What factors are effective on the CPR duration of patients under extracorporeal cardiopulmonary resuscitation: a single-center retrospective study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is an alternative method for patients with reversible causes of cardiac arrest (CA) after conventional cardiopulmonary resuscitation (CCPR). However, cardiopulmonary resuscitation (CPR) duration during ECPR can vary due to multiple factors. Healthcare providers need to understand these factors to optimize the resuscitation process and improve outcomes. The aim of this study was to examine the different variables impacting the duration of CPR in patients undergoing ECPR.

METHODS

This retrospective, single-center, observational study was conducted on adult patients who underwent ECPR due to in-hospital CA (IHCA) or out-of-hospital CA (OHCA) at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. Univariate and multivariate binary logistic regression analyses were performed to identify the prognostic factors associated with CPR duration, including demographic and clinical variables, as well as laboratory tests.

RESULTS

The mean ± standard division age of the 48 participants who underwent ECPR was 41.50 ± 13.15 years, and 75% being male. OHCA and IHCA were reported in 77.1% and 22.9% of the cases, respectively. The multivariate analysis revealed that several factors were significantly associated with an increased CPR duration: higher age (OR: 1.981, 95%CI: 1.021-3.364, P = 0.025), SOFA score (OR: 3.389, 95%CI: 1.289-4.911, P = 0.013), presence of comorbidities (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), OHCA (OR: 3.715, 95%CI: 1.907-5.219, P = 0.026), and prolonged collapse-to-CPR time (OR: 1.446, 95%CI:1.092-3.014, P = 0.001). Additionally, the study found that the initial shockable rhythm was inversely associated with the duration of CPR (OR: 0.271, 95%CI: 0.161-0.922, P = 0.045). However, no significant associations were found between laboratory tests and CPR duration.

CONCLUSION

These findings suggest that age, SOFA score, comorbidities, OHCA, collapse-to-CPR time, and initial shockable rhythm are important factors influencing the duration of CPR in patients undergoing ECPR. Understanding these factors can help healthcare providers better predict and manage CPR duration, potentially improving patient outcomes. Further research is warranted to validate these findings and explore additional factors that may impact CPR duration in this population.

Risk factors for neurological disability outcomes in patients under extracorporeal membrane oxygenation following cardiac arrest: An observational study

OBJECTIVES

This study aimed to identify factors associated with neurological and disability outcomes in patients who underwent ECMO following cardiac arrest.

METHODS

This retrospective, single-center, observational study included adult patients who received ECMO treatment for in-hospital cardiac arrest (IHCA) or out-of-hospital cardiac arrest (OHCA) between February 2016 and March 2020. Factors associated with neurological and disability outcomes in these patients who underwent ECMO were assessed.

SETTING

Hamad General Hospital, Qatar.

MAIN OUTCOME MEASURES

Neurological disability outcomes were assessed using the Modified Rankin Scale (mRS) and the Cerebral Performance Category (CPC) scale.

RESULTS

Among the 48 patients included, 37 (77 %) experienced OHCA, and 11 (23 %) had IHCA. The 28-day survival rate was 14 (29.2 %). Of the survivors, 9 (64.3 %) achieved a good neurological outcome, while 5 (35.7 %) experienced poor neurological outcomes. Regarding disability, 5 (35.7 %) of survivors had no disability, while 9 (64.3 %) had some form of disability. The results showed significantly shorter median time intervals in minutes, including collapse to cardiopulmonary resuscitation (CPR) (3 vs. 6, P = 0.001), CPR duration (12 vs. 35, P = 0.001), CPR to extracorporeal cardiopulmonary resuscitation (ECPR) (20 vs. 40, P = 0.001), and collapse-to-ECPR (23 vs. 45, P = 0.001), in the good outcome group compared to the poor outcome group.

CONCLUSION

This study emphasizes the importance of minimizing the time between collapse and CPR/ECMO initiation to improve neurological outcomes and reduce disability in cardiac arrest patients. However, no significant associations were found between outcomes and other demographic or clinical variables in this study. Further research with a larger sample size is needed to validate these findings.

IMPLICATIONS FOR CLINICAL PRACTICE

The study underscores the significance of reducing the time between collapse and the initiation of CPR and ECMO. Shorter time intervals were associated with improved neurological outcomes and reduced disability in cardiac arrest patients.

Prognostic effects of cardiopulmonary resuscitation (CPR) start time and the interval between CPR to extracorporeal cardiopulmonary resuscitation (ECPR) on patient outcomes under extracorporeal membrane oxygenation (ECMO): a single-center, retrospective observational study

BACKGROUND

The impact of the chronological sequence of events, including cardiac arrest (CA), initial cardiopulmonary resuscitation (CPR), return of spontaneous circulation (ROSC), and extracorporeal cardiopulmonary resuscitation (ECPR) implementation, on clinical outcomes in patients with both out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA), is still not clear. The aim of this study was to investigate the prognostic effects of the time interval from collapse to start of CPR (no-flow time, NFT) and the time interval from start of CPR to implementation of ECPR (low-flow time, LFT) on patient outcomes under Extracorporeal Membrane Oxygenation (ECMO).

METHODS

This single-center, retrospective observational study was conducted on 48 patients with OHCA or IHCA who underwent ECMO at Hamad General Hospital (HGH), the tertiary governmental hospital of Qatar, between February 2016 and March 2020. We investigated the impact of prognostic factors such as NFT and LFT on various clinical outcomes following cardiac arrest, including 24-hour survival, 28-day survival, CPR duration, ECMO length of stay (LOS), ICU LOS, hospital LOS, disability (assessed using the modified Rankin Scale, mRS), and neurological status (evaluated based on the Cerebral Performance Category, CPC) at 28 days after the CA.

RESULTS

The results of the adjusted logistic regression analysis showed that a longer NFT was associated with unfavorable clinical outcomes. These outcomes included longer CPR duration (OR: 1.779, 95%CI: 1.218-2.605, P = 0.034) and decreased survival rates for ECMO at 24 h (OR: 0.561, 95%CI: 0.183-0.903, P = 0.009) and 28 days (OR: 0.498, 95%CI: 0.106-0.802, P = 0.011). Additionally, a longer LFT was found to be associated only with a higher probability of prolonged CPR (OR: 1.818, 95%CI: 1.332-3.312, P = 0.006). However, there was no statistically significant connection between either the NFT or the LFT and the improvement of disability or neurologically favorable survival after 28 days of cardiac arrest.

CONCLUSIONS

Based on our findings, it has been determined that the NFT is a more effective predictor than the LFT in assessing clinical outcomes for patients with OHCA or IHCA who underwent ECMO. This understanding of their distinct predictive abilities enables medical professionals to identify high-risk patients more accurately and customize their interventions accordingly.

SARS-CoV-2 infection triggers more potent antibody-dependent cellular cytotoxicity (ADCC) responses than mRNA-, vector-, and inactivated virus-based COVID-19 vaccines

Neutralizing antibodies (NAbs) are elicited after infection and vaccination and have been well studied. However, their antibody-dependent cellular cytotoxicity (ADCC) functionality is still poorly characterized. Here, we investigated ADCC activity in convalescent sera from infected patients with wild-type (WT) severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) or omicron variant compared with three coronavirus disease 2019 (COVID-19) vaccine platforms and postvaccination breakthrough infection (BTI). We analyzed ADCC activity targeting SARS-CoV-2 spike (S) and nucleocapsid (N) proteins in convalescent sera following WT SARS-CoV-2-infection (n = 91), including symptomatic and asymptomatic infections, omicron-infection (n = 8), COVID-19 vaccination with messenger RNA- (mRNA)- (BNT162b2 or mRNA-1273, n = 77), adenovirus vector- (n = 41), and inactivated virus- (n = 46) based vaccines, as well as post-mRNA vaccination BTI caused by omicron (n = 28). Correlations between ADCC, binding, and NAb titers were reported. ADCC was elicited within the first month postinfection and -vaccination and remained detectable for ≥3 months. WT-infected symptomatic patients had higher S-specific ADCC levels than asymptomatic and vaccinated individuals. Also, no difference in N-specific ADCC activity was seen between symptomatic and asymptomatic patients, but the levels were higher than the inactivated vaccine. Notably, omicron infection showed reduced overall ADCC activity compared to WT SARS-CoV-2 infection. Although post-mRNA vaccination BTI elicited high levels of binding and NAbs, ADCC activity was significantly reduced. Also, there was no difference in ADCC levels across the four vaccines, although NAbs and binding antibody titers were significantly higher in mRNA-vaccinated individuals. All evaluated vaccine platforms are inferior in inducing ADCC compared to natural infection with WT SARS-CoV-2. The inactivated virus-based vaccine can induce N-specific ADCC activity, but its relevance to clinical outcomes requires further investigation. Our data suggest that ADCC could be used to estimate the extra-neutralization level against COVID-19 and provides evidence that vaccination should focus on other Fc-effector functions besides NAbs. Also, the decreased susceptibility of the omicron variant to ADCC offers valuable guidance for forthcoming efforts to identify the specific targets of antibodies facilitating ADCC.

Cardiac Rehabilitation Using the Family-Centered Empowerment Model is Effective in Improving Long-term Mortality in Patients with Myocardial Infarction: A 10-year Follow-Up Randomized Clinical Trial

INTRODUCTION

Cardiac rehabilitation (CR) play a critical role in reducing the risk of future cardiovascular events and enhancing the quality of life for individuals who have survived a heart attack.

AIM

To assess the mortality rates and stability of the effects in myocardial infarction (MI) survivors after implementing a Family-Centered Empowerment Model (FCEM)-focused hybrid cardiac rehabilitation program.

METHODS

This double-blind randomized controlled clinical trial, conducted at Shariati Hospital, an academic teaching hospital in Tehran, Iran (2012-2023), involved 70 MI patients and their families. Participants were randomly assigned to an FCEM intervention group or standard CR control group. The intervention commenced after the MI patient's safe discharge from the CCU and continued for the entire 10-year follow-up period. Various questionnaires were utilized to collect data on mortality rates and health-related quality of life (HRQoL).

RESULTS

The 10-year follow-up period revealed lower mortality rates in the intervention group (5.7%, 11.4%, and 17.1% at 5, 7, and 10 years, respectively) compared to the control group (20%, 37.1%, and 48.9%). After adjusting for age, gender, and BMI, the control group had a four times higher mortality risk (HR: 4.346, 95% CI 1.671-7.307, P = 0.003). The FCEM-focused program demonstrated a significant and sustained positive impact on participants' quality of life for 48 months, with greater improvement compared to the control group.

CONCLUSION

This study highlights the effectiveness of FCEM-based hybrid CR programs in enhancing long-term patient outcomes and reducing mortality rates among MI survivors. Further research is needed to explore the potential benefits in larger samples and diverse populations.

TRIAL REGISTRATION

This study (Identifier: NCT02402582) was registered in the ClinicalTrials.gov on 03/30/2015.

Anticoagulation and Bleeding during Veno-Venous Extracorporeal Membrane Oxygenation: Insights from the PROTECMO Study

Rationale: Definitive guidelines for anticoagulation management during veno-venous extracorporeal membrane oxygenation (VV ECMO) are lacking, whereas bleeding complications continue to pose major challenges. Objectives: To describe anticoagulation modalities and bleeding events in adults receiving VV ECMO. Methods: This was an international prospective observational study in 41 centers, from December 2018 to February 2021. Anticoagulation was recorded daily in terms of type, dosage, and monitoring strategy. Bleeding events were reported according to site, severity, and impact on mortality. Measurements and Main Results: The study cohort included 652 patients, and 8,471 days on ECMO were analyzed. Unfractionated heparin was the initial anticoagulant in 77% of patients, and the most frequently used anticoagulant during the ECMO course (6,221 d; 73%). Activated partial thromboplastin time (aPTT) was the most common test for monitoring coagulation (86% of days): the median value was 52 seconds (interquartile range, 39 to 61 s) but dropped by 5.3 seconds after the first bleeding event (95% confidence interval, -7.4 to -3.2; P < 0.01). Bleeding occurred on 1,202 days (16.5%). Overall, 342 patients (52.5%) experienced at least one bleeding event (one episode every 215 h on ECMO), of which 10 (1.6%) were fatal. In a multiple penalized Cox proportional hazard model, higher aPTT was a potentially modifiable risk factor for the first episode of bleeding (for 20-s increase; hazard ratio, 1.07). Conclusions: Anticoagulation during VV ECMO was a dynamic process, with frequent stopping in cases of bleeding and restart according to the clinical picture. Future studies might explore lower aPTT targets to reduce the risk of bleeding.

Evaluation of psychological distress, burnout and structural empowerment status of healthcare workers during the outbreak of coronavirus disease (COVID-19): a cross-sectional questionnaire-based study

BACKGROUND

In light of several recent studies, there is evidence that the coronavirus disease 2019 (COVID-19) pandemic has caused various mental health concerns in the general population, as well as among healthcare workers (HCWs). The main aim of this study was to assess the psychological distress, burnout and structural empowerment status of HCWs during the COVID-19 outbreak, and to evaluate its predictors.

METHODS

This multi-center, cross-sectional web-based questionnaire survey was conducted on HCWs during the outbreak of COVID-19 from August 2020 to January 2021. HCWs working in hospitals from 48 different countries were invited to participate in an online anonymous survey that investigated sociodemographic data, psychological distress, burnout and structural empowerment (SE) based on Depression Anxiety and Stress Scale 21 (DASS-21), Maslach Burnout Inventory (MBI) and Conditions for work effectiveness questionnaire (CWEQ_II), respectively. Predictors of the total scores of DASS-21, MBI and CWEQ-II were assessed using unadjusted and adjusted binary logistic regression analysis.

RESULTS

Out of the 1030 HCWs enrolled in this survey, all completed the sociodemographic section (response rate 100%) A total of 730 (70.9%) HCWs completed the DASS-21 questionnaire, 852 (82.6%) completed the MBI questionnaire, and 712 (69.1%) completed the CWEQ-II questionnaire. The results indicate that 360 out of 730 responders (49.3%) reported severe or extremely severe levels of stress, anxiety, and depression. Additionally, 422 out of 851 responders (49.6%) reported a high level of burnout, while 268 out of 712 responders (37.6%) reported a high level of structural empowerment based on the DASS-21, MBI, and CWEQ-II scales, respectively. In addition, the analysis showed that HCWs working in the COVID-19 areas experienced significantly higher symptoms of severe stress, anxiety, depression and higher levels of burnout compared to those working in other areas. The results also revealed that direct work with COVID-19 patients, lower work experience, and high workload during the outbreak of COVID-19 increase the risks of negative psychological consequences.

CONCLUSION

Health professionals had high levels of burnout and psychological symptoms during the COVID-19 emergency. Monitoring and timely treatment of these conditions is needed.

A Path towards Timely VAP Diagnosis: Proof-of-Concept Study on Pyocyanin Sensing with Cu-Mg Doped Graphene Oxide

In response to the urgent requirement for rapid, precise, and cost-effective detection in intensive care units (ICUs) for ventilated patients, as well as the need to overcome the limitations of traditional detection methods, researchers have turned their attention towards advancing novel technologies. Among these, biosensors have emerged as a reliable platform for achieving accurate and early diagnoses. In this study, we explore the possibility of using Pyocyanin analysis for early detection of pathogens in ventilator-associated pneumonia (VAP) and lower respiratory tract infections in ventilated patients. To achieve this, we developed an electrochemical sensor utilizing a graphene oxide-copper oxide-doped MgO (GO - Cu - Mgo) (GCM) catalyst for Pyocyanin detection. Pyocyanin is a virulence factor in the phenazine group that is produced by Pseudomonas aeruginosa strains, leading to infections such as pneumonia, urinary tract infections, and cystic fibrosis. We additionally investigated the use of DNA aptamers for detecting Pyocyanin as a biomarker of Pseudomonas aeruginosa, a common causative agent of VAP. The results of this study indicated that electrochemical detection of Pyocyanin using a GCM catalyst shows promising potential for various applications, including clinical diagnostics and drug discovery.

Epigenetic age acceleration in surviving versus deceased COVID-19 patients with acute respiratory distress syndrome following hospitalization

BACKGROUND

Aging has been reported as a major risk factor for severe symptoms and higher mortality rates in COVID-19 patients. Molecular hallmarks such as epigenetic alterations and telomere attenuation reflect the biological process of aging. Epigenetic clocks have been shown to be valuable tools for measuring biological age in various tissues and samples. As such, these epigenetic clocks can determine accelerated biological aging and time-to-mortality across various tissues. Previous reports have shown accelerated biological aging and telomere attrition acceleration following SARS-CoV-2 infection. However, the effect of accelerated epigenetic aging on outcome (death/recovery) in COVID-19 patients with acute respiratory distress syndrome (ARDS) has not been well investigated.

RESULTS

In this study, we measured DNA methylation age and telomere attrition in 87 severe COVID-19 cases with ARDS under mechanical ventilation. Furthermore, we compared dynamic changes in epigenetic aging across multiple time points until recovery or death. Epigenetic age was measured using the Horvath, Hannum, DNAm skin and blood, GrimAge, and PhenoAge clocks, whereas telomere length was calculated using the surrogate marker DNAmTL. Our analysis revealed significant accelerated epigenetic aging but no telomere attrition acceleration in severe COVID-19 cases. In addition, we observed epigenetic age deceleration at inclusion versus end of follow-up in recovered but not in deceased COVID-19 cases using certain clocks. When comparing dynamic changes in epigenetic age acceleration (EAA), we detected higher EAA using both the Horvath and PhenoAge clocks in deceased versus recovered patients. The DNAmTL measurements revealed telomere attrition acceleration in deceased COVID-19 patients between inclusion and end of follow-up and a significant change in dynamic telomere attrition acceleration when comparing patients who recovered versus those who died.

CONCLUSIONS

EAA and telomere attrition acceleration were associated with treatment outcomes in hospitalized COVID-19 patients with ARDS. A better understanding of the long-term effects of EAA in COVID-19 patients and how they might contribute to long COVID symptoms in recovered individuals is urgently needed.

Body composition and muscle strength at the end of ICU stay are associated with 1-year mortality, a prospective multicenter observational study

BACKGROUND & AIMS

After a prolonged intensive care unit (ICU) stay patients experience increased mortality and morbidity. The primary aim of this study was to assess the prognostic value of nutritional status, body mass composition and muscle strength, as assessed by body mass index (BMI), bioelectrical impedance analysis (BIA), handgrip (HG) test, and that of the biological features to predict one-year survival at the end of a prolonged ICU stay.

METHODS

This was a multicenter prospective observational study. Survivor patients older than 18 years with ICU length of stay >72 h were eligible for inclusion. BIA and HG were performed at the end of the ICU stay. Malnutrition was defined by BMI and fat-free mass index (FFMI). The primary endpoint was one-year mortality. Multivariable logistic regression was performed to determine parameters associated with mortality.

RESULTS

572 patients were included with a median age of 63 years [53.5; 71.1], BMI of 26.6 kg/m2 [22.8; 31.3], SAPS II score of 43 [31; 58], and ICU length of stay of 9 days [6; 15]. Malnutrition was observed in 142 (24.9%) patients. During the 1-year follow-up after discharge, 96 (18.5%) patients died. After adjustment, a low HG test score (aOR = 1.44 [1.11; 1.89], p = 0.01) was associated with 1-year mortality. Patients with low HG score, malnutrition, and Albuminemia <30 g/L had a one-year death rate of 41.4%. Conversely, patients with none of these parameters had a 1-year death rate of 4.1%.

CONCLUSION

BIA to assess FFMI, HG and albuminemia at the end of ICU stay could be used to predict 1-year mortality. Their ability to identify patients eligible for a structured recovery program could be studied.

Ambulatory extracorporeal membrane oxygenation simulator: The next frontier in clinical training

BACKGROUND

Current medical simulators for extracorporeal membrane oxygenation (ECMO) are expensive and rely on low-fidelity methodologies. This creates a challenge that demands a new approach to eliminate high costs and integrate with critical care environments, especially in light of the scarce resources and supplies available after the COVID-19 pandemic.

METHODS

To address this challenge, we examined the current state-of-the-art medical simulators and collaborated closely with Hamad Medical Corporation (HMC), the primary healthcare provider in Qatar, to establish criteria for advancing the cutting-edge ECMO simulation. This article presents a comprehensive ambulatory high-realism and cost-effective ECMO simulator.

RESULTS

Over the past 3 years, we have surveyed relevant literature, gathered data, and continuously developed a prototype of the system modules and the accompanying tablet application. By doing so, we have successfully addressed the issue of cost and fidelity in ECMO simulation, providing an effective tool for medical professionals to improve their understanding and treatment of patients requiring ECMO support.

CONCLUSIONS

This paper will focus on presenting an overall ambulatory ECMO simulator, detailing the various sub-systems and emphasizing the modular casing of the physical components and the simulated patient monitor.

A Prospective Cohort Study (OUTSTRIP-COVID) on Functional and Spirometry Outcomes in COVID-19 ICU Survivors at 3 Months

Purpose

COVID-19 pandemic resulted in a significant number of critical care admissions secondary to severe pneumonia and acute respiratory distress syndrome. We evaluated the short-, medium- and long-term outcomes of lung function and quality of life in this prospective cohort study and reported the outcomes at 7 weeks and 3 months from discharge from intensive care unit.

Methods

A prospective cohort study of ICU survivors with COVID-19 was conducted from August 2020 to May 2021 to evaluate baseline demographic and clinical variables as well as determine lung function, exercise capacity, and health-related quality of life (HRQOL) using spirometry and 6-minute walk test (6MWT) conducted in accordance with American Thoracic Society standards, and SF-36 (Rand), respectively. SF-36 is a generic 36 question standardized health survey. Descriptive and inferential statistics (alpha = 0.05) were used to analyse the data.

Results

At baseline, 100 participants were enrolled in the study of whom 76 followed up at 3 months. Majority of the patients were male (83%), Asians (84%) and less than 60 years of age (91%). HRQOL showed significant improvement in all domains of SF-36, except in emotional wellbeing. Spirometry variables also showed significant improvement in all variables over time with greatest improvement in percentage predicted Forced expiratory volume 1 (79% vs 88% p < 0.001). 6MWT showed significant improvement in variables of walk distance, dyspnea, and fatigue with greatest improvement in change in oxygen saturation (3% vs 1.44% p < 0.001). Intubation status did not impact the changes in SF-36, spirometry or 6MWT variables.

Conclusion

Our findings suggest that ICU survivors of COVID-19 have significant improvement in their lung function, exercise capacity and HRQOL within 3 months of ICU discharge regardless of intubation status.

A CRISPR-based approach using dead Cas9-sgRNA to detect SARS-CoV-2

Rapid, highly specific, and robust diagnostic kits to detect viruses and pathogens are needed to control disease spread and transmission globally. Of the many different methods proposed to diagnose COVID-19 infection, CRISPR-based detection of nucleic acids tests are among the most prominent. Here, we describe a new way of using CRISPR/Cas systems as a rapid and highly specific tool to detect the SARS-CoV-2 virus using the in vitro dCas9-sgRNA-based technique. As a proof of concept, we used a synthetic DNA of the M gene, one of the SARS-CoV-2 virus genes, and demonstrated that we can specifically inactivate unique restriction enzyme sites on this gene using CRISPR/Cas multiplexing of dCas9-sgRNA-BbsI and dCas9-sgRNA-XbaI. These complexes recognize and bind to the target sequence spanning the BbsI and XbaI restriction enzyme sites, respectively, and protect the M gene from digestion by BbsI and/or XbaI. We further demonstrated that this approach can be used to detect the M gene when expressed in human cells and from individuals infected with SARS-CoV-2. We refer to this approach as dead Cas9 Protects Restriction Enzyme Sites, and believe that it has the potential to be applied as a diagnostic tool for many DNA/RNA pathogens.

Assessment of Broadly Reactive Responses in Patients With MERS-CoV Infection and SARS-CoV-2 Vaccination

Importance

In the ongoing COVID-19 pandemic, there remain unanswered questions regarding the nature and importance of the humoral immune response against other coronaviruses. Although coinfection of the Middle East respiratory syndrome coronavirus (MERS-CoV) with the SARS-CoV-2 has not been documented yet, several patients previously infected with MERS-CoV received the COVID-19 vaccine; data describing how preexisting MERS-CoV immunity may shape the response to SARS-CoV-2 following infection or vaccination are lacking.

Objective

To characterize the cross-reactive and protective humoral responses in patients exposed to both MERS-CoV infection and SARS-CoV-2 vaccination.

Design, Setting, and Participants

This cohort study involved a total of 18 sera samples collected from 14 patients with MERS-CoV infection before (n = 12) and after (n = 6) vaccination with 2 doses of COVID-19 mRNA vaccine (BNT162b2 or mRNA-1273). Of those patients, 4 had prevaccination and postvaccination samples. Antibody responses to SARS-CoV-2 and MERS-CoV were assessed as well as cross-reactive responses to other human coronaviruses.

Main Outcomes and Measures

The main outcomes measured were binding antibody responses, neutralizing antibodies, and antibody-dependent cellular cytotoxicity (ADCC) activity. Binding antibodies targeting SARS-CoV-2 main antigens (spike [S], nucleocapsid, and receptor-binding domain) were detected using automated immunoassays. Cross-reactive antibodies with the S1 protein of SARS-CoV, MERS-CoV, and common human coronaviruses were analyzed using a bead-based assay. Neutralizing antibodies (NAbs) against MERS-CoV and SARS-CoV-2 as well as ADCC activity against SARS-CoV-2 were assessed.

Results

A total of 18 samples were collected from 14 male patients with MERS-CoV infection (mean [SD] age, 43.8 [14.6] years). Median (IQR) duration between primary COVID-19 vaccination and sample collection was 146 (47-189) days. Prevaccination samples had high levels of anti-MERS S1 immunoglobin M (IgM) and IgG (reactivity index ranging from 0.80 to 54.7 for IgM and from 0.85 to 176.3 for IgG). Cross-reactive antibodies with SARS-CoV and SARS-CoV-2 were also detected in these samples. However, cross-reactivity against other coronaviruses was not detected by the microarray assay. Postvaccination samples showed significantly higher levels of total antibodies, IgG, and IgA targeting SARS-CoV-2 S protein compared with prevaccination samples (eg, mean total antibodies: 8955.0 AU/mL; 95% CI, -5025.0 to 22936.0 arbitrary units/mL; P = .002). In addition, significantly higher anti-SARS S1 IgG levels were detected following vaccination (mean reactivity index, 55.4; 95% CI, -9.1 to 120.0; P = .001), suggesting potential cross-reactivity with these coronaviruses. Also, anti-S NAbs were significantly boosted against SARS-CoV-2 (50.5% neutralization; 95% CI, 17.6% to 83.2% neutralization; P < .001) after vaccination. Furthermore, there was no significant increase in antibody-dependent cellular cytotoxicity against SARS-CoV-2 S protein postvaccination.

Conclusions and Relevance

This cohort study found a significant boost in cross-reactive NAbs in some patients exposed to MERS-CoV and SARS-CoV-2 antigens. These findings suggest that isolation of broadly reactive antibodies from these patients may help guide the development of a pancoronavirus vaccine by targeting cross-reactive epitopes between distinct strains of human coronaviruses.

Transfusion practice in patients receiving VV ECMO (PROTECMO): a prospective, multicentre, observational study

BACKGROUND

In patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) packed red blood cell (PRBC) transfusion thresholds are usually higher than in other patients who are critically ill. Available guidelines suggest a restrictive approach, but do not provide specific recommendations on the topic. The main aim of this study was, in a short timeframe, to describe the actual values of haemoglobin and the rate and the thresholds for transfusion of PRBC during VV ECMO.

METHODS

PROTECMO was a multicentre, prospective, cohort study done in 41 ECMO centres in Europe, North America, Asia, and Australia. Consecutive adult patients with acute respiratory distress syndrome (ARDS) who were receiving VV ECMO were eligible for inclusion. Patients younger than 18 years, those who were not able to provide informed consent when required, and patients with an ECMO stay of less than 24 h were excluded. Our main aim was to monitor the daily haemoglobin concentration and the value at the point of PRBC transfusion, as well as the rate of transfusions. The practice in different centres was stratified by continent location and case volume per year. Adjusted estimates were calculated using marginal structural models with inverse probability weighting, accounting for baseline and time varying confounding.

FINDINGS

Between Dec 1, 2018, and Feb 22, 2021, 604 patients were enrolled (431 [71%] men, 173 [29%] women; mean age 50 years [SD 13·6]; and mean haemoglobin concentration at cannulation 10·9 g/dL [2·4]). Over 7944 ECMO days, mean haemoglobin concentration was 9·1 g/dL (1·2), with lower concentrations in North America and high-volume centres. PRBC were transfused on 2432 (31%) of days on ECMO, and 504 (83%) patients received at least one PRBC unit. Overall, mean pretransfusion haemoglobin concentration was 8·1 g/dL (1·1), but varied according to the clinical rationale for transfusion. In a time-dependent Cox model, haemoglobin concentration of less than 7 g/dL was consistently associated with higher risk of death in the intensive care unit compared with other higher haemoglobin concentrations (hazard ratio [HR] 2·99 [95% CI 1·95-4·60]); PRBC transfusion was associated with lower risk of death only when transfused when haemoglobin concentration was less than 7 g/dL (HR 0·15 [0·03-0·74]), although no significant effect in reducing mortality was reported for transfusions for other haemoglobin classes (7·0-7·9 g/dL, 8·0-9·9 g/dL, or higher than 10 g/dL).

INTERPRETATION

During VV ECMO, there was no universally accepted threshold for transfusion, but PRBC transfusion was invariably associated with lower mortality only when done with haemoglobin concentration of less than 7 g/dL.

FUNDING

Extracorporeal Life Support Organization.

Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study

PURPOSE

In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials.

METHODS

We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021.

RESULTS

2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28.

CONCLUSIONS

HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.

Persistence of spike-specific immune responses in BNT162b2-vaccinated donors and generation of rapid ex-vivo T cells expansion protocol for adoptive immunotherapy: A pilot study

Introduction

The BNT162b2 mRNA-based vaccine has shown high efficacy in preventing COVID-19 infection but there are limited data on the types and persistence of the humoral and T cell responses to such a vaccine.

Methods

Here, we dissect the vaccine-induced humoral and cellular responses in a cohort of six healthy recipients of two doses of this vaccine.

Results and discussion

Overall, there was heterogeneity in the spike-specific humoral and cellular responses among vaccinated individuals. Interestingly, we demonstrated that anti-spike antibody levels detected by a novel simple automated assay (Jess) were strongly correlated (r=0.863, P<0.0001) with neutralizing activity; thus, providing a potential surrogate for neutralizing cell-based assays. The spike-specific T cell response was measured with a newly modified T-spot assay in which the high-homology peptide-sequences cross-reactive with other coronaviruses were removed. This response was induced in 4/6 participants after the first dose, and all six participants after the second dose, and remained detectable in 4/6 participants five months post-vaccination. We have also shown for the first time, that BNT162b2 vaccine enhanced T cell responses also against known human common viruses. In addition, we demonstrated the efficacy of a rapid ex-vivo T cell expansion protocol for spike-specific T cell expansion to be potentially used for adoptive-cell therapy in severe COVID-19, immunocompromised individuals, and other high-risk groups. There was a 9 to 13.7-fold increase in the number of expanded T cells with a significant increase of anti-spike specific response showing higher frequencies of both activation and cytotoxic markers. Interestingly, effector memory T cells were dominant in all four participants' CD8+ expanded memory T cells; CD4+ T cells were dominated by effector memory in 2/4 participants and by central memory in the remaining two participants. Moreover, we found that high frequencies of CD4+ terminally differentiated memory T cells were associated with a greater reduction of spike-specific activated CD4+ T cells. Finally, we showed that participants who had a CD4+ central memory T cell dominance expressed a high CD69 activation marker in the CD4+ activated T cells.

Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series

OBJECTIVES

Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO.

DESIGN

A Retrospective review of electronic data for routine care of patients on ECMO.

SETTING

Tertiary, university-affiliated national ECMO center.

PARTICIPANTS

Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support.

INTERVENTIONS

No intervention was conducted during this study.

MEASUREMENTS AND MAIN RESULTS

Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection.

CONCLUSIONS

In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.

Emerging COVID-19 variants and their impact on SARS-CoV-2 diagnosis, therapeutics and vaccines

The emergence of novel and evolving variants of SARS-CoV-2 has fostered the need for change in the form of newer and more adaptive diagnostic methods for the detection of SARS-CoV-2 infections. On the other hand, developing rapid and sensitive diagnostic technologies is now more challenging due to emerging variants and varying symptoms exhibited among the infected individuals. In addition to this, vaccines remain the major mainstay of prevention and protection against infection. Novel vaccines and drugs are constantly being developed to unleash an immune response for the robust targeting of SARS-CoV-2 and its associated variants. In this review, we provide an updated perspective on the current challenges posed by the emergence of novel SARS-CoV-2 mutants/variants and the evolution of diagnostic techniques to enable their detection. In addition, we also discuss the development, formulation, working mechanisms, advantages, and drawbacks of some of the most used vaccines/therapeutic drugs and their subsequent immunological impact.Key messageThe emergence of novel variants of the SARS-CoV-2 in the past couple of months, highlights one of the primary challenges in the diagnostics, treatment, as well as vaccine development against the virus.Advancements in SARS-CoV-2 detection include nucleic acid based, antigen and immuno- assay-based and antibody-based detection methodologies for efficient, robust, and quick testing; while advancements in COVID-19 preventive and therapeutic strategies include novel antiviral and immunomodulatory drugs and SARS-CoV-2 targeted vaccines.The varied COVID-19 vaccine platforms and the immune responses induced by each one of them as well as their ability to battle post-vaccination infections have all been discussed in this review.

DNA methylation predicts the outcome of COVID-19 patients with acute respiratory distress syndrome

BACKGROUND

COVID-19 infections could be complicated by acute respiratory distress syndrome (ARDS), increasing mortality risk. We sought to assess the methylome of peripheral blood mononuclear cells in COVID-19 with ARDS.

METHODS

We recruited 100 COVID-19 patients with ARDS under mechanical ventilation and 33 non-COVID-19 controls between April and July 2020. COVID-19 patients were followed at four time points for 60 days. DNA methylation and immune cell populations were measured at each time point. A multivariate cox proportional risk regression analysis was conducted to identify predictive signatures according to survival.

RESULTS

The comparison of COVID-19 to controls at inclusion revealed the presence of a 14.4% difference in promoter-associated CpGs in genes that control immune-related pathways such as interferon-gamma and interferon-alpha responses. On day 60, 24% of patients died. The inter-comparison of baseline DNA methylation to the last recorded time point in both COVID-19 groups or the intra-comparison between inclusion and the end of follow-up in every group showed that most changes occurred as the disease progressed, mainly in the AIM gene, which is associated with an intensified immune response in those who recovered. The multivariate Cox proportional risk regression analysis showed that higher methylation of the "Apoptotic execution Pathway" genes (ROC1, ZNF789, and H1F0) at inclusion increases mortality risk by over twofold.

CONCLUSION

We observed an epigenetic signature of immune-related genes in COVID-19 patients with ARDS. Further, Hypermethylation of the apoptotic execution pathway genes predicts the outcome.

TRIAL REGISTRATION

IMRPOVIE study, NCT04473131.

High-temporal resolution profiling reveals distinct immune trajectories following the first and second doses of COVID-19 mRNA vaccines

Knowledge of the mechanisms underpinning the development of protective immunity conferred by mRNA vaccines is fragmentary. Here, we investigated responses to coronavirus disease 2019 (COVID-19) mRNA vaccination via high-temporal resolution blood transcriptome profiling. The first vaccine dose elicited modest interferon and adaptive immune responses, which peaked on days 2 and 5, respectively. The second vaccine dose, in contrast, elicited sharp day 1 interferon, inflammation, and erythroid cell responses, followed by a day 5 plasmablast response. Both post-first and post-second dose interferon signatures were associated with the subsequent development of antibody responses. Yet, we observed distinct interferon response patterns after each of the doses that may reflect quantitative or qualitative differences in interferon induction. Distinct interferon response phenotypes were also observed in patients with COVID-19 and were associated with severity and differences in duration of intensive care. Together, this study also highlights the benefits of adopting high-frequency sampling protocols in profiling vaccine-elicited immune responses.

Variability in Skeletal Muscle Protein Synthesis Rates in Critically Ill Patients

(1) Background: Muscle protein synthesis in critically ill patients is, on average, normal despite dramatic muscle loss, but the variation is much larger than in controls. Here, we evaluate if this variation is due to 1) heterogeneity in synthesis rates, 2) morphological variation or infiltrating cells, or 3) heterogeneity in the synthesis of different protein fractions. (2) Methods: Muscle biopsies were taken from both legs of critically ill patients (n = 17). Mixed and mitochondrial protein synthesis rates and morphologies were evaluated in both legs. Synthesis rates of myosin and actin were determined in combined biopsies and compared with controls. (3) Results: Muscle protein synthesis rates had a large variability in the patients (1.4-10.8%/day). No differences in mixed and mitochondrial protein synthesis rates between both legs were observed. A microscopic examination revealed no morphological differences between the two legs or any infiltrating inflammatory cells. The synthesis rates for myosin were lower and for actin they were higher in the muscles of critically ill patients, compared with the controls. (4) Conclusions: The large variation in muscle protein synthesis rates in critically ill patients is not the result of heterogeneity in synthesis rates, nor due to infiltrating cells. There are differences in the synthesis rates of different proteins, but these do not explain the larger variations.

Cost-Effectiveness Analysis of Out-Of-Hospital versus In-Hospital Extracorporeal Cardiopulmonary Resuscitation for Out-Hospital Refractory Cardiac Arrest

It has been speculated that out-of-hospital cardiac arrest (OHCA) patients' survival might be improved by implementing extracorporeal cardiopulmonary resuscitation (ECPR) before arrival to hospital. Therefore, we sought to assess the cost-effectiveness of OH-ECPR versus in-hospital (IH)-ECPR in OHCA patients in Qatar. From the hospital perspective, a conventional decision-analytic model was constructed to follow up the clinical and economic consequences of OH-ECPR versus IH-ECPR in a simulated OHCA population over one year. The primary outcome was the survival at discharge after arrest as well as the overall direct healthcare costs of managing OHCA patients. The robustness of this model was evaluated via sensitivity analyses. The OH-ECPR yielded 16% survival at discharge after arrest compared to 7% with IH-ECPR, [risk ratio (RR)=0.91; 95%CI 0.79 to 1.06; P=0.26]. Incorporating the uncertainty associated with this survival rate, and based on the estimated willingness to pay threshold in Qatar, the OH-ECPR was cost-effective with an incremental cost-effectiveness ratio of QAR 464,589 (USD 127,634). Sensitivity and uncertainty analyses confirmed the robustness of the study outcome. This is the first cost-effectiveness evaluation of OH-ECPR versus IH-ECPR in OHCA patients. OH-ECPR is potentially an economically acceptable resuscitative strategy in Qatar.

IoT-based Mock Oxygenator for Extracorporeal Membrane Oxygenation Simulator

BACKGROUND

Training is an essential aspect of providing high-quality treatment and ensuring patient safety in any medical practice. Because extracorporeal membrane oxygenation (ECMO) is a complicated operation with various elements, variables, and irregular situations, doctors must be experienced and knowledgeable about all conventional protocols and emergency procedures. The conventional simulation approach has a number of limitations. The approach is intrinsically costly since it relies on disposable medical equipment (i.e., oxygenators, heat exchangers, pumps) that must be replaced regularly due to the damage caused by the liquid used to simu- late blood. The oxygenator, which oxygenates the blood through a tailored membrane in ECMO, acts as a replacement for the patient's natural lung. For the context of simulation-based training (SBT) oxygenators are often expensive and cannot be recy- cled owing to contamination issues.

METHODS

Consequently, it is advised that the training process include a simu- lated version of oxygenators to optimize re-usability and decrease training expenses. Toward this goal, this article demonstrates a mock oxygenator for ECMO SBT, designed to precisely replicate the real machine structure and operation.

RESULTS

The initial model was reproduced using 3D modeling and printing. Addi- tionally, the mock oxygenator could mimic frequent events such as pump noise and clotting. Furthermore, the oxygenator is integrated with the modular ECMO simula- tor using cloud-based communication technology that goes in hand with the internet of things (IoT) technology to provide remote control via an instructor tablet applica- tion (App).

CONCLUSIONS

The final 3D modeled oxygenator body was tested and integrated with the other simulation modules at Hamad Medical Corporation (HMC) with several participants to evaluate the effectiveness of the training session.

Impact of prolonged requirement for insulin on 90-day mortality in critically ill patients without previous diabetic treatments: a post hoc analysis of the CONTROLING randomized control trial

BACKGROUND

Stress hyperglycemia can persist during an intensive care unit (ICU) stay and result in prolonged requirement for insulin (PRI). The impact of PRI on ICU patient outcomes is not known. We evaluated the relationship between PRI and Day 90 mortality in ICU patients without previous diabetic treatments.

METHODS

This is a post hoc analysis of the CONTROLING trial, involving 12 French ICUs. Patients in the personalized glucose control arm with an ICU length of stay ≥ 5 days and who had never previously received diabetic treatments (oral drugs or insulin) were included. Personalized blood glucose targets were estimated on their preadmission usual glycemia as estimated by their glycated A1c hemoglobin (HbA1C). PRI was defined by insulin requirement. The relationship between PRI on Day 5 and 90-day mortality was assessed by Cox survival models with inverse probability of treatment weighting (IPTW). Glycemic control was defined as at least one blood glucose value below the blood glucose target value on Day 5.

RESULTS

A total of 476 patients were included, of whom 62.4% were male, with a median age of 66 (54-76) years. Median values for SAPS II and HbA1C were 50 (37.5-64) and 5.7 (5.4-6.1)%, respectively. PRI was observed in 364/476 (72.5%) patients on Day 5. 90-day mortality was 23.1% in the whole cohort, 25.3% in the PRI group and 16.1% in the non-PRI group (p < 0.01). IPTW analysis showed that PRI on Day 5 was not associated with Day 90 mortality (_IPTWHR = 1.22; CI 95% 0.84-1.75; p = 0.29), whereas PRI without glycemic control was associated with an increased risk of death at Day 90 (_IPTWHR = 3.34; CI 95% 1.26-8.83; p < 0.01).

CONCLUSION

In ICU patients without previous diabetic treatments, only PRI without glycemic control on Day 5 was associated with an increased risk of death. Additional studies are required to determine the factors contributing to these results.

Recurrent Cardiac Arrests Due to Amniotic Fluid Embolism

Amniotic fluid embolism (AFE) is a rare but devastating complication of pregnancy and is associated with high morbidity and mortality. Identifiable maternal risk factors for AFE include older age, multiparity, cesarean section, and placenta previa, while fetal factors include male gender, fetal distress, and death. AFE presents with respiratory distress, seizure, and circulatory collapse and can be complicated with disseminated intravascular coagulopathy, multiorgan failure, and death. In our case, we present a patient who underwent elective cesarean section for placenta previa, which was complicated by sudden cardiac arrest immediately after delivering the placenta in the operating theatre followed by disseminated intravascular coagulation (DIC). The patient developed massive post-partum hemorrhage secondary to the underlying DIC, which required a massive blood transfusion along with platelets, fresh frozen plasma (FFP), and tranexamic acid. The Society of Maternal-Fetal Medicine proposed criteria for the diagnosis of AFE, which include clinical features and laboratory findings. The presence of a DIC picture is considered to be the hallmark finding that helps to differentiate between AFE and other conditions with similar presentation. Treatment of amniotic fluid embolism depends on early recognition and supportive care. 

Mortality Prediction Utilizing Blood Biomarkers to Predict the Severity of COVID-19 Using Machine Learning Technique

Healthcare researchers have been working on mortality prediction for COVID-19 patients with differing levels of severity. A rapid and reliable clinical evaluation of disease intensity will assist in the allocation and prioritization of mortality mitigation resources. The novelty of the work proposed in this paper is an early prediction model of high mortality risk for both COVID-19 and non-COVID-19 patients, which provides state-of-the-art performance, in an external validation cohort from a different population. Retrospective research was performed on two separate hospital datasets from two different countries for model development and validation. In the first dataset, COVID-19 and non-COVID-19 patients were admitted to the emergency department in Boston (24 March 2020 to 30 April 2020), and in the second dataset, 375 COVID-19 patients were admitted to Tongji Hospital in China (10 January 2020 to 18 February 2020). The key parameters to predict the risk of mortality for COVID-19 and non-COVID-19 patients were identified and a nomogram-based scoring technique was developed using the top-ranked five parameters. Age, Lymphocyte count, D-dimer, CRP, and Creatinine (ALDCC), information acquired at hospital admission, were identified by the logistic regression model as the primary predictors of hospital death. For the development cohort, and internal and external validation cohorts, the area under the curves (AUCs) were 0.987, 0.999, and 0.992, respectively. All the patients are categorized into three groups using ALDCC score and death probability: Low (probability < 5%), Moderate (5% < probability < 50%), and High (probability > 50%) risk groups. The prognostic model, nomogram, and ALDCC score will be able to assist in the early identification of both COVID-19 and non-COVID-19 patients with high mortality risk, helping physicians to improve patient management.

Predictive Biomarkers of Intensive Care Unit and Mechanical Ventilation Duration in Critically-Ill Coronavirus Disease 2019 Patients

Introduction: Detection of early metabolic changes in critically-ill coronavirus disease 2019 (COVID-19) patients under invasive mechanical ventilation (IMV) at the intensive care unit (ICU) could predict recovery patterns and help in disease management. Methods: Targeted metabolomics of serum samples from 39 COVID-19 patients under IMV in ICU was performed within 48 h of intubation and a week later. A generalized linear model (GLM) was used to identify, at both time points, metabolites and clinical traits that predict the length of stay (LOS) at ICU (short ≤ 14 days/long >14 days) as well as the duration under IMV. All models were initially trained on a set of randomly selected individuals and validated on the remaining individuals in the cohort. Further validation in recently published metabolomics data of COVID-19 severity was performed. Results: A model based on hypoxanthine and betaine measured at first time point was best at predicting whether a patient is likely to experience a short or long stay at ICU [area under curve (AUC) = 0.92]. A further model based on kynurenine, 3-methylhistidine, ornithine, p-cresol sulfate, and C24.0 sphingomyelin, measured 1 week later, accurately predicted the duration of IMV (Pearson correlation = 0.94). Both predictive models outperformed Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and differentiated COVID-19 severity in published data. Conclusion: This study has identified specific metabolites that can predict in advance LOS and IMV, which could help in the management of COVID-19 cases at ICU.

Advanced Thermochromic Ink System for Medical Blood Simulation

Simulators for extracorporeal membrane oxygenation (ECMO) have problems of bulky devices and low-fidelity methodologies. Hence, ongoing efforts for optimizing modern solutions focus on minimizing expenses and blending training with the intensive care unit. This is particularly evident following the coronavirus pandemic, where economic resources have been extensively cut. In this paper, as a part of an ECMO simulator for training management, an advance thermochromic ink system for medical blood simulation is presented. The system was developed and enhanced as a prototype with successful and reversible transitions between dark and bright red blood color to simulate blood oxygenation and deoxygenation in ECMO training sessions.

A Modular Approach for a Patient Unit for Extracorporeal Membrane Oxygenation Simulator

Despite many advancements in extracorporeal membrane oxygenation (ECMO), the procedure is still correlated with a high risk of patient complications. Simulation-based training provides the opportunity for ECMO staff to practice on real-life scenarios without exposing ECMO patients to medical errors while practicing. At Hamad Medical Corporation (HMC) in Qatar, there is a critical need of expert ECMO staff. Thus, a modular ECMO simulator is being developed to enhance the training process in a cost-effective manner. This ECMO simulator gives the instructor the ability to control the simulation modules and run common simulation scenarios through a tablet application. The core modules of the simulation system are placed in the patient unit. The unit is designed modularly such that more modules can be added throughout the simulation sessions to increase the realism of the simulation sessions. The new approach is to enclose the patient unit in a trolley, which is custom-designed and made to include all the components in a modular fashion. Each module is enclosed in a separate box and then mounted to the main blood simulation loop box using screws, quick connect/disconnect liquid fittings, and electrical plugs. This method allows fast upgrade and maintenance for each module separately as well as upgrading modules easily without modifying the trolley’s design. The prototype patient unit has been developed for portability, maintenance, and extensibility. After implementation and testing, the prototype has proven to successfully simulate the main visual and audio cues of the real emergency scenarios, while keeping costs to a minimum.

Association between periodontitis and severity of COVID-19 infection: A case-control study

AIM

COVID-19 is associated with an exacerbated inflammatory response that can result in fatal outcomes. Systemic inflammation is also a main characteristic of periodontitis. Therefore, we investigated the association of periodontitis with COVID-19 complications.

MATERIALS AND METHODS

A case-control study was performed using the national electronic health records of the State of Qatar between February and July 2020. Cases were defined as patients who suffered COVID-19 complications (death, ICU admissions or assisted ventilation), and controls were COVID-19 patients discharged without major complications. Periodontal conditions were assessed using dental radiographs from the same database. Associations between periodontitis and COVID 19 complications were analysed using logistic regression models adjusted for demographic, medical and behaviour factors.

RESULTS

In total, 568 patients were included. After adjusting for potential confounders, periodontitis was associated with COVID-19 complication including death (OR = 8.81, 95% CI 1.00-77.7), ICU admission (OR = 3.54, 95% CI 1.39-9.05) and need for assisted ventilation (OR = 4.57, 95% CI 1.19-17.4). Similarly, blood levels of white blood cells, D-dimer and C Reactive Protein were significantly higher in COVID-19 patients with periodontitis.

CONCLUSION

Periodontitis was associated with higher risk of ICU admission, need for assisted ventilation and death of COVID-19 patients, and with increased blood levels of biomarkers linked to worse disease outcomes.

Performance evaluation of five ELISA kits for detecting anti-SARS-COV-2 IgG antibodies

Objectives

To evaluate and compare the performances of five commercial ELISA assays (EDI, AnshLabs, Dia.Pro, NovaTec, and Lionex) for detecting anti-SARS-CoV-2 IgG.

Methods

Seventy negative control samples (collected before the COVID-19 pandemic) and samples from 101 RT-PCR-confirmed SARS-CoV-2 patients (collected at different time points from symptom onset: ≤7, 8–14 and >14 days) were used to compare the sensitivity, specificity, agreement, and positive and negative predictive values of each assay with RT-PCR. A concordance assessment between the five assays was also conducted. Cross-reactivity with other HCoV, non-HCoV respiratory viruses, non-respiratory viruses, and nuclear antigens was investigated.

Results

Lionex showed the highest specificity (98.6%; 95% CI 92.3–99.8), followed by EDI and Dia.Pro (97.1%; 95% CI 90.2–99.2), NovaTec (85.7%; 95% CI 75.7–92.1), then AnshLabs (75.7%; 95% CI 64.5–84.2). All ELISA kits cross-reacted with one anti-MERS IgG-positive sample, except Lionex. The sensitivity was low during the early stages of the disease but improved over time. After 14 days from symptom onset, Lionex and NovaTec showed the highest sensitivity at 87.9% (95% CI 72.7–95.2) and 86.4% (95% CI 78.5–91.7), respectively. The agreement with RT-PCR results based on Cohen’s kappa was as follows: Lionex (0.89) > NovaTec (0.70) > Dia.Pro (0.69) > AnshLabs (0.63) > EDI (0.55).

Conclusion

The Lionex and NovaLisa IgG ELISA kits, demonstrated the best overall performance.

The first consecutive 5000 patients with Coronavirus Disease 2019 from Qatar; a nation-wide cohort study

Background

There are limited data on Coronavirus Disease 2019 (COVID-19) outcomes at a national level, and none after 60 days of follow up. The aim of this study was to describe national, 60-day all-cause mortality associated with COVID-19, and to identify risk factors associated with admission to an intensive care unit (ICU).

Methods

This was a retrospective cohort study including the first consecutive 5000 patients with COVID-19 in Qatar who completed 60 days of follow up by June 17, 2020. The primary outcome was all-cause mortality at 60 days after COVID-19 diagnosis. In addition, we explored risk factors for admission to ICU.

Results

Included patients were diagnosed with COVID-19 between February 28 and April 17, 2020. The majority (4436, 88.7%) were males and the median age was 35 years [interquartile range (IQR) 28–43]. By 60 days after COVID-19 diagnosis, 14 patients (0.28%) had died, 10 (0.2%) were still in hospital, and two (0.04%) were still in ICU. Fatal COVID-19 cases had a median age of 59.5 years (IQR 55.8–68), and were mostly males (13, 92.9%). All included pregnant women (26, 0.5%), children (131, 2.6%), and healthcare workers (135, 2.7%) were alive and not hospitalized at the end of follow up.

A total of 1424 patients (28.5%) required hospitalization, out of which 108 (7.6%) were admitted to ICU. Most frequent co-morbidities in hospitalized adults were diabetes (23.2%), and hypertension (20.7%). Multivariable logistic regression showed that older age [adjusted odds ratio (aOR) 1.041, 95% confidence interval (CI) 1.022–1.061 per year increase; P < 0.001], male sex (aOR 4.375, 95% CI 1.964–9.744; P < 0.001), diabetes (aOR 1.698, 95% CI 1.050–2.746; P 0.031), chronic kidney disease (aOR 3.590, 95% CI 1.596–8.079, P 0.002), and higher BMI (aOR 1.067, 95% CI 1.027–1.108 per unit increase; P 0.001), were all independently associated with increased risk of ICU admission.

Conclusions

In a relatively younger national cohort with a low co-morbidity burden, COVID-19 was associated with low all-cause mortality. Independent risk factors for ICU admission included older age, male sex, higher BMI, and co-existing diabetes or chronic kidney disease.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12879-020-05511-8.

Flow controlled ventilation in Acute Respiratory Distress Syndrome associated with COVID-19: A structured summary of a study protocol for a randomised controlled trial

Objectives

This study aims to demonstrate the positive effects on oxygenation of flow-controlled ventilation compared to conventionally ventilated patients in patients suffering from Acute respiratory distress syndrome (ARDS) associated with COVID-19.We define ARDS according to the “Berlin” definition integrating the oxygenation index (P/F ratio), the level of Positive End Expiratory Pressure (PEEP), radiological and clinical findings.

Trial design

This is a prospective, randomized (1:1 ratio), parallel group feasibility study in adult patients with proven COVID-19 associated ARDS.

Participants

All adult patients admitted to the ICU of Hamad Medical Corporation facilities in Qatar because of COVID-19 infection who develop moderate to severe ARDS are eligible. The inclusion criteria are above 18 years of age, proven COVID-19 infection, respiratory failure necessitating intubation and mechanical ventilation, ARDS with a P/F ratio of at least 200mmHg or less and a minimum PEEP 5cmH2O, BMI less 30 kg/ m2. The following exclusion criteria: no written consent, chronic respiratory disease, acute or chronic cardiovascular disease, pregnancy or need for special therapy (prone position and/or Extracorporeal membrane oxygenation).

Intervention and comparator

After randomisation, the group A patients will be ventilated with the test-device for 48 hours. The settings will be started with the pre-existing-PEEP. The upper pressure will be determined to achieve a tidal volume of 6 ml/kg lean body mass, while the respiratory rate will be set to maintain an arterial pH above 7.2.

In group B, the ventilator settings will be adjusted by the attending ICU team in accordance with lung-protective ventilation strategy.

All other treatment will be unchanged and according to our local policies/guidelines.

Main outcomes

The primary end point is PaO2. As this is a dynamic parameter, we will record it every 6-8 hours and analyse it sequentially.

Randomisation

The study team screens the ventilated patients who fulfil the inclusion criteria and randomise using a 1:1 allocation ratio after consenting using a closed envelope method. The latter were prepared and sealed in advance by an independent person.

Blinding (masking)

Due to the technical nature of the study (use of a specific ventilator) blinding is only possible for the data-analysts and the patients.

Numbers to be randomised (sample size)

The sample size calculation based on the assumption of an effect size (change in PaO2) of 1.5 SDS in the primary endpoint (PaO2), an intended power of 80%, an alpha error of 5% and an equal sample ratio results in n=7 patients needed to treat. However, to compensate for dropouts we will include 10 patients in each group, which means in total 20 patients.

Trial Status

The local registration number is MRC-05-018 with the protocol version number 3. The date of approval is 14^th April 2020. Recruitment began 28th May 2020 and is expected to end in September 2020.

Trial registration

The protocol was registered before starting subject recruitment under the title: “Flow controlled ventilation in ARDS associated with COVID-19” in ClinicalTrials.org with the registration number: NCT04399317. Registered on 22 May 2020.

Full protocol

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Characteristics and predictors of burnout among healthcare professionals: a cross-sectional study in two tertiary hospitals

BACKGROUND

The pattern and impact of burnout among the medical staff are not yet well defined. However, the consequences of burnout are not limited to the healthcare providers but also may affect their family, colleagues and patients in a negative manner. We aimed to assess the characteristics and predictors of burnout among health professionals at two large tertiary hospitals.

METHODS

We conducted a cross-sectional study during the period from July 2018 to 31 December 2018. Data, via Maslach Burnout Inventory survey, were collected from physicians and other healthcare workers in two hospitals.

RESULTS

A total of 624 responses to questionnaires were analysed. Half of the respondents were physicians, and men constituted the majority. About 10% (95% CI, 7.8 to 12.5) of the respondents satisfied the criteria of burnout. Emotional exhaustion (EE) was observed in 45.7%, depersonalisation (DP) in 26.9% and personal accomplishment (PA) in 41.2% of the respondents. There was a positive correlation between EE and DP (r=0.627, p=0.001), and a weak negative correlation between DP and PA (r=-0.195, p=0.001). Young age, less experience, trauma surgery, lack of habits and getting depressed ≥1 time/week were predictors of burnout.

CONCLUSIONS

Burnout affects one-tenth of the health professionals in the tertiary hospitals in Qatar. Physicians are more likely to have higher DP and lower PA, whereas nurses prone to have higher EE. In this study, no gender discrepancy is appreciated and the junior medical staff is at a higher risk of burnout.

Towards next generation cannulation simulators

Background: Cannulation, in extracorporeal membrane oxygenation (ECMO), is the act of inserting a cannula through the body¹. For femoral veins, femoral arteries, and the jugular vein, the cannula stops at the inferior vena cava (IVC) beside the hepatic vein and at the beginning of the distal aorta, and the superior vena cava at the right atrium, respectively. Cannulation is considered a critical operation and requires intensive training. Simulation-based training (SBT) is the gold standard, allowing for training in risk-free, versatile, and realistic environments². A research collaboration was established between Hamad Medical Corporation and Qatar University College of Engineering to support the development of the ECMO training programme. Initially an ECMO machine simulator was developed with thermochromic ink to simulate blood and modules that simulate common emergencies practitioners may face during ECMO runs³. This cannulation simulator is now being designed to close the gap in the market in relation to cost and fidelity^4,5. Methods: The cannulation simulator is composed of several modules. Firstly, a 3D-printed femoral pad mold was constructed to facilitate the production of cannulation pads (Figure 1(a), (c)). Secondly, cannulation pads were designed so they are anatomically correct and ultrasound compatible. For the arteries, the superficial artery was added at the access point to simulate possible incorrect routes for the cannula. Furthermore, the orientation of the veins and arteries were set to further resemble the human anatomy, where the arteries are situated above the veins (Figure 1(a), (b)). In addition to the implementation of a closed loop linking the jugular to the femoral, cannulation access points with a pump connected to a tank between them to regulate the flow. The blood flow in the arteries was enhanced with a pump to simulate a pulsatile flow while the flow in the veins is laminar as seen in the single loop implementation (Figure 1(h)). The connection of the pump to the embedded system is shown in Figure 1(g). The junctional point in the IVC was designed in the venous loop to allow for two cannulas to pass and an alternative path simulating the renal vein was added. A force sensing resistor (FSR) was connected to detect and measure incorrect entry of the guide-wire as this, in real-time scenarios, could cause internal bleeding to the patient (Figure 1(g)). Lastly, the Y-connector showing the renal vein entry is shown in Figure 1(d) and (e). Results: Tests were done on the system namely on the FSR to recalibrate it in the presence of liquid. Tests on the pulsatile flow were conducted to optimize for realism in terms of pressure. Since both jugular and femoral cannulation access points are included, the simulator can be used for training for all ECMO modes including veno-arterial and veno-venous. After testing, the main limitations of the current prototype include the flexibility of the tubes, limits on FSR measurements, and the rigidity of the available 3D printing material. Conclusion: After implementing the stated features, the anticipated outcome is a realistic and cost-efficient ECMO cannulation simulator.

Indapamide-induced Severe Hyponatremia in a Middle-aged Male Patient within Two Weeks

Hyponatremia is one of the most common electrolyte abnormalities and is associated with many conditions. It has been reported in patients receiving diuretics as a physiological consequence of the therapy. We report an unusual case of severe hyponatremia of 100 mmol/L (Normal range (NR): 136-145 mmol/L) in a 54-year-old middle-aged gentleman within two weeks of commencement of Indapamide, a thiazide-like diuretic. After immediate treatment with intravenous 3% hypertonic saline infusion, discontinuation of indapamide, and ruling out other possible causes of hyponatremia, his serum sodium level improved. He was discharged without having any complicated hospital course and was also followed up for a further five months. The aim of our case report is to highlight an important and life-threatening complication associated with the most commonly prescribed drug and to manage it through cautious correction and monitoring of sodium levels.

Addressing the challenges of ECMO simulation

INTRODUCTION/AIM

The patient's condition and high-risk nature of extracorporeal membrane oxygenation (ECMO) therapy force clinical services to ensure clinicians are properly trained and always ready to deal effectively with critical situations. Simulation-based education (SBE), from the simplest approaches to the most immersive modalities, helps promote optimum individual and team performance. The risks of SBE are negative learning, inauthenticity in learning and over-reliance on the participants' suspension of disbelief. This is especially relevant to ECMO SBE as circuit/patient interactions are difficult to fully simulate without confusing circuit alterations.

METHODS

Our efforts concentrate on making ECMO simulation easier and more realistic in order to reduce the current gap there is between SBE and real ECMO patient care. Issues to be overcome include controlling the circuit pressures, system failures, patient issues, blood colour and cost factors. Key to our developments are the hospital-university collaboration and research funding.

RESULTS

A prototype ECMO simulator has been developed that allows for realistic ECMO SBE. The system emulates the ECMO machine interface with remotely controllable pressure parameters, haemorrhaging, line chattering, air bubble noise and simulated blood colour change.

CONCLUSION

The prototype simulator allows the simulation of common ECMO emergencies through innovative solutions that enhance the fidelity of ECMO SBE and reduce the requirement for suspension of disbelief from participants. Future developments will encompass the patient cannulation aspect.

Enteral versus parenteral early nutrition in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2)

BACKGROUND

Whether the route of early feeding affects outcomes of patients with severe critical illnesses is controversial. We hypothesised that outcomes were better with early first-line enteral nutrition than with early first-line parenteral nutrition.

METHODS

In this randomised, controlled, multicentre, open-label, parallel-group study (NUTRIREA-2 trial) done at 44 French intensive-care units (ICUs), adults (18 years or older) receiving invasive mechanical ventilation and vasopressor support for shock were randomly assigned (1:1) to either parenteral nutrition or enteral nutrition, both targeting normocaloric goals (20-25 kcal/kg per day), within 24 h after intubation. Randomisation was stratified by centre using permutation blocks of variable sizes. Given that route of nutrition cannot be masked, blinding of the physicians and nurses was not feasible. Patients receiving parenteral nutrition could be switched to enteral nutrition after at least 72 h in the event of shock resolution (no vasopressor support for 24 consecutive hours and arterial lactate <2 mmol/L). The primary endpoint was mortality on day 28 after randomisation in the intention-to-treat-population. This study is registered with ClinicalTrials.gov, number NCT01802099.

FINDINGS

After the second interim analysis, the independent Data Safety and Monitoring Board deemed that completing patient enrolment was unlikely to significantly change the results of the trial and recommended stopping patient recruitment. Between March 22, 2013, and June 30, 2015, 2410 patients were enrolled and randomly assigned; 1202 to the enteral group and 1208 to the parenteral group. By day 28, 443 (37%) of 1202 patients in the enteral group and 422 (35%) of 1208 patients in the parenteral group had died (absolute difference estimate 2·0%; [95% CI -1·9 to 5·8]; p=0·33). Cumulative incidence of patients with ICU-acquired infections did not differ between the enteral group (173 [14%]) and the parenteral group (194 [16%]; hazard ratio [HR] 0·89 [95% CI 0·72-1·09]; p=0·25). Compared with the parenteral group, the enteral group had higher cumulative incidences of patients with vomiting (406 [34%] vs 246 [20%]; HR 1·89 [1·62-2·20]; p<0·0001), diarrhoea (432 [36%] vs 393 [33%]; 1·20 [1·05-1·37]; p=0·009), bowel ischaemia (19 [2%] vs five [<1%]; 3·84 [1·43-10·3]; p=0·007), and acute colonic pseudo-obstruction (11 [1%] vs three [<1%]; 3·7 [1·03-13·2; p=0·04).

INTERPRETATION

In critically ill adults with shock, early isocaloric enteral nutrition did not reduce mortality or the risk of secondary infections but was associated with a greater risk of digestive complications compared with early isocaloric parenteral nutrition.

FUNDING

La Roche-sur-Yon Departmental Hospital and French Ministry of Health.

[Crossed perceptions about malnutrition in patients and their doctors in oncology]

Malnutrition is common in oncology. However, it is often detected too late and nutritional support is sub-optimal. The patient's opinion, although often sought in therapeutic decisions in oncology, does not appear to be frequently taken into account in dietetic management. In NutriCancer2012 study, we interviewed patients, relatives and doctors about their perceptions of the impact of malnutrition and its quality of care. Of the 2209 patients questioned, majority said they were concerned about nutrition with 75% considering it essential to take appropriate nutritional care but only 19% self-reported link between malnutrition and fatigue. Physicians underestimated impact of malnutrition on patient's "quality of life". Doctors referred to the lack of human resources and knowledge in nutrition, and more than 80% wished the creation of nutrition teams. Sensitization of the general public and patients (and relatives) as soon as the cancer diagnosis could lead to better malnutrition's screening. Better nutrition training for physicians and creation of nutrition team could optimize management and improve efficacy during cancer treatments.

Daily urinary urea excretion to guide intermittent hemodialysis weaning in critically ill patients

Background

There are no easily available markers of renal recovery to guide intermittent hemodialysis (IHD) weaning. The aim of this study was to identify markers for IHD weaning in critically ill patients with acute kidney injury (AKI).

Methods

We performed a retrospective single-center cohort study of patients treated with IHD for at least 7 days and four dialysis sessions for AKI between 2006 and 2011 in an intensive care unit (ICU) of a French university hospital. Blood and urinary markers were recorded on the day of the last IHD in the ICU for unweaned patients and 2 days after the last IHD for weaned patients. Factors associated with IHD weaning were identified by multiple logistic regression. The areas under the receiver operating characteristic curve (AUROC) and the characteristics of the best diagnostic thresholds were compared.

Results

Sixty-seven patients were analyzed, including thirty-seven IHD-weaned patients. Urine output [odds ratio (OR) 1.59, 95 % confidence interval (CI) 1.20–2.10 (per ml/kg/24 h increase); P = 0.01] and urinary urea concentration [OR 1.29, 95 % CI 1.01–1.64 (per 10 mmol/L increase); P = 0.04] were both associated with IHD weaning. The optimal diagnostic thresholds for IHD weaning were urine output greater than 8.5 ml/kg/24 h, urinary urea concentration greater than 148 mmol/L, and daily urea excretion greater than 1.35 mmol/kg/24 h, with accuracy of 82.1 %, 76.1 %, and 92.5 % (P = 0.03), respectively. The AUROC of daily urinary urea excretion (0.96) was greater than the AUROC of urine output (0.86) or the AUROC of urinary urea concentration (0.83) (P < 0.001).

Conclusions

A daily urinary urea excretion greater than 1.35 mmol/kg/24 h was found to be the best marker for weaning ICU patients with AKI from IHD.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1225-5) contains supplementary material, which is available to authorized users.

Therapeutic hypothermia after nonshockable cardiac arrest: the HYPERION multicenter, randomized, controlled, assessor-blinded, superiority trial

BACKGROUND

Meta-analyses of nonrandomized studies have provided conflicting data on therapeutic hypothermia, or targeted temperature management (TTM), at 33°C in patients successfully resuscitated after nonshockable cardiac arrest. Nevertheless, the latest recommendations issued by the International Liaison Committee on Resuscitation and by the European Resuscitation Council recommend therapeutic hypothermia. New data are available on the adverse effects of therapeutic hypothermia, notably infectious complications. The risk/benefit ratio of therapeutic hypothermia after nonshockable cardiac arrest is unclear.

METHODS

HYPERION is a multicenter (22 French ICUs) trial with blinded outcome assessment in which 584 patients with successfully resuscitated nonshockable cardiac arrest are allocated at random to either TTM between 32.5 and 33.5°C (therapeutic hypothermia) or TTM between 36.5 and 37.5°C (therapeutic normothermia) for 24 hours. Both groups are managed with therapeutic normothermia for the next 24 hours. TTM is achieved using locally available equipment. The primary outcome is day-90 neurological status assessed by the Cerebral Performance Categories (CPC) Scale with dichotomization of the results (1 + 2 versus 3 + 4 + 5). The primary outcome is assessed by a blinded psychologist during a semi-structured telephone interview of the patient or next of kin. Secondary outcomes are day-90 mortality, hospital mortality, severe adverse events, infections, and neurocognitive performance. The planned sample size of 584 patients will enable us to detect a 9% absolute difference in day-90 neurological status with 80% power, assuming a 14% event rate in the control group and a two-sided Type 1 error rate of 4.9%. Two interim analyses will be performed, after inclusion of 200 and 400 patients, respectively.

DISCUSSION

The HYPERION trial is a multicenter, randomized, controlled, assessor-blinded, superiority trial that may provide an answer to an issue of everyday relevance, namely, whether TTM is beneficial in comatose patients resuscitated after nonshockable cardiac arrest. Furthermore, it will provide new data on the tolerance and adverse events (especially infectious complications) of TTM at 32.5-33.5°C.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01994772 .

Impact of early enteral versus parenteral nutrition on mortality in patients requiring mechanical ventilation and catecholamines: study protocol for a randomized controlled trial (NUTRIREA-2)

Background

Nutritional support is crucial to the management of patients receiving invasive mechanical ventilation (IMV) and the most commonly prescribed treatment in intensive care units (ICUs). International guidelines consistently indicate that enteral nutrition (EN) should be preferred over parenteral nutrition (PN) whenever possible and started as early as possible. However, no adequately designed study has evaluated whether a specific nutritional modality is associated with decreased mortality. The primary goal of this trial is to assess the hypothesis that early first-line EN, as compared to early first-line PN, decreases day 28 all-cause mortality in patients receiving IMV and vasoactive drugs for shock.

Methods/Design

The NUTRIREA-2 study is a multicenter, open-label, parallel-group, randomized controlled trial comparing early PN versus early EN in critically ill patients requiring IMV for an expected duration of at least 48 hours, combined with vasoactive drugs, for shock. Patients will be allocated at random to first-line PN for at least 72 hours or to first-line EN. In both groups, nutritional support will be started within 24 hours after IMV initiation. Calorie targets will be 20 to 25 kcal/kg/day during the first week, then 25 to 30 kcal/kg/day thereafter. Patients receiving PN may be switched to EN after at least 72 hours in the event of shock resolution (no vasoactive drugs for 24 consecutive hours and arterial lactic acid level below 2 mmol/L). On day 7, all patients receiving PN and having no contraindications to EN will be switched to EN. In both groups, supplemental PN may be added to EN after day 7 in patients with persistent intolerance to EN and inadequate calorie intake. We plan to recruit 2,854 patients at 44 participating ICUs.

Discussion

The NUTRIREA-2 study is the first large randomized controlled trial designed to assess the hypothesis that early EN improves survival compared to early PN in ICU patients. Enrollment started on 22 March 2013 and is expected to end in November 2015.

Trial registration

ClinicalTrials.gov Identifier: NCT01802099 (registered 27 February 2013)