Biomarker-guided duration of antibiotic treatment in children hospitalised with confirmed or suspected bacterial infection: statistical analysis plan for the BATCH trial and PRECISE sub-study.

INTRODUCTION: The BATCH trial is a multi-centre randomised controlled trial to compare procalcitonin-guided management of severe bacterial infection in children with current management. PRECISE is a mechanistic sub-study embedded into the BATCH trial. This paper describes the statistical analysis plan for the BATCH trial and PRECISE sub-study. METHODS: The BATCH trial will assess the effectiveness of an additional procalcitonin test in children (aged 72 h to 18 years) hospitalised with suspected or confirmed bacterial infection to guide antimicrobial prescribing decisions. Participants will be enrolled in the trial from randomisation until day 28 follow-up. The co-primary outcomes are duration of intravenous antibiotic use and a composite safety outcome. Target sample size is 1942 patients, based on detecting a 1-day reduction in intravenous antibiotic use (90% power, two-sided) and on a non-inferiority margin of 5% risk difference in the composite safety outcome (90% power, one-sided), while allowing for up to 10% loss to follow-up. RESULTS: Baseline characteristics will be summarised overall, by trial arm, and by whether patients were recruited before or after the pause in recruitment due to the COVID-19 pandemic. In the primary analysis, duration of intravenous antibiotic use will be tested for superiority using Cox regression, and the composite safety outcome will be tested for non-inferiority using logistic regression. The intervention will be judged successful if it reduces the duration of intravenous antibiotic use without compromising safety. Secondary analyses will include sensitivity analyses, pre-specified subgroup analyses, and analysis of secondary outcomes. Two sub-studies, including PRECISE, involve additional pre-specified subgroup analyses. All analyses will be adjusted for the balancing factors used in the randomisation, namely centre and patient age. CONCLUSION: We describe the statistical analysis plan for the BATCH trial and PRECISE sub-study, including definitions of clinical outcomes, reporting guidelines, statistical principles, and analysis methods. The trial uses a design with co-primary superiority and non-inferiority endpoints. The analysis plan has been written prior to the completion of follow-up. TRIAL REGISTRATION: BATCH: ISRCTN11369832, registered 20 September 2017, doi.org/10.1186/ISRCTN11369832. PRECISE: ISRCTN14945050, registered 17 December 2020, doi.org/10.1186/ISRCTN14945050.

Monoclonal Antibodies in Hospitalised Patients with COVID-19: The Role of SARS-COV-2 Serostatus in an Evolving Pandemic.

Appropriately selected neutralising monoclonal antibodies (nmAbs) are an effective treatment for patients with mild or moderate coronavirus disease 2019 (COVID-19) who are at high risk of progression to severe disease. In contrast, the efficacy of nmAbs in patients hospitalised with COVID-19 has been mixed, and clinical benefit has largely been restricted to seronegative patients [i.e. those lacking endogenous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies] in the trials with positive outcomes. This review summarises the major clinical trial data investigating nmAb treatment for hospitalised patients with COVID-19, and explores current definitions of seropositivity, what they mean in a late-pandemic context and discusses the current late-pandemic challenges associated with defining 'seroprotection' in a clinically meaningful way. We conclude that following widespread vaccination, increasing numbers of prior infections and emerging viral variants, seropositivity now reflects a range of immune coverage rather than a binary tool with which to aid decision-making on a clinically actionable timescale. Treatment decisions with nmAbs in a late-pandemic context would therefore likely best rely on information regarding clinical status, time since symptom onset, underlying patient condition(s) and the dominant circulating variant, should they be approved for future use in hospitalised patients with COVID-19.

Prevalence and Predictors of Anxiety among Stable Hospitalized COVID-19 Patients in Malaysia.

The COVID-19 pandemic has created anxiety among hospitalized SARS-CoV-2 patients. Therefore, this study aimed to determine the prevalence of anxiety and its associated factors among stable inpatient COVID-19 patients in Malaysia. Method: A cross-sectional study was conducted using a web-based online survey involving 401 patients from Malaysia's leading COVID-19 hospitals from 15th April until 30th June 2020, who were chosen using quota sampling. The General Anxiety Disorders 7 items (GAD-7) scale, the Coping Orientation to Problems Experienced Inventory (Brief-COPE) and a socio-demographic profile questionnaire were used. Descriptive analysis and multiple logistic regression were performed using SPSS v23 to determine the prevalence of anxiety and its associated factors. Result: The results showed that the prevalence of anxiety was 7.0%. Multiple logistic regression analysis revealed that female gender (p < 0.05), a fear of infection (p < 0.05), a lack of information (p < 0.05), a maladaptive coping mechanism of behavioral disengagement (p < 0.001) and self-blame (p < 0.001) were significantly associated with anxiety. Meanwhile, adaptive coping mechanisms via instrumental support (p < 0.001) were a significant protective predictor of anxiety. Conclusions: COVID-19 infection has had a significant influence on the mental health of patients. Findings in our study provide baseline data on the prevalence of anxiety among stabilized COVID-19 inpatients in Malaysia. Despite the relatively low prevalence, the data have the potential to improve the present mental health monitoring system and the deployment of suitable treatments in dealing with similar circumstances.

Acute kidney injury among hospitalised patients who died due to COVID-19 in the Eastern Cape, South Africa.

BACKGROUND: Acute kidney injury (AKI) commonly occurs in coronavirus disease 2019 (COVID-19) patients who have been hospitalised and is associated with a poor prognosis. This study aimed to determine the incidence of AKI among COVID-19 patients who died in a regional hospital in South Africa. METHODS: This retrospective record review was conducted at the Mthatha Regional Hospital in South Africa's Eastern Cape province. Data were collected between 10 July 2020 and 31 January 2021. RESULTS: The incidence of AKI was 38% among the hospitalised patients who died due to COVID-19. Most study participants were female, with a mean age of 63.3 ± 16 years. The most common symptom of COVID-19 at the time of hospitalisation was shortness of breath, followed by fever and cough. Half of the patients had hypertension, while diabetes, human immunodeficiency viruses (HIV) and tuberculosis (TB) were other comorbidities. At admission, the average oxygen saturation was 75.5% ± 17. CONCLUSION: The study revealed a high incidence of AKI among hospitalised patients who died due to COVID-19. It also found that those received adequate crystalloid fluids at the time of admission had a lower incidence of AKI.Contribution: Acute kidney injury can be prevented by adequate fluid management during early stage of COVID-19. Majority of COVID-19 patients were referred from lower level of care and primary care providers have their first encounter with these patients. Adequate fluid resuscitation in primary care settings can improve the outcome of hospitalised COVID-19 patients.

Influence of smoking history on the evolution of hospitalized in COVID-19 positive patients: Results from the SEMI-COVID-19 registry.

Introduction: Smoking can play a key role in SARS-CoV-2 infection and in the course of the disease. Previous studies have conflicting or inconclusive results on the prevalence of smoking and the severity of the coronavirus disease (COVID-19). Methods: Observational, multicenter, retrospective cohort study of 14,260 patients admitted for COVID-19 in Spanish hospitals between February and September 2020. Their clinical characteristics were recorded and the patients were classified into a smoking group (active or former smokers) or a non-smoking group (never smokers). The patients were followed up to one month after discharge. Differences between groups were analysed. A multivariate logistic regression and Kapplan Meier curves analysed the relationship between smoking and in-hospital mortality. Results: The median age was 68.6 (55.8-79.1) years, with 57.7% of males. Smoking patients were older (69.9 (59.6-78.0 years)), more frequently male (80.3%) and with higher Charlson index (4 (2-6)) than non-smoking patients. Smoking patients presented a worse evolution, with a higher rate of admission to the intensive care unit (ICU) (10.4 vs. 8.1%), higher in-hospital mortality (22.5 vs. 16.4%) and readmission at one month (5.8 vs. 4.0%) than in non-smoking patients. After multivariate analysis, smoking remained associated with these events. Conclusions: Active or past smoking is an independent predictor of poor prognosis in patients with COVID-19. It is associated with higher ICU admissions and in-hospital mortality.

Introducción: El tabaquismo puede tener un papel importante en la infección por SARS-CoV-2 y en el curso de la enfermedad. Los estudios previos muestran resultados contradictorios o no concluyentes sobre la prevalencia de fumar y la severidad en la enfermedad por coronavirus (COVID-19). Material y métodos: Estudio de cohortes observacional, multicéntrico y retrospectivo de 14.260 pacientes que ingresaron por COVID-19 en hospitales españoles desde febrero a septiembre de 2020. Se registraron sus características clínicas y se clasificaron en el grupo con tabaquismo si tabaquismo activo o previo o en el grupo sin tabaquismo si nunca habían fumado. Se realizó un seguimiento hasta un mes después del alta. Se analizaron las diferencias entre grupos. La relación entre tabaquismo y mortalidad intrahospitalaria se valoró mediante una regresión logística multivariante y curvas de Kapplan Meier. Resultados: La mediana de edad fue 68,6 (55,8­79,1) años, con un 57,7% de varones. El grupo con tabaquismo presentó mayor edad (69,9 (59,6­78,0 años)), predominio masculino (80,3%) y mayor índice de Charlson (4 (2−6)). La evolución fue peor en estos pacientes, con una mayor tasa de ingreso en UCI (10,4 vs 8,1%), mayor mortalidad intrahospitalaria (22,5 vs 16,4%) y reingreso al mes (5,8 vs 4,0%) que el grupo sin tabaquismo. Tras el análisis multivariante, el tabaquismo permanecía asociado a estos eventos. Conclusiones: El tabaquismo de forma activa o pasada es un factor predictor independiente de mal pronóstico en los pacientes con COVID-19, estando asociada a mayor probabilidad de ingreso en UCI y a mayor mortalidad intrahospitalaria.

Mortality risk factors among hospitalised COVID-19 patients

Introduction: COVID-19 is an acute viral infection that mainly affects the respiratory system leading to mortality. Therefore, positive COVID-19 patients may require intensive care unit (ICU) admission in severe cases. Many factors are thought to exacerbate the symptoms of COVID-19 resulting in increased mortality, smoking, hypertension and type 2 diabetes mellitus (T2DM) are on the top of these factors. Objective(s): This study was designed to detect the strength of association between death rate among COVID-19 ICU admitted patients and being smokers, type 2 diabetes mellitus (T2DM), or hypertension. Material(s) and Method(s): A cross-sectional study was conducted. A sample of 302 patients included all COVID-19 patients admitted to the ICU of the central hospital in Amman, Jordan, in July 2021. Result(s) and Conclusion(s): Of the total 302 patients, 171 were smokers. the death rate among smokers (67.25%) was significantly higher than (53.43%) among non-smokers X2= 5.966, p=0.0145. We found that 118 cases had T2DM. the death rate among patient with T2DM (62.71%) was insignificantly higher than (60.32%) among non-diabetic patients X2= 0.172, p=0.67. Of the 130 COVID-19 patients with hypertension, the death rate was (70.76%) significantly higher than (54.1%) among those without hypertension X2= 8.70, p=0.0031. Moreover, by using the OR and 95% CI. Interestingly, we found that smokers were almost two times significantly more prone to death than nonsmokers (OR=1.79, 95%CI:1.12 - 2.86, p=0.015). Also, patients with hypertension were two times significantly more prone to death than normotensive patients, (OR=2.06, 95% CI: 1.27 - 3.33, p=0.0034). On the other hand, T2DM showed an insignificant risk factor (OR=1.11) for death. 95% CI: 0.687- 1.78, p=0.6780. Smoking and hypertension act as significant risk factors to increase mortality in COVID-19 patients.

Maternal mortality and its determining factors among hospitalised mothers in Tehran, Iran, 2013-2020.

The maternal mortality ratio (MMR) is a significant indicator of the quality of a health care system. Despite considerable progress in reducing MMR in Iran in the past few years, we still face a long road ahead in eliminating preventable maternal deaths. In the present study, we evaluated all 80 cases of maternal deaths in 20 hospitals under the supervision of Tehran University of Medical Sciences between March 20 2013 and March 19 2020. During this time, these hospitals recorded 335,216 live births, with an MMR of 24 per 100,000 live births. The average age of deceased mothers was 31.9 ± 6.9 years. Direct causes accounted for 48.75% of maternal deaths, with haemorrhage being the most common direct cause of mortality (17.5%). Moreover, cancer (17.5%) and cardiovascular diseases (17.5%) were the most common indirect causes of maternal mortality. Even after accounting for the COVID-19 pandemic's effects, we have noticed an increase in maternal mortality. As a result, implementing a comprehensive approach for high-risk pregnancies is critical.Impact StatementWhat is already known on this subject? Although we have been able to reduce MMR in Iran to a reasonable level, previous measures would not be sufficient to accomplish future goals. Furthermore, we have a long way to go before reaching the ultimate goal of eradicating avoidable maternal deaths by 2030.What do the results of this study add? The causes, determinants and risk factors of maternal mortality were investigated in this study. With this level of detail, we can observe a steadily increase in MMR in recent years, regardless of the COVID-19 pandemic. The majority of pregnancy-related deaths can be avoided.What are the implications of these findings for clinical practice and/or further research? MMR reduction is a measurable goal that can be attained by improving financial resources, implementing safe delivery, team training, preparing multidisciplinary care with integration for high-risk pregnant women, establishing good provider relationships, and communicating with patients and providers for early warning signs and structural changes.

Post-COVID-19 conditions in Ecuadorian patients: an observational study.

BACKGROUND: Post-COVID-19 disease is not yet clearly described, presenting significant clinical variability across populations and patients. This paper compares post-COVID symptoms in three patient groups with mild, moderate, and severe infections in Ecuadorian outpatients. METHODS: An epidemiological, observational, descriptive, and cross-sectional study was performed, and carried out in Quito, Ecuador. 1,366 non-hospitalized participants between 12 to 85 years, diagnosed with COVID-19 infection by molecular RT-PCR were included in the study. Demographic characteristics, including age groups, sex, ethnic group, work type, residence type, comorbidities, diagnosis, symptoms, and treatment were studied. FINDINGS: 1,366 outpatient Ecuadorian patients were analysed with SARS-CoV2 infection confirmed with a PCR+ test. The mean age was 39 (± 10) years, distributed by age groups ranging between 12 and 85 years; 81.41% were between 18 and 54 years. 50.29% were men, and 49.71% were women. INTERPRETATION: 64.3% of patients had symptoms between 4 to 6 weeks after infection, 21.1% showed ongoing symptoms between 6 to 12 weeks, and 14.6% had symptoms for more than 12 weeks. The most common symptom was fatigue in 67.3% of patients, followed by headache in 45.2%, body pain in 42.3%, and sleep disorders (insomnia, sleep apnoea, restless leg syndrome) in 36.5%. 69.3% of patients showed mild infection, 21.7% moderate, and 9.0% severe infection. On average, patients' daily life activities showed a 6.8% mean degree of impact following infection. A sedentary lifestyle (walking less than 30 minutes a day) was the most critical risk factor (40.3%), followed by being a health worker (11.87%). Patients aged ≥55 years with HTN, CKD, smoking, and sedentary lifestyle were 4.39, 1.92, 9.19, 4.07, and 2.42 times more likely to have a severe infection level. At least 30% of patients do not feel recovered from COVID-19 infection. FUNDING: The author declares that the financial resources for the preparation of this research come from their self-management.

Declining Mortality Rate of Hospitalised Patients in the Second Wave of the COVID-19 Epidemics in Italy: Risk Factors and the Age-Specific Patterns.

BACKGROUND: Mortality rate from COVID-19 in Italy is among the world's highest. We aimed to ascertain whether there was any reduction of in-hospital mortality in patients hospitalised for COVID-19 in the second-wave period (October 2020-January 2021) compared to the first one (February-May 2020); further, we verified whether there were clusters of hospitalised patients who particularly benefitted from reduced mortality rate. METHODS: Data collected related to in-patients' demographics, clinical, laboratory, therapies and outcome. Primary end-point was time to in-hospital death. Factors associated were evaluated by uni- and multivariable analyses. A flow diagram was created to determine the rate of in-hospital death according to individual and disease characteristics. RESULTS: A total of 1561 patients were included. The 14-day cumulative incidence of in-hospital death by competing risk regression was of 24.8% (95% CI: 21.3-28.5) and 15.9% (95% CI: 13.7-18.2) in the first and second wave. We observed that the highest relative reduction of death from first to second wave (more than 47%) occurred mainly in the clusters of patients younger than 70 years. CONCLUSIONS: Progress in care and supporting therapies did affect population over 70 years to a lesser extent. Preventive and vaccination campaigns should focus on individuals whose risk of death from COVID-19 remains high.

Women report more symptoms and impaired quality of life: a survey of Finnish COVID-19 survivors.

BACKGROUND: The long-term sequelae after COVID-19 are not yet fully known. Our aim was to evaluate subjective symptoms and quality of life in Finnish hospitalized COVID-19 patients at six months follow-up. METHODS: Hospitalised adult patients with laboratory-confirmed SARS-CoV-2 infection from March to June 2020 were recruited. We conducted a survey on demographics and comorbidities, ten specific symptoms, and a RAND-36 quality of life questionnaire six months after hospital discharge. We collected clinical data manually from medical records. RESULTS: 101 patients (54 male) out of 246 invited completed the survey. Their median age was 60 years, and the mean hospital length of stay was 15 d. Most patients (90%) experienced symptoms, the most common of which were tiredness (88%), fatigue (79%), sleeping problems (76%), and dyspnoea (70%). In regard to gender, women showed a shorter time of hospitalization (p = .048) and lower peak flow of supplementary oxygen (p = .043). Women reported more frequently dyspnoea, fatigue, tiredness, sleeping problems, and mood problems (p = .008-.033), and a lower quality of life in seven of eight dimensions (p < .001-.015). Five explanatory variables for the reduced quality of life were identified in multivariate analysis: age, female sex, BMI, sleep apnoea, and duration of mechanical ventilation. Of the patients who worked full-time before COVID-19, 11% had not returned to work. CONCLUSIONS: Most patients experienced symptoms six months after hospital discharge. Women reported more symptoms and a lower quality of life than men. These findings highlight the differences in recovery between men and women and call for active rehabilitation of COVID-19 patients.

A randomized open-label trial to evaluate the efficacy and safety of triple therapy with aspirin, atorvastatin, and nicorandil in hospitalised patients with SARS Cov-2 infection: A structured summary of a study protocol for a randomized controlled trial.

OBJECTIVES: The pathophysiology of SARS-Cov-2 is characterized by inflammation, immune dysregulation, coagulopathy, and endothelial dysfunction. No single therapeutic agent can target all these pathophysiologic substrates. Moreover, the current therapies are not fully effective in reducing mortality in moderate and severe disease. Hence, we aim to evaluate the combination of drugs (aspirin, atorvastatin, and nicorandil) with anti-inflammatory, antithrombotic, immunomodulatory, and vasodilator properties as adjuvant therapy in covid- 19. TRIAL DESIGN: Single-centre, prospective, two-arm parallel design, open-label randomized control superiority trial. PARTICIPANTS: The study will be conducted at the covid centre of Dr. Rajendra Prasad Government Medical College Tanda Kangra, Himachal Pradesh, India. All SARS-CoV-2 infected patients requiring admission to the study centre will be screened for the trial. All patients >18years who are RT-PCR/RAT positive for SARS-CoV-2 infection with pneumonia but without ARDS at presentation (presence of clinical features of dyspnoea hypoxia, fever, cough, spo2 <94% on room air and respiratory rate >24/minute) requiring hospital admission and consenting to participate in the trial will be included. Patients with documented significant liver disease/dysfunction (AST/ALT > 240), myopathy and rhabdomyolysis (CPK > 5x normal), allergy or intolerance to statins, allergy or intolerance to aspirin, patients taking medications with significant interaction with statins, prior statin use (within 30 days), prior aspirin use (within 30 days), history of active GI bleeding in past three months, coagulopathy, thrombocytopenia (platelet count < 100000/ dl), pregnancy, active breastfeeding, patient unable to take oral or nasogastric medications, patients in altered mental status, shock, acute renal failure, acute coronary syndrome, sepsis and ARDS at presentation will be excluded. INTERVENTION AND COMPARATOR: After randomization, participants in the intervention group will receive aspirin, atorvastatin, and nicorandil (Fig. 1). Atorvastatin will be prescribed as 40 mg starting dose followed by 40 mg oral tablets once daily for ten days or till hospital discharge whichever is later. Aspirin dose will be 325 starting dose followed by 75 mg once daily for ten days or till hospital discharge whichever is later. Nicorandil will be given as 10 mg starting dose followed by 5mg twice daily ten days or till hospital discharge whichever is later. All patients in the intervention and control group will receive a standard of care for covid management as per national guidelines. All patients will receive symptomatic treatment with antipyretics, adequate hydration, anticoagulation with low molecular weight heparin, intravenous remdesivir, corticosteroids (intravenous dexamethasone for 5 days or more duration if oxygen requirement increasing or inflammatory markers are raised), and oxygen support. Patients will receive treatment for comorbid conditions as per guidelines. Fig. 1 Schematic study design MAIN OUTCOMES: The patients will be followed up for outcomes during the hospital stay or for ten days whichever is longer. The primary outcome will be in-hospital mortality. Any progression to ARDS, shock, acute kidney injury, impaired consciousness, length of hospital stay, length of mechanical ventilation (invasive plus non-invasive) will be secondary outcomes. Changes in serum markers (CRP, D -dimer, S ferritin) will be other secondary outcomes. The safety endpoints will be hepatotoxicity (ALT/AST > 3x ULN; hyperbilirubinemia), myalgia-muscle ache, or weakness without creatine kinase (CK) elevation, myositis-muscle symptoms with increased CK levels (3-10) ULN, rhabdomyolysis-muscle symptoms with marked CK elevation (typically substantially greater than 10 times the upper limit of normal [ULN]) and with creatinine elevation (usually with brown urine and urinary myoglobin) observed during the hospital stay. RANDOMIZATION: Computer-generated block randomization will be used to randomize the participants in a 1:1 ratio to the active intervention group A (Aspirin, Atorvastatin, Nicorandil) plus conventional therapy and control group B conventional therapy only. BLINDING (MASKING): The study will be an open-label trial. NUMBERS TO BE RANDOMIZED (SAMPLE SIZE): A total of 396 patients will participate in this study, which is randomly divided with 198 participants in each group. TRIAL STATUS: The first version of the protocol was approved by the institutional ethical committee on 1st February 2021, IEC /006/2021. The recruitment started on 8/4/2021 and will continue until 08/07/2021. A total of 281 patients have been enrolled till 21/5/2021. TRIAL REGISTRATION: The trial has been prospectively registered in Clinical Trial Registry - India (ICMR- NIMS): CTRI/2021/04/032648 [Registered on: 8 April 2021]. FULL PROTOCOL: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol. The study protocol has been reported under the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines.

Clinical outcomes of hospitalised COVID-19 patients at Mthatha Regional Hospital, Eastern Cape, South Africa: A retrospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a public health crisis that threatens the current health system. The sudden expansion in the need for inpatient and intensive care facilities raised concerns about optimal clinical management and resource allocation. Despite the pressing need for evidence to make context-specific decisions on COVID-19 management, evidence from South Africa remained limited. This study aimed to describe the clinical characteristics and outcomes of COVID-19 hospitalised patients. METHODS: A retrospective cross-sectional study design was used to evaluate the clinical outcomes of hospitalised adult patients (≥ 18 years old) with laboratory-confirmed COVID-19 illness at Mthatha Regional Hospital (MRH), Eastern Cape. RESULTS: Of the 1814 patients tested for COVID-19 between 20 March 2020 and 31 July 2020 at MRH, two-thirds (65.4%) were female. About two-thirds (242) of the 392 patients (21.6%) who tested positive for this disease were hospitalised and one-third (150) were quarantined at home. The mean age of the patients tested for COVID-19 was 42.6 years and there was no difference between males and females. The mean age of hospitalised patients was 55.5 years and the mean age of hospitalised patients who died (61.3 years) was much higher than recovered (49.5 years). Overall, 188 (77.6%) hospitalised patients had clinical comorbidity on admission. Diabetes (36.8%) and hypertension (33.1%) were the most common comorbidities amongst COVID-19 hospitalised patients. CONCLUSION: The majority of the patients who were hospitalised for COVID-19 were elderly and had high baseline comorbidities. Advance age and underlying comorbidities (diabetes, hypertension and HIV) were associated with high mortality in hospitalised COVID-19 patients.

Spiritual Support During COVID-19 in England: A Scoping Study of Online Sources.

Spiritual support is a key element of holistic care, and better healthcare professionals training and stronger strategic guidelines become urgent in light of health disasters and emergencies, such as the COVID-19 pandemic. To this end, the aim of this study was to explore spiritual support provision within mass and social media and the websites of spiritual leaders, institutions and NHS chaplaincy units during COVID-19 in England, between March and May 2020. A scoping review design informed by Levac and colleagues' five-staged framework was adopted, and adapted with a multi-strategy search to scope the different domains of online sources. Results revealed that spiritual support for dying patients, their families, health care staff, spiritual leaders and chaplains, had to be drastically reduced, both in quality and quantity, as well as being provided via different technological devices or domestic symbolic actions. No mention was found of a central strategy for the provision of spiritual support. This study points to the importance of developing centralized strategies to prepare healthcare systems and professionals in relation to spiritual support provision, both routinely and during health disasters and emergencies. Further research will have to explore innovative practices, in particular the role of digital technologies, in spiritual support provision.

Delirium in Older People with COVID-19: Clinical Scenario and Literature Review.

Delirium is a potentially fatal acute brain dysfunction that is characterised by inattention and fluctuating mental changes. It is indicative of an acute serious organ failure or acute infection. Delirium is also associated with undesirable health outcomes that include prolonged hospital stay, long-term cognitive decline and increased mortality. The new SARS-CoV-2 shows, not only pulmonary tropism but also, neurotropism which results in delirium in the acute phase illness particularly in the older age groups. The current assessment for COVID-19 in older people does not routinely include screening for delirium. Implementation of a rapid delirium screening tool is necessary because, without screening, up to 75% of cases can be missed. Delirium can also be exaggerated by health care policies that recommend social isolation and wearing personal protective equipment in addition to less interaction with patients. Non-pharmacological intervention for delirium prevention and management may be helpful if implemented as early and as often as possible in hospitalised older people with COVID-19. A holistic approach that includes psychological support in addition to medical care is needed for older people admitted to hospital with COVID-19.

Exploring the experience of health professionals who cared for patients with coronavirus infection: Hospitalised isolation and self-image.

AIMS AND OBJECTIVES: This study aimed to examine the lived experience of physicians and nurses who underwent hospitalised isolation during the Middle East respiratory syndrome coronavirus outbreak that hit Korea in 2015, and how it may have affected their professional self-image. BACKGROUND: Health professionals caring for patients during infectious outbreaks such as the Middle East respiratory syndrome have reported negative psychological effects. However, little is known about how the experience influences their professional self-image. DESIGN: An interpretive phenomenological approach was applied using individual in-depth interviews. METHODS: Through purposeful and snowball sampling, 11 health professionals who had experienced hospital isolation due to suspicious symptoms of Middle East respiratory syndrome during the outbreak, participated in face-to-face interviews (50-90 min). We adhered to the Consolidated Criteria for Reporting Qualitative Research guideline for reporting. RESULTS: Six themes were identified: (a) engulfed in chaos and exhaustion; (b) feeling hurt and constrained by the rejection and blame; (c) anxiety induced by the enclosed environment; (d) dread of this uncertain and critical disease; (e) sustained by family and colleagues; and (f) reflection at this turning point, expanding self-understanding and seeking a balance. CONCLUSION: Hospitalised isolation was a "turning point" that appeared to change health professionals' sense of identity and direction. RELEVANCE TO CLINICAL PRACTICE: Preparedness for infectious epidemics should ensure tangible assistance, protection, and clear communication with health professionals, with careful attention to their psychological needs and affirmation of their self-image in the aftermath.