Incidence and microbiological characteristics of ventilator-associated pneumonia assessed by bronchoalveolar lavage and endotracheal aspirate in COVID-19 patients: COV-AP study

Introduction: Diagnosis of ventilator-associated pneumonia (VAP) in COVID-19 patients remains challenging. Also, the lack of gold standard for microbiological sampling undermines clinical judgement and management. We studied incidences of microbiologically-confirmed VAP comparing endotracheal aspirate (ETA) and bronchoalveolar lavage (BAL) in COVID-19 patients. Etiological agreement between ETA and BAL was then assessed. Method(s): Single-center prospective cohort study (NCT04766983). Patients were enrolled within 48 h from intubation;surveillance ETA ( ETASURV) was performed twice weekly. ETA ( ETACX) and BAL ( BALCX) samples were collected upon VAP suspicion (Johanson's criteria). CDC definitions were used for microbiological confirmation. ETA-BAL agreement (interrater reliability and Cohen's kappa) and clinical/microbiological data were assessed for the first episodes of suspected VAP per patients. Result(s): Ninety intensive care (ICU) patients enrolled from 01/2021 to 05 06/2022, of which 26 females (28.9%);median age was 60 [52-66] years. In-ICU mortality was 30/90 (33.3%), median length of stay in survivors 19 (10-32) days. Fifty-three patients (58.9%) had >= 1 episode of suspected VAP after 6 [5;10] days from ICU admission. ETASURV were available in 52 cases, 2 [1;3] days before VAP suspect, and tested positive in 28 (53.8%). ETACX and BALCX resulted positive in 35 (66.0%) and 29 (54.7%) of episodes. Main microbiological results are displayed in Fig. 1, panel A. Etiological agreement between techniques is shown in Fig. 1, panel B. Incidence rate of VAP suspicions per 1000 ventilator-days was 60.2 (95% CI 43.9-76.4), while incidence rates of microbiologically-confirmed VAP were 27.4 (18.3-36.5) with ETACXand 18.9 (95% CI 12.0-25.8) with BALCX, respectively. Conclusion(s): We observed different incidence of VAP in COVID-19 ICU patients depending on sampling method. Etiological agreement between techniques yielded limited interrater reliability. The potential clinical impact needs further studies.

Insights into the lung microenvironment after severe COVID-19

The SARS-CoV-2 is the betacoronavirus responsible for the coronavirus disease 2019 (COVID-19) pandemic. Severe COVID-19 affects approximately 10-15% of patients and results in prolonged morbidity and mortality. Little is known about the immunophenotypic changes of the lung parenchyma driven by the viral infection in patients who die of severe COVID-19. Ultrasound-guided lung biopsies (LB) were collected (IRB approval#1561/21) within few hours from death in 15 severe COVID-19 patients between November 2020 and January 2021, in two patients who underwent lung transplantation after COVID-19 and in one patient who had surgery for bacterial superinfection during COVID-19 disease. All samples underwent histologic and immunohistochemistry evaluation and molecular profiling using the nCounter Host Response and Coronavirus Panel plus. As controls, lungs from end-stage usual interstitial pneumonia (UIP;n=9) and from lobectomy for lung cancer (Norm;n=5) were used. Eleven lungs (61%) were positive for SARS-CoV-2 RNA. Signs of diffuse alveolar damage (DAD) were observed in 6 patients (30%). COVID-19 lungs showed a marked macrophage infiltration with M2 polarization compared with controls. Globally, COVID-19 lungs showed distinct molecular profiles from UIP or Norm lungs. Specifically, a marked upregulation of interferon-genes that was directly correlated with SARS-CoV-2 genes was seen in COVID-19 lungs. COVID-19-specific genes signatures (Log2FC >1.5;adj p<0.05) obtained using VENN diagram showed impairment of the STAT3-pathway accompanied by the upregulation of the NFkB signaling. Results herein provide new insights into lung alterations induced by severe COVID-19 and suggest novel potential targets for therapeutic intervention.

Involvement of the contact pathway in COVID-19 coagulopathy

Background: A novel acquired coagulopathy characterized by a severe procoagulant imbalance is common in COVID-19 patients and is associated with the clinical severity of the disease. Aim(s): Our study aims to elucidate the underlying mechanisms of coagulation activation in COVID-19 patients. Method(s): Symptomatic COVID-19 patients during Milan first wave were consecutively enrolled and stratified into 3 groups based on the intensity of care: Low, requiring only high-flow oxygen by nasal cannula;intermediate, requiring continuous positive airway pressure;high, requiring mechanical ventilation. Blood samples were tested for markers of activation of the intrinsic pathway (FXIa, FXIIa) together with its physiologic inhibitor (C1-inhibitor), of the extrinsic pathway (FVIIa), of global activation of the coagulation cascade (D-dimer, FDP, FM) and of fibrinolysis (plasminogen, t-PA, alpha2-antiplasmin, PAI-1). Result(s): 111 patients were included: 26 at low, 42 intermediate and 43 high care-intensity. Median age was 59 +/- 12 (34 patients >65 years);32 patients (29%) developed a venous thrombosis and 12 (11%) died (Table). Median D-dimer, FDP and FM plasma levels were higher in COVID-19 patients compared to controls, with a gradient of increase across the three care intensities, while all the fibrinolytic pathway parameters were in the normal range. Median plasma levels of FVIIa were lower in COVID-19 patients (27.5 mU/ml) than in controls (40.1 mU/ml) while median plasma levels of FXIIa and FXIa were higher in COVID-19 patients (11.2 and 11.3 mU/ml) than in controls (7.2 and 5.5 mU/ml), with a gradient of increase across the three care intensities. C1-inhibitor plasma levels were above the normal range in all the 3 COVID-19 patients' groups (Figure). Conclusion(s): Our study showed a prevalent activation of the contact pathway over the extrinsic pathway of the coagulation cascade in COVID-19 patients, which is proportional to the clinical severity of the infection, opening the possibility for targeted anticoagulant therapies. (Table Presented).

Evaluating the Endothelial Impairments in COVID-19 Patients Using Near-Infrared Spectroscopy: the HEMOCOVID-19 trial

HEMOCOVID-19 is a multi-center trial aiming to assess the microvascular and endothelial health of severe COVID-19 patients in the intensive care using near-infrared spectroscopy. Here, we present the preliminary results, showing that peripheral microcirculatory alterations are associated with the severity of acute respiratory distress syndrome. © 2022 The Author(s).

Russels viper venom (RVV) clotpro essay correlates with anti-xa activity during veno-venous ecmo

Introduction: The ClotPro system (enicor GmbH, Germany) is a novel rotational viscoelastic analyzer that assesses the coagulation cascade through different reagents. Russels Viper Venom (RVV) is a direct activator of fX to fXa, and it is mostly employed to monitor direct oral anticoagulants. IN test evaluates the intrinsic pathway of coagulation via ellagic acid addition. The ability of these tests to monitor heparin administration during veno-venous ECMO (vvECMO)-compared to the gold standard anti-Xa activity-is to be cleared. Objective: To evaluate the correlation of RVV and IN test clotting time (CT) with anti-Xa activity during unfractioned heparin (UFH) administration in vvECMO. Methods: Intensive care unit (ICU) patients undergoing vvECMO and continuous UFH administration were enrolled. Standard coagulation tests, anti-Xa activity, RVV and IN test were simultaneously conducted. Results: Eight patients were enrolled (September 2020-February 2021), for a total of 53 observations (5 [2-9] per patient). SARS-CoV2 infection was the main diagnosis (50%), followed by Legionella pneumonia, HSV pneumonia, bridge to lung transplantation and COPD relapse. Age was 54.0 [42.5-60.5] years old, body mass index was 26.6 [24.1-28.5] kg/m2. Prolongation of RVV and IN CT was observed in our cohort (see Table 1 for the main study findings), and it was found to be strongly correlated to plasma anti-Xa activity (Figures 1, 2). Conclusions: RVV and IN test clotting time at ClotPro system might be used for anti-coagulation monitoring during vvECMO and UFH administration. Further studies are needed for clinical translatability of these findings.

Anemia and iron metabolism in patients with sars-cov-2 infection: The role of inflammation and hypoxia

Background: Coronavirus Disease (COVID-19) could be considered as a human model of marked inflammation combined with severe hypoxia. In this setting, both erythropoiesis and iron metabolism appear to be profoundly affected by inflammatory and hypoxic stimuli, which act in the opposite direction. In patients with SARS-CoV-2 infection, Hb levels tend to be relatively high even in the context of severe disease and marked inflammation. A better understanding of erythropoiesis and iron metabolism in COVID-19 could contribute to elucidate the relationship between hypoxia and inflammation on erythropoietic control. Aims: To investigate the prevalence of anemia, the alterations of iron homeostasis,and the relationship between inflammation,hypoxia and erythropoiesis in a cohort of COVID-19 patients admitted both to medical wards and intensive care unit (ICU). Methods: We retrospectively analyzed data of 303 patients with COVID- 19 (178 subjects admitted to medical wards and 125 subjects admitted to the ICU). Biochemical parameters were collected on admission (T0), after 7 days of hospitalization (T1) and at discharge/death (T2). Results: The median age of the patients was 62 years (53-71) and 72% were males. ICU patients had lower mean Hb levels compared to non- ICU patients (11.3±1.8 vs 12.8±1.8 g/dL at T0, 10.2±1.6 vs 12.2±1.9 g/ dL at T1, 10±1.4 vs 12±1.7 g/dL at T2;p<0.001). Mean Hb concentration did not fall under 12 g/dl in the non-ICU group and under 10 g/ dl in the ICU group during hospitalization. Hb decreased by approximately 1 g/dl in both cohorts during the first 7 days of hospitalization, then remained stable until discharge. ICU patients also showed increased inflammatory markers and ferritin levels (1401 vs 839 mcg/l at T0, p<0.001;913 vs 832 mcg/L at T1, p ns;764 vs 651 mcg/L at T2, p ns). There were no significant differences in other iron parameters between groups. Hypoxia was a prominent feature of ICU patients (P/F ratio 91 vs 224, p<0.001). Patients who were anemic on admission maintained relatively constant Hb concentrations from T0 to T2 (10.8 g/dL at T0, 10.2 g/dL at T1 and 10.4 g/dL at T2), thus remaining in a range of mild to moderate anemia. Conversely, the non-anemic group displayed a greater reduction of Hb levels (13.7 g/dl at T0, 12.7 g/dl at T1, 12 g/dl at T2). Anemic subjects were more hypoxic than non-anemic patients (P/F 151 vs 292 at T0, p<0.001) and showed significantly higher levels of CRP (10.8 vs 6.6 mg/dL), IL-6 (60.3 vs 47.7 ng/L) and leukocyte count (7290 vs 6130 x109/L). Ferritin was higher in anemic patients at T0 and T1 (1220 vs 926 mcg/L and 852 vs 896 mcg/L, p ns), decreasing more at T2 (655 vs 763 mcg/L, p ns). Median hepcidin levels, which were available for a limited subset of non- ICU patients, were elevated during the whole period: 233 ng/mL at T0, 95 ng/mL at T1 and 60 ng/mL at T2. Summary/Conclusion: In patients with SARS-CoV-2 infection, two main factors influence erythropoiesis and iron homeostasis: systemic inflammation and profound hypoxia. Markedly high ferritin and hepcidin levels reflect a strong inflammatory response. However, COVID-19 patients tend to have disproportionately high Hb levels in the contest of the inflammatory milieu. The absolute reduction in Hb levels is more prominent in patients who displayed normal Hb on admission. Conversely, anemic and profoundly hypoxic subjects show constant mean Hb levels over time. Thus, we can hypothesize that the erythropoietic drive provided by hypoxia could counterbalance the effect of inflammation on hepcidin regulation, preventing Hb levels from falling dramatically during hospitalization.

Prevalence of neurological post-COVID-19 manifestations

Background and aims: Although COVID-19 infection predominantly manifests with respiratory symptoms, recent studies have also reported the occurrence of neurological involvement in the acute phase as well as in the follow-up of recovered subjects Methods: Our study focuses on assessing the prevalence of neurological sequelae in COVID-19 patients hospitalized at Ospedale Maggiore Policlinico in Milan. Seventy-five COVID-19 recovered subjects followed a general follow-up protocol including pneumological, infectious and cardiovascular assessment 5-10 months after the onset of SARS-CoV2 infection;among them, a subset of 53 patients was evaluated through a self-administered 18-item questionnaire developed ad-hoc addressing sensory, motor and cognitive neurological symptoms. Results: Collected data has shown that 77.4% patients developed at least one neurological sequela, and 46.3% presented with more than three symptoms. Among symptomatic patients, the most prevalent manifestations were insomnia (65.9%) and daytime sleepiness (46.3%), followed by walking difficulties (31.7%). Other less frequent symptoms were headache (15.1%), hyposmia and hypogeusia (15.1%), and tremor (9.4%). Prevalence of symptoms 18-item questionnare showing the distribution of neurological manifestations Conclusion: Post-COVID-19 manifestations are reported in about 90% of recovered patients. This preliminary study suggests that neurological findings represent a significant part of such manifestations. We are currently expanding the questionnaire to a larger cohort of patients and correlating our findings with patients' demographical and clinical features, as well as with the severity of the previous SARSCoV2 infection. Currently, the same questionnaire is also being validated and administered to age-and sex-matched healthy controls who have not developed symptoms suggestive of Covid-19, and a cohort of non-COVID-19 hospitalized patients.

Interventions for the prevention and treatment of COVID-19: a living mapping of research and living network meta-analysis

Objectives: This is a protocol for a Cochrane Review (intervention). The objectives are as follows:. To provide a living mapping of registered randomized trials, and to assess and rank where appropriate the relative effects of interventions for the prevention and treatment of COVID-19. Our approach has been described in Boutron 2020 and Nguyen 2020. As part of the methodological process of living systematic reviews, we will continuously (i.e. every working day) collect and critically appraise results from all eligible RCTs addressing specific clinical outcomes related to COVID-19. We will synthesize the available study results using pairwise meta-analyses and when possible and appropriate, network meta-analyses (NMAs). The interventions and the research questions considered will evolve over time and will be guided by end-users’ needs. We will report our updated evidence synthesis every week, and will make all results available on a website: www.covid-nma.com. In addition, we will update this Cochrane Review at least once every six months, or as soon as the certainty of evidence (assessed with the GRADE methodology) changes. We will wait until the accumulating evidence changes one or more of the following aspects of the review, before incorporating it and re-publishing the Cochrane Review:. the findings of one or more critical outcomes;the credibility (e.g. GRADE rating) of one or more critical outcomes;new settings, population, interventions, comparisons or outcomes studied;or new serious adverse events. We will develop a steering committee of epidemiologists, methodologists, statisticians and clinicians with content expertise. This committee will meet regularly and discuss the conduct of the project, difficulties encountered and possible changes in the protocol according to new knowledge becoming available for the disease. Changes to the protocol could include, for example, changes in the search strategy, eligibility criteria (e.g. study design), research questions for the pairwise meta-analyses, or outcomes. The steering committee will systematically discuss and achieve consensus on the changes to the protocol. The process will also evolve over time according to new knowledge available regarding COVID-19.

Lung Transplantation for Acute Respiratory Distress Syndrome Related to COVID-19: The Lesson Learned from the First Two Cases

Purpose The respiratory system, and namely the lung, is undoubtedly the preferential target of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The clinical pictures are extremely various, up to the intensive care unit (ICU) admission for acute respiratory distress syndrome (ARDS). Lung transplantation (LT) is a consolidate therapeutic option for end-stage chronic respiratory diseases. Its role in an acute setting is questionable, particularly due to lack of experiences, donor shortage, and the difficulty to fully evaluate the potential recipient. We report our preliminary experience with the first two cases of LT for SARS-CoV-2 related ARDS, trying to provide some food for thought. Methods We retrospectively analysed our first two cases of bilateral LT for ARDS after COVID-19. We recorded data on pre-transplantation clinical course, transplantation management and outcomes. Results The two patients had a similar clinical evolution of COVID-19. Transplantations were successful in both cases;the first patient is alive and in good condition 5 months after transplantation, while the second died 62 days after surgery. Table 1 shows clinical details and relevant time-points. Conclusion Our experience showed that LT for COVID-19 is feasible. Importantly, observing a dedicated protocol made the procedure safe for the healthcare staff involved. On the other hand, our second unsuccessful case poses relevant questions: first of all, lung transplantation should be reserved to highly selected patient, after careful clinical, infective as well as psychiatric evaluation. The ethical aspects should also be considered in this situation, with regard to the centre rate mortality on waiting list. Anyway, the potential role of LT in the acute and sub-acute/chronic settings suggests the need for maintaining LT centre active during pandemic. Finally, COVID-19, once more, imposes to share clinical experiences.

Interventions for the treatment of COVID-19: a living network meta analysis (Protocol)

Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess and rank where appropriate the relative effects of interventions for the treatment of COVID-19.

Effect of heparin on viscoelastic parameters of COVID-19 critically ill patients. A Viscoelastic Coagulation Monitor (VCM) analysis

Background: Viscoelastic Coagulation Monitor (VCM-Entegrion, Durham, NC) is a portable, recently validated device developed to quickly evaluate the viscoelastic properties of whole blood activated by direct contact with a glass surface. We employed VCM as daily assessment of COVID-19 critically ill patients. Aim of the study was to assess whether VCM parameters were modified by heparin administration. Methods: Retrospective cohort study on COVID-19 critically ill patients who were tested with VCM during their ICU stay from March 25th to June 8th. Anticoagulation was provided either with unfractionated (UFH) or with low molecular weight (LMWH) heparin, per institutional protocol. VCM analysis was simultaneously run to standard coagulation tests Results: Thirty-six patients were included in the study for a total of 151 measurements. ECMO patients (N=4) received UFH, the remaining (except one that was heparin-free) received LMWH, for a total of 52 samples on UFH, 86 samples on LMWH, and 13 samples without any anticoagulant. The administration of UFH influenced VCM parameters towards hypocoagulability whereas LMWH did not. No flat-line tracings were observed. The correlation between VCM Clotting Time and UFH dose was moderate (Spearman's rho = 0.48, p = <0.001), the correlation between aPTT and UFH was weak (Spearman's rho = 0.35, p = 0.010). As expected, no correlation was found between VCM parameters and LMWH dose. Conclusions: VCM parameters were modified only by anticoagulant doses of UFH in a cohort of COVID-19 critically ill patients. VCM could be further evaluated as a tool for UFH anticoagulation monitoring.

Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy.

The first person-to-person transmission of the 2019 novel coronavirus in Italy on 21 February 2020 led to an infection chain that represents one of the largest known COVID-19 outbreaks outside Asia. In northern Italy in particular, we rapidly experienced a critical care crisis due to a shortage of intensive care beds, as we expected according to data reported in China. Based on our experience of managing this surge, we produced this review to support other healthcare services in preparedness and training of hospitals during the current coronavirus outbreak. We had a dedicated task force that identified a response plan, which included: (1) establishment of dedicated, cohorted intensive care units for COVID-19-positive patients; (2) design of appropriate procedures for pre-triage, diagnosis and isolation of suspected and confirmed cases; and (3) training of all staff to work in the dedicated intensive care unit, in personal protective equipment usage and patient management. Hospital multidisciplinary and departmental collaboration was needed to work on all principles of surge capacity, including: space definition; supplies provision; staff recruitment; and ad hoc training. Dedicated protocols were applied where full isolation of spaces, staff and patients was implemented. Opening the unit and the whole hospital emergency process required the multidisciplinary, multi-level involvement of healthcare providers and hospital managers all working towards a common goal: patient care and hospital safety. Hospitals should be prepared to face severe disruptions to their routine and it is very likely that protocols and procedures might require re-discussion and updating on a daily basis.