Epigenetic activation of antiviral sensors and effectors of interferon response pathways during SARS-CoV-2 infection

Recent studies have shown that methylation changes identified in blood cells of COVID-19 patients have a po-tential to be used as biomarkers of SARS-CoV-2 infection outcomes. However, different studies have reported different subsets of epigenetic lesions that stratify patients according to the severity of infection symptoms, and more importantly, the significance of those epigenetic changes in the pathology of the infection is still not clear. We used methylomics and transcriptomics data from the largest so far cohort of COVID-19 patients from four geographically distant populations, to identify casual interactions of blood cells' methylome in pathology of the COVID-19 disease. We identified a subset of methylation changes that is uniformly present in all COVID-19 patients regardless of symptoms. Those changes are not present in patients suffering from upper respiratory tract infections with symptoms similar to COVID-19. Most importantly, the identified epigenetic changes affect the expression of genes involved in interferon response pathways and the expression of those genes differs be-tween patients admitted to intensive care units and only hospitalized. In conclusion, the DNA methylation changes involved in pathophysiology of SARS-CoV-2 infection, which are specific to COVID-19 patients, can not only be utilized as biomarkers in the disease management but also present a potential treatment target

Early acute kidney injury and transition to renal replacement therapy in critically ill patients with SARS-CoV-2 requiring veno-venous extracorporeal membrane oxygenation

Background Critically ill patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) requiring veno-venous extracorporeal membrane oxygenation (vv-ECMO) are at risk for acute kidney injury (AKI). Currently, the incidence of AKI and progression to kidney replacement therapy (RRT) in critically ill patients with vv-ECMO for severe COVID-19 and implications on outcome are still unclear. Methods Retrospective analysis at the University Medical Center Hamburg-Eppendorf (Germany) between March 1st, 2020 and July 31st, 2021. Demographics, clinical parameters, AKI, type of organ support, length of ICU stay, mortality and severity scores were assessed. Results Ninety-one critically ill patients with SARS-CoV-2 requiring ECMO were included. The median age of the study population was 57 (IQR 49–64) years and 67% ( n  = 61) were male. The median SAPS II and SOFA Score on admission were 40 (34–46) and 12 (10–14) points, respectively. We observed that 45% ( n  = 41) developed early-AKI, 38% (n = 35) late-AKI and 16% ( n  = 15) no AKI during the ICU stay. Overall, 70% ( n  = 64) of patients required RRT during the ICU stay, 93% with early-AKI and 74% with late-AKI. Risk factors for early-AKI were younger age (OR 0.94, 95% CI 0.90–0.99, p  = 0.02) and SAPS II (OR 1.12, 95% CI 1.06–1.19, p  < 0.001). Patients with and without RRT were comparable regarding baseline characteristics. SAPS II (41 vs. 37 points, p  < 0.05) and SOFA score (13 vs. 12 points, p  < 0.05) on admission were significantly higher in patients receiving RRT. The median duration of ICU (36 vs. 28 days, p  = 0.27) stay was longer in patients with RRT. An ICU mortality rate in patients with RRT in 69% ( n  = 44) and in patients without RRT of 56% ( n  = 27) was observed ( p  = 0.23). Conclusion Critically ill patients with severe SARS-CoV-2 related ARDS requiring vv-ECMO are at high risk of early acute kidney injury. Early-AKI is associated with age and severity of illness, and presents with high need for RRT. Mortality in patients with RRT was comparable to patients without RRT.Open Access funding enabled and organized by Projekt DEAL.Universitätsklinikum Hamburg-Eppendorf (UKE) (5411

(1 → 3)-β-d-Glucan-guided antifungal therapy in adults with sepsis: the CandiSep randomized clinical trial

Purpose To investigate whether (1 → 3)-β-d-Glucan (BDG)-guidance shortens time to antifungal therapy and thereby reduces mortality of sepsis patients with high risk of invasive Candida infection (ICI). Methods Multicenter, randomized, controlled trial carried out between September 2016 and September 2019 in 18 intensive care units enrolling adult sepsis patients at high risk for ICI. Patients in the control group received targeted antifungal therapy driven by culture results. In addition to targeted therapy, patients in the BDG group received antifungals if at least one of two consecutive BDG samples taken during the first two study days was ≥ 80 pg/mL. Empirical antifungal therapy was discouraged in both groups. The primary endpoint was 28-day-mortality. Results 339 patients were enrolled. ICI was diagnosed in 48 patients (14.2%) within the first 96 h after enrollment. In the BDG-group, 48.8% (84/172) patients received antifungals during the first 96 h after enrollment and 6% (10/167) patients in the control group. Death until day 28 occurred in 58 of 172 patients (33.7%) in the BDG group and 51 of 167 patients (30.5%) in the control group (relative risk 1.10; 95% confidence interval, 0.80–1.51; p  = 0.53). Median time to antifungal therapy was 1.1 [interquartile range (IQR) 1.0–2.2] days in the BDG group and 4.4 (IQR 2.0–9.1, p  < 0.01) days in the control group. Conclusions Serum BDG guided antifungal treatment did not improve 28-day mortality among sepsis patients with risk factors for but unexpected low rate of IC. This study cannot comment on the potential benefit of BDG-guidance in a more selected at-risk population.Open Access funding enabled and organized by Projekt DEAL.Bundesministerium für Bildung und Forschung http://dx.doi.org/10.13039/501100002347Deutsche Forschungsgemeinschaft http://dx.doi.org/10.13039/501100001659Universitätsklinikum Jena (8979

Patientin mit Symptomen einer posttraumatischen Belastung nach Intensivmedizin – ein Fallbericht der PICTURE-Studie

Hintergrund Intensivmedizinische Aufenthalte führen bei vorbelasteten Menschen häufig zu Symptomen einer posttraumatischen Belastungsstörung (Post-ICU-PTBS). In der Nachsorge spielen HausärztInnen eine wichtige Rolle. Falldarstellung Eine 58-jährige Patientin entwickelt nach erlebter Sepsis eine Post-ICU-PTBS. Sie erhält durch ihre Hausärztin eine Kurzform der Narrativen Expositionstherapie (NET) und erfährt eine deutliche Symptombesserung. Schlussfolgerung Die angewandte Kurzform der NET kann für die Behandlung von leicht- bis mittelgradigen Symptomen einer Post-ICU-PTBS geeignet sein.Background Care in the intensive care unit (ICU) often introduces symptoms of post-traumatic stress disorder (post-ICU PTSD) in individuals with prior adverse experiences. General practitioners play an important role in follow-up care. Case report A 58-year-old woman developed post-ICU PTSD symptoms after she experienced sepsis. She received brief narrative exposure therapy (NET) from her general practitioner and experienced significant improvement of symptoms. Conclusion A brief version of NET might be appropriate for the treatment of patients with mild to moderate post-ICU PTSD symptoms

Ferric carboxymaltose assessment of morbidity and mortality in patients with iron deficiency and chronic heart failure ( FAIR ‐ HF2 ‐ DZHK05 ) trial: baseline characteristics and comparison to other relevant clinical trials

Aims: Prior randomized trials have reported conflicting evidence regarding the efficacy of intravenous (IV) iron in patients with heart failure with reduced ejection fraction (HFrEF) and iron deficiency (ID). Methods and results: FAIR‐HF2 is a double‐blind, randomized, controlled trial evaluating the efficacy of IV ferric carboxymaltose in patients with HFrEF and ID. We report the baseline characteristics of enrolled patients and compare them with other major trials of IV iron in HFrEF (FAIR‐HF, CONFIRM‐HF, AFFIRM‐AHF, IRONMAN, and HEART‐FID). A total of 1105 patients were randomized between March 2017 and November 2023. Most patients were men (67%) and median age was 72 (interquartile range [IQR] 63–79) years. More than one‐third had a heart failure hospitalization within the preceding 12 months (36%), and 53% were hospitalized at randomization. Common comorbidities included hypertension (79%), coronary artery disease (74%), dyslipidaemia (67%), and diabetes (46%). The median left ventricular ejection fraction was 58% (IQR 42–77) and mean estimated glomerular filtration rate was 58 (IQR 42–77) ml/min/1.73 m2. A total of 1064 (96%) patients were on renin–angiotensin system inhibitors (angiotensin receptor–neprilysin inhibitors [ARNI] 38%), 1016 (92%) on beta‐blockers, and 779 (71%) on mineralocorticoid receptor antagonists; and 261 (24%) of patients were on sodium–glucose cotransporter 2 (SGLT2) inhibitors, which is much higher than prior trials. A higher proportion of patients had ischaemic HFrEF (78%) compared to preceding trials. The baseline median haemoglobin (g/dl) was 12.7 (IQR 11.8–13.4), median serum ferritin (μg/dl) was 63 (IQR 36–90), and median transferrin saturation (%) was 16.5 (IQR 11.8–22.9), resembling that of other trials. The mean 6‐min walk distance at enrolment was 314 ± 118 m. Conclusion: The FAIR‐HF2 trial represents a contemporary cohort of patients with baseline characteristics mostly similar to prior trial populations. Use of SGLT2 inhibitors and ARNI in FAIR‐HF2 was higher than in prior trials

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Impact of bleeding and thrombosis on outcome of 945 COVID-19 VV-ECMO cases from a German registry

Bleeding and thromboembolic events (BTE) increase the mortality of COVID-19 acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO). The current analysis aimed to assess frequency and determinants of BTE according to their location and severity in a retrospective analysis of the German ECMO COVID-19 registry. Logistic regression was applied to identify factors influencing ICU survival as well as variables associated with risks of BTE. In total, 708 of 945 patients (75%) suffered from BTE. Overall, 1,348 events were registered, including 406 (30%) major bleeding and 258 (19%) major thromboembolic events. Most common major bleeding locations were intracranial ( n  = 133, 10%) and pulmonary bleeding ( n  = 116, 9%). In-ICU survival was 35, 46% without BTE and 22% with major bleeding ( p  14 days (OR: 2.9; CI 1.8–4.7; p  < 0.001) and platelet counts <100.000/μL ≥ 72 h (OR: 2.0; CI 1.1–3.6; p  = 0.018). Hence, prevention, early recognition and treatment of major bleedings are key to increase the survival of COVID-19 ECMO. In this regard, our data indicate that the implementation of early weaning strategies to minimize duration of ECMO therapy and prevention of prolonged thrombocytopenia with platelet counts <100.000/μl ≥ 72 h could decrease the risk of devastating bleeds and could ameliorate survival. Clinical trial registration Registered in the German Clinical Trials Register (study ID: DRKS00022964), retrospectively registered, September 7th 2020, https://drks.de/DRKS00022964 .Graphical abstract Graphic illustrating the longitudinal characterization of COVID-19 ECMO based on bleeding and thromboembolic severity. A pie chart shows hemostatic complication percentages: 28% major bleeding, 25.1% no bleeding/thromboembolism, 24.2% minor events, 13.5% only major thromboembolism, 9.1% only major bleeding. A bar chart shows survival rates: 46% no bleeding, 43% only thromboembolism, 38% minor events, 35% overall, 22% major bleeding/thromboembolism. A forest plot details major bleeding risk factors. Survival decreases with major bleeding. Based on Herrmann J. et al. 2024

Key characteristics impacting survival of COVID-19 extracorporeal membrane oxygenation

Background Severe COVID-19 induced acute respiratory distress syndrome (ARDS) often requires extracorporeal membrane oxygenation (ECMO). Recent German health insurance data revealed low ICU survival rates. Patient characteristics and experience of the ECMO center may determine intensive care unit (ICU) survival. The current study aimed to identify factors affecting ICU survival of COVID-19 ECMO patients. Methods 673 COVID-19 ARDS ECMO patients treated in 26 centers between January 1st 2020 and March 22nd 2021 were included. Data on clinical characteristics, adjunct therapies, complications, and outcome were documented. Block wise logistic regression analysis was applied to identify variables associated with ICU-survival. Results Most patients were between 50 and 70 years of age. PaO2/FiO2 ratio prior to ECMO was 72 mmHg (IQR: 58–99). ICU survival was 31.4%. Survival was significantly lower during the 2nd wave of the COVID-19 pandemic. A subgroup of 284 (42%) patients fulfilling modified EOLIA criteria had a higher survival (38%) (p = 0.0014, OR 0.64 (CI 0.41–0.99)). Survival differed between low, intermediate, and high-volume centers with 20%, 30%, and 38%, respectively (p = 0.0024). Treatment in high volume centers resulted in an odds ratio of 0.55 (CI 0.28–1.02) compared to low volume centers. Additional factors associated with survival were younger age, shorter time between intubation and ECMO initiation, BMI > 35 (compared to < 25), absence of renal replacement therapy or major bleeding/thromboembolic events. Conclusions Structural and patient-related factors, including age, comorbidities and ECMO case volume, determined the survival of COVID-19 ECMO. These factors combined with a more liberal ECMO indication during the 2nd wave may explain the reasonably overall low survival rate. Careful selection of patients and treatment in high volume ECMO centers was associated with higher odds of ICU survival