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1.
Infezioni in Medicina ; 30(3):432-439, 2022.
Article in English | EMBASE | ID: covidwho-2033632

ABSTRACT

Introduction: Liposomal amphotericin use is limited in developing countries due to its extremely high cost and availability. Therefore, the study aimed to evaluate deoxycholate amphotericin B’s utility and adverse effect profile in patients with mucormycosis. Methodology: This retrospective cohort study from 2019 to 2021 included patients with proven mucormy-cosis who received deoxycholate amphotericin B for more than or equal to five days and had at least three creatinine values on treatment. Baseline demographic details, risk factors and treatment details of all the patients were recorded. In addition, the details of treat-ment-related adverse effects and outcomes were ascer-tained. Results: Of the 57 included patients, a history of diabe-tes, COVID-19 and steroid use was present in 49 (86%), 43 (75.4%) and 33 (57.9%) patients, respectively. Isolat-ed rhino-orbital mucormycosis was the most common presentation (n=49, 86%). The median time of fol-low-up was 48 (30.5-90) days. A total of 8 (14%) pa-tients died during the hospital stay. The median dura-tion of amphotericin treatment was 21 (14-40) days. Thirty-nine patients (68.4%) developed hypokalaemia on treatment, while 27 (47.4%) patients developed hy-pomagnesaemia. A total of 34 (59.6%) patients developed AKI on treatment. The median day of development of AKI was 6 (4-10) days. The median baseline, highest and final creatinine values were 0.78 (0.59-0.94) mg/dl, 1.27 (0.89-2.16) mg/dl and 0.93 (0.74-1.59) mg/ dl respectively. The median percentage change from baseline to highest value and last follow-up value was 45% (0.43%-161%) and 25% (-4.8%-90.1%) respectively. The final creatinine was less than 150% of the baseline in 36 (63.2%) patients. Conclusion: Deoxycholate amphotericin is an accept-able alternative for treating mucormycosis in re-source-constrained settings.

2.
Infezioni in Medicina ; 30(3):403-411, 2022.
Article in English | EMBASE | ID: covidwho-2033629

ABSTRACT

Cases with SARS-CoV-2 RT-PCR negative pneumonia are an understudied group with uncertainty remain-ing regarding their treatment approach. We aimed to compare the clinical and radiological characteristics of RT-PCR positive and clinically diagnosed RT-PCR negative COVID-19. This was a single-centre retrospective study conducted at a tertiary care hospital in Western India. All patients (age ≥18 years) with suspicion of COVID-19 with SARI (severe acute respiratory infec-tions) who were subjected to RT-PCR testing (nasal/ oropharyngeal swab) were included. Based on RT-PCR results, patients were categorized and compared for demographic, clinical, and biochemical characteristics and outcomes. Out of 500 patients, 339 (67.8%) found RT-PCR positive. Except for the radiological findings, both groups differ in clinical presentation, disease severity (inflammatory markers), and outcome. RT-PCR-positive patients had raised ferritin, NLR (Neutrophil-Lymphocyte ratio), LDH, and high mortality compared to the swab-negative group. In-hospital mortality was also significantly high in RT-PCR positive group (HR=1.9, 95% CI=1.4-2.5, p=0.001). On mul-tivariate analysis, NLR, ferritin, and d-dimer were the independent predictors of mortality in RT-PCR-posi-tive (p=0.038, 0.054, and 0.023). At the same time, raised TLC (total leukocyte count) and procalcitonin were the risk factors for poor outcomes in RT-PCR-negative patients (p=0.041 and 0.038). We found significantly raised ferritin, NLR, and LDH levels and increased mortality in RT-PCR positive patients compared to RT-PCR neg-ative. Incorporating clinical features, radiological, and biochemical parameters could be prudent while managing the RT-PCR-negative patients.

3.
JAMS Journal of Acupuncture and Meridian Studies ; 15(4):247-254, 2022.
Article in English | EMBASE | ID: covidwho-2033620

ABSTRACT

Background: Coronavirus disease 2019 (COVID-19) is an infectious disease caused by a coronavirus (SARS-CoV-2) that can induce cytokine storm. To this point, no specific drug has been effective for curing COVID-19. Objectives: The aim of this study was to determine the effects of a combination of acupuncture intervention and pharmacologic treatment in hospitalized COVID-19 patients with mild-moderate symptoms. Methods: A single-blinded randomized controlled clinical trial of hospitalized COVID-19 patients confirmed by RT-PCR examination with mild-moderate symptoms was conducted from August to September 2020. Participants were assigned to the treatment group (receiving pharmacologic treatment and manual acupuncture intervention) or the control group (receiving only pharmacologic treatment). Laboratory outcomes, including complete blood count, C-reactive protein (CRP) and ferritin levels, and erythrocyte sedimentation rate (ESR), were measured before and after the intervention. For clinical outcomes, we evaluated the duration of the cough symptom. Results: We found that participants in the treatment group had a shorter duration of the cough symptom compared to the control group, and the difference was statistically significant. In the treatment group, we found an increase in the percentage of lymphocyte count and ESR, while in the control group, both parameters were decreased;however, the differences were not statistically significant. There was a decrease in the mean of CRP and ferritin levels in both groups, and the differences were not statistically significant. Conclusion: Our study has shown promising results for the effects of combined treatment of acupuncture and pharmacologic treatment on the duration of the cough symptom in hospitalized COVID-19 patients with mild-moderate symptoms. Further large-scale studies with rigorous design are needed to examine these preliminary results

4.
Indian Journal of Forensic Medicine and Toxicology ; 16(3):302-308, 2022.
Article in English | EMBASE | ID: covidwho-2033604

ABSTRACT

Introduction: COVID-19 the deadly virus, was declared a pandemic by WHO in March, 2020 because of its virulent nature. It has been a piece of work to understand the mechanism of action and the disease pathology of the virus, due to its novel origin. The quality of healthcare is seen to be severely degrading during these times. The two different types of COVID tests that are commonly available in the facility are RTPCR and Rapid Antigen Test or RAT. These help to identify whether the person is infected with the virus or not. With the current management being successful in majority of the cases, we should also consider strengthening the existing modalities. Objective: To find the prevalence of COVID-19 patients and study their clinical course and outcome Material and methods: Data regarding covid-19 patients was collected on basis of demographic profile by using google foms questionnaire at Dr. D.Y. Patil Hospital, Navi Mumbai. Results: A total of 500 patients were included in the present study with male preponderance with 61.4%. 99% patients were tested COVID positive, 73.2% had a history of exposure to COVID patients, 80% had a positive travel history, 99% lab tests were positive. 50.4% duration of the treatment lasted for 7-14 days. 67.6% were treated in the wards, whereas, the remaining 32.4% were treated in the ICU. 19.6% patients required mechanical ventilator support. 51% patients required oxygen therapy. 80.2% did not require intubation. All the patients were on antibiotics, and majority of the patients, i.e. 99.8% were on immuno-boosters as well. Antivirals were administered in 80.6%. 82.8% were discharged with a negative swab. Out of the 17.2% patients with positive swab, mortality was seen in 6.2% patients. 3.4% patients were referred to different centers, while the treatment of the remaining 7.6% patients was continued for a longer period of time. Conclusion: A stepwise perspective of non-pharmaceutical interventions, screening and testing procedures, implementation and compliance to distancing, hygiene measures and use of masks at airports, railway stations, other public places with pragmatic testing and tracing are effective measures that can be implemented. Worldwide numerous clinical trials are taking place for the treatment and prevention of COVID-19. Although, there is a rapid comprehensive expansion in regard to COVID-19 and few agents appear to be promising, there are no definitely proven effective therapies at this time. Evaluation of several agents by Scientists and researchers are progressive and commendable.

5.
Indian Journal of Forensic Medicine and Toxicology ; 16(3):165-172, 2022.
Article in English | EMBASE | ID: covidwho-2033602

ABSTRACT

Background: The respiratory system is most affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2). However, COVID-19 can appear in a variety of ways. It has found a link between higher liver enzymes and COVID-19 infection, implying that the virus can induce liver damage through direct hepatotoxic injury, medication toxicity, or an immune-mediated response. Materials and Methods: In the southern Iraqi province of Basra, a cross-sectional observational study is being conducted in a single center (Basra teaching hospital) to estimate the prevalence of liver damage among hospitalized patients and identify those at risk. Results: The study found that most of the patients have a normal liver function test at the time of diagnosis and or admission, but after hospitalization, there is a statistically significant increase in the liver enzymes that is positively related to the disease severity and cytokine storm and also lead to more extended hospital staying and further mortality. Fortunately, the degree of liver damage is of mild severity in the majority of patients. Still, the severe form of liver damage was also noticed in some patients, especially those with a higher degree of lung involvement and severely desaturates with raised inflammatory markers. Conclusions: Elevated liver enzymes are prevalent, but the majority is mild with COVID-19 disease. Liver function abnormalities, particularly increased levels of AST and ALT, are not only common in COVID-19, but they are also linked to poor outcomes, mainly if severe liver damage has occurred.

6.
Acta Pharmaceutica Hungarica ; 91(3-4):106-107, 2021.
Article in English | EMBASE | ID: covidwho-2033588

ABSTRACT

ATMPs - a new era A boy from Hungary, Zente, was one and a half years old when the crowd-funding campaign to finance his life-saving medicine Zolgensma concluded with a happy end. He was the third European patient that received the new gene therapy, which replaces the function of the missing or nonworking survival motor neuron 1 (SMN1) gene with a new, working copy of a human SMN gene that helps motor neuron cells work properly and survive. From a European perspective, it has been almost 15 years by now since regulatory framework for advanced therapy medicinal products (ATMPs) had been established to ensure the free movement of these medicines within the European Union, to facilitate their access to the EU market, and to foster the competitiveness of European pharmaceutical companies in the field. Zolgensma has been approved in the EU in May 2020. The FDA expects it will be reviewing and approving up to 20 cell and gene therapies each year until 2025. Rapid development of technology and better understanding of the manufacturing challenges are not the only prerequisites of the growth. Assessment of products like Zolgensma requires very specific knowledge and often an adaptive approach from regulators. They have to gain enough experience and need to be able to summarize knowledge in guidelines that would help developers of products that are substantially different from traditional medicines. FDA issued seven new guidelines in January 2020, in which, for example, they highlight the importance of long-term follow-up for gene therapies that offer one-time fix for inherited diseases and where pre-market studies may have limited value. 2. Regulatory tools These examples may already show that rapid change in technology leads to new kinds of medicines that require a properly adapted regulatory system. Patients would expect state-of-the-art medicines within the shortest possible time frame, however, authorities are traditionally more cautious. Still, there are several various initiatives from the EMA and the FDA to foster early access to medicines. Some of these have been available for a longer time. EMA's accelerated assessment reduces the timeframe for review of innovative applications of medicines with major public health interest. Conditional marketing authorisation grants authorization before a complete dataset is available, and compassionate use allows the use of an unauthorized medicine for patients with an unmet medical need. A more recent regulatory tool of EMA is the priority medicines scheme (PRIME) that aims to enhance support for the development of medicines that are expected to make a real difference to patients. Early dialogue between EMA and the developers is a crucial part of the tool, together with accelerated assessment and continuous scientific advice and protocol assistance. Up to now, 282 applications for PRIME eligibility have been assessed by the CHMP of which 95 have received a green light. Most of the applicants are small and medium size enterprises, and the major therapeutic area is oncology. FDA has similar programs, such as the Fast Track, Breakthrough Therapy and Priority Review designations, and is also aiming to facilitate and accelerate development and marketing authorization of key medicines. By 2018, about 70% of new drug approvals by the FDA were expedited, compared to about 50% in 2010. The result is a growing pro-portion of medicines authorized with less premarket evidence, a trade-off, that most patients with fatal or debilitating disease would likely accept. Nevertheless, conditional approval requires a strong post-marketing attention from regulators, and lack of enough evidence sometimes leads to difficult decisions. In April 2019 a fast-tracked cancer drug, Lartruvo was withdrawn because a large study was not able to prove a favourable benefit-risk profile, which was established previously on a smaller patient population. The regulators approach is not expected to be changed, but experience from such cases would gradually be built into the decision-making process. In addition to this real world evidence (RWE) and patient recorded outcomes may also help in decision making. 3. Digital revolution The rapid development of biotechnology is not the only area where an adaptive regulatory approach is needed. Digital medicine is a new field, as smartphones and sensors open up new ways of generating data. For example, collecting and analysing RWE seems to be a good solution for single arm studies where randomized trials are not feasible. FDA has approved easy-to-use devices that are able to track several physiological systems of our body, which in turn can give a boost to developments in this field. In addition to these simpler devices, digital revolution in terms of artificial intelligence (AI) and cognitive machine learning is another challenge that our regulatory systems should tackle. It has been recently announced that a new drug candidate, a long-acting and potent serotonin 5-HT1A receptor agonist, which was created using an artificial intelligence platform, will enter into clinical study. There are also numerous radiological applications based on AI, including computer aideddetection and diagnosis software, where images are analysed, and clinically relevant findings suggested to aid diagnostic decisions. Many of these new developments require a tailored approach from regulators to find a way for authorization within the existing regulatory framework. The fact, that many of these new developments are carried out by academic research groups or small companies without extensive regulatory experience, adds an extra layer of difficulty. To meet this challenge, EMA and the Heads of Medicines Agencies have established the EU-Innovation Network, to support medicine innovation and early development. As a milestone of its function, beginning in 1 February 2020 a pilot for simultaneous scientific advice is starting, where the applicants will receive a consolidated advice from the participating agencies. Innovative products often require specific expertise;therefore this new form of advice is also extremely beneficial for regulators as they are able to learn from each other and broaden their knowledge. 4. Conclusions The rapid development of pharmaceutical and digital technology requires a concerted action from all stakeholders. Or, as we all experience, a global pandemic can be an important driving force of the evolution of regulatory policies. Appropriate usage of currently available regulatory tools and a continuous discussion between academia, industry and regulators would be the only way to ensure quick access to state-of-the-art, safe and efficacious medicines, and medical devices. It is clearly shown currently by the concerted action of various stakeholders and series of rolling reviews which led to the expedited authorization of COVID-19 vaccines.

7.
Current Journal of Neurology ; 21(2):83-90, 2022.
Article in English | EMBASE | ID: covidwho-2033507

ABSTRACT

Background: Fatigue is one of the most frequent complaints in patients with motor neuron diseases (MNDs), with a significant impact on the quality of life (QOL). There is lack of enough evidence for current pharmacological or non-pharmacological treatments of fatigue in this population to be applied in clinical setting. Energy conservation strategies are one of the key interventions for fatigue management in chronic diseases. We aimed to investigate the effect of applying these techniques in the fatigue management of patients with MND. Methods: This randomized controlled trial (RCT) study was carried out on 28 patients with MND. Participants were randomly assigned to either the intervention or control group. In addition to routine treatment, patients in the intervention group participated in 3 weekly 1-hour energy conservation programs provided by an experienced occupational therapist. The Fatigue Severity Scale (FSS) score, 36-Item Short Form Survey (SF-36), and Canadian Occupational Performance Measure (COPM) were measured at baseline, immediately after the last intervention session, and one month later. Results: FSS and COPM significantly changed after the course in the intervention group (P < 0.001 and P = 0.001, respectively). Both FSS and COPM improved significantly toward the final assessment only in the intervention group. The SF-36 changes were not significant in each of the groups. Conclusion: According to the findings of the present study, using energy conservation strategies could lead to better mid-term fatigue management and occupational performance improvement, but it did not improve QOL in patients with MND.

8.
Acta Medica Iranica ; 60(6):329-337, 2022.
Article in English | EMBASE | ID: covidwho-2033504

ABSTRACT

Solid-organ transplantation recipients were assumed highly vulnerable to coronavirus disease 2019 (COVID-19). However, the results of previous studies in patients with orthotopic heart transplantation (OHT) under immunosuppressive therapy are contradictory. Therefore, we aimed to assess the prevalence of COVID-19 infection and associated risk factors, along with the six-month outcomes in COVID-19 positive OHT patients. This single-center telephone-based survey was conducted on OHT patients. Using a detailed questionnaire, exposure to COVID-19, related symptoms, and preventive self-care measures were collected. Outcomes of COVID-19-positive patients were reassessed using another survey six months later. 118 OHT patients (male: n=87, 73.7%) were included with a mean age of 45.3±13.1 years. Sixteen patients (13.5%) reported one or more symptoms compatible with COVID-19, of whom 12 (10.2%) tested positive. Our results indicated no statistically significant association between COVID-19 and comorbidities. Poor adherence to self-care measures and contact with positive index cases were both significantly associated with COVID-19 infection (P<0.001). A later six months follow-up showed that two out of 12 (16.6%) COVID-19 positive OHT patients died. There was no statistically significant difference between the prevalence of COVID-19 in our patients compared to Iran’s general population (P=251.0). Non-compliance with personal protective protocols and a history of contact with COVID-19 cases were the most risk factors for COVID-19 infection in OHT patients.

9.
Journal of Clinical and Diagnostic Research ; 16(8):DC33-DC38, 2022.
Article in English | EMBASE | ID: covidwho-2033411

ABSTRACT

Introduction: It is crucial to determine possible factors associated with exacerbation of the disease due to the alarming global spread, morbidity and mortality associated with Coronavirus Disease-2019 (COVID-19). It is important to determine the co-morbidities associated with this disease which will help in better treatment of patients in time and to make amendments to management policy. Aim: To compare the clinical features, and predisposing factors (socio-demographic factors and co-morbidities) influencing the outcome in COVID-19 infected patients admitted in a tertiary care centre in the first and second wave of COVID-19 pandemic. Materials and Methods: The retrospective study was conducted at the Department of Microbiology, Dr. Shankarrao Chavan Government Medical College, Nanded, Maharashtra, India. The data was collected from the electronic resource which was maintained by the institute Integrated Disease Surveillance Program (IDSP) health record reporting database for the duration of June 2020 to August 2021. This data included patient’s demographic details (age, sex, address, contact number), other details (history of close contacts, international travel) clinical history, different types of symptoms (ICMR patient category), co-morbidities, number of patients requiring ICU admission, type of sample, the outcome in terms of death and discharge, cause of death. The analysis was done for the complete data and then for two separate durations of the first and second wave which were compared later with Chi-square test (Bivariate analysis). Results: A total of 8841 patients were involved and the majority of patients in the study were between the age group of 30-75 years, there was a predominance of males in first and second waves with 6514 (73.7%) and 5795 (58.6%) respectively. The paediatric patients had a mortality rate of 100% (n=7) found in the second wave. Fever (39%) and dyspnea (22%) were found as the commonest presentation in both waves. Gastrointestinal manifestations were observed relatively more in the second wave. The serious patients on ventilator were found to have (>91%) the highest mortality. It appeared that the highest attributable risk to severity and mortality (eight to ten times increased) was due to hypertension, diabetes and other co-morbidities. Pregnancy did not predisposed to be as a risk factor. Conclusion: Prompt management and preventive care are needed for patients with co-morbidities to avoid the exacerbation of COVID-19 as well as drug cross interactions.

10.
National Journal of Physiology, Pharmacy and Pharmacology ; 12(7):958-961, 2022.
Article in English | EMBASE | ID: covidwho-2033363

ABSTRACT

Background: Coronavirus disease 2019 (COVID-19) has rapidly become a worldwide concern ever since first being reported from Wuhan, China in December 2019. With no known cure, there is widespread fear-provoking interest in studying the factors contributing to mortality. Aim and Objectives: The current study was undertaken with a view to try to understand the cause of morbidity and mortality. Materials and Methods: A retrospective study done in our Institution on COVID-19 patients admitted over a course of 3 months after approval from Institutional Ethics Committee. Results: We had 17 deaths over the period under consideration whereas 73 patients improved (mortality = 19%, n = 90). Most of the patients were in the 41–80 years age group (>70%). No gender preponderance was found with mortality in each being around 20%. A clear correlation between co-morbidities and mortality was found with no person without any comorbidity succumbing to the disease. Respiratory and Heart conditions were found to contribute most to mortality with patients presenting with shortness of breath being most at risk. Similarly, a Neutrophil: Lymphocyte ratio greater than 12 was found to significantly increase the mortality. Conclusion: Patients with comorbidities need to be monitored closely with treatment being directed at improving the respiratory outcome.

11.
Journal of Asthma and Allergy ; 15:1143-1154, 2022.
Article in English | EMBASE | ID: covidwho-2032690

ABSTRACT

Background: Asthma attacks are life-threatening episodes that place a costly burden on the individual and the community in both high-and low-income countries including Ethiopia. There is scant information on the determinant of it in the study area. Objective: To identify determinants of asthma attack among adult asthmatic patients attending at public hospitals of West Shoa Zone, Oromia Regional State, Ethiopia. Methods: An institutional-based unmatched case–control study design was conducted. In this study, 300 participants (100 cases and 200 controls) were included. A pre-tested structured questionnaire was used to collect data. After the data were entered into Epidata version 3.1, it was exported to SPSS version 25 for analysis. First, bivariable logistic regression was performed. Independent variables with a p-value < 0.25 in binary logistic regression were entered into a multivariable logistic regression model. In the multivariable logistic regression model, independent variables with a p-value < 0.05 were considered to be significant determinants of the outcome variable of the study. Results: This finding identified that upper respiratory tract infection (AOR = 5.89, 95% CI: 2.72, 12.79), obstructive sleep apnea (AOR = 3.48, 95% CI: 1.58, 7.66), passive smoker (AOR = 5.93, 95% CI: 2.07, 16.96), spring season (AOR = 2.49, 95% CI: 1.27, 4.89), pet ownership (AOR = 3.63, 95% CI: 1.82, 7.22), kitchen smoke (AOR = 2.31, 95% CI: 1.6, 4.6), rhinitis (AOR = 4.49, 95% CI: 2.25, 8.93) and being jobless (AOR = 5.68, 95% CI: 1.94, 16.68) were significant determinants of asthma attack. Conclusion: In this study, upper respiratory tract infection, obstructive sleep apnea, passive smoker, spring season, kitchen smoke, pet ownership, rhinitis, and being jobless were identified as significant determinants of an asthma attack. Because asthma attacks are lifethreatening events, effective methods and interventions on determinants of asthma attack incidence should be implemented.

12.
BMJ Supportive and Palliative Care ; 11:A84, 2021.
Article in English | EMBASE | ID: covidwho-2032532

ABSTRACT

Background With changes in NHS commissioning which aim for greater integration across larger areas and increased resourcing pressures experienced by hospices;strategic partnerships between hospices have never been more necessary. The recent Hospice UK Future Vision Programme (2020) set out principles of sustainability for hospices, many of which can be best achieved by working together. In 2017 our two hospices established a partnership;managed through a memorandum of understanding (MOU), it set out a shared ambition, agreed principles for engagement and the partnership's governance structure. Aims The partnership agreed to:•Work together with integrity and probity for the benefit of patients and the public.•Improve outcomes and experiences through early collaboration and planning.•Deliver high-quality standards of patient care, consistently and equitably across the system.•Lead the way in strategic planning of services that are safe and sustainable•Identify/share opportunities for good practice in transparent and value-for-money partnership arrangements. Achievements so far/Results Our hospices have developed supportive relationships and regular communication between leadership teams, operational managers and boards. Working collaboratively in:•Joint external education delivery - sharing resources, contacts and income.•Rehabilitation - supporting development of one partner's service through senior leadership and joint occupational therapy post.•Fundraising - trialling a joint mass-participation event.•Retail - supporting personal development of new income generation director and establishing improvements for retail.•Commissioning -to support negotiations with commissioners and increase influence across integrated care system.•Medical support - sharing senior medical resource to support development/business continuity.•Bed capacity - sharing inpatient capacity during COVID-19 - related closures.•Staff wellbeing - shared health/wellbeing month funded by NHS England. Conclusions By working together, we've achieved service improvements, shared expertise, increased efficiency and maintained business continuity. We continue to look for opportunities to work together for the furtherance of our stated aims as outlined in the MOU.

13.
BMJ Supportive and Palliative Care ; 11:A42, 2021.
Article in English | EMBASE | ID: covidwho-2032484

ABSTRACT

Background Farleigh Hospice provides palliative and end-oflife care to the people of Mid Essex (population c. 400,000), with a dedicated inpatient unit (IPU) and community services. Problem The first wave of the COVID-19 pandemic catalysed organisational change with creation of 'Locality Care Teams' and the upskilling of non-clinical members of staff. Subsequently, the IPU closed and staff were reassigned to Locality Care Teams in November 2021, mobilising the workforce to care for more patients. However, there was a resulting potential for some patient and carer needs to go unmet. Intervention A community-based nurse-led 'Virtual Ward' was created in mid-December at rapid pace, to support people to die at home. A detailed SOP was developed, specifying the purpose of the Virtual Ward, eligibility criteria, and referral, assessment and discharge processes. This information was disseminated to all teams. Data were collected throughout the time of IPU closure. Outcome Within a short time, the virtual ward was well-utilised (mean 8.6 admissions per month). Referrals to the Virtual Ward were largely appropriate with mean length of stay seven days, median three days. 80% of patients admitted to the Virtual Ward died as expected while under its care;none were admitted to acute care services. Informal feedback has been positive from referrers, patients and family caregivers. Learning The temporary closure of the IPU could have caused patient and carer needs to go unmet. Instead, the rapid set up of the Virtual Ward, alongside the reassignment of IPU staff and arrangements with other regional hospices, has enabled the local population's end-of-life care needs to be well met. During the pandemic the greatest need for palliative care services has been in the community (Etkind, Bone, Lovell, et al., 2020;Costantini, Sleeman, Peruselli, 2020). Farleigh Hospice's reconfiguration of services has proven to be effective and responsive. There is a need for more robust data collection to evaluate outcomes particularly with regard to patient and family caregiver feedback.

14.
BMJ Supportive and Palliative Care ; 11:A37-A38, 2021.
Article in English | EMBASE | ID: covidwho-2032473

ABSTRACT

Background In 2020 Highland Hospice faced the challenge of continuing the rehabilitation service delivered by our inpatient physiotherapist and occupational therapist. The service was originally delivered by admission to the unit for a five-day (Respiratory) or 10-day (Neurological) stay with intensive multi-disciplinary team rehabilitation. The team adapted the delivery of this service due to COVID-19 restrictions using the Zoom platform (licensed version). Aim To continue to provide ongoing rehabilitation for palliative care patients during COVID-19. Methods Referrals were received as usual from respiratory/ neuro nurses or consultant. Screening was carried out in a weekly meeting with the allied health professionals and doctors. Appropriate patients were contacted by telephone to schedule an initial assessment before setting up a Zoom call or home visit to set up technology. Patients were seen in person (if hearing or technology was an issue), or virtually for 6- 12 weeks. Results Of the eleven patients to date there were challenges for some but all participated and benefited. A survey was sent to participants. Three people responded. All three respondents said their goals were clear after the first session.•The respondents either mostly agreed/or agreed that their symptoms were better controlled.•Activity levels had increased.•Ability to cope was better.•Knowledge of helpful techniques was better and,•Quality of life was better after attending the service for the 6- 12 week period. Feedback from participants includes: 'The service was friendly and positive';'It helped me immensely';'a friend had been in respiratory crisis and I was able to help her while she waited for the ambulance - that felt good'. Conclusion Despite challenges, a virtual approach for palliative rehabilitation provided beneficial outcomes for patients who would not have been able to attend in person. This method will likely form a part of our services going forward.

15.
Anaesthesia ; 77:19, 2022.
Article in English | EMBASE | ID: covidwho-2032358

ABSTRACT

Sedation is integral to facilitating interventions on the intensive care unit (ICU), which would otherwise be intolerable;however, in excess it may prolong intubation and lead to brain dysfunction such as delirium [1]. This is a frequently under-diagnosed problem in the ICU, shown to result in worsened neurological outcomes [2]. The Critical Care Pain Observation Tool (CPOT), Richmond Agitation- Sedation Score (RASS), Confusion Assessment Method for the ICU (CAMICU) are validated to assess for pain, over-sedation and delirium, respectively. We explored how effectively these were used in a hospital in the Northeast of England to address over-sedation and delirium. Methods Adults intubated and ventilated on critical care were identified, and the most recent 24 h of bedside observation charts examined for completion of 4-h RASS, 4-h CPOT and 12-h CAM-ICU assessments. For those over-sedated during this time, we assessed whether sedation was appropriately titrated or held. Patients on neuromuscular blocking agents, with acute brain injury or with specific indication for deep sedation were excluded. Results Fifty-five patient-days were audited, during which sedation was utilised in 71% (n = 39). Overall, pain and RASS were monitored well, assessed at 88% and 91% of 4-h opportunities, respectively;however, CAM-ICU was recorded at only 15% of opportunities. Where documented, RASS scores were within target (-2 to 1) 45% of the time. Where out of range, this was almost exclusively due to oversedation (RASS ≤ -3). Eighty-five per cent (n = 33) of patients were over-sedated on at least one occasion in the last 24 h. Of these, 39% (n = 13) had their sedation neither titrated nor held during this time. Notably, this was the case for 55% (n = 11) of the 20 patients intubated for COVID-19, in contrast to only 15% (n = 2) of the 13 patients intubated for other reasons. Discussion Over-sedation in ICU remains prevalent despite adequate RASS surveillance. This is particularly true among COVID-19 patients. Further, infrequent CAM-ICU use may result in delirium being missed, carrying risk of adverse neurological outcomes and mortality [2]. We have implemented protocolled PAD pathways within each bed space, to empower nurses to titrate sedation and improve awareness of CAM-ICU. Additionally, we have disseminated education on the harms of over-sedation and unrecognised delirium, and we are evaluating re-audit data to ascertain if there has been a resulting improvement in PAD management for sedated patients.

16.
Anaesthesia ; 77:19, 2022.
Article in English | EMBASE | ID: covidwho-2032357

ABSTRACT

Intensive care unit (ICU) admission has significant long-term sequelae, affecting both physical and mental health [1]. Long-term respiratory outcomes in COVID- 19 ICU patients has been of concern and the British Thoracic Society recommends a post-hospital-discharge chest X-ray (CXR) and clinic follow-up [2]. We aimed to establish the long-term health outcomes of patients with COVID-19 following admission to ICU. Methods All patients admitted to ICU at University Hospital Crosshouse with COVID-19 from 01/03/2020-31/08/2021 were identified retrospectively. A comparator prepandemic dataset of patients admitted with pneumonia from 01/07/2018-31/12/ 2019 was also identified. Re-admissions were excluded in both cohorts. Electronic notes were interrogated for demographics, outcomes and follow-up. This included attendance at our post-ICU recovery programme, InS:PIRE. Statistical analysis was by Fisher's exact test and Mann-Whitney U-test. Results A total of 135 patients were admitted during the COVID-19 period, with 52 patients admitted in the pre-pandemic period. Comparisons between the groups are shown in Table 1. Of the 78 COVID-19 survivors, 48 (61.5%) had a CXR after hospital discharge. In 50%, this was abnormal. Thirty patients (38.5%) had evidence of outpatient respiratory follow-up, with four (13.3%) were now receiving long-term oxygen therapy. Of the 37% who had completed InS:PIRE by the time of data collection, most did not feel back to baseline, with best health scores averaging 66% of normal. Impairment in usual daily activities was the main issue. (Table Presented) Discussion We demonstrate admission to ICU with COVID-19 is associated with prolonged ventilation, high mortality and significant ongoing morbidity among survivors. Chest X-rays remain abnormal in half of patients after hospital discharge and many remain significantly functionally impaired. The low rates of respiratory follow- up is concerning and may mean our study underestimates the problem. Continued follow-up of survivors of severe COVID-19 is, therefore, crucial and will allow us to identify ongoing clinical and rehabilitation needs as well as enable access to appropriate support.

17.
Anaesthesia ; 77:12, 2022.
Article in English | EMBASE | ID: covidwho-2032346

ABSTRACT

The Enhanced Recovery After Surgery (ERAS) Society issued specific guidance on peri-operative care in cardiac surgery in 2019, with 22 recommendations known to reduce morbidity and mortality. We sought to assess the baseline compliance with these guidelines at our centre, to inform targeted quality improvement. Methods Thirty consecutive patients undergoing coronary artery bypass graft (CABG) surgery at Nottingham University Hospitals NHS Trust between August and September 2021 were identified from a prospectively populated database, with additional information collected from electronic case records. The primary outcome was adherence to the individual ERAS recommendations, reported as relative frequency. Analysis was performed in Stata IC v17. Results Thirty patients (83% male, n = 25;age 67.1 ± 7.28 years) were included, with 63.3% (n = 19) urgent procedures. Median postoperative hospital stay was 7 days (range 5-22 days). Overall compliance for all patients (adjusted for non-applicability) was 51.7%, with adherence to a median of 12 (range 9-14) guideline elements per patient. Six guideline elements were not adhered to in any patients (0/30), including pre-operative carbohydrate loading, patient engagement, pre-habilitation, rigid sternal fixation, active chest tube clearance and postoperative acute kidney injury biomarker screening. Seven recommendations achieved partial compliance, with complete adherence to the remaining nine elements (Table 1). (Table Presented) Discussion This first audit cycle has identified areas for stepwise quality improvement across the spectrum of peri-operative care. Although the COVID-19 pandemic poses a challenge to the routine delivery of healthcare services, this may also provide an opportunity to address existing variation in practice and implement change as services recover.

18.
ASAIO Journal ; 68:146, 2022.
Article in English | EMBASE | ID: covidwho-2032192

ABSTRACT

Background: Revised guidelines clarify indications for extracorporeal membrane oxygenation (ECMO) support in patients with COVID-19-related acute respiratory distress syndrome (ARDS). Commercially available ECMO analytics software records granular perfusion data continuously throughout the run. To date, electronic-medical record (EMR) clinical data has not been integrated with ECMO perfusion data and analyzed with machine learning-based algorithms to improve patient care. Methods: Retrospective chart review was performed on all SARS-CoV2 positive patients cannulated to veno-venous ECMO at an urban highvolume regional referral center from March 1st, 2020, through December 31st, 2021. Categorical data including patient demographics, clinical outcomes, and laboratory data (complete blood count, basic metabolic panel, arterial blood gas, lactate, anticoagulation assays) and vital signs (pulse, arterial line blood pressure, oxygen saturation) were collected for the entirety of the ECMO run. Time-series perfusion data (arterial flow normalized to body surface area (BSA), sweep gas, delta pressures normalized to arterial flow) were captured every 60-120 seconds. We constructed a predictive long-short term memory (LSTM) predictive model that integrated clinical and time-series data using an extended machine learning (ML) framework with neural network. Primary outcome was successful ECMO decannulation. Data were truncated to discrete and relative timepoints (7, 14, 21 days, or percent of the run). Receiver operating characteristic (ROC) curves show the model's diagnostic accuracy. Results: 42 patients were included in the analysis (30 male, 12 female). Mean age was 43.9 (SD=11.5) years old, and mean duration of ECMO run was 36.2 (SD=30.1) days. 24 patients were successfully decannulated and 4 are currently supported on ECMO. When provided the complete data, the LSTM model showed an area under the ROC curve >0.95, demonstrating strong diagnostic accuracy in predicting successful ECMO decannulation (Figure 1A). When data were truncated to only the first two weeks of the ECMO run, the area under the ROC curve was 0.93 (Fig. 1B). Patterns of arterial flow normalized to BSA and sweep gas normalized to flow also appear different in patients with divergent clinical outcomes (Fig 2). Conclusion: Characterizing key determinants of ECMO support may offer intensive care unit healthcare teams potentially lifesaving information in real-time. Our machine-learning model successfully integrates clinical and perfusion data from the mind's eye of a clinician managing the care of a patient supported with ECMO. We have identified critical variables with the most meaningful impact on the mechanics of ECMO support. Our model may also help predict patient outcomes into and offer clinicians opportunities for interventions to improve care. (Figure Presented).

19.
ASAIO Journal ; 68:141, 2022.
Article in English | EMBASE | ID: covidwho-2032191

ABSTRACT

Studies have shown that SARS-CoV2 can infect the vagal nerve and its connections to the brain stem. This neuronal involvement is seen mostly in the delayed inflammatory phase. It is associated with autonomic nervous system dysfunction, resulting in decreased respiratory ventilation and impaired blood pressure as well as heart rate regulation. The dysautonomia seen in SARSCoV-2 infection can be measured, and heart rate variability (HRV) measurement is one method. Our study explores the relationship between autonomic dysfunction and mortality in patients with COVID- 19 using HRV measurement. In a prospective design, data of consecutive patients with SARS-CoV-2 positive infection admitted to Banner university of Arizona, Tucson, and whose telemetry information was available was collected between August 2020 to November 2021. We attempted to use the telemetry data to measure diurnal heart rate variation by obtaining mean average hourly heart rates, divided into 12-hour day/night periods. The primary outcome measure was mortality. The secondary outcome measured includes incidence of acute kidney injury, transfer to ICU, need for mechanical ventilation, and live discharge from hospital. 334 patients were included in the study. The baseline demographic characteristics, medical history, radiological data, laboratory data, details of medications, and hospital course were reported. Diseases associated with an autonomic dysfunction like diabetes mellitus, chronic renal failure, a history of alcohol abuse, clinical evidence of autonomic neuropathy, or a recent myocardial infarction, documented constrictive or hypertrophic cardiomyopathy, sustained non-sinus dysrhythmias, atrioventricular conduction defects will be excluded in the final analysis. Mortality was high in patients with lower heart rate variability. Compared with survivors, non-survivors were older, were less frequently women, had a higher prevalence of diabetes mellitus, longer stay in the hospital, received an organ transplant, smoking, and higher level of calcitonin. Lower heart rate variability was associated with a higher incidence of acute kidney injury, need for mechanical ventilation, and need for ECMO. This study suggests that analysis of the variability of heart rate may have prognostic implications in patients with COVID19.

20.
ASAIO Journal ; 68:140, 2022.
Article in English | EMBASE | ID: covidwho-2032190

ABSTRACT

Background: Timing of tracheostomy in COVID-19 patients supported with extracorporeal oxygenation membrane (ECMO) remains unclear. This study aims to compare the short-term outcomes in early (≤7 days from ECMO insertion) (ET) versus late (LT) tracheostomy. Methods: Charts of COVID-19 patients with tracheostomy from 2020 to 2021 were reviewed, retrospectively. Primary endpoint was in-hospital mortality. Secondary endpoints were analgesics/sedatives doses, length of treatment (LOT), and initiation of physiotherapy (PT). Results: Eight patients with ET were compared to six patients with LT. Mean age was 41.4±12.5 (ET) and 49.5±6.9 (LT) years. In both groups, 50% were male with comparable BMI. Twelve patients received venovenous (VV) and two received veno-arterial (VA) ECMO. Tracheostomy post ECMO cannulation was performed in 12 [ET:6(75%);LT:6(100%)] patients, whereas in the remaining two patients, it was performed immediately after initiation of ECMO support. Average duration of ECMO support was 48.0±21.3 (ET) than 42.2±27.0 (LT) days, P=0.34. Requirement of sedatives before [ET:6.4±4.6;LT:9.3±5.3;P=0.15] and after [ET:21.6±11.9;LT:12.2±14.0;P=0.11] along with analgesics before [ET:6.3±4.9;LT:7.0±6.5;P=0.41] and after [ET:19.0±6.9;LT:14.8±15.5;P=0.28] tracheostomy was comparable. No difference was observed in the LOT during sedatives/ analgesics dosing after tracheostomy. However, the LOT before tracheostomy was significantly longer in sedatives [ET:2.9±3.1;LT:11.8±6.2, P<0.01] and analgesics [ET:2.9±2.8;LT:9.8±3.5, P<0.01], explained by the longer interval between ECMO insertion and tracheostomy in LT group. Compared to LT, number of days from ECMO insertion to first PT session was significantly shorter in ET patients [ET:13.6±5.6;LT:26.5±4.5, P<0.01]. In-hospital mortality rate was 21.4% [ET:1(13%);LT:2(33%), P=0.33] patients with comparable ICU stay [ET:56.9±18.6;LT:50.2±26.4, P=0.30] between groups. Conclusion: Although the advantages of ET to reduce the requirement of analgesics and sedatives amongst COVID19 patients supported with ECMO were like LT group, ET was associated with early initiation of PT and improved survival.

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