Need For Invasive Mechanical Ventilation Research Articles

Early carbohydrate antigen 125 as a mortality predictor in hospitalized patients with coronavirus disease 2019.

Carbohydrate antigen 125 (CA125) is an indicator of inflammation, immune response, and impaired cardiac function. The aim was to investigate whether CA125 behaves as a biomarker of severity and poor clinical outcomes in hospitalized patients with coronavirus disease 2019 (COVID-19). Serum CA125 [Elecsys CA125 II assay-(Roche Diagnostics GmbH)] was measured in stored biobank samples from COVID-19 hospitalized patients between 01 March 2020 and 17 October 2021. Multiple logistic regression models were built to explore the association between CA125 and clinical outcomes [in-hospital all-cause mortality, need for invasive mechanical ventilation (IMV), or non-invasive respiratory support (non-IRS)], estimating odds ratios (ORs; 95% CI). The gradient of risk of CA125 was evaluated by fractional polynomials. A total of 691 patients were included, median age of 63 years (50-76), men (57.2%), with high comorbidity. At admission, 85.8% had pneumonia. Median CA125 was 10.33 U/ml (7.48-15.50). The in-hospital mortality rate was 7.2%. After adjusting for confounding factors, CA125 ≥ 15.5 U/ml (75th percentile) showed an increased risk of death [OR 2.85(1.21-6.71)], as age ≥ 65 years, diabetes, and immunosuppression. Furthermore, CA125 as a continuous variable was positive and significantly associated with the risk of death after multivariate adjustment. The mean hospital stay of the patients with CA125 ≥ 15.5 U/ml was longer than the rest of the study population. CA125 in the first 72 h of hospital admission seems a useful biomarker of mortality in hospitalized patients with moderate-severe COVID-19. If our findings are confirmed, the wide availability of this biomarker would make easy its widespread implementation in clinical practice.

Risk Stratification Based on a Pattern of Immunometabolic Host Factors Is Superior to Body Mass Index-Based Prediction of COVID-19-Associated Respiratory Failure.

Overweight and obesity are associated with chronic low-grade inflammation and represent risk factors for various diseases, including COVID-19. However, most published studies on COVID-19 defined obesity by the body mass index (BMI), which does not encounter adipose tissue distribution, thus neglecting immunometabolic high-risk patterns. Therefore, we comprehensively analyzed baseline anthropometry (BMI, waist-to-height-ratio (WtHR), visceral (VAT), epicardial (EAT), subcutaneous (SAT) adipose tissue masses and liver fat, inflammation markers (CRP, ferritin, interleukin-6), and immunonutritional scores (CRP-to-albumin ratio (CAR), modified Glasgow prognostic score, neutrophile-to-lymphocyte ratio, prognostic nutritional index)) in 58 consecutive COVID-19 patients of the early pandemic phase with regard to the necessity of invasive mechanical ventilation (IMV). Here, metabolically high-risk adipose tissues represented by increased VAT, liver fat, and WtHR strongly correlated with higher levels of inflammation, pathologic immunonutritional scores, and the need for IMV. In contrast, the prognostic value of BMI was inferior and absent with regard to SAT. Multivariable logistic regression analysis identified an optimized IMV risk prediction model employing liver fat, WtHR, and CAR. In summary, we suggest an immunometabolically risk-adjusted model to predict COVID-19-induced respiratory failure better than BMI-based stratification, which warrants prospective validation.

D-dimer-driven versus standard prophylactic anticoagulation with fondaparinux in critically ill patients with COVID-19 and coagulopathy: an open-label, randomized controlled trial

Abstract Background Anticoagulation with fondaparinux (FPX) has shown benefit to improve clinical outcomes in hospitalized patients with COVID-19. However, optimal thromboprophylaxis dosing in critically ill patients remains unknown. Purpose To evaluate the effects of D-dimer-driven (DDD) FPX compared with standard prophylactic-dose (SPD) FPX in critically ill patients with COVID-19 and associated coagulopathy. Methods This was a single-center, open-label, two-arms, parallel-group, randomized controlled trial conducted between April 1, 2021 and Feb 28, 2022. The eligible COVID-19 patients who were critically ill (defined as a presence of critical care-level organ support at enrollment) and presented with coagulopathy were randomly assigned (1:1 ratio) to receive pragmatically defined regimens of either DDD FPX or SPD FPX throughout hospitalization. The primary efficacy outcome was a composite of all-cause mortality (ACM), acute myocardial infarction (MI), confirmed arterial (ATE) or venous thromboembolisms (VTE), assessed up to 30 days. The secondary efficacy outcomes were 30-day ACM, composite thrombotic events, progression to invasive mechanical ventilation (IMV) or ARDS, and acute kidney injury (AKI). The safety outcomes included major bleeding and clinically relevant non-major bleeding (CRNMB). Outcomes were blindly adjudicated and analysed on a 30-day intention-to-treat basis. Results During allocated period, 270 (58%) of 465 patients were eligible and were equally assigned to DDD and SPD groups. The baseline characteristics were well-matched between groups (all p>0.05). At 30 days, the primary efficacy outcome was met in 49 of 135 patients (36.3%) with DDD FPX versus 47 of 135 patients (34.8%) with SPD FPX (hazard ratio [HR], 1.32; 95% CI, 0.89–1.98; p=0.17). DDD group compared with SPD group revealed no significant difference in 30-day ACM (22.9% vs 31.8%; HR, 0.73; p=0.17). At 30 days, DDD group demonstrated no significant reduction in thromboembolism, i.e. acute MI (14.1% vs 11.8%; HR, 1.53; p=0.21); ATE (3.0% vs 3.0%; HR, 1.27; p=0.74); and VTE (2.2% vs 4.4%; HR, 0.69; p=0.59) when compared with SPD group. Among those not on IMV at randomization, DDD group showed no significant reduction in the proportion of patients meeting the need for IMV (18.5% vs 32.6%; HR, 0.72; p=0.18) or progression to ARDS (17.8% vs 27.4%; HR, 0.81; p=0.43). Allocation to DDD FPX had no significant effect on the proportion of patients experiencing AKI within 30 days (17.8% vs 14.8%; HR, 1.36; p=0.39). There was no significant difference between DDD and SPD groups in terms of major bleeding (2.2% vs 0%; HR, 8.35; p=0.35) or CRNMB (3.0% vs 2.2%; HR, 1.70; p=0.48) at 30 days. Conclusions In critically ill patients with COVID-19 and coagulopathy, D-dimer-driven anticoagulation with fondaparinux did not significantly improve clinical outcomes at 30 days as compared to standard prophylactic-dose. The risk of bleeding was not significantly increased in this trial. Funding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Syarifah Ambami Rato Ebu Generał Hospital, Bangkalan, East Java, Indonesia

Major adverse cardiac events in critically ill COVID-19 patients

Abstract Background Critically ill patients hospitalized with COVID-19 are at high risk of developing major adverse cardiac events (MACE). Purpose This study aimed to identify independent predictors of MACE after intensive care unit (ICU) admission which could be used to identify high-risk patients who may benefit from preventive strategies. Methods We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded. Logistic regression analysis was performed to evaluate which clinical characteristics predicted MACE. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic). Results A total of 297 patients was included in the analysis. Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). From a total of 297 patients, 108 (36.4%) developed at least one MACE: ICU all-cause mortality (92 patients, 31.0%), new-onset heart failure (27 patients, 9.1%), acute coronary syndrome (7 patients, 2.4%), ventricular arrythmias (7 patients, 2.4%), pulmonary embolism (13 patients, 4.4%), myocarditis (4 patients, 1.3%), and stroke (5 patients, 1.7%). Univariate logistic regression analysis showed that the clinical variables associated with MACE were male sex, older age, APACHE II score, SAPS II score, hypertension, hyperlipidemia, known coronary artery disease, heart failure, new-onset atrial fibrillation, need for invasive mechanical ventilation, duration of mechanical ventilation, and vasopressor use. In multivariate logistic regression analysis, we found that the MACE's independent predictors were older age, higher APACHE II score, and new-onset atrial fibrillation. Main results are presented in Table 1. Conclusion(s) Among critically ill COVID-19 patients, older age, higher APACHE II score, and new-onset atrial fibrillation independently predicted MACE. Funding Acknowledgement Type of funding sources: None.

Atrial fibrillation in COVID-19 patients admitted to an intensive care unit: prevalence and prognosis

Abstract Background The association between atrial fibrillation (AF) and prognosis has been studied in non-COVID-19 patients, but few studies reflect the reality of critically ill COVID-19 patients admitted to a general intensive care unit (ICU). Purpose This study sought to investigate the relationship between previous and new-onset AF in COVID-19 patients admitted to an ICU and prognosis. Methods We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded from the analysis. Three groups were identified: without AF (G1), with prior history of AF (G2), and with new-onset AF (G3). Groups were compared, with special interest regarding ICU mortality, duration of mechanical ventilation, length of hospitalization, major adverse cardiac events (MACE), and re-hospitalization. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrhythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic). Results A total of 297 patients was included in the analysis: without AF (248 patients, 83.5%), with prior history of AF (15 patients, 5.1%), and with new-onset AF (34 patients, 11.4%). Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). Patients with a prior history of AF were older [median (IQR), G1 60 (16), G2 71 (12), G3 67 (15) years, p=0.001], were more likely to have a history of coronary artery disease (G1 4.9%, G2 26.7%, G3 11.8%, p=0.002), and history of heart failure (G1 6.5%, G2 33.3%, G3 17.6%, p<0.001). Patients with new-onset AF had a longer duration of mechanical ventilation [median (IQR), G1 9 (13), G2 11 (16), G3 18 (12) days, p<0.001), longer ICU length of stay [median (IQR), G1 12 (10), G2 13 (12), G3 19 (15), p=0.001], higher ICU mortality rate (G1 27.0%, G2 33.3%, G3 58.8%, p=0.001), and higher rate of MACE (G1 31.9%, G2 33.3%, G3 70.6%, p<0.001), compared to the other groups. There were no differences regarding sex distribution, other baseline comorbidities, need for invasive mechanical ventilation, vasopressor use, and re-hospitalization rates among groups. Most AF patients were treated with beta-blockers (39.6%) and amiodarone (77.1%), but only 68.8% of patients received anticoagulation (G2 92.9%, G3 58.8%), which may reflect that physicians underestimate the prognosis of new-onset AF. In multivariate analysis, new-onset AF (OR 3.07, 95% CI 1.42–6.67, p=0.005) and older age (OR 1.07, 95% CI 1.04–1.09, p<0.001) remained independent predictors of ICU mortality. Main results are presented in Table 1. Kaplan-Meier survival curves are presented in Figure 1. Conclusion(s) This study shows that critically ill COVID-19 patients with AF present a worse prognosis compared to patients without AF, and new-onset AF is an independent predictor of ICU mortality and MACE. Funding Acknowledgement Type of funding sources: None.

S50 Insulin Therapy vs Plasmapheresis in Patients With Hypertriglyceridemia-Associated Pancreatitis: A Systematic Review and Meta-Analysis

Introduction: Insulin therapy (IT) and plasmapheresis are used to treat hypertriglyceridemia-associated pancreatitis (HTAP). However, the optimal treatment modality for lowering the triglyceride level in patients with HTAP remains unclear. Therefore, we evaluated the efficacy and safety of IT and plasmapheresis in managing HTAP. Methods: We performed a comprehensive literature search using PubMed, Embase, and Web of Science databases through May 30, 2022, for all studies that compared IT vs. plasmapheresis in patients with HTAP. The primary outcomes were effectiveness (reduction in triglycerides within 24-hours of admission) and clinical outcomes, including hospital length-of-stay (LOS), mortality, acute renal failure (ARF), hypotension, and need for invasive mechanical ventilation (IMV). The secondary outcome was the overall treatment-related adverse events (AEs). Random-effects meta-analysis was conducted, and risk ratio (RR) and mean difference (MD) or standardized mean difference (SMD) for proportional and continuous variables were computed, respectively. For each outcome, forest plot, 95% confidence interval (CI), P-value (< 0.05 considered statistically significant), and I2 statistic ( > 50% considered as significant heterogeneity) were generated. Results: Six studies (1 randomized controlled trial [RCT] and 5 cohort studies) with 302 patients with HTAP (167 on IT vs. 135 on plasmapheresis) were included. Plasmapheresis was more effective than IT in reduction of triglycerides within 24-hours (SMD -0.57; 95% CI -1.02, -0.13; P=0.01, I2=56.8%, Figure 1A). However, LOS (MD -1.96; 95% CI -4.45, 0.54; P=0.12; I2=0%, Figure 1B), mortality (RR 0.68, 95% CI 0.28-1.64, P=0.39, I2=0%, Figure 1C), ARF (RR 0.44, 95% CI 0.06-3.05, P=0.41, I2=84%), hypotension (RR 0.63, 95% CI 0.16-2.52, P=0.51, I2=79%), and need for IMV (RR 0.52, 95% CI 0.12-12.35, P=0.40, I2=80%) were similar between two groups. The treatment-related AEs were significantly lower in IT than plasmapheresis (RR 0.14, 95% CI 0.04-0.51, P=0.003, I2=0%, Figure 1D). Conclusion: Our meta-analysis demonstrated that despite the greater reduction of triglycerides with plasmapheresis compared to insulin therapy, the clinical outcomes, including LOS, mortality, ARF, hypotension, and need for IMV, were comparable with lower treatment-related adverse events with insulin therapy. Future large-scale RCTs are necessary to validate our findings.Figure 1.: Forest plots comparing between insulin therapy and plasmapheresis regarding: (A) the reduction of triglyceride within 24 hours, (B) length of hospital stay, (C) mortality, and (D) treatment-related adverse events.

BARICITINIB IN HOSPITALIZED PATIENTS WITH COVID-19: META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

SESSION TITLE: Acute COVID-19 and Beyond: from Hospital to HomeboundSESSION TYPE: Original InvestigationsPRESENTED ON: 10/18/2022 02:45 pm - 03:45 pmPURPOSE: To date, only dexamethasone, tocilizumab, and casirivimab/imdevimab have been shown to reduce mortality in COVID-19 patients. Baricitinib is a selective Janus kinase 1/2 inhibitor with known anti-inflammatory and anti-viral properties. We sought to perform a meta-analysis of RCTs assessing the role of baricitinib in hospitalized patients with COVID-19 disease.METHODS: Electronic databases such as MEDLINE, EMBASE, and Cochrane Central were searched till March 20, 2022, for randomized controlled trials evaluating the efficacy of baricitinib in hospitalized COVID-19 patients. The outcomes assessed were 28-day mortality, progression to respiratory failure needing positive pressure ventilation or death, progression to mechanical ventilation or ECMO, duration of hospitalization and time to discharge.RESULTS: Four studies (with 10,815 patients) were included in the analysis. In total, 5,477 patients received baricitinib, and 5,338 patients received standard care. Pooled analysis showed a significantly decreased risk of 28-day mortality (OR 0.85, 95% CI 0.76-0.96, p=0.006) and progression to invasive mechanical ventilation or ECMO (OR 0.80, 95% CI 0.69-0.94, p=0.005) in the baricitinib arm compared to standard therapy or placebo. In addition, there was a significant reduction in duration of hospitalization (MD -1.43, 95% CI -2.46, -0.40, p=0.007) and time to recovery (MD -0.88, 95% CI -1.34, -0.41, p=0.0002).CONCLUSIONS: Baricitinib improved the patient-centric outcomes of mortality and progression to severe disease i.e., need for invasive mechanical ventilation, in hospitalized patients with COVID-19 disease compared with standard therapy alone.CLINICAL IMPLICATIONS: Baricitinib may be used in conjunction with standard of care treatments to improve morbidity and mortality in hospitalized COVID-19 patients.DISCLOSURES: No relevant relationships by Gerardo CarinoNo relevant relationships by ARKADIY FINNNo relevant relationships by Amos LalNo relevant relationships by VIJAIRAM SELVARAJ SESSION TITLE: Acute COVID-19 and Beyond: from Hospital to Homebound SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: To date, only dexamethasone, tocilizumab, and casirivimab/imdevimab have been shown to reduce mortality in COVID-19 patients. Baricitinib is a selective Janus kinase 1/2 inhibitor with known anti-inflammatory and anti-viral properties. We sought to perform a meta-analysis of RCTs assessing the role of baricitinib in hospitalized patients with COVID-19 disease. METHODS: Electronic databases such as MEDLINE, EMBASE, and Cochrane Central were searched till March 20, 2022, for randomized controlled trials evaluating the efficacy of baricitinib in hospitalized COVID-19 patients. The outcomes assessed were 28-day mortality, progression to respiratory failure needing positive pressure ventilation or death, progression to mechanical ventilation or ECMO, duration of hospitalization and time to discharge. RESULTS: Four studies (with 10,815 patients) were included in the analysis. In total, 5,477 patients received baricitinib, and 5,338 patients received standard care. Pooled analysis showed a significantly decreased risk of 28-day mortality (OR 0.85, 95% CI 0.76-0.96, p=0.006) and progression to invasive mechanical ventilation or ECMO (OR 0.80, 95% CI 0.69-0.94, p=0.005) in the baricitinib arm compared to standard therapy or placebo. In addition, there was a significant reduction in duration of hospitalization (MD -1.43, 95% CI -2.46, -0.40, p=0.007) and time to recovery (MD -0.88, 95% CI -1.34, -0.41, p=0.0002). CONCLUSIONS: Baricitinib improved the patient-centric outcomes of mortality and progression to severe disease i.e., need for invasive mechanical ventilation, in hospitalized patients with COVID-19 disease compared with standard therapy alone. CLINICAL IMPLICATIONS: Baricitinib may be used in conjunction with standard of care treatments to improve morbidity and mortality in hospitalized COVID-19 patients. DISCLOSURES: No relevant relationships by Gerardo Carino No relevant relationships by ARKADIY FINN No relevant relationships by Amos Lal No relevant relationships by VIJAIRAM SELVARAJ

Characteristics and outcomes of SARS-COV 2 critically ill patients after emergence of the variant of concern 20H/501Y.V2: A comparative cohort study.

There are currently no data regarding characteristics of critically ill patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) variant of concern (VOC) 20H/501Y.V2. We therefore aimed to describe changes of characteristics in critically ill patients with Covid-19 between the first and the second wave when viral genome sequencing indicated that VOC was largely dominant in Mayotte Island (Indian Ocean). Consecutive patients with Covid-19 and over 18 years admitted in the unique intensive care unit (ICU) of Mayotte during wave 2 were compared with an historical cohort of patients admitted during wave 1. We performed a LR comparing wave 1 and wave 2 as outcomes. To complete analysis, we built a Random Forest model (RF), that is, a machine learning classification tool- using the same variable set as that of the LR. We included 156 patients, 41 (26.3%) and 115 (73.7%) belonging to the first and second waves respectively. Univariate analysis did not find difference in demographic data or in mortality. Our multivariate LR found that patients in wave 2 had less fever (absence of fever aOR 5.23, 95% confidence interval (CI) 1.89–14.48, p = .001) and a lower simplified acute physiology score (SAPS II) (aOR 0.95, 95% CI 0.91–0.99, p = .007) at admission; at 24 hours, the need of invasive mechanical ventilation was higher (aOR 3.49, 95% CI 0.98–12.51, p = .055) and pO2/FiO2 ratio was lower (aOR 0.99, 95 % CI 0.98–0.99, p = .03). Patients in wave 2 had also an increased risk of ventilator-associated pneumonia (VAP) (aOR 4.64, 95% CI 1.54–13.93, p = .006). Occurrence of VAP was also a key variable to classify patients between wave 1 and wave 2 in the variable importance plot of the RF model. Our data suggested that VOC 20H/501Y.V2 could be associated with a higher severity of respiratory failure at admission and a higher risk for developing VAP. We hypothesized that the expected gain in survival brought by recent improvements in critical care management could have been mitigated by increased transmissibility of the new lineage leading to admission of more severe patients. The immunological role of VOC 20H/501Y.V2 in the propensity for VAP requires further investigations.

Factors Associated With Non-invasive Oxygen Therapy Failure in COVID-19 Pneumonia: A Single Center, Retrospective Study in a Tertiary Hospital in North India.

Non-invasive oxygen therapy (NIT) consists of high-flow nasal oxygen (HFNO) and continuous positive airway pressure (CPAP). NIT is routinely being used for the management of acute respiratory failure secondary to coronavirus disease-2019 (COVID-19) with variable outcomes. However, previously published studies show that NIT failure might delay endotracheal intubation and invasive mechanical ventilationand results in worse outcomes in patients with hypoxemic respiratory failure. Early prediction of failure of NIT, will help in early decision-making in initiating invasive mechanical ventilation. We retrospectively studied the predictors for NIT failure in patients with moderate to severe COVID-19. Adult patients (>18 years) admitted to the intensive care unit (ICU) with moderate to severe COVID-19 ARDSand received NIT [HFNO and CPAP non-invasive ventilation (NIV)] were included in this study. Baseline clinical and laboratory data were collected retrospectively from the electronic hospital information system. NIT failure was defined as the need for invasive mechanical ventilation after the initiation of NIT in the ICU. Univariate and multivariate logistic regression analyses were used to find out the possible predictors of NIT failure. Out of 254 patients admitted to ICU, 127 patients were initiated NIT at admission to ICU. During the course of the ICU stay, 33 (26%) patients subsequently required invasive mechanical ventilation (NIT failure). Respiratory rate-oxygenation index (ROX index) of <2.97 at two hours and <3.63 at six hours of ICU admission predicted NIT failure in our cohort of patients with a high positive predictive value. Patient selection is crucial for successful NIT in COVID-19. Application of ROX index measured in the first six hours of ICU admission helps in the identification of patients at risk of NIT failure with moderate to severeCOVID-19 ARDS.

Nasal Cannula with Long and Narrow Tubing for Non-Invasive Respiratory Support in Preterm Neonates: A Systematic Review and Meta-Analysis.

Background: Cannulas with long and narrow tubing (CLNT) are increasingly being used as an interface for noninvasive respiratory support (NRS) in preterm neonates; however, their efficacy compared to commonly used nasal interfaces such as short binasal prongs (SBP) and nasal masks (NM) has not been widely studied. Material and Methods: Medline, Embase, CENTRAL, Health Technology Assessment Database, and Web of Science were searched for randomized clinical trials (RCTs) and observational studies investigating the efficacy of CLNT compared to SBP or NM in preterm neonates requiring NRS for primary respiratory and post-extubation support. A random-effects meta-analysis was used for data synthesis. Results: Three RCTs and three observational studies were included. Clinical benefit or harm could not be ruled out for the outcome of need for invasive mechanical ventilation (IMV) for CLNT versus SBP or NM [relative risk (RR) 1.37, 95% confidence interval (CI) 0.61–3.04, certainty of evidence (CoE) low]. The results were also inconclusive for the outcome of treatment failure [RR 1.20, 95% CI 0.48–3.01, CoE very low]. Oropharyngeal pressure transmission was possibly lower with CLNT compared to other interfaces [MD −1.84 cm H20, 95% CI −3.12 to −0.56, CoE very low]. Clinical benefit or harm could not be excluded with CLNT compared to SBP or NM for the outcomes of duration of IMV, nasal trauma, receipt of surfactant, air leak, and NRS duration. Conclusion: Very low to low CoE and statistically nonsignificant results for the clinical outcomes precluded us from making any reasonable conclusions; however, the use of CLNT as an NRS interface, compared to SBP or NM, possibly transmits lower oropharyngeal pressures. We suggest adequately powered multicentric RCTs to evaluate the efficacy of CLNT when compared to other interfaces.

Breastfeeding impact on patent ductus arteriosus closure in preterm newborns

Background. Patent ductus arteriosus (PDA) is a serious problem in clinical neonatology and pediatrics. Today treatment of PDA remains debatable because of high risk of complications with medical and invasive treatment. The purpose of the study was to determine the dependence of PDA closure on the type of feeding the newborn. Materials and methods. We have made a retrospective analysis of 300 case histories of children in neonatal units. We selected two comparison groups: the main group consisted of breastfed babies born at 37 weeks gestation (n = 102); controls — preterm infants who received artificial feeding since birth (n = 198). Results. At discharge from the hospital, 44 (14.7 ± 2.0 %) children had PDA (p &lt; 0.05). The percentage of infants on artificial feeding with PDA was 2.3 times higher compared to breastfed babies: 18.2 ± 2.7 % versus 7.8 ± 2.7 % (p = 0.017 by χ2 test). Respiratory distress syndrome was more common in the control group as well: 72.7 ± 3.2 % versus 46.1 ± 4.9 % (p &lt; 0.001). Additionally, the group of formula-fed children more often had severe complications of respiratory distress syndrome: respiratory failure type III — 25.8 ± 3.1 % versus12.7 ± 3.3 % (р = 0.009); development of bronchopulmonary dysplasia — 13.1 ± 2.4 % versus 2.9 ± 1.7 % (p = 0.005). The need for invasive mechanical ventilation in the intensive care unit was observed much less often in breastfed children. Moreover, the level of respiratory disorders (type II respiratory failure) in both groups differed insignificantly (p = 0.742): 24.5 ± 4.3 % in the main group and 26.3 ± 3.1 % in controls. Conclusions. Breastfeeding from the first days of life contributes to the closure of the ductus arteriosus and the favorable course of respiratory distress syndrome in premature babies.

An algorithm to predict the need for invasive mechanical ventilation in hospitalized COVID-19 patients: the experience in Sao Paulo.

We aimed to characterize patients hospitalized for coronavirus disease 2019 (COVID-19) and identify predictors of invasive mechanical ventilation (IMV). We performed a retrospective cohort study in patients with COVID-19 admitted to a private network in Sao Paulo, Brazil from March to October 2020. Patients were compared in three subgroups: non-intensive care unit (ICU) admission (group A), ICU admission without receiving IMV (group B) and IMV requirement (group C). We developed logistic regression algorithm to identify predictors of IMV. We analyzed 1,650 patients, the median age was 53 years (42-65) and 986 patients (59.8%) were male. The median duration from symptom onset to hospital admission was 7 days (5-9) and the main comorbidities were hypertension (42.4%), diabetes (24.2%) and obesity (15.8%). We found differences among subgroups in laboratory values obtained at hospital admission. The predictors of IMV (odds ratio and 95% confidence interval [CI]) were male (1.81 [1.11-2.94], P=0.018), age (1.03 [1.02-1.05], P<0.001), obesity (2.56 [1.57-4.15], P<0.001), duration from symptom onset to admission (0.91 [0.85-0.98], P=0.011), arterial oxygen saturation (0.95 [0.92- 0.99], P=0.012), C-reactive protein (1.005 [1.002-1.008], P<0.001), neutrophil-to-lymphocyte ratio (1.046 [1.005-1.089], P=0.029) and lactate dehydrogenase (1.005 [1.003-1.007], P<0.001). The area under the curve values were 0.860 (95% CI, 0.829-0.892) in the development cohort and 0.801 (95% CI, 0.733-0.870) in the validation cohort. Patients had distinct clinical and laboratory parameters early in hospital admission. Our prediction model may enable focused care in patients at high risk of IMV.

Validity of the ROX index in predicting invasive mechanical ventilation requirement in pneumonia

BackgroundThe ROX index (Respiratory rate-OXygenation) has been described as a prediction tool to identify the need for invasive mechanical ventilation (IMV) in community-acquired pneumonia (CAP) with acute hypoxaemic respiratory failure...

Chest CT Severity Score and Systemic Inflammatory Biomarkers as Predictors of the Need for Invasive Mechanical Ventilation and of COVID-19 Patients' Mortality.

Background: Numerous tools, including inflammatory biomarkers and lung injury severity scores, have been evaluated as predictors of disease progression and the requirement for intensive therapy in COVID-19 patients. This study aims to verify the predictive role of inflammatory biomarkers [monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), systemic inflammatory index (SII), Systemic Inflammation Response Index (SIRI), Aggregate Index of Systemic Inflammation (AISI), and interleukin-6 (IL-6)] and the total system score (TSS) in the need for invasive mechanical ventilation (IMV) and mortality in COVID-19 patients. Methods: The present study was designed as an observational, analytical, retrospective cohort study and included all patients over 18 years of age with a diagnosis of COVID-19 pneumonia, confirmed through real time-polymerase chain reaction (RT-PCR) and radiological chest CT findings admitted to County Emergency Clinical Hospital of Targu-Mureș, Romania, and Modular Intensive Care Unit of UMFST “George Emil Palade” of Targu Mures, Romania between January 2021 and December 2021. Results: Non-Survivors patients were associated with higher age (p = 0.01), higher incidence of cardiac disease [atrial fibrillation (AF) p = 0.0008; chronic heart failure (CHF) p = 0.01], chronic kidney disease (CKD; p = 0.02), unvaccinated status (p = 0.001), and higher pulmonary parenchyma involvement (p < 0.0001). Multivariate analysis showed a high baseline value for MLR, NLR, SII, SIRI, AISI, IL-6, and TSS independent predictor of adverse outcomes for all recruited patients. Moreover, the presence of AF, CHF, CKD, and dyslipidemia were independent predictors of mortality. Furthermore, AF and dyslipidemia were independent predictors of IMV need. Conclusions: According to our findings, higher MLR, NLR, SII, SIRI, AISI, IL-6, and TSS values at admission strongly predict IMV requirement and mortality. Moreover, patients above 70 with AF, dyslipidemia, and unvaccinated status highly predicted IMV need and fatality. Likewise, CHF and CKD were independent predictors of increased mortality.

Body mass index and clinical outcome of severe COVID-19 patients with acute hypoxic respiratory failure: Unravelling the "obesity paradox" phenomenon.

Background and aimsAlthough obesity have been generally shown to be an independent risk factor for poor outcomes in COVID-19 infection, some studies demonstrate a paradoxical protective effect (“obesity paradox”). This study examines the influence of obesity categories on clinical outcomes of severe COVID-19 patients admitted to an intensive care unit with acute hypoxic respiratory failure requiring either non-invasive or invasive mechanical ventilation.MethodsThis is a single centre, retrospective study of consecutive COVID-19 patients admitted to the intensive care unit between 03/2020 to 03/2021. Patients were grouped according to the NICE Body Mass Index (BMI) category. Admission variables including age, sex, comorbidities, and ICU severity indices (APACHE-II, SOFA and PaO2/FiO2) were collected. Data were compared between BMI groups for outcomes such as need for invasive mechanical ventilation (IMV), renal replacement therapy (RRT) and 28-day and overall hospital mortality.Results340 patients were identified and of those 333 patients had their BMI documented. Just over half of patients (53%) had obesity. Those with extreme obesity (obesity groups II and III) were younger with fewer comorbidities, but were more hypoxaemic at presentation, than the healthy BMI group. Although non-significant, obesity groups II and III paradoxically showed a lower in-hospital mortality than the healthy weight group. However, adjusted (age, sex, APACHE-II and CCI) competing risk regression analysis showed three-times higher mortality in obese category I (sub-distribution hazard ratio = 3.32 (95% CI 1.30–8.46), p = 0.01) and a trend to higher mortality across all obesity groups compared to the healthy weight group.ConclusionsIn this cohort, those with obesity were at higher risk of mortality after adjustment for confounders. We did not identify an “obesity paradox” in this cohort. The obesity paradox may be explained by confounding factors such as younger age, fewer comorbidities, and less severe organ failures. The impact of obesity on indicators of morbidity including likelihood of requirement for organ support measures was not conclusively demonstrated and requires further scrutiny.

Predictors of invasive mechanical ventilation in hospitalized COVID-19 patients: a retrospective study from Jordan

ABSTRACT Objectives To identify early indicators for invasive mechanical ventilation utilization among COVID-19 patients. Methods This retrospective study evaluated COVID-19 patients who were admitted to hospital from 20 September 2020, to 8 August 2021. Multivariable logistic regression and machine learning (ML) methods were employed to assess variable significance. Results Among 1,613 confirmed COVID-19 patients, 365 patients (22.6%) received invasive mechanical ventilation (IMV). Factors associated with IMV included older age >65 years (OR,1.46; 95%CI, 1.13–1.89), current smoking status (OR, 1.71; 95%CI, 1.22–2.41), critical disease at admission (OR, 1.97; 95%CI, 1.28–3.03), and chronic kidney disease (OR, 2.07; 95%CI, 1.37–3.13). Laboratory abnormalities that were associated with increased risk for IMV included high leukocyte count (OR, 2.19; 95%CI, 1.68–2.87), low albumin (OR, 1.76; 95%CI, 1.33–2.34) and high AST (OR, 1.71; 95%CI, 1.31–2.22). Conclusion Our study suggests that there are several factors associated with the increased need for IMV among COVID-19 patients. These findings will help in early identification of patients at high risk for IMV and reallocation of hospital resources toward patients who need them the most to improve their outcomes.

Ability of IMPROVE and IMPROVE-DD scores to predict outcomes in patients with severe COVID-19: a prospective observational study

In this study we aimed to evaluate the ability of IMPROVE and IMPROVE-DD scores in predicting in-hospital mortality in patients with severe COVID-19. This prospective observational study included adult patients with severe COVID-19 within 12 h from admission. We recorded patients' demographic and laboratory data, Charlson comorbidity index (CCI), SpO2 at room air, acute physiology and chronic health evaluation II (APACHE II), IMPROVE score and IMPROVE-DD score. In-hospital mortality and incidence of clinical worsening (the need for invasive mechanical ventilation, vasopressors, renal replacement therapy) were recorded. Our outcomes included the ability of the IMPROVE and IMPROVE-DD to predict in-hospital mortality and clinical worsening using the area under receiver operating characteristic curve (AUC) analysis. Multivariate analysis was used to detect independent risk factors for the study outcomes. Eighty-nine patients were available for the final analysis. The IMPROVE and IMPROVE-DD score showed the highest ability for predicting in-hospital mortality (AUC [95% confidence intervals {CI}] 0.96 [0.90–0.99] and 0.96 [0.90–0.99], respectively) in comparison to other risk stratification tools (APACHE II, CCI, SpO2). The AUC (95% CI) for IMPROVE and IMPROVE-DD to predict clinical worsening were 0.80 (0.70–0.88) and 0.79 (0.69–0.87), respectively. Using multivariate analysis, IMPROVE-DD and SpO2 were the only predictors for in-hospital mortality and clinical worsening. In patients with severe COVID-19, high IMPROVE and IMOROVE-DD scores showed excellent ability to predict in-hospital mortality and clinical worsening. Independent risk factors for in-hospital mortality and clinical worsening were IMPROVE-DD and SpO2.

Outcomes in neonates with respiratory distress syndrome using Saana non-invasive ventilation

Background: In low-and-middle income countries (LMICs), neonatal mortality is still unacceptably high compared to developed nations. Respiratory distress syndrome (RDS) is one of the major contributors to high mortality rates in this population. This study was conducted to analyze the effects of Saans non-invasive ventilation (NIV), an infrastructure-independent continuous positive airway pressure (CPAP) and resuscitation device, on neonatal mortality and cost compared to current practices.Methods: This single-center, prospective, observational analytical study was to determine the efficacy of Saans NIV in delivering CPAP and resuscitation therapy to neonates diagnosed with RDS.Results: An 82% success rate was recorded while using Saans NIV for CPAP and resuscitation therapy in this study, which was far superior to the global average. This also means that 82% of the patients included in this study avoided invasive mechanical ventilation. After a cost analysis, we concluded that invasive mechanical ventilation would cost $3478 USD for treatment vs. just $155 USD for patients treated with traditional CPAP therapy.Conclusions: Infrastructure-independent devices such as Saans NIV are game-changers in LMICs. Saans NIV makes CPAP and safe resuscitation therapy available in resource-constrained settings and during transport. This study showcases that Saans NIV can significantly reduce the need for invasive mechanical ventilation and the costs associated with treating neonates.

COVID-19 in Kidney Transplant Recipients With Diabetes Mellitus: A Propensity Score Matching Analysis.

Kidney transplant recipients present higher rates of pre-existing comorbidities, in particular diabetes mellitus (DM), hypertension, and cardiac disease. We aimed to verify the main risk factors related to DM that contribute to COVID-19 progression and mortality in a kidney transplant setting. From March to August 2020, we evaluated 300 kidney transplant recipients affected by COVID-19. We used propensity score matching (PSM) to estimate the impact of DM on COVID-19. After matching, all baseline characteristics were well balanced between those with and without DM (n = 100 in each group). Case fatality rate, the requirement of invasive mechanical ventilation (IMV), and acute kidney injury (AKI) were associated with previous fasting blood glucose, and C-reactive protein (CRP), and lactate dehydrogenase (LDH) levels on admission. These findings were similar in kidney transplant patients with and without DM. Glycemia on admission and estimated glomerular filtration rate (eGFR) either on admission or basal correlated to the need of IMV and development of AKI, respectively. Poor glycaemic control, eGFR, markers of inflammation (CRP) and tissue damage (LDH) were indicative of COVID-19 burden in kidney transplant recipients and may be useful tools for risk-stratifying this population, independently of the DM status, during the pandemic.

Prognostic Value of Serum Cholinesterase Activity in Severe SARS-CoV-2-Infected Patients Requiring Intensive Care Unit Admission.

ABSTRACT.We evaluated the prognostic value of serum cholinesterase (SChE) levels in SARS-CoV-2–infected patients requiring intensive care unit (ICU) admission. This is a retrospective study of severe, critically ill, adult COVID-19 patients, all of whom had a confirmed SARS-CoV-2 infection and were admitted into the ICU of a university hospital. We included all patients admitted to our ICU and whose SChE levels were explored on ICU admission and during ICU stay. One hundred and thirty-seven patients were included. There were 100 male and 37 female patients. The mean of SChE activity on ICU admission was 5,656 ± 1,818 UI/L (range: 1926–11,192 IU/L). The SChE activity on ICU admission was significantly lower in nonsurvivors (P < 0.001). A significant association between the SChE activity on ICU admission and the need for invasive mechanical ventilation was found. We also found a significant correlation between the SChE activity and other biomarkers of sepsis (C-reactive protein, procalcitonin, and leukocytes) on ICU admission and during the ICU stay. A significant correlation among SChE nadir value activity recorded during ICU stay, the occurrence of nosocomial infection, and the outcome of studied patients was found. Our study shows that the low SChE activity value is associated with a severe outcome. It might be used as a biomarker to aid in prognostic risk stratification in SARS-CoV-2–infected patients. Further studies for external validation of our findings are needed on this subject.