Pneumomediastinum in COVID-19: a phenotype of severe COVID-19 pneumonitis? The results of the United Kingdom (POETIC) survey.

BACKGROUND: There is an emerging understanding that coronavirus disease 2019 (COVID-19) is associated with increased incidence of pneumomediastinum. We aimed to determine its incidence among patients hospitalised with COVID-19 in the United Kingdom and describe factors associated with outcome. METHODS: A structured survey of pneumomediastinum and its incidence was conducted from September 2020 to February 2021. United Kingdom-wide participation was solicited via respiratory research networks. Identified patients had SARS-CoV-2 infection and radiologically proven pneumomediastinum. The primary outcomes were to determine incidence of pneumomediastinum in COVID-19 and to investigate risk factors associated with patient mortality. RESULTS: 377 cases of pneumomediastinum in COVID-19 were identified from 58 484 inpatients with COVID-19 at 53 hospitals during the study period, giving an incidence of 0.64%. Overall 120-day mortality in COVID-19 pneumomediastinum was 195/377 (51.7%). Pneumomediastinum in COVID-19 was associated with high rates of mechanical ventilation. 172/377 patients (45.6%) were mechanically ventilated at the point of diagnosis. Mechanical ventilation was the most important predictor of mortality in COVID-19 pneumomediastinum at the time of diagnosis and thereafter (p<0.001) along with increasing age (p<0.01) and diabetes mellitus (p=0.08). Switching patients from continuous positive airways pressure support to oxygen or high flow nasal oxygen after the diagnosis of pneumomediastinum was not associated with difference in mortality. CONCLUSIONS: Pneumomediastinum appears to be a marker of severe COVID-19 pneumonitis. The majority of patients in whom pneumomediastinum was identified had not been mechanically ventilated at the point of diagnosis.

Method to Calculate Nurse-Specific Cesarean Rates for the First and Second Stages of Labor.

To date, efforts to safely lower the cesarean birth rate for women with low-risk pregnancies have largely ignored the influence of labor and delivery nurses on mode of birth. This is mainly because of the complexity involved in attributing outcomes to specific nurses whose care had the greatest effect on mode of birth. An additional level of complexity arises from the type of care given to the woman during different stages of labor. In this article, we describe a strategy to designate nurses to births using an electronic medical record flowsheet, and we describe a method to calculate nurse-specific cesarean birth rates for the first and second stages of labor. Similar to physician-specific rates, we found wide variation in nurse-specific cesarean birth rates in both stages of labor, which suggests an opportunity to learn from best practices.

How effective are 'age' tools at changing patient behaviour? A rapid review.

BACKGROUND: A common form of risk communication is to relay the relative risk (%) of an adverse outcome based on surrogate markers associated with the outcome. A novel way of communicating risk is through 'effective age' of a person or specific organ. These tools can be used to change patient behaviour. OBJECTIVE: To determine the effect of 'effective age' tools on patient behaviour as compared with more traditional methods of risk communication. STUDY SELECTION: We performed a search of the PubMed database up to February 2019 for systematic reviews and randomised controlled trials (RCT) that answered our question. Interventions were 'effective age' tools, comparators were usual care or alternative risk communication tools. Primary outcomes were behavioural change measures. FINDINGS: We included 1 overview of systematic reviews (level 1 evidence), 2 systematic reviews (level 1 evidence) and 13 RCTs (level 2 evidence). Both systematic reviews concluded the evidence base was not conclusive enough to make specific recommendations.Age tools assessed in the 13 RCTs were: 'lung age' (n=5), 'heart age' (n=3), 'health age' (n=2), 'cardiovascular age' (n=1), 'body age' (n=1) and 'net present value' (n=1). 7/13 (54%) RCTs demonstrated a clinical effect on behaviour change favouring the 'age' tool; 2/13 (15%) demonstrated a null effect; 4/13 (31%) favoured control. CONCLUSIONS: Our findings indicate that systematic review evidence needs updating. The evidence from RCTs on the effect of using age metrics on patient behaviour is poor. There is a need for high-quality trials to decrease uncertainty in the available evidence.

The transient intraluminal filament middle cerebral artery occlusion model as a model of endovascular thrombectomy in stroke.

The clinical relevance of the transient intraluminal filament model of middle cerebral artery occlusion (tMCAO) has been questioned due to distinct cerebral blood flow profiles upon reperfusion between tMCAO (abrupt reperfusion) and alteplase treatment (gradual reperfusion), resulting in differing pathophysiologies. Positive results from recent endovascular thrombectomy trials, where the occluding clot is mechanically removed, could revolutionize stroke treatment. The rapid cerebral blood flow restoration in both tMCAO and endovascular thrombectomy provides clinical relevance for this pre-clinical model. Any future clinical trials of neuroprotective agents as adjuncts to endovascular thrombectomy should consider tMCAO as the model of choice to determine pre-clinical efficacy.