Diaz Milian, Ricardo

Emerging evidence links veno-venous extracorporeal membrane oxygenation (VV-ECMO) to right ventricular (RV) dysfunction, but the relative contribution of ECMO versus underlying disease progression remains unclear. We conducted a multicenter, retrospective, propensity-matched study including 408 intubated acute respiratory distress syndrome (ARDS) patients who were admitted between January 2020 and October 2024 in a quaternary referral hospital network within the United States and underwent at least two transthoracic echocardiograms (TTEs) after intubation. Using 1:2 propensity score matching, we adjusted for baseline comorbidities, baseline hemoglobin, lactate, and worst PaO 2 /FiO 2 ratio (P/F). Longitudinal echocardiographic changes were analyzed with a cumulative link mixed model (CLMM), evaluating RV size and function as ordinal outcomes. Within 408 patients (112 received ECMO support), propensity matching identified 55 ECMO and 110 non-ECMO patients with balanced baseline characteristics. Among 469 serial echocardiograms, RV size and function worsened more frequently in ECMO patients. In longitudinal modeling, ECMO use alone was not associated with RV dilation ( p = 0.23) or dysfunction ( p = 0.43). However, longer ECMO duration was associated with RV dilation (OR: 1.04 per day, p = 0.004) and dysfunction (odds ratio [OR]: 1.04 per day, p < 0.001). Higher ECMO circuit flow had a trend toward progressive RV dilation and dysfunction but did not reach statistical significance. These findings highlight the need for vigilant RV monitoring during ECMO support.

The Omicron variant of SARS-CoV-2 is associated with milder symptoms and lower hospitalization and mortality rates than Delta variants, although the impact of Omicron on immunocompromised patients, especially solid organ transplant (SOT) recipients, is still unclear. This study compares the hospitalization rate and outcomes between immunocompromised, immunocompetent, and SOT patients during the Delta and Omicron periods. We included adult patients who tested positive for SARS-CoV-2 on PCR or nasopharyngeal antigen test between 26 June 2021 to 8 September 2022, at our institution. A total of 12,401 COVID-19 patients were included, of which 11,055 were immunocompetent, and 1346 were immunocompromised (375 SOT recipients). Throughout the Delta and Omicron outbreaks, immunocompromised patients exhibited higher comorbidities and 30-day hospitalizations, but rates of mechanical ventilation and ICU-level care were like immunocompetent patients. During the Omicron wave, immunocompromised patients had higher unadjusted relative risk estimates (RR = 2.37, 95% CI 1.96–2.87, p < 0.05) than Delta (RR = 1.58, 95% CI 1.24–2.01, p < 0.05), with higher adjusted relative risk for hospitalization in Omicron (RR = 1.50, 95% CI 1.10–2.03, p = 0.01). Analyses show increased hospitalization risk in immunocompromised during the Omicron wave compared to the Delta wave, with no significant difference in hospitalization outcomes. The relative risk of hospitalization for SOT patients was higher in both waves.

Background: The role of venous Doppler ultrasound in assessing venous congestion in the setting of post-lung transplantation surgery is unknown. We performed a feasibility study on the use of venous Doppler ultrasound in the immediate post-operative period after lung transplantation in a retrospective, single-center observational evaluation. Patients had at least two venous congestion Doppler ultrasound exams involving interrogation of IVC diameter, hepatic vein, portal vein and renal vein Doppler assessments. Results: A total of 9 patients were included in our study with a median age of 60 years, 66.7% being male, and a median BMI of 20.9. All patients had VExUS grade ≥1 on their first venous Doppler exam. All nine patients had a decrease in portal vein pulsatility from initial to final exams. Correlation between portal venous pulsatility and net fluid balance was not statistically significant R= 0.33 (P= 0.39). Other parameters, including VExUS grade, IVC diameter, HV and RV Doppler changes from initial to final ultrasound exams showed variable changes in the post-operative period. Conclusion: Venous congestion Doppler ultrasound assessments appear feasible in immediate postoperative lung transplant patients. A multitude of factors beyond fluid status likely affect waveforms.

Background: Procalcitonin (PCT) is recognized as an inflammatory biomarker, often elevated in COVID-19 pneumonia alongside other biomarkers. Understanding its association with severe outcomes and comparing its predictive ability with other biomarkers is crucial for clinical management. Objectives: This retrospective multicenter observational study aimed to investigate the association between PCT levels and adverse outcomes in hospitalized COVID-19 patients. Additionally, it sought to compare the predictive performance of various biomarkers. Design: The study analyzed data from the Society of Critical Care Medicine (SCCM) Viral Infection and Respiratory Illness Universal Study (VIRUS) registry, comprising COVID-19 patients hospitalized across multiple Mayo Clinic sites between March 2020 and June 2022. Methods: A total of 7851 adult COVID-19 patients were included. Patients were categorized into 6 groups based on the worst WHO ordinal scale. Multivariate models were constructed using peak biomarker levels within 72 hours of admission, adjusted for confounders. Results: Elevated PCT levels were independently associated with increased odds of adverse outcomes, including ICU admission (adjusted odds ratio [aOR] 1.32, 95%CI 1.27-1.38), IMV requirement (aOR 1.35, 95%CI: 1.28-1.42), and in-hospital mortality (aOR 1.30, 95%CI: 1.22-1.37). A 3.48-fold increase in IMV requirement and 3.55 times increase in in-hospital mortality were noted with peak PCT ⩾ 0.25 ng/ml. Similar associations were observed with other biomarkers like NLR (AUC 0.730), CRP, IL-6, LDH (AUC 0.800), and D-dimer (AUC 0.719). Models incorporating NLR, LDH, D-dimer, and PCT demonstrated the highest predictive accuracy, with a combined model exhibiting an area under the curve (AUC) of 0.826 (95%CI 0.803-0.849). Conclusions: Higher PCT levels were significantly linked to worse outcomes in COVID-19 patients, emphasizing its potential as a prognostic marker. Biomarker-based predictive models, particularly those including PCT, showed promising utility for risk assessment and clinical decision-making. Further prospective studies are warranted to validate these findings on a larger scale.

OBJECTIVES: To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA) implementation. DESIGN: Retrospective, Observational cohort study. SETTING: Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019. PATIENTS: Adult patients that electively underwent 1 of 19 major procedures. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011–2014 (n = 2,103,836) and PostM: 2016–2019 (n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26–30 vs 31–35) for both cohorts. More patients had inpatient palliative consultations during POD 31–60 compared with POD 1–30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31–60 compared with POD 1–30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22–8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83–9.10; p < 0.001) cohorts. CONCLUSIONS: We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.