The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Effectiveness of an mHealth intervention combining a smartphone app and smart band on body composition in an overweight and obese population: Randomized controlled trial (EVIDENT 3 study)

Background: Mobile health (mHealth) is currently among the supporting elements that may contribute to an improvement in health markers by helping people adopt healthier lifestyles. mHealth interventions have been widely reported to achieve greater weight loss than other approaches, but their effect on body composition remains unclear. Objective: This study aimed to assess the short-term (3 months) effectiveness of a mobile app and a smart band for losing weight and changing body composition in sedentary Spanish adults who are overweight or obese. Methods: A randomized controlled, multicenter clinical trial was conducted involving the participation of 440 subjects from primary care centers, with 231 subjects in the intervention group (IG; counselling with smartphone app and smart band) and 209 in the control group (CG; counselling only). Both groups were counselled about healthy diet and physical activity. For the 3-month intervention period, the IG was trained to use a smartphone app that involved self-monitoring and tailored feedback, as well as a smart band that recorded daily physical activity (Mi Band 2, Xiaomi). Body composition was measured using the InBody 230 bioimpedance device (InBody Co., Ltd), and physical activity was measured using the International Physical Activity Questionnaire. Results: The mHealth intervention produced a greater loss of body weight (–1.97 kg, 95% CI –2.39 to –1.54) relative to standard counselling at 3 months (–1.13 kg, 95% CI –1.56 to –0.69). Comparing groups, the IG achieved a weight loss of 0.84 kg more than the CG at 3 months. The IG showed a decrease in body fat mass (BFM; –1.84 kg, 95% CI –2.48 to –1.20), percentage of body fat (PBF; –1.22%, 95% CI –1.82% to 0.62%), and BMI (–0.77 kg/m2, 95% CI –0.96 to 0.57). No significant changes were observed in any of these parameters in men; among women, there was a significant decrease in BMI in the IG compared with the CG. When subjects were grouped according to baseline BMI, the overweight group experienced a change in BFM of –1.18 kg (95% CI –2.30 to –0.06) and BMI of –0.47 kg/m2 (95% CI –0.80 to –0.13), whereas the obese group only experienced a change in BMI of –0.53 kg/m2 (95% CI –0.86 to –0.19). When the data were analyzed according to physical activity, the moderate-vigorous physical activity group showed significant changes in BFM of –1.03 kg (95% CI –1.74 to –0.33), PBF of –0.76% (95% CI –1.32% to –0.20%), and BMI of –0.5 kg/m2 (95% CI –0.83 to –0.19). Conclusions: The results from this multicenter, randomized controlled clinical trial study show that compared with standard counselling alone, adding a self-reported app and a smart band obtained beneficial results in terms of weight loss and a reduction in BFM and PBF in female subjects with a BMI less than 30 kg/m2 and a moderate-vigorous physical activity level. Nevertheless, further studies are needed to ensure that this profile benefits more than others from this intervention and to investigate modifications of this intervention to achieve a global effect

Cribado combinado del primer trimestre para la predicción de la preeclampsia en gestantes con factores de alto riesgo

el objetivo principal de esta tesis es desarrollar una prueba de cribado del primer trimestre para predecir la preeclampsia -especialmente sus formas severas y precoces- y conocer su exactitud diagnóstica en un grupo de gestantes de alto riesgo a priori para el desarrollo de este síndrome

Diagnostic accuracy of prenatal ultrasound in coarctation of aorta: systematic review and individual participant data meta‐analysis

Objective: To determine the diagnostic accuracy of prenatal ultrasound in detecting coarctation of the aorta (CoA). Methods: An individual participant data meta-analysis was performed to report on the strength of association and diagnostic accuracy of different ultrasound signs in detecting CoA prenatally. MEDLINE, EMBASE and CINAHL were searched for studies published between January 2000 and November 2021. Inclusion criteria were fetuses with suspected isolated CoA, defined as ventricular and/or great vessel disproportion with right dominance on ultrasound assessment. Individual participant-level data were obtained by two leading teams. PRISMA-IPD and PRISMA-DTA guidelines were used for extracting data, and the QUADAS-2 tool was used for assessing quality and applicability. The reference standard was CoA, defined as narrowing of the aortic arch, diagnosed after birth. The most commonly evaluated parameters on ultrasound, both in B-mode and on Doppler, constituted the index test. Summary estimates of sensitivity, specificity, diagnostic odds ratio (DOR) and likelihood ratios were computed using the hierarchical summary receiver-operating-characteristics model. Results: The initial search yielded 72 studies, of which 25 met the inclusion criteria. Seventeen studies (640 fetuses) were included. On random-effects logistic regression analysis, tricuspid valve/mitral valve diameter ratio > 1.4 and > 1.6, aortic isthmus/arterial duct diameter ratio 1.4 (P = 0.048) and bidirectional flow at the foramen ovale (P = 0.012) were independently associated with CoA. Redundant foramen ovale was inversely associated with CoA (P = 0.037). Regarding diagnostic accuracy, tricuspid valve/mitral valve diameter ratio > 1.4 had a sensitivity of 72.6% (95% CI, 48.2-88.3%), specificity of 65.4% (95% CI, 46.9-80.2%) and DOR of 5.02 (95% CI, 1.82-13.9). The sensitivity and specificity values were, respectively, 75.0% (95% CI, 61.1-86.0%) and 39.7% (95% CI, 27.0-53.4%) for pulmonary artery/ascending aorta diameter ratio > 1.4, 47.8% (95% CI, 14.6-83.0%) and 87.6% (95% CI, 27.3-99.3%) for aortic isthmus diameter Z-score of < -2 in the sagittal view and 74.1% (95% CI, 58.0-85.6%) and 62.0% (95% CI, 41.6-78.9%) for aortic isthmus diameter Z-score of < -2 in the three-vessel-and-trachea view. Hypoplastic aortic arch had a sensitivity of 70.0% (95% CI, 42.0-88.6%), specificity of 91.3% (95% CI, 78.6-96.8%) and DOR of 24.9 (95% CI, 6.18-100). The diagnostic yield of prenatal ultrasound in detecting CoA did not change significantly when considering multiple categorical parameters. Five of the 11 evaluated continuous parameters were independently associated with CoA (all P < 0.001) but all had low-to-moderate diagnostic yield. Conclusions: Several prenatal ultrasound parameters are associated with an increased risk for postnatal CoA. However, diagnostic accuracy is only moderate, even when combinations of parameters are considered. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.Depto. de MedicinaDepto. de Salud Pública y Materno - InfantilFac. de MedicinaTRUEpubAPC financiada por la UC

Cardiovascular and renal health: Preeclampsia as a risk marker.

BACKGROUND Cardiovascular (CVD) and chronic kidney disease (CKD) in women have unique risk factors related to hormonal status and obstetric history that must be taken into account. Pregnancy complications, such as preeclampsia (PE), can reveal a subclinical predisposition for the development of future disease that may help identify women who could benefit from early CVD and CKD prevention strategies. MATERIALS AND METHODS Review of PE and its association with future development of CVD and CKD. RESULTS Multiple studies have established an association between PE and the development of ischemic heart disease, chronic hypertension, peripheral vascular disease, stroke and CKD. It has not been sufficiently clarified if this relation is a causal one or if it is mediated by common risk factors. Nevertheless, the presence of endothelial dysfunction and thrombotic microangiopathy during pregnancies complicated with PE makes us believe that PE may leave a long-term imprint. Early identification of women who have had a pregnancy complicated by PE becomes a window of opportunity to improve women's health through adequate follow-up and targeted preventive actions. Oxidative stress biomarkers and vascular ultrasound may play a key role in the early detection of this arterial damage. CONCLUSIONS The implementation of preventive multidisciplinary targeted strategies can help slow down CVD and CKD's natural history in women at risk through lifestyle modifications and adequate blood pressure control. Therefore, we propose a series of recommendations to guide the prediction and prevention of CVD and CKD throughout life of women with a history of PE.The present work has been funded by the Instituto de Salud Carlos III with the project “Cardiovascular health in women with a history of early preeclampsia” (grant PI19/01579), and by the Spanish Society of Cardiology, through a Grant for Translational Research Projects in Cardiology (grant TP18/0308).S

Prediction of perinatal survival in early‐onset fetal growth restriction: role of placental growth factor

Fondos FEDERObjective To analyze the ability to predict perinatal survival and severe neonatal morbidity of cases with early-onset fetal growth restriction (eoFGR) using maternal variables, ultrasound parameters and angiogenic markers at the time of diagnosis. Methods This was a prospective observational study in a cohort of singleton pregnancies with a diagnosis of eoFGR (< 32 weeks of gestation). At diagnosis of eoFGR, complete assessment was performed, including ultrasound examination (anatomy, biometry and Doppler assessment) and maternal serum measurement of the angiogenic biomarkers, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF). Logistic regression models for the prediction of perinatal survival (in cases diagnosed at < 28 weeks) and severe neonatal morbidity (in all liveborn cases) were calculated. Results In total, 210 eoFGR cases were included, of which 185 (88.1%) survived perinatally. The median gestational age at diagnosis was 27 + 0 weeks. All cases diagnosed at ≥ 28 weeks survived. In cases diagnosed < 28 weeks, survivors (vs non-survivors) had a higher gestational age (26.1 vs 24.4 weeks), estimated fetal weight (EFW; 626 vs 384 g), cerebroplacental ratio (1.1 vs 0.9), PlGF (41 vs 18 pg/mL) and PlGF multiples of the median (MoM; 0.10 vs 0.06) and lower sFlt-1/PlGF ratio (129 vs 479) at the time of diagnosis (all P < 0.001). The best combination of two variables for predicting perinatal survival was provided by EFW and PlGF MoM (area under the receiver-operating-characteristics curve (AUC), 0.84 (95% CI, 0.75–0.92)). These were also the best variables for predicting severe neonatal morbidity (AUC, 0.73 (95% CI, 0.66–0.80)). Conclusions A model combining EFW and maternal serum PlGF predicts accurately perinatal survival in eoFGR cases diagnosed before 28 weeks of gestation. Prenatal prediction of severe neonatal morbidity in eoFGR cases is modest regardless of the model used. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.European CommissionMinisterio de Economía, Industria y Competitividad (España)Instituto de Salud Carlos III (España)Depto. de Salud Pública y Materno - InfantilFac. de MedicinaTRUEpu

Angiogenesis-Related Biomarkers (sFlt-1/PLGF) in the Prediction and Diagnosis of Placental Dysfunction: An Approach for Clinical Integration

Placental dysfunction is involved in a group of obstetrical conditions including preeclampsia, intrauterine growth restriction, and placental abruption. Their timely and accurate recognition is often a challenge since diagnostic criteria are still based on nonspecific signs and symptoms. The discovering of the role of angiogenic-related factors (sFlt-1/PlGF) in the underlying pathophysiology of placental dysfunction, taking into account that angiogenesis-related biomarkers are not specific to any particular placental insufficiency-related disease, has marked an important step for improving their early diagnosis and prognosis assessment. However, sFlt-1/PlGF has not been yet established as a part of most guidelines. We will review the current evidence on the clinical utility of sFlt-1/PlGF and propose a new protocol for its clinical integration

Use of dynamic network in the wildlife-livestock interface to study endemic and emerging diseases

Resumen del póster presentado a la Joint Virtual Conference of the WDA and EWDA, celebrada del 31 de agosto al 2 de septiembre de 2021.Dynamic networks are an analytical tool highly valued in epidemiology due to their potential to identify individuals or communities with a key role in the transmission of pathogens. By including the temporal dimension in the analysis is possible to consider the potential process of pathogen transmission along the time. This approach becomes more necessary in those interfaces where emerging diseases mean a challenge. The objective of this work was to characterise the network of interactions in a multi-host extensive system where wild boar (Sus scrofa) and red deer (Cervus elaphus) cohabit with livestock, and to simulate the potential transmission of Mycobacterium tuberculosis complex (MTB) and African swine fever virus (ASFV) within a dynamic network. To this end 6 red deer, 6 wild boar, 3 cattle and 10 domestic pigs were collared during autumn 2017–winter 2018 using GPS and proximity devices; besides, indirect interactions between animals through water points (as a potential source of pathogens) were considered. Close interspecific interactions were found to be scarce, but water points acted as an attractant for both wildlife and livestock, resulting in a high number of interspecific indirect interactions. The simulation showed that transmission of MTB may occur preferably from red deer to cattle in our studied system; in the case of ASFV, our simulation suggests that transmission from wild boar to pigs occurs more probably through water points. The results of this preliminary work highlight the relevant role that certain wild species could play in the transmission of pathogens in multihost systems. More in deep studies are necessary to understand the real role of water points for the transmission of the two diseases considered, both for pathogen maintenance or carcasses presence. Also, more empirical data (e.g. more collared individuals) is needed to estimate more reliable rates of interactions, specifically for direct interactions.Peer reviewe

Prediction of postnatal circulation in pulmonary atresia/critical stenosis with intact ventricular septum: systematic review and external validation of models

ObjectiveA favorable postnatal prognosis in cases ofpulmonary atresia/critical stenosis with intact ventricu-lar septum (PA/CS-IVS) is generally equated with thepossibility of achieving biventricular (BV) repair. Identi-fication of fetuses that will have postnatal univentricular(UV) circulation is key for prenatal counseling, opti-mization of perinatal care and decision-making regardingfetal therapy. We aimed to evaluate the accuracy ofCorrespondence to:Dr C. Villala ́ın, Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Avenida de C ́ordoba,Madrid 28041, Spain (e-mail: [email protected])Accepted: 23 January 2023published models for predicting postnatal circulation inPA/CS-IVS using a large internationally derived validationcohort.MethodsThis was a systematic review of publisheduni- and multiparametric models for the predictionof postnatal circulation based on echocardiographicfindings at between 20 and 28 weeks of gestation.Models were externally validated using data fromthe International Fetal Cardiac Intervention Registry.Sensitivity, specificity, predictive values, area underthe receiver-operating-characteristics curves (AUCs) andproportion of cases with truevspredicted outcome werecalculated.ResultsEleven published studies that reported prog-nostic parameters of postnatal circulation were iden-tified. Models varied widely in terms of the mainoutcome (UV (n=3), non-BV (n=3), BV (n=3),right-ventricle-dependent coronary circulation (n=1) ortricuspid valve size at birth (n=1)) and in terms ofthe included predictors (single parameters only (n=6),multiparametric score (n=4) or both (n=1)), and weredeveloped on small sample sizes (range, 15 – 38). Ninemodels were validated externally given the availability ofthe required parameters in the validation cohort. Tricus-pid valve diameterZ-score, tricuspid regurgitation, ratiosbetween right and left cardiac structures and the presence. Postnatal circulation in pulmonary atresia15of ventriculocoronary connections (VCC) were the mostcommonly evaluated parameters. Multiparametric mod-els including up to four variables (ratios between rightand left structures, right ventricular inflow duration, pres-ence of VCC and tricuspid regurgitation) had the bestperformance (AUC, 0.80 – 0.89). Overall, the risk of UVoutcome was underestimated and that of BV outcomewas overestimated by most models.ConclusionsCurrent prenatal models for the predictionof postnatal outcome in PA/CS-IVS are heterogeneous.Multiparametric models for predicting UV and non-BVcirculation perform well in identifying BV patients buthave low sensitivity, underestimating the rate of fetusesthat will ultimately have UV circulation. Until betterdiscrimination can be achieved, fetal interventions mayneed to be limited to only those cases in which non-BVpostnatal circulation is certain.Objetivo.Un pron ́ostico postnatal favorable en casos de atresia pulmonar/estenosis cr ́ıtica con tabique interventricularintacto (PA/CS-IVS, por sus siglas en ingl ́es) se equipara generalmente con la posibilidad de lograr una reparaci ́onbiventricular (BV). La identificaci ́on de los fetos que tendr ́an circulaci ́on univentricular (UV) postnatal es clave parael asesoramiento prenatal, la optimizaci ́on de los cuidados perinatales y la toma de decisiones relativas a la terapiafetal. El objetivo fue evaluar la precisi ́on de los modelos publicados para predecir la circulaci ́on postnatal en casos dePA/CS-IVS utilizando para ello una gran cohorte de validaci ́on estimada a partir de datos internacionales.M ́etodos.El estudio consisti ́oenunarevisi ́on sistem ́atica de los modelos uni- y multiparam ́etricos publicados para lapredicci ́on de la circulaci ́on postnatal basados en los hallazgos ecocardiogr ́aficos entre las semanas 20 y 28 de gestaci ́on.Los modelos se validaron externamente utilizando datos del Registro Internacional de Intervenciones Card ́ıacas Fetales.Se calcularon la sensibilidad, la especificidad, los valores predictivos, el ́area bajo las curvas (ABC) de caracter ́ısticasoperativas del receptor y la proporci ́on de casos con resultado verdadero frente a resultado pronosticado.Resultados.Se identificaron once estudios publicados en los que se hab ́ıan reportado par ́ametros pron ́osticos de lacirculaci ́on postnatal. Los modelos variaron ampliamente en cuanto al resultado principal (UV (n=3), no-BV (n=3), BV(n=3), la circulaci ́on coronaria dependiente del ventr ́ıculo derecho (n=1)oeltama ̃no de la v ́alvula tric ́uspide al nacer(n=1)) y en cuanto a los predictores incluidos (s ́olo par ́ametros ́unicos (n=6), puntuaci ́on multiparam ́etrica (n=4) oambos (n=1)), y se desarrollaron a partir de muestras peque ̃nas (rango, 15 – 38).Dada la disponibilidad de los par ́ametros requeridos en la cohorte de validaci ́on, se validaron externamente nuevemodelos. La puntuaci ́on est ́andar (Z) del di ́ametro de la v ́alvula tric ́uspide, la insuficiencia tricusp ́ıdea, los cocientesentre las estructuras card ́ıacas derecha e izquierda y la presencia de conexiones ventr ́ıculo-coronarias (CVC) fueronlos par ́ametros evaluados con mayor frecuencia. El mejor desempe ̃no (ABC, 0,80 – 0,89) correspondi ́o a los modelosmultiparam ́etricos que inclu ́ıan hasta cuatro variables (cocientes entre las estructuras derecha e izquierda, duraci ́on delinflujo ventricular derecho, presencia de CVC e insuficiencia tricusp ́ıdea). En general, en la mayor ́ıa de los modelos sesubestim ́o el riesgo del resultado UV y se sobreestim ́oeldelresultadoBV.Conclusiones.Los modelos prenatales actuales para la predicci ́on del resultado postnatal en la PA/CS-IVS sonheterog ́eneos. Los modelos multiparam ́etricos para predecir la circulaci ́on UV y no-BV funcionan bien para laidentificaci ́on de pacientes BV, pero tienen una sensibilidad baja, que subestima la tasa de fetos que finalmente tendr ́ancirculaci ́on UV. Hasta que se consiga una mejor forma para poder discriminar entre casos, puede ser necesario limitarlas intervenciones fetales ́unicamente a aquellos en los que est ́e asegurado que la circulaci ́on postnatal es no-BV.©2023 The Authors.Ultrasound in Obstetrics & Gynecologypublished by John Wiley &SYSTEMATIC REVIEWSons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.Depto. de MedicinaFac. de MedicinaTRUEpubAPC financiada por la UC