Comparison of Hospitalized COVID-19 Patients in Terms of Disease Course According to the Presence of Gastrointestinal Symptoms Before and After Admission.

BACKGROUND: This study aimed to find the prevalence of gastrointestinal symptoms in hospitalized COVID-19 patients and to investigate the effects of gastrointestinal symptoms on the course of the disease during hospitalization. METHODS: Patients who were hospitalized due to COVID-19 were included in this retrospective study. The diagnostic method of COVID-19 was either a positive reverse transcription polymerase chain reaction test or a typical finding in chest computed tomography. This study was conducted by contacting patients by phone 1 month after they were discharged from hospital to investigate gastrointestinal symptoms. Patients' laboratory findings at the time of admission, medications they used, and clinical findings were obtained from hospital records retrospectively. Patients with gastrointestinal symptoms were divided into 2 groups according to the start of treatment: pre-treatment and post-treatment groups. RESULTS: At least 1 gastrointestinal symptom (anorexia, weight loss, diarrhea, nausea, vomiting, and abdominal pain) was present in 67.5% of 435 patients (55.6% male, mean age 52.8). If anorexia and weight loss are excluded, the rate of the presence of at least 1 gastrointestinal symptom is 54%. Gastrointestinal symptoms were present in 48.9% before the initiation of COVID-19 treatment. The most prevalent 3 symptoms were anorexia, weight loss, and diarrhea (56%, 52%, and 35.6%, respectively). Presence of pre-treatment gastrointestinal symptoms was associated with elevated C-reactive protein levels. Pre-treatment gastrointestinal symptoms were more common in those who received oxygen supply and who were intubated. Resolution of gastrointestinal symptoms takes longer time in those who were admitted to intensive care unit. Weight loss and diarrhea were more common in COVID-19 patients with gastrointestinal symptoms who were intubated than who were not intubated. Abdominal pain was not found to be a significant predictor of disease severity. CONCLUSION: The prevalence of at least 1 gastrointestinal symptom in hospitalized COVID-19 patients was 67%. The most prevalent symptoms were anorexia, weight loss, and diarrhea. Presence of pre-treatment gastrointestinal symptoms was associated with elevated C-reactive protein levels, use of oxygen supply, and intubation. Gastrointestinal symptoms persist longer in those admitted to intensive care unit.

Effect of prone positioning on end-expiratory lung volume, strain and oxygenation change over time in COVID-19 acute respiratory distress syndrome: A prospective physiological study.

Background: Prone position (PP) is a recommended intervention in severe classical acute respiratory distress syndrome (ARDS). Changes in lung resting volume, respiratory mechanics and gas exchange during a 16-h cycle of PP in COVID-19 ARDS has not been yet elucidated. Methods: Patients with severe COVID-19 ARDS were enrolled between May and September 2021 in a prospective cohort study in a University Teaching Hospital. Lung resting volume was quantitatively assessed by multiple breath nitrogen wash-in/wash-out technique to measure the end-expiratory lung volume (EELV). Timepoints included the following: Baseline, Supine Position (S1); start of PP (P0), and every 4-h (P4; P8; P12) until the end of PP (P16); and Supine Position (S2). Respiratory mechanics and gas exchange were assessed at each timepoint. Measurements and main results: 40 mechanically ventilated patients were included. EELV/predicted body weight (PBW) increased significantly over time. The highest increase was observed at P4. The highest absolute EELV/PBW values were observed at the end of the PP (P16 vs S1; median 33.5 ml/kg [InterQuartileRange, 28.2-38.7] vs 23.4 ml/kg [18.5-26.4], p < 0.001). Strain decreased immediately after PP and remained stable between P4 and P16. PaO2/FiO2 increased during PP reaching the highest level at P12 (P12 vs S1; 163 [138-217] vs 81 [65-97], p < 0.001). EELV/PBW, strain and PaO2/FiO2 decreased at S2 although EELV/PBW and PaO2/FiO2 were still significantly higher as compared to S1. Both absolute values over time and changes of strain and PaO2/FiO2 at P16 and S2 versus S1 were strongly associated with EELV/PBW levels. Conclusion: In severe COVID-19 ARDS, EELV steadily increased over a 16-h cycle of PP peaking at P16. Strain gradually decreased, and oxygenation improved over time. Changes in strain and oxygenation at the end of PP and back to SP were strongly associated with changes in EELV/PBW. Whether the change in EELV and oxygenation during PP may play a role on outcomes in COVID-ARDS deserves further investigation. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT04818164].

Incidence, Risk Factors, and Prognosis of Bloodstream Infections in COVID-19 Patients in Intensive Care: A Single-Center Observational Study.

BACKGROUND: Critically ill COVID-19 patients are prone to bloodstream infections (BSIs). AIM: To evaluate the incidence, risk factors, and prognosis of BSIs developing in COVID-19 patients in the intensive care unit (ICU). METHODS: Patients staying at least 48 h in ICU from 22 March 2020 to 25 May 2021 were included. Demographic, clinical, and laboratory data were analyzed. RESULTS: The median age of the sample (n = 470) was 66 years (IQR 56.0-76.0), and 64% were male. The three most common comorbidities were hypertension (49.8%), diabetes mellitus (32.8%), and coronary artery disease (25.7%). Further, 252 BSI episodes developed in 179 patients, and the BSI incidence rate was 50.2 (95% CI 44.3-56.7) per 1000 patient-days. The source of BSI is central venous catheter in 42.5% and lower respiratory tract in 38.9% of the episodes. Acinetobacter baumannii (40%) and carbapenem-resistant Klebsiella pneumoniae (21%) were the most common pathogens. CRP levels were lower in patients receiving tocilizumab. Multivariable analysis revealed that continuous renal replacement therapy, extracorporeal membrane oxygenation, and treatment with a combination of methylprednisolone and tocilizumab were independent risk factors for BSI. The estimated cumulative risk of developing first BSI episode was 50% after 6 days and 100% after 25 days. Of the 179 patients, 149 (83.2%) died, and a statistically significant difference (p < 0.001) was found in the survival distribution in favor of the group without BSI. CONCLUSION: BSI is a common complication in COVID-19 patients followed in the ICU, and it can lead to mortality. Failure in infection control measures, intensive immunosuppressive treatments, and invasive interventions are among the main factors leading to BSIs.

Ciddi COVID-19 Hastalarında Tosilizumab Tedavisinin Mortaliteye Etkisi

Amaç: COVID-19 ağır pnömoni ve ARDS ile seyredebilmektedir. Tedavide interlökin-6 reseptör antikorları ve steroid kullanılmakla beraber etkinlikleri tartışmalıdır. ARDS nedeniyle yoğun bakımda takip edilen hastalarda tosilizumab tedavisinin mortalite üzerine etkisini araştırdık. Gereç ve Yöntem: Tek merkezli, retrospektif çalışmada Cerrahpaşa Tıp Fakültesi Yoğun Bakım Ünitesi'ne ciddi COVID-19 tanısı ile kabul edilen ve 48 saatten daha uzun süreli yatışı olan erişkin hastalar dahil edildi. Hastalar tosilizumab sonrası 7 gün takip edildi.Standart tedaviye rağmen kötüleşen solunum yetersizliği nedeniyle mekanik ventilasyon desteği gereken ve belirgin akut faz yanıtı olan (CRP, ferritin, LDH, D-dimer) hastalara 24 saat içinde tosilizumab 2x400 mg uygulandı. Tosilizumab alan hastalar (tosilizumab grubu), standart tedavi alanlarla (kontrol grubu) karşılaştırıldı. Íki grup arasındaki demografik ve klinik farkları en aza indirmek için 1:1 oranında propensity skoru eşleştirmeli çok değişkenli bir Cox modeli uygulandı. Birincil sonlanım noktası mortalite, ikinci sonlanım noktaları mekanik ventilasyon gereksinimi ve laboratuvar testlerindeki değişimler olarak belirlendi. Hastalar sekonder enfeksiyon açısından da incelenmiştir. Bulgular: Mart-Mayıs 2020 arası yoğun bakıma kabul edilen 160 hastanın 56’sına (%35) tosilizumab verildi. Hastalarla ilgili özellikler Tablo 1’de özetlenmiştir. Tosilizumab alan ve almayan hastalar arasındaki demografik ve klinik farkları en aza indirmek için yaş, cinsiyet, APACHE II ve kronik hastalıklar değişken olarak alındı ve propensity skoru eşleştirmesi kullanılarak kontrol grubu belirlendi. Tosilizumab alan grupta 22 hasta (%39,3), kontrol grubunda 28 hasta (%50) öldü (p=0,25) (Tablo 2). Tosilizumab grubunda giriş P/F değeri anlamlı olarak daha düşüktü (p=0,019). Her iki grupta invazif mekanik ventilasyon gereksinimi benzerdi. Tosilizumab alan hastaların LDH değerleri çalışma süresi boyunca daha yüksek (Şekil 1) iken tosilizumab uygulama sonrası CRP ve fibrinojen anlamlı şekilde düştü (p<0,001). Sekonder enfeksiyon oranları her iki grupta benzerdi (%45 vs %45 p>0,05). Sonuç: Yoğun bakımda yatan ağır COVID-19 hastalarında tosilizumab kullanımı mortalite oranını ve invazif mekanik ventilasyon gereksinimini azaltmamıştır. Tosilizumab ile sekonder enfeksiyon sıklığında artış görülmedi. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Yoğun Bakımda COVID-19 ARDS ile Ízlenen Olgularda Ferritin Düzeyleri ile Prognoz Arasındaki Ílişkinin Değerlendirilmesi

Amaç: Yoğun bakımda koronavirüs hastalığı-19 (COVID-19) ARDS (CARDS) nedeniyle takip ve tedavi edilen hastalarda yüksek ferritin düzeyleri ile mortalite ve prognoz arasındaki ilişkiyi değerlendirmeyi amaçladık. Gereç ve Yöntem: Yoğun bakım ünitemizde CARDS nedeniyle izlenen ağır hipoksemik solunum yetmezlikli, invaziv mekanik ventilatör desteğindeki 150 hasta çalışmaya dahil edildi. Yoğun bakımda ölen ve yoğun bakımdan taburculuğu sağlanan hastaların 1. gün, 3. gün ve 7. gündeki ferritin değerleri ile yoğun bakım mortaliteleri karşılaştırıldı. Bulgular: Çalışmaya dahil edilen 150 hastadan yaşayan (n=40) ve ölen (n=110) hastaların 1. (752 vs 687,5), 3. (635 vs 674) ve 7. (684 vs 676,24) gün ferritin değerleri arasında istatistiksel olarak anlamlı fark saptanmadı. Hastaların yoğun bakım mortlitesi %73,3 idi. Sonuç: Ferritin, vücuttaki demir depolarının iyi bir göstergesi olmakla birlikte enflamatuvar süreçlerde makrofajlar tarafından salgılanarak düzeyinin yükseldiği bilinmektedir. Makrofaj aktivasyon sendromu, Erişkin Still hastalığı gibi bir çok enflamatuvar hastalıkta hiperferritinemi ön plandadır. COVID-19 enfeksiyonu seyirinde de ferritin düzeyleri oldukça yükselmekte ve yüksek ferritin düzeylerinin enflamatuvar sürecin iyi bir göstergesi olduğu düşünülmektedir. COVID-19 enfeksiyonu ile ilgili henüz bilinmeyen pek çok faktör mevcut olsa da hastalığın prognozunu ön görmek yakın takip edilmesi gereken ve yoğun bakım yatış gereksinimi olan olguların değerlendirilmesi açısından yol gösterici olacaktır. Çalışmamızda yüksek ferritin düzeyleri CARDS olgularında kötü prognostik gösterge ve yüksek mortalite oranları ile ilişkili bulundu. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Yoğun Bakımda Vitamin C Tedavisinin COVID-19 Hastalarının Organ Fonksiyonlarına Etkisi

Amaç: Yoğun bakımda Koronavirüs hastalığı-2019 (COVID-19 ) enfeksiyonu nedeniyle takip ve tedavi edilen hastalarda intravenöz (IV) vitamin C tedavisinin SOFA skoru, C-reaktif protein (CRP ) ve mortalite üzerine etkisini değerlendirmeyi amaçladık. Gereç ve Yöntem: Yoğun Bakım Ünitemizde COVID-19 enfeksiyonu nedeniyle gelişen hipoksemik solunum yetmezliğiyle tedavi edilen hastaların verileri retrospektif olarak incelenmiştir. Çalışmaya 150 hasta dahil edildi. Hastalar C vitamini almayan grup (grup 1, n: 50) ve IV vitamin C tedavisi uygulananlar da IV 6 gr vitamin C tedavisi alanlar (grup 2, n: 50): ve IV 15 gr vitamin C tedavisi alanlar (grup 3, n: 50) şeklinde gruplandırıldı. Tedavinin 1. günü, 3. günü ve 7. günündeki SOFA skorları, enflamasyon biyobelirteci olan CRP düzeyleri ve gruplar arası mortalite oranları incelendi. Bulgular: Grup 1’deki hastaların tedavinin 1. ve 7. günündeki SOFA skorları (7,1 vs 4,7) ve CRP (118,2 vs 92,9) değerleri arasında istatistiksel anlamlı fark saptandı (p<0,05). Grup 2 ’deki hastaların 1., 3. ve 7. gün SOFA skorları arasında anlamlı fark saptanmadı, ancak 1. ve 7. gün CRP (183,6 vs 89,2) değerlerinde istatistiksel anlamlı fark saptandı (p<0,05). Grup 3’ teki hastaların ise tedavinin 1., 3. ve 7. günlerindeki SOFA skorları ve CRP değerleri arasında istatistiksel anlamlı farklılık saptanmadı. Gruplar arası yoğun bakım mortaliteleri arasında anlamlı fark saptanmadı (%62,5 v s %60,95 vs %69,2) (Tablo 1).. Sonuç: COVID-19 enfeksiyonuna yönelik halen etkin bir antiviral ajan bulunamamıştır. Bu nedenle enfeksiyon esnasında gelişen enflamasyon ve sitokin fırtınası sistemik steroid tedavisi, antisitokin tedaviler ve destekleyici antioksidan etkinliği bilinen ajanlarla kontrol altına alınmaya çalışılmaktadır . Vitamin C reaktif oksijen ürünleri üzerinde etkili güçlü bir antioksidandır ancak, farmakolojik yüksek dozlarda demir ve bakır gibi geçiş metallerinin varlığında pro-oksidan etki göstermektedir. Çalışmamızda 15 gr çok yüksek doz vitamin C tedavisinin organ fonksiyonları üzerine olumlu bir etkisinin olmadığı ancak 6 gr vitamin C tedavisinin CRP düzeylerini anlamlı düşürdüğü ve enflamasyonu azalttığı gözlemlenmiştir. Gruplar arası mortalitede fark olmaması COVID-19 enfeksiyonu esnasında ortaya çıkan enflamasyonu mevcut tedavilerle kontrol altına alınmasının güç olduğunu ve yeni tedavi modalitelerinin geliştirilmesi gerektiğini düşündürmektedir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Air leaks in COVID-19 pneumonia.

The novel coronavirus infection 2019 (COVID-19), which was first identified in Wuhan, China in December 2019 and caused a pandemic, is mostly survived with mild symptoms, while invasive and non-invasive mechanical ventilation support is required in some patients. Pneumothorax, pneumomediastinum, and subcutaneous emphysema may develop in COVID-19 patients. In this study, cases of pneumothorax, pneumomediastinum, and subcutaneous emphysema in patients who were followed in the intensive care unit with the diagnosis of COVID-19 were evaluated. In conclusion, although rare, these complications can be fatal and increase the severity of the disease, which already has a high mortality rate in the intensive care unit. Early detection and management of these complications can reduce morbidity and mortality.

Rapid and Effective Vitamin D Supplementation May Present Better Clinical Outcomes in COVID-19 (SARS-CoV-2) Patients by Altering Serum INOS1, IL1B, IFNg, Cathelicidin-LL37, and ICAM1.

BACKGROUND: We aimed to establish an acute treatment protocol to increase serum vitamin D, evaluate the effectiveness of vitamin D3 supplementation, and reveal the potential mechanisms in COVID-19. METHODS: We retrospectively analyzed the data of 867 COVID-19 cases. Then, a prospective study was conducted, including 23 healthy individuals and 210 cases. A total of 163 cases had vitamin D supplementation, and 95 were followed for 14 days. Clinical outcomes, routine blood biomarkers, serum levels of vitamin D metabolism, and action mechanism-related parameters were evaluated. RESULTS: Our treatment protocol increased the serum 25OHD levels significantly to above 30 ng/mL within two weeks. COVID-19 cases (no comorbidities, no vitamin D treatment, 25OHD <30 ng/mL) had 1.9-fold increased risk of having hospitalization longer than 8 days compared with the cases with comorbidities and vitamin D treatment. Having vitamin D treatment decreased the mortality rate by 2.14 times. The correlation analysis of specific serum biomarkers with 25OHD indicated that the vitamin D action in COVID-19 might involve regulation of INOS1, IL1B, IFNg, cathelicidin-LL37, and ICAM1. CONCLUSIONS: Vitamin D treatment shortened hospital stay and decreased mortality in COVID-19 cases, even in the existence of comorbidities. Vitamin D supplementation is effective on various target parameters; therefore, it is essential for COVID-19 treatment.

The Role of Obesity in Predicting the Clinical Outcomes of COVID-19.

INTRODUCTION: The aim of this was to describe the predictors of mortality related to COVID-19 infection and to evaluate the association between overweight, obesity, and clinical outcomes of COVID-19. METHODS: We included the patients >18 years of age, with at least one positive SARS-CoV-2 reverse transcriptase-polymerase chain reaction. Patients were grouped according to body mass index values as normal weight <25 kg/m2 (Group A), overweight from 25 to <30 kg/m2 (Group B), Class I obesity 30 to <35 kg/m2 (Group C), and ≥35 kg/m2 (Group D). Mortality, clinical outcomes, laboratory parameters, and comorbidities were compared among 4 groups. RESULTS: There was no significant difference among study groups in terms of mortality. Noninvasive mechanical ventilation requirement was higher in group B and D than group A, while it was higher in Group D than Group C (Group B vs. Group A [p = 0.017], Group D vs. Group A [p = 0.001], and Group D vs. Group C [p = 0.016]). Lung involvement was less common in Group A, and presence of hypoxia was more common in Group D (Group B vs. Group A [p = 0.025], Group D vs. Group A [p < 0.001], Group D vs. Group B [p = 0.006], and Group D vs. Group C [p = 0.014]). The hospitalization rate was lower in Group A than in the other groups; in addition, patients in Group D have the highest rate of hospitalization (Group B vs. Group A [p < 0.001], Group C vs. Group A [p < 0.001], Group D vs. Group A [p < 0.001], Group D vs. Group B [p < 0.001], and Group D vs. Group C [p = 0.010]). CONCLUSION: COVID-19 patients with overweight and obesity presented with more severe clinical findings. Health-care providers should take into account that people living with overweight and obesity are at higher risk for COVID-19 and its complications.

Tocilizumab in COVID-19: The Cerrahpasa-PREDICT score.

BACKGROUND: Cytokine release syndrome (CRS), characterized by overproduction of proinflammatory cytokines in the course of severe coronavirus disease 2019 (COVID-19), has been suggested as the major cause of mortality. Tocilizumab, a recombinant humanized monoclonal antibody against human IL-6 receptor, poses a therapeutic option for the treatment of CRS leading to severe acute respiratory syndrome in coronavirus-2 (SARS-CoV-2) infection. METHODS: We performed a single-center retrospective study to reveal the outcome of COVID-19 patients on tocilizumab and proposed "the Cerrahpasa-PREDICT score", a new clinical scoring system using clinical and laboratory parameters that would help predicting the 28-day mortality of COVID-19 patients receiving tocilizumab. RESULTS: Eighty-seven patients (median age: 59 years) were included of whom 75.8% were male. Tocilizumab use significantly improved clinical and laboratory parameters. The 28-day mortality rate on tocilizumab was 16.1%. The Cerrahpasa-PREDICT score, consisting of platelet counts, procalcitonin, D-dimer levels, SO2R and the time from symptom onset to tocilizumab administration had a positive predictive value of 94.5% and negative predictive value of 92.9% for anticipating 28-day mortality. CONCLUSIONS: Severe COVID-19 should closely be monitored for the signs of hyperinflammation. We showed that administration of tocilizumab early in the course of the disease (prior to ICU admission) resulted in a favorable outcome. Close monitoring usually aids identifying patients who would benefit from tocilizumab. In this regard, the Cerrahpasa-PREDICT score might serve as a practical tool for estimating the 28-day mortality in COVID-19 patients who received tocilizumab and would facilitate timely recognition of fatal cases to be evaluated for other therapeutic options.