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Introduction: During the COVID-19 pandemic, virtual interviews for resident and fellowship applicants became the standard. However, studies evaluating the experience of virtual interviews format are lacking. Accordingly, we sought to survey both gastroenterology fellowship applicants and interviewing faculty members about their experiences with the virtual interview process. Method(s): Interviewees and faculty at 13 different gastroenterology fellowship programs at academic medical centers across the United States completed a post-interview survey. The online survey was conducted during the 2020 ERAS fellowship interview season via Google Forms. The survey responses were anonymously collected and reported. Result(s): A total of 177 gastroenterology fellowship applicants and 83 faculty members completed the electronic surveys. Most participants reported a positive experience with 91% and 84% of applicants and faculty respectively, scoring at least 4 points on a 5-point scale. Eighty-8 percent and 85% of applicants and faculty respectively, reported that they had enough insight about the applicant or the fellowship program during the interview. Over 67% of applicants reported cost-savings of greater than $1,000 per interview. Thirty-6 percent of applicants reported that they missed the personal interaction with the current gastroenterology fellows in the respective programs and the experience of physically touring the facility. Twenty-7 percent and 25% of applicants and faculty experienced technical difficulties during the interview process, respectively. Thirty-one percent and 22% of applicants and faculty would like for the virtual interviews to be the standard of future fellowship interviews, while 35% and 42% of applicants and faculty would consider it in the future, respectively. Figure 1 shows the ranking process for both applicants and faculty. Conclusion(s): Virtual interviews were perceived as effective and cost-saving by both gastroenterology fellowship applicants and faculty members. The virtual experience was widely accepted by most applicants and faculty, with high potential to become the standard of fellowship interview process in the future. However, a substantial portion experienced technical difficulty. Further improvements in technology are needed to optimize the process and increase the acceptance of the virtual interview experience. (Figure Presented).
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INTRODUCTION: Previous randomized trials suggest the benefit of inhaled budesonide for COVID-19 patients in outpatient settings. We evaluated available studies on the effect of the therapeutic use of inhaled corticosteroids (ICS) on mortality and pertinent clinical outcomes. METHOD(S): A comprehensive literature search was conducted across the WHO, LitCOVID, and EMBASE databases from inception until June 30th, 2022. The primary outcome was overall mortality and secondary outcomes included symptom-based clinical improvement rates at day 14, ER visits or hospitalization, and adverse events. Data analysis was performed using Review Manager Software, version 5.2, to evaluate the combined odds ratio (OR) with 95% confidence intervals (CI) using a random-effects model. RESULT(S): Nine studies (7 RCTs (3 budesonide, 3 ciclesonide, 1 fluticasone RCTs), & 2 observational studies) were included in the mortality meta-analysis. Of the 3,934 patients included, 103 patients died (44 out of 1925 in the ICS group and 59 out of 2009 in the non-ICS group). The odds of mortality in the therapeutic ICS use group were lower compared to the non-ICS therapy group (OR 0.78, 95% CI 0.48-1.28, p-value=0.33, I2=0%). The result was statistically insignificant, possibly due to the low mortality rate. But therapeutic ICS showed statistically significant clinical improvement rates at day 14 (5 RCTs;3 Ciclesonide, 2 Budesonide) (OR 1.56, 95% CI 1.31-1.86, p < 0.0001, I2=0%). The number of ED visits/Hospitalization rate, and adverse events were not statistically significant between the groups (OR 0.73, 95% CI 0.32-1.70, p= 0.47 I2=75% and OR 1.10 95% CI 0.67-1.82, p=0.70, I2=28%). CONCLUSION(S): This meta-analysis shows that the therapeutic use of ICS in COVID-19 is associated with higher symptom-based clinical improvement rates. Although the reduction in mortality odds remained insignificant, as the overall mortality rates were low which increased the confidence interval overall. Early administration of ICS showed a trend towards the reduced likelihood of urgent care needs. Well-designed trials are needed to explore ICS efficacy in patients with a high risk of disease progression and in reducing the incidence of long-term COVID-19 symptoms or post-acute sequelae of SARS-CoV-2.
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INTRODUCTION: Studies of hospitalized patients with COVID-19 have found varying clinical outcomes associated with underlying respiratory conditions and inhaled corticosteroid use. We performed a systematic review to summarize the effect of the pre-hospital use of inhaled corticosteroids on the clinical outcomes in patients with COVID-19. METHOD(S): A comprehensive literature accrual was conducted across the WHO, CDC, and LitCovid PubMed COVID-19 databases from inception until June 30th, 2022. The Overall mortality was the primary outcome, and the secondary outcomes were the need for intensive care unit (ICU) admission and the need for invasive mechanical ventilation (IMV). All included studies were observational and reported the desired outcomes with pre-hospital use of ICS in COVID-19 patients. Data analysis was performed using Review Manager Software, version 5.2 to evaluate the combined odds ratio (OR) with respective 95% confidence intervals (CI) using a random-effects model. RESULT(S): Nineteen studies assessed mortality and were included in the meta-analysis. A total of 1,122,329 patients were included, of which 10,466 patients died (2,289 out of 824,005 in ICS arm patients and 8,177 out of 298,324 in the non-ICS arm), resulting in the unadjusted odds of death (OR 1.36, 95% CI 1.09-1.70, I2=82%). However, In the subgroups analyses of COPD patients (8 studies;598 out of 106,659 in the ICS arm and 353 out of 44,496 in the non-ICS arm) and Asthma patients (7 studies;705 out of 714,126 in the ICS arm and 179 out of 222,577 in the non-ICS arm), significantly increased risk of death was not shown (OR 1.20, 95% CI 0.93-1.57, I2=32%, OR 1.61, 95% CI 0.97-2.66, I2=82% respectively). There were no significantly increased odds in the assessed secondary outcomes;ICU admission (13 studies, OR 1.11, 95% CI 0.82-1.51, I2=84%), need for mechanical ventilation (7 studies, OR 1.21, 95% CI 1.00-1.45, I2=0%). CONCLUSION(S): Prehospital use of ICS in COVID-19 patients is associated with higher odds of overall mortality in unadjusted analysis. However, this was not shown in the subgroup of patients with a history of COPD or Asthma. Other clinical outcomes such as the need for ICU admission and mechanical ventilation show similar trends. Future research with well-designed clinical trials is needed to validate our findings.
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INTRODUCTION: The reduction of mortality in COVID-19 has been clinically established only for Dexamethasone and Tocilizumab to date, but the overall mortality in COVID-19 remains high. Baricitinib is a Janus Kinase 1/2 Inhibitor with known anti-inflammatory and anti-viral properties. The US FDA recently approved Baricitinib for the treatment of hospitalized adults with COVID-19 requiring either supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO). We performed a meta-analysis of Randomized Controlled Trials (RCT) and observational studies assessing the effect of Baricitinib on mortality outcomes in hospitalized patients with COVID-19. METHOD(S): A systematic literature search was conducted on electronic databases including NIH LitCovid, WHO COVID-19 database, EMBASE, and Cochrane Central from inception until June 30th, 2022. Randomized Controlled Trials and observational studies evaluating the efficacy of Baricitinib in hospitalized patients with COVID-19 were screened for the assessment of all-cause mortality as the outcome. RESULT(S): Twenty-three studies (18 observational and 5 RCTs) were included in the mortality meta-analysis. Of the 16,390 patients (4,565 observational, 11,825 RCTs), 2,139 patients died (903 out of 7,610 in the Baricitinib arm and 1,236 out of 8,780 in the non-Baricitinib arm). Using the random-effects model, the odds of mortality in the therapeutic Baricitinib use showed a statistically significant reduction in all-cause mortality in hospitalized COVID-19 patients (OR 0.67, 95% CI 0.50-0.90;p=0.008, I2=79%). A similar trend of decreased mortality was observed in the subgroup analysis by study design (Observational OR 0.59, 95% CI 0.35-0.97, p=0.04, I2=83%;RCTs OR 0.72, 95% CI 0.56-0.93, p=0.01, I2=53%). CONCLUSION(S): Baricitinib used along with the standard of care treatments is associated with a reduction in mortality in hospitalized patients with COVID-19 disease.
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INTRODUCTION: Coagulopathy and thromboembolic events are poor prognostic indicators of COVID-19 disease. There is a discrepancy in the results of different studies regarding the effects of chronic anticoagulation on clinical outcomes. This systematic review aims to summarize the evidence on the impact of chronic anticoagulation on clinical outcomes in COVID-19. METHOD(S): A Literature search was performed on LitCovid PubMed, WHO, and Embase databases from inception (December 2019) till May 2022. Our eligibility criteria included original studies that reported the association between prior use of anticoagulants for unrelated indications at the time of COVID-19 diagnosis and the patient outcomes in adults suffering from COVID-19. The risk of thromboembolic events in COVID-19 infected patients on chronic anticoagulation is the primary outcome and severity of COVID-19 disease in terms of ICU admission or invasive mechanical ventilation/intubation requirements, and all-cause mortality were the secondary outcomes. Random effects models were used to compute crude ODDs ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals (CIs). RESULT(S): A total of 44 observational studies met our inclusion criteria. In unadjusted analysis, prior anticoagulation was not associated with reduced risk of thromboembolic events in COVID-19 patients (N=43851, 9 studies, OR 0.67 [0.22, 2.07];p= 0.49;I2= 95%). However, pre-hospital use of anticoagulants significantly increase the risk of allcause mortality in COVID-19 patients (N= 580601;37 studies, OR 1.56 [1.22, 2.01];p=0.0005;I2= 97%). There was no statistically significant association between prehospital anticoagulants usage and COVID-19 disease severity (N=186239;20 studies, OR 0.96 [0.70, 1.33];p= 0.82;I2= 88%). Pooling adjusted estimates revealed no statistically significant association between pre-hospital use of anticoagulants and risk of Thromboembolic events in COVID-19 patients (aOR= 0.85 [0.34, 2.12];p= 0.72), COVID-19 related mortality (aOR= 0.93 [0.82, 1.07];p= 0.32), and the severity of COVID-19 infection (aOR= 0.96 [0.72, 1.30];p= 0.81). CONCLUSION(S): Prehospital use of anticoagulation was not significantly associated with reduced risk of thromboembolic events, improved survival, and lower severity of disease in COVID-19 patients.
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Despite exhaustive efforts by the global healthcare to treat COVID-19, the death toll continues to rise. Ivermectin, a known anti-parasitic agent, when re-purposed for treating COVID-19, has demonstrated positive results in several studies. We aim to evaluate the benefit and risk of Ivermectin therapy in COVID-19 patients. METHODS: We conducted a systematic search for full-text manuscripts published from February 1, 2020, to August 15, 2021, that focused on the efficacy and safety of Ivermectin use in COVID-19. Overall mortality and need for intensive care unit (ICU) admission were primary outcomes;secondary outcomes were adverse effects, need for mechanical ventilation, viral clearance, time to viral clearance, need for hospitalization, and length of hospital stay. Random-effects models were used for the quantitative and qualitative analyses. RESULTS: A total of 52 studies (n= 17561) were included in the qualitative analysis and out of these, 44 studies (n=14019) were included in the quantitative analysis. In the qualitative analysis of Ivermectin treatment, a mortality rate of 3.6%, ICU admission rate of 5.4%, mechanical ventilation rate of 3.9%, and adverse event rate of 6.6% were observed. In the overall mortality meta-analysis, odds of death were lower in the Ivermectin-arm compared to the non-Ivermectin arm (OR 0.54, p=0.009). However, in the subgroup analysis of 15 randomized controlled trials, we observed lower odds of mortality in the mild/moderate sub-group (OR 0.31, p=0.06) but without statistical significance. In the severe/critical sub-group, odds were only marginally lowered and were not statistically significant.(OR 0.86, p=0.56). The benefit with Ivermectin was not statistically significant in the meta-analysis of the need for ICU admission (OR 0.48, p=0.17), mechanical ventilation (OR=0.75, p=0.12) and duration of hospitalization (MD -1.80, p= 0.06). The meta-analysis of adverse effects was inconclusive (OR 0.87, p=0.30). Ivermectin, frequently used as adjunctive treatment, was linked with higher odds of achieving viral clearance (OR 3.52, p=0.0002), in a shorter duration (MD -4.12, p=0.02) as well as reduction in the need for hospitalization (OR 0.34, p=0.008). CONCLUSIONS: In the updated quantitative analysis, we found that mortality benefit with Ivermectin treatment is uncertain. Trends of decreased need for ICU admissions and mechanical ventilation, and duration of hospitalization were observed but were not significant. Mostly as an adjuvant treatment, Ivermectin may help accelerate viral clearance as well as reduce the need for hospitalization. Meta-analysis for adverse events suggested that there may be no difference in the adverse event rate with Ivermectin and other treatments, but this cannot be concluded with confidence. The qualitative analysis showed that Ivermectin led to better clinical outcomes in COVID-19 patients and a lower incidence of adverse events. CLINICAL IMPLICATIONS: Well-designed larger observational studies and clinical trials are needed to confirm Ivermectin's mortality benefit in COVID-19 and to further investigate its ideal dosage and timing in the disease course, drug interactions, and possible synergistic drug combinations to achieve maximum benefit. We also need to evaluate the impact of Ivermectin in patients infected with the newly emerging strains and its role in vaccinated patients. Finally, we recommend physicians to exercise caution while prescribing Ivermectin for COVID-19 while we await evidence-based guidelines. DISCLOSURES: No relevant relationships by Vikas Bansal, source=Web Response No relevant relationships by Abhishek Bhurwal, source=Web Response No relevant relationships by Shree Spandana Ghanta, source=Web Response No relevant relationships by Smruti Karale, source=Web Response No relevant relationships by Rahul Kashyap, source=Web Response No relevant relationships by Hira Khan, source=Web Response No relevant relationships by Janaki Makadia, source=Web Response No relevant relationsh ps by Ishita Mehra, source=Web Response No relevant relationships by HEMANT MUTNEJA, source=Web Response No relevant relationships by ROMIL SINGH, source=Web Response No relevant relationships by Muhammad Tayyeb, source=Web Response No relevant relationships by Aysun Tekin, source=Web Response
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INTRODUCTION: Corticosteroid use in COVID 19 patients has been a much debated topic, and there has been no clear evidence so far supporting it as an effective medication to reduce the inflammatory response and improve mortality rates. We aim to review the data on mortality benefits observed with the use of corticosteroids in COVID-19. METHODS: A comprehensive literature search was conducted across the three largest COVID 19 database provided by WHO, CDC, and LitCovid PubMed Database from inception to July 19th, 2020. We included studies that compared the risk of death among patients with and without use of systemic corticosteroids. We then summarized risk estimates into two random-effect metaanalyses;one with randomized controlled trials and another one with observational studies. We analyzed data in Review Manager Software, version 5.2 (Nordic Cochrane Center, Copenhagen, Denmark), to evaluate combined odds ratio (OR) for RCTs and observational studies with respective 95% confidence intervals (CI) using a random-effects model. RESULTS: Out of total 23 articles, 11 studied were included in final meta-analysis. Among these, 3889 patients were treated with corticosteroids and 5954 were not. The metaanalysis of five clinical trials/prospective studies indicated that administration of corticosteroid significantly reduces the mortality compared to the no corticosteroid use (OR 0.52, 95% CI 0.31-0.87, p-value 0.01;I2=76%). However the meta-analysis of six retrospective observational studies/case series showed summed odds ratio of 2.69;95% CI 0.66 to 10.99, p-value 0.17, I2=94%, suggesting increased risk of mortality with use of systemic steroids. CONCLUSIONS: We observed mortality benefits from metaanalysis on available RCTs. On the contrary, a meta-analysis of observational studies suggested a higher risk of death in similar patients;however, the grade of confidence in this subgroup's results is lower due to inherent methodological limitations.
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INTRODUCTION: In the current COVID-19 pandemic, as no proven effective treatment is available, the most efficient strategy is to re-purpose existing antiviral drugs. Remdesivir has demonstrated broad spectrum antiviral activity against an array of RNA virus families. Our systematic review and metaanalysis provides a detailed overview of existing literature on remdesivir in COVID-19 to evaluate the benefits and adverse events of this potential drug. METHODS: A systematic search was conducted for articles published between inception and July 31, 2020 focusing on the use of remdesivir in COVID-19. The primary outcomes were defined as mortality rate and median days to recovery and the secondary outcome was pooled adverse events rate and pooled drug discontinuation rate. Statistical analysis was performed using the Comprehensive Meta-Analysis software package (Bio stat, Englewood, NJ, USA). RESULTS: Six studies were included in our meta-analysis. A total of 1858 patients were included. In patients treated with remdesivir, the median recovery time was 15.84 days (95% CI 11.68-20.00, p<0.0001) and the pooled mortality rate was 9.9% (95% CI 7.0%- 13.8%, p <0.0001). The results of three clinical trials indicated that administration of remdesivir significantly reduces the mortality compared to the placebo (OR 0.70, 95% CI 0.58-0.84, p-value 0.000) as well as shortens the recovery time (OR 1.32;95% CI 1.12 to 1.55, p <.001). However, treatment with remdesivir was associated with adverse effects (62.5%, 95% CI 35.9%- 83.3%, p=0.36) eventually warranting the discontinuation of the drug (16.7%, 95% CI 7.2%- 34.3%, p<0.001). CONCLUSIONS: The results of our meta-analysis suggests that pooled mortality rate of patients of COVID-19 with remdesivir is low. The median recovery time was found to be over two weeks. Our meta-analysis suggests that there may be a favorable risk-benefit profile for remdesivir compared with placebo in severe COVID-19 infection.
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INTRODUCTION: Learning objective: The primary objective of this review is to examine studies reporting association of mortality in COVID-19 patients with obesity. A secondary objective is to similarly assess associations with higher severity of the disease in COVID-19 patients in regards with obesity. METHODS: We searched multiple COVID-19 databases (WHO, CDC, LIT-COVID) for randomized trials and longitudinal studies from all over the world reporting mortality and severity published before July 18th, 2020. Meta-analyses were performed using 6 studies for mortality outcome comparison and 24 for the severity outcome. Mantel-Haenszel odds ratios were generated to describe the overall effect side using random effect models. To account for between study results variations, multivariate meta-regression was performed with pre-selected covariates using maximum likelihood method for both the mortality and severity models. RESULTS: Our findings showed the presence of obesity did not significantly influence mortality (Mantel-Haenszel OR=1.16, 95% CI 0.67 to 2.007, p=0.59, I2= 96.12%). However, obese patients were likely to have severe disease (Mantel-Haenszel OR=1.56, 95% CI 1.32 to 1.84, I2=58.7%) in comparison to not being on ACEI/ARBs in COVID-19 positive patients. Multivariate meta-regression for the severity model demonstrated that 100% of between study variation could be explained by differences in proportion of diabetes, pulmonary disease, hypertension and age. CONCLUSIONS: We found that obesity leads to significantly increased severity of COVID-19 but has no association with mortality. Therefore, the inclusion of body mass index in prognostic scores and improvement of guidelines for the intensive care of patients with obesity are highly recommended.