Respiratory Mechanics and Association With Inflammation in COVID-19-Related ARDS.

BACKGROUND: The novel coronavirus-associated ARDS (COVID-19 ARDS) often requires invasive mechanical ventilation. A spectrum of atypical ARDS with different phenotypes (high vs low static compliance) has been hypothesized in COVID-19. METHODS: We conducted a retrospective analysis to identify respiratory mechanics in COVID-19 ARDS. Berlin definition was used to categorize severity of ARDS. Correlational analysis using t test, chi-square test, ANOVA test, and Pearson correlation was used to identify relationship between subject variables and respiratory mechanics. The primary outcome was duration of mechanical ventilation. Secondary outcomes were correlation between fluid status, C- reactive protein, PEEP, and D-dimer with respiratory and ventilatory parameters. RESULTS: Median age in our cohort was 60.5 y with predominantly male subjects. Up to 53% subjects were classified as severe ARDS (median [Formula: see text] = 86) with predominantly low static compliance (median Cst- 25.5 mL/cm H2O). The overall mortality in our cohort was 61%. The total duration of mechanical ventilation was 35 d in survivors and 14 d in nonsurvivors. High PEEP (r = 0.45, P < .001) and D-dimer > 2,000 ng/dL (P = .009) correlated with significant increase in physiologic dead space without significant correlation with [Formula: see text]. Higher net fluid balance was inversely related to static compliance (r = -0.24, P = .045), and elevation in C- reactive protein was inversely related to [Formula: see text] (r = -0.32, P = .02). CONCLUSIONS: In our cohort of mechanically ventilated COVID-19 ARDS subjects, high PEEP and D-dimer were associated with increase in physiologic dead space without significant effect on oxygenation, raising the question of potential microvascular dysfunction.

Clinical Outcomes in Critically Ill Coronavirus Disease 2019 Patients: A Unique New York City Public Hospital Experience.

To explore demographics, comorbidities, transfers, and mortality in critically ill patients with confirmed severe acute respiratory syndrome coronavirus 2. DESIGN: Retrospective cohort study. SETTING: Data were collected from a large tertiary care public hospital ICU that is part of the largest public healthcare network in the United States. PATIENTS: One-hundred thirty-seven adult (≥ 18 yr old) ICU patients admitted between March 10, 2020, and April 7, 2020, with follow-up collected through May 18, 2020. INTERVENTIONS: None. MEASUREMENTS: Demographic, clinical, laboratory, treatment, and outcome data extracted from electronic medical records. MAIN RESULTS: The majority of patients were male (99/137; 72.3%) and older than 50 years old (108/137; 78.9%). The most reported ethnicity and race were Hispanic (61/137; 44.5%) and Black (23/137; 16.7%). One-hundred six of 137 patients had at least one comorbidity (77.4%). One-hundred twenty-one of 137 (78.1%) required mechanical ventilation of whom 30 (24.8%) moved to tracheostomy and 46 of 137 (33.6%) required new onset renal replacement therapy. Eighty-two of 137 patients (59.9%) died after a median of 8 days (interquartile range 5-15 d) in the ICU. Male sex had a trend toward a higher hazard of death (hazard ratio, 2.1 [1.1-4.0]) in the multivariable Cox model. CONCLUSIONS: We report a mortality rate of 59.9% in a predominantly Hispanic and Black patient population. A significant association between comorbidities and mortality was not found in multivariable regression, and further research is needed to study factors that impact mortality in critical coronavirus disease 2019 patients. We also describe how a public hospital developed innovative approaches to safely manage a large volume of interhospital transfers and admitted patients.

Predictors of False-Negative Focused Assessment With Sonography for Trauma Examination in Pediatric Blunt Abdominal Trauma.

OBJECTIVES: This study investigated associations between patient and injury characteristics and false-negative (FN) focused assessment with sonography for trauma (FAST) in pediatric blunt abdominal trauma (BAT). We also evaluated the effects of FN FAST on in-hospital mortality and length of stay (LOS) variables. METHODS: This retrospective cohort studied children younger than 18 years between January 1, 2002, and December 31, 2013, with BAT, documented FAST, and pathologic fluid on computed tomography, surgery, or autopsy. Multivariable and bivariate analyses were used to assess associations between FN FAST and patient injury characteristics, mortality, and hospital LOS. RESULTS: A total of 141 pediatric BAT patients with pathologic free fluid were included. There were no patient or injury characteristics, which conferred increased odds of an FN FAST. Splenic and bladder injury were negatively associated with FN FAST odds ratio of 0.4 (95% confidence interval [CI], 0.2-0.8) and 0.1 (95% CI, 0-0.8). Abbreviated Injury Scale score of 4 or greater to the abdomen and extremity was negatively associated with FN FAST odds ratio of 0.1 (95% CI, 0-0.3) and 0.3 (95% CI, 0.1-0.9). There was no association between FN FAST and mortality. Patients with an FN FAST had increased hospital LOS after controlling for sex, age, and Injury Severity Score. CONCLUSIONS: Clinicians need to be cautious applying a single initial FAST to patients with minor abdominal trauma or with suspected injuries to organs other than the spleen or bladder. Formalized studies to develop risk stratification tools could allow clinicians to integrate FAST into the pediatric patient population in the safest manner possible.

How can clinical practices pragmatically increase physical activity for patients with type 2 diabetes? A systematic review.

Although regular physical activity (PA) is a cornerstone of treatment for type 2 diabetes (T2D), most adults with T2D are sedentary. Randomized controlled trials (RCTs) have proven the effectiveness of PA behavioral interventions for adults with T2D but have rarely been conducted in healthcare settings. We sought to identify PA interventions that are effective and practical to implement in clinical practice settings. Our first aim was to use the valid Pragmatic-Explanatory Continuum Indicator Summary 2 (PRECIS-2) tool to assess the potential for future implementation of PA interventions in clinical practice settings. Our second aim was to identify interventions that effectively increased PA and glycemic control among the interventions in the top tertile of PRECIS-2 scores. We searched PubMed MEDLINE from January 1980 through May 2015 for RCTs of behavioral PA interventions coordinated by clinical practices for patients with T2D. Dual investigators assessed pragmatism by PRECIS-2 scores, and study effectiveness was extracted from original RCT publications. The PRECIS-2 scores of the 46 behavioral interventions (n = 13,575 participants) ranged from 3.0 to 4.8, where 5 is the most pragmatic score. In the most pragmatic tertile of interventions (n = 16) by PRECIS-2 scores, 30.8 and 31.3% of interventions improved PA outcomes and hemoglobin A1c, respectively. A minority of published evidence-based PA interventions for adults with T2D were both effective and pragmatic for clinical implementation. These should be tested for dissemination using implementation trial designs.