Blood Rna Biomarkers Distinguish Immune Responses to Covid-19 Viremia Versus Comorbid Infections

INTRODUCTION: While the COVID-19 syndrome is triggered by infection and expansion of the SARS-CoV2 RNA virus, secondary opportunistic infections can be a significant contributor to morbidity. In prior studies, our group employed RNA sequencing of whole blood RNA to identify RNA biomarkers of COVID-19 infection and severity. In the present studies, those biomarkers were expanded. METHOD(S): We performed a single-center prospective cohort study of SARS-COV2 infected ICU patients (n=20) during the peak of the Omicron wave (Jan-Feb 2022). Participants were consented for a venous blood draw into an RNA preservative. Samples were stored at -80degree C. Stored blood was used for RNA purification and droplet digital PCR quantitation of 6 novel RNA biomarkers for bacterial (DEFA1), biofilm (ALPL, IL8RB/CXCR2), and viral infections (IFI27, RSAD2). Viral titer in blood was analyzed in parallel by ddPCR for SARS-CoV2 sequences (BioRad, EUA). RESULT(S): Among clinical biomarkers, Pearson correlational analysis with SOFA scores identified lactate (r=0.24), BMI (r=0.34), creatinine (r=0.58), and LDH (r=0.68), as the best predictors. Viremic titer was not associated with SOFA scores (r=-0.07). Among the RNA biomarkers ALPL (r=0.48), a biofilm marker, showed the best correlation with SOFA score. The RNA biomarkers of viral infection IFI27 (r=0.72) and RSAD2 (r=0.42) were positively correlated with SARSCoV2 viral titer, suggesting that the host immune response is proportional to the viremia of COVID-19. CONCLUSION(S): Collectively, the results suggest that whole blood RNA transcripts involved in the host immune response can indicate the presence and severity of infection, including unexpected comorbidities. Furthermore, these biomarkers can distinguish between viremia, biofilms, and other types of infections that may undermine recovery from COVID-19.

For whom does the bell toll? oneyear follow-up on ed responder burnout during the COVID-19 pandemic

BACKGROUND: The COVID-19 (COVID) pandemic has caused incalculable damages throughout the U.S., with over 34-million infections and 600,000 deaths as of July 2021. Many medical personnel on the frontline, especially within emergency departments, experienced immense burnout. Although the extent of the burnout at the beginning of the pandemic has been reported in the literature, there is a paucity of data on how that has evolved over time. We aimed to survey providers a year into the pandemic on stress and burnout in the setting of new vaccine availability. METHODS: Two online surveys were distributed among healthcare providers at a tertiary academic center between 2020 and 2021. The initial survey was composed of questions evaluating the level of burnout and risk perception. The latter had the same questions for comparison, as well as questions regarding vaccination status and the Professional Quality of Life Scale (PROQOL). Chi-squared tests were used to compare the results. RESULTS: There were 63 responses in 2020 and 78 responses in 2021. 94% received the COVID vaccine in 2021. Measures of risk perception, specifically “Feels job is imposing great risk” and “Afraid of falling ill with COVID” saw statistically significant decreases (87% to 62%, p= 0.001;76% to 45%, p< 0.001, respectively). Meanwhile, while the point estimate for “feeling extra stress at work” and “thinking about resigning” also decreased, neither were statistically significant (85% to 76%, p=0.148;11% to 9%, p= 0.673, respectively). The PROQOL results from 2021 showed most responders experienced either moderate or high levels of Burnout and Post-traumatic stress, but also Compassion Satisfaction (85%, 62%, and 96%, respectively). CONCLUSIONS: During the 1-year study period there were significant improvements in terms of risk perception, though burnout and stress remained high. The reduction in risk perception may be related to vaccination, given the high rate of vaccination among this group and temporal correlation. However further research is necessary to support this relationship, as well as identify other potential factors to help reduce burnout in future pandemics.

Are ultrasounds as safe as chest radiographs at assessing complications of endotracheal intubations?

INTRODUCTION: Endotracheal tube (ETT) complications are common in intensive care unit (ICU) settings due to ETT malpositioning and migration. Point-of-care ultrasound (POCUS) has shown promise in predicting accurate ETT position but the safety profile compared to chest x-rays (CXR) remains unknown. We assessed whether a POCUS-guided repositioning protocol was non-inferior to CXRs for adverse clinical outcomes. METHODS: Intubated patients enrolled from 4 multidisciplinary ICUs over a 1-month period were randomized into two arms: CXR-guided or POCUS-guided daily monitoring of ETT position. In the POCUS-arm, novice sonographers assessed ETT positioning daily (normal range: superior balloon border between the 3rd-7th tracheal rings) and recommended repositioning maneuvers accordingly. The protocol allowed clinicians to use CXR landmarks if they did not agree with POCUS recommendations. The CXR-arm used radiographic landmarks (normal range: ETT tip 5±2cm from carina) without sonography. Exclusion criteria included COVID-19 status, C-spine precautions, prone positioning, anterior neck wounds, or planned extubation within 24 hours. Investigators used Fisher's exact test (α-error 5%) to compare rates of ETT bronchial or vocal cord migration, balloon rupture, unplanned extubation, repositioning maneuvers, and ventilator associated pneumonia (VAP). RESULTS: 22 patients met inclusion criteria with 11 patients in the POCUS-arm (35 ventilator-days) and 11 patients in the CXR-arm (36 ventilator-days). There was no significant difference in adverse events between the CXRand POCUS-arms (7.50% v 3.13%;p=0.41). There were 6 instances of patients crossing-over from the POCUS-arm to the CXR-arm but a secondary intention-to-treat analysis showed no impact on significance (7.50% v 3.13%;p=0.41). 3 VAP episodes occurred in the CXR-arm and 1 vocal cord herniation occurred in the POCUS-arm. Repositioning was more common in the CXR-arm than the POCUS-arm (23.5% v 0.00%;p=0.02). CONCLUSIONS: The use of POCUS compared to daily CXRs to monitor ETT positioning appears similar in terms of the adverse clinical outcomes. Further investigation is needed to assess if this non-inferiority remains with higher sample sizes.

Endotracheal tube surveillance: Can point-of-care ultrasound replace chest radiographs?

INTRODUCTION: There are many potential complications associated with endotracheal tube (ETTs) malpositioning in critical care settings, such as bronchial migration or vocal cord herniation. These events can prolong patient recovery and lengthen ICU stays. The goal of this study is to demonstrate that point of care ultrasound (POCUS) is noninferior to chest x-ray (CXR) in identifying proper ETT depth. METHODS: We conducted an observational cohort study of intubated patients across 4 multidisciplinary ICUs at an urban academic hospital who underwent daily POCUS assessment of ETT positioning by novice sonographers (medical students). ICU/ED physicians led 4 hour-long informal trainings to teach medical students POCUS technique. Subjects were excluded if they were COVID positive, in c-spine precautions, had recent neck surgery or planned to be extubated within 24 hours. Patient ETT position was measured using POCUS assessment (balloon cuff border ending between 3-7 tracheal rings) and compared to daily radiographic CXR landmarks (5 cm ± 2 cm above carina). Recommendations based on sonographic and radiographic landmarks were compared to assess sensitivity and specificity of POCUS to evaluate need for ETT repositioning. Statistical significance was assessed using the Clopper-Pearson binomial confidence interval. RESULTS: 20 patients were enrolled for a total of 62 ventilator-days. The cohort was majority female (55%), Black/African American (75%) and mean age 55 ± 18 years. In 58 instances (93.5%), both sonographic and radiographic landmarks agreed on maintenance of ETT position. In 1 instance (1.6%), sonographers recommended ETT repositioning while radiographic landmarks did not. In 3 instances (4.8%), ETTs appeared in place by sonographic but not radiographic landmarks. The data yields a specificity of 98.31% CI [90.91,99.96] for proper ETT placement with a negative likelihood ratio of 1.02 CI [.98, 1.05] and NPV of 95.08% CI [94.92,95.24]. CONCLUSION: The high specificity and NPV values suggest that if ETT position appears within normal limits on POCUS (tip of ETT between 3-7 tracheal rings), ETT position is likely adequately positioned even when performed by novices. Further studies should investigate the use of POCUS as a monitoring alternative and as a reliable tool post-intubation to confirm ETT depth.

Correlational analysis of eaa with other inflammatory markers in critically ill SARS-CoV-2 patients

INTRODUCTION: The Endotoxin Activity Assay (EAA) is a lab analysis to detect primed neutrophils in inflammatory states such as sepsis. Its use as a potential biomarker in SARS-CoV-2 patients has not been previously studied. Other markers such as CRP, ESR, LDH, ferritin, d-dimer, WBC count, procalcitonin, and IL-6 have all been shown to be reliable predictors of inflammatory states. We sought to find out the correlation between EAA and other inflammatory markers in patients admitted to the ICU with SARS-CoV-2 infection. METHODS: This is a prospective cohort analysis of SARSCoV- 2 patients admitted to the ICU at a single academic hospital from March to June 2020. Values for all study variables were obtained from each COVID-positive patient on days 1, 2, and 7 of ICU stay, and also for the onset of mechanical ventilation, vasopressors, acute kidney injury, and increase in ferritin >50% from the level at admission. Logistic and linear regression analyses were used to compare EAA with IL-6, CRP, ferritin, ESR, LDH, d-dimer, WBC, and procalcitonin. RESULTS: A total of 214 EAA results were recorded from 99 patients, with characteristics of: median age 61.84, 45% female, 74% Black, 21% Hispanic, 4% White, and 1% Asian. A significant linear regression equation was found between EAA and CRP: F (1, 168)=19.20, p<.0001, with an R2 of 0.1031 and Pearson's r of 0.32109, indicating a moderate correlation. Significant Spearman Correlation Coefficients were found between EAA and CRP, LDH, and D-dimer: ρ (169)=0.2896, p=0.0001;ρ (180)=0.179, p=0.01;ρ (165)=0.169, p=0.03, suggesting a mild correlation. Other markers did not show a significant correlation with EAA: IL-6 ρ (35)=0.144, p=0.40;Ferritin ρ (173)=0.0533 p=0.48;ESR ρ (37)=0.067, p=0.69;WBC ρ (213)=0.057, p=0.40;Procalcitonin ρ (14)=0.014, p=0.96. CONCLUSIONS: EAA has a statistically significant positive correlation with CRP, LDH, and D-dimer, but not with IL-6, ferritin, ESR, WBC, and procalcitonin. Further studies exploring the relationship between EAA and other biomarkers can establish the validity and reliability of EAA in inflammatory states such as COVID sepsis. This can help identify the role of EAA as an adjunct biomarker to assess the efficacy of therapeutic strategies and to prognosticate and predict mortality in patients with SARS-CoV-19.

Endotoxin levels, as measured by eaa, are elevated in COVID-19 patients admitted to the ICU

INTRODUCTION/HYPOTHESIS: Endotoxin Activity Assay (EAA), which measures the chemiluminescent response of the neutrophils to endotoxin using an anti-endotoxin antibody, has been used to predict mortality in patients with gramnegative sepsis. Recent evidence has shown that this indirect method of endotoxin measurement does not account for other causes that may excite or depress neutrophil activity. We sought to evaluate the levels of EAA in patients with severe COVID-19 infections without bacteremia but rather a systemic inflammatory state and acute respiratory distress syndrome. METHODS: This is a single-center, prospective cohort analysis of SARS-CoV-2-positive patients admitted to the ICU at a single academic hospital, from March to June 2020. EAA levels were obtained from each COVID-positive patient at ICU admission. Demographics, as well as the development of bacteremia on blood culture, were abstracted from medical records. Initial EAA values were categorized into low EAA (<0.4), intermediate EAA (0.41-0.60), high EAA (0.61-0.80), and severely high EAA (>0.80). RESULTS: A total of 78 patients were included in the study, with baseline characteristics as follows: mean age 62.9 years, 46% female, with a racial distribution of 72% Black, 15% White, and 4% Asian. Of the 78 COVID-positive patients, only eight were confirmed positive for bacteremia, while the remaining patients had two negative blood cultures. Of the eight bacteremic patients, the EAA level was low in zero patients, intermediate in three, high in four, and severely high in one patient, resulting in 100% of patients with intermediate or higher EAA level. Of the 70 patients without bacteremia, the EAA level was low in 13, intermediate in 10, high in 34, and severely high in 13, resulting in 81.4% of patients with an intermediate or higher EAA level. CONCLUSIONS: Elevated levels of EAA representing significant endotoxemia are frequently observed in nonbacteremic patients with severe SARS-CoV-2 viral infection. The source of the endotoxemia is unidentified. Possible explanations include gut bacterial translocation from the endothelial cell dysfunction that is known to occur with COVID 19 infection, or that EAA is an indicator of a primed neutrophil state. Further investigation of the elevated EAA levels seen in COVID -19 infections is warranted.

Does intubation of COVID-19 patients save lives? a descriptive analysis of a prospective registry

INTRODUCTION: As the COVID-19 pandemic continues, respiratory management strategies emerged as a primary concern. The mortality rate for patients with COVID19 who require intubation, and the predictors of mortality for this specific population are poorly characterized with only a few case series and retrospective studies. Published mortality rates of patients requiring intubation have ranged from as low as 35% to as high as 80%. Given the overall high mortality rate associate with intubation, growing literature calls for further efforts to characterize this critical population. METHODS: Analysis of a single urban academic center prospective database of intubated patients with COVID-19, including transferred patients. Descriptive statistics were used to characterize the intubated patients. Logistic regression was performed to account for age, gender, BMI, race, history of diabetes, COPD, and asthma. RESULTS: From March 2020 to July 2020, 369 COVID-19 patients were included in the registry 93 of whom were intubated. Of those intubated, mean age was 57.3 years, with an average BMI of 32.5. 63.7% of the intubated patients were males, with 62.6% Black, 24.2% Hispanic, and 13.2% Caucasian. We report an overall mortality of 80%, with a crude odds ratio of 28.5 (95% CI: 14.5 - 55.8) for death associated with intubation. Logistic modeling revealed that age and gender are significantly associated with mortality, with mortality odds increasing approximately 9% for each year of age, and 2.8 times higher for males. BMI, race, and history of diabetes, COPD, and asthma did not meet statistical significance for association with mortality, nor were there any significant interaction effects. Holding age and gender constant, the odds ratio for death associated with intubation increases to 105.3 (95% CI: 38.5-287.8). CONCLUSIONS: We report a high mortality rate of intubated patients, which may be multifactorial from being a referral center accepts critically ill patients, including evaluation for ECMO. Furthermore, our institution was an early adopter of noninvasive ventilation methods in an attempt to avoid intubation whenever possible. Ultimately, further studies are needed to better characterize those COVID-19 patients that require intubation and what variables are more closely associated with morbidity and mortality.

Potential biomarkers for severe ards in the setting of SARS-CoV-2 ICU admission

INTRODUCTION: Acute respiratory disease syndrome (ARDS) is due to compromised lung oxygen exchange in the setting of severe alveolar inflammation. This can be assessed and diagnosed using the ratio of alveolar oxygen saturation (PaO2) to the fraction of inspired oxygen (FiO2), P-F ratio. In hospitalized COVID-19 patients, the role of trending inflammatory markers to categorize levels of ARDS severity in the clinical setting has yet to be established. In this study, we describe the correlational relationship of five biomarkers to the PaO2/FiO2 ratio (P-F ratio), a key diagnostic criterion, and a measure of severity in ARDS. METHODS: This is a prospective cohort analysis of SARs-CoV-2 patients admitted to the ICU at a single urban academic center from March to June 2020. Levels of Endotoxin activity assay (EAA), CRP, ferritin, LDH, and d-dimer were obtained from intubated patients throughout their ICU stay. PaO2 and FiO2 values matching the same days as the biomarkers and demographic information were abstracted from the medical record. The inflammatory markers were matched to the P-F ratios of the same day, and Spearman Correlation Coefficients were performed to detect the relationship between them. RESULTS: A total of 45 intubated COVID patients were included, with baseline characteristics of: median age 55 years and 33% female, 62% Black, 27% Hispanic, 9% Asian, and 2% White. Spearman Correlation Coefficient (ρ) showed statistically significant relationships between P/F ratios and EAA, IL-6, CRP, and ESR, with respective values of: ρ (89)=-0.2366, p=0.02;ρ (13)=-0.7143, p=0.006;ρ (77)=-0.3670, p=0.001;ρ (17)=-0.5569, p=0.02. ρ was also calculated between P/F ratios and Ferritin, D-dimer, WBC, and LDH with respective values of: ρ (77)=0.0819, p=0.47;ρ (78)=-0.2105, p=0.06;ρ (88)=-0.1046, p=0.33;ρ (73)=0.0420, p=0.72, showing no statistically significant relationship between these variables. CONCLUSIONS: EAA, IL-6, CRP, and ESR levels had a statistically significant negative correlation with the P-F ratio. Elevations in these biomarkers correlated with worsening P-F ratios, suggesting that they could serve as useful biomarkers to predict ARDS severity. Additional studies are needed to further understand the trend of these biomarkers and validate their clinical use in prognostication in ARDS.