DFV890: a new oral NLRP3 inhibitor—tested in an early phase 2a randomised clinical trial in patients with COVID-19 pneumonia and impaired respiratory function

Background

Coronavirus-associated acute respiratory distress syndrome (CARDS) has limited effective therapy to date. NLRP3 inflammasome activation induced by SARS-CoV-2 in COVID-19 contributes to cytokine storm.

Methods

This randomised, multinational study enrolled hospitalised patients (18–80 years) with COVID-19-associated pneumonia and impaired respiratory function. Eligible patients were randomised (1:1) via Interactive Response Technology to DFV890 + standard-of-care (SoC) or SoC alone for 14 days. Primary endpoint was APACHE II score at Day 14 or on day-of-discharge (whichever-came-first) with worst-case imputation for death. Other key assessments included clinical status, CRP levels, SARS-CoV-2 detection, other inflammatory markers, in-hospital outcomes, and safety.

Findings

Between May 27, 2020 and December 24, 2020, 143 patients (31 clinical sites, 12 countries) were randomly assigned to DFV890 + SoC (n = 71) or SoC alone (n = 72). Primary endpoint to establish clinical efficacy of DFV890 vs. SoC, based on combined APACHE II score, was not met; LSM (SE), 8·7 (1.06) vs. 8·6 (1.05); p = 0.467. More patients treated with DFV890 vs. SoC showed ≥ 1-level improvement in clinical status (84.3% vs. 73.6% at Day 14), earlier clearance of SARS-CoV-2 (76.4% vs. 57.4% at Day 7), and mechanical ventilation-free survival (85.7% vs. 80.6% through Day 28), and there were fewer fatal events in DFV890 group (8.6% vs. 11.1% through Day 28). DFV890 was well tolerated with no unexpected safety signals.

Interpretation

DFV890 did not meet statistical significance for superiority vs. SoC in primary endpoint of combined APACHE II score at Day 14. However, early SARS-CoV-2 clearance, improved clinical status and in-hospital outcomes, and fewer fatal events occurred with DFV890 vs. SoC, and it may be considered as a protective therapy for CARDS.

Trial registration

ClinicalTrials.gov, NCT04382053.

Supplementary Information

The online version contains supplementary material available at 10.1007/s15010-022-01904-w.

Outcomes of COVID-19 in Cancer Patients who Developed Acute Kidney Injury During Hospitalization in a Tertiary Care Hospital in India

Background: The development of acute kidney injury (AKI) in patients infected with COVID-19 has been observed to be associated with poor outcomes. Our study aimed to measure the outcomes of COVID-19 in cancer patients who developed AKI during hospitalization and the predictive baseline clinical and laboratory factors associated with the development of AKI. Materials and Methods: This retrospective cohort study was conducted at a COVID hospital that included only cancer patients with COVID-19 infection. Acute kidney injury (AKI) was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria. The demographic, clinical, laboratory and outcomes data were collected from the hospital electronic database and abstracted from the case files. Results: Thirteen (12.8%) of the total 102 cancer patients developed AKI during hospitalization. Out of 13, 11 (84.6%) patients presented with hypoxemia during admission and required oxygen support. Breathlessness [Odds Ratio (OR) (95% CI): 5.8 (1.1-31.3)] or hypoxemia [OR 22.6 (2.6-194.5)] at the time of presentation and requirement of oxygen support [OR 7.5 (1.4-40.5)] were significantly associated with AKI after adjusting for age, gender, vaccination status and comorbidities. Median baseline values of inflammatory markers were significantly higher among those who developed AKI. Out of 102, 27 (26.5%) patients had in-hospital mortality. Mortality was high among those who developed AKI compared to those who didn’t develop AKI (92.3% vs 16.1%, p-value: <0.001). Conclusions: The cancer patients infected by COVID-19 and who developed AKI were more vulnerable to poor outcomes in terms of in-hospital mortality. The patients with severe disease at presentation and higher levels of baseline inflammatory markers CRP, ferritin, and D-Dimer were more susceptible to the development of AKI and in turn, led to a higher risk of in-hospital mortality in these patients. 

Impact of COVID-19 Pandemic on Medical Practices

The COVID-19 pandemic has affected human life in all spheres. However, the medical and health practices seen changed a lot since the arrival of this pandemic. This article describes the positive and negative impact of covid in the medical field. The integration of telehealth needs to be emphasized and positive changes like hand hygiene, wearing a mask, and appropriate social distancing and online interactive learning may be useful in health care practices. Although, the negative effects of the pandemic like ignoring the patients with other comorbidity and deteriorating mental health of HCW must be kept in mind and should be properly addressed.  

Airway management, procedural data, and in-hospital mortality records of patients undergoing surgery for mucormycosis associated with coronavirus disease (COVID-19)

Purpose

Although unexpected airway difficulties are reported in patients with mucormycosis, the literature on airway management in patients with mucormycosis associated with Coronavirus disease is sparse.

Methods

In this retrospective case record review of 57 patients who underwent surgery for mucormycosis associated with coronavirus disease, we aimed to evaluate the demographics, airway management, procedural data, and in-hospital mortality records.

Results

Forty-one (71.9%) patients had a diagnosis of sino-nasal mucormycosis, fourteen (24.6%) patients had a diagnosis of rhino-orbital mucormycosis, and 2 (3.5%) patients had a diagnosis of palatal mucormycosis. A total of 44 (77.2%) patients had co-morbidities. The most common co-morbidities were diabetes mellitus in 42 (73.6%) patients, followed by hypertension in 21 (36.8%) patients, and acute kidney injury in 14 (28.1%) patients. We used the intubation difficulty scale score to assess intubating conditions. Intubation was easy to slightly difficult in 53 (92.9%) patients. In our study, mortality occurred in 7 (12.3%) patients. The median (range) mortality time was 60 (27–74) days. The median (range) time to hospital discharge was 53.5 (10–85) days. The median [interquartile range] age of discharged versus expired patients was 47.5 [41,57.5] versus 64 [47,70] years (P = 0.04), and median (interquartile range) D-dimer levels in discharged versus expired patients was 364 [213, 638] versus 2448 [408,3301] ng/mL (P = 0.03).

Conclusion

In patients undergoing surgery for mucormycosis associated with the coronavirus disease, airway management was easy to slightly difficult in most patients. Perioperative complications can be minimized by taking timely and precautionary measures.

Perioperative anaesthetic management in cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC): a retrospective analysis in a single tertiary care cancer centre

Objectives

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is associated with increased morbidity and mortality. We retrospectively analysed the perioperative anesthetic management in patients undergoing HIPEC surgery.

Methods

After ethics approval, we reviewed the records of patients who underwent CRS/HIPEC from 2015 until 2020. We noted the peritoneal carcinomatosis index (PCI), blood loss, anastomoses done, total amount of fluid given, delta temperature and duration of surgery. These were correlated with the need for postoperative ventilation, length of ICU stay, Clavien–Dindo score and 30 day mortality.

Results

Of the 180 patients reviewed, the majority were women (85%) with a mean age of 48 years who had ovarian tumors (n=114). The total amount of fluid given was associated with an increased length of ICU stay (p=0.008). Prolonged surgery resulted in increased length of ICU stay (p<0.001), need for postoperative ventilation (p=0.006) and a poor Clavien–Dindo score (p=0.039). A high PCI score correlated with increased ICU stay, 30 day mortality (p<0.001), and the need for postoperative ventilation (0.005).

Conclusions

PCI, duration of surgery and blood loss were major predictors of postoperative morbidity. Additionally, the amount of fluid given and delta temperature affected patient outcome and should be individualized to the patient’s needs.

Silent Hypoxia in Coronavirus disease-2019: Is it more dangerous? -A retrospective cohort study

BACKGROUND

Hypoxia in patients with COVID-19 is one of the strongest predictors of mortality. Silent hypoxia is characterised by the presence of hypoxia without dyspnoea. Silent hypoxia has been shown to affect the outcome in previous studies.

METHODS

This was a retrospective study of a cohort of patients with SARS-CoV-2 infection who were hypoxic at presentation. Clinical, laboratory and treatment parameters in patients with silent hypoxia and dyspnoeic hypoxia were compared. Multivariate logistic regression models were fitted to identify the factors predicting mortality.

RESULTS

Among 2080 patients with COVID-19 admitted to our hospital, 811 patients were hypoxic with SpO₂ <94% at the time of presentation. Among them, 174 (21.45%) did not have dyspnoea since the onset of COVID-19 symptoms. Further, 5.2% of patients were completely asymptomatic for COVID-19 and were found to be hypoxic only on pulse oximetry. The case fatality rate in patients with silent hypoxia was 45.4% as compared to 40.03% in dyspnoeic hypoxic patients (P = 0.202). The odds ratio of death was 1.1 (95% CI: 0.41-2.97) in the patients with silent hypoxia after adjusting for baseline characteristics, laboratory parameters, treatment and in-hospital complications, which did not reach statistical significance (P = 0.851).

CONCLUSION

Silent hypoxia may be the only presenting feature of COVID-19. As the case fatality rate is comparable between silent and dyspnoeic hypoxia, it should be recognised early and treated as aggressively. Because home isolation is recommended in patients with COVID-19, it is essential to use pulse oximetry in the home setting to identify these patients.

Pain management policy formulation at a tertiary care teaching institute in India: A prospective observational study

BACKGROUND

Access to pain management has been recognized as a fundamental human right. Inadequate pain relief hampers the quality of life and has a physiological and psychosocial impact on the patient and caregivers. Inadequate pain relief remains the leading cause of suffering in hospitalized patients worldwide.

OBJECTIVE

The objective of this article is to provide adequate pain relief to hospitalized patients through proper assessment, treatment, and monitoring of pain by the trained health-care workers through a sustainable and effective institutional pain management policy.

METHODS

The formulation of pain management policy at a tertiary care teaching institute was conducted in three phases - Phase 1: need assessment by an open-label, uncontrolled, prospective observational study over 1 month period, Phase 2: teaching, training, and awareness of health-care workers, and Phase 3: constitution of the committee at the institute level with the formation of pain resource teams.

RESULTS

An open-label, prospective observational study conducted over 1 month revealed that among 814 hospitalized patients, 108 out of 235 (46%) patients in medical and 385 out of 579 (66.5%) patients in the surgical cohort had NRS score of ≥3, implying an inadequate pain relief even at 24 h following medical or surgical intervention, respectively.

CONCLUSION

The provision of effective and adequate pain relief to hospitalized patients requires trained health-care workers and a uniform and structured pain management policy at the institutional level. Recognition and addressal of the barriers and challenges while framing an institutional pain policy is of utmost importance.

Institutional end-of-life care policy for inpatients at a tertiary care centre in India: A way forward to provide a system for a dignified death

India has a high share in the global burden of chronic terminal illnesses. However, there is a lack of a uniform system in providing better end-of-life care (EOLC) for large patients in their terminal stage of life. Institutional policies can be a good alternative as there is no national level policy for EOLC. This article describes the important aspects of the EOLC policy at one of the tertiary care institutes of India. A 15 member institutional committee including representatives from various departments was formed to develop this institutional policy. This policy document is aimed at helping to recognize the potentially non-beneficial or harmful treatments and provide transparency and accountability of the process of limitation of treatment through proper documentation that closely reflects the Indian legal viewpoint on this matter. Four steps are proposed in this direction: (i) recognition of a potentially non-beneficial or harmful treatment by the physicians, (ii) consensus among all the caregivers on a potentially non-beneficial or harmful treatment and initiation of the best supportive care pathway, (iii) initiation of EOLC pathways, and (iv) symptom management and ongoing supportive care till death. The article also focuses on the step-by-step process of formulation of this institutional policy, so that it can work as a blueprint for other institutions of our country to identify the infrastructural needs and resources and to formulate their own policies.

Self-limiting severe neutropenia in a patient with COVID-19

Neutropenia is a rare haematological complication of COVID-19 infection in immunocompetent patients. There is sparse literature on neutropenia in patients with COVID-19, except a few case reports. We encountered a similar case in an intensive care unit that developed severe neutropenia on day 24 of illness. Neutropenia resolved spontaneously on 4th day of its appearance. The patient was isolated and kept under close observation, antibiotics were upgraded and strict asepsis was maintained. Thus, we observed in a patient with no comorbidities and uncomplicated neutropenia that strict measures to prevent infection may suffice and the undue risk of hematopoietic therapy can be avoided. An expert opinion should always be sought in such cases as the presence of complications may require an aggressive approach.

Surviving COVID-19 is Half the Battle; Living Life with Perceived Stigma is Other Half: A Cross-Sectional Study

BACKGROUND

Year 2020 started with global health crisis known as COVID-19. In lack of established tools and management protocols, COVID-19 had become breeding ground for fear and confusion, leading to stigma toward affected individuals.

METHOD

A cross-sectional study was conducted to estimate prevalence of stigma in discharged COVID-19 patients from a COVID hospital in India. Participants were approached telephonically using a semistructured questionnaire to record their experiences. Questions were asked regarding stigma at six major domains of daily life. Among total 1,673 discharged participants, 600 were conveniently selected and out of them 311 responded on telephonic interviews.

RESULT

We found that 182 (58.52%) participants (95% CI: 53.04-64.00) have self-perceived stigma, 163 (52.41%) participants (95% CI: 46.86-57.96) experienced quarantine-related stigma, 222 (71.38%) participants (95% CI: 66.36-76.40) experienced neighborhood stigma, 214 (68.81%) participants (95% CI: 63.66-73.95) experienced stigma while going out in marketplaces, 180 (57.88%) participants (95% CI: 52.39-63.37) experienced stigma at their work place, and 207 (66.56%) participants (95% CI: 61.31-71.80) reported stigma experienced by their family members. With a total of 84.5% (95% CI: 80.06-88.39) participants experiencing stigma at some domain and about 42.8% of participants facing stigma at all six domains. The commonest noted cause of stigma was fear of getting infected, reported by 184 (59.2%) participants.

CONCLUSION

This study shows high prevalence of stigma in COVID-19 patients suffering in their common domains of daily lives.

Characteristics and outcomes of 231 COVID-19 cases admitted at a tertiary facility in India: An observational cohort study

BACKGROUND

Ongoing pandemic because of COVID-19 has spread across countries, with varied clinical features and severity. Awareness of clinical course among asymptomatic and symptomatology in symptomatic cases is essential for patients' management as well as optimal utilization of health services (in resource limited settings) based on clinical status and risk factors. This study aimed to describe the clinical characteristics and outcomes of patients admitted with COVID-19 illness in the initial phase of the pandemic in India.

METHODS

It was an observational study. Patients aged 18 years or more, with confirmed SARS-CoV-2 infection, asymptomatic or mildly ill, were included. Patients with moderate-severe disease at admission or incomplete clinical symptomatology records were excluded. Data regarding demography, comorbidities, clinical features and course, treatment, results of SARS-CoV-2 RT-PCR, chest radiographs, and laboratory parameters were obtained retrospectively from hospital records. The outcome was noted in terms of course, patients discharged, still admitted (at the time of the study), or death.

RESULTS

Out of 231 cases, most were males (78.3%) with a mean age of 39.8 years. Comorbidities were present in 21.2% of patients, diabetes mellitus and hypertension being the most common. The most common symptoms were dry cough (81, 35%), fever (64, 27.7%), sore throat (36, 15.6%); asymptomatic infection noted in 108 (46.8%) patients. The presence of comorbidities was an independent predictor of symptomatic disease (OR-2.66; 95%CI 1.08-6.53, P = 0·03). None of the patients progressed to moderate-severe COVID-19, and there were no deaths.

CONCLUSIONS

A large proportion of patients remained asymptomatic whereas those with comorbidities were more likely to be symptomatic. Most with mild disease had a stable disease course, barring few complication in those with comorbidities. The pandemic continues to grow as large number of asymptomatic cases may go undiagnosed.

CARE: A Holistic Approach Toward Patients During Pandemic: Through the Eyes of a Palliative Physician

Words pandemic and panic, if cannot be used synonymously, can definitely be exchanged metaphorically. Pandemics are outcome of an unanticipated crisis, therefore it is always associated with panic and hence it requires a comprehensive approach to get resolved. On the contrary, during the event of an overwhelming pandemic, due to lack of protocols, the entire health-care system faces crisis and it becomes a tedious task to reallocate and reschedule the resource and knowledge for the uninterrupted and smooth delivery of services. Therefore, pandemics need an evidence-based subjective approach toward the patient and family members for addressal and resolution of complex issues arisen due to the disease. A good contingency plan and approach for combating a pandemic is the utmost solution for providing complete holistic care. A comprehensive care approach model is the need of the hour to provide the holistic care during pandemics. In this article, we propose a model of CARE approach that can be useful in providing holistic care during the times of pandemic.

A Child with Acute Lymphoblastic Leukemia in Institutional Isolation during the COVID Pandemic: A Multifaceted Responsibility

The occurrence of the COVID-19 pandemic has caused big challenges in medical communities due to its unpredictable and uncertain nature. It leads to a great deal of physical and psychological concerns. It is more prone to patients with comorbidities such as hypertension and diabetes mellitus and also to immune-compromised patients such as cancer patients. Children are no exception. Acute lymphoblastic leukemia (ALL) is the most common malignancy in the pediatric age group. In this case, we discuss the concerns and reflect the issues of a 10-year-old boy of ALL who was tested COVID positive during the evaluation and treatment of his disease and was admitted in a COVID isolation center along with his mother who was COVID negative.

Concerns of Health-care Professionals Managing COVID Patients under Institutional Isolation during COVID-19 Pandemic in India: A Descriptive Cross-sectional Study

Objective

Health-care professionals (HCPs) are the frontline warriors in the time of this uncertain and unpredictable crisis of COVID. They face many challenges while caring for these patients, yet they are expected to cope with it and deliver their duties for the betterment of humankind. Our primary aim was to identify and assess the concerns of HCPs working in COVID area in a tertiary institutional isolation center.

Methodology

An online Google-based questionnaire survey was distributed through various social media platforms after approval of the institutional review board to a total of 100 HCPs who were treating and managing COVID-positive patients.

Results

Of 100 responses, 72% were concerned about the risk of infection to self and family, while 46% reported disruption of their daily activities at a personal level. At the institutional level, 17% were concerned about inadequate personal protective equipment-related challenges. 20% had inadequate knowledge and training about COVID. 16% of participants were anxious all the time, 11% feared all the time, and 12% had stress all the time while treating COVID patients. Connectedness and communication with family and friends, word of appreciation, music, and TV were few strategies to cope up with these challenges.

Conclusion

There is a need to identify and address the concerns and challenges faced by HCPs and to develop a comprehensive strategy and guideline to provide a holistic care and to ensure their security in the workplace.

Central Venous Catheter as Peritoneal Indwelling Catheter for the Management of Recurrent Malignant Ascites: A Case Series

Background

Malignant ascites is an accumulation of fluid in the peritoneal cavity due to the manifestation of terminal metastatic malignancies. Accumulation of ascitic fluid could cause abdominal distention, early satiety, and shortness of breath. The onset and progression of these symptoms are not only distressing but also cause deterioration of the quality of life. Malignant ascites is associated with poor prognosis with anticipated life expectancy ranging from 1 to 4 months. Therapeutic paracentesis is the mainstay of palliation for malignant ascites. It only provides a temporary relief of symptoms, ascites re-accumulates, and paracentesis has to be repeated.

Objectives

The aim of this case series was to evaluate our experiences when treating malignant ascites with placement of central venous catheter in the peritoneal cavity, with special emphasis on patient satisfaction, comfort of caregiver, technical success, and adverse events.

Methods

Five patients with advanced disease and recurrent malignant ascites who required multiple paracentesis were selected for placement of 7-FG triple-port Central venous catheter in the peritoneal cavity. Maximum fluids that can be tapped were removed in ward. Patients and their relatives were assessed for satisfaction with the procedure.

Results

Out of 5 patients, 3 were female and 2 male (age between 46 and 62 years). Two patients had carcinoma gallbladder and one each of carcinoma ovary, breast, and prostate. All patients were followed up till 1 month from catheter placement. Patients and their relatives were well satisfied in terms of frequent hospital visit for paracentesis.

Conclusion

In summary, we suggest that central venous catheter may be used as indwelling peritoneal catheter for the symptom management of recurrent malignant ascites. It provides a relatively safe and cost-effective alternative to serial large-volume paracentesis that requires multiple hospital admissions.