Lung abscess following ventilator-associated pneumonia during COVID-19: a retrospective multicenter cohort study

BACKGROUND

Patients undergoing mechanical ventilation (MV) for COVID-19 exhibit an increased risk of ventilator-associated pneumonia (VAP). The occurrence of lung abscesses following VAP in these patients has been poorly studied. We aimed to describe the incidence, characteristics, risk factors and prognosis of lung abscesses complicating VAP after COVID-19.

METHODS

We conducted an observational, retrospective study in three French intensive care units. Patients admitted for acute respiratory failure with a confirmed SARS-CoV-2 PCR and requiring MV for more than 48 h were included.

RESULTS

Among the 507 patients included, 326 (64%) had a documented VAP. Of these, 23 (7%) developed a lung abscess. Enterobacterales (15/23, 65%) were the main documentation, followed by non-fermenting Gram-negative bacilli (10/23, 43%) and Gram-positive cocci (8/23, 35%). Lung abscesses were mainly plurimicrobial (15/23, 65%). In multivariate analysis, a plurimicrobial 1st VAP episode (OR (95% CI) 2.93 (1.16-7.51); p = 0.02) and the use of hydrocortisone (OR (95% CI) 4.86 (1.95-12.1); p = 0.001) were associated with lung abscess development. Intensive care unit (ICU) mortality of patients with lung abscesses reached 52%, but was not significantly higher than for patients with VAP but no lung abscess. Patients with lung abscesses had reduced ventilator-free days at day 60, a longer duration of MV and ICU stay than patients with VAP but no lung abscess (respectively, 0 (0-3) vs. 16 (0-42) days; p < 0.001, 49 (32-73) vs. 25 (11-41) days; p < 0.001, 52 (36-77) vs. 28 (16-47) days; p < 0.001).

CONCLUSIONS

Lung abscessing pneumonia is not uncommon among COVID-19 patients developing VAP. A plurimicrobial first VAP episode and the use of hydrocortisone are independently associated with this complication. In COVID-19 patients with persistent VAP, a chest CT scan investigating the evolution toward lung abscess should be considered.

Protecting workers in the temporary staffing industry

BACKGROUND

Workers hired through temporary staffing companies have a high rate of severe and fatal injuries despite the legally mandated, shared responsibility of the temporary staffing company and the host company to assure safe work.

AIMS

The aim of this study was to elucidate the perspective of temporary staffing personnel on approaches to mitigating injury risk among the workers they hire.

METHODS

Based on a conceptual model representing the interplay between work and health, we conducted a 'brainstorm' of temporary staffing personnel regarding perceived barriers to protecting temporary workers. A content/context analysis used standard qualitative methods, and the findings were triangulated with notes taken during the discussion.

RESULTS

Temporary staffing employers describe loss of control of the working conditions once workers are placed at host/client companies. Further, they describe a contentious relationship between temporary staffing and host companies, where it is difficult to hold host companies to account. Other barriers to providing temporary workers with a safe work environment include the temp companies' lack of knowledge of site-specific hazards, the poor quality of onsite Occupational Safety and Health training, and ignoring Occupational Safety and Health Administration (OSHA) requirements.

CONCLUSIONS

The perspective of temporary staffing companies should be considered to address the lack of cooperation and shifted responsibility described in this study. Policy and practice changes could include requiring contract language, implementing communication about safety, either sharing workers' compensation purchase or removing exclusive remedy protections from hosts, and prescribing safety training, such as an OSHA 10-h programme. Suggested interventions need further study.

Incidence, Outcomes and Risk Factors of Recurrent Ventilator Associated Pneumonia in COVID-19 Patients: A Retrospective Multicenter Study

Background: High incidence of ventilator associated pneumonia (VAP) has been reported in critically ill patients with COVID-19. Among these patients, we aimed to assess the incidence, outcomes and risk factors of VAP recurrences. Methods: We conducted an observational retrospective study in three French intensive care units (ICUs). Patients admitted for a documented COVID-19 from March 2020 to May 2021 and requiring mechanical ventilation (MV) for ≥48 h were included. The study main outcome was the incidence of VAP recurrences. Secondary outcomes were the duration of MV, ICU and hospital length of stay and mortality according to VAP and recurrences. We also assessed the factors associated with VAP recurrences. Results: During the study period, 398 patients met the inclusion criteria. A total of 236 (59%) of them had at least one VAP episode during their ICU stay and 109 (46%) of these patients developed at least one recurrence. The incidence of VAP recurrence considering death and extubation as competing events was 29.6% (IC = [0.250−0.343]). Seventy-eight percent of recurrences were due to the same bacteria (relapses). Patients with a VAP recurrence had a longer duration of MV as compared with one VAP and no VAP patients (41 (25−56) vs. 16 (8−30) and 10 (5−18) days; p < 0.001) and a longer ICU length of stay (46 (29−66) vs. 22 (12−36) and 14 (9−25) days; p < 0.001). The 90-day mortality was higher in the recurrence group as compared with the no VAP group only (31.2 vs. 21.0% (p = 0.021)). In a multivariate analysis including bacterial co-infection at admission, the use of immunosuppressive therapies and the bacteria responsible for the first VAP episode, the duration of MV was the only factor independently associated with VAP recurrence. Conclusion: In COVID-19 associated respiratory failure, recurrences affected 46% of patients with a first episode of VAP. VAP recurrences were mainly relapses and were associated with a prolonged duration of MV and ICU length of stay but not with a higher mortality. MV duration was the only factor associated with recurrences.

Incidence and associated factors of cetuximab-induced hypersensitivity infusion reactions in 1392 cancer patients treated in four French areas: a possible association with Lyme disease?

BACKGROUND

Previous studies have observed an increased incidence of Cetuximab-induced hypersensitivity infusion reactions (CI-IRs) in the southeastern states of the USA. Tick's bites were suspected of generating cross-reactions between cetuximab and alpha-gal. This study aims was to describe the incidence and associated risk factors of CI-IRs, in the French areas chosen according to their Lyme disease incidence.

PATIENTS AND METHODS

A retrospective chart review was conducted on patients that received cetuximab infusion from January 2010 to June 2019 in 4 French areas with different Lyme disease incidence rates.

RESULTS

Of 1392 patients, 117 (8.4%) experienced a CI-IR, including 68 severe (grade 3 or 4) reactions (4.9%). This CI-IR incidence was significantly higher in the Lyme disease high-risk area than in the other areas (13.2% versus 7.1%, 8.1% and 6.4%; P = 0.016). Sex (P = 0.53), premedication (P = 0.91), primary cancer location (P = 0.46) and chemotherapy regimen type (P = 0.78) had no impact on CI-IR incidence in the overall population. In the head and neck squamous cell carcinoma (HNSCC) patient subgroup, CI-IRs were significantly more frequent in the high-risk area (16.4% versus 6.7%, 7.1% and 7.0%; P = 0.0015).

CONCLUSION

This study suggests that patients treated in the French area with the highest incidence of Lyme disease are at a higher risk of CI-IRs.

The role of personality assessment in forensic driving license renewal procedures. A study supported by the MMPI-2 test

The main function of the medical-psychological assessment to evaluate fitness to drive (FTD) is to safeguard the community against risks posed by drivers who, owing to psycho-physical disease, personality disturbances, abuse of psychotropic substances or drugs, can be a hazard to safety on the roads. In the context of psychodiagnostic investigations, the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) test is the gold standard tool supporting clinical assessments conducted to evaluate a subject's capacity to predict her/his own actions, attitudes, risk propensity, level of conformity to social norms. Other important features of the tool include the specific scales aimed at individuating behaviors adopted with the intent to elude or hide existing personality problems. These behaviors are very frequent in the field of medicolegal, psychological and psychiatric assessments, including FTD evaluations. In this study, the MMPI 2 test was administered to 154 subjects for whom Driving Licence (DL) Medical Commissions based in the south of Italy had required specific personality assessments, compared to a control group of 186 subjects with no clinical or psychodiagnostic problems. The question posed in our study was to understand whether the test was able to detect differences between the personalities of the subjects belonging to the two groups. The results obtained demonstrated significant differences between the experimental group and the controls, shown by the MMPI-2 variables, in particular the clinical Hs scale,the supplementary scales: GF, Re, AAS, APS and the content scales DEP and TRT, as well as the PSY-5 Disc and Nege scales.

Impact of Dexamethasone and Inhaled Nitric Oxide on Severe Acute Kidney Injury in Critically Ill Patients with COVID-19

Background: Acute kidney injury (AKI) is the second most frequent condition after acute respiratory distress syndrome (ARDS) in critically ill patients with severe COVID-19 and is strongly associated with mortality. The aim of this multicentric study was to assess the impact of the specific treatments of COVID-19 and ARDS on the risk of severe AKI in critically ill COVID-19 patients. Methods: In this cohort study, data from consecutive patients older than 18 years admitted to 6 ICUs for COVID-19-related ARDS requiring invasive mechanical ventilation were included. The incidence and severity of AKI, defined according to the 2012 KDIGO definition, were monitored during the entire ICU stay until day 90. Patients older than 18 years admitted to the ICU for COVID-19-related ARDS requiring invasive mechanical ventilation were included. Results: 164 patients were included in the final analysis; 97 (59.1%) displayed AKI, of which 39 (23.8%) had severe stage 3 AKI, and 21 (12.8%) required renal replacement therapy (RRT). In univariate analysis, severe AKI was associated with angiotensin-converting enzyme inhibitors (ACEI) exposure (p = 0.016), arterial hypertension (p = 0.029), APACHE-II score (p = 0.004) and mortality at D28 (p = 0.008), D60 (p < 0.001) and D90 (p < 0.001). In multivariate analysis, the factors associated with the onset of stage 3 AKI were: exposure to ACEI (OR: 4.238 (1.307−13.736), p = 0.016), APACHE II score (without age) (OR: 1.138 (1.044−1.241), p = 0.003) and iNO (OR: 5.694 (1.953−16.606), p = 0.001). Prone positioning (OR: 0.234 (0.057−0.967), p = 0.045) and dexamethasone (OR: 0.194 (0.053−0.713), p = 0.014) were associated with a decreased risk of severe AKI. Conclusions: Dexamethasone was associated with the prevention of the risk of severe AKI and RRT, and iNO was associated with severe AKI and RRT in critically ill patients with COVID-19. iNO should be used with caution in COVID-19-related ARDS.

Is it possible to start quadruple therapy in patients with a new diagnosis of HF and reduced ejection fraction? Real-life data from the TIDY-HF registry

Background

The 2021 European heart failure (HF) guidelines recommended treatment with an inhibitor of the renin-angiotensin-aldosterone axis (RAAS), a beta-blocker (BB), a mineralocorticoid receptor antagonist (MRA), and a cotransporter sodium-glucose type 2 inhibitor (SGLT2) in patients with HF and left ventricular ejection fraction (LVEF) ≤40%. However, there is little evidence on implementing quadruple therapy in clinical practice.

Purpose

Study the implementation of quadruple therapy in patients with a new diagnosis of HF and reduced ejection fraction in clinical practice.

Methods

A prospective multicenter registry (38 centers in Spain) was carried out, including all patients newly diagnosed with HF with LVEF ≤40% in clinical practice. Their baseline and laboratory characteristics were recorded and their pharmacological treatment: at baseline (discharged from hospitalization or first outpatient visit within a maximum period of 1 month after the echocardiographic diagnosis), one month, and 3 months later.

Results

On 1th of March 2022, 349 patients were included, with baseline treatment data in 289. The mean age was 65.0±14.2 years, and 72.1% were men. The mean LVEF was 28.5±7.3%, with 57.6% in NYHA II and 29.1% in NYHA III–IV. The most frequent causes of cardiomyopathy were: ischemic (25.1%), tachycardiomyopathy (16.6%), and idiopathic (15.7%). 46.4% were dyslipidemic, 57.5% hypertensive and 33.3% diabetic. 65.1% of the patients were in sinus rhythm. Before HF diagnosis, 44.6% had been treated with RAASi, 22.8% with BB, 7.8% with MRA, 8.1% with iSGLT2, and 24.5% with diuretics. The drugs used at baseline and the changes during follow-up are shown in Table 1.

Conclusions

According to our cohort, almost 60% of newly diagnosed patients with HF and reduced LVEF start quadruple therapy during the first month after diagnosis, with sacubitril/valsartan being the preferred RAASi in most cases. The implementation of drugs with prognostic benefit is above 70% at baseline and exceeds 80% at one month of follow-up, with a progressive reduction in loop diuretics during follow-up.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Spanish Society of Cardiology

Medullary sponge kidney: unusual finding in kidney transplant recipient

Background

Medullary sponge kidney is generally considered a benign condition, gold standard for the diagnosis is urography but it has almost been replaced by UroCT that did not present the same sensibility. Although it is really rare, our sonography’s findings were consistent with medullary sponge kidney in the transplanted kidneys.

Case presentation

A 45-year-old woman with a long history of double-kidney transplantation complained of frequent urinary tract infections, a history of vague loin pain and came to our attention for sonography follow-up. Her kidney function was normal, we did not find signs of infections in the transplanted kidneys and urinary findings were normal. Curiously, the transplanted kidneys came from a newborn and the patient received a double-kidney transplantation in order to guarantee a satisfactory renal function.

Conclusions

Despite a long history of kidney transplantation, genetic disease should not be forgotten when symptoms and images recall to specific inherited alterations. Sonography has to be considered in diagnostic path of kidney cystic disease.

Pre-Ischemic Hypothermic Oxygenated Perfusion Alleviates Protective Molecular Markers of Ischemia-Reperfusion Injury in Rat Liver

To expand the pool of organs, hypothermic oxygenated perfusion (HOPE), one of the most promising perfusion protocols, is currently performed after cold storage (CS) at transplant centers (HOPE-END). We investigated a new timing for HOPE, hypothesizing that performing HOPE before CS (HOPE-PRE) could boost mitochondrial protection allowing the graft to better cope with the accumulation of oxidative stress during CS. We analyzed liver injuries at 3 different levels. Histologic analysis demonstrated that, compared to classical CS (CTRL), the HOPE-PRE group showed significantly less ischemic necrosis compared to CTRL vs HOPE-END. From a biochemical standpoint, transaminases were lower after 2 hours of reperfusion in the CTRL vs HOPE-PRE group, which marked decreased liver injury. qPCR analysis on 37 genes involved in ischemia-reperfusion injury revealed protection in HOPE-PRE and HOPE-END compared to CTRL mediated through similar pathways. However, the CTRL vs HOPE-PRE group demonstrated an increased transcriptional level for protective genes compared to the CTRL vs HOPE-END group. This study provides insights on novel biomarkers that could be used in the clinic to better characterize graft quality improving transplantation outcomes.

[Current approaches to anesthetic management in thoracic surgery-An evaluation from the German Thoracic Registry]

BACKGROUND

While many hospitals in Germany perform thoracic surgery, anesthetic techniques and methods that are actually used are usually only known for individual departments. This study describes the general anesthetic management of three typical thoracic surgical procedures across multiple institutions.

MATERIAL AND METHODS

The German Thoracic Registry recorded 4614 patients in 5 institutions between 2016 and 2019. Hospitals with a minimum number of more than 50 thoracic procedures per year are eligible for inclusion in the registry. To analyze the anesthetic management, a matching process yielded three comparable patient groups (n = 1506) that differed solely in the surgical procedure. Three surgical procedures with varying degrees of invasiveness were selected: Group A = video-assisted thoracoscopic surgery (VATS) with wedge resection, group B = VATS with lobectomy, group C = open thoracotomy. Statistical analysis was performed descriptively using relative and absolute frequencies. Dichotomous variables were compared using the χ²-test.

RESULTS

The study enrolled patients with a median age of 65.6 years. The mean value of the American Society of Anesthesiologists (ASA) classification was 2.8. One lung ventilation was most commonly performed (group A = 98.2%, group B = 99.4%, group C = 98.0%) with double lumen tubes (DLT). Bronchial blockers (group A = 0.2%, group B = 0.4%, group C = 0%) were rarely used. Primary bronchoscopy was used to control double lumen tubes after insertion in the majority of cases (group A = 77.5%, group B = 73.1%, group C= 79.7%). Continuous positive airway pressure (CPAP, group A = 1.2%, group B = 1.4%, group C = 5.1%) and jet ventilation (group A = 1.6%, group B = 1.6%, group C = 1.4%) were rarely used intraoperatively. In group C, the administration of a vasopressor was also more frequently required (group A = 59.9%, group B = 77.8%, group C = 86%). A central venous catheter was established in 30.1% of all patients in group A, 39.8% in group B and 73.3% in group C. Patients in group A received an arterial catheter less frequently (71.7%) when compared to groups B (96.4%) and C (95.2%). Total intravenous anesthesia with propofol was used in most patients (group A = 67.7%, group B 61.6%, group C 75.7%). Propofol supplemented by volatile anesthetics was used less frequently (group A = 28.5%, group B = 35.5%, group C = 23.7%). With increasing invasiveness of the surgical procedure, placement of an epidural catheter was preferred (group A = 18.9%, group B = 29.5%, group C = 64.1%). Paravertebral catheters (group A = 7.6%, group B = 4.4%, group C = 4.8%) or a single infiltration of the paravertebral space were performed less frequently (group A = 7.8%, group B = 17.7%, group C = 11.6%). Postoperatively, some patients (3.4-25.7%) were transferred to the general ward. The largest proportion of patients transferred to a general ward underwent less invasive thoracic procedures (group A). When the extent of resection was greater (group B and group C) patients were mostly transferred to an intermediate care unit (IMC) or an intensive care unit (ICU). The insertion of invasive catheters was neither associated with the patients' ASA classification nor preoperative pathologic pulmonary function.

CONCLUSION

Our data indicate that less invasive thoracic operations are associated with a reduction of invasive anesthetic procedures. As the presented data are descriptive, further studies are required to determine the impact of invasive anesthetic procedures on patient-related outcomes. This evaluation of the anesthetic management in experienced thoracic anesthesiology departments represents the next step towards establishing national quality standards and promoting structural quality in thoracic anesthesia.

MO303: Impact of Dexamethasone and Inhaled Nitric Oxide on Severe Acute Kidney Injury in Critically ill Patients With COVID-19

BACKGROUND AND AIMS

Kidney failure is the second most frequent condition after acute respiratory distress syndrome (ARDS) in critically ill patients with severe COVID-19 and is strongly associated with mortality. The aim of this multicentric study was to assess the impact of the specific treatments of COVID-19 and ARDS on the risk of severe acute kidney injury (AKI) in critically ill COVID patients.

METHOD

Data from a prospectively collected database of consecutive patients hospitalized in six ICUs for COVID-19 was retrospectively analysed. The incidence and severity of AKI were monitored during the entire ICU stay. Patients older than 18 years hospitalized in for COVID-19-related ARDS requiring mechanical ventilation were included.

RESULTS

A total of 164 patients were included in the final analysis, 97 (59.1%) displayed AKI, of which 39 had severe stage 3 AKI and 21 (12.8%) requiring renal replacement therapy (RRT). In univariate analysis, severe AKI was associated with ACEI exposure (P = .016), high blood pressure (P = .029), APACHE-II score (P = .004) and mortality at D28 (P = .008), D60 (P <  .001) and D90 (P <  .001). In multivariate analysis, the factors associated with the onset of stage 3 AKI were: exposure to CEI [OR: 4.238 (1.307–13.736); P = .016], APACHE II score (without age) [OR: 1.138 (1.044–1.241); P = .003] and iNO [OR: 5.694 (1.953–16.606); P = .001], protective factors were prone positioning [OR: 0.234 (0.057–0.967); P = .045] and dexamethasone [OR: 0.194 (0.053–0.713); P = .014].

CONCLUSION

Dexamethasone seems to prevent the risk of severe AKI and RRT, and iNO seems associated with severe AKI and RRT in critically ill patients with COVID-19. iNO must be used with caution in COVID-19 related ARDS.

OUP accepted manuscript

Background

Physiotherapy is a major cornerstone of enhanced rehabilitation after surgery (ERAS) and reduces the development of atelectasis after thoracic surgery. By initiating physiotherapy in the post-anaesthesia care unit (PACU), the aim was to evaluate whether the ultra-early initiation of rehabilitation (in the first hour following tracheal extubation) would improve the outcomes of patients undergoing elective thoracic surgery.

Methods

A case–control study with a before-and-after design was conducted. From a historical control group, patients were paired at a 3:1 ratio with an intervention group. This group consisted of patients treated with the ultra-early rehabilitation programme after elective thoracic surgery (clear fluids, physiotherapy, and ambulation). The primary outcome was the incidence of postoperative atelectasis and/or pneumonia during the hospital stay.

Results

After pairing, 675 patients were allocated to the historical control group and 225 patients to the intervention group. A significant decrease in the incidence of postoperative atelectasis and/or pneumonia was found in the latter (11.4 versus 6.7 per cent respectively; P = 0.042) and remained significant on multivariate analysis (OR 0.53, 95 per cent c.i. 0.26 to 0.98; P = 0.045). A subgroup analysis of the intervention group showed that early ambulation during the PACU stay was associated with a further significant decrease in the incidence of postoperative atelectasis and/or pneumonia (2.2 versus 9.5 per cent; P = 0.012).

Conclusions

Ultra-early rehabilitation in the PACU was associated with a decrease in the incidence of postoperative atelectasis and/or pneumonia after major elective thoracic surgery.

Impact of Sex Hormones on Macrophage Responses to Coxiella burnetii

Introduction

Q fever, a zoonosis caused by Coxiella burnetii, affects more males than females despite a similar level of exposure. A protective role of estradiol has been reported in mice, suggesting that sex hormones are involved in C. burnetii infection. We wondered whether the responses of monocytes and monocyte-derived macrophages (MDMs) to C. burnetii are influenced by sex hormones.

Materials and Methods

The bacterial intracellular fate in monocytes was studied using quantitative PCR, and monocyte cytokine production in response to C. burnetii was assessed using qRT-PCR and immunoassays. Before infection, MDMs from males and females were incubated with testosterone and estradiol, respectively.

Results

Bacterial uptake and persistence were similar in monocytes from males and females but were slightly increased in male MDMs. The expression of inflammatory genes, including those encoding TNF and CXCL10, was higher in MDMs from females than in MDMs from males infected by C. burnetii. Adding testosterone to male MDMs amplified their immunoregulatory properties, including increased expression of IL10 and TGFB genes and TGF-β production in response to C. burnetii. In contrast, adding estradiol to MDMs from females had no effect on their inflammatory profile.

Conclusion

The stronger inflammatory profile of macrophages from females may have a protective role, likely under estrogen control, while testosterone may affect disease progression by promoting an anti-inflammatory response. This finding may have consequences for personalized management of patients with Q fever.

Effects of colostrum management on transfer of passive immunity and the potential role of colostral bioactive components on neonatal calf development and metabolism

Neonatal dairy and beef calves are required to ingest adequate volumes of high-quality colostrum during their first hours of life to acquire transfer of passive immunity (TPI). As such, immunoglobulin G (IgG) has largely been the focus of colostrum research over recent decades. Yet, little is known about the additional bioactive compounds in colostrum that potentially influence newborn calf development and metabolism. The purpose of this narrative review is to synthesize research regarding the effects of colostrum management practices on TPI, as well as to address the potential role of additional colostral bioactive molecules, including oligosaccharides, fatty acids, insulin, and insulin-like growth factor-I, in promoting calf development and metabolism. Due to the importance of IgG in ensuring calf immunity and health, we review past research describing the process of colostrogenesis and dam factors influencing the concentrations of IgG in an effort to maximize TPI. We also address the transfer of additional bioactive compounds in colostrum and prepartum management and dam factors that influence their concentrations. Finally, we highlight key areas of future research for the scientific community to pursue to ultimately improve the health and welfare of neonatal dairy calves.

Association between mortality and highly antimicrobial-resistant bacteria in intensive care unit-acquired pneumonia

Data on the relationship between antimicrobial resistance and mortality remain scarce, and this relationship needs to be investigated in intensive care units (ICUs). The aim of this study was to compare the ICU mortality rates between patients with ICU-acquired pneumonia due to highly antimicrobial-resistant (HAMR) bacteria and those with ICU-acquired pneumonia due to non-HAMR bacteria. We conducted a multicenter, retrospective cohort study using the French National Surveillance Network for Healthcare Associated Infection in ICUs ("REA-Raisin") database, gathering data from 200 ICUs from January 2007 to December 2016. We assessed all adult patients who were hospitalized for at least 48 h and presented with ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii. The association between pneumonia caused by HAMR bacteria and ICU mortality was analyzed using the whole sample and using a 1:2 matched sample. Among the 18,497 patients with at least one documented case of ICU-acquired pneumonia caused by S. aureus, Enterobacteriaceae, P. aeruginosa, or A. baumannii, 3081 (16.4%) had HAMR bacteria. The HAMR group was associated with increased ICU mortality (40.3% vs. 30%, odds ratio (OR) 95%, CI 1.57 [1.45-1.70], P < 0.001). This association was confirmed in the matched sample (3006 HAMR and 5640 non-HAMR, OR 95%, CI 1.39 [1.27-1.52], P < 0.001) and after adjusting for confounding factors (OR ranged from 1.34 to 1.39, all P < 0.001). Our findings suggest that ICU-acquired pneumonia due to HAMR bacteria is associated with an increased ICU mortality rate, ICU length of stay, and mechanical ventilation duration.

Management of SARS-CoV-2 pneumonia in intensive care unit: An observational retrospective study comparing two bundles

Purpose

To compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients.

Materials and methods

Our retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence.

Results

129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO₂/FiO₂ ratio < 125 were associated with in-hospital mortality.

Conclusion

Within the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.

Impact of dexamethasone on the incidence of ventilator-associated pneumonia and blood stream infections in COVID-19 patients requiring invasive mechanical ventilation: a multicenter retrospective study

Background

Dexamethasone decreases mortality in patients with severe coronavirus disease 2019 (COVID-19) and has become the standard of care during the second wave of pandemic. Dexamethasone is an immunosuppressive treatment potentially increasing the risk of secondary hospital acquired infections in critically ill patients. We conducted an observational retrospective study in three French intensive care units (ICUs) comparing the first and second waves of pandemic to investigate the role of dexamethasone in the occurrence of ventilator-associated pneumonia (VAP) and blood stream infections (BSI). Patients admitted from March to November 2020 with a documented COVID-19 and requiring mechanical ventilation (MV) for ≥ 48 h were included. The main study outcomes were the incidence of VAP and BSI according to the use of dexamethasone. Secondary outcomes were the ventilator-free days (VFD) at day-28 and day-60, ICU and hospital length of stay and mortality.

Results

Among the 151 patients included, 84 received dexamethasone, all but one during the second wave. VAP occurred in 63% of patients treated with dexamethasone (DEXA+) and 57% in those not receiving dexamethasone (DEXA−) (p = 0.43). The cumulative incidence of VAP, considering death, duration of MV and late immunosuppression as competing factors was not different between groups (p = 0.59). A multivariate analysis did not identify dexamethasone as an independent risk factor for VAP occurrence. The occurrence of BSI was not different between groups (29 vs. 30%; p = 0.86). DEXA+ patients had more VFD at day-28 (9 (0–21) vs. 0 (0–11) days; p = 0.009) and a reduced ICU length of stay (20 (11–44) vs. 32 (17–46) days; p = 0.01). Mortality did not differ between groups.

Conclusions

In this cohort of COVID-19 patients requiring invasive MV, dexamethasone was not associated with an increased incidence of VAP or BSI. Dexamethasone might not explain the high rates of VAP and BSI observed in critically ill COVID-19 patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00876-8.

Depression in midlife women attending a menopause clinic is associated with a history of childhood maltreatment

A growing body of literature has suggested that the perimenopause and the early postmenopausal years are associated with an increased risk of experiencing symptoms of depression and the development of first-onset and recurrent episodes of major depressive disorder. Multiple risk factors have been identified, including stressful life events and lower socioeconomic status, as well as early life adversity. The objective of the current study was to characterize the influence of early life childhood maltreatment and incident depression among women experiencing bothersome menopausal symptoms. Participants were recruited from two university-affiliated specialty clinics caring for women with bothersome menopausal symptoms. Assessments included the Childhood Trauma Questionnaire (CTQ), the Center for Epidemiological Studies - Depression (CES-D) scale and the Greene Climacteric Scale. Findings from this cross-sectional study indicate that adverse childhood experiences, as measured using the CTQ, were highly prevalent among women seeking care for bothersome menopausal symptoms (66%). Further, a greater score on the CTQ was significantly associated with higher CES-D scores, as well as with a greater burden of menopausal symptoms, after adjusting for confounding. Our findings lend support to the growing body of literature suggesting that early life stress affects mental health well into adulthood.

Can Thoracic Ultrasound on Admission Predict the Outcome of Critically Ill Patients with SARS-CoV-2? A French Multi-Centric Ancillary Retrospective Study

Introduction

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have led to massive admissions to intensive care units (ICUs). An ultrasound examination of the thorax is widely performed on admission in these patients. The primary objective of our study was to assess the performance of the lung ultrasound score (LUS) on ICU admission to predict the 28-day mortality rate in patients with SARS-CoV-2. The secondary objective was to asses the performance of thoracic ultrasound and biological markers of cardiac injury to predict mortality.

Methods

This multicentre, retrospective, observational study was conducted in six ICUs of four university hospitals in France from 15 March to 3 May 2020. Patients admitted to ICUs because of SARS-CoV-2-related acute respiratory failure and those who received an LUS examination at admission were included. The area under the receiver-operating characteristics (ROC) curve was determined for the LUS score to predict the 28-day mortality rate. The same analysis was performed for the Simplified Acute Physiology Score, left ventricular ejection fraction, cardiac output, brain natriuretic peptide and ultra-sensitive troponin levels at admission.

Results

In 57 patients, the 28-day mortality rate was 21%. The area under the ROC curve of the LUS score value on ICU admission was 0.68 [95% CI 0.54–0.82; p = 0.05]. In non-intubated patients on ICU admission (n = 40), the area under the ROC curves was 0.84 [95% CI 0.70–0.97; p = 0.005]. The best cut-off of 22 corresponded to 85% specificity and 83% sensitivity.

Conclusions

LUS scores on ICU admission for SARS-CoV-2 did not efficiently predict the 28-day mortality rate. Performance was better for non-intubated patients at admission. Performance of biological cardiac markers may be equivalent to the LUS score.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01702-0.

Bedside POCUS during ward emergencies is associated with improved diagnosis and outcome: an observational, prospective, controlled study

Background

Rapid response teams are intended to improve early diagnosis and intervention in ward patients who develop acute respiratory or circulatory failure. A management protocol including the use of a handheld ultrasound device for immediate point-of-care ultrasound (POCUS) examination at the bedside may improve team performance. The main objective of the study was to assess the impact of implementing such a POCUS-guided management on the proportion of adequate immediate diagnoses in two groups. Secondary endpoints included time to treatment and patient outcomes.

Methods

A prospective, observational, controlled study was conducted in a single university hospital. Two teams alternated every other day for managing in-hospital ward patients developing acute respiratory and/or circulatory failures. Only one of the team used an ultrasound device (POCUS group).

Results

We included 165 patients (POCUS group 83, control group 82). Proportion of adequate immediate diagnoses was 94% in the POCUS group and 80% in the control group (p = 0.009). Time to first treatment/intervention was shorter in the POCUS group (15 [10–25] min vs. 34 [15–40] min, p < 0.001). In-hospital mortality rates were 17% in the POCUS group and 35% in the control group (p = 0.007), but this difference was not confirmed in the propensity score sample (29% vs. 34%, p = 0.53).

Conclusion

Our study suggests that protocolized use of a handheld POCUS device at the bedside in the ward may improve the proportion of adequate diagnosis, the time to initial treatment and perhaps also survival of ward patients developing acute respiratory or circulatory failure.

Clinical Trial Registration NCT02967809. Registered 18 November 2016, https://clinicaltrials.gov/ct2/show/NCT02967809.

A Granulocytic Signature Identifies COVID-19 and Its Severity

Background

An unbiased approach of SARS-CoV-2-induced immune dysregulation has not been undertaken so far. We aimed to identify previously unreported immune markers able to discriminate COVID-19 patients from healthy controls and to predict mild and severe disease.

Methods

An observational, prospective, multicentric study was conducted in patients with confirmed COVID-19: mild/moderate (n=7) and severe (n=19). Immunophenotyping of whole blood leukocytes was performed in patients upon hospital ward or intensive care unit admission and in healthy controls (n=25). Clinically relevant associations were identified through unsupervised analysis.

Results

Granulocytic (neutrophil, eosinophil and basophil) markers were enriched during COVID-19 and discriminated between mild and severe patients. Increased counts of CD15 ⁺CD16 ⁺ neutrophils, decreased granulocytic expression of integrin CD11b, and Th2-related CRTH2 downregulation in eosinophils and basophils established a COVID-19 signature. Severity was associated with the emergence of PDL1 checkpoint expression in basophils and eosinophils. This granulocytic signature was accompanied by monocyte and lymphocyte immunoparalysis. Correlation with validated clinical scores supported pathophysiological relevance.

Conclusion

Phenotypic markers of circulating granulocytes are strong discriminators between infected and uninfected individuals as well as between severity stages. COVID-19 alters the frequency and functional phenotypes of granulocyte subsets with the emergence of CRTH2 as a disease biomarker.

Intervention to promote physical activation and improve sleep and response feeding in infants for preventing obesity early in life, the baby-act trial: Rationale and design

Infant obesity is increasing in the US, particularly among Hispanics. Rapid weight gain during infancy increases the risk of obesity later in life and could be prevented through multi-modal interventions addressing multiple risk factors through population-level programs.

OBJECTIVES

1) determine the extent to which the intervention, compared with the usual care control condition, improves healthy weight gain and specific behaviors (physical activity, sleep, diet) in the first year of life and 2) evaluate the cost of the intervention as a modification of the current WIC standard of care.

METHODS

The lifestyle intervention focuses on age-appropriate infant physical activation, healthy sleep and sedentary patterns, and response feeding, by improving parenting skills delivered through a combination of technology (web-platform and text messages) and phone counseling. It is being tested among caregivers of infant participants of the Puerto Rico WIC program through a cluster-randomized controlled trial in 14 WIC clinics in San Juan starting in pregnancy until the infant is 12 months of age. The main outcome is infant rate of weight gain at 12 months; secondary outcomes include objectively measured hours of infant movement, sedentary behaviors and sleep, diet quality score and response feeding behaviors. We are also recording fees, time and personnel involved in the intervention development, maintenance and dissemination.

CONCLUSIONS

If successful, the intervention could be incorporated as a 'best practice' through WIC policy as a means to strengthen obesity prevention efforts to improve minority health and eliminate health disparities among Hispanics and possibly other at-risk groups beyond the childhood period. Clinicaltrials.gov registration: NCT03517891.

Photodynamic therapy (PDT) in non-surgical treatment of periodontitis

Periodontitis represents a major problem for patients, since it is not possible to eliminate the bacteria that are responsible for this pathology with a pharmacological treatment. The present study included forty-four patients with periodontitis, who had undergone disinfection via photodynamic therapy (PDT) using a laser source having a 635 nm wavelength associated with a photoactivable substance (methylene blue). Clinical assessment of plaque index (PI), bleeding on probing (BOP), probing depth (PD), calculus index (CI), gingival recession (REC) and clinical attachment level (CAL) were recorded at base line, 1 month (4 weeks) after treatment and again 3 months (12 weeks) after treatment, while site radiography (RX) and microbiological test (MT) were recorded at base line and 3 months (12 weeks) after treatment. The outcomes show a good efficacy of the PDT in the elimination of the periodontal pathogenic microflora and in the improvement of the clinical parameters considered: from the base line to the final check after 12 weeks it has been observed a reduction in REC of about 16.9%, a reduction of CAL of about 17.85%, a reduction of the BoP of about 93.3%, a reduction of the PD of about 17%, a reduction of the CI of about 66.3%, a reduction of PI of about 44%, and microbiologically a reduction of the total amount of bacteria with proven parodontopathic properties (red complex bacteria) of about 58.74%. Within the limits of the present study, PDT can be reasonably considered as a good carrier that leads to significant improvements in the parameters (clinical and microbiological) considered.

Antimicrobial efficacy of photodynamic therapy (PDT) in periodontitis and peri-implantitis: A systematic review

To systematically review the literature regarding the antimicrobial effects of photodynamic therapy (PDT) on multi-bacterial species in periodontitis and peri-implantitis disease. The addressed focused question was: "Does PDT show antimicrobial efficacy against multi-bacterial species colonization in periodontal pockets and on the surface of dental implants?" Electronic databases including MEDLINE and EMBASE up to and including December 2018 were searched. Of the ninety studied analyzed, seven were included, four for the study of PDT in peri-implantitis disease and three for periodontal disease. All studies reported the multibacterial species outcomes after the application of antimicrobial PDT. All studies showed a significant reduction in the bacterial load, both in studies based on periodontal and peri-implantary disease, with an average reduction of the total amount of bacterial load of 99.3%. Moreover, the change in clinical parameters is equally important, with an average reduction of PPD of 1.01 mm (from 4.92 to 3.49 ± SD with a percentage reduction of 29%); of BoP of 50%; of RCAL of 1.19 mm (from 9.93 to 8.74, with an average percentage reduction of 12%); of PI of 0.3 (from 1 to 0.7 with a percentage reduction of 30%) and of GI of 1.2 (from 1.8 to 0.6 with a percentage reduction of 66.6%). This review demonstrated significant reduction in the bacterial load in periodontal pocket and dental implant surface with the use of PDT. The results of this review should be considered preliminary and further studies with standardized laser parameters are needed to obtain strong conclusions.

Effects of Hydroxychloroquine on Covid-19 in Intensive Care Unit Patients: Preliminary Results

•

Usefulness of antivirals and hydroxychloroquine in Covid-19 patients in the Intensive care unit (ICU) is not evidence-based.

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No association between hydroxychloroquine plasma concentration, viral load evolution, and clinical outcome for Covid-19.

•

These results indicate that administration of hydroxychloroquine in critically ill patients would not be useful.

During the Covid-19 pandemic, many intensive care unit (ICU) patients received hydroxychloroquine. The primary objective of this study was to assess the effects of hydroxychloroquine according to its plasma concentration in ICU patients. A single-center retrospective study was performed from March to April 2020 in an ICU of a university hospital. All patients admitted to the ICU with confirmed Covid-19 pneumonia and treated with hydroxychloroquine were included. The study compared 17 patients in whom the hydroxychloroquine plasma concentration was in the therapeutic target (on-target) and 12 patients in whom the plasma concentration was below the target (off-target). The follow-up of patients was 15 days. No association was found between hydroxychloroquine plasma concentration and viral load evolution (P = 0.77). There was no significant difference between the two groups for duration of mechanical ventilation, length of ICU stay, in-hospital mortality, and 15-days mortality. These findings indicate that hydroxychloroquine administration for Covid-19 patients hospitalized in ICU is not associated with improved outcomes. Larger multicenter studies are needed to confirm these results.

Comparative study of lung ultrasound and chest computed tomography scan in the assessment of severity of confirmed COVID-19 pneumonia

Purpose

The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO₂)/fractional inspired oxygen (FiO₂) ratio.

Methods

A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included.

Results

One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68–0.87; p < 0.0001). A high LUS score was associated with the use of mechanical ventilation, and with a SpO₂/FiO₂ ratio below 357.

Conclusion

In known SARS-CoV-2 pneumonia patients, the LUS score was predictive of pneumonia severity as assessed by a chest CT scan and clinical features. Within the limitations inherent to our study design, LUS can be used to assess SARS-CoV-2 pneumonia severity.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06186-0) contains supplementary material, which is available to authorized users.

The role of 5-HTTLPR in autism spectrum disorder: New evidence and a meta-analysis of this polymorphism in Latin American population with psychiatric disorders

The autism spectrum disorder (ASD) is a complex disorder encompassing a broad phenotypic and genotypic variability. The short (S)/long (L) 5-HTTLPR polymorphism has a functional role in the regulation of extracellular serotonin levels and both alleles have been associated to ASD. Most studies including European, American, and Asian populations have suggested an ethnical heterogeneity of this polymorphism; however, the short/long frequencies from Latin American population have been under-studied in recent meta-analysis. Here, we evaluated the 5-HTTLPR polymorphism in Colombian individuals with idiopathic ASD and reported a non-preferential S or L transmission and a non-association with ASD risk or symptom severity. Moreover, to recognize the allelic frequencies of an under-represented population we also recovered genetic studies from Latin American individuals and compared these frequencies with frequencies from other ethnicities. Results from meta-analysis suggest that short/long frequencies in Latin American are similar to those reported in Caucasian population but different to African and Asian regions.

105 Optimization of a five-day fixed-time embryo transfer program in dairy heifers: Use of gonadotrophin-releasing hormone at initiation of the protocol

Optimized fixed-time embryo transfer (FTET) protocols for synchronization of recipients have the potential to improve the overall efficiency and profitability of embryo transfer (ET) programs. The objective of the present study was to evaluate the effect of dose of gonadotrophin-releasing hormone (GnRH) at initiation of a 5-day synchronization protocol for FTET. Holstein heifers (n=2689) at two locations were synchronized using a 5-day CO-Synch protocol as follows: Day 0: CIDR inserted, Day 5: CIDR removed, prostaglandin (PG)F2α treatment (500μg cloprostenol), Day 6: PGF2α treatment, Day 8: GnRH (100μg of gonadorelin). On Day 0, at the time of CIDR insertion, heifers were assigned in a completely randomised design to the following groups: Single (a single dose of GnRH; 100μg of gonadorelin), Double (200μg of gonadorelin) or No GnRH (control). All heifers received an Estrotect patch placed on Day 5 and evaluated for signs of oestrus on Day 8. At location A, heifers were evaluated by ultrasonography 5 days after GnRH to determine presence and size of corpus luteum (CL), whereas at location B presence and location of CL were determined by transrectal palpation at the time of transfer. Heifers with a CL received an embryo 7±1 days after GnRH administration, and pregnancy was determined by ultrasonography 41 and 63 days after GnRH. Data were analysed by generalized linear mixed models. Oestrus expression was greater in heifers that received Single and Double GnRH than in the No GnRH group (P=0.001). Similarly, utilisation rate (number transferred per number treated) was greater for heifers in the Single and Double GnRH group than for those in the No GnRH group (P=0.02). Pregnancy data were analysed for a subset of recipients using data from Day 41 (n=2267) and Day 63 (n=2042). The analysis of fertility outcomes included as covariates the type of embryo (invitro fresh or frozen and invivo fresh or frozen), embryo stage, embryo quality, interval from GnRH to transfer, and oestrus expression. Pregnancies per embryo transfer (P/ET) at Days 41 and 63 were not different between treatment groups (P=0.86), and there was no interaction between type of embryo and treatment (P&gt;0.15). Pregnancy loss between Days 41 and 63 was not different (P=0.49) between treatments groups. In conclusion, the removal of the initial GnRH from a 5-day FTET protocol resulted in a slight but significant reduction in the utilisation rate and the percentage of heifers showing oestrus. However, there was no detrimental effect on fertility. As a result, the overall cost of the FTET program can be reduced by eliminating the need for the initial GnRH treatment without compromising fertility. Table 1.Reproductive performance in recipients receiving different doses of gonadotrophin-releasing hormone (GnRH) at initiation of the synchronization protocol Treatment Oestrus (n) Utilisation rate (n) P/ET1 D41 (n) P/ET D63 (n) Pregnancy loss (n) No GnRH 69.2%B (621/898) 85.0%B (763/898) 41.6% (308/740) 39.9% (268/672) 4.3% (12/280) Single GnRH 76.1%A (685/900) 88.8%A (799/900) 42.7% (329/770) 39.5% (272/689) 6.5% (19/291) Double GnRH 75.3%A (671/891) 88.7%A (790/891) 41.5% (314/757) 38.9% (265/681) 5.4% (15/280) A,BValues with different superscripts within a column differ (P&lt;0.05). 1P/ET=pregnancies per embryo transfer.

P581Electronic health records (EHRs) data validation in atherosclerotic/cardiovascular clinical phenotypes

Background

Research efforts to develop strategies to effectively identify patients and reduce the burden of cardiovascular diseases is essential for the future of the health system. Most research studies have used only coded parts of electronic health records (EHRs) for case-detection obtaining missed data cases, reducing study quality and in some case bias findings. Incorporating information from free-text into case-detection through Big Data and Artificial Intelligence techniques improves research quality. Savana has developed EHRead, a powerful technology that applies Natural Language Processing, Machine Learning and Deep Learning, to analyse and automatically extracts highly valuable medical information from unstructured free text contained in the EHR to support research and practice.

Purpose

We aimed to validate the linguistic accuracy performance of Savana, in terms of Precision (P), Recall (R) and overall performance (F-Score) in the cardiovascular domain since this is one of the most prevalent disease in the general population. This means validating the extent to which the Savana system identifies mentions to atherosclerotic/cardiovascular clinical phenotypes in EHRs.

Methods

The project was conducted in 3 Spanish sites and the system was validated using a corpus that consisted of 739 EHRs, including the emergency, medical and discharge records, written in free text. These EHRs were randomly selected from the total number of clinical documents generated during the period of 2012–2017 and were fully anonymized to comply with legal and ethical requirements. Two physicians per site reviewed records (randomly selected) and annotated all direct references to atherosclerotic/cardiovascular clinical phenotypes, following the annotation guidelines previously developed. A third physician adjudicated discordant annotations. Savana's performance was automatically calculated using as validation resource the gold standard created by the experts.

Results

We found good levels of performance achieved by Savana in the identification of mentions to atherosclerotic/cardiovascular clinical phenotypes, yielding an overall P, R, and F-score of 0.97, 0.92, and 0.94, respectively. We also found that going through all the EHRs and identifying the mentions to atherosclerotic/cardiovascular clinical phenotypes, the expert spent ∼ 60h while Savana ∼ 36 min.

Conclusion(s)

Innovative techniques to identify atherosclerotic/cardiovascular clinical phenotypes could be used to support real world data research and clinical practice. Overall Savana showed a high performance, comparable with those obtained by an expert physician annotator doing the same task. Additionally, a significant reduction of time in using automatic information extraction system was achieved.