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1.
Front Public Health ; 10: 986933, 2022.
Article in English | MEDLINE | ID: covidwho-2080294

ABSTRACT

Background: With the rapid development of "Internet + medicine" and the impact of the COVID-19 epidemic, online health communities have become an important way for patients to seek medical treatment. However, the mistrust between physicians and patients in online health communities has long existed and continues to impact the decision-making behavior of patients. The purpose of this article is to explore the influencing factors of patient decision-making in online health communities by identifying the relationship between physicians' online information and patients' selection behavior. Methods: In this study, we selected China's Good Doctor (www.haodf.com) as the source of data, scrapped 10,446 physician data from December 2020 to June 2021 to construct a logit model of online patients' selection behavior, and used regression analysis to test the hypotheses. Results: The number of types of services, number of scientific articles, and avatar in physicians' personal information all has a positive effect on patients' selection behavior, while the title and personal introduction hurt patients' selection behavior. Online word-of-mouth positively affected patients' selection behavior and disease risk had a moderating effect. Conclusion: Focusing on physician-presented information, this article organically combines the Elaboration likelihood model with trust source theory and online word-of-mouth from the perspective of the trusted party-physician, providing new ideas for the study of factors influencing patients' selection behavior in online health communities. The findings provide useful insights for patients, physicians, and community managers about the relationship between physician information and patients' selection behavior.


Subject(s)
COVID-19 , Physicians , Humans , Likelihood Functions , COVID-19/epidemiology , Trust
2.
Current Respiratory Medicine Reviews ; 18(3):171-178, 2022.
Article in English | EMBASE | ID: covidwho-2065266

ABSTRACT

Exercise training is paramount in improving aerobic capacity, lung function, reducing the symptoms of dyspnea, and reconditioning the lean skeletal muscles. Many literature and guidelines have advocated the importance of exercise intervention in addressing the secondary impairment to post covid-19 infection, including home-based therapy and telerehabilitation. Pulmonary hypertension (PH) was previously thought to be contraindicated by exercise training;however, exercise was later found to be beneficial and relatively safe in chronic PH. However, there is a lack of highquality evidence on the safety and effectiveness of exercise training in post-COVID-19 infected individuals with PH. Pulmonary hypertension has been documented to be one of the post-COVID-19 complications. PH occurred due to COVID-19 infection should be carefully considered before subjecting them to exercise training, especially in home-based therapy. This article aims to discuss the differing etiological factor, pathophysiological backgrounds, and the possible disease long-term outcomes that may compromise the safety of exercise training in post-COVID-19 patients complicated with PH. By understanding the risk of developing PH, risk assessment and stratification can be explicitly outlined for a safe exercise prescription through proper patient selections. Any possible complications can be anticipated;hence, proper preventive strategies can be instituted.

3.
International Journal of Stroke ; 17(2 Supplement):6-7, 2022.
Article in English | EMBASE | ID: covidwho-2064670

ABSTRACT

Background: Cerebral venous sinus thrombosis (CVST) is an important cause of stroke with a generally favourable prognosis if diagnosed and treated early. Despite advances over recent years, the management remains variable. The current trend for initial treatment is a dose-adjusted intravenous heparin infusion or low-molecular-weight-heparin (LMWH) such as enoxaparin. Once the patient has stabilized, they are transitioned to longterm anticoagulation such as warfarin therapy or direct oral anticoagulants (DOAC) for 3-6 months, depending on risk factors. The use of a heparin infusion brings many known difficulties and complexities impacting on patient care and length of stay within hospital. Current literature suggests that enoxaparin may be superior to heparin in the treatment of CVST. Aim(s): To conduct an internal audit of patients diagnosed with CVST over a twelve-month period at the Princess Alexandra Hospital. This audit will provide foundation to develop an evidence-based hospital protocol for CVST management. Method(s): A search through the hospital imaging system identified all relevant patients. Information was collected on the initial treatment, specifically comparing the use of heparin to enoxaparin and the duration. Consideration of risk factors, aetiology and complications were summarized. During the recent era of COVID-19, we also collected data on COVID-related CVST and COVID vaccine-related CVST. Finally, we recorded the maintenance anticoagulation treatment that was commenced. Result(s): The purpose of this audit is to critically reflect on current hospital practice with a view to improve patient outcomes, safety, satisfaction, and cost-effective care. We hypothesise that in select cases, it will be a safe and preferable alternative to use enoxaparin as initial therapy over a heparin infusion. Furthermore, with appropriate patient selection, DOACs may be an appropriate maintenance therapy. Conclusion(s): The evidence for medical management of CVST is continuously evolving. This evidence must be carefully evaluated before being widely adopted at a local level.

4.
Cardiology in the Young ; 32(Supplement 2):S56-S57, 2022.
Article in English | EMBASE | ID: covidwho-2062107

ABSTRACT

Background and Aim: The considerable overlap in case definition and clinical features between patients with COVID-19 associated Multisystem Inflammatory Syndrome in Children (MIS-C) and Kawasaki disease (KD) suggests shared pathogenesis. We sought to compare demographic, clinical presentation, management and outcomes of patients by COVID-19 status. Method(s): The International KD Registry (IKDR) began enrolling patients with clinical features of either acute MIS-C or KD or fever with hyperinflammation beginning in January 2020. The IKDR is unique regarding broad patient selection and includes sites from North, Central and South America, Europe, Asia and the Middle East. Patient groups stratified by COVID-19 status were compared. Result(s): As of October 6, 2021, 1330 patients were registered from 31 sites. COVID status was POSITIVE for 59% (confirmed household COVID-19 contact and/or positive SARS-CoV-2 PCR or serology), POSSIBLE for 4% (suggestive clinical features but some negative tests or absent exposure), NEGATIVE for 23%, and UNKNOWN (no known exposure and testing not com-pleted) for 14% (TABLE). Most of the UNKNOWN patients were from early in the COVID-19 pandemic before MIS-C was defined and before COVID-19 serologic testing was widely used. POSITIVE and POSSIBLE patients were older, had fewer KD clinical criteria, greater gastrointestinal symptoms, were more likely to present with shock and require ICU admission and inotropic support. POSSIBLE patients had greater days from symptom onset to first immune modulation treatment, with no differences between groups regarding days from admission to first treatment. Most patients in each group received intravenous immune globu-lin, with POSITIVE and POSSIBLE patients more likely to have received steroids and anakinra. NEGATIVE and UNKNOWN patients had higher maximal coronary artery Z scores, with a trend to having higher categories of aneurysm involvement. Conclusion(s): While there was considerable overlap in presentation, management and outcomes between COVID-19 POSITIVE/POSSIBLE (presumed MIS-C) and COVID NEGATIVE/UNKNOWN patients (presumed KD), COVID-19 POSITIVE/POSSIBLE patients had more severe presentations and required more intensive management, although coronary artery outcomes trended to be less severe. Patient recruitment con-tinues, and in-depth comparison of laboratory features and appli-cation of machine learning approaches to patient differentiation and prediction of optimal management pathways are forthcoming.

5.
Chest ; 162(4):A1111-A1112, 2022.
Article in English | EMBASE | ID: covidwho-2060770

ABSTRACT

SESSION TITLE: Impact of Health Disparities and Differences SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Vulnerable patients, including minorities and underserved populations whose care relies on public hospitals, have limited access to advanced cardiac or respiratory care in shock centers or extracorporeal membrane oxygenation (ECMO)-capable hospitals, especially when socioeconomic or insurance barriers play a role in patient selection. Our aim is to describe the implementation of an ECMO program for cardiac and respiratory failure during the COVID-19 pandemic in the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care for minorities. METHODS: We collected clinical, demographic and socioeconomic data of all patients undergoing ECMO at Bellevue Hospital Center, the shock and ECMO center for New York City’s Health and Hospitals’ network. This public health system includes 11 Hospitals and provides care to 1 million New Yorkers. The decision to proceed with ECMO took place with a multidisciplinary team discussion, which was also in charge of providing longitudinal care during their hospitalization. RESULTS: A total of 49 patients were included [30 veno-venous (VV) ECMO, 19 venoarterial (VA) ECMO, including 9 extracorporeal cardiopulmonary resuscitation (ECPR)] from April 1st, 2020 to March 30th, 2022. The median age was 42.6 years, 57% were male, 38% were Hispanic, 35% African American, 14% white, 6% Asian and 8.2% had other ethnicities;33% were uninsured, 49% lived below the poverty level reported for New York City and 20% were undocumented. Level of education was 8th grade or less in 2.1%, high school in 24.5%, ≤ 2 years of college in 10.2%, >4 years of college in 12.2% and unknown in 51%. ECMO survival was 56% for VV ECMO, 44% for VA ECMO and 33% for ECPR. Survival to discharge was 56% for VV, 33% for VA and 33% for ECPR. One VV ECMO patient was bridged to lung transplant, there were no patients bridged to LVAD or heart transplant. Bleeding complications occurred in 3 patients (6%) and there were no procedural related complications. CONCLUSIONS: Our multidisciplinary ECMO program demonstrates feasibility to provide care to underserved and vulnerable populations with outcomes comparable to the national average, despite the challenges related to the potential limitations in bridging strategies for such patients. While socioeconomic and insurance status have a key role in bridging options for ECMO, they should not be a major determinant in denying patients advanced cardiopulmonary support if clinically indicated. CLINICAL IMPLICATIONS: Access to advance cardiorespiratory therapies including ECMO for vulnerable populations is a present need and is feasible with a multidisciplinary team DISCLOSURES: Speaker/Speaker's Bureau relationship with Zoll Please note: 3 years Added 04/04/2022 by Carlos Alviar, value=Honoraria No relevant relationships by Fariha Asef No relevant relationships by Sripal Bangalore No relevant relationships by Samuel Bernard No relevant relationships by Lauren Bianco No relevant relationships by Nishay Chitkara No relevant relationships by Jennifer Cruz No relevant relationships by Michael DiVita Research support relationship with Eurofins Viracor Please note: 12/1/2021 ongoing Added 12/23/2021 by Randal Goldberg, value=Grant/Research Support No relevant relationships by Kerry Hena No relevant relationships by William Howe No relevant relationships by Norma Keller no disclosure on file for Ma-Rosario Mertola;no disclosure on file for Thor Milland;No relevant relationships by vikramjit mukherjee No relevant relationships by Kayla Nunemacher No relevant relationships by Mansi Patel No relevant relationships by Radu Postelnicu No relevant relationships by Deepak Pradhan No relevant relationships by Vito Stasolla no disclosure on file for Amit Uppal;No relevant relationships by Susan Vlahakis No relevant relationships by Kah Loon Wan no disclosure on file for Victoria Yunaev;

6.
Chest ; 162(4):A978-A979, 2022.
Article in English | EMBASE | ID: covidwho-2060744

ABSTRACT

SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Extracorporeal membrane oxygenation (ECMO), typically veno-venous, is used to treat COVID19 patients with severe acute respiratory distress syndrome (ARDS) and is associated with decreased mortality in some reports. This study sought to determine the effect of ECMO versus conventional invasive mechanical ventilation (IMV) on hospital mortality for ARDS due to COVID19, and to compare functional status at discharge. METHODS: This was a retrospective, multicenter cohort study of adult patients admitted for COVID19 within a large US hospital network between March 1, 2020 and October 31, 2021. Patients were included if they required IMV with a fraction of inspired oxygen (FiO2) of at least 80% or VV ECMO. Patients were excluded if they were not independent, had a history of severe neurologic impairment, chronic obstructive pulmonary disease, chronic systolic heart failure, end stage renal disease, cirrhosis, metastatic malignancy, or a length of stay <24 hours. ECMO criteria and management were at the discretion of the treating center. Conventional IMV patients were assigned a randomized pseudo-baseline, and coarsened exact matching was used to match ECMO to conventional IMV patients based on age, sex, body mass index, pre-baseline severity of hypoxemia, prone positioning, receipt of corticosteroids, Tocilizumab, Baricitinib, acute renal replacement therapy, and vasopressors. Differences in hospital mortality and discharge destination were assessed through weighted logistic regression and weighted multinomial logit regression, respectively. RESULTS: We identified 207,965 patients across 168 hospitals for review, and 10,571 patients met study criteria. After matching, 275 ECMO patients and 5,808 conventional IMV patients were available for comparison. ECMO was associated with a significant mortality reduction, 36% versus 61% (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.34-0.57). Compared to conventional IMV survivors, ECMO survivors were significantly more likely to be discharged to acute rehabilitation than long term acute care (relative risk ratio (RRR) 2.23, 95% CI 1.16-4.32). ECMO survivors were also significantly more likely to be discharged to another acute care hospital for further management (RRR 3.21, 95% CI 1.75-5.92). CONCLUSIONS: This study demonstrates that ECMO support is significantly associated with reduced mortality in patients with severe ARDS due to COVID19 compared to conventional invasive mechanical ventilation. Further studies are needed to aid in prognostication, patient selection, and timing of intervention to maximize the benefit of this limited resource. CLINICAL IMPLICATIONS: These findings illustrate the importance of timely referral to an ECMO center for severely ill COVID19 patients, and may influence ECMO-capable centers to expand the use of ECMO in appropriate patients for this indication. DISCLOSURES: No relevant relationships by Elliott Cohen No relevant relationships by Katherine Cyr No relevant relationships by Jeffrey DellaVolpe No relevant relationships by Jamie Jarzembowski No relevant relationships by Chandra Kunavarapu no disclosure on file for Thomas Mcrae;Employee relationship with HCA Healthcare Please note: 6/1/2017 to current Added 04/04/2022 by Daniel Schlauch, value=Salary No relevant relationships by Owen Stell No relevant relationships by sage whitmore

7.
Chest ; 162(4):A631-A632, 2022.
Article in English | EMBASE | ID: covidwho-2060653

ABSTRACT

SESSION TITLE: Long COVID: It Can Take Your Breath Away SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: Survivors of COVID-19 hospitaliaztion may be at high risk for interstitial lung disease (ILD). The incidence and natural history of post-COVID ILD may vary in cancer and non-cancer patients, particularly if survival is lower in cancer patients. We sought to determine the incidence of ILD at 3 and 6 months after hospital discharge in cancer and non-cancer patients METHODS: We analyzed a prospective cohort of patients discharged after COVID-19 hospitalization between March 2020 and March 2021. Cancer patients were referred to post-COVID clinics 3 months after discharge, while non-cancer patients self-referred to post-COVID clinics at a tertiary referral center. We classified patients into 4 groups: Group 1, asymptomatic without ILD;Group 2, symptomatic without ILD;Group 3, ILD with spontaneous improvement by 6 months;Group 4, persistent ILD at 6 months. Group 1 patients were not seen after initial visits, while all others returned at 6 and 12 months after discharge. We hypothesized that initial COVID-19 severity, measured by the Radiologic Severity Index (RSI) on admission CT, would be associated with irreversible ILD. RSI measures radiologic severity by measuring percentage of involvement (normal - 0, <25% involvement-1, 25-50% involvement-2, 50-75% involvement-3, >75% involvement–4) and multiplying by a score based on the predominant pattern of infiltrate (normal-1, ground glass-2, consolidation-3) in six zones (left, right;upper, middle, lower) to yield a score between 0-72. We used logistic regression to measure whether admission CT RSI was associated with ILD at 3 months. RESULTS: 609 cancer patients were hospitalized with COVID-19 during the study period, of whom 85 (14%) died in-hospital, and 31 (5%) were sent home to hospice. A further 63 (10%) patients died before post-COVID evaluation. Similar data were not available for non-cancer patients due to self-referral. 98 cancer patients and 75 non-cancer patients were seen in post-COVID clinics. Among cancer patients, 20 were Group 1 (20%);8, Group 2 (8%);42, Group 3 (43%);24, Group 4 (25%);5 (5%) lacked post-COVID imaging. ILD was seen in 68% of patients at 3 months, but only in 25% at 6 months. 6% of all hospitalized cancer patients developed ILD. Among non-cancer patients: Group 1, 2 patients (3%);Group 2, 3 patients (4%);Group 3, 26 patients (35%);Group 4, 14 patients (19%);30 (40%) had no post-COVID imaging. Higher RSI at COVID admission associated with ILD at 3 months in non-cancer patients (OR 1.03, 95% CI 1.00-1.07, p=0.054) but not cancer patients (OR 1.3, 95% CI 0.4-4.5). CONCLUSIONS: Initial COVID-19 severity is associated with ILD 3 months after discharge in non-cancer patients but not cancer patients. CLINICAL IMPLICATIONS: ILD is common in survivors of COVID-19 hospitalization, particularly in non-cancer patients hospitalized for severe infection. These data may guide patient selection for referral to post-COVID clinics. DISCLOSURES: No relevant relationships by Roberto Adachi No relevant relationships by Diwakar Balachandran No relevant relationships by Lara Bashoura No relevant relationships by Christopher Bertini No relevant relationships by Kodwo Dickson Owner/Founder relationship with Pulmotect, Inc Please note: 2010-present by Scott Evans, value=Royalty No relevant relationships by Saadia Faiz no disclosure on file for Bruno Granwehr;no disclosure submitted for Shannon Holloway;No relevant relationships by Maryam Kaous no disclosure on file for Fareed Khawaja;No relevant relationships by Lyndon Lee No relevant relationships by Joanna Manzano No relevant relationships by Isabel Mira-Avendano No relevant relationships by Alyssa Mohammed No relevant relationships by Mayoora Muthu No relevant relationships by Sungryong Noh Research relationship with United Therapeutics;PhaseBio Please note: $5001 - $20000 by Bela Patel, value=Grant/Research No relevant relationships by Vickie Shannon onsultant relationship with Psioxus Therapeutics Please note: 3/1/20-7/1/20 by Ajay Sheshadri, value=Consulting fee Consultant relationship with Enanta Pharmaceuticals Please note: 01/01/21-ongoing by Ajay Sheshadri, value=Consulting fee No relevant relationships by Hui Song

8.
Chest ; 162(4):A432-A433, 2022.
Article in English | EMBASE | ID: covidwho-2060596

ABSTRACT

SESSION TITLE: COVID-19: Other Considerations in Management SESSION TYPE: Original Investigations PRESENTED ON: 10/18/2022 02:45 pm - 03:45 pm PURPOSE: Since its emergence in December 2019, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) has spread across the world, claiming millions of lives. With the publication of RECOVERY trial and REMAP-CAP trial, tocilizumab is recommended as additional therapy in select COVID populations by various professional societies. Although not observed initially in several randomized trials, concerns regarding serious secondary infections have been raised. Hereby, we seek to describe the epidemiology of infectious complications after tocilizumab in COVID patients admitted to a tertiary community hospital and to determine related risk factors for infections. METHODS: A retrospective cohort study was conducted among COVID patients requiring noninvasive or invasive ventilation who received tocilizumab at our hospital between June 2020 to December 2021. We define infectious complications as positive culture grown on a specimen that was also treated with antibiotics by the primary team. Baseline demographics and laboratory values are obtained through electronic medical records. Continuous outcomes are analyzed with parametric and non-parametric testing. Categorical variables are analyzed using the Chi-Square test. Risk factors are identified through Probit regression analysis and stepwise analysis. Statistics are performed using SPSS and STATA. RESULTS: 52 patients are identified with a median age of 63 and 46.2% female sex. Median hospital admission time since COVID diagnosis is 2 days and median tocilizumab administered time is 6.5 days. Common comorbidities include hypertension (63.5%), hyperlipidemia (50%) and diabetes (44.2%). Infectious complications are documented in 30 patients (57.7%), with 29 episodes of pneumonia, 7 episodes of urinary tract infection, and 4 episodes of bacteremia. Common organisms include MSSA (21%), Pseudomonas aeruginosa (19%), Klebsiella species (13%) and MRSA (5%). There are 9 cases of multidrug-resistant bacterial infection and 3 episodes of invasive fungal infection (1 Candidemia and 2 invasive aspergilloses). 22 patients (43.3%) died in the hospital before discharge with a median alive time after tocilizumab of 16.5 days. Hyperglycemia on admission (defined as a random glucose >200 mg/dl), hypertension and antibiotic use before tocilizumab are independent risk factors associated with infectious complications during regression analysis. Age >65 is the single most significant factor associated with death in the hospital. CONCLUSIONS: In real-world experience, infectious complications are not uncommon in COVID patients who receive tocilizumab. Our analyses show that potential risk factors for developing infections include a history of hypertension, hyperglycemia on admission and antibiotic use before tocilizumab. CLINICAL IMPLICATIONS: More rigorous criteria in patient selection and patient monitoring should be explored in future trials involving tocilizumab in COVID patients. DISCLOSURES: No relevant relationships by Zauraiz Anjum No relevant relationships by Ming-Yan Chow No relevant relationships by Ahmed Elkhapery No relevant relationships by Hafsa Faisal No relevant relationships by Lakshmi G Nair No relevant relationships by Charoo Iyer No relevant relationships by Hongli Liu No relevant relationships by Chengu Niu No relevant relationships by Kaiwen Zhu

9.
ASAIO Journal ; 68(Supplement 3):21, 2022.
Article in English | EMBASE | ID: covidwho-2057441

ABSTRACT

Extracorporeal CO2 removal (ECCO2R) is an effective therapy for correcting hypercapnia and respiratory acidosis. However, appropriate patient selection for optimal ECCO2R outcomes is not well defined. The goal of this retrospective, multicenter study was to determine patient and ECCO2R therapy characteristics which predict mortality in acute respiratory failure patients treated with the Hemolung ECCO2R system (ALung Technologies). The Hemolung Registry was queried for patients with acute respiratory failure. The Registry contains patient demographics, baseline and on- ECCO2R physiologic parameters, ICU survival and Hemolung performance data. Predictors of ICU survival were identified using a multivariable logistical regression analysis. 159 Hemolung patients were included in the analysis. Patients primarily had COVID-19 (55%) or non-COVID-19 ARDS (36%). Survival to ICU discharge was 41%. The median age of survivors was lower (49 vs 58 years), the use of adjunct therapies was lower in survivors (35.4% vs 64.9%), and a greater proportion of survivors received the recommended level of anticoagulation (43.1% vs 23.4%). ECCO2R complications were not significantly different between ICU survivors and non-survivors. COVID-19 diagnosis and a P/F < 100 at the start of Hemolung therapy were each independently associated with ICU mortality. This is the first study specifically evaluating patient and ECCO2R therapy characteristics that independently predict mortality in patients presenting with acute respiratory failure. The results of this study can provide insight in patient selection for future clinical trials and real-world use. Due to the retrospective nature of this study survival to hospital discharge data was not available.

10.
Journal of the Intensive Care Society ; 23(1):169-171, 2022.
Article in English | EMBASE | ID: covidwho-2043011

ABSTRACT

Introduction: Early cuff deflation and one way valve placement inline for patients who are ventilated with a tracheostomy allows for the restoration of verbal communication with concomitant psychological benefits, and enables assessment of bulbar function, delirium, pain, airway patency and speech and language problems.1,2 Such an approach has not been shown to impact respiratory or ventilatory outcomes.3-5 Whilst the benefits may seem obvious, the practice of using one way valves inline has not been widely documented and there are a few published patient selection criteria or protocols, but no national guidelines. Our multidisciplinary team designed a novel decision making tool and protocol to improve specialist service provision. Objectives: This was a retrospective audit of i) our decision making tool and ii) our protocol for early cuff deflation, one way valve inline placement and ventilator adjustments in a specialist tertiary referral neuroscience intensive care unit. Methods: The decision making tool and protocol guides the selection of patients and the approach to early cuff deflation. We performed a retrospective analysis of medical and therapy electronic patient records on consecutive patients with whom we had used this tool and protocol over a two year period from December 2018 -December 2020. Data included diagnosis, primary mode of ventilation, aim of first cuff deflation, time tolerated for first cuff deflation (minutes), and number of days between first cuff deflation and decannulation. Results: Eighteen consecutive patients were selected for early cuff deflation using the decision making tool with the following diagnoses: Encephalitis (5), COVID pneumonitis (5), Guillain Barre Syndrome (4), Intracerebral haemorrhage (1), Posterior communicating artery aneurysm (1), Motor Neurone Disease (1), Syringomyelia (1). At the time of the initial assessment, the ventilation status was: 10 patients on CPAP/PS, 4 on SIMV, 2 on High Flow Oxygen Therapy and 2 on a period of self-ventilation. The decision making tool defined the aim of the initial trial as laryngeal wean for 10 patients and to facilitate communication for 8. The median time for one way valve use for the initial trial was 10 minutes (range 4-25). There were no deleterious effects from following the protocol. All patients received further one way valve inline trials, and seventeen were weaned from the ventilator without respiratory compromise. One patient with Motor Neurone Disease remained ventilator dependent. Seventeen patients were subsequently decannulated (median 26.5 days after initial cuff deflation, range 12-209). Conclusions: Eighteen neurointensive care patients were successfully able to use a one way valve inline in accordance with our decision making tool and protocol. It is hoped that our practice will prompt a wider discussion amongst different intensive care multidisciplinary teams about careful patient selection and judicious use of a one way valve inline. We plan to collect patient's experience of the practice and to update our protocol with emerging evidence around optimal ventilator settings for using one way valves inline.

11.
Journal of the Intensive Care Society ; 23(1):181-182, 2022.
Article in English | EMBASE | ID: covidwho-2042982

ABSTRACT

Introduction: The North East London Critical Care Transfer And Retrieval (NECCTAR) Service provides a complete adult critical transfer capability. During the second wave of the COVID-19 pandemic, London was the epicentre of critical care activity1. Resource pressures escalated rapidly to unprecedented levels of demand.1 Beds for regional decompression became increasingly rare within London, necessitating long-range transfer. These were considered to be journeys over two hours in duration and to hospitals outside of the M25. NECCTAR was the first critical care transport service during this peak to decompress a London-based COVID-19 patient to a bed sourced nationally. Although longer-range ground transfers are associated with inherent risks, these can be mitigated through a dedicated transfer team and equipment.2,3 NECCTAR was required to rapidly and iteratively design a framework for long-range transfers. The service leadership drew on experience from aeromedical pre-hospital resources. Detailed case review was undertaken to refine the standard operating procedure. As pandemic pressures have reduced, the guidance has now become translatable to longer-distance repatriation and specialist transfers. Objective: To develop and refine a novel framework for maintaining patient safety during long-range critical care unit transfer. Methods: Risks associated with long-range critical care ground transfers were broadly identified as patient, staff, and equipment/technical risks. Ethical considerations were prominent in planning. Risks were categorised for standard operating procedure design purposes. Data were contemporaneously recorded for all taskings from point of referral to completion. The risks and their mitigations are summarised in Table 1. Results: An iteratively designed standard operating procedure was developed. NECCTAR has been referred 29 long-range missions and has completed 20 (68.9%) of these. Long-range taskings are significantly less likely to result in a completed transfer (68.9% v 88.3%, Fisher's p=0.029), predominately due to unanticipated changes in clinical status prior to departure. The longest duration of time and distance travelled under NECCTAR care was 5 hours, 32 minutes and 278 kilometres, respectively. All completed long-range transfers were followed up to discharge from intensive care;there were no significant adverse events in this group. Conclusion: NECCTAR has developed a framework that ensures stringent patient selection and transfers by a dedicated, senior-led crew with multiple risk mitigations. A strong governance process has informed updates to maintain patient safety. This framework has now been adapted for repatriation and specialist transfers and would also be generalisable to major incidents, including biohazard events and natural disasters.

12.
Nordic Journal of Nursing Research ; 42(3):117-122, 2022.
Article in English | CINAHL | ID: covidwho-2020804

ABSTRACT

In this article, we describe and critically reflect on how the PEPPA framework, a Participatory Evidence-based Patient-focused Process for Advanced Practice Nursing, was used to develop a new model of care including the nurse practitioner (NP) role in an emergency department in Norway, where the role is in its infancy. While there is limited earlier research on the applicability of the PEPPA framework, it was here found to be useful. Supported by the framework, we mapped the current model of care, identified stakeholders and participants, determined the need for a new model of care, identified priority problems and goals, and defined the new model of care and the NP role. The PEPPA framework is recommended to develop new models of care including the NP role. Nonetheless, the process has not been straightforward. It is noted that to communicate and establish the new role in a setting as demanding as an emergency department takes time. Support from the management team is essential to succeed in developing and establishing new models of care and new nursing roles, such as the nurse practitioner role.

13.
Surgery for Obesity and Related Diseases ; 18(8):S20, 2022.
Article in English | EMBASE | ID: covidwho-2004507

ABSTRACT

Katherine Ho Tucson AZ1, Chiu-Hsieh Hsu Tucson AZ1, Yazan Ashouri Tucson AZ1, Saad Ajmal Tucson AZ1, Iman Ghaderi Tucson AZ1 University of Arizona1 Introduction: The COVID-19 pandemic had affected the health systems across the world since early 2020 with a concern about access to medical care during the first wave of COVID-19 pandemic. The aim of this study was to examine the effect of COVID-19 on the patient selection for elective bariatric surgery using Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. Methods: MBSAQIP data for 2016-2020 was queried. Log-normal regression was performed to evaluate patient characteristics. Comparison between cases performed in 2020 and previous years was derived using Wilcoxon rank-sum test for continuous variables and Fisher’s exact test for categorical variables for laparoscopic vs. robotic-assisted approaches. Results: A total of 822,558 patients underwent robotic (R) and laparoscopic (L) sleeve gastrectomy and Roux-en-Y gastric-bypass (R-SG, L-SG, R-RYGB, and L-RYGB, respectively). Comorbidities were lower in the cases performed in 2020 compared to pre-COVID years in both the laparoscopic and robotic approaches of SG and RYGB. Conclusion: Patients who underwent elective bariatric surgery during COVID-19 pandemic in 2020 tend to have less comorbidities comparing to the patients who had bariatric surgery prior to COVID-19. It is possible that bariatric centers decreased offering surgeries to high-risk patients.

14.
Multiple Sclerosis and Related Disorders ; 59, 2022.
Article in English | EMBASE | ID: covidwho-2004363

ABSTRACT

Objective(s): Gaps in current evidence and guidance leave clinicians with unanswered questions on the use of cladribine tablets for the treatment of multiple sclerosis (MS) during the COVID-19 pandemic, particularly relating to COVID-19 vaccination. We describe a consensus-based program led by international MS experts with the aim of supplementing current guidelines and treatment labels by providing timely recommendations relating to COVID-19 vaccination and the use of cladribine tablets in clinical practice. Material(s) and Method(s): A steering committee (SC) of 10 international MS experts identified seven clinical questions to answer concerning the use of cladribine tablets and COVID-19 vaccination, which addressed issues relating to patient selection, timing and efficacy, and safety. Clinical recommendations addressing each question were drafted using available evidence combined with expert opinion from the SC. An extended faculty of 28 MS experts, representing 19 countries, in addition to the SC members, voted on the recommendations. Consensus on recommendations was achieved when ≥75% of respondents expressed an agreement score of 7–9, on a 9-point scale. Result(s): Consensus was achieved on all 13 recommendations. Clinical recommendations are provided on whether all patients with MS receiving cladribine tablets should be vaccinated against COVID-19, and whether they should be prioritized;the timing of vaccination around dosing of cladribine tablets (i.e., before and after a treatment course);and the safety of COVID-19 vaccination for these patients. Conclusion(s): There was overwhelming consensus that the risks of COVID-19 outweigh risks of vaccination in people with MS who are being treated with cladribine tablets, and all people with MS treated with cladribine tablets should be vaccinated against COVID-19 as soon as possible, unless they have a contraindication. The consensus provides timely guidance on patient selection, timing, efficacy, and safety of COVID-19 vaccination in patients receiving cladribine tablets, which is relevant to decision-making in everyday clinical practice.

15.
Hum Vaccin Immunother ; : 2109364, 2022 Aug 26.
Article in English | MEDLINE | ID: covidwho-2004925

ABSTRACT

During the Covid-19 pandemic, the urgent need for safe and effective vaccines has led to many vaccine trials, implying fast and extensive recruitment of volunteers. In France, until 2020, vaccine clinical research participants were usually recruited locally, through center-based pools of volunteers, and local communication plans. Covireivac is a French public online platform launched on 10/01/2020 that enables national, large-scale recruitment of volunteers for Covid-19 vaccine studies. On the Covireivac website, all adult participants registered online, gave their informed consent, and filled out two online forms with information on their identity, health status (comorbidities, treatments), and known exposure to SARS-CoV-2. Since July 2021, volunteers could mention if their children are interested in participating in a Covid-19 vaccine trial. The objective of this work is to describe Covireivac's volunteer characteristics registered from 10/01/2020 to 11/02/2022. To identify independent volunteer characteristics associated with a period of registration we performed a multivariate logistic regression. Among 54,424 registrations, 52,391 (96%) were analysed; 61% were male (n = 31,893), median age was 50 y; 13% (n = 6586) were healthcare workers. At registration, 15,879 volunteers (33%) reported at least one comorbidity, among whom 16% (n = 7349) were obese and 17% (n = 8346) had hypertension. Most volunteers registered during the first month (n = 35,876, 66%). The Covireivac platform allowed quick and large recruitment of potential volunteers for Covid-19 vaccine trials and could be used on a larger scale for vaccine trials in France. It could facilitate recruitment in vaccine trials and provide sponsors with better visibility of the recruitment capacities of clinical research centers.

16.
Clinical Oncology ; 34(4):e176-e177, 2022.
Article in English | EMBASE | ID: covidwho-2003976

ABSTRACT

Purpose: Dose-dense (dd) chemotherapy regimens reduce breast cancer recurrence and mortality with no significant increase in non-cancer related mortality [1]. However, uptake is poor, probably due to concerns regarding toxicity. We aimed to quantify rates of toxicity and dose reduction in patients receiving dd epirubicin and cyclophosphamide (EC), and to identify any associated patient factors. Methods: This was a retrospective and prospective study. Patients receiving neoadjuvant or adjuvant dd EC (epirubicin 90 mg/m2 and cyclophosphamide 600 mg/m2 2-weekly) between 2018 and 2021 at two London hospitals were identified from electronic records. Baseline ECOG performance status (PS), incidence of dose delay, dose reduction and hospital admission were identified from electronic records. Results: 108 patients received dd EC, 49 (45%) in the neoadjuvant and 59 (55%) in the adjuvant setting, receiving a total of 422 cycles. Median age was 47 years (25–69 years). 105 patients (95%) had a baseline PS of 0;the other 6 (5%) a PS of 1. 99 patients (92%) received 4 cycles of dd EC as planned, of which 84 (78%) had no dose reductions. 3 patients were converted to the standard regimen due to toxicity. 5 patients had cycles omitted due to toxicity (n = 2) or other causes. One patient died due to COVID-19. 16 patients (15%) had a dose reduction. Treatment was delayed by at least 1 week in 18 patients (17%). The most common reasons for this were haematological toxicity (n = 6) and infection (n = 4). 6 patients (6%) had both delays and dose reductions. 8 patients (7%) were admitted to hospital during treatment, 4 of whom had febrile neutropenia. Conclusion: This real world data demonstrate that dd chemotherapy can be delivered in routine practice. The rates of dose reduction and delay were comparable to those found in standard regimes [1]. Patient selection by oncologists is an important factor. Reference [1] Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Increasing the dose intensity of chemotherapy by more frequent administration or sequential scheduling: a patient-level meta-analysis of 37 298 women with early breast cancer in 26 randomised trials. Lancet 2019;393(10179):1440–52.

17.
Annals of Surgical Oncology ; 29(SUPPL 2):S419, 2022.
Article in English | EMBASE | ID: covidwho-1928245

ABSTRACT

INTRODUCTION: With the pressure to reduce both cost of care and in-patient hospitalizations, particularly in the COVID era, several groups have reported the feasibility of outpatient mastectomies utilizing enhanced recovery after surgery (ERAS) programs. Having converted most mastectomies to the outpatient setting in 2009, we examined our experience sending patients home the same day, including patient selection, unexpected admission and post-operative complications, to better inform institutions considering their own outpatient mastectomy programs. METHODS: With approval from the Institutional Review Board, we performed a retrospective cohort study of patients undergoing mastectomy at a single academic medical center from 2014-2020. Patient population included all patients undergoing mastectomy for malignant disease or risk reduction and excluded patients having immediate breast reconstruction. RESULTS: Of 1678 patients undergoing mastectomy in this time period, 810 did not have immediate reconstruction. Overall, 428 (53%) were planned as outpatient procedures. This was dependent on the type of procedure;unilateral mastectomy (UM) (70%), modified radical mastectomy (MRM) (50%), bilateral simple mastectomies (BSM) (39%) and MRM with contralateral prophylactic mastectomy (MRM/CPM) (25%). The latter two increased over the time course of the study. Admission was associated with ASA status (34% ASA 1/2 vs 51% ASA 3/4, p< 0.001). The most significant predictor was surgeon, with rates ranging from 85% to 46% for UM, 80% to 13% for MRM, 68% to 18% for BSM and 55% to 9% for MRM/CPM. Overall, 16 (3.7%) same-day surgery patients were admitted while 14 (3.8%) 23-hour admission patients were converted to inpatient admissions. Post-operative hematomas requiring a second operation were more common with planned admission compared to those planned for same day discharge (19 (4.9%) vs. 10 (2.3%), p=0.036). CONCLUSIONS: Mastectomies (including bilateral and modified radical mastectomies) without reconstruction can be safely performed on an outpatient basis. Rates of unexpected hospitalizations and post-operative complications are low and there is no difference between those patients planning on same-day discharge and those planned for admission.

18.
American Journal of Respiratory and Critical Care Medicine ; 205(1), 2022.
Article in English | EMBASE | ID: covidwho-1927828

ABSTRACT

Rationale: International organizations, including the World Health Organization and Extracorporeal Life Support Organization have recommended the use of extracorporeal membrane oxygenation (ECMO) in the management of patients with Coronavirus Disease-19 (COVID-19) related acute respiratory distress syndrome (ARDS) based on favorable outcomes shown by some studies from earlier parts of the pandemic. Mortality rates of COVID-19 patients with the use of ECMO has ranged from 40-94%. Some reports suggest early initiation of ECMO leads to better outcomes before refractory hypoxemia leads to multi-organ failure. However, the predictors of mortality among COVID-19 patients treated with ECMO remain unclear. Also, ECMO has been associated with potentially life-threatening bleeding and thromboembolic complications. This study aims to identify the risk factors associated with the mortality in COVID-19 patients managed with ECMO and to assess the effect of ECMO related complications on mortality. Methods: Retrospective analysis of adult patients with COVID-related ARDS treated with ECMO at the ICUs of a quaternary care hospital between 03/01/2020 and 08/31/2021. Demographics, clinical characteristics, and outcomes of the patients who survived were compared with those who did not survive. Hemorrhagic complications were defined as bleeding requiring transfusion, hemorrhagic stroke and coagulopathy with International Normalized Ratio (INR) > 3. Thrombotic complications were defined as limb ischemia and ischemic stroke. Myocardial dysfunction was defined as a drop in ejection fraction to less than 30%, liver dysfunction as alanine transaminase (ALT) greater than 5 times of upper normal limit (ULN), and kidney involvement as acute kidney injury (AKI) requiring dialysis. Results: Of the 31 COVID-19 patients managed with ECMO during the study period, 11 (36%) patients survived. Both groups were similar in terms of age, gender, comorbidity burden (measured by Charlson Comorbidity Index), and severity of illness at the time of ICU admission (assessed by APACHE-IV score). Days spent on mechanical ventilation (MV) before ECMO cannulation were lower in survivors as compared to non-survivors but the difference was not statistically different. The incidence of complications was not statistically different between two groups. Conclusion: Our study shows a survival rate in COVID-19 patients treated with ECMO that is similar to previously reported studies. Our study did not reveal any significant predictive differences between survivors and nonsurvivors, thereby continuing to make the process of patient selection for ECMO challenging during this pandemic. Our study is limited by a relatively small sample size and therefore larger studies will be needed to confirm our findings.

19.
Ambulatory Surgery ; 28(1):8-10, 2022.
Article in English | EMBASE | ID: covidwho-1893983

ABSTRACT

The COVID-19 pandemic has affected the UK in many ways;with the NHS being put under unprecedented pressure. It led to the cessation of elective surgery for months;causing a back log of deteriorating patients. With the introduction of COVID vaccines and a call for return to normality, new ways of delivering elective surgery to waiting patients, presents an opportunity to find sustainable ways to ensure continuity of treatment in an unstable health economy. The challenges of Covid to ambulatory surgery are outlined and strategies to overcome these challenges discussed.

20.
Journal of Biological Regulators and Homeostatic Agents ; 36(2):305-312, 2022.
Article in English | EMBASE | ID: covidwho-1866085

ABSTRACT

Introduction: Baldness is a current problem in aesthetic medicine. This cosmetic defect can lead to serious psychological and emotional stress. Most of the time, the solution to this problem consists of removing or attenuating its cause: alopecia. Among the current hair restoration technique to treat alopecia, one is the biocompatible artificial hair implant. Materials and Methods: The certified medical device used for this study is the biocompatible artificial hair Biofibre4.0. The clinical study was done by collecting clinical data from 18 clinics located in 15 different countries and 4 continents to evaluate the efficacy, safety, and performance of a new artificial hair device generation compared to previous artificial hair. Automatic and manual implanter were utilized by doctors participating in these trials. A new needles material was also used for this study. The standard medical protocol was applied with some differences in the doctor’s personal experience, patient’s situation, and climate. Results: The data collected show that in a sample of about 1337 patients treated in 2020/2021, inflammation and infections are around 7%, and curling is <1%. There were no phenomena of fibre breakage. Itching appeared in about <3% of cases. The problems encountered in most cases were mild and resolvable with appropriate therapy, and only in rare cases (<1%) it was necessary to proceed with the total removal of the fibres. In some cases (<1%), it was just necessary to partially extract the fibres that cause recurrent discomfort for the patient. In most patients, satisfaction was 96%. The limitations in patient movement and lowering of the immune response in many of them caused by COVID SARS 2 might partially affect the final data. Conclusion: This surgery does not imply scar formation and hospitalization. It can be used alone or with other treatments to provide psychological benefits and improve quality of life. Indications are poor donor area, request for immediate aesthetic result and scarce trauma. Patient selection, respect for medical protocol and proper aftercare must be complied with. Contraindicated cases must be avoided, and partial or total removal of fibres is required in case of recurrent problems. Additional improvements to this technique are expected to enable an ever vaster application.

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