Risk Of Respiratory Distress Syndrome Research Articles

Prevalence of respiratory distress syndrome in premature twins compared to premature singletons

<p><strong>Aim</strong> To estimate prevalence of respiratory distress syndrome in preterm twins compared to preterm singletons. <br /><strong>Methods</strong> This is a retrospective observational point prevalence study conducted at the level of three neonatal intensive care units. Medical records of all preterm newborns (<37 weeks of gestation) with respiratory distress syndrome treated in a two-year period were reviewed. The birth order of twins, gestational age and mortality were analyzed.<br /><strong>Results</strong> Out of 809 preterm newborns, 104 (12.9%) were twins. Median gestational age at birth was 30.3 (IQR 31.4–34.2) weeks. Respiratory distress syndrome was diagnosed in 525 (64.9 %) preterm newborns, of which 441 singletons and 84 twins. Prevalence of respiratory distress syndrome in first-born twins was not significantly higher compared with singletons, 67.3% (35/52) vs. 62.6 % (441/705), respectively (p=0.06). Prevalence of respiratory distress syndrome in second-born twins was 94.2 % (49/52), which was significantly higher compared with both singletons and first-born twins (p<0.001). The mortality rate of preterm newborns was significantly higher in second-born twins compared with singletons and first-born twins, 15.4 % vs. 6.8 %  (p<0.001) and 15.4 % vs. 5.5% (p<0.001), respectively. <br /><strong>Conclusion</strong> There was a higher risk of respiratory distress syndrome and higher mortality rate in twins compared with singletons, but only in second-born twins the difference was statistically significant.</p>

P-754 Association between ovarian hyperstimulation syndrome and adverse obstetric and neonatal outcomes in Korea: a nationwide health insurance database study

Abstract Study question Does OHSS affect maternal and neonatal outcomes in perinatal life? Summary answer OHSS is associated with an increased risk of postpartum hemorrhage, large birth weight, neonatal respiratory distress syndrome, and intraventricular hemorrhage. What is known already Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic condition caused by ovulation induction. Golan et al.(1989)’s clinical staging system categorizes OHSS into mild, moderate, and severe based on the clinical characteristics. Among them, severe OHSS is considered potentially fatal and requires hospitalization. In 2021, a systematic review of 3,303 pregnant patients with OHSS and 89,720 pregnant patients without OHSS, drawn from 13 studies, revealed a notable impact of OHSS on preterm birth. However, owing to the characteristics of spontaneous resolution in the relatively early stages of pregnancy, no large-scale study has confirmed the OHSS and pregnancy outcomes. Study design, size, duration This retrospective study utilized a combined dataset from two primary sources: the Korea National Health Insurance (KNHI) claims database and the National Health Screening Program for Infants and Children (NHSP-IC) database. We identified all women who delivered between January 1, 2012, and December 31, 2020 from KNHI claims database. Pregnancy outcomes including preterm birth and PPH were identified from NHSP-IC database and KNHI claims database, respectively. Participants/materials, setting, methods We enrolled all women who delivered between January 1, 2012, and December 31, 2020 (N = 3,446,520). Women diagnosed with multiple pregnancy or had missing data were excluded (N = 2,565,461). The participants were divided into three groups according to the presence or absence of an ovarian hyperstimulation diagnosis code (ICD-10 code N981) and hospitalization within 3 months before pregnancy: non-OHSS group (N = 2,562,562), mild-to-moderate OHSS group (N = 2,293), severe OHSS group (N = 606). Main results and the role of chance In this study, mothers in the ovarian hyperstimulation group had a younger age and a higher rate incidence of primiparity and cesarean section. In the ovarian hyperstimulation group, a significantly high proportion of patients was diagnosed with pre-pregnancy hypertension or diabetes mellitus and gestational hypertension or gestational diabetes. The risk of postpartum hemorrhage was 38.2% higher in the mild-to-moderate OHSS group than in the non-OHSS group (adjusted odds ratio (aOR): 1.382, 95% confidence interval (CI): 1.223–1.562). No difference was found in the average birth weight of newborns according to the presence or absence of OHSS. However, the risk of macrosomia was elevated by 62.4% in the severe OHSS group (aOR: 1.624, 95% CI: 1.168–2.259) than the non-OHSS group. The mild-to-moderate OHSS group had a 36.8% higher risk of respiratory distress syndrome compared with the non-OHSS group (aOR: 1.368, 95% CI: 1.149–1.629). The mild-to-moderate OHSS group had a 2.697-fold increased risk of intraventricular hemorrhage compared with the non-OHSS group (aOR: 2.697, 95% CI: 1.338–5.437). Limitations, reasons for caution A limitation lies in the unknown details of the controlled ovarian stimulation protocol, type and dose of gonadotrophin used, hormone concentration, and embryo transfer method used due to the data structure. Despite the potential variations in the causes of hospitalization, hospitalized patients were classified into the severe OHSS group. Wider implications of the findings Although OHSS occurs during early pregnancy, further research is required to determine its long-term effects. Especially, if the incidence of IVH is significantly higher in the OHSS group, particularly among uncommon full-term neonates, further studies are warranted. Trial registration number Not Applicable

Ethanol promotes protease activated receptor 1: Chemokine (C-X-C motif) receptor 4 heteromerization and enhances thrombin-induced impairment of human lung endothelial cell barrier function

-Ethanol enhances the propensity of PAR1 and CXCR4 to form heteromers.-Ethanol increases PAR1:CXCR4 heteromer expression in human lung microvascular endothelial cells (HULEC-5a).-Ethanol enhances the efficacy of PAR1 to activate Gα12 upon thrombin stimulation in cells co-expressing CXCR4.-Ethanol dose-dependently increases the efficacy of thrombin to impair HULEC-5a barrier function at clinically relevant concentrations.-Interference with PAR1:CXCR4 heteromerization mitigates effects of ethanol on thrombin-induced impairment of HULEC-5a barrier function.-Our findings provide a molecular mechanism that is likely to contribute to the increased risk of acute respiratory distress syndrome with alcohol abuse.

Exploring outcomes in hospitalized patients with COVID-19 based on nutritional status: Comparing those with and without a cancer diagnosis.

e23068 Background: This study explores how nutritional status impacts COVID-19 outcomes, particularly in patients with cancer. Obesity is known to heighten risk of adult respiratory distress syndrome in COVID-19, malnutrition and its associated effects related to the immune response, respiratory compromise, debility, and other adverse outcomes has not been well defined in this patient population. Methods: In this retrospective cohort study, we examined data from the Charleston Area Medical Center’s (CAMC) COVID-19 Registry, involving 5,479 adult, symptomatic, PCR-positive COVID-19 hospitalized patients (3/1/20 to 1/20/24). Low nutritional status (LNS) was defined as Body Mass Index (BMI) < 18.5 kg/m² or serum albumin < 3.5g/dL). Demographics, comorbidities, lab values, treatments, and outcomes were assessed. Propensity score matching (3:1) non-cancer patients vs those with an active cancer diagnosis was undertaken using sex, age, and BMI. SAS 9.4 was utilized for the analysis. The groups were compared using Chi-square/Fisher’s Exact tests for categorical variables and t-tests for continuous variables. Multivariate analysis was utilized to determine predictors of adverse outcomes. Results: A cohort of 1,146 non-cancer and 382 active cancer patients were included in the study. The LNS subgroup had a higher frequency of active cancer (29.2% vs 19.3%, p < 0.001), higher rates of diabetes (27.0% vs17.8%, p = 0.03) and chronic kidney disease (18.8% vs 11.7%, p = 0.02). They had greater frequencies of abnormal ferritin levels (57.8% vs 42.7%, p < 0.001), CRP levels > 3 mg/L (96.6% vs 90.3%, p < 0.001), and elevated procalcitonin levels > 0.05 ng/mL (71.2% vs 50.1%, p < 0.001). LNS patients had a higher mortality rate (22.3% vs 9.7%, p < 0.001), a higher need for mechanical ventilation (19.3% vs 9.5%, p < 0.001), and intensive care unit (ICU) admission (35.7% vs 19.5%, p < 0.001. Predictors of mortality included LNS (OR = 2.2, 95%CI [1.5-3.2], p < 0.001), an active cancer diagnosis (OR = 1.7, 95% CI [1.2-2.6], p = 0.003), chronic kidney disease (OR = 1.8 95%CI [1.3-2.5], p = 0.004) and concurrent bacterial pneumonia (OR = 4.9 95%CI [3.3-7.2], p < 0.001). Conclusions: In patients with COVID-19, those with LNS had higher rates of co-morbid conditions including active cancer, higher rates of elevated inflammatory markers, mechanical ventilation, ICU admission, and mortality. Predictors of mortality included concurrent bacterial pneumonia, cancer diagnosis and chronic kidney disease, with LNS increasing the risk of mortality by more than two-fold. These results support the recommendation of early nutritional assessment and a multi-disciplinary approach to aggressive nutritional support in the COVID-19 patient population particularly in those with a concurrent high-risk condition such as cancer.

Clinical Characteristics and Outcomes of Disseminated Strongyloidiasis in the United States-A Multicenter Network Analysis.

Human strongyloidiasis is a potentially life-threatening parasitic disease among immunocompromised hosts. We aim to determine the factors and mortality associated with disseminated strongyloidiasis. We conducted a U.S.-based multicenter retrospective cohort study to determine 90-day clinical outcomes for people diagnosed with Strongyloides infection in the TriNetX patient database. We identified adult patients with the International Classification of Diseases (10th revision, clinical modification) code for Strongyloides infection (B78) or a positive Strongyloides IgG antibody test and captured outcomes at 90 days. We identified 5,434 patients with strongyloidiasis, of whom 48 had disseminated strongyloidiasis for 0.9% prevalence of disseminated disease. Systemic connective tissue disorders, pulmonary eosinophilia, liver cirrhosis, blood disorders (monoclonal gammopathy, aplastic anemia, and lymphoid malignancy), malnutrition, alcohol use disorder, and transplantation status were frequent in patients with disseminated disease. Mortality was significantly higher in people with disseminated disease at 30 days (21%). The 90-day risk of hospitalization, bacteremia, and acute respiratory distress syndrome (ARDS) was higher in those with disseminated infection. People with disseminated strongyloidiasis had a heightened risk of hospitalization, bacteremia, acute respiratory distress syndrome, and mortality. The population at risk for severe strongyloidiasis infection is evolving, reflecting conditions in which glucocorticoids or additional immunosuppressive medications are commonly used for treatment.

Maternal and neonatal outcomes associated with multiple repeat cesarean deliveries: A registry-based study from Qatar.

Cesarean delivery (CD) is associated with increased maternal and neonatal morbidity compared to vaginal delivery, particularly in cases classified as emergency procedures or when there are multiple CDs. This retrospective cohort study aims to examine the incidence of maternal and neonatal complications in women with multiple CDs. This study used data from a national perinatal database obtained from a single tertiary maternity care hospital. Women who delivered a singleton live birth after 24 weeks of gestation by CD were stratified into five groups based on the number of CDs, with the last group having five or more CDs. The women were divided into those with five or more CDs (Group 5) versus those with fewer than five (Groups 1 to 4). The maternal outcomes included intra-operative surgical complications, blood loss, and intensive care unit (ICU) admission. The neonatal outcomes included preterm birth, neonatal ICU (NICU) admission, respiratory distress syndrome (RDS), and perinatal death. Of the 6,316 women in the study, 2,608 (41.3%) had a primary CD. 30.3%, 17.5%, and 7.3% of the cohort had their second, third, and fourth CDs, respectively. Women undergoing the 5th CD and above formed the remaining 3.5% (227). Women in Group 5 had the highest risk of suffering a surgical complication (3.1%, p=0.015) and postpartum hemorrhage (7.5%, p=0.010). 24% of babies in Group 5 were born preterm (p<0.001). They also had a 3.5 times higher risk of having a surgical complication (RR=3.5, 95% CI 1.6-7.6, p=0.002), a 1.8 times higher risk of developing postpartum hemorrhage (RR=1.8, 95% CI 1.1-2.9, p=0.014), a 1.7 times higher risk of delivering between 32-37 weeks of gestation (RR=1.7, 95% CI 1.3-2.2, p<0.001), a higher risk of the baby getting admitted to NICU (RR=1.3, 95% CI 1.0-1.6, p=0.038), and developing RDS (RR=1.5, 95% CI 1.2-2.0, p=0.002) compared to Groups 1-4. The risks of neonatal outcomes such as NICU admission (RR 2.9, 95% CI 2.1-4.0) and RDS (RR 3.5, 95% CI 2.3-5.5) were much higher in elective CDs performed at term compared to preterm births (p<0.001 for both). Maternal morbidity significantly increases with the increasing number of CD. The increased risk of RDS and NICU admissions in the neonate with multiple CDs reflects lower gestational age and birthweight in these groups-consideration of preoperative steroids for lung maturation in these women to reduce neonatal morbidity warrants further discussion.

Elevated Hemoglobin A1c and the Risk of Developing ARDS in Two Cohort Studies

BackgroundOnly a subset of patients at risk for acute respiratory distress syndrome (ARDS) go on to develop it, and the contribution of preexisting comorbidities, such as diabetes, to ARDS risk is not well understood. Prior studies of the association between diabetes and ARDS yielded conflicting results. Research QuestionDoes assessing ARDS risk based on hemoglobin A1c (HbA1c) as a marker of long-term blood glucose levels, rather than a charted diagnosis of diabetes, clarify the relationship between diabetes and ARDS? Study Design and MethodsUsing data from two prospective observational cohorts of critically ill adults (VALID and EARLI), we analyzed the association between clinical HbA1c category and development of ARDS in patients with a risk factor for ARDS and at least one clinical HbA1c measurement within the 180 days prior through 14 days after enrollment. Results599 patients in VALID and 276 in EARLI met inclusion criteria, of whom 164 and 58 developed ARDS, respectively. Patients with a charted diagnosis of diabetes were not more likely to develop ARDS (VALID: 24.6% ARDS in non-diabetics vs. 30.0% in diabetics, p=0.14; EARLI: 19.6% vs. 22.8%, p=0.55). However, in VALID, patients categorized as diabetic with inadequate glycemic control based on their HbA1c had an increased risk of developing ARDS compared to those with a non-diabetic HbA1c (20.9% vs. 34.0%; p=0.0073), a finding that persisted in multivariable analysis (OR for diabetic with inadequate glycemic control vs. non-diabetic range HbA1c = 1.25, 95% CI 1.01-1.57). These findings were not reproduced in the smaller EARLI cohort, but were appreciated when the cohorts were combined for analysis. InterpretationElevated HbA1c may be associated with risk of developing ARDS, independent of clinical diagnosis of diabetes, but prospective validation is needed. If confirmed, these findings suggest that inadequate glycemic control could be an unrecognized risk factor for ARDS.

Smoking on the risk of acute respiratory distress syndrome: a systematic review and meta-analysis

BackgroundThe relationship between smoking and the risk of acute respiratory distress syndrome (ARDS) has been recognized, but the conclusions have been inconsistent. This systematic review and meta-analysis investigated the association between smoking and ARDS risk in adults.MethodsThe PubMed, EMBASE, Cochrane Library, and Web of Science databases were searched for eligible studies published from January 1, 2000, to December 31, 2023. We enrolled adult patients exhibiting clinical risk factors for ARDS and smoking condition. Outcomes were quantified using odds ratios (ORs) for binary variables and mean differences (MDs) for continuous variables, with a standard 95% confidence interval (CI).ResultsA total of 26 observational studies involving 36,995 patients were included. The meta-analysis revealed a significant association between smoking and an increased risk of ARDS (OR 1.67; 95% CI 1.33–2.08; P < 0.001). Further analysis revealed that the associations between patient-reported smoking history and ARDS occurrence were generally similar to the results of all the studies (OR 1.78; 95% CI 1.38–2.28; P < 0.001). In contrast, patients identified through the detection of tobacco metabolites (cotinine, a metabolite of nicotine, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of tobacco products) showed no significant difference in ARDS risk (OR 1.19; 95% CI 0.69–2.05; P = 0.53). The smoking group was younger than the control group (MD − 7.15; 95% CI − 11.58 to − 2.72; P = 0.002). Subgroup analysis revealed that smoking notably elevated the incidence of ARDS with extrapulmonary etiologies (OR 1.85; 95% CI 1.43–2.38; P < 0.001). Publication bias did not affect the integrity of our conclusions. Sensitivity analysis further reinforced the reliability of our aggregated outcomes.ConclusionsThere is a strong association between smoking and elevated ARDS risk. This emphasizes the need for thorough assessment of patients' smoking status, urging healthcare providers to vigilantly monitor individuals with a history of smoking, especially those with additional extrapulmonary risk factors for ARDS.

Endothelial knockdown of the tumor suppressor, WWOX, increases inflammation in ventilator-induced lung injury.

Chronic cigarette smoke exposure decreases lung expression of WWOX which is known to protect the endothelial barrier during infectious models of acute respiratory distress syndrome (ARDS). Proteomic analysis of WWOX-silenced endothelial cells (ECs) was done using tandem mass tag mass spectrometry (TMT-MS). WWOX-silenced ECs as well as those isolated from endothelial cell Wwox knockout (EC Wwox KO) mice were subjected to cyclic stretch (18% elongation, 0.5 Hz, 4 h). Cellular lysates and media supernatant were harvested for assays of cellular signaling, protein expression, and cytokine release. These were repeated with dual silencing of WWOX and zyxin. Control and EC Wwox KO mice were subjected to high tidal volume ventilation. Bronchoalveolar lavage fluid and mouse lung tissue were harvested for cellular signaling, cytokine secretion, and histological assays. TMT-MS revealed upregulation of zyxin expression during WWOX knockdown which predicted a heightened inflammatory response to mechanical stretch. WWOX-silenced ECs and ECs isolated from EC Wwox mice displayed significantly increased cyclic stretch-mediated secretion of various cytokines (IL-6, KC/IL-8, IL-1β, and MCP-1) relative to controls. This was associated with increased ERK and JNK phosphorylation but decreased p38 mitogen-activated kinases (MAPK) phosphorylation. EC Wwox KO mice subjected to VILI sustained a greater degree of injury than corresponding controls. Silencing of zyxin during WWOX knockdown abrogated stretch-induced increases in IL-8 secretion but not in IL-6. Loss of WWOX function in ECs is associated with a heightened inflammatory response during mechanical stretch that is associated with increased MAPK phosphorylation and appears, in part, to be dependent on the upregulation of zyxin.NEW & NOTEWORTHY Prior tobacco smoke exposure is associated with an increased risk of acute respiratory distress syndrome (ARDS) during critical illness. Our laboratory is investigating one of the gene expression changes that occurs in the lung following smoke exposure: WWOX downregulation. Here we describe changes in protein expression associated with WWOX knockdown and its influence on ventilator-induced ARDS in a mouse model.

The use of antenatal corticosteroids in preterm labour for the prevention of perinatal mortality in hospitals in Tanzania.

Antenatal corticosteroids (ACS) are given to pregnant women at risk of preterm delivery to hasten the maturation of the lungs, lowering the risk of newborn respiratory distress syndrome (RDS) and perinatal mortality. The aim of this study was to determine whether exposure to ACS was associated with lower rates of perinatal mortality and RDS in preterm infants delivered by women with preterm labour. This is a secondary analysis of data from four hospitals in Mwanza, Tanzania. All singletons and twins born to women who were in preterm labour between July 2019 and February 2020 and delivered in-hospital between 24 and 34 weeks of gestation were included. Data were recorded from participants' medical records and analysed using STATA Version 14. Over an eight-month period, 588 preterm infants were delivered to 527 women. One hundred and ninety (36.1%) women were given ACS. Infants who were exposed to ACS in utero had a lower rate of perinatal mortality (6.8% vs 19.1%) and RDS (12.3% vs 25.9%) compared to those not exposed to ACS. In adjusted multivariable models, ACS exposure was related to a lower risk of perinatal mortality, aRR 0.23 (95% CI 0.13 - 0.39), and RDS, aRR 0.45 (95% CI 0.30 - 0.68). ACS significantly reduced the risk of perinatal mortality and RDS among preterm infants exposed to ACS in utero and delivered by women in preterm labour. The use of ACS should be encouraged in low-resource settings where preterm birth is prevalent to improve perinatal outcomes.

The epidemiology and treatment outcomes of COVID-19 patients admitted to an intensive care unit in an Iranian hospital in Neyshabur city.

The COVID-19 pandemic and the infection of numerous individuals from diverse societies have emerged as major global challenges. Given the limited resources in intensive care units, effective bed management and resource allocation require a deep understanding of the disease. This study aimed to assess the epidemiology and treatment outcomes of COVID-19 patients admitted to an intensive care unit in an Iranian hospital in Neyshabur city. This cross-sectional study was conducted on COVID-19 patients hospitalized in intensive care units in Razavi Khorasan, Iran in 2021. Census sampling was used to include all intensive care units. Of the initial 480 cases, 54 cases were excluded based on the exclusion criteria, leaving 426 cases for the study. Data were collected with the help of a data collection form that was designed by the researcher and its content validity and reliability were measured with Cronbach's alpha coefficient (α = 89%.). Data were analyzed with SPSS version 20 software. Descriptive and inferential statistics were used to analyze the data. Mean, standard deviation, and interquartile range indicators were used for descriptive statistics, and absolute frequency and relative frequency (percentage) were used to show numbers and ratios. The mean (SD) age of the patients was 66.33 (15.05) years, and 49.3% were female. The results showed that arterial blood oxygen saturation, respiratory rate, and Alzheimer's disease were significant variables for predicting mortality. Furthermore, arterial blood oxygen saturation, respiratory rate, and the need for transfusion of blood products were significant variables in predicting hospitalization and the risk of acute respiratory distress syndrome (ARDS). This study demonstrated that arterial blood oxygen saturation, respiratory rate, and Alzheimer's disease are crucial variables for predicting death. Furthermore, arterial blood oxygen saturation and respiratory rate are significant factors in predicting the risk of ARDS.

Increased platelet to red blood cell transfusion ratio associated with acute kidney injury in children with life-threatening bleeding.

Transfusion may increase the risk of organ failure through immunomodulatory effects. The primary objective of this study was to assess for patient or transfusion-related factors that are independently associated with the risk of acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in a cohort of children with life-threatening bleeding from all etiologies. In a secondary analysis of the prospective observational massive transfusion in children (MATIC) study, multivariable logistic regression was performed in an adjusted analysis to determine if blood product ratios or deficits were independently associated with AKI or ARDS in children with life-threatening bleeding. There were 449 children included with a median (interquartile range, IQR) age of 7.3 years (1.7-14.7). Within 5 days of the life-threatening bleeding event, AKI occurred in 18.5% and ARDS occurred in 20.3% of the subjects. Every 10% increase in the platelet to red blood cell transfusion ratio is independently associated with a 12.7% increase in the odds of AKI (adjusted odds ratio 1.127; 95% confidence interval 1.025-1.239; p-value .013). Subjects with operative or medical etiologies were independently associated with an increased risk of AKI compared to those with traumatic injury. No transfusion-related variables were independently associated with the risk of developing ARDS. The use of increased platelet to red blood cell transfusion ratios in children with life-threatening bleeding of any etiology may increase the risk of AKI but not ARDS. Prospective trials are needed to determine if increased platelet use in this cohort increases the risk of AKI to examine possible mechanisms.

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.

Maternal and neonatal outcomes of dichorionic twin pregnancies achieved with assisted reproductive technology: meta-analysis of contemporary data.

Assisted reproductive technology (ART) is commonly used to achieve pregnancy and often results in dichorionic diamniotic (DCDA) twin pregnancies. However, the potential risks of ART on maternal and neonatal outcomes in these pregnancies are not well understood. The objective is to compare the maternal and neonatal outcomes in DCDA twin pregnancies between those achieved through ART and those spontaneously conceived (SC). We carried out a systematic comprehensive search of electronic databases; namely, PubMed, Embase, Scopus, and the Cochrane Library, from inception to March 2023 with a study period of recruitment between 2003 and 2023. We included all studies comparing the maternal and neonatal outcomes of DCDA twin pregnancies between those achieved by ART and those SC. We analyzed data from 18 cohort studies involving 10,485 women with DCDA twin pregnancies. The meta-analysis showed that ART-conceived pregnancies had a significantly higher risk of preeclampsia or gestational hypertension (GH), gestational diabetes mellitus (GDM), placenta previa (PP), placental abruption (PA), postpartum hemorrhage (PPH), and elective and emergency cesarean sections than SC twin pregnancies. The absolute risks of these complications remained relatively low. We also found a slightly higher risk of respiratory distress syndrome (RDS) and congenital malformations in ART-conceived infants compared to the risks in SC infants. Finally, the risk of neonatal intensive care unit (NICU) admissions was significantly higher in ART-conceived infants than in SC infants, but with high heterogeneity. We found associations between DCDA twin pregnancies conceived through ART and increased frequencies of adverse maternal outcomes. However, the absolute risks of these complications remained low, and the benefits of ART for achieving successful pregnancies may well outweigh the potential risks. Additionally, ART-conceived DCDA twin pregnancies may pose higher risks of RDS, congenital malformations and NICU, admissions than SC DCDA twin pregnancies.

Association of dynamics of anellovirus loads with hospital-acquired pneumonia in brain-injured patients during the intensive care unit stay.

Critical illness induces immune disorders associated with an increased risk of hospital-acquired pneumonia (HAP) and acute respiratory distress syndrome (ARDS). Torque Teno Virus (TTV), from the Anelloviridae family, are proposed as a biomarker to measure the level of immunosuppression. Our objective was to describe the kinetics of TTV DNA loads and their association with critical-illness related complications. We performed a longitudinal study in 115 brain-injured patients from a prospective cohort, collected endotracheal and blood samples at three time points (T1, T2, T3) during the two weeks post-admission in intensive care unit, and measured viral DNA loads using the TTV R-gene® kit (Biomerieux) and a pan-Anelloviridae in house qRT-PCR. TTV DNA was detected in the blood of 69, 71, and 64% of brain-injured patients at T1, T2 and T3 respectively. Time-associated variations of TTV and Anellovirus (AV) DNA loads were observed. Using a linear mixed-effects model, we found that HAP and ARDS were associated with lower blood AV DNA loads. Our results show that HAP or ARDS in critically ill patients are associated to changes in AV DNA loads, and should be evaluated further as a biomarker of immune disorders leading to these complications.

Respiratory Distress Syndrome (RDS) in Newborns with Hypoxic-Ischemic Encephalopathy (HIE).

Respiratory distress syndrome (RDS) and hypoxic-ischemic encephalopathy (HIE) are frequent causes of death and disability in neonates. This study included newborns between January 2021 and July 2022 at the University Clinic for Gynecology and Obstetrics, Skopje. Up to date criteria for HIE/RDS for term and for preterm infants as well for the severity of HIE/RDS were used in a comprehensive analysis of cranial ultrasonography, neurological status, neonatal infections, Apgar score, bradycardia and hypotension, X-ray of the lungs, FiO2, acid-base status, assisted ventilation and use of surfactant. Three groups were created: HIE with RDS (42 babies), HIE without RDS (30 babies) and RDS without HIE in 38 neonates. All newborns with severe (third) degree of HIE died. Intracranial bleeding was found in 35.7% in the first group and 30% in the second group, and in the third group in 53.3%. The need for surfactant in the HIE group with RDS is 59.5%, and in the RDS group without HIE 84.2%. DIC associated with sepsis was found in 13.1-50% in those groups. In newborns with HIE and bradycardia, the probability of having RDS was on average 3.2 times higher than in those without bradycardia. The application of the surfactant significantly improved the pH, pO2, pCO2, BE and chest X-ray in children with RDS. An Apgar score less than 6 at the fifth minute increases the risk of RDS by 3 times. The metabolic acidosis in the first 24 hours increases the risk of death by 23.6 times. The combination of HIE/ RDS significantly worsens the disease outcome. The use of scoring systems improved the early detection of high risk babies and initiation of early treatment increased the chances for survival without disabilities.

Maternal and perinatal outcomes in twin pregnancies following assisted reproduction: a systematic review and meta-analysis involving 802462 pregnancies.

ART is associated with higher rates of twin pregnancies than singleton pregnancies. Whether twin pregnancies conceived following ART have additional maternal and neonatal complications compared with non-ART twin pregnancies is not known. The objective was to quantify the risk of adverse maternal and perinatal outcomes among twin pregnancies conceived following ART compared with non-ART and natural conception. Existing reviews vary in the reported outcomes, with many studies including triplet pregnancies in the study population. Therefore, we aimed to perform an up-to-date review with an in-depth analysis of maternal and perinatal outcomes limited to twin pregnancies. We searched electronic databases MEDLINE and EMBASE from January 1990 to May 2023 without language restrictions. All cohort studies reporting maternal and perinatal outcomes following ART compared with non-ART twin pregnancies and natural conception were included. Case-control studies, case reports, case series, animal studies, and in vitro studies were excluded. The Newcastle-Ottawa Scale was used to assess the methodological quality of the studies. Using random-effects meta-analysis, the estimates were pooled and the findings were reported as odds ratios (OR) with 95% CI. We included 111 studies (802462 pregnancies). Twin pregnancies conceived following ART were at higher risk of preterm birth at <34 weeks (OR 1.33, 95% CI 1.14-1.56, 29 studies, I2 = 73%), <37 weeks (OR 1.26, 95% CI 1.19-1.33, 70 studies, I2 = 76%), hypertensive disorders in pregnancy (OR 1.29, 95% CI 1.14-1.46, 59 studies, I2 = 87%), gestational diabetes mellitus (OR 1.61, 95% CI 1.48-1.75, 51 studies, I2 = 65%), and caesarean delivery (OR 1.80, 95% CI 1.65-1.97, 70 studies, I2 = 89%) compared with non-ART twins. The risks for the above maternal outcomes were also increased in the ART group compared with natural conception. Of the perinatal outcomes, ART twins were at significantly increased risk of congenital malformations (OR 1.17, 95% CI 1.05-1.30, 39 studies, I2 = 59%), birthweight discordance (>25% (OR 1.31, 95% CI 1.05-1.63, 7 studies, I2 = 0%)), respiratory distress syndrome (OR 1.32, 95% CI 1.09-1.60, 16 studies, I2 = 61%), and neonatal intensive care unit admission (OR 1.24, 95% CI 1.14-1.35, 32 studies, I2 = 87%) compared with non-ART twins. When comparing ART with natural conception, the risk of respiratory distress syndrome, intensive care admissions, and birthweight discordance >25% was higher among the ART group. Perinatal complications, such as stillbirth (OR 0.83, 95% CI 0.70-0.99, 33 studies, I2 = 49%), small for gestational age <10th centile (OR 0.90, 95% CI 0.85-0.95, 26 studies, I2 = 36%), and twin-twin transfusion syndrome (OR 0.45, 95% CI 0.25-0.82, 9 studies, I2 = 25%), were reduced in twin pregnancies conceived with ART versus those without ART. The above perinatal complications were also fewer amongst the ART group than natural conception. ART twin pregnancies are associated with higher maternal complications than non-ART pregnancies and natural conception, with varied perinatal outcomes. Women seeking ART should be counselled about the increased risks of ART twin pregnancies and should be closely monitored in pregnancy for complications. We recommend exercising caution when interpreting the study findings owing to the study's limitations.

Flow-Limited and Reverse-Triggered Ventilator Dyssynchrony Are Associated With Increased Tidal and Dynamic Transpulmonary Pressure.

Ventilator dyssynchrony may be associated with increased delivered tidal volumes (V t s) and dynamic transpulmonary pressure (ΔP L,dyn ), surrogate markers of lung stress and strain, despite low V t ventilation. However, it is unknown which types of ventilator dyssynchrony are most likely to increase these metrics or if specific ventilation or sedation strategies can mitigate this potential. A prospective cohort analysis to delineate the association between ten types of breaths and delivered V t , ΔP L,dyn , and transpulmonary mechanical energy. Patients admitted to the medical ICU. Over 580,000 breaths from 35 patients with acute respiratory distress syndrome (ARDS) or ARDS risk factors. None. Patients received continuous esophageal manometry. Ventilator dyssynchrony was identified using a machine learning algorithm. Mixed-effect models predicted V t , ΔP L,dyn , and transpulmonary mechanical energy for each type of ventilator dyssynchrony while controlling for repeated measures. Finally, we described how V t , positive end-expiratory pressure (PEEP), and sedation (Richmond Agitation-Sedation Scale) strategies modify ventilator dyssynchrony's association with these surrogate markers of lung stress and strain. Double-triggered breaths were associated with the most significant increase in V t , ΔP L,dyn , and transpulmonary mechanical energy. However, flow-limited, early reverse-triggered, and early ventilator-terminated breaths were also associated with significant increases in V t , ΔP L,dyn , and energy. The potential of a ventilator dyssynchrony type to increase V t , ΔP L,dyn , or energy clustered similarly. Increasing set V t may be associated with a disproportionate increase in high-volume and high-energy ventilation from double-triggered breaths, but PEEP and sedation do not clinically modify the interaction between ventilator dyssynchrony and surrogate markers of lung stress and strain. Double-triggered, flow-limited, early reverse-triggered, and early ventilator-terminated breaths are associated with increases in V t , ΔP L,dyn , and energy. As flow-limited breaths are more than twice as common as double-triggered breaths, further work is needed to determine the interaction of ventilator dyssynchrony frequency to cause clinically meaningful changes in patient outcomes.

Urokinase-type plasminogen activator and plasminogen activator inhibitor-1 complex as a serum biomarker for COVID-19.

Patients with coronavirus disease-2019 (COVID-19) have an increased risk of thrombosis and acute respiratory distress syndrome (ARDS). Thrombosis is often attributed to increases in plasminogen activator inhibitor-1 (PAI-1) and a shut-down of fibrinolysis (blood clot dissolution). Decreased urokinase-type plasminogen activator (uPA), a protease necessary for cell-associated plasmin generation, and increased tissue-type plasminogen activator (tPA) and PAI-1 levels have been reported in COVID-19 patients. Because these factors can occur in free and complexed forms with differences in their biological functions, we examined the predictive impact of uPA, tPA, and PAI-1 in their free forms and complexes as a biomarker for COVID-19 severity and the development of ARDS. In this retrospective study of 69 Japanese adults hospitalized with COVID-19 and 20 healthy donors, we found elevated free, non-complexed PAI-1 antigen, low circulating uPA, and uPA/PAI-1 but not tPA/PAI-1 complex levels to be associated with COVID-19 severity and ARDS development. This biomarker profile was typical for patients in the complicated phase. Lack of PAI-1 activity in circulation despite free, non-complexed PAI-1 protein and plasmin/α2anti-plasmin complex correlated with suPAR and sVCAM levels, markers indicating endothelial dysfunction. Furthermore, uPA/PAI-1 complex levels positively correlated with TNFα, a cytokine reported to trigger inflammatory cell death and tissue damage. Those levels also positively correlated with lymphopenia and the pro-inflammatory factors interleukin1β (IL1β), IL6, and C-reactive protein, markers associated with the anti-viral inflammatory response. These findings argue for using uPA and uPA/PAI-1 as novel biomarkers to detect patients at risk of developing severe COVID-19, including ARDS.

Vital signs and work of breathing assessment in the emergency department as predictor for acute respiratory failure in COVID-19 pneumonia

Coronavirus disease 2019 (COVID-19) with acute respiratory failure (ARF) has a high mortality rate. This study aimed to investigate the vital signs and work of breathing parameters in COVID-19 pneumonia patients to predict ARF. We predicted the risk of acute respiratory distress syndrome (ARDS) in COVID-19 patients within 72 hours of admission to the emergency department (ED) and determined cut-off values. We performed an observational prospective cohort study at the tertiary referral Persahabatan Hospital in Jakarta, Indonesia, from July to December 2020. The vital signs were as follows: of respiratory rate (RR), heart rate (HR), pulse oxygen saturation (SpO2), mean arterial pressure (MAP), and axillary body temperature. The work of breathing, which was indicated by nasal flaring and the contraction of the sternocleidomastoid and abdominal muscles, was assessed one hour after a triage examination. The ARF was monitored within 72 hours. The cut-off values of vital signs were determined using the Youden index. In total, 71 (13.65%) of the 520 patients had ARF within 72 hours of admission. The mean values of RR, HR, MAP and SpO2 in the ARF group were 26 breaths/minute, and 102 pulses/minute, at 100 and 92%, respectively. All ARF patients had nasal flaring, 86.4% had a contraction of the sternocleidomastoid, and 67.6%had a contraction of the abdominal muscle. The cut-off values for predicting ARF were as follows: RR &gt;23 breaths/minute (sensitivity 83.1%; specificity 86%), SpO2 &lt;93% (sensitivity 80.5%; specificity 75.2%), HR = 92 pulses/minute (sensitivity 71.8%; sensitivity 75.2%), and MAP = 93.5 (specificity 64.8%; sensitivity 60.4%). Our results indicate that vital signs and work of breathing within the first hour in the emergency department can predict ARF in COVID-19 pneumonia patients within 72 hours.