Supplemental Oxygen Requirement Research Articles

“EPIDEMIOLOGICAL AND CLINICAL CHARACTERIZATION OF COVID19 PATIENTS: A RETROSPECTIVE OBSERVATIONAL STUDY OF 245 CASES IN A GOVERNMENT TEACHING INSTITUTE OF NORTH INDIA.”

Background and objectives: Worldwide literature on presentation of patients infected with novel coronavirus shows huge variability in terms of severity and outcome depending on the demographic characteristics of the affected population. We aim to present epidemiological and clinical characteristics of COVID-19 patients admitted at our facility. Methods: Retrospective analysis of epidemiological, and clinical characteristics of patients admitted at a dedicated COVID hospital in North India. Results: Records of 245 patients were analyzed. The mean (SD) age was 32 (17.87) years ranging from 1 day to 81 years. Children <18 years of age constituted around 18% of the study population of which only about a fourth (23%) were symptomatic. About 52.4% of patients were males. Almost 40% cases were detected through contact tracing of known infected patients and in about 56% cases the source of infection was indeterminate. About 67% were asymptomatic and most of the symptomatic patients had mild disease. Among the symptomatic patients cough (19.9%) and fever (17.1%) were most common symptoms followed by throat irritation. Comorbidities were present in 32 (13.06%) patients, of which hypertension in 6.12% was the most common. There were 22 (8.97%) health care workers (HCW) among the patients. Majority of the affected HCW were working in areas with relatively low infection risk. Six (2.44%) patients required oxygen supplementation. The mean duration of stay in hospital was 9.6 ±.57 days. Interpretations & Conclusions: Our observations indicate a relatively younger age of affected population and high proportion of asymptomatic patients. Children are usually asymptomatic with relatively better prognosis.

Convalescent plasma for COVID-19 - encouraging signals of efficacy.

Convalescent plasma for COVID-19 - encouraging signals of efficacy.

Unusual Clinical Manifestations and Outcome of Multisystem Inflammatory Syndrome in Children (MIS-C) in a Tertiary Care Hospital of North India.

Till date, there is paucity of published literature on clinical manifestations of Coronavirus disease 2019 (COVID-19) in children from low-middle-income countries (LMIC). Most of the reports are from Europe, USA or China. Our study aimed to capture data on varied and unusual clinical presentation and management of MIS-C (Multisystem Inflammatory Syndrome in Children) with COVID-19 and compare the MIS-C and non-MIS-C children. This was a single-centre cohort study of 41 COVID positive children 0–12 years age hospitalized between 1 April 2020 and 31 July 2020. Data were entered into standardized WHO Case Report Form and analysed using strata 15.0 statistical software. Twenty out of 41 children fulfilled the criteria of MIS-C. Male-to-female ratio in the cohort was 1.73:1. In MIS-C cases, predominant clinical manifestation was fever (100%), neurological manifestations (80%), lower respiratory tract infection (50%), rash (35%) and acute gastroenteritis (25%). They were categorized into Acute Encephalitis-like illness in 35%, Kawasaki-like disease, Toxic Shock-like syndrome and Comorbidity with systemic complications in 20% each. Ninety percent of MIS-C cases required oxygen supplementation with odds ratio (OR) 18 (3.22–100.48), whereas 65% required mechanical ventilation with OR 37.14 (4.08–338.10). Most of them had raised inflammatory markers and hepatic enzymes derangement. Steroids, Intravenous immunoglobulin and supportive therapy were mainstay of management for MIS-C group. Most MIS-C group children had multisystem involvement with predominant neurological manifestations at time of presentation. Delay in diagnosis and referral may have adversely affected the prognosis and outcome.

High-risk chest radiographic features associated with COVID-19 disease severity.

ObjectivesHigh-risk CXR features in COVID-19 are not clearly defined. We aimed to identify CXR features that correlate with severe COVID-19.MethodsAll confirmed COVID-19 patients admitted within the study period were screened. Those with suboptimal baseline CXR were excluded. CXRs were reviewed by three independent radiologists and opacities recorded according to zones and laterality. The primary endpoint was defined as hypoxia requiring supplemental oxygen, and CXR features were assessed for association with this endpoint to identify high-risk features. These features were then used to define criteria for a high-risk CXR, and clinical features and outcomes of patients with and without baseline high-risk CXR were compared using logistic regression analysis.Results109 patients were included. In the initial analysis of 40 patients (36.7%) with abnormal baseline CXR, presence of bilateral opacities, multifocal opacities, or any upper or middle zone opacity were associated with supplemental oxygen requirement. Of the entire cohort, 29 patients (26.6%) had a baseline CXR with at least one of these features. Having a high-risk baseline CXR was significantly associated with requiring supplemental oxygen in univariate (odds ratio 14.0, 95% confidence interval 3.90–55.60) and multivariate (adjusted odds ratio 8.38, 95% CI 2.43–28.97, P = 0.001) analyses.ConclusionWe identified several high-risk CXR features that are significantly associated with severe illness. The association of upper or middle zone opacities with severe illness has not been previously emphasized. Recognition of these specific high-risk CXR features is important to prioritize limited healthcare resources for sicker patients.

DAMPening Mortality in COVID-19: Therapeutic Insights From Basic Cardiometabolic Studies on S100A8/A9.

DAMPening Mortality in COVID-19: Therapeutic Insights From Basic Cardiometabolic Studies on S100A8/A9.

Severity of COVID-19 in hospitalized patients with and without atopic disease

BackgroundData from the 2009 influenza pandemic suggested asthma might protect from severe disease in hospitalized patients. Asthma does not appear to increase risk for hospitalization or mortality with COVID-19. ObjectiveThis study was undertaken to see if atopy actually protected those hospitalized with COVID-19. MethodsRetrospective chart review on all patients testing positive for SARS-CoV-2 over 2 months at a major adult and pediatric tertiary referral center hospital. Charts were evaluated for history of atopic disease, as were the need for ICU admission, requirement for supplemental oxygen and/or intubation, and in hospital mortality. ResultsNo significant differences in outcomes for patients (n = 275) based on atopic disease were noted: ICU admission, 43% versus 44.7% (atopic versus no atopic disease, respectively; p = 0.84); supplemental oxygen use, 79.1% versus 73.6% (p = 0.36); intubation rate, 35.8% versus 36.5% (p = 0.92); and mortality rate, 13.4% versus 20.7% (p = 0.19). More patients with atopic disease had COPD listed as a diagnosis in their chart (38.8% versus 17.3%, p < 0.001). COPD was associated with an increased rate of ICU admission (aOR = 2.22 (1.15, 4.30) p = 0.02) and intubation (aOR = 2.05 (1.07, 3.92) p = 0.03). After adjusting for COPD, patients with atopic disease had a trend for reduced mortality (aOR 0.55 (0.23, 1.28), p = 0.16), but those with asthma did not (p > 0.2). ConclusionSeverity of COVID-19 in hospitalized patients does not differ based on atopic status. However, adjusting for presence of COPD led to a suggestion of possible reduced severity in patients with atopy but not asthma.

COVID-19 in teriflunomide-treated patients with multiple sclerosis: A case report and literature review

Background. Teriflunomide is an immunomodulatory drug approved for Multiple Sclerosis (MS) treatment that inhibits dihydroorotate dehydrogenase, a mitochondrial enzyme involved in the de novo pyrimidine synthesis pathway. This mechanism can produce antiviral effects, thus teriflunomide has gained attention during COVID-19 pandemic. Moreover, in the last months, some case-reports have been published describing MS patients treated with teriflunomide who developed mild and self-limiting forms of COVID-19. MethodsHere, we describe the case of a 57-year-old man affected by MS, and treated with teriflunomide, who developed a mild form of SARS-CoV-2 infection. Moreover, we provide a detailed literature review about the available cases of COVID-19 in MS patients treated with teriflunomide. We report clinical features, disease course and outcome, and we discuss similarities and differences among patients. ResultsApart from the present report, since February 2020, five papers have been published describing 14 MS patients who developed SARS-CoV-2 infection during teriflunomide treatment. Patients were mostly female (53%), with an average age of 50.5 (±11.3) years. Median EDSS was 2.25 (range 0–6). The average time on treatment with teriflunomide was 3.7 (± 1.6) years. Relevant comorbidities were present in 4 patients (27%). Regarding SARS-CoV-2 infection, the most common symptom was fever (100%) followed by gastrointestinal disturbances (67%), fatigue (55%) and cough (55%). 5 patients were hospitalized and 2 required oxygen support. In patient hospitalized (n=5) compared to the others (n=10), age was significantly higher (59.6 vs 45.9 years, p=0.025) while gender, EDSS, duration of teriflunomide therapy and comorbidities were not significantly different. Outcome was good for all patients with a variable recovery time, ranging from few days to some weeks. Teriflunomide was continued during the entire course of SARS-CoV-2 infection in all patients except for two. Compared to the patients already described, our patient was 7 years older, average time on teriflunomide treatment was about 2.5 years shorter, and median EDSS was 1.5 point lower. Despite significant comorbidities, the outcome was good since our patient was hospitalized but he did not require oxygen supplementation nor intensive care and was able to return at home after only 10 days. Teriflunomide therapy was continued throughout the period. ConclusionAvailable data suggest that teriflunomide therapy should not be discontinued in MS patients who develop SARS-CoV-2 infection, also in presence of significant comorbidities or clinical conditions requiring hospitalization. Additional studies are necessary to assess if the drug can also have a protective role against SARS-CoV-2.

Transmission of SARS-CoV-2 Delta Variant Among Vaccinated Healthcare Workers, Vietnam

Background: Data on breakthrough SARS-CoV-2 Delta variant infections are limited.Methods: We studied breakthrough infections among healthcare workers of a major infectious diseases hospital in Vietnam. We collected demographics, vaccination history and results of PCR diagnosis alongside clinical data. We measured SARS-CoV-2 (neutralizing) antibodies at diagnosis, and at week 1, 2 and 3 after diagnosis. We sequenced the viruses using ARTIC protocol.Findings: Between 11th–25th June 2021 (week 7–8 after dose 2), 69 healthcare workers were tested positive for SARS-CoV-2. 62 participated in the clinical study. 49 were (pre)symptomatic with one requiring oxygen supplementation. All recovered uneventfully. 23 complete-genome sequences were obtained. They all belonged to the Delta variant, and were phylogenetically distinct from the contemporary Delta variant sequences obtained from community transmission cases, suggestive of ongoing transmission between the workers. Viral loads of breakthrough Delta variant infection cases were 251 times higher than those of cases infected with old strains detected between March-April 2020. Time from diagnosis to PCR negative was 8–33 days (median: 21). Neutralizing antibody levels after vaccination and at diagnosis of the cases were lower than those in the matched uninfected controls. There was no correlation between vaccine-induced neutralizing antibody levels and viral loads or the development of symptoms.Interpretation: Breakthrough Delta variant infections are associated with high viral loads, prolonged PCR positivity, and low levels of vaccine-induced neutralizing antibodies, explaining the transmission between the vaccinated people. Physical distancing measures remain critical to reduce SARS-CoV-2 Delta variant transmission.Funding: Wellcome (106680/B/14/Z and 204904/Z/16/Z).Declaration of Interest: None to declare.Ethical Approval: The study was approved by the Institutional Review Board of HTD and the Oxford Tropical Research Ethics Committee, University of Oxford, UK.

Tocilizumab Improves the Prognosis of COVID-19 in Patients with High IL-6

Background: Despite direct viral effect, the pathogenesis of coronavirus disease 2019 (COVID-19) includes an overproduction of cytokines including interleukin 6 (IL-6). Therefore tocilizumab (TCZ), a monoclonal antibody against IL-6 receptors, became considered as a possible therapeutic option.Methods: Patients were selected from the SARSTer national database, which included 2332 individuals with COVID-19 and the current study included 825 adult patients with moderate to severe course. The retrospective analysis was performed in 170 patients treated with TCZ and 655 without this medication or any other anti-cytokine therapy. The end-points of treatment effectiveness were a rate of death, need for mechanical ventilation, and clinical improvement.Results: Patients treated with TCZ were balanced compared to non-TCZ regarding gender, age, BMI, and prevalence of coexisting conditions. Significant effect of TCZ on death was demonstrated in patients with baseline IL-6 >100 pg/ml (hazard ratio [HR]: 0.27, 95% confidence interval [CI]:0.10-0.78), or those needing oxygen supplementations who worsened within 7 days of hospitalization (HR: 0.38, 95% CI:0.16-0.88). The best effectiveness of TCZ was achieved in patients with a combination of baseline IL-6>100 pg/ml and either SpO2 ≤90% (HR for death, mechanical ventilation and clinical improvement after 21 or 28 days: 0.07, 0.14, 5.53, 5.18 respectively) or requiring oxygen supplementation (HR for death and clinical improvement after 21 or 28 days, 0.18, 2.66, 2.85 respectively).Conclusions: Tocilizumab administration in COVID-19 reduces mortality and speed up clinical improvement in patients with a baseline concentration of IL-6>100 pg/ml, particularly if they need oxygen supplementation due to SpO2 ≤90%.Funding Statement: The study was supported by the Polish Association of Epidemiologists and Infectiologists and Medical Research Agency.Declaration of Interests: RF reports grants from Abbvie, Gilead, Merck, personal fees from Gilead, Abbvie, Merck, Roche, and non-financial support from Abbvie, Gilead, and Merck outside the submitted work. DZM, PP reports personal fees from Gilead and Abbvie, outside the submitted work. JJ reports personal fees from Gilead, Abbvie, Bausch Health, Merck, Promed, Roche, and non-financial support from Abbvie, Gilead, and Merck outside the submitted work. KS reports personal fees from Gilead, Abbvie, Merck, outside the submitted work KT reports personal fees from Gilead, Abbvie, Merck, Promed, Roche, and non-financial support from Abbvie, Gilead, and Merck outside the submitted work. JK reports personal fees from Gilead, Merck, ViiV, Janssen outside the submitted work. IML reports personal fees from Gilead, Abbvie and Pfizer ABK, JP, BB, KK, MP, AP, DK, MTZ, CI, MRog, MRor declare no competing interests.Ethics Approval Statement: The study received the approval of the Ethics Committee of the Medical University of Białystok.

Inhaled Nitric Oxide via High-Flow Nasal Cannula in Patients with Acute Respiratory Failure Related to COVID-19.

INTRODUCTIONLimited evidence exists regarding use of inhaled nitric oxide (iNO) in spontaneously breathing patients. We evaluated the effectiveness of continuous iNO via high-flow nasal cannula (HFNC) in COVID-19 respiratory failure.METHODSWe performed a multicenter cohort study of patients with respiratory failure from COVID-19 managed with HFNC. Patients were stratified by administration of iNO via HFNC. Regression analysis was used to compare the need for mechanical ventilation and secondary endpoints including hospital mortality, length of stay, acute kidney injury, need for renal replacement therapy, and need for extracorporeal life support.RESULTSA total of 272 patients were identified and 66 (24.3%) of these patients received iNO via HFNC for a median of 88 h (interquartile range: 44, 135). After 12 h of iNO, supplemental oxygen requirement was unchanged or increased in 52.7% of patients. Twenty-nine (43.9%) patients treated with iNO compared to 79 (38.3%) patients without iNO therapy required endotracheal intubation (P = .47). After multivariable adjustment, there was no difference in need for mechanical ventilation between groups (odds ratio: 1.53; 95% confidence interval [CI]: 0.74-3.17), however, iNO administration was associated with longer hospital length of stay (incidence rate ratio: 1.41; 95% CI: 1.31-1.51). No difference was found for mortality, acute kidney injury, need for renal replacement therapy, or need for extracorporeal life support.CONCLUSIONIn patients with COVID-19 respiratory failure, iNO delivered via HFNC did not reduce oxygen requirements in the majority of patients or improve clinical outcomes. Given the observed association with increased length of stay, judicious selection of those likely to benefit from this therapy is warranted.

Telehealth Outpatient Monitoring of a SARS-CoV-2 Familial Cluster Infection in Peru: Adapting to a Healthcare Crisis

The coronavirus disease 2019 (COVID-19) epidemic is evolving in Latin America despite implementation of government measures. We report a familial cluster in Lima, Peru, with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Two young and two middle-aged adults with a wide range of COVID-19 manifestations experienced successful management under telehealth outpatient monitoring. Telehealth monitoring was scheduled as suggested by Peruvian Ministry of Health Guidelines and was performed by a designated physician who assessed the patients and prescribed treatment. On May 14, 2020, a 25-year-old male, who worked treating COVID-19 patients, reported constitutional symptoms and tested positive for SARS-CoV-2. Clinical improvement was achieved with azithromycin and ivermectin therapy. He had been in contact with his parents (Cases 2 and 3) and his sister (Case 4). Cases 2 and 3 developed moderate pulmonary compromise requiring oxygen supplementation and pharmacological therapy, including corticosteroids and anticoagulation, under home medical assessment and telehealth monitoring. Case 4 developed mild symptoms and periorbital rash, an atypical dermatological finding. To our knowledge this represents the first report of a familial cluster with COVID-19 that was successfully managed under scheduled telehealth outpatient monitoring in Latin America.

Clinical characteristics and outcomes for pregnant women diagnosed with COVID-19 disease at the University of Benin Teaching Hospital, Benin City, Nigeria.

Introductionthe novel coronavirus disease (COVID-19) pandemic has challenged health systems around the world. This study was designed to describe the socio-demographic characteristics of pregnant women with COVID-19 infection, the common clinical features at presentation and the pregnancy outcome at the University of Benin Teaching Hospital, Edo State, Nigeria.Methodsa cross-sectional analytical study of all confirmed cases of COVID-19 infection from April to September 2020.Resultsout of 69 suspected cases that were tested, 19 (28.4%) were confirmed with COVID-19 infection. The common presenting complaints were fever (68.4 %), cough (57.9 %), sore throat (31.6%), malaise (42.1%), loss of taste (26.3%), anosmia (21.1%), and difficulty with breathing (10.6%). In terms of treatment outcome, 57.9% delivered while 36.8% recovered with pregnancy on-going, and 1 (5.3%) maternal death. Of the 11 women who delivered, 45.4% had vaginal deliveries and 54.6 % had Caesarean section. The mean birth weight was 3.1kg and most of the neonates (81.8%) had normal Apgar scores at birth. There was 1 perinatal death from prematurity, birth asphyxia, and intrauterine growth restriction. The commonest diagnosed co-morbidity of pregnancy was preeclampsia and it was significantly associated with severe COVID-19 disease requiring oxygen supplementation (P = 0.028).Conclusionthe clinical symptoms of COVID-19 in pregnancy are similar to those described in the non-pregnant population. It did not seem to worsen the maternal or foetal pregnancy outcome. The occurrence of preeclampsia is significantly associated with severe COVID-19 infection requiring respiratory support.

553. Critically Ill patients Receiving Tocilizumab Compared With Those Not Receiving Tocilizumab for Treatment of COVID-19

BackgroundBackground::Immune modulation in patients with clinical features suggestive of a cytokine release syndrome (CRS) has become a pharmacologic target for potential treatment of COVID-19 and prevention of ARDS. Tocilizumab is an IL-6 receptor blocker FDA-approved for chimeric antigen receptor (CAR) T cell-induced severe or life-threatening CRS. The objective of this study was to describe clinical outcomes associated with tocilizumab compared with those not receiving tocilizumab in critically ill patients with severe COVID-19.MethodsMethods:Retrospective case series of 49 adult patients admitted to an intensive care unit with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients receiving tocilizumab were compared with those not receiving tocilizumab. The primary outcome was clinical improvement (decrease in supplemental oxygen requirement, discharge from ICU, or live discharge from hospital). Secondary endpoints included mortality and frequency of extubation. All comparative endpoints were assessed at 2 weeks after ICU admission.ResultsResults:49 patients were identified with SARS-CoV-2 who were admitted to an ICU, 16 received tocilizumab. Baseline characteristics were similar; most were African American males with comorbidities such as obesity, cardiovascular disease, and diabetes. The time from symptom onset to positive test and subsequent intubation were similar (4 and 7 days, respectively). 75% received one dose (all received 8 mg/kg). The median time from symptom onset to tocilizumab administration was 11 days.In patients receiving tocilizumab compared with those not receiving tocilizumab, there were similar rates of clinical improvement (44% versus 61%, p=0.27), extubation (31% versus 45%, p=0.60), and mortality (18% versus 19%, p >0.99, respectively). 81% of the tocilizumab group had resolution of fever and 75% had improvement in C-reactive protein levels.ConclusionConclusion:In this study of patients with progressed disease, outcomes were similar regardless of receipt of tocilizumab. Randomized controlled trials are needed to assess the impact of earlier administration and identify clinical characteristics to assist with selection of appropriate patients who may benefit from tocilizumab.Disclosures All Authors: No reported disclosures

Safety, tolerability, and outcomes of losartan use in patients hospitalized with SARS-CoV-2 infection: A feasibility study.

BackgroundRetrospective studies on the use of Renin-Angiotensin-Aldosterone System blockade in patients with Coronavirus Disease 2019 (COVID-19) have been informative but conflicting, and prospective studies are required to demonstrate the safety, tolerability, and outcomes of initiating these agents in hospitalized patients with COVID-19 and hypertension.Methods and findingsThis is a single center feasibility study encompassing two cohorts: (1) prospective cohort (April 21, 2020 to May 29, 2020) and (2) retrospective cohort (March 7, 2020 to April 1, 2020) of hospitalized patients with real-time polymerase chain reaction (PCR) positive SARS-CoV-2 by nasopharyngeal swab. Key inclusion criteria include BP > 130/80 and a requirement of supplemental oxygen with FiO2 of 25% or higher to maintain SpO2 > 92%. Key exclusion criteria included hyperkalemia and acute kidney injury (AKI) at the time of enrollment. Prospective cohort consisted of de novo initiation of losartan and continuation for a minimum of 7 days and assessed for adverse events (AKI, hyperkalemia, transaminitis, hypotension) and clinical outcomes (change in SpO2/FiO2 and inflammatory markers, need for ICU admission and mechanical ventilation). Retrospective cohort consisted of continuation of losartan (prior-to-hospitalization) and assessment of similar outcomes. In the prospective cohort, a total of 250 hospitalized patients were screened and inclusion/exclusion criteria were met in 16/250 patients and in the retrospective cohort, a total of 317 hospitalized patients were screened and inclusion/exclusion criteria were met in 14/317 patients. Most common adverse event was hypotension, leading to discontinuation in 3/16 (19%) and 2/14 (14%) patients in the prospective and retrospective cohort. No patients developed AKI in the prospective cohort as compared to 1/14 (7%) patients in the retrospective cohort, requiring discontinuation of losartan. Hyperkalemia occurred in 1/16 (6%) and 0/14 patients in the prospective and retrospective cohorts, respectively. In the prospective cohort, 3/16 (19%) and 2/16 (13%) patients required ICU admission and mechanical ventilation. In comparison, 3/14 (21%) required ICU admission and mechanical ventilation in the retrospective cohort. A majority of patients in both cohorts (14/16 (88%) and 13/14 (93%) patients from the prospective and retrospective cohort) were discharged alive from the hospital. A total of 9/16 (prospective) and 5/14 (retrospective) patients completed a minimum 7 days of losartan. In these 9 patients in the prospective cohort, a significant improvement in SpO2/FiO2 ratio was observed from day 1 to 7. No significant changes in inflammatory markers (initiation, peak, and day 7) were observed in either cohort.ConclusionIn this pilot study we demonstrate that losartan was well-tolerated among hospitalized patients with COVID-19 and hypertension. We also demonstrate the feasibility of patient recruitment and the appropriate parameters to assess the outcomes and safety of losartan initiation or continuation, which provides a framework for future randomized clinical trials.

A comparative study of efficacy and safety of oral ketamine and oral midazolam as premedicant for paediatric cardiac catheterization

Use of an effective sedative premedicant significantly minimizes the emotional trauma associated with perioperative anxiety and its sequelae. Currently, oral midazolam is the most commonly used premedicant in most of the countries followed by oral ketamine. Aims and Objectives: To compare the efficacy and safety of oral ketamine and oral midazolam as premedicant for paediatric cardiac catheterization. Materials and Methods: This study was carried out in the tertiary care centre in sixty patients randomly assigned into two groups of thirty patients each, to compare the efficacy of oral ketamine and oral midazolam pre medication as sedative for paediatric patients undergoing cardiac catheterization using various parametes and observation scale of response and Visual Analogue scale. Data collected was analysed and the statistical significance of these intra-group and inter-group observations thus made was determined using either a ‘Chi Square test’ or an ‘Unpaired T-test’ or Mann whitney test. Results: The demographic trends in all the groups were comparable. The type of procedure performed were also comparable in both the groups. The mean heart rate, mean systolic and diastolic blood pressures, mean arterial blood pressure were higher in the ketamine group than in the midazolam group. Though there was fall in oxygen saturation in both the groups the ketamine group required oxygen supplementation more than midazolam group though it was statistically insignificant. The mean onset of sedation was earlier for midazolam than for ketamine. Also the parental separation was smoother and calmer in patients who had oral midazolam than oral ketamine. Similarly while positioning the children for cath study also patients medicated with midazolam showed better response than those medicated with ketamine. The response to local anaesthetic injection during femoral vessels cannulation also showed midazolam with better results. The adverse effects such as secretions, nystagmus,

Treatment modalities for coronavirus disease 2019 (COVID-19)

Management of coronavirus disease 2019 (COVID-19) infection is based on limited data and keeps changing rapidly as new clinical data emerge. Remdesivir has shown to reduce duration of hospital stay and has been approved for treatment. In RECOVERY trial, corticosteroids lowered 28-day mortality in patients requiring oxygen supplementation or mechanical ventilation. Convalescent plasma did not live up to its initial promise and is not the standard of care for treatment at present. There’s not enough evidence for use of Hydroxychloroquine, Interleukin-6 inhibitors and many other investigational drugs. Bamlanivimab, casirivimab- imdevimab combo, all monoclonal antibodies, have recently been approved for use in mild to moderate COVIID-19, when there’s a high risk of progression to severe disease. Treatment of COVID-19 depends on stage and severity of disease. Antiviral medications are likely to be most effective when used early. Later in the disease, anti-inflammatory medications, anticoagulants and immunomodulators may be more effective. The world is waiting and hoping for a safe and effective vaccine which can put an end to this worldwide pandemic. Keywords: COVID-19; treatment; coronavirus disease; remdesivir; favipravir; hydroxychloroquine; COVID antibody therapies

Comorbidities, COPD and COVID 19

Abstract Coronavirus disease 2019 caused by the severe acute respiratory syndrome coronavirus 2 is one of the most pressing health care concerns in 2020. The continually growing number of new cases, the global outspread of the virus and the severity of the disease determined the World Health Organization to declare the outbreak a pandemic. Twenty per cent of the patients present severe and critical forms that frequently require oxygen supplementation and intensive care unit admission. That is why, to provide optimal care, it is imperative to identify at-risk patients. Patients with associated chronic diseases are more prone to develop severe and critical forms of the infection. Although the chronic pulmonary obstructive disease is present only in a limited number of coronavirus disease 2019 patients, it is most commonly associated with lung disease and a poor outcome than other comorbidities.

Coronavirus Disease 2019 Infection in a Patient Population with Lung Cancer: Incidence, Presentation, and Alternative Diagnostic Considerations

IntroductionLung cancer is associated with severe coronavirus disease 2019 (COVID-19) infections. Symptom overlap between COVID-19 and lung cancer may complicate diagnostic evaluation. We aimed to investigate the incidence, symptoms, differential diagnosis, and outcomes of COVID-19 in patients with lung cancer. MethodsTo determine an at-risk population for COVID-19, we retrospectively identified patients with lung cancer receiving longitudinal care within a single institution in the 12 months (April 1, 2019 to March 31, 2020) immediately preceding the COVID-19 pandemic, including an “active therapy population” treated within the last 60 days of this period. Among patients subsequently referred for COVID-19 testing, we compared symptoms, laboratory values, radiographic findings, and outcomes of positive versus negative patients. ResultsBetween April 1, 2019 and March 31, 2020, a total of 696 patients received longitudinal care, including 406 (58%) in the active therapy population. Among 55 patients referred for COVID-19 testing, 24 (44%) were positive for COVID-19, representing a cumulative incidence of 3.4% (longitudinal population) and 1.5% (active therapy population). Compared with patients who were COVID-19 negative, those who were COVID-19 positive were more likely to have a supplemental oxygen requirement (11% versus 54%, p = 0.005) and to have typical COVID-19 pneumonia imaging findings (5 versus 56%, p = 0.001). Otherwise, there were no marked differences in presenting symptoms. Among patients who were COVID-19 negative, alternative etiologies included treatment-related toxicity (26%), atypical pneumonia (22%), and disease progression (22%). A total of 16 patients positive for COVID-19 (67%) required hospitalization, and seven (29%) died from COVID-related complications. ConclusionsCOVID-19 was infrequent in this lung cancer population, but these patients experienced high rates of morbidity and mortality. Oncologists should maintain a low threshold for COVID-19 testing in patients with lung cancer presenting with acute symptoms.

Safety and efficacy of inhaled nebulised interferon beta-1a (SNG001) for treatment of SARS-CoV-2 infection: a randomised, double-blind, placebo-controlled, phase 2 trial

BackgroundSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection carries a substantial risk of severe and prolonged illness; treatment options are currently limited. We assessed the efficacy and safety of inhaled nebulised interferon beta-1a (SNG001) for the treatment of patients admitted to hospital with COVID-19.MethodsWe did a randomised, double-blind, placebo-controlled, phase 2 pilot trial at nine UK sites. Adults aged 18 years or older and admitted to hospital with COVID-19 symptoms, with a positive RT-PCR or point-of-care test, or both, were randomly assigned (1:1) to receive SNG001 (6 MIU) or placebo by inhalation via a mouthpiece daily for 14 days. The primary outcome was the change in clinical condition on the WHO Ordinal Scale for Clinical Improvement (OSCI) during the dosing period in the intention-to-treat population (all randomised patients who received at least one dose of the study drug). The OSCI is a 9-point scale, where 0 corresponds to no infection and 8 corresponds to death. Multiple analyses were done to identify the most suitable statistical method for future clinical trials. Safety was assessed by monitoring adverse events for 28 days. This trial is registered with Clinicaltrialsregister.eu (2020-001023-14) and ClinicalTrials.gov (NCT04385095); the pilot trial of inpatients with COVID-19 is now completed.FindingsBetween March 30 and May 30, 2020, 101 patients were randomly assigned to SNG001 (n=50) or placebo (n=51). 48 received SNG001 and 50 received placebo and were included in the intention-to-treat population. 66 (67%) patients required oxygen supplementation at baseline: 29 in the placebo group and 37 in the SNG001 group. Patients receiving SNG001 had greater odds of improvement on the OSCI scale (odds ratio 2·32 [95% CI 1·07–5·04]; p=0·033) on day 15 or 16 and were more likely than those receiving placebo to recover to an OSCI score of 1 (no limitation of activities) during treatment (hazard ratio 2·19 [95% CI 1·03–4·69]; p=0·043). SNG001 was well tolerated. The most frequently reported treatment-emergent adverse event was headache (seven [15%] patients in the SNG001 group and five [10%] in the placebo group). There were three deaths in the placebo group and none in the SNG001 group.InterpretationPatients who received SNG001 had greater odds of improvement and recovered more rapidly from SARS-CoV-2 infection than patients who received placebo, providing a strong rationale for further trials.FundingSynairgen Research.

Efficacy of therapeutic plasma exchange in the treatment of penn class 3 and 4 cytokine release syndrome complicating COVID-19

ObjectivesCytokine release syndrome (CRS) is a potentially severe complication of COVID-19 most commonly resulting in respiratory failure. This ten-patient study was designed to determine the efficacy of therapeutic plasma exchange (TPE) in improving oxygenation and in reducing the cytokine load in a critically ill subset of patients. MethodsFive single volume plasma exchanges over eight days within a 14-day study period. In mechanically ventilated patients, oxygenation was measured via the PaO2/FiO2 (P/F) ratio and the oxygenation index (OI) daily for 14 days. Supplemental oxygen requirements were tracked daily for non-ventilated patients. ResultsNon-ventilated patients were liberated from supplemental oxygen after TPE. The response was rapid with an 87% average reduction in oxygenation requirements following and average time to return to room air of 5.25 days. All mechanically ventilated patients demonstrated improvement in oxygenation with a 78% average improvement in the P/F ratio and a 43% improvement in OI. C-reactive protein (CRP) and serum levels of IL-6, IL-8, IL-10, TNFα, IFNγ and GM-CSF, were measured daily with immediate post TPE levels drawn on days 1, 2, 4, 6 and 8. All patients demonstrated significant reductions in CRP, IL-6, IL-10 and TNFα. ConclusionsIn the majority of patients with Penn class 3 and 4 CRS complicating COVID-19, TPE demonstrated a prompt improvement in oxygenation and reduction in cytokine load without compromising patient safety. As this pilot study was envisioned to be hypothesis generating, expanded trials using TPE alone and in conjunction with novel pharmacologic agents are warranted. RegistrationClinicalTrials.gov NCT04374149.