Spanish Society of Cardiovascular & Endovascular Surgery registry of interventions in patients with congenital heart disease: 2021, and retrospective of the previous decade

The Spanish Society of Cardiovascular & Endovascular Surgery presents the 2012-2021 report of the activity in congenital cardiovascular surgery, based on a voluntary and anonymous registration involving most of Spanish centres. This article is complementary to the 2021 cardiovascular surgery annual report, and they are published together. In 2021, still marked by the aftermath of the COVID-19 pandemic, the decline in our 2020 congenital activity persists, compared with previous years. We included data from the previous 10 years, in order to obtain real information related to our activity with these relatively scarce pathologies. In the last decade, a total of 20,139 congenital heart surgeries were performed, accounting for 9.5% of all major surgery (congenital + acquired) performed in Spain during that period. Of these surgeries, 81.5% of them required extracorporeal circulation and 18.5% not. We highlight the interventions in neonates and adult patients, which mean respectively 18% and 21% of our whole activity and are a real challenge. The most prevalent congenital heart pathologies operated on were: septal defects in cases requiring extracorporeal circulation, and ductus in patients without extracorporeal circulation. The presented data are adjusted to the basic Aristotle score of preoperative surgical risk. The observed mortality of surgeries with extracorporeal circulation was 3.07% (Aristotle: 6.29), and without cardiopulmonary bypass 2.25% (Aristotle: 4.82). Our national registry of surgical activity in congenital heart disease shows good results, allows us to compare ourselves within a national and international framework, design improvement strategies, set objectives and improve the quality of our actions.Copyright © 2023 Sociedad Espanola de Cirugia Cardiovascular y Endovascular

Clinical and paraclinical manifestations at hospital admission (triage) and their association with severity inpatients for SARS-CoV-2 pneumonia

OBJECTIVE: To explored whether initial laboratory data and symptoms predict further clinical outcome. MATERIALS AND METHODS: Retrospective cohort study. Clinical records from March to September 2020 were revised to extract clinical-demographic characteristics, laboratory data and outcomes from patients with SARS-CoV-2 pneumonia, admitted to Centro Medico Nacional 20 de Noviembre, ISSSTE, Mexico City. RESULT(S): One thousand three patients were evaluated at the Emergency-Triage, diagnosed with SARS-CoV-2 and received further in-hospital medical attention. Most of the patients were younger than 65 years-old, male and showed co-morbid conditions, such as obesity, hypertension or diabetes mellitus. After standard therapy, 389 cases (39%) required mechanical ventilation, vasopressor agents or showed fatal outcome. Higher values of C-reactive protein, D-dimer, procalcitonin and low O2 saturation at triage significantly predicted mechanical ventilation (p <0.05) and mortality (p <0.05);while presenting symptoms like fever, myalgia, cough and ageusia showed a particular association with longer hospital stage (p < 0.05). CONCLUSION(S): Laboratory values and presenting symptoms, both evaluated at hospital admission, showed different ability to predict clinical severity, mortality and longer hospitalization time in patients with COVID-19 pneumonia. These results could be useful in possible future pandemic waves of SARS-CoV-2.Copyright © 2022 Comunicaciones Cientificas Mexicanas S.A. de C.V.. All rights reserved.

A Quality Improvement Project Impacts Resident Satisfaction with the Depart Process

Purpose of Study The current depart process resulted in slow work-flow and patient safety and equity concerns. The QI project aimed to improve resident satisfaction with the hospital discharge process. Methods Used The QI project was designed using the Model for Improvement. Starting April 2020, Plan-Do-Study-Act cycles included: hiring clinical team coordinators;creating standard depart instructions for diabetic ketoacidosis, pyelonephritis, seizures, croup and dehydration;uploading instructions to Powerchart;and clinician reminders to use instructions with families. Measures examined monthly, included resident satisfaction and patient readmissions. Summary of Results Resident satisfaction improved from 4.8 (February 2020) to 7.8 (August 2020) for the overall discharge process;from 5.3 to 7.9 for family education on all key points;from 6.0 to 7.7 for smooth transition of care;from 3.0 to 7.4 for no language barriers;and from 3.0 to 6.7 for no unnecessary delays, on a scale of 0/strongly disagree/ terrible to 10/strongly agree/excellent. Readmissions also trended downward. Conclusions During this QI project to address the depart process, resident satisfaction improved and readmissions declined. These results are encouraging, but should be interpreted in the context of decreased patient census due to COVID-19 and non-respiratory season, which may have decreased workload and increased education time and interpreter access. Next steps include PDSAs related to health literacy and Spanish translation.

Simultaneous systemic thrombosis as a manifestation of COVID-19.

BACKGROUND: The current COVID-19 pandemic mainly affects the respiratory system;however, with the increase in cases worldwide, there is evidence of compromise at the cardiovascular level, which can manifest as acute myocardial infarction, myocarditis, pericarditis, myopericarditis, heart failure, cardiogenic shock, vasculitis, deep vein thrombosis, pulmonary embolism, ischemic stroke, acute arterial insufficiency, arrhythmias, and sudden death. CLINICAL CASE: A 70-year-old male patient who simultaneously presented multisystemic thrombosis manifested by cerebral vascular event, pulmonary thromboembolism, acute myocardial infarction and acute arterial insufficiency in the context of SARSCoV-2 pneumonia. CONCLUSION(S): In patients with COVID-19 there is a high thrombogenic potential secondary to blood stasis, hypercoagulability and endothelial dysfunction, which worsens the prognosis and increases mortality, mainly in patients who require ICU stay, so an adequate thromboprophylactic or anticoagulant scheme and follow-up in the convalescent phase must be provided to detect sequelae associated with COVID-19.Copyright © 2022 Comunicaciones Cientificas Mexicanas S.A. de C.V.. All rights reserved.

COVID 19 and the Related Risk with the Apearance of Arterial Hypertension

Arterial hypertension is a chronic inflammatory disease of a vascular nature and systemic and non-transmissible related to COVID-19. The objective was to determine the risk of presenting Arterial Hypertension in patients with COVID-19 through different diagnostic tests, as well as to establish the consequences of inadequate management of cardiovascular disease. The databases: Medline, Scielo, Redalyc, Latindex, SCOPUS, Dialnet, Cumed and Lilacs were reviewed. As a result, it was possible to identify the risk of suffering from hypertension in COVID-19 patients, a common aggravating factor in cardiovascular diseases, among them congestive heart failure or coronary heart disease, in the same way, a non-modifiable risk factor for suffering from arterial hypertension was age, therefore, the greater the age, the greater the risk of morbi-mortality. It was determined that the risk of presenting Arterial Hypertension was cardiovascular disease, which get worse with age and the use of antihypertensive drugs, and it was established that the consequences of inadequate management of this disease affect the person's subsequent lifestyle due to the consequences of it.

Ophthalmic manifestations in patients recovered from COVID-19 in Mexico.

INTRODUCTION AND OBJECTIVES: Although the ophthalmic manifestations appear to be associated with the coronavirus disease 2019 (COVID-19), there is not enough evidence. Hence, the aim of this study was to determine the various types and frequency of ophthalmic manifestations in patients recovered from SARS-CoV-2 infection in Mexico. MATERIAL AND METHODS: This retrospective, observational and descriptive study included all patients recovered from SARS-CoV-2 infection attending the tertiary level hospital of Mexican Social Security Institute (IMSS) from June 2020 to June 2022. During the hospital admission of patients, the demographic data such age, name, gender was recorded. Ophthalmologic examination was performed under torchlight by an ophthalmologist in the Department of Ophthalmology from IMSS. Data was compiled and statistically analyzed using Fisher's exact test and Spearman correlation. RESULTS: A total of 3081 SARS-CoV-2-positive patients were recorded, of which 318 (10.32%) met the inclusion criteria. Of them, 21 (6.60%) had ophthalmic manifestations and the female-to-male ratio was 1.6:1. The mean age (±SD) was 47.95±15.27 years and the median (interquartile range) time from the diagnosis of COVID-19, as defined by positive SARS-CoV-2 RT-PCR testing, to detection of the ophthalmic manifestation was 31 (142) days. The most common ocular manifestation was orbital mucormycosis (23.80%). Interestingly, the presence of ophthalmic manifestations was not associated with severe COVID-19 (p=0.665). CONCLUSIONS: The ophthalmic manifestations are infrequent in patients recovered from severe COVID-19. Nevertheless, further large sample studies are needed to confirm these findings.

[Ophthalmic manifestations in patients recovered from COVID-19 in Mexico]. / Manifestaciones oftálmicas en pacientes recuperados de COVID-19 en México.

Introduction and objectives: Although the ophthalmic manifestations appear to be associated with the coronavirus disease 2019 (COVID-19), there is not enough evidence. Hence, the aim of this study was to determine the various types and frequency of ophthalmic manifestations in patients recovered from SARS-CoV-2 infection in Mexico. Material and methods: This retrospective, observational and descriptive study included all patients recovered from SARS-CoV-2 infection attending the tertiary level hospital of Mexican Social Security Institute (IMSS) from June 2020 to June 2022. During the hospital admission of patients, the demographic data such age, name, gender was recorded. Ophthalmologic examination was performed under torchlight by an ophthalmologist in the Department of Ophthalmology from IMSS. Data was compiled and statistically analyzed using Fisher's exact test and Spearman correlation. Results: A total of 3,081 SARS-CoV-2-positive patients were recorded, of which 318 (10.32%) met the inclusion criteria. Of them, 21 (6.60%) had ophthalmic manifestations and the female-to-male ratio was 1.6:1. The mean age (±SD) was 47.95 ± 15.27 years and the median (interquartile range) time from the diagnosis of COVID-19, as defined by positive SARS-CoV-2 RT-PCR testing, to detection of the ophthalmic manifestation was 31 (142) days. The most common ocular manifestation was orbital mucormycosis (23.80%). Interestingly, the presence of ophthalmic manifestations was not associated with severe COVID-19 (p = 0.665). Conclusions: The ophthalmic manifestations are infrequent in patients recovered from severe COVID-19. Nevertheless, further large sample studies are needed to confirm these findings.

Burnout syndrome, anxiety, depression and occupational well-being among Peru hospital staff during the COVID-19 pandemic

Introduction: The COVID-19 pandemic has had serious consequences for the mental health of individuals, especially health care providers, who have experienced symptoms of stress, anxiety and depression that affect their personal, family and social lives. This situation has led health entities to evaluate the negative effects and to design interventions. Objective: To establish the relationship between burnout syndrome, anxiety, depression and work well-being, considering sociodemographic and work variables, including differences according to the type of work. Methods: The present study is non-causal, comparative, cross-sectional and prospective. The sampling was intentional non-probabilistic, with a total of 366 participants from three hospitals in Ancash (Peru) under COVID-19 conditions during the second wave. For the measurement of the variables, the Maslach Burnout Inventory, the Goldberg anxiety/depression subscales and the Sánchez-Cánovas work well-being subscales were used. Results: The results indicated multiple relationships among burnout syndrome, anxiety, depression and work well-being (p <0.05). Likewise, these relationships were also presented considering some sociodemographic and labor variables (p <0.05). Conclusions: The variables studied have a significant relationship in the health care personnel examined. Based on these findings, it is possible to have a baseline of the mental health of health personnel to plan interventions that emphasize those variables and groups at risk that require special attention. © 2022, Editorial Ciencias Medicas. All rights reserved.

Exploration Metrics Based on Scientific Mapping in the Use of Social Networks and Politics 2.0

The data exploration metrics through scientific mapping aim to find out the level of interest in social networks and politics 2.0 within the scientific community worldwide;the development of literary production in times of pandemic to which research is limited;the creation of both research and review articles sectioned by countries, authors, and keywords within the search carried out in the Scopus database. In the first instance, an analysis of the scientific literature is carried out in the primary citation index that is used worldwide to measure high-impact scientific production, such as Scopus;a total of 139,710 jobs were obtained, which were filtered only in the years of the COVID-19 pandemic, resulting in several jobs of 17,049. The results that could be analyzed through scientific mapping showed that scientific production increased in the keyword social networks (online) with several authors who mostly belong to developed and English-speaking countries;Mexico is the only country in Latin America within the results obtained through the maps. Finally, the analysis of the clusters relates keywords such as social networks, machine learning, and big data;within the systematic review, there are still no studies related to politics 2.0;therefore, it is concluded that the political keyword 2.0 still has no connection in terms of high-impact scientific production. © 2023, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

Clinical profile, symptomatology and sequelae of longCOVID patients

Introduction: Long-COVID patients are individuals that have ongoing symptoms persisting for weeks to months after SARS-CoV-2 infection. The incidence is increasing and more studies are necessary to deepen the knowledge of these patients. Objective(s): To investigate the clinical profile, symptomatology and sequelae of long-COVID patients. Method(s): In this observational study, long-COVID patients were included and evaluated by an internet survey. Sociodemographic data were obtained from the patient together with the COVID-19 Yorkshire Rehabilitation Screening Tool (C19-YRS). Consent of the patient was sought at the beginning of the survey. Result(s): Finally, 89 patients were included in the study. The main age was 43,34 +/-7,85 years, they were overweight, and non-smokers (84%), the 85,4% were females and the median time of infection was 8,18 +/-3,93 months. The results have shown significant impairments in dyspnea at rest or under exercise, personal care, pain, fatigue, psychological distress, and quality of life after COVID infection. Additionally, patients have referred sensitivity of the throat, voice and swallowing impairment, gastrointestinal disorders, and attention and memory problems. Conclusion(s): Patients with long- COVID present multiple sequelae that affect their health status, being necessary more future studies.

Cultural enterprises as an alternative for local development

The business sector in Colombia has experienced processes such as globalization, the covid-19 pandemic, tax reforms, which articulated results in excessive competition, uncertainty and crisis in economic terms and the cultural entrepreneurs of the municipality of Monteria do not escape this. In this order of ideas, the objective of this research work aims to analyze the potential of cultural business units to generate alternatives for local development. © GKA Ediciones, authors.

Lymphocytic exhaustion in Covid-19 patients

Introduction: The persistence of the SARS-CoV-2 virus is related to inflammation and lymphopenia in severe Covid19. Longitudinal follow-up of patients is scarce and would be of help to determine if the different immune responses lead to different clinical presentations Methods: Longitudinal prospective observational study of 91 patients. They were classified into viral phase, early inflammatory, and late inflammatory. We included clinical data, immune cell count, proinflammatory cytokine levels, serum inflammatory markers and tissue damage. Result(s): Lymphocyte count was lower with greater severity, and double in survivors. It remained stable during evolution, but with variations depending on the level of severity: critical and deceased patients, had a very low initial count (500/mm3) that did not increase;severe patients the initial lymphopenia (900/mm3) normalized during hospitalization;and moderate, showed a normal and stable count. The correlation of the initial innate immune response cytokine TNF-a with the T-cell-derived (CD4+) cytokines, IFN-g and IL-17A, was significant at all severity levels, although this correlation decreased in the late inflammatory phase. Furthermore, in patients who reached critical status or died, there was not the sustained increase in IFN-g levels observed in less severe Covid-19 (p<0.001), coinciding with the persistent lymphopenia in those patients. Conclusion(s): Our results confirm a drop in lymphocyte counts and decreased production of effector T-cell cytokines in the most severe patients, especially in the late phase of evolution, in line with the lymphocyte depletion described in critical and fatal Covid-19 disease.

Evolution ofIL-6 as possible marker of viral control in Covid-19

Introduction: Persistence of SARS-Cov-2 leads to immunosuppression and lack of viral control. Better understanding of the immune response throughout the course of evolution is important for a better patient management. Method(s): Prospective observational longitudinal study of 91 hospitalised patients with different degrees of severity (moderate, severe, critical). In 72 we obtained >=2 blood samples and classified them into viral phase (1-9 days after clinical onset), early inflammatory (10-16), and late inflammatory (>17). We included clinical data, immune cell counts, proinflammatory cytokine levels, serum inflammatory markers, and tissue damage. Result(s): We observed higher serum IL-6 levels in the more severe groups, from the first sample. In inflammatory phases, we found a significant decrease in IL-6 and LDH in moderate, severe and survivors, and high persistence in critical and deceased patients. The biphasic behavior of IL-6 described, first neutrophil recruitment, epithelial and endothelial damage and then, after achieving viral control, CD4 differentiation, Th cells response and potentiation of Ac response, could explain these differences between those who do not achieve viral control (critical, deceased) and those who do. Conclusion(s): - IL-6 levels at 10-16 days may indicate whether or not viral control is achieved and whether there may be progression to critical stage/death.

Effects of confinement due to COVID-19 in the child population of Alava on vitamin D status, weight and body composition

The coronavirus disease (COVID-19) pandemic brought with it a state of alarm as of March 14, 2020, which implied a restriction on the mobility of the general population and home confinement. One of the main concerns raised by isolation was the substantial reduction in energy expenditure due to children spending more time sitting or participating in activities that involve very low rates of energy expenditure, such as watching television, managing the different networks social One of the nutrients that could be affected due to these changes in lifestyle is vitamin D The longitudinal observational study of a single cohort was carried out in boys and girls from Alava aged between 3-16 years, whose follow-up is carried out in the outpatient clinics of the University Hospital of Alava. For this study, data from a period prior to the lockdown (November 2019-February 2020) was compared with data from the period after the lockdown (May 2020- June 2020). Once the favorable opinion was obtained and after consulting the database of the Pediatric consultation of the University Hospital of Alava, it was observed that 230 girls and boys met the parameters for inclusion in the study. After eliminating those who did not have a previous or subsequent analysis of vitamin D, the sample size was reduced to 76 Results: - An increase in size: they are in the growth phase. - An increase in weight - An increase in the body mass index: In this case, this index also increased from 19.5to19.9 - A drop in physical activity - An increase in the number of hours that participants spent on electronic devices. - An increase in the percentage of girls and boys who help in the kitchen: After confinement, the percentage increased to 70%. - An increase in the weekly consumption of snacks(p<0.005). - There were no changes in the number of daily meals, servings of fruit, vegetables, dairy products, fish, red meat, eggs or sugary drinks- There were no differences in the number of hours the participants slept before and during the lockdown. - An increase in glucoset (p<0.005) although both parameters are within normal values. - An increase in vitamin D: 22.35 ng/dL on average, which rose to 25.57 ng/dL.This difference is significant (p<0.005), although both parameters are within normal levels.This increase may be due to the fact that after confinement the population wanted to go out and took more time in the street.In addition, shops and interior sites were closed.

Masks during COVID-19 times

Since the first incident of COVID-19 pandemic in Wuhan, China, face masks have become an important tool for preventing the spread of COVID-19, and personal protection from contracting the virus. In Mexico, the most used masks are disposable surgical masks, N95, and KN95 filtering masks. However, at the beginning and during the higher contagion stages, due to inadequate information at this time, most people were unable to use the masks, affecting health personnel. In this manuscript, we intend to review the characteristics of the masks, the commonly used manufacturing materials for masks' production, and mechanisms through which the masks work such as the initial impact mechanism, interception mechanism, diffusion mechanism, and electrostatic attraction mechanism;presenting such information with the purpose of explaining the basic but necessary aspects of masks. This is in a bid to prepare the people ready for the appropriate use of face masks of future pandemics such as the one we have now. Finally, the importance of scientific research in understanding the use and development of masks is mentioned. © 2022 Facultad de Quimica, UNAM. All rights reserved.

Impact of plasmapheresis on severe COVID-19.

The clinical course of COVID-19 may show severe presentation, potentially involving dynamic cytokine storms and T cell lymphopenia, which are leading causes of death in patients with SARS-CoV-2 infection. Plasma exchange therapy (PLEX) effectively removes pro-inflammatory factors, modulating and restoring innate and adaptive immune responses. This clinical trial aimed to evaluate the impact of PLEX on the survival of patients with severe SARS-CoV-2 and the effect on the cytokine release syndrome. Hospitalized patients diagnosed with SARS-CoV-2 infection and cytokine storm syndrome were selected to receive 2 sessions of PLEX or standard therapy. Primary outcome was all-cause 60-days mortality; secondary outcome was requirement of mechanical ventilation, SOFA, NEWs-2 scores modification, reduction of pro-inflammatory biomarkers and hospitalization time. Twenty patients received PLEX were compared against 40 patients receiving standard therapy. PLEX reduced 60-days mortality (50% vs 20%; OR 0.25, 95%CI 0.071-0.880; p = 0.029), and this effect was independent from demographic variables and drug therapies used. PLEX significantly decreased SOFA, NEWs-2, pro-inflammatory mediators and increased lymphocyte count, accompanied with a trend to reduce affected lung volume, without effect on SatO2/FiO2 indicator or mechanical ventilation requirement. PLEX therapy provided significant benefits of pro-inflammatory clearance and reduction of 60-days mortality in selected patients with COVID-19, without significant adverse events.

Clinical epidemiological characterization of patients affected by COVID-19 in a General Hospital of Veracruz, Mexico

Background. Since the beginning of the pandemic and its passage through the different affected continents, there have been differences in the presentation depending in part on the characteristics of each population, so it is important to know how it behaves in the local population. Methods. Clinical-epidemiological study in adults hospitalized for suspected COVID-19 at the General Hospital 71 of the City of Veracruz, Mexico, from April to December 2020. Demographic and clinical characteristics are studied, as well as a comparative and stratified analysis was performed by intubation and death. Results. 1212 patients are included, 53% are men, average age 49 years. 20.5% reported sudden onset of symptoms;the most frequent: fever (79.8%), headache (75.2%), cough (71%), myalgia (62%), arthralgia (58%) and dyspnea (46.3%). Comorbidities were reported in 54.7%, the most frequent: Hypertension (29.2%), Diabetes (29.1%) and obesity (13.9%). Regarding the outcomes, 120 (9.9%) required intubation and 300 (25%) died. Men requiring intubation were significantly older than women [62.5 vs 37.5%;p = 0.027]. The mean age of the intubated patients was higher compared to that of the non-intubated [60.5 vs 44.8 years;p = 0.001]. The male gender had a risk association for intubation. The group aged 60 years or older compared to those aged 59 years or younger had a higher risk of intubation. Clinical variables that had a risk association with intubation were: dyspnea, chest pain and prostration. Among comorbidities, hypertension and diabetes had a risk association with intubation. Female gender and headache had a protective association for intubation. In addition, odynophagia, rhinorrhea, and abdominal pain showed a protective association for intubation. There was no difference in terms of gender by death. The mean age of the patients who died was significantly older [64.5 vs 43.8 years;p = 0.001]. The clinical variables that had a risk association with death were: dyspnea, chest pain, polypnea, cyanosis and prostration. The protective variables were: rhinorrhea, odynophagia, headache and conjunctivitis Conclusion. By studying a population affected by COVID, its own characteristics and inherent risks can be known to help take local diagnosis and treatment strategies that ensure a better outcome for those affected.

Comparative analysis between Polymerized Type I Collagen and Baricitinib as potential treatment for COVID-19

Background. Baricitinib is a treatment authorized by the FDA for the treatment of moderate to severe COVID-19, despite this there are few approved drugs;polymerized type I collagen (PTIC) is a drug that has been used in Mexico with great potential for treating moderate to severe cases of COVID-19. Methods. Comparative, descriptive and retrospective analysis of two populations of adult patients affected by COVID-19 confirmed by antigen test or RT-PCR as well as CO-RADS 6 CT, who consented to be treated between 2020 and 2021, a population using oral baricitinib at a dose of 4mg/day/14 days and another using polymerized type I collagen intramuscularly at a dose of 1.5ml every 12 hours for 3 days, followed by 1.5ml every 24 hours for 4 days;The most affected age and gender, comorbidities and laboratory abnormalities are analyzed, as well as improvement in inflammatory and oxygenation indices measured by pulse oximetry and SAFI (SpO2/FiO2), finally the outcome of the patients and the presence of adverse events. Results. 80 patients for each group, the most affected gender was male;the average age in the PTIC group was 51 years and in the baricitinib group it was 56 years;the main comorbidities were obesity, diabetes and hypertension in both groups;the decrease in acute phase reactants such as CRP, D-dimer and ferritin was greater in the PTIC group compared to the baricitinib group, the latter drug requiring a regimen of more days to achieve the objectives of the first drug (PTIC 7 days and baricitinib 14 days);Similarly, in oxygenation measured, the PTIC group reached goals in less time compared to the baricitinib group, which required twice as many days of treatment to achieve adequate oxygenation;Regarding the outcomes, there was a higher mortality in the baricitinib group compared to the PTIC group (6.25% vs 3.75%). Regarding adverse events reported for the PTIC group, they were minor and related to the intramuscular administration of the drug in 7 patients, while in the baricitinib group, 5 patients were reported with added bacterial pneumonia. Conclusion. Polymerized type I collagen has anti-inflammatory and immunomodulatory potential similar to baricitinib in cases of moderate to severe COVID-19, even reaching treatment goals in less time both in inflammatory indices and in oxygenation indices.