Severity Of Illness In Patients Research Articles

Outcomes of SARS-CoV-2 infection among children and young people with pre-existing rheumatic and musculoskeletal diseases

ObjectivesSome adults with rheumatic and musculoskeletal diseases (RMDs) are at increased risk of COVID-19-related death. Excluding post-COVID-19 multisystem inflammatory syndrome of children, children and young people (CYP) are overall less...

Implementation of corticosteroids in treatment of COVID-19 in the ISARIC WHO Clinical Characterisation Protocol UK: prospective, cohort study

SummaryBackgroundDexamethasone was the first intervention proven to reduce mortality in patients with COVID-19 being treated in hospital. We aimed to evaluate the adoption of corticosteroids in the treatment of COVID-19 in the UK after the RECOVERY trial publication on June 16, 2020, and to identify discrepancies in care.MethodsWe did an audit of clinical implementation of corticosteroids in a prospective, observational, cohort study in 237 UK acute care hospitals between March 16, 2020, and April 14, 2021, restricted to patients aged 18 years or older with proven or high likelihood of COVID-19, who received supplementary oxygen. The primary outcome was administration of dexamethasone, prednisolone, hydrocortisone, or methylprednisolone. This study is registered with ISRCTN, ISRCTN66726260.FindingsBetween June 17, 2020, and April 14, 2021, 47 795 (75·2%) of 63 525 of patients on supplementary oxygen received corticosteroids, higher among patients requiring critical care than in those who received ward care (11 185 [86·6%] of 12 909 vs 36 415 [72·4%] of 50 278). Patients 50 years or older were significantly less likely to receive corticosteroids than those younger than 50 years (adjusted odds ratio 0·79 [95% CI 0·70–0·89], p=0·0001, for 70–79 years; 0·52 [0·46–0·58], p<0·0001, for >80 years), independent of patient demographics and illness severity. 84 (54·2%) of 155 pregnant women received corticosteroids. Rates of corticosteroid administration increased from 27·5% in the week before June 16, 2020, to 75–80% in January, 2021.InterpretationImplementation of corticosteroids into clinical practice in the UK for patients with COVID-19 has been successful, but not universal. Patients older than 70 years, independent of illness severity, chronic neurological disease, and dementia, were less likely to receive corticosteroids than those who were younger, as were pregnant women. This could reflect appropriate clinical decision making, but the possibility of inequitable access to life-saving care should be considered.FundingUK National Institute for Health Research and UK Medical Research Council.

Is there an association between inflammatory/anti-oxidant markers and the presence of psychotic symptoms or severity of illness in mood and psychotic disorders? A multi-centric study on a drug-free sample

The immune and antioxidant systems are intimately connected and their role in the etiology of major psychiatric disorders is currently under study. The aim of this study was to evaluate the potential associations between inflammatory/antioxidant peripheral markers and presence of psychotic symptoms or severity of illness in patients affected by major psychiatric disorders.One hundred and twenty-six drug-free patients were included. A blood sample was collected to measure total/B/T lymphocytes and plasma levels of albumin, total bilirubin, uric acid, C-reactive protein, and vitamins A and E. Severity of illness was assessed using psychometric scales. Groups of patients divided according to diagnosis were compared in terms of measured markers using multivariate analyses of variance (MANOVAs). Linear and logistic regression analyses were performed to investigate the potential association between markers and severity of illness or presence/absence of psychotic symptoms.Albumin plasma levels were higher in patients with substance-induced psychotic disorder (SIPD) than subjects affected by schizophrenia (F ​= ​4.923; p ​= ​0.003). Lower vitamin E (OR ​= ​0.81; p ​= ​0.014) and T lymphocyte (OR ​= ​0.99; p ​= ​0.048) plasma levels were predictive of lifetime psychotic symptoms. Lower vitamin A levels were associated with higher Montgomery-Åsberg Depression Rating Scale scores (β ​= ​-24.26; p ​= ​0.029), independent of diagnosis.Patients with SIPD may be less vulnerable to oxidative stress. The severity of depressive symptoms, inversely associated with vitamin A plasma levels, is likely to be modulated by the degree of inflammation. Patients presenting with lifetime psychotic symptoms may be more vulnerable to oxidative stress and may have a higher activation of humoral immunity.

Resistin production does not affect outcomes in a mouse model of acute surgical sepsis.

Because of the strong correlation between the blood concentration of circulating resistin and the illness severity of septic patients, resistin has been proposed as a mediator of sepsis pathophysiology. In vitro data indicate that human resistin directly impairs neutrophil migration and intracellular bacterial killing, although the significance of these findings in vivo remain unclear. The objectives of the present study were: (1) to validate the expression of human resistin in a clinically relevant, murine model of surgical sepsis, (2) to assess how sepsis-induced changes in resistin correlate with markers of infection and organ dysfunction, and (3) to investigate whether the expression of human resistin alters immune function or disease outcomes in vivo. 107 male, C57BL/6 mice transgenic for the human resistin gene and its promoter elements (Retn+/-/-, or Retn+) were generated on a Retn-/- (mouse resistin knockout, or Rko) background. Outcomes were compared between age-matched transgenic and knockout mice. Acute sepsis was defined as the initial 24 h following cecal ligation and puncture (CLP). Physiologic and laboratory parameters correlating to the human Sequential Organ Failure Assessment (SOFA) Score were measured in mice, and innate immune cell number/function in the blood and peritoneal cavity were assessed. CLP significantly increased circulating levels of human resistin. The severity of sepsis-induced leukopenia was comparable between Retn+ and Rko mice. Resistin was associated with increased production of neutrophil reactive oxygen species, a decrease in circulating neutrophils at 6 h and an increase in peritoneal Ly6Chi monocytes at 6 h and 24 h post-sepsis. However, intraperitoneal bacterial growth, organ dysfunction and mouse survival did not differ with resistin production in septic mice. Ex vivo resistin-induced impairment of neutrophil function do not appear to translate to increased sepsis severity or poorer outcomes in vivo following CLP.

Trends in Illness Severity, Hospitalization, and Mortality for Community-Onset Pneumonia at 118 US Veterans Affairs Medical Centers.

BackgroundDeaths from pneumonia were decreasing globally prior to the COVID-19 pandemic, but it is unclear whether this was due to changes in patient populations, illness severity, diagnosis, hospitalization thresholds, or treatment. Using clinical data from the electronic health record among a national cohort of patients initially diagnosed with pneumonia, we examined temporal trends in severity of illness, hospitalization, and short- and long-term deaths.DesignRetrospective cohortParticipantsAll patients >18 years presenting to emergency departments (EDs) at 118 VA Medical Centers between 1/1/2006 and 12/31/2016 with an initial clinical diagnosis of pneumonia and confirmed by chest imaging report.ExposuresYear of encounter.Main MeasuresHospitalization and 30-day and 90-day mortality. Illness severity was defined as the probability of each outcome predicted by machine learning predictive models using age, sex, comorbidities, vital signs, and laboratory data from encounters during years 2006–2007, and similar models trained on encounters from years 2015 to 2016. We estimated the changes in hospitalizations and 30-day and 90-day mortality between the first and the last 2 years of the study period accounted for by illness severity using time covariate decompositions with model estimates.ResultsAmong 196,899 encounters across the study period, hospitalization decreased from 71 to 63%, 30-day mortality 10 to 7%, 90-day mortality 16 to 12%, and 1-year mortality 29 to 24%. Comorbidity risk increased, but illness severity decreased. Decreases in illness severity accounted for 21–31% of the decrease in hospitalizations, and 45–47%, 32–24%, and 17–19% of the decrease in 30-day, 90-day, and 1-year mortality. Findings were similar among underrepresented patients and those with only hospital discharge diagnosis codes.ConclusionsOutcomes for community-onset pneumonia have improved across the VA healthcare system after accounting for illness severity, despite an increase in cases and comorbidity burden.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07413-8.

Proper Titration Orders Are Essential for Patient Safety.

Proper Titration Orders Are Essential for Patient Safety.

The ratio of red blood cell distribution width to serum calcium predicts severity of patients with acute pancreatitis.

Illness severity of patients with acute pancreatitis (AP) at early stage is crucial because the identified moderate and severe cases need early intensive care to reduce the risk of serious complications such as multi-organ failure. Although red blood cell distribution width(RDW)and serum calcium(Ca)alone can be used as predictors of the severity of AP, they have low sensitivity and specificity. Thus, this study is aimed at evaluating the value of the ratio of RDW to serum calcium, which can all be acquired on admission, in predicting the severity of AP. This study was based on a retrospective cohort study on patients with AP at the emergency department (ED) of West China Hospital Hospital from January 2016 to June 2016. We divided the patients with AP into two groups, mild acute pancreatitis (MAP) and moderate severe acute pancreatitis (MSAP)+severe acute pancreatitis (SAP). A receiver-operating characteristic (ROC) curve analysis was used to valuate the predictive value of the ratio of RDW to serum calcium for the severity of AP patients and the cut-off value for the ratio of RDW to serum calcium was calculated with sensitivity and specificity. P<0.05 was considered statistically significant. A total of 666 AP patients were enrolled in this study. These patients were divided into MAP (n=518) and MSAP+SAP (n=148) groups. The AUC of RDW/ Ca was 0.912 (95% CI 0.887 to 0.937, P<0.001), larger than the AUCs of RDW (AUC=0.768, 95% CI 0.723 to 0.812, P<0.001) and Ca (AUC=0.875, 95% CI 0.844 to 0.906, P<0.001). The optimal cut-off value for RDW/ Ca to predict MSAP and SAP was 7.04 (sensitivity=0.885, specificity=0.834). The RDW/Ca might be a valuable predictor of the severity of patients with AP.

A randomized double-blind placebo-controlled clinical trial of nitazoxanide for treatment of mild or moderate COVID-19.

SummaryBackgroundThere is an urgent need for treatments of mild or moderate COVID-19 in an outpatient setting.MethodsA randomized double-blind placebo-controlled clinical trial in 36 centers in the U.S. between August 2020 and February 2021 investigated the safety and effectiveness of oral nitazoxanide 600 mg twice daily for five days in outpatients with symptoms of mild or moderate COVID-19 enrolled within 72 h of symptom onset (ClinicalTrials.gov NCT04486313). Efficacy endpoints were time to sustained clinical recovery (TSR, a novel primary endpoint) and proportion of participants progressing to severe illness within 28 days (key secondary).Findings1092 participants were enrolled. 379 with laboratory-confirmed SARS-CoV-2 infection were analyzed. In the primary analysis, median (IQR) TSR were 13·3 (6·3, >21) and 12·4 (7·2, >21) days for the nitazoxanide and placebo groups, respectively (p = 0·88). 1 of 184 (0·5%) treated with nitazoxanide progressed to severe illness compared to 7 of 195 (3·6%) treated with placebo (key secondary analysis, odds ratio 5·6 [95% CI 0·7 - 46·1], relative risk reduction 85%, p = 0·07). In the pre-defined stratum with mild illness at baseline, nitazoxanide-treated participants experienced reductions in median TSR (3·1 days, p = 0·09) and usual health (5·2 days, p < 0·01) compared to placebo. Nitazoxanide was safe and well tolerated.InterpretationFurther trials with larger numbers are warranted to evaluate efficacy of nitazoxanide therapy in preventing progression to severe illness in patients at high risk of severe illness and reducing TSR in patients with mild illness.

India's Second COVID Wave: How is it different from the First Wave?

PurposeIndia is witnessing the resurgence of the COVID-19 pandemic in the form of a hard-hitting second wave. We wanted to compare the clinical profile of the first wave (April-June 2020) with the second wave (March-May 2021) of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), to help prioritize the target population group and management strategies. This will further help in the management of any upcoming third COVID wave.Methods & MaterialsWe conducted a retrospective observational study and examined the demographic profile, symptoms, illness severity, baseline investigations, treatment given, comorbidities, and outcomes of the COVID-19 patients belonging to the first (W1) and the second (W2) waves of the Indian COVID pandemic.ResultsW2 had most people affected in the age group 50.5 (17.7) years compared with 37•1 (16•9) for W1. Baseline oxygen saturation was lower for W2 [84•0 (13•4) % versus(v/s) 91•9 (7•4) %] than W1. 70.2 % of the cases belonged to the severe category in W2 compared to 37.5% in W1. The level of hepatic transaminases was higher for W2 [AST, 108.3 (99.3) v/s 54.6 (69.3); ALT, 97.6 (82.3) v/s 58.7 (69.7) IU/L] than W1. CT severity score in W2 [29.5 (6.7)] was greater than W1 [23•2 (11•5)] [All P<0.05]. The standardized mortality ratio for W2 was 3.5 times that of W1. Higher proportion of patients require oxygen (81.8% v/s 11.2%), high flow nasal cannula (11.4% v/s 5.6%), non-invasive ventilation (41.2% v/s 1.5%), invasive ventilation (24.5% v/s 0.9%), and ICU admissions (56.4% v/s 12.0%) in W2 as compared with W1. We found the second wave to be stronger in terms of oxygen requirement, organ dysfunction, and mortalityConclusionHigher age, oxygen and ventilator requirement, ICU admissions, and organ failure are more prevalent in the second COVID wave that has hit India compared to the first wave and is associated with more deaths. India swiftly needs to scale up the prevalent ICU set up and oxygen production capacity to help accommodate the higher load.

The relationship between the lipid profiles and inflammation in patients with sepsis

To explore the relationship between the changes in the lipid profiles and the intensity of inflammatory response and disease severity in patients with sepsis, in order to find a biomarker that can quickly evaluate the condition and prognosis of sepsis. A retrospective analysis was performed on 449 patients with sepsis admitted to department of critical care medicine of the First Affiliated Hospital of Zhengzhou University from October 2019 to May 2021, and 355 patients without sepsis hospitalized in the same period served as the control. The general demographic data, blood lipid and other clinical indicators within 24 hours after admission were collected and compared between the two groups. Bivariate correlation study was used to analyze the relationship between blood lipid levels and inflammation indicators and severity of illness in patients with sepsis. The receiver operator characteristic curve (ROC curve) was drawn to evaluate the predictive value of each blood lipid component on the 28-day mortality of patients with sepsis. According to the results of ROC curve analysis, the blood lipids were divided into two groups with different levels, and the Kaplan-Meier survival curve was used to compare the cumulative survival rates of the two groups without end-point event (the 28-day mortality was the end-point event). Compared with non-septic patients, the levels of plasma total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were significantly lower in patients with sepsis [TC (mmol/L): 2.93±1.33 vs. 4.01±1.14, HDL-C (mmol/L): 0.78±0.47 vs. 1.16±0.40, LDL-C (mmol/L): 1.53±1.00 vs. 2.71±0.98, all P < 0.05]. In patients with sepsis, plasma cholesterol levels were correlated with the degree of inflammation and severity of the disease to varying degrees, but the HDL-C had the strongest correlation with interleukin-6 (IL-6; r = -0.551, P = 0.000), procalcitonin (PCT, r = -0.598, P = 0.000), sequential organ failure assessment (SOFA; r = -0.285, P = 0.000). The ROC curve analysis showed that among all blood lipid components, HDL-C had the highest predictive value for 28-day mortality of sepsis patients, and the area under the ROC curve (AUC) was 0.718, when the best cut-off value was 0.69 mmol/L, the sensitivity and specificity were 67.3% and 65.2% respectively, and the positive predictive value and negative predictive value were 60.6% and 71.5% respectively. According to Kaplan-Meier survival curve analysis, the mortality of sepsis patients with HDL-C ≤ 0.69 mmol/L was significantly higher than the patients with HDL-C > 0.69 mmol/L, and the difference was statistically significant (P < 0.000 1). In addition, the 28-day mortality [59.73% (135/226) vs. 28.70% (64/223)], the incidence of multiple organ dysfunction [41.15% (93/226) vs. 31.84% (71/223)], the probability of requiring mechanical ventilation and vasoactive drugs [mechanical ventilation: 56.64% (128/226) vs. 46.18% (103/223); vasoactive drugs: 54.42% (123/226) vs. 38.57% (86/223)], the positive rate of microbial culture [45.58% (103/226) vs. 35.43% (79/223)], and the probability of drug-resistant bacteria [19.91% (45/226) vs. 10.31% (23/223)] in the low HDL-C group of sepsis patients were all higher than the high HDL-C group, the differences were statistically significant (all P < 0.05). Plasma cholesterol levels, especially the HDL-C levels, can well reflect the intensity of inflammation and the severity of the disease in patients with sepsis. And the HDL-C levels can be used as a good biomarker for predicting the short-term prognosis of sepsis.

Endotheliopathy is associated with slower liberation from mechanical ventilation: a cohort study

BackgroundEndotheliopathy is suggested as pivotal pathophysiology of sepsis and trauma-associated organ failure, but its role in acute respiratory failure is not yet determined. We investigated if endotheliopathy biomarkers at ICU admission are associated with illness severity and clinical outcomes in patients with acute respiratory failure requiring mechanical ventilation.MethodsWe conducted a prospective single-center cohort study including 459 mechanically ventilated adults at ICU admission. Plasma levels of three endotheliopathy biomarkers were measured at ICU admission: Syndecan-1, soluble Thrombomodulin (sTM), and Platelet Endothelial Cell Adhesion Molecule-1 (PECAM-1). The primary outcome was the rate of liberation from mechanical ventilation, which is presented together with the rate of the competing risk of death while still on mechanical ventilation. Secondary outcomes were PaO2/FiO2-ratios on admission and on last measurement in patients dying within five days, and 30-day all-cause mortality. The primary outcome and 30-day all-cause mortality were analyzed using Cox regression, controlled for gender, age, chronic obstructive pulmonary disease, septic shock, heart failure, PaO2/FiO2-ratio at admission, respiratory infection, acute kidney injury, and bilirubin. PaO2/FiO2-ratios were analyzed using linear regression, controlled for age, chronic obstructive pulmonary disease, respiratory infection, and shock.ResultsPatients with high sTM were liberated from mechanical ventilation at a lower rate (adjusted hazard ratio (HR) 0.71, for an increase from the 25th to the 75th percentile, 95% confidence interval (CI) 0.54–0.93, p = 0.01). Patients with high PECAM-1 were liberated from mechanical ventilation at a lower rate, but only during the first 5 days (adjusted HR 0.72, for an increase from the 25th to the 75th percentile, 95% CI 0.58–0.9, p < 0.01). High levels of Syndecan-1 and PECAM-1 were associated with a higher rate of death while still on mechanical ventilation. sTM and PECAM-1 were negatively associated with PaO2/FiO2-ratio at ICU admission and no biomarker was associated with last measured PaO2/FiO2-ratio. High levels of all biomarkers were associated with higher 30-day all-cause mortality.ConclusionIn acute respiratory failure, endotheliopathy biomarkers are associated with lower rates of liberation from mechanical ventilation, hypoxemia at ICU admission, and 30-day all-cause mortality.Graphic

Combined and interactive effects of alcohol drinking and cigarette smoking on the risk of severe illness and poor clinical outcomes in patients with COVID-19: a multicentre retrospective cohort study

ObjectivesCigarette smoking is an established risk factor for illness severity and adverse outcomes in patients with COVID-19. Alcohol drinking may also be a potential risk factor for disease severity. However, the combined and interactive effects of drinking and smoking on COVID-19 have not yet been reported. This study aimed to examine the combined and interactive effects of alcohol drinking and cigarette smoking on the risk of severe illness and poor outcomes in patients with COVID-19. Study designThis was a multicentre retrospective cohort study. MethodsThis study retrospectively reviewed the data of 1399 consecutive hospitalised COVID-19 patients from 43 designated hospitals. Patients were grouped according to different combinations of drinking and smoking status. Multivariate mixed-effects logistic regression models were used to estimate the combined and interactive effects of drinking and smoking on the risk of severe COVID-19 and poor clinical outcomes. ResultsIn the study population, 7.3% were drinkers/smokers, 4.3% were drinkers/non-smokers and 4.9% were non-drinkers/smokers. After controlling for potential confounders, smokers or drinkers alone did not show a significant increase in the risk of severe COVID-19 or poor clinical outcomes compared with non-drinkers/non-smokers. Moreover, this study did not observe any interactive effects of drinking and smoking on COVID-19. Drinkers/smokers had a 62% increased risk (odds ratio = 1.62, 95% confidence interval: 1.01-2.60) of severe COVID-19 but did not have a significant increase in the risk for poor clinical outcomes compared with non-drinkers/non-smokers. ConclusionsCombined exposure to drinking and smoking increases the risk of severe COVID-19, but no direct effects of drinking or smoking, or interaction effects of drinking and smoking, were detected.

Plasma orexin A does not reflect severity of illness in the intensive care units patients with systemic inflammation

BackgroundSystemic inflammatory response occurs by sepsis and invasive surgery. Recent articles suggest that not only CRP but also procalcitonin, presepsin, and neutrophil gelatinase-associated lipocalin may reflect the severity of systemic inflammation. In addition, as systemic inflammation could degenerate orexin neurons, plasma orexin A might also be a good biomarker to predict the severity. Thus, we have determined relation between plasma biomarker and severity of illness score in patients with systemic inflammation.MethodsPrevious database (UMIN000018427) was used to secondly determine which plasma biomarkers may predict the severity of illness in the ICU patients with systemic inflammation (n = 57, 31 non-sepsis surgical patients and 26 sepsis patients). We measured plasma levels of orexin A, CRP, procalcitonin, presepsin, and neutrophil gelatinase-associated lipocalin were measured, and APACHE II score was assessed in these patients at their admission to the ICU. Data are shown as mean ± SD. Statistical analyses were done with unpaired t test. The correlation between APACHE II score and plasma biomarkers were examined using Pearson’s correlation coefficient and a least squares linear regression line.ResultsDemographic data did not differ between sepsis and non-sepsis groups. However, APACHE-II score was significantly higher in sepsis group than those in non-sepsis group (20.9 ± 6.6 vs 15.8 ± 3.2, p < 0.01). There were significant correlations between APACHE II score and plasma CRP (r = 0.532, p < 0.01), procalcitonin (r = 0.551, p < 0.01), presepsin (r = 0.510, p < 0.01), and neutrophil gelatinase-associated lipocalin (r = 0.466, P < 0.01) except orexin A.ConclusionAll plasma biomarkers tested except orexin A may reflect the severity of illness in patients with systemic inflammation.

Analysis of epidemiological and clinical profile in COVID-19 deaths in a tertiary care ICU setup: a retrospective observational study

There are numerous publications describing the epidemiology and clinical outcome of patients infected with COVID-19. However, limited studies solely describing the fatalities, especially in India. In this retrospective, single-centre analysis of patients’ case records, we aim to describe and discuss the demographics, clinical, laboratory findings in 201 patients who expired as a result of SARS CoV-2 infection. Electronic medical files of all confirmed COVID-19 patients, admitted to the ICU between 1st February 2020 and 15th July 2020, were scanned retrospectively and data was collected from files of the fatalities only, without revealing patient identity at any point. The data, including demographics (age, sex, comorbidities), clinical presentation, baseline laboratory parameters, SOFA score and duration of illness was recorded and analyzed statistically. A total of 201 deceased patients were included in the study, out of which 58.2% were males. The median age was 59 years (IQR: 47.5 – 65 years) which appears to be less than a lot of studies conducted outside India. Majority of patients had classical influenza-like symptoms at presentation (74.1%), but a sizable number also had extra-pulmonary manifestations (24.9%). Eight patients had isolated neurological presentation. It was found that number of comorbidities increased, and duration of illness decreased with increasing age, and this was statistically significant (p 0.03 and 0.01, respectively). SOFA score was found to be an important marker of severity of illness in COVID patients. ARDS remained the primary cause of death in 87.1% patients, although septic shock was observed in 34.8%. Six patients expired due to a high suspicion of pulmonary thromboembolism.

Asthma and COVID-19 Associations: Focus on IgE-Related Immune Pathology.

Management of patients with asthma during the coronavirus disease 2019 (COVID-19) pandemic is a concern, especially since asthma predisposes patients to respiratory problems. Interestingly, asthma characterized by type 2 inflammation, also known as T-helper type 2-high endotype, displays a cellular and molecular profile that may confer protective effects against COVID-19. The results of experimental and clinical studies have established the actions of immunoglobulin E (IgE) in inducing airway hyperreactivity and weakening an interferon-mediated antiviral response following respiratory viral infection. Robust evidence supports the beneficial effect of the anti-IgE biologic treatment omalizumab on reducing respiratory virus-induced asthma exacerbations and reducing the frequency, duration, and severity of respiratory viral illness in patients with asthma. Indeed, accumulating reports of patients with severe asthma treated with omalizumab during the pandemic have reassuringly shown that continuing omalizumab treatment during COVID-19 is safe, and in fact may help prevent the severe course of COVID-19. Accordingly, guidance issued by the Global Initiative for Asthma recommends that all patients with asthma continue taking their prescribed asthma medications, including biologic therapy, during the COVID-19 pandemic. The impact of biologic treatments on patients with asthma and COVID-19 will be better understood as more evidence emerges.

The big five model in bipolar disorder: a latent profile analysis and its impact on longterm illness severity

BackgroundUsing a personality typing approach, we investigated the relationship between personality profiles and the prediction of longterm illness severity in patients with bipolar disorder (BD). While previous research suggests associations between BD and traits from the NEO-FFI profiles, the current study firstly aimed to identify latent classes of NEO-FFI profiles, and, secondly, to examine their impact on the longterm prognosis of BD.MethodsBased on the NEO-FFI profiles of 134 euthymic patients diagnosed with BD (64.2% female, mean age = 44.3 years), successive latent profile analyses were conducted. Subsequently, a subsample (n = 80) was examined prospectively by performing multiple regression analysis of the latent classes to evaluate the longitudinal course of the disease (mean: 54.7 weeks) measured using a modified Morbidity Index.ResultsThe latent profile analyses suggested a 3-class model typifying in a resilient (n = 68, 51%), vulnerable (n = 55, 41%) and highly vulnerable (n = 11, 8%) class. In the regression analysis, higher vulnerability predicted a higher longterm Morbidity Index (R2 = 0.28).ConclusionsSubgroups of patients with BD share a number of discrete personality features and their illness is characterized by a similar clinical course. This knowledge is valuable in a variety of clinical contexts including early detection, intervention planning and treatment process.

Investigating the cognitive capacity constraints of an ICU care team using a systems engineering approach

BackgroundICU operational conditions may contribute to cognitive overload and negatively impact on clinical decision making. We aimed to develop a quantitative model to investigate the association between the operational conditions and the quantity of medication orders as a measurable indicator of the multidisciplinary care team’s cognitive capacity.MethodsThe temporal data of patients at one medical ICU (MICU) of Mayo Clinic in Rochester, MN between February 2016 to March 2018 was used. This dataset includes a total of 4822 unique patients admitted to the MICU and a total of 6240 MICU admissions. Guided by the Systems Engineering Initiative for Patient Safety model, quantifiable measures attainable from electronic medical records were identified and a conceptual framework of distributed cognition in ICU was developed. Univariate piecewise Poisson regression models were built to investigate the relationship between system-level workload indicators, including patient census and patient characteristics (severity of illness, new admission, and mortality risk) and the quantity of medication orders, as the output of the care team’s decision making.ResultsComparing the coefficients of different line segments obtained from the regression models using a generalized F-test, we identified that, when the ICU was more than 50% occupied (patient census > 18), the number of medication orders per patient per hour was significantly reduced (average = 0.74; standard deviation (SD) = 0.56 vs. average = 0.65; SD = 0.48; p < 0.001). The reduction was more pronounced (average = 0.81; SD = 0.59 vs. average = 0.63; SD = 0.47; p < 0.001), and the breakpoint shifted to a lower patient census (16 patients) when at a higher presence of severely-ill patients requiring invasive mechanical ventilation during their stay, which might be encountered in an ICU treating patients with COVID-19.ConclusionsOur model suggests that ICU operational factors, such as admission rates and patient severity of illness may impact the critical care team’s cognitive function and result in changes in the production of medication orders. The results of this analysis heighten the importance of increasing situational awareness of the care team to detect and react to changing circumstances in the ICU that may contribute to cognitive overload.

High Prevalence of Fungal and NDM-OXA Producing Gram-Negative Bacterial Superinfections in the Second Wave of Coronavirus Disease 2019 in India: Experience from a Dedicated Coronavirus Disease 2019 Hospital in North India.

During the second wave of coronavirus disease 2019 (COVID-19), superinfection caused by fungus and multidrug-resistant bacteria worsened the severity of illness in COVID-19 patients. Limited studies from India reported the antimicrobial resistance pattern of secondary infections. In this study, we aim to study the epidemiology of pathogens causing superinfections and genotyping of Gram-negative isolates in COVID-19 patients. This retrospective study was conducted at a dedicated COVID-19 center, India. The identification of bacteria/fungi was done by Vitek2® and matrix-assisted laser desorption/ionization-time of flight mass spectrometry system. Identification of beta-lactamase genes was done using thermal cycler. The diagnosis of mucormycosis was based on 10% potassium hydroxide direct microscopy. Statistical analyses were performed using STATA version 15.1 (StataCorp., College Station, TX, USA). For continuous variables, mean and standard deviation were computed. For comparing proportions of secondary infections across admission location and outcomes, the Chi-squared test of independence was used. To compare the mean and median between intensive care units and outcomes, an independent t-test and a Mann-Whitney test were used. Of all the clinical samples, 45.4% of samples were cultured positive for secondary infections. Acinetobacter baumannii (35%) was the most common Gram-negative pathogen, while among Gram positive, it was Enterococcus faecium (40%). Among fungus, Candida spp. (61%) predominates followed by molds. Colistin and tigecycline proved effective against these pathogens. blaNDM was the most prevalent gene followed by the blaOX among the carbapenemase genes. The mortality rate among COVID-19 patients with secondary infection was significantly higher compared to the overall mortality rate in COVID-19 patients.

Relation of expressed emotions and burden of care in primary caregivers to severity of illness in schizophrenia patients: A cross-sectional, hospital based study

Background: Negative expressed emotions are a significant characteristic of the family milieu that has been found to predict symptom relapse in schizophrenia and may be related to severity of illness and burden of care. Aim: The aim of this article is to study the expressed emotions and burden of care in primary caregiver of patients suffering from schizophrenia, with relation to severity of illness. Methods: This cross-sectional, hospital-based study included 60 schizophrenia patients and their primary caregivers. Positive and Negative Syndrome Scale (PANSS), modified Global Assessment of Functioning scale (mGAF), and Family Emotional Involvement and Criticism Scale (FEICS) were applied on the patients. Burden Assessment Schedule (BAS) was applied on the caregivers. Results: Patients were mostly male, symptomatic, diagnosed as paranoid schizophrenia and aged between 20 and 50 years. Caregivers were predominantly married and employed. Expressed emotions and burden of care were significantly related to caregiver and patient education, gender, employment, marital status, type of family, diagnosis, duration of illness, caregiver relation, duration of care giving, and severity of schizophrenia symptoms. Burden of care showed significant variations according to patient and caregiver economic status, domicile, religion, and age. Both expressed emotions and burden of care had moderately positive and statistically significant correlation with severity of the disease. Conclusion: Both expressed emotions and burden of care in primary caregiver of patients suffering from schizophrenia are influenced by a number of sociodemographic, clinical, and disease-related factors. Thus increase or decrease in expressed emotions and burden of care is caused by the complex interaction of various factors that the patients and caregivers experience.

A study on significance and correlation of red cell distribution width with severity of clinical illness in COVID-19 patients

A study on significance and correlation of red cell distribution width with severity of clinical illness in COVID-19 patients