Dynamics of disease characteristics and clinical management of critically ill COVID-19 patients over the time course of the pandemic: an analysis of the prospective, international, multicentre RISC-19-ICU registry.

BACKGROUND It remains elusive how the characteristics, the course of disease, the clinical management and the outcomes of critically ill COVID-19 patients admitted to intensive care units (ICU) worldwide have changed over the course of the pandemic. METHODS Prospective, observational registry constituted by 90 ICUs across 22 countries worldwide including patients with a laboratory-confirmed, critical presentation of COVID-19 requiring advanced organ support. Hierarchical, generalized linear mixed-effect models accounting for hospital and country variability were employed to analyse the continuous evolution of the studied variables over the pandemic. RESULTS Four thousand forty-one patients were included from March 2020 to September 2021. Over this period, the age of the admitted patients (62 [95% CI 60-63] years vs 64 [62-66] years, p < 0.001) and the severity of organ dysfunction at ICU admission decreased (Sequential Organ Failure Assessment 8.2 [7.6-9.0] vs 5.8 [5.3-6.4], p < 0.001) and increased, while more female patients (26 [23-29]% vs 41 [35-48]%, p < 0.001) were admitted. The time span between symptom onset and hospitalization as well as ICU admission became longer later in the pandemic (6.7 [6.2-7.2| days vs 9.7 [8.9-10.5] days, p < 0.001). The PaO2/FiO2 at admission was lower (132 [123-141] mmHg vs 101 [91-113] mmHg, p < 0.001) but showed faster improvements over the initial 5 days of ICU stay in late 2021 compared to early 2020 (34 [20-48] mmHg vs 70 [41-100] mmHg, p = 0.05). The number of patients treated with steroids and tocilizumab increased, while the use of therapeutic anticoagulation presented an inverse U-shaped behaviour over the course of the pandemic. The proportion of patients treated with high-flow oxygen (5 [4-7]% vs 20 [14-29], p < 0.001) and non-invasive mechanical ventilation (14 [11-18]% vs 24 [17-33]%, p < 0.001) throughout the pandemic increased concomitant to a decrease in invasive mechanical ventilation (82 [76-86]% vs 74 [64-82]%, p < 0.001). The ICU mortality (23 [19-26]% vs 17 [12-25]%, p < 0.001) and length of stay (14 [13-16] days vs 11 [10-13] days, p < 0.001) decreased over 19 months of the pandemic. CONCLUSION Characteristics and disease course of critically ill COVID-19 patients have continuously evolved, concomitant to the clinical management, throughout the pandemic leading to a younger, less severely ill ICU population with distinctly different clinical, pulmonary and inflammatory presentations than at the onset of the pandemic

Tipificación del fenotipo inflamatorio en el asma bronquial en niños de 7 a 14 años, mediante recuento celular y determinación de citoquinas en esputo inducido

Introducción: La inducción de esputo es una técnica escasamente invasora para el estudio y la monitorización de la inflamación de la vía aérea. Objetivos: El objetivo principal del estudio fue comparar el perfil celular y los niveles de citoquinas Th1 y Th2 en esputo inducido entre niños asmáticos atópicos, asmáticos no atópicos y sanos. Métodos: La inducción de esputo fue realizada mediante inhalación de suero salino hipertónico a concentraciones crecientes (3%, 4% y 5%). Se determinó la fracción exhalada de óxido nítrico en los pacientes asmáticos y se midió la FEV1 al inicio y después de cada período de inhalación para garantizar la seguridad de los niños. El procesado del esputo se hizo siguiendo el método de Pizzichini y cols. Se separó el esputo de la saliva y se añadió un volumen de solución de ditiotreitol igual a 4 veces el peso del esputo. Se agitó la mezcla y después de colocarla en banco mecedor durante 10 minutos se añadieron 4 volúmenes de PBS de Dulbecco. La suspensión resultante se filtró a través de una gasa de nylon de 48 micras, centrifugándose a continuación durante 10 minutos a 2.500 rpm para obtener un pellet (sedimento) celular donde se determinaron el recuento celular total y la viabilidad celular y un sobrenadante que se guardó a -80ºC para la determinación de citoquinas. Se consideró una buena muestra si la viabilidad celular era > 60% y la contaminación por células escamosas < 20%. Mediante citocentrífuga se obtuvieron las preparaciones y tras tinción de May-Grünwald-Giemsa se realizó el recuento celular diferencial con microscopio óptico. Los niveles de IFN-gamma, IL-2, IL-10, IL-8, IL-6, IL-4, IL-5, IL-1beta, TNF-alfa, e IL-12p70 en el sobrenadante se determinaron mediante citometría de flujo (Bender Medsystem, USA). El análisis estadístico se realizó con el programa SPSS15.0. Se aplicaron los siguientes tests paramétricos o no paramétricos según los grupos seguían o no una distribución normal (prueba de normalidad de Kolmogorow-Smirnov), y según fuera apropiado: t de Student para datos no apareados, análisis de la varianza de una vía, test no paramétricos de la U de Mann-Witney, y de Kruskal-Wallis, Chi-cuadrado, prueba exacta de Fisher y correlación lineal de Pearson. Se consideraron significativos valores de p < 0,05. Los resultados se expresaron como media y desviación estándar (DE) o mediana y rango intercuartílico. Resultados: Se realizó inducción de esputo a 77 niños asmáticos (52 varones) y a 31 sanos (17 varones) de 7 a 15 años. Entre los asmáticos, 51 no recibían tratamiento y 26 recibían corticoides inhalados. Diecisiete pacientes presentaban un asma no atópica y 60 asma atópica. Se obtuvieron 64 muestras en los asmáticos (83,1% de las inducciones) y 24 muestras en los niños sanos (77,4%) de las que 49 y 18 adecuadas respectivamente. La mediana de eosinófilos en esputo inducido de los asmáticos atópicos (1,5%) fue mayor que en los no atópicos (0%) (p=0,02) y que en los niños sanos (0%) (p=0,003). Las citoquinas Th2 (IL-4 e IL-5) y Th1 (IFNgamma, IL-2 e IL-12p70) fueron superiores en los asmáticos atópicos que en los sanos y en los asmáticos no atópicos (p<0,0001). La IL-8 fue mayor en los niños asmáticos (atópicos y no atópicos) que en los controles (p<0,0001). La IL-10 fue mayor en los controles que en los asmáticos atópicos (p=0,03). No existieron diferencias en el resto de citoquinas (IL-6, IL-1beta y TNF-alfa). Conclusiones: El perfil inflamatorio de los niños asmáticos muestra un aumento en las citoquinas proinflamatorias en el esputo inducido respecto a los niños sanos. Existen diferencias en el perfil de citoquinas en esputo inducido entre los niños asmáticos atópicos y no atópicos.Introduction: Sputum induction is a semi-invasive technique for the study and monitorization of airway inflammation. Objectives: The aim of the present study was to compare the cellular profile and the Th1 and Th2 cytokine levels in induced sputum between atopic asthmatic, non atopic asthmatic and healthy children. Methods: Sputum induction was performed by inhalation of a hypertonic saline solution at increasing concentrations (3%, 4% and 5%). Fractional exhaled nitric oxide was determinate in asthmatic patients and FEV1 was measured at the start and after each period of inhalation to ensure children’s safety. Sputum examination was performed as described by Pizzichini et al. Sputum was separated from contaminating saliva and a weighed aliquot was dispersed with four volumes of freshly prepared dithiothreitol solution. The mixture was vortexed, and after being rocked for 10 minutes, 4 volumes of Dulbecco’s PBS was added. The suspension was then filtered through 48-µm nylon gauze and centrifuged at 2500 rpm for 10 minutes. This resulted in the formation of a cell pellet and supernatant solution. The supernatant was stored at -80º C for analysis of cytokines. Total cell count and cell viability was determined in the cell pellet. We considered good sample if there was cell viability ≥ 60% and contamination by squamous cells < 20%. Cytospin cell preparations were made using a cytocentrifuge and slides were stained with May-Grünwald-Giemsa to determine the differential cell count using optic microscopy. In sputum sample supernatants IFN-γ, IL-2, IL-10, IL-8, IL-6, IL-4, IL-5, IL-1β, TNF-α, and IL-12p70 levels were determined by flow cytometry (Bender Medsystem, USA). Statistical analyse was performed with SPSS® 15.0 program. Parametric and non-parametric tests were applied according to normal distribution (Kolmogorov-Smirnov test): Student’s t-test for independent samples, ANOVA, Mann-Whitney U test and Kruskal-Wallis as non-parametric tests, Chi-square test and Pearson’s correlation. Values of p < 0.05 were considered significant. Results are expressed as mean and standard deviation (SD) or median and interquartile range. Results: Sputum induction was performed in 77 asthmatic children (52 boys) and in 31 healthy children (17 boys) from 7 to 15 years old. Fifty one of asthmatic children were with no treatment and 26 were receiving inhaled corticosteroids. Seventeen patients had non atopic asthma and 60 had atopic asthma. We obtained 64 samples in patients (83.1% of inductions) and 24 samples in healthy children (77.4%). We considered 49 and 18 good samples respectively. Median eosinophil count in atopic asthma (1.5%) was higher than in nonatopic asthma (0%) (p=0.02) or healthy children (0%) (p=0.003). Th2 cytokines (IL-4 and IL-5) and Th1 cytokines (IFNγ, IL-2 and IL-12p70) were higher in atopic asthmatic children than in healthy and non atopic asthmatic children (p<0,0001). IL-8 was higher in asthmatic children (atopic and non atopic) than controls (p<0,0001). IL-10 was higher in controls than atopic asthmatic children (p=0,03). There were no differences in the other cytokines (IL-6, IL-1β and TNF-α). Conclusions: The inflammatory profil of asthmatic children shows an increase in proinflammatory cytokines in induced sputum respect to healthy children. There are differences in cytokine profile of induced sputum in atopic and non atopic asthmatic children

Tipificación del fenotipo inflamatorio en el asma bronquial en niños de 7 a 14 años, mediante recuento celular y determinación de citoquinas en esputo inducido

Descripció del recurs: 8 setembre 2011Introducción: La inducción de esputo es una técnica escasamente invasora para el estudio y la monitorización de la inflamación de la vía aérea. Objetivos: El objetivo principal del estudio fue comparar el perfil celular y los niveles de citoquinas Th1 y Th2 en esputo inducido entre niños asmáticos atópicos, asmáticos no atópicos y sanos. Métodos: La inducción de esputo fue realizada mediante inhalación de suero salino hipertónico a concentraciones crecientes (3%, 4% y 5%). Se determinó la fracción exhalada de óxido nítrico en los pacientes asmáticos y se midió la FEV1 al inicio y después de cada período de inhalación para garantizar la seguridad de los niños. El procesado del esputo se hizo siguiendo el método de Pizzichini y cols. Se separó el esputo de la saliva y se añadió un volumen de solución de ditiotreitol igual a 4 veces el peso del esputo. Se agitó la mezcla y después de colocarla en banco mecedor durante 10 minutos se añadieron 4 volúmenes de PBS de Dulbecco. La suspensión resultante se filtró a través de una gasa de nylon de 48 micras, centrifugándose a continuación durante 10 minutos a 2.500 rpm para obtener un pellet (sedimento) celular donde se determinaron el recuento celular total y la viabilidad celular y un sobrenadante que se guardó a -80ºC para la determinación de citoquinas. Se consideró una buena muestra si la viabilidad celular era &gt; 60% y la contaminación por células escamosas &lt; 20%. Mediante citocentrífuga se obtuvieron las preparaciones y tras tinción de May-Grünwald-Giemsa se realizó el recuento celular diferencial con microscopio óptico. Los niveles de IFN-gamma, IL-2, IL-10, IL-8, IL-6, IL-4, IL-5, IL-1beta, TNF-alfa, e IL-12p70 en el sobrenadante se determinaron mediante citometría de flujo (Bender Medsystem, USA). El análisis estadístico se realizó con el programa SPSS15.0. Se aplicaron los siguientes tests paramétricos o no paramétricos según los grupos seguían o no una distribución normal (prueba de normalidad de Kolmogorow-Smirnov), y según fuera apropiado: t de Student para datos no apareados, análisis de la varianza de una vía, test no paramétricos de la U de Mann-Witney, y de Kruskal-Wallis, Chi-cuadrado, prueba exacta de Fisher y correlación lineal de Pearson. Se consideraron significativos valores de p &lt; 0,05. Los resultados se expresaron como media y desviación estándar (DE) o mediana y rango intercuartílico. Resultados: Se realizó inducción de esputo a 77 niños asmáticos (52 varones) y a 31 sanos (17 varones) de 7 a 15 años. Entre los asmáticos, 51 no recibían tratamiento y 26 recibían corticoides inhalados. Diecisiete pacientes presentaban un asma no atópica y 60 asma atópica. Se obtuvieron 64 muestras en los asmáticos (83,1% de las inducciones) y 24 muestras en los niños sanos (77,4%) de las que 49 y 18 adecuadas respectivamente. La mediana de eosinófilos en esputo inducido de los asmáticos atópicos (1,5%) fue mayor que en los no atópicos (0%) (p=0,02) y que en los niños sanos (0%) (p=0,003). Las citoquinas Th2 (IL-4 e IL-5) y Th1 (IFNgamma, IL-2 e IL-12p70) fueron superiores en los asmáticos atópicos que en los sanos y en los asmáticos no atópicos (p&lt;0,0001). La IL-8 fue mayor en los niños asmáticos (atópicos y no atópicos) que en los controles (p&lt;0,0001). La IL-10 fue mayor en los controles que en los asmáticos atópicos (p=0,03). No existieron diferencias en el resto de citoquinas (IL-6, IL-1beta y TNF-alfa). Conclusiones: El perfil inflamatorio de los niños asmáticos muestra un aumento en las citoquinas proinflamatorias en el esputo inducido respecto a los niños sanos. Existen diferencias en el perfil de citoquinas en esputo inducido entre los niños asmáticos atópicos y no atópicos.Introduction: Sputum induction is a semi-invasive technique for the study and monitorization of airway inflammation. Objectives: The aim of the present study was to compare the cellular profile and the Th1 and Th2 cytokine levels in induced sputum between atopic asthmatic, non atopic asthmatic and healthy children. Methods: Sputum induction was performed by inhalation of a hypertonic saline solution at increasing concentrations (3%, 4% and 5%). Fractional exhaled nitric oxide was determinate in asthmatic patients and FEV1 was measured at the start and after each period of inhalation to ensure children's safety. Sputum examination was performed as described by Pizzichini et al. Sputum was separated from contaminating saliva and a weighed aliquot was dispersed with four volumes of freshly prepared dithiothreitol solution. The mixture was vortexed, and after being rocked for 10 minutes, 4 volumes of Dulbecco's PBS was added. The suspension was then filtered through 48-µm nylon gauze and centrifuged at 2500 rpm for 10 minutes. This resulted in the formation of a cell pellet and supernatant solution. The supernatant was stored at -80º C for analysis of cytokines. Total cell count and cell viability was determined in the cell pellet. We considered good sample if there was cell viability ≥ 60% and contamination by squamous cells &lt; 20%. Cytospin cell preparations were made using a cytocentrifuge and slides were stained with May-Grünwald-Giemsa to determine the differential cell count using optic microscopy. In sputum sample supernatants IFN-γ, IL-2, IL-10, IL-8, IL-6, IL-4, IL-5, IL-1β, TNF-α, and IL-12p70 levels were determined by flow cytometry (Bender Medsystem, USA). Statistical analyse was performed with SPSS® 15.0 program. Parametric and non-parametric tests were applied according to normal distribution (Kolmogorov-Smirnov test): Student's t-test for independent samples, ANOVA, Mann-Whitney U test and Kruskal-Wallis as non-parametric tests, Chi-square test and Pearson's correlation. Values of p &lt; 0.05 were considered significant. Results are expressed as mean and standard deviation (SD) or median and interquartile range. Results: Sputum induction was performed in 77 asthmatic children (52 boys) and in 31 healthy children (17 boys) from 7 to 15 years old. Fifty one of asthmatic children were with no treatment and 26 were receiving inhaled corticosteroids. Seventeen patients had non atopic asthma and 60 had atopic asthma. We obtained 64 samples in patients (83.1% of inductions) and 24 samples in healthy children (77.4%). We considered 49 and 18 good samples respectively. Median eosinophil count in atopic asthma (1.5%) was higher than in nonatopic asthma (0%) (p=0.02) or healthy children (0%) (p=0.003). Th2 cytokines (IL-4 and IL-5) and Th1 cytokines (IFNγ, IL-2 and IL-12p70) were higher in atopic asthmatic children than in healthy and non atopic asthmatic children (p&lt;0,0001). IL-8 was higher in asthmatic children (atopic and non atopic) than controls (p&lt;0,0001). IL-10 was higher in controls than atopic asthmatic children (p=0,03). There were no differences in the other cytokines (IL-6, IL-1β and TNF-α). Conclusions: The inflammatory profil of asthmatic children shows an increase in proinflammatory cytokines in induced sputum respect to healthy children. There are differences in cytokine profile of induced sputum in atopic and non atopic asthmatic children

Implementation of a Gene Panel for Genetic Diagnosis of Primary Ciliary Dyskinesia

Introduction: Primary ciliary dyskinesia (PCD) is characterized by an alteration in the ciliary structure causing difficulty in the clearance of respiratory secretions. Diagnosis is complex and based on a combination of techniques. The objective of this study was to design a gene panel including all known causative genes, and to corroborate their diagnostic utility in a cohort of Spanish patients. Methods: This was a multicenter cross-sectional study of patients with a high suspicion of PCD, according to European Respiratory Society criteria, designed around a gene panel for massive sequencing using SeqCap EZ capture technology that included 44 genes associated with PCD. Results: We included 79 patients, 53 of whom had a diagnosis of confirmed or highly probable PCD. The sensitivity of the gene panel was 81.1%, with a specificity of 100%. Candidate variants were found in some of the genes of the panel in 43 patients with PCD, 51.2% (22/43) of whom were homozygotes and 48.8% (21/43) compound heterozygotes. The most common causative genes were DNAH5 and CCDC39. We found 52 different variants, 36 of which were not previously described in the literature. Conclusions: The design and implementation of a tailored gene panel produces a high yield in the genetic diagnosis of PCD. This panel provides a better understanding of the causative factors involved in these patients and lays down the groundwork for future therapeutic approaches

Machine learning using the extreme gradient boosting (XGBoost) algorithm predicts 5-day delta of SOFA score at ICU admission in COVID-19 patients

Background: Accurate risk stratification of critically ill patients with coronavirus disease 2019 (COVID-19) is essential for optimizing resource allocation, delivering targeted interventions, and maximizing patient survival probability. Machine learning (ML) techniques are attracting increased interest for the development of prediction models as they excel in the analysis of complex signals in data-rich environments such as critical care. Methods: We retrieved data on patients with COVID-19 admitted to an intensive care unit (ICU) between March and October 2020 from the RIsk Stratification in COVID-19 patients in the Intensive Care Unit (RISC-19-ICU) registry. We applied the Extreme Gradient Boosting (XGBoost) algorithm to the data to predict as a binary out- come the increase or decrease in patients’ Sequential Organ Failure Assessment (SOFA) score on day 5 after ICU admission. The model was iteratively cross-validated in different subsets of the study cohort. Results: The final study population consisted of 675 patients. The XGBoost model correctly predicted a decrease in SOFA score in 320/385 (83%) critically ill COVID-19 patients, and an increase in the score in 210/290 (72%) patients. The area under the mean receiver operating characteristic curve for XGBoost was significantly higher than that for the logistic regression model (0.86 vs . 0.69, P < 0.01 [paired t -test with 95% confidence interval]). Conclusions: The XGBoost model predicted the change in SOFA score in critically ill COVID-19 patients admitted to the ICU and can guide clinical decision support systems (CDSSs) aimed at optimizing available resources

Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort

Background: Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is wide‑ spread. While the risks and benefts of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefts of diferent respiratory sup‑ port strategies, employed in intensive care units during the frst months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. Methods: Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclas‑ sifed into standard oxygen therapy ≥10 L/min (SOT), high-fow oxygen therapy (HFNC), noninvasive positive-pressureBackground: Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. Methods: Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups. Results: Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016). Conclusion: In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk