End-expiratory lung volumes as a potential indicator for COVID-19 associated acute respiratory distress syndrome: a retrospective study (preprint)

Background End-expiratory lung volume (EELV) has been observed to decrease in acute respiratory distress syndrome (ARDS). Yet, research investigating EELV in patients with COVID-19 associated ARDS (CARDS) remains limited. It is unclear EELV serve as a potential metric for monitoring disease progression and identifying patients with ARDS at increased risk of adverse outcomes.Study Design and Methods: This retrospective study included mechanically ventilated patients with CARDS during the initial phase of epidemic control in Shanghai. EELV was measured within 48 hours post-intubation, followed by regular assessments every 3–4 days. Chest CT scans, performed within a 24-hour window around each EELV measurement, were analyzed using AI software. Differences in patient demographics, clinical data, respiratory mechanics, EELV, and chest CT findings were assessed using linear mixed models (LMM).Results Out of the 38 enrolled patients, 26.3% survived until discharge from the ICU. In the survivor group, EELV, EELV/PBW and EELV/preFRC were significantly higher than those in the non-survivor group (survivor group vs non-survivor group: EELV: 1455 vs 1162 ml, P = 0.049; EELV/PBW: 24.1 vs 18.5 ml/kg, P = 0.011; EELV/preFRC: 0.45 vs 0.34, P = 0.005). Follow-up assessments showed a sustained elevation of EELV/PBW and EELV/preFRC among the survivors. Additionally, EELV exhibited a positive correlation with total lung volume and residual lung volume, while demonstrating a negative correlation with lesion volume determined through chest CT scans analyzed using AI software.Conclusion EELV is a useful indicator for assessing disease severity and monitoring the prognosis of patients with CARDS.

Efficacy and safety of glucocorticoids use in patients with COVID- 19: a systematic review and network meta‑analysis (preprint)

Background Currently, some meta-analyses on COVID-19 have suggested that glucocorticoids use can reduce the mortality rate of COVID-19 patients, utilization rate of invasive ventilation, and improve the prognosis of patients. However, optimal regimen and dosages of glucocorticoid remain unclear. Therefore, the purpose of this network meta-analysis is to analyze the efficacy and safety of glucocorticoids in treating COVID-19 at regimens. Methods This meta-analysis retrieved randomized controlled trials from the earliest records to December 30, 2022, published in PubMed, Embase, Cochrane Library, CNKI Database and Wanfang Database, which compared glucocorticoids with placebos for their efficacy and safety in the treatment of COVID-19, Effects of different treatment regimens, types and dosages (high-dose methylprednisolone, very high-dose methylprednisolone, Pulse therapy methylprednisolone, medium-dose hydrocortisone, high-dose hydrocortisone, high-dose dexamethasone, very high-dose dexamethasone and placebo) on 28-day all-caused hospitalization mortality, hospitalization duration, mechanical ventilation requirement, ICU admission and safety outcome were compared. Results In this network meta-analysis, a total of 10544patients from 19 randomized controlled trials were finally included, involving a total of 9 glucocorticoid treatment regimens of different types and dosages. According to the analysis results, the 28-day all-cause mortality rate was the lowest in the treatment with pulse therapy methylprednisolone (OR 0.08, 95% CI 0.02, 0.42), but the use of high-dose methylprednisolone (OR 0.85, 95% CI 0.59, 1.22), very high-dose dexamethasone (OR 0.95, 95% CI 0.67, 1.35), high-dose hydrocortisone (OR 0.64, 95% CI 0.34, 1.22), medium-dose hydrocortisone (OR 0.80, 95% CI 0.49, 1.31) showed no benefit in prolonging the 28-day survival of patient. Compared with placebo, the treatment with very high-dose methylprednisolone (MD= -3.09;95%CI: -4.10, -2.08) had the shortest length of hospital stay, while high-dose dexamethasone (MD= -1.55;95%CI: -3.13,0.03) and very high-dose dexamethasone (MD= -1.06;95%CI: -2.78,0.67) did not benefit patients in terms of length of stay. Conclusions Considering the available evidence, this network meta‑analysis suggests that the prognostic impact of glucocorticoids in patients with COVID-19 may depend on the regimens of glucocorticoids. It is suggested that pulse therapy methylprednisolone is associated with lower 28-day all-cause mortality, very high-dose methylprednisolone had the shortest length of hospital stay in patients with COVID-19. Trial registration: PROSPERO CRD42022350407 (22/08/2022).

Estimating vaccine-preventable COVID-19 deaths under counterfactual vaccination scenarios in the United States (preprint)

In early 2021, effective SARS-CoV-2 (COVID-19) vaccines became available in the United States; by mid-April 2021, vaccine availability outstripped demand, daily vaccination rates peaked, and COVID-19 vaccines were found highly effective in adult populations. Accurate estimates of the number of vaccine-preventable deaths had higher vaccination rates been attained could have helped local policymakers and possibly persuaded more to get vaccinated. Because existing estimation methodologies are limited, for the period 1/1/21 – 4/30/22, we simulated the number of vaccine-preventable deaths associated with two-dose COVID-19 vaccination that incorporated state-level population, death, and vaccination numbers and three scenarios of vaccination rate achievement. Nationally, we found that had 100% of the population became fully vaccinated during the period examined, 318,979 deaths, or approximately 50% of actual COVID-19 deaths, might have been prevented; had 85% been so, 28% might have been prevented. Across states, we found substantial variation in the proportion of avoidable COVID-19 deaths that might have been avoided at the state level, from 25% in Massachusetts to 74% in Alaska. Our findings are sobering when considering the painful deaths, the survivors’ anguish, and the diversion of scarce and expensive healthcare resources that might have been averted had peak vaccination administration efforts been maintained.

Correlation between parents’ social media use, educational level, COVID-19 vaccination status and vaccine hesitancy for their children in Singapore

AimsAfter the approval of the paediatric COVID-19 vaccines, the uptake was slower compared to the teenagers and adults in Singapore. Studies have shown that parents with higher social media usage are more hesitant to vaccinate their children. Our research aims to determine: (1) correlation between profile of parents in Singapore and source of information versus vaccine hesitancy, (2) their opinions towards paediatric COVID-19 vaccines.MethodsA prospective, anonymous, and voluntary electronic survey was performed in Singapore from 14/Nov/2021 for 12 weeks. Demographic data was obtained. Time spent on social media (Facebook, YouTube, Twitter, Weibo, Instagram) and total device usage per week were divided into high and low usage: high usage being more than 12 hours/week of social media and/or 6 hours/day of device use. Vaccine hesitancy was a self-assessed variable by the participants. Results were analysed using Chi-square and Fisher’s exact tests with SPSS. Statistical significance was defined to be 2-sided p <.05.ResultsWe surveyed 628 parents (mean (SD) of 39.1(6.7) years old), with 69.1% being mothers, with a median of 2 children each. 90.1% had at least pre-university education. Majority (99.2%) had received at least 1 dose of the COVID-19 vaccine. 61.4% had at least 1 child eligible for paediatric COVID-19 vaccine and 27.6% had at least 1 teenager. Respondents spent a mode of 1 to 12 hours per week on social media and 1 to 6 hours per day on digital devices. 85.8% and 61.0% believed that mRNA COVID-19 vaccines were most effective, and safest against COVID-19, respectively. The most read source for health information was from print material such as health pamphlets (50.8%) rather than social media (35.7%).Contrary to other studies, parents with high usage of digital devices were more willing to give mRNA vaccines to their teenagers (84.0% vs 16.0%, p<.001). COVID-19 unvaccinated parents were also more childhood vaccine hesitant. (100% vs 18.3%, p< .001). Comparing to lower educated parents, parents with at least pre-university education were less vaccine hesitant (30.5% vs 56.5%, p<.001). They were more likely to receive COVID-19- related information via other print material (91.2% vs 8.8%, p=.010). Among parents with at least pre-university education, 53.0% obtained most of their COVID-19 related information from print material compared to social media (35.1%). Parents who personally knew someone with a bad reaction to the COVID-19 vaccine correlates to hesitancy towards childhood vaccines (18.9% vs 14.2%, p<.001).ConclusionVaccine hesitancy is correlated with low device and social media usage, parents’ unvaccinated status, low education status. Despite high usage of social media and digital devices, parents with a higher level of education were more likely to obtain information regarding COVID-19 vaccines from print material rather than social media. Health education regarding vaccine safety through print media may encourage more parents to vaccinate their children and may help to reassure them that benefits overweigh the risks to increase uptake.

Design and implementation of an experimental device by the pendant drop method for measuring surface tension of pulmonary fluid (preprint)

The quantitative measurement of pulmonary fluid surface tension in many lung diseases including respiratory distress syndrome (RDS), pneumonia, COVID-19 and acute respiratory distress syndrome (ARDS) has great physiological and clinical significance. The conventional techniques like film balances and bubble methods, however, are hard to use in the clinical practice due primarily to a limitation of small sample volume. In this work, we developed an experimental device based on the pendant drop method to clinically measure surface tension of pulmonary fluids in ARDS patients. We provided a detailed discussion of the theoretical background to the design of hardware and software as well as validation of measurement precision. The measured surface tensions of the two test liquids, pure water and dimethyl silicone oil, are 72.35±1.00 mN⁄m and 21.38±0.61 mN⁄m, respectively, in good agreement with the corresponding literature values of 72.02 mN⁄m and 21.10 mN⁄m at room temperature of 25℃.Using this experimental setup, we tentatively measured surface tensions of four pulmonary fluid samples from several mechanically ventilated ARDS patients. The results showed that the measured surface tension at 25±1℃ is within the range of 23.8～53.9 mN/m, comparable with reported values in the literature. Further, the calculation of the Worthington number showed that the data obtained are sufficiently accurate. We came to the conclusion that the pendant drop tensiometry is a powerful tool in the studies of pulmonary fluid surface properties due to a small sample size, high degree automation and freedom from contamination.

Estimating Vaccine-Preventable COVID-19 Deaths Under Counterfactual Vaccination Scenarios in the United States (preprint)

ImportanceWith an abundant supply of COVID-19 vaccines becoming available in spring and summer 2021, the major barrier to high vaccination rates in the United States has been a lack of vaccine demand. This has contributed to a higher rate of deaths from SARS-CoV-2 infections amongst unvaccinated individuals as compared to vaccinated individuals. It is important to understand how low vaccination rates directly impact deaths resulting from SARS-CoV-2 infections in unvaccinated populations across the United States. ObjectiveTo estimate a lower bound on the number of vaccine-preventable deaths from SARS-CoV-2 infections under various scenarios of vaccine completion, for every state of the United States. Design, Setting, and ParticipantsThis counterfactual simulation study varies the rates of complete vaccination coverage under the scenarios of 100%, 90% and 85% coverage of the adult (18+) population of the United States. For each scenario, we use U.S. state-level demographic information in conjunction with county-level vaccination statistics to compute a lower bound on the number of vaccine-preventable deaths for each state. ExposuresCOVID-19 vaccines, SARS-CoV-2 infection Main Outcomes and MeasuresDeath from SARS-CoV-2 infection ResultsBetween January 1st, 2021 and April 30th, 2022, there were 641,305 deaths due to COVID-19 in the United States. Assuming each state continued peak vaccination capacity after initially achieving its peak vaccination rate, a vaccination rate of 100% would have led to 322,324 deaths nationally, that of 90% would have led to 415,878 deaths, and that of 85% would have led to 463,305 deaths. As a comparison, using the state with the highest peak vaccination rate (per million population each week) for all the states, a vaccination rate of 100% would have led to 302,344 deaths nationally, that of 90% would have led to 398,289 deaths, and that of 85% would have led to 446,449 deaths. Conclusions and RelevanceOnce COVID-19 vaccine supplies peaked across the United States, if there had been 100% COVID-19 vaccination coverage of the over 18+ population, a conservative estimate of 318,981 deaths could have been potentially avoided through vaccination. For a 90% vaccination coverage, we estimate at least 225,427 deaths averted through vaccination, and at least 178,000 lives saved through vaccination for an 85% vaccination coverage.

Genetic characteristics and nucleic acid detection results of SARS-CoV-2 in 2297 clinical samples

Objective To analyze the genomics characteristics and nucleic acid detection results of the severe Acute respiratory syndrome coronavirus 2（SARS-CoV-2） in 2 297 clinical samples collected in January and February, 2020 in Laboratory of Microbiology of Changsha Municipal Center for Disease Control and Prevention. Methods Viral RNA of throat swabs or respiratory tract specimens of coronavirus disease 2019（COVID-19） suspected cases from January 19, 2020 to February 29, 2020 was extracted and SARS-CoV-2 nucleic acid was detected by real-time reverse transcription polymerase chain reaction.The full length genome of SARS-CoV-2 in positive samples was enriched by using viral genome capture kit and sequenced on Illumina MiSeq platform.The raw reads were mapped and aligned with SPAdes software v 3.13.0.Reference SARS-CoV-2 sequences were obtained from GISAID（https://www.gisaid.org） andviral genetic evolution and antigen variation were analyzed. Results A total of 215 SARS-Co V2-nucleic acid positive samples were identified from 2 297 clinical samples.Among the SARS-Co V2-positive samples, 110 were males and 105 were from females.The male to female ratio was 1.05∶1.The highest positive rate was among 40-<60 years old people（11.35%） and the lowest positive rate was in children under 6 years old（5.49%）.The peak of newly confirmed cases was in the 5 th week（January 26 to February 1, 2020） and then decreased.There was no newly positive case after February 25, 2020.Five SARS-Co V2-whole genome sequences were obtained and there were 4 to 6 nucleotide mutations compared to the Wuhan reference strain, and the homology was more than 99.90%.Most mutations occurred only once except C8782 T and T28144 C, indicating random mutations.Phylogenetic analysis revealed that the 5 sequences belonged to the L/B or S/A lineages and were highly homologous with strains prevalent in other provinces of China at the same time. Conclusions With the quick nucleic acid tests and quarantine measures, the SARS-Co V2-positive cases in Changsha began to decline after a 2-week increasing period, and there was no new confirmed cases 6 weeks later.The genomes of SARS-Co V-2 prevalent in Changsha are highly homology with the Wuhan strains in the early 2020 and no obvious mutation is found in the local pandemic period. Reset

Incidence, Risk Factors, and Outcomes of Patients with COVID‑19‑Associated Pulmonary Aspergillosis (CAPA) in Intensive Care Units: A Systematic Review and Meta-Analysis Of 29 Cohort Studies (preprint)

Background Patients with Coronavirus disease 2019 (COVID-19) admitted to an intensive care unit (ICU) might develop COVID-19-related pulmonary Aspergillosis (CAPA). We aimed to identify studies systematically that describe the incidence and risks factors of CAPA, and to assess its outcome. Methods Two authors independently searched ScienceDirect, PubMed, CNKI, MEDLINE (OVID), and MedRXIV from December 31, 2019 to Feb 27, 2021. We included observational cohort studies that investigated patients with CAPA admitted to an ICU. We assessed the quality of all included studies using the Newcastle–Ottawa Scale). The meta-analysis was registered with PROSPERO (CRD42021242179).ResultsTwenty-nine cohort studies with 2095 patients with COVID-19 admitted to an ICU and 264 patients who developed to CAPA were included (Pooled incidence: 0.14, 95% confidence interval [CI] = 0.11–0.17). The overall mortality and case fatality rate of CAPA were 0.07 (0.05–0.09) and 0.51 (0.44–0.58), respectively. Patients with COVID‑19 would develop CAPA at 7.28 days after mechanical ventilation (range, 5.48–9.08). Compared with patients without CAPA, those with CAPA had a significantly lower median body mass index (27.32 vs. 28.97 kg/m2, P = 0.034), higher median creatinine level (127.94 vs. 88.23 µmol/L, P = 014), and were more likely to receive corticosteroids therapy (41.0% vs. 38.0%, risk ratio [RR] = 1.98, 95% CI=1.08–3.63) and renal replacement therapy (42.0% vs. 28.2%, RR = 1.61, 95% CI=1.04–2.50) during admission. Remarkably, patients with CAPA were associated significantly with a 1.66‑fold higher mortality (RR = 1.66, 95% CI=1.31–2.12) without significant heterogeneity and publication bias. ConclusionsPatients with COVID-19 admitted to an ICU might develop CAPA and have higher all‑cause mortality. We recommend conducting prospective screening for CAPA among patients with severe COVID-19, especially for those who receive mechanical ventilation over 7 days. 

Delayed Initiation of ECMO is Associated With Poor Prognosis in Severe COVID-19 Patients: A Multicenter Retrospective Cohort Study (preprint)

Background: Extracorporeal membrane oxygenation (ECMO) is a rapidly evolving therapy for acute lung and/or heart failure. However, information on the application of ECMO in severe coronavirus disease 2019 (COVID-19) is limited, such as the initiation time, especially in the ECMO instrument shortages period and regions, not all the listed patients could be treated with ECMO in time. This study aims to investigate and clear the timing of ECMO initiation related to the prognosis of severe COVID-19 patients. And emphasize the initiation time of ECOM application no more than 24 hours, when the ECMO completion trigger is tripped.Methods: In this retrospective, multi-center cohort study, we enrolled all ECMO patients with confirmed COVID-19 at three hospitals between Dec 29, 2019 and Apr 5, 2020. Demographic data, clinical presentation, laboratory profile, clinical course, treatments, complications and outcomes were collected. The primary outcomes were analyzed by ECMO weaning rate and 60-day mortality after ECMO.Results: A total of 31 patients were included in the analysis, 60-day mortality rate after ECMO was 71% and ECMO weaning rate was 26%. Due to ECMO instrument shortages, patients were divided into delayed ECMO groups (3 [IQR, 2-5] days) and early ECMO groups (0.5 [IQR, 0-1] days) based on the initiation time of ECMO. There were 14 patients in the early treatment group and 17 patients in the delayed group. Early initiation of ECMO was associated with decreased 60-day mortality after ECMO (50% vs. 88%, P=0.044) and increased ECMO weaning rate (50% vs. 6%, P=0.011).Conclusions: In the ECMO supported COVID-19 patients, delayed initiation of ECMO is a risk factor and associated with a poorer prognosis for these patients.Trial Registration: Chinese Clinical Trial Registry identifier: ChiCTR2000030947.Funding Statement: Not applicable.Declaration of Interests: The authors declare that they have no competing interests.Ethics Approval Statement: The study was approved by Jinyintan Hospital ethics board.

Secondary Infection in Severe and Critical COVID-19 Patients in China: A Multicenter Retrospective Study (preprint)

Background. Since 2020 COVID-19 pandemic became an emergent public sanitary incident. The epidemiology data and the impact on prognosis of secondary infection in severe and critical COVID-19 patients in China remained largely unclear.Methods. We retrospectively reviewed medical records of all adult patients with laboratory-confirmed COVID-19 who were admitted to ICUs from January 18th 2020 to April 26th 2020 at two hospitals in Wuhan, China and one hospital in Guangzhou, China. We measured the frequency of bacteria and fungi cultured from respiratory tract, blood and other body fluid specimens. The risk factors for and impact of secondary infection on clinical outcomes were also assessed. Results. Secondary infections were very common (86.6%) when patients were admitted to ICU for >72 hours. The majority of infections were respiratory, with the most common organisms being Klebsiella pneumoniae (24.5%), Acinetobacter baumannii (21.8%), Stenotrophomonas maltophilia (9.9%), Candida albicans (6.8%), and Pseudomonas spp. (4.8%). Furthermore, the proportions of multidrug resistant (MDR) bacteria and carbapenem resistant Enterobacteriaceae (CRE) were high. We also found that age ≥60 years and mechanical ventilation ≥13days independently increased the likelihood of secondary infection. Finally, patients with positive cultures had reduced ventilator free days in 28 days and patients with CRE and/or MDR bacteria positivity showed lower 28 day survival rate.Conclusions. In a retrospective cohort of severe and critical COVID-19 patients admitted to ICUs in China, the prevalence of secondary infection was high, especially with CRE and MDR bacteria, resulting in poor clinical outcomes.

Clinical characteristics and manifestations in older patients with COVID-19 (preprint)

Background: To investigate the clinical characteristics and manifestations of older patients with coronavirus disease 2019 (COVID-19). Methods: : In this retrospective study, 566 patients with confirmed COVID-19 were enrolled and the clinical characteristics, laboratory findings, complications and outcome data were collected and analyzed. Results: : Among the 566 patients (median age, 61.5 years) with COVID-19, 267 (47.2%) patients were male and 307 (54.2%) were elderly. Compared with younger patients, older patients had more underlying comorbidities and laboratory abnormalities. A higher rate of acute respiratory distress syndrome (ARDS), acute cardiac injury and heart failure was observed in the older group as compared with younger and middle-aged groups, particularly those oldest-old patients (>75 years) had more multi-organ damage. Older patients with COVID-19 were more likely to suffer from acute cardiac injury in cases with preexistenting cardiovascular diseases, while there was no difference among the three groups when patients had no history of cardiovascular diseases. Older patients present more severe with the mortality of 18.6%, which was higher than that in younger and middle-aged patients ( P <0.05). Multivariable analysis showed that age, lymphopenia, ARDS, acute cardiac injury, heart failure and skeletal muscle injury were associated with death in older patients, while glucocorticoids may be harmful. Conclusions: : Older patients, especially the oldest-old patients were more likely to exhibit significant systemic inflammation, pulmonary and extrapulmonary organ damage and a higher mortality. Advanced age, lymphopenia, ARDS, acute cardiac injury, heart failure and skeletal muscle injury were independent predictors of death in older patients with COVID-19 and glucocorticoids should be carefully administered in older patients.

Corticosteroid therapy for corona virus disease 2019-related acute respiratory distress syndrome: a cohort study with propensity score analysis (preprint)

Background: The impact of corticosteroid therapy on outcomes of patients with Coronavirus disease-2019 (COVID-19) is highly controversial. We aimed to compare the risk of death between COVID-19-related ARDS patients with corticosteroid treatment and those without. Methods In this single-centre retrospective observational study, patients with ARDS caused by COVID-19 between 24 December 2019 and 24 February 2020 were enrolled. The primary outcome was 60-day in-hospital death. The exposure was prescribed systemic corticosteroids or not. Time-dependent Cox regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for 60-day in-hospital mortality. Results A total of 382 patients including 226 (59.2%) patients who received systemic corticosteroids and 156 (40.8%) patients with standard treatment were analyzed. The maximum dose of corticosteroids was 80.0 (IQR 40.0–80.0) mg equivalent methylprednisolone per day, and duration of corticosteroid treatment was 7.0 (4.0–12.0) days in total. In Cox regression analysis using corticosteroid treatment as a time-varying variable, corticosteroid treatment was associated with a significant reduction in risk of in-hospital death within 60 days (HR, 0.48; 95% CI, 0.25, 0.93; p  = 0.0285). The association remained significantly after adjusting for age, sex, Sequential Organ Failure Assessment score at hospital admission, propensity score of corticosteroid treatment, and comorbidities (HR: 0.51; CI: 0.27, 0.99; p  = 0.0471). Corticosteroids were not associated with delayed viral RNA clearance in our cohort. Conclusion In this clinical practice setting, low-to-moderate dose corticosteroid treatment was associated with reduced risk of death in COVID-19 patients who developed ARDS.

The incidence, risk factors and prognosis of acute kidney injury in severe and critically ill patients with COVID-19 in mainland China: a retrospective study (preprint)

Background: Since the clinical correlates, prognosis and determinants of AKI in patients with Covid-19 remain largely unclear, we perform a retrospective study to evaluate the incidence, risk factors and prognosis of AKI in severe and critically ill patients with Covid-19.Methods: We reviewed medical records of all adult patients (>18 years) with laboratory-confirmed Covid-19 who were admitted to the intensive care unit (ICU) between January 23rd 2020 and April 6th 2020 at Wuhan JinYinTan Hospital and The First Affiliated Hospital of Guangzhou Medical University. The clinical data, including patient demographics, clinical symptoms and signs, laboratory findings, treatment [including respiratory supports, use of medications and continuous renal replacement therapy (CRRT)] and clinical outcomes, were extracted from the electronic records, and we access the incidence of AKI and the use of CRRT, risk factors for AKI, the outcomes of renal diseases, and the impact of AKI on the clinical outcomes.Results: Among 210 subjects, 131 were males (62.4%). The median age was 64 years (IQR: 56-71). Of 92 (43.8%) patients who developed AKI during hospitalization, 13 (14.1%), 15 (16.3%) and 64 (69.6%) patients were classified as stage 1, 2 and 3, respectively. 54 cases (58.7%) received CRRT. Age, sepsis, Nephrotoxic drug, IMV and elevated baseline Scr were associated with AKI occurrence. The renal recover during hospitalization among 16 AKI patients (17.4%), who had a significantly shorter time from admission to AKI diagnosis, lower incidence of right heart failure and higher P/F ratio. Of 210 patients, 93 patients deceased within 28 days of ICU admission. AKI stage 3, critical disease, greater age and minimum P/F <150mmHg independently associated with it.Conclusions: Among patients with Covid-19, the incidence of AKI was high. age , sepsis, nephrotoxic drug, IMV and baseline Scr were strongly associated with the development of AKI. Time from admission to AKI diagnosis, right heart failure and P/F ratio were independently associated with the potential of renal recovery. Finally, AKI KIDGO stage 3 independently predicted the risk of death within 28 days of ICU admission.

COVID-19: Repeated video-watching vs. combined video-watching and live demonstration as training to health care providers for donning and doffing personal protective equipment (preprint)

Background During the COVID-19 pandemic, not only was there a lack of personal protective equipment (PPE) for health care workers but a dearth in training in respect of its donning and doffing. This study compared two training methods for donning and doffing PPE in order to teach health care workers how to do so more effectively and quickly.Method A total of 48 health care workers were recruited and randomly divided into two groups. Group A watched a 10-minute demonstration (demo) video repeated four times, while Group B watched the same demo video twice followed by a 10-minute live demo twice. The learning time of both groups was the same, and an examination was performed immediately after the completion of training. The examination scores of Group A and Group B were recorded according to the checklist (Appendix 1). The time taken for the participants to don and doff PPE, their satisfaction with the training, and the confidence to don and doff PPE were analyzed.Results The average score of Group B was better than that of Group A, with a mean (SD) of 94.92 (1.72) vs. 86.63 (6.34), respectively (P < 0.001). The average time spent by Group B to do the examination was shorter than that of Group A, with a mean (SD) of 17.67 (1.01) vs. 21.75 (1.82), respectively (P < 0.001). The satisfaction and confidence of Group B were higher than those of group A (P < 0.001).Conclusions Compared with repeated video-watching learning, the video-watching plus a live demonstration teaching method is more suitable for health care workers to learn how to put on and remove personal protective equipment.

A Randomized, Single-blind, Group sequential, Active-controlled Study to evaluate the clinical efficacy and safety of α-Lipoic acid for critically ill patients with coronavirus disease 2019(COVID-19) (preprint)

Object: To evaluate the clinical efficacy and safety of -Lipoic acid (ALA) for critically ill patients with coronavirus disease 2019 (COVID-19). Methods: A randomized, single-blind, group sequential, active-controlled trial was performed at JinYinTan Hospital, Wuhan, China. Between February 2020 and March 2020, 17 patients with critically ill COVID-19 were enrolled in our study. Eligible patients were randomly assigned in a 1:1 ratio to receive either ALA (1200 mg/d, intravenous infusion) once daily plus standard care or standard care plus equal volume saline infusion (placebo) for 7 days. All patients were monitored within the 7 days therapy and followed up to day 30 after therapy. The primary outcome of this study was the Sequential Organ Failure Estimate (SOFA) score, and the secondary outcome was the all-cause mortality within 30 days. Result: Nine patients were randomized to placebo group and 8 patients were randomized to ALA group. SOFA score was similar at baseline, increased from 4.3 to 6.0 in the placebo group and increased from 3.8 to 4.0 in the ALA group (P=0.36) after 7 days. The 30-day all-cause mortality tended to be lower in the ALA group (3/8, 37.5%) compared to that in the placebo group (7/9, 77.8%, P=0.09). Conclusion: In our study, ALA use is associated with lower SOFA score increase and lower 30-day all-cause mortality as compared with the placebo group. Although the mortality rate was two-folds higher in placebo group than in ALA group, only borderline statistical difference was evidenced due to the limited patient number. Future studies with larger patient cohort are warranted to validate the role of ALA in critically ill patients with COVID-19. Keywords: Pneumonia; COVID-19; SARS-CoV-2 ; -Lipoic acid

Countermeasures and treatment for aortic acute syndrome with novel coronavirus pneumonia / 中华外科杂志

@#The novel coronavirus pneumonia (NCP) has cost a great loss to the health and economic property of Chines people. Under such a special circumstance, how to deal with such patients with acute aortic syndrome has become a serious challenge. Rapid diagnosis of concomitant NCP, safe and effective transportation, implementation of the interventional procedure, protection of vascular surgical team and postoperative management and follow-up of such patients have become urgent problems for us. Combined with the latest novel government documents, the literature and the experiences from Wuhan, we answered the above questions briefly and plainly. It also hopes to inspire the national vascular surgeons to manage critical emergencies in vascular surgery and even routine vascular diseases with NCP, as a final point to limit the severe epidemic situation, and minimize the damage of NCP.

Heart injury signs are associated with higher and earlier mortality in coronavirus disease 2019 (COVID-19) (preprint)

Importance: Heart injury can be easily induced by viral infection such as adenovirus and enterovirus. However, whether coronavirus disease 2019 (COVID-19) causes heart injury and hereby impacts mortality has not yet been fully evaluated. Objective: To explore whether heart injury occurs in COVID-19 on admission and hereby aggravates mortality later. Design, Setting, and Participants A single-center retrospective cohort study including 188 COVID-19 patients admitted from December 25, 2019 to January 27, 2020 in Wuhan Jinyintan Hospital, China; follow up was completed on February 11, 2020. Exposures: High levels of heart injury indicators on admission (hs-TNI; CK; CK-MB; LDH; -HBDH). Main Outcomes and Measures: Mortality in hospital and days from admission to mortality (survival days). Results: Of 188 patients with COVID-19, the mean age was 51.9 years (standard deviation: 14.26; range: 21~83 years) and 119 (63.3%) were male. Increased hs-TnI levels on admission tended to occur in older patients and patients with comorbidity (especially hypertension). High hs-TnI on admission ([≥] 6.126 pg/mL), even within the clinical normal range (0~28 pg/mL), already can be associated with higher mortality. High hs-TnI was associated with increased inflammatory levels (neutrophils, IL-6, CRP, and PCT) and decreased immune levels (lymphocytes, monocytes, and CD4+ and CD8+ T cells). CK was not associated with mortality. Increased CK-MB levels tended to occur in male patients and patients with current smoking. High CK-MB on admission was associated with higher mortality. High CK-MB was associated with increased inflammatory levels and decreased lymphocytes. Increased LDH and -HBDH levels tended to occur in older patients and patients with hypertension. Both high LDH and -HBDH on admission were associated with higher mortality. Both high LDH and -HBDH were associated with increased inflammatory levels and decreased immune levels. hs-TNI level on admission was negatively correlated with survival days (r= -0.42, 95% CI= -0.64~-0.12, P=0.005). LDH level on admission was negatively correlated with survival days (r= -0.35, 95% CI= -0.59~-0.05, P=0.022). Conclusions and Relevance: Heart injury signs arise in COVID-19, especially in older patients, patients with hypertension and male patients with current smoking. COVID-19 virus might attack heart via inducing inflammatory storm. High levels of heart injury indicators on admission are associated with higher mortality and shorter survival days. COVID-19 patients with signs of heart injury on admission must be early identified and carefully managed by cardiologists, because COVID-19 is never just confined to respiratory injury.

Standardized diagnosis and treatment of colorectal cancer during the outbreak of novel coronavirus pneumonia in Renji hospital / 中华胃肠外科杂志

Novel coronavirus pneumonia (NCP) is currently raging in China. It has been proven that NCP can be transmitted from human to human and cause hospital infection, which seriously threatens surgical staffs and inpatients. Although colorectal surgery is not a front-line subject in the fight against the epidemic, but in this special situation, now it is a difficult task that with the premise of how to maximize the protection for patients and their families, health of medical staff, and the safety of wards and hospitals, we can provide the highest quality medical services to ensure the orderly development of previous clinical work. Referring to the "Diagnosis and Treatment Scheme for NCP (Trial Version 4 and 5)" and combining the actual practice situation in our hospital with the "Summary of New Coronavirus Files of Shanghai Renji Hospital", we summarize how to carry out the clinical practice of colorectal surgery under the situation of the prevention and control of the NCP epidemiology, meanwhile under such situation aiming the procedure of diagnose and treatment for emergency patients with colorectal tumor, we share the experiences of the diagnosis of colorectal tumor, the management of patients with colorectal cancer who are scheduled to be admitted for surgery, the protection of wards, the perioperative management. More importantly, we introduce in detail the operative management and perioperative management of colorectal surgery patients suspected or diagnosed with new coronary pneumonia, including prevention and control measures for medical staff, operating rooms and surgical instruments. The main points are as follows: (1) Multidisciplinary team (MDT) must be run through the diagnosis and treatment of colorectal cancer. The members include not only routine departments, but also respiratory department and infectious department. (2) Colonoscopy examination may cause cross infection of NCP to patients and doctors. Therefore, it is prior to examine the emergency cases and life-threatening patients (bleeding, obstruction, gastrointestinal foreign bodies, etc.). If the emergent patients (intestinal obstruction) with suspected or confirmed NCP, the surgeons must perform emergency surgery, and intestinal decompressive tube through colonoscopy is not recommended. (3) The colorectal cancer patients with suspected or confirmed NCP should be placed in the isolated room with separate medical devices, and the operative room with negative pressure (under-5 Pa) must be separated. All disposable medical items, body fluids and feces of the patients in perioperative periods must be unified disposed according to the medical waste standard. (4) The surgical medical workers who process colorectal cancer patients with NCP must be protected by three-level. After operation, the medical workers must receive medical observation and be isolated for 14 days. We hope our "Renji experience" will be beneficial to colleagues.