What can we Learn from Patients who Died from Covid-19 Following Escalation to a Respiratory High Dependency Unit for Trial of Non-Invasive Respiratory Support?

Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.

Outcomes Following Bronchial Artery Embolisation for Haemoptysis in Cystic Fibrosis.

BACKGROUND: Bronchial artery embolisation (BAE) is recommended for the treatment of massive haemoptysis in cystic fibrosis (CF), but there are no randomised controlled trials of this therapy and its role in sub-massive haemoptysis is unclear. This study aimed to determine the outcomes and safety of BAE in adults with CF. MATERIALS AND METHODS: All patients with CF undergoing BAE at our centre between March 2011 and January 2015 were identified at the time of the procedure. Patient records were reviewed at hospital discharge, death or one month post-procedure (whichever was soonest). Follow-up continued to January 2016. Severity of haemoptysis was classified as: massive (>240 ml/24 h or >100 ml/day for ≥2 days), moderate-severe (>20 ml/24 h) or mild (<20 ml/24 h). RESULTS: Twenty-seven patients underwent 51 BAE procedures over a median follow-up period of 26 months (range 1-54). Ten patients (37%) required more than one BAE during the study. BAE was performed for massive haemoptysis in 18 cases (35%). Haemoptysis recurred after 31 (61%) of BAE procedures with no difference in recurrence rates between massive and sub-massive haemoptysis. Side effects were reported after 61% of procedures with chest pain the most common adverse event . Mortality after first BAE in the study was 3.9% at 30 days and 14.8% at 12 months. No significant predictors of mortality were identified. CONCLUSIONS: BAE is often effective in controlling haemoptysis but is associated with considerable morbidity and high recurrence rates.

The effect of the weather on pulmonary exacerbations and viral infections among adults with cystic fibrosis.

The effect of changes in the weather on the respiratory health of patients with cystic fibrosis (CF) is unclear. We conducted a prospective study to determine the impact of climate and season on the incidence of viral respiratory infections (VRI) and pulmonary exacerbations (PEx) among adults with CF. Between December 2010 and April 2012, 98 adults with CF were followed for 12 months. Polymerase chain reaction assays for nine viruses were performed on sputum, nose and throat swabs every 2 months and additionally at onset of PEx. Hourly temperature and relative humidity measurements were recorded throughout the study. Statistical analysis utilized generalized estimating equation (GEE) models. Pre-specified criteria for VRI and PEx were met at 29% and 37% of visits, respectively. Rhinovirus accounted for 72% of identified viruses. Incidence of rhinovirus peaked in autumn while non-rhinovirus VRI peaked in winter. Rhinovirus was associated with increased mean temperatures (OR 1.07; p = 0.001), while non-rhinovirus VRI was associated with lower mean temperatures (OR 0.87; p < 0.001). PEx occurred frequently throughout the study with no clear seasonal pattern observed. There was no significant association between climate variables and the incidence of either PEx or antibiotic prescription. There is a seasonal pattern to VRI in adults with CF. The incidence of VRI but not PEx is associated with changes in ambient temperature.

Pulmonary complications of cystic fibrosis.

The life expectancy of patients with cystic fibrosis (CF) has steadily increased over recent decades with a corresponding increase in the frequency of complications of the disease. Radiologists are increasingly involved with managing and identifying the pulmonary complications of CF. This article reviews the common manifestations of CF lung disease as well as updating radiologists with a number of less well-known complications of the condition. Early and accurate detection of the pulmonary effects of CF are increasingly important to prevent irreversible lung damage and give patients the greatest possibility of benefiting from the new therapies becoming available, which correct the underlying defect causing CF.

Cystic fibrosis, primary ciliary dyskinesia and non-cystic fibrosis bronchiectasis: update 2008-11.

A review is presented of key clinical papers published in Thorax and elsewhere between 2008 and April 2011 which have advanced our understanding of cystic fibrosis (CF), primary ciliary dyskinesia and non-CF bronchiectasis. Studies were identified through searches of the Thorax archive and the Medline database. Within the field of CF, the following key themes were studied: diagnosis in equivocal CF, assessment of CF lung disease, novel therapies addressing the basic defect in CF, maintenance pulmonary therapies, management of early Pseudomonas infection, the microbiology of CF lung disease, renal impairment in CF and controversies in lung transplantation in CF.

Methoxyindole synthesis in the retina of the frog (Rana esculenta) during a diurnal period.

In the present study, the synthesis of methoxyindoles in the neural part and in the pigment epithelial layer of the retina of the frog eye was investigated on the basis of naturally occurring substrate at regular intervals during a 24 hour period. Melatonin, 5-methoxytryptophol and 5-methoxyindole acetic acid were synthesized by the neural part of the retina only, while 5-methoxytryptamine and 5-methoxytryptophan were produced by both, the neural part of the retina and the pigment epithelium. The synthesis of melatonin and of 5-methoxytryptamine showed a diurnal rhythmicity. The results obtained clearly indicate that another cell type, i.e. pigment cells, is involved in indole metabolism besides photoreceptor elements. A possible functional relationship between different methoxyindoles and different retino-motor processes in the amphibian eye is discussed.

Fine structural localization of adenosine triphosphatase activities in the saccus vasculosus of the rainbow trout, Salmo gairdneri Richardson.

The following characteristics of the adenosine triphosphatases (ATPase) in the saccus vasculosus were studied in Salmo gairdneri Richardson: 1) distributional pattern, 2) cytochemical properties in relation to different substrates, inhibitors, pH and bivalent metal ions, and 3) ultrastructural localization. Ultracytochemical studies using modifications of the Washstein-Meisel technique showed that within the pH range 7.1-8.0 several Mg++ or Ca++-activated ATPase are localized on the intracellular surface of membranes and in the cytoplasm of ependymal coronet cells and tanycytes ("supporting cells", "Zwischenzellen", glial cells"). The high ATPase activity at the level of the specialized luminal plasma membranes of coronet cell globules and of tanycyte microvilli is discussed in relation to phenomena of active transport and a possible resulting transfer of low-molecular weight substances into and/or from the cerebrospinal fluid (CSF). The localization of ATPase on the specialized membranes of primary vesicles is considered in connection with available structural and enzyme-cytochemical data on a possible function of these cell organelles in storage and release of substances (including Ca++ ions?). The cytoplasmic ATPase activity in coronet cells is ascribed to microtubules and/or possible existing contractile proteins/filaments, presumably concerned with internal transport or motility processes. In tanycytes ATPase activity is believed to be associated with the characteristic microfilamentous system of still unknown function. The ATPase activity in the (9 + 0) ciliary apparatus of globules could not be interpreted in terms of motility. The present study provides further support to the proposed hypothesis of the transport function of the saccus vasculosus, and an extension of the concept in the sense that not only the principal coronet cells, but also the tanycytes of this circumventricular organ are involved in CSF-homeostasis.