Early Administration Of Corticosteroids Research Articles

Macrophagic activation syndrome complicating miliary tuberculosis: A case report

Macrophage activation syndrome (MAS), also known as hemophagocytic syndrome or lymphohistiocytic activation syndrome, is a rare but potentially fatal disease. It results from inappropriate stimulation of macrophages in the bone marrow and lymphoid organs. The diagnosis of MAS is based on a combination of clinical, biological, and histological or cytological signs. MAS is categorized into primary forms, which mainly affect newborns and infants with a family history, and secondary forms, which occur in the context of neoplastic, autoimmune, or infectious diseases. Treatment involves addressing the specific causative agent of MAS and, in certain cases, early administration of corticosteroids and immunoglobulins. MAS is rarely associated with tuberculosis. We report the case of an immunocompetent patient presenting with miliary tuberculosis complicated by macrophage activation syndrome.

Reducing Time from Pediatric Emergency Department Arrival to Dexamethasone Administration in Wheezing Patients.

Asthma exacerbations are common presentations to pediatric emergency departments. Standard treatment for moderate-to-severe exacerbations includes administration of oral corticosteroids concurrently with bronchodilators. Early administration of corticosteroids has been shown to decrease emergency department length of stay (LOS) and hospitalizations. Our SMART aim was to reduce the time from arrival to oral corticosteroids (dexamethasone) administration in pediatric patients ≥2 years of age with an initial Pediatric Asthma Severity Score >6 from 60 to 30 minutes within 6 months. We used the model for improvement with collaboration between ED physicians, nursing, pharmacy, and respiratory therapists. Interventions included nursing education, dosage rounding in the electronic medical record, supplying triage with 1-mg tablets and a pill crusher, updates to an asthma nursing order set and pertinent chief complaints triggering nurses to document a Pediatric Asthma Severity Score in the electronic medical record and use the order set. Our primary outcome measure was the time from arrival to dexamethasone administration. Secondary outcome measures included ED LOS for discharged patients and admission rate. We used statistical process control to analyze changes in measures over time. From October 2021 to March 2022, the average time for dexamethasone administration decreased from 59 to 38 minutes. ED LOS for discharged asthma exacerbation patients rose with overall ED LOS for all patients during the study period. There was no change in the admission rate. Using quality improvement methodology, we successfully decreased the time from ED arrival to administration of dexamethasone in asthma exacerbation patients from 59 to 38 minutes over 10 months.

Differentiating Acute Interstitial Nephritis From Immune Checkpoint Inhibitors From Other Causes

Differentiating Acute Interstitial Nephritis From Immune Checkpoint Inhibitors From Other Causes

Association between early corticosteroid administration and long-term survival in non-infectious pulmonary complications after allogeneic hematopoietic stem cell transplantation.

Non-infectious pulmonary complications (NIPCs) after allogeneic hematopoietic stem cell transplantation (HSCT) are associated with poor outcomes. It is important to maximize the effectiveness of primary treatment because secondary treatment has not been established. We analyzed data from 393 patients who underwent allogeneic HSCT during a 10-year period. Thirty-seven were diagnosed with NIPCs, which consisted of idiopathic pneumonia syndrome, bronchiolitis obliterans, and interstitial lung disease including cryptogenic organizing pneumonia. Among these, 18 died (Dead group) while 19 remained alive (Alive group) during the study period. The median time between NIPC diagnosis and first administration of ≥ 1mg/kg/day corticosteroids (prednisolone dose equivalent) was significantly longer in the Dead group than the Alive group, at 9days versus 4days (p = 0.01). We further divided these cases into those who received prednisolone within seven days and after 8days. We found that the ≤ 7days group were more likely to survive after their NIPC diagnosis compared to the ≥ 8days group (p = 0.06). Our analysis showed that early initiation of corticosteroid therapy is associated with long-term survival in NIPCs.

Effectiveness of Corticosteroid Therapy for Non-Severe COVID-19 in Patients Not Requiring Supplemental Oxygen Who Have Risk Factors for Severe Disease.

Because they suppress cytokine production, corticosteroids are a candidate therapy for coronavirus disease 2019 (COVID-19). However, the effectiveness of corticosteroids is unclear for non-severe COVID-19 that does not require supplemental oxygen. This study investigated the effectiveness of corticosteroid therapy for patients with non-severe COVID-19. This retrospective observational study analyzed data from 10 patients with non-severe COVID-19 who received corticosteroid therapy at our center between July 1, 2020 and January 31, 2021. The median age of the 10 patients was 60 years, and nine were male. Nine of the 10 patients had multiple comorbid conditions (e.g., hypertension, diabetes, and obesity). Although blood oxygen saturation was maintained above 95%, all patients had persistent fever and deterioration in chest imaging findings, which led to initiation of corticosteroid treatment. The median duration symptom onset to initiation of corticosteroid therapy was 8 days. All patients received dexamethasone 6 mg/day as corticosteroid therapy, and the median period was 7.5 days. After the start of corticosteroid therapy, clinical improvement was rapid in all patients, and no patient developed severe disease. The latest World Health Organization guidance recommends against corticosteroid treatment for patients with non-severe COVID-19. In this report, early administration of corticosteroids during the non-critical phase, when oxygen supplementation was not required, was associated with early improvement and prevention of severe disease in patients with risk factors for severe COVID-19 and worsening clinical symptoms.

The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock.

Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes. Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity. Twelve academic PICUs in the United States. Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration. None. Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212). This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.

Association between Administration of Systemic Corticosteroids and the Recovery of Olfactory and/or Gustatory Functions in Patients with COVID-19: A Prospective Cohort Study

AIM: This study is a prospective cohort study aimed to assess the effect of systemic corticosteroids administration time in the recovery of gustatory and olfactory sensations dysfunction (ageusia and anosmia) in COVID-19 patients. MATERIALS AND METHODS: Sixty-seven COVID-19 patients with symptoms of ageusia and anosmia were recruited (that their COVID infection was confirmed using polymerase chain reaction). Daily 10 mg of systemic corticosteroids were prescribed in the 1st week and then reduced to 5 mg in the 2nd week to all the patients to observe taste and smell sensation recovery. All data were recorded and then analyzed. Patients were then grouped into two groups (early and late groups) according to the duration of their taste and smell dysfunction. RESULTS: Regression analysis showed that early corticosteroid administration resulted in a significant decrease in recovery time of ageusia and anosmia (0.27 [0.2–0.35], p < 0.001). Patients in the early administration group (<1 week) showed faster improvement in regaining taste and smell functions than in the late administration group (>1 week) with significant difference (p < 0.001). CONCLUSIONS: The use of systemic corticosteroids in early phases of covid-19 infection help in faster recovery of ageusia and anosmia.

497. Moderate Versus High Dose Corticosteroids in Adult Patients with Severe COVID-19: Less Is More

BackgroundThe early administration of corticosteroids (CS) in patients with severe COVID-19 (hospitalized with need for supplemental oxygen) has been the only therapy to improve survival. However, the optimal dosing of CS remains unclear. Beginning March 2020 methylprednisolone (MP) in a dose of 40mg twice daily (high dose CS - HDC) was adopted at our institution. Based on emerging trials, this dose of MP was reduced to 16mg twice daily (moderate dose CS – MDC) in November 2020. The study aims to evaluate the outcome difference in patients receiving HDC versus MDC. MethodsThis pre-post quasi-experimental study was done at Henry Ford Hospital, an 877-bed tertiary care hospital in Detroit, Michigan. Consecutive patients in the HDC group from September 1, 2020 to November 15, 2020 were compared to the MDC group from November 30, 2020 to January 20, 2021. Only hospitalized patients with severe COVID-19 were included. The primary outcome was 28-day mortality. Secondary outcomes included progression to mechanical ventilation, length of hospital stay, discharge on supplemental oxygen and CS-associated adverse events. Patient demographics were evaluated using descriptive statistics. Bivariate and multivariable logistic regression analysis was planned to test the association between primary outcome and exposure. Results470 patients were evaluated, 218 and 252 in the HDC and MDC groups respectively. Clinical characteristics and severity of illness on admission were comparable in both groups (Table 1). Among comorbidities - lung disease, cardiovascular disease and hypertension were higher in MDC. Antibiotic and tocilizumab use were lower in MDC. Significantly more patients in MDC group received oral CS. There was no difference in mortality between HDC and MDC through bivariate and multivariate analysis (14.7% and 13.5%, p < 0.712, adjusted OR 0.913 [0.514-1.619]) (Table 2,3). Median length of hospital stay was 5 and 6 days in HDC and MDC respectively (p < 0.001). There was no difference in CS-associated adverse events. ConclusionThe survival in severe COVID-19 patients treated with MDC is comparable to HDC. Oral corticosteroids are an equally effective option.Disclosures Rachel Kenney, PharmD, Medtronic, Inc. (Other Financial or Material Support, spouse is an employee and shareholder)

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status.

To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities. Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA. We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P=.01), have longer inpatient length of stay (31 vs 29 hours, P=.01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P=.02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures. At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.

Colitis after checkpoint blockade: A retrospective cohort study of melanoma patients requiring admission for symptom control.

BackgroundImmune checkpoint inhibitors (CPIs) have revolutionized oncologic therapy but can lead to immune‐related adverse events (irAEs). Corticosteroids are first‐line treatment with escalation to biologic immunosuppression in refractory cases. CPI‐related gastroenterocolitis (GEC) affects 20%‐50% of patients receiving CPIs and can carry significant morbidity and mortality. Severe CPI‐related GEC is not well‐described. We present the clinical characterization of all CPI‐related GEC requiring admission at a single institution.MethodsClinical, laboratory, radiographic, and endoscopic data were extracted from charts of all melanoma patients ≥18 years of age admitted to one institution for CPI‐related GEC, from February 5, 2011 to December 13, 2016. Patients were followed until December 31, 2017 for further admissions. Survival, outcomes, and pharmaceutical‐use analyses were performed.ResultsMedian time‐to‐admission from initial CPI exposure was 73.5 days. Median length of stay was 4.5 days. About 50.0% required second‐line immunosuppression. Readmission for recrudescence occurred in 33.3%. Common Terminology Criteria for Adverse Events (CTCAE) grade was not significantly associated with outcomes. Hypoalbuminemia (P = 0.005), relative lymphopenia (P = 0.027), and decreased lactate dehydrogenase (P = 0.026) were associated with second‐line immunosuppression. There was no difference in progression‐free survival (PFS) or OS (P = 0.367, 0.400) for second‐line immunosuppression. Subgroup analysis showed that early corticosteroid administration (P = 0.045) was associated with decreased PFS.ConclusionsSevere CPI‐related GEC typically manifests within 3 months of immunotherapy exposure. Rates of second‐line immunosuppression and readmission for recrudescence were high. CTCAE grade did not capture the degree of severity in our cohort. Second‐line immunosuppression was not associated with poorer oncologic outcomes; however, early corticosteroid exposure was associated with decreased PFS. Further investigation is warranted.

Community-Acquired Bacterial Meningitis in Adults

Community-acquired bacterial meningitis (CABM) is a life-threatening infection that can be complicated by neurological deficits among survivors. These outcomes have prompted interventions in prevention and treatment. These include an ever-expanding list of vaccines and adjunctive therapy, including early corticosteroid administration. Researchers conducted a prospective cohort study in the Netherlands to provide a contemporary evaluation of the disease's incidence, clinical aspects, and management. Adult (aged …

The Role of Corticosteroids in Adult Respiratory Distress Syndrome caused by Viridans Group Streptococci Bacteremia in Neutropenic Patients.

In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bacteremia in neutropenic patients with cancer. The clinical course of VGS bacteremia can be devastating including septic shock and adult respiratory distress syndrome (ARDS). It has been suggested that septicemia with VGS triggers the development of noncardiogenic pulmonary edema in patients with pre-existing damage of the lungs due to aggressive cytotoxic treatment. Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.

G384 Predictive value of the Kobayashi Score for IVIG resistance in Kawasaki Disease in the UK

AimsThe Kobayashi score, based on clinical and laboratory data, successfully predicts resistance to intravenous immunoglobulin (IVIG) treatment in children with Kawasaki Disease (KD) in a Japanese setting, where it is...

Evidence for and Against Intravitreous Corticosteroids in Addition to Intravitreous Antibiotics for Acute Endophthalmitis

The use of adjunctive intravitreous corticosteroids in endophthalmitis is controversial. Preclinical models showed that early administration of corticosteroids may be important although they reported mixed results in terms of their effects on antibiotic pharmacokinetics, control of infection and prevention of retinal damage. Most published retrospective clinical studies showed no beneficial effects associated with their use. However, a single well-conducted retrospective study showed a deleterious effect. Randomized controlled trials also showed a lack of beneficial effects. At the present time, the best available evidences do not support the routine use of adjunctive intravitreous corticosteroids for treatment of acute endophthalmitis.

Corticosteroid Timing and Length of Stay for Children With Asthma in the Emergency Department

To determine if early treatment with oral corticosteroids to pediatric patients with asthma exacerbations in the emergency department could decrease their length of stay.Children between the ages of 2 and 18 years who presented to the emergency department with acute asthma exacerbations and received oral corticosteroids, either prednisolone or dexamethasone, were included.Retrospective chart review of 882 children who were seen over the 12-month study period was performed. A standardized asthma treatment algorithm was used as a guide based on severity of exacerbation, but the treating physician decided medications used. Timing of corticosteroid administration and length of stay was calculated by the electronic medical record. Children receiving corticosteroids within 60 minutes of triage were compared with those receiving corticosteroids ≥61 minutes after triage. The 2 groups were compared using either Student’s t test or χ2 test, based on the level of measurement.Children treated with corticosteroids within 60 minutes had a mean length of stay of 157 minutes, whereas children treated later than 60 minutes had a mean length of stay of 182 minutes (P < .0001). The greatest decrease in length of stay was among children who were categorized as having a moderate exacerbation and had a mean 38-minute decrease in length of stay if treated with corticosteroids in the first hour. Both study groups had similar baseline characteristics; however, the group receiving corticosteroids within 60 minutes had a higher percentage of severe exacerbations. Subjects who received dexamethasone had a 19-minute shorter length of stay compared with patients treated with prednisolone. Of the subjects treated with dexamethasone, those who received it in the first 60 minutes had a mean 34-minute decrease in length of stay compared with those treated with prednisolone. Early treatment with albuterol within 60 minutes or after did not affect length of stay.Early corticosteroid administration within 60 minutes of triage in pediatric patients with asthma exacerbations was associated with a significant decrease in the overall length of stay. This study suggested that choice of oral corticosteroid, dexamethasone over prednisolone, may also affect the length of stay.Previous studies have found early corticosteroid administration to lessen admission rates to the hospital. Although this study did not show a difference in admission rates, this study did support early corticosteroid administration within the emergency department to help lessen length of stay. Properties of dexamethasone make it appear superior to prednisolone, but prospective randomized trials are necessary, as previous studies did not show significant improvements for decrease in length of stay or in admissions. As treatment protocols become more common, a prospective study that validates early use of oral corticosteroids and choice of oral steroid may help to both lessen the length of stay and decrease hospital admissions for asthma exacerbations. A limitation of this study was that type of oral steroid medication and other asthma medication use was left to the discretion of the treating physician, which may affect length of stay as well.

Children with Asthma in the ED

In the research study "Corticosteroid Timing and Length of Stay for Children With Asthma in the Emergency Department," the authors conducted a retrospective medical record review of children with emergency department (ED) visits to a Connecticut Medical Center in 2007. Their aim was to determine whether administration of oral corticosteroids to patients with acute asthma exacerbation would decrease the mean length of stay in the ED by 10 min or more. We review and critique this article and use a case study module to illustrate the importance of these research findings and also the larger body of evidence supporting the early administration of corticosteroids in acute asthma.

Early treatment of chlorine-induced airway hyperresponsiveness and inflammation with corticosteroids

Chlorine (Cl2) is an industrial gas that is highly toxic and irritating when inhaled causing tissue damage and an acute inflammatory response in the airways followed by a long-term airway dysfunction. The aim of this study was to evaluate whether early anti-inflammatory treatment can protect against the delayed symptoms in Cl2-exposed mice.BALB/c mice were exposed by nose-only inhalation using 200ppm Cl2 during 15min. Assessment of airway hyperresponsiveness (AHR), inflammatory cell counts in bronchoalveolar lavage, occurrence of lung edema and lung fibrosis were analyzed 24h or 14days post-exposure. A single dose of the corticosteroid dexamethasone (10 or 100mg/kg) was administered intraperitoneally 1, 3, 6, or 12h following Cl2 exposure.High-dose of dexamethasone reduced the acute inflammation if administered within 6h after exposure but treated animals still displayed a significant lung injury. The effect of dexamethasone administered within 1h was dose-dependent; high-dose significantly reduced acute airway inflammation (100mg/kg) but not treatment with the relatively low-dose (10mg/kg). Both doses reduced AHR 14days later, while lung fibrosis measured as collagen deposition was not significantly reduced.The results point out that the acute inflammation in the lungs due to Cl2 exposure only partly is associated with the long-term AHR. We hypothesize that additional pathogenic mechanisms apart from the inflammatory reactions contribute to the development of long-term airway dysfunction. By using this mouse model, we have validated early administration of corticosteroids in terms of efficacy to prevent acute lung injury and delayed symptoms induced by Cl2 exposure.

Diffuse Alveolar Damage as an Isolated Finding after Lung Transplantation: Beneficial Effect of Corticotherapy

Purpose Some patients (pts) after lung transplantation experienced adult respiratory distress syndrome (ARDS) in the early post-transplant period. Diffuse alveolar damage (DAD) is the histologic correlates of most patients with ARDS and can occurred as an isolated finding. The aim of this study was to report our experience with isolated DAD and to highlight the beneficial impact of corticotherapy. Methods and Materials From January 2008 through September 2012, we prospectively identified all pts with ARDS and who had undergone transbronchial lung biopsies. Courses of radiologic score, C-reactive protein level, PaO2/FiO2 ratio and sequential organ failure assessment (SOFA) score were noted after treatment by corticosteroids. Results Of the 152 lung transplanted pts, isolated DAD occurred in 8 pts (5.3%) after 7.0 ±3.6 days [range 3–13]. Pts (34.5±11.4 yrs-old) underwent 6 bilateral lung and 2 cardiopulmonary transplantations. A median of 6.5 [3-14.5] units of packed erythrocytes were transfused during the 24 hours post transplantation. All patients received corticotherapy (2mg/kg for 2 weeks). Courses of radiologic score, C-reactive protein level, PaO2/FiO2 ratio and SOFA score are summarized in figure 1 . Five pts developed pneumonia 9±3 days after corticotherapy initiation. Duration of mechanical ventilation was 29±20 days. Cellular or humoral rejection occurred in 3 and 2 pts respectively. One patient died. Conclusions Early administration of corticosteroids after isolated DAD improved dramatically the severity of lung injury and the associated generalized inflammatory state. However, the presence of isolated DAD complicated the post operative course after transplantation.

A six-month prospective study to find out the treatment outcome, prognosis and offending drugs in toxic epidermal necrolysis from an urban institution in Kolkata

Toxic epidermal necrolysis is the life-threatening dermatological emergency, most often an adverse cutaneous drug reaction with high mortality. A 6-month prospective study was conducted in our institution to find out the offending drugs, to assess the prognosis on admission using SCORTEN: Severity of illness score and to find out the treatment outcome. Anticonvulsants, NSAIDs and sulphonamides are the common offending agents; but in our study, 2 were due to homeopathic medicines. Out of 20 patients, on the date of admission SCORTEN prognostic score was 2 in 11 patients, 3 in 8 patients and 4 in 1 patient. Eighteen patients were treated with dexamethasone intramuscular injection and 2 patients got intravenous immunoglobulin (IVIG). All patients survived without any mortality. Though improvement was slightly faster with IVIG, early administration of corticosteroids was also of encouraging efficacy and should be considered in developing countries due to low cost. No mortality in our study suggests need to validate the SCORTEN index in our country in a large number of patients.

Pharmacotherapy for Acute Respiratory Distress Syndrome

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) represent a continuum of a clinical syndrome of respiratory failure due to refractory hypoxia. Acute respiratory distress syndrome is differentiated from ALI by a greater degree of hypoxemia and is associated with higher morbidity and mortality. The mortality for ARDS ranges from 22-41%, with survivors usually requiring long-term rehabilitation to regain normal physiologic function. Numerous pharmacologic therapies have been studied for prevention and treatment of ARDS; however, studies demonstrating clear clinical benefit for ARDS-related mortality and morbidity are limited. In this focused review, controversial pharmacologic therapies that have demonstrated, at minimum, a modest clinical benefit are discussed. Three pharmacologic treatment strategies are reviewed in detail: corticosteroids, fluid management, and neuromuscular blocking agents. Use of corticosteroids to attenuate inflammation remains controversial. Available evidence does not support early administration of corticosteroids. Additionally, administration after 14days of disease onset is strongly discouraged. A liberal fluid strategy during the early phase of comorbid septic shock, balanced with a conservative fluid strategy in patients with ALI or ARDS during the postresuscitation phase, is the optimum approach for fluid management. Available evidence supports an early, short course of continuous-infusion cisatracurium in patients presenting with severe ARDS. Evidence of safe and effective pharmacologic therapies for ARDS is limited, and clinicians must be knowledgeable about the areas of controversies to determine application to patient care.