Coronavirus Disease 2019 in Pediatric Emergency Room: The Dilemma of Cycle Threshold Value

Objective The havoc caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic could not have been predicted, with children being affected worldwide. Testing for SARS-CoV-2 infection helped to define the interventions against the spread of the disease. A polymerase chain reaction (PCR) test has been the mainstay of diagnostic testing. Cycle threshold (Ct) is a semiquantitative value that indicates approximately how much viral genetic material was in the sample. The aim of this study was to evaluate the impact of Ct values among children with SARS-CoV-2 infection. Methods Between May 3, 2020 and August 3, 2020, clinical laboratory input and the data of patients with positive SARS-CoV-2 PCR tests were retrospectively studied. Results There was no statistical significance between Ct values and the patient's status, symptoms other than fever, or other laboratory findings. However, the Ct value of patients who had symptoms at the time of admission to the hospital was significantly lower. Conclusion In this study, symptomatic patients had lower Ct than asymptomatic patients that reflected higher viral loads. In evidence-based medicine applications, it might be useful to correlate the clinical history with laboratory test results. Even symptomatic patients with high Ct value coinfections, or an alternative acute infection, should be considered. © 2022. Thieme. All rights reserved.

High-flow cannula for frail patients with SARS-CoV-2 infection non-eligible for intensive care unit management.

OBJECTIVES: High-flow nasal cannula (HFNC) was widely used during the COVID-19 pandemic in intensive care units (ICU), but there is no recommendation for elderly patients non-eligible for ICU management. We aimed to describe the outcomes of HFNC treatment in patients with COVID-19 who are not eligible for ICU management. METHODS: Retrospective bicentric cohort study performed between September 1, 2020 and June 30, 2021 in two infectious diseases departments of Colmar Hospital and Antoine Beclere University Hospital, France. RESULTS: Sixty-four patients were treated with HFNC: 33 in Colmar and 31 in Beclere hospital (median age: 85 years; IQ, 82-92). Of these, 16 patients survived (25%). Surviving patients had a lower Charlson comorbidity index score than deceased patients (five vs six; p=0.02). CONCLUSIONS: Despite a high death rate, with survivors being younger and having fewer comorbidities, HFNC is an easy tool to implement in non-ICU wards for the frailest patients.

Efficacy and safety of high-flow nasal cannula therapy in elderly patients with acute respiratory failure.

INTRODUCTION: To assess the efficacy and safety of high-flow nasal cannula (HFNC) in elderly patients with acute respiratory failure (ARF) not due to COVID-19, refractory to treatment with conventional oxygen therapy and/or intolerant to noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) and without criteria for admission to intensive care units (ICU). METHODS: Prospective observational study of patients with ARF treated with HFNC who presented clinical and arterial blood gas deterioration after 24 h of medical treatment and oxygenation by conventional systems. The degree of dyspnoea, gas exchange parameters (arterial O2 pressure/inspired O2 fraction ratio (PaO2/FiO2); oxygen saturation measured by oximetry/ inspired fraction of oxygen (Sp02/Fi02), ROX index), degree of patient tolerance and mortality were evaluated. These were measured at discharge from the emergency department (ED), 24 h after treatment with conventional oxygenation and 60, 120 min and 24 h after initiation of HFNC. The results were analyzed for all patients as a whole and for patients with hypercapnia (arterial carbon dioxide tension (PaCO2) < 45 mmHg) separately. RESULTS: 200 patients were included in the study between November 2019 and November 2020, with a mean age of 83 years, predominantly women (61.9%), obese (Body Mass Index (BMI) 31.1), with high comorbidity (Charlson index 4) and mild-moderate degree of dependence (Barthel 60). A number of 128 patients (64%) were hypercapnic. None had respiratory acidosis (pH 7.39). Evaluation at 60 min, 120 min and 24 h showed significant improvement in all patients and in the subgroup of hypercapnic patients with respect to baseline parameters in respiratory rate (RR), dyspnoea, ROX index, PaO2/FiO2, SpO2/FiO2 and patient comfort. No changes in PaCO2 or level of consciousness were observed. HFNC was well tolerated. Ten patients (5%) died due to progression of the disease causing ARF. CONCLUSIONS: HFNC is an effective and safe alternative in elderly patients with ARF not due to COVID-19, refractory to treatment with conventional oxygen therapy and/or intolerant to NIV or CPAP and without criteria for admission to ICU.

Clinical Dilemma of Diabetic Ketoacidosis and COVID-19 Infection

The COVID-19 Pneumonia with diabetic ketoacidosis is a dreadful health condition. Diabetic ketoacidosis is one of the severe metabolic complications and it can be precipitated by infection. We presented a case of 48 years female with no known comorbidities who presented with COVID-19 symptoms and with Diabetic Ketoacidosis. The case presented with elevated inflammatory markers, high anion gap metabolic acidosis with type I respiratory failure. During admission, the oxygen saturation had marked drop, later her improvement was steady followed by gradual tapering of the oxygenation. Marked improvement was noticed in the subsequent follow-up. COVID-19 infection can be precipitated by preexisting diabetes or newly diagnosed diabetes and the severity of COVID-19 infection is more pronounced in patients with diabetes mellitus, thus should be managed timely and accordingly. The scarce studies among the COVID-19 cases with diabetic ketoacidosis reflect the need for further studies for the availability of a wider range of information. Copyright © 2021, Kathmandu University. All rights reserved.

Clinical profile and outcome of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 infection: a single-center observational study from South India

Background: Multisystem inflammatory syndrome in children (MIS-C) is a post-infectious sequelae of acute COVID-19 infection affecting children. This study was done over a period of 12 months from December 2020 to November 2021 to describe the clinical presentation, laboratory abnormalities, and outcome of children with MIS-C. Method(s): Seventy-eight children below 12 years of age who satisfied the WHO diagnostic criteria for MIS-C were included in the study. Clinical parameters were recorded at admission. Relevant laboratory investigations, radiological studies, and outcome were documented. Result(s): The most commonly affected age group was 6-12 years with a female predominance. COVID RTPCR was negative in all patients. Most cases presented 2-6 weeks after the onset of acute COVID-19 infection. Lethargy, poor feeding, vomiting, abdominal pain, loose stools, cough, and cold are common symptoms of MIS-C syndrome in children and the common signs were rash, conjunctival congestion, hypotension, tachycardia, tachypnea, and hypoxemia. Gastrointestinal system was the commonly affected followed by the hepatic, renal, and cardiovascular systems. Coronary artery abnormalities were seen in 20% of cases. IVIg was the mainstay of therapy used in 95% of patients. Mortality was 1.3%. Cases responded well to IVIg and steroids. Conclusion(s): Overall, the short-term outcome was favorable with low mortality in our study cohort. One-fifth of children had coronary artery abnormalities during acute phase underscoring the need for long-term follow-up. Copyright © 2022, The Author(s).

Hafnia, a case of translocated septicemia

Case Report: Hafnia alvei, a member of the Enterococcus family, is a gram-negative anaerobe native to the gastrointestinal tract. While very rarely pathogenic, it has historically been associated with gastroenteritis, meningitis, bacteremia, pneumonia, and nosocomial wound infections. Here we report a non-fatal case of Hafnia-septicemia following recent ERCP for Choledocholithiasis. Case Report: 73-year-old Caucasian male with Chronic obstructive pulmonary disease, chronic kidney disease Stage 5, diabetes mellitus and hypertension who presented to the Emergency Department (ED) with a chief complaint of chills and fevers as well as worsening dry hacking cough and intermittent shortness of breath. Of note, patient had presented to the ED the previous day with abdominal pain and nausea after undergoing ERCP for Choledocholithiasis from day prior. Computed tomography (CT) imaging from 1st ED visit showed no acute signs of pancreatitis, however patient was noted to have bibasilar opacities. Lipase was normal at 39. Other lab work was significant for leukocytosis to 11 000. Patient's abdominal pain and nausea resolved while in the ED, he also denied shortness of breath and was breathing comfortably on room air. He was discharged from the ED with 7-day course of Azithromycin for community acquired pneumonia. On return visit next day, patient reported new onset shortness of breath and fevers. Physical exam was remarkable for hypoxia requiring 2 liters nasal cannula, and tachycardia to 104. Patient tested negative for Covid -19. Patient admitted for acute hypoxic respiratory failure and sepsis secondary to presumed bacterial pneumonia. Patient was started on IV Vancomycin and Cefepime and required oxygen support for hypoxia. He showed marked improvement by day two of hospitalization and was weaned off oxygen. Admission Blood cultures were positive for gram negative rods after 24 hours and subsequently grew Hafnia that was pan sensitive except to Ampicillin + Sulbactam. Repeat blood cultureswere negative 24 hours later. Patient was deemed medically stable on day 3 of admission and discharged on PO Levofloxacin for 10-day course for Hafnia septicemia and pneumonia. Discussion(s): When considering the etiology of septicemia especially in the context of a recent gastrointestinal procedure, translocation of anaerobic bacteria should be on the differential. Hafnia alvei is a rare pathologic cause of septicemia with only a handful of reported cases upon literature review. Copyright © 2023 Southern Society for Clinical Investigation.

Does Perfusion Index in Term Neonate with Late-Onset Pneumonia Predict Disease Severity and Prognosis?

Objective: Pneumonia is an important disease that causes sepsis in newborns and constitutes the majority of deaths due to infections, especially in developing countries. Pulse oximeters that are widely used in clinics, can determine heart rate, arterial oxygen saturation, additionally perfusion index (PI). In this study, the role of PI in determining the severity and prognosis of the disease in newborns with late-onset pneumonia (LOP);the relationship between PI and respiratory support need and Silverman Anderson Retraction Score (SAS) were aimed to determine. Material(s) and Method(s): In this prospective study, 30 term newborns diagnosed with late-onset pneumonia (LOP) were at the time of hospitalization,at the 24th hours of their treatment, and discharge;in the control group, PI measurements were made from the right upper extremity every 10 seconds for 3 minutes at the discharge of 30 term healthy newborns between December 2017 and June 2018. By comparing the data, it was aimed to determine the relationship of PI with the severity of the disease, prognosis, need for respiratory support and Silverman Anderson Retraction Score (SAS). Result(s): Their mean birth weights was 2000 - 4600 g the mean was 3570 g in the study, 2800 - 4100 g the mean was 3610 g in the control group and there was no significant difference (p>0.05);Gestational ages were 365/7 - 413/7, mean 392/7 in the study group, 373/7 - 405/7 in the control group, mean 396/7 weeks, and the statistical difference between the groups was not significant (p>0.05). The ratio of female/male was similar in the groups. Their median age was 9.5 days (3-27) in the control, 21 days (5-28) in the study group, and higher in the study group (p<0.05). The median capillary refill time was 1.7 seconds in the control, 1.6 seconds in the study group, and similar between the groups. The mean PI was 2.3+/-0.9 in the control group. In the study group, it was 3.6+/-1.2 on hospitalization, 3.2+/-1.2 on the first day, 3.4+/-0.7 at discharge. In the study group, PI values on hospitalization and first day were higher (p<0.05). There were reticular infiltration 50% bilateral, 30% right paracardiac, 10% left paracardiac, 3.3% right lower lobe. Alpha hemolytic streptococci in 1 (3.3%), Acinetobacter iwoffii in 1 (3.3%), Respiratory syncytial virus 6 (20%), Coronavirus 4 (13.3%), Rhinovirus 2 (6.7%) and Influenza A 1 (3.3%) patient were determined. We applied free flow oxygen 17 (56.7%), oxygen by hood 5 (16.7%), heated humidified high-flow nasal cannula 1 (3.3%), nasal continuous airway pressure 4 (13.3%), nasal intermittent positive pressure ventilation 4 (13.3%) cases. PI was higher in the patients needing positive pressure on admission (p<0.05). A positive correlation was found between SAS and PI on admission in the study group (p=0.008). The number of patients whose PI decreased during hospitalization increased over time. Conclusion(s): In the neonates with LOP, the severity of the disease, the need for respiratory support and prognosis cannot be predicted by PI. There was no relation between SAS and PI. It was concluded that more accurate results can be achieved by measuring PI using more patients, more sensitive probes and technically more advanced monitors. New studies should be conducted to determine the role of PI in demonstrating well-being and early detection of life-threatening conditions in the healthy newborns. Copyright © 2022 Ankara Pediatric Hematology Oncology Training and Research Hospital. All rights reserved.

Clinical Findings and Outcomes From Subjects With COVID-19 Pneumonia in an Intermediate Respiratory Care Unit.

BACKGROUND: Many patients with COVID-19 require respiratory support and close monitoring. Intermediate respiratory care units (IRCU) may be valuable to optimally and adequately implement noninvasive respiratory support (NRS) to decrease clinical failure. We aimed at describing intubation and mortality in a novel facility entirely dedicated to COVID-19 and to establish their outcomes. METHODS: This was a retrospective, observational study performed at one hospital in Spain. We included consecutive subjects age > 18 y, admitted to IRCU with COVID-19 pneumonia, and requiring NRS between December 2020-September 2021. Data collected included mode and usage of NRS, laboratory findings, endotracheal intubation, and mortality at day 30. A multivariable Cox model was used to assess risk factors associated with clinical failure and mortality. RESULTS: A total of 1,306 subjects were included; 64.6% were male with mean age of 54.7 y. During the IRCU stay, 345 subjects clinically failed NRS (85.5% intubated; 14.5% died). Cox model showed a higher clinical failure in IRCU upon onset of symptoms and hospitalization was < 10 d (hazard ratio [HR] 1.59 [95% CI 1.24-2.03], P < .001) and PaO2 /FIO2 < 100 mm Hg (HR 1.59 [95% CI 1.27-1.98], P < .001). These variables were not associated with increased 30-d mortality. CONCLUSIONS: The IRCU was a valuable option to manage subjects with COVID-19 requiring NRS, thus reducing ICU overload. Male sex, gas exchange, and blood chemistry at admission were associated with worse prognosis, whereas older age, gas exchange, and blood chemistry were associated with 30-d mortality. These findings may provide a basis for better understanding outcomes and to improve management of noninvasively ventilated patients with COVID-19.

Ventilatory associated barotrauma in COVID-19 patients: A multicenter observational case control study (COVI-MIX-study).

BACKGROUND: The risk of barotrauma associated with different types of ventilatory support is unclear in COVID-19 patients. The primary aim of this study was to evaluate the effect of the different respiratory support strategies on barotrauma occurrence; we also sought to determine the frequency of barotrauma and the clinical characteristics of the patients who experienced this complication. METHODS: This multicentre retrospective case-control study from 1 March 2020 to 28 February 2021 included COVID-19 patients who experienced barotrauma during hospital stay. They were matched with controls in a 1:1 ratio for the same admission period in the same ward of treatment. Univariable and multivariable logistic regression (OR) were performed to explore which factors were associated with barotrauma and in-hospital death. RESULTS: We included 200 cases and 200 controls. Invasive mechanical ventilation was used in 39.3% of patients in the barotrauma group, and in 20.1% of controls (p<0.001). Receiving non-invasive ventilation (C-PAP/PSV) instead of conventional oxygen therapy (COT) increased the risk of barotrauma (OR 5.04, 95% CI 2.30 - 11.08, p<0.001), similarly for invasive mechanical ventilation (OR 6.24, 95% CI 2.86-13.60, p<0.001). High Flow Nasal Oxygen (HFNO), compared with COT, did not significantly increase the risk of barotrauma. Barotrauma frequency occurred in 1.00% [95% CI 0.88-1.16] of patients; these were older (p=0.022) and more frequently immunosuppressed (p=0.013). Barotrauma was shown to be an independent risk for death (OR 5.32, 95% CI 2.82-10.03, p<0.001). CONCLUSIONS: C-PAP/PSV compared with COT or HFNO increased the risk of barotrauma; otherwise HFNO did not. Barotrauma was recorded in 1.00% of patients, affecting mainly patients with more severe COVID-19 disease. Barotrauma was independently associated with mortality. TRIAL REGISTRATION: this case-control study was prospectively registered in clinicaltrial.gov as NCT04897152 (on 21 May 2021).

Delivery of high flow oxygen through nasal vs. tracheal cannulas: A bench study.

Background: The use of high flow oxygen therapy (HFOT) has significantly escalated during the COVID-19 pandemic. HFOT can be delivered through both dedicated devices and ICU ventilators. HFOT can be administered to a patient via a nasal cannula (NC). In intubated patients, a tracheal cannula (TC) is used instead. In this study, we aim to compare the work of breathing (WOB) using a TC or NC and to explore whether differences exist among HFOT devices. Methods: Seven HFOT devices (three dedicated and four ICU ventilators) were connected to a manikin head (Laerdal Medical) through a NC (Optiflow 3S, large size, Fisher and Paykel Healthcare) or a TC (OPT 970 Optiflow+, Fisher and Paykel Healthcare). Each device was also attached to a manikin head that was connected to a lung simulator (ASL5000, Ingmar Medical), set at 40 ml/cmH2O compliance, 10 cmH2O/L/s resistance, and sinusoidal inspiratory effort (muscular pressure 10 cmH2O, rate 30 breaths/min). HFOT was delivered at 40 L/min and at 21% inspired oxygen fraction. The total WOB per breath and its resistive and elastic components were automatically analyzed breath by breath over the last 20 breaths by using Campbell's diagram. Results: The WOB and its resistive and elastic components were significantly lower with the TC than with the NC for every device, and systematically lower with the reference device than with others. These differences were, however, very small and may be not clinically relevant. Conclusion: The WOB is lower with the TC than with the NC and with the reference device, compared with the most recent devices.

A Prospective Observational Study on Short and Long-Term Outcomes of COVID-19 Patients with Acute Hypoxic Respiratory Failure Treated with High-Flow Nasal Cannula.

(1) The use of high-flow nasal cannula (HFNC) combined with frequent respiratory monitoring in patients with acute hypoxic respiratory failure due to COVID-19 has been shown to reduce intubation and mechanical ventilation. (2) This prospective, single-center, observational study included consecutive adult patients with COVID-19 pneumonia treated with a high-flow nasal cannula. Hemodynamic parameters, respiratory rate, inspiratory fraction of oxygen (FiO2), saturation of oxygen (SpO2), and the ratio of oxygen saturation to respiratory rate (ROX) were recorded prior to treatment initiation and every 2 h for 24 h. A 6-month follow-up questionnaire was also conducted. (3) Over the study period, 153 of 187 patients were eligible for HFNC. Of these patients, 80% required intubation and 37% of the intubated patients died in hospital. Male sex (OR = 4.65; 95% CI [1.28; 20.6], p = 0.03) and higher BMI (OR = 2.63; 95% CI [1.14; 6.76], p = 0.03) were associated with an increased risk for new limitations at 6-months after hospital discharge. (4) 20% of patients who received HFNC did not require intubation and were discharged alive from the hospital. Male sex and higher BMI were associated with poor long-term functional outcomes.

Effect of the Early Combination of Continuous Positive Airway Pressure and High-Flow Nasal Cannula on Mortality and Intubation Rates in Patients With COVID-19 and Acute Respiratory Distress Syndrome. The DUOCOVID Study.

INTRODUCTION: Non invasive respiratory support (NIRS) is useful for treating acute respiratory distress syndrome (ARDS) secondary to COVID-19, mainly in mild-moderate stages. Although continuous positive airway pressure (CPAP) seems superior to other NIRS, prolonged periods of use and poor adaptation may contribute to its failure. The combination of CPAP sessions and high-flow nasal cannula (HFNC) breaks could improve comfort and keep respiratory mechanics stable without reducing the benefits of positive airway pressure (PAP). Our study aimed to determine if HFNC+CPAP initiates early lower mortality and endotracheal intubation (ETI) rates. METHODS: Subjects were admitted to the intermediate respiratory care unit (IRCU) of a COVID-19 monographic hospital between January and September 2021. They were divided according to Early HFNC+CPAP (first 24h, EHC group) and Delayed HFNC+CPAP (after 24h, DHC group). Laboratory data, NIRS parameters, and the ETI and 30-day mortality rates were collected. A multivariate analysis was performed to identify the risk factors associated with these variables. RESULTS: The median age of the 760 included patients was 57 (IQR 47-66), who were mostly male (66.1%). The median Charlson Comorbidity Index was 2 (IQR 1-3) and 46.8% were obese. The median PaO2/FiO2 upon IRCU admission was 95 (IQR 76-126). The ETI rate in the EHC group was 34.5%, with 41.8% for the DHC group (p=0.045), while 30-day mortality was 8.2% and 15.5%, respectively (p=0.002). CONCLUSIONS: Particularly in the first 24h after IRCU admission, the HFNC+CPAP combination was associated with a reduction in the 30-day mortality and ETI rates in patients with ARDS secondary to COVID-19.

National Trends in Pediatric Critical Asthma Severity during the Covid-19 Pandemic

INTRODUCTION: Asthma exacerbations in children have historically been attributed to a combination of viral infection, environmental exposures, and individual patient attributes. The COVID-19 pandemic has provided a unique opportunity to evaluate variations in asthma severity during a time of changing viral exposure patterns and patient behaviors. This study describes the trends in pediatric critical asthma severity during the COVID-19 pandemic. METHOD(S): We performed a retrospective analysis of the Virtual Pediatric Systems (VPS) database. Inclusion criteria were: patients admitted to a pediatric intensive care unit in the United States from 2014-2021 with a discharge diagnosis of "asthma with acute exacerbation" or "asthma with status asthmaticus." Asthma severity was determined by the maximum level of respiratory support required during the admission, from lowest to highest: 1-Heated high flow nasal cannula;2-Non-invasive positive pressure;3-Endotracheal intubation;4-Inhaled anesthetics or ECMO. Patients were divided into Pre-COVID, Pandemic Era 2020, and 2021 groups based on the date of admission, with the start of the COVID-19 pandemic defined as April 1, 2020. Subgroup analysis was performed based on race/ethnic group. RESULT(S): A total of 51,746 patients were identified in the VPS database that met the stated criteria. The average number of admissions per month was 713 and 206 in the Pre-COVID and Pandemic groups, respectively. Patients categorized as "Severe" (severity levels 3 & 4) represented 3.8% and 4.7% of admissions, respectively (p< 0.05). Patients categorized as "Moderate" (severity level 2) represented 16.9% and 21.7% of admissions, respectively (p< 0.05). Asthma mortality rates were found to be 0.3% and 0.7%, respectively (p< 0.05). Subgroup analysis by race/ ethnic group found that asthma severity by race/ethnicity was unchanged from the pre-COVID baseline. CONCLUSION(S): During the COVID-19 pandemic, the number of critical asthma admissions decreased while the average severity and mortality rate in those patients increased. Further study is needed to determine whether these findings are due to delayed presentation to healthcare, changes in viral exposure patterns, or other factors.

Outcomes of Cancer Patients Hospitalized with Covid-19 and Shock

INTRODUCTION: There is heterogeneous evidence on the effect of coronavirus disease 2019 (COVID-19) on the outcomes of cancer patients. Although cancer and shock are independently associated with low survival in hospitalized patients, data on the outcomes of COVID-19 in patients with both cancer and shock is scarce. Therefore, we aimed to describe the outcomes of cancer patients with COVID-19 and shock. METHOD(S): A cohort study of adult cancer patients with COVID-19 that developed shock and were hospitalized to the University of Texas MD Anderson Cancer Center between 03/2020 to 02/2021. Baseline demographic, cancer, and clinical characteristics were collected. Primary outcome was hospital mortality. Secondary outcomes included requirements of invasive mechanical ventilation (IMV), renal replacement therapy (RRT), hospital length of stay (LOS), 30- day mortality, and 90-day mortality. RESULT(S): Out of the 515 patients that were admitted to a dedicated COVID-19 unit, 53 (10.3%) developed shock;their median age was 65 (IQR 5-73), most were male (59%), white (64%), and the median body mass index was 30 (IQR 26-35). Of them, 27 (51%) had hematological cancers, and 26 (49%) solid tumors. Overall, 18 (34%) patients had undergone cancer-directed chemotherapy within 1 month before admission. The median admission sequential organ failure assessment score was 3 (IQR 2-5.3). Most patients (98%) were treated with corticosteroids. The majority of patients (91%) received oxygen therapy through a high flow nasal cannula (HFNC), and 35 (68%) required IMV. RRT was initiated in 14 (26%) patients. The median hospital LOS was 24 (IQR 13-37). The hospital, 30-day, and 90-day mortality rates were 62% (33 patients), 70% (37 patients), and 70% (37 patients), respectively. CONCLUSION(S): Patients with cancer, COVID-19 infection, and shock displayed high mortality rates. These results are similar to those previously reported in non-COVID patients. Future well-designed observational studies should use matching techniques to identify the real impact of COVID-19 on mortality in cancer patients with shock.

Does Timing of Smoking Cessation Have an Impact on Covid-19 Outcomes?

INTRODUCTION: The relationship between smoking and increased morbidity/mortality with COVID19 is well documented;however, there is little data on the relationship between former smokers (FS) and COVID19. Risk stratification of FS is dependent on years since smoking cessation (SC). We conducted a study to determine, if years since SC influenced COVID19 outcomes. METHOD(S): A retrospective cohort study at a single institution. Inclusion criteria: age >= 18 and admitted to the hospital from Jan 2020 to Nov 2021 for COVID19. Patients were divided into two categories;SC < 15 years, and SC > 15 years. The primary outcome was mortality, with secondary outcomes: requirement of nasal cannula (NC), NIV, and mechanical ventilation (MCV). Odds ratios (OR) were calculated for all outcomes. Post-hoc age-adjusted odds ratios (AOR) for age < 75, were calculated for all outcomes. Mortality data was collected on all patients, and OR were calculated between FS, smokers (CS), and non-smokers (NS). RESULT(S): The total number of patients was 608 with 256 being FS, 308 non-smokers, 30 CS, and 14 unknown smoking status. The mean age of FS was 70. There were 154 males (60%) 102 females (40%). Total FS < 75 was 152. Obesity rates were 64.1% and 67.6%, T2DM (Diabetes Mellitus) rates were 34.3% and 59.5% in SC < 15 and SC > 15, respectively. There was no difference in mortality between the two groups, OR (OR 0.81, CI 0.46-1.40, p=0.45) and AOR (AOR 0.79, 0.37-1.69, p=0.54). There was an increased risk of MCV for the SC < 15 group (OR 2.1, CI 1.02-4.57, p=0.04). AOR did not replicate this trend. There was no difference in patients requiring NC (AOR 1.38, CI 0.70-2.74, p=0.36) or MCV (AOR 1.65, CL 0.69- 3.91, p=0.25) between the two groups. SC < 15 had lower rates of NIV (AOR 0.36, CI 0.15-0.90, p=0.029). There was no difference in mortality between FS and CS (OR 1.69, CI 0.70-4.19, p=0.24). The FS group had higher rates of mortality than NS (OR 1.43, CI 1.00-2.05, p=0.048). CONCLUSION(S): Regardless of the timing of SC, FS have the same mortality and MCV rates with COVID19. High comorbidity burden was noted in both population groups, with the SC > 15 group having higher rates of T2DM. Further studies are needed to determine the full effect of SC on COVID19 outcomes, including effect of pack years.

Prone Positioning for Nonintubated Covid-19 Patients: A Systematic Review and Meta-Analysis

INTRODUCTION: Since the early pandemic, prone positioning (PP) has been broadly utilized for non-intubated COVID-19 patients, but results from recently published randomized controlled trials (RCTs) are contradictory. We aimed to systematically synthesize the outcomes associated with PP for non-intubated COVID-19 patients. METHOD(S): Two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, and ClinicalTrials.gov for RCTs of PP in nonintubated adult patients with COVID-19 and published in English from January 1st, 2020 to July 1st, 2022. The same two independent groups extracted the data and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies and the GRADE approach to assess certainty/quality of the evidence. The primary outcome was the reported cumulative intubation risk, while secondary outcomes included mortality, need for escalating respiratory support, hospital length of stay, ICU admission, and adverse events. The study protocol was prospectively registered with PROSPERO, CRD42022343625. RESULT(S): 12 RCTs with 2,886 patients were included. For non-intubated COVID-19 patients, PP significantly reduced the intubation risk (risk ratio [RR] 0.85, 95%CI 0.75 to 0.96), compared to supine position. Subgroup analysis showed a significant reduction in intubation risk among patients supported by high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) (RR 0.83, 95%CI 0.73 to 0.94) but not in patients with conventional oxygen therapy (RR 1.02, 95%CI 0.67 to 1.56). No significant reduction was seen in mortality (RR 0.96, 95%CI 0.82 to 1.13), need for escalating respiratory support (RR 1.03, 95%CI 0.77 to 1.37), hospital length of stay (MD 0.35 days, 95%CI -0.57 to 1.26), ICU admission (RR 0.75, 95%CI 0.51 to 1.10), and adverse events. No obvious risk of bias and publication bias was found for the primary outcome. CONCLUSION(S): In non-intubated COVID-19 patients, PP reduced the need for intubation, in particular among those requiring respiratory support with HFNC or NIV, but did not reduce mortality, need for escalating respiratory support, hospital length of stay, and ICU admission.

Effects of COVID-19 Vaccines on Outcomes Among Hospitalized COVID-19 Patients

Background. After COVID-19 vaccinations, breakthrough infections appear to be of public health concern. There is limited data regarding clinical effectiveness of COVID-19 vaccination. Our aim was to determine the differences in clinical outcomes among COVID-19 unvaccinated versus vaccinated patients who required hospitalization. Methods. This was a retrospective cohort study of COVID-19 hospitalized patients between 7/25/21 and 9/6/2021. Previously infected COVID-19 patients were excluded. The patients were classified as fully vaccinated vs. unvaccinated (CDC guidelines). The primary outcome included the need for advance oxygen therapy (high flow nasal cannula, non-invasive ventilation, mechanical ventilation), ICU admission, or 28-day all-cause mortality. We performed a subgroup analysis according to the immunocompetent status and older age (>=65 years). Results. We enrolled 207 patients, stratified as unvaccinated (n=147 [71%]) vs. fully vaccinated (n=60 [29%]). Unvaccinated patients were younger (median age 58 vs. 71 years old, p< 0.001) and more likely to require oxygen (n=105[71%] vs. n=35[58%], p=0.07) compared to vaccinated patients. Unvaccinated patients were more likely to reach the primary outcome (n=59 [40%] vs. n=16 [26%], p=0.08) when compared to vaccinated patients. The subgroup analyses revealed that unvaccinated patients had higher rates of the primary outcome when >=65 years old ( n=27/46 [58.7%] vs. n=13/37 [35.1%], p=0.047), immunocompetent (n=57/139 [41%] vs. 13/53 [24.5%]) and both groups combined (n=22/39 [56%] vs. 11/38 [28.9%], p=0.021), respectively. Conclusion. Unvaccinated patients represented the largest proportion of hospitalized patients. Unvaccinated patients were younger and required oxygen therapy. Unvaccinated immunocompetent patients aged >= 65 had worse outcomes compared to vaccinated patients. Further studies are needed to identify unmeasured characteristics that may be associated with poor clinical outcomes.

Clinical significance of antineutrophil cytoplasmic antibody positivity in patients infected with SARS-CoV-2

Background. The Coronavirus Disease 2019 (COVID-19) is well-known for its broad spectrum of immune-related phenotypes similar to those seen in autoimmune or inflammatory diseases. Furthermore, evidence has gradually accumulated that COVID-19 may induce systemic inflammatory manifestations such as multisystem inflammatory syndrome, haemophagocytic syndromes, and systemic vasculitis. Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a small vessel vasculitis characterised by necrotising vasculitis. So far, there have been several case reports regarding AAV occurrence after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, which have indicated a triggering potential of SARS-CoV-2 infection for AAV occurrence. This study investigated the rate of ANCA positivity and its clinical significance in COVID-19 patients. Methods. This study included 178 patients infected with SARS-CoV-2 who were enrolled in a cohort of a single center. Myeloperoxidase (MPO)-ANCA and proteinase 3 (PR3)-ANCA from the stored blood sera were measured using the immunoassay kits. Mortality, mechanical ventilator care, and severe infection were assessed as poor outcomes. Severe infection was defined as a medical condition that required a high-flow nasal cannula and/or mechanical ventilator care. The 2022 American College of Rheumatology and the European Alliance of Associations for Rheumatology classification criteria for the three subtypes of AAV were applied only to patients who had MPO-ANCA or PR3-ANCA among the study subjects Results. The detection rate of ANCA positivity was 18.5%: MPO-ANCA and PR3-ANCA were found in 22 (12.4%) and 14 (7.9%) patients. Patients with ANCA positivity exhibited a lower cumulative survival rate than those without, but the difference was not statistically significant (P = 0.057). However, neither MPO-ANCA nor PR3-ANCA affected the three poor outcomes. According to the new criteria, 12 (6.7%) and 21 (11.8%) patients were classified as having granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) Neither ANCA positivity nor ANCA subtype (MPO-ANCA and PR3-ANCA) positivity had a significant influence on poor outcomes of SARS-CoV-2. ANCA: antineutrophil cytoplasmic antibody;MPO: myeloperoxidase;PR3: proteinase 3;SARS-CoV-2: severe acute respiratory syndrome coronavirus 2. Conclusion. SARS-CoV-2 infection may increase the rate of ANCA positivity, which may not affect poor outcomes but contribute to the classification of GPA and MPA despite uncertain clinical significance.