Background: Growth differentiation factor 15 (GDF-15) is a strong prognostic marker in sepsis and cardiovascular disease (CVD). The prognostic importance of GDF-15 in COVID-19 is unknown. Methods: Consecutive, hospitalized patients with laboratory-confirmed infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and symptoms of COVID-19 were enrolled in the prospective, observational COVID MECH study. Biobank samples were collected at baseline, day 3 and day 9. The primary endpoint was admission to the intensive care unit or death during hospitalization, and the prognostic performance of baseline and serial GDF-15 concentrations were compared with that of established infectious disease and cardiovascular biomarkers. Results: Of the 123 patients enrolled, 35 (28%) reached the primary endpoint; these patients were older, more often had diabetes mellitus, had lower oxygen saturations and higher National Early Warning Score on baseline. Baseline GDF-15 concentrations were elevated (>95th percentile in age-stratified healthy individuals) in 97 (79%), and higher concentrations were associated with detectable SARS-CoV-2 viremia and hypoxemia (both p<0.001). Patients reaching the primary endpoint had higher concentrations of GDF-15 (median 4225 [IQR 3197-5972] pg/mL vs 2187 [1344-3620] pg/mL, p<0.001). The C-statistic value was 0.78 (95% confidence interval 0.70-0.86). The association between GDF-15 and outcome persisted after adjusting for age, sex, race, body mass index, estimated glomerular filtration rate and previous myocardial infarction, heart failure or atrial fibrillation (p<0.001), and was superior and incremental to interleukin-6, C-reactive protein, procalcitonin, ferritin, D-dimer, cardiac troponin T and N-terminal pro-B-type natriuretic peptide. Increase in GDF-15 from baseline to day 3 was also greater in patients reaching the primary endpoint (median 1208 [IQR 0-4305] pg/mL versus -86 [IQR -322-491] pg/mL, p<0.001). Conclusions: GDF-15 is elevated in the majority of patients hospitalized with COVID-19, and higher concentrations are associated with SARS-CoV-2 viremia, hypoxemia and worse outcome. The prognostic importance of GDF-15 was additional and superior to established cardiovascular and inflammatory biomarkers.

Purpose: To perform a systematic review and meta-analysis of acute kidney injury (AKI) in trauma patients admitted to the intensive care unit (ICU). Methods:We conducted a systematic literature search of studies on AKI according to RIFLE, AKIN or KDIGO criteria in trauma patients admitted to the ICU (PROSPERO CRD42017060420). We searched PubMed, Cochrane Database of Systematic Reviews, UpToDate and NICE through 3 December 2018. Data were collected on incidence of AKI, risk factors, renal replacement therapy (RRT), renal recovery, length of stay (LOS) and mortality. Pooled analyses with random effects models yielded mean differences, OR, and RR, with 95% CI.Results: 24 observational studies comprising 25182 patients were included. Study quality (Newcastle-Ottawa scale) was moderate. Study heterogeneity was substantial. Incidence of post-traumatic AKI in the ICU was 24% (20-29), whereof 13% (10-16) mild, 5% (3-7) moderate, and 4% (3-6) severe AKI. Risk factors for AKI were African American descent, high age, chronic hypertension, diabetes mellitus, high Injury Severity Score, abdominal injury, shock, low Glasgow Coma Scale (GCS), high APACHE II score, and sepsis. AKI patients had 6.0 (4.0-7.9) days longer ICU LOS and increased risk of death ]) compared to non-AKI patients. In patients with AKI, RRT was used in 10% (6-15). Renal recovery occurred in 96% (78-100) of patients.Conclusions: AKI occurred in 24% of trauma patients admitted to the ICU, with an RRT use among these of 10%. Presence of AKI was associated with increased LOS and mortality, but renal recovery in AKI survivors was good.

Fig 1.Relation between arterial oxygen saturations (Sa O2 ) and arterial partial pressures of carbon dioxide (Pa CO2 ) in eight volunteers breathing air in a hypobaric chamber at ambient pressure 42.1 kPa, corresponding to a pressure altitude of~22 000 ft. 5 Inspiratory oxygen pressure is 7.5 kPa. The model predicts that an increase in Pa CO2 from 2.5 to 4.5 kPa would decrease Sa O2 from 87% to 50%. R 2 ¼0.88, P<0.001.

Pre-injury ASA-PS score was an independent predictor of mortality after trauma, also after adjusting for the major variables in the traditional TRISS (Trauma and Injury Severity Score) formula. Including pre-injury ASA-PS score might improve the predictive power of a survival prediction model without complicating it.

BackgroundNational Early Warning Score (NEWS) was designed to detect deteriorating patients in hospital wards, specifically those at increased risk of ICU admission, cardiac arrest, or death within 24 h. NEWS is not validated for use in Emergency Departments (ED), but emerging data suggest it may be useful. A criticism of NEWS is that patients with chronic poor oxygenation, e.g. severe chronic obstructive pulmonary disease (COPD), will have elevated NEWS also in the absence of acute deterioration, possibly reducing the predictive power of NEWS in this subgroup. We wanted to prospectively evaluate the usefulness of NEWS in unselected adult patients emergently presenting in a Norwegian ED with respiratory distress as main symptom.MethodsIn respiratory distressed patients, NEWS was calculated on ED arrival, after 2–4 h, and the next day. Manchester Triage Scale (MTS) category, age, gender, comorbidity (ASA score), ICU-admission, ventilatory support, and discharge diagnoses were noted. Survival status was tracked for >90 days through the Population Registry. Data are medians (25–75th percentiles). Factors predicting 90-day survival were analysed with multiple logistic regression.ResultsWe included 246 patients; 71 years old (60–80), 89 % home-dwelling, 74 % ASA 3–4, 72 % MTS 1–2, 88 % admitted to hospital. NEWS on arrival was 5 (3–7). NEWS correlated closely with MTS category and maximum in-hospital level of care (ED, ward, high-dependency unit, ICU). Sixteen patients died in-hospital, 26 died after discharge within 90 days. Controlled for age, ASA score, and COPD, a higher NEWS on ED arrival predicted poorer 90-day survival. Increased NEWS also correlated with decreased 30-day- and in-hospital survival and a decreased probability for home-dwelling patients to be discharged directly home.DiscussionIn respiratory distressed patients, NEWS on ED arrival correlated closely with triage category and need of ICU admission and predicted long-term out-of-hospital survival controlled for age, comorbidity, and COPD.ConclusionsNEWS should be explored in the ED setting to determine its role in clinical decision-making and in communication along the acute care chain.

The impaired mucociliary clearance in CF causes widespread inflammatory paranasal sinus disease, with inflammatory patterns more often requiring extensive surgery, with a higher risk of cerebrospinal fluid leak or bleeding, or involving areas that are more difficult to reach with the endoscope.

Genetically verified CF patients had less developed sinuses, lacked pneumatization variants, and more often had anatomic variants that predispose to complications during FESS. Normally developed sinuses and pneumatization variants in some genetically unverified CF patients (CF-1, CF-0) suggest that these patients may be erroneously diagnosed.

IntroductionAnatomic injury, physiological derangement, age, and injury mechanism are well-founded predictors of trauma outcome. We aimed to develop and validate the first Scandinavian survival prediction model for trauma.MethodsEligible were patients admitted to Oslo University Hospital Ullevål within 24 h after injury with Injury Severity Score ≥ 10, proximal penetrating injuries or received by a trauma team. The derivation dataset comprised 5363 patients (August 2000 to July 2006); the validation dataset comprised 2517 patients (August 2006 to July 2008). Exclusion because of missing data was < 1%. Outcome was 30-day mortality. Logistic regression analysis incorporated fractional polynomial modelling and interaction effects. Model validation included a calibration plot, Hosmer–Lemeshow test and receiver operating characteristic (ROC) curves.ResultsThe new survival prediction model included the anatomic New Injury Severity Score (NISS), Triage Revised Trauma Score (T-RTS, comprising Glascow Coma Scale score, respiratory rate, and systolic blood pressure), age, pre-injury co-morbidity scored according to the American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and an interaction term. Fractional polynomial analysis supported treating NISS and T-RTS as linear functions and age as cubic. Model discrimination between survivors and non-survivors was excellent. Area (95% confidence interval) under the ROC curve was 0.966 (0.959–0.972) in the derivation and 0.946 (0.930–0.962) in the validation dataset. Overall, low mortality and skewed survival probability distribution invalidated model calibration using the Hosmer–Lemeshow test.ConclusionsThe Norwegian survival prediction model in trauma (NORMIT) is a promising alternative to existing prediction models. External validation of the model in other trauma populations is warranted.