Sepsis induces accelerated catabolism of skeletal muscle, but the extent and clinical relevance of quadriceps atrophy remain unclear. This systematic review investigated studies that applied bedside ultrasound (US) to measure the quadriceps in adults (≥18 years) with sepsis or septic shock admitted to intensive care units (ICUs). Four databases were searched through June 8, 2025, and six prospective cohorts (234 patients) met the PEOS criteria. All studies reported a reduction in muscle mass or thickness during hospitalization, with assessments conducted between 48 h after ICU admission and up to 14 days. The magnitude of muscle loss varied considerably across studies, with median reductions in rectus femoris and quadriceps thickness ranging from 10% to 30%. Greater muscle loss was associated with important clinical outcomes, such as longer ICU stays, prolonged mechanical ventilation, and reduced muscle strength after discharge. These findings suggest that quadriceps loss, as measured by ultrasound, may serve as a prognostic indicator of these clinical outcomes. Heterogeneity in cutoff points, measurement timing, and metrics prevented meta-analysis and highlighted methodological gaps, including small sample sizes and lack of standardized protocols. Nonetheless, the US proved to be a feasible, repeatable, and radiation-free tool for serial monitoring of muscle in sepsis. Multicenter studies using standardized measurement of rectus femoris cross-sectional area and robust clinical outcomes are needed to establish reference trajectories and guide nutritional or rehabilitation interventions aimed at mitigating catabolism and enhancing functional recovery.

OBJECTIVES:Antibiotic stewardship is crucial to reduce antimicrobial overuse and multidrug-resistant microorganisms. Biomarker-guided strategies, especially with procalcitonin, safely reduce antibiotic exposure, but their use in routine practice remains limited. C-reactive protein (CRP) may offer a similarly effective, more accessible alternative. We evaluated whether integrating CRP into a multifaceted stewardship strategy delivered through a mobile clinical decision support system (CDSS) could safely reduce antibiotic use. METHODS:In this single-center, open-label randomized controlled trial, adults with suspected or confirmed bacterial infections who initiated antibiotics within 72 hours were enrolled. The intervention group followed an algorithm combining CRP values with clinical and microbiological criteria, while the control group received evidence-based recommendations emphasizing fixed antibiotic durations. Recommendations were delivered via a smartphone application to the research team. The primary outcome was antibiotic duration for the index infection. RESULTS:Among 110 patients (median age 67 years; 62% male; median peak CRP 117 mg/L), baseline characteristics were balanced. Protocol adherence was 67%. Antibiotic duration was shorter in the CRP group (median 6.0 vs 7.0 days; p=0.015), with no significant differences in safety outcomes. CONCLUSION:A CRP-based strategy implemented through a digital CDSS safely reduced antibiotic duration. Multicenter validation is warranted.

Abstract Background During the COVID-19 pandemic, several scoring systems have been developed and tested to stratify patients according to their risk levels, enabling the proper allocation of resources and increasing the likelihood of successful outcomes. However, there remains a gap in the availability of an effective tool for predicting in-hospital mortality among COVID-19 patients admitted to the intensive care unit (ICU). Most of the studies are bounded my methodological flaws which may lead to different bias, and uses data before the emergence of new variants and the broad use of vaccionation, that my impact scores' performance. We aimed to address this gap by developing a novel risk score and comparing it with other existing scores using more recent data. Area under the ROC curve of the AB2CO risk score Methods This multicenter observational study included adult (≥18 years) patients with laboratory-confirmed COVID-19 who were admitted to 18 ICUs from 9 Brazilian cities, from September/2021 to July/2022. A total of 558 patients were included in the analysis, median age was 69 years (interquartile range 58-78), 56.3% were men, 19.7% required invasive mechanical ventilation (IMV), and 44.8% died during hospitalization. Potential predictors were selected based on a thorough literature review. Generalized Additive Models were used to assess outcomes and predictors, while LASSO regression was employed to develop the mortality score. Risk groups stratification were divided based on the predicted death probability as intermediate, high, and very high risk. Calibration plot of the AB2CO risk score Results The final model, named AB2CO, comprised 6 variables: age, pO2/FiO2, respiratory function (respiratory rate or indication of IMV), COPD, and obesity. The AB2CO model showed an area under the Receiver Operating Characteristic curve of 0.781 (95% CI 0.744 to 0.819), good overall performance and an excellent calibration. Furthermore, on a complete case analysis the score achieved a discrimination ability of 0.783 (CI 95% 0.743-0.822), and it was compared with other existing scores and exhibited better performance than all of them. Conclusion The AB2CO score is a simple and easy tool, based on only six varibles routinely available in ICU. It may provide guidance for clinical decisions. Discrimination ability for each risk score applied in the Brazilian database of COVID-19 patients admitted to the intensive care unit, and comparison of the derived and other existing scores. Disclosures All Authors: No reported disclosures

The lingering effects of COVID-19 may impair survivors' long-term health-related quality of life (HRQoL). However, multicentre studies focusing on the Omicron variant, particularly in middle- and low-income settings, are scarce. We conducted a prospective cohort study across 24 Brazilian hospitals between December 2021 and March 2024, when Omicron was the predominant variant. Adult COVID-19 survivors were followed for 12 months via telephone interviews. The primary outcome was HRQoL at 12 months, assessed using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L; range -0.17 to 1.0). All-cause mortality was a secondary outcome. Among 649 participants (47.9% women; median age 71 years), the median EQ-5D-3L utility score at 12 months was 0.69 (IQR 0.41-0.80), and survival was 86.6%. Factors associated with lower HRQoL included female sex, age ≥ 60 years, Charlson comorbidity index ≥ 1, and need for respiratory support. Mortality was associated with age ≥ 60 years (HR 2.81), CCI ≥ 2 (HR 2.17), need for low-flow oxygen therapy (HR 2.03), and BMI ≥ 25 kg/m² (HR 0.58). One year after hospitalization, Omicron survivors in Brazil showed impaired HRQoL and high mortality. Older age, comorbidities, and need for oxygen therapy were linked to worse outcomes. Long-term support strategies are needed for these vulnerable populations.

Urine-based immunoassay is a non-invasive method with demonstrated utility in detecting anti-SARS-CoV-2 antibodies in unvaccinated patients with COVID-19. To evaluate urine’s potential for serological surveys in a real-world setting, SARS-CoV-2 serology was performed on urine samples from vaccinated individuals, both with and without prior confirmed COVID-19. (1) Methods: An in-house indirect ELISA was used to measure antibodies against recombinant spike (S) and nucleocapsid (N) proteins of SARS-CoV-2 in urine and paired serum from 149 individuals vaccinated with Janssen AD26.COV2.S, an S protein-based COVID-19 vaccine. (2) Results: Anti-S and anti-N levels were higher in the urine and serum of participants with confirmed prior COVID-19 compared to those without prior infection. Urinary anti-S effectively distinguished vaccinated individuals with (AUC = 0.96) and without (AUC = 0.88) prior infection from negative controls (non-vaccinated, non-previously infected individuals) (p < 0.0001). Among vaccinated participants, urinary anti-S and anti-N identified prior infection, with AUC values of 0.73 (p < 0.0001) and 0.60 (p = 0.03), respectively, being recorded. (3) Conclusions: Findings indicate that urinary anti-SARS-CoV-2 antibodies reflect AD26.COV2.S vaccination and previous COVID-19. To further advance the methodology, studies with larger sample sizes and a greater diversity of COVID-19 vaccines are required.

Scorpion stings have a fatality rate of 0.16%, with the majority of deaths occurring in children. The resources currently available for diagnosing cardiac dysfunction caused by scorpion stings, the most common cause of death, are echocardiograms and laboratory tests, such as troponin, creatine phosphokinase-MB (CKMB), and Brain natriuretic peptide (BNP). The present study aims to evaluate the accuracy of the biomarkers soluble Supression tumorigenicity 2 (sST2) and Heart-type fatty-acid-binding protein (FABP3) in detecting cardiac dysfunction in patients stung by scorpions. This work is a prospective cross-sectional study, carried out between December 2020 and May 2022, with patients, aged 0-19 years, stung by a scorpion. Serum or plasma samples from all patients with signs of severity upon hospital admission were collected and tested with standardized cardiac damage biomarker kits. The results were compared with cardiac dysfunction detected by cardiac ultrasound. This study included 49 patients, the majority female (51%), with a median age of 3.6 years. Left ventricular dysfunction was identified in 13 patients (26.5%), with 7 cases classified as severe. The biomarkers of sST2 and FABP-3 showed an association with left ventricular dysfunction, presenting AUCs of 0.77 and 0.81, respectively. The cut-off values determined for both biomarkers showed a sensitivity of 92.3%. Ultrasensitive troponin presented an AUC of 0.89, with a sensitivity of 84.6%. The study showed an association between sST2 and FABP-3, as well as the presence of acute cardiac dysfunction, identified by cardiac ultrasound. Both biomarkers demonstrated sensitivity in identifying patients with signs of cardiac damage, similar to troponin. The results related to cardiac dysfunction may be linked to the early detection of cardiac lesions and subclinical dysfunctions, enabling faster and more effective interventions. Limitations of this study include the small sample size, data collection in a single center, and the lack of serial measurements of biomarkers.

Introduction The escalating resistance of microorganisms to antimicrobials poses a significant public health threat. Strategies that use biomarkers to guide antimicrobial therapy—most notably Procalcitonin (PCT) and C-reactive protein (CRP)—show promise in safely reducing patient antibiotic exposure. While CRP is less studied, it offers advantages such as lower cost and broader availability compared with PCT.Methods and analysis This randomised clinical trial aims to evaluate a novel algorithm for non-critically ill adult patients. The algorithm incorporates key clinical variables and CRP behaviour. It will be applied through a mobile application as a digital clinical decision support system. The primary goal will be to assess the algorithm’s effectiveness in reducing treatment duration compared with standard care based on current guidelines, while ensuring patient safety by monitoring the occurrence of adverse events.Ethics and dissemination Only patients who agree to participate in the study after reading the informed consent form will be included. This project was submitted for consideration to the Research Ethics Committee of the Federal University of Minas Gerais (COEP-UFMG) and received approval (Approval Number: 5.905.290). Collection of clinical and laboratory data from 200 patients is expected, extracted from electronic medical records and laboratory systems, along with serum samples stored for potential future analyses. Data will be preserved using the Research Electronic Data Capture platform, and serum samples will be stored in a regulated biorepository at UFMG. Access will be controlled via credentials, with privacy protections and anonymisation prior to sharing, which will occur during scientific publications.Trial registration number This trial was registered on ClinicalTrials.gov (NCT05841875) and was last updated on 5 December 2024 at 12:49.

This study aimed to identify phenotypes of long COVID symptoms in adults following Omicron infection and assess their association with health-related quality of life (HRQoL). We analyzed three prospective observational studies in Brazil, enrolling adult patients who sought care for symptomatic Omicron infection between December 2021 and March 2023. The infection was confirmed by either an antigen test or reverse transcriptase polymerase chain reaction. Long COVID symptoms were assessed three months after enrollment through structured interviews. Phenotypes of Long COVID-19 were identified using a machine learning-based clustering approach. Exploratory analyses were conducted to examine predisposing factors and health-related quality of life utilities, measured by EQ-5D-3 L, associated with each phenotype. A total of 2,989 patients were analyzed (39

Abstract Introduction The greater predisposition to infections, as well as the possibility of a worse response to treatment, can lead to the excessive use of antimicrobials among cancer patients. C-reactive protein (CRP) has gained prominence as a tool for monitoring therapeutic responses and reducing the duration of antibiotic therapy; however, few studies have analyzed this protein in cancer patient populations. We hypothesize that cancer patients with a good response to antibiotic therapy show a faster decline in serum CRP levels, which would allow us to identify candidates for short-course treatments. Objective To evaluate the behavior of serum CRP levels among adult cancer patients using antibiotic therapy, and its association with the duration of this treatment, therapeutic response, and clinical recurrence. Methods This work consisted of a retrospective study with cancer patients admitted to a university hospital between September 2018 and December 2019. Adults (age ≥ 18 years) who underwent at least one course of antibiotic therapy were included. CRP behavior over the first 7 days of treatment was classified as: i) good response: when the CRP value on the fifth day of therapy reached 50% or less of the peak value detected in the first 48 h of treatment, and ii) poor response: Maintenance, within the same interval, of a CRP value > 50% of the peak value in the first 48 h. The duration of antibiotic therapy was categorized as up to seven full days or more. Outcomes were assessed by events that occurred during the 30 days of hospitalization or until hospital discharge. Primary outcome: Clinical recurrence of the index infection. Secondary outcomes: i) Death from any cause; ii) microbiological recurrence; iii) therapeutic response; iv) colitis associated with Clostridioides difficile; and v) isolation of multi-resistant bacteria, whether in clinical or surveillance samples. Results The final analysis consisted of 212 patients, with a median age (IQ) of 59.2 (48 – 67) years old and a predominance of females (65%), who were hypertensive (35%), smokers (21%), and diabetics (17.8%). There was no difference in clinical recurrence between the two groups (8.1% vs. 12.2%; p = 0.364), with a lower 30-day mortality in the good CRP response group (32.2% vs. 14.5%; p = 0.002). Despite the tendency towards a lower occurrence of other secondary outcomes in the good response group, these differences were not statistically significant. In the poor CRP response group, outcomes like clinical recurrence, mortality, and therapeutic response were significantly worse, regardless of the duration of antibiotic treatment. Conclusion In this study, cancer patients with a good CRP response during antibiotic therapy presented lower mortality and a higher proportion of satisfactory therapeutic responses. CRP can be a useful tool when combined with other clinical information in optimizing the duration of antimicrobial treatment in a hospitalized cancer population.

Severe community-acquired pneumonia (sCAP) remains one of the leading causes of admission to the intensive care unit, thus consuming a large share of resources and is associated with high mortality rates worldwide. The evidence generated by clinical studies in the last decade was translated into recommendations according to the first published guidelines focusing on severe community-acquired pneumonia. Despite the advances proposed by the present guidelines, several challenges preclude the prompt implementation of these diagnostic and therapeutic measures. The present article discusses the challenges for the broad implementation of the sCAP guidelines and proposes solutions when applicable.

Abstract Background Use of serum procalcitonin (PCT), an inflammatory biomarker for bacterial infections, has shown promising results for early stopping antibiotic treatment among patients with respiratory infections and sepsis. There is need for additional data regarding effectiveness and safety of this concept among patients with cancer. Methods Individual data of patients with a documented diagnosis of cancer and proven or suspected respiratory infection and/or sepsis were extracted from previous trials where adult patients were randomized to receive antibiotic treatment based on a PCT protocol or usual care (control group). The primary efficacy and safety endpoints were antibiotic exposure and 28-day all-cause mortality. Results This individual-patient data meta-analysis included 777 patients with a diagnosis of cancer from 15 randomized-controlled trials. Regarding efficacy, there was a 18% reduction in antibiotic exposure in patients randomized to PCT-guided care compared to usual care ([days] 8.2 ± 6.6 vs. 9.8 ± 7.3; adjusted difference, − 1.77 [95% CI, − 2.74 to − 0.80]; p < 0.001). Regarding safety, there were 72 deaths in 379 patients in the PCT-guided group (19.0%) compared to 91 deaths in 398 participants in the usual care group (22.9%) resulting in an adjusted OR of 0.78 (95% CI, 0.60 to 1.02). A subgroup analysis showed a significant reduction in mortality in patients younger than 70 years (adjusted OR, 0.58 [95% CI, 0.40 to 0.86]). Conclusion Result of this individual patient meta-analysis from 15 previous trials suggests that among patients with cancer and suspected or proven respiratory infection or sepsis, use of PCT to guide antibiotic treatment decisions results in reduced antibiotic exposure with a possible reduction in mortality, particularly among younger patients.

IntroductionScorpionism is a public health problem, especially in tropical regions. In Brazil, the prevalence of envenomation by scorpions is high, and the average national lethality is around 0.16 percent. The Tityus serrulatus scorpion is the primary species of medical importance. However, objective tools to predict and define the severity of these envenomations are lacking.Materials and methodsThis was an observational study conducted among patients aged 0-19 years with scorpionism. Patients were admitted to a reference hospital between December 2020 and May 2022. Point-of-care ultrasound was performed within 24 hours of the scorpion sting.ResultsForty-nine patients were included, with a median age of 3.6 (interquartile range 2.3-5.3) years and a predominance of females (51 percent). Fifteen patients (30.6 percent) presented major life-threatening signs, 32 (65.3 percent) minor systemic manifestations, and two (4.1 percent) only local manifestations. Left ventricular dysfunction was identified in 13 patients (26.5 percent). Ten patients (20.4 percent) presented pattern B (visualization of three or more B lines in the evaluated quadrant) in at least one lung window. The sensitivity and specificity of cardiac and pulmonary ultrasound to identify the most severely ill patients were 86 percent and 94 percent, respectively.DiscussionThe changes found on point-of-care ultrasound were associated with life-threatening signs. All patients with class III envenomation were referred to the intensive care unit, showing the importance of early identification of this subgroup. The main limitations were the small sample size and the fact that admission to intensive care was not based on systematic criteria.ConclusionsPoint-of-care ultrasound is able to identify early signs of pulmonary congestion and heart failure in scorpionism. It can be useful for the objective selection of patients who are at a higher risk of complications and death and who require intensive support; it may also be valuable for periodic reassessments. Point-of-care ultrasound is a valuable tool for identifying and monitoring severe cases of scorpionism.

PurposeTo develop a mortality risk score for COVID-19 patients admitted to intensive care units (ICU), and to compare it with other existing scores.Materials and MethodsIt is a retrospective observational study, including consecutive adult patients with laboratory-confirmed COVID-19 admitted to ICUs of 18 hospitals from nine Brazilian cities, from 09/2021 to 07/2022. Potential predictors were selected based on the literature review. Generalized Additive Models were used to examine outcomes and predictors. LASSO regression was used to derive the mortality score.ResultsFrom 558 patients, median age was 69 years (IQR 58-78), 56.3% were men, 19.7% required mechanical ventilation (MV), and 44.8% died. The final model comprised six variables: age, pO2/FiO2, respiratory function (respiratory rate or if in MV), chronic obstructive pulmonary disease, and obesity. The AB2CO had an AUROC of 0.781 (95% CI 0.744 to 0.819), good overall performance (Brier score=0.191) and an excellent calibration (slope=1.063, intercept=0.015, p-value=0.834). The model was compared with other scores and displayed better discrimination ability than the majority of them.ConclusionsThe AB2CO score is a fast and easy tool to be used upon ICU admission.

The COVID-19 pandemic that affected the world between 2019 and 2022 showed the need for new tools to be tested and developed to be applied in global emergencies. Although standard diagnostic tools exist, such as the reverse-transcription polymerase chain reaction (RT-PCR), these tools have shown severe limitations when mass application is required. Consequently, a pressing need remains to develop a rapid and efficient screening test to deliver reliable results. In this context, near-infrared spectroscopy (NIRS) is a fast and noninvasive vibrational technique capable of identifying the chemical composition of biofluids. This study aimed to develop a rapid NIRS testing methodology to identify individuals with COVID-19 through the spectral analysis of swabs collected from the oral cavity. Swab samples from 67 hospitalized individuals were analyzed using NIR equipment. The spectra were preprocessed, outliers were removed, and classification models were constructed using partial least-squares for discriminant analysis (PLS-DA). Two models were developed: one with all the original variables and another with a limited number of variables selected using ordered predictors selection (OPS-DA). The OPS-DA model effectively reduced the number of redundant variables, thereby improving the diagnostic metrics. The model achieved a sensitivity of 92%, a specificity of 100%, an accuracy of 95%, and an AUROC of 94% for positive samples. These preliminary results suggest that NIRS could be a potential tool for future clinical application. A fast methodology for COVID-19 detection would facilitate medical diagnoses and laboratory routines, helping to ensure appropriate treatment.

AIM:To evaluate the agreement between the bedside ultrasound in a single epigastric window and the plain X-ray to confirm the positioning of the enteral catheter in critically ill patients. MATERIAL AND METHODS:This was an observational, cross-sectional study conducted in two Intensive Care Units of a university hospital. The ultrasound exams were carried out immediately after the introduction of the enteral catheter, using only the epigastric window, with an injection of 5 ml of air associated with 5 ml of saline solution. In all cases, the plain radiography was taken to confirm the positioning of the enteral catheter and to define the beginning of nutritional therapy. RESULTS:This study included 83 patients, the positioning of the enteral catheter was confirmed by plain radiography in all cases and by ultrasound in 81 (97.6%) patients. The median duration of the ultrasound exam was 2 (2-3) minutes, while the time spent between the request for the X-ray and the release of the exam for a doctor's appointment was 225 (120-330) minutes. CONCLUSION:Bedside ultrasound proved to be an effective, quick, and safe method to confirm the position of the enteral catheter in critically ill patients.

Severe acute respiratory infections, such as community-acquired pneumonia, hospital-acquired pneumonia, and ventilator-associated pneumonia, constitute frequent and lethal pulmonary infections in the intensive care unit (ICU). Despite optimal management with early appropriate empiric antimicrobial therapy and adequate supportive care, mortality remains high, in part attributable to the aging, growing number of comorbidities, and rising rates of multidrug resistance pathogens. Biomarkers have the potential to offer additional information that may further improve the management and outcome of pulmonary infections. Available pathogen-specific biomarkers, for example, Streptococcus pneumoniae urinary antigen test and galactomannan, can be helpful in the microbiologic diagnosis of pulmonary infection in ICU patients, improving the timing and appropriateness of empiric antimicrobial therapy since these tests have a short turnaround time in comparison to classic microbiology. On the other hand, host-response biomarkers, for example, C-reactive protein and procalcitonin, used in conjunction with the clinical data, may be useful in the diagnosis and prediction of pulmonary infections, monitoring the response to treatment, and guiding duration of antimicrobial therapy. The assessment of serial measurements overtime, kinetics of biomarkers, is more informative than a single value. The appropriate utilization of accurate pathogen-specific and host-response biomarkers may benefit clinical decision-making at the bedside and optimize antimicrobial stewardship.

BACKGROUND: Temperature fluctuations are critical indicators of a patient's condition in intensive care units (ICUs). While invasive methods offer a more reliable measurement of core temperature, they carry greater risks of complications, limiting their use in most situations. This underscores the need for research evaluating the reliability of non-invasive temperature monitoring methods. OBJECTIVES: This study aimed to assess the accuracy and precision of four non-invasive temperature measurement techniques compared to pulmonary artery temperature, considered the gold standard. DESIGN AND SETTING: We conducted a cross-sectional clinical study with repeated measures in the ICUs at Hospital das Cl & iacute;nicas da Universidade Federal de Minas Gerais and Hospital Fel & iacute;cio Rocho, Belo Horizonte, Brazil. METHODS: All patients admitted with a pulmonary artery catheter were included. We simultaneously recorded temperatures from the pulmonary artery, axillary area, oral cavity, temporal artery, and tympanic membrane. Bland-Altman plots were employed to assess the agreement between the different temperature measurements. RESULTS: A total of 48 patients participated, with a mean age of 54 years. Females comprised 66.67% of the sample. Compared to pulmonary artery temperature, the accuracy and precision (mean and standard deviation) of the non-invasive methods were: axillary (-0.42 degrees C, 0.59 degrees C), oral (-0.30 degrees C, 0.37 degrees C), tympanic membrane (-0.21 degrees C, 0.44 degrees C), and temporal artery (-0.25 degrees C, 0.61 degrees C). Notably, in patients with abnormal body temperature (non-normothermic), only oral and tympanic membrane methods maintained their accuracy and precision. CONCLUSIONS: The non-invasive thermometers evaluated in this study demonstrated acceptable accuracy and precision (within the clinically relevant threshold of 0.5 degrees C) compared to pulmonary artery temperature. Among the non-invasive methods, the tympanic membrane measurement proved to be the most reliable, followed by the oral method.