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Intro: Dexamethasone, a corticosteroid, was recently demonstrated to be the only medication capable of reducing mortality in severe COVID disease in the UK's Recovery Trial. There is a need to compare different steroids because it is well recognised that different corticosteroids have varied pharmacodynamic properties. The aim of our study was to compare outcomes in severe or critical COVID-19 when treated with Dexamethasone versus Methyl prednisolone. Method(s): We conducted a retrospective quasi-experimental, non-randomized study to determine whether intravenous or oral dexamethasone reduces mortality compared with intravenous methylprednisolone in patients with severe or critical COVID-19.The study was conducted on all patients aged 18 and over admitted at a 700-bedded academic medical center.The primary outcome was the mortality. The secondary outcome included length of stay. Finding(s): A total of 706 hospitalized patients with moderate to severe COVID- 19 were included in the study. There were n=217 patients in Dexamethasone group, n= 393 patients in Methylprednisolone group and n=96 patients who did not receive steroids.Among the baseline characteristics between the groups, there was no significant difference in median age (55 years in dexamethsone group vs 57 years in methyl prednisolone group p=0.09). There was male predominance in methylprednisolone group (74% versus 54% p<0.001) and a greater proportion of patients who required invasive mechanical ventilation (13.7% versus 3.2% p<0.001). Mortality was found to be significantly higher in methylprednisolone group compared to dexamethasone group on univariate logistic regression analysis (13.7% versus 3.2% p<0.001) and longer length of stay (7 days versus 4 days p<0.001). In multivariable model, dexamethsone was found to be associated with lower risk of mortality (aOR: 0.24;95% CI: (0.09- 0.62)(p=0.003) and lesser length of stay (aOR: 0.87;95% CI: (0.82-0.92) (p<0.001). Conclusion(s): Dexamethasone was associated with lower mortality and lesser length of stay when compared to Methyl prednisolone in moderate to critical COVID-19.Copyright © 2023
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Objective: To determine the frequency and outcomes of invasive pulmonary aspergillosis (IPA) in patients with influenza, COVID-19 and community acquired pneumonia (CAP) admitted in critical care units of a tertiary care hospital in Pakistan. Method(s): A prospective cross sectional study was conducted at the Aga Khan University from Nov 2019-June 2020. Adult patients admitted in critical care units with CAP, influenza and COVID-19 pneumonia were included. IPA was diagnosed as per EORTC/MSG criteria. Clinical information and outcome were collected on predesigned performa. Result(s): A total of 140 patients [70 Influenza, 35 COVID-19 and 35 CAP] were included. Of total, 20(14.2%) patients were found to have invasive aspergillosis with 10/35(28.5%), 9/75(12.8%) and 1/35(2.8%) patients in COVID-19, influenza and CAP groups, respectively. Duration of symptoms was 12.5+/-12.13 days in CAPA and 7.56+/-4.0 days in IAPA patients (p=0.24). Mean APCHE II score was 17.4+/-8.42 and 16.6+/-6.27 in patients with CAPA and IAPA respectively (p=0.85). 9(90%) CAPA patients required vasopressor support compared to 3(33%) patients in IAPA (p=0.020). 7(70%) CAPA patients required invasive mechanical ventilation compared to 4(44%) IAPA patients (p=0.37). Length of stay in hospital was highest in CAPA patients (18.3+/-7.28 days) compared to IAPA patients (11.7+/-5.33 days) (p=0.036). The number of deaths in IAPA patients and CAPA patients was 3(33.3%) and 5(50%), respectively (p=0.526). Conclusion(s): A higher proportion of patients with COVID-19 developed IPA compared to influenza and CAP. CAPA patients had a significantly longer stay in hospital and mortality.
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Objective: To determine the preference for home quarantine and its reasons among health professionals during the COVID-19 pandemic. Study Design: Cross-sectional study. Place and Duration: Department of Obstetrics/Gynecology, Liaquat University of Medical and Health Sciences Jamshoro, and other affiliated hospitals with LUMHS, from Apr to Sep 2021. Methodology: Eighty home-quarantined health professionals (HPs) at our institute following the exposure to confirm COVID-19 cases were included. A pre-designed questionnaire was used to analyze its reliability using Cronbach's alpha value in SPSS after completing the home quarantine period and analyzed. Results: We enrolled 80 health professionals. 43 (53.8%) were PG Trainees, followed by consultant (20%), doctors (20.0%), nurses (6.2%), and technicians (6.9%). The mean quarantined period was 15.72 ± 6.15 days (7-20 days). Doctors, PG trainees, and nurses perceived a greater level of irritability than the other health professionals. We found an association between irritability and advanced age, confinement, and being single. Generally, PG Trainee revealed higher physical activity (p= <0.001). Physical activity was significantly lower among respondents who were unmarried (p= 0.004). Conclusion: Increased satisfaction and a more homelike environment, less aggravation of symptoms, and a mild level of depression and anxiety among health care professionals were associated with home quarantine measures during the COVID-19 pandemic. © 2022, Army Medical College. All rights reserved.
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Aims: To assess medical students' perception of online teaching to suggest transforming the future curriculum in low-economic countries. Study Design: Cross-sectional online interview study. Place and Duration of Study: A team of collaborators interviewed final year medical and dental students of Pakistan from 07/08/2020 till 17/09/2020. Methodology: A questionnaire was developed based on open and close-ended questions in Google forms;focusing on institutional preparedness, views on online education, the institute's closure and COVID-19, and long-term effects of closure of the institute. Independent fellow researchers systematically analyzed the unaltered transcripts of the responses, and themes were then identified and coded to conclude the results. SPSS version 23 used for analysis. As this study was based on final year students. Results: In response to an invitation email, 2442/2661 (91.77%) students voluntarily participate in this qualitative study. Most participants were females (1614, 66.10%). Closing down institutes was directly linked to a lack of motivation and feel of helplessness. As most showed dissatisfaction with online teaching compounded by psychological effects, students feared losing clinical skills and life during the pandemic. Conclusion: The psychological impact of the crisis led to resistance to accepting the change for a better outcome. Incorporating telemedicine, different interactive learning style to online teaching, and resilience training would result in fruitful outcomes. Developed countries may also guide build infrastructure in developing countries to develop a more robust online teaching methodology in the long-run.
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Background: Vaccination for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has already resulted in a reduction in new infection and mortality cases. Preliminary reports indicate variable and reduced antibody response in multiple sclerosis (MS) patients treated with different disease-modifying therapies (DMTs). Objective and Aim: To determine the effects of different DMT on the humoral response after COVID-19 vaccination in MS patients. Methods: A total of 154 MS patients were vaccinated with one of three available SARS-CoV-2 vaccines (BNT162b2, mRNA-1273, and Ad26.COV2.S). The humoral response was determined by measurement of either unspecific IgG antibodies or anti-spike IgG antibodies. The time between vaccination and serological testing and time from the last infusion date (if applicable) to testing were determined. Humoral response greater than 1.0 was considered as positive and suggestive of acquired immunity. Results: Overall, 89 out of 127 (70.1%) and 15 out of 27 (55.6%) MS patients had a positive anti-S1 test and unspecific IgG test, respectively. Excluded from the analysis were two patients who had only one dose of the mRNA vaccine with negative seroconversion and four patients with a history of SARS-CoV-2 PCRpositive test and positive seroconversion. In the remaining sample, there were no sex and age differences in seroconversion (both p>0.05). Based on DMT groups, seroconversion was seen in 22/26 (84.6%) patients treated with interferon-β, 18/19 (94.7%) on glatiramer acetate, 14/16 (87.5%) on natalizumab, 6/10 (60%) on teriflunomide, 3/8 (37.5%) on sphingosine-1-phosphate (S1P) modulators, 9/9 (100%) on dimethyl fumarate, 0/3 (0%) on cladribine (but all of these patients had prior ocrelizumab from 8 to 9 months prior), 4/28 (14.3%) on anti-CD20 depleters, and 3/5 (60%) on off-label medications. 87.5% (21/24) of non-treated MS patients had positive seroconversion. Seroconverted MS patients treated with anti-CD20 had numerically greater time from the last infusion to the first vaccination (162.3 vs. 80.9 days). Conclusion: MS patients treated with B-cell depleting medications and S1P modulators have significantly lower seroconversion after COVID-19 vaccination when compared to DMT-naive patients and other DMT groups. Future studies should determine the risk of severe clinical outcomes in vaccinated patients with no evidence of seroconversion.
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: CT Chest is considered as one of the important modalities for the diagnosis and assessment of progression of COVID-19 disease. We conducted a study highlighting salient features of CT chest in patients with COVID-19 in a tertiary care center in Karachi, Pakistan. METHODS: This was a cross-sectional study done at Aga khan university from April 2020 to December 2020. Adult patients who had a positive COVID-19 PCR and underwent CT scan chest were included in the study. Five hundred and eighteen patients who underwent CT scan chest were selected for screening. One hundred and twelve patients who were positive for COVID-19 PCR were selected for review. Two patients were later excluded as they had chronic changes on CT scan due to underlying comorbidities. RESULTS: Among the study cohort of 110 patients, 70 (63.7 %) were males and 40 (36.4 %) were females with a mean age of 56.5 ± 14.8 years (range 46-67 years). Out of 110 patients, 79 underwent high-resolution CT (HRCT) scan and 31 underwent contrast-enhanced CT chest. The most common abnormality seen on CT was ground-glass opacities (79%), followed by consolidation (62%), crazy paving pattern (32%), vascular enlargement sign (27%) and fibrotic-like features or reticulations (21%). Furthermore, air bronchogram sign was seen in 21%, pleural effusion was seen in 8% and lymphadenopathy in 7% of patients. CONCLUSIONS: CT scan chest is a key tool of investigation in the diagnosis of COVID-19 disease. Studies from across the world have identified specific CT scan patterns that can aid in the diagnosis of the disease. This is a study from a low to middle-income country that describes the spectrum of radiological features found in COVID-19 and has also focused on certain atypical features associated with COVID-19. CLINICAL IMPLICATIONS: Certain radiological features like ground-glass opacities and consolidation are a known features of COVID-19. This study emphasizes on the most frequent radiological features of COVID seen in a tertiary care hospital in Pakistan. Chest CT imaging has a high negative predictive value and high sensitivity for diagnosing COVID-19 and can be considered as an alternative primary screening tool for COVID-19 in epidemic areas. Moreover, a negative RT-PCR test and a positive CT chest finding can suggest COVID-19. Hence as a clinician and radiologist, one should be aware of all the spectrum of radiological features so that early diagnosis and management can be facilitated. DISCLOSURES: No relevant relationships by Safia Awan, source=Web Response No relevant relationships by Kulsoom Fatima, source=Web Response no disclosure on file for Basit Salam;No relevant relationships by Aqusa Zahid, source=Web Response No relevant relationships by Syed Muhammad Zubair, source=Web Response No relevant relationships by Ali Zubairi, source=Web Response
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Aim: To assess the results of chest x ray radiographs of patients positive for Covid-19, presented at the tertiary care hospital according to the classification by the British Society of Thoracic Imaging (BSTI. Place and Duration: In COVID-19 Ward (Department of Medicine) Sheikh Zayed Hospital, Lahore for three months duration from January 2021 to March 2021. Methods: A total of 96 patients were selected. In this observational study, positive COVID-19 patient determined by the reverse transcriptase polymerase chain reaction (RT-PCR) were enrolled for this study above the age of 14 years. CXR results were classified conferring to BSTI documentation and classification in terms of percentage and frequency. Results: Chest rays of 96 patients who tested positive for Covid-19 by RT-PCR over the age of 14 years were examined. Chest X-rays are classified according to the BSTI Covid-19 X-ray classification. Out of 96 patients, 10 patients (10.41%) had normal chest x-rays, 19 (19.80%) patients had classic bilateral, peripheral and basal consolidation / ground glass opacity (GMO), 60 (62.5%) had unspecified group,7(7.29%) patients have poor quality X-ray film. The unilateral involvement was noticed in 15 and bilateral in 49 patients, 12 of the patients had diffuse involvement on chest radiograph and peripheral involvement in 39 patients. According to regional dominance, 41 of the unspecified (42.70%) had middle and lower lung involvement, 7 (7.29%) had only the middle zone, and 8 (8.33%) had involvement of lower zone. Conclusions: In this study, Covid-19 chest X-rays are usually presented as ground glass opacity, mixed consolidation with GGOs in the middle and lower peripheral areas of the bilateral lung. Chest X-ray BSTI classification is used to classify Covid-19 severity in our patients, thus differentiating in the classic Covid-19 of the middle zone versus low zone involvement.
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Introduction: Various national guidance from the LordCarter 2016 report to the NHS Long term plan haveemphasised the need to transform traditional hospitalpharmacy and make work streams more efficient.[1] A clinical trials pharmacist has historically validated clinical trialmedicines. Whilst this is good practice for non-chemotherapyprescriptions, it is not a requirement of the Clinical TrialRegulations.[2] Interruption to validate trial prescriptionscan have a negative impact on pharmacists' duty and consequently patient outcomes. With limited data available, thisissue has been highlighted by anecdotal evidence. Due to theoften complex requirements associated with trials, the research team are responsible for assessing the suitability oftreatment. This includes checking interactions with concomitant medication, reviewing blood results and patient counselling. The clinical aspect of the pharmacist validation istherefore removed, allowing technicians to be involved in thescreening of suitable prescriptions. Much is written on technicians extending their roles in the clinical setting, but thisservice improvement focuses on enhancing their role withinthe pharmacy clinical trials department.Aim: To evaluate the amount of pharmacists' time savedby the introduction of technician screening of clinical trialprescriptions.Method: A risk-based proforma was created and usedby a pharmacist to assess clinical trial prescriptions for thesuitability of screening by a Band 7 technician. Only prescriptions with pre-printed doses, no aseptic preparationor additional medicines, were approved for technicianscreening. The process of screening therefore only involvesthe checking of patient and prescriber details, allergy statusand possibly a medication randomisation. The techniciansunder-went an in-house training including the screening ofprescriptions under pharmacist supervision. A quantitativedata collection tool was used to review the screening/validation of all nonchemotherapy clinical trial prescriptionsreceived at two sites over a two-week period in September2020. The data collection tool was piloted and all data wasanalysed using Microsoft Excel. Results: A total of 89 prescriptions were received. 56(63%) were eligible for technician screening, of which a suitable technician validated 50%.Across both sites a total time of 360 minutes were spentvalidating/screening prescriptions including solving prescription related issues. Combining the time taken by a pharmacistto return from a clinical area and screening time consequentlysaved a total of 227 minutes of pharmacists' time.Conclusion: Distributing the workload amongst trainedstaff saves pharmacist's time, which can be utilised on clinical and complex tasks. This does not eliminate the requirement of a pharmacist to validate prescriptions however;itreduces the frequency and streamlines the service. Furtherdata collection is required to analyse the direct impact onpatients' and any changes in the number of reported errors.A limitation to the study is the lack of data prior to implementation as a comparator. Additionally, during data collection there were no suitable technicians available at onesite due to the Covid-19 pandemic, resulting in only 50%of eligible prescriptions being screened by a technician.Ultimately, this does not change the outcome;enhancingtechnician's roles allows pharmacists' time to be used moreefficiently.