Eosinophilic Mucin: A Predictor for Disease Severity in Chronic Rhinosinusitis

2020 ◽  
pp. 194589242094382
Author(s):  
Aykut A. Unsal ◽  
Camilo Reyes ◽  
Paul Biddinger ◽  
Stilianos E. Kountakis
Keyword(s):  
Chronic Rhinosinusitis ◽  
Disease Severity ◽  
Severe Disease ◽  
High Power Field ◽  
Tissue Eosinophilia ◽  
Potential Marker ◽  
Independent Variable ◽  
The Impact ◽  
Snot 22 ◽  
Tissue Eosinophil

Objective The presence of tissue eosinophilia is a determinate of disease severity in patients with chronic rhinosinusitis (CRS). The impact of eosinophilic mucin (EM) as an independent variable has not yet been elucidated. Study Design Retrospective review. Setting Tertiary academic clinic. Subjects Methods: CRS patients who failed medical therapy were classified by tissue eosinophilia, presence of polyps and EM. Tissue eosinophilia count per high power field (HPF) as well as the presence of EM were determined by pathologic examination of sinus tissue removed during surgery. Sinonasal Outcomes Test (SNOT-22), Lund-Mackay (LM), and Lund-Kennedy (LK) scores were compared between all groups preoperatively and postoperatively up to two and a half years (30 months). Results 192 patients with CRS were included in the study. 87 were diagnosed with eosinophilic CRS with polyps, 58 with eosinophilic CRS without polyps, 14 with noneosinophilic CRS with polyps, and 33 with noneosinophilic CRS without polyps. Only patients with eosinophilia had EM on pathology. Of eosinophilic CRS, 50% of patients with polyps and 12% of cases without polyps demonstrated EM, respectively. EM presence portended more severe disease in patients with eosinophilia on subjective and objective scores preoperatively (P < 0.005). Postoperatively, EM patients experienced a greater improvement of symptoms, but continued to have worse endoscopy scores until 1.5 years. A tissue eosinophil count of 30 or greater per HPF was identified as a potential marker for the development of EM. Conclusions The presence of eosinophilic mucin predicts overall worse disease severity in patients with eosinophilic CRS.

Clinical Examination of Tissue Eosinophilia in Patients with Chronic Rhinosinusitis and Nasal Polyposis

2016 ◽  
Vol 155 (1) ◽  
pp. 173-178 ◽  
Author(s):  
Sarah A. Gitomer ◽  
Cynthia R. Fountain ◽  
Todd T. Kingdom ◽  
Anne E. Getz ◽  
Stefan H. Sillau ◽  
...  
Keyword(s):  
Chronic Rhinosinusitis ◽  
Disease Severity ◽  
Severe Asthma ◽  
Case Series ◽  
Medication Usage ◽  
Mucosal Disease ◽  
Tissue Eosinophilia ◽  
Chronic Corticosteroid ◽  
Histopathologic Findings ◽  
Tissue Eosinophil

Objective (1) Describe clinical and histopathologic findings in patients with chronic rhinosinusitis with nasal polyps (CRSwNP). (2) Determine if tissue and serum eosinophilia predicts disease severity in CRSwNP. Study Design Case series with chart review. Setting Academic hospital specializing in respiratory and allergic disease. Subjects Patients with CRSwNP treated from 2008 to 2010. Methods Clinical data were collected; sinus computed tomography (CT) scans were scored according to the Lund-Mackay system; and surgical specimens were evaluated for degree of tissue eosinophilia. Statistical analysis was performed to compare eosinophilia with indicators of disease severity. Results Seventy CRSwNP patients were included, with a mean Lund-Mackay score of 16.7; 62.1% of patients had severe asthma, and 62.9% were aspirin sensitive. Elevated tissue eosinophil level did not correlate with medication usage, olfactory symptoms, or Lund-Mackay scores, nor did it correlate with presence of asthma or aspirin-sensitivity (P = .09). Patients with mild asthma had significantly more tissue eosinophils versus patients with severe asthma, possibly because of the high amount of chronic corticosteroid use in severe asthmatics. There was no correlation between tissue and serum eosinophil counts (P = .97), but there was a significant positive correlation between CT score and peripheral eosinophil level (P < .05). Conclusions Higher serum eosinophil levels may indicate more extensive mucosal disease as measured on CT scan. Neither serum nor tissue eosinophilia predicted disease severity in our retrospective analysis of CRSwNP patients, and serum eosinophil level did not serve as a marker of tissue eosinophilia.

Distinct Patterns of Tissue Remodeling and Their Prognostic Role in Chronic Rhinosinusitis

ORL ◽  
2021 ◽  
pp. 1-7
Author(s):  
Ho Yun Lee ◽  
Jung-Soo Pyo ◽  
Su Jin Kim
Keyword(s):  
Chronic Rhinosinusitis ◽  
Structural Changes ◽  
Squamous Metaplasia ◽  
Tissue Remodeling ◽  
Sinus Surgery ◽  
Prognostic Role ◽  
High Power Field ◽  
Tissue Eosinophilia ◽  
Allergy Test ◽  
Stromal Edema

<b><i>Introduction:</i></b> Tissue remodeling refers to structural changes that occur in damaged tissue and is associated with disease severity in asthma. However, the characteristics of tissue remodeling and its prognostic role in chronic rhinosinusitis (CRS) remain unclear. In this report, we evaluated the clinical implications of tissue remodeling in CRS. <b><i>Methods:</i></b> We performed a retrospective cohort study of adult patients who underwent endoscopic sinus surgery for bilateral CRS. The histopathology of sinus mucosa was determined by evaluating the inflammatory cell count and tissue remodeling markers (squamous metaplasia, subepithelial gland proliferation, basement membrane [BM] thickening, stromal edema, and fibrosis). Eosinophilic CRS (ECRS) was defined as an eosinophil count &#x3e;15/high-power field in the biopsied tissue. Patient characteristics, allergy test grade, preoperative Lund-Mackay score (LMS), and pre- and postoperative Lund-Kennedy scores (LKSs) were analyzed. <b><i>Results:</i></b> Of the identified patients, 59.1% were classified as ECRS and the remaining 40.9% as non-ECRS. Regarding tissue remodeling markers, stromal edema was seen in 90.9%, BM thickening in 63.6%, and stromal fibrosis in 34.1% of patients. In cases with stromal edema and BM thickening, greater tissue eosinophilia was observed, while stromal fibrosis decreased tissue eosinophilia (<i>p</i> &#x3c; 0.05). Prognostically, subepithelial gland proliferation alone was an independent risk factor for poor postoperative endoscopic findings (odds ratio: 8.250, 95% confidence interval: 1.128–60.319, <i>p</i> = 0.038). <b><i>Conclusions:</i></b> Tissue eosinophilia was commonly associated with BM thickening and stromal edema. Subepithelial gland proliferation predicted a poor surgical prognosis in CRS. These findings imply that tissue remodeling provides additional information not only on the CRS endotype but also on the postsurgical prognosis.

scholarly journals The interplay between environmental exposures and COVID-19 risks in the health of children

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Peter D. Sly ◽  
Brittany A. Trottier ◽  
Catherine M. Bulka ◽  
Stephania A. Cormier ◽  
Julius Fobil ◽  
...  
Keyword(s):  
Air Pollution ◽  
Air Quality ◽  
Disease Severity ◽  
Research Effort ◽  
Severe Disease ◽  
Environmental Exposures ◽  
Research Strategy ◽  
Lessons Learned ◽  
Research Questions ◽  
The Impact

Abstract Background An unusual feature of SARS-Cov-2 infection and the COVID-19 pandemic is that children are less severely affected than adults. This is especially paradoxical given the epidemiological links between poor air quality and increased COVID-19 severity in adults and that children are generally more vulnerable than adults to the adverse consequences of air pollution. Objectives To identify gaps in knowledge about the factors that protect children from severe SARS-Cov-2 infection even in the face of air pollution, and to develop a transdisciplinary research strategy to address these gaps. Methods An international group of researchers interested in children’s environmental health was invited to identify knowledge gaps and to develop research questions to close these gaps. Discussion Key research questions identified include: what are the effects of SAR-Cov-2 infection during pregnancy on the developing fetus and child; what is the impact of age at infection and genetic susceptibility on disease severity; why do some children with COVID-19 infection develop toxic shock and Kawasaki-like symptoms; what are the impacts of toxic environmental exposures including poor air quality, chemical and metal exposures on innate immunity, especially in the respiratory epithelium; what is the possible role of a “dirty” environment in conveying protection – an example of the “hygiene hypothesis”; and what are the long term health effects of SARS-Cov-2 infection in early life. Conclusion A concerted research effort by a multidisciplinary team of scientists is needed to understand the links between environmental exposures, especially air pollution and COVID-19. We call for specific research funding to encourage basic and clinical research to understand if/why exposure to environmental factors is associated with more severe disease, why children appear to be protected, and how innate immune responses may be involved. Lessons learned about SARS-Cov-2 infection in our children will help us to understand and reduce disease severity in adults, the opposite of the usual scenario.

scholarly journals JAK2 Phosphorylation Signals and Their Associated Cytokines Involved in Chronic Rhinosinusitis with Nasal Polyps and Correlated with Disease Severity

Biomolecules ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. 1059
Author(s):  
Yu-Tsai Lin ◽  
Wei-Chih Chen ◽  
Ming-Hsien Tsai ◽  
Jing-Ying Chen ◽  
Chih-Yen Chien ◽  
...  
Keyword(s):  
Chronic Rhinosinusitis ◽  
Disease Severity ◽  
Nasal Polyps ◽  
Inflammatory Diseases ◽  
Janus Kinase ◽  
Sinus Surgery ◽  
Control Group ◽  
Jak2 Inhibitor ◽  
Ifn Γ ◽  
Snot 22

Janus kinase 2 (JAK2) is a member of the JAK family that transduces cytokine-mediated signals via the JAKs/STATs (signal transducer and activator of transcription proteins) pathway, which plays an important role in many inflammatory diseases. This study investigates the association of p-JAK2 and JAK2-associated cytokines from nasal polyp (NP) tissue with disease severity, and evaluates the p-JAK2-mediated STATs in chronic rhinosinusitis (CRS) with NP. Sixty-one CRSwNP patients with nasal polyps undergoing endoscopic sinus surgery were enrolled, while the turbinate tissues from 26 nasal obstruction patients were examined as the control group. Elevated levels of p-JAK2 were detected in CRSwNP, and significantly correlated with scores of disease severity (LMK-CT, TPS, and SNOT-22). Expressions of the JAK2-associated cytokines, such as IL-5, IL-6, IL-13, G-CSF, and IFN-γ were significantly higher in CRSwNP than in the controls, while the levels of IL-5, IL-6, IL-13, or G-CSF had positive correlation with scores of disease severity. Moreover, markedly increased expression of p-STAT3 in CRSwNP was observed relative to the control. Taken together, these data showed that the JAK2-associated cytokines including IL-6 and G-CSF may stimulate JAK2 phosphorylation to activate p-STAT3, indicating an association with disease severity and supporting its development of JAK2 inhibitor as a potential therapeutic agent for CRS.

The impact of multiple sclerosis severity on health state utility values: Evidence from Australia

2016 ◽  
Vol 23 (8) ◽  
pp. 1157-1166 ◽  
Author(s):  
Hasnat Ahmad ◽  
Bruce V Taylor ◽  
Ingrid van der Mei ◽  
Sam Colman ◽  
Beth A O’Leary ◽  
...  
Keyword(s):  
Multiple Sclerosis ◽  
Disease Severity ◽  
Severe Disease ◽  
Health Utility ◽  
Health State Utility ◽  
Health State ◽  
Utility Values ◽  
Health State Utility Values ◽  
Economic Analyses ◽  
The Impact

Background: The measurement of health state utility values (HSUVs) for a representative sample of Australian people with multiple sclerosis (MS) has not previously been performed. Objectives: Our main aim was to quantify the HSUVs for different levels of disease severities in Australian people with MS. Method: HSUVs were calculated by employing a ‘judgement-based’ method that essentially creates EQ-5D-3L profiles based on WHOQOL-100 responses and then applying utility weights to each level in each dimension. A stepwise linear regression was used to evaluate the relationship between HSUVs and disease severity, classified as mild (Expanded Disability Status Scale (EDSS) levels: 0–3.5), moderate (EDSS levels: 4–6) and severe (EDSS levels: 6.5–9.5). Results: Mean HSUV for all people with MS was 0.53 (95% confidence interval (CI): 0.52–0.54). Utility decreased with increasing disease severity: 0.61 (95% CI: 0.60–0.62), 0.51 (95% CI: 0.50–0.52) and 0.40 (95% CI: 0.38–0.43) for mild, moderate and severe disease, respectively. Adjusted differences in mean HSUV between the three severity groups were statistically significant. Conclusion: For the first time in Australia, we have quantified the impact of increasing severity of MS on health utility of people with MS. The HSUVs we have generated will be useful in further health economic analyses of interventions that slow progression of MS.

Changes in Sleep Quality Following Treatment for Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

2021 ◽  
pp. 194589242110614
Author(s):  
Jacob Fried ◽  
Erick Yuen ◽  
David A. Gudis ◽  
Rodney J. Schlosser ◽  
Shaun A. Nguyen ◽  
...  
Keyword(s):  
Sleep Apnea ◽  
Sleep Quality ◽  
Chronic Rhinosinusitis ◽  
Meta Analysis ◽  
Patient Reported Outcome Measures ◽  
Cochrane Library ◽  
Patient Reported ◽  
Sleep Parameters ◽  
The Impact ◽  
Snot 22

Background Chronic rhinosinusitis (CRS) presents with broad and systemic manifestations, including impaired sleep; however, the impact of CRS treatments upon sleep is unknown. Objective To establish the effect of medical or surgical CRS treatment on subjective and objective sleep metrics for patients not previously diagnosed with sleep apnea. Methods Review of PubMed, Scopus, Web of Science, and the Cochrane Library was performed from the databases’ date of inception through August 13, 2020, for studies evaluating the effect of CRS treatment on sleep quality. All studies reporting on subjective and objective sleep parameters for patients with CRS, with completed pre- and posttreatment data were included. Studies composed of patients with diagnosed sleep apnea were excluded. Results Sixteen unique studies reporting data on a total of 1770 patients (mean age, 50.6 ± 15.6 (n = 1675) years) following treatment for CRS were included. Patient-reported outcome measures, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Scale, demonstrated mean posttreatment differences of −2.8 (95% CI: −4.9 to −0.7), −2.4 (95% CI: −3.7 to −1.2), and −1.2 (95% CI: −1.6 to −0.7), respectively. The SNOT-22 and its sleep domain demonstrated a mean posttreatment difference of −23.5 (95% CI: −31.7 to −15.3) and −5.4 (95% CI: −6.8 to −4.0), respectively. EpSS, FSS and SNOT-22 exceeded their respective reported MCID values. Objective findings did not significantly change with treatment; mean difference: AHI: 0.7 (95% CI: −1.5 to 2.9), oxygen nadir: 0.3 (95% CI: −0.4 to 0.9). Conclusions Treatment of CRS may lead to clinically meaningful reduction in disease burden and improvements in both overall sleep quality and patient-reported fatigue. Despite clinically meaningful quality of life improvements, objective sleep parameters did not demonstrate corresponding posttreatment improvements.

scholarly journals Multiparametric Analysis of Factors Associated With Eosinophilic Chronic Rhinosinusitis With Nasal Polyps

2020 ◽  
pp. 014556132096035
Author(s):  
Gian Luca Fadda ◽  
Andrea Galizia ◽  
Giuseppe Galizia ◽  
Paolo Castelnuovo ◽  
Maurizio Bignami ◽  
...  
Keyword(s):  
Chronic Rhinosinusitis ◽  
Nasal Polyps ◽  
Predictive Biomarker ◽  
Blood Eosinophil ◽  
High Power Field ◽  
Diverse Range ◽  
Blood Eosinophilia ◽  
Tissue Eosinophilia ◽  
Eosinophilic Chronic Rhinosinusitis ◽  
Clinical Records

Introduction: Previous studies have reported a diverse range of threshold values for blood eosinophilia. In addition, a single predictive biomarker for eosinophilic chronic rhinosinusitis (CRS) with nasal polyps (ECRSwNP) has not yet been identified. Objectives: The aim of this study is to compare the clinical characteristics of ECRSwNP and non-ECRSwNP to evaluate the preoperative risk of tissue eosinophilia of chronic rhinosinusitis with nasal polyps (CRSwNP) through a multiparametric statistical analysis. Methods: One hundred ten patients with evidence of chronic polypoid rhinosinusitis were included in this study and clinical records were retrospectively reviewed. Eosinophilic CRSwNP was diagnosed based on the presence of at least 10 eosinophils per high-power field. The demographic and clinical features of ECRSwNP and non-ECRSwNP are described. The values of blood eosinophilia as predictors of tissue eosinophilia have been identified using receiver operating characteristic curves. As the predictive value of the identified cutoff through regression analysis was low, we evaluated whether other risk factors could be statistically associated with ECRSwNP, and from this, a new predictive model was proposed for the identification of eosinophilic nasal polyps before surgery. Results: We found that the best method for predicting ECRSwNP is based on a model having asthma, blood eosinophil percentage, posterior ethmoid value in Lund-Mackay score, and modified Lund-Kennedy score as explanatory variables. Conclusions: This study provides new data for a better understanding of the polypoid CRS endotypes, and the proposed model allows the endotype to be identified preoperatively.

How Does Age Impact Presentation and Outcomes in Chronic Rhinosinusitis?

2020 ◽  
Vol 129 (9) ◽  
pp. 872-877
Author(s):  
Thomas Holmes ◽  
Chadi Makary ◽  
Aykut A. Unsal ◽  
Paul Biddinger ◽  
Camilo Reyes-Gelves ◽  
...  
Keyword(s):  
Young Adults ◽  
Elderly Patients ◽  
Chronic Rhinosinusitis ◽  
Statistical Difference ◽  
Prognostic Indicators ◽  
Level Of Evidence ◽  
Tissue Eosinophilia ◽  
Short And Long Term ◽  
Snot 22

Objectives/Hypothesis: The presence of eosinophilia and nasal polyps are well-established prognostic indicators of chronic rhinosinusitis (CRS). The importance of demographic background, such as age, as independent variables has not been elucidated while taking these factors into account. Study Design: Respective review. Methods: CRS patients who underwent primary surgical treatment were subdivided based on age (young adults = age 18-39, adults = age 40-64, and elderly = age 65+). Groups were then subdivided based on tissue eosinophilia and nasal polyposis. Sinonasal Outcome Test (SNOT-22), Lund-Kennedy (LK) endoscopy scores, and Lund-McKay (LM) CT scores were compared preoperatively, and postoperatively during a 5-year period. Results: A total of 431 CRS patients identified and then subsequently broken down into 63 young adults (YA), 209 adults (A), and 159 elderly (E). There was no statistical difference between tissue eosinophilia and presence of polyps between the groups. All three groups had similar short- and long-term SNOT-22 patterns postoperatively. At presentation, young adults had significantly higher SNOT-22 score (33.2 YA, 25.3 A, 23.5 E, P = .029) and significantly higher rhinologic scores (1.9 YA, 1.3 A, 1.3 E, P = .0012) than the adult and elderly patients. Objective disease severity using LK endoscopy scores were only significantly higher in young adults at 1-year time ( P = .0026). There was no statistical difference between the groups in regards to preoperative LM CT scores. Conclusions: Young adults are more likely to present with overall higher subjective SNOT-22 scores over adults and elderly patients, despite similar objective findings in the groups. Short- and long-term postoperative improvement holds across all age groups. Level of Evidence: 4

PHQ-9 and SNOT-22: Elucidating the Prevalence of Depression in Chronic Rhinosinusitis

2019 ◽  
Vol 162 (1) ◽  
pp. 142-147 ◽  
Author(s):  
Laura J. Vandelaar ◽  
Zi Yang Jiang ◽  
Alok Saini ◽  
William C. Yao ◽  
Amber U. Luong ◽  
...  
Keyword(s):  
Chronic Rhinosinusitis ◽  
Retrospective Chart Review ◽  
Clinical Settings ◽  
Prevalence Of Depression ◽  
Patient Health ◽  
History Of ◽  
Sinonasal Outcome Test ◽  
The Impact ◽  
History Of Depression ◽  
Snot 22

Objective Chronic rhinosinusitis (CRS) has been associated with comorbid depression, yet the prevalence of depression among all patients with CRS is not well described. The Patient Health Questionnaire–9 (PHQ-9), a validated instrument for diagnosing depression, has been used to assess depression in a variety of clinical settings. PHQ-9 scores ≥10 are the threshold for a depression diagnosis. The purpose of this study was to assess the prevalence of depression in a rhinology practice and compare the PHQ-9 with the 22-item Sinonasal Outcome Test (SNOT-22). Study Design Retrospective chart review. Setting Tertiary rhinology practice. Subjects and Methods During the 2-month period ending April 30, 2018, all rhinology patients were asked to complete the PHQ-9 and SNOT-22. Results Among 216 patients, 46 (21.3%) had a self-reported history of depression, and 39 (18.1%) had a PHQ-9 score ≥10. Of the 39 patients screening positive for depression, 18 (41.9%) had no history of depression. Comparison of PHQ-9 with overall SNOT-22 score had a Pearson’s coefficient of 0.632 ( P < .005). Logistic regression showed that the highest 2 quintiles of SNOT-22 scores had an odds ratio of 60.6 (95% CI, 9.7-378.3) for a positive depression screen (PHQ-9 score ≥10). Conclusion Depression rates (estimated by PHQ-9 responses) among rhinology patients are similar to chronic disease populations; depression may be underdiagnosed in rhinology patients. Higher SNOT-22 scores were associated with higher PHQ-9 scores. Further studies are warranted to understand the impact of comorbid conditions of depression and CRS in patient quality of life.

scholarly journals The COVID-19 Hospitalization Metric in the Pre- and Post-vaccination Eras as a Measure of Pandemic Severity: A Retrospective, Nationwide Cohort Study

2021 ◽  
Author(s):  
Nathanael Fillmore ◽  
Jennifer La ◽  
Chunlei Zheng ◽  
Shira Doron ◽  
Nhan Do ◽  
...  
Keyword(s):  
Disease Severity ◽  
Severe Disease ◽  
Supplemental Oxygen ◽  
Case Definition ◽  
Vaccination Status ◽  
P Value ◽  
Case Definitions ◽  
Pandemic Severity ◽  
Vaccine Availability ◽  
The Impact

Abstract Importance: Since the early days of the pandemic, COVID-19 hospitalizations have been used as a measure of pandemic severity. However, case definitions do not include assessments of disease severity, which may be impacted by prior vaccination.Objective: To measure how the severity of respiratory disease changed among inpatients with documented SARS-CoV-2 infection and to measure the impact of vaccination status on these trends, in order to evaluate the accuracy of the metric of “hospitalization plus a positive SARS-CoV-2 test” for tracking pandemic severity.Design: Retrospective cohort of inpatients with laboratory-confirmed SARS-CoV-2. All data were obtained from electronic health records.Setting: Multi-center, nationwide study conducted in the healthcare system of the US Department of Veterans Affairs (VA) from March 1, 2020, through June 30, 2021.Participants: All VA patients admitted to a VA hospital with a laboratory-confirmed SARS-CoV-2 infection within the 14-days prior to admission or during the hospital admission.Main Outcome: Moderate-to-severe COVID-19 disease, defined by use of any supplemental oxygen or documented SpO2 <94%, during an inpatient hospitalization between one day before and two weeks after a positive SARS-CoV-2 test.Exposure: SARS-CoV-2 vaccination status at the time of hospitalization. Patients were regarded as fully vaccinated starting 14 days after receiving the second of a 2-dose regimen or 14 days after receipt of a single-dose vaccine.Results: Among 47,742 admissions in 38,508 unique patients with laboratory-confirmed SARS-CoV-2, N=28,731 met the criteria for moderate-to-severe COVID-19. The proportion with moderate-to-severe disease prior to widespread vaccine availability was 64.0% (95% CI, 63.1-64.9%) versus 52.0% in the later period (95% CI, 50.9-53.2%), p-value for non-constant effect, <0.001. Disease severity in the vaccine era among hospitalized patients was lower among both unvaccinated (55.0%, 95% CI, 53.7-56.4%) and vaccinated patients (42.6%, 95% CI, 40.6-44.8%).Conclusions and Relevance: The proportion of hospitalizations that are due to severe COVID-19 has changed with vaccine availability, thus, increasing proportions of mild and asymptomatic cases are included in hospitalization reporting metrics. The addition of simple measures of disease severity to the case definition of a SARS-CoV-2 hospitalization is a straightforward and objective change that should improve the value of the metric for tracking SARS-CoV-2 disease burden.

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