Clinical Outcomes, Costs, and Cost-effectiveness of Strategies for Adults Experiencing Sheltered Homelessness During the COVID-19 Pandemic

IMPORTANCE

Approximately 356 000 people stay in homeless shelters nightly in the United States. They have high risk of contracting coronavirus disease 2019 (COVID-19).

OBJECTIVE

To assess the estimated clinical outcomes, costs, and cost-effectiveness associated with strategies for COVID-19 management among adults experiencing sheltered homelessness.

DESIGN, SETTING, AND PARTICIPANTS

This decision analytic model used a simulated cohort of 2258 adults residing in homeless shelters in Boston, Massachusetts. Cohort characteristics and costs were adapted from Boston Health Care for the Homeless Program. Disease progression, transmission, and outcomes data were taken from published literature and national databases. Surging, growing, and slowing epidemics (effective reproduction numbers [Re], 2.6, 1.3, and 0.9, respectively) were examined. Costs were from a health care sector perspective, and the time horizon was 4 months, from April to August 2020.

EXPOSURES

Daily symptom screening with polymerase chain reaction (PCR) testing of individuals with positive symptom screening results, universal PCR testing every 2 weeks, hospital-based COVID-19 care, alternative care sites (ACSs) for mild or moderate COVID-19, and temporary housing were each compared with no intervention.

MAIN OUTCOMES AND MEASURES

Cumulative infections and hospital-days, costs to the health care sector (US dollars), and cost-effectiveness, as incremental cost per case of COVID-19 prevented.

RESULTS

The simulated population of 2258 sheltered homeless adults had a mean (SD) age of 42.6 (9.04) years. Compared with no intervention, daily symptom screening with ACSs for pending tests or confirmed COVID-19 and mild or moderate disease was associated with 37% fewer infections (1954 vs 1239) and 46% lower costs ($6.10 million vs $3.27 million) at an Re of 2.6, 75% fewer infections (538 vs 137) and 72% lower costs ($1.46 million vs $0.41 million) at an Re of 1.3, and 51% fewer infections (174 vs 85) and 51% lower costs ($0.54 million vs $0.26 million) at an Re of 0.9. Adding PCR testing every 2 weeks was associated with a further decrease in infections; incremental cost per case prevented was $1000 at an Re of 2.6, $27 000 at an Re of 1.3, and $71 000 at an Re of 0.9. Temporary housing with PCR every 2 weeks was most effective but substantially more expensive than other options. Compared with no intervention, temporary housing with PCR every 2 weeks was associated with 81% fewer infections (376) and 542% higher costs ($39.12 million) at an Re of 2.6, 82% fewer infections (95) and 2568% higher costs ($38.97 million) at an Re of 1.3, and 59% fewer infections (71) and 7114% higher costs ($38.94 million) at an Re of 0.9. Results were sensitive to cost and sensitivity of PCR and ACS efficacy in preventing transmission.

CONCLUSIONS AND RELEVANCE

In this modeling study of simulated adults living in homeless shelters, daily symptom screening and ACSs were associated with fewer severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections and decreased costs compared with no intervention. In a modeled surging epidemic, adding universal PCR testing every 2 weeks was associated with further decrease in SARS-CoV-2 infections at modest incremental cost and should be considered during future surges.

A review of chest radiographic patterns in mild to moderate novel corona virus disease 2019 at an urban hospital in Ghana

INTRODUCTION

The novel corona virus disease 2019 (COVID-19) was diagnosed in Wuhan, China in December 2019 and, in Ghana, in March 2020. As of 30th July 2020, Ghana had recorded 35,142 cases. COVID-19 which can be transmitted by both symptomatic and asymptomatic individuals usually manifest as pneumonia with symptoms like fever, cough, dyspnoea and fatigue. The current non-availability of a vaccine or drug for COVID-19 management calls for early detection and isolation of affected individuals. Chest imaging has become an integral part of patient management with chest radiography serving as a primary imaging modality in many centres.

METHODS

The study was a retrospective study conducted at Ga East Municipal Hospital (GEMH). Chest radiographs of patients with mild to moderate disease managed at GEMH were evaluated. The age, gender, symptom status, comorbidities and chest x-ray findings of the patients were documented.

RESULTS

11.4 % of the patients had some form of respiratory abnormality on chest radiography with 88.9% showing COVID-19 pneumonia features. 93.8% showed ground glass opacities (GGO), with 3.1% each showing consolidation (CN) only and CN with GGO. There was a significant association between COVID-19 radiographic features and patient's age, symptom status and comorbidities but not with gender.

CONCLUSION

Most radiographs were normal with only 11% showing COVID-19-like abnormality. There was a significant association between age, symptom status and comorbidities with the presence of COVID-19 like features but not for gender. There was no association between the extent of the lung changes and patient characteristics.

FUNDING

None declared.

Clinical Features of Esophageal Eosinophilia According to Endoscopic Phenotypes

Objective Esophageal eosinophilia (EE), a histological hallmark of eosinophilic esophagitis, is classified into two endoscopic phenotypes: localized and diffuse EE. Our aim was to determine the prevalence of EE localized in the lower esophagus and to describe its clinical features in comparison with diffuse EE. Methods Data from 81 consecutive patients with EE were retrospectively investigated. EE was histologically defined as ≥15 eosinophils per high-power field. Based on the endoscopic appearance with a histological assessment, EE was classified as either diffuse or localized type. We compared the clinical features, including the medical treatment and natural course, between the two types. Results Of the 81 patients, 52 (64.2%) had diffuse EE, and 29 (35.8%) had localized EE. Among men patients, localized EE was significantly more common than diffuse EE. In localized EE, dysphagia and food impaction were less prevalent, and the presence of rings was significantly less common than in diffuse EE. Acid-suppressive therapy was administered to only 3 of the 29 patients with localized EE. In asymptomatic patients, especially those with localized EE, endoscopic abnormalities did not worsen but rather improved in some findings, such as with regard to furrows or exudate, during the natural course of three years without medical treatment. Conclusion Localized EE has a strong predilection for men patients and accounted for more than one third of all cases of EE. This condition appears to be less symptomatic and necessitates milder medical treatment than diffuse EE and might not worsen progressively.

Assessment of Nicotine and Cannabis Vaping and Respiratory Symptoms in Young Adults

IMPORTANCE

Rates of e-cigarette use (ie, nicotine vaping) and cannabis vaping continue to increase among youth and young adults. However, the association of nicotine and cannabis vaping with independent respiratory health outcomes has not been well studied.

OBJECTIVE

To investigate associations of nicotine and cannabis vaping with bronchitic symptoms, wheeze, and shortness of breath.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey data on self-reported lifetime, 6-month, and 30-day vaping from 2553 young adults recruited from high schools in Southern California were collected from June 2018 to October 2019. Of these participants, 94% provided data for shortness of breath and wheeze, and 86% provided data for chronic bronchitis.

MAIN OUTCOMES AND MEASURES

Self-reported nicotine and cannabis vaping were measured on a Likert-type scale using the following responses: (1) never used, (2) lifetime but no past 6-month use, (3) past 6-month use but no use in the past 30 days, (4) use on 1 or 2 of the past 30 days, and (5) use on 3 or more of the past 30 days. Three respiratory health outcomes were assessed separately on the basis of self-reported symptoms: bronchitic symptoms in the previous 12 months (ie, daily cough for 3 months in a row, congestion or phlegm other than with a cold, and/or bronchitis), wheeze in the previous 12 months, and shortness of breath when hurrying on level ground or walking up a slight hill.

RESULTS

Of 2553 participants in the analytic sample (mean [SD] age, 19.3 [0.79] years; 1477 [57.9%] female individuals), 1095 of 2553 young adults (42.9%) reported vaping nicotine and 939 of 2553 (38.4%) reported vaping cannabis. Compared with those who never vaped cannabis, individuals who vaped cannabis in their lifetime but not in the past 60 months (204 of 2553 [8.4%]; adjusted odds ratio [aOR], 1.83 [95% CI, 1.08-3.10]), in the past 6 months but not in the last 30 days (490 of 2443 [20.1%]; aOR, 1.58 [95% CI, 1.02-2.46]), 1-2 days in the past 30 days (90 of 2443 [3.7%]; aOR, 2.83 [95% CI, 1.46-5.50]), and 3 or more days in the past 30 days (155 of 2443 [6.3%]; aOR, 2.14 [95% CI, 1.16-3.92]) had significantly higher odds of chronic bronchitic symptoms after adjusting for nicotine vaping, cigarette smoking, cannabis smoking, and sociodemographic characteristics. Cannabis vaping 3 or more times in the last 30 days was also associated with increased odds of wheeze (aOR, 2.27 [95% CI, 1.17-4.37]). Associations of cannabis vaping with shortness of breath and nicotine vaping with any respiratory health outcome were not statistically significant in fully adjusted models.

CONCLUSIONS AND RELEVANCE

Findings of this cross-sectional study suggest that cannabis vaping is associated with increased risk of bronchitic symptoms and wheeze in young adults. Further research is needed to understand the temporality of the association and the mechanisms underlying the difference between nicotine and cannabis vaping in the risk of bronchitic symptoms and wheeze.

Monocyte absolute count as a preliminary tool to distinguish between SARS-CoV-2 and influenza A/B infections in patients requiring hospitalization

Since the most frequent symptoms of novel coronavirus 2019 disease (COVID-19) are common in influenza A/B (FLU), predictive models to distinguish between COVID-19 and FLU using standardized non-specific laboratory indicators are needed. The aim of our study was to evaluate whether a recently dynamic nomogram, established in the Chinese population and based on age, lymphocyte percentage and monocyte absolute count, might apply to a different context. We collected data from 299 patients (243 with COVID-19 and 56 with FLU) at Policlinico Umberto I, Sapienza University of Rome. The nomogram included age, lymphocyte percentage and monocyte absolute count to differentiate COVID-19 from FLU. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for all associations. Multivariate logistic regression models were used to adjust for potential confounding. A p-value of less than 0.05 was considered statistically significant. Patients with COVID-19 had higher age, lymphocyte percentage and monocyte absolute count than patients with FLU. Although univariate analysis confirmed that age, lymphocyte percentage and monocyte absolute count were associated with COVID-19, only at multivariate analysis was monocyte count statistically significant as a predictive factor of COVID-19. Using receiver operating characteristic (ROC) curves, we found that a monocyte count >0.35x1000/mL showed an AUC of 0.680 (sensitivity 0.992, specificity 0.368). A dynamic nomogram including age, lymphocyte percentage and monocyte absolute count cannot be applied to our context, probably due to differences in demographic characteristics between Italian and Chinese populations. However, our data showed that monocyte absolute count is highly predictive of COVID-19, suggesting its potential role above all in settings where prompt PCR nasopharyngeal testing is lacking.

Self-reported symptoms among participants in a population-based screening program

BACKGROUND

A limited number of studies have explored the association between self-reported symptoms and the risk of breast cancer among participants of population based screening programs.

METHODS

We performed descriptive statistics on recall, screen-detected and interval cancer, positive predictive value and histopathological tumour characteristics by symptom group (asymptomatic, lump, and skin or nipple changes) as reported from 785,642 women aged 50-69 when they attended BreastScreen Norway 1996-2016. Uni- and multivariable mixed effects logistic regression models were used to analyze the association between symptom group and screen-detected or interval cancer. Results were presented as odds ratios and 95% confidence intervals (CI).

RESULTS

A lump or skin/nipple change was reported in 6.2% of the 3,307,697 examinations. The rate of screen-detected cancers per 1000 examinations was 45.2 among women with a self-reported lump and 5.1 among asymptomatic women. Adjusted odds ratio of screen-detected cancer was 10.1 (95% CI: 9.3-11.1) and 2.0 (95% CI: 1.6-2.5) for interval cancer among women with a self-reported lump versus asymptomatic women. Tumour diameter, histologic grade and lymph node involvement of screen-detected and interval cancer were less prognostically favourable for women with a self-reported lump versus asymptomatic women.

CONCLUSION

Despite targeting asymptomatic women, 6.2% of the screening examinations in BreastScreen Norway was performed among women who reported a lump or skin/nipple change when they attended screening. The odds ratio of screen-detected cancer was higher for women with versus without symptoms. Standardized follow-up guidelines might be beneficial for screening programs in order to take care of women reporting signs or symptoms of breast cancer when they attend screening.

Assessing the severity of pulmonary embolism among patients in the emergency department: Utility of RV/LV diameter ratio

Background

Acute pulmonary embolism (APE) is a major cause of death from cardiovascular disease. Right ventricular systolic dysfunction (RVD) caused by APE is closely related to a poor outcome. Early risk stratification of APE is a vital step in prognostic assessment. The objective of this study was to investigate the usefulness of computed tomographic pulmonary angiography (CTPA) measured right ventricular (RV)/ left ventricular (LV) diameter ratio by the emergency department (ED) specialists for early risk stratification of APE patients in ED.

Methods

The retrospective data of 229 APE patients were reviewed. Two ED specialists measured both RV and LV diameters on a single transverse scan perpendicular to the long axis of the heart. The patients were divided into two groups, RV/LV diameter ratio <1 and ratio >1. CTPA measured RV/LV diameter ratio were analyzed and compared with sPESI score, cardiac biomarkers such as N-Terminal Pro-B-Type Natriuretic Peptide (NT-pro-BNP), high sensitivity cardiac troponin T (hs-cTnT), and RVD measured by echocardiography (Echo).

Results

The mean age in RV/LV > 1 group was significantly higher than that of the other group (67.81±2.7 years vs. 60.68±3.2 years). Also, there were more hypertension patients (44.4% vs. 33.3%), and mean arterial pressure (MAP) was lower. A significantly higher ICU admission rate (28.05% vs. 11.61%) was shown in RV/LV >1 group, and five patients expired only in RV/LV > 1 group. RVD by Echo demonstrated the highest sensitivity, specificity, and negative predictive value (NPV) (values of 94.3%, 81.1%, 95.5%). RV/LV >1 diameter ratio by CTPA showed usefulness equivalent to cardiac biomarkers. RV/LV >1 patients’ cardiac enzymes were higher, and there were more RVD in RV/LV >1 group.

Conclusion

Simple measurement of RV/LV diameter ratio by ED specialist would be a help to the clinicians in identifying and stratifying the risk of the APE patients presenting in the ED.

The value of coronary computed tomography angiography in assessing the cardiac circulation of an outpatient-based population

To evaluate the perfusion of coronary circulation and its related factors and the difference in the peak filling times in aortic sinus and coronary sinus by coronary computed tomography angiography (CCTA).From January 1 to August 1, 2018, 61 outpatients with angina pectoris were recruited, completed a questionnaire about risk factors and underwent CCTA, which was also used to assess the stenosis of different coronary artery segments.The duration of circulation was 9.50 ± 2.43 seconds in patients with flat T wave, which was shorter than the duration in normal subjects (P = .021). However, other cardiovascular risk factors showed no effect on the duration of circulation. In addition, the duration of circulation was closely related to the peak filling time of coronary sinus [r(s) = 0.681]. We further divided the circulation time difference (delta) values into 3 levels (<6, 6-12, and ≥12 seconds).It showed that the circulation duration (Y) was associated with:Therefore, the cardiac circulation duration was negatively related to the degree of stenosis in the 1 diagonal and proximal LCA.It compensates for the inability of CCTA to assess circulation at rest simply by determining the peak filling time in the aortic sinus and the coronary sinus. Moderate cardiac microcirculation duration was related to a low incidence of clinical symptoms and electrocardiogram disorders, which was determined mainly by the diagonal and left circumflex branch 1 of LCA.

Clinical Analysis of Neonates Born to Mothers with or without COVID-19: A Retrospective Analysis of 48 Cases from Two Neonatal Intensive Care Units in Hubei Province

OBJECTIVE

The perinatal consequences of neonates born to severe acute respiratory syndrome-associated coronavirus-2 (SARS-CoV-2) infected mothers are uncertain. This study aimed to compare the differences in clinical manifestation, laboratory results, and outcomes of neonates born to mothers with or without coronavirus disease 2019 (COVID-19).

STUDY DESIGN

A total of 48 neonates were admitted to Tongji Hospital and HuangShi Maternal and Child Healthcare Hospital from January 17 to March 4, 2020. The neonates were divided into three groups according to the mothers' conditions: neonates born to mothers with confirmed COVID-19, neonates born to mothers with clinically diagnosed COVID-19, and neonates born to mothers without COVID-19. The clinical data of mothers and infants in the three groups were collected, compared, and analyzed.

RESULTS

The deliveries occurred in a negative pressure isolation room, and the neonates were separated from their mothers immediately after birth for further observation and treatment. None of the neonates showed any signs of fever, cough, dyspnea, or diarrhea. SARS-CoV-2 reverse transcriptase-polymerase chain reaction of the throat swab and feces samples from the neonates in all three groups was negative. No differences were detected in the whole blood cell, lymphocytes, platelet, and liver and renal function among the three groups. All mothers and their infants showed satisfactory outcomes, including a 28-week preterm infant.

CONCLUSION

The clinical manifestations, radiological, and biochemical results did not show any difference between the three groups. No evidence of vertical transmission was found in this study whether the pregnant women developed coronavirus infection in the third (14 cases) or second trimester (1 case).

KEY POINTS

· Characteristics of neonates born to mothers with and without COVID-19 have been compared.. · All the 48 cases presented in the study had good outcomes.. · A 28-week preterm born to COVID-19 mother presented to be clear of SARS-COV-2 infection..

Clinical features and multidisciplinary treatment outcome of COVID-19 pneumonia: A report of three cases

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a pandemic threatening global public health. In the current paper, we describe our successful treatment of three COVID-19 pneumonia patients cases including severe cases and cases with mortality risk factors. One 32-year-old male COVID-19 patient was diagnosed with severe COVID-19 pneumonia and moderate ARDS. The second COVID-19 pneumonia patient had a history of diabetes and chronic bronchitis. The third case of COVID-19 pneumonia was an 82-year old female patient. All three cases had severe COVID pneumonia and therefore were aggressively managed with a multidisciplinary and personalized therapeutic approach that included nutritional support, antiviral pharmacotherapy, active control of comorbidities, prevention of complication development and psychological intervention. Our experience highlights the importance of the use of a multidisciplinary therapeutic approach that tailors to the specific condition of the patient in achieving a favorable clinical outcome.

Cough reflex testing in acute stroke: A survey of current UK service provision and speech and language therapist perceptions

BACKGROUND

Silent aspiration (SA)-airway entry of food, drink or other material without a cough response-is common post-stroke. Clinical swallowing examination misses up to 40% of dysphagic patients with SA. This may put these patients at risk of aspiration pneumonia, prolonged length of hospital stay and increased healthcare costs. After stroke, the laryngeal cough reflex is frequently impaired with significant relationships between pneumonia rates and reduced cough strength and sensitivity. There has been a significant amount of recent interest in cough reflex testing (CRT) as a potential means to improve clinical identification of patients at risk of SA. However, there is a lack of consensus regarding the methodology and protocols for use of CRT with widely varying outcomes reported in the literature.

AIMS

To provide an overview of current practice in the UK with regards to clinical use of CRT by speech and language therapists (SLTs) in acute stroke settings and to explore the perceptions regarding its potential application in clinical dysphagia management and the barriers and facilitators associated with adopting CRT in clinical practice.

METHODS & PROCEDURES

A cross-sectional web-based survey was developed, piloted and delivered. The survey targeted all UK-based SLTs working in acute stroke settings.

OUTCOMES & RESULTS

A total of 129 SLTs with varying levels of experience of CRT from all regions of the UK responded. Only four SLT services in the UK were reported to be currently using CRT clinically with acute stroke patients. A total of 29% of respondents who were not using CRT were considering introducing CRT into their service's dysphagia protocol. Variation was reported in the procedures and protocols. Overall, users reported improved confidence in the clinical detection of SA and felt that the introduction of CRT had improved their patient-related outcomes. Issues included difficulties procuring citric acid, implications for SLT time (including service set-up and delivery of CRT) and restricted access to instrumental assessments.

CONCLUSIONS & IMPLICATIONS

This survey gives valuable insight into the current practice and perceptions of SLTs in the UK working in acute stroke settings in relation to CRT. It highlights discrepancies between reported approaches and recommendations from existing guidelines and validation studies. The variation in responses indicates a need to develop a consensus statement and further research to guide practice. What this study adds What is already known on the subject CRT is gaining popularity as a screening tool for the clinical identification of SA with acute stroke patients. However, there is a lack of consensus in the literature regarding the methodology and protocols with widely varying outcomes. Further work needs to be done to standardize its use, especially if it is to be incorporated into dysphagia protocols for use in the acute stroke setting. What this paper adds to existing knowledge This survey of SLTs working in acute stroke settings highlights variability in practice in CRT service delivery in the UK, reflecting findings from the existing CRT literature. What are the potential or actual clinical implications of this work? The findings of this study support the need for further research relating to clinical screening tests for SA and standardization of methodology and protocols for CRT use if its use is to be continued clinically.

Trend of Olfactory and Gustatory Dysfunction in COVID-19 Patients in a Quarantine Facility

BACKGROUND

Olfactory and gustatory dysfunction has been reported as characteristic symptoms of coronavirus disease 2019 (COVID-19). This study evaluated olfactory and gustatory dysfunction in mild COVID-19 patients using validated assessment methods.

METHODS

A prospective surveillance study was conducted for mild COVID-19 patients who were isolated at the Gyeonggi International Living and Treatment Support Center (LTSC), Korea. Olfactory function was assessed using the Korean version of the Questionnaire of Olfactory Disorders (QOD) and Cross-Cultural Smell Identification Test (CC-SIT). Gustatory function was assessed using an 11-point Likert scale and 6-n-propylthiouracil, phenylthiocarbamide, and control strips. All patients underwent nasal and oral cavity endoscopic examination.

RESULTS

Of the 62 patients at the LTSC, 15 patients (24.2%) complained of olfactory or gustatory dysfunction on admission. Four of 10 patients who underwent functional evaluation did not have general symptoms and 2 were asymptomatic. The mean short version of QOD-negative statements and QOD-visual analogue scale scores were 13 ± 6 and 4.7 ± 3.6, respectively. The mean CC-SIT score was 8 ± 2. No patients showed anatomical abnormalities associated with olfactory dysfunction on endoscopic examination. The mean Likert scale score for function was 8 ± 2, and there were no abnormal lesions in the oral cavity of any patient.

CONCLUSIONS

The prevalence of olfactory and gustatory dysfunction was 24.2% in mild COVID-19 patients. All patients had hyposmia due to sensorineural olfactory dysfunction, which was confirmed using validated olfactory and gustatory evaluation methods and endoscopic examination. Olfactory and gustatory dysfunction may be characteristic indicators of mild COVID-19.

Long-Term Benefits of Pulmonary Rehabilitation in Patients With COPD: A 2-Year Follow-Up Study

BACKGROUND

Pulmonary rehabilitation (PR) improves exercise capacity in patients with COPD in the short term.

RESEARCH QUESTION

In patients with COPD, does 8 weeks of PR confer long-term benefits on symptoms of dyspnea, anxiety, and depression, and on quality of life, 2 years after completion?

STUDY DESIGN AND METHODS

One hundred and sixty-five patients with COPD completed an 8-week, community-based, comprehensive PR program, comprising 2-h sessions twice weekly. Sessions included aerobic exercise and an educational program. Patients were encouraged to perform daily walking exercise up to 30 min at home. We evaluated a number of outcome measures at baseline, 8 weeks, and 2 years, including the following: dyspnea measured with the modified Medical Research Council (mMRC) questionnaire, quality of life assessed with the St. George's Respiratory Questionnaire (SGRQ), and anxiety measured with the Anxiety Inventory for Respiratory Disease (AIR) and the Depression Anxiety Stress Scale (DASS). In addition, we measured exercise capacity, using the Incremental Shuttle Walk Test (ISWT), at baseline and 8 weeks.

RESULTS

Mean age (SD) was 72 (8.6) years; 55% were men. At 8 weeks, improvements in mMRC, SGRQ, ISWT, DASS, and AIR were all statistically significant (P < .001). During the 2-year follow-up, changes observed at 8 weeks were maintained for anxiety symptoms, and for symptoms, impact, and total SGRQ scores. In multivariate analysis, initial elevated levels of dyspnea, depression, anxiety, and decreased exercise capacity predicted greater quality of life improvement at 2 years (all P < .001).

INTERPRETATION

Over a 2-year period, an effective 8-week PR program provides sustained improvement in anxiety and quality of life. Short-term improvements in dyspnea, depression, and stress symptoms at 8 weeks were not maintained at 2 years.

Feeling scared or worried self-report in children receiving cancer treatments using the Symptom Screening in Pediatrics Tool (SSPedi)

INTRODUCTION

The objectives of this study were to describe reports of bother for feeling scared or worried among children with cancer and pediatric hematopoietic stem cell transplant (HSCT) recipients, and to identify factors associated with it.

METHODS

We included children receiving cancer treatments who were 8-18 years of age. Three patient types were enrolled: inpatients receiving active cancer treatment, outpatients receiving maintenance acute lymphoblastic leukemia chemotherapy, and outpatients in survivorship. Amount of bother due to feeling scared or worried yesterday or today was self-reported using the Symptom Screening in Pediatrics Tool (SSPedi) on a 0-4 scale. Risk factors were evaluated using logistic regression.

RESULTS

Among the 502 children included, 225 (45.0%) reported any degree of bother (score ≥ 1) and 29 (5.8%) reported severe bother (score ≥ 3) for feeling scared or worried. In multiple regression evaluating any bother, boys were less likely to be bothered (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.41-0.87) and inpatients receiving active cancer treatment were more likely to be bothered compared to outpatients in survivorship (OR 3.58, 95% CI 2.00-6.52). The only factor associated with being severely bothered by feeling scared or worried was clinic visit or admission due to fever (OR 4.57, 95% CI 1.24-13.60).

DISCUSSION

We found 45% of children receiving cancer treatments reported being bothered by feeling scared or worried. Girls and inpatients receiving active treatment experienced more bother of any degree, while visiting the hospital due to fever was associated with being severely bothered. Future work should identify interventions to prevent or alleviate this symptom.

Outpatient Management of COVID-19: Rapid Evidence Review

Common presenting symptoms of coronavirus disease 2019 include fever, dry cough, shortness of breath, and fatigue. However, patients may have a wide range of symptoms representing a spectrum of mild to severe illness. Symptoms in children tend to be milder and may include fever, cough, and feeding difficulty. The incubation period is two to 14 days, although symptoms typically appear within five days of exposure. Multiple testing modalities exist, but infection should be confirmed by polymerase chain reaction testing using a nasopharyngeal swab. There are no evidence- based treatments appropriate for use in the outpatient setting; management is supportive and should include education about isolation. In hospitalized patients, remdesivir should be considered to reduce time to recovery, and low-dose dexamethasone should be considered in patients who require supplemental oxygen. Overall, 85% of patients have mild illness, whereas 14% have severe disease requiring hospitalization, including 5% who require admission to an intensive care unit. Predictors of severe disease include increasing age, comorbidities, lymphopenia, neutrophilia, leukocytosis, low oxygen saturation, and increased levels of C-reactive protein, d-dimer, transaminases, and lactate dehydrogenase.

Effects of Ginger on clinical manifestations and paraclinical features of patients with Severe Acute Respiratory Syndrome due to COVID-19: A structured summary of a study protocol for a randomized controlled trial

OBJECTIVES

We investigate the effects of Ginger, compared to the usual therapeutic regimen on clinical manifestations and paraclinical features in patients with confirmed COVID-19 that are moderately ill.

TRIAL DESIGN

This is a single center, randomized, double-blind, placebo-controlled clinical trial with parallel group design.

PARTICIPANTS

Inclusion criteria: 1. Patients admitted to Severe Acute Respiratory Syndrome (SARS) Departments at Shahid Mohammadi Hospital, Bandar Abbas, Iran 2. Age ≥18 years (weight ≥35 kg) 3. Hospitalized ≤48 hours 4. Confirmed SARS-CoV-2 diagnosis (Positive polymerase chain reaction (PCR)) 5. Moderate pneumonia and lung involvement in imaging 6. Signing informed consent and willingness of study participant to accept randomization to any assigned treatment arm Exclusion criteria: 1. Underlying diseases, including heart disease, chronic hypertension, severe renal failure, severe liver failure, and thyroid disorders 2. Use of warfarin, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), diuretics, corticosteroids, and antiarrhythmic drugs 3. Severe and critical pneumonia 4. History of known allergy to Ginger 5. Pregnancy and breastfeeding INTERVENTION AND COMPARATOR: Intervention group: The standard treatment regimen for COVID-19 along with Ginger-based herbal tablets (Vomigone ®, Dineh Pharmaceutical Company, Iran) at a dose of 1000 mg three times a day for a period of seven days.

CONTROL GROUP

The standard treatment for COVID-19 based on the Iranian Ministry of Health and Medical Education's protocol, along with Vomigone-like placebo tablets (Dineh Pharmaceutical Company, Iran) at a dose of two tablets three times a day for a period of seven days.

MAIN OUTCOMES

The primary outcome is recovery rate of clinical symptoms, including fever, dry cough, tiredness, and GI symptoms as well as paraclinical features, including thrombocytopenia, lymphocytopenia, and C-reactive protein within seven days of randomization. Time to improvement of clinical and paraclinical features along with the incidence of serious adverse events are the secondary outcomes within seven days of randomization.

RANDOMIZATION

An interactive web-based system will be used to allocate eligible participants, based on the inclusion and exclusion criteria, to one of the two study arms (in a 1:1 ratio) using block randomization.

BLINDING (MASKING)

All study participants, research coordinators, clinicians, nurses, and investigators will be blinded to the group assignment.

NUMBERS TO BE RANDOMIZED (SAMPLE SIZE)

A total of 84 participants will be randomized into two groups of 42 patients.

TRIAL STATUS

The protocol is Version 1.0, May 23, 2020. Recruitment began July 21, 2020, and is anticipated to be completed by October 30, 2020.

TRIAL REGISTRATION

This clinical trial has been registered in the Iranian Registry of Clinical Trials (IRCT). The registration number is " IRCT20200506047323N1 ". Registration date is 23 May 2020.

FULL PROTOCOL

The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol.

Age differences in clinical features and outcomes in patients with COVID-19, Jiangsu, China: a retrospective, multicentre cohort study

OBJECTIVES

To determine the age-specific clinical presentations and incidence of adverse outcomes among patients with COVID-19 in Jiangsu, China.

DESIGN AND SETTING

Retrospective, multicentre cohort study performed at 24 hospitals in Jiangsu, China.

PARTICIPANTS

625 patients with COVID-19 enrolled between 10 January and 15 March 2020.

RESULTS

Of the 625 patients (median age, 46 years; 329 (52.6%) men), 37 (5.9%) were children (18 years or younger), 261 (41.8%) young adults (19-44 years), 248 (39.7%) middle-aged adults (45-64 years) and 79 (12.6%) elderly adults (65 years or older). The incidence of hypertension, coronary heart disease, chronic obstructive pulmonary disease and diabetes comorbidities increased with age (trend test, p<0.0001, p=0.0003, p<0.0001 and p<0.0001, respectively). Fever, cough and shortness of breath occurred more commonly among older patients, especially the elderly, compared with children (χ2 test, p=0.0008, 0.0146 and 0.0282, respectively). The quadrant score and pulmonary opacity score increased with age (trend test, both p<0.0001). Older patients had many significantly different laboratory parameters from younger patients. Elderly patients had the highest proportion of severe or critically-ill cases (33.0%, χ2 test p<0.0001), intensive care unit use (35.4%, χ2 test p<0.0001), respiratory failure (31.6%, χ2 test p<0.0001) and the longest hospital stay (median 21 days, Kruskal-Wallis test p<0.0001).

CONCLUSIONS

Elderly (≥65 years) patients with COVID-19 had the highest risk of severe or critical illness, intensive care use, respiratory failure and the longest hospital stay, which may be due partly to their having a higher incidence of comorbidities and poor immune responses to COVID-19.

Segmental Histological Normalisation Occurs in Ulcerative Colitis but Does Not Improve Clinical Outcomes

BACKGROUND AND AIMS

Complete histological normalisation and reduction of inflammation severity in patients with ulcerative colitis are associated with improved clinical outcomes, but the clinical significance of normalisation of only segments of previously affected bowel is not known. We examined the prevalence, pattern, predictors, and clinical outcomes associated with segmental histological normalisation in in patients with ulcerative colitis.

METHODS

Medical records of patients with confirmed ulcerative colitis and more than one colonoscopy were sought. Segmental histological normalisation was defined as histological normalisation of a bowel segment [rectum, left-sided or right-sided colon] that had previous evidence of chronic histological injury. We assessed the variables influencing these findings and whether segmental normalisation was associated with improved clinical outcomes.

RESULTS

Of 646 patients, 32% had segmental and 10% complete histological normalisaton when compared with their maximal disease extent. Most [88%] had segmental normalisation in a proximal-to-distal direction. Others had distal-to-proximal or patchy normalisation. On multivariate analysis, only current smoking [p = 0.040] and age of diagnosis ≤16 years [p = 0.028] predicted segmental histological normalisation. Of 310 who were in clinical remission at initial colonoscopy, 77 [25%] experienced clinical relapse after median 1.3 [range 0.06-7.52] years. Only complete histological normalisation of the bowel was associated with improved relapse-free survival (hazard ratio [HR] 0.23; 95% confidence interval [CI] 0.08-0.68; p = 0.008].

CONCLUSIONS

Segmental histological normalisation occurs in 32% of patients with ulcerative colitis and is increased in those who smoke or were diagnosed at younger age. Unlike complete histological normalisation, segmental normalisation does not signal improved clinical outcomes.

COVID-19 in systemic lupus erythematosus: Data from a survey on 417 patients

BACKGROUND

Systemic lupus erythematosus (SLE) is a chronic disease characterised by autoimmunity and increased susceptibility to infections. COVID-19 is a systemic viral disease currently spreading as a pandemic. Little is known about the impact of COVID-19 in patients with SLE.

OBJECTIVE

to acquire information on the impact of COVID-19 in SLE.

METHODS

A 26-item anonymous questionnaire investigating demographics, SLE clinical features, COVID-19 diagnoses and changes in treatments and daily habits was administered to patients with SLE from three referral centres through www.surveymonkey.com over 10 days. Data from the survey were compared to those from published estimates about the general population.

RESULTS

Four-hundred-seventeen patients responded to the survey. More than 60% of subjects complained of symptoms that are also associated to COVID-19. Fourteen COVID-19 diagnoses (five confirmed by polymerase chain reaction) were reported, in contrast to a 0.73% prevalence of confirmed cases in Lombardy. One hospitalisation was reported. Fever, anosmia, dry cough, a self-reported history of neuropsychiatric SLE and a recent contact with confirmed COVID-19 cases were more strongly associated with COVID-19, as were symptoms and lower compliance to behavioural preventive measures in patients' contacts. No protective effect was seen in subjects on hydroxychloroquine.

CONCLUSION

COVID-19 morbidity might only moderately be increased in most patients with SLE, although limited information can be inferred on more severe cases. Hydroxychloroquine apparently seems not to confer protection to infection per se, although other beneficial roles cannot be excluded. Containment policies and behavioural preventive measures could have a major role in limiting the impact of COVID-19 in patients with SLE.

Breast imaging and cancer diagnosis during the COVID-19 pandemic: recommendations from the Italian College of Breast Radiologists by SIRM

The Italian College of Breast Radiologists by the Italian Society of Medical Radiology (SIRM) provides recommendations for breast care provision and procedural prioritization during COVID-19 pandemic, being aware that medical decisions must be currently taken balancing patient's individual and community safety: (1) patients having a scheduled or to-be-scheduled appointment for in-depth diagnostic breast imaging or needle biopsy should confirm the appointment or obtain a new one; (2) patients who have suspicious symptoms of breast cancer (in particular: new onset palpable nodule; skin or nipple retraction; orange peel skin; unilateral secretion from the nipple) should request non-deferrable tests at radiology services; (3) asymptomatic women performing annual mammographic follow-up after breast cancer treatment should preferably schedule the appointment within 1 year and 3 months from the previous check, compatibly with the local organizational conditions; (4) asymptomatic women who have not responded to the invitation for screening mammography after the onset of the pandemic or have been informed of the suspension of the screening activity should schedule the check preferably within 3 months from the date of the not performed check, compatibly with local organizational conditions. The Italian College of Breast Radiologists by SIRM recommends precautions to protect both patients and healthcare workers (radiologists, radiographers, nurses, and reception staff) from infection or disease spread on the occasion of breast imaging procedures, particularly mammography, breast ultrasound, breast magnetic resonance imaging, and breast intervention procedures.

Tuberculosis under anti-TNF therapy: case series of a center (reporting the experience from the period 2006-2019)

Patients with inflammatory rheumatic diseases refractory to conventional disease modifying antirheumatic drugs (DMARDs)have been treated with biologics for the last two decades. It is also known that patients under biotechnological therapy present a higher risk of developing Tuberculosis (TB).Portugal has now a TB incidence classified as low. National recommendations advise on latent TB screening before the beginning of the biological therapy. This screening consists in the detection of risk factors and/or signs and symptoms of latent TB through clinical history, physical examination, chest X-ray, tuberculin skin test and Interferon Gamma Release Assay (IGRA) test. We describe five clinical cases of patients who underwent biotechnological therapy at our Hospital after 2006 and developed TB.