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Aims: This questionnaire-based survey was designed to assess the acquaintance, apprehension, and perceptions of parents toward the COVID-19 pandemic and toward seeking dental care for their children in Visnagar, Gujarat, India. Settings and Design: This was a questionnaire-based cross-sectional study. Subjects and Methods: The online Google survey form included 6 units with 27 close-ended questions in twin languages (regional and English). Inquiries covered demographics, changes in daily acts, dietary traditions, and preparedness to seek child oral care during November 2020 to January 2021. Results: Out of 400 parents, 172 responded to the electronic survey form. Over half of the guardians affirmed that alveolar treatment could fan out COVID-19. Around 90% resorted to medication (self-medication - 39%, home remedies - 32.6%, and teledentistry - 17.4%) to evade personal dental visits for their children. Conclusions: The awareness about COVID-19 and precautions was significantly high. Though parents were unaware about safeguards practiced by dentists during Covid19. Measures were taken to correct misconceptions among parents about safe dental procedures.
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The social work experiences of COVID are differentially experienced within and between countries. This chapter is a co-production that draws on narratives by social work academics and social work practitioners in India and Australia, which highlight inequities. From the voices of co-producers, four thematic areas that arose are discussed: People and the State: Migrants, Refugees, and Citizens;Women, Mobility, and Violence;Digital Divide: Access to Communities and Social Work Practice;and Role of Social Workers: Relief and Systemic Interventions. The rich narratives highlight the expertise of social workers as complementary to the dominant reliance on health professional interventions. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.
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Introduction: In 2020, stroke and ambulance clinicians in North Central (NC) London and East Kent introduced prehospital video triage, which permitted stroke specialist assessment of suspected stroke patients on scene. Key aims included reducing conveyance of non-stroke patients to stroke services and reducing transmission of Covid-19. Method(s): Rapid, mixed-method evaluation of prehospital video triage in NC London and East Kent (conducted July 2020-September 2021), drawing on: * Interviews with ambulance and stroke clinicians (n=27);observations (n=12);documents (n=23). * Survey of ambulance clinicians (n=233). * Descriptive analysis of local ambulance conveyance data (n=1,400;April-September 2020). * Difference-in-differences regression analysis: team-level national audit data, assessing changes in delivery of clinical interventions in NC London and East Kent relative to elsewhere in England (n=137,650;2018-2020). Result(s): Clinicians perceived prehospital video triage as usable, safe, and preferable to 'business-as-usual'. Several interrelated factors influenced implementation: impetus of Covid- 19, facilitative local governance, receptive professional values, engaging clinical leadership, active training approaches, and stable audio-visual signal. Stroke clinician capacity was a risk to sustainability. Neither area saw increased time from symptom onset to arrival at services. Delivery of clinical interventions either remained unchanged or improved significantly, relative to elsewhere in England. Conclusion(s): Prehospital video triage in NC London and East Kent was perceived as usable, acceptable, and safe;it was associated with some significant improvements in secondary care processes. Key influences included national and local context, characteristics of triage services, and implementation approaches.
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Introduction: Acute kidney injury (AKI) is associated with a very high mortality and an increased risk for progression to chronic kidney disease (CKD). Preclinical studies have identified that NAD+ augmentation as a potential strategy for the prevention and treatment of AKI. NAD+ is the final metabolized form of vitamin B3. A recent clinical study found that COVID-19 related AKI was associated with NAD+ biosynthetic impairment arising in the context of ischemic, inflammatory, or toxic kidney injury. Since there is no availability of vitamin B3 in the country, we tested if I.V. vitamin B complex (vitamin B1, B6 and B12) could improve renal recovery in patients with AKI. By oxidation, vitamin B6 through the pathway of pentose phosphate leads to the formation of NADPH (nicotamide adenine phosphate dinucleotide) an analog of NAD+. Method(s): We conducted randomized, blind, placebo-controlled study in hospitalized patients with AKI (NCT04893733). During the study I.V. vitamin B complex or placebo was given twice a day for 5 consecutive days. In each patient, a protocol-based treatment approach for AKI was used (STOP AKI protocol from the ISN 0by25 trial https://doi.org/10.1371/journal.pmed.1003408). Serum creatinine (sCr) was measured using a point of care device (NOVA Biomedical Xpress CREA) at enrollment and every 24 hours for 7 days, and then at day 30, and day 90. We evaluated if vitamin B complex could improve renal recovery in patients with AKI, reduce the risk of De Novo CKD or CKD progression, and improve survival. Result(s): From September 2020 to September 2021, 260 patients were enrolled. Baseline characteristics are shown on table 1. The drop in sCr values by day 7 was higher in the vitamin B complex group (1.04 vs. 0.33 mg/dl;p < 0.001). Complete recovery was higher in patients randomized to vitamin B complex (59.2% vs. 34.6%;p=0.001), no difference was found in terms of partial recovery (26.2% vs. 27.7%;p=0.888). Non-recovery was lower in patients who received vitamin B complex as compared to placebo (16.6% vs. 37.7%;p < 0.001). At 3 months, the incidence of de novo CKD was lower in patients who received vitamin B complex (19.2% vs. 26.9%;p=0.043) in patients with CKD the progression of the disease was lower in patients who received vitamin B complex (13.1% vs. 20.8%;p=0.023). No differences were found in terms of 90-day mortality (Vitamin B complex 74.3% vs. Placebo 80.1%;0.554). The relative risk of Vitamin B complex for renal recovery was 0.37 (95% CI 0.242 - 0.593;p<0,0001) with a NNT of 3.1 patients with a relative risk for CKD progression or De Novo CKD of 0.47 (95% CI 0.28 - 0.79;p = 0.005) with a NNT of 4.8 patients. Conclusion(s): Vitamin B complex could accelerate renal recovery in patients with AKI;reduce the incidence of De Novo CKD and CKD progression. Our results support ongoing studies investigating the therapeutic potential of NAD+ augmentation as a means to mitigate kidney injury. Conflict of interest Potential conflict of interest: Nova Biomedical MedtronicCopyright © 2023
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Background: The explosive rise of Mucormycosis (MM) in India and other parts of the world has been described as the 'epidemic following the COVID-19 pandemic'. We report a series of 5 COVID-19 associated pulmonary MM (CAPM) cases with an aggressive clinical course. Method(s): Only confirmed pulmonary mucormycosis cases with COVID infection were included. Demographic,bronchoscopy,microbiological and histopathological details were collected and analysed. Result(s): 5 patients were included (3 males),with an average age of 61.2 yrs. While all five had diabetes mellitus, 4/5 had an average HbA1C > 9. Median duration from COVID symptom onset to MM diagnosis was 19 days. The most common CXR finding was patchy consolidation in 4/5 patients, concurrent empyema in 1, and a thick-walled cavity in another. Fungal smear of the BAL/biopsy was positive in all patients. Histopathology was consistently positive in all, fungal culture was positive in 3/5, and fungal PCR was positive in 2 cases. Endobronchial necrosis was noted in 4/5 cases. All patients were initiated on amphotericin B but could not be operated due to instability and extensive bilateral disease. The late presentation,comorbidities,critical state and fulminant course led to demise within 4 days of diagnosis in 4/5 patients. Dual infection with Aspergillus and Mucor spp. was seen in 3/5 patients. Concurrent MDR bacterial infection present in all patients may have added to mortality. Conclusion(s): Critical CAPM following COVID 19 infection was difficult to diagnose and treat,with an aggressive course and fatal outcome. Bronchoscopy was an invaluable tool in diagnosis and prognostication but could not impact the outcomes.
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The global outbreak of SARS-CoV-2 has spurred a reassessment of Municipal Solid Waste management strategies and approaches. A significant need for sanitation and hygiene was accentuated for disease prevention and control with the onset of the pandemic. With an alteration of the status quo in waste management system, an unprecedented amount of face masks, protective equipment, and other biological wastes was generated in the form of Municipal Solid Waste. This upsurge of potentially infected wastes originated a risk of transmission amongst frontline workers. Furthermore, the potential contamination of Municipal Solid Waste was rendered as a legitimate threat due to improper collection practices, disposal and handling of solid waste. Several novel waste disposal techniques and waste management policies were also introduced during this period. However, the sanitation-policy making-occupational safety nexus remains inadequately explored under the prevalent COVID-19 scenario. Through the prism of shifting waste composition, this review offers a global assessment of existing solid waste management systems during the COVID-19 pandemic. The physiological and psychological hazards faced by the frontline workers were explored and instances of best-case and worst-case policies on solid waste handling were recorded. Modern methods of waste disposal and latest trends of policymaking were evaluated. A model study of unsupervised learning via Partition Around Medoids cluster analysis was undertaken to reveal underlying patterns of waste management policies. Although, the clusters were formed devoid of any socio-economic parameters, this study strives to indicate proof of concept and can serve as a precursor to advanced clustering studies. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
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Background and Aim: The World Health Organization (WHO) acknowledged coronavirus epidemic as a pandemic and declared the outbreak as a public health emergency of international concern. Emerging research has suggested that these various restrictions, as well as the fear of the virus itself, may have caused children to experience negative mental health consequences. Due to increased amounts of time spent at home the parents need to be aware about the changes in the mental and physical health of the children. This study, thus aimed to survey the effects of the COVID-19 pandemic lockdown on physical and mental health of school-going children. Material(s) and Method(s): A cross sectional survey was designed to analyse the impact of COVID-19 on the physical and mental health of children. The data is collected with the use of online survey platform. A semi structured questionnaire was developed with several open and close ended questions to examine the effect of lockdown on the mental and physical health of the children from parent-reported changes. Any mental health issues and emotional problems newly emerged or aggravated during lockdown were also enlisted. Another objective was to determine the level of awareness amongst parents about the importance of PA for the child. Result(s): A total of 200 children were included in the study. When the comparison was done in time from before and after lockdown, it was found that the hours spent on mobile were increased from 2 hours to 5 hours. There was significant decrease in the time spend for physical activity. A total of 65% of the respondents reported that there was change in the behaviour of the children. Around 58% of the children had shown the physical changes like eyestrain, fatigue, neck pain, head ache, lower back pain and major problem with increase in weight of children. Conclusion(s): More research is needed to improve our understanding of the long-term impacts of the COVID-19 pandemic on children's mental health, especially with regards to the identification of protective factors found in children who may have been less affected by the pandemic. Copyright © 2023, Institute of Medico-legal Publication. All rights reserved.
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Background: Acute kidney injury (AKI) is common in coronavirus disease 2019 (COVID-19). It is unknown if hospital-acquired AKI (HA-AKI) and community-acquired AKI (CA-AKI) convey a distinct prognosis. The study aim was to evaluate the incidence and risk factors associated with both CA-AKI and HA-AKI. Method(s): Consecutive patients (>18 years) hospitalized with a positive antigen or RT-PCR result for COVID-19 who meet the criteria for AKI, have known CKD or with kidney transplant were included in this prospective cohort study. Patient information was recorded from the time of diagnosis and renal function was followed up at 48 hours, 7 days, 14 days, at discharge, and at 6 months. Result(s): From July 1st to May 30th 2021, we included 100 hospitalized patients with AKI, 68% were male and mean age was 68+/-11. Seventy-two (72%) corresponded to CA-AKI, and 28% to HA-AKI. Compared to patients with HA-AKI, subjects with CA-AKI have higher baseline sCr (1.15+/-0.46 vs.1.06+/-0.26, p <0.001);had more diabetes (14[19.4%] vs. 1[3,6%], p=0.035);and presented to the emergency department with more severe disease. However the presence of >=2 comorbidities were higher in HA-AKI (27.7% vs. 32,1%, p=0.014). Mortality rates were not different between CA-AKI and HA-AKI (14 [19%] vs. 5 [18%], p=0.856). Complete renal recover was more frequent in CA-AKI (16[22%] vs. 5[18%], p<0,001) with lower incidence of de novo CKD (13 [29%] vs.13 [65%], p=0.033) or CKD progression (8[18%] vs. 0[0%], p=0.033]. Conclusion(s): CA-AKI and HA-AKI portend an adverse prognosis in COVID-19 patients. Nevertheless, CA-AKI was associated with a higher rate of renal recovery and lower incidence of long term adverse outcomes like de novo CKD or CKD progression. HA-AKI is likely part of the multiorgan failure, has a more severe course than CA-AKI, and that kidney injury contributes to worse outcomes.
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BACKGROUND: Over 454,000 hospitalizations have been associated with atrial fibrillation (AF) as a primary diagnosis . Guideline treatment of AF may improve outcomes and subsequently, reduce healthcare resource utilization (HCRU) and total cost of care (TCOC). Previous studies have assessed cost and HCRU in the Medicare population, but there is limited published data on the commercial population. OBJECTIVE(S): This study's primary objective was to measure TCOC in newly diagnosed non-valvular atrial fibrillation (NVAF) patients within a commercial health plan. METHOD(S): This retrospective case-control study used a commercial health plan claims database to identify members diagnosed with incident NVAF between January 1, 2018, and December 31, 2018 (first diagnosis was index) with 12-month continuous enrollment pre- and post-index and baseline CHA2DS2-VASc >= 2 (N = 1,717). This study period was chosen to capture pre-COVID-19 data. Members with >= 1 claim for an oral anticoagulant (OAC) on or after the index date (treated cohort) were compared to an untreated cohort. Inverse probability of treatment weighting was used to adjust for differences in baseline characteristics. Costs were assessed for medical and pharmacy utilization over a 12-month period. RESULT(S): Compared to the untreated cohort (n = 860), the treated cohort (n = 857, 49.9%) had higher mean - inpatient (IP) costs ($34,023 vs $25,135), emergency room costs ($3,861 vs $2,375), pharmacy costs ($9,054 vs $5,222) and TCOC costs ($69,489 vs $43,950). A higher IP diagnosis of NVAF was observed in the treated cohort compared to the untreated cohort (18.2% vs 3.6%). Rates of stroke were higher in the treated cohort compared to the untreated cohort (3.27% vs 0.14%). Among those receiving an OAC (treated cohort), 67.7% had a treatment duration of <=180 days during the 12-month follow-up period. CONCLUSION(S): Using nationwide commercial claims data, the study showed TCOC was higher for those treated with OAC compared to patients not treated with OAC which prompted additional analyses to better explain the findings. Although recognized AF management guidelines are available, recommended treatment with OAC in patients at high risk for stroke remains suboptimal (50%) with limited duration of therapy. Key study limitations include small sample size and potential channeling bias. The results provide previously unreported data for a younger population with commercial insurance and contribute to a growing body of data showing a gap in care in patients with NVAF. Study outcomes highlight an opportunity for improved care management and better communication with providers and patients along the care pathway.
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SESSION TITLE: Lessons Learned from Critical Care Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 12:25 pm - 01:25 pm INTRODUCTION: Local compression of the anterior chest wall (CACC) or abdomen has been shown to unexpectedly improve respiratory system compliance in patients with severe acute respiratory distress syndrome (ARDS). The mechanism is thought to be similar to prone positioning, causing a redistribution of transpulmonary pressures. Limited data exists regarding this topic, particularly as it applies to COVID-19. We describe two cases of improved compliance and oxygenation with CACC in individuals with COVID-19 related ARDS, including one with prior lung transplantation. CASE PRESENTATION: Case 1: The patient was an unvaccinated 79 year-old man diagnosed with COVID-19 on admission. One week later, he progressed to requiring CPAP therapy. He was intubated the following week. Prone ventilation was initially attempted, but this was discontinued due to hemodynamic instability. Despite neuromuscular blockade and lung-protective ventilation, the patient's respiratory mechanics continued to worsen. CACC was then initiated using a 10 lb sandbag on the upper thorax, resulting in improved compliance (8 to 11.4 mL/cmH2O) and driving pressure (30 to 21 cmH2O). While CACC allowed room to adjust PEEP, there was no significant change in oxygenation or paCO2. Case 2: The patient was a fully vaccinated 46 year-old man with a history of bilateral lung transplant for cystic fibrosis, who tested positive for COVID-19 and was treated with sotrovimab as an outpatient. Despite early treatment, the patient had worsening hypoxia necessitating admission, treatment with bilevel PAP therapy, and subsequent intubation. Prone ventilation was initiated, but discontinued after 1 day due to worsening hemodynamics and poor improvement. CACC was then employed using two 5 lb sandbags with an improvement in compliance (16.7 to 21.1 mL/cmH2O). There was also a significant improvement in oxygenation (P/F ratio 115 from 86) and a decrease in paCO2. Following this favorable response, prone positioning was resumed, demonstrating similar improvement in respiratory mechanics. DISCUSSION: These cases demonstrate improved respiratory mechanics with CACC, which may be due to a reduction in end-inspiratory over-distention. In the first case, CACC allowed for an increase in PEEP when prone ventilation was not tolerated. In the second case, it was a tool that directed clinicians to resume prone positioning, with favorable improvement in oxygenation. The decrease in paCO2 may signify improved V/Q matching and dead space ventilation. CONCLUSIONS: This case series illustrates CACC as a potential therapeutic and diagnostic tool for clinicians to make lung-protective ventilator adjustments in responders. Trials of CACC may improve compliance and oxygenation in these patients, and may indicate those who would benefit from further prone positioning. Additional investigation is needed to clarify the clinical role of CACC for the management of COVID-19 related ARDS. Reference #1: Marini JJ, Gattinoni L. Improving lung compliance by external compression of the chest wall. Crit Care. 2021;25(1):264. Published 2021 Jul 28. doi:10.1186/s13054-021-03700-8 DISCLOSURES: Speaker/Speaker's Bureau relationship with boehringer ingelheim Please note: $5001 - $20000 by Brad Bemiss, value=Travel and payment for lecture No relevant relationships by Anila Khan No relevant relationships by Rishi Mehta No relevant relationships by Jason Peng
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Introduction: Western experience shows that with subsequent waves of corona virus disease-2019 (Covid-19), children were affected more and required hospitalization. Universal Covid-19 vaccination among children is difficult to advocate given the low severity of Covid-19 in this age group. Objectives: This study assesses vaccine hesitancy (VH) among an urban-majority survey-population in Ahmedabad, Gujarat and the factors bearing on it. Method: A 26-point questionnaire was circulated among parents with children up to 18 years of age online as well as offline, assessing age, education, urban vs. rural dwelling, previous Covid-19 and Covid-19 vaccination status and the existing information regarding Covid-19 in children in previous and impending waves. Intention of the respondents to vaccinate their children immediately, wait-and-watch or not vaccinate at all and reasons leading to it were explored. The primary outcome was VH (wait-and-watch or not-opting-tovaccinate). Intention to vaccinate immediately was taken as reference. We used multinomial logistic regression to assess the association of outcome with age, gender, education, previous Covid-19 and vaccination status. Analysis was done using STATA-16 software.Results: Of 1102 respondents, VH was reported by 37.6%. Respondents who were older, females, unvaccinated, believed Covid-19 would not be more severe among children and those having safety concerns with vaccines were more likely to report VH. Vaccine related information obtained from healthcare workers was associated with the least VH. Rapid development and approval of vaccines did not affect VH. Conclusions: Age, gender, Covid-19 vaccination status of parents and perception of severity of Covid-19 among children were major determinants of VH in our study. Source of vaccine-related (mis)information concerns related to short and long-term safety of vaccines was significantly associated with VH © Open Access Article published under the Creative Commons Attribution CC-BY License
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BACKGROUND: In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. OBJECTIVE: To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. DESIGN: A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality);acceptability (whether or not clinicians want to use it);impact (on outcomes, safety, experience and cost-effectiveness);and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23);a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400;April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650;July 2018 to December 2020). RESULTS: (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability - relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for 'refresher' courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability - most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety - clinical leaders monitored and managed potential patient safety issues;clinicians felt strongly that services were safe. Implementation - several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact on safety and quality: we found no evidence of increased times from symptom onset to arrival at services or of stroke clinical interventions reducing in studied areas. We found several significant improvements relative to the rest of England (possibly resulting from other service changes). LIMITATIONS: We could not interview patients and carers. Ambulance data had no historic or regional comparators. Stroke audit data were not at patient level. Several safety issues were not collected routinely. Our survey used a convenience sample. CONCLUSIONS: Prehospital video triage was perceived as usable, acceptable and safe in both areas. FUTURE RESEARCH: Qualitative research with patients, carers and other stakeholders and quantitative analysis of patient-level data on care delivery, outcomes and cost-effectiveness, using national controls. Focus on sustainability and roll-out of services. STUDY REGISTRATION: This study is registered as PROSPERO CRD42021254209. FUNDING: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research;Vol. 10, No. 26. See the NIHR Journals Library website for further project information.
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Introduction: Pain, agitation, delirium, weakness, and sleep deprivation are well recognized symptoms during an ICU stay.1 In 2019, our institution set up an ICU Liberation Working Group (ILWG)2, aiming to reduce the harmful effects of these symptoms. This interprofessional working group encompassed medical, pharmacy, nursing and allied health members and utilised a multifocal approach. Objectives: To review the impact of various initiatives implemented on the outcomes of the ABCDEF (A2F) bundle in the last two years. Methods: These initiatives are based on each aspect of the A2F bundle. As shown in Table 1, the interventions were each targeted to one aspect of the A2F bundle and were grouped under four themes of teaching, operational interventions, informatics, and guidelines/policies. These interventions were audited regularly, with the results displayed on awareness boards, aiming to encourage staff engagement. An ICU Liberation week was also held to improve awareness and compliance with the A2F bundle. Results: Audit cycles were performed in April 2019, December 2019, and November 2020, assessing data representing each arm of the A2F bundle. Two-thirds of the audit standards showed a significant improvement after initial interventions were employed. The third cycle showed improvement has been maintained in half of the standards. Unfortunately, adherence did reduce in several fields. The greatest improvement was seen in sedation target documentation. A further cycle in January 2021 assessed the impact of COVID-19 on A2F application, showing a reduction across most audit criteria. There were, however, improvements in family updates and early mobilisation. Conclusion: The ongoing work of an interprofessional ILWG has shown a cohesive approach application of the A2F bundle, which has resulted in improved harm prevention and management. The impact of COVID-19 has been shown to have reduced our ability to provide improvements in A2F application. Ongoing interventions are a bespoke sleep tool and more detailed CAM-ICU assessment, designed to elucidate the underlying causes of sleep disruption and delirium. A focused quality improvement project has started, where specific interventions are to be trialed on one ICU before expectant deployment throughout other ICUs. Data will continue to be collected and presented to further assess the most effective methodology for application of the A2F bundle.
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Aim and background: Severe COVID-19 pneumonia can be lifethreatening with a high mortality, largely due to an uncontrolled systemic hyperinflammatory response, generally referred to as cytokine storm. Tempering the immune response with immunomodulators has been considered as a potential therapeutic option. Except for a few, data on the effectiveness of different immunomodulating drugs are scarce and are limited to a few case reports and retrospective observational-cohort studies. Additionally, in the pandemic due to shortages, various immunomodulators were used with limited data on their effectiveness. This study looks at various immunomodulators used in the 2nd wave of COVID-19, and their impact on outcomes. Materials and methods: Retrospective analysis of 124 patients with severe COVID-19 disease who were treated with immunomodulators. The study population included patients above 18 years of age with confirmed COVID-19 admitted to ICU with severe pneumonia. All patients received standard of care treatment at the time of hospital admission according to the hospital protocols and updated data on treatment of COVID-19. Patients were considered eligible for immunomodulatory treatment if they showed rapidly worsening hypoxia and elevated inflammatory markers, as per standard recommendations. Immunomodulators were administered depending on the availability of specific agents at time of treatment. The immunomodulators used were tocilizumab, itolizumab, bevacizumab, pulse dose steroid with methylprednisolone and baricitinib. Results: 124 patients were treated with immunomodulators, 45 (36.3%) of them survived, and 79 (63.7%) passed away. Mean age in survivors was 48.2, and in non-survivors was 54.8, which was statistically significant. Diabetes and hypertension were the most common comorbidities observed. 97/124 patients (78.2%) received immunomodulator therapy within 48 hours of ICU admission, out of which 41 (42.2%) recovered and 56 (57.7%) passed away. 21/124 (21.8%) patients received immunomodulators after 48 hours of admission, and had a high mortality with only 3 (14.2%) recovering and 18 (85.7%) dead. There was a significant reduction in CRP levels post immunomodulator therapy among survivors compared to nonsurvivors. The mean invasive ventilator days were 4.27 and there was a significant difference among survivors and non-survivors. Among survivors (45) in our study, we found that immunomodulator therapy was seen to avoid mechanical ventilation in severe COVID patients (33) who received immunomodulator therapy early within 48 hours of ICU admission as seen by the improvement on a 7-point ordinal scale. The mean ventilator days for patients who received immunomodulator therapy after intubation were also reduced. Most common adverse events were found with itolizumab administration. Secondary infections were more in non-survivors and secondary bacterial pneumonia was the commonest. Conclusion: Our descriptive study showed that the early administration(<48 hours) of various immunomodulators reduced the need for ventilation and the number of ventilator days, compared to administration after 48 hours. There was an increased incidence of secondary bacterial infections among the non-survivors.
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Introduction: The 1st wave of COVID-19 spread rapidly affecting most countries globally in a short duration. Many countries suffered the 2nd wave of COVID-19 infection, months after the 1st wave, largely driven by viral mutants with high transmissibility and reduced susceptibility to neutralising antibodies (1-3). Despite COVID-19 being the common etiology, the two waves have significant differences impacting both current understanding and future planning of the impact of COVID-19. This study from a tertiary ICU is a comparative analysis focusing on the cardinal differences in COVID-19 ICU patients between the two waves, with respect to baseline demographics, clinical features, disease severity, and outcomes. Materials and methods: Retrospective data was collected from the medical records of all patients with COVID-19 disease admitted to the intensive care unit (ICU) in the 1st and 2nd wave of the pandemic. COVID-19 disease was confirmed by means of a positive RT-PCR or a rapid antigen test (RAT) on a nasopharyngeal swab or respiratory sample. Baseline demographic and clinical data, disease severity, and outcomes were analysed. Results: 419 patients (74.9% males) were admitted to the ICU between July and December 2020 and 206 (65% males) patients between April and June 2021. The mean age of patients admitted in the 1st wave was 59.84 ± 13.7 (mean ± SD) years and the 2nd wave was 55.31 ± 14.9 years (p = 0.038). The duration from symptom onset to admission (Median, IQR) was 5 days (3, 7) for the 1st wave and 5 days (3, 8) for the 2nd wave. 74.5% (312/419) of the patients in the 1st wave and 64.5% (129/206) in the 2nd wave had one or more comorbidities (p = 0.05). The median CRP values were 83.0 mg% (IQR 31.45, 159.7) for the 1st wave and 93.0 mg% (IQR 48.0, 141.0) for the 2nd wave, respectively, statistically not significant. 31.8% (131/412) of the ICU patients in the 1st wave and 52.3% (103/196) in the 2nd wave required mechanical ventilator support (p < 0.05). The overall ICU mortality was 32.1% (134/418) for the 1st and 52.5% (104/198) for the 2nd wave (p value?). Conclusion: There is a significant difference between the 2 waves in age, comorbidities, and mortality, likely related to viral mutants, vaccination policies, and social mobility dynamics.
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Aim and background: The COVID-19 pandemic has raised significant concerns over secondary infections because of the widespread use of steroids, immunomodulators, and empiric antimicrobials as part of the recommended treatment protocol. Various studies have shown that COVID-19 infection by itself predisposes to secondary infections. During the 2nd wave of the COVID-19 pandemic, there has been an unprecedented epidemic of secondary invasive fungal infections. This study analyses the prevalence, details, and outcomes of secondary infections in critical COVID-19 patients admitted to a tertiary intensive care unit (ICU) in India. Materials and methods: Retrospective study of secondary infections in ICU patients between April and June 2021. Demographic data, details of immunomodulator therapy, secondary bacterial and fungal infections, antimicrobial susceptibility data, and clinical outcomes of these patients were analyzed. Results: 71/238 (29.83%) ICU patients developed secondary bacterial and fungal infections. The mortality in patients with secondary infections was significantly higher [80.28% (p < 0.05)], compared to overall ICU mortality of 51.68%. In patients with secondary infections, 67.6% were referred from other hospitals after receiving initial treatment and 64.79% had received various immunomodulator therapies. Patients on prolonged mechanical ventilation (>7 days) and indwelling central venous (>7 days) and urinary catheters (>7.5 days) had higher secondary infection rates and higher mortality. There was positive significant growth in 80 respiratory samples, 34 blood samples, and 17 urine samples. Gram-negative bacteria were isolated in 85.91% and 32.39% had fungal isolates. Klebsiella pneumoniae followed by Acinetobacter baumannii were the predominant bacteria and Candida spp followed by Mucormycosis were the predominant fungal pathogens. Multi-drug resistant (MDR) infections were common among the isolates (70.59%). 49.3% of secondary infection patients had polymicrobial infections including fungal infections with higher mortality of 83%. Conclusion: There is a significantly high incidence of secondary MDR bacterial and fungal infection including Mucormycosis in critically ill COVID-19 patients, with an adverse impact on mortality. Risk factors included the use of steroids, immunomodulators, severe COVID-19 infection, empiric broad-spectrum antibiotics, invasive ventilation, and central venous and urinary catheterization, and prolonged ICU stay.
ABSTRACT
Background and aims: Liver injury is common in patients with coronavirus disease-2019 (COVID-19) infection. Recently, few studies have reported the development of autoimmune hepatitis (AIH) following COVID-19 vaccination. However, there is a lack of studies reporting the outcomes of AIH following ChAdOx1 (vector-based) and BBV152 (inactivated virus) from India. Herewe aimed to describe the clinical profile of patients who developed AIH following COVID-19 vaccination. The causal association is attributed based on the temporal relationship in patients with no prior liver diseases. Method: Patients presenting with deranged liver functions following COVID-19 vaccination to hepatology clinic were included. Virus infections were ruled out in all patients either by serology or viral quantification methods. We aimed to assess the demographics, clinical profile, and outcome of patients with vaccine-induced AIH (V-AIH) in the absence of known liver disease. Results: A total of 31 patients presented with altered liver chemistries following vaccination. Seventeen patients were diagnosed with VAIH (age-39.8 ± 11.4 years;males-70.4%). None of the patient had history of alcohol overconsumption. Seventy six percent of patients had received ChAdOx1 and 23.53% had received BBV152 vaccine (Table). Seventy six percent of patients following first dose of vaccine and 23.5% following second dose of vaccinewere diagnosed as V-AIH. Mean duration for development of symptoms after first dosewas 25.7 days. Common symptom at presentation was jaundice in 82.3% of patients. Antinuclear antibodywas positive in 71% of patients and 17% patients were negative for all serological markers of autoimmune hepatitis but had elevated IgG levels. Fifty-nine percent of patients required immunosuppression of which 41% percet of patients received oral steroids, 17% patients received intravenous steroids for 3 days followed by oral steroid, 12% patients received azathioprine. One patient succumbed to pneumonia with multiorgan failure by day 30. At 3 months, it was observed that only 17% patients needed prolonged immunosuppression and had deranged liver functions until last follow-up. Mean duration of recovery amongst rest of 76.4% patients was 5.15 ± 3.1 weeks.