Clinical characteristics, risk factors and outcomes in patients with severe COVID-19 registered in the International Severe Acute Respiratory and Emerging Infection Consortium WHO clinical characterisation protocol: a prospective, multinational, multicentre, observational study

Due to the large number of patients with severe coronavirus disease 2019 (COVID-19), many were treated outside the traditional walls of the intensive care unit (ICU), and in many cases, by personnel who were not trained in critical care. The clinical characteristics and the relative impact of caring for severe COVID-19 patients outside the ICU is unknown. This was a multinational, multicentre, prospective cohort study embedded in the International Severe Acute Respiratory and Emerging Infection Consortium World Health Organization COVID-19 platform. Severe COVID-19 patients were identified as those admitted to an ICU and/or those treated with one of the following treatments: invasive or noninvasive mechanical ventilation, high-flow nasal cannula, inotropes or vasopressors. A logistic generalised additive model was used to compare clinical outcomes among patients admitted or not to the ICU. A total of 40 440 patients from 43 countries and six continents were included in this analysis. Severe COVID-19 patients were frequently male (62.9%), older adults (median (interquartile range (IQR), 67 (55-78) years), and with at least one comorbidity (63.2%). The overall median (IQR) length of hospital stay was 10 (5-19) days and was longer in patients admitted to an ICU than in those who were cared for outside the ICU (12 (6-23) days versus 8 (4-15) days, p<0.0001). The 28-day fatality ratio was lower in ICU-admitted patients (30.7% (5797 out of 18 831) versus 39.0% (7532 out of 19 295), p<0.0001). Patients admitted to an ICU had a significantly lower probability of death than those who were not (adjusted OR 0.70, 95% CI 0.65-0.75; p<0.0001). Patients with severe COVID-19 admitted to an ICU had significantly lower 28-day fatality ratio than those cared for outside an ICU.

The AAPRISS Platform: Learning and Taking Action to Reduce Social Inequalities in Health to help PHIR

Key messages

Mixed structures housing spaces for both research and action, which create a dynamic of Population Health Intervention Research, are showing themselves to be effective and seem to meet a need. But the financial stability of this mixed structures is insufficient to sustain their activities and promote sustainable reduction of social inequalities in health.

Femoral Blood Flow Determination with a Multichannel Digital Pulsed Doppler: An Experimental Study on Anesthetized Dogs

Since Satomura first described an ultrasonic device using the Doppler effect to detect blood flow in 1959, more recent advances in medical engineer ing have met the need for non-invasive, quantitative measurement of blood flow in peripheral arteries.1 This goal can now be achieved with the use of a pulsed Doppler combined with an A-mode scan to estimate the angle of the ultrasound beam and the dimensions of the vessel.

Although several authors have already published data concerning blood flow volume obtained by continuous wave or pulsed Doppler devices in human peripheral arteries2,3,4 or in animal experiments,5,6,7 the accuracy of their meas urements was only correlated with indirect blood flow determinations such as electromagnetic flowmetry or venous occlusion plethysmography.

The present study compares the values of blood flow volume obtained by a Multichannel Digital Pulsed Doppler (MDPD) and by direct timed blood collec tion (DTBC) in the canine common femoral artery.

Metabolite profiling and quantitative genetics of natural variation for flavonoids in Arabidopsis

Little is known about the range and the genetic bases of naturally occurring variation for flavonoids. Using Arabidopsis thaliana seed as a model, the flavonoid content of 41 accessions and two recombinant inbred line (RIL) sets derived from divergent accessions (Cvi-0×Col-0 and Bay-0×Shahdara) were analysed. These accessions and RILs showed mainly quantitative rather than qualitative changes. To dissect the genetic architecture underlying these differences, a quantitative trait locus (QTL) analysis was performed on the two segregating populations. Twenty-two flavonoid QTLs were detected that accounted for 11-64% of the observed trait variations, only one QTL being common to both RIL sets. Sixteen of these QTLs were confirmed and coarsely mapped using heterogeneous inbred families (HIFs). Three genes, namely TRANSPARENT TESTA (TT)7, TT15, and MYB12, were proposed to underlie their variations since the corresponding mutants and QTLs displayed similar specific flavonoid changes. Interestingly, most loci did not co-localize with any gene known to be involved in flavonoid metabolism. This latter result shows that novel functions have yet to be characterized and paves the way for their isolation.

Gene expression profiling of Arabidopsis meiocytes

Meiosis is a special type of cell division present in all organisms that reproduce by sexual reproduction. It ensures the transition between the sporophytic and gametophytic state and allows gamete production through meiotic recombination and chromosome number reduction. In this paper, we describe a technique for the isolation of Arabidopsis thaliana male meiocytes. From this cellular material, it was then possible to develop large-scale transcriptome studies using CATMA microarrays and thus to obtain an overview of genes expressed during Arabidopsis meiosis. The expression profiles were studied with either stringent statistical criteria or by performing clustering. Both methods resulted in gene clusters enriched in meiosis-specific genes (from 14- to 55-fold). Analysis of these data provided a unique set of genes that will be pivotal to further analysis aimed at understanding the meiotic process.

A pilot study to assess an online training module to quickly identify drugs on resuscitation trays

OBJECTIVE

To measure the median time required for healthcare professionals to identify drugs on resuscitation trays and to assess the usefulness of an online training module used to identify drugs on resuscitation trays.

STUDY DESIGN

This is a descriptive pilot study conducted in a mother-child university hospital center with a convenience sample of physicians, residents, nurses, pharmacists, pharmacy students or pharmacy technicians (10/group).

METHOD

Participants were given a questionnaire before and after using a simulation module to identify drugs on resuscitation drug trays (30 questions on the full trays with 43 drugs and 15 questions on the partial trays with 21 drugs). The identification times were measured for each drug and for each tray.

RESULTS

The median time to identify the drugs varied from 4s (range 2-46) for dextrose to 18s (range 4-78) for epinephrine. The median times to locate a drug on full and partial trays were, respectively: pharmacists 7 (2-103) and 6 (1-31), physicians 10 (3-78) and 7 (2-61) and nurses 10 (3-83) and 7 (2-53). All 60 participants strongly agreed that the online simulation module was a good tool for healthcare staff and that it would allow them to locate drugs more quickly in emergency situations.

CONCLUSION

The online simulation module can be used by various groups of professionals and it can allow them to locate drugs on resuscitation tray more rapidly during an emergency.

Finger dominance

Two hundred and ninety-eight normal participants were reviewed to assess finger dominance. Participants were recruited from several large hospitals across the north-west of England and the study was done under blind conditions. From the 298 people originally in the trial, six had to be excluded as the dominant finger could not be confirmed with certainty. The index finger was the most dominant in 82.5% of the test group. However, in 10.6% of the test group, the middle finger was found to be the most dominant.

Dynamic structure of Agrobacterium tumefaciens Ti plasmids

Agrobacterium tumefaciens C58F is a variant of strain C58 which generates a high proportion of avirulent mutants in the presence of the virulence (vir) gene inducer acetosyringone. These mutants are altered in the Ti plasmid and do not respond to the acetosyringone signal (C. Fortin, E. W. Nester, and P. Dion, J. Bacteriol. 174:5676-5685, 1992). The physical organization of the Ti plasmid was compared in strain C58 and its variant. One feature distinguishing pTiC58F from its parent plasmid was the presence of the insertion element IS426. Three copies of this element were detected in the strain C58 chromosome, whereas two additional copies were found in strain C58F, including one copy in the Ti plasmid. This particular copy of IS426 was associated with the region of arginine and nopaline catabolism of pTiC58F. Most of the avirulent mutants recovered following growth of strain C58F in the presence of acetosyringone were complemented by clones carrying either virA or virG. Element IS426 was no longer found in the arginine and nopaline catabolism region of the Ti plasmids from the virA and virG mutants, but it resided in the particular KpnI fragment containing the modified vir locus. Behavior of a strain C58F derivative, which was inactivated in a chromosomal component required for the response to acetosyringone, was consistent with the possibility that vir gene induction is essential to the massive production of avirulent mutants.

Pulsed Doppler assessment of deep femoral artery hemodynamics: a preliminary report

The functional capability of the deep femoral artery (DFA) as a collateral channel is an important feature in patients suffering peripheral arterial occlusive disease (PAOD). A noninvasive method of indirect quantification of the DFA blood flow volume is presented. In normal lower limbs, it was found that the common femoral artery (CFA) mean blood flow volume was maintained at 59% of its resting value when the superficial femoral artery (SFA) was occluded by a pneumatic cuff placed around the thigh. The reduction of the mean flow volume is mainly due to an increase of the diastolic backward flow, while the maximum systolic flow remains constant. In a few patients with various degrees of stenosis of the DFA, we observed a much greater drop in mean CFA blood flow volume than in normal subjects. On the basis of this preliminary study, we conclude that: --When the normal SFA is occluded, pulsatile flow through the CFA is maintained. --Occlusion flow reflects the runoff and the compliance of the DFA bed. --Occlusion flow is diminished in patients with DFA stenosis. It is suggested that this non-invasive test might help the physician to assess the involvement of the DFA in PAOD. Further investigation is needed to establish the correlation between quantitative occlusion blood flow volume and the degree of DFA stenosis.

Chronic pancreatic pleural effusions and ascites

The occurrence of pleural effusion or ascites, secondary to internal pancreatic fistula, is a rare clinical syndrome and diagnosis is, therefore, often missed. The fluid accumulation has been attributed to disruption of the pancreatic duct or to rupture of a pseudocyst. In a 20 year period, 106 patients were hospitalized in the department of surgery, CHUV, with a diagnosis of chronic or chronic relapsing pancreatitis, and 77 with that of pancreatic pseudocyst. During this time, five patients with chronic pancreatic and pleural or peritoneal effusions have been observed. These five cases present a good pattern of the possible causes and evolution of the disease. Wirsungography is of great value for the surgical management of these patients, allowing the right technique to be chosen for each particular case. Surgery caused disappearance of the effusions in our five patients.

[Modification of arterial blood flow using venous occlusion plethysmography]

Arterial blood flow volume was registered simultaneously by pulsed Doppler and venous occlusion plethysmography in 14 limbs of healthy subjects aged 25 to 36 years. The results were as follows: from the beginning of venous occlusion and during venous filling phase, arterial flow diminishes to 73% of its initial value. This diminution is due to a progressive decrease in arterial systolic flow as well as an increase in diastolic arterial reflux. The results reflect the increase in peripheral resistance as well as the elasticity of the arteries, which, during the diastole, return upstream a part of the arterial systolic flow.

Comparison between segmental and selective blood flow volume of the lower limbs: a plethysmographic and ultrasonic study of normal subjects at rest

In order to find the correlations existing between segmental and selective arterial blood flow volume, 20 healthy subjects have been submitted to calf venous occlusion plethysmography and Multichannel Digital Pulsed Doppler examination of the common femoral and popliteal arteries at rest. We found a linear correlation only between mean popliteal artery blood flow volume and plethysmographic calf blood flow volume (r = 0,41; p less than 0,01). We therefore suggest that venous occlusion plethysmography should not be used for the assessment of aorto-iliac and common femoral hemodynamics after direct arterial reconstructive surgery. Its use should be complementary to pulsed Doppler blood flow volume determination at the femoro-popliteal level, along with the usual pressure measurement.

Long-term follow-up after a distal splenorenal shunt procedure. A clinical and hemodynamic study

Of 26 patients who underwent distal splenorenal shunting 4 or more years ago (1969 to 1978), 10 died 3 to 87 months postoperatively (mean 38.5 months). Six deaths were due to liver failure, two to hemorrhagic peptic ulcer disease (the shunt remained patent in each patient), one to brain hemorrhage, and one to sepsis. Eight of the surviving patients resumed professional activity, one showed transient signs of encephalopathy, one had a single episode of recurrent variceal bleeding that could be managed conservatively, and no patient had ascites. Eight patients were investigated angiographically and endoscopically. Preoperative and postoperative measurements of the portal vein showed a decreased diameter in five patients and no opacification in the other three 29 to 97 months after surgery. At endoscopy four patients had small residual esophageal varices, one patient had none, and the other three had large varicosities with variceal pressures between 30 and 40 cm H2O in two and above 40 cm H2O in one. Although the incidence of postoperative encephalopathy and variceal bleeding was low after distal splenorenal shunting, the operation did not prevent a decrease in hepatopetal portal flow and did not always abolish the esophageal varices.

[Clipping for prophylactic partial occlusion of the inferior vena cava]

The partial occlusion of the inferior vena cava in the prevention of fatal pulmonary embolism has been used for years in different ways. Over a period of one, and a half year, we put 11 clips of Miles, once for prophylaxis and 10 times after pulmonary embolism. Two patients died during the first 15 postoperative days. Seven patients had a phlebologic control by a Doppler ultrasound, venous plethysmography, isotopic cavography, and grey scale ultrasound. It has been proved that the inferior vena cava was permeable in 6 of the 7 controlled patients. The indications as well as the late results of these operations are discussed.

Strain gauge plethysmographic studies after clipping of the inferior vena cava

Assessment of the hemodynamic effects of the IVC clipping by strain gauge plethysmography provides accurate quantitative data. These correlate very well with the other means of investigation used in the study. Eight patients were controlled in the Vascular Laboratory 9 to 43 months after clipping of the inferior vena cava. They submitted to clinical evaluation, Doppler ultrasound, isotopic venography, abdominal sonography, and strain gauge plethysmography of the lower extremities. This last method provided quantitative data; maximal venous outflow was found to be equivalent in the 8 patients included in the study and in a control group of 20 healthy young volunteers. Strain gauge plethysmography results correlate well with the other means of investigation and demonstrate the efficacy of the dilated venous collateral channels in restoring a normal venous return.