What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support?

Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.

Association Between Self-Regulation of Learning, Forced Labor Insertion, Technological Barriers, and Dropout Intention in Chile

Early dropout and retention of students are critical problems in both secondary and higher education. Existing models that predict the intention to drop out require the incorporation of complex variables strongly related to student success, such as self-regulated learning. Moreover, new possible predictors have emerged in the context of a pandemic. This study set out to validate scales that measure the phases of self-regulation of learning in Chilean secondary school students and determine the association between self-regulation, forced labor insertion, technological barrier, and intention to quit during COVID-19. An instrumental design was carried out, where 251 students participated, and a cross-sectional predictive design with a sample of 171. Results showed adequate psychometric properties in assessment scales for self-regulation. Furthermore, the logistic regression model carried out to predict the dropout intention was significant. The final model showed that external causal attributions, planning self-evaluation, forced labor insertion, and technological barriers were significant predictors, achieving a success rate of 84.8%. In conclusion, although many factors are considered in dropout intention models, this study incorporated self-regulation skills that can be promoted in students and systematically integrated into school programs to help reduce dropout rates in secondary education, therefore contributing to a successful transition to higher education. Copyright © 2021 Sáez-Delgado, Mella-Norambuena, López-Angulo, Olea-González, García-Vásquez and Porter.

Improved COVID-19 outcomes in a large non-invasive respiratory support cohort despite new variants

P217 Table 1A comparison of first and second wave characteristics, treatment and outcome data First wave Second wave Mean difference (95%CI) X2 (df) P value Age (years) 69.0 (52.0, 80.0) 62.0 (52.0, 71.0) -3.4 (-7.8 to +1.1) - 0.14 Sex: - Male - Female 49 (69.0%) 22 (31.0%) 180 (65.0%) 97 (35.0%) - 0.4 (1) 0.52 BMI (kg/m2) 28.5 (24.9, 33.6) 29.6 (24.8, 34.9) +0.6 (-1.7 to +2.9) - 0.63 Clinical Frailty Score: - 1 to 2 (fit) 18 (25.4%) 132 (47.7%) - 15.6 (5) 0.008 CT severity score - Moderate/severe - Severe 11 (29.7%) 23 (62.2%) 131 (52.2%) 113 (45.0%) - 16.0 (3) 0.0012 CRP prior to rHDU admission (mg/L) 180.6 (118.0, 210.0) 124.1 (78.1, 175.6) -44.1 (-66.9 to -21.3) - 0.0002 Spike gene testing - VOC B.1.1.7 variant - Wild-type - Ambiguous - - - 143 (67.1%) 57 (26.8%) 13 (6.1%) - - - Dexamethasone 3 (4.2%) 266 (96.0%) - 271.4 (1) <0.0001 Remdesivir 4 (5.6%) 198 (71.5%) - 100.6 (1) <0.0001 CPAP as primary respiratory support 32 (45.1%) 248 (89.5%) - 71.1 (1) <0.0001 Able to adopt semi- or full- prone position 42 (59.2%) 237 (85.6%) - 24.8 (1) <0.0001 Admission outcome (all) - Died - Discharged 36 (50.7%) 35 (49.3%) 74 (26.7%) 201 (72.5%) - 14.7 (1) 0.0001 rHDU outcome (‘For Intubation’) - Died - Off respiratory support - Intubated 0 (0.0%) 14 (41.2%) 20 (58.8%) 7 (3.3%) 152 (72.4%) 51 (24.3%) - 17.3 (2) 0.0002 ConclusionOur single centre experience shows that rHDU mortality and intubation rates have improved over time in spite of the emergence of new variants. Improvements in outcome are likely to be multi-factorial. Our data support the benefit of pharmacological COVID-19 therapies in a rHDU population as well as the use of CPAP and awake proning. Other potential causes for improved outcomes are lower serological and radiological COVID-19 severity in our wave two cohort as well as reduced rates of frailty.Referencehttps://medrxiv.org/content/10.1101/2021.03.11.21253364v1

Secondary infection rates and antibiotic prescribing in a COVID-19 hdu population

Introduction Secondary infection in COVID-19 has been associated with adverse outcomes and high mortality. The prevalence of secondary infection in COVID-19 and optimal antimicrobial strategies remain unclear. Methods Retrospective case-note review of patients with COVID-19 admitted to our institution's high dependency unit (HDU) from March to June 2020. Patients were PCR-positive for SARS-CoV-2 or had classical CT appearances and a compatible clinical presentation for COVID-19. Microbiological tests, antimicrobial prescriptions and clinical outcomes were recorded. Results 84 patients were identified. Median age was 68.5 years and 29/84 (34.5%) were female. Respiratory support included HFNO (n=39), CPAP (n=56), non-invasive ventilation (n=3) and invasive ventilation (n=14). Overall mortality was 36/84 (42.9%). 6/84 patients (7.1%) had evidence of secondary infection (>105 CFUs on bronchoalveolar lavage (BAL);positive sputum culture or positive blood culture excluding skin contaminants). 28/84 (33.3%) had a respiratory sample sent: BAL n=10;sputum culture n=2;Legionella antigen n=15;throat swab multiplex PCR n=3;Biofire respiratory viral panel n=7. BAL was positive in 3/10 cases (Enterococcus faecium;Serratia marcescens and Escherichia coli;Pseudomonas aeruginosa). One sputum culture was positive for M. abscessus. 71/84 (84.5%) had blood cultures. 8 (11.2%) were positive, of which 6 were considered skin contaminants and not deemed true secondary infection (coagulase negative Staphylococci n=5;Lysinibacillus sp. n=1;Proteus mirabilis n=1;Staphylococcus epidermidis and Serratia marcescens n=1). All 84 patients received antimicrobials. 32 (38.1%) received a macrolide, predominantly azithromycin. Macrolide usage was not associated with mortality or admission length, but was associated with increased intubation rate (28.1% vs 9.6%, p=0.027) Initial antibiotic treatment was monotherapy in 45 (53.6%) cases and dual therapy in 39 (46.4%). Initial treatment with two antibiotics versus monotherapy was not associated with mortality but was associated with increased intubation rate (25.6% vs 8.9%, p=0.040) and increased mean admission length (16.5 vs 11.6 days, p=.036). Discussion Robust evidence of secondary infection in patients with COVID-19 was uncommon in our cohort. Increased intubation rates in patients prescribed a macrolide and those initially prescribed dual antibiotic therapy is likely to reflect more severe disease. There is considerable potential for enhanced antimicrobial stewardship in further waves of COVID-19.