Efficacy and safety of corticosteroid therapy in patients with cardiac arrest: A meta-analysis of randomized controlled trials.

BACKGROUND: The clinical benefits of steroid therapy during cardiac arrest (CA) are unclear. Several recent clinical trials have shown that administering corticosteroid therapy during CA may improve patient outcomes. The purpose of the present study was to determine whether providing corticosteroids improves outcomes for patients following CA. METHODS: We searched the PubMed, Embase, Cochrane Library, Web of Science and CNKI databases for randomized controlled trials comparing corticosteroid therapy to placebo during CA. RESULTS: Eleven relevant studies involving a total of 2273 patients were included in the meta-analysis. The statistical analysis showed that corticosteroid treatment during CA was significantly associated with an increased rate of sustained return of spontaneous circulation (ROSC) (OR: 2.05, 95% CI: 1.24 to 3.37, P < 0.01). Corticosteroid treatment during CA did not show a significant benefit in favorable neurological outcomes (OR: 1.13, 95% CI: 0.81 to 1.58, P = 0.49) or overall survival rate at hospital discharge (OR: 1.29, 95% CI: 0.74 to 2.26, P = 0.38). However, in the subgroup analysis, we found that patients had a significantly increased survival rate and ROSC if the dose of corticosteroid therapy above 100 mg methylprednisolone. The statistical analysis revealed no significant differences in adverse events. CONCLUSION: High-dose corticosteroid treatment (above 100 mg methylprednisolone) is associated with better overall survival rate at hospital discharge and ROSC outcomes. However, there is uncertainty regarding whether this treatment results in a benefit or harm to the favorable neurological outcomes at hospital discharge.

Coronavirus disease 2019 (COVID-19): cytokine storms, hyper-inflammatory phenotypes, and acute respiratory distress syndrome.

Coronavirus Disease 2019 (COVID-19) was first identified in China at the end of 2019. Acute respiratory distress syndrome (ARDS) represents the most common and serious complication of COVID-19. Cytokine storms are a pathophysiological feature of COVID-19 and play an important role in distinguishing hyper-inflammatory subphenotypes of ARDS. Accordingly, in this review, we focus on hyper-inflammatory host responses in ARDS that play a critical role in the differentiated development of COVID-19. Furthermore, we discuss inflammation-related indicators that have the potential to identify hyper-inflammatory subphenotypes of COVID-19, especially for those with a high risk of ARDS. Finally, we explore the possibility of improving the quality of monitoring and treatment of COVID-19 patients and in reducing the incidence of critical illness and mortality via better distinguishing hyper- and hypo-inflammatory subphenotypes of COVID-19.

The clinical and immunological features of pediatric COVID-19 patients in China.

In December 2019, the corona virus disease 2019 (COVID-19) caused by novel coronavirus (SARS-CoV-2) emerged in Wuhan, China and rapidly spread worldwide. Few information on clinical features and immunological profile of COVID-19 in paediatrics. The clinical features and treatment outcomes of twelve paediatric patients confirmed as COVID-19 were analyzed. The immunological features of children patients was investigated and compared with twenty adult patients. The median age was 14.5-years (range from 0.64 to 17), and six of the patients were male. The average incubation period was 8 days. Clinically, cough (9/12, 75%) and fever (7/12, 58.3%) were the most common symptoms. Four patients (33.3%) had diarrhea during the disease. As to the immune profile, children had higher amount of total T cell, CD8+ T cell and B cell but lower CRP levels than adults (P < 0.05). Ground-glass opacity (GGO) and local patchy shadowing were the typical radiological findings on chest CT scan. All patients received antiviral and symptomatic treatment and the symptom relieved in 3-4 days after admitted to hospital. The paediatric patients showed mild symptom but with longer incubation period. Children infected with SARS-CoV-2 had different immune profile with higher T cell amount and low inflammatory factors level, which might ascribed to the mild clinical symptom. We advise that nucleic acid test or examination of serum IgM/IgG antibodies against SARS-CoV-2 should be taken for children with exposure history regardless of clinical symptom.

A Peptide-Based Magnetic Chemiluminescence Enzyme Immunoassay for Serological Diagnosis of Coronavirus Disease 2019.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel ß-coronavirus, causes severe pneumonia and has spread throughout the globe rapidly. The disease associated with SARS-CoV-2 infection is named coronavirus disease 2019 (COVID-19). To date, real-time reverse-transcription polymerase chain reaction (RT-PCR) is the only test able to confirm this infection. However, the accuracy of RT-PCR depends on several factors; variations in these factors might significantly lower the sensitivity of detection. METHODS: In this study, we developed a peptide-based luminescent immunoassay that detected immunoglobulin (Ig)G and IgM. The assay cutoff value was determined by evaluating the sera from healthy and infected patients for pathogens other than SARS-CoV-2. RESULTS: To evaluate assay performance, we detected IgG and IgM in the sera from confirmed patients. The positive rate of IgG and IgM was 71.4% and 57.2%, respectively. CONCLUSIONS: Therefore, combining our immunoassay with real-time RT-PCR might enhance the diagnostic accuracy of COVID-19.

Does training improve diagnostic accuracy and inter-rater agreement in applying the Berlin radiographic definition of acute respiratory distress syndrome? A multicenter prospective study.

BACKGROUND: Poor inter-rater reliability in chest radiograph interpretation has been reported in the context of acute respiratory distress syndrome (ARDS), although not for the Berlin definition of ARDS. We sought to examine the effect of training material on the accuracy and consistency of intensivists' chest radiograph interpretations for ARDS diagnosis. METHODS: We conducted a rater agreement study in which 286 intensivists (residents 41.3%, junior attending physicians 35.3%, and senior attending physician 23.4%) independently reviewed the same 12 chest radiographs developed by the ARDS Definition Task Force ("the panel") before and after training. Radiographic diagnoses by the panel were classified into the consistent (n = 4), equivocal (n = 4), and inconsistent (n = 4) categories and were used as a reference. The 1.5-hour training course attended by all 286 intensivists included introduction of the diagnostic rationale, and a subsequent in-depth discussion to reach consensus for all 12 radiographs. RESULTS: Overall diagnostic accuracy, which was defined as the percentage of chest radiographs that were interpreted correctly, improved but remained poor after training (42.0 ± 14.8% before training vs. 55.3 ± 23.4% after training, p < 0.001). Diagnostic sensitivity and specificity improved after training for all diagnostic categories (p < 0.001), with the exception of specificity for the equivocal category (p = 0.883). Diagnostic accuracy was higher for the consistent category than for the inconsistent and equivocal categories (p < 0.001). Comparisons of pre-training and post-training results revealed that inter-rater agreement was poor and did not improve after training, as assessed by overall agreement (0.450 ± 0.406 vs. 0.461 ± 0.575, p = 0.792), Fleiss's kappa (0.133 ± 0.575 vs. 0.178 ± 0.710, p = 0.405), and intraclass correlation coefficient (ICC; 0.219 vs. 0.276, p = 0.470). CONCLUSIONS: The radiographic diagnostic accuracy and inter-rater agreement were poor when the Berlin radiographic definition was used, and were not significantly improved by the training set of chest radiographs developed by the ARDS Definition Task Force. TRIAL REGISTRATION: The study was registered at ClinicalTrials.gov (registration number NCT01704066 ) on 6 October 2012.

Value of Kidney Disease Improving Global Outcomes Urine Output Criteria in Critically Ill Patients: A Secondary Analysis of a Multicenter Prospective Cohort Study.

BACKGROUND: Urine output (UO) is an essential criterion of the Kidney Disease Improving Global Outcomes (KDIGO) definition and classification system for acute kidney injury (AKI), of which the diagnostic value has not been extensively studied. We aimed to determine whether AKI based on KDIGO UO criteria (KDIGOUO) could improve the diagnostic and prognostic accuracy, compared with KDIGO serum creatinine criteria (KDIGOSCr). METHODS: We conducted a secondary analysis of the database of a previous study conducted by China Critical Care Clinical Trial Group (CCCCTG), which was a 2-month prospective cohort study (July 1, 2009 to August 31, 2009) involving 3063 patients in 22 tertiary Intensive Care Units in Mainland of China. AKI was diagnosed and classified separately based on KDIGOUOand KDIGOSCr. Hospital mortality of patients with more severe AKI classification based on KDIGOUOwas compared with other patients by univariate and multivariate regression analyses. RESULTS: The prevalence of AKI increased from 52.4% based on KDIGOSCrto 55.4% based on KDIGOSCrcombined with KDIGOUO. KDIGOUOalso resulted in an upgrade of AKI classification in 7.3% of patients, representing those with more severe AKI classification based on KDIGOUO. Compared with non-AKI patients or those with maximum AKI classification by KDIGOSCr, those with maximum AKI classification by KDIGOUOhad a significantly higher hospital mortality of 58.4% (odds ratio [OR]: 7.580, 95% confidence interval [CI]: 4.141-13.873, P< 0.001). In a multivariate logistic regression analysis, AKI based on KDIGOUO (OR: 2.891, 95% CI: 1.964-4.254, P< 0.001), but not based on KDIGOSCr (OR: 1.322, 95% CI: 0.902-1.939, P = 0.152), was an independent risk factor for hospital mortality. CONCLUSION: UO was a criterion with additional value beyond creatinine criterion for AKI diagnosis and classification, which can help identify a group of patients with high risk of death.

Prevalence, risk factors, clinical course, and outcome of acute kidney injury in Chinese intensive care units: a prospective cohort study.

BACKGROUND: Acute kidney injury (AKI) has been recognized as a major healthcare problem affecting millions of patients worldwide. However, epidemiologic data concerning AKI in China are still lacking. The objectives of this study were to characterize AKI defined by RIFLE criteria, assess the association with hospital mortality, and evaluate the impact of AKI in the context of other risk factors. METHODS: This prospective multicenter observational study enrolled 3,063 consecutive patients from 1 July 2009 to 31 August 2009 in 22 ICUs across mainland China. We excluded patients who were admitted for less than 24 hours (n = 1623), younger than 18 years (n = 127), receiving chronic hemodialysis (n = 29), receiving renal transplantation (n = 1) and unknown reasons (n = 28). There were 1255 patients in the final analysis. AKI was diagnosed and classified according to RIFLE criteria. RESULTS: There were 396 patients (31.6%) who had AKI, with RIFLE maximum class R, I, and F in 126 (10.0%), 91 (7.3%), and 179 (14.3%) patients, respectively. Renal function deteriorated in 206 patients (16.4%). In comparison with non AKI patients, patients in the risk class on ICU admission were more likely to progress to the injury class (odds ratio (OR) 3.564, 95% confidence interval (CI) 1.706 - 7.443, P = 0.001], while patients in the risk class (OR 5.215, 95% CI 2.798-9.719, P < 0.001) and injury class (OR 13.316, 95% CI 7.507-23.622, P < 0.001) had a significantly higher probability of deteriorating into failure class. The adjusted hazard ratios for 90-day mortality were 1.884 for the risk group, 3.401 for the injury group, and 5.306 for the failure group. CONCLUSIONS: The prevalence of AKI was high among critically ill patients in Chinese ICUs. In comparison with non-AKI patients, patients with RIFLE class R or class I on ICU admission were more susceptibility to progression to class I or class F. The RIFLE criteria were robust and correlated well with clinical deterioration and mortality.

[The influence of pre-B-cell colony enhancing factor on adhesive molecule in pulmonary cells in rats with acute lung injury/acute respiratory distress syndrome].

OBJECTIVE: To observe the influence of pre-B-cell colony enhancing factor (PBEF) on intercellular cell adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) in lung tissue of rats with acute lung injury/acute respiratory distress syndrome (ALI/ARDS) induced by oleic acid. METHODS: A total of 40 male adult Sprague-Dawley (SD) rats were divided into control, model, drug intervention and vehicle control groups according to the random digits table with 10 rats in each group. ALI/ARDS was reproduced in the rats of model, drug intervention and vehicle control groups by injection of oleic acid (0.15 ml/kg) through the tail vein. The rats in drug intervention and vehicle control groups received the specific PBEF inhibitor FK866 (10 mg/kg), while vehicle control group received the same volume of the vehicle only. Six hours after ALI/ARDS was successfully reproduced, bronchoalveolar alveolar lavage fluid (BALF) was obtained for the measurement of the contents of tumor necrosis factor-α (TNF-α) and interleukin-1ß (IL-1ß) by enzyme linked immunosorbent assay (ELISA). Lung tissue was obtained for pathological examination, and also for the measurement of the expression of PBEF, ICAM-1 and VCAM-1 mRNA by reverse transcription-polymerase chain reaction (RT-PCR), and also the protein levels of PBEF, ICAM-1 and VCAM-1 by immunohistochemistry. RESULTS: Compared with rats in control group, the lung tissue of rats in model group showed distinctive pathological changes, the contents of TNF-α and IL-1ß in BALF were increased (TNF-α: 656.51±47.13 ng/L vs. 84.82±7.84 ng/L, IL-1ß: 379.60±31.55 ng/L vs. 74.56±8.51 ng/L, both P<0.01), the mRNA and protein expression of PBEF, ICAM-1 and VCAM-1 were significantly increased (PBEF mRNA: 0.581±0.079 vs. 0.186±0.051, ICAM-1 mRNA: 0.558±0.060 vs. 0.176±0.070, VCAM-1 mRNA: 0.646±0.059 vs. 0.226±0.047; PBEF protein: 0.089±0.024 vs. 0.037±0.011, ICAM-1 protein: 0.061±0.012 vs. 0.025±0.008, VCAM-1 protein: 0.072±0.013 vs. 0.033±0.010, all P<0.01). Compared with model group, amelioration of pathological change was found in lung tissue of rats in drug intervention group, the contents of TNF-α and IL-1ß in BALF were reduced (TNF-α: 478.80±72.93 ng/L vs. 656.51±47.13 ng/L, IL-1ß: 244.62±52.17 ng/L vs. 379.60±31.55 ng/L, both P<0.05), and the mRNA and protein expression of PBEF, ICAM-1 and VCAM-1 were lowered (PBEF mRNA: 0.456±0.110 vs. 0.581±0.079, ICAM-1 mRNA: 0.413±0.073 vs. 0.558±0.060, VCAM-1 mRNA: 0.483±0.062 vs. 0.646±0.059; PBEF protein: 0.059±0.010 vs. 0.089±0.024, ICAM-1 protein: 0.043±0.007 vs. 0.061±0.012, VCAM-1 protein: 0.050±0.009 vs. 0.072±0.013, all P<0.05). CONCLUSION: PBEF could aggravate migration of pro-inflammatory cells to infiltrate the lung tissue by increasing the expression of ICAM-1 and VCAM-1, thus it plays an important role in the development of ALI/ARDS.

[Difference between single hole exhalation valve and plateau exhalation valve when used in patients treated with BiPAP Vision ventilator for chronic obstructive pulmonary disease with hypercapnia].

OBJECTIVE: To observe difference in clinical effect between single hole exhalation valve and plateau exhalation valve when used in patients treated with BiPAP Vision ventilator for chronic obstructive pulmonary disease (COPD) with hypercapnia. METHODS: Forty seven patients with hypercapnia due to COPD, who were admitted to the central intensive care unit (ICU) in the First Affiliated Hospital of Chongqing Medical University from October 2008 to July 2010, treated with noninvasive positive pressure ventilation (NIPPV) by BiPAP Vision ventilator, were enrolled in the study. The patients were divided randomly into NIPPV with application of single hole exhalation valve group (n=22) and plateau exhalation valve group (n=25). In each group, parameters of the arterial blood gas, including arterial partial pressure of oxygen (PaO(2)) and arterial partial pressure of carbon dioxide (PaCO2), were measured at the time points of 0, 2, 4, 8, 24, 48 hours of NIPPV and 24 hours post NIPPV. RESULTS: The general conditions were similar in both groups at 0 hour. Compared with that of 0 hour, marked improvement in PaO(2) (mm Hg, 1 mm Hg=0.133 kPa, single hole exhalation valve group: 70.4±10.2, 78.7± 10.4, 82.6±9.2, 86.5±9.6, 90.4±9.0, 91.3±8.9 vs. 57.2±16.4; plateau exhalation valve group: 71.1±12.3, 77.9±11.6, 83.3±8.9, 85.9±8.2, 89.4±8.2, 92.1±8.5 vs. 56.9±17.2) and obvious lowering of PaCO(2) (mm Hg, single hole exhalation valve group: 76.3±11.9, 74.1±12.7, 71.3±11.2, 67.4±10.5, 65.4±8.2, 61.4±7.9 vs. 85.7±19.2; plateau exhalation valve group: 72.6±10.5, 70.1±11.5, 67.4±10.1, 63.9±9.7, 62.8±7.7, 59.1±7.3 vs. 86.3±17.9) were observed at the time points of 2, 4, 8, 24, 48 hours of NIPPV and 24 hours post NIPPV in both groups (all P<0.05). Comparing single hole exhalation valve group with plateau exhalation valve group, PaO2 showed no statistical significance at the same time point (all P>0.05). However, PaCO(2) was significantly lower in plateau exhalation valve group than that in single hole exhalation valve group at the time points of 2, 4, 8 and 24 hours (all P<0.05). CONCLUSION: During BiPAP Vision ventilator in NIPPV treatment of patients with COPD complicated with CO2 retention , single hole exhalation valve and plateau exhalation valve both resulted in marked improvement in PaO2 and obvious decrease in PaCO2. Plateau exhalation valve corrected CO2 retention more quickly and effectively than side hole exhalation valve probably by preventing CO2 rebreathing by the patients.