Prospective, randomized, controlled trial assessing the effects of a driving pressure-limiting strategy for patients with acute respiratory distress syndrome due to community-acquired pneumonia (STAMINA trial): protocol and statistical analysis plan

BACKGROUND

Driving pressure has been suggested to be the main driver of ventilator-induced lung injury and mortality in observational studies of acute respiratory distress syndrome. Whether a driving pressure-limiting strategy can improve clinical outcomes is unclear.

OBJECTIVE

To describe the protocol and statistical analysis plan that will be used to test whether a driving pressure-limiting strategy including positive end-expiratory pressure titration according to the best respiratory compliance and reduction in tidal volume is superior to a standard strategy involving the use of the ARDSNet low-positive end-expiratory pressure table in terms of increasing the number of ventilator-free days in patients with acute respiratory distress syndrome due to community-acquired pneumonia.

METHODS

The ventilator STrAtegy for coMmunIty acquired pNeumoniA (STAMINA) study is a randomized, multicenter, open-label trial that compares a driving pressure-limiting strategy to the ARDSnet low-positive end-expiratory pressure table in patients with moderate-to-severe acute respiratory distress syndrome due to community-acquired pneumonia admitted to intensive care units. We expect to recruit 500 patients from 20 Brazilian and 2 Colombian intensive care units. They will be randomized to a driving pressure-limiting strategy group or to a standard strategy using the ARDSNet low-positive end-expiratory pressure table. In the driving pressure-limiting strategy group, positive end-expiratory pressure will be titrated according to the best respiratory system compliance.

OUTCOMES

The primary outcome is the number of ventilator-free days within 28 days. The secondary outcomes are in-hospital and intensive care unit mortality and the need for rescue therapies such as extracorporeal life support, recruitment maneuvers and inhaled nitric oxide.

CONCLUSION

STAMINA is designed to provide evidence on whether a driving pressure-limiting strategy is superior to the ARDSNet low-positive end-expiratory pressure table strategy for increasing the number of ventilator-free days within 28 days in patients with moderate-to-severe acute respiratory distress syndrome. Here, we describe the rationale, design and status of the trial.

Effects of Glycemic Variability in Critically Ill Patients with Coronavirus Disease 2019: A Retrospective Observational Study

Aim and background

Hyperglycemia is considered an adaptive metabolic manifestation of stress and is associated with poor outcomes. Herein, we analyzed the association between glycemic variability (GV) and hospital mortality in patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU), and the association between GV and mechanical ventilation (MV), ICU stay, length of hospital stays, renal replacement therapy (RRT), hypoglycemia, nosocomial infections, insulin use, and corticosteroid class.

Materials and methods

In this retrospective observational study, we collected information on blood glucose levels during the first 10 days of hospitalization in a cohort of ICU patients with COVID-19 and its association with outcomes.

Results

In 239 patients, an association was observed between GV and hospital mortality between the first and last quartiles among patients without diabetes [odds ratio (OR), 3.78; confidence interval, 1.24-11.5]. A higher GV was associated with a greater need for RRT (p = 0.002), regular insulin (p < 0.001), and episodes of hypoglycemia (p < 0.001). Nosocomial infections were associated with intermediate GV quartiles (p = 0.02). The corticosteroid class had no association with GV (p = 0.21).

Conclusion

Glycemic variability was associated with high mortality in patients with COVID-19 and observed in the subgroup of patients without diabetes.

Clinical significance

Glycemic control in critically ill patients remains controversial and hyperglycemia is associated with worse outcomes. Diabetes mellitus (DM) is one of the most prevalent comorbidities in patients with COVID-19. In addition, they require corticosteroids due to pulmonary involvement, representing a challenge and an opportunity to better understand how glycemic changes can influence the outcome of these patients.

How to cite this article

Boschi E, Friedman G, Moraes RB. Effects of Glycemic Variability in Critically Ill Patients with Coronavirus Disease 2019: A Retrospective Observational Study. Indian J Crit Care Med 2024;28(4):381-386.

Erratum: Evaluation of the characteristics of infection prevention and control programs and infection control committees in Brazilian hospitals: A countrywide cross-sectional study - CORRIGENDUM

[This corrects the article DOI: 10.1017/ash.2023.136.].

Evaluation of the characteristics of infection prevention and control programs and infection control committees in Brazilian hospitals: A countrywide cross-sectional study

Objective

Data are scarce regarding hospital infection control committees and compliance with infection prevention and control (IPC) recommendations in Brazil, a country of continental dimensions. We assessed the main characteristics of infection control committees (ICCs) on healthcare-associated infections (HAIs) in Brazilian hospitals.

Methods

This cross-sectional study was conducted in ICCs of public and private hospitals distributed across all Brazilian regions. Data were collected directly from the ICC staff by completing an online questionnaire and during on-site visits through face-to-face interviews.

Results

In total, 53 Brazilian hospitals were evaluated from October 2019 to December 2020. All hospitals had implemented the IPC core components in their programs. All centers had protocols for the prevention and control of ventilator-associated pneumonia as well as bloodstream, surgical site, and catheter-associated urinary tract infections. Most hospitals (80%) had no budget specifically allocated to the IPC program; 34% of the laundry staff had received specific IPC training; and only 7.5% of hospitals reported occupational infections in healthcare workers.

Conclusions

In this sample, most ICCs complied with the minimum requirements for IPC programs. The main limitation regarding ICCs was the lack of financial support. The findings of this survey support the development of strategic plans to improve IPCs in Brazilian hospitals.

Clinical outcomes and lung mechanics characteristics between COVID-19 and non-COVID-19-associated acute respiratory distress syndrome: a propensity score analysis of two major randomized trials

OBJECTIVE

To compare the lung mechanics and outcomes between COVID-19-associated acute respiratory distress syndrome and non-COVID-19-associated acute respiratory distress syndrome.

METHODS

We combined data from two randomized trials in acute respiratory distress syndrome, one including only COVID-19 patients and the other including only patients without COVID-19, to determine whether COVID-19-associated acute respiratory distress syndrome is associated with higher 28-day mortality than non-COVID-19 acute respiratory distress syndrome and to examine the differences in lung mechanics between these two types of acute respiratory distress syndrome.

RESULTS

A total of 299 patients with COVID-19-associated acute respiratory distress syndrome and 1,010 patients with non-COVID-19-associated acute respiratory distress syndrome were included in the main analysis. The results showed that non-COVID-19 patients used higher positive end-expiratory pressure (12.5cmH2O; SD 3.2 versus 11.7cmH2O SD 2.8; p < 0.001), were ventilated with lower tidal volumes (5.8mL/kg; SD 1.0 versus 6.5mL/kg; SD 1.2; p < 0.001) and had lower static respiratory compliance adjusted for ideal body weight (0.5mL/cmH2O/kg; SD 0.3 versus 0.6mL/cmH2O/kg; SD 0.3; p = 0.01). There was no difference between groups in 28-day mortality (52.3% versus 58.9%; p = 0.52) or mechanical ventilation duration in the first 28 days among survivors (13 [IQR 5 - 22] versus 12 [IQR 6 - 26], p = 0.46).

CONCLUSION

This analysis showed that patients with non-COVID-19-associated acute respiratory distress syndrome have different lung mechanics but similar outcomes to COVID-19-associated acute respiratory distress syndrome patients. After propensity score matching, there was no difference in lung mechanics or outcomes between groups.

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

OBJECTIVE

To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria.

METHODS

We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform.

RESULTS

The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database.

CONCLUSION

The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

IMPACTO-MR: a Brazilian nationwide platform study to assess infections and multidrug resistance in intensive care units

OBJECTIVE

To describe the IMPACTO-MR, a Brazilian nationwide intensive care unit platform study focused on the impact of health care-associated infections due to multidrug-resistant bacteria.

METHODS

We described the IMPACTO-MR platform, its development, criteria for intensive care unit selection, characterization of core data collection, objectives, and future research projects to be held within the platform.

RESULTS

The core data were collected using the Epimed Monitor System® and consisted of demographic data, comorbidity data, functional status, clinical scores, admission diagnosis and secondary diagnoses, laboratory, clinical, and microbiological data, and organ support during intensive care unit stay, among others. From October 2019 to December 2020, 33,983 patients from 51 intensive care units were included in the core database.

CONCLUSION

The IMPACTO-MR platform is a nationwide Brazilian intensive care unit clinical database focused on researching the impact of health care-associated infections due to multidrug-resistant bacteria. This platform provides data for individual intensive care unit development and research and multicenter observational and prospective trials.

SOBREVIDA DOS PACIENTES COM COVID-19 ADMITIDOS NAS UNIDADES DE TERAPIA INTENSIVA DO HOSPITAL GERAL DE CAXIAS DO SUL

Introdução/Objetivo

Métodos

Resultados

Conclusão

On-site visible-near IR prediction of iodine number and fatty acid composition of subcutaneous fat of raw hams as phenotypes for a heavy pig breeding program

The quality of subcutaneous fat of raw hams is a trait of interest in selective breeding programs for pig lines used in dry-cured ham production, and rapid, non-invasive methods for its assessment are available. However, the efficacy of such methods to provide indicator traits for breeding programs needs to be proven. The study investigated the accuracy of on-site visible-near IR spectroscopy predictions of iodine number and fatty acid (FA) composition of raw ham subcutaneous fat, and it evaluated their effectiveness as indicator traits of ham fat quality in a pig breeding program. Prediction equations were developed using visible-near IR spectra acquired at the slaughterhouse from five sites in subcutaneous fat of raw hams of 1025 crossbred pigs. Pigs were raised, under standardized rearing and feeding conditions, in the sib-testing program of the Goland C21 boar line and slaughtered at nine months of age and average body weight of 166 ± 15 kg. Accuracy was generally relatively poor, but R² in external validation was >0.7 for iodine number and concentration of C18:2n-6, polyunsaturated FAs and omega-6 FAs. To assess the effectiveness of the on-site predictions as indicator traits in a breeding program, (co)variance components of the measured traits (OBS) and of their predictions using in-lab (in-lab-PR) or on-site (on-site-PR) spectrometers were estimated. Available records for OBS were 6814 and 2048, for iodine number and FA composition, respectively. Predictions using in-lab were available for pigs slaughtered between 2006 and 2014, for a total of 10 153 records. Predictions using on-site were obtained from spectra collected since 2011, for a total of 10 296 records. The estimated heritabilities for the investigated traits ranged from 0.34 to 0.50 and were greater for on-site-PR than for OBS. Genetic correlations between OBS and in-lab-PR were very close to 1.00 for all the investigated traits, whereas those between OBS and on-site-PRED ranged from 0.86 to 0.94. On-site visible-IR predictions are accurate enough to support the use of this technique for large-scale phenotyping of raw ham fat quality, even when dealing with animals of a single genetic line raised in standardized conditions, and may be implemented as indicator traits in breeding programs.

[Gastroesophageal reflux disease: therapeutic features (Part II)]

Gastroesophageal reflux disease (GERD) can be defined as a condition resulting from the reflux of stomach contents into the esophagus. Its pharmacological treatment is aimed at symptom relief, healing of erosions and ulcerations and prevention of relapses. Based on the pathophysiology, the ideal treatment is directed to enhance basal sphincter pressure or decrease the frequency of TLESR, restore esophageal "clearance", accelerate gastric emptying and highten mucosal resistance as well as reduce or inhibit gastric acid secretion. Most of these targets are currently achievable because the availability of different types of drugs, however the "ideal" pharmacologic treatment of GERD does not exist. Current remedies for GERD include life style changes along with a wide array of antisecretory drugs, such as antacids, H2-antagonists and proton pump inhibitors (PPI). Surgery, based on anti-reflux procedures, and endoscopic approaches may have a role in the management of patients with GERD.

[Gastroesophageal reflux disease: clinical and pathophysiological features (part I)]

Gastroesophageal reflux disease (GERD) can be described as a clinical picture resulting from the reflux of stomach contents into the esophagus. The actual prevalence of GERD remains unestablished, although this disorder is generally common in old patients, male sex and in subsets of patients with pulmonary manifestations such as asthma. From a pathophysiological stand-point, GERD is thought to have a multifactorial etiology which involves genetics, anatomical, functional, environmental, hormonal and pharmacological factors. GERD has different clinical presentations which may be divided in three main classes: typical symptoms (heartburn and regurgitation); atypical or extraesophageal symptoms (angina-like chest pain, asthma, chronic cough and laryngitis); and complications (ulcers, strictures and Barrett's esophagus). In GERD diagnosis a key role is played by: accurate symptom evaluation, response to proton pump inhibitors and, finally, at least one in a life-time endoscopy. Moreover, barium swallow X-ray, 24-h esophageal pH monitoring and gastro-esophageal manometry can be useful to support diagnosis in some unusual cases or in cases partially or unresponsive to standard pharmacologic treatment.

The Campi Flegrei caldera: unrest mechanisms and hazards

In the last four decades, Campi Flegrei caldera has been the world’s most active caldera characterized by intense unrest episodes involving huge ground deformation and seismicity, but, at the time of writing, has not culminated in an eruption. We present a careful review, with new analyses and interpretation, of all the data and recent research results. We deal with three main problems: the tentative reconstruction of the substructure; the modelling of unrest episodes to shed light on possible pre-eruptive scenarios; and the probabilistic estimation of the hazards from explosive pyroclastic products. The results show, for the first time at a volcano, that a very peculiar mechanism is generating episodes of unrest, involving mainly activation of the geothermal system from deeper magma reservoirs. The character and evolution of unrest episodes is strongly controlled by structural features, like the ring-fault system at the borders of the caldera collapse. The use of detailed volcanological, mathematical and statistical procedures also make it possible to obtain a detailed picture of eruptive hazards in the whole Neapolitan area. The complex behaviour of this caldera, involving interaction between magmatic and geothermal phenomena, sheds light on the dynamics of the most dangerous types of volcanoes in the world.

Apoptosis and adaptive responses to oxidative stress in human endothelial cells exposed to cyclosporin A correlate with BCL-2 expression levels

Treatment of transplanted patients with cyclosporin A (CSA) may cause adverse effects such as nephrotoxicity and hypertension. As CSA is known to induce oxidative stress in several tissues, it may cause vascular problems by triggering oxidative stress in endothelial cells (EC). However, oxidative stress has been reported for acute exposure to CSA concentrations exceeding its clinical range, whereas immunosuppression requires life-long treatment with therapeutic concentrations. We therefore compared the effects of 21 h pharmacological (200 microM) vs. 8 days clinical (0.5-2.5 microM) doses of CSA on cultured human EC. Pharmacological doses of CSA cause a decrease in cell density via apoptosis and a down-regulation of the antiapoptotic protein Bcl-2. However, these effects are independent of CSA-induced oxidative stress. In contrast, therapeutic concentrations of CSA cause Bcl-2 up-regulation and modification of EC morphology, both effects blocked by antioxidants. Therefore, a low level of oxidants may act in EC as second messengers that up-regulate Bcl-2, thus promoting survival of impaired EC. Our data suggest that the oxidative stress induced by clinical concentrations of CSA may be involved in the adverse effects of the drug on the vascular system of transplanted patients via an adaptive response involving Bcl-2 up-regulation rather than an apoptotic process

Regulation of Bcl-2 protein expression during oxidative stress in neuronal and in endothelial cells

The relationship between oxidative stress and Bcl-2 expression was investigated in two different experimental models of oxidative stress. Acute oxidative stress was assessed by measuring, with fluorescence microscopy and cytofluorimetry, the increase in fluorescence of the oxidation-sensitive probe dihydrorhodamine 123, both in retinal rod receptor cells exposed to bright light (0.32 mW/cm(2) for 15 minutes) and in human endothelial cells treated with the immunosuppressant cyclosporin A (200 microM for 21 h). In both cell types, acute oxidative stress reduced Bcl-2 expression and also caused a significant increase in the level of nucleosomes. Interestingly, chronic treatment with clinical concentrations of cyclosporin A (0.5-2.5 microM for 8 days) led to a significant increase in Bcl-2 expression, while nucleosomes were similar to control level. This suggests that up-regulation of Bcl-2 protein by low levels of oxidants may represent a critical factor in cellular adaptation to drug toxicity.