0.9% saline versus Plasma-Lyte as initial fluid in children with diabetic ketoacidosis (SPinK trial): a double-blind randomized controlled trial

Normal saline or balanced salt solutions for fluid administration with a focus on critical care and emergency medicine settings

In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Addressing COVID-19 contagion through the HVAC systems by reviewing indoor airborne nature of infectious microbes: Will an innovative air recirculation concept provide a practical solution?

As the world continues to grapple with the reality of coronavirus disease, global research communities are racing to develop practical solutions to adjust to the new challenges. One such challenge is the control of indoor air quality in the COVID-19 era and beyond. Since COVID-19 became a global pandemic, the "super spread" of the virus has continued to amaze policymakers despite measures put in place by public health officials to sensitize the general public on the need for social distancing, personal hygiene, etc. In this work, we have reviewed the literature to demonstrate, by investigating the historical and present circumstances, that indoor spread of infectious diseases may be assisted by the conditions of the HVAC systems. While little consideration has been given to the possibility of indoor airborne transmission of the virus, the available reports have demonstrated that the virus, with average aerodynamic diameter up to 80-120 nm, is viable as aerosol in indoor atmosphere for more than 3 h, and its spread may be assisted by the HVAC systems. Having reviewed the vulnerability of the conventional ventilation systems, we recommend innovative air circulation concept supported by the use of UVGI in combination with nanoporous air filter to combat the spread of SARS-CoV-2 and other harmful microbes in enclosed spaces.

Fluid and electrolyte therapy in childhood diabetic ketoacidosis management: A rationale for new national guideline

Fluid and electrolyte therapy in childhood diabetic ketoacidosis (DKA) management has been controversial. Previous National Institute for Health and Care Excellence (NICE) 2015 guidance advocated a restricted fluid regimen while more recent guidelines have advocated a more liberal approach to fluid replacement in DKA. At the core of the debate is the need to avoid developing cerebral oedema as a complication. Although subtle asymptomatic cerebral oedema is common in children presenting in DKA, clinically apparent cerebral oedema is rare and has been reported in approximately 0.5%-1% of DKA cases in children. Recent research evidence has shown that there was no clear evidence of a difference in rates of clinically apparent cerebral injury in children in DKA managed with a range of fluid volumes and rates of rehydration. In view of this, NICE has updated its guideline. In this paper, we review literature evidence underpinning the current understanding of the pathophysiology of cerebral oedema in children and discuss the rationale for the new NICE guidance.

Direct and indirect effects of SARS-CoV-2 on wastewater treatment

The novel SARS-CoV-2 is expanding internationally. While the current focus is on limiting its transmission from direct contact with infected patients and surfaces during the pandemic, the secondary transmission potential via sewage should not be underestimated, especially in low-income and developing countries with weak wastewater treatment technologies. Recent studies have indicated SARS-CoV-2 positivity also be detected in the feces of patients. Therefore, the risk of transmission and infection can be increased into sewage by the fecal-oral way, mainly in some parts of the globe with a high amount of open defecation. This review collected scattered data and recent studies about the direct and indirect effects of coronavirus in the water cycle. The direct impacts of COVID-19 on wastewater are related to the presence of the coronavirus and suitable viral removal methods in different phases of treatment in wastewater treatment plants. The indirect effects of COVID-19 on wastewater are related to the overuse of cleaning and disinfecting products to protect against viral infection and the overuse of certain drugs to protect against virus or novel mental problems and panic to COVID-19 and consequently their presence in wastewater. This unexpected situation leads to changes in the quality of wastewater and brings adverse and harmful effects for the human, aquatic organisms, and the environment. Therefore, applying effective wastewater treatment technologies with low toxic by-products in wastewater treatment plants will be helpful to prevent the increasing occurrence of these extra contaminants in the environment.

Coronavirus-disease-2019-induced antiphospholipid-like syndrome: a case report

BACKGROUND

This paper describes a case of antiphospholipid syndrome-like condition caused by coronavirus disease 2019. The medical community still faces many diagnostic and therapeutic challenges vis-à-vis coronavirus disease 2019. Ultimately, coronavirus disease 2019 is diagnosed on the basis of laboratory and radiological findings. Considering the high rate of mortality due to coagulation abnormalities and thrombosis among coronavirus disease 2019 patients, it is important to pay attention to the differential diagnoses of coronavirus disease 2019 and other diseases following thrombotic events.

CASE DESCRIPTION

The patient was a 56-year-old Iranian man who underwent coronary artery bypass graft surgery and mitral valve repair. During hospitalization, the patient showed an elevated level of anticardiolipin antibody (immunoglobulin G isotype), antiphospholipid antibodies, and thrombosis in the brachial artery of the left hand, based on which a differential diagnosis of antiphospholipid syndrome was made. However, ultimately, the coronavirus disease 2019 polymerase chain reaction test and computed tomography scan of the lungs showed that the patient had coronavirus disease 2019.

CONCLUSION

According to the few studies performed on coronavirus disease 2019 patients, elevated levels of the isotypes of antiphospholipid antibodies in coronavirus disease 2019 patients create conditions similar to antiphospholipid syndrome, which, in the absence of reliable coronavirus disease 2019 testing, can lead to misdiagnosis and consequently delayed or improper treatment. Therefore, to provide timely and appropriate treatment, it is important to pay attention to differential diagnosis.

Predicting clinical outcomes among hospitalized COVID-19 patients using both local and published models

BACKGROUND

Many models are published which predict outcomes in hospitalized COVID-19 patients. The generalizability of many is unknown. We evaluated the performance of selected models from the literature and our own models to predict outcomes in patients at our institution.

METHODS

We searched the literature for models predicting outcomes in inpatients with COVID-19. We produced models of mortality or criticality (mortality or ICU admission) in a development cohort. We tested external models which provided sufficient information and our models using a test cohort of our most recent patients. The performance of models was compared using the area under the receiver operator curve (AUC).

RESULTS

Our literature review yielded 41 papers. Of those, 8 were found to have sufficient documentation and concordance with features available in our cohort to implement in our test cohort. All models were from Chinese patients. One model predicted criticality and seven mortality. Tested against the test cohort, internal models had an AUC of 0.84 (0.74-0.94) for mortality and 0.83 (0.76-0.90) for criticality. The best external model had an AUC of 0.89 (0.82-0.96) using three variables, another an AUC of 0.84 (0.78-0.91) using ten variables. AUC's ranged from 0.68 to 0.89. On average, models tested were unable to produce predictions in 27% of patients due to missing lab data.

CONCLUSION

Despite differences in pandemic timeline, race, and socio-cultural healthcare context some models derived in China performed well. For healthcare organizations considering implementation of an external model, concordance between the features used in the model and features available in their own patients may be important. Analysis of both local and external models should be done to help decide on what prediction method is used to provide clinical decision support to clinicians treating COVID-19 patients as well as what lab tests should be included in order sets.

TNF-α Blockers Showed Prophylactic Effects in Preventing COVID-19 in Patients with Rheumatoid Arthritis and Seronegative Spondyloarthropathies: A Case-Control Study

INTRODUCTION

The interaction between angiotensin-converting enzyme 2 (ACE2) and SARS-CoV-2 is a crucial factor in the viral infections leading to the release of inflammatory proteins, such as TNF-α. Thus, it is hypothesized that TNF-α blockers can prevent either COVID-19 incidence or its serious symptoms. TNF-α blockers are prescribed to treat various autoimmune disorders, including rheumatoid arthritis (RA) and seronegative spondyloarthropathies (SpA). Therefore, the objective of this work was to examine this hypothesis that TNF-α blockers can prevent COVID-19 incidence in patients with RA or SpA.

METHODS

A case-control study was conducted through interviews based on a structured questionnaire to investigate the frequency of COVID-19 incidence in 254 eligible patients with RA or SpA about whom 45% were under treatment with one type of TNF-α blockers including infliximab, adalimumab, and etanercept at least for 3 months during the COVID-19 pandemic. Interviews were carried out twice, at the beginning and the end of the study (June-December 2020). Patients with COVID-19 during the study or before that were considered as cases. The control group was patients without COVID-19 experience. Data were analyzed using descriptive statistics, and logistic regression was used to determine the relationships between COVID-19 incidence and independent variables.

RESULTS

A small percentage of patients treated with TNF-α blockers (5.22%, 6/115) experienced COVID-19, while a large percentage of patients with COVID-19 did not receive TNF-α blockers (27.34%, 38/139). According to odds ratio, adalimumab, infliximab, and etanercept decreased significantly the risk of developing COVID-19 up to 96.8, 95, and 80.3% (p < 0.05), respectively. Therefore, TNF-α blockers could probably decrease the chances of the COVID-19 incidence in patients with RA or SpA.

CONCLUSIONS

A direct and positive correlation between the use of TNF-α blockers and a reduction in the incidence of COVID-19 could suggest the prophylactic role of these drugs in preventing COVID-19 in patients with RA and SpA.

Corilagin and 1,3,6-Tri-O-galloy-β-D-glucose: potential inhibitors of SARS-CoV-2 variants

The COVID-19 disease caused by the virus SARS-CoV-2, first detected in December 2019, is still emerging through virus mutations. Although almost under control in some countries due to effective vaccines that are mitigating the worldwide pandemic, the urgency to develop additional vaccines and therapeutic treatments is imperative. In this work, the natural polyphenols corilagin and 1,3,6-tri-O-galloy-β-d-glucose (TGG) are investigated to determine the structural basis of inhibitor interactions as potential candidates to inhibit SARS-CoV-2 viral entry into target cells. First, the therapeutic potential of the ligands are assessed on the ACE2/wild-type RBD. We first use molecular docking followed by molecular dynamics, to take into account the conformational flexibility that plays a significant role in ligand binding and that cannot be captured using only docking, and then analyze more precisely the affinity of these ligands using MMPBSA binding free energy. We show that both ligands bind to the ACE2/wild-type RBD interface with good affinities which might prevent the ACE2/RBD association. Second, we confirm the potency of these ligands to block the ACE2/RBD association using a combination of surface plasmon resonance and biochemical inhibition assays. These experiments confirm that TGG and, to a lesser extent, corilagin, inhibit the binding of RBD to ACE2. Both experiments and simulations show that the ligands interact preferentially with RBD, while weak binding is observed with ACE2, hence, avoiding potential physiological side-effects induced by the inhibition of ACE2. In addition to the wild-type RBD, we also study numerically three RBD mutations (E484K, N501Y and E484K/N501Y) found in the main SARS-CoV-2 variants of concerns. We find that corilagin could be as effective for RBD/E484K but less effective for the RBD/N501Y and RBD/E484K-N501Y mutants, while TGG strongly binds at relevant locations to all three mutants, demonstrating the significant interest of these molecules as potential inhibitors for variants of SARS-CoV-2.

Monocyte-driven atypical cytokine storm and aberrant neutrophil activation as key mediators of COVID-19 disease severity

Epidemiological and clinical reports indicate that SARS-CoV-2 virulence hinges upon the triggering of an aberrant host immune response, more so than on direct virus-induced cellular damage. To elucidate the immunopathology underlying COVID-19 severity, we perform cytokine and multiplex immune profiling in COVID-19 patients. We show that hypercytokinemia in COVID-19 differs from the interferon-gamma-driven cytokine storm in macrophage activation syndrome, and is more pronounced in critical versus mild-moderate COVID-19. Systems modelling of cytokine levels paired with deep-immune profiling shows that classical monocytes drive this hyper-inflammatory phenotype and that a reduction in T-lymphocytes correlates with disease severity, with CD8+ cells being disproportionately affected. Antigen presenting machinery expression is also reduced in critical disease. Furthermore, we report that neutrophils contribute to disease severity and local tissue damage by amplification of hypercytokinemia and the formation of neutrophil extracellular traps. Together our findings suggest a myeloid-driven immunopathology, in which hyperactivated neutrophils and an ineffective adaptive immune system act as mediators of COVID-19 disease severity.

Point-of-care ultrasound for the evaluation of venous cannula position in neonatal extracorporeal membrane oxygenation

OBJECTIVE

To assess the ability of point-of-care ultrasound (POCUS) to identify venous cannula position in neonates on extracorporeal membrane oxygenation (ECMO) and compare with conventional imaging.

STUDY DESIGN

Retrospective review of 37 infants on ECMO with 51 POCUS studies between January 2017 and October 2019. Studies were reviewed for identification of venous cannula location and compared with plain radiography and echocardiography. Kappa statistic and predictive values were calculated.

RESULTS

Venous cannula tip position was identified in 90% of POCUS studies. Fifty percent of the cannula tips were malpositioned. Plain radiography, the most commonly used method for evaluating tip position, showed poor agreement (57%) with POCUS (kappa 0.13). There was substantial agreement (89%) between echocardiography and POCUS (kappa 0.78).

CONCLUSION

This study provides preliminary evidence that POCUS is more accurate than plain radiography for the evaluation of ECMO venous cannula position. Adoption of this practice may prevent potentially catastrophic ECMO complications.

Nervous System Involvement in COVID-19: a Review of the Current Knowledge

The current pandemic of the new human coronavirus (CoV), i.e., severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created an urgent global condition. The disease, termed coronavirus disease 2019 (COVID-19), is primarily known as a respiratory tract infection. Although SARS-CoV-2 directly invades the lungs, COVID-19 is a complex multi-system disease with varying degrees of severity and affects several human systems including the cardiovascular, respiratory, gastrointestinal, neurological, hematopoietic, and immune systems. From the existing data, most COVID-19 cases develop a mild disease typically presented with fever and respiratory illness. However, in some patients, clinical evidence suggests that COVID-19 might progress to acute respiratory distress syndrome (ARDS), multi-organ dysfunction, and septic shock resulting in a critical condition. Likewise, specific organ dysfunction seems to be related to the disease complication, worsens the condition, and increases the lethality of COVID-19. The neurological manifestations in association with disease severity and mortality have been reported in COVID-19 patients. Despite the continuously increasing reports of the neurological symptoms of SARS-CoV-2, our knowledge about the possible routes of nervous system involvement associated with COVID-19 is limited. Herein, we will primarily describe the critical aspects and clinical features of SARS-CoV-2 related to nervous system impairment and then discuss possible routes of SARS-CoV-2 nervous system involvement based on the current evidence.

Mobile phones of paediatric hospital staff are never cleaned and commonly used in toilets with implications for healthcare nosocomial diseases

An ever-increasing number of medical staff use mobile phones as a work aid, yet this may pose nosocomial diseases. To assess and report via a survey the handling practices and the use of phones by paediatric wards healthcare workers. 165 paediatric healthcare workers and staff filled in a questionnaire consisting of 14 questions (including categorical, ordinal and numerical data). Analysis of categorical data used non-parametric techniques such as the Chi-squared test. Although 98% of respondents (165 in total) report that their phones may be contaminated, 56% have never cleaned their devices. Of the respondents that clean their devices, 10% (17/165) had done so with alcohol swabs or disinfectant within that day or week; and an additional 12% respondents (20/165) within that month. Of concern, 52% (86/165) of the respondents use their phones in the bathroom, emphasising the unhygienic environments in which mobile phones/smartphones are constantly used. Disinfecting phones is a practice that only a minority of healthcare workers undertake appropriately. Mobile phones, present in billions globally, are therefore Trojan Horses if contaminated with microbes and potentially contributing to the spread and propagation of micro-organisms as per the rapid spread of SARS-CoV-2 virus in the world.

Cytokine signatures of end organ injury in COVID-19

Increasing evidence has shown that Coronavirus disease 19 (COVID-19) severity is driven by a dysregulated immunologic response. We aimed to assess the differences in inflammatory cytokines in COVID-19 patients compared to contemporaneously hospitalized controls and then analyze the relationship between these cytokines and the development of Acute Respiratory Distress Syndrome (ARDS), Acute Kidney Injury (AKI) and mortality. In this cohort study of hospitalized patients, done between March third, 2020 and April first, 2020 at a quaternary referral center in New York City we included adult hospitalized patients with COVID-19 and negative controls. Serum specimens were obtained on the first, second, and third hospital day and cytokines were measured by Luminex. Autopsies of nine cohort patients were examined. We identified 90 COVID-19 patients and 51 controls. Analysis of 48 inflammatory cytokines revealed upregulation of macrophage induced chemokines, T-cell related interleukines and stromal cell producing cytokines in COVID-19 patients compared to the controls. Moreover, distinctive cytokine signatures predicted the development of ARDS, AKI and mortality in COVID-19 patients. Specifically, macrophage-associated cytokines predicted ARDS, T cell immunity related cytokines predicted AKI and mortality was associated with cytokines of activated immune pathways, of which IL-13 was universally correlated with ARDS, AKI and mortality. Histopathological examination of the autopsies showed diffuse alveolar damage with significant mononuclear inflammatory cell infiltration. Additionally, the kidneys demonstrated glomerular sclerosis, tubulointerstitial lymphocyte infiltration and cortical and medullary atrophy. These patterns of cytokine expression offer insight into the pathogenesis of COVID-19 disease, its severity, and subsequent lung and kidney injury suggesting more targeted treatment strategies.

Clinical impact of implementing humidified high-flow nasal cannula on interhospital transport among children admitted to a PICU with respiratory distress: a cohort study

Background

There is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use.

Methods

We performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010–December 2019. Patients were divided in pre-intervention era (2010–2014) and post-intervention era (2015–2019).

Results

1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7–4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1–4.2) and 1.7 (0.9–3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3–4.9) and 2.1 (1.2–4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49–0.83, p = 0.001) with the predicted reduction of PICU length of stay being − 10.6 h (95% confidential interval − 16.9 to − 4.3 h), and decreased respiratory support use (− 25.1 h, 95% confidential interval − 47.9 to − 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport.

Conclusions

The implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03620-7.

Reinforcing our defense or weakening the enemy? A comparative overview of defensive and offensive strategies developed to confront COVID-19

Developing effective strategies to confront coronavirus disease 2019 (COVID-19) has become one of the greatest concerns of the scientific community. In addition to the vast number of global mortalities due to COVID-19, since its outbreak, almost every aspect of human lives has changed one way or another. In the present review, various defensive and offensive strategies developed to confront COVID-19 are illustrated. The Administration of immune-boosting micronutrients/agents, as well as the inhibition of the activity of incompetent gatekeepers, including some host cell receptors (e.g. ACE2) and proteases (e.g. TMPRSS2), are some efficient defensive strategies. Antibody/phage therapies and specifically vaccines also play a prominent role in the enhancement of host defense against COVID-19. Nanotechnology, however, can considerably weaken the virulence of SARS-CoV-2, utilizing fake cellular locks (compounds mimicking cell receptors) to block the viral keys (spike proteins). Generally, two strategies are developed to interfere with the binding of spike proteins to the host cell receptors, either utilizing fake cellular locks to block the viral keys or utilizing fake viral keys to block the cellular locks. Due to their evolutionary conserved nature, viral enzymes, including 3CLpro, PLpro, RdRp, and helicase are highly potential targets for drug repurposing strategy. Thus, various steps of viral replication/transcription can effectively be blocked by their inhibition, leading to the elimination of SARS-CoV-2. Moreover, RNA decoy and CRISPR technologies likely offer the best offensive strategies after viral entry into the host cells, inhibiting the viral replication/assembly in the infected cells and substantially reducing the quantity of viral progeny.

Natural language processing to assess the epidemiology of delirium-suggestive behavioural disturbances in critically ill patients

Background: There is no gold standard approach for delirium diagnosis, making the assessment of its epidemiology difficult. Delirium can only be inferred though observation of behavioural disturbance and described with relevant nouns or adjectives. Objective: We aimed to use natural language processing (NLP) and its identification of words descriptive of behavioural disturbance to study the epidemiology of delirium in critically ill patients. Study design: Retrospective study using data collected from the electronic health records of a university-affiliated intensive care unit (ICU) in Melbourne, Australia. Participants: 12 375 patients Intervention: Analysis of electronic progress notes. Identification using NLP of at least one of a list of words describing behavioural disturbance within such notes. Results: We analysed 199 648 progress notes in 12 375 patients. Of these, 5108 patients (41.3%) had NLP-diagnosed behavioural disturbance (NLP-Dx-BD). Compared with those who did not have NLP-Dx-DB, these patients were older, more severely ill, and likely to have medical or unplanned admissions, neurological diagnosis, chronic kidney or liver disease and to receive mechanical ventilation and renal replacement therapy (P < 0.001). The unadjusted hospital mortality for NLP-Dx-BD patients was 14.1% versus 9.6% for patients without NLP-Dx-BD. After adjustment for baseline characteristics and illness severity, NLP-Dx-BD was not associated with increased risk of death (odds ratio [OR], 0.94; 95% CI, 0.80-1.10); a finding robust to multiple sensitivity, subgroups and time of observation subcohort analyses. In mechanically ventilated patients, NLP-Dx-BD was associated with decreased hospital mortality (OR, 0.80; 95% CI, 0.65-0.99) after adjustment for baseline severity of illness and year of admission. Conclusions: NLP enabled rapid assessment of large amounts of data identifying a population of ICU patients with typical high risk characteristics for delirium. Moreover, this technique enabled identification of previously poorly understood associations. Further investigations of this technique appear justified.

The role of human C5a as a non-genomic target in corticosteroid therapy for management of severe COVID19

Complement system plays a dual role; physiological as well as pathophysiological. While physiological role protects the host, pathophysiological role can substantially harm the host, by triggering several hyper-inflammatory pathways, referred as "hypercytokinaemia". Emerging clinical evidence suggests that exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV2), tricks the complement to aberrantly activate the "hypercytokinaemia" loop, which significantly contributes to the severity of the COVID19. The pathophysiological response of the complement is usually amplified by the over production of potent chemoattractants and inflammatory modulators, like C3a and C5a. Therefore, it is logical that neutralizing the harmful effects of the inflammatory modulators of the complement system can be beneficial for the management of COVID19. While the hunt for safe and efficacious vaccines were underway, polypharmacology based combination therapies were fairly successful in reducing both the morbidity and mortality of COVID19 across the globe. Repurposing of small molecule drugs as "neutraligands" of C5a appears to be an alternative for modulating the hyper-inflammatory signals, triggered by the C5a-C5aR signaling axes. Thus, in the current study, few specific and non-specific immunomodulators (azithromycin, colchicine, famotidine, fluvoxamine, dexamethasone and prednisone) generally prescribed for prophylactic usage for management of COVID19 were subjected to computational and biophysical studies to probe whether any of the above drugs can act as "neutraligands", by selectively binding to C5a over C3a. The data presented in this study indicates that corticosteroids, like prednisone can have potentially better selectively (Kd ∼ 0.38 μM) toward C5a than C3a, suggesting the positive modulatory role of C5a in the general success of the corticosteroid therapy in moderate to severe COVID19.

The perfusion index histograms predict patent ductus arteriosus requiring treatment in preterm infants

The impact of patent ductus arteriosus (PDA) on vital sign trends represented as histograms, and perfusion index in particular, is unknown. This study aimed to split continuously obtained PI and other vital signs before, during, and after medical treatment of PDA, into histogram bins, and determine the utility of PI and other vital sign histograms in the early prediction of hemodynamically significant PDA (hsPDA). In 34 infants at a mean gestational age of 26 ± 2.1 weeks, we prospectively collected vital signs for three different periods, 24 h before starting treatment of PDA, during PDA treatment, and 24 h after completion of the course of treatment, and confirmed PDA closure by echo. Histograms with three comparable periods were obtained from preterm infants who did not require treatment for PDA and analyzed for comparison. The duration of time spent in each histogram bin was determined for each time epoch. Episodes of low PI < 0.4 and high PI > 2 were significantly longer in duration in infants with PDA before treatment compared to those in infants with PDA during and after treatment. The arterial oxygen saturation (SpO₂) < 80% was also longer in duration in infants with PDA before compared to that in infants with PDA during and after treatment. Low PI < 0.4 correlated with most echocardiography indices of hsPDA.Conclusion: We conclude that a patent ductus arteriosus requiring treatment in preterm infants ≤ 29 weeks GA was associated with significant fluctuations between a low PI < 0.4 alternating with a high PI > 2, reflecting the dynamic nature of hsPDA shunt volume. PI variability may be an early marker of hsPDA. What is Known: • The perfusion index is a continuous underutilized parameter provided by pulse oximetry to assess the peripheral perfusion. • The perfusion index helps predict conditions with hemodynamic instability. What is New: • The perfusion index assessed as daily histogram trends can predict patent ductus arteriosus requiring treatment.

Balanced crystalloids versus saline in critically ill adults with low plasma bicarbonate: A secondary analysis of a clinical trial

PURPOSE

We aimed to determine if balanced crystalloids compared with saline improve outcomes in critically ill adults admitted with low plasma bicarbonate.

MATERIALS AND METHODS

We performed a secondary analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). We included patients who presented to the Emergency Department with a first measured plasma bicarbonate less than 20 mmol/L. Among these patients, we compared the effect of balanced crystalloid versus saline on the primary outcome of major adverse kidney events within 30 days (MAKE30), defined as a composite of death, new renal-replacement therapy, or persistent renal dysfunction (final inpatient creatinine ≥200% baseline). Secondary outcomes included 30 day in-hospital mortality, receipt of new RRT, persistent renal dysfunction, incident AKI, and vasopressor-free days.

RESULTS

Among the 2029 patients with an initial plasma bicarbonate concentration < 20 mmol/L, there was no difference in the incidence of MAKE30 between those assigned to balanced crystalloid versus saline (21.8% vs 21.3%; P = 0.93). Secondary outcomes were similar between the balanced crystalloid and saline groups.

CONCLUSIONS

Among critically ill adults presenting to the Emergency Department, initial plasma bicarbonate concentration does not appear to be a useful marker to guide the selection of balanced crystalloid versus saline.

Survival of pediatric patients after cardiopulmonary resuscitation for in-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

In-hospital cardiac arrest is a major public health issue. It is a serious condition; most probably end up with death within a few minutes even with corrective measures. However, cardiopulmonary resuscitation is expected to increase the probability of survival and prevent neurological disabilities in patients with cardiac arrest. Having a pooled prevalence of survival to hospital discharge after cardiopulmonary resuscitation is vital to develop strategies targeted to increase probability of survival among patients with cardiac arrest. Therefore, this systematic review and meta-analysis was aimed to assess the pooled prevalence of survival to hospital discharge among pediatric patients who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest.

METHODS

PubMed, Google Scholar, and Cochrane review databases were searched. To have current (five-year) evidence, only studies published in 2016 to 2020 were included. The weighted inverse variance random-effects model at 95%CI was used to estimate the pooled prevalence of survival. Heterogeneity assessment, test of publication bias, and subgroup analyses were also employed accordingly.

RESULTS

Twenty-five articles with a total sample size of 28,479 children were included in the final analysis. The pooled prevalence of survival to hospital discharge was found to be 46% (95% CI = 43.0-50.0%; I2 = 96.7%; p < 0.001). Based on subgroup analysis by "continent" and "income level", lowest prevalence of pooled survival was observed in Asia (six studies; pooled survival =36.0% with 95% CI = 19.01-52.15%; I2 = 97.4%; p < 0.001) and in low and middle income countries (six studies, pooled survival = 34.0% with 95% CI = 17.0-51.0%, I2 = 97.67%, p < 0.001) respectively.

CONCLUSION

Although there was an extremely high heterogeneity among reported results (I2 = 96.7%), in this meta-analysis more than half of pediatric patients (54%) who underwent cardiopulmonary resuscitation for in-hospital cardiac arrest did not survived to hospital discharge. Therefore, developing further strategies and encouraging researches might be crucial.

COVID-19: breaking down a global health crisis

Coronavirus disease 2019 (COVID-19) is the second pandemic of the twenty-first century, with over one-hundred million infections and over two million deaths to date. It is a novel strain from the Coronaviridae family, named Severe Acute Respiratory Distress Syndrome Coronavirus-2 (SARS-CoV-2); the 7th known member of the coronavirus family to cause disease in humans, notably following the Middle East Respiratory syndrome (MERS), and Severe Acute Respiratory Distress Syndrome (SARS). The most characteristic feature of this single-stranded RNA molecule includes the spike glycoprotein on its surface. Most patients with COVID-19, of which the elderly and immunocompromised are most at risk, complain of flu-like symptoms, including dry cough and headache. The most common complications include pneumonia, acute respiratory distress syndrome, septic shock, and cardiovascular manifestations. Transmission of SARS-CoV-2 is mainly via respiratory droplets, either directly from the air when an infected patient coughs or sneezes, or in the form of fomites on surfaces. Maintaining hand-hygiene, social distancing, and personal protective equipment (i.e., masks) remain the most effective precautions. Patient management includes supportive care and anticoagulative measures, with a focus on maintaining respiratory function. Therapy with dexamethasone, remdesivir, and tocilizumab appear to be most promising to date, with hydroxychloroquine, lopinavir, ritonavir, and interferons falling out of favour. Additionally, accelerated vaccination efforts have taken place internationally, with several promising vaccinations being mass deployed. In response to the COVID-19 pandemic, countries and stakeholders have taken varying precautions to combat and contain the spread of the virus and dampen its collateral economic damage. This review paper aims to synthesize the impact of the virus on a global, micro to macro scale.

Radiological pattern in ARDS patients: partitioned respiratory mechanics, gas exchange and lung recruitability

BACKGROUND

The ARDS is characterized by different degrees of impairment in oxygenation and distribution of the lung disease. Two radiological patterns have been described: a focal and a diffuse one. These two patterns could present significant differences both in gas exchange and in the response to a recruitment maneuver. At the present time, it is not known if the focal and the diffuse pattern could be characterized by a difference in the lung and chest wall mechanical characteristics. Our aims were to investigate, at two levels of PEEP, if focal vs. diffuse ARDS patterns could be characterized by different lung CT characteristics, partitioned respiratory mechanics and lung recruitability.

METHODS

CT patterns were analyzed by two radiologists and were classified as focal or diffuse. The changes from 5 to 15 cmH₂O in blood gas analysis and partitioned respiratory mechanics were analyzed. Lung CT scan was performed at 5 and 45 cmH₂O of PEEP to evaluate lung recruitability.

RESULTS

One-hundred and ten patients showed a diffuse pattern, while 58 showed a focal pattern. At 5 cmH₂O of PEEP, the driving pressure and the elastance, both the respiratory system and of the lung, were significantly higher in the diffuse pattern compared to the focal (14 [11-16] vs 11 [9-15 cmH₂O; 28 [23-34] vs 21 [17-27] cmH₂O/L; 22 [17-28] vs 14 [12-19] cmH₂O/L). By increasing PEEP, the driving pressure and the respiratory system elastance significantly decreased in diffuse pattern, while they increased or did not change in the focal pattern (Δ_15-5: - 1 [- 2 to 1] vs 0 [- 1 to 2]; - 1 [- 4 to 2] vs 1 [- 2 to 5]). At 5 cmH₂O of PEEP, the diffuse pattern had a lower lung gas (743 [537-984] vs 1222 [918-1974] mL) and higher lung weight (1618 [1388-2001] vs 1222 [1059-1394] g) compared to focal pattern. The lung recruitability was significantly higher in diffuse compared to focal pattern 21% [13-29] vs 11% [6-16]. Considering the median of lung recruitability of the whole population (16.1%), the recruiters were 65% and 22% in the diffuse and focal pattern, respectively.

CONCLUSIONS

An early identification of lung morphology can be useful to choose the ventilatory setting. A diffuse pattern has a better response to the increase of PEEP and to the recruitment maneuver.

Randomized controlled trial of convalescent plasma therapy against standard therapy in patients with severe COVID-19 disease

Convalescent plasma (CP) therapy in COVID-19 disease may improve clinical outcome in severe disease. This pilot study was undertaken to inform feasibility and safety of further definitive studies. This was a prospective, interventional and randomized open label pilot trial in patients with severe COVID-19. Twenty COVID-19 patients received two 200 ml transfusions of convalescent patient CP over 24-h compared with 20 who received standard of care. The primary outcome was the requirement for ventilation (non-invasive or mechanical ventilation). The secondary outcomes were biochemical parameters and mortality at 28 days. The CP group were a higher risk group with higher ferritin levels (p < 0.05) though respiratory indices did not differ. The primary outcome measure was required in 6 controls and 4 patients on CP (risk ratio 0.67, 95% CI 0.22-2.0, p = 0.72); mean time on ventilation (NIV or MV) did not differ. There were no differences in secondary measures at the end of the study. Two patients died in the control and one patient in the CP arm. There were no significant differences in the primary or secondary outcome measures between CP and standard therapy, although a larger definitive study is needed for confirmation. However, the study did show that CP therapy appears to be safe in hospitalized COVID-19 patients with hypoxia.Clinical trials registration NCT04356534: 22/04/2020.

Maintenance fluid management in pediatrics: Current practice and quality improvement achievements

The long-standing use of hypotonic fluids in pediatric maintenance fluids has been challenged in recent years due to concerns over iatrogenic hyponatremia causing morbidity and mortality. Newer research has highlighted the safety of isotonic fluid alternatives. The American Academy of Pediatrics published an evidenced-based Clinical Practice Guideline in December of 2018 (Feld et al., 2018) to support the routine use of isotonic solutions in pediatric maintenance fluids. This article will also highlight relevant history, current practice, and a quality improvement project to standardize isotonic fluid use in the inpatient pediatric setting.

Cell-free DNA maps COVID-19 tissue injury and risk of death and can cause tissue injury

INTRODUCTION

The clinical course of coronavirus 2019 (COVID-19) is heterogeneous, ranging from mild to severe multiorgan failure and death. In this study, we analyzed cell-free DNA (cfDNA) as a biomarker of injury to define the sources of tissue injury that contribute to such different trajectories.

METHODS

We conducted a multicenter prospective cohort study to enroll patients with COVID-19 and collect plasma samples. Plasma cfDNA was subject to bisulfite sequencing. A library of tissue-specific DNA methylation signatures was used to analyze sequence reads to quantitate cfDNA from different tissue types. We then determined the correlation of tissue-specific cfDNA measures to COVID-19 outcomes. Similar analyses were performed for healthy controls and a comparator group of patients with respiratory syncytial virus and influenza.

RESULTS

We found markedly elevated levels and divergent tissue sources of cfDNA in COVID-19 patients compared with patients who had influenza and/or respiratory syncytial virus and with healthy controls. The major sources of cfDNA in COVID-19 were hematopoietic cells, vascular endothelium, hepatocytes, adipocytes, kidney, heart, and lung. cfDNA levels positively correlated with COVID-19 disease severity, C-reactive protein, and D-dimer. cfDNA profile at admission identified patients who subsequently required intensive care or died during hospitalization. Furthermore, the increased cfDNA in COVID-19 patients generated excessive mitochondrial ROS (mtROS) in renal tubular cells in a concentration-dependent manner. This mtROS production was inhibited by a TLR9-specific antagonist.

CONCLUSION

cfDNA maps tissue injury that predicts COVID-19 outcomes and may mechanistically propagate COVID-19–induced tissue injury.

FUNDING

Intramural Targeted Anti–COVID-19 grant, NIH.

Mesenchymal stem/stromal cells as a valuable source for the treatment of immune-mediated disorders

Over recent years, mesenchymal stem/stromal cells (MSCs) and their potential biomedical applications have received much attention from the global scientific community in an increasing manner. Firstly, MSCs were successfully isolated from human bone marrow (BM), but in the next steps, they were also extracted from other sources, mostly from the umbilical cord (UC) and adipose tissue (AT). The International Society for Cellular Therapy (ISCT) has suggested minimum criteria to identify and characterize MSCs as follows: plastic adherence, surface expression of CD73, D90, CD105 in the lack of expression of CD14, CD34, CD45, and human leucocyte antigen-DR (HLA-DR), and also the capability to differentiate to multiple cell types including adipocyte, chondrocyte, or osteoblast in vitro depends on culture conditions. However, these distinct properties, including self-renewability, multipotency, and easy accessibility are just one side of the coin; another side is their huge secretome which is comprised of hundreds of mediators, cytokines, and signaling molecules and can effectively modulate the inflammatory responses and control the infiltration process that finally leads to a regulated tissue repair/healing or regeneration process. MSC-mediated immunomodulation is a direct result of a harmonic synergy of MSC-released signaling molecules (i.e., mediators, cytokines, and chemokines), the reaction of immune cells and other target cells to those molecules, and also feedback in the MSC-molecule-target cell axis. These features make MSCs a respectable and eligible therapeutic candidate to be evaluated in immune-mediated disorders, such as graft versus host diseases (GVHD), multiple sclerosis (MS), Crohn's disease (CD), and osteoarthritis (OA), and even in immune-dysregulating infectious diseases such as the novel coronavirus disease 2019 (COVID-19). This paper discussed the therapeutic applications of MSC secretome and its biomedical aspects related to immune-mediated conditions. Sources for MSC extraction, their migration and homing properties, therapeutic molecules released by MSCs, and the pathways and molecular mechanisms possibly involved in the exceptional immunoregulatory competence of MSCs were discussed. Besides, the novel discoveries and recent findings on immunomodulatory plasticity of MSCs, clinical applications, and the methods required for their use as an effective therapeutic option in patients with immune-mediated/immune-dysregulating diseases were highlighted.

Impact of comorbidity burden on mortality in patients with COVID-19 using the Korean health insurance database

We aimed to investigate the impact of comorbidity burden on mortality in patients with coronavirus disease (COVID-19). We analyzed the COVID-19 data from the nationwide health insurance claims of South Korea. Data on demographic characteristics, comorbidities, and mortality records of patients with COVID-19 were extracted from the database. The odds ratios of mortality according to comorbidities in these patients with and without adjustment for age and sex were calculated. The predictive value of the original Charlson comorbidity index (CCI) and the age-adjusted CCI (ACCI) for mortality in these patients were investigated using the receiver operating characteristic (ROC) curve analysis. Among 7590 patients, 227 (3.0%) had died. After age and sex adjustment, hypertension, diabetes mellitus, congestive heart failure, dementia, chronic pulmonary disease, liver disease, renal disease, and cancer were significant risk factors for mortality. The ROC curve analysis showed that an ACCI threshold > 3.5 yielded the best cut-off point for predicting mortality (area under the ROC 0.92; 95% confidence interval 0.91–0.94). Our study revealed multiple risk factors for mortality in patients with COVID-19. The high predictive power of the ACCI for mortality in our results can support the importance of old age and comorbidities in the severity of COVID-19.

Neuropsychiatric Complications of COVID-19

PURPOSE OF REVIEW

To describe the presentation, etiologies, and suggested management of post-acute COVID-19 neuropsychiatric symptoms.

RECENT FINDINGS

Over 30% of patients hospitalized with COVID-19 may exhibit cognitive impairment, depression, and anxiety that persist for months after discharge. These symptoms are even more common in patients who required intensive care for severe effects of the virus. In addition to the pandemic-related psychological stress, multiple biological mechanisms have been proposed to understand the neuropsychiatric symptoms observed with COVID-19. Given limited research regarding effective interventions, we recommend pharmacologic and behavioral strategies with established evidence in other medically-ill populations. Long-term, neuropsychiatric complications of COVID-19 are common and consequential. Because these are likely to co-occur with other medical problems, patients recovering from COVID-19 are best managed in clinics with highly coordinated care across disciplines and medical specialties. Future research is needed to inform appropriate interventions.

Clinical characteristics and outcome of critically ill COVID-19 patients with acute kidney injury: a single centre cohort study

BACKGROUND

Acute kidney injury (AKI) is a common manifestation among patients critically ill with SARS-CoV-2 infection (Coronavirus 2019) and is associated with significant morbidity and mortality. The pathophysiology of renal failure in this context is not fully understood, but likely to be multifactorial. The intensive care unit outcomes of patients following COVID-19 acute critical illness with associated AKI have not been fully explored. We conducted a cohort study to investigate the risk factors for acute kidney injury in patients admitted to and intensive care unit with COVID-19, its incidence and associated outcomes.

METHODS

We reviewed the medical records of all patients admitted to our adult intensive care unit suffering from SARS-CoV-2 infection from 14th March 2020 until 12th May 2020. Acute kidney injury was defined using the Kidney Disease Improving Global Outcome (KDIGO) criteria. The outcome analysis was assessed up to date as 3rd of September 2020.

RESULTS

A total of 81 patients admitted during this period. All patients had acute hypoxic respiratory failure and needed either noninvasive or invasive mechanical ventilatory support. Thirty-six patients (44%) had evidence of AKI (Stage I-33%, Stage II-22%, Renal Replacement Therapy (RRT)-44%). All patients with AKI stage III had RRT. Age, diabetes mellitus, immunosuppression, lymphopenia, high D-Dimer levels, increased APACHE II and SOFA scores, invasive mechanical ventilation and use of inotropic or vasopressor support were significantly associated with AKI. The peak AKI was at day 4 and mean duration of RRT was 12.5 days. The mortality was 25% for the AKI group compared to 6.7% in those without AKI. Among those received RRT and survived their illness, the renal function recovery is complete and back to baseline in all patients.

CONCLUSION

Acute kidney injury and renal replacement therapy is common in critically ill patients presenting with COVID-19. It is associated with increased severity of illness on admission to ICU, increased mortality and prolonged ICU and hospital length of stay. Recovery of renal function was complete in all survived patients.

Hematological Findings in COVID-19 and Insights to Stem Cell Therapy: From Bench to Practice

Context: As the COVID-19 was spreading to all countries, its manifestations were identifying gradually, which were related to several organs. Evidence Acquisition: COVID-19 is associated with distinct hematological changes, increased serum inflammatory markers, and coagulopathy. Most of these changes are related to the patients’ prognosis and mortality, particularly in those with severe disease. Results: Firstly, we discussed the associations between COVID-19 clinical features and complications, and secondly, its hematological findings and coagulopathy are investigated. Conclusions: Such associations not only may shed light on our prognostic view of patients with COVID-19 but also will entail significant therapeutic implications. One of its key implications is to utilize the mesenchymal stem cells (MSCs) to treat patients with COVID-19. Herein, this kind of novel therapy will be discussed, as well.

Coronavirus disease 2019 (COVID-19): survival analysis using deep learning and Cox regression model

Coronavirus (COVID-19) is one of the most serious problems that has caused stopping the wheel of life all over the world. It is widely spread to the extent that hospital places are not available for all patients. Therefore, most hospitals accept patients whose recovery rate is high. Machine learning techniques and artificial intelligence have been deployed for computing infection risks, performing survival analysis and classification. Survival analysis (time-to-event analysis) is widely used in many areas such as engineering and medicine. This paper presents two systems, Cox_COVID_19 and Deep_ Cox_COVID_19 that are based on Cox regression to study the survival analysis for COVID-19 and help hospitals to choose patients with better chances of survival and predict the most important symptoms (features) affecting survival probability. Cox_COVID_19 is based on Cox regression and Deep_Cox_COVID_19 is a combination of autoencoder deep neural network and Cox regression to enhance prediction accuracy. A clinical dataset for COVID-19 patients is used. This dataset consists of 1085 patients. The results show that applying an autoencoder on the data to reconstruct features, before applying Cox regression algorithm, would improve the results by increasing concordance, accuracy and precision. For Deep_ Cox_COVID_19 system, it has a concordance of 0.983 for training and 0.999 for testing, but for Cox_COVID_19 system, it has a concordance of 0.923 for training and 0.896 for testing. The most important features affecting mortality are, age, muscle pain, pneumonia and throat pain. Both Cox_COVID_19 and Deep_ Cox_COVID_19 prediction systems can predict the survival probability and present significant symptoms (features) that differentiate severe cases and death cases. But the accuracy of Deep_Cox_Covid_19 outperforms that of Cox_Covid_19. Both systems can provide definite information for doctors about detection and intervention to be taken, which can reduce mortality.

Insights into the actions of angiotensin-1 receptor (AT1R) inverse agonists: Perspectives and implications in COVID-19 treatment

New coronavirus SARS-CoV-2 (COVID-19) has caused chaos in health care systems. Clinical manifestations of COVID-19 are variable, with a complex pathophysiology and as yet no specific treatment. It has been suggested that the renin-angiotensin-aldosterone system has a possible role in the severity of cases and the number of deaths. Our hypothesis is that drugs with inverse agonist effects to the angiotensin-1 receptor can be promising tools in the management of patients with COVID-19, possibly avoiding complications and the poor evolution in some cases. Any risk factors first need to be identified, and the most appropriate time to administer the drugs during the course of the infection also needs to be established. Several angiotensin receptor blockers (ARB) have a favorable profile and are important candidates for the treatment of COVID-19. In this review we discussed a set of compounds with favorable profile for COVID-19 treatment, including azilsartan, candesartan, eprosartan, EXP3174, olmesartan, telmisartan, and valsartan. They are effective as inverse agonists and could reduce the "cytokine storm" and reducing oxidative stress. As COVID-19 disease has several evolution patterns, the effectiveness of ARB therapy would be related to infection "timing", patient risk factors, previous use of ARBs, and the specific molecular effects of an ARB. However, controlled studies are needed to identify whether ARBs are beneficial in the treatment of patients with COVID-19.

The use of electrical impedance tomography for individualized ventilation strategy in COVID-19: a case report

BACKGROUND

Clinical management of COVID-19 requires close monitoring of lung function. While computed tomography (CT) offers ideal way to identify the phenotypes, it cannot monitor the patient response to therapeutic interventions. We present a case of ventilation management for a COVID-19 patient where electrical impedance tomography (EIT) was used to personalize care.

CASE PRESENTATION

The patient developed acute respiratory distress syndrome, required invasive mechanical ventilation, and was subsequently weaned. EIT was used multiple times: to titrate the positive end-expiratory pressure, understand the influence of body position, and guide the support levels during weaning and after extubation. We show how EIT provides bedside monitoring of the patient´s response to various therapeutic interventions and helps guide treatments.

CONCLUSION

EIT provides unique information that may help the ventilation management in the pandemic of COVID-19.

Protocol Failure Detection: The Conflation of Acute Respiratory Distress Syndrome, SARS-CoV-2 Pneumonia and Respiratory Dysfunction

In medicine, protocols are applied to assure the provision of the treatment with the greatest probability of success. However, the development of protocols is based on the determination of the best intervention for the group. If the group is heterogeneous, there will always be a subset of patients for which the protocol will fail. Furthermore, over time, heterogeneity of the group may not be stable, so the percentage of patients for which a given protocol may fail may change depending on the dynamic patient mix in the group. This was thrown into stark focus during the severe acute respiratory syndrome-2 coronavirus (SARS-CoV-2) pandemic. When a COVID-19 patient presented meeting SIRS or the Berlin Criteria, these patients met the criteria for entry into the sepsis protocol and/or acute respiratory distress syndrome (ARDS) protocol, respectively and were treated accordingly. This was perceived to be the correct response because these patients met the criteria for the "group" definitions of sepsis and/or ARDS. However, the application of these protocols to patients with SARS-CoV-2 infection had never been studied. Initially, poor outcomes were blamed on protocol noncompliance or some unknown patient factor. This initial perception is not surprising as these protocols are standards and were perceived as comprising the best possible evidence-based care. While the academic response to the pandemic was robust, recognition that existing protocols were failing might have been detected sooner if protocol failure detection had been integrated with the protocols themselves. In this review, we propose that, while protocols are necessary to ensure that minimum standards of care are met, protocols need an additional feature, integrated protocol failure detection, which provides an output responsive to protocol failure in real time so other treatment options can be considered and research efforts rapidly focused.

Acute Kidney Injury in Pediatric Diabetic Kidney Disease

Diabetic kidney disease (DKD) is a common complication of type 1 and 2 diabetes and often presents during adolescence and young adulthood. Given the growing incidence of both type 1 and type 2 diabetes in children and adolescents, DKD represents a significant public health problem. Acute kidney injury (AKI) in youth with diabetes is strongly associated with risk of DKD development. This review will summarize the epidemiology and pathophysiology of AKI in children with diabetes, the relationship between AKI and DKD, and the potential therapeutic interventions. Finally, we will appraise the impact of the recent COVID-19 infection pandemic on AKI in children with diabetes.

Perioperative management of arteriovenous malformation guided by integrated evaluation of hemodynamics

We aimed to demonstrate the value of monitoring infants with arteriovenous malformation (AVM) during endovascular embolization with integrated evaluation of hemodynamics (IEH) and guiding decisions according to the underlying pathophysiology. This is a retrospective analysis of the perioperative hemodynamics data for 2 complex cases of AVM transferred to Khaula Hospital in Oman for interventional management. We described the value of novel physiological insights gained from comprehensive IEH and provided a systematic approach to the perioperative management. Postoperative targeted neonatal echo (TNE) was used to guide the weaning of the cardiovascular medications within 24 h. Both cases showed significant right ventricle (RV) volume overload before surgery. Narrowing of the pulse pressure (PP) during or after endovascular embolization was used as a marker of compromised systemic blood flow in real time followed by an assessment by TNE to guide the appropriate therapy.Conclusion: Integrated evaluation of hemodynamics is helpful to guide perioperative physiologic-based management of AVM. What is Known: • The preoperative management of hemodynamic compromise due to AVM has been described in many articles. • Perioperative management of AVM and related hemodynamics is a challenge to the intensive care team. What is New: • Integrated evaluation of hemodynamics is a comprehensive assessment and helpful in understanding the underlying physiologic changes during intervention with AVM. • This integrated evaluation can lead to physiologic-based medical recommendation with subsequent improvement.

Answering the Challenge of COVID-19 Pandemic Through Innovation and Ingenuity

The novel coronavirus disease 2019 (COVID-19) pandemic has created a maelstrom of challenges affecting virtually every aspect of global healthcare system. Critical hospital capacity issues, depleted ventilator and personal protective equipment stockpiles, severely strained supply chains, profound economic slowdown, and the tremendous human cost all culminated in what is questionably one of the most profound challenges that humanity faced in decades, if not centuries. Effective global response to the current pandemic will require innovation and ingenuity. This chapter discusses various creative approaches and ideas that arose in response to COVID-19, as well as some of the most impactful future trends that emerged as a result. Among the many topics discussed herein are telemedicine, blockchain technology, artificial intelligence, stereolithography, and distance learning.

Modeling intra-abdominal volume and respiratory driving pressure during pneumoperitoneum insufflation-a patient-level data meta-analysis

During pneumoperitoneum, intra-abdominal pressure (IAP) is usually kept at 12-14 mmHg. There is no clinical benefit in IAP increments if they do not increase intra-abdominal volume IAV. We aimed to estimate IAV (ΔIAV) and respiratory driving pressure changes (ΔP_RS) in relation to changes in IAP (ΔIAP). We carried out a patient-level meta-analysis of 204 adult patients with available data on IAV and ΔP_RS during pneumoperitoneum from three trials assessing the effect of IAP on postoperative recovery and airway pressure during laparoscopic surgery under general anesthesia. The primary endpoint was ΔIAV, and the secondary endpoint was ΔP_RS. The endpoints' response to ΔIAP was modeled using mixed multivariable Bayesian regression to estimate which mathematical function best fitted it. IAP values on the pressure-volume (PV) curve where the endpoint rate of change according to IAP decreased were identified. Abdomino-thoracic transmission (ATT) rate, that is, the rate ΔP_RS change to ΔIAP was also estimated. The best-fitting function was sigmoid logistic and linear for IAV and ΔP_RS response, respectively. Increments in IAV reached a plateau at 6.0 [95%CI 5.9-6.2] L. ΔIAV for each ΔIAP decreased at IAP ranging from 9.8 [95%CI 9.7-9.9] to 12.2 [12.0-12.3] mmHg. ATT rate was 0.65 [95%CI 0.62-0.68]. One mmHg of IAP raised ΔP_RS 0.88 cmH₂O. During pneumoperitoneum, IAP has a nonlinear relationship with IAV and a linear one with ΔP_RS. IAP should be set below the point where IAV gains diminish.NEW & NOTEWORTHY We found that intra-abdominal volume changes related to intra-abdominal pressure increase reached a plateau with diminishing gains in commonly used pneumoperitoneum pressure ranges. We also found a linear relationship between intra-abdominal pressure and respiratory driving pressure, a known marker of postoperative pulmonary complications.

Fighting against COVID-19: preparedness and implications on clinical practice in primary care in Shenzhen, China

Background

The new coronavirus pneumonia (NCP) caused by COVID-19 has affected more than 46 million people worldwide. In China, primary care has played a vital role during the COVID-19 outbreak, and it is important to examine the challenges faced by general practitioners (GPs). This study investigated the roles, preparedness and training needs of GPs in China in managing the NCP outbreak. Based on the outcomes of the study, we hope to take lessons and identify how GPs could be supported in delivering their gatekeeping roles and clinical duties in times of infectious disease outbreak.

Methods

An online survey on the official website of Shenzhen Continuing Education Center. It included questions on GPs’ demographics, their awareness of COVID-19 and their preparedness in managing suspected cases of NCP, as well as referrals and their training needs. Conditional multi-variate logistic models were used to investigate the relationships between GPs’ preparedness, situational confidence and anxiety.

Results

GPs’ clinical practice was significantly affected. GPs endeavoured to answer a flood of COVID-19-related enquiries, while undertaking community preventive tasks. In addition to in-person consultations, GP promoted COVID-19 awareness and education through telephone consultations, physical posters and social media. Overall GPs in Shenzhen felt well supported with adequate Personal Protective Equipment (PPE) and resources from secondary care services. Higher levels of self-perceived preparedness (OR = 2.19; 95%CI, 1.04–4.61), lower level of anxiety (OR = 0.56; 95%CI, 0.29–1.09) and fewer perceived family worries (OR = 0.37; 95%CI, 0.12–1.12) were associated with better confidence in coping at work.

Conclusions

Training and supporting GPs while reducing their (and their families’) anxiety increase their confidence in delivering the important roles of gatekeeping in face of major disease outbreaks.

Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes

IMPORTANCE

Acute kidney injury (AKI) occurs commonly during diabetic ketoacidosis (DKA) in children, but the underlying mechanisms and associations are unclear.

OBJECTIVE

To investigate risk factors for AKI and its association with neurocognitive outcomes in pediatric DKA.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was a secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a prospective, multicenter, randomized clinical trial comparing fluid protocols for pediatric DKA in 13 US hospitals. Included DKA episodes occurred among children age younger than 18 years with blood glucose 300 mg/dL or greater and venous pH less than 7.25 or serum bicarbonate level less than 15 mEq/L.

EXPOSURES

DKA requiring intravenous insulin therapy.

MAIN OUTCOMES AND MEASURES

AKI occurrence and stage were assessed using serum creatinine measurements using Kidney Disease: Improving Global Outcomes criteria. DKA episodes with and without AKI were compared using univariable and multivariable methods, exploring associated factors.

RESULTS

Among 1359 DKA episodes (mean [SD] patient age, 11.6 [4.1] years; 727 [53.5%] girls; 651 patients [47.9%] with new-onset diabetes), AKI occurred in 584 episodes (43%; 95% CI, 40%-46%). A total of 252 AKI events (43%; 95% CI, 39%-47%) were stage 2 or 3. Multivariable analyses identified older age (adjusted odds ratio [AOR] per 1 year, 1.05; 95% CI, 1.00-1.09; P = .03), higher initial serum urea nitrogen (AOR per 1 mg/dL increase, 1.14; 95% CI, 1.11-1.18; P < .001), higher heart rate (AOR for 1-SD increase in z-score, 1.20; 95% CI, 1.09-1.32; P < .001), higher glucose-corrected sodium (AOR per 1 mEq/L increase, 1.03; 95% CI, 1.00-1.06; P = .001) and glucose concentrations (AOR per 100 mg/dL increase, 1.19; 95% CI, 1.07-1.32; P = .001), and lower pH (AOR per 0.1 increase, 0.63; 95% CI, 0.51-0.78; P < .001) as variables associated with AKI. Children with AKI, compared with those without, had lower scores on tests of short-term memory during DKA (mean [SD] digit span recall: 6.8 [2.4] vs 7.6 [2.2]; P = .02) and lower mean (SD) IQ scores 3 to 6 months after recovery from DKA (100.0 [12.2] vs 103.5 [13.2]; P = .005). Differences persisted after adjusting for DKA severity and demographic factors, including socioeconomic status.

CONCLUSIONS AND RELEVANCE

These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.

COVID-19 and multiorgan failure: A narrative review on potential mechanisms

The outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) in December 2019 form Wuhan, China leads to coronavirus disease 2019 (COVID-19) pandemic. While the common cold symptoms are observed in mild cases, COVID-19 is accompanied by multiorgan failure in severe patients. The involvement of different organs in severe patients results in lengthening the hospitalization duration and increasing the mortality rate. In this review, we aimed to investigate the involvement of different organs in COVID-19 patients, particularly in severe cases. Also, we tried to define the potential underlying mechanisms of SARS-CoV2 induced multiorgan failure. The multi-organ dysfunction is characterized by acute lung failure, acute liver failure, acute kidney injury, cardiovascular disease, and as well as a wide spectrum of hematological abnormalities and neurological disorders. The most important mechanisms are related to the direct and indirect pathogenic features of SARS-CoV2. Although the presence of angiotensin-converting enzyme 2, a receptor of SARS-CoV2 in the lung, heart, kidney, testis, liver, lymphocytes, and nervous system was confirmed, there are controversial findings to about the observation of SARS-CoV2 RNA in these organs. Moreover, the organ failure may be induced by the cytokine storm, a result of increased levels of inflammatory mediators, endothelial dysfunction, coagulation abnormalities, and infiltration of inflammatory cells into the organs. Therefore, further investigations are needed to detect the exact mechanisms of pathogenesis. Since the involvement of several organs in COVID-19 patients is important for clinicians, increasing their knowledge may help to improve the outcomes and decrease the rate of mortality and morbidity.

Offsite Construction for Emergencies: A focus on Isolation Space Creation (ISC) measures for the COVID-19 pandemic

The outbreak of a pandemic of global concern, the Corona Virus Disease 2019 (COVID-19) has tested the capacity of healthcare facilities to the brim in many developed countries. In a minacious fashion of rapid spread and extreme transmission rate, COVID-19 has triggered a shortage of healthcare facilities such as hospital bed spaces and ventilators. Various strategies have been adopted by the worst-hit countries to slacken or halt the spread of the virus. Common Isolation Space Creation (ISC) measures for the COVID-19 pandemic containment includes self-isolation at home, isolation at regular hospitals, isolation at existing epidemic hospitals, isolation at retrofitted buildings for an emergency, isolation at Temporary Mobile Cabins (TMCs), isolation at newly constructed temporary hospitals for COVID-19. This study evaluates the ISC measures and proposes offsite and modular solutions for the construction industry and built environment to respond to emergencies. While this study has proposed a solution for creating emergency isolation spaces for effective containment of such pandemic, other critical COVID-19 challenges such as the shortage of healthcare staff and other facilities are not addressed in this study.

Atypical presentation of COVID-19; an observational retrospective study

BACKGROUND

COVID-19 infection may present with atypical signs and symptoms and false negative polymerase chain reaction (PCR) tests predisposing healthy people and health care workers to infection. The aim of the current study is to evaluate the features of atypical presentations in COVID-19 infection in a referral center in Tehran, Iran.

METHODS

Hospital database of inpatients admitted to Loghman Hakim hospital between February 20th and May 11th, 2020 was reviewed and all patients with final diagnosis of COVID-19 infection were evaluated for their presenting symptoms. Patients with chief complaints of "fever", "dyspnea", and/or "cough" as typical presentations of COVID-19 were excluded and those with other clinical presentations were included.

RESULTS

Nineteen patients were included with a mean age of 51 ± 19 years, of whom, 17 were males (89%). Median [IQR] Glasgow coma scale (GCS) was 14 [13, 15]. Almost 10 had referred with chief complaint of methanol poisoning and overdose on substances of abuse. Only 8 cases (42%) had positive COVID-19 test. Nine (47%) needed invasive mechanical ventilation, of whom, two had positive COVID-19 test results (p = ns). Eight patients (42%) died with three of them having positive PCRs.

CONCLUSIONS

In patients referring to emergency departments with chief complaint of poisoning (especially poisonings that can result in dyspnea including substances of abuse and toxic alcohols), gastrointestinal, and constitutional respiratory symptoms, attention should be given not to miss possible cases of COVID-19.

Prevalence and Associated Risk Factors of Mortality Among COVID-19 Patients: A Meta-Analysis

OBJECTIVES

The main aim of this study was to find the prevalence of mortality among hospitalized COVID-19 infected patients and associated risk factors for death.

METHODS

Three electronic databases including PubMed, Science Direct and Google Scholar were searched to identify relevant cohort studies of COVID-19 disease from January 1, 2020, to August 11, 2020. A random-effects model was used to calculate pooled prevalence rate (PR), risk ratio (RR) and 95% confidence interval (CI) for both effect measures. Cochrane chi-square test statistic Q, [Formula: see text], and [Formula: see text] tests were used to measure the presence of heterogeneity. Publication bias and sensitivity of the included studies were also tested.

RESULTS

In this meta-analysis, a total of 58 studies with 122,191 patients were analyzed. The pooled prevalence rate of mortality among the hospitalized COVID-19 patients was 18.88%, 95% CI (16.46-21.30), p < 0.001. Highest mortality was found in Europe [PR 26.85%, 95% CI (19.41-34.29), p < 0.001] followed by North America [PR 21.47%, 95% CI (16.27-26.68), p < 0.001] and Asia [PR 14.83%, 95% CI (12.46- 17.21), p < 0.001]. An significant association were found between mortality among COVID-19 infected patients and older age (> 65 years vs. < 65 years) [RR 3.59, 95% CI (1.87-6.90), p < 0.001], gender (male vs. female) [RR 1.63, 95% CI (1.43-1.87), p < 0.001], ICU admitted patients [RR 3.72, 95% CI (2.70-5.13), p < 0.001], obesity [RR 2.18, 95% CI (1.10-4.34), p < 0.05], hypertension [RR 2.08,95% CI (1.79-2.43) p < 0.001], diabetes [RR 1.87, 95% CI (1.23-2.84), p < 0.001], cardiovascular disease [RR 2.51, 95% CI (1.20-5.26), p < 0.05], and cancer [RR 2.31, 95% CI (1.80-2.97), p < 0.001]. In addition, significant association for high risk of mortality were also found for cerebrovascular disease, COPD, coronary heart disease, chronic renal disease, chronic liver disease, chronic lung disease and chronic kidney disease.

CONCLUSION

This meta-analysis revealed that the mortality rate among COVID-19 patients was highest in the European region and older age, gender, ICU patients, patients with comorbidity had a high risk for case fatality. Those findings would help the health care providers to reduce the mortality rate and combat this pandemic to save lives using limited resources.

Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis: A Subgroup Analysis of Cluster Randomized Clinical Trials

IMPORTANCE

Saline (0.9% sodium chloride), the fluid most commonly used to treat diabetic ketoacidosis (DKA), can cause hyperchloremic metabolic acidosis. Balanced crystalloids, an alternative class of fluids for volume expansion, do not cause acidosis and, therefore, may lead to faster resolution of DKA than saline.

OBJECTIVE

To compare the clinical effects of balanced crystalloids with the clinical effects of saline for the acute treatment of adults with DKA.

DESIGN, SETTING, AND PARTICIPANTS

This study was a subgroup analysis of adults with DKA in 2 previously reported companion trials-Saline Against Lactated Ringer's or Plasma-Lyte in the Emergency Department (SALT-ED) and the Isotonic Solutions and Major Adverse Renal Events Trial (SMART). These trials, conducted between January 2016 and March 2017 in an academic medical center in the US, were pragmatic, multiple-crossover, cluster, randomized clinical trials comparing balanced crystalloids vs saline in emergency department (ED) and intensive care unit (ICU) patients. This study included adults who presented to the ED with DKA, defined as a clinical diagnosis of DKA, plasma glucose greater than 250 mg/dL, plasma bicarbonate less than or equal to 18 mmol/L, and anion gap greater than 10 mmol/L. Data analysis was performed from January to April 2020.

INTERVENTIONS

Balanced crystalloids (clinician's choice of Ringer lactate solution or Plasma-Lyte A solution) vs saline for fluid administration in the ED and ICU according to the same cluster-randomized multiple-crossover schedule.

MAIN OUTCOMES AND MEASURES

The primary outcome was time between ED presentation and DKA resolution, as defined by American Diabetes Association criteria. The secondary outcome was time between initiation and discontinuation of continuous insulin infusion.

RESULTS

Among 172 adults included in this secondary analysis of cluster trials, 94 were assigned to balanced crystalloids and 78 to saline. The median (interquartile range [IQR]) age was 29 (24-45) years, and 90 (52.3%) were women. The median (IQR) volume of isotonic fluid administered in the ED and ICU was 4478 (3000-6372) mL. Cumulative incidence analysis revealed shorter time to DKA resolution in the balanced crystalloids group (median time to resolution: 13.0 hours; IQR: 9.5-18.8 hours) than the saline group (median: 16.9 hours; IQR: 11.9-34.5 hours) (adjusted hazard ratio [aHR] = 1.68; 95% CI, 1.18-2.38; P = .004). Cumulative incidence analysis also revealed shorter time to insulin infusion discontinuation in the balanced crystalloids group (median: 9.8 hours; IQR: 5.1-17.0 hours) than the saline group (median: 13.4 hours; IQR: 11.0-17.9 hours) (aHR = 1.45; 95% CI, 1.03-2.03; P = .03).

CONCLUSIONS AND RELEVANCE

In this secondary analysis of 2 cluster randomized clinical trials, compared with saline, treatment with balanced crystalloids resulted in more rapid resolution of DKA, suggesting that balanced crystalloids may be preferred over saline for acute management of adults with DKA.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT02614040; NCT02444988.