Association Of Estimated Plasma Volume with New Onset Acute Kidney Injury in Hospitalized COVID-19 Patients.

PURPOSE: To explore the association of estimated plasma volume (ePV) and plasma volume status (PVS) as surrogates of volume status with new-onset AKI and in-hospital mortality among hospitalized COVID-19 patients. MATERIALS AND METHODS: We performed a retrospective multi-center study on COVID-19-related ARDS patients who were admitted to the Mayo Clinic Enterprise health system. Plasma volume was calculated using the formulae for ePV and PVS, and longitudinal analysis was performed to find the association of ePV and PVS with new-onset AKI during hospitalization as the primary outcome and in-hospital mortality as a secondary outcome. RESULTS: Our analysis included 7616 COVID-19 patients with new-onset AKI occurring in 1365 (17.9%) and a mortality rate of 25.96% among them. A longitudinal multilevel multivariate analysis showed both ePV (OR 1.162; 95% CI 1.048-1.288, p=0.004) and PVS (OR 1.032; 95% CI 1.012-1.050, p=0.001) were independent predictors of new onset AKI. Higher PVS was independently associated with increased in-hospital mortality (OR 1.038, 95% CI 1.007-1.070, p=0.017), but not ePV (OR 0.868, 95% CI 0.740-1.018, p=0.082). CONCLUSION: A higher PVS correlated with a higher incidence of new-onset AKI and worse outcomes in our cohort of hospitalized COVID-19 patients. Further large-scale and prospective studies are needed to understand its utility.

Association of antibiotics with the outcomes in COVID-19 pneumonia patients with elevated PCT levels.

OBJECTIVE: To assess antibiotics impact on outcomes in COVID-19 pneumonia patients with varying procalcitonin (PCT) levels. METHODS: This retrospective cohort study included 3665 COVID-19 pneumonia patients hospitalized at five Mayo Clinic sites (March 2020 to June 2022). PCT levels were measured at admission. Patients' antibiotics use and outcomes were collected via the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry. Patients were stratified into high and low PCT groups based on the first available PCT result. The distinction between high and low PCT was demarcated at both 0.25 ng/ml and 0.50 ng/ml. RESULTS: Our cohort consisted of 3665 patients admitted with COVID-19 pneumonia. The population was predominantly male, Caucasian and non-Hispanic. With the PCT cut-off of 0.25 ng/ml, 2375 (64.8 %) patients had a PCT level <0.25 ng/mL, and 1290 (35.2 %) had PCT ≥0.25 ng/ml. While when the PCT cut off of 0.50 ng/ml was used we observed 2934 (80.05 %) patients with a PCT <0.50 ng/ml while 731(19.94 %) patients had a PCT ≥0.50 ng/ml. Patients with higher PCT levels exhibited significantly higher rates of bacterial infections (0.25 ng/ml cut-off: 4.2 % vs 7.9 %; 0.50 ng/ml cut-off: 4.6 % vs 9.2 %). Antibiotics were used in 66.0 % of the cohort. Regardless of the PCT cutoffs, the antibiotics group showed increased hospital length of stay (LOS), intensive care unit (ICU) admission rate, and mortality. However, early de-escalation (<24 h) of antibiotics correlated with reduced hospital LOS, ICU LOS, and mortality. These results were consistent even after adjusting for confounders. CONCLUSION: Our study shows a substantial number of COVID-19 pneumonia patients received antibiotics despite a low incidence of bacterial infections. Therefore, antibiotics use in COVID pneumonia patients with PCT <0.5 in the absence of clinical evidence of bacterial infection has no beneficial effect.

"Feed a Cold, Starve a Fever?" A Review of Nutritional Strategies in the Setting of Bacterial Versus Viral Infections.

PURPOSE OF REVIEW: Some data, mostly originally derived from animal studies, suggest that low glucose intake is protective in bacterial sepsis but detrimental in overwhelming viral infections. This has been interpreted into a broad belief that different forms of sepsis may potentially require different nutritional management strategies. There are a few mechanistic differences between the host interactions with virus and bacteria which can explain why there may be opposing responses to macronutrient and micronutrient during the infected state. Here, we aim to review relevant evidence on the mechanisms and pathophysiology of nutritional management strategies in various infectious syndromes and summarize their clinical implications. RECENT FINDINGS: Newer literature - in the context of the SARS-CoV-19 pandemic - offers some insight to viral infections. There is still limited clinically applicable data during infection that clearly delineate the role of nutrition during an active viral vs bacterial infections. Based on contrasting findings in different models of viruses and bacteria, the macronutrient and micronutrient needs may depend more on specific infectious organisms that may not be generalizable as bacterial versus viral. Overall, the metabolic effects of sepsis are context dependent, and various host-specific (e.g., age, baseline nutritional status, immune status, comorbidities) and illness variables (phase, duration, and severity of illness) play a significant role in determining the outcome besides pathogen-specific (virus or bacterial or fungi and combined infections) factors. Microbe therapy (probiotics and prebiotics) seems to have therapeutic potential in both viral and bacterial infected states, and this seems like a promising area for further practical research.

Are We Ready for Clinical Therapy based on Cerebral Autoregulation? A Pro-con Debate.

Cerebral autoregulation (CA) is a physiological mechanism that maintains constant cerebral blood flow regardless of changes in cerebral perfusion pressure and prevents brain damage caused by hypoperfusion or hyperperfusion. In recent decades, researchers have investigated the range of systemic blood pressures and clinical management strategies over which cerebral vasculature modifies intracranial hemodynamics to maintain cerebral perfusion. However, proposed clinical interventions to optimize autoregulation status have not demonstrated clear clinical benefit. As future trials are designed, it is crucial to comprehend the underlying cause of our inability to produce robust clinical evidence supporting the concept of CA-targeted management. This article examines the technological advances in monitoring techniques and the accuracy of continuous assessment of autoregulation techniques used in intraoperative and intensive care settings today. It also examines how increasing knowledge of CA from recent clinical trials contributes to a greater understanding of secondary brain injury in many disease processes, despite the fact that the lack of robust evidence influencing outcomes has prevented the translation of CA-guided algorithms into clinical practice.

Synbiotics and Surgery: Can Prebiotics and Probiotics Affect Inflammatory Surgical Outcomes?

PURPOSE OF REVIEW: Prebiotics, probiotics, and synbiotics have received increasing attention over the years for their beneficial impact on the gut microbiome and for their systemic anti-inflammatory effects. They have also been shown to improve surgical outcomes. Here, we review the inflammatory effects of surgery as well as the data which suggests a benefit of prebiotics, probiotics, and synbiotics taken in the perioperative period. RECENT FINDINGS: Synbiotics and fermented foods may have an even greater anti-inflammatory effect than probiotics or prebiotics alone. Recent data suggest that the anti-inflammatory effects and microbiome changes brought on by prebiotics, probiotics, and synbiotics have the potential to improve surgical outcomes. We highlight the potential to alter systemic inflammation, surgical and hospital-acquired infections, colorectal cancer formation, recurrence, and anastomotic leak. Synbiotics could also impact metabolic syndrome. Prebiotics, probiotics, and especially synbiotics may be extremely beneficial when taken in the perioperative period. Even short-term gut microbiome pre-habilitation could alter surgical outcomes significantly.

Association between new-onset anosmia and positive SARS-CoV-2 tests among people accessing outpatient testing in Toronto, Ontario: a retrospective cross-sectional study.

BACKGROUND: Reports have suggested that anosmia is strongly associated with SARS-CoV-2 infection, but patients were often asked about this symptom after their diagnosis. This study assessed associations between prospectively reported anosmia and other symptoms related to SARS-CoV-2 infection, and SARS-CoV-2 positivity in community testing centres in Toronto, Ontario. METHODS: We conducted a retrospective cross-sectional study in which data were collected from 2 COVID-19 assessment centres affiliated with 2 hospitals in Toronto, Ontario, from Apr. 5 to Sept. 30, 2020. We included symptomatic profiles of all people who underwent a SARS-CoV-2 test at either clinic within the study period. We used generalized estimating equations to account for repeat visits and to assess associations between anosmia and other symptoms and SARS-CoV-2 positivity. RESULTS: A total of 83 443 SARS-CoV-2 tests were conducted across the 2 sites for 72 692 participants during the study period. Of all tests, 1640 (2.0%) were positive; 837 (51.0%) of people who tested positive were asymptomatic. The adjusted odds ratio for the association between anosmia and test positivity was 5.29 (95% confidence interval [CI] 4.50-6.22), with sensitivity of 0.138 (95% CI 0.121-0.154), specificity of 0.980 (95% CI 0.979-0.981), a positive predictive value of 0.120 (95% CI 0.106-0.135) and a negative predictive value of 0.983 (95% CI 0.982-0.984). INTERPRETATION: Anosmia had high specificity and a positive predictive value of 12% for SARS-CoV-2 infection in this community population with low prevalence of SARS-CoV-2 positivity. The presence of anosmia should increase clinical suspicion of SARS-CoV-2 infection, and our findings suggest that people presenting with this symptom should be tested.

Retrospective study of pulmonary function tests in patients presenting with isolated reduction in single-breath diffusion capacity: implications for the diagnosis of combined obstructive and restrictive lung disease.

OBJECTIVE: To examine the frequency and spectrum of diseases associated with isolated reduction in the diffusing capacity of lung for carbon monoxide (D(Lco)). PATIENTS AND METHODS: We retrospectively identified all potentially dyspneic patients who had pulmonary function tests (PFTs) performed at the Mayo Clinic in Jacksonville, Fla, between January 1, 1990, and June 30, 2000, that showed reduced D(Lco) (< 70% of predicted), normal lung volumes (total lung capacity and residual volume > 80% and < 120% of predicted, respectively), and airflow variables (forced expiratory volume in 1 second and forced vital capacity values > 80% of predicted and forced expiratory volume in 1 second/forced vital capacity ratio > 70% of predicted). Only patients who had also undergone chest computed tomography (CT) and echocardiography within 1 month of PFTs were studied. RESULTS: Of the 38,095 patients who underwent PFTs during the study period, 179 (0.47%; 95% confidence interval [CI], 0.40%-0.54%) had isolated D(Lco) abnormalities. The 27 patients (15.1%; 95% CI, 10.2%-21.2%) who had also undergone chest CT and echocardiography within 1 month of PFTs form the study cohort reported herein. Their mean D(Lco) was 50% +/- 15% (95% CI, 45%-56%) with average normal pulse oxygen saturation at rest and mild hypoxemia with activity. Thirteen of the 27 patients (48%; 95% CI, 28.7%-68.1%) had underlying emphysema evident on CT. Eleven of these 13 patients had emphysema associated with a restrictive lung process. The 14 patients without emphysema had interstitial lung disease, pulmonary vascular disease, and other isolated findings. Six patients with combined emphysema and idiopathic pulmonary fibrosis accounted for the largest percentage (22%) of patients with Isolated D(Lco) reduction. The mean +/- SD smoking history of the 27 patients in the study cohort was 36 +/- 33 pack-years (range, 0-116 pack-years). CONCLUSION: Dyspneic patients with respiratory symptoms and normal lung volumes and airflows associated with Isolated reduction in D(Lco) should be evaluated for underlying diseases such as emphysema, with or without a concomitant restrictive process, and pulmonary vascular disease.

Utilidad de un cuestionario de factores pronósticos en la evaluación de pacientes con artritis reumatoide / Utility of a questionnaire of prognostic factors in the evaluation of patients with rheumatoid arthritis

El Objetivo fue elaborar un cuestionario para evaluar factores pronósticos (PPS) al inicio de la enfermedad, clasificarla según la severidad y correlacionarlo con variables conocidas de desenlace como la discapacidad, mortalidad y utilización de servicios de salud y cirugía. Pacientes y Métodos: se revisaron los factores pronósticos que han mostrado asociación con peores desenlaces de la AR en los diferentes estudios. Estas asociaciones se clasificaron en leves, moderadas y fuertes de acuerdo a los riesgos relativos publicados en la literatura o por consenso entre investigadores cuando no había suficientes elementos de juicio. Para el cuestionario se excluyeron variables de laboratorio costosas para el medio como los anticuerpos anticitrulina o el HLA. De acuerdo al puntaje, los pacientes se clasificaron en leves: menos de diez puntos en el puntaje; moderados, de once a veinte puntos y severos, más de veinte puntos. Los resultados se compararon con las variables de desenlace. Resultados: las variables escogidas para el cuestionario fueron: Asociación Leve: un punto: edad, sexo, menopausia temprana, tabaquismo, bachillerato incompleto, estrato social, depresión. Asociación Moderada: dos puntos: VSG mayor de 40, PCR mayor de 6, inflamación en rodillas, codos y manos y duración de la AR más de seis meses sin tratamiento modificador. Asociación fuerte: tres puntos: Factor reumatoide, presencia de erosiones radiográficas, más de veinte articulaciones afectadas al inicio, HAQ mayor de 1 y presencia de manifestaciones extra-articulares. El mayor puntaje de PPS se correlacionó de manera importante con estrato social (P: 0.004), compromiso de grandes articulaciones (p: 0.0008), duración de la AR sin tratamiento (p: 0.0007), HAQ mayor de 1 (p: 0.0001), FR positivo (p: 0.0008), PCR (p: 005) y erosiones radiográficas (p: 0.00003). Cuando se analizaron los grupos por discapacidad (HAQ mayor de 1) comparando leves frente a moderados a severos se encontró únicamente asociación con sexo femenino (p: 0.1), y presencia de más de veinte articulaciones inflamadas (p: 0.009). No hubo asociación con otras variables de desenlace. Conclusiones El PPS correlacionó con variables diferentes a las del HAQ, lo que sugiere evaluación de aspectos diferentes de la AR considerando la multifactorialidad de la enfermedad y su repercusión en el desenlace

Depresión, estrés y desesperanza en pacientes con artritis reumatoide del caribe colombiano / Depression and stress in caribbean patients with RA

Objetivos. La depresión es frecuente en pacientes con artritis reumatoide (AR). El objetivo de este estudio fue conocer su prevalencia en nuestro medio, identificar factores de riesgo y determinar la mejor forma de identificarla tempranamente. Pacientes y métodos. Se escogieron 40 pacientes con AR, según los criterios del American College of Rheumatology (ACR), que acuden a consulta al Hospital de la Universidad del Norte (HUN), de forma consecutiva y al azar que desearon participar. Debían tener de 30 a 70 años y no presentar trastornos psiquiátricos conocidos ni comorbilidad grave. A todos los pacientes se les aplicó el mismo día una batería de pruebas que incluyeron: prueba de Apgar (funcionabilidad familiar), Aims, inventario de Beck (BDI) y prueba de Zung (depresión), índice de desesperanza aprendida (AHÍ por sus siglas en inglés, artritis helplessness índex) y test de eventos estresantes en vida. Se lleno el índice de Thompson y se anotaron variables clínicas y demográficas. Se consideró el BDI como el "standard" para diagnosticar depresión. Los resultados fueron analizados con el programa Epi-Info 6.04. Resultados. Edad promedio 48 años (30-69). estrato bajo (71 por ciento). La prevalencia de depresión de 25 por ciento (10/40) según la prueba de Beck, 32.5 por ciento según el Zung y 40 por ciento según el Aims. La correlación del inventario de Beck y el test de Zung fue estadísticamente significativa, no así con el Comparando el Zung con el BDI la sensibilidad fue de 90 por ciento y la especificidad de 83.3 por ciento, VPP de 64.3 por ciento y VPN de 96,2 por ciento. Todos los pacientes mostraron algún grado de desesperanza. Conclusiones. La depresión en pacientes del caribe con AR es frecuente (25 a 40 por ciento según la prueba), aunque menor que la reportada en otras áreas del país. El test de Zung tuvo buena sensibilidad y especificidad cuando se comparó con el inventario de Beck y puede ser una alternativa para diagnosticar depresión

Influencia del factor reumatoide (FR) en la severidad asociada a la artritis reumatoidea (AR) en población colombiana / Influence of the rheumatoid factor (RF) in the severity of rheumatoid arthritis (RF) in Colombian Patients

Los pacientes con RF positivo a titulos altos, tuvieron mayor discapacidad funcional medida por HAQ y mayor utilización de DMARD (medicamentos modificadores de la AR). Es importante titular siempre el FR.