors (PitNETs) are the third most common intracranial neoplasms in adults, accounting for approximately 16.5% of all tumors in this location . ApproxiNonfunctioning PitNETs are considered benign neoplasms; however, a large proportion of them are characterized by the invasive growth that is manifested by infiltration of adjacent structures by the tumor. Invasive growth has important clinical implications because it hampers complete tumor resection, which is a basic treatment of nonfunctioning gonadotroph tumors and results in tumor recurrence –4. It isMicroRNAs (miRNAs) are small noncoding RNA particles that play a pivotal role in posttranscriptional gene silencing. They act mainly as gene silencers through interaction with mRNA particles containing fully or partially complementary sequence . MicroRNA number of miRNAs were shown to be differentially expressed in nonfunctioning pituitary tumors compared with normal pituitary . These aThe impaired miRNA expression contributes to invasiveness and metastasis of human cancers . miRNAs In this study, we made an attempt to identify miRNAs with expression related to invasive growth of nonfunctioning gonadotroph PitNETs. For this purpose, the whole miRNA expression profiles of invasive and noninvasive tumors were compared, and subsequently, the expression of selected miRNAs was determined in an independent patients' cohort.Tissue samples from 100 patients were collected during transsphenoidal surgery and immediately frozen in liquid nitrogen for storage at −80°C. Part of each tumor was assessed histopathologically. Histopathological assessment included both ultrastructural investigation and immunohistochemistry according to WHO 2004 criteria, which were applicable at the time of sample collection . Tumor iThe study included gonadotropic tumors that represent the most common histopathological subtype of nonfunctioning PitNETs. Five patients with null cell adenomas were also enrolled. These five samples were immunonegative for all hormones but clearly showed features of gonadotropinomas in ultrastructural examination. Patient profiles are presented in Total RNA was isolated using the MirVana miRNA Isolation Kit (Thermo Fisher Scientific) and rotor stator homogenizer Omni Tissue Master . The RNA quality was assessed spectrophotometrically using the NanoDrop 2000 (Thermo Fisher Scientific). Isolated RNA was stored at −80°C until analyses.μg of total RNA was used for sequencing library construction with an Ion Total RNA-Seq Kit v2 (Thermo Fisher Scientific), according to the manufacturer's protocol. Ion Xpress™ RNA-Seq Barcode Kit was used for hybridization and ligation of RNA adapters that allows for multiplexed sequencing. RNA reverse transcription and subsequent cDNA purification and library size selection were performed using Nucleic Acid Binding Beads. cDNA was PCR-amplified, followed by DNA purification and size selection. The amount and size distribution of the amplified DNA was determined using Bioanalyzer 2100 using a High Sensitivity DNA Kit (Agilent). The length of miRNA ligation products in barcoded libraries ranged between 94 and114 bp. Template preparation for clonal amplification of up to four miRNA libraries at a concentration of 18 pM and loading of the PI chip were performed using Ion Chef Instrument, with Ion PI™ Hi-Q™ Chef Kit (Thermo Fisher Scientific). Ion Proton Sequencer (Thermo Fisher Scientific) was used for sequencing. Unmapped bam files were converted into fastq files with a bamToFastq script from bedtools. Read mapping to known human miRNAs (according to miRBase v.22) and reads quantification were performed using miRDeep2.14. Data normalization and differential expression analysis were performed using DESeq2. Filtration for low-expression miRNAs and miRNA genes with less than five sequencing reads in at least half of the samples were excluded. Fold change of expression (FC), calculated as read counts ratio of invasive/noninvasive NFPAs, was used as a measure of expression difference between the groups of samples. Differentially expressed miRNAs were defined as those which met criterion of p-value <0.05.The quality of small RNA fractions was assessed using Agilent 2100 Bioanalyzer with Small RNA Kit Chip (Agilent) and measured with Qubit RNA HS Assay Kits (Thermo Fisher Scientific). One μl volume contained 2 μl of diluted cDNA, 1x SYBR Green Master Mix (Exiqon), and miRNA LNA PCR primer set (Exiqon). The following predesigned miRCURY LNA™ primer assays were used: YP00204601 (hsa-miR184), YP00204142 (hsa-miR181a-2-3p), YP00204470 (hsa-miR-93-3p), YP02116206 (hsa-miR-574-5p), YP00206037 (hsa-miR-185-5p), YP02109903 (hsa-miR-3200-5p), YP00203906 (5s RNA), YP00203907 (U6 RNA), YP00203902 (SNORD44), and YP00203905 (SNORA66) (Qiagen). All qRT-PCR measurements were performed in technical triplicate. The 2−ΔCT method was used for calculation of relative expression level. Reference genes were selected upon the evaluation of expression stability using RefFinder software [miRCURY LNA™ miRNA PCR System (Qiagen) was used for measurement of miRNA expression levels. Fifty nanograms of total RNA was reverse-transcribed with miRCURY LNA™ Universal RT miRNA PCR and cDNA synthesis kit (Exiqon). cDNA was diluted x25. qPCR reactions were performed in 384-well format using 7900HT PCR system (Applied Biosystems). qPCR reaction of 5 U test. ROC curve analyses were applied for testing potential diagnostic value. The two-sided Fisher's exact test was used for analyzing proportions. Data were analyzed and visualized using GraphPad Prism (GraphPad Software). Heatmap graphs and hierarchical clustering were done with Cluster 3.0 and TreeView 1.6 software . Complete linkage clustering with Euclidean distance as similarity metrics were used.Quantitative continuous variables were analyzed by a two-sided Mann–Whitney Twenty gonadotropic PitNET samples, including 11 invasive and 9 noninvasive tumors, were subjected to miRNA expression analysis with next-generation sequencing of small RNA using semiconductor sequencing. Sequencing of small RNA libraries generated an average of 2,497,367 reads per sample, which were mapped to the human genome (hg19) and used for quantification of expression levels of known miRNAs. Sequencing reads were annotated to 1,528 miRNAs, and after filtering out those with low expression, the measurements of 405 miRNAs were used in the analyses.The principal component analysis (PCA)  indicatep-value <0.05. Only seven of them met p-value <0.01, and none met adjusted p-value <0.05. Expression of 29 differentially expressed miRNAs is visualized with heatmap in When miRNA expression profiles of invasive and noninvasive tumors were compared to identify miRNA with different expression levels, 29 miRNAs met the criterion of p=0.0216); however, an explicit classification into invasive and noninvasive tumors was not found ; hsa-miR-181a-2-3p AUG = 0,7879 ; hsa-miR-93-3p AUG = 0.8485 ; hsa-miR-574-5p AUG = 0,7879 ; hsa-miR-185-5p AUG = 0.7778 ; hsa-miR-3200-5p AUG = 0.8182 . ROC curves are presented in ROC curve analysis was applied for all differentially expressed miRNAs to determine which of them may potentially serve as classifiers of tumor invasiveness status. Six miRNAs showed AUG significantly higher than 0.5, including hsa-miR-184 AUG = 0,8384 . Unfortunately, the results of ROC curve analysis with AUG value of 0.654 indicate that this miRNA is not a useful classifier of invasiveness status. No significant difference in the expression of hsa-miR-184, hsa-miR-181a-2-3p, hsa-miR-93-3p, or hsa-miR-574-5p was observed between invasive and noninvasive tumors. The results of qRT-PCR-based analysis are presented in hsa-miR-185-5p was the only miRNA with differential expression level in the PitNET samples of validation cohort stratified according to invasiveness status (FC = 2.2, The majority of nonfunctioning gonadotropic PitNETs are benign and slow-growing tumors, and patients achieve a long-term remission after tumor resection, which is the basic method of treatment. Unfortunately, some tumors are characterized by a more aggressive growth and represent an important clinical problem. Invasive growth of pituitary tumor is considered one of the main causes of tumor recurrence, and it is a commonly approved prognostic factor of increased risk of recurrence after surgery .The molecular background of invasive growth of pituitary tumors is still unclear; however, it is believed that specific biological mechanisms contribute to their more aggressive growth and infiltrating nature . The posmiRNAs play a role in posttranscriptional regulation of gene expression and protein translation. Since impaired miRNA expression can affect cellular phenotype, it also may potentially trigger the ability of invasive growth in cancer cells . This isp < 0.05 for differentially expressed miRNAs. We believe this could be applied since additional validation on independent patients cohort was planned for this study. With this criterion, 29 miRNAs could be identified as differentially expressed, but classification of the discovery set of PitNET samples based on these miRNAs did not allow for the unequivocal distinction between invasive and noninvasive tumors. These results, along with the basic overall PCA data, allow for the conclusion that tumors stratified according to invasiveness status hardly differ in the miRNA expression profile.In our study, we determined the whole profile of miRNA expression in nonfunctioning gonadotropic pituitary tumors and tried to verify the hypothesis that invasive and noninvasive PitNETs differ in expression of miRNAs. The analysis of whole miRNA expression profile involved 20 patients with a particular subtype of pituitary tumors, and due to this relatively small number of patients, we used a relaxed statistical criterion of unadjusted A few reports showing the role of miRNA in invasive growth of different subtypes of pituitary tumors were published . Since rp < 0.05 and fold change >2. None of these miRNAs has been identified in our data, which may be partially explained by the fact that the authors included combined gonadotropinomas and silent ACTH and GH-producing tumors in the study group.A research most comparable to our study has been published by Wu S et al., who compared miRNA profiles in invasive and noninvasive nonfunctioning pituitary tumors with microarrays . In the In the studies focused on a priori selected particular miRNAs in nonfunctioning pituitary tumors, differential expression in invasive and noninvasive PitNETs was observed in hsa-miR-376B-3p  as well This inconsistency of data from different investigations is in line with a more general, apparent low reproducibility of the results of the research on invasion-related molecules. The results of most studies, including those with high-throughput methods, are not consistent with the other ones, as highlighted in recently published review articles , 26. ThiAdditionally, the molecular background of invasive growth of pituitary tumors seems to be complex. Many different molecular changes, different regulatory layers, and signaling pathways play a role in acquisition of invasive phenotype by the cells . CompariSince classifiers of tumors invasiveness status are of potential clinical usefulness, we applied ROC curve analysis for 29 miRNAs differentially expressed in invasive and noninvasive tumors. This allowed for identification of six miRNAs: hsa-miR-184, hsa-miR-181a-2-3p, hsa-miR-93-3p, hsa-miR-574-5p, hsa-miR-185-5p, and hsa-miR-3200-5p that could potentially serve as biomarkers of invasive growth potential.Little is known about the role of these miRNAs in pituitary tumors. Only one of them, hsa-miR-93, was previously described as related to invasive growth status of PitNETs. Its decreased expression was observed in invasive nonfunctioning tumors , accordiWhen focusing on the more general role of these miRNAs in human tumors, contradictory results can be found in the literature indicating their role as both oncogenic and oncosuppressive depending on tumor type. Hsa-miR-184 seems to be a suppressive miRNA in some tumors like glioma and nasopharyngeal carcinoma , 32, butValidation of the usefulness of six putative miRNA classifiers of invasive growth was performed by PCR-based analysis of expression of selected miRNAs in the independent validation cohort of 80 patients that were classified with the same criteria as discovery group patients to exclude differences in defining tumor invasive growth. qRT-PCR analyses were done on both discovery and validation cohorts to exclude the impact of different methods on validation procedure.Significant difference between invasive and noninvasive tumors was observed only for one of the selected miRNAs, that is, hsa-miR-185-5p. Unfortunately, sensitivity and specificity analysis for this miRNA used as a classifier of invasive growth status did not confirm its usefulness as an effective marker.qRT-PCR results of hsa-miR-184, hsa-miR-181a-2-3p, and hsa-miR-574-5p confirmed the difference of the tumors stratified according to the status of invasive growth in the discovery group, as identified with NGS that indicates the accordance of both analytical methods, but no significant difference was observed in validation cohort. Assessment of hsa-miR-93-3p expression with qRT-PCR assay did not confirm the difference between invasive and noninvasive PitNETs in neither discovery nor validation cohort. Thus, it did not confirm the previously reported downregulation of this miRNA in invasive nonfunctioning tumors .We conclude that our results suggest the lack of universal miRNA profile of the tumor that determines invasive growth. It does not imply that expression of particular miRNA does not play a role in the aggressive phenotype of nonfunctioning pituitary tumors, as shown by some previous functional experiments , 25, 43.Differences in the levels of miRNAs between invasive and noninvasive nonfunctioning gonadotropic PitNETs are very slight, and tumor miRNA expression seems not to be a source of a promising classifier of invasiveness and potential biomarker.


The use of alerts from the Bronx RHIO, a health information exchange (HIE) to identify James J. Peters VAMC patients diagnosed with COVID-19 in the community was described to facilitate COVID-19 VA primary care follow-up. COVID-19 hospitalization and testing alerts were delivered on a Bronx RHIO facility report. VA COVID-19 follow-up care by telephone and video was guided by local COVID-19 clinical pathways, electronic health record (EHR) templates, and tracking through a database. VA received 180 RHIO alerts for 111 unique patients, and 88 had positive non-VA testing from March to June 2020. 41% of the 88 had non-VA admissions and 23% died. 63% received VA primary care follow-up of COVID-19 symptoms documented by custom EHR templates. The HIE identified 11% of the facility COVID-19 patients. HIE alerts can be used to identify facility COVID-19 patients diagnosed in the community and facilitate follow-up by their VA primary care teams. LAY SUMMARYVeterans receive care in both VA and community settings including during the COVID-19 pandemic. At the James J. Peters VA in Bronx, Veterans with COVID-19 symptoms, some previously hospitalized, receive telephone, less often video, follow-up care from their primary care teams until resolution of symptoms. The follow-up includessymptom assessment and management, triage to a higher level of care if needed, mental health care, and infection control advice for patients and their caregivers. The hospital wished to identify its patients diagnosed with COVID-19 outside of the VA and extend the same follow-up care by their familiar primary care teams. This study describes how the facility used their local health information exchange (HIE), an electronic method to share health information between facilities, to identify their patients diagnosed outside the VA, and provide them follow-up of COVID-19 symptoms during the New York pandemic surge from March to the end of June 2020. Bronx RHIO HIE alerts identified 88 patients with positive non-VA COVID-19 testing. 63% received VA primary care COVID-19 symptom follow-up. 41% were hospitalized at non-VA sites and 23% died. 11% of the total facility patients (813) diagnosed with COVID-19 by the end of June 2020 were from the Bronx RHIO.New York City was the epicenter of COVID-19 in the spring of 2020. In New York City, between March and the end June of 2020, there were over 200,000 cases of COVID-19 and over 50,000 hospitalizations. There were almost 50,000 cases in the Bronx where the James J Peters VA Medical Center (JJP VAMC) is located.At the outset of the pandemic, JJP VAMC developed a program with local subject matter experts from infection control, primary care, informatics, and nursing to provide ambulatory assessment, triage, and management of facility patients with COVID-19 symptoms, using clinical pathways. Follow-up care was conducted by nurses and licensed independent practitioners primarily via telephone and secure video through the VA video platform, VA Video Connect. Some clinicians and patients corresponded via secure messaging via the VA’s health portal, My HealtheVet. The COVID-19 ambulatory program content was standardized through locally developed electronic health record (EHR) templates which were updated as national VA COVID-19 templates were created and as public health recommendations evolved.During the COVID-19 pandemic, most facility Veterans were tested and treated at the JJP VAMC, but facility patients were also tested, treated, and admitted for COVID-19 at non-VA sites. Knowledge of non-VA COVID-19 test results and treatment was essential to provide the same ambulatory COVID-19 primary care follow-up as patients diagnosed at the facility. However, there was no local or national standard process in place to identify VA patients diagnosed with COVID-19 in the community and to relay it to their VA primary care teams to initiate ambulatory symptom follow-up.,Health information exchange (HIE) is the one method by which VA clinicians obtain healthcare information from local community healthcare systems such as for test results and admissions. Health information exchange is defined as the electronic transfer of clinical, administrative, or other information necessary for the delivery of health care across diverse systems or organizations.Lenert et al. wrote about the importance of health information exchanges for COVID-19 in the June 2020 JAMIA: “The coronavirus disease 2019 (COVID-19) response imposes unprecedented challenges on our healthcare system. To address these challenges, the health information needed to safely care for a patient needs to flow across provider platforms in a given region without impediment”.The JJP VAMC is a partner with the Bronx Regional Health Information Organization (Bronx RHIO), a local HIE. VA providers have had access to the Bronx RHIO since 2008To describe the use of alerts from the Bronx RHIO, a health information exchange, to identify patients enrolled at the JJP VAMC diagnosed with COVID-19 in the community to facilitate COVID-19 follow-up by their VA primary care teams during the New York City pandemic surge from March to June 2020.The setting for the study is the JJP VAMC located in the Bronx, New York. The JJP VAMC is an academic tertiary care VA medical center with comprehensive inpatient services, three community clinics, a nursing home, and a long-term spinal cord unit.In this study, alerts of hospitalization events and COVID-19 molecular and serology test results were delivered on a facility patient roster via a Bronx RHIO report accessed by a RHIO-credentialed VA staff member to facilitate downstream ambulatory follow-up by the patient’s VA primary care team. Primary care COVID-19 serial symptom assessment, triage, and management follow-up were documented in custom electronic templates in the VA EHR, VistA. Primary care team members tracked their COVID-19 patients through a custom local primary care COVID-19 database . This stVA RHIO-credentialled staff members checked the Bronx RHIO COVID-19 roster daily and entered the non-VA results into the EHR through a template created to document outside COVID-19 molecular and serology results with structured data elements. The primary care team was notified of the test results through the template via a signature request. For some patients, the primary care team directly queried the RHIO and documented outside results on the same template after patients informed them of their outside COVID-19 results.Primary care staff used clinical pathways to guide their ambulatory follow-up of COVID-19 patients diagnosed at non-VA sites, using the same EHR templates for documentation with structured data elements used for patients diagnosed at the facility. The serial follow-up EHR template included structured symptom assessment and management, triage to a higher level if care for worsening symptoms, mental health assessment, and infection control advice. A discharge from monitoring template documented resolution of symptoms with guidance on release from home isolation. Templates were not used in secure messaging correspondence.Primary care teams tracked their COVID-19 patients with a custom facility primary care COVID-19 database report. Summary statistics were calculated for the patient cohort using SAS version 9.4 .Due to a New York State executive order, the requirement for a veteran to consent for RHIO access was waived during this time period. Since March 2020, The Bronx RHIO has provided COVID-19 alerts and reporting customized for each member organization including the JJP VAMC.A total of 180 COVID-19 Bronx RHIO alerts for 111 unique patients were received by RHIO VA-credentialed team members from April 6, 2020 through June 23, 2020 for non-VA testing, after alerting was turned on starting March 14, 2020. Of those patients, 88 (79%) had positive COVID-19 molecular and/or serology testing performed at non-VA sites. During this time, additional 725 JJP VAMC patients were diagnosed with COVID-19 via within-facility laboratory testing. Thus, non-VA outside-system testing contributed 88 of the 813 JJP VAMC patient cases (11%).Of the 88 patients who had a positive non-VA COVID-19 laboratory test result, 36 (41%) were admitted to hospitals in the community and 12 (14%) died in those facilities. Combined VA and RHIO data revealed a total of 20 (23%) deaths following a positive non-VA COVID-19 laboratory test result.The VA RHIO team informed primary care of positive COVID-19 testing for 65 (74%) of the 88 patients. For the remaining 23, the primary care team had documented the positive outside testing prior to the alert through other information channels. Thus, the RHIO identified at least 65 COVID-19 patients who would not otherwise have been identified within the VA facility. Overall, 55 (63%) of the 88 patients with outside COVID-19 positive results had VA primary care COVID-19 pathway-guided ambulatory follow-up care documented through custom COVID-19 her-templated notes and additional 12 patients (14%) had follow-up for COVID-19 with any VA clinician in the EHR without template use as per chart review.This study presents an example of a process to utilize health information exchange alert notification to identify VA patients diagnosed with COVID-19 in the community to facilitate ambulatory telephone and less often video follow-up by their VA primary care team to manage their COVID-19 infection. The primary care COVID-19 symptom assessment and management were documented through custom EHR templates and tracked through a custom primary care COVID-19 data analytics report. The HIE alert process enabled Veterans diagnosed with COVID-19 outside the VA to receive the same serial symptom follow-up by their established primary care teams as those diagnosed at the facility. The process was created early in the pandemic when New York City was overwhelmed by admissions and recommended home management for most patients for COVID-19 symptoms unless severe.For the COVID-19 pandemic, the laboratory result alerts supplied by the Bronx RHIO provided 11% of the total positive COVID results for the facility as of July 2020. Approximately 63% of facility patients with COVID-19 RHIO alerts subsequently received COVID-19 follow-up care by their primary care teams via custom EHR templates and 76% received follow-up by any VA clinical staff member with or without the templates as per chart review. Possible explanations of lack of documented EHR follow-up COVID-19 care include delayed education on template use for some primary care teams, redeployment of staff to inpatient and emergency areas, follow-up calls without EHR documentation, COVID-19 follow-up via secure messaging in the VA health portal, and the large number of outpatients with COVID-19 symptoms VA primary care staff were tracking during this time period.Bronx RHIO alerts accounted for approximately 21% of facility-wide COVID-19 deaths by July 2020. Veterans with COVID-19 identified through non-VA testing likely died at a high rate because non-VA sites were only testing severely ill hospitalized patients initially and the JJP VAMC extended testing to outpatients by late March. As such, the Bronx VA RHIO alerts for non-VA testing were for severely ill patients whereas the JJP VAMC test results included inpatients and outpatients. Swab, testing reagent and personal protective equipment shortages early in the pandemic influenced local facility and public health policy on testing.A major limitation of this study’s COVID-19 alert workflow is usability. Providers prefer to receive external alerts and view external data automatically within their EHR interface. Donohue et al. noted that HIE adoption would be facilitated through “reminders about external data, data displays combining both internal and external data, ease to extract and send data, clinical reports, and images to another provider and, conversely to incorporate external data into one’s own EHR”.Another limitation of this workflow process is New York State consent requirements for HIEs. Consent is currently temporarily waived by the state during the pandemic for the VA. The VA previously also required opt-in consent for HIE use but shifted to an opt-out approach since April 2020 due to the Mission Act.A last limitation to this study is missing COVID-19 data from RHIO member partners, local non-member medical facilities, and missing COVID-19 deaths not reported to the JJP VAMC or RHIO members.The VA is working toward greater interoperability with its community partners under VHA Office of Interoperability through the Veterans Health Information Exchange (VHIE) program.Health information exchange alerts can be used to identify facility patients diagnosed in the community for COVID-19 including those deceased and to facilitate ambulatory COVID-19 symptom follow-up of those patients by primary care teams at the VA. This study presents an example of a workflow which could be replicated by VA or non-VA sites to utilize HIE to link patients diagnosed with COVID-19 outside their primary source of health care to their primary care teams at their home facility for follow-up upon diagnosis or inpatient discharge until resolution of their infection.The data underlying this article cannot be shared publicly to protect the privacy of individuals included in the study.RS, KJ, NK, SR, JH, and KB designed the process and study. KJ, JH, SR, and RS curated the data. KJ and RS performed analyses. RS drafted the manuscript, and all authors contributed critical edits and approved the final manuscript.


The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease (COVID-19) determines the angiotensin converting enzyme 2 (ACE2) down-regulation and related decrease in angiotensin II degradation. Both these events trigger “cytokine storm” leading to acute lung and cardiovascular injury. A selective therapy for COVID-19 has not yet been identified. Clinical trials with remdesivir gave discordant results. Thus, healthcare systems have focused on “multi-targeted” therapeutic strategies aiming at relieving systemic inflammation and thrombotic complications. No randomized clinical trial has demonstrated the efficacy of renin angiotensin system antagonists in reducing inflammation related to COVID-19. Dexamethasone and tocilizumab showed encouraging data, but their use needs to be further validated. The still-controversial efficacy of these treatments highlighted the importance of organ injury prevention in COVID-19. Neprilysin (NEP) might be an interesting target for this purpose. NEP expression is increased by cytokines on lung fibroblasts surface. NEP activity is elevated in acute respiratory distress syndrome and it is conceivable that it is also high in COVID-19. NEP is implicated in the degradation of natriuretic peptides, bradykinin, substance P, adrenomedullin, and apelin that account for prevention of organ injury. Thus, NEP/angiotensin receptor type 1 (AT1R) inhibitor sacubitril/valsartan (SAC/VAL) may increase levels of these molecules and block AT1Rs required for ACE2 endocytosis in SARS-CoV-2 infection. Moreover, SAC/VAL has a positive impact on acute heart failure that is very frequently observed in deceased COVID-19 patients. The current review aims to summarize actual therapeutic strategies for COVID-19 and to examine the data supporting the potential benefits of SAC/VAL in COVID-19 treatment. The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has become a major concern all over the world. The disease induced by SARS-CoV-2 is named COVID-19. It refers to an interstitial pneumonia with distinctive vascular features, consisting of severe endothelialitis associated with the presence of a wide cellular injury .,47.46,47On the basis of these considerations, we may hypothesize that, during SARS-CoV-2 infection, the clinical picture of ARDS is worsened by an abnormally increased cytokine production at pulmonary level that is less antagonized because NP degradation is mediated by NEP up-regulation in lung fibroblasts. The following “cytokine storm” might induce NEP up-regulation in other districts, especially the heart and endothelium, thereby increasing the degradation of protective compounds  that, in turn, could account for the systemic severe effects of COVID-19 .Therefore, we think that in a “multi-targeted” therapeutic strategy for COVID-19, where the inflammatory burden is antagonized by specific anti-inflammatory drugs such as corticosteroids (dexamethasone) and tocilizumab, NEP antagonism becomes relevant for prevention of organ injury .Sacubitril/valsartan (SAC/VAL) is a well-tolerated NEP/AT1R inhibitor (ARNI) providing concomitant antagonism of NEP  and blockade of AT1Rs . It has been successfully used in the treatment of chronic . HoweverA wide variety of important histological lesions have been observed during autopsy of patients who died from SARS-CoV-2 infection  59]. Mo. Mo59]. In the United States, there has been a disproportionately high rate of COVID-19-related hospitalizations and death among older individuals and African Americans . Both poThus, dysregulation of NPs pathway seems to be associated with more severe COVID-19 and it is conceivable that increasing NPs levels by SAC/VAL administration could be beneficial to counteracting the adverse effects of SARS-CoV-2 infection.In an experimental and clinical study of ARDS, the activity of NEP was significantly increased in the alveolar air space, thereby suggesting a pivotal role of this enzyme in acute lung injury . In factTherefore, inhibition of NPs degradation by SAC/VAL might play a protective role in the lung during SARS-CoV-2 infection. The mechanisms underlying myocardial injury during COVID-19 remain unknown. In particular, it is still unclear whether acute injury is a primary infective phenomenon or secondary to lung disease. Two principal hypotheses have been formulated . The firSAC/VAL might account for cardiovascular protection through the reduction in endothelial cells and cardiomyocyte apoptosis by affecting NPs, BK and apelin isoforms’ degradation in SARS-CoV-2-infected patients  51,52].,52.51,52It is remarkable that acute HF is the consequence of a wide myocardial injury and one of the most frequently observed complications (49% of cases) in deceased COVID-19 patients . Given tSARS-CoV-2 is closely related to SARS-CoV. In fact, they both use ACE2 as the receptor-binding domain for their S protein . Virus bSAC/VAL blocks AT1R, which is required for ACE2 endocytosis . This efSAC/VAL is not in contrast with other drugs commonly used in COVID-19 therapy. Because of its inhibitory effect on degradation of atrial NPs leading to a reduction in IL-6 release, SAC/VAL might have a synergistic effect with IL-6R antagonist tocilizumab . ConsistNevertheless, we have to keep in mind that there are also some limitations to SAC/VAL use. As an example, hypotension is a very frequent potential collateral effect of this therapy and SAC/VAL is not to be used if blood systolic pressure is below 100 mmHg . HoweverThe observed benefit of in-hospital ACE inhibitors/ARBs’ use compared to non-ACE inhibitors/ARBs drugs in COVID-19 patients is consistent with the anti-inflammatory effects of both these pharmacological classes [Firstly, we propose to analyse the impact of a previous SAC/VAL therapy on COVID-19 severity. We expect a reduced severity of COVID-19 in this cluster of patients. If this is the case, the following step could be a randomized-controlled study aimed to test the effect of SAC/VAL addition to standard therapy on mortality and on other secondary endpoints  in moderate COVID-19. The causative relation between SAC/VAL administration and prognosis improvement could be validated by relief of increased urinary cGMP, which is a good detector of the biological effect of SAC/VAL on NPs-mediated activation of NPs receptors , in COVIIn the absence of selective antiviral therapies, healthcare systems have focused on “multi-targeted” therapeutic strategies aiming at relieving systemic inflammation and preventing thrombotic complications in COVID-19 patients. The still-controversial efficacy of these treatments highlighted the importance of organ injury prevention. In this context, the ARNI SAC/VAL could play a relevant role. Future randomized trials will be required to support this hypothesis.


Cardiovascular disease is a major cause of mortality worldwide. The advent of human-induced pluripotent stem cells (hiPSCs) technology have enabled the reliable generation of individual-derived cardiomyocytes (CMs) . TogetheCells, Horikoshi and colleagues [2+), as well as the key metabolic transcription regulator peroxisome proliferator-activator receptor alpha (PPARα) (a major regulator of genes involved in fatty acid β-oxidation). Thus, in terms of morphology and transcript profile, hiPSC-CMs cultured in the fatty acid-enriched maturation media appeared much more “sarcomerically” mature than those kept in a glucose-based media.In their recent report in lleagues  differenlleagues . The autHow did the above translate into the metabolic capacity of the mature hiPSC-CMs? The authors measured and showed that the mature hiPSC-CM populations have a significantly higher oxygen consumption rate (OCR), indicating that these cells have either an increased mitochondrial maturity or an enhanced mitochondrial oxidative capacity. Furthermore, when cells were given palmitate, mature hiPSC-CMs displayed a larger change than the control hiPSC-CMs in both basal and maximal OCR. This palmitate-induced OCR in matured hiPSC-CMs is abolished by the fatty acid oxidation inhibitor etomoxir, but not by 2-deoxyglucose inhibition of glycolysis. Matured hiPSC-CMs thus appear much more capable of utilizing exogenous palmitate for energy than the control iPSC-CMs. Interestingly, assessments of glycolytic flux parameters via measurements of the extracellular acidification rate (ECAR) indicated that ECAR levels in terms of glycolysis, glycolytic capacity, and glycolytic reserve were all significantly higher in mature hiPSC-CMs. These mature hiPSC-CMs, despite their fatty acid utilizing capability, are thus not impaired in terms of glycolytic capacity, and could readily switch to glucose as an energy substrate when necessary.The findings of Horikoshi and colleagues, as the authors claimed, showed that fatty acid-containing maturation medium can promote hiPSC-CMs to undergo maturation . As the