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

Procalcitonin and C-reactive protein to rule out early bacterial coinfection in COVID-19 critically ill patients

Although the prevalence of community-acquired respiratory bacterial coinfection upon hospital admission in patients with coronavirus disease 2019 (COVID-19) has been reported to be < 5%, almost three-quarters of patients received antibiotics. We aim to investigate whether procalcitonin (PCT) or C-reactive protein (CRP) upon admission could be helpful biomarkers to identify bacterial coinfection among patients with COVID-19 pneumonia. Methods: We carried out a multicentre, observational cohort study including consecutive COVID-19 patients admitted to 55 Spanish intensive care units (ICUs). The primary outcome was to explore whether PCT or CRP serum levels upon hospital admission could predict bacterial coinfection among patients with COVID-19 pneumonia. The secondary outcome was the evaluation of their association with mortality. We also conducted subgroups analyses in higher risk profile populations. Results: Between 5 February 2020 and 21 December 2021, 4076 patients were included, 133 (3%) of whom presented bacterial coinfection. PCT and CRP had low area under curve (AUC) scores at the receiver operating characteristic (ROC) curve analysis [0.57 (95% confidence interval (CI) 0.51–0.61) and 0.6 (95% CI, 0.55–0.64), respectively], but high negative predictive values (NPV) [97.5% (95% CI 96.5–98.5) and 98.2% (95% CI 97.5–98.9) for PCT and CRP, respectively]. CRP alone was associated with bacterial coinfection (OR 2, 95% CI 1.25–3.19; p = 0.004). The overall 15, 30 and 90 days mortality had a higher trend in the bacterial coinfection group, but without significant difference. PCT ≥ 0.12 ng/mL was associated with higher 90 days mortality. Conclusion: Our study suggests that measurements of PCT and CRP, alone and at a single time point, are not useful for ruling in or out bacterial coinfection in viral pneumonia by COVID-19

The forgiveness: a condition for the peace. Nursing and Public Health students University of Antioquia

Colombia está viviendo un momento histórico con la firma de los acuerdos de paz que dan fin a una violencia de más de 50 años. Importa saber qué significa para las personas la paz, en especial para los estudiantes de Salud Pública y Enfermería quienes son parte del futuro y la transformación del país. Objetivo: comprender el significado que le dan a la paz los estudiantes de Salud Pública y Enfermería. Metodología: investigación cualitativa ‐ etnográfica, realizada en Medellín, Colombia. Se entrevistaron 16 estudiantes. Para el análisis de la información se codificaron y categorizaron las entrevistas. Ética: El principio de confidencialidad y el respeto mutuo fueron los criterios que primaron durante la investigación. Resultados: Los estudiantes consideran la paz como derecho y deber, por lo tanto tienen que comprender a las personas que han participado en el conflicto armado en Colombia, para lograr tranquilidad en la población; para algunos la paz significa un imposible, para otros puede ser viable. El perdón es ambiguo porque está condicionado a los sentimientos que les generó el conflicto armado; los estudiantes que tuvieron experiencias directas perdonan, si los excombatientes sufren y los de experiencias indirectas, perdonan si estos pagan por los delitos. Conclusión: Hay dos miradas sobre la paz y una es que la paz es un imposible, por lo tanto ni entienden ni perdonan; la otra mirada es que la paz es posible y se perdona.Colombia is experiencing a historic moment after the signing of the peace agreements that ended over 50 years of violence. It is important to know the meaning of peace for people, especially for nursing and Public Health students because they are part of the future and the transformation of the country. Objective: to understand the meaning that Nursing and Public Health students give to peace. Methodology: qualitative - ethnographic research, carried out in Medellín, Colombia. 16 students were interviewed. For the analysis of the information, the interviews were codified and categorized. Ethics: Confidentiality and mutual respect were the criteria that prevailed during the investigation. Results: Students consider peace as a right and a duty. To achieve tranquility in the population it is necessary to understand the people who have been part in the armed conflict in Colombia. For some people peace means an impossible, for others it can be viable. Forgiveness is ambiguous because it is conditioned by the feelings generated during the armed conflict; for the students that report direct experiences forgiveness is conditioned to the suffering of the excombatants, and for those with indirect experiences, forgiveness can happened if they pay for the crimes. Conclusion: There are two views about peace, for some students peace is impossible, therefore people do not understand and they will not forgive; for others peace is possible, and people can forgive

Microbiological diagnosis of pulmonary invasive aspergillosis in critically ill patients with severe SARS-CoV-2 pneumonia: a bronchoalveolar study

Background: Diagnosing COVID-19-associated pulmonary aspergillosis (CAPA) can be challenging since radiological and clinical criteria in the critically ill patient are nonspecific. Microbiological diagnostic support is therefore crucial. The aim of this study was to document the incidence of aspergillosis using bronchoalveolar lavage (BAL) as the diagnostic method and to determine the performance of the current mycological diagnostic tests most widely used for the diagnosis of CAPA, together with evaluation of the Asp lateral flow device (LFD). Methods: Prospective cohort study conducted between March 2020 and June 2022. Inclusion criteria were critically ill patients admitted to the ICU with SARS-CoV-2 pneumonia requiring invasive mechanical ventilation. Diagnostic bronchoscopy and BAL were performed at the beginning of invasive mechanical ventilation. The sensitivity, specificity, positive and negative predictive value (PPV and NPV), positive and negative likelihood ratio (LR + and LR-) of BAL culture, direct examination with calcofluor white stain, ELISA (Platelia) and LFD (AspLFD) for detection of galactomannan (GM) were evaluated. Aspergillus-qPCR was applied when discrepancies between diagnostic tests arose. Results: Of the 244 critically ill patients with SARS-CoV-2 pneumonia admitted to the ICU, the majority (n = 200, 82%) required invasive mechanical ventilation. Diagnostic bronchoscopic procedures were performed in 160 patients (80%), who were enrolled in this study. The incidence of CAPA was 18.7% (n = 30). LFD-GM demonstrated a sensitivity of 84%, specificity of 99%, PPV 94%, NPV 97%, LR(+) of 84, and LR(-) of 0.16. At GM-ELISA indices of ≥ 0.5 and ≥ 1.0, sensitivity was 92% and 79%, specificity was 95% and 99%, PPV 76% and 91%, NPV 99% and 96%, LR(+) 18 and 79, and LR(-) 0.08 and 0.21, respectively. The optimal cut-off index from the ROC curve was 0.48, with sensitivity of 95% and specificity of 95%. Conclusions: Using a diagnostic strategy based on bronchoscopy and BAL, we documented a high incidence of pulmonary aspergillosis in patients with severe SARS-CoV-2 pneumonia. Asp-LFD showed moderate sensitivity and excellent specificity, with a high PPV, and could be used for rapid diagnosis of patients with suspected CAPA10 página

Estudio epidemiológico, morfológico y microbiológico de la isquemia crónica de miembros inferiores estadio IV

Objetivos: Evaluar en pacientes con diagnóstico de isquemia crónica de miembros inferiores estadio IV las características epidemiológicas, los factores pronósticos que influyen en el desarrollo de la enfermedad y en el resultado final del proceso (amputación menor, amputación mayor e isquemia crónica no revascularizable). Comparar su evolución, en función del tipo de lesión isquémica y determinar qué factores han influido en el desarrollo de la enfermedad y las complicaciones durante su estancia en el hospital y su repercusión en la tasa de amputación. Material y métodos: Se ha realizado un estudio retrospectivo a partir de una base de datos completada de forma prospectiva con los datos de 267 pacientes ingresados en 388 ocasiones durante el periodo del 1 de enero de 2006 al 31 de diciembre de 2010 en el Servicio de Angiología, Cirugía Vascular y Endovascular del Hospital Universitario Miguel Servet de Zaragoza con el diagnóstico principal de isquemia crónica de miembros inferiores estadio IV. Para clasificar las complicaciones quirúrgicas hemos utilizado la clasificación de Clavien-Dindo. Posteriormente se ha realizado el análisis estadístico descriptivo (media, mediana, frecuencia), bivariante (Chi cuadrado, T de Student, Kruskal-Wallis), multivariante (regresión logística binaria) y de supervivencia (Curvas de Kaplan-Meier). Resultados: La edad media de los pacientes fue de 74 años y una proporción de ingresos por paciente de 1.3. El 64% padecían diabetes, el 75% hipertensión arterial y el 65% eran fumadores. Un 40% tenían antecedentes de enfermedad cardiológica y un 22% de enfermedad renal. El 48% de los pacientes eran dependientes para las actividades básicas de la vida diaria. Respecto a su enfermedad vascular, el 60% presentaba dolor de reposo y el 45% tenía antecedentes de claudicación. En el análisis multivariante los factores de riesgo asociados a la amputación mayor han sido el ingreso prolongado (p=0.001), el reingreso (p=0.002, OR=3.4), la dislipemia (p=0.028, OR=2.4), la cirugía de revascularización (p=0.038, OR=2.3), el cultivo positivo de la lesión primaria (p=0.029, OR=3) y la necesidad de opiáceos mayores para la analgesia (p=0.004, OR=3.1) En el análisis multivariante los factores de riesgo asociados a la presencia de complicaciones han sido el ingreso prolongado (p<0.001), la HTA (p=0.040, OR=2.3), la EPOC (p=0.049, OR=2.2), la IRC (p=0.012, OR=2.4), el ASA IV (p=0.018, OR=3.4), la amputación menor (p=0.015, OR=2.4), la amputación mayor (p=0.001, OR=4.7) y la cirugía de revascularización (p<0.001, OR=3.9). Hemos observado como los pacientes con isquemia crónica de miembros inferiores estadio IV presentan una edad avanzada y múltiples comorbilidades. Su manejo perioperatorio es complejo y están expuesto a padecer complicaciones, sobre todo de causa cardiovascular (amputación mayor, infarto agudo de miocardio, isquemia cerebrovascular)

Major candidate variables to guide personalised treatment with steroids in critically ill patients with COVID-19: CIBERESUCICOVID study

Purpose: Although there is evidence supporting the benefits of corticosteroids in patients affected with severe coronavirus disease 2019 (COVID-19), there is little information related to their potential benefits or harm in some subgroups of patients admitted to the intensive care unit (ICU) with COVID-19. We aim to investigate to find candidate variables to guide personalized treatment with steroids in critically ill patients with COVID-19. Methods: Multicentre, observational cohort study including consecutive COVID-19 patients admitted to 55 Spanish ICUs. The primary outcome was 90-day mortality. Subsequent analyses in clinically relevant subgroups by age, ICU baseline illness severity, organ damage, laboratory findings and mechanical ventilation were performed. High doses of corticosteroids (≥ 12 mg/day equivalent dexamethasone dose), early administration of corticosteroid treatment (< 7 days since symptom onset) and long term of corticosteroids (≥ 10 days) were also investigated. Results: Between February 2020 and October 2021, 4226 patients were included. Of these, 3592 (85%) patients had received systemic corticosteroids during hospitalisation. In the propensity-adjusted multivariable analysis, the use of corticosteroids was protective for 90-day mortality in the overall population (HR 0.77 [0.65–0.92], p = 0.003) and in-hospital mortality (SHR 0.70 [0.58–0.84], p < 0.001). Significant effect modification was found after adjustment for covariates using propensity score for age (p = 0.001 interaction term), Sequential Organ Failure Assessment (SOFA) score (p = 0.014 interaction term), and mechanical ventilation (p = 0.001 interaction term). We observed a beneficial effect of corticosteroids on 90-day mortality in various patient subgroups, including those patients aged ≥ 60 years; those with higher baseline severity; and those receiving invasive mechanical ventilation at ICU admission. Early administration was associated with a higher risk of 90-day mortality in the overall population (HR 1.32 [1.14–1.53], p < 0.001). Long-term use was associated with a lower risk of 90-day mortality in the overall population (HR 0.71 [0.61–0.82], p < 0.001). No effect was found regarding the dosage of corticosteroids. Moreover, the use of corticosteroids was associated with an increased risk of nosocomial bacterial pneumonia and hyperglycaemia. Conclusion: Corticosteroid in ICU-admitted patients with COVID-19 may be administered based on age, severity, baseline inflammation, and invasive mechanical ventilation. Early administration since symptom onset may prove harmful.15 página

Ten Issues to Update in Nosocomial or Hospital-Acquired Pneumonia: An Expert Review

Nosocomial pneumonia, or hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP) are important health problems worldwide, with both being associated with substantial morbidity and mortality. HAP is currently the main cause of death from nosocomial infection in critically ill patients. Although guidelines for the approach to this infection model are widely implemented in international health systems and clinical teams, information continually emerges that generates debate or requires updating in its management. This scientific manuscript, written by a multidisciplinary team of specialists, reviews the most important issues in the approach to this important infectious respiratory syndrome, and it updates various topics, such as a renewed etiological perspective for updating the use of new molecular platforms or imaging techniques, including the microbiological diagnostic stewardship in different clinical settings and using appropriate rapid techniques on invasive respiratory specimens. It also reviews both Intensive Care Unit admission criteria and those of clinical stability to discharge, as well as those of therapeutic failure and rescue treatment options. An update on antibiotic therapy in the context of bacterial multiresistance, in aerosol inhaled treatment options, oxygen therapy, or ventilatory support, is presented. It also analyzes the out-of-hospital management of nosocomial pneumonia requiring complete antibiotic therapy externally on an outpatient basis, as well as the main factors for readmission and an approach to management in the emergency department. Finally, the main strategies for prevention and prophylactic measures, many of them still controversial, on fragile and vulnerable hosts are reviewed.30 página