Timely administration of tocilizumab improves outcome of hospitalized COVID-19 patients.

INTRODUCTION: The aim of this study was to determine the efficacy of early tocilizumab treatment for hospitalized patients with COVID-19 disease. METHODS: Open-label randomized phase II clinical trial investigating tocilizumab in patients with proven COVID-19 admitted to the general ward and in need of supplemental oxygen. The primary endpoint of the study was 30-day mortality with a prespecified 2-sided significance level of α = 0.10. A post-hoc analysis was performed for a combined endpoint of mechanical ventilation or death at 30 days. Secondary objectives included comparing the duration of hospital stay, ICU admittance and duration of ICU stay and the duration of mechanical ventilation. RESULTS: A total of 354 patients (67% men; median age 66 years) were enrolled of whom 88% received dexamethasone. Thirty-day mortality was 19% (95% CI 14%-26%) in the standard arm versus 12% (95% CI: 8%-18%) in the tocilizumab arm, hazard ratio (HR) = 0.62 (90% CI 0.39-0.98; p = 0.086). 17% of patients were admitted to the ICU in each arm (p = 0.89). The median stay in the ICU was 14 days (IQR 9-28) in the standard arm versus 9 days (IQR 5-14) in the tocilizumab arm (p = 0.014). Mechanical ventilation or death at thirty days was 31% (95% CI 24%-38%) in the standard arm versus 21% (95% CI 16%-28%) in the tocilizumab arm, HR = 0.65 (95% CI 0.42-0.98; p = 0.042). CONCLUSIONS: This randomized phase II study supports efficacy for tocilizumab when given early in the disease course in hospitalized patients who need oxygen support, especially when concomitantly treated with dexamethasone. TRIAL REGISTRATION: https://www.trialregister.nl/trial/8504.

Patient-Generated Subjective Global Assessment Short Form better predicts length of stay than Short Nutritional Assessment Questionnaire.

OBJECTIVE: Malnutrition screening instruments used in hospitals mainly include criteria to identify characteristics of malnutrition. However, to tackle malnutrition in an early stage, identifying risk factors for malnutrition in addition to characteristics may be valuable. The aim of this study was to determine the predictive validity of the Patient-Generated Subjective Global Assessment (PG-SGA SF), which addresses malnutrition characteristics and risk factors, and the Short Nutritional Assessment Questionnaire (SNAQ), which addresses mainly malnutrition characteristics, for length of stay (LOS) in a mixed hospital population. METHODS: Patients (N = 443) were screened with the PG-SGA SF and SNAQ in the first 72 h after admission to the lung, cardiology, or surgery ward. The McNemar-Bowker test was used to investigate the symmetry between the SNAQ and PG-SGA SF categorization for low, medium, and high risk. The predictive value of the PG-SGA SF and SNAQ was assessed by γ-regression before and after adjusting for several confounders. RESULTS: Of the 443 patients included, 23% and 58% were categorized as being at medium/high risk for malnutrition according to the SNAQ and PG-SGA SF, respectively. The regression analysis indicated that LOS of high-risk patients according to PG-SGA SF was 36% longer than that of low-risk patients (P = 0.001). LOS in patients at high risk according to the SNAQ did not significantly differ from that of SNAQ low-risk patients. CONCLUSIONS: The PG-SGA SF, as a proactive malnutrition screening instrument, predicts LOS in various hospital wards, whereas the SNAQ, as a reactive instrument, does not. Therefore, we recommend the PG-SGA SF for proactive screening for malnutrition risk.

Are Dutch patients willing to be seen by a physician assistant instead of a medical doctor?

BACKGROUND: The employment of physician assistants (PAs) is a strategy to improve access to care. Since the new millennium, a handful of countries have turned to PAs as a means to bridge the growing gap between the supply and demand of medical services. However, little is known about this new workforce entity from the patient's perspective. The objective of this study was to assess the willingness of Dutch patients to be treated by a PA or a medical doctor (MD) under various time constraints and semi-urgent medical scenarios. METHODS: A total of 450 Dutch adults were recruited to act as surrogate patients. A convenience sample was drawn from patients in a medical office waiting room in a general hospital awaiting their appointments. Each participant was screened to be naive as to what a PA and a nurse practitioner are and then read a definition of a PA and an MD. One of three medical scenarios was assigned to the participants in a patterned 1-2-3 strategy. Patients were required to make a trade-off decision of being seen after 1 hour by a PA or after 4 hours by a doctor. This forced-choice method continued with the same patient two more times with 30 minutes and 4 hours and another one of 2 hours versus 4 hours for the PA and MD, respectively. RESULTS: Surrogate patients chose the PA over the MD 96 % to 98 % of the time (depending on the scenario). No differences emerged when analysed by gender, age, or parenthood status. CONCLUSION: Willingness to be seen by a PA was tested a priori to determine whether surrogate Dutch patients would welcome this new health-care provider. The findings suggest that employing PAs, at least in concept, may be an acceptable strategy for improving access to care with this population.

Health status in routine clinical practice: validity of the clinical COPD questionnaire at the individual patient level.

BACKGROUND: There is a growing interest to use health status or disease control questionnaires in routine clinical practice. However, the validity of most questionnaires is established using techniques developed for group level validation. This study examines a new method, using patient interviews, to validate a short health status questionnaire, the Clinical COPD Questionnaire (CCQ), at the individual patient level. METHODS: Patients with COPD who visited an outpatient clinic completed the CCQ before the consultation, and the specialist physician completed it after the consultation. After the consultation all patients had a semi-structured in-depth interview. The patients' CCQ scores were compared with those of the treating clinician, and with mean scores from 5 clinicians from a pool of 20 who scored the CCQ after reading the transcript of the in-depth interviews only. Agreement was assessed using Lin's concordance correlation coefficient (CCC), and Blant and Altman plots. Interviews with patients with low agreement were reviewed for possible explanations. RESULTS: A total of 44 COPD patients (32 male, mean age 66 years, FEV1 45% of predicted) participated. Agreement between the patients' CCQ scores and those of the treating clinicians (CCC = 0.87) and the mean score of the reviewing clinicians (CCC = 0.86) was very high. No systematic error was detected. No explanation for individuals with low agreement was found. CONCLUSION: The validity of the CCQ on the individual patient level, as assessed by these methods, is good. Individual health status assessment with the CCQ is therefore sufficiently accurate to be used in routine clinical practice.