Requirement For Non-invasive Ventilation Research Articles

Unveiling the impact: Exploring thrombotic outcomes in hospitalized patients with COVID-19—Comparing those with and without a cancer diagnosis.

e23318 Background: There is a shared hypercoagulable association of COVID-19 and cancer, noting an increased risk of thromboembolic events (TEE)in both conditions. The current study focuses on patients with concurrent COVID-19 and underlying cancer and compares incidence of TEE and related outcomes in this complex intersection of acute viral infection and oncological challenges. Methods: In this retrospective cohort study, we examined data from the Charleston Area Medical Center’s (CAMC) COVID-19 Registry, involving 5,479 adult, symptomatic, PCR-positive COVID-19 hospitalized patients (3/1/2020 to 1/20/2024). Demographics, co-morbidities, lab values, treatments, and outcomes were assessed. Propensity score matching (3:1) non-cancer patients vs those with an active cancer diagnosis was undertaken using sex and age. SAS 9.4 was utilized for the analysis. The groups were compared using Chi-square/Fisher’s Exact tests for categorical variables and t-tests for continuous variables and a logistic regression modelling to determine differences in key variables, the incidence of thromboembolic events and other outcomes. Results: After propensity matching, 1,623 non-cancer and 427 active cancer patients were included. The incidence of venous thromboembolism (VTE) was higher in the active cancer group (9.42% vs 4.2%, P < 0.001) with no significant differences in acute stroke. Intensive care unit (ICU) admissions, mechanical or non-invasive ventilation requirement, and mortality were not different although more patients with cancer were discharged to hospice (11.8% vs 3.3%, P < 0.001). However, mean D-dimer results in both groups were > 2.5 mg/L, it was not performed consistently. The active cancer group had greater frequencies of abnormal ferritin levels (59.1% vs 49.1%, P=0.01), and elevated procalcitonin levels > 0.05 ng/mL (72.9% vs 60.6%, p < 0.001). Among key treatments, remdesivir was used more frequently in cancer patients (41.4% vs 35.7%, P < 0.01). In addition to the cancer diagnosis (OR = 1.729 95% CI [1.1-2.8] P =0.02), LOS > / = 7days was also a predictor of TEE (OR= 1.825 95% CI [1.1-2.9] P < 0.01). Conclusions: Symptomatic VTE rates in our COVID-19 and active cancer cohort align with published studies. Diligence in evaluation of D-dimer, early detection of TEE and adherence to published guidelines in prophylaxis and treatment is recommended.

Use of the Serum Level of Cholinesterase as a Prognostic Marker of Nonfatal Clinical Outcomes in Patients Hospitalized with Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) contributes to a poor prognosis. Reliable biomarkers to predict adverse outcomes during hospitalization are important. To investigate the relationship between the serum cholinesterase (ChE) level and adverse clinical outcomes, including hypoxemia severity, hypercapnia, duration of hospital stay (DoHS), and noninvasive ventilation (NIV) requirement, in patients with AECOPD. Patients hospitalized with AECOPD in the Wuhu Hospital of Traditional Chinese Medicine between January 2017 and December 2021 were included. A total of 429 patients were enrolled. The serum ChE level was significantly lower in patients with hypercapnia, who required NIV during hospitalization and who had a DoHS of >10 days, with an oxygenation index < 300. The ChE level was correlated negatively with the C-reactive protein level and neutrophil-to-lymphocyte ratio and correlated positively with the serum albumin level. Multivariate logistic regression analysis indicated that a serum ChE level of ≤4116 U/L (OR = 2.857, 95% CI = 1.46-5.58, p = 0.002) was associated significantly with NIV requirement. The serum ChE level was correlated significantly with complicating severe hypoxemia, hypercapnia, prolonged DoHS, and the need for NIV in patients hospitalized with AECOPD. The serum ChE level is a clinically important risk-stratification biomarker in patients hospitalized with AECOPD.

Characterisation of Ferritin-Lymphocyte Ratio in COVID-19.

Introduction: The ferritin-lymphocyte ratio (FLR) is a novel inflammatory biomarker for the assessment of acute COVID-19 patients. However, the prognostic value of FLR for predicting adverse clinical outcomes in COVID-19 remains unclear, which hinders its clinical translation. Methods: We characterised the prognostic value of FLR in COVID-19 patients, as compared to established inflammatory markers. Results: In 217 study patients (69 years [IQR: 55-82]; 60% males), FLR was weakly correlated with CRP (R = 0.108, p = 0.115) and white cell count (R = -0.144; p = 0.034). On ROC analysis, an FLR cut-off of 286 achieved a sensitivity of 86% and a specificity of 30% for predicting inpatient mortality (AUC 0.60, 95% CI: 0.53-0.67). The negative predictive values of FLR for ruling out mortality, non-invasive ventilation requirement and critical illness (intubation and/or ICU admission) were 86%, 85% and 93%, respectively. FLR performed similarly to CRP (AUC 0.60 vs. 0.64; p = 0.375) for predicting mortality, but worse than CRP for predicting non-fatal outcomes (all p < 0.05). On Kaplan-Meier analysis, COVID-19 patients with FLR values > 286 had worse inpatient survival than patients with FLR ≤ 286, p = 0.041. Conclusions: FLR has prognostic value in COVID-19 patients, and appears unrelated to other inflammatory markers such as CRP and WCC. FLR exhibits high sensitivity and negative predictive values for adverse clinical outcomes in COVID-19, and may be a good "rule-out" test. Further work is needed to improve the sensitivity of FLR and validate its role in prospective studies for guiding clinical management.

A retrospective evaluation of a multidisciplinary management strategy implemented to optimize outpatient care, hospitalization rates and clinical outcomes in a single-centre cohort of COVID-19-positive pregnant women in Australia during the Omicron BA.1 surge

Abstract Background During the Omicron BA.1 surge between 12 January and 18 February 2022, 189 COVID-19-positive pregnant women were managed by the Peninsula Health Positive Pathways program, in the Mornington Peninsula, Victoria, Australia. A multidisciplinary specialist team was rapidly assembled to work in conjunction with the Pathways COVID-19 physicians and monitoring team, to optimize patient care. Objective The aim is to describe the processes utilized to care for the pregnancy cohort from the time of enrolment to the COVID Monitor until recovery including outpatient monitoring, treatment strategies, hospital review criteria, and clinical outcomes including rate of hospitalization, oxygen requirements, and maternal and foetal outcomes during the study period. Method Outpatients were monitored daily by the Pathways program, while COVID-19 physicians and obstetricians conducted early telehealth review of patients after diagnosis. Members of the multidisciplinary team met on a virtual platform twice daily, and institution-specific treatment guidelines and hospital review criteria were established. Enoxaparin prophylaxis was delivered to the homes of selected patients, and inhaled budesonide was utilized for patients who did not require oxygen, who were immunocompromised, and who had significant respiratory symptoms or risk factors for deterioration. Sotrovimab was offered to women as per the existing Australian National COVID-19 Clinical Evidence Taskforce eligibility criteria. A service evaluation was undertaken adopting a retrospective cohort approach. Results There was minimal maternal morbidity and no mortality with 24/189 (12.7%) women requiring hospitalization, 18/189 (9.5%) requiring same-day emergency department presentations only, and 4/189 (2.1%) requiring oxygen, with no requirement for non-invasive ventilation or intensive care unit admission. Sixteen patients delivered live newborns during the study period, and there were two pregnancy losses at 7 and 19 weeks gestation, respectively, in patients with prior pregnancy complications. Conclusion A multidisciplinary approach involving virtual communication twice daily between treating specialist physicians may be a broadly applicable model to optimize care of pregnant women with COVID-19.

Clinical Characteristics, Outcomes, and Risk Factors of Patients Hospitalized for COVID-19 across the Latest Pandemic Waves: Has Something Changed?

Despite the availability of vaccines and antivirals and the biological evolution of SARS-CoV-2, the rate of hospitalizations and deaths from COVID-19 remains high in Italy. It is crucial to understand whether and how the clinical characteristics of patients hospitalized for COVID-19 have changed over 2021–2022 and which risk factors are currently associated with adverse outcomes to develop targeted interventions. In this study, we present and compare the characteristics and outcomes of 310 patients with COVID-19 who were hospitalized between 1 August and 9 December 2021, when the Delta SARS-CoV-2 variant was prevalent (Group A), and between 3 January and 30 June 2022, when the Omicron variant was predominant (Group B). Using Survival Analysis, we estimated the cumulative 28-day hazard ratio (H.R.) of Intensive Care Unit (ICU) admission/death of patients in Group B vs. A. We built uni- and multivariate Cox regression models for the overall population and each group to identify risk factors for ICU admission/death among patient features. We found that Group B had a comparable risk of ICU admission/death (HR 1.60, 95% Confidence Interval, C.I. 1.00–2.58, p = 0.05) but a higher prevalence of elderly and co-morbid subjects than Group A. Non-invasive ventilation requirement was associated with adverse outcomes in both Group A (HR 21.03, 95% C.I. 5.34–82.80, p &lt; 0.001) and Group B (HR 4.53, 95% C.I. 2.39–8.59, p &lt; 0.001), as well as in the overall population (HR 3.88, 95% C.I. 2.49–6.06, p &lt; 0.001). During the Omicron wave, elderly and co-morbid subjects had the highest risk of hospitalization and poor outcomes.

Risk factors for development of acute kidney injury and acute kidney disease in critically ill children.

Acute kidney injury (AKI) is common among critically ill children and these children are at risk of developing acute kidney disease (AKD). A prospective cohort study was conducted on children aged > 1month to ≤ 18years old admitted to the pediatric intensive care unit (ICU) of Hong Kong Children's Hospital from 6/2020 to 6/2021. The incidences and risk factors of both AKI and AKD were determined. There were 254 eligible admissions (58.3% inmales, with a median age of 4.9 [9.7] years). The overall AKI incidence was 41.7% and 56% of children who remained hospitalized inthe pediatric ICU for ≥ 7days after acquiring AKI developed AKD. Cardiac surgery, bone marrow transplantation and requirement of inotropes were risk factors for both AKI and AKD. The requirement of non-invasive ventilation [relative risk (RR): 2.625 (1.361, 5.064)], total medication dose [RR 1.006 (1.002, 1.010)] and maximal medication intensity [RR 1.154 (1.038, 1.283)] were additional determinants of AKI. Factors indicating more severe AKI and AKI progression were predictive of AKD development. The overall mortality in the pediatric ICUwas 3.1%. AKI was significantly associated with mortality (p < 0.001), longer length of hospitalization in the pediatricICU (p < 0.001) and hospital stay (p < 0.001). AKD was associated with a lower estimated glomerular filtration rate at dischargefrom the pediatric ICU (p = 0.036). AKI and AKD were common among critically ill children, and were associated with significant morbidity and mortality. Few modifiable risk factors, especially those related to nephrotoxic medication exposure, were associated with AKI development and AKD progression.

COVID-19 infection among vaccinated and unvaccinated: Does it make any difference?

There is a probability that vaccination may lead to reduction in the severity and complications associated with COVID-19 infection among hospitalized patients. This study aimed to determine the characteristics, clinical profiles, and outcomes of COVID-19 infection in vaccinated and non-vaccinated patients. This prospective observational cohort study was conducted at the Aga Khan University Hospital (AKUH) and recruited COVID-19 patients admitted between June 1st and September 30th, 2021. Patients' demographics, date of admission and discharge, comorbid conditions, immunization status for COVID-19 infection, presenting complaints, lab workup and computed tomography (CT) scan findings were obtained from the medical records. The primary outcome of the study was patients' condition at discharge and the secondary outcomes included level of care, length of stay (LOS), requirement of non-invasive ventilation (NIV) and inotropic support. Among a cohort of 434 patients, 37.7% (n = 164), 6.6% (n = 29) and 55.5% (n = 241) were fully vaccinated, partially vaccinated, and unvaccinated, respectively. Around 3% and 42.9% of the patient required inotropic and NIV support respectively; however, there was no discernible difference between them in terms of vaccination status. In case of unvaccinated patients there were significantly increased number of critical care admissions (p-value 0.043). Unvaccinated patients had significantly higher median serum procalcitonin, ferritin, LDH and D-dimer levels. Around 5.3% (n = 23) of the patient required invasive ventilation and it was more common in unvaccinated patients (p-value 0.04). Overall, mortality rate was 12.2% (n = 53) and this was higher (16.2%, n = 39) in unvaccinated patients as compared to fully vaccinated patients (6.1%, n = 10, p-value 0.006). Through this preliminary data, we can conclude that patient can develop severe and critical COVID-19 infection despite being vaccinated but this proportion is low as compared to unvaccinated population. So, uninterrupted endeavors need to be done to vaccinate as many individuals as possible. Furthermore, more effective vaccinations need to be developed to lessen the high death toll of COVID-19 infection.

Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease.

Magnesium sulfate for acute exacerbations of chronic obstructive pulmonary disease.

Abstract No.: ABS1330: A prospective observational study on ultra-sound of the diaphragm in weaning mechanically ventilated patients

Background and Aims:Weaning mechanically ventilated patients is a challenging task in the intensive care unit. Rapid shallow breathing index (RSBI) is a known weaning index to guide extubation. The aim of our study was to determine the use of diaphragm ultra-sound in weaning these patients.Methods:After obtaining ethics committee approval and Clinical Trials Registry India registration, this prospective study was performed on 200 patients on mechanical ventilation for more than 24 hours. After meeting clinical weaning criteria, spontaneous breathing trial (SBT) was performed for 1 hour to assess weaning and then trachea was extubated. Independent observers recorded RSBI and performed bedside ultra-sound of the diaphragm before extubation to measure diaphragm thickening fraction (DTF) and diaphragmatic excursion (DE). We assessed the predictability of weaning success with DTF and DE. Weaning failure was defined as the requirement of non-invasive ventilation or re-intubation within 48 h.Results:One hundred and seventy one patients out of 200 were successfully weaned. The area under the receiver operating characteristic curve (AUROC) values for RSBI, DTF, and DE for successful weaning prediction were 0.422, 0.654, and 0.809, respectively. The predictability using cut-off values were RSBI <82 (sensitivity 94%, specificity 31%, Youden’s index 0.25), DTF >37% (sensitivity 80%, specificity 52%, Youden’s index 0.31), and DE >1.21 cm (sensitivity 94%, specificity 71%, Youden’s index 0.65). The AUROC values for the combination of RSBI–DTF and RSBI–DE were 0.656 and 0.807, respectively.Conclusion:Diaphragm ultra-sound helps in determining weaning readiness in mechanically ventilated patients. Both DTF and DE showed a higher specificity than RSBI, and the combination of RSBI–DE and RSBI–DTF further increased the specificity in successful weaning.ParameterCut off rangeSensitivity %Specificity %PPV %NPV %Youden’s IndexAUROCRSBI<8294.031.089.045.00.250.422DTF (%)>37%79.551.790.730.00.310.654DE (cm)>1.2193.671.495.264.50.650.809RSBI-DTF> 0.85466.769.092.726.00.360.656RSBI-DE>0.73893.071.495.262.50.640.807

Study of Disease Severity and Outcomes in COVID-19 Patients With Chronic Kidney Disease at a Tertiary Care Hospital in South India.

Background: Coronavirus disease 2019 (COVID-19) disproportionately affects individuals with various comorbidities. Among these, chronic kidney disease (CKD) has been shown to be strongly associated with the progression to severe disease. This study aimed to assess the severity and disease outcomes in patients with COVID-19 infection and CKD.Methods: This is a retrospective study conducted at a tertiary care hospital from July 2021 to September 2021. The case records of patients with CKD and COVID-19 were studied. They were compared with age and gender-matched controls equally. The presenting symptoms, clinical course, severity of illness, laboratory markers, need for ventilator support, and mortality outcomes were studied.Results: In total, 40 CKD and 40 non-CKD patients with COVID-19 were included in the study. It was also observed that among the patients with CKD, more patients had fever, breathlessness, and diarrhea. The requirement for noninvasive ventilation, ventilator, and inotropes was on the higher average for patients with CKD. Overall mortality was 27.5% in the CKD group and 2.5% in the non-CKD group, which was statistically significant (p = 0.002).Conclusions: COVID-19 patients with CKD had more severe illnesses with a requirement of ventilator support and had higher mortality than the patients without CKD. Patients with CKD are a key subset of patients with COVID-19 for whom more aggressive early treatment and stricter preventive measures may be beneficial.

Sildenafil for treating patients with COVID-19 and perfusion mismatch: a pilot randomized trial

BackgroundSARS-CoV-2 seems to affect the regulation of pulmonary perfusion. Hypoperfusion in areas of well-aerated lung parenchyma results in a ventilation–perfusion mismatch that can be characterized using subtraction computed tomography angiography (sCTA). This study aims to evaluate the efficacy of oral sildenafil in treating COVID-19 inpatients showing perfusion abnormalities in sCTA.MethodsTriple-blinded, randomized, placebo-controlled trial was conducted in Chile in a tertiary-care hospital able to provide on-site sCTA scans and ventilatory support when needed between August 2020 and March 2021. In total, 82 eligible adults were admitted to the ED with RT-PCR-confirmed or highly probable SARS-COV-2 infection and sCTA performed within 24 h of admission showing perfusion abnormalities in areas of well-aerated lung parenchyma; 42 were excluded and 40 participants were enrolled and randomized (1:1 ratio) once hospitalized. The active intervention group received sildenafil (25 mg orally three times a day for seven days), and the control group received identical placebo capsules in the same way. Primary outcomes were differences in oxygenation parameters measured daily during follow-up (PaO2/FiO2 ratio and A-a gradient). Secondary outcomes included admission to the ICU, requirement of non-invasive ventilation, invasive mechanical ventilation (IMV), and mortality rates. Analysis was performed on an intention-to-treat basis.ResultsTotally, 40 participants were enrolled (20 in the placebo group and 20 in the sildenafil group); 33 [82.5%] were male; and median age was 57 [IQR 41–68] years. No significant differences in mean PaO2/FiO2 ratios and A-a gradients were found between groups (repeated-measures ANOVA p = 0.67 and p = 0.69). IMV was required in 4 patients who received placebo and none in the sildenafil arm (logrank p = 0.04). Patients in the sildenafil arm showed a significantly shorter median length of hospital stay than the placebo group (9 IQR 7–12 days vs. 12 IQR 9–21 days, p = 0.04).ConclusionsNo statistically significant differences were found in the oxygenation parameters. Sildenafil treatment could have a potential therapeutic role regarding the need for IMV in COVID-19 patients with specific perfusion patterns in sCTA. A large-scale study is needed to confirm these results.Trial Registration: Sildenafil for treating patients with COVID-19 and perfusion mismatch: a pilot randomized trial, NCT04489446, Registered 28 July 2020, https://clinicaltrials.gov/ct2/show/NCT04489446.

Role of diaphragm ultrasound in weaning mechanically ventilated patients: A prospective observational study.

ABSTRACTBackground and Aims:Weaning from mechanical ventilation based on clinical parameters and rapid shallow breathing index (RSBI) is associated with a higher weaning failure. Bedside ultrasound of the diaphragm is gaining popularity to assess the diaphragm function. The aim of our study was to determine the use of diaphragm ultrasound in weaning ventilated patients.Methods:This prospective study was done on 200 adult patients on mechanical ventilation for more than 24 h. After meeting the clinical weaning criteria, a spontaneous breathing trial (SBT) was performed. RSBI was recorded and a bedside ultrasound of the diaphragm was performed to measure diaphragmatic excursion (DE) and diaphragm thickening fraction (DTF) before extubation. We assessed the predictability of weaning success of RSBI, DE and DTF by determining the area under the receiver operating characteristic (AUROC) curve and Youden’s index. The requirement of non-invasive ventilation or re-intubation within 48 h was considered a weaning failure.Results:Out of the 200 patients studied, 171 were successfully weaned. The AUROC values for RSBI, DTF, DE, RSBI-DTF and RSBI-DE for successful weaning prediction were 0.422, 0.654, 0.809, 0.656 and 0.807, respectively. The predictability using cut-off values were DE >1.21 cm (sensitivity 94%, specificity 71%, Youden’s index 0.65), DTF >37% (sensitivity 80%, specificity 52%, Youden’s index 0.31) and RSBI <82 (sensitivity 94%, specificity 31%, Youden’s index 0.25).Conclusion:Diaphragm ultrasound helps in predicting successful weaning in mechanically ventilated patients. Both DE and DTF showed a higher specificity than RSBI and a combination of RSBI-DE and RSBI-DTF was better than using RSBI alone.

Epidemiological Characteristics of Hospitalized Patients with Moderate versus Severe COVID-19 Infection: A Retrospective Cohort Single Centre Study.

COVID-19 has a devastating impact worldwide. Recognizing factors that cause its progression is important for the utilization of appropriate resources and improving clinical outcomes. In this study, we aimed to identify the epidemiological and clinical characteristics of patients who were hospitalized with moderate versus severe COVID-19 illness. A single-center, retrospective cohort study was conducted between 3 March and 9 September 2020. Following the CDC guidelines, a two-category variable for COVID-19 severity (moderate versus severe) based on length of stay, need for intensive care or mechanical ventilation and mortality was developed. Data including demographic, clinical characteristics, laboratory parameters, therapeutic interventions and clinical outcomes were assessed using descriptive and inferential analysis. A total of 1002 patients were included, the majority were male (n = 646, 64.5%), Omani citizen (n = 770, 76.8%) and with an average age of 54.2 years. At the bivariate level, patients classified as severe were older (Mean = 55.2, SD = 16) than the moderate patients (Mean = 51.5, SD = 15.8). Diabetes mellitus was the only significant comorbidity potential factor that was more prevalent in severe patients than moderate (n = 321, 46.6%; versus n = 178, 42.4%; p < 0.001). Under the laboratory factors; total white cell count (WBC), C-reactive protein (CRP), Lactate dehydrogenase (LDH), D-dimer and corrected calcium were significant. All selected clinical characteristics and therapeutics were significant. At the multivariate level, under demographic factors, only nationality was significant and no significant comorbidity was identified. Three clinical factors were identified, including; sepsis, Acute respiratory disease syndrome (ARDS) and requirement of non-invasive ventilation (NIV). CRP and steroids were also identified under laboratory and therapeutic factors, respectively. Overall, our study identified only five factors from a total of eighteen proposed due to their significant values (p < 0.05) from the bivariate analysis. There are noticeable differences in levels of COVID-19 severity among nationalities. All the selected clinical and therapeutic factors were significant, implying that they should be a key priority when assessing severity in hospitalized COVID-19 patients. An elevated level of CRP may be a valuable early marker in predicting the progression in non-severe patients with COVID-19. Early recognition and intervention of these factors could ease the management of hospitalized COVID-19 patients and reduce case fatalities as well medical expenditure.

Multi-Arm Trial of Inflammatory Signal Inhibitors (MATIS) for Hospitalised Patients with Mild or Moderate COVID-19 Pneumonia: A Structured Summary of a Study Protocol for a Randomised Controlled Trial

Multi-Arm Trial of Inflammatory Signal Inhibitors (MATIS) for Hospitalised Patients with Mild or Moderate COVID-19 Pneumonia: A Structured Summary of a Study Protocol for a Randomised Controlled Trial

Impact of a care bundle for patients with blunt chest injury (ChIP): A multicentre controlled implementation evaluation.

BackgroundBlunt chest injury leads to significant morbidity and mortality. The aim of this study was to evaluate the effect of a multidisciplinary chest injury care bundle (ChIP) on patient and health service outcomes. ChIP provides guidance in three key pillars of care for blunt chest injury—respiratory support, analgesia and complication prevention. ChIP was implemented using a multi-faceted implementation plan developed using the Behaviour Change Wheel.MethodsThis controlled pre-and post-test study (two intervention and two non-intervention sites) was conducted from July 2015 to June 2019. The primary outcome measures were unplanned Intensive Care Unit (ICU) admissions, non-invasive ventilation use and mortality.ResultsThere were 1790 patients included. The intervention sites had a 58% decrease in non-invasive ventilation use in the post- period compared to the pre-period (95% CI 0.18–0.96). ChIP was associated with 90% decreased odds of unplanned ICU admissions (95% CI 0.04–0.29) at the intervention sites compared to the control groups in the post- period. There was no significant change in mortality. There were higher odds of health service team reviews (surgical OR 6.6 (95% CI 4.61–9.45), physiotherapy OR 2.17 (95% CI 1.52–3.11), ICU doctor OR 6.13 (95% CI 3.94–9.55), ICU liaison OR 55.75 (95% CI 17.48–177.75), pain team OR 8.15 (95% CI 5.52 –-12.03), analgesia (e.g. patient controlled analgesia OR 2.6 (95% CI 1.64–3.94) and regional analgesia OR 8.8 (95% CI 3.39–22.79), incentive spirometry OR 8.3 (95% CI 4.49–15.37) and, high flow nasal oxygen OR 22.1 (95% CI 12.43–39.2) in the intervention group compared to the control group in the post- period.ConclusionThe implementation of a chest injury care bundle using behaviour change theory was associated with a sustained improvement in evidence-based practice resulting in reduced unplanned ICU admissions and non-invasive ventilation requirement.Trial registrationANZCTR: ACTRN12618001548224, approved 17/09/2018

Methylprednisolone in adults hospitalized with COVID-19 pneumonia : An open-label randomized trial (GLUCOCOVID).

PurposeTo determine whether a 6-day course of methylprednisolone (MP) improves outcome in patients with severe SARS-CoV‑2 (Corona Virus Disease 2019 [COVID-19]).MethodsThe study was a multicentric open-label trial of COVID-19 patients who were aged ≥ 18 years, receiving oxygen without mechanical ventilation, and with evidence of systemic inflammatory response who were assigned to standard of care (SOC) or SOC plus intravenous MP (40 mg bid for 3 days followed by 20 mg bid for 3 days). The primary outcome was a composite of death, admission to the intensive care unit, or requirement for noninvasive ventilation. Both intention-to-treat (ITT) and per protocol (PP) analyses were performed.ResultsA total of 91 patients were screened, and 64 were randomized (mean age70 ± 12 years). In the ITT analysis, 14 of 29 patients (48%) in the SOC group and 14 of 35 (40%) in the MP group suffered the composite endpoint (40% versus 20% in patients under 72 years and 67% versus 48% in those over 72 years; p = 0.25). In the PP analysis, patients on MP had a significantly lower risk of experiencing the composite endpoint (age-adjusted risk ratio 0.42; 95% confidence interval, CI 0.20–0.89; p = 0.043).ConclusionThe planned sample size was not achieved, and our results should therefore be interpreted with caution. The use of MP had no significant effect on the primary endpoint in ITT analysis; however, the PP analysis showed a beneficial effect due to MP, which consistent with other published trials support the use of glucocorticoids in severe cases of COVID-19.Supplementary InformationThe online version of this article (10.1007/s00508-020-01805-8) contains supplementary material, which is available to authorized users.

The Efficacy and Safety of Hydroxychloroquine in Patients with COVID-19: A Multicenter National Retrospective Cohort.

IntroductionHydroxychloroquine (HCQ) is an antimalarial drug that received worldwide news and media attention in the treatment of patients with coronavirus disease 2019 (COVID-19). This drug was used on the basis of its antimicrobial and antiviral properties despite lack of definite evidence of clinical efficacy. In this study, we aim to assess the efficacy and safety of using HCQ in treatment of patients with COVID-19 who were admitted in acute care hospitals in Bahrain.MethodsWe conducted a retrospective cohort study on a random sample of patients admitted with COVID-19 between 24 February and 31 July 2020. The study was conducted in four acute care COVID-19 hospitals in Bahrain. Data was extracted from the medical records. The primary endpoint was the requirement of non-invasive ventilation, intubation, or death. Secondary endpoint was length of hospitalization for survivors. Three methods of analysis were used to control for confounding factors: logistic multivariate regression, propensity score adjusted regression, and matched propensity score analysis.ResultsA random sample of 1571 patients were included, 440 of whom received HCQ (treatment group) and 1131 did not receive it (control group). Our results showed that HCQ did not have a significant effect on primary outcomes due to COVID-19 infection when compared to controls after adjusting for confounders (OR 1.43, 95% CI 0.85–2.37, P = 0.17). Co-administration of azithromycin had no effect on primary outcomes (OR 2.7, 95% CI 0.82–8.85, P = 0.10). HCQ was associated with increased risk of hypoglycemia (OR 10.9, 95% CI 1.72—69.49, P = 0.011) and diarrhea (OR 2.8, 95% CI 1.4–5.5, P = 0.003), but not QT prolongation (OR 1.92, 95% CI 0.95–3.9, P = 0.06) or cardiac arrhythmia (OR 1.06, 95% CI 0.55–2.05, P = 0.85).ConclusionOur results showed no significant beneficial effect of using hydroxychloroquine on the outcome of patients with COVID-19. Moreover, the risk of hypoglycemia due to hydroxychloroquine would possess a significant risk for out-of-hospital use.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00397-8.

Staging model for amyotrophic lateral sclerosis in Singapore.

Introduction:A clinical-based staging model would guide physicians in the prompt management of the evolving symptoms and functional needs of patients with amyotrophic lateral sclerosis (ALS).Methods:We aimed to delineate the clinical trajectory of ALS in Singapore and test the degree of congruity of King's College staging for ALS (King's staging) among Singapore patients. In this retrospective cohort study, clinical milestones used for staging were identical to King's staging: stage 1 corresponded to symptom onset; stage 2A corresponded to diagnosis; stage 2B corresponded to two central nervous system (CNS) regions; stage 3B corresponded to three CNS regions; stage 4A corresponded to requirement of supportive enteric feeding; and stage 4B corresponded to requirement of non-invasive ventilation, of which bulbar, diaphragmatic, upper and lower limb pyramidal involvements each constituted one CNS region. Standardised timings from disease onset (0) to death (1) among Singapore patients with ALS were measured.Results:46 patients with ALS were reviewed. Results were largely congruous with King's staging. Results for patients with limb-onset ALS were: diagnosis (0.35); two CNS region involvement (0.42); three CNS region involvement (0.63); diaphragmatic involvement (0.81); and bulbar involvement (0.73). Results for patients with bulbar-onset ALS were: diagnosis (0.14); two CNS region involvement (0.28); three CNS region involvement (0.42); diaphragmatic involvement (0.62); and bulbar involvement (0.67).Conclusion:King's staging can be used to model ALS trajectory in Singapore due to the large degree of congruity seen. Easily remembered and accessible knowledge of ALS staging will allow prompt management of the evolving needs of patients with ALS.

Vitamin D status and outcomes for hospitalised older patients with COVID-19

PurposeOlder adults are more likely to be vitamin D deficient. The aim of the study was to determine whether these patients have worse outcomes with COVID-19.MethodsWe conducted a prospective cohort...

Predictors of respiratory decline in myotonic dystrophy type 1 (DM1): a longitudinal cohort study.

We studied 33 patients affected by juvenile and adult myotonic dystrophy type 1 (DM1). The aim of the study was to assess clinical and laboratory parameters that could predict the requirement of noninvasive ventilation (NIV) in DM1. Secondary outcome was to assess the interplay between genetic profile, muscle impairment severity and presence of cardiac comorbidities.Patients with genetic diagnosis of DM1 were recruited. An abnormal trinucleotide repeat (CTG) expansion of dystrophy protein kinase gene (DMPK) on chromosome 19q13.3 was the prerequisite for inclusion. The number of triplet repeats was measured in genomic DNA to classify subjects. A multidisciplinary team evaluated the patients every 6-8months up to 18years with serial cardiological and respiratory function assessments. Neurological progression was monitored using a validated DM1-specific rating scale (MIRS). Independent variables considered for the study outcomes were gender, genetic status, age of presentation, MIRS scores, and results of pulmonary function tests (PFTs).Patients were 17 males (51.5%) and 16 females (48.5%). 16 cases were younger than mean age of 31.4years, the remaining 17 were up to 65. 12 subjects (36.4%) underwent NIV during follow up. Cardiac comorbidities were detected in 63.6% of cases and in 91% of patients in NIV. Among PFTs, forced vital capacity (FVC) was a reliable indicator of respiratory decline. FVC values were significantly associated with clinical muscle severity assessed by MIRS.Severity of muscular impairment, CTG expansion size, age and presence of cardiac comorbidities predict respiratory impairment in DM1.