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Introduction: High-flow nasal cannula oxygen (HFNC) and non-invasive ventilation (NIV), have been widely used in patients with acute hypoxic respiratory failure (AHRF) due to coronavirus disease 2019 (COVID-19). Their impact on clinical outcomes of COVID-19 is uncertain. Therefore, we performed this meta-analysis to evaluate the effect of HFNC vs. NIV in COVID-19-related AHRF. Method(s): PubMed and Embase were searched through December 15, 2021, for eligible studies comparing the outcomes of HFNC vs. NIV in patients with COVID-19-related AHRF. Our primary outcome was intubation rate. The secondary outcomes were mortality, length of hospital stay (LOS), and changes in PaO2/FiO2 ratio. Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained by using a random-effect model. Result(s): Eleven studies involving 1380 patients (525 received HFNC and 855 received NIV) were included. There were no differences in intubation rate, mortality, or LOS between the two groups (Figure). HFNC achieved a lower level of PaO2/FiO2 ratio improvement than NIV (MD 0.40 days, 95% CI 0.08, 0.72, P=0.02, Figure). Conclusion(s): Our study demonstrated that despite NIV achieving a higher level of PaO2/FiO2 ratio improvement than HFNC, HFNC is non-inferior to NIV in intubation, mortality, and LOS among patients with COVID-19-related AHRF. Large-scale RCTs are needed to validate our findings.
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In the COVID-19 pandemic, to minimize aerosol-generating procedures, cardiac magnetic resonance imaging (CMR) was utilized at our institution as an alternative to transesophageal echocardiography (TEE) for diagnosing infective endocarditis (IE). This retrospective study evaluated the clinical utility of CMR for detecting IE among 14 patients growing typical microorganisms on blood cultures or meeting modified Duke Criteria. Seven cases were treated for IE. In 2 cases, CMR results were notable for possible leaflet vegetations and were clinically meaningful in guiding antibiotic therapy, obtaining further imaging, and/or pursuing surgical intervention. In 2 cases, vegetations were missed on CMR but detected on TEE. In 3 cases, CMR was non-diagnostic, but patients were treated empirically. There was no difference in antibiotic duration or outcomes over 1 year. CMR demonstrated mixed results in diagnosing valvular vegetations and guiding clinical decision-making. Further prospective controlled trials of CMR Vs TEE are warranted. © 2022 Elsevier Inc.
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Introduction/Background COVID-19 and influenza typically present in a very similar clinical picture. The co-infection of influenza among COVID-19 patients (i.e., flurona) can occur in the fall and winter of the year. The prevalence of flurona was estimated to be 0.4% and 4.5% in America and Asia, respectively. The damage of respiratory ciliated cells by the influenza virus can facilitate COVID-19 infection. Few studies reported COVID-19 co-infection with influenza virus. The majority of flurona cases affected older patients with co-morbidities. The co-infection of influenza among COVID-19 patients was associated with more severe disease, especially among older patients with co-morbidities. Young and healthy adults are less likely to develop severe COVID-19 leading to ARDS even with co-infection. However, severe COVID-19 can still occur regardless of age and co-morbidities. Herein, we report a case of severe ARDS in a young and previously healthy adult secondary to flurona that was successfully treated with targeted combination therapy with oseltamivir and remdesivir. Objective(s) A 21-year-old Caucasian male patient without significant past medical history presented the ED with a chief complaint of fatigue, cough, and generalized body aches. The patient mentioned that symptoms started a few days before his presentation. He suspected it was the flu, so he did not seek medical care initially. However, his symptoms continued to worsen, to the point that he could not move without getting severely out of breath. He was tachycardic, tachypneic in the emergency department (ED). His COVID-19 swab returned positive, and a respiratory pathogen panel was also positive for influenza A infection. Initial CTA was negative for PE but showed extensive multifocal bilateral infiltrates consistent with viral pneumonia. He was started on a high-flow nasal cannula. Still, his oxygen was peaking around 85% with increased work of breathing. The patient also did not tolerate BiPAP. Therefore, the patient was intubated in the ED and admitted to the intensive care unit (ICU). He was started on a five-day course of oseltamivir, remdesivir, and intravenous methylprednisolone. The patient remained intubated and mechanically ventilated on the next day, and PaO2/FIO2 ratio was 100. He was started on ARDS treatment protocol, and daily prone positioning was initiated. Gradually the patient started to improve. On day nine, he successfully passed a CPAP trial and was extubated. His ICU stay was complicated by the development of a small segmental PE that was treated with IV heparin. He also had upper GI bleeding, and esophagogastroduodenoscopy revealed a bleeding gastric ulcer, which was successfully managed with endoscopic clipping. The patient gradually improved, and his oxygen requirements decreased significantly over the next few days. He was discharged home with no supplemental oxygen on apixaban and pantoprazole. Methods Our study highlights the importance of screening for co-infecting influenza virus in COVID-19 patients, which could be the leading cause of disease severity. Early detection of flurona can play an important role in managing these patients, especially if they develop ARDS. Targeted combined therapy against influenza and COVID-19 with oseltamivir and remdesivir may effectively mitigate the morbidity and mortality of these patients. Improving compliance with flu vaccination is highly recommended to reduce influenza virus transmission during this long COVID-19 pandemic and reduce the risk of COVID-19 severity.
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Background. A naive Bayes classifier is a popular tool used in assigning variables an equal and independent contribution to a binary decision. With respect to COVID-19 severity, the naive Bayes classifier can consider different variables, such as age, gender, race/ethnicity, comorbidities, and initial laboratory values to determine the probability a patient may need to be admitted or transferred to an intensive care unit (ICU). The aim of this study was to develop a screening tool to detect COVID-19 patients that may require escalation to ICU status. Methods. Patients hospitalized with COVID-19 were gathered from the end of March 2020 to the end of May 2020 from four hospitals in our metropolitan area. We began searching for potential variables to include in the classification model using chi-square analysis or calculating the optimal cutpoint to separate ICU and non-ICU status. After identifying significant variables, we began using standard procedures to construct a classifier. The dataset was split 7:3 to create samples for training and testing. To appraise the model's performance, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), area under the curve (AUC), and the Matthew's correlation coefficient (MCC) were calculated. Results. A total of 574 COVID-19 patients were included in the study. There were 402 patients in the training sample and 172 patients in the testing sample. The naive Bayes classifier demonstrated an overall accuracy result of 75.6% (95% CI;68.5% - 81.8%) using the 14 variables listed in Table 1. The model was able to correctly classify 84.9% of ICU status patients (sensitivity), but only 54.7% of non-ICU status patients (specificity). The PPV and the NPV were 80.1% and 61.7%, respectively. The AUC was 0.717 (95% CI;0.629 - 0.805) and the MCC was 0.410. Conclusion. Our naive Bayes classifier operates by recognizing certain aspects of severe COVID-19 cases and looking for the probability of the variables in said patients. We present a classification model that potentially could be used alongside other tools to screen patients with COVID-19 early in their hospital course to identify those needing escalation to ICU level care.
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: The use of ascorbic acid or vitamin C in patients with COVID-19 pneumonia is a topic of significant investigation. Some argue it decreases the rate of mortality in severe cases of COVID-19 pneumonia, while others argue that it provides no additional benefits to a patient's outcome. This literature review looks at patients with COVID-19 pneumonia, and investigates the role of high dose vitamin C (HDVC) in reducing mortality, length of intensive care unit (ICU) stay, and length of hospital stay. METHODS: A thorough search of the literature was conducted to perform a meta-analysis of the available studies that compared the efficacy of HDVC to standard care or placebo in patients with severe COVID-19 pneumonia. This search was performed using PubMed, Embase, and Cochrane for data on the subject matter of study from inception to April 20, 2021. We considered randomized controlled trials, cohort studies, case-control studies, and case series. From each study, we collected the number of patients with severe COVID-19 pneumonia who underwent treatment with either HDVC or standard care/placebo. The primary outcome was the rate of mortality. Secondary outcomes were ICU length of stay and length of hospital stay. The random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CIs). A p-value <0.05 was considered statistically significant. Heterogeneity was assessed using Higgins I2 index. RESULTS: Three randomized controlled trials and one retrospective cohort study involving 290 patients were including in the meta-analysis. The rate of mortality was not significantly lower in those receiving HDVC when compared to standard care/placebo (7.3% vs. 13.7%, RR 0.60, 95% CI 0.27-1.36, p= 0.22, I2= 15%). Two studies reported the length of hospital stay, which was not significantly lower in those receiving HDVC when compared to the standard care/placebo group (MD= 0.22 days, 95% CI -0.14-0.59, p= 0.23, I2= 0%). Two studies reported length of ICU stay, which was found to be significantly higher in patients receiving HDVC compared to those receiving standard care/placebo (MD= 0.38 days, 95% CI -0.01-0.75, p= 0.04, I2= 0%). CONCLUSIONS: Our meta-analysis demonstrates that the use of HDVC for patients with severe COVID-19 pneumonia does not significantly reduced the rate of mortality when compared to standard care/placebo. HDVC also does not did not significantly reduce the length of hospital stay and was in-fact found to increase the length of ICU stay. Further data should be collected to confirm our findings. CLINICAL IMPLICATIONS: The use of HDVC for patients with severe COVID-19 pneumonia is not effective in reducing mortality, and may in-fact come at the cost of longer ICU stays for patients who receive HDVC rather than standard care. DISCLOSURES: No relevant relationships by Hyder Ali, source=Web Response No relevant relationships by Modar Alom, source=Web Response No relevant relationships by Mohammed Awad, source=Web Response No relevant relationships by Azizullah Beran Beran, source=Web Response No relevant relationships by prabath herath mudiyanselage, source=Web Response No relevant relationships by Saffa Iftikhar, source=Web Response No relevant relationships by Nithin Kesireddy, source=Web Response No relevant relationships by Waleed Khokher, source=Web Response No relevant relationships by Rakin Rashid, source=Web Response
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Prone positioning (PP) in awake patients has been recently proposed as an adjunctive treatment for spontaneously breathing non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to reduce the risk of intubation. However, the magnitude of the effect of PP on clinical outcomes (e.g., the risk of endotracheal intubation, intensive care unit [ICU] admission, or mortality) in these patients remains uncertain. Therefore, we performed a systematic review and meta-analysis to evaluate the effectiveness of PP to improve the clinical outcomes in non-intubated patients with COVID-19. METHODS: We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases from inception through February 24, 2020 for all the studies all studies that all compared PP versus no PP in non-intubated patients with COVID-19. The primary outcome of interest was the rate of endotracheal intubation. The secondary outcomes were in-hospital mortality and intensive care unit (ICU) rates. Pooled odds risk (OR) and 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS: A total of five studies (two randomized controlled trials and three observational studies), involving 470 non-intubated patients with COVID-19 (185 patients received PP and 285 did not) were included. The mean age was 59.82 years, and males represented 67% of total patients. The follow-up period ranged from 14 to 30 days. The endotracheal intubation rate was similar between PP and control groups (OR 0.75, 95% CI 0.41-1.35, P = 0.33, I2 = 20%). There was no difference in the in-hospital mortality rate between the two groups (OR 0.68, 95% CI 0.16-2.85, P = 0.60, I2 = 60%). Four studies reported the risk of ICU admission and demonstrated no difference between the two groups (OR 0.77, 95% CI 0.30-1.95, P = 0.58, I2 = 37%). CONCLUSIONS: Our meta-analysis demonstrated that prone positioning in non-intubated COVID-19 patients did not reduce the risk of endotracheal intubation. Furthermore, PP failed to reduce in-hospital mortality and ICU admission rates. CLINICAL IMPLICATIONS: Although our meta-analysis showed that prone positioning might not reduce the risks of intubation, in-hospital mortality, or ICU admission rate in spontaneously breathing non-intubated COVID-19 patients, more large-scale trials with a standardized protocol for prone positioning are needed to better evaluate the effectiveness of prone positioning in this select population. DISCLOSURES: No relevant relationships by Ragheb Assaly, source=Web Response No relevant relationships by Hazem Ayesh, source=Web Response No relevant relationships by Azizullah Beran Beran, source=Web Response No relevant relationships by Sami Ghazaleh, source=Web Response No relevant relationships by Waleed Khokher, source=Web Response No relevant relationships by Saif-Eddin Malhas, source=Web Response No relevant relationships by Aadil Maqsood, source=Web Response No relevant relationships by Reem Matar, source=Web Response No relevant relationships by Mohammed Mhanna, source=Web Response No relevant relationships by Omar Sajdeya, source=Web Response No relevant relationships by Omar Srour, source=Web Response
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TOPIC: Chest Infections TYPE: Original Investigations PURPOSE: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become a worldwide pandemic and leading cause morbidity and mortality globally. Due to their immunomodulatory functions, micronutrient supplements such as vitamin D, vitamin C, and zinc have been used for the management of viral illnesses. Furthermore, recent studies have shown low serum vitamin C, vitamin D, and zinc levels in critically ill patients with COVID-19. However, the role of these micronutrients in reducing mortality in patients with COVID-19 remains unclear. Therefore, we conducted this meta-analysis to provide a quantitative assessment of the effect of vitamin D, vitamin C, and zinc on mortality in COVID-19. METHODS: We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases from inception through April 24, 2021. All the studies that compared adding micronutrient supplements such as vitamin C, vitamin D, and zinc versus standard-of-care (SOC) in patients with COVID-19 were included. The outcome of interest was the mortality rate. All statistical analyses were performed using the Review Manager software (RevMan 5.3). Pooled risk ratios (RR) and corresponding 95% confidence intervals (CI) were calculated using the random-effects model. A P-value <0.05 was considered statistically significant. RESULTS: Four studies evaluated vitamin C in 390 patients (201 in vitamin C and 189 in SOC). Seven studies assessed vitamin D in 1251 patients (457 in vitamin D and 794 in SOC). Five evaluated zinc in 1506 patients (776 in zinc and 730 in SOC). Both vitamin C (RR 0.60, 95% CI 0.27-1.36, P = 0.22) and vitamin D (RR 0.94, 955 CI 0.46-1.94, P = 0.87) did not significantly reduce mortality. However, zinc was associated with an 33% reduction in mortality compared to SOC (RR 0.67, 95% CI 0.54-0.84, P = 0.0005). CONCLUSIONS: Our meta-analysis demonstrated that zinc reduced mortality in COVID-19 patients. However, vitamin C and D did not show significant improvemnt in mortality. CLINICAL IMPLICATIONS: Micronutrient supplements, especially zinc, may play a role in the treatment of COVID-19. However, it is unclear whether the magnitude of the effects of these micronutrients are clinically meaningful. Further research is needed to better evaluate the utility of these micronutrient supplements in the management of COVID-19. DISCLOSURES: No relevant relationships by Waleed Abdulsattar, source=Web Response No relevant relationships by Ragheb Assaly, source=Web Response No relevant relationships by Hazem Ayesh, source=Web Response No relevant relationships by Azizullah Beran Beran, source=Web Response No relevant relationships by Dana Ghazaleh, source=Web Response No relevant relationships by Waleed Khokher, source=Web Response No relevant relationships by Mohammed Mhanna, source=Web Response No relevant relationships by Asmaa Mhanna, source=Web Response No relevant relationships by Wasef Sayeh, source=Web Response No relevant relationships by Omar Srour, source=Web Response No relevant relationships by Jamie Stewart, source=Web Response
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IntroductionCoronaviruses are one of the common viruses that can cause diseases for humans and animals. In December 2019, a new coronavirus (Novel Coronavirus) was detected as the cause of pneumonia and then respiratory failure. One of the modalities that have been used for treatment is prone positioning. The purpose of this meta-analysis was to investigate the efficacy of awake early prone positioning on COVID-19 patients with respiratory failure.Methods We performed a comprehensive search in the literature for studies that evaluated prone positioning in COVID-19. We searched the databases of PubMed/MEDLINE, Embase, World Health Organization COVID-19 Database, LitCOVID, and Web of Science Core Collection databases from January 1, 2020, until November 30, 2020. The search was not limited by language, study design, or country of origin. Two researchers (MA and SG) independently selected the studies;discrepancies were resolved by a third researcher (OS). We considered randomized controlled trials, cohort studies, case-control studies, and case series. We excluded animal studies, case reports, reviews, editorials, and letters to editors. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The random-effects model was used to calculate the odds ratios (OR), and confidence intervals (CI). Our main outcomes were intubation rate and mortality rate for patients who were admitted to the hospital with hypoxic respiratory failure. Results We included 3 studies in our meta-analysis with a total of 290 patients. There was no significant difference between prone positioned awake patients compared to non-prone positioned awake patients regarding intubation rate OR 1.48 ( 95% CI: 0.751-2.927, P-value: 0.257 ) (Figure 1) and mortality rate OR 0.54 ( 95% CI: 0.219-1.326, Pvalue: 0.179) (Figure 2). Conclusion Early awake prone positioning does not have a significant impact on nonintubated COVID-19 patients with respiratory failure according to our meta-analysis. More randomized controlled trials should be done to evaluate the efficacy.