Chest X-ray for predicting mortality and the need for ventilatory support in COVID-19 patients presenting to the emergency department

Objectives: To evaluate the inter-rater agreement of chest X-ray (CXR) findings in coronavirus disease 2019 (COVID-19) and to determine the value of initial CXR along with demographic, clinical, and laboratory data at emergency department (ED) presentation for predicting mortality and the need for ventilatory support. Methods: A total of 340 COVID-19 patients who underwent CXR in the ED setting (March 1\u201313, 2020) were retrospectively included. Two reviewers independently assessed CXR abnormalities, including ground-glass opacities (GGOs) and consolidation. Two scoring systems (Brixia score and percentage of lung involvement) were applied. Inter-rater agreement was assessed by weighted Cohen\u2019s kappa (\u3ba) or intraclass correlation coefficient (ICC). Predictors of death and respiratory support were identified by logistic or Poisson regression. Results: GGO admixed with consolidation (n = 235, 69%) was the most common CXR finding. The inter-rater agreement was almost perfect for type of parenchymal opacity (\u3ba = 0.90), Brixia score (ICC = 0.91), and percentage of lung involvement (ICC = 0.95). The Brixia score (OR: 1.19; 95% CI: 1.06, 1.34; p = 0.003), age (OR: 1.16; 95% CI: 1.11, 1.22; p < 0.001), PaO2/FiO2 ratio (OR: 0.99; 95% CI: 0.98, 1; p = 0.002), and cardiovascular diseases (OR: 3.21; 95% CI: 1.28, 8.39; p = 0.014) predicted death. Percentage of lung involvement (OR: 1.02; 95% CI: 1.01, 1.03; p = 0.001) and PaO2/FiO2 ratio (OR: 0.99; 95% CI: 0.99, 1.00; p < 0.001) were significant predictors of the need for ventilatory support. Conclusions: CXR is a reproducible tool for assessing COVID-19 and integrates with patient history, PaO2/FiO2 ratio, and SpO2 values to early predict mortality and the need for ventilatory support. Key Points: \u2022 Chest X-ray is a reproducible tool for assessing COVID-19 pneumonia. \u2022 The Brixia score and percentage of lung involvement on chest X-ray integrate with patient history, PaO2/FIO2ratio, and SpO2values to early predict mortality and the need for ventilatory support in COVID-19 patients presenting to the emergency department

Hemodynamic characteristics of COVID-19 patients with acute respiratory distress syndrome requiring mechanical ventilation. An invasive assessment using right heart catheterization

Aims Interstitial pneumonia due to coronavirus disease 2019(COVID-19) is often complicated by severe respiratory failure. In addition to reduced lung compliance and ventilation/perfusion mismatch, a blunted hypoxic pulmonary vasoconstriction has been hypothesized, that could explain part of the peculiar pathophysiology of the COVID-19 cardiorespiratory syndrome. However, no invasive haemodynamic characterization of COVID-19 patients has been reported so far. ..................................................................................................................................................................... Methods and results Twenty-one mechanically-ventilated COVID-19 patients underwent right heart catheterization. Their data were compared both with those obtained from non-mechanically ventilated paired control subjects matched for age, sex and body mass index, and with pooled data of 1937 patients with \u2018typical\u2019 acute respiratory distress syndrome (ARDS) from a systematic literature review. Cardiac index was higher in COVID-19 patients than in controls [3.8 (2.7\u20134.5) vs. 2.4 (2.1 \u20132.8) L/min/m 2 , P < 0.001], but slightly lower than in ARDS patients (P = 0.024). Intrapulmonary shunt and lung compliance were inversely related in COVID-19 patients (r = 120.57, P = 0.011) and did not differ from ARDS patients. Despite this, pulmonary vascular resistance of COVID-19 patients was normal, similar to that of control subjects [1.6 (1.1 \u20132.5) vs. 1.6 (0.9\u20132.0) WU, P = 0.343], and lower than reported in ARDS patients (P < 0.01). Pulmonary hypertension was present in 76% of COVID-19 patients and in 19% of control subjects (P < 0.001), and it was always post-capillary. Pulmonary artery wedge pressure was higher in COVID-19thaninARDSpatients,and inversely related to lung compliance (r = 120.46, P = 0.038) Conclusions The haemodynamic pro\ue002le of COVID-19 patients needing mechanical ventilation is characterized by combined cardiopulmonary alterations. Low pulmonary vascular resistance, coherent with a blunted hypoxic vasoconstriction, is associated with high cardiac output and post-capillary pulmonary hypertension, that could eventually contribute to lung stiffness and promote a vicious circle between the lung and the heart

Antecedent use of renin-angiotensin system inhibitors is associated with reduced mortality in elderly hypertensive Covid-19 patients

Objectives: The effect of renin-angiotensin system inhibitors (RASIs) on mortality in patients with coronavirus disease (Covid-19) is debated. From a cohort of 1352 consecutive patients admitted with Covid-19 to Papa Giovanni XXIII Hospital in Bergamo, Italy, between February and April 2020, we selected and studied hypertensive patients to assess whether antecedent (prior to hospitalization) use of RASIs might affect mortality from Covid-19 according to age. Methods and results: Arterial hypertension was present in 688 patients. Overall mortality (in-hospital or shortly after discharge) was 35% (N = 240). After adjusting for 26 medical history variables via propensity score matching, antecedent use of RASIs (N = 459, 67%) was associated with a lower mortality in older hypertensive patients (age above the median of 68 years in the whole series), whereas no evidence of a significant effect was found in the younger group of the same population (P interaction = 0.001). In an analysis of the subgroup of 432 hypertensive patients older than 68 years, we considered two RASI drug subclasses, angiotensin-converting enzyme inhibitors (ACEIs, N = 156) and angiotensin receptor blockers (ARBs, N = 140), and assessed their respective effects by taking no-antecedent-use of RASIs as reference. This analysis showed that both antecedent use of ACEIs and antecedent use of ARBs were associated with a lower Covid-19 mortality (odds ratio(ACEI) = 0.57, 95% confidence interval 0.36--0.91, P = 0.018) (odds ratio(ARB) = 0.49, 95% confidence interval 0.29--0.82, P = 0.006). Conclusion: In the population of over-68 hypertensive Covid-19 patients, antecedent use of ACEIs or ARBs was associated with a lower all-cause mortality, whether in-hospital or shortly after discharge, compared with no-antecedent-use of RASIs

Eficiência de diferentes bicos e volumes de calda no controle de tripes em cebola Efficiency of different nozzle types and volume of the insecticide solution in the control of thrips in onions

O objetivo do trabalho foi avaliar a eficiência de diferentes volumes de calda e tipo de bico no controle químico de Thrips tabaci em cebola. Dois experimentos foram conduzidos na EPAGRI, Estação Experimental de Ituporanga, SC, no período de agosto a dezembro de 1996 e 1997. Os tratamentos com bico leque e respectivos níveis de vazão foram XR 110 015 VS® - 236 L/ha, XR 110 02 VS® - 316 L/ha, XR 110 03 VS® - 472 L/ha, XR 110 04 VS® - 632 L/ha, XR 110 05 VS® - 788 L/ha, TJ 60 110 02 VS® - 316 L/ha, TJ 60 110 04 VS® - 632 L/ha; com bico cone foram Conejet TSVS® - 236 L/ha, Conejet TXVK 18® - 472 L/ha, Conejet TXVK 26® - 632 L/ha, D6 Difusor V5® - 600 L/ha, além da testemunha, sem tratamento. O delineamento experimental utilizado foi blocos ao acaso com quatro repetições. O tamanho de parcela foi de 2,8 m x 3,0 m. O inseticida usado foi clorpirifós 0,72 g. i.a./ha. A amostragem de ninfas de T. tabaci foi realizada no campo em cinco plantas escolhidas ao acaso em cada parcela. A redução populacional de tripes foi semelhante entre os diferentes volumes de calda e tipos de bico utilizados. Portanto, os bicos cone e leque aplicando volumes de calda entre 236 a 788 L/ha, apresentaram a mesma eficiência no controle de T. tabaci em cebola.<br>The objective of this work was to evaluate the efficiency of different nozzle types and volume of the insecticide solution in controlling thrips (Thrips tabaci) in onions. The work was carried out from August to December, 1996 and 1997. The treatments consisted of different nozzle types (fan and cone) and different flow rates. Fan nozzles were XR 110 015 VS® - 236 L/ha, XR 110 02 VS® - 316 L/ha, XR 110 03 VS® - 472 L/ha, XR 110 04 VS® - 632 L/ha, XR 110 05 VS® - 788 L/ha, TJ 60 110 02 VS® - 316 L/ha, TJ 60 110 04 VS - 632 L/ha; and cone nozzles were Conejet TSVS® - 236 L/ha, Conejet TXVK 18® - 472 L/ha, Conejet TXVK 26® - 632 L/ha, D6 Difusor V5® - 600 L/ha. Besides these treatments there was an untreated check. The experimental design was of randomized complete blocks with four replications. The insecticide used was chlorpyrifos 0.72 g.a.i./ha. The evaluation of the number of nimphs of T. tabaci was made weekly in the field using five plants per plot. The fan or cone nozzle applying 236 L/ha to 788 L/ha of the insecticide solution (chlorpyrifos) gave similar thrips control