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        "titulo" => "La posici&#243;n prona en los pacientes con COVID-19 y s&#237;ndrome de distr&#233;s respiratorio agudo que recibieron oxigenoterapia convencional&#58; un estudio retrospectivo"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Flow chart of patient selection&#46; ARDS&#58; acute respiratory distress syndrome&#59; IMV&#58; invasive mechanical ventilation&#59; NIMV&#58; non-invasive mechanical ventilation&#59; HFNC&#58; high-flow nasal cannula&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Coronavirus disease 2019 &#40;COVID-19&#41; is caused by the severe acute respiratory syndrome coronavirus 2 &#40;SARS-CoV-2&#41;&#44; which emerged in Wuhan &#40;China&#41; in December 2019&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> Although most cases are mild&#44; nearly 20&#37; of patients require hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> Despite supportive care&#44; one third of hospitalized patients meet the Berlin criteria for acute respiratory distress syndrome &#40;ARDS&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3&#44;4</span></a> and may need admission to intensive care unit &#40;ICU&#41;&#46; Overall mortality ranged 21&#8211;26&#37; with advanced age&#44; male sex and comorbidities being the strongest predictors of in-hospital mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Apart from dexamethasone&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> to date the mainstay of treatment if COVID-19 are supplemental oxygen therapy and best supportive care&#44; including invasive mechanical ventilation &#40;IMV&#41; in severe ARDS&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> Prone position &#40;PP&#41; is the only technique that has demonstrated to increase survival in patients with severe ARDS receiving IMV&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">9</span></a> However&#44; due to a sudden increase in hospitalizations&#44; exceeding ICU capacity&#44; PP has been attempted in non-intubated awake patients with COVID-19 and severe ARDS in conventional medical wards&#44;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10&#8211;12</span></a> despite inconsistent results on the impact of this intervention on mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">13</span></a> In this study&#44; we evaluated the impact on in-hospital mortality of PP in spontaneously breathing patients with COVID-19 and severe ARDS&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">This study is based on the data from the SEMI-COVID-19 Registry&#46; This Registry is an ongoing nationwide&#44; multicenter&#44; observational retrospective cohort of adult patients admitted to Spanish hospitals from March 1st&#44; 2020 because of microbiologically confirmed COVID-19&#46; Characteristics of the Registry are detailed elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> In this study we included patients aged 18&#8211;75 years old who presented pneumonia and severe ARDS &#40;PaO<span class="elsevierStyleInf">2</span>&#47;FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mmHg&#41;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">4</span></a> during hospitalization&#46; Exclusion criteria were&#58; &#40;a&#41; ICU admission&#44; &#40;b&#41; use of non-invasive mechanical ventilation &#40;NIMV&#41;&#44; &#40;c&#41; use of high-flow nasal cannula &#40;HFNC&#41; oxygen therapy&#44; &#40;d&#41; moderate or severe dependence for activities of daily living &#40;e&#41; solid or hematologic cancer&#44; &#40;f&#41; chronic dialysis&#44; &#40;g&#41; neurodegenerative disease or hemiplegia&#46; The primary outcome was death during hospitalization&#46; Patients in whom PP during spontaneous breathing was used for at least one day were compared to those who did not receive this treatment&#46; PP indication and duration were decided at clinical discretion and this information was not recorded in the registry&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Baseline characteristics between groups were compared using Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test and Fisher&#39;s exact test&#46; Univariate logistic regression was used to estimate the crude effect of prone position on mortality&#44; as well as the effect of those baseline variables that were different between both groups &#40;<span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;10&#41; or considered as clinically relevant&#46; Afterwards&#44; a multivariate logistic regression model was elaborated&#44; including as confounders the variables that showed a univariate effect on mortality or those a priori &#40;outcome-blinded&#41; considered as relevant according to literature review<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> and clinical plausibility &#40;age&#44; sex&#44; Charlson Comorbidity Index &#40;CCI&#41;&#44; heart failure&#44; altered mental status&#44; and treatment with tocilizumab or corticosteroids&#41;&#46; Beginning with the maximum model containing all the variables&#44; we use an investigator-guided backward elimination method to estimate the final model&#44; iteratively excluding non-significant variables until all variables of the model showed <span class="elsevierStyleItalic">p</span>-values<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46; The goodness of fit of the model was evaluated with the area under the receiver operating characteristics curve &#40;AUC&#41;&#46; The 95&#37; confidence interval &#40;95&#37; CI&#41; of AUC was calculated using the binomial exact method&#46; All statistical analyses were performed using Stata 15&#46;2&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Until August 31st&#44; 2020&#44; the SEMI-COVID-19 Registry included 17&#44;084 patients&#44; of which 163 presented severe ARDS and met inclusion criteria and did not meet any exclusion criteria &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Prone position was used in 60 patients &#40;36&#46;8&#37;&#41;&#46; Baseline characteristics&#44; treatment received and outcomes in both groups are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Patients who receive PP were younger&#44; had less comorbidity&#44; presented higher C-reactive protein and D-dimer levels at admission&#44; and received more corticosteroids and tocilizumab&#46; Besides&#44; although the proportion of patients with altered mental status at presentation did not meet our pre-specified criteria of <span class="elsevierStyleItalic">p</span>-value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;10 to be considered different between the two groups&#44; we considered the difference clinically relevant &#40;7&#46;8&#37; vs 15&#46;3&#37;&#41;&#46; Ninety out of 163 patients &#40;55&#46;2&#37;&#41; died&#46; Patients who died were older and have more comorbidity &#40;<a class="elsevierStyleCrossRef" href="#sec0010">Supplementary Table 1</a>&#41;&#46; Patients treated with PP presented lower mortality &#40;62&#46;1&#37; vs 43&#46;3&#37;&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0229&#41;&#44; with an estimated crude OR of 0&#46;47 &#40;95&#37; CI 0&#46;24&#8211;0&#46;89&#41;&#46; In the adjusted model&#44; use of PP showed a protective effect on mortality &#40;OR 0&#46;42&#44; 95&#37; CI 0&#46;18&#8211;0&#46;98&#41;&#44; after adjusting for age&#44; CCI and altered mental status at presentation &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The AUC of this adjusted model was 0&#46;861 &#40;95&#37; CI 0&#46;799&#8211;0&#46;912&#41;&#46; Although it could be arguable to remove corticosteroids and tocilizumab as confounders in the adjusted analysis&#44; the exclusion of these variables did not modify the protective effect of PP on mortality&#44; and the accuracy of our adjusted model to predict in-hospital death was very good&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Despite PP is a well-established evidence-based practice in patients with typical ARDS undergoing IMV&#44; there is very limited evidence of its use in non-ventilated awake patients and derived mostly from case reports and uncontrolled cohorts using a wide variety of PP protocols&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13&#44;14</span></a> Besides&