Association of Different Risk Scores and 30-Day Mortality in Kidney Transplant Recipients with COVID-19.

Background and Objectives: Clinical risk scores were poorly examined in kidney transplant recipients (KTR) with COVID-19. Materials and Methods: This observational study compared the association and discrimination of clinical risk scores (MEWS, qCSI, VACO, PSI/PORT, CCI, MuLBSTA, ISTH-DIC, COVID-GRAM and 4C) with 30-day mortality in 65 hospitalized KTRs with COVID-19. Cox regression was used to derive hazard ratios (HR) and 95% confidence intervals (95% CI), and discrimination was assessed by Harrell's C. Results: A significant association with 30-day mortality was demonstrated for MEWS (HR 1.65 95% CI 1.21-2.25, p = 0.002); qCSI (HR 1.32 95% CI 1.15-1.52, p < 0.001); PSI/PORT (HR 1.04 95% CI 1.02-1.07, p = 0.001); CCI (HR 1.79 95% CI 1.13-2.83, p = 0.013); MuLBSTA (HR 1.31 95% CI 1.05-1.64, p = 0.017); COVID-GRAM (HR 1.03 95% CI 1.01-1.06, p = 0.004); and 4C (HR 1.79 95% CI 1.40-2.31, p < 0.001). After multivariable adjustment, significant association persisted for qCSI (HR 1.33 95% CI 1.11-1.59, p = 0.002); PSI/PORT (HR 1.04 95% CI 1.01-1.07, p = 0.012); MuLBSTA (HR 1.36 95% CI 1.01-1.85, p = 0.046); and 4C Mortality Score (HR 1.93 95% CI 1.45-2.57, p < 0.001) risk scores. The best discrimination was observed with the 4C score (Harrell's C = 0.914). Conclusions: Risk scores such as qCSI, PSI/PORT and 4C showed the best association with 30-day mortality amongst KTRs with COVID-19.

Neurologic Biomarkers, Neuroimaging, and Cognitive Function in Persistent Atrial Fibrillation: A Cross-Sectional Study.

The aim of this study was to evaluate the specific neurologic biomarkers, neuroimaging findings, and cognitive function in patients with persistent atrial fibrillation (AF) undergoing electrical cardioversion, compared to control subjects. This cross-sectional study included 25 patients with persistent AF undergoing electrical cardioversion and 16 age- and sex-matched control subjects. Plasma levels of glial fibrillary acidic protein (GFAP), neurofilament light protein (NFL), and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), as well as parameters of neuroimaging and cognitive function, were compared between the groups. Neuroimaging was performed using the standard magnetic resonance imaging (MRI) protocol. Cognitive function was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Cognitive Function Index. Further analysis of neurologic biomarkers was performed based on the subsequent electrical cardioversion. There was no significant difference in GFAP (median of 24.7 vs. 28.7 pg/mL, p = 0.347), UCH-L1 (median of 112.8 vs. 117.7 pg/mL, p = 0.885), and NFL (median of 14.2 vs. 15.4 pg/mL, p = 0.886) levels between AF patients and control subjects. Similarly, neuroimaging showed no between-group difference in large cortical and non-cortical lesions (n = 2, 8.0% vs. n = 0, 0.0%, p = 0.246), small non-cortical lesions (n = 5, 20.0% vs. n = 5, 31.3%, p = 0.413), white matter hyperintensity (n = 23, 92.0% vs. n = 14, 87.5%, p = 0.636), and thromboembolic lesions (n = 0, 0.0% vs. n = 1, 6.3%, p = 0.206). Cognitive assessment did not show any between-group difference in the PROMIS index (52.2 ± 9.6 vs. 51.2 ± 6.2, p = 0.706). Finally, there were no significant dynamics in neurologic biomarkers following electrical cardioversion (p > 0.05). This hypothesis-generating study did not find a significant difference in neurologic biomarkers, neuroimaging findings, or cognitive function between patients with persistent AF and controls. The restoration of sinus rhythm was not significantly associated with a change in neurologic biomarkers. Further powered longitudinal studies are needed to re-assess these findings in an AF population.

Performance of Derived Laboratory Biomarkers with Regard to 30-Day Mortality in Kidney Transplant Recipients with COVID-19.

There are limited data on the performance of laboratory-derived biomarkers in kidney transplant recipients (KTR) with COVID-19. This observational study enrolled 65 KTR with COVID-19 who were treated at the University Hospital of Split up to March 2022. Laboratory-derived biomarkers (neutrophile-to-lymphocyte (NLR) ratio, platelet-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, De Ritis ratio, C-reactive protein (CRP)-to-albumin ratio, lactate dehydrogenase (LDH)-to-hemoglobin ratio, CRP-to-lymphocyte ratio, red cell distribution width-to-albumin ratio, platelet-to-albumin ratio, D-Dimer-to-albumin ratio, D-Dimer-to-NLR ratio, LDH-to-albumin ratio, and LDH-to-white blood cell (WBC) ratio) were calculated, and their performance with regard to 30-day mortality was determined. Mortality events occurred in 12 patients (18.5%), which was significantly associated with increased De Ritis (HR 3.83, 95% CI 1.57-9.35, p = 0.003), CRP-to-albumin (HR 1.36, 95% CI 1.13-1.64, p = 0.001), LDH-to-hemoglobin (HR 1.44, 95% CI 1.07-1.92, p = 0.015), CRP-to-lymphocyte (HR 1.03, 95% CI 1.01-1.07, p = 0.003), D-dimer-to-albumin (HR 4.94, 95% CI 1.38-7.24, p = 0.038), LDH-to-albumin (HR 1.20, 95% CI 1.05-1.36, p = 0.008), and LDH-to-WBC (HR 1.03 95% CI 1.01-1.05, p = 0.024) ratios. Out of these, the best area-under-the-curve (AUC) values were achieved with De Ritis (AUC 0.691), CRP-to-albumin (AUC 0.764), LDH-to-hemoglobin (AUC 0.877), CRP-to-lymphocyte (AUC 0.739), and LDH-to-albumin (AUC 0.827) ratios, while the best discrimination displayed LDH-to-hemoglobin ratio (Harrell's C 0.808 and Somers' D 0.616). The overall calibration was satisfactory for all models. Derived laboratory biomarkers such as the de Ritis, CRP-to-albumin, LDH-to-hemoglobin, CRP-to-lymphocyte, and LDH-to-albumin ratios show significant association and discrimination with all-cause mortality in KTR with COVID-19, suggesting its potential risk stratification role.

Association of the novel CROW-65 risk score and mortality in hospitalized kidney transplant recipients with COVID-19 : A retrospective observational study.

BACKGROUND: Kidney transplant recipients (KTR) are a group of patients with heterogeneous risks for adverse outcomes with COVID-19, but risk stratification tools in this patient group are lacking. METHODS AND PARTICIPANTS: This retrospective observational, hypothesis-generating study included 49 hospitalized adult KTR patients with COVID-19 at the University Hospital of Split (August 2020 to October 2021) and evaluated the performance of novel risk score CROW-65 (age, Charlson Comorbidity Index [CCI] lactate dehydrogenase to white blood cell [LDH:WBC] ratio, and respiratory rate oxygenation [ROX index]). The primary outcome of the study was 30-day postdischarge all-cause mortality. RESULTS: A total of 8 fatal events (16.3%) occurred during the study follow-up. When comparing CROW-65 by survival status, it was significantly increased in patients with fatal event (P < 0.001). Using the Cox proportional hazards regression analysis, the CROW-65 risk score showed statistically significant association with mortality (HR 1.11, 95% CI 1.01-1.23, P = 0.027), while receiving operator characteristics (ROC) showed significant discrimination of all-cause mortality with an AUC of 0.85 (95% CI 0.72-0.94, P < 0.001), and satisfactory calibration (χ2 4.91, P = 0.555 and Harrell's C 0.835). Finally, survival Kaplan-Meier analysis confirmed significantly higher cumulative incidence of mortality with increasing risk score tertiles and curve separation after 13 days (P = 0.009). CONCLUSION: A novel risk score CROW-65 showed significant association with all-cause mortality in KTR yielding important hypothesis-generating findings. Further powered studies should reassess the performance of CROW-65 risk score in this population, including predictability, calibration and discrimination.

Effects of Different Inhalation Therapy on Ventilator-Associated Pneumonia in Ventilated COVID-19 Patients: A Randomized Controlled Trial.

The effect of routine inhalation therapy on ventilator-associated pneumonia (VAP) in mechanically ventilated patients with the coronavirus disease (COVID-19) has not been well-defined. This randomized controlled trial included 175 eligible adult patients with COVID-19 who were treated with mechanical ventilation at the University Hospital of Split between October 2020 and June 2021. Patients were randomized and allocated to a control group (no routine inhalation) or one of the treatment arms (inhalation of N-acetylcysteine; 5% saline solution; or 8.4% sodium bicarbonate). The primary outcome was the incidence of VAP, while secondary outcomes included all-cause mortality. Routine inhalation therapy had no effect on the incidence of bacterial or fungal VAP nor on all-cause mortality (p > 0.05). Secondary analyses revealed a significant reduction of Gram-positive and methicillin-resistant Staphylococcus aureus (MRSA) VAP in the treatment groups. Specifically, the bicarbonate group had a statistically significantly lower incidence of Gram-positive bacterial VAP (4.8%), followed by the N-acetylcysteine group (10.3%), 5% saline group (19.0%), and control group (34.6%; p = 0.001). This difference was driven by a lower incidence of MRSA VAP in the bicarbonate group (2.4%), followed by the N-acetylcysteine group (7.7%), 5% saline group (14.3%), and control group (34.6%; p < 0.001). Longer duration of ventilator therapy was the only significant, independent predictor of any bacterial or fungal VAP in the multivariate analysis (aOR 1.14, 95% CI 1.01−1.29, p = 0.038 and aOR 1.05, 95% CI 1.01−1.10, p = 0.028, respectively). In conclusion, inhalation therapy had no effect on the overall VAP incidence or all-cause mortality. Further studies should explore the secondary findings of this study such as the reduction of Gram-positive or MRSA-caused VAP in treated patients.

Can Lung Imaging Scores and Clinical Variables Predict Severe Course and Fatal Outcome in COVID-19 Pneumonia Patients? A Single-Center Observational Study.

COVID-19 prediction models mostly consist of combined clinical features, laboratory parameters, and, less often, chest X-ray (CXR) findings. Our main goal was to propose a prediction model involving imaging methods, specifically ultrasound. This was a single-center, retrospective cohort observational study of patients admitted to the University Hospital Split from November 2020 to May 2021. Imaging protocols were based on the assessment of 14 lung zones for both lung ultrasound (LUS) and computed tomography (CT), correlated to a CXR score assessing 6 lung zones. Prediction models for the necessity of mechanical ventilation (MV) or a lethal outcome were developed by combining imaging, biometric, and biochemical parameters. A total of 255 patients with COVID-19 pneumonia were included in the study. Four independent predictors were added to the regression model for the necessity of MV: LUS score, day of the illness, leukocyte count, and cardiovascular disease (χ2 = 29.16, p < 0.001). The model accurately classified 89.9% of cases. For the lethal outcome, only two independent predictors contributed to the regression model: LUS score and patient's age (χ2 = 48.56, p < 0.001, 93.2% correctly classified). The predictive model identified four key parameters at patient admission which could predict an adverse outcome.

Acute Appendicitis in Children Younger than Five Years of Age: Diagnostic Challenge for Pediatric Surgeons.

Background: The aim of this study is the evaluation of clinical signs and outcomes of treatment in children under five years of age who underwent appendectomy because of acute appendicitis. Patients and Methods: From January 2009 until December 2018, 90 patients (54 boys and 36 girls) younger than five years of age, treated with appendectomy because of acute appendicitis, were included in this study. Patients were divided into two groups, depending on the intra-operative finding of non-perforated (Group I; n = 32) or perforated (Group II; n = 58) appendicitis. The groups were compared regarding demographic, clinical, and laboratory data and outcomes of treatment. Results: Of 1687 appendectomies in this period, 90 (5.3%) of them were performed in patients aged five years or younger. There were 58 (64.4%) patients with perforated appendix. Positive correlation between the rate of perforation and the age of patients was found. Perforation rates were significantly higher in younger patients (100%, <1 year; 100%, 1-2 y; 83.3%, 2-3 y; 71.4%, 3-4 y; 78.6%, 4-5 y, and 47.3%, 5 y) (p = 0.037). Vomiting and diarrhea were found more commonly in the group of perforated appendix (p < 0.002, p < 0.001), while constipation was found more often in the patients whose appendix was not perforated (p < 0.001). The median duration of symptoms (48 h vs. 16 h; p < 0.001) and median duration of hospitalization (7.5 d vs. 5 d; p < 0.001) were notably longer for the group of patients with perforated than the group of patients with non-perforated appendix. All complications occurred in the group of perforated appendix with total incidence of 4.4%. Conclusion: The clinical presentation of acute appendicitis for children aged five years or younger is often unusual, and establishing the proper diagnosis is often delayed. Patient age is tied closely to the stage of acute appendicitis, so the youngest patients present with more advanced stages of disease and are at greater risk of perforation. Acute appendicitis should be considered in all cases where a child is having abdominal pain, fever, and diarrhea, which has been shown to be present significantly more often in children with perforated appendix.