Purpose: To accommodate the unprecedented number of critically ill patients with pneumonia caused by coronavirus disease 2019 (COVID-19) expansion of the capacity of intensive care unit (ICU) to clinical areas not previously used for critical care was necessary. We describe the global burden of COVID-19 admissions and the clinical and organizational characteristics associated with outcomes in critically ill COVID-19 patients.Methods: Multicenter, international, point prevalence study, including adult patients with SARS-CoV-2 infection confirmed by polymerase chain reaction (PCR) and a diagnosis of COVID-19 admitted to ICU between February 15th and May 15th, 2020.Results: 4994 patients from 280 ICUs in 46 countries were included. Included ICUs increased their total capacity from 4931 to 7630 beds, deploying personnel from other areas. Overall, 1986 (39.8%) patients were admitted to surge capacity beds. Invasive ventilation at admission was present in 2325 (46.5%) patients and was required during ICU stay in 85.8% of patients. 60-day mortality was 33.9% (IQR across units: 20%-50%) and ICU mortality 32.7%. Older age, invasive mechanical ventilation, and acute kidney injury (AKI) were associated with increased mortality. These associations were also confirmed specifically in mechanically ventilated patients. Admission to surge capacity beds was not associated with mortality, even after controlling for other factors.

Background: Weaning failure is common in mechanically ventilated patients, and if ultrasound can predict weaning outcome remains controversial. The purpose of this study was to evaluate the diaphragmatic function (thickness and excursion) measured by ultrasound as a predictor of the extubation outcome. Methods: We included 62 mechanically ventilated patients from the chest intensive care unit in this study. Sixty-two patients who successfully passed the spontaneous breathing trial (SBT) were enrolled. The transthoracic ultrasound of the diaphragm was performed during an SBT to the assess diaphragmatic function (excursion and thickness), and they were classified into the successful extubation group and the failed extubation group. Results: There was a statistically significant increase in the successful extubation group in the diaphragmatic excursion and thickness fraction (p<0.001), a statistically significant negative correlation between the diaphragmatic function and the duration of the mechanical ventilation, and a statistically significant negative correlation between the diaphragmatic excursion and the Acute Physiology and Chronic Health Evaluation II. The diaphragmatic excursion cutoff value predictive of weaning was 1.25 cm, with a specificity of 82.1% and a sensitivity of 97.1% respectively, and the diaphragmatic thickness cutoff value predictive of weaning was 21.5%, with a specificity of 60.7% and a sensitivity of 91.2%, respectively. Conclusion: The diaphragmatic ultrasonography was found to be a promising tool for predicting the extubation outcome for mechanically ventilated patients.

Background: Conducted studies showed that the ADC (apparent diffusion coefficient) values of malignant mediastinal lesions are significantly lower than those of benign lesions. Investigators determined cut-off ADC values to differentiate the two; concluding that ADC value is a promising noninvasive, imaging parameter that helps assess and characterize mediastinal tumors. Taking this a step forward, the primary objective of our prospective study was to investigate the potential of DW-MRI (diffusion-weighted magnetic resonance imaging) to characterize malignant mediastinal lesions using their ADC values. Thirty-three patients that underwent MRI of the chest with DWI and latter pathologically diagnosed with a malignant mediastinal lesion were included in this study. Lesions' ADC values were measured and correlated with the histopathological results. The statistical significance of differences between measurements was tested using the one-way ANOVA (analysis of variance) test; p values equal to or less than 0.05 were considered significant. Results: There was no statistically significant difference between the ADC mean values of the histopathological groups of lesions assessed with the overlap of their ADC mean values. The average ADC mean value of NHL (non-Hodgkin lymphoma) was evidently lower than that of HD (Hodgkin disease) with no overlap between their ADC mean values. DWI failed at characterizing one lesion in this study as a malignant tumor, namely an immature teratoma (germ-cell tumor). Again DWI could not be used to evaluate a mass, latter pathologically diagnosed as an angiosarcoma, because of its overall hemorrhagic nature showing no definite non-hemorrhagic soft tissue components. The aforementioned results did not differ considerably when minimum ADC was used instead of mean ADC. Conclusion: There was no statistically significant difference between the ADC values of the malignant mediastinal lesions evaluated. However, regarding lymphoma subtypes, our limited sample study of lymphoma suggested a considerable difference between the ADC values of Hodgkin disease and non-Hodgkin lymphoma.

Background The COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients. Methods This is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson’s Chi-squared and continuous variables by Mann–Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the “full” matching method. Results Data were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO. Conclusions In patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021). Graphical abstract

Background: Higher expression of angiotensin-converting enzyme-2 (ACE-2) in addition to neuropilin-1 (NRP-1) can lead to a cytokine storm which is correlated to higher mortality rate and contributes to the progression of renal diseases and the pathogenesis of coronary heart disease (CHD) in COVID-19 patients. Aim: We herein sought to examine correlations between cytokine levels, ACE-2 and NRP-1 expression, renal function biomarkers, and cardiac enzymes in COVID-19 patients. Patients and Methods: For the study, 50 healthy subjects and 100 COVID-19 patients were enrolled. Then, confirmed cases of COVID-19 were divided into two groups—those with moderate infection and those with severe infection—and compared to healthy controls. Serum creatinine, urea, CK-MB, LDH, troponin I, IL-1β, IL-4, IL-10, IL-17, and INF-γ levels were estimated. We also studied the gene expression for ACE-2 and NRP-1 in blood samples utilizing quantitative real-time polymerase chain reaction (qRT-PCR). Results: All COVID-19 patients demonstrated a significant increase in the levels of serum creatinine, urea, CK-MB, LDH, and troponin I, as well as examined cytokines compared to the healthy controls. Furthermore, ACE-2 mRNA and NRP-1 mRNA expression levels demonstrated a significant increase in both severe and moderate COVID-19 patient groups. In the severe group, serum creatinine and urea levels were positively correlated with IL-10, INF-γ, NRP-1, and ACE-2 expression levels. Moreover, LDH was positively correlated with all the examined cytokine, NRP-1, and ACE-2 expression levels. Conclusion: Deficits in renal and cardiac functions might be attributable to cytokine storm resulting from the higher expression of ACE-2 and NRP-1 in cases of COVID-19.