Serum Ferritin as a Predictor of Outcomes in Hospitalized Patients with Covid-19 Pneumonia

Purpose: Elevated ferritin levels are associated with poor outcomes in Covid-19 patients. Optimal timing of ferritin assessment and the merit of longitudinal values remains unclear. Methods: Patients admitted to Henry Ford Hospital with confirmed SARS-CoV-2 were studied. Regression models were used to determine the relation between ferritin and mortality, need for mechanical ventilation, ICU admission, and days on the ventilator. Results: 2265 patients were evaluated. Patients with an initial ferritin of > 490 ng/mL had an increased risk of death (OR 3.4, P < .001), admission to the ICU (OR 2.78, P < .001) and need for mechanical ventilation (OR 3.9, P < .001). There was no difference between admission and Day 1 ICU ferritin levels (611.5 ng/mL vs. 649 ng/mL respectively; P = .07). The decline in ferritin over ICU days 1-4 was similar between survivors and non-survivors. A change in ferritin levels from admission to ICU Day 1 (P = .330), or from ICU Day 1 to 2 (P = .788), did not predict days on the ventilator. Conclusions: Initial Ferritin levels were highly predictive of ICU admission, the need for mechanical ventilation and in-hospital mortality. However, longitudinal measures of ferritin throughout the hospital stay did not provide additional predictive value.

Association between convalescent plasma treatment and mortality in COVID-19: a collaborative systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Convalescent plasma has been widely used to treat COVID-19 and is under investigation in numerous randomized clinical trials, but results are publicly available only for a small number of trials. The objective of this study was to assess the benefits of convalescent plasma treatment compared to placebo or no treatment and all-cause mortality in patients with COVID-19, using data from all available randomized clinical trials, including unpublished and ongoing trials (Open Science Framework, https://doi.org/10.17605/OSF.IO/GEHFX ).

METHODS

In this collaborative systematic review and meta-analysis, clinical trial registries (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform), the Cochrane COVID-19 register, the LOVE database, and PubMed were searched until April 8, 2021. Investigators of trials registered by March 1, 2021, without published results were contacted via email. Eligible were ongoing, discontinued and completed randomized clinical trials that compared convalescent plasma with placebo or no treatment in COVID-19 patients, regardless of setting or treatment schedule. Aggregated mortality data were extracted from publications or provided by investigators of unpublished trials and combined using the Hartung-Knapp-Sidik-Jonkman random effects model. We investigated the contribution of unpublished trials to the overall evidence.

RESULTS

A total of 16,477 patients were included in 33 trials (20 unpublished with 3190 patients, 13 published with 13,287 patients). 32 trials enrolled only hospitalized patients (including 3 with only intensive care unit patients). Risk of bias was low for 29/33 trials. Of 8495 patients who received convalescent plasma, 1997 died (23%), and of 7982 control patients, 1952 died (24%). The combined risk ratio for all-cause mortality was 0.97 (95% confidence interval: 0.92; 1.02) with between-study heterogeneity not beyond chance (I2 = 0%). The RECOVERY trial had 69.8% and the unpublished evidence 25.3% of the weight in the meta-analysis.

CONCLUSIONS

Convalescent plasma treatment of patients with COVID-19 did not reduce all-cause mortality. These results provide strong evidence that convalescent plasma treatment for patients with COVID-19 should not be used outside of randomized trials. Evidence synthesis from collaborations among trial investigators can inform both evidence generation and evidence application in patient care.

Outcomes in Medical Intensive Care Patients Housed in Geographically Distant Units

OBJECTIVE

The purpose of this study is to determine whether in patients admitted to a medical intensive care unit (ICU) service there are outcome differences between those in a medical ICU bed ("home") and a geographically distant subspecialty ICU bed ("overflow").

METHODS

We performed a retrospective cohort study of 4091 patients admitted to a medical ICU of a large tertiary-care urban teaching hospital. Depending on bed availability, some patients were housed in surgical or cardiac subspecialty ICUs while still being cared for by the primary medical ICU service. We assessed the association of these overflow patients with readmission rates and ICU and hospital length of stay (LOS). Potential differences in care was assessed by measuring the number of central line days, urinary catheter days, and ventilator days.

RESULTS

Of the 4091 consecutive patients admitted to the medical ICU, 362 (9%) were housed in an overflow ICU and 3729 (91%) were home patients. There was no difference in demographics, patient characteristics, ICU admission diagnosis, or risk of mortality between the 2 groups. Compared to home patients, overflow patients had a higher rate of readmission to the ICU (10.5% vs 6.63% respectively P = .006), a slightly shorter ICU LOS (median 2 [interquartile range, IQR: 1-4] days versus home group of 2 [IQR: 1-5] days; P = .001), and a slightly longer hospital LOS (overflow 7 [IQR: 4-17] days vs home 7 [IQR: 4-13] days, P = .001). There was no differences in number of central venous catheter days, urinary catheter days, ventilator days, or mortality.

CONCLUSIONS

Medical ICU patients who are housed in ICUs geographically distant from the primary team's location have increased morbidity when compared to patients admitted to the home ICU. However, there are no differences in number of central venous catheter days, urinary catheter days, ventilator days, or mortality.

Anaerobic antibiotic usage for pneumonia in the medical intensive care unit

BACKGROUND AND OBJECTIVE

Pneumonia is a common admitting diagnosis in the intensive care unit (ICU). When aspiration is suspected, antibiotics to cover anaerobes are frequently used, but in the absence of clear risk factors, current guidelines have questioned their role. It is unknown how frequently these guidelines are followed.

METHODS

We conducted a single-centre observational study on practice patterns of anaerobic antibiotic use in consecutive patients admitted to the ICU with aspiration pneumonia (Asp), community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP).

RESULTS

A total of 192 patients were studied (Asp: 20, HCAP: 107, CAP: 65). Overall, 59 patients received anaerobic antibiotics (Asp: 90%, HCAP: 28%, CAP 17%) but a significant proportion of these patients did not meet criteria to receive them. Inappropriate anaerobic antibiotic use was 12/20 for Asp, 27/107 for HCAP and 9/65 for CAP. Mortality probability model III at zero hours (MPM0) score and a diagnosis of Asp were predictors of receiving inappropriate anaerobic antibiotics. Receiving inappropriate anaerobic antibiotics was associated with a longer ICU length of stay (LOS; 7 days (interquartile range (IQR): 7-21) vs 4 days (IQR:2-9), P = 0.017).

CONCLUSION

For patients in the ICU admitted with pneumonia, there is a high occurrence of inappropriately prescribed anaerobic antibiotics, the use of which was associated with a longer ICU LOS.

Dedicated multidisciplinary ventilator bundle team and compliance with sedation vacation

BACKGROUND

How compliance with a ventilator bundle is monitored varies from institution to institution. Some institutions rely on the primary intensive care unit team to review the bundle during their rounds; others rely on a separate team of health care personnel that may include representatives from disciplines such as nursing, respiratory therapy, and pharmacy.

OBJECTIVES

To compare rates of compliance with ventilator bundle components between a dedicated ventilator bundle rounding team and the primary intensive care unit rounding team in a 68-bed medical intensive care unit.

METHODS

A query of the medical intensive care unit's database was used to retrospectively determine rates of compliance with specific ventilator bundle components at a tertiary care hospital in an urban community for 1 year.

RESULTS

Compared with the intensive care unit rounding team, the ventilator bundle rounding team had better compliance with sedation vacation (61.7% vs 54.0%, P < .001). Rates of compliance with spontaneous breathing trials and prophylaxis of peptic ulcer disease were similar in both study groups.

CONCLUSIONS

A dedicated ventilator bundle rounding team improves compliance with sedation vacation, but not with spontaneous breathing trials and prophylaxis of peptic ulcer disease. In a large-volume tertiary center, a dedicated ventilator bundle rounding team may be more effective than the primary rounding team in achieving compliance with some bundle components.

A welder with pneumosiderosis: a case report

Pneumosiderosis or Welder's lung is an occupational lung disease which is usually seen after chronic exposure to iron dust. We present a case of a 64-year-old welder in whom the diagnosis of pneumosiderosis was made by lung biopsies. We also briefly review the literature regarding the disease, its prognosis and association with development of lung cancer. Avoidance of iron dust exposure and implementing prevention strategies in people at risk are the mainstay of therapy.

Monocytes recruited to the lungs of mice during immune inflammation ingest apoptotic cells poorly

Apoptotic cells must be cleared to resolve inflammation, but few resident alveolar macrophages (AMo) from normal lungs ingest apoptotic cells. We examined how Mo ingestion of apoptotic cells is altered during immune inflammation induced by intratracheal challenge of primed C57BL/6 mice using sheep red blood cells. Resident AMo were labeled in situ before challenge using intravenous PKH26 to distinguish them from recruited monocytes. Using flow cytometry, we identified phagocytosis of fluorescently-labeled apoptotic thymocytes by alveolar mononuclear phagocytes in vitro and in vivo, and measured surface molecule expression. Intratracheal challenge induced rapid recruitment of monocytes, peaking at Day 3 and decreasing thereafter, whereas numbers of resident AMo did not change significantly. At all times, the percentage of phagocytes ingesting apoptotic thymocytes in vitro was greater among resident AMo (28-45%) than among recruited monocytes (9-19%), but was low in both cell types relative to ingestion of immunoglobulin-opsonized targets. There was also a nonsignificant trend toward lower ingestion by monocytes in vivo. MerTK, a receptor tyrosine kinase crucial for apoptotic cell phagocytosis, was expressed by resident AMo, but not by recruited monocytes. Relative to resident AMo, monocytes recruited to the alveolus ingest apoptotic cells meagerly, possibly due to absence of MerTK expression.

Resident murine alveolar and peritoneal macrophages differ in adhesion of apoptotic thymocytes

Apoptotic cells must be cleared efficiently by macrophages (Mø) to prevent autoimmunity, yet their ingestion impairs Mø microbicidal function. The principal murine resident lung phagocyte, the alveolar Mø (AMø), is specifically deficient at apoptotic cell ingestion, both in vitro and in vivo, compared with resident peritoneal Mø (PMø). To further characterize this deficiency, we assayed static adhesion in vitro using apoptotic thymocytes and resident AMø and PMø from normal C57BL/6 mice. Adhesion of apoptotic thymocytes by both types of Mø was rapid, specific, and cold-sensitive. Antibody against the receptor tyrosine kinase MerTK (Tyro12) blocked phagocytosis but not adhesion in both types of Mø. Surfactant protein A increased adhesion and phagocytosis by AMø, but not to the levels seen using PMø. Adhesion was largely cation-independent for PMø and calcium-dependent for AMø. Adhesion was not inhibited in either Mø type by mAbs against beta1 or beta3 integrins or scavenger receptor I/II (CD204), but AMø adhesion was inhibited by specific mAbs against CD11c/CD18. Thus, resident murine tissue Mø from different tissues depend on qualitatively disparate receptor systems to bind apoptotic cells. The decreased capacity of murine AMø to ingest apoptotic cells is only partially explained by reduced initial adhesion.