Pulmonary Rehabilitation for Post-COVID-19.

PURPOSE: Patients with COVID-19 often report persistent respiratory symptoms. Limited data exist on how to mitigate long-term sequelae of exercise intolerance and dyspnea. We aimed to study the role of pulmonary rehabilitation (PR) in patients with post-COVID-19. METHODS: This was an observational study. Consecutive patients with post-COVID-19, admitted to three separate outpatient PR programs, were enrolled. The program consisted of 8-12 wk of PR sessions (3 times/wk). Data were gathered at the initial visit and discharge. The primary outcome was the change in the 6-min walk test (6MWT) distance. Secondary outcomes included the Shortness of Breath Questionnaire (SOBQ), modified Borg dyspnea scale, Patient Health Questionnaire-9 (PHQ-9), and Lung Information Needs Questionnaire (LINQ). RESULTS: A total of 56 patients completed the PR program (age 62.8 ± 14.7 yr, 57% were men). At baseline, the mean 6MWT was 313.3 ± 193.8 m. On average, the 6MWT improved by 84.3 m after PR ( P < .0001). Apart from the modified Borg dyspnea scale, there was improvement across secondary outcomes: SOBQ (-16.9 points), PHQ-9 (-2.6 points), and LINQ (-4.2 points); all P < .05. CONCLUSION: Pulmonary rehabilitation showed a promising positive effect on patients with with post-COVID-19. It improved exercise capacity, perception of dyspnea, depressive symptoms, and patient knowledge needed to manage their lung disease. Pulmonary rehabilitation should be considered for post-COVID-19 patients.

Blood Eosinophils and Pulmonary Rehabilitation in COPD.

Background: Blood eosinophils predict the response to therapy, risk of exacerbation, and readmission in COPD. This study investigates whether blood eosinophils predict pulmonary rehabilitation (PR) outcomes in COPD. Methods: We categorized patients into eosinophilic (blood eosinophils ≥300 cells/ml) or noneosinophilic (<300 cells/ml). In a retrospective design, we compared changes within and between the two groups on BODE index, 6-minute walk test (6MWT), FEV1, and mMRC dyspnea scale. Results: Of 206 patients enrolled, 176 were included for analysis; 90 were eosinophilic. BODE index improved in both groups: (MD -1.25; 95% CI (-0.45, -4.25), P ≤ 0.001) in the eosinophilic and (MD -1.33; 95% CI (-1.72, -0.94), P ≤ 0.001) in the noneosinophilic, but a higher BODE index remained in the eosinophilic (4.98); adjusted mean change (ß): 0.7 (95% CI (0.15, 1.26), P=0.01). 6MWT improved by 29.3 m in the eosinophilic (95% CI (14.2, 44.4), P ≤ 0.001) vs. 115.1 m in the noneosinophilic (95% CI (-30.4, 260.6), P=0.12). FEV1 did not change in the eosinophilic (MD -0.6; 95% CI (-2.64, 1.48), P=0.58), but improved by 2.5% in the noneosinophilic (MD 2.5; 95% CI (0.77, 4.17), P=0.005). There were no significant between-group differences in 6MWT and FEV1; adjusted mean changes (ß) were -9.69 m (95% CI (-39.51, 20.14), P=0.52) and -2.31% (95% CI (-5.69, 1.08), P=0.18), respectively. There were no significant within- or between-group changes in the mMRC scale. Conclusion: Although PR improves the BODE index in both eosinophilic and noneosinophilic COPD, a higher eosinophil count (≥300 cells/ml) is associated with a higher (worse) BODE index. Blood eosinophils may predict PR outcomes.

Asynchronous group learning in learn from the learner approach: A Learning Object That Enhances and Facilitates Distance Self and Shared Learning.

Learning with the learner in an asynchronous group learning approach is a promising method of education that provides a rich, interactive, and socially mediated education. As online learning became more prevalent, and more users are adopting this approach, innovative and theory-based educational activities became necessary. In this article, we introduce and describe a novel form of asynchronous, interactive, and socializing educational activity using educational technology. The educational session is based on a small group learning activity that is made available for all learners anywhere and anytime. The approach avoids the trap of using educational technology for mere simulation of in-person learning. Based on learning theories, learning with the learner enhances interactive, self-directed, experiential, and social learning. Future development and enhancement with ongoing discussions through online chat platforms open the door for the continuous evolution of the concept.

The level of impaired esophageal bolus transit measured by multichannel intraluminal impedance: Cross-sectional study.

BACKGROUND: Esophageal motility disorders (EMDs) are often diagnosed manometrically, yet the underlying pathology is not always clear. Esophageal function testing (EFT), which incorporates manometry and multichannel intraluminal impedance (MII), is considered a useful tool in the assessment of EMDs. OBJECTIVE: This study aims to assess the most likely level of impaired bolus transit within the esophagus which may help further localize and characterize EMDs. METHODS: In a retrospective study design, we reviewed consecutive EFTs over a period of 12 months. Data included diagnosis, presenting symptoms, and EFT results of liquid and viscous swallows. Each patient underwent 10 liquid and 10 viscous swallows, and bolus transit is measured at 5, 10, 15 and 20 cm above the gastroesophageal junction (GEJ). We recorded the initial level of impaired bolus transit for each swallow. RESULTS: A total of 2358 swallows in 118 patients was included for analysis. Of these, 837 swallows (35.5%) were incompletely transmitted. The proportions of impaired bolus transit were 39%, 41%, 15.6%, 4.4% at 20 cm, 15 cm, 10 cm, and 5 cm above the GEJ, respectively. The common symptoms at presentation were dysphagia (47%), heartburn (44%), chest pain (24.6%) and regurgitation (18%). The mean lower esophageal sphincter (LES) pressure was 24 ± 13.9 mmHg whereas the mean contraction amplitude was 84 ± 46.6 mmHg. CONCLUSION: In patients with abnormal esophageal clearance, the most likely levels of impaired bolus transit are 15 and 20 cm above the GEJ. These levels of the esophagus should be a focus of attention in future studies evaluating the pathophysiology of esophageal dysmotility.

Temperature control in critically ill patients with fever: A meta-analysis of randomized controlled trials.

PURPOSE: Fever is frequently encountered in ICU. It is unclear if targeted temperature control is beneficial in critically ill patients with suspected or confirmed infection. We conducted a systemic review and meta-analysis to answer this question. METHODS: We systematically reviewed major databases before January 2020 to identify randomized controlled trials (RCTs) that compared antipyretic with placebo for temperature control in non-neurocritical ill adult patients with suspected or confirmed infection. Outcomes of interest were 28-day mortality, temperature level, hospital mortality, length of stay, shock reversal, and patient comfort. RESULT: 13 RCTs enrolling 1963 patients were included. No difference in 28-day mortality between antipyretic compared with placebo (risk ratio [RR] 1.03; 95% CI 0.79-1.35). Lower temperature levels were achieved in the antipyretic group (MD [mean difference] -0.41; 95% CI -0.66 to -0.16). Antipyretic use did not affect the risk of hospital mortality (RR 0.97; 95% CI 0.73-1.30), ICU length of stay (MD -0.07; 95% CI -0.70 to 0.56), or shock reversal (RR 1.11; 95% CI 0.76-1.62). CONCLUSION: Antipyretic therapy effectively reduces temperature in non-neurocritical ill patients but does not reduce mortality or impact other outcomes.

Ability of a single negative ultrasound to rule out deep vein thrombosis in pregnant women: A systematic review and meta-analysis.

BACKGROUND: The diagnostic accuracy of ultrasound (US) for suspected lower extremity deep vein thrombosis (DVT) in nonpregnant patients has been well validated. However, in pregnant women with suspected DVT and an initial negative US, serial US is generally recommended. We aimed to determine the ability of single negative US to exclude DVT in symptomatic pregnant women. METHODS: Two authors independently reviewed the following databases: MEDLINE, PubMed, and EMBASE from inception until February 2019. We assessed the risk of bias using the CLARITY group tool for prognostic studies and performed a random effects meta-analysis to report the pooled false negative rate of a single leg ultrasound. RESULTS: Eight studies (seven prospective and one retrospective) were included. An overlap among study populations was identified in four of the manuscripts. Two authors performed data re-extraction from these hard copy research charts. Risk of bias was low for the included populations and method of measurement, and low or high for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, six were diagnosed with DVT during repeat serial testing (0.94%) and three developed DVT or PE during 3-month follow-up after serial ultrasonography (0.47%). The pooled false-negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42-2.56), I2  = 27%. CONCLUSION: The false-negative rate is low with a single US for suspected DVT in pregnancy. Our results will help inform shared decision-making around planning repeat ultrasound scans in these patients.

Adherence to Guidelines for Inpatient Pharmacologic Management of Type 2 Diabetes in Adults and Glycemic Outcomes.

OBJECTIVES: Diabetes is often poorly managed in hospitals. This study assessed the level of adherence to current Canadian practice guidelines for inpatient pharmacologic management of type 2 diabetes and whether it affected the frequency of hyperglycemia or hypoglycemia. METHODS: Retrospectively, we assessed the first 3 days of routine inpatient capillary blood glucose measurement (CBGM) records for hyperglycemia (>8 mmol/L fasting, >10 mmol/L nonfasting) and hypoglycemia (<4 mmol/L) in adults with drug-treated type 2 diabetes admitted to internal medicine without metabolic decompensation or nil per os (NPO) status at 2 hospitals during October through December 2014. Patients, divided according to their admission orders into guideline-adherent versus guideline-nonadherent groups were compared for frequency of hyperglycemia and hypoglycemia. Factors predicting guideline adherence were assessed. RESULTS: Of 150 patients with diabetes who were admitted, 108 met entry criteria. A total of 89 patients received guideline-based care (82%), whereas 19 patients did not (18%). Charlson index and preadmission medications did not predict guideline-based care, but admitting physicians' seniority did (junior, senior resident, attending physician; p=0.05). In the adherent group, 43% of CBGMs were hyperglycemic, versus 64% in the nonadherent group (p=0.01). For hypoglycemia, proportions were 2% versus 1%, respectively (p=0.21). CONCLUSIONS: Adherence to guidelines for inpatient type 2 diabetes management is good and may be greater with more training. Hyperglycemia was more common in patients who did not receive guideline-based care. Hypoglycemia was uncommon and did not appear to be more common in the guideline-adherent group, although numbers were small. These results may alleviate physicians' fear that providing adequate insulin to hospitalized patients may cause hypoglycemia.