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1.
Transplant Cell Ther ; 29(5): 321.e1-321.e9, 2023 05.
Article in English | MEDLINE | ID: covidwho-2313869

ABSTRACT

Allogeneic hematopoietic stem cell transplantation (HSCT) recipients are at risk of various complications during post-transplantation follow-up. Some patients may refer to an emergency department (ED) for medical attention, but data on ED visits by HSCT recipients are lacking. In the present study, we aimed to assess ED utilization in HSCT recipients and associated risk factors during post-transplantation follow-up, identify subgroups of HSCT recipients presenting to the ED, analyze outcomes and prognostic factors for hospitalization and 30-day mortality after ED visits, and assess mortality hazard following an ED presentation. The study involved a retrospective single-center longitudinal analysis including 557 consecutive recipients of allogeneic HSCT at the Medical University of Vienna, Austria, between January 2010 and January 2020. Descriptive statistics, event estimates accounting for censored data with competing risks, latent class analysis, and multivariate regression models were used for data analysis. Out of 557 patients (median age at HSCT, 49 years [interquartile range (IQR), 39 to 58 years]; 233 females and 324 males), 137 (25%) presented to our center's ED at least once during post-HSCT follow-up (median individual follow-up, 2.66 years; IQR, .72 to 5.59 years). Cumulative incidence estimates of a first ED visit in the overall cohort were 19% at 2 years post-HSCT, 25% at 5 years post-HSCT, and 28% at 10 years post-HSCT. These estimates were increased to 34%, 41%, and 43%, respectively, in patients residing in Vienna. Chronic graft-versus-host disease (GVHD) was the sole risk factor showing a statistically significant association with ED presentation in multivariate analysis (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.63 to 3.35). Patients presented to the ED with various and often multiple symptoms. We identified 3 latent patient groups in the ED, characterized mainly by the time from HSCT, chronic GVHD, and documented pulmonary infection. Hospitalization was required in 132 of all 216 analyzed ED visits (61%); in-hospital mortality and 30-day mortality rates were 13% and 7%, respectively. Active acute GVHD, systemic steroids, documented infection, pulmonary infiltrates, and oxygen supplementation were statistically significant predictors of hospitalization; shorter time from HSCT, pulmonary infiltrates, and hemodynamic instability were independent risk factors for 30-day mortality. ED presentation during the last 30 days increased the mortality hazard in the overall cohort (HR, 4.56; 95% CI, 2.68 to 7.76) after adjustment for relevant confounders. One-quarter of the patients visited the ED for medical attention at least once during post-HSCT follow-up. Depending on the presence of identified risk factors, a significant proportion of patients may require hospitalization and be at risk for adverse outcomes. Screening for these risk factors and specialist consultation should be part of managing most HSCT recipients presenting to the ED.


Subject(s)
Graft vs Host Disease , Hematopoietic Stem Cell Transplantation , Male , Female , Humans , Middle Aged , Retrospective Studies , Transplantation, Homologous/adverse effects , Graft vs Host Disease/epidemiology , Graft vs Host Disease/etiology , Risk Factors , Hematopoietic Stem Cell Transplantation/adverse effects
2.
Ann Pharmacother ; : 10600280221151106, 2023 Feb 11.
Article in English | MEDLINE | ID: covidwho-2238889

ABSTRACT

BACKGROUND: No previous literature has compared methadone with oxycodone for intravenous (IV) opioid weaning. OBJECTIVE: To determine if a weaning strategy using enteral methadone or oxycodone results in faster time to IV opioid discontinuation. METHODS: This was a single-center, retrospective, cohort medical record review of mechanically ventilated adults in an intensive care unit (ICU) who received a continuous IV infusion of fentanyl or hydromorphone for ≥72 hours and an enteral weaning strategy using either methadone or oxycodone from January 1, 2020, through December 31, 2021. Differences between groups were controlled for using Cox proportional hazards models. The primary outcome was time to continuous IV opioid discontinuation from the initiation of enteral opioids. Secondary outcomes included the primary endpoint stratified for COVID-19, duration of mechanical ventilation, ICU and hospital length of stay, and safety measures. RESULTS: Ninety-three patients were included, with 36 (38.7%) patients receiving methadone and 57 (61.3%) receiving oxycodone. Patients weaned using methadone received IV opioids significantly longer before the start of weaning (P = 0.04). However, those on methadone had a significantly faster time to discontinuation of IV opioids than those on oxycodone, mean (standard deviation) 104.7 (79.4) versus 158.3 hours (171.2), P = 0.04, and, at any time, were 1.89 times as likely to be weaned from IV opioids (hazard ratio, HR 1.89, 95% confidence interval, CI 1.16-3.07, P = 0.01). CONCLUSION AND RELEVANCE: This was the first study showing enteral methadone was associated with a shorter duration of IV opioids without differences in secondary outcomes compared with oxycodone. Prospective research is necessary to confirm this finding.

4.
Journal of the Intensive Care Society ; 23(1):55-56, 2022.
Article in English | EMBASE | ID: covidwho-2043016

ABSTRACT

Introduction: Comparatively little is known about drug requirements in patients admitted to ICU with COVID-19 pneumonitis. We analysed drug usage for patients admitted during the first wave of the pandemic, comparing these with a retrospective cohort admitted with Influenza pneumonia. Methods: Forty-nine ventilated patients with COVID-19 pneumonitis were identified through ICNARC, ten were excluded as duration of stay < 7 days or not needing ventilation. Further three were excluded due to missing data and one due to ECMO escalation. Results: The median age was 61 years;length of stay 22 days and 68% survived ICU. Table 1 describes the use of Infusions and enteral medications. Discussion: Propofol was used in most (43% patient-hours in ICU/median duration = 234 hours). All patients received opiate infusions (mainly morphine or alfentanil in similar proportions) and 91% received muscle relaxants, for prolonged periods. Over half received Midazolam (median 106 hours) as an adjunct or substitute to Propofol as patients were difficult to sedate, required longer ventilation, paralysis and concerns with Propofol associated hypertriglyceridemia. Over two-third received alpha agonist infusions (median 68.5 hours) as adjunctive sedation or delirium management. Three quarters of patients received a furosemide infusion (median 90 hours), the evidence extrapolated from studies such as FACTT.1 Around three quarters received Human Albumin (median 100 grams over 3 days). Nearly a quarter received nebulized Prostacyclin for refractory hypoxia, often associated with saturation of HME filters and ventilatory difficulties.2 Over half of patients received Carbocisteine (median 13 days). Clonidine and Risperidone to manage delirium were used in a third (median 10.5 and 11 days respectively), as was Acetazolamide to restore pH and aid weaning. Over a third were prescribed enteral opiates and nearly a quarter received benzodiazepines to manage withdrawal symptoms. Just under a half of patients received Melatonin. Antibiotic usage was high with a median of 3 Antibiotics used (median duration 15 days/61% of patient days). Diagnosing superadded infection such as VAP was challenging3 and we did not routinely monitor serum Procalcitonin levels. We also compared prescribing habits with 12 influenza patients (11 survivors) identified using similar inclusion criteria and found patients with COVID-19 were older (61 versus 51 years ) with longer ICU stays (median 22 versus 20 days). They were also more likely to receive enteral Carbocisteine, Clonidine, Acetazolamide, Morphine and Diazepam. Conclusion: We were able to generate valuable data on prescribing in ventilated patients with COVID-19 pneumonitis during the first wave. Through this, we are able to use drug usage as a surrogate for issues such as delirium, drug withdrawal, antibiotic prescribing and nursing workload in general.

5.
Journal of the Intensive Care Society ; 23(1):189-190, 2022.
Article in English | EMBASE | ID: covidwho-2042991

ABSTRACT

Introduction: Awareness of medical staff burnout has grown significantly over recent years and has been thrown into the limelight during the COVID-19 pandemic. Extraordinary burden has been placed on the junior members of the workforce during this time. One survey showed over half of junior doctors said they considered changing career.1 Another survey demonstrated that 44% were suffering from burnout or other mental health conditions.2 Objectives: The aim of our survey was to assess trainee welfare and highlight areas for improvement within our intensive care unit. Methods: Members of the medical workforce within our intensive care unit were asked to complete an online survey in December 2020 and April 2021. Burnout was quantified using an external online survey available via the BMA website.3 Our survey questions covered topics such as expectation and reality of workload, as well as working environment. Results: The survey was distributed to all non-consultant members of the medical team. These included registrars, core trainees, foundation doctors, clinical fellows and advanced critical care practitioners. 18 responded to the initial survey and 15 to the second. 56% reported high or very high levels of burnout in December compared to 47% in April. No-one reported low burnout at either time point. The majority found the workload to be as expected or higher. Morning intensive care teaching was highlighted as a positive aspect of the working environment in our ICU, while the lack of break spaces was a negative factor. Conclusions: The findings from our survey correlated with wider national surveys. Although burnout levels improved slightly between December 2020 and April 2021, there is still a long way to go to get this to an acceptable level. Factors that play into this include the workload expectation. More senior members of the team found the workload to be higher than initially expected. One of the factors causing this disparity was that they were expected to supervise others, often those who had been re-deployed from non-ICU specialties with limited experience of critical care. Since these surveys, the out of hours staffing has been increased with the aim to improve the workload burden. Strict social distancing rules resulted in break space capacity being severely reduced. Roomcapacity restrictions created a divide between nursing and medical staff as they had no area to share break periods. A coffee afternoon (Brew and a Vent) was organised to bring the team back together, modelled on the Coffee and a Gas scheme from the Association of Anaesthetists.4 The team felt galvanised by regular morning teaching which has resulted in the employment of a teaching fellow to coordinate this going forward. There is clearly large scope for improvement with regards to staff wellbeing, but small steps have been made in the right direction. Our surveys have shown that small interventions can go a long way to improving staff morale, especially when the suggestions for change have come from the juniors themselves.

6.
American Journal of Respiratory and Critical Care Medicine ; 205:1, 2022.
Article in English | English Web of Science | ID: covidwho-1880448
7.
Disaster Prevention and Management ; 31(3):182-192, 2022.
Article in English | ProQuest Central | ID: covidwho-1874086

ABSTRACT

Purpose>The purpose of the paper is to challenge and address the limitations of the traditional system of knowledge production that is embedded in disaster and climate change research studies, and research studies in general. It argues that knowledge production in research processes conforms to colonialist thinking or west-inspired approaches. Such a system often results in the omission of crucial information due to a lack of participation, inclusion and diversity in knowledge production.Design/methodology/approach>The paper proposes practices and recommendations to decolonise knowledge production in disaster and climate change research studies, and research studies in general. It provides a brief literature review on the concepts of decolonisation of knowledge and epistemological freedom, and its origins;assesses the need for knowledge decolonisation, emphasising on the integration of local knowledge from grassroots women-led initiatives in instances where disasters and crises are being investigated in vulnerable communities, especially in the Global South;and finally the paper proposes to decolonise knowledge production through activating co-learning and co-production. The practices have been developed from the work of relevant authors in the field and case studies.Findings>Through a brief literature review on previous discourses on the topic of knowledge decolonisation and analysis of recent case studies on disaster and crisis management and community resilience, the paper finds that there exists a lack of pluralism and inclusion in epistemology which limits the pursuit to obtain the whole truth in the production of knowledge in research studies.Originality/value>This paper adds to the discussion of decolonisation of knowledge in the field of disaster and climate change research studies, and research processes in general. It provides in-depth analyses of recent case studies of emerging community resilience and local practices that were crucial in the face of the coronavirus disease 2019 (COVID-19) crisis.

8.
Wien Klin Wochenschr ; 134(9-10): 371-376, 2022 May.
Article in English | MEDLINE | ID: covidwho-1844383

ABSTRACT

BACKGROUND: Cancer patients infected with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) have an increased risk of mortality. Here, we investigated predictive factors for coronavirus disease 2019 (COVID-19) associated mortality in patients with neoplastic diseases treated throughout Austria. METHODS: In this multicentric nationwide cohort study, data on patients with active or previous malignant diseases and SARS-CoV­2 infections diagnosed between 13 March 2020 and 06 April 2021 were collected. Collected data included the stage of the malignant disease and outcome parameters 30 days after the diagnosis of SARS-CoV­2 infection. RESULTS: The cohort consisted of 230 individuals of which 75 (32.6%) patients were diagnosed with hematologic malignancies and 155 (67.4%) with solid tumors. At a median follow-up of 31 days after COVID-19 diagnosis, 38 (16.5%) patients had died due to COVID-19. Compared to survivors, patients who died were older (62.4 vs. 71.4 years, p < 0.001) and had a higher ECOG performance status (0.7 vs. 2.43, p < 0.001). Furthermore, higher neutrophil counts (64.9% vs. 73.8%, p = 0.03), lower lymphocyte counts (21.4% vs. 14%, p = 0.006) and lower albumin levels (32.5 g/l vs. 21.6 g/l, p < 0.001) were observed to be independent risk factors for adverse outcomes. No association between mortality and systemic antineoplastic therapy was found (p > 0.05). In 60.6% of the patients, therapy was postponed due to quarantine requirements or hospital admission. CONCLUSION: Mortality of Austrian cancer patients infected with SARS-CoV­2 is comparable to that of other countries. Furthermore, risk factors associated with higher mortality were evident and similar to the general population. Treatment delays were frequently observed.


Subject(s)
COVID-19 , Neoplasms , Austria/epidemiology , COVID-19 Testing , Cohort Studies , Humans , Neoplasms/diagnosis , Neoplasms/epidemiology , Neoplasms/therapy , SARS-CoV-2 , Time-to-Treatment
9.
Geoforum ; 131: 105-115, 2022 May.
Article in English | MEDLINE | ID: covidwho-1734405

ABSTRACT

The COVID-19 pandemic has forced a re-examination of our societies and in particular urban health. We argue that urban health needs to address three inter-related challenge areas - the unequal impacts of climate change, changing patterns of urbanization, and the changing role of the local government - across multiple spatial scales: from individual, households to neighbourhoods, cities, and urban hinterlands. Urban health calls for nimble institutions to provide a range of responses while adapting to crisis situations, and which operate beyond any one spatial scale. We illustrate our argument by drawing on South and Southeast Asian examples where responses to the pandemic have confronted these challenges across scales. A multiscalar definition of urban health offers an opportunity to challenge dominant approaches to urban health in research, policy, and practice.

10.
Int J Med Inform ; 160: 104688, 2022 04.
Article in English | MEDLINE | ID: covidwho-1654584

ABSTRACT

BACKGROUND: Building Machine Learning (ML) models in healthcare may suffer from time-consuming and potentially biased pre-selection of predictors by hand that can result in limited or trivial selection of suitable models. We aimed to assess the predictive performance of automating the process of building ML models (AutoML) in-hospital mortality prediction modelling of triage COVID-19 patients at ICU admission versus expert-based predictor pre-selection followed by logistic regression. METHODS: We conducted an observational study of all COVID-19 patients admitted to Dutch ICUs between February and July 2020. We included 2,690 COVID-19 patients from 70 ICUs participating in the Dutch National Intensive Care Evaluation (NICE) registry. The main outcome measure was in-hospital mortality. We asessed model performance (at admission and after 24h, respectively) of AutoML compared to the more traditional approach of predictor pre-selection and logistic regression. FINDINGS: Predictive performance of the autoML models with variables available at admission shows fair discrimination (average AUROC = 0·75-0·76 (sdev = 0·03), PPV = 0·70-0·76 (sdev = 0·1) at cut-off = 0·3 (the observed mortality rate), and good calibration. This performance is on par with a logistic regression model with selection of patient variables by three experts (average AUROC = 0·78 (sdev = 0·03) and PPV = 0·79 (sdev = 0·2)). Extending the models with variables that are available at 24h after admission resulted in models with higher predictive performance (average AUROC = 0·77-0·79 (sdev = 0·03) and PPV = 0·79-0·80 (sdev = 0·10-0·17)). CONCLUSIONS: AutoML delivers prediction models with fair discriminatory performance, and good calibration and accuracy, which is as good as regression models with expert-based predictor pre-selection. In the context of the restricted availability of data in an ICU quality registry, extending the models with variables that are available at 24h after admission showed small (but significantly) performance increase.


Subject(s)
COVID-19 , Triage , Hospital Mortality , Humans , Intensive Care Units , Netherlands/epidemiology , Prognosis , Retrospective Studies , SARS-CoV-2
11.
Revue des Maladies Respiratoires Actualités ; 14(1):6, 2022.
Article in French | ScienceDirect | ID: covidwho-1586711

ABSTRACT

Introduction La vaccination contre la Covid a été recommandée chez les patients transplantés d’organes solides en début d’année 2021, selon un schéma comprenant 3 doses chez les patients n’ayant pas présenté d’infection par la Covid 19 et selon un schéma comprenant 2 injections chez les patients ayant été infectés par la Covid. Méthodes Nous avons étudié la réponse vaccinale après un schéma complet dans une cohorte de patients transplantés pulmonaires et cardiopulmonaires à l’hôpital Marie Lannelongue. Selon les recommandations de l’OMS, l’absence de réponse vaccinale est définie par une sérologie dont le taux est<30 BAU/ml. Le taux d’Anticorps considéré comme protecteur est un taux>260 BAU/ml. Les patients dont le taux est compris entre 30 et 260 BAU/ml sont considérés comme faiblement répondeurs. La sérologie a été effectuée entre 1 et 3 mois après la dernière injection. Résultats Dans notre cohorte comprenant 373 patients, une sérologie Covid a pu être obtenue chez 75% des patients. Une absence complète de séroconversion a été constatée chez 75% des patients. Une séroconversion avec un taux d’anticorps considéré comme protecteur n’a été obtenu que chez 14% des patients, dont la moitié a présenté une infection par la Covid. Par ailleurs, 11% des patients ont été faiblement répondeurs. Conclusion Notre étude mono-centrique suggère une très faible réponse vaccinale chez les patients transplantés pulmonaires et cardiopulmonaires, suggérant la réalisation d’une 4e dose chez les patients partiellement répondeurs et/ou un traitement par anticorps monoclonaux spécifiques chez les patients non répondeurs.

14.
Neurology ; 96(15 SUPPL 1), 2021.
Article in English | EMBASE | ID: covidwho-1407925

ABSTRACT

Objective: To assess patients' and providers' perspective and experience with rapid implementation of telemedicine in outpatient setting at onset of COVID 19 pandemic. Background: Telemedicine in outpatient setting has been sparsely used in Neurology Department prior to COVID19 pandemic. The COVID-19 pandemic forced an unprecedent reorganization of clinical care delivery worldwide. Understanding the experience and satisfaction with telemedicine is important to finding pathways for improving the health care delivery in ambulatory setting. Design/Methods: Electronic Medical Records from a large southeastern Michigan health system were queried for adult neurology visits between March-May 2020. Surveys containing questions on experience and satisfaction with telemedicine visits were sent to patients and providers. Sociodemographic and reason for visit data were collected from patients and providers. Results: Out of over 3000 televisits, 276 patients responded of which 66% were female, 75% white, 42% had a telephone, 29% a video, 26% had both appointments. Mean age was 60.8. 85% reported a satisfactory experience, receiving expected amount of information (71%). Over 50% felt it was easy to schedule a visit and had less waiting time than clinic visit. 92% reported acceptable video/audio quality during telemedicine visit and 70% preferred combination type of visits in the future, while 8% preferred only televists. Out of 34 neurologist responders, 64% were female, 61% white, 42% had <5 years in practice, 64% did not have previous telemedicine experience. 88% reported at least moderate satisfaction, 61% preferring video and 3% telephone encounters. Providers felt that through telemedicine they satisfied patients' concerns 65%, completed history and counseling satisfactory (80%), but not physical examination (20%). 86% plan on using telemedicine in the future. Conclusions: Patients and providers had satisfactory experience with telemedicine during COVID 19 pandemic, suggesting that telemedicine is feasible for adult neurology care. However, the majority of patients prefer a combination of telemedicine and clinic visit.

15.
Environ Urban ; 33(1): 239-254, 2021 Apr.
Article in English | MEDLINE | ID: covidwho-873810

ABSTRACT

The COVID-19 pandemic is an evolving urban crisis. This research paper assesses impacts of the lockdown on food security and associated coping mechanisms in two small cities in Bangladesh (Mongla and Noapara) during March to May 2020. Due to restrictions during the prolonged lockdown, residents (in particular low-income groups) had limited access to livelihood opportunities and experienced significant or complete loss of income. This affected both the quantity and quality of food consumed. Coping strategies reported include curtailing consumption, relying on inexpensive starchy staples, increasing the share of total expenditure allocated to food, taking out loans and accessing relief. The pandemic has exacerbated the precariousness of existing food and nutrition security in these cities, although residents with guaranteed incomes and adequate savings did not suffer significantly during lockdown. While coping strategies and the importance of social capital are similar in small and large cities, food procurement and relationships with local governments show differences.

16.
J Intern Med ; 288(4): 469-476, 2020 10.
Article in English | MEDLINE | ID: covidwho-810836

ABSTRACT

INTRODUCTION: Higher comorbidity and older age have been reported as correlates of poor outcomes in COVID-19 patients worldwide; however, US data are scarce. We evaluated mortality predictors of COVID-19 in a large cohort of hospitalized patients in the United States. DESIGN: Retrospective, multicenter cohort of inpatients diagnosed with COVID-19 by RT-PCR from 1 March to 17 April 2020 was performed, and outcome data evaluated from 1 March to 17 April 2020. Measures included demographics, comorbidities, clinical presentation, laboratory values and imaging on admission. Primary outcome was mortality. Secondary outcomes included length of stay, time to death and development of acute kidney injury in the first 48-h. RESULTS: The 1305 patients were hospitalized during the evaluation period. Mean age was 61.0 ± 16.3, 53.8% were male and 66.1% African American. Mean BMI was 33.2 ± 8.8 kg m-2 . Median Charlson Comorbidity Index (CCI) was 2 (1-4), and 72.6% of patients had at least one comorbidity, with hypertension (56.2%) and diabetes mellitus (30.1%) being the most prevalent. ACE-I/ARB use and NSAIDs use were widely prevalent (43.3% and 35.7%, respectively). Mortality occurred in 200 (15.3%) of patients with median time of 10 (6-14) days. Age > 60 (aOR: 1.93, 95% CI: 1.26-2.94) and CCI > 3 (aOR: 2.71, 95% CI: 1.85-3.97) were independently associated with mortality by multivariate analyses. NSAIDs and ACE-I/ARB use had no significant effects on renal failure in the first 48 h. CONCLUSION: Advanced age and an increasing number of comorbidities are independent predictors of in-hospital mortality for COVID-19 patients. NSAIDs and ACE-I/ARB use prior to admission is not associated with renal failure or increased mortality.


Subject(s)
Betacoronavirus/genetics , Coronavirus Infections/epidemiology , Diabetes Mellitus/epidemiology , Disease Management , Hypertension/epidemiology , Pneumonia, Viral/epidemiology , Age Factors , COVID-19 , Comorbidity , Coronavirus Infections/therapy , Diabetes Mellitus/therapy , Female , Follow-Up Studies , Hospital Mortality/trends , Humans , Hypertension/therapy , Inpatients , Male , Michigan/epidemiology , Middle Aged , Pandemics , Pneumonia, Viral/therapy , Prevalence , Prognosis , RNA, Viral/analysis , Retrospective Studies , Risk Factors , SARS-CoV-2 , Survival Rate/trends
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