Requirement For Invasive Mechanical Ventilation Research Articles

Risk Factors for Pediatric Critical COVID-19: A Systematic Review and Meta-Analysis.

Risk stratification is a cornerstone of the Pediatric Infectious Diseases Society COVID-19 treatment guidance. This systematic review and meta-analysis aimed to define the clinical characteristics and comorbidities associated with critical COVID-19 in children and adolescents. Two independent reviewers screened the literature (Medline and EMBASE) for studies published through August 31, 2023, that reported outcome data on patients aged ≤21 years with COVID-19. Critical disease was defined as an invasive mechanical ventilation requirement, intensive care unit admission, or death. Random effects models were used to estimate pooled odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was explored through subgroup analyses. Among 10,178 articles, 136 studies met the inclusion criteria for review. Data from 70 studies, which collectively examined 172,165 children and adolescents with COVID-19, were pooled for meta-analysis. In previously healthy children, the absolute risk of critical disease from COVID-19 was 4% (95% CI, 1%-10%). Compared with no comorbidities, the pooled OR for critical disease was 3.95 (95% CI, 2.78-5.63) for the presence of one comorbidity and 9.51 (95% CI, 5.62-16.06) for ≥2 comorbidities. Key risk factors included cardiovascular and neurological disorders, chronic pulmonary conditions (excluding asthma), diabetes, obesity, and immunocompromise, all with statistically significant ORs >2.00. While the absolute risk for critical COVID-19 in children and adolescents without underlying health conditions is relatively low, the presence of one or more comorbidities was associated with markedly increased risk. These findings support the importance of risk stratification in tailoring pediatric COVID-19 management.

Malnutrition elevates delirium and ICU stay among critically ill older adult COVID-19 patients.

Malnutrition among intensive care unit (ICU) patients is associated with a higher risk of mortality and prolonged hospitalization. However, the influence of malnutrition on severe outcomes of ICU patients with coronavirus disease 2019 (COVID-19) is unclear. By evaluating the effect of malnutrition on the outcomes of COVID-19 in the ICU in older adult patients, this study will contribute to new knowledge of assessing the nutritional status and recovery of these patients. In the current single center prospective study, 310 critically ill COVID-19 patients with an age range of ≥65 years were recruited. Data on demographic characteristics, laboratory parameters, comorbidities, medications, and types of mechanical ventilation were collected in the first 24 h of ICU admission. Malnutrition was defined based on the two-step approach of the Global Leadership Initiative on Malnutrition (GLIM) scale at baseline. During the 45 days after the baseline, we collected data on delirium incidence, mortality, invasive mechanical ventilation (IMV) requirement, length of ICU and hospital admission, and re-hospitalization. In this study, the prevalence of malnutrition was 63.4% among critically ill COVID-19 patients. During the 45-day follow-up, 190 (61.3%) COVID-19 deaths were recorded among the baseline 310 patients. After controlling for potential confounders, malnutrition was associated with an increased risk of delirium so malnourished COVID-19 patients had a significantly 35% higher risk of delirium than those without malnutrition (HR: 1.35, 95% CI: 1.01-1.83). Such a significant association was not for COVID-19 mortality and IMV requirement. In addition, malnutrition was associated with a significantly 84% greater odds of prolonged ICU admission (OR: 1.84, 95% CI: 1.09-3.10). No significant association was seen between malnutrition and re-hospitalization and also prolonged hospital admission. Malnutrition was associated with an increased risk of delirium and prolonged ICU admission among critically ill older adult COVID-19 patients. Prevention, diagnosis, and treatment of malnutrition could be a key component in improving outcomes in these patients.

A randomised clinical trial of awake prone positioning in COVID-19 suspects with acute hypoxemic respiratory failure

BackgroundAwake prone position (APP) has been reported to improve oxygenation in patients with COVID-19 disease and to reduce the requirement for invasive mechanical ventilation for patients requiring support with high flow nasal cannula. There is conflicting data for patients requiring lower-level oxygen support. Research questionDoes APP reduce escalation of oxygen support in COVID-19 patients requiring supplementary oxygen?The primary outcome was defined as an escalation of oxygen support from simple supplementary oxygen (NP, HM, NRB) to NIV (CPAP or BiPAP), HFNC or IMV; OR from NIV (CPAP or BiPAP) or HFNC to IMV by day30. Study designTwo center, prospective, non-blind, randomised controlled trial. Patients with confirmed or suspected COVID-19 pneumonia requiring ≥ 5 liters/min oxygen to maintain saturations ≥ 94 % were randomised to either APP or control group. The APP group received a 3-h APP session three times per day for three days. ResultsBetween 9 May and July 13, 2021, 89 adults were screened and 61 enrolled, 31 to awake prone position and 30 controls. There was no difference in the primary outcome, 7 (22.6 %) patients randomised to APP and 9 (30.0 %) controls required escalation of oxygen support (OR 0.68 (0.22–2.14), P = 0.51). There were no differences in any secondary outcomes, in APP did not improve oxygenation. InterpretationIn COVID-19 patients, the use of APP did not prevent escalation of oxygen support from supplementary to invasive or non-invasive ventilation or improve patient respiratory physiology. Trial registrationNCT04853979 (clinicaltrials.gov).

Factors Associated With Failure of Non-invasive Ventilation in Preterm Neonates Requiring Initial Respiratory Support.

Non-invasive ventilation (NIV) modalities minimize the requirement for invasive mechanical ventilation (IMV) in preterm neonates, therefore improving neonatal outcomes, as IMV is linked to increased complications. However, NIV has demonstrated an elevated likelihood of failure, for which various studies have been done, but very little research is available addressing the factors that are responsible for NIV failure in resource-limited areas of developing nations. Understanding the underlying factors and their association with NIV failure in very and moderately preterm neonates at a tertiary care hospital would be important in devising targeted strategies to increase NIV success and newborn outcomes. To compare the following factors in neonates of 28-34 weeks gestational age with or without failure of NIV: fraction of inspired oxygen (FiO2) at the time of initiating NIV, time at surfactant administration, respiratory distress syndrome presence, antenatal steroid use, time taken for post-surfactant administration stabilization, gestational age, development of bronchopulmonary dysplasia, and average weight gained or lost. This was a longitudinal observational study. One hundred two preterm neonates with a gestational age of 28-34 weeks in the neonatal intensive care unit (NICU) requiring NIV support within 24 hours of admission. Eligible newborns were re-evaluated at 72 hours after commencing NIV. Outcome was evaluated as success (no NIV or NIV with positive end-expiratory pressure (PEEP)<8 cm H2O and FiO2<0.7) or failure (NIV with PEEP≥8 cm H2O or FiO2≥0.7,intubation, or death). It was compared with regard to many parameters. About 40 (39%) study participants reported NIV failure within 72 hours of initiating NIV. In the NIV failure group, male babies constituted 75% (P = 0.027), the median gestational age (IQR) was 29 (29-31) weeks (P = 0.015), the median birth weight (IQR) was 1088 (960-1293.5) grams (P = 0.003), and the median weight gain or loss (IQR) was a loss of 21 (-70.5 to 11.75) grams (P<0.001). Vaginal birth comprised 67.5% of the NIV failure group, showing greater failure rates than births out of lower segment cesarean section (LSCS) (P = 0.003) Conclusion: NIV failure showed a significant association with lesser gestational age, male sex, lowerbirth weight, vaginal method of delivery, and lesserweight gain during hospital stay.

Performance of oxygenation indices and risk scores to predict invasive mechanical ventilation and mortality in COVID-19

BackgroundInformation on the performance of oxygenation indices (OIs) and risk scores in patients requiring invasive mechanical ventilation (IMV) is limited. We determine the performance of the OIs and risk scores in hospitalized patients with COVID-19 to predict the requirement of IMV and death at 28 days after admission.MethodsA retrospective study of diagnostic tests in patients admitted to the emergency department, hospitalization, and intensive care unit diagnosed with COVID-19. The receiver operating characteristic curve (ROC-curve) were built with the OIs and risk scores to predict IMV and mortality.ResultsA total of 1402 subjects entered the final analysis, of whom 19.5% (274/1402) received IMV and 23.0% (323/1402) died at 28 days. The ROC-curve of the delta PaO2/FiO2 ratio for the requirement of IMV and mortality at 28-day was 0.589 (95% CI: 0.546–0.632) and 0.567 (95% CI: 0.526–0.608), respectively. PaO2/FiO2 ≤ 300 shows a ROC curve of 0.669 (95% CI: 0.628–0.711) to predict IMV. PaO2/FiO2 ≤ 300 and 4 C mortality score in mortality at 28 days showed an ROC-curve of 0.624 (95% CI: 0.582–0.667) and 0.706 (95% CI: 0.669–0.742), respectively.ConclusionPaO2/FiO2 ≤ 300, 4 C mortality score ≥ 8, SOFA score ≥ 4 y SaO2/FiO2 ≤ 300 were weak predictors of the IMV requirement from admission, and 4 C mortality score ≥ 8 was weak predictors of the mortality from admission in patients with pulmonary involvement by COVID-19.

Factors associated with mortality among hospitalized patients with COVID-19 disease treated with convalescent plasma.

The use of convalescent plasma (CP) for hospitalized patients with SARS-CoV-2 infection might be a useful option in certain settings. Soon after the outbreak of COVID-19, the National Ministry of Health of Argentina recommended the use of CP transfusion for hospitalized patients with COVID-19 disease. Between 1 June and 3 October 2020, 480 patients, excluding those on invasive mechanical ventilation (IMV), received at least one CP infusion in the province of Santa Fe. We aimed to find factors associated with mortality among this cohort of patients. The median age was 60 years (interquartile range: 49-69 years) and 320 (66.7%) were males. Most of these patients (93.75%) received a single CP infusion, 82.1% and 95.6% before day 4 and day 7 of hospitalization, respectively. Anti-SARS-CoV-2 titers were determined in the CP units administered using Elecsys Anti-SARS-CoV-2 S assay. At 28 days of follow-up, 250 patients were discharged (52.1%), 131 (27.3%) remained hospitalized without and 16 (3.3%) with oxygen requirement, 27 (5.6%) were on IMV, and 56 (11.7%) had died. In the multivariate logistic regression analysis, the factors significantly associated with 28-day mortality were (i) requirement of IMV, (ii) the administration of CP after the third day of hospitalization, (iii) age, and (iv) number of comorbidities. The qualitative and quantitative analyses of antibodies against SARS-CoV-2 in the infused CP were not associated with mortality. Our findings may imply a seemingly favorable effect of CP administration among patients with severe COVID-19 disease when infused sooner after hospitalization.IMPORTANCEThe use of convalescent plasma (CP) could be an option for patients with severe COVID-19, especially in poor-resource countries where direct antiviral drugs are not commercially available. Currently, the U.S. Food and Drug Administration limits the CP administration for outpatients and inpatients with COVID-19 who are immunocompromised and only if high levels of anti-SARS-CoV-2 antibodies are confirmed in the CP unit. Although most of the randomized clinical trials failed to show a clear-cut benefit of CP in hospitalized patients with severe COVID-19, other studies have shown that if given early in the course of the disease, it might be a useful therapeutic option. In this retrospective study, we demonstrated that early treatment (within 3 days of hospitalization) was significantly associated with reduced 28-day mortality compared with those patients treated beyond day 3. The results from our study add up to the scientific evidence on the use of CP as a relatively safe, cheap, and possibly effective therapy in certain patients suffering from severe SARS-CoV-2 infection.

Latin-American Registry of Cardiovascular Disease and COVID-19: Final Results.

Socioeconomic factors contribute to a more severe impact of COVID-19 in Latin American and Caribbean (LA&C) countries than in developed countries. Patients with a severe or critical illness can develop respiratory and cardiovascular complications. To describe a LA&C population with COVID-19 to provide information related to this disease, in-hospital cardiovascular complications, and in-hospital mortality. The CARDIO COVID-19-20 Registry is an observational, multicenter, prospective, and hospital-based registry of patients with confirmed COVID-19 infection that required in-hospital treatment in LA&C. Enrollment of patients started on May 01, 2020, and ended on June 30, 2021. The CARDIO COVID-19-20 Registry included 3260 patients from 44 institutions of 14 LA&C countries. 63.2% patients were male and median age was 61.0 years old. Most common comorbidities were overweight/obesity (49.7%), hypertension (49.0%), and diabetes mellitus (26.7%). Most frequent cardiovascular complications during hospitalization or reported at discharge were cardiac arrhythmia (9.1%), decompensated heart failure (8.5%), and pulmonary embolism (3.9%). The number of patients admitted to the Intensive Care Unit (ICU) was 1745 (53.5%), and median length of their stay at the ICU was 10.0 days. Support required in ICU included invasive mechanical ventilation (34.2%), vasopressors (27.6%), inotropics (10.3%), and vasodilators (3.7%). Rehospitalization after 30-day post discharge was 7.3%. In-hospital mortality and 30-day post discharge were 25.5% and 2.6%, respectively. According to our findings, more than half of the LA&C population with COVID-19 assessed required management in ICU, with higher requirement of invasive mechanical ventilation and vasoactive support, resulting in a high in-hospital mortality and a considerable high 30-day post discharge rehospitalization and mortality.

Association of Immune Semaphorins with COVID-19 Severity and Outcomes.

Semaphorins have recently been recognized as crucial modulators of immune responses. In the pathogenesis of COVID-19, the activation of immune responses is the key factor in the development of severe disease. This study aimed to determine the association of serum semaphorin concentrations with COVID-19 severity and outcomes. Serum semaphorin concentrations (SEMA3A, -3C, -3F, -4D, -7A) were measured in 80 hospitalized adult patients with COVID-19 (moderate (n = 24), severe (n = 32), critical, (n = 24)) and 40 healthy controls. While SEMA3C, SEMA3F and SEMA7A serum concentrations were significantly higher in patients with COVID-19, SEMA3A was significantly lower. Furthermore, SEMA3A and SEMA3C decreased with COVID-19 severity, while SEMA3F and SEMA7A increased. SEMA4D showed no correlation with disease severity. Serum semaphorin levels show better predictive values than CRP, IL-6 and LDH for differentiating critical from moderate/severe COVID-19. SEMA3F and SEMA7A serum concentrations were associated with the time to recovery, requirement of invasive mechanical ventilation, development of pulmonary thrombosis and nosocomial infections, as well as with in-hospital mortality. In conclusion, we provide the first evidence that SEMA3A, SEMA3C, SEMA3F and SEMA7A can be considered as new biomarkers of COVID-19 severity.

Impact of vaccination in the mortality of Colombian adults with acute respiratory distress syndrome due to SARS-CoV-2 who required invasive mechanical ventilation

IntroductionVaccination for SARS-CoV-2 made it possible to reduce severe cases that require invasive mechanical ventilation (IMV) and care in the ICU. However, its impact on severe disease is not clear. The objective was to assess whether adults with severe SARS-CoV-2 pneumonia who required mechanical ventilation had a different clinical behaviour in terms of mortality, depending on their vaccination status. MethodologyRetrospective cohort study, in adults with severe pneumonia due to SARS-CoV-2 requiring IMV and ICU. Clinical outcomes were evaluated according to vaccination status, controlling for comorbidities. ResultsTwo hundred patients (24% vaccinated, age 61±13 years, men 68%) were analysed. The vaccinated had lower CRP at admission, distension pressure and PEEP requirement for IMV. Mortality (43.8 vs 36.8%, P: .335), hospital stay, ICU stay, and time on IMV were similar between groups. Acute kidney injury and haemodialysis requirement (0 vs 9.2%, P: .03) were more frequent in the unvaccinated. There was no association between mortality and receiving at least one dose of vaccination (RR 1.21; CI 95% 0.829–1.774, P: .335). ConclusionsVaccination did not impact mortality. However, our data suggest that it may reduce the inflammatory state produced by the disease and the occurrence of acute kidney injury and the requirement for haemodialysis. Future studies will be required to assess the impact of the type of vaccine and/or the number of doses received.

Impacto de la vacunación en la mortalidad de adultos colombianos con síndrome de dificultad respiratoria aguda por SARS-CoV-2 que requirieron ventilación mecánica invasiva

IntroductionVaccination for SARS-CoV-2 made it possible to reduce severe cases that require invasive mechanical ventilation (IMV) and care in the ICU. However, its impact on severe disease is not clear. The objective was to assess whether adults with severe SARS-CoV-2 pneumonia who required mechanical ventilation had a different clinical behavior in terms of mortality, depending on their vaccination status. MethodologyRetrospective cohort study, in adults with severe pneumonia due to SARS-CoV-2 requiring IMV and ICU. Clinical outcomes were evaluated according to vaccination status, controlling for comorbidities. ResultsTwo hundred patients (24% vaccinated, age 61 ± 13 years, men 68%) were analyzed. The vaccinated had lower CRP at admission, distension pressure and PEEP requirement for IMV. Mortality (43.8 vs 36.8%, p: 0.335), hospital stay, ICU stay, and time on IMV were similar between groups. Acute kidney injury and hemodialysis requirement (0 vs 9.2%, p: 0.03) were more frequent in the unvaccinated. There was no association between mortality and receiving at least one dose of vaccination (RR 1.21; CI 95% 0.829–1.774, p: 0.335). ConclusionsVaccination did not impact mortality. However, our data suggest that it may reduce the inflammatory state produced by the disease and the occurrence of acute kidney injury and the requirement for hemodialysis. Future studies will be required to assess the impact of the type of vaccine and/or the number of doses received.

Yoğun bakım ünitesinde lenfoma tanısı ile takip edilen hastalarda sağkalımı etkileyen faktörler

Purpose: This retrospective analysis aimed to elucidate the key factors influencing survival outcomes in patients diagnosed with lymphoma and admitted to an Intensive Care Unit (ICU). &#x0D; Materials and Methods: The study cohort comprised individuals aged 18 or older diagnosed with lymphoma and admitted to the ICU between November 2015 and February 2023. Data were collected on patients' demographic characteristics, primary hematological diagnoses, reasons for ICU admission, laboratory parameters, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, Sequential Organ Failure Assessment (SOFA) scores, clinical trajectory, and 28-day mortality rates. Patients were stratified into two categories based on their mortality outcomes: Survivors and non-survivors.&#x0D; Results: A total of 165 patients were included in the study, with a mean age of 52.41 ± 17.99 years; 63% were male. Table 1 summarizes the demographic characteristics, clinical trajectories, and 28-day mortality rates. The APACHE II and SOFA scores of the patients were 34 (7–53) and 12 (10–14), respectively. The predominant reasons for ICU admission were sepsis (58.2%) and acute respiratory failure (57.6%). Vasopressor necessity prior to and during ICU stay was 23.6% and 92.4%, respectively. During ICU monitoring, thrombocytopenia, and acute kidney injury (AKI) were observed in 77.6% and 66.4% of patients, respectively; 10% required renal replacement therapy. The 28-day mortality rate was 84.8%. Kaplan-Meier analysis revealed that patients with a SOFA score ≥ 9 had a significantly reduced survival time of 4.5 ± 0.4 days compared to those with lower SOFA scores (14.3 ± 2.6 days). Patients with AKI and those requiring invasive mechanical ventilation (IMV) exhibited reduced survival times of 4.7 ± 0.5 days and 5.6 ± 0.5 days, respectively. Elevated SOFA scores (HR 2.355, 95% CI 1.485–3.734), presence of AKI (HR 1.511, 95% CI 1.055–2.163), and the need for IMV (HR 5.721, 95% CI 1.377–23.770) were significantly correlated with increased 28-day mortality. Receiver Operating Characteristic (ROC) curve analysis identified the optimal SOFA cut-off point for predicting 28-day mortality as nine, with an Area Under the Curve (AUC) of 0.897, sensitivity 83.6% and specificity 92%.&#x0D; Conclusions: The findings of this study underscore the elevated mortality rates among lymphoma patients admitted to the ICU. Our data suggest that several factors serve as significant predictors of 28-day mortality in this patient population. Specifically, elevated APACHE II scores, SOFA scores, the presence of AKI, and the requirement for IMV emerged as crucial indicators associated with adverse survival outcomes. Consequently, these factors warrant meticulous monitoring and could inform targeted interventions to improve survival rates among lymphoma patients in critical care settings.

Mortality Risk Factors in Pediatric Onco-Critical Care Patients and Machine Learning Derived Early Onco-Critical Care Phenotypes in a Retrospective Cohort.

To use supervised and unsupervised statistical methodology to determine risk factors associated with mortality in critically ill pediatric oncology patients to identify patient phenotypes of interest for future prospective study. This retrospective cohort study included nonsurgical pediatric critical care admissions from January 2017 to December 2018. We determined the prevalence of multiple organ failure (MOF), ICU mortality, and associated factors. Consensus k-means clustering analysis was performed using 35 bedside admission variables for early, onco-critical care phenotype development. Single critical care unit in a subspeciality pediatric hospital. None. There were 364 critical care admissions in 324 patients with underlying malignancy, hematopoietic cell transplant, or immunodeficiency reviewed. Prevalence of multiple organ failure, ICU mortality, determination of early onco-critical care phenotypes. ICU mortality was 5.2% and was increased in those with MOF (18.4% MOF, 1.7% single organ failure [SOF], 0.6% no organ failure; p ≤ 0.0001). Prevalence of MOF was 23.9%. Significantly increased ICU mortality risk was associated with day 1 MOF (hazards ratio [HR] 2.27; 95% CI, 1.10-6.82; p = 0.03), MOF during ICU admission (HR 4.16; 95% CI, 1.09-15.86; p = 0.037), and with invasive mechanical ventilation requirement (IMV; HR 5.12; 95% CI, 1.31-19.94; p = 0.018). Four phenotypes were derived (PedOnc1-4). PedOnc1 and 2 represented patient groups with low mortality and SOF. PedOnc3 was enriched in patients with sepsis and MOF with mortality associated with liver and renal dysfunction. PedOnc4 had the highest frequency of ICU mortality and MOF characterized by acute respiratory failure requiring invasive mechanical ventilation at admission with neurologic dysfunction and/or severe sepsis. Notably, most of the mortality in PedOnc4 was early (i.e., within 72 hr of ICU admission). Mortality was lower than previously reported in critically ill pediatric oncology patients and was associated with MOF and IMV. These findings were further validated and expanded by the four derived nonsynonymous computable phenotypes. Of particular interest for future prospective validation and correlative biological study was the PedOnc4 phenotype, which was composed of patients with hypoxic respiratory failure requiring IMV with sepsis and/or neurologic dysfunction at ICU admission.

Prognostic Markers in COVID-19 Patients in Intensive Care: Can Hemostatic Parameters Predict Mortality?

Objective: Our study aimed to investigate whether primarily hemostasis parameters and secondarily demographic, clinical, and laboratory values could predict the mortality of critically ill Coronavirus Disease 2019 (COVID-19) patients. Methods: We retrospectively examined 180 laboratory-confirmed adult intensive care unit (ICU) patients with COVID-19. A total of 145 patients with complete records were included in the study. The patients were divided into two groups: deceased (n=58) and discharged (n=87). The demographic and clinical characteristics of the two groups, use of vasopressor therapy, requirement for invasive mechanical ventilation (IMV), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, duration of ICU stay, and the relationship between laboratory values on ICU admission and mortality were evaluated using cutoff values. Results: Among hemostatic parameters, only D-dimer&gt;1.08 mg L-1 was found to be a significant predictor of mortality (p=0.04), while platelet, prothrombin time (PT), activated partial thromboplastin time (aPTT), International Normalized Ratio (INR) and fibrinogen values were not significantly associated with mortality (p&gt;0.05). In addition, age &gt;76 years, hypertension (HT), need for IMV, APACHE II score &gt;23, procalcitonin (PCT) &gt;0.21 μg L-1, lymphocytes &lt;0.4 109 L-1, interleukin 6 (IL-6) &gt;93 pg mL-1 were found to be predictors of mortality (p&lt;0.05). Neutrophil and C-reactive protein (CRP) values were not significantly associated with mortality (p&gt;0.05). ABSTRACT Conclusion: Our study determined that advanced age, HT, high APACHE II score, requirement for IMV, vasopressor therapy, PCT, lymphocyte count, IL-6, and D-dimer levels could serve as predictors of mortality. Identifying predictors of mortality in COVID-19 is valuable for early recognition of disease progression and management of potential complications. Keywords: COVID-19, mortality, hemostasis, clinical markers, laboratory markers

Clinical decision thresholds for surfactant administration in preterm infants: a systematic review and network meta-analysis

The ideal threshold at which surfactant administration in preterm neonates with respiratory distress syndrome (RDS) is most beneficial is contentious. The aim of this systematic review was to determine the optimal clinical criteria to guide surfactant administration in preterm neonates with RDS. The systematic review was registered in PROSPERO (CRD42022309433). Medline, Embase, CENTRAL and CINAHL were searched from inception till 16th May 2023. Only randomized controlled trials (RCTs) were included. A Bayesian random effects network meta-analysis (NMA) evaluating 33 interventions was performed. The primary outcome was requirement of invasive mechanical ventilation (IMV) within 7 days of life. 58 RCTs were included. In preterm neonates ≤30 weeks after adjusting for the confounding factor of modality of surfactant administration, an arterial alveolar oxygen tension ratio (aAO2)<0.36 (FiO2: 37-55%) was ranked the best threshold for decreasing the risk of IMV, very low certainty. Further, surfactant administration at an FiO2 40-45% possibly decreased mortality compared to rescue treatment when respiratory failure was diagnosed, certainty very low. The reasonable inference that could be drawn from these findings is that surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS requiring an FiO2 ≥ 40%. There was insufficient evidence for the comparison of FiO2 thresholds: 30% vs. 40%. The evidence was sparse for surfactant administration guided by lung ultrasound. For the sub-group >30 weeks, nebulized surfactant administration at an FiO2 < 30% possibly increased the risk of IMV compared to Intubate-Surfactant-Extubate at FiO2 < 30% and 40%, and less invasive surfactant administration at FiO2 40%, certainty very low. Surfactant administration may be considered in preterm neonates of ≤30 weeks' with RDS if the FiO2 requirement is≥40%. Future trials are required comparing lower FiO2 thresholds of 30% vs. 40% and that guided by lung ultrasound. None.

Clinical and Microbiological Outcomes and Follow-Up of Secondary Bacterial and Fungal Infections among Critically Ill COVID-19 Adult Patients Treated with and without Immunomodulation: A Prospective Cohort Study.

Nearly 10% of COVID-19 cases will require admission to the intensive care unit (ICU). Our aim was to assess the clinical and microbiological outcomes of secondary infections among critically ill COVID-19 adult patients treated with/without immunomodulation. A prospective observational cohort study was performed between 2020 and 2022 at a single ICU. The diagnosis and severity classification were established by the ECDC and WHO criteria, respectively. Eligible patients were included consecutively at admission, and followed for +30 days post-inclusion. Bloodstream-infections (BSIs), ventilator-associated bacterial pneumonia (VAP), and COVID-19-associated invasive pulmonary aspergillosis (CAPA) were defined according to international guidelines. Patient stratification was performed by immunomodulatory therapy administration (dexamethasone, tocilizumab, baricitinib/ruxolitinib). The primary outcome was any microbiologically confirmed major infectious complication, secondary outcomes were invasive mechanical ventilation (IMV) requirement and all-cause mortality. Altogether, 379 adults were included. At baseline, 249/379 (65.7%) required IMV and 196/379 (51.7%) had a cytokine storm. At +30 days post-inclusion, the rate of any microbiologically confirmed major infectious complication was 151/379 (39.8%), IMV requirement and all-cause mortality were 303/379 (79.9%) and 203/379 (53.6%), respectively. There were no statistically significant outcome differences after stratification. BSI, VAP, and CAPA episodes were mostly caused by Enterococcus faecalis (27/124, 22.1%), Pseudomonas aeruginosa (26/91, 28.6%), and Aspergillus fumigatus (20/20, 100%), respectively. Concerning the primary outcome, Kaplan-Meier analysis showed similar probability distributions between the treatment subgroups (118/299, 39.5% vs. 33/80, 41.3%, log-rank p = 0.22), and immunomodulation was not retained as its independent predictor in multivariate logistic regression. Secondary infections among critically ill COVID-19 adult patients represent a relevant burden, probably irrespective of immunomodulatory treatment.

Impacts of pregnancy and menopause on COVID-19 severity: A systematic review and meta-analysis of 4.6 million women.

COVID-19 pandemic is still a public health emergency of international concern. However, whether pregnancy and menopause impact the severity of COVID-19 remain unclear. This study is performed to investigate the truth. Study appraisal and Synthesis follows PRISMA guideline. Meta-analysis is performed in random-effects model. PubMed, Embase, Cochrane database, Central, CINAHL, ClinicalTrials.gov, WHO COVID-19 database, and WHO-ICTRP are searched until March 28 2023. In total, 57 studies (4,640,275 COVID-19 women) were analyzed. Pregnant women were at a lower risk of severe COVID-19, intensive care unit (ICU) admission and disease mortality compared to those nonpregnant women with comparable comorbidities. In contrast, pregnant women with more prepregnancy comorbidities were at a higher risk of severe COVID-19, ICU admission and invasive mechanical ventilation (IMV). In addition, pregnant women with pregnancy complications had a significantly increased risk of severe COVID-19 and ICU admission. Menopause increased COVID-19 severity, IMV requirement and disease mortality. Hormone replacement therapy (HRT) inhibited COVID-19 severity in postmenopausal women. Premenopausal and postmenopausal women had a lower chance of severe illness than age-matched men. The impact of pregnancy on COVID-19 severity was significant in Americans and Caucasians, while the effect of menopause on COVID-19 severity was only significant in Chinese. Pregnancy and menopause are protective and risk factors for severe COVID-19, respectively. The protective role of pregnancy on COVID-19 is minimal and could be counteracted or masked by prepregnancy or pregnancy comorbidities. The administration of estrogen and progesterone may prevent severe COVID-19.

Effectiveness of tocilizumab in non-intubated cases with COVID-19: a systematic review and meta-analysis.

Tocilizumab, a monoclonal IL-6 receptor blocker, is an effective agent for severe-to-critical cases of COVID-19; however, its target patients for the optimum use need to be detailed. We performed a systematic review and meta-analysis to define its effect among severely ill but non-intubated cases with COVID-19. We searched PubMed, Scopus, Web of Science, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Medrxiv, and Biorxiv until February 13, 2022, for non-intubated cases, and included randomized-controlled trials (RCT) based on bias assessment. The primary outcomes were the requirement of invasive mechanical ventilation and mortality. Random effect and fixed-effect models were used. The heterogeneity was measured using the χ2 and I2 statistics, with χ2 p ≤ 0.05 and I2 ≥ 50% indicating the presence of significant heterogeneity. We registered the study to the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42021232575. Among 261 articles, 11 RCTs were included. The pooled analysis of the 11 RCTs demonstrated that the rate of mortality was significantly lower in the tocilizumab group than in the control group (20.0% and 24.2%, OR: 0.84, 95% CI 0.73-0.96, and heterogeneity I2 = 0%. p = 0.82.). The mechanical ventilation rate was lower in the tocilizumab group than the control group (27% vs 35.2%, OR: 0.76, 95% CI 0.67-0.86, and heterogeneity I2 = 6%. p = 0.39). Among non-intubated severe COVID-19 cases, tocilizumab reduces the risk of invasive mechanical ventilation and mortality compared to standard-of-care treatment.

Utility of the Brixia CXR score, C-Reactive Protein and Absolute Neutrophil Count in Predicting the Need for Invasive Mechanical Ventilation, Length of Hospital Stay, and Mortality in Moderate to Severe COVID-19 Patients

Background: The Brixia Chest X-ray (CXR) score, C-reactive protein (CRP), and the absolute neutrophil count (ANC) have been useful to predict outcomes in Coronavirus disease 2019 (COVID-19 patients). We studied the utility of the Brixia CXR score, CRP, and ANC in predicting the outcomes in terms of the need for invasive mechanical ventilation, length of stay, and mortality in moderatesevere COVID-19 patients. Materials and Methods: This was a single-centre, retrospective, study on 122 COVID -19 patients. Brixia CXR score, CRP, and ANC on admission to the hospital and the fifth day of hospital stay were noted along with the need for invasive mechanical ventilation (IMV), prolonged length of stay (LOS) ≥ 14 days, and mortality. Results: 122 patients were included for analysis. The median and interquartile range (IQR) for baseline CRP was 81.50 (39 -151) mg/L and 11.0 (4-30) mg/L (p &lt; 0.001) on the fifth day. The median and IQR for baseline Brixia score was 10.0 (7-13), and on the fifth day was 7 (4-11) (p &lt;0.001). The receiver operating characteristic curve (ROC) showed that the baseline CRP ≥ 52.5mg/L predicted both the need for IMV, with an area under the curve (AUC) of 0.628, and prolonged LOS with an AUC of 0.608. The ROC curve depicted that the baseline ANC &gt;8500/μL predicted IMV requirement with an AUC of 0.657. The fifth day CRP ≥ 32 mg/L, ANC ≥ 11,000/ μL and Brixia CXR score ≥ 7 predicted a higher mortality in hospitalized patients. Conclusion: Baseline CRP (&gt; 52.5mg/L) predicts the need for IMV and a prolonged LOS, but not mortality. Baseline ANC (&gt; 8500/μL) predicted the need for IMV. CRP, Brixia CXR score, and ANC on the fifth day were not useful to predict LOS or mortality, though there was a significant reduction in CRP and Brixia CXR score on the fifth day compared to baseline after treatment. The fifth day CRP ≥ 32 mg/L, ANC ≥ 11,000/ μL and Brixia CXR score ≥ 7 predicted a higher mortality.

Body mass index and its association with COVID-19 clinico-neurological outcomes: Findings from the Philippine CORONA study (P5-10.005)

<h3>Objective:</h3> To explore the association between body mass index (BMI) and clinico-neurological outcomes in a large cohort of patients with coronavirus disease 2019 (COVID-19). <h3>Background:</h3> We hypothesize that either abnormally low or high BMI significantly affects clinical and neurologic outcome measures in this subset of patients. <h3>Design/Methods:</h3> This is a secondary analysis of a 37-site, nationwide, multicenter, retrospective cohort study that investigated the clinical and neurological outcomes of adult patients with confirmed COVID-19 admitted from February to December 15, 2020. <h3>Results:</h3> We analyzed 4,463 patients with BMI and outcome data. A total of 790 (17.7%) and 710 (15.9%) had the primary outcome of in-hospital mortality and need for invasive mechanical ventilation (IMV), respectively. There was no significant association between WHO BMI groups and these outcomes. Using Asia-Pacific cutoffs showed a significant association between obesity and in-hospital mortality risk (P = 0.012). Being underweight was an independent predictor of prolonged IMV requirement regardless of BMI criteria used (P &lt; 0.01). Obesity correlated with the need for intensive care unit admission using Asia-Pacific cutoffs (P = 0.029). There was a significant association between any BMI abnormality and odds of severe/critical COVID-19 (P &lt; 0.05). Obese patients with concomitant acute neurological presentation/diagnosis during their COVID-19 admission were shown to have lower odds of neurologic recovery (P &lt; 0.05). <h3>Conclusions:</h3> We found BMI abnormalities to be associated with several adverse clinical and neurologic outcomes, although such associations may be more evident with the use of race-specific BMI criteria. <b>Disclosure:</b> Dr. Espiritu has nothing to disclose. Dr. Reyes has nothing to disclose. Carl Froilan Leochico has nothing to disclose. Marie Charmaine Sy has nothing to disclose. Emilio Villanueva III has received personal compensation in the range of $500-$4,999 for serving as a Consultant for LabX Corporation. Michelle Anlacan has received personal compensation in the range of $0-$499 for serving as a Consultant for Torrent Philippines. Michelle Anlacan has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Medichem Philippines. Michelle Anlacan has received personal compensation in the range of $500-$4,999 for serving on a Speakers Bureau for Hi Eisai Philippines. Michelle Anlacan has received personal compensation in the range of $0-$499 for serving on a Speakers Bureau for Natrapharm Philippines. Michelle Anlacan has received personal compensation in the range of $0-$499 for serving as an officer or member of the Board of Directors for Alzheimer’s disease association of the philippines. Michelle Anlacan has received research support from Philippine Council for Health Research and Development. Michelle Anlacan has received research support from Philippine Neurological Association. Roland Dominic Jamora has received personal compensation in the range of $500-$4,999 for serving as a Consultant for torrent. Roland Dominic Jamora has received research support from CCXDP.

The ACE rs1799752 Variant Is Associated with COVID-19 Severity but Is Independent of Serum ACE Activity in Hospitalized and Recovered Patients.

This paper assesses the association of the insertion/deletion ACE (angiotensin-converting enzyme) variant (rs1799752 I/D) and the serum ACE activity with the severity of COVID-19 as well as its impact on post-COVID-19, and we compare these associations with those for patients with non-COVID-19 respiratory disorders. We studied 1252 patients with COVID-19, 104 subjects recovered from COVID-19, and 74 patients hospitalized with a respiratory disease different from COVID-19. The rs1799752 ACE variant was assessed using TaqMan® Assays. The serum ACE activity was determined using a colorimetric assay. The DD genotype was related to risk for invasive mechanical ventilation (IMV) requirement as an indicator of COVID-19 severity when compared to the frequencies of II + ID genotypes (p = 0.025, OR = 1.428, 95% CI = 1.046-1.949). In addition, this genotype was significantly higher in COVID-19 and post-COVID-19 groups than in the non-COVID-19 subjects. The serum ACE activity levels were lower in the COVID-19 group (22.30 U/L (13.84-32.23 U/L)), which was followed by the non-COVID-19 (27.94 U/L (20.32-53.36 U/L)) and post-COVID-19 subjects (50.00 U/L (42.16-62.25 U/L)). The DD genotype of the rs1799752 ACE variant was associated with the IMV requirement in patients with COVID-19, and low serum ACE activity levels could be related to patients with severe disease.