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The aim of our paper is to present and discuss in detail the pathological lesions suggestive of tuberculosis observed in a skeleton (MMG3-75) that was excavated from the 16.sup.th -century-CE mass grave No. 3 of the Mohács National Memorial Site (Sátorhely, southwestern Hungary). The differential diagnoses of the observed bony changes, with special attention to the clival alterations, are presented. During the macromorphological, radiological, and digital microscopic examination of MMG3-75, the skull base showed mild cortical erosion and multiple, well-circumscribed osteolytic lesions at the clivus clearly evidenced by 3D imaging. In addition, endocranial granular impressions and abnormal blood vessel impressions were observed in multiple locations on the inner skull surface. Based on the differential diagnosis of the clival changes and their co-occurrence with endocranial alterations indicative of tuberculous meningitis (granular impressions and abnormal blood vessel impressions), they were most likely due to tuberculous involvement of the skull base. Additional aDNA analysis provided no evidence for the presence of Mycobacterium tuberculosis DNA in MMG3-75. To the best of our knowledge, MMG3-75 is the first reported archaeological case of tuberculous clival osteomyelitis with associated meningitis, giving us a unique insight into the occurrence of an extremely rare manifestation of tuberculosis in mediaeval Hungary.

The aim of our paper is to present and discuss in detail the pathological lesions suggestive of tuberculosis observed in a skeleton ( MMG3–75 ) that was excavated from the 16 th -century-CE mass grave No. 3 of the Mohács National Memorial Site (Sátorhely, southwestern Hungary). The differential diagnoses of the observed bony changes, with special attention to the clival alterations, are presented. During the macromorphological, radiological, and digital microscopic examination of MMG3–75 , the skull base showed mild cortical erosion and multiple, well-circumscribed osteolytic lesions at the clivus clearly evidenced by 3D imaging. In addition, endocranial granular impressions and abnormal blood vessel impressions were observed in multiple locations on the inner skull surface. Based on the differential diagnosis of the clival changes and their co-occurrence with endocranial alterations indicative of tuberculous meningitis (granular impressions and abnormal blood vessel impressions), they were most likely due to tuberculous involvement of the skull base. Additional aDNA analysis provided no evidence for the presence of Mycobacterium tuberculosis DNA in MMG3–75 . To the best of our knowledge, MMG3–75 is the first reported archaeological case of tuberculous clival osteomyelitis with associated meningitis, giving us a unique insight into the occurrence of an extremely rare manifestation of tuberculosis in mediaeval Hungary.

The aim of our paper is to present and discuss in detail the pathological lesions suggestive of tuberculosis observed in a skeleton ( MMG3–75 ) that was excavated from the 16 th -century-CE mass grave No. 3 of the Mohács National Memorial Site (Sátorhely, southwestern Hungary). The differential diagnoses of the observed bony changes, with special attention to the clival alterations, are presented. During the macromorphological, radiological, and digital microscopic examination of MMG3–75 , the skull base showed mild cortical erosion and multiple, well-circumscribed osteolytic lesions at the clivus clearly evidenced by 3D imaging. In addition, endocranial granular impressions and abnormal blood vessel impressions were observed in multiple locations on the inner skull surface. Based on the differential diagnosis of the clival changes and their co-occurrence with endocranial alterations indicative of tuberculous meningitis (granular impressions and abnormal blood vessel impressions), they were most likely due to tuberculous involvement of the skull base. Additional aDNA analysis provided no evidence for the presence of Mycobacterium tuberculosis DNA in MMG3–75 . To the best of our knowledge, MMG3–75 is the first reported archaeological case of tuberculous clival osteomyelitis with associated meningitis, giving us a unique insight into the occurrence of an extremely rare manifestation of tuberculosis in mediaeval Hungary.

Purpose Whether the use of high-flow nasal oxygen in adult patients with COVID-19 associated acute respiratory failure improves clinically relevant outcomes remains unclear. We thus sought to assess the effect of high-flow nasal oxygen on ventilator-free days, compared to early initiation of invasive mechanical ventilation, on adult patients with COVID-19. Methods We conducted a multicentre cohort study using a prospectively collected database of patients with COVID-19 associated acute respiratory failure admitted to 36 Spanish and Andorran intensive care units (ICUs). Main exposure was the use of high-flow nasal oxygen (conservative group), while early invasive mechanical ventilation (within the first day of ICU admission; early intubation group) served as the comparator. The primary outcome was ventilator-free days at 28 days. ICU length of stay and all-cause in-hospital mortality served as secondary outcomes. We used propensity score matching to adjust for measured confounding. Results Out of 468 eligible patients, a total of 122 matched patients were included in the present analysis (61 for each group). When compared to early intubation, the use of high-flow nasal oxygen was associated with an increase in ventilator-free days (mean difference: 8.0 days; 95% confidence interval (CI): 4.4 to 11.7 days) and a reduction in ICU length of stay (mean difference: − 8.2 days; 95% CI − 12.7 to − 3.6 days). No difference was observed in all-cause in-hospital mortality between groups (odds ratio: 0.64; 95% CI: 0.25 to 1.64). Conclusions The use of high-flow nasal oxygen upon ICU admission in adult patients with COVID-19 related acute hypoxemic respiratory failure may lead to an increase in ventilator-free days and a reduction in ICU length of stay, when compared to early initiation of invasive mechanical ventilation. Future studies should confirm our findings.

Background Awake prone positioning (awake-PP) in non-intubated coronavirus disease 2019 (COVID-19) patients could avoid endotracheal intubation, reduce the use of critical care resources, and improve survival. We aimed to examine whether the combination of high-flow nasal oxygen therapy (HFNO) with awake-PP prevents the need for intubation when compared to HFNO alone. Methods Prospective, multicenter, adjusted observational cohort study in consecutive COVID-19 patients with acute respiratory failure (ARF) receiving respiratory support with HFNO from 12 March to 9 June 2020. Patients were classified as HFNO with or without awake-PP. Logistic models were fitted to predict treatment at baseline using the following variables: age, sex, obesity, non-respiratory Sequential Organ Failure Assessment score, APACHE-II, C-reactive protein, days from symptoms onset to HFNO initiation, respiratory rate, and peripheral oxyhemoglobin saturation. We compared data on demographics, vital signs, laboratory markers, need for invasive mechanical ventilation, days to intubation, ICU length of stay, and ICU mortality between HFNO patients with and without awake-PP. Results A total of 1076 patients with COVID-19 ARF were admitted, of which 199 patients received HFNO and were analyzed. Fifty-five (27.6%) were pronated during HFNO; 60 (41%) and 22 (40%) patients from the HFNO and HFNO + awake-PP groups were intubated. The use of awake-PP as an adjunctive therapy to HFNO did not reduce the risk of intubation [RR 0.87 (95% CI 0.53–1.43), p  = 0.60]. Patients treated with HFNO + awake-PP showed a trend for delay in intubation compared to HFNO alone [median 1 (interquartile range, IQR 1.0–2.5) vs 2 IQR 1.0–3.0] days ( p  = 0.055), but awake-PP did not affect 28-day mortality [RR 1.04 (95% CI 0.40–2.72), p  = 0.92]. Conclusion In patients with COVID-19 ARF treated with HFNO, the use of awake-PP did not reduce the need for intubation or affect mortality.

Background Critically ill patients with coronavirus disease 19 (COVID-19) have a high fatality rate likely due to a dysregulated immune response. Corticosteroids could attenuate this inappropriate response, although there are still some concerns regarding its use, timing, and dose. Methods This is a nationwide, prospective, multicenter, observational, cohort study in critically ill adult patients with COVID-19 admitted into Intensive Care Units (ICU) in Spain from 12th March to 29th June 2020. Using a multivariable Cox model with inverse probability weighting, we compared relevant outcomes between patients treated with early corticosteroids (before or within the first 48 h of ICU admission) with those who did not receive early corticosteroids (delayed group) or any corticosteroids at all (never group). Primary endpoint was ICU mortality. Secondary endpoints included 7-day mortality, ventilator-free days, and complications. Results A total of 691 patients out of 882 (78.3%) received corticosteroid during their hospital stay. Patients treated with early-corticosteroids (n = 485) had lower ICU mortality (30.3% vs. never 36.6% and delayed 44.2%) and lower 7-day mortality (7.2% vs. never 15.2%) compared to non-early treated patients. They also had higher number of ventilator-free days, less length of ICU stay, and less secondary infections than delayed treated patients. There were no differences in medical complications between groups. Of note, early use of moderate-to-high doses was associated with better outcomes than low dose regimens. Conclusion Early use of corticosteroids in critically ill patients with COVID-19 is associated with lower mortality than no or delayed use, and fewer complications than delayed use.

It is unclear to which extent the higher mortality associated with hypertension in the coronavirus disease (COVID-19) is due to its increased prevalence among older patients or to specific mechanisms. Cross-sectional, observational, retrospective multicenter study, analyzing 12226 patients who required hospital admission in 150 Spanish centers included in the nationwide SEMI-COVID-19 Network. We compared the clinical characteristics of survivors versus non-survivors. The mean age of the study population was 67.5 ± 16.1 years, 42.6% were women. Overall, 2630 (21.5%) subjects died. The most common comorbidity was hypertension (50.9%) followed by diabetes (19.1%), and atrial fibrillation (11.2%). Multivariate analysis showed that after adjusting for gender (males, OR: 1.5, p = 0.0001), age tertiles (second and third tertiles, OR: 2.0 and 4.7, p = 0.0001), and Charlson Comorbidity Index scores (second and third tertiles, OR: 4.7 and 8.1, p = 0.0001), hypertension was significantly predictive of all-cause mortality when this comorbidity was treated with angiotensin-converting enzyme inhibitors (ACEIs) (OR: 1.6, p = 0.002) or other than renin-angiotensin-aldosterone blockers (OR: 1.3, p = 0.001) or angiotensin II receptor blockers (ARBs) (OR: 1.2, p = 0.035). The preexisting condition of hypertension had an independent prognostic value for all-cause mortality in patients with COVID-19 who required hospitalization. ARBs showed a lower risk of lethality in hypertensive patients than other antihypertensive drugs.