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1. A Regional Observational Study on COVID-19-Associated Pulmonary Aspergillosis (CAPA) within Intensive Care Unit: Trying to Break the Mold

Author

Tommaso Lupia, Giorgia Montrucchio, Alberto Gaviraghi, Gaia Musso, Mattia Puppo, Cesare Bolla, Nour Shbaklo, Barbara Rizzello, Andrea Della Selva, Erika Concialdi, Francesca Rumbolo, Anna Maria Barbui, Luca Brazzi, Francesco Giuseppe De Rosa, and Silvia Corcione

Subjects
COVID-19, Aspergillus, COVID-19-associated pulmonary aspergillosis, fungal infection, pulmonary, aspergillosis, Biology (General), QH301-705.5
Abstract

The reported incidence of COVID-19-associated pulmonary aspergillosis (CAPA) ranges between 2.4% and 35% in intensive care unit (ICU) patients, and awareness in the medical community is rising. We performed a regional retrospective observational study including patients diagnosed with CAPA defined according to the Modified AspICU Dutch/Belgian Mycosis Study Group and CAPA–EECMM, from five different ICUs, admitted between March, 2020 and September, 2021. Forty-five patients were included. The median age was 64 (IQR 60–72), mostly (73%) males. At ICU admission, the median Charlson comorbidity index was 3 (2–5), and the simplified acute physiology score (SAPS)-II score was 42 (31–56). The main underlying diseases were hypertension (46%), diabetes (36%) and pulmonary diseases (15%). CAPA was diagnosed within a median of 17 days (IQR 10–21.75) after symptoms onset and 9 days (IQR 3–11) after ICU admission. The overall 28-day mortality rate was 58%, and at univariate analysis, it was significantly associated with older age (p = 0.009) and SAPS-II score at admission (p = 0.032). The use of immunomodulatory agents, p = 0.061; broad-spectrum antibiotics, p = 0.091; positive culture for Aspergillus on BAL, p = 0.065; and hypertension, p = 0.083, were near reaching statistical significance. None of them were confirmed in multivariate analysis. In critically ill COVID-19 patients, CAPA acquired clinical relevance in terms of incidence and reported mortality. However, the risk between underdiagnosis—in the absence of specific invasive investigations, and with a consequent possible increase in mortality—and over-diagnosis (case identification with galactomannan on broncho-alveolar fluid alone) might be considered. Realistic incidence rates, based on local, real-life epidemiological data, might be helpful in guiding clinicians.

Published
2022
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2. Association between preoperative evaluation with lung ultrasound and outcome in frail elderly patients undergoing orthopedic surgery for hip fractures: study protocol for an Italian multicenter observational prospective study (LUSHIP)

Author

Vetrugno, L., Boero, E., Bignami, E., Cortegiani, A., Raineri, S. M., Spadaro, S., Moro, F., D'Inca, S., D'Orlando, L., Agro, F. E., Bernardinetti, M., Forfori, F., Corradi, F., Pregnolato, S., Mosconi, M., Bellini, V., Franchi, F., Mongelli, P., Leonardi, S., Giuffrida, C., Tescione, M., Bruni, A., Garofalo, E., Longhini, F., Cammarota, G., De Robertis, E., Giglio, G., Urso, F., Bove, T., Mattuzzi, L., Federici, N., Delrio, S., Meroi, F., Flaibani, L., Zaghis, C., Orso, D., Tomasino, S., Dottore, B., Divella, M., Mussetta, S., Musso, G., Minunno, A., Barbero, C., Puppo, M., Saturno, F., Galvano, A. N., Ippolito, M., Massari, L., Bianconi, M., Caruso, G., Ragazzi, R., Volta, C. A., Mongodi, S., Mojoli, F., Riccone, F., Scolletta, S., Macheda, S., Vulcano, S., Cosco, G., Vadala, E., Taddei, E., Isirdi, A., Vetrugno, Luigi, Boero, Enrico, Bignami, Elena, Cortegiani, Andrea, Raineri, Santi Maurizio, Spadaro, Savino, Moro, Federico, D'Incà, Stefano, D'Orlando, Lori, Agrò, Felice Eugenio, Bernardinetti, Mattia, Forfori, Francesco, Corradi, Francesco, Pregnolato, Sandro, Mosconi, Mario, Bellini, Valentina, Franchi, Federico, Mongelli, Pierpaolo, Leonardi, Salvatore, Giuffrida, Clemente, Tescione, Marco, Bruni, Andrea, Garofalo, Eugenio, Longhini, Federico, Cammarota, Gianmaria, De Robertis, Edoardo, Giglio, Giuseppe, Urso, Felice, Bove, Tiziana, and Lisa Mattuzzi, Nicola Federici, Silvia Delrio, Francesco Meroi, Luca Flaibani, Clara Zaghis, Daniele Orso, Serena Tomasino, Bruno Dottore, Michele Divella, Sabrina Mussetta, Gaia Musso, Angela Minunno, Carlo Barbero, Mattia Puppo, Francesco Saturno, Alberto Nicolò Galvano, Mariachiara Ippolito, Leo Massari, Margherita Bianconi, Gaetano Caruso, Riccardo Ragazzi, Carlo Alberto Volta, Silvia Mongodi, Francesco Mojoli, Filippo Riccone, Sabino Scolletta, Sebastiano Macheda, Serafino Vulcano, Giovanni Cosco, Eugenio Vadalà, Erika Taddei, Alessandro Isirdi

Subjects
medicine.medical_specialty, R895-920, Physical examination, 030204 cardiovascular system & hematology, law.invention, NO, Medical physics. Medical radiology. Nuclear medicine, 03 medical and health sciences, 0302 clinical medicine, Randomized controlled trial, law, medicine, Radiology, Nuclear Medicine and imaging, 030212 general & internal medicine, Prospective cohort study, lung ultrasound, Hip surgery, Hip fracture, Radiological and Ultrasound Technology, medicine.diagnostic_test, business.industry, Interventional radiology, medicine.disease, Surgery, Orthopedic surgery, Observational study, Original Article, business
Abstract

Background Hip fracture is one of the most common orthopedic causes of hospital admission in frail elderly patients. Hip fracture fixation in this class of patients is considered a high-risk procedure. Preoperative physical examination, plasma natriuretic peptide levels (BNP, Pro-BNP), and cardiovascular scoring systems (ASA-PS, RCRI, NSQIP-MICA) have all been demonstrated to underestimate the risk of postoperative complications. We designed a prospective multicenter observational study to assess whether preoperative lung ultrasound examination can predict better postoperative events thanks to the additional information they provide in the form of “indirect” and “direct” cardiac and pulmonary lung ultrasound signs. Methods LUSHIP is an Italian multicenter prospective observational study. Patients will be recruited on a nation-wide scale in the 12 participating centers. Patients aged > 65 years undergoing spinal anesthesia for hip fracture fixation will be enrolled. A lung ultrasound score (LUS) will be generated based on the examination of six areas of each lung and ascribing to each area one of the four recognized aeration patterns—each of which is assigned a subscore of 0, 1, 2, or 3. Thus, the total score will have the potential to range from a minimum of 0 to a maximum of 36. The association between 30-day postoperative complications of cardiac and/or pulmonary origin and the overall mortality will be studied. Considering the fact that cardiac complications in patients undergoing hip surgery occur in approx. 30% of cases, to achieve 80% statistical power, we will need a sample size of 877 patients considering a relative risk of 1.5. Conclusions Lung ultrasound (LU), as a tool within the anesthesiologist’s armamentarium, is becoming increasingly widespread, and its use in the preoperative setting is also starting to become more common. Should the study demonstrate the ability of LU to predict postoperative cardiac and pulmonary complications in hip fracture patients, a randomized clinical trial will be designed with the scope of improving patient outcome. Trial registration ClinicalTrials.gov, NCT04074876. Registered on August 30, 2019.

Published
2021

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