Deep spatial profiling of human COVID-19 brains reveals neuroinflammation with distinct microanatomical microglia-T-cell interactions.

COVID-19 can cause severe neurological symptoms, but the underlying pathophysiological mechanisms are unclear. Here, we interrogated the brain stems and olfactory bulbs in postmortem patients who had COVID-19 using imaging mass cytometry to understand the local immune response at a spatially resolved, high-dimensional, single-cell level and compared their immune map to non-COVID respiratory failure, multiple sclerosis, and control patients. We observed substantial immune activation in the central nervous system with pronounced neuropathology (astrocytosis, axonal damage, and blood-brain-barrier leakage) and detected viral antigen in ACE2-receptor-positive cells enriched in the vascular compartment. Microglial nodules and the perivascular compartment represented COVID-19-specific, microanatomic-immune niches with context-specific cellular interactions enriched for activated CD8+ T cells. Altered brain T-cell-microglial interactions were linked to clinical measures of systemic inflammation and disturbed hemostasis. This study identifies profound neuroinflammation with activation of innate and adaptive immune cells as correlates of COVID-19 neuropathology, with implications for potential therapeutic strategies.

Alterations in compositional and cellular properties of the subchondral bone are linked to cartilage degeneration in hip osteoarthritis.

OBJECTIVE: The subchondral bone is an emerging regulator of osteoarthritis (OA). However, knowledge of how specific subchondral alterations relate to cartilage degeneration remains incomplete. METHOD: Femoral heads were obtained from 44 patients with primary OA during total hip arthroplasty and from 30 non-OA controls during autopsy. A multiscale assessment of the central subchondral bone region comprising histomorphometry, quantitative backscattered electron imaging, nanoindentation, and osteocyte lacunocanalicular network characterization was employed. RESULTS: In hip OA, thickening of the subchondral bone coincided with a higher number of osteoblasts (controls: 3.7 ± 4.5 mm-1, OA: 16.4 ± 10.2 mm-1, age-adjusted mean difference 10.5 mm-1 [95% CI 4.7 to 16.4], p < 0.001) but a similar number of osteoclasts compared to controls (p = 0.150). Furthermore, higher matrix mineralization heterogeneity (CaWidth, controls: 2.8 ± 0.2 wt%, OA: 3.1 ± 0.3 wt%, age-adjusted mean difference 0.2 wt% [95% CI 0.1 to 0.4], p = 0.011) and lower tissue hardness (controls: 0.69 ± 0.06 GPa, OA: 0.67 ± 0.06 GPa, age-adjusted mean difference -0.05 GPa [95% CI -0.09 to -0.01], p = 0.032) were detected. While no evidence of altered osteocytic perilacunar/canalicular remodeling in terms of fewer osteocyte canaliculi was found in OA, specimens with advanced cartilage degeneration showed a higher number of osteocyte canaliculi and larger lacunocanalicular network area compared to those with low-grade cartilage degeneration. Multiple linear regression models indicated that several subchondral bone properties, especially osteoblast and osteocyte parameters, were closely related to cartilage degeneration (R2 adjusted = 0.561, p < 0.001). CONCLUSION: Subchondral bone properties in OA are affected at the compositional, mechanical, and cellular levels. Based on their strong interaction with cartilage degeneration, targeting osteoblasts/osteocytes may be a promising therapeutic OA approach. DATA AND MATERIALS AVAILABILITY: All data are available in the main text or the supplementary materials.

Clinical characteristics, risk factors, and outcomes in Chilean triple negative breast cancer patients: a real-world study.

BACKGROUND: Latin American (LA) studies on triple-negative breast cancer (TNBC) and their characteristics are scarce. This forces physicians to make clinical decisions based on data obtained from studies that include non-Hispanic patients. Our study sought to obtain local epidemiological data, including risk factors and clinical outcomes from a Chilean BC registry. METHODS: This was a retrospective population-cohort study that included patients treated at a community hospital (mid-low income) or an academic private center (high income), in the 2010-2021 period. Univariate and multivariate analyses were performed to identify prognostic factors associated with survival. RESULTS: 647 out of 5,806 BC patients (11.1%) were TNBC. These patients were younger (p = 0.0001) and displayed lower rates of screening-detected cases (p = 0.0001) compared to non-TNBC counterparts. Among TNBC patients, lower income (i. e., receiving treatment at a community hospital) was associated with poorer overall survival (HR: 1.53; p = 0.0001) and poorer BC specific survival (HR: 1.29; p = 0.004). Other risk factors showed no significant differences between TNBC and non-TNBC. As expected, 5-year OS was significantly shorter on TNBC versus non-TNBC patients (p = 0.00001). In our multivariate analyses TNBC subtype (HR: 2.30), locally advanced stage (HR: 7.04 for stage III), lower income (HR: 1.64), or non-screening detected BC (HR: 1.32) were associated with poorer OS. CONCLUSION: To the best of our knowledge, this is the largest LA cohort of TNBC patients. Interestingly, the proportion of TNBC among Chileans was smaller compared to similar studies within LA. As expected, TNBC patients had poorer survival and higher risk for early recurrence versus non-TNBC. Other relevant findings include a higher proportion of premenopausal patients among TNBC. Also, mid/low-income patients that received medical attention at a community hospital displayed lower survival versus private health center counterparts.

Access disparities and underutilization of germline genetic testing in Chilean breast cancer patients.

PURPOSE: Latin American reports on genetic cancer risk assessments are scarce. In Chile, current breast cancer (BC) guidelines do not define strategies for germline genetic testing. Our study sought to quantify the disparities in access to genetic testing in Chilean BC patients, according to international standards and their clinical characteristics to explore improvement strategies. METHODS: Retrospective analysis of invasive BC databases including patients treated in a Public Hospital (PH) and in an Academic Private Center (AC) in Santiago, Chile between 2012 and 2021. RESULTS: Of 5438 BC patients, 3955 had enough data for National Comprehensive Cancer Network (NCCN) categorization. From these, 1911 (48.3%) fulfilled NCCN criteria for germline testing, of whom, 300 were tested for germline mutations and 268 with multigene panels. A total of 65 pathogenic variants were found in this subset. As expected, BRCA1/2 mutations were the most frequent (17.7%). Access to genetic testing was higher in AC versus PH (19.6% vs. 10.3%, p = 0.0001). Other variables associated with germline genetic testing were BC diagnosis after 2018, being 45 years old or younger at diagnosis, BC family history (FH), FH of ovarian cancer, non-metastatic disease, and triple-negative subtype. CONCLUSION: In our cohort, 15% of BC patients who met NCCN criteria for germline testing were effectively tested. This percentage was even lower at the PH. Current recommendations encourage universal genetic testing for BC patients; however, our findings suggest that Chile is far from reaching such a goal and national guidelines in this regard are urgently needed. To our knowledge, this is the first study of its kind in Chile and Latin America.

Cholesteatoma Severely Impacts the Integrity and Bone Material Quality of the Incus.

Cholesteatoma can lead to progressive destruction of the auditory ossicles along with conductive hearing loss but precise data on the microstructural, cellular, and compositional aspects of affected ossicles are not available. Here, we obtained incus specimens from patients who had cholesteatoma with conductive hearing loss. Incudes were evaluated by micro-computed tomography, histomorphometry on undecalcified sections, quantitative backscattered electron imaging, and nanoindentation. Results were compared with two control groups taken from patients with chronic otitis media as well as from skeletally intact donors at autopsy. The porosity of incus specimens was higher in cholesteatoma than in chronic otitis media, along with a higher osteoclast surface per bone surface. Histomorphometric assessment revealed higher osteoid levels and osteocyte numbers in cholesteatoma incudes. Incudes affected by cholesteatoma also showed lower matrix mineralization compared with specimens from healthy controls and chronic otitis media. Furthermore, the modulus-to-hardness ratio was higher in cholesteatoma specimens compared with controls. Taken together, we demonstrated increased porosity along with increased osteoclast indices, impaired matrix mineralization, and altered biomechanical properties as distinct features of the incus in cholesteatoma. Based on our findings, a possible impact of impaired bone quality on conductive hearing loss should be further explored.

Seroprevalence of arthropod-borne bacterial infections in homeless individuals in Hamburg in 2020.

PURPOSE: The number of homeless people in Germany is steadily increasing. Due to their often precarious living conditions, this specific population may be increasingly exposed to ectoparasites that can transmit various pathogens. To assess the prevalence and thus the risk of such infections, we analyzed the seropositivity of rickettsiosis, Q fever, tularemia and bartonellosis in homeless individuals. METHODS: A total of 147 homeless adults from nine shelters in Hamburg, Germany, were included. The individuals underwent questionnaire-based interviewing, physical examination, and venous blood was drawn between May and June 2020. Blood samples were analyzed for antibodies against rickettsiae (Rickettsia typhi and R. conorii), Coxiella burnetii, Francisella tularensis and bartonellae. RESULTS AND CONCLUSION: A very low seroprevalence of R. typhi and F. tularensis infection was found (0-1%), while antibodies against R. conorii and C. burnetii were more common (7% each), followed by a relatively high seroprevalence of 14% for bartonellosis. Q fever seroprevalence was associated with the country of origin, whereas bartonellosis seroprevalence was associated with the duration of homelessness. Preventive measures targeting ectoparasites, especially body lice, should be put in place continuously.

Determinants of health-related quality of life (HRQoL) among homeless individuals during the COVID-19 pandemic.

OBJECTIVE: Thus far, there is very limited knowledge regarding homeless individuals during the COVID-19 pandemic, particularly related to the health-related quality of life (HRQoL). Thus, our aim was to evaluate HRQoL and to clarify the determinants of HRQoL among homeless individuals during the COVID-19 pandemic in Germany. METHODS: Data were taken from the national survey on psychiatric and somatic health of homeless individuals during the COVID-19 pandemic-NAPSHI (n = 616). The established EQ-5D-5L was used to quantify problems in five health dimensions, and its visual analogue scale (EQ-VAS) was used to record self-rated health status. Sociodemographic factors were included in regression analysis. RESULTS: Pain/discomfort was the most frequently reported problem (45.3%), thereafter anxiety/depression (35.9%), mobility (25.4%), usual activities (18.5%) and self-care (11.4%). Average EQ-VAS score was 68.97 (SD: 23.83), and the mean EQ-5D-5L index was 0.85 (SD: 0.24). Regressions showed that higher age and having a health insurance were associated with several problem dimensions. Being married was associated with higher EQ-VAS scores. CONCLUSIONS: Overall, our study findings showed a quite high HRQoL among homeless individuals during the COVID-19 pandemic in Germany. Some important determinants of HRQoL were identified (e.g., age or marital status). Longitudinal studies are required to confirm our findings.

[Health of homeless individuals during the COVID-19 pandemic]. / Gesundheit wohnungsloser Menschen während der COVID-19-Pandemie.

The living situation and health of homeless people differs from the general population in many ways. It is reasonable to assume that the homeless population has been particularly vulnerable during the coronavirus disease 2019 (COVID-19) pandemic. This narrative review will summarize the current literature on the health and care of homeless people during the COVID-19 pandemic. The literature research was performed between December 2022 and February 2023. In addition to the current national and international literature, findings from the "National Survey on the Psychiatric and Somatic Health of Homeless Individuals" (NAPSHI study) will be synopsized, examining psychiatric and somatic diseases as well as the care for homeless people in Germany.Homeless individuals are often mentally and physically ill and have limited access to the regular medical care system. Facilities with group rooms and dormitories pose a risk for outbreaks during the COVID-19 pandemic. As suspected, evidence of Severe Acute Respiratory Syndrome Coronavirus Type 2 (SARS-CoV­2) infections emerged more frequently in homeless individuals than in the general population during the pandemic. Many of the infected individuals were asymptomatic. High rates of those unknowingly infected homeless individuals may have contributed to the spread of the viral disease. However, uncontrolled COVID-19 outbreaks, as feared by some researchers at the beginning of the pandemic, were not observed.

Pilot study in Hamburg on the prevalence of SARS-CoV-2 infections and pandemic survey in the German funeral industry.

Funeral home and crematorium workers are an important occupational group in the corona crisis. The occupational setting led to concerns about an increased risk of infection with SARS-CoV-2. The seroprevalence in this occupational group is unclear. A questionnaire-based retrospective survey of funeral home and crematorium staff was conducted in December 2020. A second survey of funeral and crematorium staff was conducted 6 months later, in June 2021, to determine changes in pandemic management. Seroprevalence or vaccination status for SARS-CoV-2 was determined at these two time points. In December 2020, a seroprevalence of 2.3% (n = 1/44) was detected in funeral home and crematorium workers. In June 2021, one additional participant tested positive for the SARS-CoV-2 nucleocapsid. Of the participants, 48.5% (n = 16) were vaccinated at this time. The risk of SARS-CoV-2 infection for funeral home and crematorium workers is more similar to that of the general population in Hamburg, Germany. We found no evidence of an increased risk of infection at these two time points in our cohort. Further education on communicable diseases or appropriate protective measures in this occupational group for other infectious diseases would be useful in the future.

The effect of posterior compression of the facet joints for initial stability and sagittal profile in the treatment of thoracolumbar fractures: a biomechanical study.

PURPOSE: Surgical treatment of thoracolumbar A3-fractures usually comprises posterior fixation-in neutral position or distraction-potentially followed by subsequent anterior support. We hypothesized that additional posterior compression in circumferential stabilization may increase stability by locking the facets, and better restore the sagittal profile. METHODS: Burst fractures Type A3 were created in six fresh frozen cadaver spine segments (T12-L2). Testing was performed in a custom-made spinal loading simulator. Loads were applied as pure bending moments of ± 3.75 Nm in all six movement axes. We checked range of motion, neutral zone and Cobb's angle over the injured/treated segment within the following conditions: Intact, fractured, instrumented in neutral alignment, instrumented in distraction, with cage left in posterior distraction, with cage with posterior compression. RESULTS: We found that both types of instrumentation with cage stabilized the segment compared to the fractured state in all motion planes. For flexion/extension and lateral bending, flexibility was decreased even compared to the intact state, however, not in axial rotation, being the most critical movement axis. Additional posterior compression in the presence of a cage significantly decreased flexibility in axial rotation, thus achieving stability comparable to the intact state even in this movement axis. In addition, posterior compression with cage significantly increased lordosis compared to the distracted state. CONCLUSION: Among different surgical modifications tested, circumferential fixation with final posterior compression as the last step resulted in superior stability and improved sagittal alignment. Thus, posterior compression as the last step is recommended in these pathologies.

[Use of Health Care by Homeless Individuals: Results of the Hamburg Survey of Homeless Individuals]. / Inanspruchnahme von Gesundheitsleistungen bei Obdachlosen: Ergebnisse der Hamburger Obdachlosenbefragung.

OBJECTIVE: There is a lack of studies focusing on the use of health care facilities by homeless people. The aim of this study was to survey health care use by the homeless. METHODS: Data were taken from the Hamburg survey of homeless individuals (n=150, mean age:12,5 years; SD: 12,5 years). Assessment covered details of health insurance status, use of ambulatory and hospital care, medication use, and reasons for not accessing health services. RESULTS: In total, 61,2% of the homeless individuals had health insurance. About two thirds of homeless individuals (65,9%) had accessed some sort of medical services in the past 12 months. The key reason for not making use of health services was the absence of any need for treatment (74,6%). In sum, 39,8% of homeless individuals had made at least one hospital visit in the past 12 months. About one third (34,2%) had used mobile support services (mainly a mobile doctor's office). In total, 37,7% of homeless individuals took medications regularly, with 'prices too high' (63,6%) being the key reason for difficulties in access to medications. Almost one half of homeless individuals (47,0%) had not made a visit to a physician in the past three months. CONCLUSION: Additional efforts are required to improve access to health care by homeless individuals. Future research in this area is therefore necessary.

Pulmonary cement embolism is frequently observed but not a contributing factor for death in patients with cemented total hip and knee arthroplasty: a postmortem study.

PURPOSE: Bone cement is frequently used for implant fixation in orthopaedic surgery. The occurrence of pulmonary cement embolism (PCE) in hip and knee arthroplasty has been described previously, but the exact extent and frequency have not been adequately studied. A postmortem cohort provides a unique opportunity for a more detailed analysis of this phenomenon. METHODS: Through retrospective analysis of whole-body computed tomography (CT) scans and autopsy protocols, we identified 67 cases with previous cemented total hip or knee arthroplasties. A grading system originally developed for PCE after cemented spine procedures was used. Findings were compared with two control groups: 35 individuals with previous cementless total joint arthroplasty as well as 25 individuals without evidence of prostheses. RESULTS: PCE was detected in 46.3% of the cases: grade 1 (31.3%), grade 2 (10.5%), and grade 3 (4.5%). No statistically significant difference was found between hip and knee arthroplasties in terms of PCE frequency. Importantly, none of the autopsy reports listed PCE as a cause of death or a contributing factor for the patients' death. In the two control groups, only one case per group was classified as grade 1 PCE, while the remaining cases did not show any evidence of PCE. CONCLUSION: The presented data reveal a high frequency of PCE in hip and knee arthroplasties, which is almost identical to previous findings in patients with cement-augmented interventions in the spine. This way, our results underline the relevance of PCE after arthroplasty, suggesting an adaptation of surgical methods to minimize this complication.

Postmortem Stability of SARS-CoV-2 in Nasopharyngeal Mucosa.

Analyses of infection chains have demonstrated that severe acute respiratory syndrome coronavirus 2 is highly transmissive. However, data on postmortem stability and infectivity are lacking. Our finding of nasopharyngeal viral RNA stability in 79 corpses showed no time-dependent decrease. Maintained infectivity is supported by virus isolation up to 35 hours postmortem.

Hepatic Vasculopathy and Regenerative Responses of the Liver in Fatal Cases of COVID-19.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infects the nasopharynx and lungs and causes coronavirus disease-2019 (COVID-19). It may impact the heart, brain, kidney, and liver.1 Although functional impairment of the liver has been correlated with worse clinical outcomes, little is known about the pathophysiology of hepatic injury and repair in COVID-19.2,3 Histologic evaluation has been limited to small numbers of COVID-19 cases with no control subjects2,4 and demonstrated largely heterogeneous patterns of pathology.2,3.

Screen-detected breast cancer is associated with better prognosis and survival compared to self-detected/symptomatic cases in a Chilean cohort of female patients.

PURPOSE: The implementation of national breast cancer (BC) screening programs in Latin America has been rather inconsistent. Instead, most countries have opted for "opportunistic" mammogram screenings on the population at risk. Our study assessed and compared epidemiological, clinical factors, and survival rates associated with BC detected by screening (SDBC) or self-detected/symptomatic (non-SDBC) in Chilean female patients. METHODS: Registry-based cohort study that included non-metastatic BC (stage I/II/III) patients diagnosed between 1993 and 2020, from a public hospital (PH) and a private university cancer center (PC). Epidemiological and clinical data were obtained from medical records. RESULTS: A total of 4559 patients were included. Most patients (55%; n = 2507) came from PH and were diagnosed by signs/symptoms (non-SDBC; n = 3132, 68.6%); these patients displayed poorer overall (OS) and invasive disease-free survival (iDFS) compared to SDBC. Importantly, the proportion of stage I and "luminal" BC (HR + /HER2 -) were significantly higher in SDBC vs. non-SDBC. Finally, using a stage/subset-stratified age/insurance-adjusted model, we found that non-SDBC cases are at a higher risk of death (HR:1.75; p < 0.001). In contrast, patients with PC health insurance have a lower risk of death (HR: 0.60; p < 0.001). CONCLUSION: We confirm previous studies that report better prognosis/survival on SDBC patients. This is probably due to a higher proportion of stage I and luminal-A cases versus non-SDBC. In turn, the survival benefit observed in patients with PC health insurance might be attributed to a larger proportion of SDBC. Our data support the implementation of a systematic BC screening program in Chile to improve patient prognosis and survival rates.

The interdisciplinary and psychosocial gap in cancer survivorship: A longitudinal study in a Latin American Cancer Center.

BACKGROUND AND OBJECTIVES: There is lack of information on the quality of care provided to the rapidly increasing population of cancer survivors in Latin America. Our study attempts to address this gap and to identify areas needed to be improved. METHODS: A random sample of 210 breast and colorectal cancer survivors were selected from a hospital-based registry in Chile. Cancer registry information, electronic chart review, and personal interviews were used to assess medical and nonmedical care over a 5-year period. Survivorship care practices were compared to a standardized reference based on the US Institute of Medicine domains and the American Cancer Association guidelines. RESULTS: Over 80% of breast and colorectal cancer survivors received appropriate medical care, ongoing testing surveillance and risk factors assessment. Only a third of survivors were assessed for psychosocial disorders and 25% of them received interdisciplinary care. Overall, 66.1% of breast and 58.6% of colorectal cancer survivors reached the expected quality level of cancer survivorship care according to the reference standard (p < .001). CONCLUSION: Medical care practices reached a high standard in a leading cancer center in Latin America. However, a much stronger psychosocial assessment and interdisciplinary care is needed to improve survivorship cancer quality care.

CT of the medial clavicular epiphysis for forensic age estimation: hands up?

PURPOSE: The aim of this study was to assess the impact of arm position in computed tomography (CT) of the clavicle performed for forensic age estimation on clavicular position, image noise, and radiation dose. METHODS AND MATERIALS: Forty-seven CT scans of the medial clavicular epiphysis performed for forensic age estimation were conducted with either hands and arms held upwards (CTHU, 28 persons) or positioned at the body (CTHD, 19 persons). Presets were identical for both positions (70 mAs/140 kVp; Brilliance iCT, Philips). Each CT scan was reconstructed with an iterative algorithm (i-Dose 4) and evaluated at the middle of the sternoclavicular joint. Clavicular angle was measured on a.p. topograms in relation to a horizontal line. Quantitative image noise was measured in air at the level of medial clavicular epiphysis. Effective dose and scan length were recorded. RESULTS: Hands-up position compared with hands-down position resulted in a lower lateral body diameter (CTHU 41.1 ± 3.6 cm vs. CTHD 44.6 ± 3.1 cm; P = 0.03), a reduced quantitative image noise (CTHU: 39.5 ± 9.2; CTHD: 46.2 ± 8.3; P = 0.02), and lower CTDIvol (5.1 ± 1.4 mGy vs. 6.7 ± 1.8 mGy; P = 0.001). Scan length was longer in patients examined with hands up (HU: 8.5 ± 3.4 cm; HD: 6.2 ± 2.1 cm; P = 0.006). Mean effective dose for CTHU was 0.79 ± 0.32 mSv compared with 0.95 ± 0.38 mSv in CTHD (P = 0.12). Clavicular angle was 17° ± 6° in patients with hands down and 32° ± 7° in patients with hands up (P < 0.001). CONCLUSION: By elevated arm positioning, the image quality of clavicular CT scans can be improved while maintaining radiation dose compared with hands down. Clavicular position differs according to the hand position. Thus, positioning patients with elevated hands is advisable for forensic clavicular CT examinations, but multiplanar CT reconstructions should be adjusted to clavicular position and scan length should be reduced to a minimum.

Cortical threaded pedicle screw improves fatigue strength in decreased bone quality.

PURPOSE: Inadequate anchoring of pedicle screws in vertebrae with poor bone quality is a major problem in spine surgery. The aim was to evaluate whether a modified thread in the area of the pedicle could significantly improve the pedicle screw fatigue strength. METHODS: Fourteen human cadaveric vertebral bodies (L2 and L3) were used for in vitro testing. Bone density (BMD) was determined by quantitative computed tomography. Vertebral bodies were instrumented by standard pedicle screws with a constant double thread on the right pedicle and a partial doubling of the threads-quad thread-(cortical thread) in the area of the pedicle on the left pedicle. Pulsating sinusoidal, cyclic load (0.5 Hz) with increasing peak force (100 N + 0.1 N/cycles) was applied orthogonal to the screw axis. The baseline force remained constant (50 N). Fatigue test was terminated after exceeding 5.4-mm head displacement (~ 20° screw tilting). RESULTS: The mean fatigue load at failure was 264.9 N (1682 cycles) for the standard screws and was increased significantly to 324.7 N (2285 cycles) by the use of cortical threaded screws (p = 0.014). This effect is particularly evident in reduced BMD (standard thread 241.2 N vs. cortical thread 328.4 N; p = 0.016), whereas in the group of vertebrae with normal BMD no significant difference could be detected (standard thread 296.5 N vs. cortical thread 319.8 N; p = 0.463). CONCLUSIONS: Compared to a conventional pedicle screw, the use of a cortical threaded pedicle screw promises superior fatigue load in vertebrae with reduced bone quality.

Determinants of health care use among homeless individuals: evidence from the Hamburg survey of homeless individuals.

BACKGROUND: To identify the determinants of health care use among homeless individuals. METHODS: Data were taken from the Hamburg survey of homeless individuals (n = 100 individuals in the here used model, mean age 44.8 years, SD 12.5) focusing on homeless individuals in Hamburg, Germany. The number of physician visits in the past 3 months and hospitalization in the preceding 12 months were used as outcome measures. Drawing on the Andersen model of health care use as a conceptual framework, predisposing characteristics, enabling resources and need factors as well as psychosocial variables were included as correlates. RESULTS: Negative binomial regressions showed that increased physician visits were associated with being female (IRR: 4.02 [95% CI: 1.60-10.11]), absence of chronic alcohol consume (IRR: 0.26 [95% CI: 0.12-0.57]) and lower health-related quality of life (IRR: 0.97 [95% CI: 0.96-0.98]). Furthermore, logistic regressions showed that the likelihood of hospitalization was positively associated with lower age (OR: 0.93 [95% CI: 0.89-0.98]), having health insurance (OR: 8.11 [2.11-30.80]) and lower health-related quality of life (OR: 0.97 [95% CI: 0.94-0.99]). CONCLUSIONS: Our study showed that predisposing characteristics (both age and sex), enabling resources (i.e., health insurance) and need factors in terms of health-related quality of life are main drivers of health care use among homeless individuals. This knowledge may assist in managing health care use.

Autopsy Findings and Venous Thromboembolism in Patients With COVID-19: A Prospective Cohort Study.

BACKGROUND: The new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused more than 210 000 deaths worldwide. However, little is known about the causes of death and the virus's pathologic features. OBJECTIVE: To validate and compare clinical findings with data from medical autopsy, virtual autopsy, and virologic tests. DESIGN: Prospective cohort study. SETTING: Autopsies performed at a single academic medical center, as mandated by the German federal state of Hamburg for patients dying with a polymerase chain reaction-confirmed diagnosis of COVID-19. PATIENTS: The first 12 consecutive COVID-19-positive deaths. MEASUREMENTS: Complete autopsy, including postmortem computed tomography and histopathologic and virologic analysis, was performed. Clinical data and medical course were evaluated. RESULTS: Median patient age was 73 years (range, 52 to 87 years), 75% of patients were male, and death occurred in the hospital (n = 10) or outpatient sector (n = 2). Coronary heart disease and asthma or chronic obstructive pulmonary disease were the most common comorbid conditions (50% and 25%, respectively). Autopsy revealed deep venous thrombosis in 7 of 12 patients (58%) in whom venous thromboembolism was not suspected before death; pulmonary embolism was the direct cause of death in 4 patients. Postmortem computed tomography revealed reticular infiltration of the lungs with severe bilateral, dense consolidation, whereas histomorphologically diffuse alveolar damage was seen in 8 patients. In all patients, SARS-CoV-2 RNA was detected in the lung at high concentrations; viremia in 6 of 10 and 5 of 12 patients demonstrated high viral RNA titers in the liver, kidney, or heart. LIMITATION: Limited sample size. CONCLUSION: The high incidence of thromboembolic events suggests an important role of COVID-19-induced coagulopathy. Further studies are needed to investigate the molecular mechanism and overall clinical incidence of COVID-19-related death, as well as possible therapeutic interventions to reduce it. PRIMARY FUNDING SOURCE: University Medical Center Hamburg-Eppendorf.