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1.
Lancet ; 399(10319):22-23, 2022.
Article in English | Web of Science | ID: covidwho-1609766
2.
Preprint in English | MEDLINE | ID: ppcovidwho-290700

ABSTRACT

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can result in a hyperinflammatory state, leading to acute respiratory distress syndrome (ARDS), myocardial injury, and thrombotic complications, among other sequelae. Statins, which are known to have anti-inflammatory and antithrombotic properties, have been studied in the setting of other viral infections and ARDS, but their benefit has not been assessed in COVID-19. Thus, we sought to determine whether antecedent statin use is associated with lower in-hospital mortality in patients hospitalized for COVID-19. This is a retrospective analysis of patients admitted with COVID-19 from February 1 st through May 12 th , 2020 with study period ending on June 11 th , 2020. Antecedent statin use was assessed using medication information available in the electronic medical record. We constructed a multivariable logistic regression model to predict the propensity of receiving statins, adjusting for baseline socio-demographic and clinical characteristics, and outpatient medications. The primary endpoint included in-hospital mortality within 30 days. A total of 2626 patients were admitted during the study period, of whom 951 (36.2%) were antecedent statin users. Among 1296 patients (648 statin users, 648 non-statin users) identified with 1:1 propensity-score matching, demographic, baseline, and outpatient medication information were well balanced. Statin use was significantly associated with lower odds of the primary endpoint in the propensity-matched cohort (OR 0.48, 95% CI 0.36 a" 0.64, p<0.001). We conclude that antecedent statin use in patients hospitalized with COVID-19 was associated with lower inpatient mortality. Randomized clinical trials evaluating the utility of statin therapy in patients with COVID-19 are needed.

5.
American Journal of Respiratory and Critical Care Medicine ; 203(9):2, 2021.
Article in English | Web of Science | ID: covidwho-1407143
6.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1285136

ABSTRACT

Rationale Heterogeneous respiratory system static compliance (CRS) values and levels of hypoxemia in patients with novel coronavirus disease (COVID-19) requiring mechanical ventilation have been reported in previous smallcase series or studies conducted at a national level.Methods We designed a retrospective observational cohort study with rapid data gathering from the international COVID-19 Critical Care Consortium study to comprehensively describe the impact of CRS on the ventilatory management and outcomes of COVID-19 patients on mechanical ventilation (MV), admitted to intensive care units (ICU) worldwide.Results We enrolled 318 COVID-19 patients enrolled into the study from January 14th through September 31th, 2020 in 19 countries and stratified into two CRS groups. CRS was calculated as: tidal volume/[airway plateau pressure-positive endexpiratory pressure (PEEP)] and available within 48h from commencement of MV in 318 patients. Patients were mean±SD of 58.0±12.2, predominantly from Europe (54%) and males (68%). Median CRS (IQR) was 34.1 mL/cmH2O (26.5-45.5) and PaO2/FiO2 was 119 mmHg (87.1-164) and was not correlated with CRS. Female sex presented lower CRS than in males (95% CI:-13.8 to-8.5 P<0.001) and higher body mass index (34.7±10.9 vs 29.1±6.0, p<0.001). Median (IQR) PEEP was 12 cmH2O (10-15), throughout the range of CRS, while median (IQR) driving pressure was 12.3 (10-15) cmH2O and significantly decreased as CRS improved (p<0.001). No differences were found in comorbidities and clinical management between CRS strata. In addition, 28-day ICU mortality and hospital mortality did not differ between CRSgroups.Conclusions This multicentre report provides a comprehensive account of CRS in COVID-19 patients on MV-predominantly males or overweight females, in their late 50s-admitted to ICU during the first international outbreaks. Phenotypes associated with different CRS upon commencement of MV could not be identified.

7.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277343

ABSTRACT

Rationale: Higher levels of circulating interleukin-6 (IL-6) and lower respiratory system compliance have each been associated with increased mortality in severe coronavirus 2019 (COVID-19). IL-6 levels are associated with disease severity and mortality in non-COVID-19-related acute respiratory distress syndrome (ARDS). The purpose of this study was to examine the relationship between IL-6 and respiratory mechanics in COVID-19-related ARDS. Methods: This retrospective cohort study took place at two Columbia University Irving Medical Center hospitals. We identified patients age >18 years with laboratory confirmed COVID-19, who were intubated from March 1st through April 30th, 2020, and met the Berlin definition of ARDS. Electronic medical records were reviewed for clinical data. Outcomes were censored at 90 days after intubation. For patients without IL-6 levels recorded on the initial day of intubation, serum samples were obtained from the Columbia University Biobank and tested using the Quantikine Human IL-6 Immunoassay. IL-6 values were log-transformed. The primary outcome was respiratory system compliance. Secondary outcomes were calculated ventilatory ratio, PaO2:FiO2 ratio, and mortality. Linear regression and logistic regression were used for statistical analyses. Results: During the study period, 483 patients had COVID-19-associated ARDS. Median time of follow up was 37 days (IQR 11-90). At 90 days, 260 (53.8%) patients were deceased, 206 (42.7%) had been discharged, and 17 (3.5%) were still admitted. Two hundred sixteen (44.7%) patients had available data on respiratory system compliance and serum IL-6 levels from the initial day of mechanical ventilation. The median IL-6 value was 204.1 pg/ml (IQR 110-469.7). Median compliance was 25.5 ml/cmH2O (IQR 21.4-33.3), median ventilatory ratio was 1.96 (IQR 1.51-2.57), and median PaO2:FiO2 ratio was 134 (IQR 87-196). In unadjusted linear regression, higher IL-6 was associated with lower respiratory system compliance (log [IL-6] coefficient-1.80, p = 0.001) (Figure 1). This relationship remained significant when adjusting for age, sex, body mass index, race, ethnicity, and Sequential Organ Failure Assessment (SOFA) score (coefficient-2.43, p<0.001). There was no significant association between IL-6 and ventilatory ratio (0.76 p=0.08) or PaO2:FiO2 ratio (-6.15 p=0.06). Higher IL-6 was associated with higher odds of death at 90 days (OR 1.35 per unit increase in log [IL-6], p-value 0.022) when adjusting for age, sex, body mass index, race, ethnicity, and SOFA score. Conclusion: In COVID-19-associated ARDS, higher levels of IL-6 were associated with lower respiratory system compliance even adjusting for measured confounders. Higher IL-6 was also associated with higher mortality.

8.
American Journal of Respiratory and Critical Care Medicine ; 203(9), 2021.
Article in English | EMBASE | ID: covidwho-1277033

ABSTRACT

Rationale: Patients with COVID-19 commonly develop severe hypoxemic respiratory failure and require invasive mechanical ventilation (MV). The disease burden and predictors of mortality in this population remain uncertain. Methods: Prospective observational cohort study from 139 intensive care units of the international COVID-19 Critical Care Consortium. Patients enrolled from January 14th through November 31st 2020 were included in the analysis. Patient's characteristics and clinical data were assessed. Multivariable Cox proportional hazards analysis was conducted to identify indipendent predictors of mortality within 28 days from commencement of MV. Results: 1578 patients on MV were included into the analysis. Mean±SD age was 59 years±13 and patients were predominantly males (66%). 542 Patients (34.4%) died within 28 days from commencement of MV. Nonsurvivors were slightly older (mean age±SD 62±13 vs. 59±13) and presented more frequently hypertension, chronic cardiac disease and diabetes. Median (IQR) PaO2/FiO2 upon commencement of MV was 96 (68-135) and 111 (81-173) in patients who did not survive vs. survivors, respectively (p=0.04). ECMO (13% vs 25%, p<0.01), inhaled nitric oxide (11% vs 15%, p=0.02) and recruitment manoeauvres (26% vs 31%, p<0.01) were used less frequently in patients who did not survive. Independent risk factors associated with 28-day mortality included age older than 70 years (hazard ratio [HR], 2.83;95% CI, 1.32-6.07), higher creatinine levels upon ICU admission (HR, 1.20;95% CI, 1.03-1.40), and lower pH within 24h from commencement of MV (HR, 0.12;95% CI, 0.02-0.62), while a shorter period (day) from early symptoms to hospitalisation reduced mortality risks (HR, 0.96;95% CI, 0.93-0.99). Conclusions: Our findings from a large international cohort of critically-ill COVID-19 patients on mechanical ventilation emphasises that elderly patients, not promptly admitted to the hospital, and who present higher creatinine levels and acidosis are at higher risk of mortality.

9.
Perfusion ; 36(1 SUPPL):31-32, 2021.
Article in English | EMBASE | ID: covidwho-1264066

ABSTRACT

Objective: To identify the incidence of infections in those receiving immunomodulatory drugs for COVID- 19 during ECMO and the risk factors for infection. Methods: Deidentified data on all patients who had ECMO for COVID-19 till July 2020 were analysed from the ELSO Registry. A comparison cohort of patients who did not acquire superinfections during ECMO was used to identify risk factors for infection. Our primary outcome measure was incidence of infections pre- or on ECMO in patients receiving immunomodulatory drugs. Univariate analysis assessed potential associations between survival and various pre-ECMO/ECMOrelated factors. Variables (p< 0.1) entered a logistic regression model which identified predictors of infections in this cohort. Results: Of the 1237 patients who required ECMO for COVID-19 related complications, 911 patients (73.6%) received immunomodulatory drugs. 47% of these patients had superinfections, predominantly with gram negative bacteria (56%). Pre-ECMO factors associated with a higher odds of infection included immunodeficiency and treatment with selective cytokine blockers. ECMO complications (mechanical, renal, pulmonary, infectious and metabolic) increased the odds of infection. (Table 1) Patients who developed an infection preor on ECMO had significantly longer ECMO runs than those who did not (491.1±308.9 hours vs 293.4± 240.6hours, p< 0.001) with no mortality difference (45.7% Vs 43.4%, p = 0.45). Conclusions: Of the three quarter of patients who received immunomodulatory drugs for COVID-19 during ECMO, 47% had superinfections. Immunodeficiency and use of selective cytokine blockers were risk factors for infections pre or on ECMO in addition to ECMO related complications.

10.
Perfusion ; 36(1 SUPPL):44, 2021.
Article in English | EMBASE | ID: covidwho-1264064

ABSTRACT

Objective: Extracorporeal membrane oxygenation (ECMO) use in COVID-19 has been supported by major health organizations and studies, but optimal management strategies need further research. We characterize and describe the tracheostomy practice in ECMO-supported patients with acute respiratory failure related to viral pneumonia without SARS-CoV-2 in 2019 and to COVID-19 in 2020. Methods: Analysis of the Extracorporeal Life Support Organization (ELSO) Registry including patients receiving respiratory ECMO support for COVID-19 in 2020 or other viral-induced respiratory failure in 2019. We compared tracheostomy practices between the 2019 and 2020 cohorts and reported outcomes of those that receive a tracheostomy on ECMO. Results: We identified 1960 patients who received VV-ECMO support for acute respiratory failure related to COVID-19. 57% of patients received a tracheostomy during the hospitalization, and 25% had a tracheostomy placed while on ECMO. The proportion of patients receiving a tracheostomy was similar in 2019 viral disease, but tracheostomies were performed 4 days earlier in 2019 compared to 2020 (median 6.7 days [IQR 3.0- 12.0 days] vs. 11.2 days [IQR 5.8-17.0 days], p< 0.01). More patients were mobilized in 2019 than 2020, but patients who received a tracheostomy on ECMO were more likely to be mobilized in both cohorts. 8% of patients were reported as having surgical site bleeding after a tracheostomy placement on ECMO in 2020. The median ECMO duration in those who received a tracheostomy on ECMO was 23.5 days [IQR 15.8-35.3]. Hospital mortality was 45% for patients with COVID- 19 (46% for patients who received a tracheostomy on ECMO). Conclusions: Tracheostomies are commonly performed in COVID-19 patients on ECMO. The number of tracheostomies performed on ECMO in the SARS-CoV-2 pandemic is similar to other viral diseases in 2019, however, they are performed later in the ECMO run. Patients who receive a tracheostomy are more likely to achieve mobilization.

11.
Perfusion ; 36(1 SUPPL):45-46, 2021.
Article in English | EMBASE | ID: covidwho-1264054

ABSTRACT

Objective: The use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) has increased significantly in the last years, and in particular in the recent pandemic COVID-19, representing a valuable therapy to treat severe respiratory failure. However, few patients remain hypoxemic and become hemodynamically instable during V-V ECMO support requiring a change in ECMO configuration. Methods: The Extracorporeal Life Support Organization Registry was reviewed for all cases of adult ARDS in patients undergoing ECMO requiring a change in configuration during the support run. (2017 to 2019). All main aspects, if available, characterizing the patients undergoing ECMO support modifications were collected and analyzed in terms of incidence, causes, patterns, complications and outcomes. Results: Of 9936 V-V ECMO runs, there were 354 ECMO that requiring a in changing configurations (3,5%). Over the study period the proportion of ECMO changing configuration was 1,3% (136) for VA, 1,6% (166) for V-VA and 0,8(85%) for Other configurations with an increasing in configuration changing during the years. The mortality rate in the shifting population was 55%. The new configurations were associated with major bleeding, stroke and renal failure was similar. Main determinants of poor outcome were the severity of the underlying illness, the delay in recognizing evolution of the disease, the complications associated with the conversion itself, and the more complex management of the hybrid setting. Conclusions: Our review of ARDS patients showed the variation in configuration VA ECMO or Hybrid ECMO was not associated with worse survival but with a high rates of complications rates compared with VV ECMO. These data suggest that in very selected patients it may reasonable to initially instituted VV ECMO support, reserving VA or Hybrid ECMO forms for conversion for refractory cardiopulmonary failure and cardiogenic shock that represent the major reasons of VV ECMO failure.

12.
Diabetic Medicine ; 38(SUPPL 1):65, 2021.
Article in English | EMBASE | ID: covidwho-1238410

ABSTRACT

Aims: Self-management education is an essential component of type 1 diabetes care which improves health outcomes. Online mediums of education delivery are growing in popularity, offering a flexible alternative to traditional group education. Interest in online education has increased as healthcare restructuring secondary to covid-19 has restricted face-to- face offerings. We delivered and evaluated a free open online course in type 1 diabetes self-management education. Methods: Understanding type 1 diabetes was a free open online course accessible via registration on an online platform. The course was delivered over a 2-day period in December 2020 and focused on key self-management concepts featuring videos, quizzes and moderated comment sections accompanied by a daily live Q&A session. The course was evaluated via a post-course questionnaire to establish user feedback and experience. Results: 216 users started the course, with 106 users completing >75% of the course steps (completion rate 49.1%). Among the 103 users who completed the optional post-course questionnaire, 69 had type 1 diabetes and 21 were healthcare professionals. Most users agreed that the course was easy to follow (95.1%), improved their knowledge of diabetes (76.2%), motivated them to manage their diabetes (79.7%) and improved their self-management confidence (79.4%). Thematic analysis of free-text responses identified appreciation of the peer-learning environment provided with minimal technical difficulties experienced. Conclusions: Open online courses offer a remotely accessible, engaging and scalable method of self-management education delivery that motivated and improved the self-management confidence of their user base.

13.
Critical Care Medicine ; 30:30, 2021.
Article in English | MEDLINE | ID: covidwho-1209824

ABSTRACT

OBJECTIVES: Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes. DESIGN AND SETTING: We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020. SUBJECTS AND INTERVENTION: Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included. MEASUREMENTS AND MAIN RESULTS: Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39;95% CI, 25-54), Pao2 (mean difference, 20 mm Hg;95% CI, 14-25), and peripheral oxygen saturation (mean difference, 4.74%;95% CI, 3-6%). Respiratory rate decreased post prone positioning (mean difference, -3.2 breaths/min;95% CI, -4.6 to -1.9). Intubation and mortality rates were 24% (95% CI, 17-32%) and 13% (95% CI, 6-19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320];p = 0.84). No major adverse events were recorded in small subset of studies that reported them. CONCLUSIONS: Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.

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15.
Lancet ; 397(10269):95-95, 2021.
Article in English | Web of Science | ID: covidwho-1063677
16.
BMJ Innovations ; 2020.
Article in English | Scopus | ID: covidwho-947824

ABSTRACT

Introduction: Type 2 diabetes self-management education is an essential component of type 2 diabetes care that is traditionally delivered in a face-to-face setting. In response to the recent COVID-19 pandemic, innovative solutions are urgently needed, allowing provision of self-management education that can be delivered in compliance with social distancing policies. Innovations that are self-service and can deliver education efficiently at low cost are particularly appealing to healthcare providers and commissioners. Methods: We aimed to evaluate user uptake, dropout, acceptability, satisfaction, perceived short-term knowledge gain and health benefits/behaviour changes in relation to a free massive open online course (MOOC) in diabetes self-management education, created and delivered during the COVID-19 pandemic. This course, focusing on addressing knowledge and self-management needs for people with type 2 diabetes, made use of online interactive content including expert and patient videos, quizzes, moderated discussion boards and live social media that encouraged personal reflection and goal setting. User expectations and experiences were explored via survey-based methods. Here, we present our experience of developing the course and describe users' experiences. Results: 1991 users registered interest in the course over a 2-week period, with 976 users starting the course and 640 (65.6%) users completing the course in full. Users engaged well, finding the course educational, user-friendly and motivating, demonstrating high completion rates and user satisfaction. A statistically significant (p<0.001) increase in self-reported self-management ability and health knowledge was observed among participants with type 2 diabetes. Discussion: MOOCs in type 2 diabetes self-management education have great potential for delivering education efficiently at scale and low cost. Although engagement can be limited by digital literacy, benefits include flexible and remote access to up-to-date, evidence-based education delivered by a multidisciplinary team of healthcare professionals. © 2020 Author(s) (or their employer(s)).

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