Development and validation of a prognostic 40-day mortality risk model among hospitalized patients with COVID-19.

OBJECTIVES: The development of a prognostic mortality risk model for hospitalized COVID-19 patients may facilitate patient treatment planning, comparisons of therapeutic strategies, and public health preparations. METHODS: We retrospectively reviewed the electronic health records of patients hospitalized within a 13-hospital New Jersey USA network between March 1, 2020 and April 22, 2020 with positive polymerase chain reaction results for SARS-CoV-2, with follow-up through May 29, 2020. With death or hospital discharge by day 40 as the primary endpoint, we used univariate followed by stepwise multivariate proportional hazard models to develop a risk score on one-half the data set, validated on the remainder, and converted the risk score into a patient-level predictive probability of 40-day mortality based on the combined dataset. RESULTS: The study population consisted of 3123 hospitalized COVID-19 patients; median age 63 years; 60% were men; 42% had >3 coexisting conditions. 713 (23%) patients died within 40 days of hospitalization for COVID-19. From 22 potential candidate factors 6 were found to be independent predictors of mortality and were included in the risk score model: age, respiratory rate ≥25/minute upon hospital presentation, oxygenation <94% on hospital presentation, and pre-hospital comorbidities of hypertension, coronary artery disease, or chronic renal disease. The risk score was highly prognostic of mortality in a training set and confirmatory set yielding in the combined dataset a hazard ratio of 1.80 (95% CI, 1.72, 1.87) for one unit increases. Using observed mortality within 20 equally sized bins of risk scores, a predictive model for an individual's 40-day risk of mortality was generated as -14.258 + 13.460*RS + 1.585*(RS-2.524)^2-0.403*(RS-2.524)^3. An online calculator of this 40-day COVID-19 mortality risk score is available at www.HackensackMeridianHealth.org/CovidRS. CONCLUSIONS: A risk score using six variables is able to prognosticate mortality within 40-days of hospitalization for COVID-19. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT04347993.

Optimization of couch translational corrections to compensate for rotational and deformable target deviations in image guided radiotherapy.

The utilization of image-guided radiotherapy (IGRT) technologies helps correct temporal and spatial deviations of the target volume relative to planned radiation beams. With the aid of these IGRT technologies, it becomes possible to better identify the target volume before and even during radiation treatment. However, since components of the detected deviations may be translational, rotational, and deformable, the question remains whether simple treatment-couch translational movement can be optimized to compensate for these complicated deviations. Deviation of the target volume and changes in patient body shape from that acquired for treatment planning may further add to the variations from planned dose distribution. In this study, an optimization strategy is developed to investigate these issues. The optimization process involved the use of the hill climbing algorithm, the detected target volume and patient body shape, and the dose distribution based on acquired images at treatment. During the process, the planned dose distribution was iteratively adjusted to reflect the changes of depth and distance as the translational treatment couch movement was being optimized. The optimal treatment couch movement was considered achieved when the highest fraction of the detected target volume was covered by prescription dose. This optimization strategy was evaluated on clinical prostate cancer cases. For each of the cases, cone beam computed tomography (CBCT) images were acquired right after fiducial marker-based kilovolt orthogonal imaging verification and setup adjustment. Based on the CBCT images, the clinical target volume at the treatment was delineated and the translational treatment-couch movements were optimized with the developed strategy. The resultant dose coverage was compared to that without the optimization. The results showed that with the present strategy, rotational and deformable target deviations can be further compensated with translational couch correction.

Transition states for glucopyranose interconversion.

Glucose is a central molecule in biology and chemistry, and the anomerization reaction has been studied for more than 150 years. Transition-state structure is the last impediment to an in-depth understanding of its solution chemistry. We have measured kinetic isotope effects on the rate constants for approach of alpha-glucopyranose to its equilibrium with beta-glucopyranose, and these were converted into unidirectional kinetic isotope effects using equilibrium isotope effects. Saturation transfer 13C NMR spectroscopy has yielded the relative free energies of the transition states for the ring-opening and ring-closing reactions, and both transition states contribute to the experimental kinetic isotope effects. Both transition states of the anomerization process have been modeled with high-level computational theory with constraints from the primary, secondary, and solvent kinetic isotope effects. We have found the transition states for anomerization, and we have also concluded that it is forbidden for the water molecule to form a hydrogen bond bridge to both OH1 and O5 of glucose simultaneously in either transition state.

Isotope effect-mapping of the ionization of glucose demonstrates unusual charge sharing.

Isotopic substitution is known to affect kinetic rate constants and equilibrium constants in chemistry. In this study, we have used tritium substitution and high pH to probe the glucose left harpoon over right harpoon glucose(-) + H(+) equilibrium. Passing partially ionized mixtures of [(3)H]- and [(14)C]glucose over anionic exchange resin has permitted the detection of subtle differences in pK(a). We have found that, at pH 11.7 in an anionic exchange system, [(3)H]glucose always elutes ahead of the [(14)C]glucose, and we report isotope effects of 1.051 +/- 0.0007, 1.012 +/- 1.0005, 1.014 +/- 0.0004, 1.024 +/- 0.0003, 1.014 +/- 0.0004, and 1.015 +/- 0.0014 for [1-(3)H]-, [2-(3)H]-, [3-(3)H]-, [4-(3)H]-, [5-(3)H]-, and [6,6-(3)H(2)]glucose, respectively, as compared to either [2-(14)C]-or [6-(14)C]glucose. The elevated isotope effects at H1 and H4 imply unusual charge sharing in anionic aqueous glucose. Base titration of (13)C-chemical shift changes demonstrates the dominance of pyranose forms at elevated pH, and ab initio isotope effect computations on gas-phase glucose anions are presented.

Glucose binding isotope effects in the ternary complex of brain hexokinase demonstrate partial relief of ground-state destabilization.

Isotope effects can yield detailed information about contacts made between a bound compound and its host receptor or enzyme. In this study, we have measured isotope effects upon the equilibrium constant for the association of glucose and human brain hexokinase [E.C.2.7.1.1] in the presence of beta,gamma-CH(2)-ATP and compared these with data for the same equilibrium in the absence of ATP-analogue. We have found isotope effects of 1.012, 0.929, 1.031, 1.052, 0.998, and 1.032 for the competitive binding of [1-(3)H]-, [2-(3)H]-, [3-(3)H]-, [4-(3)H]-, [5-(3)H]-, or [6,6-(3)H(2)]- and either [2-(14)C]- or [6-(14)C]glucose to brain hexokinase. We observed changes only at H1, H5, and H6, and we attribute these to a slight change in the position of Asn683 and Glu742 due to nucleotide binding and to partial satisfaction of activated OH6 by the terminal nucleotide phosphorus.

Binding equilibrium isotope effects for glucose at the catalytic domain of human brain hexokinase.

We have utilized tritium isotope effects to probe the in vitro binding equilibrium between glucose and human brain hexokinase (E.C.2.7.1.1). Replacing a backbone hydrogen atom in glucose with tritium can significantly increase or decrease the equilibrium association constant. Specifically, the equilibrium tritium isotope effects are 1.027 +/- 0.002, 0.927 +/- 0.0003, 1.027 +/- 0.004, 1.051 +/- 0.001, 0.988 +/- 0.001, and 1.065 +/- 0.003 for [1-t]-, [2-t]-, [3-t]-, [4-t]-, [5-t]-, and [6,6-t(2)]glucose, respectively. We have shown that the existence of prebinding equilibrium isotope effects can contribute to binding isotope effect studies but that this effect is insignificant for glucose binding to hexokinase. The binding isotope effects are interpreted in the context of structural studies of hexokinase-glucose complexes. Ab initio calculations on 2-propanol with or without a hydrogen bonding partner, in steric collision with formaldehyde or methane, and on ethanol, cyclohexanol and 1-hydroxymethyl-tetrahydropyran are presented to clarify the magnitude of isotope effects possible in such interactions and the accompanying changes in free energy. Position-specific binding isotope effects provide direct evidence of the partial deprotonation and activation of O6 by Asp657, of other hydrogen bonding interactions with ionic residues, and of the steric compression of CH2 by the backbone carbonyl of Ser603.