Risk factors for mortality of critically ill patients with COVID-19 receiving invasive ventilation

SCARLET (Supplemental Citicoline Administration to Reduce Lung injury Efficacy Trial): study protocol for a single-site, double-blinded, placebo-controlled, and randomized Phase 1/2 trial of i.v. citicoline (CDP-choline) in hospitalized SARS CoV-2-infected patients with hypoxemic acute respiratory failure

BACKGROUND

The SARS CoV-2 pandemic has resulted in more than 1.1 million deaths in the USA alone. Therapeutic options for critically ill patients with COVID-19 are limited. Prior studies showed that post-infection treatment of influenza A virus-infected mice with the liponucleotide CDP-choline, which is an essential precursor for de novo phosphatidylcholine synthesis, improved gas exchange and reduced pulmonary inflammation without altering viral replication. In unpublished studies, we found that treatment of SARS CoV-2-infected K18-hACE2-transgenic mice with CDP-choline prevented development of hypoxemia. We hypothesize that administration of citicoline (the pharmaceutical form of CDP-choline) will be safe in hospitalized SARS CoV-2-infected patients with hypoxemic acute respiratory failure (HARF) and that we will obtain preliminary evidence of clinical benefit to support a larger Phase 3 trial using one or more citicoline doses.

METHODS

We will conduct a single-site, double-blinded, placebo-controlled, and randomized Phase 1/2 dose-ranging and safety study of Somazina® citicoline solution for injection in consented adults of any sex, gender, age, or ethnicity hospitalized for SARS CoV-2-associated HARF. The trial is named "SCARLET" (Supplemental Citicoline Administration to Reduce Lung injury Efficacy Trial). We hypothesize that SCARLET will show that i.v. citicoline is safe at one or more of three doses (0.5, 2.5, or 5 mg/kg, every 12 h for 5 days) in hospitalized SARS CoV-2-infected patients with HARF (20 per dose) and provide preliminary evidence that i.v. citicoline improves pulmonary outcomes in this population. The primary efficacy outcome will be the SpO2:FiO2 ratio on study day 3. Exploratory outcomes include Sequential Organ Failure Assessment (SOFA) scores, dead space ventilation index, and lung compliance. Citicoline effects on a panel of COVID-relevant lung and blood biomarkers will also be determined.

DISCUSSION

Citicoline has many characteristics that would be advantageous to any candidate COVID-19 therapeutic, including safety, low-cost, favorable chemical characteristics, and potentially pathogen-agnostic efficacy. Successful demonstration that citicoline is beneficial in severely ill patients with SARS CoV-2-induced HARF could transform management of severely ill COVID patients.

TRIAL REGISTRATION

The trial was registered at www.

CLINICALTRIALS

gov on 5/31/2023 (NCT05881135).

TRIAL STATUS

Currently enrolling.

Erythrocytes Functionality in SARS-CoV-2 Infection: Potential Link with Alzheimer's Disease

Coronavirus disease 2019 (COVID-19) is a rapidly spreading acute respiratory infection caused by SARS-CoV-2. The pathogenesis of the disease remains unclear. Recently, several hypotheses have emerged to explain the mechanism of interaction between SARS-CoV-2 and erythrocytes, and its negative effect on the oxygen-transport function that depends on erythrocyte metabolism, which is responsible for hemoglobin-oxygen affinity (Hb-O2 affinity). In clinical settings, the modulators of the Hb-O2 affinity are not currently measured to assess tissue oxygenation, thereby providing inadequate evaluation of erythrocyte dysfunction in the integrated oxygen-transport system. To discover more about hypoxemia/hypoxia in COVID-19 patients, this review highlights the need for further investigation of the relationship between biochemical aberrations in erythrocytes and oxygen-transport efficiency. Furthermore, patients with severe COVID-19 experience symptoms similar to Alzheimer's, suggesting that their brains have been altered in ways that increase the likelihood of Alzheimer's. Mindful of the partly assessed role of structural, metabolic abnormalities that underlie erythrocyte dysfunction in the pathophysiology of Alzheimer's disease (AD), we further summarize the available data showing that COVID-19 neurocognitive impairments most probably share similar patterns with known mechanisms of brain dysfunctions in AD. Identification of parameters responsible for erythrocyte function that vary under SARS-CoV-2 may contribute to the search for additional components of progressive and irreversible failure in the integrated oxygen-transport system leading to tissue hypoperfusion. This is particularly relevant for the older generation who experience age-related disorders of erythrocyte metabolism and are prone to AD, and provide an opportunity for new personalized therapies to control this deadly infection.

Hypertension and mortality in SARS-COV-2 infection: A meta-analysis of observational studies after 2 years of pandemic

BACKGROUND

The worldwide pandemic SARS-CoV-2 infection is associated with clinical course including a very broad spectrum of clinical manifestations, including death. Several studies and meta-analyses have evaluated the role of hypertension on prognosis, but with important limitations and conflicting results. Therefore, we decided to perform a new meta-analysis of the observational studies that explored the relationship between pre-existing hypertension and mortality risk in patients with SARS-CoV-2 infection, using more stringent inclusion criteria to overcome the limitations inherent previous meta-analyses.

METHODS

A systematic search of the on-line databases available up to 31 March 2022 was conducted, including peer-reviewed original articles, involving the adult population, where the role of hypertension on mortality due to SARS-CoV-2 infection was determined by Cox-proportional hazard models. Pooled hazard ratio (HR) was calculated by a random effect model. Sensitivity, heterogeneity, publication bias, subgroup and meta-regression analyses were performed.

RESULTS

Twenty-six studies (222,083 participants) met the pre-defined inclusion criteria. In the pooled analysis, pre-existing hypertension was significantly associated with mortality due to SARS-CoV-2 infection, both in unadjusted and adjusted models (HR: 1.55; 95% CI: 1.22 to 1.97). However, in separate analyses including results adjusted for crucial and strong predictors of mortality during SARS-CoV-2 infection (e.g. body weight), the association disappeared.

CONCLUSIONS

The results of this meta-analysis indicate that pre-existing hypertension is not an independent predictor of mortality during SARS-CoV-2 infection. Further studies should nevertheless be carried out worldwide to evaluate this role, independent of, or in interaction with, other confounders that may affect the mortality risk.

Severity of COVID-19 in Patients with Diarrhoea: A Systematic Review and Meta-Analysis

COVID-19 patients occasionally present with diarrhoea. Our objective was to estimate the risk of developing the severe disease in COVID-19 patients with and without diarrhoea and to provide a more precise estimate of the prevalence of COVID-19-associated digestive symptoms. A total of 88 studies (n = 67,794) on patients with a COVID-19 infection published between 1 January 2020 and 20 October 2022 were included in this meta-analysis. The overall prevalence of digestive symptoms was 27% (95% confidence interval (CI): 21-34%; I² = 99%). According to our data, the pooled prevalence of diarrhoea symptoms in the 88 studies analysed was 17% (95% CI: 14-20%; I² = 98%). The pooled estimate of nausea or vomiting in a total of 60 studies was 12% (95% CI: 8-15%; I² = 98%). We also analysed 23 studies with eligible individuals (n = 3800) to assess the association between the disease severity and diarrhoea. Individuals who had diarrhoea were more likely to have experienced severe COVID-19 (odds ratio: 1.71; 95% CI: 1.31-2.24; p < 0.0001; I² = 10%). Gastrointestinal symptoms and diarrhoea are frequently presenting COVID-19 manifestations that physicians should be aware of.

Evaluation of the Relationship Between Aquaporin-1, Hepcidin, Zinc, Copper, and İron Levels and Oxidative Stress in the Serum of Critically Ill Patients with COVID-19

Our study aims to determine the relationship between hepcidin, aquaporin (AQP-1), copper (Cu), zinc (Zn), iron (Fe) levels, and oxidative stress in the sera of seriously ill COVID-19 patients with invasive mechanical ventilation. Ninety persons with and without COVID-19 were taken up and separated into two groups. The first group included seriously COVID-19 inpatients having endotracheal intubation in the intensive care unit (n = 45). The second group included individuals who had negative PCR tests and had no chronic disease (the healthy control group n = 45). AQP-1, hepcidin, Zn, Cu, Fe, total antioxidant status (TAS), and total oxidant status (TOS) were studied in the sera of both groups, and the relations of these levels with oxidative stress were determined. When the COVID-19 patient and the control groups were compared, all studied parameters were found to be statistically significant (p < 0.01). Total oxidant status (TOS), oxidative stress index (OSI), and AQP-1, hepcidin, and Cu levels were increased in patients with COVID-19 compared to healthy people. Serum TAC, Zn, and Fe levels were found to be lower in the patient group than in the control group. Significant correlations were detected between the studied parameters in COVID-19 patients. Results indicated that oxidative stress may play an important role in viral infection due to SARS-CoV-2. We think that oxidative stress parameters as well as some trace elements at the onset of COVID-19 disease will provide a better triage in terms of disease severity.

Does the intubation timeline affect the in-hospital mortality of COVID-19 patients? A retrospective cohort study

Background

Effective strategies for managing coronavirus disease 19 (COVID-19) patients suffering from acute respiratory distress are constantly evolving. The timeline and threshold for transitioning from non-invasive ventilation to intermittent mandatory ventilation in critical cases who develop COVID-19-related respiratory distress are undetermined. The present research intends to investigate if emergency room intubations in COVID-19 patients affect mortality.

Methods

Between January 1, 2021 and June 30, 2021, we retrospectively reviewed chart analysis on all patients with confirmed positive COVID-19 screening and who underwent endotracheal intubation. Depending on when the intubation was performed; early in the emergency room or delayed outside the emergency room, patients were separated into two cohorts. In addition to comorbid clinical manifestations, the quick sequential organ failure assessment (qSOFA) score, and in-hospital mortality were all recorded as demographic and clinical information.

Results

Fifty-eight of the 224 corona-positive patients who underwent intubation had their intubations performed in the emergency room. Age, sex, alcohol use, and smoking status did not significantly differ between the two categories at the baseline. The mean qSOFA score was higher in the early intubation cohort (3.5; p < 0.000) along with more underlying comorbidities (3.0; p < 0.000). When compared to the late intubation cohort (45.78%), patients treated with early intubation had a significantly greater death rate (67.24%).

Conclusion

In summary, we discovered that patients who underwent intubation in the emergency units exhibited a high quick SOFA score as well as maximum co-morbid conditions than patients intubated somewhere else in the hospital. The findings of our investigation imply that intubating patients too early might be risky.

Acute respiratory distress syndrome among patients with severe COVID-19 admitted to treatment center of Wollega University Referral Hospital, Western Ethiopia

Background

Acute respiratory distress syndrome is a life-threatening condition that has a significant effect on the occurrence of morbidity and mortality among patients with severe Coronavirus disease 2019 (COVID-19). To the best of researchers’ knowledge, there is no Study on ARDS of COVID-19 in Ethiopia. Therefore, this study aimed to identify the prevalence of ARDS and associated factors among severe COVID-19 patients at Wollega University Referral Hospital.

Methods

An institution-based retrospective cross-sectional study was conducted from September 20, 2020, to June 10, 2021. Real-Time Reverse transcription-polymerase Chain Reaction (rRT-PCR) test was used to test Patients for COVID-19. Epi-data version 3.2 was used for data entry, and the final data analysis was through STATA version 14. After checking the assumption P-value<0.25 in the bivariable analysis was used to select a candidate variable for multi-variable analysis, and a p-value of <0.05 was used to declare statistical significance.

Results

In this study, the prevalence of ARDS was 32%. Almost all the patients had the clinical feature of cough (93.7%), followed by shortness of breath (79.9%), fever (77.7%), and headache (67%). Age older than 65 years (AOR = 3.35, 95%CI = 1.31, 8.55), male gender (AOR = 5.63, 95%CI = 2.15, 14.77), and low oxygen saturation level (AOR = 4.60, 95%CI = 1.15, 18.35) were the independent predictors of ARDS among severe COVID-19 patients.

Conclusion

The prevalence of ARDS among patients with severe COVID-19 was high in the study area. Therefore, elders and patients with critical conditions (low oxygen saturation) better to get special attention during COVID-19 case management to enhance good care and monitoring of the patients.

Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.

Early prolonged prone position in noninvasively ventilated patients with SARS-CoV-2-related moderate-to-severe hypoxemic respiratory failure: clinical outcomes and mechanisms for treatment response in the PRO-NIV study

Background

Whether prone position (PP) improves clinical outcomes in COVID-19 pneumonia treated with noninvasive ventilation (NIV) is unknown. We evaluated the effect of early PP on 28-day NIV failure, intubation and death in noninvasively ventilated patients with moderate-to-severe acute hypoxemic respiratory failure due to COVID-19 pneumonia and explored physiological mechanisms underlying treatment response.

Methods

In this controlled non-randomized trial, 81 consecutive prospectively enrolled patients with COVID-19 pneumonia and moderate-to-severe (paO2/FiO2 ratio < 200) acute hypoxemic respiratory failure treated with early PP + NIV during Dec 2020–May 2021were compared with 162 consecutive patients with COVID-19 pneumonia matched for age, mortality risk, severity of illness and paO2/FiO2 ratio at admission, treated with conventional (supine) NIV during Apr 2020–Dec 2020 at HUMANITAS Gradenigo Subintensive Care Unit, after propensity score adjustment for multiple baseline and treatment-related variables to limit confounding. Lung ultrasonography (LUS) was performed at baseline and at day 5. Ventilatory parameters, physiological dead space indices (DSIs) and circulating inflammatory and procoagulative biomarkers were monitored during the initial 7 days.

Results

In the intention-to-treat analysis. NIV failure occurred in 14 (17%) of PP patients versus 70 (43%) of controls [HR = 0.32, 95% CI 0.21–0.50; p < 0.0001]; intubation in 8 (11%) of PP patients versus 44 (30%) of controls [HR = 0.31, 95% CI 0.18–0.55; p = 0.0012], death in 10 (12%) of PP patients versus 59 (36%) of controls [HR = 0.27, 95% CI 0.17–0.44; p < 0.0001]. The effect remained significant within different categories of severity of hypoxemia (paO2/FiO2 < 100 or paO2/FiO2 100–199 at admission). Adverse events were rare and evenly distributed. Compared with controls, PP therapy was associated with improved oxygenation and DSIs, reduced global LUS severity indices largely through enhanced reaeration of dorso-lateral lung regions, and an earlier decline in inflammatory markers and D-dimer. In multivariate analysis, day 1 CO2 response outperformed O2 response as a predictor of LUS changes, NIV failure, intubation and death.

Conclusion

Early prolonged PP is safe and is associated with lower NIV failure, intubation and death rates in noninvasively ventilated patients with COVID-19-related moderate-to-severe hypoxemic respiratory failure. Early dead space reduction and reaeration of dorso-lateral lung regions predicted clinical outcomes in our study population.

Clinical trial registration

ISRCTN23016116. Retrospectively registered on May 1, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03937-x.

Analysis of Risk Factors for In-Hospital Death Due to COVID-19 in Patients Hospitalised at the Temporary Hospital Located at the National Stadium in Warsaw: A Retrospective Analysis

The outbreak of the SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic has affected all aspects of social life and brought massive changes to the healthcare sector. The aim of this study was to identify the factors affecting the mortality of COVID-19 patients at a temporary hospital in Warsaw (Poland). The present study was conducted based on a retrospective analysis of the medical records of patients hospitalised at the temporary hospital located at the National Stadium in Warsaw between 1 March 2020 and 30 April 2021. The study included all cases of patients who were brought directly or transferred to the National Hospital from other hospitals for further treatment. With regard to comorbidities, the analysis found that five comorbidities—namely, diabetes (OR = 1.750, 95% CI: 1.009−2.444, p < 0.05), stroke history (OR = 2.408, 95% CI: 1.208−4.801, p < 0.05), renal failure (OR = 2.141, 95% CI: 1.052−4.356, p < 0.05), chronic obstructive pulmonary disease (OR = 2.044, 95% CI: 1.133−3.690, p < 0.05) and heart failure (OR = 1.930, 95% CI: 1.154−3.227, p < 0.05)—had a significant impact on the survival of COVID-19 patients. The analysis identified 14 factors that had a significant impact on the prognosis and mortality of the COVID-19 patients studied.

Coronavirus Disease 2019 as Cause of Viral Sepsis: A Systematic Review and Meta-Analysis

OBJECTIVE

Coronavirus disease 2019 is a heterogeneous disease most frequently causing respiratory tract infection, which can induce respiratory failure and multiple organ dysfunction syndrome in its severe forms. The prevalence of coronavirus disease 2019-related sepsis is still unclear; we aimed to describe this in a systematic review.

DATA SOURCES

MEDLINE (PubMed), Cochrane, and Google Scholar databases were searched based on a prespecified protocol (International Prospective Register for Systematic Reviews: CRD42020202018).

STUDY SELECTION

Studies reporting on patients with confirmed coronavirus disease 2019 diagnosed with sepsis according to sepsis-3 or according to the presence of infection-related organ dysfunctions necessitating organ support/replacement were included in the analysis. The primary end point was prevalence of coronavirus disease 2019-related sepsis among adults hospitalized in the ICU and the general ward. Among secondary end points were the need for ICU admission among patients initially hospitalized in the general ward and the prevalence of new onset of organ dysfunction in the ICU. Outcomes were expressed as proportions with respective 95% CI.

DATA EXTRACTION

Two reviewers independently screened and reviewed existing literature and assessed study quality with the Newcastle-Ottawa Scale and the Methodological index for nonrandomized studies.

DATA SYNTHESIS

Of 3,825 articles, 151 were analyzed, only five of which directly reported sepsis prevalence. Noting the high heterogeneity observed, coronavirus disease 2019-related sepsis prevalence was 77.9% (95% CI, 75.9-79.8; I2 = 91%; 57 studies) in the ICU, and 33.3% (95% CI, 30.3-36.4; I2 = 99%; 86 studies) in the general ward. ICU admission was required for 17.7% (95% CI, 12.9-23.6; I2 = 100%) of ward patients. Acute respiratory distress syndrome was the most common organ dysfunction in the ICU (87.5%; 95% CI, 83.3-90.7; I2 = 98%).

CONCLUSIONS

The majority of coronavirus disease 2019 patients hospitalized in the ICU meet Sepsis-3 criteria and present infection-associated organ dysfunction. The medical and scientific community should be aware and systematically report viral sepsis for prognostic and treatment implications.