Virologic characterization of symptom rebound following nirmatrelvir-ritonavir treatment for COVID-19

We enrolled seven individuals with recurrent symptoms following nirmatrelvir-ritonavir treatment. High viral loads (median 6.1 log10 copies/mL) were detected at enrollment and for a median of 17 days after initial diagnosis. Three of seven had culturable virus for up to 16 days after initial diagnosis. No known resistance-associated mutations were identified.

Vaccine Breakthrough Infection with the SARS-CoV-2 Delta or Omicron (BA.1) Variant Leads to Distinct Profiles of Neutralizing Antibody Responses

There is increasing evidence that the risk of SARS-CoV-2 infection among vaccinated individuals is variant-specific, suggesting that protective immunity against SARS-CoV-2 may differ by variant. We enrolled vaccinated (n = 39) and unvaccinated (n = 11) individuals with acute, symptomatic SARS-CoV-2 Delta or Omicron infection and performed SARS-CoV-2 viral load quantification, whole-genome sequencing, and variant-specific antibody characterization at the time of acute illness and convalescence. Viral load at the time of infection was inversely correlated with antibody binding and neutralizing antibody responses. Increases in antibody titers and neutralizing activity occurred at convalescence in a variant-specific manner. Across all variants tested, convalescent neutralization titers in unvaccinated individuals were markedly lower than in vaccinated individuals. For individuals infected with the Delta variant, neutralizing antibody responses were weakest against BA.2, whereas infection with Omicron BA.1 variant generated a broader response against all tested variants, including BA.2.

Duration of viable virus shedding in SARS-CoV-2 omicron variant infection

Clinical features of SARS-CoV-2 Omicron variant infection, including incubation period and transmission rates, distinguish this variant from preceding variants. However, whether the duration of shedding of viable virus differs between omicron and previous variants is not well understood. To characterize how variant and vaccination status impact shedding of viable virus, we serially sampled symptomatic outpatients newly diagnosed with COVID-19. Anterior nasal swabs were tested for viral load, sequencing, and viral culture. Time to PCR conversion was similar between individuals infected with the Delta and the Omicron variant. Time to culture conversion was also similar, with a median time to culture conversion of 6 days (interquartile range 4-8 days) in both groups. There were also no differences in time to PCR or culture conversion by vaccination status.

Monoclonal antibody treatment drives rapid culture conversion in SARS-CoV-2 infection

Monoclonal antibodies (mAbs) are the treatment of choice for high-risk ambulatory persons with mild to moderate COVID-19. We studied viral culture dynamics post-treatment in a subset of participants receiving the mAb bamlanivimab in the ACTIV-2 trial. Viral load by qPCR and viral culture were performed from anterior nasal swabs collected on study days 0 (day of treatment), 1, 2, 3, and 7. Treatment with mAb resulted in rapid clearance of culturable virus in participants without treatment-emergent resistance. One day after treatment, 0 of 28 (0%) participants receiving mAb and 16 of 39 (41%) receiving placebo still had culturable virus (p <0.0001); nasal viral loads were only modestly lower in the mAb-treated group at days 2 and 3. Recrudescence of culturable virus was detected in three participants with emerging mAb resistance and viral load rebound. The rapid reduction in shedding of viable SARS-CoV-2 after mAb treatment highlights the potential role of mAbs in preventing disease transmission.

Detection of the omicron variant virus with the Abbott BinaxNow SARS-CoV-2 Rapid Antigen Assay

The US Centers for Disease Control and Prevention recommends rapid testing for SARS-CoV-2 infection as a key element of epidemic control. The Abbott BinaxNow is in widespread use in the United States for self-testing and as part of public health screening campaigns, but has not been evaluated for use with the omicron variant of SARS-CoV-2. We recruited individuals testing positive for COVID-19 PCR at an academic medical center. Anterior nasal swabs were stored in viral transport media and evaluated by viral load quantification and whole genome sequencing. We created serial dilutions from 2.5x103-2.5x105 viral copies/specimen for two delta and omicron specimens, respectively, and tested each with the BinaxNow assay per manufacturer instructions. Results were interpreted by three readers, blinded to the specimen variant and concentration. All omicron and delta specimens with concentrations of 100,000 copies/swab or greater were positive by the BinaxNow Assay, a concentration similar to previously reported limits of detection for this assay. Assay sensitivity diminished below that. This study demonstrates that Omicron variant SARS-CoV-2 infections are detected by the BinaxNow rapid antigen assay. Additional laboratory and clinical validation assessments are needed to better determine their limits of detection and performance in real-world settings.

Emergence of SARS-CoV-2 Resistance with Monoclonal Antibody Therapy

Resistance mutations to monoclonal antibody (mAb) therapy has been reported, but in the non-immunosuppressed population, it is unclear if in vivo emergence of SARS-CoV-2 resistance mutations alters either viral replication dynamics or therapeutic efficacy. In ACTIV-2/A5401, non-hospitalized participants with symptomatic SARS-CoV-2 infection were randomized to bamlanivimab (700mg or 7000mg) or placebo. Treatment-emergent resistance mutations were significantly more likely detected after bamlanivimab 700mg treatment than placebo (7% of 111 vs 0% of 112 participants, P=0.003). There were no treatment-emergent resistance mutations among the 48 participants who received bamlanivimab 7000mg. Participants with emerging mAb resistant virus had significantly higher pre-treatment nasopharyngeal and anterior nasal viral load. Intensive respiratory tract viral sampling revealed the dynamic nature of SARS-CoV-2 evolution, with evidence of rapid and sustained viral rebound after emergence of resistance mutations, and worsened symptom severity. Participants with emerging bamlanivimab resistance often accumulated additional polymorphisms found in current variants of concern/interest and associated with immune escape. These results highlight the potential for rapid emergence of resistance during mAb monotherapy treatment, resulting in prolonged high level respiratory tract viral loads and clinical worsening. Careful virologic assessment should be prioritized during the development and clinical implementation of antiviral treatments for COVID-19.

Virologic features of SARS-CoV-2 infection in children

BackgroundData on pediatric COVID-19 has lagged behind adults throughout the pandemic. An understanding of SARS-CoV-2 viral dynamics in children would enable data-driven public health guidance. MethodsRespiratory swabs were collected from children with COVID-19. Viral load was quantified by RT-PCR; viral culture was assessed by direct observation of cytopathic effects and semiquantitative viral titers. Correlations with age, symptom duration, and disease severity were analyzed. SARS-CoV-2 whole genome sequences were compared with contemporaneous sequences. Results110 children with COVID-19 (median age 10 years, range 2 weeks-21 years) were included in this study. Age did not impact SARS-CoV-2 viral load. Children were most infectious within the first five days of illness, and severe disease did not correlate with increased viral loads. Pediatric SARS-CoV-2 sequences were representative of those in the community and novel variants were identified. ConclusionsSymptomatic and asymptomatic children can carry high quantities of live, replicating SARS-CoV-2, creating a potential reservoir for transmission and evolution of genetic variants. As guidance around social distancing and masking evolves following vaccine uptake in older populations, a clear understanding of SARS-CoV-2 infection dynamics in children is critical for rational development of public health policies and vaccination strategies to mitigate the impact of COVID-19.

Type I, II, and III interferon signatures correspond to COVID-19 disease severity

We analyzed the plasma levels of interferons and cytokines, and the expression of interferon-stimulated genes in peripheral blood mononuclear cells in COVID-19 patients with different disease severity. Mild patients exhibited transient type I interferon responses, while ICU patients had prolonged type I interferon responses with hyper-inflammation mediated by interferon regulatory factor 1. Type II interferon responses were compromised in ICU patients. Type III interferon responses were induced in the early phase of SARS-CoV-2 infection, even in convalescent patients. These results highlight the importance of type I and III interferon responses during the early phase of infection in controlling COVID-19 progression.

SARS-CoV-2 Viremia is Associated with Distinct Proteomic Pathways and Predicts COVID-19 Outcomes

BackgroundSevere Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) plasma viremia has been associated with severe disease and death in coronavirus disease 2019 (COVID-19) in small-scale cohort studies. The mechanisms behind this association remain elusive. MethodsWe evaluated the relationship between SARS-CoV-2 viremia, disease outcome, inflammatory and proteomic profiles in a cohort of COVID-19 emergency department participants. SARS-CoV-2 viral load was measured using qRT-PCR based platform. Proteomic data were generated with Proximity Extension Assay (PEA) using the Olink platform. ResultsThree hundred participants with nucleic acid test-confirmed COVID-19 were included in this study. Levels of plasma SARS-CoV-2 viremia at the time of presentation predicted adverse disease outcomes, with an adjusted odds ratio (aOR) of 10.6 (95% confidence interval [CI] 4.4, 25.5, P<0.001) for severe disease (mechanical ventilation and/or 28-day mortality) and aOR of 3.9 (95%CI 1.5, 10.1, P=0.006) for 28-day mortality. Proteomic analyses revealed prominent proteomic pathways associated with SARS-CoV-2 viremia, including upregulation of SARS-CoV-2 entry factors (ACE2, CTSL, FURIN), heightened markers of tissue damage to the lungs, gastrointestinal tract, endothelium/vasculature and alterations in coagulation pathways. ConclusionsThese results highlight the cascade of vascular and tissue damage associated with SARS-CoV-2 plasma viremia that underlies its ability to predict COVID-19 disease outcomes.

An Accurate Upper Lid Blepharoplasty: A Key Component of Facial Rejuvenation.

Upper eyelid surgery is a common procedure performed by a variety of subspecialists including facial plastic surgeons, oculoplastic surgeons, general otolaryngologists, and plastic surgeons. Traditionally, a skin incision is marked in the preoperative setting to allow for an excision that eliminates upper eyelid hooding while preventing lagophthalmos. Many different methodologies have been proposed to maximize results and minimize complications. In this article, the authors propose a unique way to safely and effectively address dermatochalasis. The pinch technique allows for an accurate assessment of excess skin and provides a method that requires less operative time than traditional techniques. The use of both local anesthetic with epinephrine and hyaluronidase helps achieve the appropriate plane and attain better hemostasis. Importantly, the presented technique allows for reassessment and revision of the amount of skin excision before incision creation. It is a useful methodology for any surgeon performing upper lid blepharoplasty.

SARS-CoV-2 Viral Load is Associated with Increased Disease Severity and Mortality

The relationship between SARS-CoV-2 viral load and risk of disease progression remains largely undefined in coronavirus disease 2019 (COVID-19). We quantified SARS-CoV-2 viral load from participants with a diverse range of COVID-19 severity, including those requiring hospitalization, outpatients with mild disease, and individuals with resolved infection. SARS-CoV-2 plasma RNA was detected in 27% of hospitalized participants and 13% of outpatients diagnosed with COVID-19. Amongst the participants hospitalized with COVID-19, higher prevalence of detectable SARS-CoV-2 plasma viral load was associated with worse respiratory disease severity, lower absolute lymphocyte counts, and increased markers of inflammation, including C-reactive protein and IL-6. SARS-CoV-2 viral loads, especially plasma viremia, were associated with increased risk of mortality. SARS-CoV-2 viral load may aid in the risk stratification of patients with COVID-19 and its role in disease pathogenesis should be further explored.

The Changing Face of Beauty: A Global Assessment of Facial Beauty.

Beauty is difficult to define. The US population becomes more diverse by the day. Thus, traditional stereotypes of beauty in various ethnic groups become less applicable as diversity increases. Often, new and uniquely beautiful facial features and proportions emerge as different ethnicities converge. With the increased diversity in facial appearance comes increased variability in patients' goals. A successful cosmetic surgeon will cultivate an understanding of aesthetic ideals in different ethnic groups, nurture discussions with patients to determine their aesthetic goals, devise a surgical plan for each patient, and develop and refine the necessary surgical skills to perform the procedure.

Evolution of Blepharoplasty.

The eyes and periorbital region are central components of facial beauty and harmony, but the periorbital region is also one of the earliest to show signs of aging. Over the past few decades, significant progress has been made in our understanding of the anatomy in this area, as well as the deleterious effects of aging in this region. In turn, surgical philosophy and techniques have evolved to better combat changes in this area to achieve a more youthful, natural appearance.

Malignant Melanoma Arising in Red Tattoo Ink

We report the case of a 33-year-old male who presented with a malignant melanoma on his anterior chest wall. The lesion was only found in the red ink pigment of the tattoo, as were several in-transit dermal metastases. Possible explanations include a pre-existing lesion which was seeded with red ink or the possibility of the red ink causing an inflammatory reaction leading to malignant transformation. This is the first reported case of a melanoma developing in the red ink pigment of a multi-colored tattoo.

Epidermal cell proliferation in calorie-restricted aging rats.

Calorie restriction (CR) has been known to produce many beneficial health effects, and lowered cell proliferation from CR has been shown to produce anti-cancer effects in some tissues. In this study the rate of epidermal cell proliferation in aging Fischer 344 rats from ad libitum fed (AL) and CR colonies was assessed in relation to changes in epidermal thickness with age. Proliferating cell nuclear antigen (PCNA) was detected using immunohistochemical method on paraffin sections in the epidermis of dorsal skin and footpad in these animals obtained from the National Institute on Aging. The proliferating cell index was compared with morphometric measurement of epidermis in young, young adult and old animals (six per group). Data were analyzed by Excel and SPSS 14.0 softwares for statistical evaluation. Two-way analysis of variance (ANOVA) was applied to data to test the effects of age, diet, and age-diet interaction. The following significant effects were noted: (I) age and age-diet effects in dorsal skin epidermal width, and PCNA; (II) age, and diet effect on footpad epidermal thickness, and PCNA index. There was a trend of increasing epidermal thickness in the dorsal skin in normally feeding aging rats which was depressed with CR in the two younger groups. PCNA index showed a trend of attrition from young to old. The thickness of epidermis in foot pad showed a curvilinear trend in both AL and CR groups with lowest mean values in the old group, and more predominant effect in CR-exposed animals. The proliferation index in the foot pad demonstrated a trend of reduction in old specimens with lower mean values in each corresponding CR age group. This report agrees with CR-inhibited cell proliferation reported in many organs by other investigators, and the observed results might have been caused by physiological or endocrine mechanisms affecting the epithelium in these calorie-restricted animals.