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Adhikari NKJ, Hashmi M, Tirupakuzhi Vijayaraghavan BK, Haniffa R, Beane A, Webb SA, Angus DC, Gordon AC, Cook DJ, Guyatt GH, Berry LR, Lorenzi E, Mouncey PR, Au C, Pinto R, Ménard J, Sprague S, Masse MH, Huang DT, Heyland DK, Nichol AD, McArthur CJ, de Man A, Al-Beidh F, Annane D, Anstey M, Arabi YM, Battista MC, Berry S, Bhimani Z, Bonten MJM, Bradbury CA, Brant EB, Brunkhorst FM, Burrell A, Buxton M, Cecconi M, Cheng AC, Cohen D, Cove ME, Day AG, Derde LPG, Detry MA, Estcourt LJ, Fagbodun EO, Fitzgerald M, Goossens H, Green C, Higgins AM, Hills TE, Ichihara N, Jayakumar D, Kanji S, Khoso MN, Lawler PR, Lewis RJ, Litton E, Marshall JC, McAuley DF, McGlothlin A, McGuinness SP, McQuilten ZK, McVerry BJ, Murthy S, Parke RL, Parker JC, Reyes LF, Rowan KM, Saito H, Salahuddin N, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Tolppa T, Trapani T, Turgeon AF, Turner AM, Udy AA, van de Veerdonk FL, Zarychanski R, Lamontagne F. Intravenous Vitamin C for Patients Hospitalized With COVID-19: Two Harmonized Randomized Clinical Trials. JAMA 2023; 330:1745-1759. [PMID: 37877585 PMCID: PMC10600726 DOI: 10.1001/jama.2023.21407] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
Importance The efficacy of vitamin C for hospitalized patients with COVID-19 is uncertain. Objective To determine whether vitamin C improves outcomes for patients with COVID-19. Design, Setting, and Participants Two prospectively harmonized randomized clinical trials enrolled critically ill patients receiving organ support in intensive care units (90 sites) and patients who were not critically ill (40 sites) between July 23, 2020, and July 15, 2022, on 4 continents. Interventions Patients were randomized to receive vitamin C administered intravenously or control (placebo or no vitamin C) every 6 hours for 96 hours (maximum of 16 doses). Main Outcomes and Measures The primary outcome was a composite of organ support-free days defined as days alive and free of respiratory and cardiovascular organ support in the intensive care unit up to day 21 and survival to hospital discharge. Values ranged from -1 organ support-free days for patients experiencing in-hospital death to 22 organ support-free days for those who survived without needing organ support. The primary analysis used a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented efficacy (improved survival, more organ support-free days, or both), an OR less than 1 represented harm, and an OR less than 1.2 represented futility. Results Enrollment was terminated after statistical triggers for harm and futility were met. The trials had primary outcome data for 1568 critically ill patients (1037 in the vitamin C group and 531 in the control group; median age, 60 years [IQR, 50-70 years]; 35.9% were female) and 1022 patients who were not critically ill (456 in the vitamin C group and 566 in the control group; median age, 62 years [IQR, 51-72 years]; 39.6% were female). Among critically ill patients, the median number of organ support-free days was 7 (IQR, -1 to 17 days) for the vitamin C group vs 10 (IQR, -1 to 17 days) for the control group (adjusted proportional OR, 0.88 [95% credible interval {CrI}, 0.73 to 1.06]) and the posterior probabilities were 8.6% (efficacy), 91.4% (harm), and 99.9% (futility). Among patients who were not critically ill, the median number of organ support-free days was 22 (IQR, 18 to 22 days) for the vitamin C group vs 22 (IQR, 21 to 22 days) for the control group (adjusted proportional OR, 0.80 [95% CrI, 0.60 to 1.01]) and the posterior probabilities were 2.9% (efficacy), 97.1% (harm), and greater than 99.9% (futility). Among critically ill patients, survival to hospital discharge was 61.9% (642/1037) for the vitamin C group vs 64.6% (343/531) for the control group (adjusted OR, 0.92 [95% CrI, 0.73 to 1.17]) and the posterior probability was 24.0% for efficacy. Among patients who were not critically ill, survival to hospital discharge was 85.1% (388/456) for the vitamin C group vs 86.6% (490/566) for the control group (adjusted OR, 0.86 [95% CrI, 0.61 to 1.17]) and the posterior probability was 17.8% for efficacy. Conclusions and Relevance In hospitalized patients with COVID-19, vitamin C had low probability of improving the primary composite outcome of organ support-free days and hospital survival. Trial Registration ClinicalTrials.gov Identifiers: NCT04401150 (LOVIT-COVID) and NCT02735707 (REMAP-CAP).
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Affiliation(s)
- Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | | | - Rashan Haniffa
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Abi Beane
- Centre for Inflammation Research, Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Health Care, Perth, Australia
| | - Derek C Angus
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Imperial College London, London, England
- St Mary's Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Critical Care, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, England
| | - Carly Au
- Intensive Care National Audit and Research Centre, London, England
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Julie Ménard
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Sheila Sprague
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Marie-Hélène Masse
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David T Huang
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada
| | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
- University College Dublin, Dublin, Ireland
- Alfred Health, Melbourne, Australia
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Angelique de Man
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - Djillali Annane
- UVSQ University Paris Saclay, Institut-Hospitalo Universitaire Prometheus, Paris, France
- Médecine Intensive-Réanimation, Hôpital Raymond-Poincaré, Garches, France
| | - Matthew Anstey
- Sir Charles Gairdner Hospital, Nedlands, Australia
- University of Western Australia, Perth
| | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marie-Claude Battista
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Zahra Bhimani
- St Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
| | | | - Emily B Brant
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Frank M Brunkhorst
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Aidan Burrell
- Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Meredith Buxton
- Global Coalition for Adaptive Research, Larkspur, California
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Allen C Cheng
- Monash Infectious Disease, Monash Health and School of Clinical Sciences, Monash University, Clayton, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dian Cohen
- Bishop's University, Sherbrooke, Quebec, Canada
- Massawippi Valley Foundation, Ayer's Cliff, Quebec, Canada
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrew G Day
- Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada
| | - Lennie P G Derde
- European Clinical Research Alliance on Infectious Diseases, Utrecht, the Netherlands
- Intensive Care Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Lise J Estcourt
- Department of Haematology, NHS Blood and Transplant, Bristol, England
- Radcliffe Department of Medicine, University of Oxford, Oxford, England
| | | | | | - Herman Goossens
- Laboratory of Medical Microbiology, University of Antwerp, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Nao Ichihara
- Department of Cardiovascular Surgery, School of Medicine, Jikei University, Tokyo, Japan
| | | | - Salmaan Kanji
- Ottawa Hospital, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Patrick R Lawler
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- McGill University Health Centre, Montreal, Quebec, Canada
| | | | - Edward Litton
- Fiona Stanley Hospital, Department of Intensive Care Unit, University of Western Australia, Perth
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Queen's University of Belfast, Belfast, Northern Ireland
- Centre for Infection and Immunity, Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Medical Research Institute of New Zealand, Wellington
- Auckland City Hospital, Cardiothoracic and Vascular Intensive Care Unit, Auckland, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | | | - Bryan J McVerry
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Srinivas Murthy
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Rachael L Parke
- Medical Research Institute of New Zealand, Wellington
- Auckland City Hospital, Cardiothoracic and Vascular Intensive Care Unit, Auckland, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, Australia
| | - Luis Felipe Reyes
- Department of Infectious Diseases, Universidad de La Sabana, Chia, Colombia
- Department of Critical Care Medicine, Clinica Universidad de La Sabana, Chia, Colombia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Nawal Salahuddin
- National Institute of Cardiovascular Diseases, Karachi, Pakistan
| | - Marlene S Santos
- Department of Critical Care, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher W Seymour
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Manu Shankar-Hari
- Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, Scotland
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, Scotland
| | - Timo Tolppa
- National Intensive Care Surveillance, Colombo, Sri Lanka
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care, Université Laval, Quebec City, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit, Departments of Traumatology, Emergency Medicine, and Critical Care Medicine, Université Laval Research Center, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia
| | | | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg, Canada
| | - François Lamontagne
- Research Centre of the Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Rashan A, Beane A, Ghose A, Dondorp AM, Kwizera A, Vijayaraghavan BKT, Biccard B, Righy C, Thwaites CL, Pell C, Sendagire C, Thomson D, Done DG, Aryal D, Wagstaff D, Nadia F, Putoto G, Panaru H, Udayanga I, Amuasi J, Salluh J, Gokhale K, Nirantharakumar K, Pisani L, Hashmi M, Schultz M, Ghalib MS, Mukaka M, Mat-Nor MB, Siaw-frimpong M, Surenthirakumaran R, Haniffa R, Kaddu RP, Pereira SP, Murthy S, Harris S, Moonesinghe SR, Vengadasalam S, Tripathy S, Gooden TE, Tolppa T, Pari V, Waweru-Siika W, Minh YL. Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units. Wellcome Open Res 2023; 8:29. [PMID: 37954925 PMCID: PMC10638482 DOI: 10.12688/wellcomeopenres.18710.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be led by local stakeholders, performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
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Affiliation(s)
- The Collaboration for Research, Implementation and Training in Critical Care in Asia and Africa (CCAA)
- Institute of Health Informatics, University College London, London, UK
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Anaesthesia and Intensive Care Medicine, Makerere University, Kampala, Uganda
- Department of Critical Care Medicine, Apollo Hospitals Educational and Research Foundation, Chennai, India
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
- National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Uganda Heart Institute, University of Makerere, Makerere, Uganda
- D'Or Institute for Research and Education, Sao Paulo, Brazil
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- Centre for Preoperative Medicine, University College London, London, UK
- Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
- Department of Planning and Operational Research, Doctors with Africa CUAMM, Padova, Italy
- Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
- Intensive Care Medicine, University of Amsterdam, Amsterdam, The Netherlands
- General Surgery, Wazir Akbar Khan Hospital, Kabul, Afghanistan
- Department of Anaesthesiology and Intensive care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Sri Lanka
- Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya
- Department of Targeted Intervention, University College London, London, UK
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
- Teaching Hospital Jaffna, Jaffna, Sri Lanka
- AII India Institute of Medical Sciences, New Delhi, India
- Chennai Critical Care Consultants Private Limited, Chennai, India
| | - Aasiyah Rashan
- Institute of Health Informatics, University College London, London, UK
| | - Abi Beane
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arthur Kwizera
- Department of Anaesthesia and Intensive Care Medicine, Makerere University, Kampala, Uganda
| | | | - Bruce Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Cassia Righy
- National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - C. Louise Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Cornelius Sendagire
- Uganda Heart Institute, University of Makerere, Makerere, Uganda
- D'Or Institute for Research and Education, Sao Paulo, Brazil
| | - David Thomson
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Dilanthi Gamage Done
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Diptesh Aryal
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- D'Or Institute for Research and Education, Sao Paulo, Brazil
- Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Duncan Wagstaff
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Preoperative Medicine, University College London, London, UK
| | - Farah Nadia
- Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
| | - Giovanni Putoto
- Department of Planning and Operational Research, Doctors with Africa CUAMM, Padova, Italy
| | - Hem Panaru
- Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Ishara Udayanga
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
| | - John Amuasi
- Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jorge Salluh
- D'Or Institute for Research and Education, Sao Paulo, Brazil
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Luigi Pisani
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Madiha Hashmi
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | - Marcus Schultz
- Intensive Care Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mohammed Basri Mat-Nor
- Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
| | - Moses Siaw-frimpong
- Department of Anaesthesiology and Intensive care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Rashan Haniffa
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
| | - Ronnie P Kaddu
- Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya
| | | | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Steve Harris
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Swagata Tripathy
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- AII India Institute of Medical Sciences, New Delhi, India
| | - Tiffany E Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timo Tolppa
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
| | - Vrindha Pari
- Chennai Critical Care Consultants Private Limited, Chennai, India
| | | | - Yen Lam Minh
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
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Tolppa T, Pari V, Pell C, Aryal D, Hashmi M, Shamal Ghalib M, Jawad I, Tripathy S, Tirupakuzhi Vijayaraghavan BK, Beane A, Dondorp AM, Haniffa R. Determinants of Implementation of a Critical Care Registry in Asia: Lessons From a Qualitative Study. J Med Internet Res 2023; 25:e41028. [PMID: 36877557 PMCID: PMC10028509 DOI: 10.2196/41028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 11/25/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The Collaboration for Research, Implementation, and Training in Critical Care in Asia (CCA) is implementing a critical care registry to capture real-time data to facilitate service evaluation, quality improvement, and clinical studies. OBJECTIVE The purpose of this study is to examine stakeholder perspectives on the determinants of implementation of the registry by examining the processes of diffusion, dissemination, and sustainability. METHODS This study is a qualitative phenomenological inquiry using semistructured interviews with stakeholders involved in registry design, implementation, and use in 4 South Asian countries. The conceptual model of diffusion, dissemination, and sustainability of innovations in health service delivery guided interviews and analysis. Interviews were coded using the Rapid Identification of Themes from Audio recordings procedure and were analyzed based on the constant comparison approach. RESULTS A total of 32 stakeholders were interviewed. Analysis of stakeholder accounts identified 3 key themes: innovation-system fit; influence of champions; and access to resources and expertise. Determinants of implementation included data sharing, research experience, system resilience, communication and networks, and relative advantage and adaptability. CONCLUSIONS The implementation of the registry has been possible due to efforts to increase the innovation-system fit, influence of motivated champions, and the support offered by access to resources and expertise. The reliance on individuals and the priorities of other health care actors pose a risk to sustainability.
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Affiliation(s)
- Timo Tolppa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Vrindha Pari
- Chennai Critical Care Consultants Group, Chennai, India
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
- Department of Global Health, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Diptesh Aryal
- Hospital for Advanced Medicine and Surgery, Kathmandu, Nepal
| | | | | | - Issrah Jawad
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Swagata Tripathy
- Department of Anaesthesia and Intensive Care Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Bharath Kumar Tirupakuzhi Vijayaraghavan
- Chennai Critical Care Consultants Group, Chennai, India
- Critical Care Medicine Department, Apollo Hospital, Chennai, India
- Indian Registry of IntenSive Care, Chennai, India
| | - Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Arjen M Dondorp
- Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Rashan Haniffa
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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4
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Rashan A, Beane A, Ghose A, Dondorp AM, Kwizera A, Vijayaraghavan BKT, Biccard B, Righy C, Thwaites CL, Pell C, Sendagire C, Thomson D, Done DG, Aryal D, Wagstaff D, Nadia F, Putoto G, Panaru H, Udayanga I, Amuasi J, Salluh J, Gokhale K, Nirantharakumar K, Pisani L, Hashmi M, Schultz M, Ghalib MS, Mukaka M, Mat-Nor MB, Siaw-frimpong M, Surenthirakumaran R, Haniffa R, Kaddu RP, Pereira SP, Murthy S, Harris S, Moonesinghe SR, Vengadasalam S, Tripathy S, Gooden TE, Tolppa T, Pari V, Waweru-Siika W, Minh YL. Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18710.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Background: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
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Rashan A, Beane A, Ghose A, Dondorp AM, Kwizera A, Vijayaraghavan BKT, Biccard B, Righy C, Thwaites CL, Pell C, Sendagire C, Thomson D, Done DG, Aryal D, Wagstaff D, Nadia F, Putoto G, Panaru H, Udayanga I, Amuasi J, Salluh J, Gokhale K, Nirantharakumar K, Pisani L, Hashmi M, Schultz M, Ghalib MS, Mukaka M, Mat-Nor MB, Siaw-frimpong M, Surenthirakumaran R, Haniffa R, Kaddu RP, Pereira SP, Murthy S, Harris S, Moonesinghe SR, Vengadasalam S, Tripathy S, Gooden TE, Tolppa T, Pari V, Waweru-Siika W, Minh YL. Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18710.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
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Bedwell GJ, Dias P, Hahnle L, Anaeli A, Baker T, Beane A, Biccard BM, Bulamba F, Delgado-Ramirez MB, Dullewe NP, Echeverri-Mallarino V, Haniffa R, Hewitt-Smith A, Hoyos AS, Mboya EA, Nanimambi J, Pearse R, Pratheepan AP, Sunguya B, Tolppa T, Uruthirakumar P, Vengadasalam S, Vindrola-Padros C, Stephens TJ. Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study. Anesth Analg 2022; 135:1217-1232. [PMID: 36005395 DOI: 10.1213/ane.0000000000006113] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 "Bellwether" procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs). METHODS Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs. RESULTS We developed 25 pathway maps, undertook >30 periods of observation, and held >40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients' low expectations of care. CONCLUSIONS We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.
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Affiliation(s)
- Gillian J Bedwell
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Priyanthi Dias
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Lina Hahnle
- From the Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Tim Baker
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Abi Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Fred Bulamba
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Martha B Delgado-Ramirez
- Departments of Clinical Epidemiology and Biostatistics.,Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Nilmini P Dullewe
- Post Basic School of Nursing, Colombo, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | | | - Rashan Haniffa
- Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Adam Hewitt-Smith
- Elgon Centre for Health, Research and Innovation, Mbale' Uganda.,Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Alejandra Sanin Hoyos
- Anesthesia, Pontificia Universidad Javeriana, Hospital Universitario San Ignacio Bogota, Bogota, Colombia
| | - Erick A Mboya
- Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Juliana Nanimambi
- Department of Anaesthesia and Critical Care, Faculty of Health Sciences, Busitema University, Mbale, Uganda.,Elgon Centre for Health, Research and Innovation, Mbale' Uganda
| | - Rupert Pearse
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Anton Premadas Pratheepan
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Jaffna Teaching Hospital, Jaffna, Sri Lanka
| | - Bruno Sunguya
- Department of Community Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Timo Tolppa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Powsiga Uruthirakumar
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Department of Community and Family Medicine, Faculty of Medicine, University of Jaffna, Jaffna, Sri Lanka
| | | | | | - Timothy J Stephens
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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7
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Patel J, Tolppa T, Biccard BM, Fazzini B, Haniffa R, Marletta D, Moonesinghe R, Pearse R, Vengadasalam S, Stephens TJ, Vindrola-Padros C. Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis. World J Surg 2022; 46:2102-2113. [PMID: 35731268 PMCID: PMC9334384 DOI: 10.1007/s00268-022-06621-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher. METHODS Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation. RESULTS Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources. CONCLUSIONS Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge.
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Affiliation(s)
- Jignesh Patel
- Division of Surgery and Interventional Science, Centre for Perioperative Medicine, University College London, London, UK
| | - Timo Tolppa
- Network for Improving Critical Care Systems and Training, YMBA Building, Colombo, 08, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
| | - Bruce M Biccard
- Department of Anesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Brigitta Fazzini
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, Whitechapel, London, E1 1FR, UK
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, YMBA Building, Colombo, 08, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, 10400, Thailand
| | | | - Ramani Moonesinghe
- Division of Surgery and Interventional Science, Centre for Perioperative Medicine, University College London, London, UK
| | - Rupert Pearse
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, c/o ACCU Research Team, Royal London Hospital, Queen Mary University of London, London, E1 1BB, UK
| | | | - Timothy J Stephens
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, c/o ACCU Research Team, Royal London Hospital, Queen Mary University of London, London, E1 1BB, UK.
| | - Cecilia Vindrola-Padros
- Division of Surgery, Department of Targeted Intervention, University College London, London, UK
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Bradbury CA, Lawler PR, Stanworth SJ, McVerry BJ, McQuilten Z, Higgins AM, Mouncey PR, Al-Beidh F, Rowan KM, Berry LR, Lorenzi E, Zarychanski R, Arabi YM, Annane D, Beane A, van Bentum-Puijk W, Bhimani Z, Bihari S, Bonten MJM, Brunkhorst FM, Buzgau A, Buxton M, Carrier M, Cheng AC, Cove M, Detry MA, Estcourt LJ, Fitzgerald M, Girard TD, Goligher EC, Goossens H, Haniffa R, Hills T, Huang DT, Horvat CM, Hunt BJ, Ichihara N, Lamontagne F, Leavis HL, Linstrum KM, Litton E, Marshall JC, McAuley DF, McGlothlin A, McGuinness SP, Middeldorp S, Montgomery SK, Morpeth SC, Murthy S, Neal MD, Nichol AD, Parke RL, Parker JC, Reyes LF, Saito H, Santos MS, Saunders CT, Serpa-Neto A, Seymour CW, Shankar-Hari M, Singh V, Tolppa T, Turgeon AF, Turner AM, van de Veerdonk FL, Green C, Lewis RJ, Angus DC, McArthur CJ, Berry S, Derde LPG, Webb SA, Gordon AC. Effect of Antiplatelet Therapy on Survival and Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2022; 327:1247-1259. [PMID: 35315874 PMCID: PMC8941448 DOI: 10.1001/jama.2022.2910] [Citation(s) in RCA: 68] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Importance The efficacy of antiplatelet therapy in critically ill patients with COVID-19 is uncertain. Objective To determine whether antiplatelet therapy improves outcomes for critically ill adults with COVID-19. Design, Setting, and Participants In an ongoing adaptive platform trial (REMAP-CAP) testing multiple interventions within multiple therapeutic domains, 1557 critically ill adult patients with COVID-19 were enrolled between October 30, 2020, and June 23, 2021, from 105 sites in 8 countries and followed up for 90 days (final follow-up date: July 26, 2021). Interventions Patients were randomized to receive either open-label aspirin (n = 565), a P2Y12 inhibitor (n = 455), or no antiplatelet therapy (control; n = 529). Interventions were continued in the hospital for a maximum of 14 days and were in addition to anticoagulation thromboprophylaxis. Main Outcomes and Measures The primary end point was organ support-free days (days alive and free of intensive care unit-based respiratory or cardiovascular organ support) within 21 days, ranging from -1 for any death in hospital (censored at 90 days) to 22 for survivors with no organ support. There were 13 secondary outcomes, including survival to discharge and major bleeding to 14 days. The primary analysis was a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented improved survival, more organ support-free days, or both. Efficacy was defined as greater than 99% posterior probability of an OR greater than 1. Futility was defined as greater than 95% posterior probability of an OR less than 1.2 vs control. Intervention equivalence was defined as greater than 90% probability that the OR (compared with each other) was between 1/1.2 and 1.2 for 2 noncontrol interventions. Results The aspirin and P2Y12 inhibitor groups met the predefined criteria for equivalence at an adaptive analysis and were statistically pooled for further analysis. Enrollment was discontinued after the prespecified criterion for futility was met for the pooled antiplatelet group compared with control. Among the 1557 critically ill patients randomized, 8 patients withdrew consent and 1549 completed the trial (median age, 57 years; 521 [33.6%] female). The median for organ support-free days was 7 (IQR, -1 to 16) in both the antiplatelet and control groups (median-adjusted OR, 1.02 [95% credible interval {CrI}, 0.86-1.23]; 95.7% posterior probability of futility). The proportions of patients surviving to hospital discharge were 71.5% (723/1011) and 67.9% (354/521) in the antiplatelet and control groups, respectively (median-adjusted OR, 1.27 [95% CrI, 0.99-1.62]; adjusted absolute difference, 5% [95% CrI, -0.2% to 9.5%]; 97% posterior probability of efficacy). Among survivors, the median for organ support-free days was 14 in both groups. Major bleeding occurred in 2.1% and 0.4% of patients in the antiplatelet and control groups (adjusted OR, 2.97 [95% CrI, 1.23-8.28]; adjusted absolute risk increase, 0.8% [95% CrI, 0.1%-2.7%]; 99.4% probability of harm). Conclusions and Relevance Among critically ill patients with COVID-19, treatment with an antiplatelet agent, compared with no antiplatelet agent, had a low likelihood of providing improvement in the number of organ support-free days within 21 days. Trial Registration ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Simon J Stanworth
- University of Oxford, Oxford, England
- NHS Blood and Transplant, Oxford, England
| | | | - Zoe McQuilten
- Monash University, Melbourne, Victoria, Australia
- Monash Health, Melbourne, Victoria, Australia
| | | | - Paul R Mouncey
- Intensive Care National Audit and Research Centre (ICNARC), London, England
| | | | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), London, England
| | | | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Djillali Annane
- Hospital Raymond Poincaré (Assistance Publique Hôpitaux de Paris), Garches, France
- Université Versailles SQY-Université Paris Saclay, Montigny-le-Bretonneux, France
| | - Abi Beane
- University of Oxford, Oxford, England
| | | | - Zahra Bhimani
- St Michael's Hospital Unity Health, Toronto, Ontario, Canada
| | - Shailesh Bihari
- Flinders University, Bedford Park, South Australia, Australia
| | | | | | | | - Meredith Buxton
- Global Coalition for Adaptive Research, Los Angeles, California
| | - Marc Carrier
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Allen C Cheng
- Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Matthew Cove
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | | | | | - Ewan C Goligher
- Peter Munk Cardiac Centre at University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Rashan Haniffa
- University of Oxford, Bangkok, Thailand
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - Thomas Hills
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | | | | | | | - Helen L Leavis
- University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Edward Litton
- Fiona Stanley Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Australia
| | - John C Marshall
- St Michael's Hospital Unity Health, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Queen's University Belfast, Belfast, Northern Ireland
- Royal Victoria Hospital, Belfast, Northern Ireland
| | | | - Shay P McGuinness
- Monash University, Melbourne, Victoria, Australia
- Auckland City Hospital, Auckland, New Zealand
| | | | | | | | | | | | - Alistair D Nichol
- Monash University, Melbourne, Victoria, Australia
- University College Dublin, Dublin, Ireland
| | - Rachael L Parke
- Auckland City Hospital, Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | | | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | - Hiroki Saito
- St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | | | | | - Ary Serpa-Neto
- Monash University, Melbourne, Victoria, Australia
- Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Manu Shankar-Hari
- King's College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, London, England
| | | | - Timo Tolppa
- National Intensive Care Surveillance (NICST), Colombo, Sri Lanka
| | - Alexis F Turgeon
- Université Laval, Québec City, Québec, Canada
- CHU de Québec-Université Laval Research Center, Québec City, Québec, Canada
| | - Anne M Turner
- Medical Research Institute of New Zealand (MRINZ), Wellington, New Zealand
| | | | | | - Roger J Lewis
- Berry Consultants, Austin, Texas
- Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | - Steve A Webb
- Monash University, Melbourne, Victoria, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Imperial College London, London, England
- Imperial College Healthcare NHS Trust, St Mary's Hospital, London, England
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Abbas A, Abdukahil SA, Abdulkadir NN, Abe R, Abel L, Absil L, Acharya S, Acker A, Adachi S, Adam E, Adrião D, Ageel SA, Ahmed S, Ain Q, Ainscough K, Aisa T, Ait Hssain A, Ait Tamlihat Y, Akimoto T, Akmal E, Al Qasim E, Alalqam R, Alam T, Al-dabbous T, Alegesan S, Alegre C, Alessi M, Alex B, Alexandre K, Al-Fares A, Alfoudri H, Ali I, Ali Shah N, Alidjnou KE, Aliudin J, Alkhafajee Q, Allavena C, Allou N, Altaf A, Alves J, Alves JM, Alves R, Amaral M, Amira N, Ammerlaan H, Ampaw P, Andini R, Andrejak C, Angheben A, Angoulvant F, Ansart S, Anthonidass S, Antonelli M, Antunes de Brito CA, Anwar KR, Apriyana A, Arabi Y, Aragao I, Arali R, Arancibia F, Araujo C, Arcadipane A, Archambault P, Arenz L, Arlet JB, Arnold-Day C, Aroca A, Arora L, Arora R, Artaud-Macari E, Aryal D, Asaki M, Asensio A, Ashley E, Ashraf M, Ashraf S, Asim M, Assie JB, Asyraf A, Atique A, Attanyake AMUL, Auchabie J, Aumaitre H, Auvet A, Azemar L, Azoulay C, Bach B, Bachelet D, Badr C, Baig N, Baillie JK, Baird JK, Bak E, Bakakos A, Bakar NA, Bal A, Balakrishnan M, Balan V, Bani-Sadr F, Barbalho R, Barbosa NY, Barclay WS, Barnett SU, Barnikel M, Barrasa H, Barrelet A, Barrigoto C, Bartoli M, Bartone C, Baruch J, Bashir M, Basmaci R, Basri MFH, Bastos D, Battaglini D, Bauer J, Bautista Rincon DF, Bazan Dow D, Bedossa A, Bee KH, Behilill S, Beishuizen A, Beljantsev A, Bellemare D, Beltrame A, Beltrão BA, Beluze M, Benech N, Benjiman LE, Benkerrou D, Bennett S, Bento L, Berdal JE, Bergeaud D, Bergin H, Bernal Sobrino JL, Bertoli G, Bertolino L, Bessis S, Betz A, Bevilcaqua S, Bezulier K, Bhatt A, Bhavsar K, Bianchi I, Bianco C, Bidin FN, Bikram Singh M, Bin Humaid F, Bin Kamarudin MN, Bissuel F, Biston P, Bitker L, Blanco-Schweizer P, Blier C, Bloos F, Blot M, Blumberg L, Boccia F, Bodenes L, Bogaarts A, Bogaert D, Boivin AH, Bolze PA, Bompart F, Bonfasius A, Borges D, Borie R, Bosse HM, Botelho-Nevers E, Bouadma L, Bouchaud O, Bouchez S, Bouhmani D, Bouhour D, Bouiller K, Bouillet L, Bouisse C, Boureau AS, Bourke J, Bouscambert M, Bousquet A, Bouziotis J, Boxma B, Boyer-Besseyre M, Boylan M, Bozza FA, Brack M, Braconnier A, Braga C, Brandenburger T, Brás Monteiro F, Brazzi L, Breen D, Breen P, Breen P, Brett S, Brickell K, Broadley T, Browne A, Browne S, Brozzi N, Brusse-Keizer M, Buchtele N, Buesaquillo C, Bugaeva P, Buisson M, Burhan E, Burrell A, Bustos IG, Butnaru D, Cabie A, Cabral S, Caceres E, Cadoz C, Callahan M, Calligy K, Calvache JA, Cam J, Campana V, Campbell P, Campisi J, Canepa C, Cantero M, Caraux-Paz P, Cárcel S, Cardellino CS, Cardoso F, Cardoso F, Cardoso N, Cardoso S, Carelli S, Carlier N, Carmoi T, Carney G, Carpenter C, Carqueja I, Carret MC, Carrier FM, Carroll I, Carson G, Carton E, Casanova ML, Cascão M, Casey S, Casimiro J, Cassandra B, Castañeda S, Castanheira N, Castor-Alexandre G, Castrillón H, Castro I, Catarino A, Catherine FX, Cattaneo P, Cavalin R, Cavalli GG, Cavayas A, Ceccato A, Cervantes-Gonzalez M, Chair A, Chakveatze C, Chan A, Chand M, Chantalat 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The value of open-source clinical science in pandemic response: lessons from ISARIC. Lancet Infect Dis 2021; 21:1623-1624. [PMID: 34619109 PMCID: PMC8489876 DOI: 10.1016/s1473-3099(21)00565-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/16/2021] [Indexed: 12/31/2022]
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Aryal D, Beane A, Dondorp AM, Green C, Haniffa R, Hashmi M, Jayakumar D, Marshall JC, McArthur CJ, Murthy S, Webb SA, Acharya SP, Ishani PGP, Jawad I, Khanal S, Koirala K, Luitel S, Pabasara U, Paneru HR, Kumar A, Patel SS, Ramakrishnan N, Salahuddin N, Shaikh M, Tolppa T, Udayanga I, Umrani Z. Operationalisation of the Randomized Embedded Multifactorial Adaptive Platform for COVID-19 trials in a low and lower-middle income critical care learning health system. Wellcome Open Res 2021; 6:14. [PMID: 33604455 PMCID: PMC7883321 DOI: 10.12688/wellcomeopenres.16486.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 01/05/2023] Open
Abstract
The Randomized Embedded Multifactorial Adaptive Platform (REMAP-CAP) adapted for COVID-19) trial is a global adaptive platform trial of hospitalised patients with COVID-19. We describe implementation in three countries under the umbrella of the Wellcome supported Low and Middle Income Country (LMIC) critical care network: Collaboration for Research, Implementation and Training in Asia (CCA). The collaboration sought to overcome known barriers to multi centre-clinical trials in resource-limited settings. Methods described focused on six aspects of implementation: i, Strengthening an existing community of practice; ii, Remote study site recruitment, training and support; iii, Harmonising the REMAP CAP- COVID trial with existing care processes; iv, Embedding REMAP CAP- COVID case report form into the existing CCA registry platform, v, Context specific adaptation and data management; vi, Alignment with existing pandemic and critical care research in the CCA. Methods described here may enable other LMIC sites to participate as equal partners in international critical care trials of urgent public health importance, both during this pandemic and beyond.
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Affiliation(s)
- Diptesh Aryal
- Critical Care and Anaesthesia, Nepal Mediciti Hospital, Lalitpur, Bagmati Pradesh, 44600, Nepal
| | - Abi Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand, 10400, Thailand.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Arjen M Dondorp
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand, 10400, Thailand.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Central Thailand, 10400, Thailand.,Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Madiha Hashmi
- Department of Critical Care, Ziauddin University, Karachi, Sindh, Pakistan
| | - Devachandran Jayakumar
- Chennai Critical Care Consultants, Chennai, Tamil Nadu, 600 040, India.,Critical Care Medicine, Apollo Specialty Hospital OMR, Chennai, Tamil Nadu, India
| | - John C Marshall
- The Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Srinivas Murthy
- Faculty of Medicine, University of British Columbia School of Medicine, Vancouver, British Columbia, Canada
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine Monash University, Melbourne, Victoria, Australia.,School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia.,St John of God Hospital, Subiaco, Western Australia, Australia
| | - Subhash P Acharya
- Critical Care Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati Pradesh, 44600, Nepal
| | - Pramodya G P Ishani
- National Intensive Care Surveillance- MORU, Borella, Colombo, Western Province, 08, Sri Lanka
| | - Issrah Jawad
- National Intensive Care Surveillance- MORU, Borella, Colombo, Western Province, 08, Sri Lanka
| | - Sushil Khanal
- Critical Care Medicine, Grande International Hospital, Kathmandu, Bagmati Pradesh, 44600, Nepal
| | - Kanchan Koirala
- Critical Care and Anaesthesia, Nepal Mediciti Hospital, Lalitpur, Bagmati Pradesh, 44600, Nepal
| | - Subekshya Luitel
- Nepal Intensive Care Foundation, Kathmandu, Bagmati Pradesh, Nepal
| | - Upulee Pabasara
- National Intensive Care Surveillance- MORU, Borella, Colombo, Western Province, 08, Sri Lanka
| | - Hem Raj Paneru
- Pulmonary and Critical Care, Hospital for Advanced Medicine and Surgery, Kathmandu, Bagmati Pradesh, Nepal
| | - Ashok Kumar
- Department of Chest Medicine and Critical Care, Ziauddin University, Karachi, Sindh, Pakistan
| | - Shoaib Siddiq Patel
- South East Asian Research in Critical care and Health, Remedial Centre Hospital, Karachi, Sindh, Pakistan
| | | | - Nawal Salahuddin
- Pulmonary & Critical Care Medicine, National Institute of Cardiovascular Diseases, Karachi, Sindh, Pakistan
| | - Mohiuddin Shaikh
- South East Asian Research in Critical care and Health, Remedial Centre Hospital, Karachi, Sindh, Pakistan
| | - Timo Tolppa
- National Intensive Care Surveillance- MORU, Borella, Colombo, Western Province, 08, Sri Lanka
| | - Ishara Udayanga
- National Intensive Care Surveillance- MORU, Borella, Colombo, Western Province, 08, Sri Lanka
| | - Zulfiqar Umrani
- Office of Research, Innovation & Commercialization (ORIC), Zuiddin University, Karachi, Pakistan
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11
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Adhikari NKJ, Arali R, Attanayake U, Balasundaram S, Beane A, Chakravarthy V, Channanath Ashraf N, Darshana S, Devaprasad D, Dondorp AM, Fowler R, Haniffa R, Ishani P, James A, Jawad I, Jayakumar D, Kodipilly C, Laxmappa R, Mangal K, Mani A, Mathew M, Patodia S, Pattnaik R, Priyadarshini D, Pulicken M, Rabindrarajan E, Ramachandran P, Ramesh K, Rani U, Ranjit S, Ramaiyan A, Ramakrishnan N, Ranganathan L, Rashan T, Dominic Savio R, Selva J, Tirupakuzhi Vijayaraghavan BK, Tripathy S, Tolppa T, Udayanga I, Venkataraman R, Vijayan D. Implementing an intensive care registry in India: preliminary results of the case-mix program and an opportunity for quality improvement and research. Wellcome Open Res 2020; 5:182. [PMID: 33195819 PMCID: PMC7642994 DOI: 10.12688/wellcomeopenres.16152.2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/19/2022] Open
Abstract
Background: The epidemiology of critical illness in India is distinct from high-income countries. However, limited data exist on resource availability, staffing patterns, case-mix and outcomes from critical illness. Critical care registries, by enabling a continual evaluation of service provision, epidemiology, resource availability and quality, can bridge these gaps in information. In January 2019, we established the Indian Registry of IntenSive care to map capacity and describe case-mix and outcomes. In this report, we describe the implementation process, preliminary results, opportunities for improvement, challenges and future directions. Methods: All adult and paediatric ICUs in India were eligible to join if they committed to entering data for ICU admissions. Data are collected by a designated representative through the electronic data collection platform of the registry. IRIS hosts data on a secure cloud-based server and access to the data is restricted to designated personnel and is protected with standard firewall and a valid secure socket layer (SSL) certificate. Each participating ICU owns and has access to its own data. All participating units have access to de-identified network-wide aggregate data which enables benchmarking and comparison. Results: The registry currently includes 14 adult and 1 paediatric ICU in the network (232 adult ICU beds and 9 paediatric ICU beds). There have been 8721 patient encounters with a mean age of 56.9 (SD 18.9); 61.4% of patients were male and admissions to participating ICUs were predominantly unplanned (87.5%). At admission, most patients (61.5%) received antibiotics, 17.3% needed vasopressors, and 23.7% were mechanically ventilated. Mortality for the entire cohort was 9%. Data availability for demographics, clinical parameters, and indicators of admission severity was greater than 95%. Conclusions: IRIS represents a successful model for the continual evaluation of critical illness epidemiology in India and provides a framework for the deployment of multi-centre quality improvement and context-relevant clinical research.
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Affiliation(s)
- Neill K J Adhikari
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rajeshwari Arali
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Children's Hospital, Chennai, India
| | - Udara Attanayake
- Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | | | - Abi Beane
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka.,Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Vijay Chakravarthy
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | | | - Sri Darshana
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Dedeepiya Devaprasad
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Arjen M Dondorp
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Robert Fowler
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rashan Haniffa
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka.,Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Pramodya Ishani
- Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Augustian James
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Issrah Jawad
- Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Devachandran Jayakumar
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Chennai Critical Care Consultants, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Chamira Kodipilly
- Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Rakesh Laxmappa
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Nanjappa Hospital, Shimoga, India
| | - Kishore Mangal
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Eternal Hospitals, Jaipur, India
| | - Ashwin Mani
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Meghena Mathew
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Sristi Patodia
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Rajyabardhan Pattnaik
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Ispat General Hospital, Rourkela, India
| | | | - Mathew Pulicken
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Pushpagiri Hospital, Tiruvalla, India
| | - Ebenezer Rabindrarajan
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Pratheema Ramachandran
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Kavita Ramesh
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, ABC Hospitals, Vishakapatnam, India
| | - Usha Rani
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Suchitra Ranjit
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Children's Hospital, Chennai, India
| | - Ananth Ramaiyan
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Chennai Critical Care Consultants, Chennai, India
| | - Nagarajan Ramakrishnan
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Chennai Critical Care Consultants, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Lakshmi Ranganathan
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Chennai Critical Care Consultants, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Thalha Rashan
- Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Raymond Dominic Savio
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Jaganathan Selva
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Mehta Hospitals, Chennai, India
| | - Bharath Kumar Tirupakuzhi Vijayaraghavan
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Chennai Critical Care Consultants, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Swagata Tripathy
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Anaesthesia and Intensive Care Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Timo Tolppa
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Ishara Udayanga
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Network for Improving Critical care Systems and Training, NICST, Colombo, Sri Lanka
| | - Ramesh Venkataraman
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Chennai Critical Care Consultants, Chennai, India.,Critical Care Medicine, Apollo Hospitals, Chennai, India
| | - Deepak Vijayan
- Indian Registry of IntenSive care, IRIS, Chennai, India.,Critical Care Medicine, Kerala Institute of Medical Sciences, Thiruvananthapuram, India
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12
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Plumptre I, Tolppa T, Jawad ZAR, Zafar N. Donut rush to laparoscopy: post-polypectomy electrocoagulation syndrome and the 'pseudo-donut' sign. BJR Case Rep 2020; 6:20190023. [PMID: 33029357 PMCID: PMC7526999 DOI: 10.1259/bjrcr.20190023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 11/14/2019] [Accepted: 11/19/2019] [Indexed: 01/18/2023] Open
Abstract
Colonoscopic polypectomy is a routine procedure with the potential for rare but well-known complications, including perforation and bleeding. Post-polypectomy electrocoagulation syndrome (PPES) is a less recognized cause of abdominal pain following this procedure. However, it is important to diagnose PPES in order to avoid unnecessary intervention. We present the case of a patient with abdominal pain after polypectomy. The patient underwent an unnecessary diagnostic laparoscopy on the basis of misinterpreted radiological findings. Her CT scan demonstrated the "donut" sign that was suggestive of ileocaecal intussusception. This case highlights the importance of recognizing PPES as a possible cause for abdominal pain after colonoscopic polypectomy and that it may also present with a "pseudodonut" sign on CT scan. It also demonstrates the importance of communicating and then integrating full clinical details with radiological findings when formulating a differential diagnosis.
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Affiliation(s)
- Isabella Plumptre
- Department of General Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Timo Tolppa
- Department of General Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Zaynab A R Jawad
- Department of General Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | - Noman Zafar
- Department of General Surgery, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
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13
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Adhikari NKJ, Arali R, Attanayake U, Balasundaram S, Beane A, Chakravarthy V, Channanath Ashraf N, Darshana S, Devaprasad D, Dondorp AM, Fowler R, Haniffa R, Ishani P, James A, Jawad I, Jayakumar D, Kodipilly C, Laxmappa R, Mangal K, Mani A, Mathew M, Patodia S, Pattnaik R, Priyadarshini D, Pulicken M, Rabindrarajan E, Ramachandran P, Ramesh K, Rani U, Ranjit S, Ramaiyan A, Ramakrishnan N, Ranganathan L, Rashan T, Dominic Savio R, Selva J, Tirupakuzhi Vijayaraghavan BK, Tripathy S, Tolppa T, Udayanga I, Venkataraman R, Vijayan D. Implementing an intensive care registry in India: preliminary results of the case-mix program and an opportunity for quality improvement and research. Wellcome Open Res 2020; 5:182. [DOI: 10.12688/wellcomeopenres.16152.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
Background: The epidemiology of critical illness in India is distinct from high-income countries. However, limited data exist on resource availability, staffing patterns, case-mix and outcomes from critical illness. Critical care registries, by enabling a continual evaluation of service provision, epidemiology, resource availability and quality, can bridge these gaps in information. In January 2019, we established the Indian Registry of IntenSive care to map capacity and describe case-mix and outcomes. In this report, we describe the implementation process, preliminary results, opportunities for improvement, challenges and future directions. Methods: All adult and paediatric ICUs in India were eligible to join if they committed to entering data for ICU admissions. Data are collected by a designated representative through the electronic data collection platform of the registry. IRIS hosts data on a secure cloud-based server and access to the data is restricted to designated personnel and is protected with standard firewall and a valid secure socket layer (SSL) certificate. Each participating ICU owns and has access to its own data. All participating units have access to de-identified network-wide aggregate data which enables benchmarking and comparison. Results: The registry currently includes 14 adult and 1 paediatric ICU in the network (232 adult ICU beds and 9 paediatric ICU beds). There have been 8721 patient encounters with a mean age of 56.9 (SD 18.9); 61.4% of patients were male and admissions to participating ICUs were predominantly unplanned (87.5%). At admission, most patients (61.5%) received antibiotics, 17.3% needed vasopressors, and 23.7% were mechanically ventilated. Mortality for the entire cohort was 9%. Data availability for demographics, clinical parameters, and indicators of admission severity was greater than 95%. Conclusions: IRIS represents a successful model for the continual evaluation of critical illness epidemiology in India and provides a framework for the deployment of multi-centre quality improvement and context-relevant clinical research.
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14
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Plumptre I, Tolppa T, Blair M. Parent and staff attitudes towards in-hospital opportunistic vaccination. Public Health 2020; 182:39-44. [DOI: 10.1016/j.puhe.2020.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/26/2019] [Accepted: 01/09/2020] [Indexed: 10/24/2022]
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15
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Tolppa T, Vangu AM, Balu HC, Matondo P, Tissingh E. Impact of the primary trauma care course in the Kongo Central province of the Democratic Republic of Congo over two years. Injury 2020; 51:235-242. [PMID: 31864671 DOI: 10.1016/j.injury.2019.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/15/2019] [Accepted: 12/09/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The two-day Primary Trauma Care (PTC) course covers the management of injured patients and takes into account resource constraints experienced in low and middle-income countries. Currently, there are no studies on the long-term impact of the course on knowledge or attitudes. The PTC course was introduced in Kongo Central Central province in the Democratic Republic of Congo (DRC) as part of a series of interventions to improve trauma care. The aim of this study was to evaluate the impact of PTC on the trauma knowledge, confidence and attitudes regarding trauma care of healthcare workers (HCWs) in the DRC over two years. METHOD A retrospective cohort study was conducted comparing multiple-choice questionnaire (MCQ) and confidence matrix results of PTC attendees prior to the course, immediately after, and at the time of follow up at either 12, 16 or 24 months. A semi-structured questionnaire was additionally administered at follow up to explore the effect of PTC on key areas of trauma learning: skills, attitudes and relationships. RESULTS A total of 59/80 HCWs who attended the PTC course completed follow-up questionnaires. Participants were predominantly male (42/59) with a mean age of 41.6 years. There was an increase of 4.8 in MCQ scores and 9.6 in confidence scores (p < 0.01) post-PTC. MCQ scores were maintained 24 months after the course, whereas confidence scores declined (p = 0.03). At follow-up, 36/59 participants reported that equipment was not available for procedures and 52/59 felt more could be done to better manage injured patients locally. All participants believed trauma services were important and felt that the course contributed to improving the management of trauma patients. CONCLUSIONS This study found that knowledge gained from the PTC course was maintained over two years, although individuals felt less clinically confident. A refresher course may be appropriate within two years to improve relatively low overall knowledge scores and participants' confidence. Whilst resource constraints within the DRC may hinder trauma care development, the PTC course has equipped attendees with the knowledge, skills, confidence and attitudes to improve trauma service development in their region.
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Affiliation(s)
- T Tolppa
- King's Kongo Central Partnership, United Kingdom; King's Centre for Global Health, United Kingdom; King's College, London, United Kingdom; King's Health Partner, United Kingdom.
| | - A M Vangu
- King's Kongo Central Partnership, United Kingdom; King's Centre for Global Health, United Kingdom; King's College, London, United Kingdom; King's Health Partner, United Kingdom
| | - H C Balu
- Université Joseph Kasa Vubu, Boma, Kongo Central, United Kingdom
| | - P Matondo
- Hôpital Provincial de Reference de Kinkanda, Matadi, Kongo Central, United Kingdom
| | - E Tissingh
- King's Kongo Central Partnership, United Kingdom; King's Centre for Global Health, United Kingdom; King's College, London, United Kingdom; King's Health Partner, United Kingdom
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16
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Tolppa T, Plumptre I, Mouyis M. E046 Paternal fertility and conception data from a London district general hospital. Rheumatology (Oxford) 2019. [DOI: 10.1093/rheumatology/kez110.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Timo Tolppa
- Rheumatology Department, Northwick Park Hospital, London, UNITED KINGDOM
| | - Isabella Plumptre
- Rheumatology Department, Northwick Park Hospital, London, UNITED KINGDOM
| | - Maria Mouyis
- Rheumatology Department, Northwick Park Hospital, London, UNITED KINGDOM
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17
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Tolppa T, Plumptre I, Mouyis M. Reproductive rheumatology: the male perspective. Clin Rheumatol 2019; 38:1225-1226. [DOI: 10.1007/s10067-019-04461-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
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18
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Tolppa T, Lowsby R, Harrison H, Evans G, Kamara C. MORTALITY OF EMERGENCY PATIENTS IN A TERTIARY REFERRAL HOSPITAL IN SIERRA LEONE–BASELINE RATE AND CORRELATION WITH ADMISSION TRIAGE CATEGORY. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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