Methylprednisolone in severe COVID-19 with acute respiratory distress syndrome - less is more?

INTRODUCTION: Corticosteroids, particularly methylprednisolone, are part of the treatment for severe COVID-19 with acute respiratory distress syndrome (ARDS). In this study, we aimed to compare the mortalities of patients treated with higher versus lower doses of methylprednisolone. Secondary outcomes included oxygenation, need for mechanical ventilation, length of stay in intensive care unit (ICU), secondary infection, improvement of PaO2/FiO2 (PF) ratio, and inflammatory response as expressed by C-reactive protein (CRP). MATERIALS AND METHODS: A retrospective cohort study conducted at Sarawak General Hospital from 1st June to 30th September 2021. Patients who received intravenous methylprednisolone for severe COVID-19 in the ICU were identified and divided into two groups: higher dose (cumulative dose more than 10 mg per kg) and lower dose (cumulative dose less than 10 mg per kg). RESULTS: Out of a total of 165 patients, 40 (24.2%) patients received higher dose methylprednisolone. There was no significant difference in socio-demographic characteristics (age, gender, body mass index), COVID-19 vaccination status, laboratory parameters (lymphocyte count, CRP, lactate dehydrogenase, D-dimer), or usage of immunomodulator therapy between the groups. Overall mortality was 23.6%. Mortality in the higher dose group was twice as high compared to lower dose group (37.5% versus 19.2%) (OR 3.79, 95% CI 1.24-11.59, p<0.05). In addition, the higher dose cohort developed more secondary infections (87.5%) and had longer stays in ICU (median 11 days, IQR 8- 15). No significant difference was found between both cohorts in terms of CRP reduction, improvement of PF ratio, or the need for mechanical ventilation post methylprednisolone. CONCLUSION: In this study, the use of higher dose methylprednisolone in COVID-19 with ARDS was not associated with better clinical outcomes. A lower dose of methylprednisolone might be sufficient in treating severe COVID-19 with ARDS.

Moving from long case to scenario-based clinical examination: Proposals for making it feasible.

INTRODUCTION: Our faculty used one long case (LC) and three short cases for the clinical component of the final professional examinations. During the COVID-19 pandemic, the LC had to be replaced with scenario-based clinical examination (SBCE) due to the impracticability of using recently hospitalised patients. While keeping the short case component as usual, the LC had to be replaced with SBCE in 2020 for the first time at a short notice. To evaluate the positive and negative aspects of SBCE and LC to determine the feasibility of replacing LC with SBCE in future examinations. MATERIALS AND METHODS: We compared the LC scores of three previous years with those of the SBCE and studied the feedback of the three stakeholders: students, examiners, and simulated patients (SPs), regarding their experience with SBCE and the suitability of SBCE as an alternative for LC in future examinations. RESULTS: The SBCE scores were higher than those of the LC. Most of the examiners and students were not in favour of SBCE replacing LC, as such. The SPs were more positive about the proposition. The comments of the three stakeholders brought out the plus and minus points of LC and SBCE, which prompted our proposals to make SBCE more practical for future examinations. CONCLUSION: Having analysed the feedback of the stakeholders, and the positive and negative aspects of LC and SBCE, it was evident that SBCE needed improvements. We have proposed eight modifications to SBCE to make it a viable alternative for LC.

Bioactive nanocrystalline sol-gel hydroxyapatite coatings.

Sol-gel technology offers an alternative technique for producing bioactive surfaces for improved bone attachment. Previous work indicated that monophasic hydroxyapatite coatings were difficult to produce. In the present work hydroxyapatite was synthesized using the sol-gel technique with alkoxide precursors and the solution was allowed to age up to seven days prior to coating. It was found that, similar to the wet-chemical method of hydroxyapatite powder synthesis, an aging time is required to produce a pure hydroxyapatite phase. A methodology that has been successfully used to produce nanocrystalline hydroxyapatite thin film coatings via the sol-gel route on various substrates including alumina, Vycor glass, partially stabilized zirconia, Ti-6Al-4V alloy and single crystal MgO is described. Coatings produced on MgO substrates were characterized by X-ray diffraction and atomic force microscopy, while the analogous gels were examined with thermogravimetric and differential thermal analyses. The coatings were crack free and the surface was covered with small grains, of approximately 200 nm in size for samples fired to 1000 degrees C. Coating thickness varied between 70 and 1000 nm depending on the number of applied layers.

Critical ageing of hydroxyapatite sol-gel solutions.

It has been established that hydroxyapatite coatings can be produced using an alkoxide based sol-gel technique. Previous work showed that in addition to hydroxyapatite other phases including CaO were observed. A critical factor in determining the composition of the final coating is the period between solution preparation and coating deposition. The current study addresses how the ageing time affects the composition of the coating and the time required before a solution can be used to deposit monophasic coatings. Powders and coatings were produced with ageing times up to one week and examined with X-ray diffraction, thermal gravimetric analysis and differential thermal analysis. By depositing coatings after various ageing times, it was found that a solution ageing time of at least 1 day was required before monophasic hydroxyapatite coatings could be deposited. Thermogravimetric analysis showed that heating of the gel in air or in nitrogen both produced hydroxyapatite. Thermogravimetric analysis could be used as a simple and effective tool for identifying the critical ageing time required to produce high-purity hydroxyapatite coatings.

Thin hydroxyapatite coatings via sol-gel synthesis.

Production of hydroxyapatite coatings using an alkoxide-based sol-gel route requires control of solution aging time and heating schedule. 31P nuclear magnetic resonance spectroscopy was used to investigate the changes during aging of the sol and thermal gravimetric analysis employed to study the behavior of the xerogels as a function of temperature, while final products were determined using X-ray diffraction. Results from 31P nuclear magnetic resonance spectroscopy and thermal analysis revealed that sols must be aged for at least 24 h to complete the reaction of the two reactants. Deposition of the sol for coating production will then yield monophasic hydroxyapatite. Coatings produced from sols aged for less than 24 h yielded calcium oxide in addition to hydroxyapatite. Prefiring is necessary to remove most of the residual organic materials. Final heating up to 800 degrees C produces crystallization at 550 degrees C and removal of the remaining organic constituents for the formation of a thin hydroxyapatite layer.