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1.
Sensors (Basel) ; 21(12)2021 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-34204238

RESUMO

Mechanical ventilation is an essential life-support treatment for patients who cannot breathe independently. Patient-ventilator asynchrony (PVA) occurs when ventilatory support does not match the needs of the patient and is associated with a series of adverse clinical outcomes. Deep learning methods have shown a strong discriminative ability for PVA detection, but they require a large number of annotated data for model training, which hampers their application to this task. We developed a transfer learning architecture based on pretrained convolutional neural networks (CNN) and used it for PVA recognition based on small datasets. The one-dimensional signal was converted to a two-dimensional image, and features were extracted by the CNN using pretrained weights for classification. A partial dropping cross-validation technique was developed to evaluate model performance on small datasets. When using large datasets, the performance of the proposed method was similar to that of non-transfer learning methods. However, when the amount of data was reduced to 1%, the accuracy of transfer learning was approximately 90%, whereas the accuracy of the non-transfer learning was less than 80%. The findings suggest that the proposed transfer learning method can obtain satisfactory accuracies for PVA detection when using small datasets. Such a method can promote the application of deep learning to detect more types of PVA under various ventilation modes.


Assuntos
Serviços de Assistência Domiciliar , Redes Neurais de Computação , Humanos , Aprendizado de Máquina , Respiração Artificial , Ventiladores Mecânicos
2.
J Assoc Physicians India ; 69(1): 19-22, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34227770

RESUMO

Background: COVID-19 has taken a big toll on the world in terms of morbidity and mortality. The disease may progress in some of the patients leading to trigger of "cytokine storm" which is shown to be associated with adverse outcomes. Heat killed Mycobacterium w (Mw) is a known immunomodulator which is approved for the treatment of gram negative sepsis. This study was carried out to evaluate the role of Mw in the treatment of COVID-19 early in the course of the disease. Method: In this retrospective observational study, 117 (84 males, 33 females) COVID-19 patients admitted between July 3, 2020 and Aug 26, 2020 in the covid ward of Fortis Hiranandani hospital, Mumbai, were enrolled. Patients were tested COVID-19 positive on RTPCR and were treated with standard of care treatment along with Mw 0.3 ml intradermal injection per day for 3 consecutive days. Patients were evaluated for live discharge as well as changes in the levels of inflammatory markers. Results: Use of Mw was seen to be associated with rapid recovery in 116/117 patients from COVID-19 who were discharged from the hospital within 10 days. A decrease in the levels of CRP and IL6 was observed after the administration of Mw. This decrease was associated with improvement in the patients' condition. The use of Mw was seen to be associated with no systemic side effects. Conclusion: The patients of COVID-19 may deteriorate due to exaggerated production of cytokines which may result in adverse outcomes. Mw used earlier in the disease not only effectively prevents excessive cytokine production but also contribute to rapid recovery. Mw was also found to be safe in use. Larger randomized controlled trials are recommended to assess the role of Mw in COVID-19.


Assuntos
COVID-19 , Mycobacterium , Feminino , Hospitalização , Humanos , Masculino , Respiração Artificial , SARS-CoV-2 , Resultado do Tratamento
5.
Pediatr Rheumatol Online J ; 19(1): 104, 2021 Jun 30.
Artigo em Inglês | MEDLINE | ID: mdl-34193201

RESUMO

BACKGROUND: H syndrome (HS) is a rare autoinflammatory disease caused by a mutation in the solute carrier family 29, member 3 (SCL29A3) gene. It has a variable clinical presentation and little phenotype-genotype correlation. The pathognomonic sign of HS is cutaneous hyperpigmentation located mainly in the inner thighs and often accompanied by other systemic manifestations. Improvement after tocilizumab treatment has been reported in a few patients with HS. We report the first patient with HS who presented cardiogenic shock, multiorgan infiltration, and digital ischemia. CASE PRESENTATION: 8-year-old boy born to consanguineous parents of Moroccan origin who was admitted to the intensive care unit during the Coronavirus Disease-2019 (COVID-19) pandemic with tachypnoea, tachycardia, and oliguria. Echocardiography showed dilated cardiomyopathy and severe systolic dysfunction compatible with cardiogenic shock. Additionally, he presented with multiple organ dysfunction syndrome. SARS-CoV-2 polymerase chain reaction (PCR) and antibody detection by chromatographic immunoassay were negative. A previously ordered gene panel for pre-existing sensorineural hearing loss showed a pathological mutation in the SCL29A3 gene compatible with H syndrome. Computed tomography scan revealed extensive alveolar infiltrates in the lungs and multiple poor defined hypodense lesions in liver, spleen, and kidneys; adenopathy; and cardiomegaly with left ventricle subendocardial nodules. Invasive mechanical ventilation, broad antibiotic and antifungal coverage showed no significant response. Therefore, Tocilizumab as compassionate use together with pulsed intravenous methylprednisolone was initiated. Improvement was impressive leading to normalization of inflammation markers, liver and kidney function, and stabilising heart function. Two weeks later, he was discharged and has been clinically well since then on two weekly administration of Tocilizumab. CONCLUSIONS: We report the most severe disease course produced by HS described so far in the literature. Our patient's manifestations included uncommon, new complications such as acute heart failure with severe systolic dysfunction, multi-organ cell infiltrate, and digital ischemia. Most of the clinical symptoms of our patient could have been explained by SARS-CoV-2, demonstrating the importance of a detailed differential diagnosis to ensure optimal treatment. Although the mechanism of autoinflammation of HS remains uncertain, the good response of our patient to Tocilizumab makes a case for the important role of IL-6 in this syndrome and for considering Tocilizumab as a first-line treatment, at least in severely affected patients.


Assuntos
Cardiomiopatia Dilatada/fisiopatologia , Doenças Hereditárias Autoinflamatórias/fisiopatologia , Isquemia/fisiopatologia , Insuficiência de Múltiplos Órgãos/fisiopatologia , Choque Cardiogênico/fisiopatologia , Anticorpos Monoclonais Humanizados/uso terapêutico , COVID-19 , Cardiomiopatia Dilatada/diagnóstico por imagem , Cardiomiopatia Dilatada/terapia , Criança , Glucocorticoides/uso terapêutico , Doenças Hereditárias Autoinflamatórias/diagnóstico , Doenças Hereditárias Autoinflamatórias/genética , Doenças Hereditárias Autoinflamatórias/terapia , Humanos , Isquemia/terapia , Nefropatias/diagnóstico por imagem , Nefropatias/fisiopatologia , Nefropatias/terapia , Hepatopatias/diagnóstico por imagem , Hepatopatias/fisiopatologia , Hepatopatias/terapia , Pneumopatias/diagnóstico por imagem , Pneumopatias/fisiopatologia , Pneumopatias/terapia , Linfadenopatia/diagnóstico por imagem , Linfadenopatia/fisiopatologia , Linfadenopatia/terapia , Masculino , Metilprednisolona/uso terapêutico , Insuficiência de Múltiplos Órgãos/terapia , Proteínas de Transporte de Nucleosídeos/genética , Pulsoterapia , Respiração Artificial , SARS-CoV-2 , Choque Cardiogênico/terapia , Esplenopatias/diagnóstico por imagem , Esplenopatias/fisiopatologia , Esplenopatias/terapia , Dedos do Pé/irrigação sanguínea , Tomografia Computadorizada por Raios X , Resultado do Tratamento
6.
PLoS One ; 16(7): e0254129, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34197543

RESUMO

SARS-CoV-2 infection can lead to severe acute respiratory distress syndrome with the need of invasive ventilation. Pulmonary herpes simplex-1 (HSV-1) reactivation in invasively ventilated patients is a known phenomenon. To date very little is known about the frequency and the predisposing factors of HSV-1 reactivation in COVID-19. Therefore, we evaluated our cohort of invasively ventilated COVID-19 patients with severe pneumonia for HSV-1 in respiratory specimens and combined these results with functional immunomonitoring of the peripheral blood. Tracheal secretions and bronchial lavages were screened by PCR for HSV-1 positivity. Comprehensive immunophenotyping and quantitative gene expression analysis of Interferon-stimulated genes (IFI44L, MX1, RSAD2, ISIG15 and IFIT1) and IL-1 beta were performed in whole blood. Time course of infection beginning at symptom onset was grouped into three phases ("early" phase 1: day 1-10, "middle" phase 2: day 11-30 and "late" phase 3: day 31-40). Pulmonary HSV-1 reactivation was exclusively observed in the later phases 2 and 3 in 15 of 18 analyzed patients. By FACS analysis a significant increase in activated CD8 T cells (CD38+HLADR+) in phase 2 was found when compared with phase 1 (p<0.05). Expression of Interferon-stimulated genes (IFI44L, RSAD2 ISIG15, MX1, IFIT1) was significantly lower after HSV-1 detection than before. Taken together, reactivation of HSV-1 in the later phase of SARS-CoV-2- infection occurs in parallel with a drop of antiviral innate responsiveness as shown by decreased expression of Interferon-stimulated genes and a concurrent increase of highly activated CD38+HLADR+ CD8 T cells.


Assuntos
COVID-19/terapia , Herpes Simples/etiologia , Herpesvirus Humano 1/fisiologia , Respiração Artificial , Ativação Viral , Idoso , Idoso de 80 Anos ou mais , COVID-19/complicações , COVID-19/imunologia , Feminino , Herpes Simples/imunologia , Herpesvirus Humano 1/imunologia , Herpesvirus Humano 1/isolamento & purificação , Humanos , Imunidade Inata , Masculino , Pessoa de Meia-Idade , Respiração Artificial/efeitos adversos , SARS-CoV-2/imunologia , SARS-CoV-2/isolamento & purificação
7.
BMC Neurol ; 21(1): 275, 2021 Jul 12.
Artigo em Inglês | MEDLINE | ID: mdl-34253174

RESUMO

BACKGROUND: Guillain-Barre syndrome (GBS) is an inflammatory polyradiculoneuropathy characterized by rapidly evolving weakness and areflexia, reaching nadir within 4 weeks. Data on the characteristic of GBS in Saudi Arabia are limited. This study aimed to describe the clinical, electrophysiological, and laboratory characteristics and outcome of a multicenter cohort of patients with GBS. METHODS: This is a retrospective multicenter nationwide study. Patients who had GBS, identified through Brighton Criteria, between January 2015 and December 2019 were included. Data collected included demographics, clinical features, cerebrospinal fluid profile, reported electrophysiological patterns, treatment, and outcome. Reported GBS subtypes were compared using chi-square, Fisher's exact, or Mann-Whitney U tests, as appropriate. RESULTS: A total of 156 patients with GBS were included (men, 61.5%), with a median age of 38 (interquartile range, 26.25-53.5) years. The most commonly reported antecedent illnesses were upper respiratory tract infection (39.1%) and diarrhea (27.8%). All but two patients (98.7%) had weakness, 64.1% had sensory symptoms, 43.1% had facial diplegia, 33.8% had oropharyngeal weakness, 12.4% had ophthalmoplegia, and 26.3% needed mechanical ventilation. Cytoalbuminological dissociation was observed in 69.1% of the patients. GBS-specific therapy was administered in 96.8% of the patients, of whom 88.1% had intravenous immunoglobulin, and 11.9% had plasmapheresis. Approximately half of the patients were able to walk independently within 9 months after discharge, and a third regained the ability to walk independently thereafter. Death of one patient was caused by septicemia. Acute inflammatory demyelinating polyradiculoneuropathy was the most commonly reported GBS subtype (37.7%), followed by acute motor axonal neuropathy (29.5%), and acute motor-sensory axonal neuropathy (19.2%). CONCLUSION: The clinical and laboratory characteristics and outcome of GBS in the Arab population of Saudi Arabia are similar to the international cohorts. The overall prognosis is favorable.


Assuntos
Síndrome de Guillain-Barré/diagnóstico , Síndrome de Guillain-Barré/terapia , Adolescente , Adulto , Idoso , Feminino , Síndrome de Guillain-Barré/sangue , Síndrome de Guillain-Barré/epidemiologia , Humanos , Imunoglobulinas Intravenosas/uso terapêutico , Masculino , Pessoa de Meia-Idade , Plasmaferese/métodos , Prognóstico , Respiração Artificial/métodos , Estudos Retrospectivos , Arábia Saudita/epidemiologia , Resultado do Tratamento , Adulto Jovem
8.
Oxid Med Cell Longev ; 2021: 6654388, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34257816

RESUMO

Introduction: Risk stratification is an important aspect of COVID-19 management, especially in patients admitted to ICU as it can provide more useful consumption of health resources, as well as prioritize critical care services in situations of overwhelming number of patients. Materials and Methods: A multivariable predictive model for mortality was developed using data solely from a derivation cohort of 160 COVID-19 patients with moderate to severe ARDS admitted to ICU. The regression coefficients from the final multivariate model of the derivation study were used to assign points for the risk model, consisted of all significant variables from the multivariate analysis and age as a known risk factor for COVID-19 patient mortality. The newly developed AIDA score was arrived at by assigning 5 points for serum albumin and 1 point for IL-6, D dimer, and age. The score was further validated on a cohort of 304 patients admitted to ICU due to the severe form of COVID-19. Results: The study population included 160 COVID-19 patients admitted to ICU in the derivation and 304 in the validation cohort. The mean patient age was 66.7 years (range, 20-93 years), with 68.1% men and 31.9% women. Most patients (76.8%) had comorbidities with hypertension (67.7%), diabetes (31.7), and coronary artery disease (19.3) as the most frequent. A total of 316 patients (68.3%) were treated with mechanical ventilation. Ninety-six (60.0%) in the derivation cohort and 221 (72.7%) patients in the validation cohort had a lethal outcome. The population was divided into the following risk categories for mortality based on the risk model score: low risk (score 0-1) and at-risk (score > 1). In addition, patients were considered at high risk with a risk score > 2. By applying the risk model to the validation cohort (n = 304), the positive predictive value was 78.8% (95% CI 75.5% to 81.8%); the negative predictive value was 46.6% (95% CI 37.3% to 56.2%); the sensitivity was 82.4% (95% CI 76.7% to 87.1%), and the specificity was 41.0% (95% CI 30.3% to 52.3%). The C statistic was 0.863 (95% CI 0.805-0.921) and 0.665 (95% CI 0.598-0.732) in the derivation and validation cohorts, respectively, indicating a high discriminative value of the proposed score. Conclusion: In the present study, AIDA score showed a valuable significance in estimating the mortality risk in patients with the severe form of COVID-19 disease at admission to ICU. Further external validation on a larger group of patients is needed to provide more insights into the utility of this score in everyday practice.


Assuntos
COVID-19 , Hospitalização , Unidades de Terapia Intensiva , Modelos Biológicos , Oxigênio , Respiração Artificial , SARS-CoV-2/metabolismo , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/sangue , COVID-19/mortalidade , COVID-19/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Oxigênio/sangue , Medição de Risco
9.
PLoS One ; 16(7): e0254671, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34255801

RESUMO

COVID-19 represents high morbidity and mortality, its complications and lethality have increased due to bacterial superinfections. We aimed to determine the prevalence of bacterial superinfection in adults with COVID-19, hospitalized in two clinics in Medellín-Colombia during 2020, and its distribution according to sociodemographic and clinical conditions. A cross sectional study was made with 399 patients diagnosed with COVID-19 by RT-PCR. We determined the prevalence of bacterial superinfection and its factors associated with crude and adjusted prevalence ratios by a generalized linear model. The prevalence of superinfection was 49.6%, with 16 agents identified, the most frequent were Klebsiella (pneumoniae and oxytoca) and Staphylococcus aureus. In the multivariate adjustment, the variables with the strongest association with bacterial superinfection were lung disease, encephalopathy, mechanical ventilation, hospital stay, and steroid treatment. A high prevalence of bacterial superinfections, a high number of agents, and multiple associated factors were found. Among these stood out comorbidities, complications, days of hospitalization, mechanical ventilation, and steroid treatment. These results are vital to identifying priority clinical groups, improving the care of simultaneous infections with COVID-19 in people with the risk factors exposed in the population studied, and identifying bacteria of public health interest.


Assuntos
COVID-19/microbiologia , Infecções por Klebsiella/epidemiologia , Infecções Estafilocócicas/epidemiologia , Superinfecção/epidemiologia , Idoso , COVID-19/complicações , Colômbia , Tratamento Farmacológico/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Prevalência , Respiração Artificial/estatística & dados numéricos
11.
Trials ; 22(1): 460, 2021 Jul 17.
Artigo em Inglês | MEDLINE | ID: mdl-34274023

RESUMO

BACKGROUND: Hypoxia is one of the life-threatening complications of endotracheal intubation. Supplemental oxygen and ventilation play a vital role in preventing hypoxia. Bag-valve mask (BVM) ventilation is frequently used before intubation, and its ability to improve oxygenation was recently confirmed. It is still unclear if positive end-expiratory pressure (PEEP) added to BVM ventilation can further reduce hypoxia during intubation. METHODS: This will be a prospective, randomized, double-blind trial to determine if PEEP combined with BVM ventilation can reduce the incidence of hypoxia during intubation compared with conventional BVM ventilation. The lowest oxygen saturation and incidence of complications will be compiled to verify the comparative effectiveness and safety of the two groups. DISCUSSION: BMV ventilation with PEEP is hoped to further reduce the incidence of hypoxia during intubation. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2000035156 . Registered on August 2, 2020. It had begun enrollment after passing ethical review but before registration.


Assuntos
Respiração com Pressão Positiva , Respiração Artificial , Método Duplo-Cego , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Hipóxia/prevenção & controle , Intubação Intratraqueal/efeitos adversos , Respiração com Pressão Positiva/efeitos adversos , Estudos Prospectivos
12.
JAMA Netw Open ; 4(7): e2114741, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34264329

RESUMO

Importance: Randomized clinical trials have yielded conflicting results about the effects of remdesivir therapy on survival and length of hospital stay among people with COVID-19. Objective: To examine associations between remdesivir treatment and survival and length of hospital stay among people hospitalized with COVID-19 in routine care settings. Design, Setting, and Participants: This retrospective cohort study used data from the Veterans Health Administration (VHA) to identify adult patients in 123 VHA hospitals who had a first hospitalization with laboratory-confirmed COVID-19 from May 1 to October 8, 2020. Propensity score matching of patients initiating remdesivir treatment to control patients who had not initiated remdesivir treatment by the same hospital day was used to create the analytic cohort. Exposures: Remdesivir treatment. Main Outcomes and Measures: Time to death within 30 days of remdesivir treatment initiation (or corresponding hospital day for matched control individuals) and time to hospital discharge with time to death as a competing event. Associations between remdesivir treatment and these outcomes were assessed using Cox proportional hazards regression in the matched cohort. Results: The initial cohort included 5898 patients admitted to 123 hospitals, 2374 (40.3%) of whom received remdesivir treatment (2238 men [94.3%]; mean [SD] age, 67.8 [12.8] years) and 3524 (59.7%) of whom never received remdesivir treatment (3302 men [93.7%]; mean [SD] age, 67.0 [14.4] years). After propensity score matching, the analysis included 1172 remdesivir recipients and 1172 controls, for a final matched cohort of 2344 individuals. Remdesivir recipients and matched controls were similar with regard to age (mean [SD], 66.6 [14.2] years vs 67.5 [14.1] years), sex (1101 men [93.9%] vs 1101 men [93.9%]), dexamethasone use (559 [47.7%] vs 559 [47.7%]), admission to the intensive care unit (242 [20.7%] vs 234 [19.1%]), and mechanical ventilation use (69 [5.9%] vs 45 [3.8%]). Standardized differences were less than 10% for all measures. Remdesivir treatment was not associated with 30-day mortality (143 remdesivir recipients [12.2%] vs 124 controls [10.6%]; log rank P = .26; adjusted hazard ratio [HR], 1.06; 95% CI, 0.83-1.36). Results were similar for people receiving vs not receiving dexamethasone at remdesivir initiation (dexamethasone recipients: adjusted HR, 0.93; 95% CI, 0.64-1.35; nonrecipients: adjusted HR, 1.19; 95% CI, 0.84-1.69). Remdesivir recipients had a longer median time to hospital discharge compared with matched controls (6 days [interquartile range, 4-12 days] vs 3 days [interquartile range, 1-7 days]; P < .001). Conclusions and Relevance: In this cohort study of US veterans hospitalized with COVID-19, remdesivir treatment was not associated with improved survival but was associated with longer hospital stays. Routine use of remdesivir may be associated with increased use of hospital beds while not being associated with improvements in survival.


Assuntos
Monofosfato de Adenosina/análogos & derivados , Alanina/análogos & derivados , Antivirais/uso terapêutico , COVID-19/tratamento farmacológico , Mortalidade Hospitalar , Tempo de Internação , Alta do Paciente , Veteranos , Monofosfato de Adenosina/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Alanina/uso terapêutico , COVID-19/mortalidade , Feminino , Hospitalização , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Pandemias , Respiração Artificial , Estudos Retrospectivos , SARS-CoV-2 , Índice de Gravidade de Doença , Análise de Sobrevida , Estados Unidos , Serviços de Saúde para Veteranos Militares
13.
J Clin Neurosci ; 90: 345-350, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34275573

RESUMO

ABO blood groups are associated with genetically predisposed variations in von Willebrand factor (VWF) resulting in higher risks of thrombotic events in non-O blood types and bleeding complications in blood type O. The role of ABO blood groups in progression of traumatic intracranial hemorrhage (TICH) is unknown. Given statistically lower VWF levels in blood type O in the general population, we hypothesized that blood type O patients have a higher risk of such progression. A retrospective review of adult trauma patients with isolated TICH admitted to a Level 1 trauma center over eight years was conducted. Patients were categorized with blood type O and non-O (types A, B, AB) delineation. The primary outcome was radiological progression of TICH during the first 24 h. Secondary outcomes included surgical intervention after follow-up computed tomography (CT), complications, days on mechanical ventilation (DMV), intensive care unit (ICU) length of stay (LOS), hospital LOS, and mortality. Of 949 patients, 432 (45.5%) had blood type O. When comparing O and non-O groups, no significant differences were found in gender, age, race, admission vital signs, Glasgow Coma Scale, coagulation profile, TICH type, or Injury Severity Score. No difference in TICH progression was found between O and non-O groups: 73 (17%) vs 80 (15%), respectively, p = 0.55. Blood type O mortality was 12 (3% vs. 23 (4%), p = 0.174). Rate of TICH surgical intervention after follow-up CT, DMV, complications, and ICU and hospital LOS did not differ. No association between ABO blood types and radiological progression of TICH was identified.


Assuntos
Sistema ABO de Grupos Sanguíneos , Hemorragia Intracraniana Traumática/sangue , Adulto , Idoso , Cuidados Críticos , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Escala de Gravidade do Ferimento , Hemorragia Intracraniana Traumática/diagnóstico por imagem , Hemorragia Intracraniana Traumática/terapia , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Respiração Artificial , Estudos Retrospectivos , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Fator de von Willebrand
14.
BMJ Open ; 11(7): e050321, 2021 07 19.
Artigo em Inglês | MEDLINE | ID: mdl-34281931

RESUMO

OBJECTIVE: To describe mortality of in-hospital patients with COVID-19 and compare risk factors between survivors and non-survivors. DESIGN: Prospective cohort of adult inpatients. SETTING: Tertiary healthcare teaching hospital in Guadalajara, Mexico. PARTICIPANTS: All patients with confirmed COVID-19 hospitalised from 25 March to 7 September 2020 were included. End of study: 7 November 2020. PRIMARY OUTCOME MEASURES: Patient survival analysed by the Kaplan-Meier method and comparison of factors by the log-rank test. Mortality risk factors analysed by multivariate Cox's proportional-hazard model. RESULTS: One thousand ten patients included: 386 (38%) died, 618 (61%) alive at discharge and six (0.6%) remained hospitalised. There was predominance of men (63%) and high frequency of overweight-obesity (71%); hypertension (54%); diabetes (40%); and lung (9%), cardiovascular (8%) and kidney diseases (11%); all of them significantly more frequent in non-survivors. Overweight-obesity was not different between groups, but severity of disease (Manchester Triage System and quick Sequential Organ Failure Assessment) was significantly worse in non-survivors, who were also significantly older (65 vs 45 years, respectively) and had haematological, biochemical, coagulation and inflammatory biomarkers more altered than survivors. Mortality predictors were invasive mechanical ventilation (IMV; OR 3.31, p<0.0001), admission to intensive care unit (ICU; OR 2.18, p<0.0001), age (OR 1.02, p<0.0001), Manchester Triage System (urgent OR 1.44, p=0.02; immediate/very urgent OR 2.02, p=0.004), baseline C reactive protein (CRP; OR 1.002, p=0.009) and antecedent of kidney disease (OR 1.58, p=0.04) CONCLUSIONS: Mortality in hospitalised patients with COVID-19 in this emerging country centre seemed to be higher than in developed countries. Patients displayed a high frequency of risk factors for poor outcome, but the need for IMV, ICU admission, older age, more severe disease at admission, antecedent of kidney disease and higher CRP levels significantly predicted mortality.


Assuntos
COVID-19 , Adulto , Idoso , Estudos de Coortes , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , México/epidemiologia , Estudos Prospectivos , Respiração Artificial , Fatores de Risco , SARS-CoV-2
15.
Scand J Trauma Resusc Emerg Med ; 29(1): 90, 2021 Jul 08.
Artigo em Inglês | MEDLINE | ID: mdl-34238331

RESUMO

BACKGROUND: Temporary circulatory support is a bridge between acute circulatory failure and definitive treatment or recovery. Currently, venoarterial extracorporeal membrane oxygenation (VA-ECMO) is considered to be one of the effective circulatory support methods, although cardiac function monitoring during the treatment still needs further investigation. Inflection point of arterial oxygen partial pressure (IPPaO2) may occur at an early stage in part of patients with a good prognosis after VA-ECMO treatment, and the relationship between time of IPPaO2 (tIPPaO2) and recovery of cardiac function or prognosis remains unclear. METHODS: To investigate this relationship, we retrospectively analyzed the clinical data of 71 patients with different conditions after treatment with VA-ECMO in the emergency center of Jiangsu Province Hospital between May 2015 and July 2020. Spearman's correlation analysis was used for the correlation between tIPPaO2 and quantitative data, and ROC curve for the predictive effect of tIPPaO2 on the 28-day mortality. RESULTS: Thirty-five patients were admitted because of refractory cardiogenic shock (26 of 35 survived) and the remaining 36 patients due to cardiac arrest (13 of 36 survived). The overall survival rate was 54.9% (39 of 71 survived). Acute physiology and chronic health evaluation II, ECMO time, tIPPaO2, continuous renal replacement therapy time, mechanical ventilation time, and bleeding complications in the survival group were lower than those in the non-survival group, with length of stay, intensive care unit stay, and platelet levels were being higher. The tIPPaO2 was negatively correlated with ejection fraction, and the shorter tIPPaO2 resulted in a higher 28-day survival probability, higher predictive value for acute myocardial infarction and fulminant myocarditis. CONCLUSIONS: Therefore, tIPPaO2 could be a reliable qualitative indicator of cardiac function in patients treated with VA-ECMO, which can reveal appropriate timing for adjusting VA-ECMO flow or weaning. TRIAL REGISTRATION: ChiCTR1900026105 .


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca/terapia , Choque Cardiogênico/terapia , APACHE , Adulto , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Pressão Parcial , Prognóstico , Respiração Artificial , Estudos Retrospectivos , Taxa de Sobrevida
16.
Physiol Rep ; 9(13): e14802, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34250766

RESUMO

In severe acute respiratory distress syndrome (ARDS), extracorporeal membrane oxygenation (ECMO) is a life-prolonging treatment, especially among COVID-19 patients. Evaluation of lung injury progression is challenging with current techniques. Diagnostic imaging or invasive diagnostics are risky given the difficulties of intra-hospital transportation, contraindication of biopsies, and the potential for the spread of infections, such as in COVID-19 patients. We have recently shown that particle flow rate (PFR) from exhaled breath could be a noninvasive, early detection method for ARDS during mechanical ventilation. We hypothesized that PFR could also measure the progress of lung injury during ECMO treatment. Lipopolysaccharide (LPS) was thus used to induce ARDS in pigs under mechanical ventilation. Eight were connected to ECMO, whereas seven animals were not. In addition, six animals received sham treatment with saline. Four human patients with ECMO and ARDS were also monitored. In the pigs, as lung injury ensued, the PFR dramatically increased and a particular spike followed the establishment of ECMO in the LPS-treated animals. PFR remained elevated in all animals with no signs of lung recovery. In the human patients, in the two that recovered, PFR decreased. In the two whose lung function deteriorated while on ECMO, there was increased PFR with no sign of recovery in lung function. The present results indicate that real-time monitoring of PFR may be a new, complementary approach in the clinic for measurement of the extent of lung injury and recovery over time in ECMO patients with ARDS.


Assuntos
COVID-19/fisiopatologia , Lipopolissacarídeos/toxicidade , Lesão Pulmonar/fisiopatologia , Pulmão/fisiopatologia , Material Particulado/análise , Síndrome do Desconforto Respiratório/fisiopatologia , Animais , Gasometria/métodos , COVID-19/induzido quimicamente , Oxigenação por Membrana Extracorpórea/métodos , Pulmão/efeitos dos fármacos , Lesão Pulmonar/induzido quimicamente , Material Particulado/efeitos adversos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/induzido quimicamente , Suínos
17.
Bratisl Lek Listy ; 122(8): 590-593, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34282626

RESUMO

OBJECTIVES: It was aimed to demonstrate the applicability of the prone position with high-flow oxygen to COVID-19 patients with severe respiratory failure in the service in September when the number of cases and the need for intensive care were increased. MATERIAL AND METHODS: The prone position was applied for a minimum of 30-minute periods for at least four hours a day. The patients' oxygen saturation levels and respiration rates were monitored before and 30 minutes after prone positioning. RESULTS: Ten patients, nine males (9/1, M/F), were included in the study. Mean oxygen saturation at baseline was 75.8±12.14 (min: 50 %; max: 90 %) and all patients had high oxygen demand. The oxygen saturation of the patients differed significantly before and after (83.4±6.38 %; 90±5.31 %, p <0.001) prone positioning. Similarly, respiration rates differed significantly before and after (23.9±6; 21.4±4.97, p <0.001) prone positioning. Two patients died during treatment. CONCLUSION: This study highlights the promise of prone positioning performed in ward conditions for improving oxygenation in COVID-19. While the study contains a small group, it may provide guidance for the clinical management of COVID-19 patients to prevent the need for intensive care in the challenging course of therapy (Tab. 2, Fig. 2, Ref. 15).


Assuntos
COVID-19 , Humanos , Unidades de Terapia Intensiva , Masculino , Posicionamento do Paciente , Decúbito Ventral , Respiração Artificial , SARS-CoV-2
18.
Ann Palliat Med ; 10(6): 6270-6278, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34237954

RESUMO

BACKGROUND: The hypoxemia condition after mechanical ventilation (MV) weaning is not rare among sepsis patients, so we compared the efficacy in two different intervention groups: high-flow nasal cannula device group and non-invasive positive pressure ventilation (NPPV) group. METHODS: This is a retrospective cohort study. Participants were patients with sepsis receiving high-flow nasal catheter (HFNC) device or NPPV within 24 hours after weaning from MV. The primary outcome was tracheal re-intubation within 72 hours after extubation. Secondary outcomes included: oxygenation index, complication rate, patient comfort evaluation, HFNC/NPPV treatment time, ICU length of stay (LOS), ICU mortality, and in-hospital 28-day mortality. RESULTS: A total of 283 patients were included in the study with 167 in the HFNC group and 116 in the NPPV group. The re-intubation rates after extubation in both groups were respectively 4.2% and 5.2% without significant difference. Patients in the HFNC group experienced lower incidence of delirium, reflux aspiration, facial pressure ulcer and other complications, and higher score of patients comfort than that in the NPPV group. There was no significant difference in ICU LOS, ICU mortality and in-hospital 28-day mortality between the two groups. CONCLUSIONS: HFNC and NPPV have similar efficacy in the sequential treatment of sepsis patients after weaning from MV. Compared with NPPV, those extubated to HFNC had lower rate of complications such as reflux aspiration and facial pressure ulcers. The patients extubation to HFNC is more comfortable (and associated with less delirium) than to NPPV.


Assuntos
Respiração Artificial , Sepse , Cânula , Humanos , Unidades de Terapia Intensiva , Respiração com Pressão Positiva , Estudos Retrospectivos , Sepse/terapia
19.
JAMA Netw Open ; 4(7): e2116901, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-34255046

RESUMO

Importance: The National COVID Cohort Collaborative (N3C) is a centralized, harmonized, high-granularity electronic health record repository that is the largest, most representative COVID-19 cohort to date. This multicenter data set can support robust evidence-based development of predictive and diagnostic tools and inform clinical care and policy. Objectives: To evaluate COVID-19 severity and risk factors over time and assess the use of machine learning to predict clinical severity. Design, Setting, and Participants: In a retrospective cohort study of 1 926 526 US adults with SARS-CoV-2 infection (polymerase chain reaction >99% or antigen <1%) and adult patients without SARS-CoV-2 infection who served as controls from 34 medical centers nationwide between January 1, 2020, and December 7, 2020, patients were stratified using a World Health Organization COVID-19 severity scale and demographic characteristics. Differences between groups over time were evaluated using multivariable logistic regression. Random forest and XGBoost models were used to predict severe clinical course (death, discharge to hospice, invasive ventilatory support, or extracorporeal membrane oxygenation). Main Outcomes and Measures: Patient demographic characteristics and COVID-19 severity using the World Health Organization COVID-19 severity scale and differences between groups over time using multivariable logistic regression. Results: The cohort included 174 568 adults who tested positive for SARS-CoV-2 (mean [SD] age, 44.4 [18.6] years; 53.2% female) and 1 133 848 adult controls who tested negative for SARS-CoV-2 (mean [SD] age, 49.5 [19.2] years; 57.1% female). Of the 174 568 adults with SARS-CoV-2, 32 472 (18.6%) were hospitalized, and 6565 (20.2%) of those had a severe clinical course (invasive ventilatory support, extracorporeal membrane oxygenation, death, or discharge to hospice). Of the hospitalized patients, mortality was 11.6% overall and decreased from 16.4% in March to April 2020 to 8.6% in September to October 2020 (P = .002 for monthly trend). Using 64 inputs available on the first hospital day, this study predicted a severe clinical course using random forest and XGBoost models (area under the receiver operating curve = 0.87 for both) that were stable over time. The factor most strongly associated with clinical severity was pH; this result was consistent across machine learning methods. In a separate multivariable logistic regression model built for inference, age (odds ratio [OR], 1.03 per year; 95% CI, 1.03-1.04), male sex (OR, 1.60; 95% CI, 1.51-1.69), liver disease (OR, 1.20; 95% CI, 1.08-1.34), dementia (OR, 1.26; 95% CI, 1.13-1.41), African American (OR, 1.12; 95% CI, 1.05-1.20) and Asian (OR, 1.33; 95% CI, 1.12-1.57) race, and obesity (OR, 1.36; 95% CI, 1.27-1.46) were independently associated with higher clinical severity. Conclusions and Relevance: This cohort study found that COVID-19 mortality decreased over time during 2020 and that patient demographic characteristics and comorbidities were associated with higher clinical severity. The machine learning models accurately predicted ultimate clinical severity using commonly collected clinical data from the first 24 hours of a hospital admission.


Assuntos
COVID-19 , Bases de Dados Factuais , Previsões , Hospitalização , Modelos Biológicos , Índice de Gravidade de Doença , Adulto , Idoso , Idoso de 80 Anos ou mais , COVID-19/etnologia , COVID-19/mortalidade , Comorbidade , Grupos Étnicos , Oxigenação por Membrana Extracorpórea , Feminino , Humanos , Concentração de Íons de Hidrogênio , Masculino , Pessoa de Meia-Idade , Pandemias , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2 , Estados Unidos , Adulto Jovem
20.
CMAJ Open ; 9(3): E718-E727, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34257090

RESUMO

BACKGROUND: As in other jurisdictions, the demographics of people infected with SARS-CoV-2 changed in Quebec over the course of the first COVID-19 pandemic wave, and affected those living in residential care facilities (RCFs) disproportionately. We evaluated the association between clinical characteristics and outcomes of hospitalized patients with COVID-19, comparing those did or did not live in RCFs. METHODS: We conducted a retrospective case series of all consecutive adults (≥ 18 yr) admitted to the Jewish General Hospital in Montréal with laboratory-confirmed SARS-CoV-2 infection from Mar. 4 to June 30, 2020, with in-hospital follow-up until Aug. 6, 2020. We collected patient demographics, comorbidities and outcomes (i.e., admission to the intensive care unit, mechanical ventilation and death) from medical and laboratory records and compared patients who did or did not live in public and private RCFs. We evaluated factors associated with the risk of in-hospital death with a Cox proportional hazard model. RESULTS: In total, 656 patients were hospitalized between March and June 2020, including 303 patients who lived in RCFs and 353 patients who did not. The mean age was 72.9 (standard deviation 18.3) years (range 21 to 106 yr); 349 (53.2%) were female and 118 (18.0%) were admitted to the intensive care unit. The overall mortality rate was 23.8% (156/656), but was higher among patients living in RCFs (36.6% [111/303]) compared with those not living in RCFs (12.7% [45/353]). Increased risk of death was associated with age 80 years and older (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.35-4.24), male sex (HR 1.74, 95% CI 1.25-2.41), the presence of 4 or more comorbidities (HR 2.01, 95% CI 1.18-3.42) and living in an RCF (HR 1.62, 95% CI 1.09-2.39). INTERPRETATION: During the first wave of the COVID-19 epidemic in Montréal, more than one-third of RCF residents hospitalized with SARS-CoV-2 infection died during hospitalization. Policies and practices that prevent future outbreaks of SARS-CoV-2 infection in this setting must be implemented to prevent high mortality in this vulnerable population.


Assuntos
Moradias Assistidas/estatística & dados numéricos , COVID-19/mortalidade , Hospitalização/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Moradias Assistidas/tendências , COVID-19/diagnóstico , COVID-19/epidemiologia , COVID-19/virologia , Estudos de Casos e Controles , Comorbidade , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Modelos de Riscos Proporcionais , Quebeque/epidemiologia , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , SARS-CoV-2/genética , SARS-CoV-2/isolamento & purificação , Populações Vulneráveis/estatística & dados numéricos
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