Objectives We investigated the impact of anemia based on admission hemoglobin (Hb) level as a prognostic risk factor for severe outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). Methods A single-center, retrospective cohort study was conducted from a random sample of 733 adult patients (age ≥ 18 years) obtained from a total of 4356 laboratory confirmed SARS-CoV-2 cases who presented to the Emergency Department of Montefiore Medical Center between March–June 2020. The primary outcome was a composite endpoint of in-hospital severe outcomes of COVID-19. A secondary outcome was in-hospital all-cause mortality. Results Among the 733 patients included in our final analysis, 438 patients (59.8%) presented with anemia. 105 patients (14.3%) had mild, and 333 patients (45.5%) had moderate-severe anemia. Overall, 437 patients (59.6%) had a composite endpoint of severe outcomes. On-admission anemia was an independent risk factor for all-cause mortality, (Odds Ratio 1.52, 95% CI [1.01–2.30], p = 0.046) but not for composite severe outcomes. However, moderate-severe anemia (Hb < 11 g/dL) on admission was independently associated with both severe outcomes (OR1.53, 95% CI [1.05–2.23], p = 0.028) and mortality (OR 1.67, 95% CI [1.09–2.56], p = 0.019) during hospitalization. Conclusion Anemia on admission was independently associated with increased odds of all-cause mortality in patients hospitalized with COVID-19. Furthermore, moderate-severe anemia (Hb <11 g/dL) was an independent risk factor for severe COVID-19 outcomes. Moving forward, COVID-19 patient management and risk stratification may benefit from addressing anemia on admission.

Despite similar components, the heterogeneity of skin characteristics across the human body is enormous. It is classically believed that site-specific fibroblasts in the dermis control postnatal skin identity by modulating the behavior of the surface-overlying keratinocytes in the epidermis. To begin testing this hypothesis, we characterized the gene expression differences between volar (ventral; palmoplantar) and nonvolar (dorsal) human skin. We show that KERATIN 9 (KRT9) is the most uniquely enriched transcript in volar skin, consistent with its etiology in genetic diseases of the palms and soles. In addition, ectopic KRT9 expression is selectively activated by volar fibroblasts. However, KRT9 expression occurs in the absence of all fibroblasts, although not to the maximal levels induced by fibroblasts. Through gain-of-function and loss-of-function experiments, we demonstrate that the mechanism is through overlapping paracrine or autocrine canonical WNTeb-catenin signaling in each respective context. Finally, as an in vivo example of ectopic expression of KRT9 independent of volar fibroblasts, we demonstrate that in the human skin disease lichen simplex chronicus, WNT5a and KRT9 are robustly activated outside of volar sites. These results highlight the complexities of site-specific gene expression and its disruption in skin disease. Site-specific epidermal differentiation programs define the heterogeneity of skin identity across the human body. It is generally believed that positional skin identity is regulated by epithelial (keratinocytes) and mesenchymal (fibroblasts) interactions. 1e5 Indeed, three-dimensional skin equivalent models and transplantation experiments show that epidermal stratification during the keratinocyte differentiation program is remarkably disrupted in the absence of fibroblasts, 2,4,5 demonstrating that epidermal development and homeostasis are regulated by extrinsic factors released by fibroblasts. Such interactions have been further clarified through an analysis of the differential localization of epidermal keratins in distinct epidermal layers and body sites. Volar (palmoplantar) skin is characterized by thick epidermal layers, less pigmentation, and lack of hair. In addition to these features, cytoskeleton KERATIN (KRT) 9 6 has been thought to be almost exclusively localized to volar keratinocytes, 1,6e9 indicating that KRT9 can be a unique marker for volar skin. To date, many clinical studies have reported that KRT9 mutations cause epidermolytic palmoplantar keratoderma, characterized by compensatory thickened epidermal layers in the palms and soles. 10 Conditional deletion of Krt9 in a murine model demonstrated that Krt9 is responsible for maintaining mechanical integrity and terminal differentiation of volar skin.

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