A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

[Montreal 1976] [Material gráfico]

Contiene fotografías pertenecientes al archivo fotográfico del diario "Región", publicadas entre 1974 y 1976, aunque la mayoría en 1976Todas las fotografías firmadas por Foto E. Gar (Oviedo), Cifra Gráfica, y EF

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Nurses' perceptions of aids and obstacles to the provision of optimal end of life care in ICU

Contains fulltext : 172380.pdf (publisher's version ) (Open Access

LkH

We present new millimeter observations made with the IRAM interferometer and 30 m telescope of the ionized wind from the massive young stellar object LkHα   101. Several recombination lines, including higher order transitions, were detected for the first time at radio wavelengths in this source. From three α-transitions, we derive an accurate value for the stellar velocity and for the first time, an unambiguous expansion velocity of the wind that is 55 km s-1. This velocity is much slower than reported previously, and the resulting mass loss rate is 1.8 × 10-6  M⊙ yr-1. The wideband continuum spectra and the interferometer visibilities show that the density of the wind falls off more steeply than what is compatible with constant-velocity expansion. We argue that these properties indicate that the wind is launched from a radially narrow region of the circumstellar disk, and we propose that slow speed and a steep density gradient are characteristic properties of the evolutionary phase, where young stars of intermediate and high mass clear away the gaseous component of their accretion disks. The recombination lines are emitted close to local thermal equilibrium, but the higher order transitions appear systematically broader and weaker than expected, probably because of impact broadening. Finally, we show that LkHα   101 shares many properties with MWC 349, the only other stellar wind source where radio recombination lines have been detected, with some of them masing. We argue that LkHα   101 evades masing at millimeter wavelengths because of the disk’s smaller size and unfavorable orientation. Some amplification may however be detectable at shorter wavelengths

A non-LTE radiative transfer model to study ionized outflows and disks. The case of MWC349A

Context. The best example of a massive star with an ionized outflow launched from its photoevaporating disk is MWC349A. The large amount of reported radio-continuum and radio-recombination line (RRL) observations toward this galactic UC-HII region offers a unique possibility to build a model of the ionized envelope of this source. Aims. To understand the physical conditions and kinematics of the ionized region of the circumstellar disk and also of the outflow of MWC349A. Methods. We compared the bulk of radio-continuum maps, RRL profiles, and the H30α centroid map published to date with the predictions of our non-LTE 3D radiative transfer model, MOdel for REcombination LInes (MORELI), which we describe here in detail. Results. Our non-LTE 3D radiative transfer model provides new evidence that the UC-HII region of MWC349A is composed of an ionized circumstellar disk rotating in Keplerian fashion around a star of 38 M⊙, and an ionized outflow expanding with a terminal velocity of 60 km s-1 and rotating in the same sense as the disk. The model shows that while maser amplification is the dominant process involved for Hnα RRL emission with quantum numbers n < 41, stimulated emission is relevant for the emission of RRLs with n > 41 up at least the H76α line. Conclusions. For the first time, we present a model of MWC349A which satisfactorily explains the vast amount of reported observational data for a very wide range of frequencies and angular resolutions

Disk and wind kinematics in MWC 349 A

Context. Recombination-line maser emission arising from MWC 349 A offers a unique possibility to study the disk kinematics and the origin of ionized outflows driven by massive stars. Aims. We aim to constrain the disk inclination and its kinematics as well as the main parameters of the outflow launching processes. Methods. We used the IRAM interferometer to measure the relative positions of the H30α centroid emission as a function of the radial velocity with an accuracy of  ~2 mas (2.4 AU) for the strongest maser features and  ~5 mas (6 AU) for the weaker line wings. Results. In addition to the east-west velocity gradient expected for a rotating disk, our data reveal for the first time the complex velocity gradients perpendicular to the disk that are related to the ejection of the ionized gas from the disk. Conclusions. From the comparison of the data with non-LTE 3D radiative transfer model predictions of the H30α line we conclude that the kinematics in the outer parts of the disk is represented by pure Keplerian rotation. We constrain the wind launching radius to less than 25 AU, much smaller than the gravitational radius of  ~150 AU. The ionized outflow seems to be launched from the disk surface because it is rotating in the same sense than the disk. Disk wind models seem to explain the inferred kinematics