Mechanical Ventilatory Support Research Articles

Risk factors for acute kidney injury in patients hospitalized with COVID-19.

Acute kidney injury (AKI) occurs frequently in COVID-19 patients and is associated with greater morbidity and mortality. Knowing the risks of AKI allows for identification, prevention, and timely treatment. This study aimed to identify the risk factors associated with AKI in hospitalized patients. A descriptive, retrospective, cross-sectional, and analytical component study of adult patients hospitalized with COVID-19 from March 1 to December 31, 2020 was carried out. AKI was defined by the creatinine criteria of the KDIGO-AKI guidelines. Information, regarding risk factors, was obtained from electronic medical records. Out of the 934 patients, 42.93% developed AKI, 60.59% KDIGO-1, and 9.9% required renal replacement therapy. Patients with AKI had longer hospital stay, higher mortality, and required more intensive care unit (ICU) admission, mechanical ventilation, and vasopressor support. Multivariate analysis showed that age (OR 1.03; 95% CI 1.02-1.04), male sex (OR 2.13; 95% CI 1.49-3.04), diabetes mellitus (DM) (OR 1.55; 95% CI 1.04-2.32), chronic kidney disease (CKD) (OR 2.07; 95% CI 1.06-4.04), C-reactive protein (CRP) (OR 1.02; 95% CI 1.00-1.03), ICU admission (OR 1.81; 95% CI 1.04-3.16), and vasopressor support (OR 7.46; 95% CI 3.34-16.64) were risk factors for AKI, and that bicarbonate (OR 0.89; 95% CI 0.84-0.94) and partial pressure arterial oxygen/inspired oxygen fraction index (OR 0.99; 95% CI 0.98-0.99) could be protective factors. A high frequency of AKI was documented in COVID-19 patients, with several predictors: age, male sex, DM, CKD, CRP, ICU admission, and vasopressor support. AKI occurred more frequently in patients with higher disease severity and was associated with higher mortality and worse outcomes.

Beta 2-microglobulin is an independent risk marker of acute kidney injury in adult patients with hemophagocytic lymphohistiocytosis.

The role of beta2-microglobulin (β2-MG) in predicting acute kidney injury (AKI) in hemophagocytic lymphohistiocytosis patients has been poorly studied. This study aimed to analyze the clinical characteristics of hemophagocytic lymphohistiocytosis patients and identify risk factors that predict AKI development. This retrospective observational cohort study conducted ata single-centerinvolved 938 patients diagnosedwith hemophagocytic lymphohistiocytosis, who were divided into AKI groupand non-AKI group. Patient data were collected and analyzed usingunivariate and multivariate binary logistic regression to identify potiential risk factors associated with AKI occurrence. RESULTS: Among the enrolled patients, 486 were male (51.9%), the median age was 37years (interquartile range, 28.0, 52.0), 58.4%experienced AKI. Mechanical ventilation (8.0% vs. 0.8%) and vasopressor support (21.7% vs. 4.1%) occurred at significantly higher rates in the AKI group compared to the non-AKI group, with significantly higher in-hospital mortality (5.5% vs. 1.3%) and 28-day mortality (12.8% vs. 5.4%). When β2-MG was used as a continuous variable, multifactorial analysis showed that β2-MG, transplantation, and vasopressor support were independently associated with risk for the development of AKI. The incidence ofmorbidity and mortality in patients with hemophagocytic lymphohistiocytosis complicated by AKIremains high. Monitoring levels ofβ2-MG may provide clinicians with timely indicatorsofchanges in renal function, facilitating adjustments to treatment strategies.

Pediatric Takotsubo cardiomyopathy: a review and insights from a national multicentric registry

Abstract Funding Acknowledgements None. Background Takotsubo syndrome (TTS) in the pediatric population is an infrequent but relevant cause of morbidity and mortality, with limited studies addressing its clinical course and prognosis. Objectives We aimed to analyze the clinical features and prognosis of pediatric TTS in a nation-wide multicenter registry and considering the published literature. Methods we included a total of 54 patients from 4 different hospitals in Spain, as well as pediatric TTS patients from the published literature. Comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between pediatric and adult population features. Results Comparison between the RETAKO general population is detailed in Table 1. Pediatric patients with TTS had a median age of 11 years (IQR = 4-14). When compared to the RETAKO general population, they were more often male (51.9% vs 23.3%, p<0.001), and displayed a higher prevalence of secondary forms (90.7% vs 35.6% in adults, p<0.001). Regarding race, 11 cases (20.4%) were from Asia and 42 (77.8%) were Caucasian; whereas in RETAKO 1420 (94.9%) were Caucasians, with under 5 cases (<0.1%) being Asian. Pediatric patients presented less commonly with angina (11.1% vs 64.1%, p<0.001) or dyspnea (30% vs 41.7%, p<0.001), compared to the general RETAKO cohort. Nevertheless, pediatric patients with TTS exhibited a higher Killip status on admission (Killip IV 74.1% vs 10.5%, p<0.001), and higher needs of vasoactive and mechanical ventilatory support during hospitalization. Regarding complementary exams, pediatric patients presented with lower LVEF on admission (30.5+10.4 vs 36.9+16.9, p = 0.014) together with greater prevalence of atypical (basal or midventricular) TTS patterns on echocardiography (30.2% vs 15.8%, p = 0.006). Additionally, there were significantly less ST-segment alterations in the pediatric population (either ST-segment elevation or depression), without differences on T wave inversion in the admission ECG. During follow-up, all-cause deaths (11.1% vs 12,5%, p = 0.761) and TTS recurrences (3.8% vs 3,8%, p = 0.863) were similar between groups. Conclusions TTS in the pediatric population presents a distinctive clinical profile, with higher prevalence of atypical symptoms and physical triggers; as well as higher rates of cardiogenic shock on admission and similar mortality and recurrence rates than those of the adult population. This study provides valuable insights into understanding pediatric TTS and underscored the necessity for further research in this age group.Table 1

The utility of qSOFA in assessing outcomes of patients with acute heart failure in a level II hospital: a single-center retrospective analysis

Abstract Funding Acknowledgements None. Introduction High all-cause mortality is associated with acute heart failure (AHF) hospitalization, both when the condition first develops and when it worsens. Although there are several risk models for patients with chronic heart failure (CHF), it is unknown whether these scoring systems may be applied to patients with ADHF to predict their chance of developing the condition. Purpose Acute Heart failure (AHF) patients benefit from accurate risk assessment. Those stratified with worse prognosis may benefit more from continuous and close monitoring, with subsequent prompt intervention in case of deterioration. Currently, there is a lack of a universally accepted risk score that can accurately predict outcomes in acute heart failure (AHF). Undeniably, sepsis and AHF share several clinical features. These similarities encourage the sepsis-to-AHF translation of SOFA and qSOFA scores. We compared different scoring systems used in sepsis and assessed their predictive accuracy. Methodology This retrospective study included all patients with acute heart failure admitted in a private teaching hospital between January 2014 and January 2023. This study included newly admitted adult patients with new-onset AHF or acute on chronic heart failure. Baseline qSOFA, SIRS, and SOFA values were determined. Receiver Operating Characteristics - Area under the Curve (ROC-AUC) analysis assessed these scores' ability to predict mortality, whereas chi-square and Fischer's exact test assessed secondary outcome risk. Results 545 patients were included in the study. The majority were males with a mean age of 65 years. Most patients in the study required oxygen support, were classified as NOHRIA A, and with NYHA Functional Class II. Renal and respiratory failures were prominent upon arrival. About 11% met ≥2 points in qSOFA. Therein, systolic BP of <100 mmHg was the most frequent criterion met. The primary endpoint, that is in-hospital mortality, occurred in 9.52% of patients. A positive qSOFA, defined as a score of 2 or more, was consistent in the majority of those meeting the primary endpoint (Chi2 = 264.698, p<0.001). The ROC analysis of qSOFA (AUC 0.949, 95% CI 0.924–0.974, accuracy of 73%), SOFA (AUC 0.935, 95% CI 0.887–0.983, accuracy of 72%), and SIRS criteria (AUC 0.939, 95% CI 0.917–0.961, accuracy of 72%) show no fundamental differences regarding the prediction of the primary endpoint. Patients with positive qSOFA criteria were more frequently affected by organ failure (OR 5.386, p <0.001), needed more vasopressors (OR 4.921, p < 0.001), notably with an ejection fraction <40% (OR 3.363, p <0.001), and required mechanical ventilator support more often (OR 3.794, p<0.001). Conclusion In conclusion, qSOFA used in Acute Heart Failure is a valuable tool in the early detection of in-hospital mortality and detection of worse outcomes, hence should be considered when making therapeutic strategies and decisions.AUC for Primary OutcomesSecondary Outcomes

Comparison of Weaning Strategies in Patients Receiving Venovenous Extracorporeal Membrane Oxygenation: An Exploratory Retrospective Study.

Venovenous extracorporeal membrane oxygenation (VV ECMO) facilitates the reduction of mechanical ventilation (MV) support in acute respiratory failure. Contrary to increasing evidence regarding its initiation, the optimal timing of VV ECMO weaning in interaction with MV weaning is undetermined. In this retrospective study, 47 patients who received VV ECMO between 2013 and 2021 and survived ≥1 day after ECMO cessation were divided according to their MV status before ECMO removal: 28 patients were classified into an "ECMO weaning during assisted MV/spontaneous breathing" group and 19 into an "ECMO weaning during controlled MV" group. Extracorporeal membrane oxygenation duration was longer in the "assisted MV/spontaneous breathing" group (17 [Interquartile range (IQR) = 11-35] vs. 6 [5-11] days, p < 0.001). These patients had a longer intensive care unit (ICU) stay after ECMO start (48 [29-66] vs. 31 [15-40] days, p = 0.01). No significant differences were found for MV duration after ECMO start (30 [19-45] vs. 19 [12-30] days, p = 0.06) and further ICU survival (86% vs. 89%, p ≥ 0.9). There was a trend toward more patients with mechanical ECMO complications in the "assisted MV/spontaneous breathing" group (57% vs. 32%, p = 0.08). Thus, our results suggest a possible benefit of early ECMO weaning during controlled MV.

Diuretic response after neonatal cardiac surgery: a report from the NEPHRON collaborative.

Multicenter early diuretic response (DR) analysis of single furosemide dosing following neonatal cardiac surgery is lacking to inform whether early DR predicts adverse clinical outcomes. We performed a retrospective cohort study utilizing data from the NEPHRON registry. Random forest machine learning generated receiver operating characteristic-area under the curve (ROC-AUC) and odds ratios for mechanical ventilation (MV) and respiratory support (RS). Prolonged MV and RS were defined using ≥ 90th percentile of observed/expected ratios. Secondary outcomes were prolonged CICU and hospital length of stay (LOS) and kidney failure (stage III acute kidney injury (AKI), peritoneal dialysis, and/or continuous kidney replacement therapy on postoperative day three) assessed using covariate-adjusted ROC-AUC curves. A total of 782 children were included. Cumulative urine output (UOP) metrics were lower in prolonged MV and RS patients, but DR poorly predicted prolonged MV (highest AUC 0.611, OR 0.98, sensitivity 0.67, specificity 0.53, p = 0.006, 95% OR CI 0.96-0.99 for cumulative 6-h UOP) and RS (highest AUC 0.674, OR 0.94, sensitivity 0.75, specificity 0.54, p < 0.001, 95% CI 0.91-0.97 UOP between 3 and 6h). Secondary outcome results were similar. DR had fair discrimination for kidney failure (AUC 0.703, OR 0.94, sensitivity 0.63, specificity 0.71, 95% OR CI 0.91-0.98, p < 0.001, cumulative 6-h UOP). Early DR poorly discriminated patients with prolonged MV, RS, and LOS in this cohort, though it may identify severe postoperative AKI phenotype. Future work is warranted to determine if early DR or late postoperative DR later, in combination with other AKI metrics, may identify a higher-risk phenotype.

The development and implementation of a low-cost mechanical ventilator in a low-middle-income country during the COVID-19 pandemic: The Unisabana-HERONS

BackgroundThe COVID-19 pandemic in Latin America generated the need to develop low-cost, fast-manufacturing mechanical ventilators. The Universidad de La Sabana and the Fundacion Neumologica Colombiana designed and manufactured the Unisabana-HERONS (USH) ventilator. Here, we present the preclinical and clinical study results to evaluate its effectiveness and safety characteristics in an animal model (Yorkshire Sow) and five patients with acute respiratory failure receiving mechanical ventilatory support for 24 h. MethodsThe effectiveness and safety outcomes included maintaining arterial blood gases and pulse oximetry saturation (SpO2), respiratory pressures and volumes (during continuous monitoring) in the range of ARDS and lung-protective strategy goals, and the occurrence of barotrauma. A significance level of 0.05 was used for statistical tests. This clinical trial was registered on Clinicaltrials.gov (NCT04497623) and approved by the ethics committee. ResultsAmong patients treated with the Unisabana-HERONS, the most frequent causes of acute respiratory failure were pneumonia in 3/5 (60 %) and ARDS in 2/5 (40 %). During the treatment, the ventilatory parameters related to lung protection protocols were kept within the safety range, and vital signs and blood gas were stable. The percentage of time that the respiratory pressures or volumes were out of safety range were plateau pressure >30 cm H2O: 0.00 %; driving pressure >15 cm H2O: 0.06 %; mechanical power >15 J/min: 0.00 %; and Tidal volume >8 mL/kg: 0.00 %. There were no adverse events related to the ventilator. The usability questionnaire retrieved a median score for all items between 9 and 10 (best score: 10), indicating great ease of use. ConclusionThe Unisabana-HERONS ventilator effectively provided adequate gas exchange and maintained the ventilatory parameters in the range of lung protection strategies in humans and an animal model. Furthermore, it is straightforward to use and is a low-cost medical device.

Evaluation of the impact of trained pediatric intensivists on patient management in intensive care unit: An uncontrolled before-after study

It is known that the presence of a pediatric intensivist in the pediatric intensive care unit (PICU) improves the quality of patient care and treatment. In this study, it was aimed to determine the differences in the quality of patient care between the period when a pediatric intensivist is actively working and the period when he/she is not actively working. This is a retrospective cohort observational study conducted in Batman Training and Research Hospital. Children aged 1 month to 18 years old admitted to the PICU between October 2020 and March 2021 were enrolled in the study. The 6-month period without an intensivist was compared with the period when the patients were treated by a pediatric intensivist. Demographic data and mortality of the group were recorded and compared between groups. There was no statistically significant difference between the groups in terms of number, gender, and age. The mean Pediatric Risk of Mortality (PRISM) score and Pediatric Death Rate (PDR) were higher in group 2, and these differentiations were statistically significant (0.39 ± 0.18vs 4.57 ± 2.36, p&lt;0.001; 1.08 ± 0.15 vs 2,05 ± 1.25, p&lt;0.001). Although mortality was statistically higher in group 2, there were no invasive procedures like mechanical ventilatory support, dialysis, and central venous catheter applications in group 1. The ratio of patient acceptance from other hospitals was higher in group 2 (p&lt;0.001). In intensive care units under the management of intensivists, clinical follow-up of critical and risky patients can be performed on-site. This protects from transfer difficulties. Invasive interventions can be performed on patients with less risk, and yet mortality is below average. Pediatric intensive care units should be managed by pediatric intensivists and their numbers should be increased.

Yoğun Bakım Ünitesinde Geriatrik Kritik Hastalarda Ultrason Kullanımının Akciğer Patolojilerini Tespit Etmedeki Rolünün Prognoz, Mortalite ve Skorlamalarla Karşılaştırılması

Objective: It is crucial to correctly and promptly diagnose pulmonary diseases and to initiate treatment in elderly patients diagnosed with respiratory failure who are on mechanical ventilator support. The aim of this study is to investigate the effect of lung ultrasound (USG) on prognosis and mortality in geriatric patients we follow up in the intensive care unit, by scoring. Methods: Patients who were followed up in the intensive care unit were grouped as AUSG group (n=48), those who underwent lung USG and NAUSG group (n=74) who underwent chest radiography, computed tomography (CT), magnetic resonance imaging (MRI) or bronchoscopy. The hospital information management system was used to compare the two groups in terms of diagnosis time, number of additional consultations, treatment and discharge time, hospital stay, mortality, and scores. The arterial blood gas analysis, complete blood count, biochemistry, procalcitonin, C-reactive protein, and endotracheal aspirate culture results of the patients were recorded. The clinical pulmonary infection score, pneumonia severity index-65, pulmonary severity index, and acute physiology and chronic health evaluation 2 scores of the groups were compared. Results: The diagnosis time in Group AUSG was 1 ± 0.64 day, the treatment time was 10 ± 4.62 day, and the number of required consultations was 1 ± 0.68, which was significantly lower than in Group NAUSG (p&lt;0.05). The mortality rate was 14 (29.2%) patients in Group AUSG and 25 (33.8%) patients in Group NAUSG (p&gt;0.05). When comparing the scores of the patients, the clinical pulmonary infection score, pneumonia severity index-65 (4 ± 0.79), and pulmonary severity index (3 ± 0.87) were significantly lower in Group AUSG (p&lt;0.05). There was no significant difference in acute physiology and chronic health evaluation 2 scores. Conclusion: Performing lung USG for the diagnosis and treatment of critically ill elderly patients can lead to earlier detection and treatment of lung pathologies, reducing mortality rates, unnecessary imaging and consultations. Its advantages include easy and rapid bedside application and simultaneous results. Keywords: Geriatrics, ultrasonography, lung, prognosis, mortality

H-intensity scale score to estimate CSF GluN1 antibody titers with one-time immunostaining using a commercial assay.

Anti-NMDA receptor encephalitis is an autoimmune disorder caused by autoantibodies (abs) against the conformational epitope on GluN1 subunits. GluN1-abs have been determined with cell-based assay (CBA) co-expressing GluN1/GluN2 subunits. However, commercial fixed CBA expressing only GluN1 subunit has increasingly been used in clinical practice. The ab titers can be determined with serial dilutions, but its clinical significance remains unclear. We aimed to develop an H-intensity scale (HIS) score to estimate GluN1-ab titers in cerebrospinal fluid (CSF) with one-time immunostaining using both commercial CBA and immunohistochemistry and report its usefulness. "H" is the initial of a patient with high CSF GluN1-ab titers (1:2,048). We first determined the reliability of CBA in 370 patients with suspected autoimmune encephalitis by comparing the results between commercial CBA and established assay in Dalmau's Lab. Then, we made positive control panels using the patient H's CSF diluted in a fourfold serial dilution method (1:2, 1:8, 1:32, 1:128, 1:512, and 1:2,048). Based on the panels, we scored the intensity of ab reactivity of 79 GluN1-ab-positive patients' CSF (diluted at 1:2) on a scale from 0 to 6 (with ≥1 considered positive). To assess inter-assay reliability, we performed immunostaining twice in 21 patients' CSF. We investigated an association between the score of CSF obtained at diagnosis and the clinical/paraclinical features. The sensitivity and specificity of CBA were 93.7% (95% CI: 86.0-97.3) and 98.6% (95% CI: 96.5-99.5), respectively. Linear regression analysis showed a good agreement between the scores of the first and second assays. Patients with a typical spectrum, need for mechanical ventilation support, autonomic symptoms/central hypoventilation, dyskinesias, speech dysfunction, decreased level of consciousness, preceding headache, ovarian teratoma, and CSF leukocyte count >20 cells/µL had a higher median HIS score than those without, but HIS score was not associated with sex, age at onset, or seizure. HIS score at diagnosis had a significant effect on 1-year functional status. The severity of disease and four of the six core symptoms were associated with higher GluN1-ab titers in CSF at diagnosis, which may play a role in poor 1-year functional status. An incomplete phenotype can be attributed to low CSF GluN1-ab titers.

Activity of protein C, protein S and antithrombin 3 in COVID-19 patients treated with different modalities of oxygen supplementation

Abstract Objectives COVID-19 in it is more severe form is characterized by a hyperinflammatory condition, hypercoagulation state and the appearance of pulmonary microembolism. In this study we wanted to correlate levels of D-Dimer, protein C, protein S and antithrombin 3 with severity of disease and clinical outcome. Methods We included 134 of patients who were divided in 3 groups regarding oxygen support (high flow oxygen therapy, mechanical ventilation and oxygen supplementation with nasal cannula or mask). Results Concentration of D-Dimer, and activity of protein C and antithrombin 3 are presented as mean±SD and differed significantly between patients on mechanical ventilation (3.26 ± 1.15 mg/L, 86 ± 22.55 %, 81.21 ± 17.61 %)/HFNO (2.35 ± 1.68 mg/L, 109.6 ± 26.96 %, 94.67 ± 17.49 %)/BNC (1.37 ± 1.17 mg/L, 116.92 ± 28.16 %, 103.29 ± 15.63 %) with p&lt;0.001 for all parameters. Mortality in oxygen group was 10.9 %, in HFNC group 40.7 % and in mechanical ventilated group 80 %. Conclusions determination of anticoagulant factors in COVID-19 patients may indicate which of them are at increased risk of developing severe disease, venous thromboembolism and fatal clinical outcome.

Comparison of BAP65, DECAF, PEARL, and MEWS Scores in Predicting Respiratory Support Need in Hospitalized Exacerbation of Chronic Obstructive Lung Disease Patients.

Prognostic models aid clinical practice with decision-making on treatment and hospitalization in exacerbation of chronic obstructive lung disease (ECOPD). Although there are many studies with prognostic models, diagnostic accuracy is variable within and between models. We compared the prognostic performance of the BAP65 score, DECAF score, PEARL score, and modified early warning score (MEWS) in hospitalized patients with ECOPD, to estimate ventilatory support need. This cross-sectional study consisted of 139 patients. Patients in need of noninvasive or invasive mechanical ventilation support are grouped as ventilatory support groups (n = 54). Comparison between receiver operating characteristic curves revealed that the DECAF score is significantly superior to the PEARL score (p = 0.04) in discriminating patients in need of ventilatory support. DECAF score with a cutoff value of 1 presented the highest sensitivity and BAP65 score with a cutoff value of 2 presented the highest specificity in predicting ventilatory support need. Multivariable analysis revealed that gender played a significant role in COPD exacerbation outcome, and arterial pCO2 and RDW measurements were also predictors of ventilatory support need. Within severity indexes, only the DECAF score was independently associated with the outcome. One-point increase in DECAF score created a 1.43 times higher risk of ventilatory support need. All severity indexes showed a correlation with age, comorbidity index, and dyspnea. BAP65 and DECAF scores also showed a correlation with length of stay. Objective and practical classifications are needed by clinicians to assess prognosis and initiate treatment accordingly. DECAF score is a strong candidate among severity indexes.

Radiological Features of Herpetic Encephalitis in Children

BackgroundNonspecific clinical manifestations and unclear radiological features may delay treatment initiation in pediatric patients with Herpes simplex encephalitis (HSE). The aim of this study is to analyze the clinical and radiological features of the disease. MethodsClinical, laboratory, and magnetic resonance imaging (MRI) data were obtained retrospectively from a group of 37 hospitalized pediatric patients older than two months and with a polymerase chain reaction-confirmed HSE diagnosis. Clinical severity (i.e., mechanical ventilatory support) and outcome at discharge (i.e., pediatric modified Rankin Scale [ped-mRS]) were also assessed. ResultsMedian age was 14 months (interquartile range: 10-36). All patients survived, 15 (41%) had complete recovery (i.e., ped-mRS = 0), and 10 (27%) had significant residual disability at discharge (i.e., ped-mRS ≥3). Brain MRI was obtained in 31 patients. T2-hyperintense lesions were usually bilateral (28, 90%) and multifocal (30, 97%). Hemorrhage and mass effect were observed in 13 (42%) and 15 (48%) patients, respectively. Parenchymal lesions involved the temporal lobes (94%), insula (90%), parietal lobes (84%), and frontal lobes (61%). Occipital lesions were rare. In multivariable binary logistic regression models the presence of altered consciousness was associated with mechanical ventilation (odds ratio [OR] = 8.2, Nagelkerke R2 = 0.22), whereas the involvement of the occipital lobes (OR = 7.8) and the administration of vasopressors (OR = 12.1) were independent predictors of poor outcome (Nagelkerke R2 = 0.41). ConclusionsBrain MRI is useful for diagnosis and outcome assessment in pediatric HSE. Radiological patterns with common frontotemporal involvement overlap adults, but multifocal and parietal lobe abnormalities are observed as well.

Wedge Resection and Optimal Solutions for Invasive Pulmonary Fungal Infection and Long COVID Syndrome—A Case Report and Brief Literature Review

A rise in fungal infections has been observed worldwide among patients with extended hospital stays because of the severe infection caused by the new coronavirus pandemic. A 62-year-old female patient was admitted with a severe form of Coronavirus disease 2019 (COVID-19) and spent four weeks in the intensive care unit (ICU) requiring mechanical ventilation support before being moved to a tertiary hospital for further testing. Aspergillus fumigatus filamentous fungus, Candida spp., and positive bacteriology for multidrug-resistant Klebsiella pneumoniae and Proteus mirabilis were identified by bronchial aspirate cultures. The patient’s progress was gradually encouraging while receiving oral antifungal and broad-spectrum antibiotic therapy along with respiratory physical therapy; but ultimately, thoracic surgery was necessary. Long-lasting tissue damage and severe, persistent inflammatory syndrome were the two main pathophysiological mechanisms that led to significant outcomes regarding lung lesions that were rapidly colonized by fungi and resistant flora, cardiac damage with sinus tachycardia at the slightest effort, and chronic inflammatory syndrome, which was characterized by marked asthenia, myalgias, and exercise intolerance.

Thrombosis in severely ill patients admitted in ICU due to COVID-19 pneumonia. Data from a Greek Hospital

Background: SARS-CoV-2 can lead to a prothrombotic state and the activation of the body's coagulation mechanism, resulting in thrombotic episodes, especially in critically ill patients. The rates of thromboembolic disease in patients with COVID-19 vary and range from 10-40%, while in Greece the existing epidemiological data on the incidence of thromboembolic disease in the ICU are limited. Aim This study aimed to determine the proportion of hospitalized COVID-19 patients who developed thromboembolic disease (pulmonary embolism, deep vein thrombosis, or arterial embolism). It was also crucial to investigate at the relationship between the incidence of VTE (venothrombosis-VTE) and Covid infection in ICU patients. After 28 days from ICU admission, the survival rate of patients with Covid infection admitted to ICUs within the specified time frame was also noted. Method and Material: The study included 85 patients with Covid-19 infection who were hospitalized in two ICU departments in a large adult hospital in Athens between June and September 2021. The occurrence of VTE was diagnosed by computed tomography angiography, regarding the pulmonary embolism and with triplex veins of the lower extremities. Various epidemiological factors, laboratory findings and characteristics of the patients' hospitalization in the Intensive Care Unit were recorded. Results: The incidence of VTE in patients with Covid-19 infection admitted to the Intensive Care Unit was 14% (12/85 patients). Patients who experienced VTE during their hospitalization in the Intensive Care Unit had more days on mechanical ventilation support, more days on vasoconstrictor drugs, and had been transfused more times with blood plasma. In the multivariate analysis that followed, it was found that total days of mechanical ventilation (p=0.02), total days of vasoconstrictor administration (p=0.03) and plasma transfusion (p=0.03) were still statistically significant. Conclusion: In patients with Covid-19 infection and hospitalization in the Intensive Care Unit, longer stay on mechanical respiratory support, more days of vasoconstrictor drug administration and plasma administration are independent predisposing factors for the occurrence of VTE.

Long-term outcomes of heart transplantation in adults with congenital heart disease: The impact of single-ventricle versus biventricular physiology

ObjectiveCongenital heart disease is a risk factor for mortality after orthotopic heart transplantation; however, the impact of preoperative circulation type and primary congenital heart disease diagnosis remains poorly delineated. MethodsWe retrospectively reviewed patients with adult congenital heart disease aged 16 years or more who underwent orthotopic heart transplantation at our institution between 2008 and 2022. Patients were categorized as having single-ventricle or biventricular circulation. The primary end point was 5-year post-transplant survival. ResultsSixty-one patients with adult congenital heart disease (single-ventricle: n = 26 [42.6%], biventricular: n = 35 [57.4%]) underwent orthotopic heart transplantation at 33.7 [interquartile range, 19.1-48.7] years. The most common congenital heart disease diagnosis was hypoplastic left heart syndrome (n = 11, 42.3%) in the single-ventricle group and congenitally corrected transposition of the great arteries (n = 7, 20.0%) in the biventricular group. Twenty-four patients previously underwent Fontan palliation. At transplant, patients in the single-ventricle group were younger (18.5 [interquartile range, 17.6-32.3] years vs 45.0 [interquartile range, 33.0-52.2] years, P < .001) and more likely to have biopsy-proven cirrhosis (46.2% vs 14.3%, P = .01) and protein-losing enteropathy (42.3% vs 2.9%, P < .001). Patients in the single-ventricle group also had longer bypass times (223.4 ± 65.3 minutes vs 187.4 ± 59.5 minutes, P = .03) and longer durations of mechanical ventilatory support (3.5 [interquartile range, 2.0-6.0] days vs 1.0 [interquartile range, 1.0-2.0] days, P < .001). Operative mortality was comparable (11.5% vs 8.6%, P = 1). Median follow-up was 6.0 [interquartile range, 2.4-10.0] years. Five-year survival was worse in the single-ventricle group (66.0% ± 10.0% vs 91.3% ± 4.8%, P = .03), as was freedom from major rejection (58.3% ± 10.2% vs 84.0% ± 6.6%, P = .02). In univariable analysis, hypoplastic left heart syndrome and Fontan circulation were risk factors for post-transplant mortality (hypoplastic left heart syndrome: hazard ratio, 5.0, P < .001; Fontan: hazard ratio, 3.5, P = .03). ConclusionsAdult patients with congenital heart disease undergoing heart transplant with single-ventricle physiology experienced a more complicated post-transplant course, with worse long-term survival and freedom from rejection. Multicenter studies are required to guide orthotopic heart transplantation decision-making in this complex cohort.

The management of neonatal venous thrombosis – an interdisciplinary team effort

Managing venous thrombosis in neonates poses numerous difficulties. Thrombotic events, whether arterial or venous, in newborns, can lead to significant morbidity and mortality within the hospitalized infant population. Neonates represent the age group with the highest susceptibility to developing thrombosis among pediatric patients. The evolving coagulation system, the necessity for intensive care, which often involves invasive procedures, and the presence of coexisting medical conditions collectively render neonates more prone to developing thrombosis compared to older children. Neonatal thrombosis is intertwined with the well-being of the mother and the newborn. We report a case of a very preterm newborn (30 weeks of gestation), extremely low birth weight (900g), with a multitude of prematurity related complications, who developed venous thrombosis at 5 weeks of life. She underwent prolonged hospitalization in the NICU, required mechanical ventilation, received nutritional and metabolic support via a central venous catheter, and complex treatments for sepsis with Staphylococcus CoNS. Genetic and hematology consults raised questions about the genetic basis of the thrombosis pathology, specifically thrombophilia or a RASopathy (Phenotype Noonan-like Syndrome). The prompt identification of risk factors leads to early therapeutic intervention, and multidisciplinary assessments are necessary to manage it. Conclusions. Neonatal thrombosis is impacted by many risk factors, encompassing genetic predispositions and perinatal complications. Notably, the NICU's environment is pivotal. Extended periods of immobility, invasive procedures, and the utilization of medical devices such as central venous catheters heighten the vulnerability to thrombosis in these fragile patients.

Mitral Annular Plane Systolic Excursion: An Early Marker of Subclinical Left Ventricular Function in COVID-19 Survivors

Introduction: The left ventricular (LV) function can be affected by COVID-19. Mitral annular plane systolic excursion (MAPSE) is a measurement that reflects the function of the LV. The association between MAPSE and LV function in COVID-19 survivors is not well understood, and this study aimed to explore that relationship. Material and methods: The retrospective cross-sectional study comprised 99 patients with a history of SARS-CoV-2 infection. These patients experienced symptoms lasting more than 2 months following the initial SARS-CoV-2 virus infection, including fatigue, shortness of breath, chest pain, and cough. The patients were categorized into two groups based on their MAPSE measurements: those with low MAPSE (&lt;12 mm) and those with non-low MAPSE (&gt;12 mm). MAPSE measurements were acquired using transthoracic echocardiography (TTE). Results: COVID-19 patients with low MAPSE, global longitudinal strain (GLS) (%) ([-17.61±0.95] - [-18.90±1.08], p &lt;0.001) and mitral E/A ratio ([0.83±0.39] - [0.97±0.23], p = 0.028) were statistically significant compared to the the group without low MAPSE. Left atrial volume index (LAVI) in mm/m2 ([37.24±2.11] - [35.34±2.50], p =0.001) was higher in the group of COVID-19 patients with lower MAPSE. High-sensitivity troponin T (Hs-TnT) (OR: 2.019, 95% CI: 1.043-3.712, p =0.028), intensive care unit (ICU) admission (OR: 1.432, 95% CI: 1.004-2.708, p =0 .037) and need for invasive mechanical ventilation (IMV) support (OR: 1.306, 95% CI: 1.128-2.630, p =0.004) were identified as independent predictors of reduced MAPSE. Conclusions: SARS-CoV-2 infection may lead to reduced or impaired MAPSE values, indicative of impaired LV function, in COVID-19 survivors. Additionally, our study revealed that elevated levels of (Hs-TnT), admission to the ICU, and the need for IMV support were predictive factors for low MAPSE values. These findings underscore the potential cardiac implications of COVID-19 and highlight the importance of monitoring cardiac function in patients with severe disease manifestations.

Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19

Supplemental oxygen is ubiquitously used in patients with COVID-19 and severe hypoxemia, but a lower dose may be beneficial. To assess the effects of targeting a Pao2 of 60 mm Hg vs 90 mm Hg in patients with COVID-19 and severe hypoxemia in the intensive care unit (ICU). Multicenter randomized clinical trial including 726 adults with COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 11 ICUs in Europe from August 2020 to March 2023. The trial was prematurely stopped prior to outcome assessment due to slow enrollment. End of 90-day follow-up was June 1, 2023. Patients were randomized 1:1 to a Pao2 of 60 mm Hg (lower oxygenation group; n = 365) or 90 mm Hg (higher oxygenation group; n = 361) for up to 90 days in the ICU. The primary outcome was the number of days alive without life support (mechanical ventilation, circulatory support, or kidney replacement therapy) at 90 days. Secondary outcomes included mortality, proportion of patients with serious adverse events, and number of days alive and out of hospital, all at 90 days. Of 726 randomized patients, primary outcome data were available for 697 (351 in the lower oxygenation group and 346 in the higher oxygenation group). Median age was 66 years, and 495 patients (68%) were male. At 90 days, the median number of days alive without life support was 80.0 days (IQR, 9.0-89.0 days) in the lower oxygenation group and 72.0 days (IQR, 2.0-88.0 days) in the higher oxygenation group (P = .009 by van Elteren test; supplemental bootstrapped adjusted mean difference, 5.8 days [95% CI, 0.2-11.5 days]; P = .04). Mortality at 90 days was 30.2% in the lower oxygenation group and 34.7% in the higher oxygenation group (risk ratio, 0.86 [98.6% CI, 0.66-1.13]; P = .18). There were no statistically significant differences in proportion of patients with serious adverse events or in number of days alive and out of hospital. In adult ICU patients with COVID-19 and severe hypoxemia, targeting a Pao2 of 60 mm Hg resulted in more days alive without life support in 90 days than targeting a Pao2 of 90 mm Hg. ClinicalTrials.gov Identifier: NCT04425031.

Urinary cadmium concentration is associated with the severity and clinical outcomes of COVID-19: a bicenter observational cohort study

BackgroundCadmium and nickel exposure can cause oxidative stress, induce inflammation, inhibit immune function, and therefore has significant impacts on the pathogenesis and severity of many diseases. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can also provoke oxidative stress and the dysregulation of inflammatory and immune responses. This study aimed to assess the potential associations of cadmium and nickel exposure with the severity and clinical outcomes of patients with coronavirus disease 2019 (COVID-19).MethodsWe performed a retrospective, observational, bicenter cohort analysis of patients with SARS-CoV-2 infection in Taiwan between June 2022 and July 2023. Cadmium and nickel concentrations in blood and urine were measured within 3 days of the diagnosis of acute SARS-CoV-2 infection, and the severity and clinical outcomes of patients with COVID-19 were analyzed.ResultsA total of 574 patients were analyzed and divided into a severe COVID-19 group (hospitalized patients) (n = 252; 43.9%), and non-severe COVID-19 group (n = 322; 56.1%). The overall in-hospital mortality rate was 11.8% (n = 68). The severe COVID-19 patients were older, had significantly more comorbidities, and significantly higher neutrophil/lymphocyte ratio, C-reactive protein, and interleukin-6 than the non-severe COVID-19 patients (all p < 0.05). Blood and urine cadmium and urine nickel concentrations were significantly higher in the severe COVID-19 patients than in the non-severe COVID-19 patients. Among the severe COVID-19 patients, those in higher urine cadmium/creatinine quartiles had a significantly higher risk of organ failure (i.e., higher APACHE II and SOFA scores), higher neutrophil/lymphocyte ratio, lower PaO2/FiO2 requiring higher invasive mechanical ventilation support, higher risk of acute respiratory distress syndrome, and higher 60-, 90-day, and all-cause hospital mortality (all p < 0.05). Multivariable logistic regression models revealed that urine cadmium/creatinine was independently associated with severe COVID-19 (adjusted OR 1.643 [95% CI 1.060–2.547], p = 0.026), and that a urine cadmium/creatinine value > 2.05 μg/g had the highest predictive value (adjusted OR 5.349, [95% CI 1.118–25.580], p = 0.036).ConclusionsUrine cadmium concentration in the early course of COVID-19 could predict the severity and clinical outcomes of patients and was independently associated with the risk of severe COVID-19.