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Purpose of Review: Respiratory drive is frequently deranged in the ICU, being associated with adverse clinical outcomes. Monitoring and modulating respiratory drive to prevent potentially injurious consequences merits attention. This review gives a general overview of the available monitoring tools and interventions to modulate drive., Recent Findings: Airway occlusion pressure (P0.1) is an excellent measure of drive and is displayed on ventilators. Respiratory drive can also be estimated based on the electrical activity of respiratory muscles and measures of respiratory effort; however, high respiratory drive might be present in the context of low effort with neuromuscular weakness. Modulating a deranged drive requires a multifaceted intervention, prioritizing treatment of the underlying cause and adjusting ventilator settings for comfort. Additional tools include changes in PEEP, peak inspiratory flow, fraction of inspired oxygen, and sweep gas flow (in patients receiving extracorporeal life-support). Sedatives and opioids have differential effects on drive according to drug category. Monitoring response to any intervention is warranted and modulating drive should not preclude readiness to wean assessment or delay ventilation liberation., Summary: Monitoring and modulating respiratory drive are feasible based on physiological principles presented in this review. However, evidence arising from clinical trials will help determine precise thresholds and optimal interventions., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Imaging for staging ovarian cancer is important to determine the extent of disease. The primary objective of this study was to compare gated 18F-fluorodeoxyglucose positron emission tomography coupled with computed tomography (FDG PET/CT) and standard CT scan with intravenous contrast to diagnose thoracic involvement in patients with advanced ovarian cancer prior to treatment. The secondary objective was to estimate changes in the International Federation of Gynecology and Obstetrics (FIGO) stage and clinical management resulting from gated PET/CT., Methods: The IMAGE trial is a non-randomized phase II clinical trial comparing standard CT scanning with gated PET/CT in diagnosing thoracic involvement in a non-selected group of patients with suspected ovarian cancer on a contrast CT scan. Three sets of PET images were obtained comprising an ungated 2 min whole body image, a static 7.5 min image of the upper abdomen and thorax, and a gated end-expiratory image over the upper abdomen and thorax. Images were evaluated for specificity, sensitivity, diagnostic accuracy, and the proportion of patients with changes in FIGO stage and subsequent clinical management was compared between imaging techniques., Results: A total of 84 patients were enrolled based on a standard CT scan, 67 of whom were eligible for gated PET/CT scans. Diagnostic accuracy with gated PET/CT was more than 80% for lesions in lung, liver, extra-abdominal sites, and pleura, but less than 50% for extra-abdominal lymph nodes. Compared with CT scan at baseline, 46% of patients who had 7.5 min gated PET/CT had disease upstaged from stage III to IV, and 8% had disease downstaged from stage IV to III. However, this led to a change of management in only 5% of patients., Conclusions: Gated PET/CT enables upstaging; however, in our institution it altered clinical management only in a minority of patients., Trial Registration Number: NCT02258165., Competing Interests: Competing interests: AO reports grants, personal fees, and other funding from SurgicalPerformance Pty Ltd, and grants from Medtronic, not directly related to the subject of this manuscript. AO reports consultancy fees from Baxter Healthcare Australia and New Zealand and Astra Zeneca Australia, not directly related to the subject of this manuscript. In addition, AO has a trademark licensed to SurgicalPerformance Pty Ltd. All other authors declare they have nothing to disclose., (© IGCS and ESGO 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The CheckMate 816 study, a global phase III randomized trial, demonstrated that neoadjuvant treatment with nivolumab plus chemotherapy significantly improves event-free survival in patients with resectable non-small cell lung cancer (NSCLC). Additionally, the treatment significantly increases the rate of complete pathological response. We present the results of CheckMate 816 in an Argentine subpopulation to evaluate the efficacy and safety of the neoadjuvant treatment., Materials and Methods: A retrospective observational and descriptive study was conducted at a high-volume single center in Argentina from January 2023 to March 2024. Patients received 360 mg of nivolumab plus chemotherapy and a platinum doublet every three weeks for three cycles before undergoing definitive surgery. The results were compared with the international trial and the Japanese population subgroup., Results: Nine patients received neoadjuvant therapy, of whom eight underwent definitive surgery. All patients achieved complete (R0) resection, and in three cases, a complete pathological response was observed. Currently, all are alive and disease-free., Discussion: The results obtained in the Argentine subpopulation were consistent with those observed in the global population and the Japanese subgroup. A high proportion of patients achieved a complete pathological response, an early indicator of therapeutic efficacy. Neoadjuvant therapy with nivolumab plus chemotherapy could be considered an effective treatment option for Argentine patients with resectable NSCLC.

Objective: To explore the association of maternal characteristics, oxygenation, and mechanical ventilatory parameters with fetal and neonatal outcomes., Methods: The present study was a multicenter, binational (Argentina/Colombia), prospective, cohort study, conducted in 21 intensive care units (ICUs) and including pregnant or postpartum patients with COVID-19 pneumonia requiring advanced respiratory support and their fetuses/neonates. Advanced respiratory support was defined as high-flow nasal cannula (HFNC), non-invasive ventilation (NIV) or invasive mechanical ventilation (IMV)., Results: A total of 91 patients were admitted to 21 ICUs: 63 (69%) antepartum and 28 (31%) postpartum. Among those admitted antepartum (63), delivery was induced in 43 (68.3%), being the reasons mostly maternal (28/43; 65.1%). Of 71 births, 64 (90%) were preterm. A total of 14 fetal/neonatal losses (14/91;15.4%) occurred. The main differences between patients whose fetuses/neonates survived versus those who did not survive were in APACHE II (12 [7-15] vs. 16.5 [14-20]; P = 0.003), SOFA 24 (4 [3-5] vs. 6.5 [5-8]; P = 0.001), gestational age at delivery (32.9 ± 3 vs. 27.6 ± 6.2; P = 0.014), acute respiratory distress syndrome (54 [70.1%] vs. 14 [100%]; P = 0.011), septic shock (26 [33.8%] vs. 9 [64.3%]; P = 0.031), IMV (55 [71.4%] vs. 14 [100%]; P = 0.019) and plateau pressure before delivery (23 [21-26] vs. 28 [27-30]; P = 0.019). The incidence of fetal/neonatal mortality among 47 pregnant patients requiring IMV with SpO 2  < 95% versus SpO 2 >95% before intubation was 12/35 (34.28%) versus 1/12 (8.33%), respectively; P = 0.163. The incidence of fetal/neonatal mortality among those with SpO 2 <95% versus SpO 2 >95% before delivery was 5/18 (27.77%) versus 8/29 (25.58%), respectively; P = 0.999., Conclusion: The vast majority of births were preterm. Among patients admitted antepartum, most deliveries were induced for maternal reasons. Fetal/neonatal losses were associated with gestational age at delivery, maternal severity of illness on admission and certain ventilatory parameters but not with maternal oxygenation, as is commonly the focus in these patients., (© 2024 International Federation of Gynecology and Obstetrics.)

Objective: Susac syndrome (SuS), multiple sclerosis (MS), and primary angiitis of the central nervous system (PACNS) present diagnostic challenges due to overlapping clinical features. We aimed to enhance diagnostic precision by developing the SPAMS (SuS, PACNS, MS) score, a practical radiological tool., Methods: This multicenter study included 99 patients (43 SuS, 37 MS, 19 PACNS) from South American countries. Relevant MRI features were identified through an elastic-net model determined key variables., Results: The SPAMS score assigned 2 points for snowball lesions, 1 point for spokes-like lesions, or if there are more than 4 lesions in the corpus callosum, corpus callosum involvement, or cerebellar involvement. It subtracted 1 point if gadolinium-enhancing lesions or 4 points if Dawson's fingers are present. Bootstrapping validated the optimal cutoff at 2 points, exhibiting a diagnostic performance of area under the curve = 0.931, sensitivity = 88%, specificity = 89%, positive predictive value = 88%, negative predictive value = 89%, and accuracy = 88%., Interpretation: When specific MRI findings coexisted, the SPAMS score differentiated SuS from MS and PACNS. Access to MRI and standard protocol sequences makes it a valuable tool for timely diagnosis and treatment, potentially preventing disability progression and severe clinical outcomes. ANN NEUROL 2024;96:846-854., (© 2024 American Neurological Association.)

Background: Stroke is a feared complication of transcatheter aortic valve replacement (TAVR). Patients undergoing TAVR typically have multiple comorbidities, such as carotid artery stenosis (CAS). We conducted the present meta-analysis to determine the risk of stroke and mortality following TAVR in patients with CAS., Methods: We searched PubMed/Medline, Scopus, ScienceDirect, and Cochrane Clinical Trials databases for clinical studies that compared CAS ≥50% and CAS ≥70% versus non-CAS TAVR population. The endpoints included the 30-day incidence of stroke or transient ischemic attack (TIA) and 30-day all-cause of mortality., Results: We identified seven studies that included 12,418 patients in the CAS group and 102,316 in the control group. CAS ≥50% was not associated with an increased risk of 30-day stroke or TIA after TAVR [risk ratio (RR): 1.38; 95% confidence interval (95% CI): 0.95-2.02; p = 0.09]. However, patients with CAS ≥70% had an increased risk of stroke or TIA (RR: 1.43; 95% CI: 1.02-2.01; p = 0.04). No difference in 30-day all-cause mortality was observed between CAS ≥50% or CAS ≥70% and control groups (RR: 1.09; 95% CI: 0.79-1.52; p = 0.59 and RR: 1.11; 95% CI: 0.85-1.45; p = 0.43, respectively)., Conclusions: CAS ≥70% was associated with an increased risk of stroke or TIA following TAVR compared with patients without CAS., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Sodium increases during acute kidney injury (AKI) recovery. Both hypernatremia and positive fluid balances are associated with increased mortality. We aimed to evaluate the association between daily fluid balance and daily plasma sodium during the recovery from AKI among critical patients., Methods: Adult patients with AKI were enrolled in four ICUs and followed up for four days or until ICU discharge or hemodialysis initiation. Day zero was the peak day of creatinine. The primary outcome was daily plasma sodium; the main exposure was daily fluid balance., Results: 93 patients were included. The median age was 66 years; 68% were male. Plasma sodium increased in 79 patients (85%), and 52% presented hypernatremia. We found no effect of daily fluid balance on plasma sodium (β -0.26, IC95%: -0.63-0.13; p = 0.19). A higher total sodium variation was observed in patients with lower initial plasma sodium (β -0.40, IC95%: -0.53 to -0.27; p < 0.01), higher initial urea (β 0.07, IC95%: 0.04-0.01; p < 0.01), and higher net sodium balance (β 0.002, IC95%: 0.0001-0.01; p = 0.05)., Conclusions: The increase in plasma sodium is common during AKI recovery and can only partially be attributed to the water and electrolyte balances. The incidence of hypernatremia in this population of patients is higher than in the general critically ill patient population., Competing Interests: Declaration of competing interest The Authors of this study declare that there is no conflict of interest., (Copyright © 2023. Published by Elsevier Inc.)

Background and Aims: Smoking is considered the main cause of preventable death world-wide. This study aimed to review the efficacy and safety of cytisine for smoking cessation., Methods: This review included an exhaustive search of databases to identify randomized controlled trials (RCTs) in health centers of any level with smokers of any age or gender investigating the effects of cytisine at standard dosage versus placebo, varenicline or nicotine replacement therapy (NRT)., Results: We identified 12 RCTs. Eight RCTs compared cytisine with placebo at the standard dose covering 5922 patients, 2996 of whom took cytisine, delivering a risk ratio (RR) of 2.25 [95% confidence interval (CI) = 1.42-3.56; I 2  = 88%; moderate-quality evidence]. The greater intensity of behavioral therapy was associated directly with the efficacy findings (moderate-quality evidence). The confirmed efficacy of cytisine was not evidenced in trials conducted in low- and middle-income countries. We estimate a number needed to treat (NNT) of 11. Two trials compared the efficacy of cytisine versus NRT, and the combination of both studies yields modest results in favor of cytisine. Three trials compared cytisine with varenicline, without a clear benefit for cytisine. Meta-analyses of all non-serious adverse events in the cytisine group versus placebo groups yielded a RR of 1.24 (95% CI = 1.11-1.39; participants = 5895; studies = 8; I 2  = 0%; high-quality evidence)., Conclusions: Cytisine increases the chances of successful smoking cessation by more than twofold compared with placebo and has a benign safety profile, with no evidence of serious safety concerns. Limited evidence suggests that cytisine may be more effective than nicotine replacement therapy, with modest cessation rates., (© 2023 Society for the Study of Addiction.)

Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur., Competing Interests: Disclosure The authors have no conflicts of interest relevant to the content of this article., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: During the COVID-19 pandemic, patients with worse evolution presented clinical deterioration 7-10 days after the onset of symptoms, which suggests that the inflammatory response could participate in the pathophysiology of the disease. The objective of this study was to evaluate the association between plasma C-reactive protein (PCr) on hospital admission and mechanical ventilation requirement during hospitalization in adults with COVID-19., Methods: Retrospective, observational cohort at a private center in the province of Buenos Aires. Hospitalized adults diagnosed with COVID-19 by nasal swab using real time transcription polymerase chain reaction or antigen were included. The primary outcome was the association between high plasma PCr values on hospital admission (≥8 mg/L) and mechanical ventilation requirement during hospitalization., Results: Of the 1,242 patients enrolled, 19.4% required mechanical ventilation and 11.7% died during the hospitalization. The PCr of the patients who required mechanical ventilation was higher than that of those who did not require mechanical ventilation (9.45 [5.20-18.70] mg/L vs 4.95 [1.80-10.70] mg/L; p < 0.01). PCr analyzed as a continuous variable (OR = 1.39; 95%CI 1.21-1.60; p < 0.001) and as a categorical variable (≥8 mg/L) (OR = 2.66; 95%CI 2.19 -3.78, p < 0.001) presented a significant association with the requirement of mechanical ventilation during hospitalization. Additionally, a significant association was found between PCr and in-hospital mortality., Conclusion: Plasma PCr on hospital admission could predict clinical evolution in adult patients hospitalized for COVID-19., (Universidad Nacional de Córdoba)

Objectives: To evaluate gender differences in workplace violence (WPV) against physicians and nurses in Latin America., Study Design: Cross-sectional study., Methods: A cross-sectional electronic survey was conducted between January 11 and February 28, 2022. A prespecified gender analysis was performed., Results: Among the 3056 responses to the electronic survey, 57% were women, 81.6% were physicians, and 18.4% were nurses. At least one act of violence was experienced by 59.2% of respondents, with verbal violence being the most common (97.5%). Women experienced more WPV than men (65.8% vs 50.4%; P < 0.001; odds ratio [OR]: 1.89; 95% confidence interval [CI]: 1.63-2.19). Women were more likely to report at least one episode of WPV per week (19.2% vs 11.9%, P < 0.001), to request for psychological help (14.5% vs 9%, P = 0.001) and to experience more psychosomatic symptoms. In addition, women were more likely to report having considered changing their job after an aggression (57.6% vs 51.3%, P = 0.011) and even leaving their job (33% vs 25.7%, P = 0.001). In a multivariate analysis, being a woman (OR: 1.76), working in emergency departments (OR: 1.99), and with COVID-19 patients (OR: 3.3) were independently associated with more aggressive interactions, while older age (OR: 0.95) and working in a private setting (OR: 0.62) implied lower risk., Conclusions: Women are more likely to experience WPV and to report more psychosomatic symptoms after the event. Preventive measures are urgently needed, with a special focus on high-risk groups such as women., (Copyright © 2023 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

Objective: This study aimed to assess if a color scale in the endotracheal tube (ETT) can help operators to correctly select the size and depth of placement of the ETT and decrease the time required to complete the procedure and compared with the usual numeric ETT scale in a mannequin model., Study Design: The study was conducted in eight centers. Each size of the ETT was identified with a different color. The experimental ETTs had two different colored areas, one for the mouthpiece and another to identify where the ETT should be taped above the lip (an area of 1 cm. The operators were trained as part of the protocol using an instructional video. Four clinical scenarios requiring endotracheal intubation were designed and randomly assigned. Each operator had to select the size and depth of ETT based on the birth weight (BW), and then had to perform four intubations., Results: A total of 108 operators performed 432 intubations. No differences were found in the correct placement and selection of the ETT. Median time (in seconds) required for intubation using numeric versus experimental tube was: for ETT Ø NRP (Neonatal Resuscitation Program) 2.5, 11.5 versus 8 ( p  < 0.001), ETT Ø 3, 12 versus 10 ( p  < 0.001), ETT Ø 3.5, 15.5 versus12 ( p  = 0.003), ETT Ø 4, 12 versus11 ( p  = 0.019)., Conclusion: No significant difference was observed in the selection and correct placement of the ETT. However, the intubation time was significantly shorter using the experimental ETT. This device could improve the effectiveness of intubation by reducing the time needed to properly place the ETT at mid trachea., Key Points: · It is an innovative intervention to try to solve a great inconvenience of daily practice.. · The study also raises the difficulty in maintaining the ability of endotracheal intubation.. · It proposes a scale that ensures the correct location with a safe fixation zone.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: To describe the rate of failure of the first transition to pressure support ventilation (PSV) after systematic spontaneous awakening trials (SATs) in patients with acute hypoxemic respiratory failure (AHRF) and to assess whether the failure is higher in COVID-19 compared with AHRF of other etiologies. To determine predictors and potential association of failure with outcomes., Design: Retrospective cohort study., Setting: Twenty-eight-bedded medical-surgical ICU in a private hospital (Argentina)., Patients: Subjects with arterial pressure of oxygen (AHRF to Fio 2 [Pao 2 /Fio 2 ] < 300 mm Hg) of different etiologies under controlled mechanical ventilation (MV)., Interventions: None., Measurements and Main Results: We collected data during controlled ventilation within 24 hours before SAT followed by the first PSV transition. Failure was defined as the need to return to fully controlled MV within 3 calendar days of PSV start. A total of 274 patients with AHRF (189 COVID-19 and 85 non-COVID-19) were included. The failure occurred in 120 of 274 subjects (43.7%) and was higher in COVID-19 versus non-COVID-19 (49.7% and 30.5%; p = 0.003). COVID-19 diagnosis (odds ratio [OR]: 2.22; 95% CI [1.15-4.43]; p = 0.020), previous neuromuscular blockers (OR: 2.16; 95% CI [1.15-4.11]; p = 0.017) and higher fentanyl dose (OR: 1.29; 95% CI [1.05-1.60]; p = 0.018) increased the failure chances. Higher BMI (OR: 0.95; 95% CI [0.91-0.99]; p = 0.029), Pao 2 /Fio 2 (OR: 0.87; 95% CI [0.78-0.97]; p = 0.017), and pH (OR: 0.61; 95% CI [0.38-0.96]; p = 0.035) were protective. Failure groups had higher 60-day ventilator dependence ( p < 0.001), MV duration ( p < 0.0001), and ICU stay ( p = 0.001). Patients who failed had higher mortality in COVID-19 group ( p < 0.001) but not in the non-COVID-19 ( p = 0.083)., Conclusions: In patients with AHRF of different etiologies, the failure of the first PSV attempt was 43.7%, and at a higher rate in COVID-19. Independent risk factors included COVID-19 diagnosis, fentanyl dose, previous neuromuscular blockers, acidosis and hypoxemia preceding SAT, whereas higher BMI was protective. Failure was associated with worse outcomes., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Cardiogenic shock(CS) after ST-segment elevation myocardial infarction(STEMI) has an in-hospital mortality of 50%. The ORBI score identifies patients at risk of CS after primary angioplasty. We aim to validate the score in an Argentinian cohort. A retrospective validation analysis was carried out from a cohort of patients with STEMI in 2 centers in Buenos Aires Metropolitan Area. The predictive value of the score were estimated through its discrimination power by AUC-ROC and calibration with the Hosmer Lemeshow (HL) goodness of fit test. Four hundred and twenty-four patients were analyzed. The incidence of CS was 8.5%. The median ORBI score was 10 (IQR 7-13) vs 5 in those without CS (IQR 3-7) (P < 0.0001). The performance of the test showed an AUC-ROC of 0.80 (95%CI 0.73-0.87; P < 0.0001); and a HL X² of 4.26 (P = 0.74). The ORBI score presented an adequate predictive capacity and calibration, suggesting its possible application in this population., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Current evidence on obstetric patients requiring advanced ventilatory support and impact of delivery on ventilatory parameters is retrospective, scarce, and controversial., Research Question: What are the ventilatory parameters for obstetric patients with COVID-19 and how does delivery impact them? What are the risk factors for invasive mechanical ventilation (IMV) and for maternal, fetal, and neonatal mortality?, Study Design and Methods: Prospective, multicenter, cohort study including pregnant and postpartum patients with COVID-19 requiring advanced ventilatory support in the ICU., Results: Ninety-one patients were admitted to 21 ICUs at 29.2 ± 4.9 weeks; 63 patients (69%) delivered in ICU. Maximal ventilatory support was as follows: IMV, 69 patients (76%); high-flow nasal cannula, 20 patients (22%); and noninvasive mechanical ventilation, 2 patients (2%). Sequential Organ Failure Assessment during the first 24 h (SOFA 24 ) score was the only risk factor for IMV (OR, 1.97; 95% CI, 1.29-2.99; P = .001). Respiratory parameters at IMV onset for pregnant patients were: mean ± SD plateau pressure (PP), 24.3 ± 4.5 cm H 2 O; mean ± SD driving pressure (DP), 12.5 ± 3.3 cm H 2 O; median static compliance (SC), 31 mL/cm H 2 O (interquartile range [IQR], 26-40 mL/cm H 2 O); and median Pao 2 to Fio 2 ratio, 142 (IQR, 110-176). Respiratory parameters before (< 2 h) and after (≤ 2 h and 24 h) delivery were, respectively: mean ± SD PP, 25.6 ± 6.6 cm H 2 O, 24 ± 6.7 cm H 2 O, and 24.6 ± 5.2 cm H 2 O (P = .59); mean ± SD DP, 13.6 ± 4.2 cm H 2 O, 12.9 ± 3.9 cm H 2 O, and 13 ± 4.4 cm H 2 O (P = .69); median SC, 28 mL/cm H 2 O (IQR, 22.5-39 mL/cm H 2 O), 30 mL/cm H 2 O (IQR, 24.5-44 mL/cm H 2 O), and 30 mL/cm H 2 O (IQR, 24.5-44 mL/cm H 2 O; P = .058); and Pao 2 to Fio 2 ratio, 134 (IQR, 100-230), 168 (IQR, 136-185), and 192 (IQR, 132-232.5; P = .022). Reasons for induced delivery were as follows: maternal, 43 of 71 patients (60.5%); maternal and fetal, 21 of 71 patients (29.5%); and fetal, 7 of 71 patients (9.9%). Fourteen patients (22.2%) continued pregnancy after ICU discharge. Risk factors for maternal mortality were BMI (OR, 1.10; 95% CI, 1.006-1.204; P = .037) and comorbidities (OR, 4.15; 95% CI, 1.212-14.20; P = .023). Risk factors for fetal or neonatal mortality were gestational age at delivery (OR, 0.67; 95% CI, 0.52-0.86; P = .002) and SOFA 24 score (OR, 1.53; 95% CI, 1.13-2.08; P = .006)., Interpretation: Contrary to expectations, pregnant patient lung mechanics were similar to those of the general population with COVID-19 in the ICU. Delivery was induced mainly for maternal reasons, but did not change ventilatory parameters other than Pao 2 to Fio 2 ratio. SOFA 24 score was the only risk factor for IMV. Maternal mortality was associated independently with BMI and comorbidities. Risk factors for fetal and neonatal mortality were SOFA 24 score and gestational age at delivery., (Copyright © 2022 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The use of telemedicine has quickly increased during of the COVID-19 pandemic. Given that unmet needs and barriers to multiple sclerosis (MS) care have been reported, telemedicine has become an interesting option to the care of these patients. The objective of these consensus recommendations was to elaborate a guideline for the management of people with MS using telemedicine in order to contribute to an effective and high-quality healthcare., Methods: A panel of Argentinean neurologist's experts in neuroimmunological diseases and dedicated to the diagnosis, management,and care of MS patients gathered virtually during 2021 and 2022 to conduct a consensus recommendation on the use of telemedicine in clinical practice in adult people with MS. To reach consensus, the methodology of "formal consensus RAND/UCLA Appropriateness method" was used., Results: Recommendations were established based on relevant published evidence and expert opinion focusing on definitions, general characteristics and ethical standards, diagnosis of MS, follow-up (evaluation of disability and relapses of MS), identification and treatment of relapses, and finally disease-modifying treatments using telemedicine., Conclusion: The recommendations of this consensus would provide a useful guide for the proper use of telemedicine for the assessment, follow-up, management, and treatment of people with MS. We suggest the use of these guidelines to all the Argentine neurologists committed to the care of people with MS., (© 2022. Fondazione Società Italiana di Neurologia.)

Competing Interests: The authors have disclosed no conflicts of interest.

Background: Patients requiring mechanical ventilation due to COVID-19 have different characteristics of evolution and outcome compared to the general ICU population. Although early weaning from mechanical ventilation is associated with improved outcomes, inadequate identification of patients unable to be weaned may lead to extubation failure and increased days on mechanical ventilation. Outcomes related to mechanical ventilation weaning in this population are scare and inconclusive. Therefore, the objective of this study was to describe the characteristics of mechanical ventilation weaning in subjects with acute respiratory failure induced by COVID-19., Methods: This was a multi-center, prospective cohort study. We included adult subjects requiring at least 12 h of mechanical ventilation due to COVID-19 infection admitted to any participating ICUs. Characteristics of the mechanical ventilation weaning and extubation process, as well as clinical results, were the primary outcome variables. Weaning types were defined according to previously described and internationally recognized categories., Results: Three hundred twenty-six subjects from 8 ICUs were included. A spontaneous breathing trial (SBT) was not performed in 52.1% of subjects. One hundred twenty-eight subjects were extubated, and 29.7% required re-intubation. All the subjects included could be classified by Weaning according to a New Definition (WIND) classification (group 0 = 52.1%, group 1 = 28.5%, group 2 = 8.0%, and group 3 = 11.3%) with statistically significant differences in duration of mechanical ventilation ( P < .001) and ICU length of stay ( P < .001) between groups., Conclusions: The mechanical ventilation weaning process in subjects with COVID-19 was negatively affected by the disease, with many subjects never completing an SBT. Even though temporal variables were modified, the clinical outcomes in each weaning group were similar to those previously reported., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2023 by Daedalus Enterprises.)

Background: The evidence regarding benefits of high-flow nasal cannula (HFNC) in patients with COVID-19 is controversial. The aim of this study was to evaluate the impact of HFNC in comparison with standard oxygen therapy on the frequency of endotracheal intubation at 28 d in subjects with acute hypoxemic respiratory failure (AHRF) secondary to SARS-CoV-2 infection., Methods: A retrospective, age- and sex-matched-paired, cohort study was conducted in subjects with moderate-to-severe AHRF. Intervention group was treated with HFNC, and control group was treated with standard oxygen therapy. Baseline characteristics and clinical evolution were analyzed. Mantel-Haenszel test was used for categorical variables. Paired samples Wilcoxon test was used for quantitative variables. Multivariate analysis was performed using conditional multiple logistic regression., Results: Eighty-four subjects were included. The median time from admission to progression of oxygen therapy to F IO 2 ≥ 0.5 or HFNC was 1 (interquartile range [IQR] 0-3) d. P aO 2 /F IO 2 at the time of oxygen therapy progression showed a median of 150.5 (IQR 100.0-170.0) for the entire sample and was lower in HFNC group compared with control group (median 135 [IQR 96-162] vs median 158 [IQR 132-174], respectively, P = .02). Endotracheal intubation at 28 d was observed in 54.8% HFNC and 73.8% standard oxygen (unadjusted odds ratio 0.38 [95% CI 0.13-1.07], P = .069). In the multivariate analysis, presence of dyspnea at hospital admission, Sequential Organ Failure Assessment score, and P aO 2 /F IO 2 at time of progression of oxygen therapy to F IO 2 ≥ 0.5 was identified as confounding factors for the association between the intervention group and the outcome. Use of HFNC was not an independent predictor of endotracheal intubation frequency after adjusting confounders (odds ratio 0.26 [95% CI 0.04-1.51], P = .13)., Conclusions: In this study, HFNC therapy in subjects with AHRF secondary to COVID-19 was not an independent predictor of endotracheal intubation, compared with standard oxygen therapy, after adjusting for confounders., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Background: Oxygen therapy via high-flow nasal cannula generates physiologic changes that impact ventilatory variables of patients. However, we know that there are detrimental effects on airway mucosa related to inhalation of gases. The objective of this study was to evaluate the performance in terms of absolute humidity, relative humidity, and temperature of different brands of heated humidifiers and circuits in the invasive mode during the use of high-flow oxygen therapy in flows between 30 and 100 L/min., Methods: A prospective observational study conducted at the Sanatorio Anchorena equipment analysis laboratory; September 5 to October 20, 2019., Results: A statistically significant interaction was found among the programmed flows and the different combinations of devices and circuits for the delivery of absolute humidity ( P < .001). An effect of flow on delivered absolute humidity was found, regardless of the equipment and circuit combination ( P < .001). However, in the invasive mode, the combination of the Fisher&Paykel MR850 heated humidifier with the Medtronic-Dar circuit, the Intersurgical circuit, and the AquaVENT circuit always reached or achieved absolute humidity values > 33 mg/L, even at flows up to 100 L/min. The combination of the Flexicare FL9000 heated humidifier with the Fisher&Paykel RT202 circuit, the Fisher&Paykel Evaqua 2 circuit, the Flexicare circuit, the AquaVENT circuit, and the GGM circuit achieved similar results. The mean (SD) of absolute humidity delivered in the invasive mode (36.2 ± 5.9 mg/L) was higher compared with the noninvasive mode (26.8 ± 7.2 mg/L) ( P < .001), regardless of circuit and programmed flows., Conclusions: When heated humidifiers were used in the invasive mode for high-flow oxygen therapy, absolute humidity depended not only on the heated humidifiers and the combination of circuits but also on the programmed flow, especially at flows > 50 L/min. Moreover, the heated humidifiers exhibited different behaviors, in some cases inefficient, in delivering adequate humidification. However, some equipment improved performance when set to the invasive mode., Competing Interests: Mr Plotnikow discloses relationships with Medtronic Argentina and Vapotherm. The remaining authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Purpose: To identify determinants of oxygenation over time in patients with COVID-19 acute respiratory distress syndrome (ARDS); and to analyze their characteristics according to Berlin definition categories., Materials and Methods: Prospective cohort study including consecutive mechanically ventilated patients admitted between 3/20/2020-10/31/2020 with ARDS. Epidemiological and clinical data on admission; outcomes; ventilation, respiratory mechanics and oxygenation variables were registered on days 1, 3 and 7 for the entire population and for ARDS categories., Results: 1525 patients aged 61 ± 13, 69% male, met ARDS criteria; most frequent comorbidities were obesity, hypertension, diabetes and respiratory disease. On admission, 331(21%), 849(56%) and 345(23%) patients had mild, moderate and severe ARDS; all received lung-protective ventilation (mean tidal volumes between 6.3 and 6.7 mL/kg PBW) and intermediate PEEP levels (10-11 cmH 2 O). PaO 2 /FiO 2 , plateau pressure, static compliance, driving pressure, ventilation ratio, pH and D-dimer >2 mg/L remained significantly different among the ARDS categories over time. In-hospital mortality was, respectively, 55%, 58% and 70% (p < 0.000). Independent predictors of changes of PaO 2 /FiO 2 over time were BMI; preexistent respiratory disease; D-dimer >2 mg/L; day 1-PEEP, and day 1-ventilatory ratio., Conclusion: Hypoxemia in patients with COVID-19-related ARDS is associated with comorbidities, deadspace and activated coagulation markers, and disease severity-reflected by the PEEP level required., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Supraventricular tachycardia (SVT) is the main tachyarrhythmia in the newborn (NB) that requires urgent resolution. Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency that mainly affects premature infants. Although these conditions are recognized as distinct pathologies, literature reports suggest that episodes of SVT may predispose patients to NEC secondary to disturbances in mesenteric blood flow and a decrease in tissue perfusion. We present here the clinical case of a premature neonate who developed NEC after an isolated SVT event with low cardiac output., Competing Interests: None., (Sociedad Argentina de Pediatría.)

Objetive: To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population., Design: A prospective, multicenter, observational study was carried out., Setting: Intensive Care., Patients: We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12 h since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals., Interventions: None., Variables: All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND., Results: The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR 3.48 IC 95% 1.22-11.66; p = 0.028), failure to implement NIV before MV (OR 2.76 IC 95% 1.02-7.10; p = 0.038), diagnosis of sepsis (OR 2.46 IC 95% 1.09-5.47; p = 0.027) and extubation failure (OR 4.50 IC 95% 2.05-9.90; p < 0.001)., Conclusions: The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies., (Copyright © 2021 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.)

A total of 5642 hematopoietic cell transplants (HCT) in 5445 patients (2196-40% allogeneic and 3249-60% autologous) were reported by 127 teams in 14 Latin American countries that answered the 2018 LABMT/WBMT Global Transplant Activity survey. The transplant rate (defined as the number of first transplants per 10 million inhabitants per year) was 85 (51 autologous and 34 allogeneic) in 2018. The main indications for allogeneic HCT were acute leukemias (60%), while plasma cell disorders and lymphomas were the most common conditions warranting autologous HCT (50 and 36%, respectively). In the allogeneic HCT, HLA-identical siblings were the main type of donor (44%) followed by related mismatched/haploidentical donors (32%). Peripheral blood stem cells were used in 98% of the autologous and in 64% of the allogeneic transplants. From 2012 to 2018, there was a 64% increase of reported HCT (54% in autologous and 80% in allogeneic). In the allogeneic setting, the most pronounced increase in donor type was observed in haploidentical relatives (from 94 procedures in 2012 up to 710 in 2018), surpassing unrelated donors as of 2017. Significant trends detected in Latin America include rising numbers of the procedures reported, a faster increase in allogeneic HCT compared with autologous HCT and a significant increase in family mismatched/haploidentical donors. The LABMT/WBMT activity survey provides useful data to understand the HCT activity and trends in Latin America., (© 2022. The Author(s), under exclusive licence to Springer Nature Limited.)

The Worldwide Network of Blood and Marrow Transplantation (WBMT) pursues the mission of promoting hematopoietic cell transplantation (HCT) for instance by evaluating activities through member societies, national registries and individual centers. In 2016, 82,718 first HCT were reported by 1,662 HCT teams in 86 of the 195 World Health Organization member states representing a global increase of 6.2% in autologous HCT and 7.0% in allogeneic HCT and bringing the total to 1,298,897 procedures. Assuming a frequency of 84,000/year, 1.5 million HCT were performed by 2019 since 1957. Slightly more autologous (53.5%) than allogeneic and more related (53.6%) than unrelated HCT were reported. A remarkable increase was noted in haploidentical related HCT for leukemias and lymphoproliferative diseases, but even more in non-malignant diseases. Transplant rates (TR; HCT/10 million population) varied according to region reaching 560.8 in North America, 438.5 in Europe, 76.7 in Latin America, 53.6 in South East Asia/Western Pacific (SEA/WPR) and 27.8 in African/East Mediterranean (AFR/EMR). Interestingly, haploidentical TR amounted to 32% in SEA/WPR and 26% in Latin America, but only 14% in Europe and EMR and 4.9% in North America of all allogeneic HCT. HCT team density (teams/10 million population) was highest in Europe (7.7) followed by North America (6.0), SEA/WPR (1.9), Latin America (1.6) and AFR/EMR (0.4). HCT are increasing steadily worldwide with narrowing gaps between regions and greater increase in allogeneic compared to autologous activity. While related HCT is rising, largely due to increase in haploidentical HCT, unrelated HCT is plateauing and cord blood HCT is in decline.

During the SARS-CoV-2 pandemic, there was a marked requirement for critical care beds, supplies and trained professionals to assist patients with severe respiratory failure. The Argentine Society of Intensive Care (SATI) designed a study to characterize these aspects in intensive care units (ICUs). Multicenter, prospective cohort study; the participating ICUs completed a form at the end of the study (31/10/2020) on hospital characteristics, number of beds in pre- and intra-pandemic critical areas, incorporation of professionals, technological resources, and workload. Fifty-eight ICUs participated; 28(48%) were located in Buenos Aires Province, 22(38%) in Buenos Aires Autonomous City and 10 (17%) in other provinces; 31 (53%) of UCIs belonged to the public sector; 23 (47%) to the private-social security. In 35/58 (60%) of the hospitals critical care beds increased from 902 to 1575 (75%), 37% in ICU and 63% mainly in Coronary Care Unit and Emergency-shock room. In 41/55 (75%) UCIs, staff were incorporated: 27(49%) physicians (70% intensivists), 36 (65%) nurses, 28 (51%) respiratory therapists, 20(36%) cleaning staff, and 1(2%) others. A 96% of the ICUS reported having sufficient ventilators and 95% enough supplies and PPE. Of all patients on invasive mechanical ventilation, 55% [43-64] had COVID-19. Oxygen therapy was required as noninvasive support in 14% [8-24] of COVID-19 admissions. There was a significant expansion of critical operational areas, secondary to the increase in beds, staff, and adequate availability of ventilators and essential supplies. The burden of critical illness from COVID-19 was intense, with more than half of patients on mechanical ventilation.

Coronavirus disease-19 has emerged as a devastating global public health crisis. An increased frequency of arterial and venous thrombosis was observed in COVID-19 infection. The objective of this study was to describe the thromboembolic complications of patients hospitalized for COVID-19 and their evolution. A prospective single-center study was conducted that compared the characteristics, risk factors, thromboembolic event rate, hospital stay and mortality among patients admitted to intensive care or general ward. The mean age of population was 46 ± 18 years, and 52% were female. The global rate of thromboembolic events was 4.4%, significantly higher in intensive unit patients (29% vs 1.4%; p < 0.001) despite the high use of prophylactic heparin (91.1% vs. 84.9%; p < 0.1). The independent predictive factors for the development of thromboembolic events were: age, D-dimer and creatinine. Of the patients admitted to intensive care, 45.1% required mechanical ventilation. Overall mortality was 4.3%, significantly higher in intensive care patients than in the general hospital ward (29% vs. 1.3%; p < 0.0001). Patients requiring hospitalization due to infection secondary to COVID-19 have a high rate of thromboembolic events despite the use of thromboprophylaxis with heparin, generating a negative prognostic impact on the survival of patients admitted to intensive care.

Background: Two orotracheal extubation techniques are described in the literature: the traditional technique and the positive-pressure technique. Although prior studies reported better clinical outcomes with the positive-pressure extubation technique, its superiority has not been extensively studied yet. This study was to determine whether the positive-pressure orotracheal extubation technique, compared with the traditional orotracheal extubation technique, reduces the incidence of major postextubation complications (up to 60 min) in critically ill adult subjects., Methods: This was a multi-center randomized clinical trial. Subjects age > 18 y, requiring invasive mechanical ventilation through an endotracheal tube, who met the orotracheal extubation criteria were included and randomized to traditional extubation group (removing the endotracheal tube by applying continuous endotracheal suctioning during the entire procedure) or positive-pressure group (application of pressure support mode at 15/10 cm H 2 O during cuff deflation and extubation). The primary measure was postextubation major complications, defined as the clinical evidence of at least one of the following: desaturation, upper-airway obstruction, or vomiting., Results: A total of 725 subjects was randomly assigned to the traditional extubation group ( n = 358) and positive-pressure group ( n = 367). Seventeen subjects were eliminated and not included in the per-protocol analysis. Of 708 subjects, 185 (26.1%) developed at least one major complication. The incidence was 27.8% (96/345) in the traditional group compared with 24.5% (89/363) in the positive-pressure group. No statistically significant differences were observed between the 2 groups (absolute risk 3% [95 CI -3 to 10]; relative risk, 0.88 [95 CI 0.69-1.13], P = .32)., Conclusions: Despite the trend toward the positive-pressure group, no statistically significant differences were observed. Our findings agree with the literature in that positive-pressure extubation is a safe procedure; therefore, both techniques may be used during extubation in critically ill adult patients., Competing Interests: The authors have declared no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Introduction and Objectives: Viral infections have been described to increase the risk of decompensation in patients with cirrhosis. We aimed to determine the effect of SARS-CoV-2 infection on outcome of hospitalized patients with cirrhosis and to compare the performance of different prognostic models for predicting mortality., Patients: We performed a prospective cohort study including 2211 hospitalized patients with confirmed SARS-CoV-2 infection from April 15, 2020 through October 1, 2020 in 38 Hospitals from 11 Latin American countries. We registered clinical and laboratory parameters of patients with and without cirrhosis. All patients were followed until discharge or death. We evaluated the prognostic performance of different scoring systems to predict mortality in patients with cirrhosis using ROC curves., Results: Overall, 4.6% (CI 3.7-5.6) subjects had cirrhosis (n = 96). Baseline Child-Turcotte-Pugh (CTP) class was assessed: CTP-A (23%), CTP-B (45%) and CTP-C (32%); median MELD-Na score was 19 (IQR 14-25). Mortality was 47% in patients with cirrhosis and 16% in patients without cirrhosis (P < .0001). Cirrhosis was independently associated with death [OR 3.1 (CI 1.9-4.8); P < .0001], adjusted by age, gender, and body mass index >30. The areas under the ROC curves for performance evaluation in predicting 28-days mortality for Chronic Liver Failure Consortium (CLIF-C), North American Consortium for the Study of End-Stage Liver Disease (NACSELD), CTP score and MELD-Na were 0.85, 0.75, 0.69, 0.67; respectively (P < .0001)., Conclusions: SARS-CoV-2 infection is associated with elevated mortality in patients with cirrhosis. CLIF-C had better performance in predicting mortality than NACSELD, CTP and MELD-Na in patients with cirrhosis and SARS-CoV-2 infection. Clinicaltrials.gov:NCT04358380., (Copyright © 2021 Fundación Clínica Médica Sur, A.C. Published by Elsevier España, S.L.U. All rights reserved.)

Objectives: To explore variables associated with adverse maternal/fetal/neonatal outcomes among pregnant/postpartum patients admitted to ICU for hypertensive disorders of pregnancy (HDP)., Methods: Multicenter, prospective, national cohort study., Results: Variables independently associated with maternal/fetal/neonatal mortality among 172 patients were as follows: Acute Physiology and Chronic Health Evaluation-II (APACHE-II)(OR1.20[1.06-1.35]), gestational age (OR0.698[0.59-0.82]) and aspartate aminotransferase (AST)(OR1.004[1.001-1.006]). Positive likelihood ratio for headache, epigastric pain, and visual disturbances to predict composite adverse outcomes were 1.23(1.16-1.30), 0.76(0.59-1.02), and 1.1(0.98-1.2), respectively., Conclusions: Maternal/fetal mortality due to HDP was independently associated with severity of illness on admission, gestational age, and elevated AST. Accuracy of clinical symptoms to predict composite adverse outcomes was low.

Objective: To compare gas exchange indices behavior by using liberal versus conservative oxygenation targets in patients with moderate to severe acute respiratory distress syndrome secondary to COVID-19 under invasive mechanical ventilation. We also assessed the influence of high FiO2 on respiratory system mechanics., Methods: We prospectively included consecutive patients aged over 18 years old with a diagnosis of COVID-19 and moderate-severe acute respiratory distress syndrome. For each patient, we randomly applied two FiO2 protocols to achieve SpO2 88% - 92% or 96%. We assessed oxygenation indices and respiratory system mechanics., Results: We enrolled 15 patients. All the oxygenation indices were significantly affected by the FiO2 strategy (p < 0.05) selected. The PaO2/FiO2 deteriorated, PA-aO2 increased and Pa/AO2 decreased significantly when using FiO2 to achieve SpO2 96%. Conversely, the functional shunt fraction was reduced. Respiratory mechanics were not affected by the FiO2 strategy., Conclusion: A strategy aimed at liberal oxygenation targets significantly deteriorated gas exchange indices, except for functional shunt, in COVID-19-related acute respiratory distress syndrome. The respiratory system mechanics were not altered by the FiO2 strategy.Clinical Trials Register: NCT04486729.

Hematopoietic cells transplants are technically complex and expensive imposing a huge burden on health care systems, especially those in developing countries and regions. In 2017 > 4500 transplants were done in 13 Latin American countries with established transplant programmes. We interrogated data on transplant rate, cost, funding source, hospital type, Gini coefficient and the United Nations Development Programme Inequality-Adjusted Human Development Index to determine co-variates associated with transplant development. Transplant rates varied almost 30-fold between the 13 countries from 345 in Uruguay to 12 in Venezuela with a regional transplant rate 7-8-fold lower compared with the US and EU. We found significant correlations between higher transplant cost, public funding, transplants in private hospitals with transplant rate. Low cost per transplant regardless of payor and transplants done in public hospitals were associated with low transplant rates. In contrast, high cost per transplant funded by the government and transplants done in private hospitals were associated with high transplant rates. Surprisingly, we found transplant rates were higher when transplants cost more, when they were done in private for-profit hospitals and payed for with public funds. These data give insights how to increase transplant rates in Latin America and other developing regions., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Although COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country., Methods: In this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete., Findings: Between March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52-70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7-22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0-7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H 2 O (8-12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO 2 ) to fractional inspired oxygen (FiO 2 ) was 160 (IQR 111-218), respiratory system compliance 36 mL/cm H 2 O (29-44), driving pressure 12 cm H 2 O (10-14), and FiO 2 0·60 (0·45-0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01-1·03]), Charlson score (1·16 [1·11-1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10-1·71]), vasopressor use on day 1 (1·29 [1·07-1·55]), D-dimer concentration (1·02 [1·01-1·03]), PaO 2 /FiO 2 on day 1 (0·998 [0·997-0·999]), arterial pH on day 1 (1·01 [1·00-1·01]), driving pressure on day 1 (1·05 [1·03-1·08]), acute kidney injury (1·66 [1·36-2·03]), and month of admission (1·10 [1·03-1·18]) as independent predictors of mortality., Interpretation: In patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere., Funding: None., Translation: For the Spanish translation of the Summary see Supplementary Materials section., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: We aimed to describe the epidemiology, risk factors, and clinical outcomes of co-infections and superinfections in onco-hematological patients with COVID-19., Methods: International, multicentre cohort study of cancer patients with COVID-19. All patients were included in the analysis of co-infections at diagnosis, while only patients admitted at least 48 h were included in the analysis of superinfections., Results: 684 patients were included (384 with solid tumors and 300 with hematological malignancies). Co-infections and superinfections were documented in 7.8% (54/684) and 19.1% (113/590) of patients, respectively. Lower respiratory tract infections were the most frequent infectious complications, most often caused by Streptococcus pneumoniae and Pseudomonas aeruginosa. Only seven patients developed opportunistic infections. Compared to patients without infectious complications, those with infections had worse outcomes, with high rates of acute respiratory distress syndrome, intensive care unit (ICU) admission, and case-fatality rates. Neutropenia, ICU admission and high levels of C-reactive protein (CRP) were independent risk factors for infections., Conclusions: Infectious complications in cancer patients with COVID-19 were lower than expected, affecting mainly neutropenic patients with high levels of CRP and/or ICU admission. The rate of opportunistic infections was unexpectedly low. The use of empiric antimicrobials in cancer patients with COVID-19 needs to be optimized., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Spontaneous breathing can be deleterious in patients with previously injured lungs, especially in acute respiratory distress syndrome. Moreover, the failure to assume spontaneous breathing during mechanical ventilation and the need to switch back to controlled mechanical ventilation are associated with higher mortality. There is a gap of knowledge regarding which parameters might be useful to predict the risk of patient self-inflicted lung injury and to detect the inability to assume spontaneous breathing. We report a case of patient self-inflicted lung injury, the corresponding basic and advanced monitoring of the respiratory system mechanics and physiological and clinical results related to spontaneous breathing. The patient was a 33-year-old Caucasian man with a medical history of AIDS who developed acute respiratory distress syndrome and needed invasive mechanical ventilation after noninvasive ventilatory support failure. During the controlled ventilation periods, a protective ventilation strategy was adopted, and the patient showed clear clinical and radiographic improvement. However, during each spontaneous breathing period under pressure support ventilation, despite adequate initial parameters and a strictly adjusted ventilatory setting and monitoring, the patient developed progressive hypoxemia and worsening of respiratory system mechanics with a clearly correlated radiographic deterioration (patient self-inflicted lung injury). After failing three spontaneous breathing assumption trials, he died on day 29 due to refractory hypoxemia. Conventional basic and advanced monitoring variables in this case were not sufficient to identify the aptitude to breathe spontaneously or to predict the risk and development of patient self-inflicted lung injury during partial support ventilation.