Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IPNA clinical practice recommendations on care of pediatric patients with pre-existing kidney disease during seasonal outbreak of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic, instigated by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has profoundly impacted healthcare infrastructures around the globe. While children are usually asymptomatic or have mild symptoms, children with pre-existing kidney conditions require specialized attention. This pivotal report, championed by the International Pediatric Nephrology Association (IPNA), delivers precise and actionable recommendations tailored for pediatric patients with kidney ailments in this pandemic landscape. Central to our findings are rigorous infection control protocols. These are particularly stringent in high-risk zones, emphasizing telehealth's indispensable role, the significance of curtailing in-person consultations, and the imperative of following rigorous guidelines in regions with heightened COVID-19 prevalence. Additionally, the report delves into vaccination approaches for children with kidney issues, highlighting that the choice of vaccine is often governed by regional accessibility and policy frameworks, rather than a universal preference. A notable observation is the potential correlation between COVID-19 vaccines and specific kidney disorders. However, establishing a direct causal link remains elusive. In summary, our research accentuates the critical need for specialized pediatric kidney care during global health crises and reaffirms the continuous research imperative, especially regarding vaccination ramifications.

Effect of hydrocortisone on mortality in patients with severe community-acquired pneumonia : The REMAP-CAP Corticosteroid Domain Randomized Clinical Trial

PURPOSE

To determine whether hydrocortisone improves mortality in severe community-acquired pneumonia (CAP).

METHODS

In an international adaptive randomized controlled platform trial testing multiple interventions, adults admitted to the intensive care unit (ICU) with severe CAP were randomized to a 7-day course of intravenous hydrocortisone (50 mg every 6 h) or control (no corticosteroid). The primary end point was 90-day all-cause mortality, analyzed iteratively by a Bayesian hierarchical model estimating distinct treatment effects for patients presenting with influenza (Y/N) and shock (Y/N).

RESULTS

Fixed 7-day course hydrocortisone enrollment was stopped for futility (< 5% probability of > 20% relative improvement). Of 658 patients enrolled, 536 were randomized to hydrocortisone and 122 to control. Vital status at day 90 was missing for 15 patients. Day 90 mortality was 15% (78/521) and 9.8% (12/122) for the hydrocortisone and control groups. The adjusted odds ratio ranged from 1.52 to 1.63 (with all 95% CrI crossing 1), while the probability of > 20% relative reduction of day 90 mortality ranged from 7.1 to 3.3% across influenza and shock strata. Results were consistent in sensitivity and pre-specified secondary outcomes. In exploratory analyses, the duration of shock appeared lower in the hydrocortisone group compared with control (median (IQR) of 2 (2-5) days compared to control 3 (2-6.75) days, p value = 0.05).

CONCLUSIONS

Among patients with severe CAP, treatment with a 7-day course of hydrocortisone, compared with no hydrocortisone, appears unlikely to yield a large reduction in mortality. Smaller benefits and possible harm are not excluded.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02735707 (registration date: November 4th, 2016).

Lessons from the PROTECT-CH COVID-19 platform trial in care homes

Background

Coronavirus disease-2019 was associated with significant mortality and morbidity in care homes in 2020-1. Repurposed antiviral drugs might reduce morbidity and mortality through reducing viral transmission, infection, replication and inflammation. We aimed to compare the safety and efficacy of potential antiviral drugs in care home residents.

Methods

We designed a cluster-randomised, open-label, blinded end-point platform trial to test drugs in a postexposure prophylaxis paradigm. Participants aged 65+ years from United Kingdom care homes, with or without nursing, were eligible for participation. Care homes were to be allocated at random by computer to administer 42 days of antiviral agent (ciclesonide or niclosamide) plus standard care versus standard care alone to residents. The primary outcome at 60 days after randomisation comprised the most serious outcome, which was defined as all-cause mortality, all-cause hospitalisation, severe acute respiratory syndrome coronavirus 2 infection or no infection. Analysis would be by intention to treat using ordinal logistic regression. Other outcomes included individual components of the primary outcome, transmission, plus health economic and process evaluation outcomes. The planned sample size was 300 care homes corresponding to 9600 residents. With ~40% of care homes predicted to develop an outbreak during the trial, we needed to recruit 750 homes/24,000 residents.

Results

We initiated the trial including protocol, approvals, insurance, website, database, data algorithms, intervention selection and training materials. We built a network of principal investigators and staff (91) and care homes (299) to support the trial. However, we never contracted care homes or general practitioners since the trial was stopped in September 2021, as vaccination in care homes had significantly reduced infections. Multiple delays significantly delayed the start date, such as: (1) reduced prioritisation of pandemic trials in 2021; (2) cumbersome mechanisms for choosing the investigational medicinal products; (3) contracting between National Institute for Health and Care Research and the investigational medicinal product manufacturers; (4) publicising the investigational medicinal products; (5) identification of sufficient numbers of care homes; (6) identification and contracting with several thousand general practitioners; (7) limited research nurse availability and (8) identification of adequate insurance to cover care homes for research. Generic challenges included working across the four home nations with their different structures and regulations.

Limitations

The feasibility of contracting between the sponsor and the principal investigators, general practitioners and care homes; screening, consent and treatment of care home residents; data acquisition and the potential benefit of postexposure prophylaxis were never tested.

Conclusions

The success of vaccination meant that the role of postexposure prophylaxis of coronavirus disease-2019 in care home residents was not tested. Significant progress was made in developing the infrastructure and expertise necessary for a large-scale clinical trial of investigational medicinal products in United Kingdom care homes.

Future work

The role of postexposure prophylaxis of coronavirus disease-2019 in care home residents remains undefined. Significant logistical barriers to conducting research in care homes need to be removed urgently before future studies are possible. Further work is required to develop the infrastructure for clinical trials of investigational medicinal products in care homes. Serious consideration should be given to building and then hibernating a pandemic-ready platform trial suitable for care home research.

Funding

This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR133443.

A feasibility study on cortisol and cortisone as biomarkers for psychological stress in wastewater-based epidemiology

Psychological stress has a significant impact on individuals' quality of life and health. Traditionally, psychological stress assessment relies on self-reported tools such as the Perceived Stress Scale (PSS), which are inherently subjective. This study aims to evaluate the feasibility of using wastewater-based epidemiology (WBE) to assess cortisol and cortisone as biomarkers for psychological stress. We conducted sampling and monitoring of cortisol and cortisone concentrations at both a small-scale campus setting (five weeks) and a large-scale municipal wastewater treatment plant (12 months), calculating the mass loads of these hormones. At the campus level, while the mass load of cortisone was higher during exam weeks compared to regular class weeks, and higher in females than in males, no significant differences were observed in the mass load of cortisol. The mass load results of cortisone were consistent with the findings of the PSS-14 questionnaire. These results suggest that cortisone is a more suitable biomarker for psychological stress assessment. In the large-scale municipal wastewater samples, seasonal variations were observed, with higher levels of cortisol and cortisone in winter compared to summer, likely due to the COVID-19 outbreak in winter and the presence of external pharmaceutical sources. The results indicate that cortisone is more suitable for small-scale stress assessments, as larger-scale evaluations may be more significantly influenced by wastewater transport or sampling methodologies.

Comparison of effectiveness and safety between baricitinib and tocilizumab in severe COVID-19: a retrospective study

BACKGROUND

Immunomodulators tocilizumab and baricitinib have been used for the treatment of severe COVID-19, however, there are only few published studies comparing their efficacy.

RESEARCH DESIGN AND METHODS

All consecutive non-ICU hospitalized severe COVID-19 patients who received baricitinib or tocilizumab, were included retrospectively. Primary outcomes were mortality or intubation on day 14, time to oxygen therapy weaning and duration of hospitalization. Safety was measured as treatment-related adverse events.

RESULTS

321 hospitalized patients with severe COVID-19 were included (mean age 62.4 years ± 14.7); 241 (75.1%) received baricitinib (mean age 64.2 years ± 15.2) and 80 (24.9%) tocilizumab (mean age 57.3 ± 11.7). Patients who received baricitinib presented significantly lower risk of mortality or intubation on day 14, compared to the tocilizumab group after adjusting for age, sex, vaccination, Charlson comorbidity index, body mass index, remdesivir administration and WHO ordinal scale at enrollment (OR: 0.42, 95% CI: 0.20-0.86). In the augmented inverse-probability weighting regression, the protective role of baricitinib remained statistically significant (OR: 0.76, 95% CI: 0.66-0.88). No difference in secondary bacterial infections was detected, but tocilizumab was associated with significant higher rate of liver injury (Odds Ratio, 95%CI, p < 0.001).

CONCLUSIONS

Our study suggests survival and safety are significantly better for baricitinib compared to tocilizumab in severe COVID-19. Clinical randomized trials are needed for confirmation.

The immunopathogenesis of a cytokine storm: The key mechanisms underlying severe COVID-19

A cytokine storm is marked by excessive pro-inflammatory cytokine release, and has emerged as a key factor in severe COVID-19 cases - making it a critical therapeutic target. However, its pathophysiology was poorly understood, which hindered effective treatment. SARS-CoV-2 initially disrupts angiotensin signalling, promoting inflammation through ACE-2 downregulation. Some patients' immune systems then fail to shift from innate to adaptive immunity, suppressing interferon responses and leading to excessive pyroptosis and neutrophil activation. This amplifies tissue damage and inflammation, creating a pro-inflammatory loop. The result is the disruption of Th1/Th2 and Th17/Treg balances, lymphocyte exhaustion, and extensive blood clotting. Cytokine storm treatments include glucocorticoids to suppress the immune system, monoclonal antibodies to neutralize specific cytokines, and JAK inhibitors to block cytokine receptor signalling. However, the most effective treatment options for mitigating SARS-CoV-2 infection remain vaccines as a preventive measure and antiviral drugs for the early stages of infection. This article synthesizes insights into immune dysregulation in COVID-19, offering a framework to better understand cytokine storms and to improve monitoring, biomarker discovery, and treatment strategies for COVID-19 and other conditions involving cytokine storms.

Sepsis subphenotypes, theragnostics and personalized sepsis care

Heterogeneity between critically ill patients with sepsis is a major barrier to the discovery of effective therapies. The use of machine learning techniques, coupled with improved understanding of sepsis biology, has led to the identification of patient subphenotypes. This exciting development may help overcome the problem of patient heterogeneity and lead to the identification of patient subgroups with treatable traits. Re-analyses of completed clinical trials have demonstrated that patients with different subphenotypes may respond differently to treatments. This suggests that future clinical trials that take a precision medicine approach will have a higher likelihood of identifying effective therapeutics for patients based on their subphenotype. In this review, we describe the emerging subphenotypes identified in the critically ill and outline the promising immune modulation therapies which could have a beneficial treatment effect within some of these subphenotypes. Furthermore, we will also highlight how bringing subphenotype identification to the bedside could enable a new generation of precision-medicine clinical trials.

Identification and Estimation of Causal Effects Using Non-Concurrent Controls in Platform Trials

Platform trials are multi-arm designs that simultaneously evaluate multiple treatments for a single disease within the same overall trial structure. Unlike traditional randomized controlled trials, they allow treatment arms to enter and exit the trial at distinct times while maintaining a control arm throughout. This control arm comprises both concurrent controls, where participants are randomized concurrently to either the treatment or control arm, and non-concurrent controls, who enter the trial when the treatment arm under study is unavailable. While flexible, platform trials introduce the challenge of using non-concurrent controls, raising questions about estimating treatment effects. Specifically, which estimands should be targeted? Under what assumptions can these estimands be identified and estimated? Are there any efficiency gains? In this article, we discuss issues related to the identification and estimation assumptions of common choices of estimand. We conclude that the most robust strategy to increase efficiency without imposing unwarranted assumptions is to target the concurrent average treatment effect (cATE), the ATE among only concurrent units, using a covariate-adjusted doubly robust estimator. Our studies suggest that, for the purpose of obtaining efficiency gains, collecting important prognostic variables is more important than relying on non-concurrent controls. We also discuss the perils of targeting ATE due to an untestable extrapolation assumption that will often be invalid. We provide simulations illustrating our points and an application to the ACTT platform trial, resulting in a 20% improvement in precision compared to the naive estimator that ignores non-concurrent controls and prognostic variables.

Epidemiological and clinical characteristics of COVID-19 mortality: a retrospective study

Background

The global impact of SARS-CoV-2 and its associated coronavirus disease (COVID-19) has necessitated urgent characterization of prognostic biomarkers. This study aimed to delineate the epidemiological and clinical predictors of mortality among hospitalized COVID-19 patients.

Methods

A retrospective cohort study was conducted on 123 patients with laboratory-confirmed COVID-19 admitted to Huoshenshan Hospital (Wuhan, China) from 1 February 2020 to 30 April 2020. Kaplan-Meier curve and multivariate Cox regression were used to assess the independent factors with survival time. Statistical significance was set at a p-value of <0.05.

Results

The cohort exhibited a mortality rate of 49.6% (61/123), with the critical clinical type (HR = 7.970, p = 0.009), leukocytosis (HR = 3.408, p = 0.006), and lymphopenia (HR = 0.817, p = 0.038) emerging as independent predictors of reduced survival. Critical-type patients demonstrated significantly elevated inflammatory markers (neutrophils: 10.41 ± 6.23 × 109/L; CRP: 104.47 ± 29.18 mg/L) and coagulopathy (D-dimer: 5.21 ± 2.34 μg/ml) compared to non-critical cases. Deceased patients exhibited pronounced metabolic derangements, including hyperglycemia (9.81 ± 2.07 mmol/L) and hepatic dysfunction (ALP: 174.03 ± 30.13 U/L).

Conclusion

We revealed the epidemiological and clinical features of different clinical types of SARS-CoV-2 as summarized in this paper. We found that critical type, leukocyte, and lymphocyte are risk factors that affect survival time, which could be an early and helpful marker to improve management of COVID-19 patients.

Osteonecrosis following Steroid Therapy in COVID-19 Patients: An Outlook on the Emerging Problem

Steroids are used in management of coronavirus disease 2019 (COVID-19) patients with severe illness and their use has been demonstrated to decrease mortality. Although life-saving, steroids are well documented as risk factors for osteonecrosis. Osteonecrosis of the hip can be debilitating and surgery may be required to improve the quality of life. With the increasing number of COVID-19 cases, osteonecrosis of the hip and other joints resulting from steroid use is expected to show a sharp rise in the coming years. In this review we discuss the association between steroids and osteonecrosis, indications for steroid therapy in COVID-19 patients, and incidence, diagnosis, and treatment of osteonecrosis secondary to steroids in COVID-19.

The development of therapeutics and vaccines against COVID-19

Since the COVID-19 pandemic, it has caused a great threat to the global economy and public health, initiatives have been launched to control the spread of the virus. To explore the efficacy of drugs, a large number of clinical trials have been carried out, with the purpose of providing guidelines based on high-quality evidence for clinicians. We mainly discuss therapeutic agents for COVID-19 and explain the mechanism, including antiviral agents, tocilizumab, Janus kinase (JAK) inhibitors, neutralizing antibody therapies and corticosteroids. In addition, the COVID-19 vaccine has been proven to be efficacious in preventing SARS-CoV-2 infection. We systematically analyzed four mainstream vaccine platforms: messenger RNA (mRNA) vaccines, viral vector vaccines, inactivated vaccines and protein subunit vaccines. We evaluated the therapeutic effects of drugs and vaccines through enumerating the most typical clinical trials. However, the emergence of novel variants has further complicated the interpretation of the available clinical data, especially vaccines and antibody therapies. In the post-epidemic era, therapeutic agents are still the first choice for controlling the progression of disease, whereas the protective effect of vaccines against different strains should be assessed comprehensively.

The association between early corticosteroid use and the risk of secondary infections in hospitalized patients with COVID-19: a double-edged sword. Results from the international SCCM discovery viral infection and respiratory illness universal study (VIRUS) COVID-19 registry

Background

Corticosteroids improve survival in hospitalized COVID-19 patients needing supplemental oxygen. However, concern exists about increased risk of secondary infections. This study investigated the impact of early corticosteroids use on these infections.

Methods

Data from the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 registry were analyzed for adult patients, stratified by early corticosteroid use (within 48 h of admission). The primary outcome was documented secondary infections, including bacteremia, bacterial pneumonia, empyema, meningitis/encephalitis, septic shock, and ventilator-associated pneumonia. Univariate and multivariable logistic regression models were used to assess the association between early corticosteroids and these outcomes.

Results

Among 17,092 eligible patients, with 13.5% developed at least one secondary bacterial infection during hospitalization. Patients receiving early corticosteroids were older (median 63 years) compared to those who did not (median 60 years), with a similar gender distribution (42.5% vs. 44.2% female). Unadjusted analysis revealed a higher risk for any secondary infection (OR 1.93, 95% CI 1.76-2.12). This association persisted for specific infections including bacteremia (OR 2.0, 95% CI 1.58-2.54), bacterial pneumonia (OR 1.5, 95% CI 1.27-1.77), and septic shock (OR 1.67, 95% CI 1.44-1.93). However, the effect on meningitis/encephalitis (OR 0.62, 95% CI 0.24-1.57) and ventilator-associated pneumonia (VAP; OR 1.08, 95% CI 0.75-1.57) was non-significant. Adjusted analysis maintained significance for any secondary infection (OR 1.15, 95% CI 1.02-1.29), bacteremia (OR 1.43, 95% CI 1.09-1.88), and infections with unknown sources (OR 1.63, 95% CI 1.31-2.02). Notably, the association weakened and became non-significant for bacterial pneumonia (OR 0.98, 95% CI 0.81-1.20) and septic shock (OR 0.94, 95% CI 0.79-1.11), while it became significant for meningitis/encephalitis (OR 0.26, 95% CI 0.08-0.82). VAP remained non-significant (OR 0.87, 95% CI 0.56-1.34).

Conclusion

Early use of corticosteroids increased overall secondary infection risk in hospitalized COVID-19 patients, but the impact varied. Risk of bacteremia was notably increased, while the association with bacterial pneumonia and septic shock weakened after adjustment becoming non-significant and surprisingly reduced meningitis/encephalitis risk was noted suggesting the complexity of corticosteroid effects. Further research is needed to understand how corticosteroids influence specific secondary infections, and thereby optimize the treatment strategies.

Examining the bias-efficiency tradeoff from incorporation of nonconcurrent controls in platform trials: A simulation study example from the adaptive COVID-19 treatment trial

BACKGROUND

Platform trials typically feature a shared control arm and multiple experimental treatment arms. Staggered entry and exit of arms splits the control group into two cohorts: those randomized during the same period in which the experimental arm was open (concurrent controls) and those randomized outside that period (nonconcurrent controls). Combining these control groups may offer increased statistical power but can lead to bias if analyses do not account for time trends in the response variable. Proposed methods of adjustment for time may increase type I error rates when time trends impact arms unequally or when large, sudden changes to the response rate occur. However, there has been limited exploration of the degree of type I error inflation one can plausibly expect in real-world scenarios.

METHODS

We use data from the Adaptive COVID-19 Treatment Trial (ACTT) to mimic a realistic platform trial with a remdesivir control arm. We compare four strategies for estimating the effect of interferon beta-1a (the ACTT-3 experimental arm) relative to remdesivir (data from ACTT-1, ACTT-2, and ACTT-3) on recovery and death by day 29: utilizing concurrent controls only (the prespecified analysis), pooling all remdesivir arm data without adjustment (the "unadjusted-pooled" analysis), adjusting for time as a categorical variable, and a Bayesian hierarchical model implementation which adjusts for time trends using smoothing techniques (the "Bayesian time machine"). We compare type I error rates and relative efficiency of each method in simulation settings based on observed ACTT remdesivir arm data.

RESULTS

The unadjusted-pooled approach provided substantially different estimates of the effect of interferon beta-1a relative to remdesivir compared with the concurrent-only and model-based approaches, indicating that changes in recovery and death rates over time were not ignorable across different stages of ACTT. The model-based approaches rely on an assumption of constant treatment effects for each arm in the platform relative to control; error rates more than doubled in settings where this was not satisfied. Relative efficiency of the model-based approaches compared with the concurrent-only analysis was moderate.

CONCLUSIONS

In simulation settings where key model assumptions were not met, potential efficiency gains from incorporation of nonconcurrent controls were outweighed by the risk of substantial type I error rate inflation. This leads us to advise against these strategies for primary analyses in confirmatory clinical trials, aligning with current FDA guidance advising against comparisons to nonconcurrent controls in COVID-19 settings. The model-based adjustment methods may be useful in other settings, but we recommend performing the concurrent-only analysis as a reference for assessing the degree to which nonconcurrent controls drive results.

Adapt to survive and thrive: the time is now for adaptive platform trials for preterm birth

In this Viewpoint, we discuss the challenges facing perinatal clinical researchers, many of which are unique to this field, and how traditional two-arm randomised trials using frequentist analysis might no longer be fit for purpose for perinatology. We propose a solution: the adoption of adaptive platform trials (APTs) with Bayesian methodology to address perinatal research questions to improve outcomes of preterm birth. APTs use a master protocol as a foundation to efficiently assess multiple interventions simultaneously for a particular disease. APTs can study these interventions in a perpetual manner, with interventions allowed to enter or leave the platform on the basis of preplanned decision algorithms. In this Viewpoint, we outline the ways in which APTs can overcome some of the issues facing perinatal clinical research, and the challenges and essential requirements for the design and implementation of perinatal APTs that should be considered.

Ventriculitis incidence and outcomes in patients with aneurysmal subarachnoid hemorrhage: a prospective observational study

OBJECTIVE

To define the incidence of ventriculostomy-associated infections and their impact on the mortality and functional outcomes of patients with aneurysmal subarachnoid hemorrhage.

METHODS

We prospectively included all consecutive adult aneurysmal subarachnoid hemorrhage patients admitted to the neurological intensive care units of the Instituto Estadual do Cérebro Paulo Niemeyer (Rio de Janeiro, Brazil) and Hospital Cristo Redentor (Rio Grande do Sul, Brazil) who required external ventricular drains from July 2015 to December 2020. Daily clinical and laboratory variables were collected at admission and during the hospital stay. The presence of ventriculostomy-associated infections was evaluated daily, according to the Centers for Disease Control and Prevention and Infectious Diseases Society of America criteria. Hospital and 12-month outcomes were compared between patients with and without ventriculostomy-associated infections via both univariate and multivariate analyses.

RESULTS

Out of the 676 patients screened, 271 received external ventricular drains (40%) and were included in the study. The mean age was 54 years (IQR 46-63), 198 were female (72%), 47% had poor grade status (World Federation of Neurological Surgeons scale 4 and 5), and 75% had modified Fisher 3 or 4. The mean time from admission to external ventricular drain placement was 8.8 days. Ventriculostomy-associated infections developed in 127 patients (47%), and the mean time from external ventricular drain to ventriculostomy-associated infection diagnosis was 4.4 days. Hospital and 12-month mortality rates did not differ between the ventriculostomy-associated infection group and the nonventriculostomy-associated infection group (36% versus 40% and 43% versus 49%, respectively). Poor functional outcomes, defined as modified Rankin scores of 4 to 6, showed no difference between groups at hospital discharge (ventriculostomy-associated infections 75% versus nonventriculostomy-associated infections 73%; p = NS) or at 12 months (ventriculostomy-associated infections 49% versus nonventriculostomy-associated infections 53%; p = NS).

CONCLUSION

Ventriculostomy-associated infections are common complications after aneurysmal subarachnoid hemorrhage. Although it was not associated with hospital mortality or functional outcomes in our cohort, improving diagnostic accuracy and preventive measures is essential for better understanding the long-term impact of one of the most severe infectious complications after aneurysmal subarachnoid hemorrhage.

The relationship between steroid treatment and mortality in patients with COVID-19 followed up in an intensive care unit

Aim

Optimal treatment of the coronavirus disease (COVID-19) is still unclear. It has been reported that the use of different doses of corticosteroid treatments may reduce mortality. In our study, we aimed to find the effect of corticosteroid treatment dose on mortality of patients followed up in intensive care due to COVID-19.

Methods

Our retrospective, descriptive and single-centre study included 102 patients diagnosed with COVID-19 who were followed up in intensive care unit, 28 of whom received pulse steroids and 74 of whom received high dose steroids. Laboratory values, duration of intensive care unit and mortality rates of the patients were evaluated.

Results

Mortality was found to be statistically significantly lower in the group receiving pulse steroid compared to the group receiving high dose steroid. In multivariate logistic regression analysis, age and pulse steroid were found to be independent predictors of mortality. According to this analysis, each 10-year increase in age increased mortality by 4.8%, whereas pulse steroid decreased mortality by 79.4%.

Conclusion

In our study, we found that mortality was statistically significantly lower in the group of patients receiving pulse steroids than in the group receiving high dose steroids. We found that the number of patients using pulse steroids was statistically significantly lower in the group with mortality. We found that age and pulse steroid independently determined the patients with mortality.

Eligibility Criteria of Randomized Clinical Trials in Critical Care Medicine

Importance

Eligibility criteria for randomized clinical trials (RCTs) are designed to select clinically relevant patient populations. However, not all eligibility criteria are strongly justified, potentially excluding marginalized groups, and limiting the generalizability of trial findings.

Objective

To summarize and evaluate the justification of exclusion criteria in published RCTs in critical care medicine.

Evidence Review

A systematic sampling review of parallel-group RCTs published in the top 5 general internal medicine journals by impact factor (The Lancet, New England Journal of Medicine, Journal of the American Medical Association, British Medical Journal, and Annals of Internal Medicine) between January 1, 2018, and February 23, 2023, was conducted. RCTs enrolling adults in intensive care units (ICUs) and RCTs enrolling critically ill patients who required life-sustaining interventions typically initiated in the ICU were included. All study exclusion criteria were categorized as either poorly justified, potentially justified, or strongly justified, adapting previously established criteria, independently and in duplicate.

Findings

In total, 225 studies were identified, 75 of which were included. The median (IQR) number of exclusion criteria per trial was 19 (14-24), with 1455 total exclusion criteria. Common exclusion criteria were related to the risk of adverse reaction to interventions (302 criteria [20.8%]), followed by inability to obtain consent (120 criteria [8.2%]), and treatment limitation decisions (97 criteria [6.7%]). Most exclusion criteria were either strongly justified (1080 criteria [74.2%]) or potentially justified (297 criteria [20.4%]), whereas 5.4% (78 criteria) were poorly justified. Of the 78 poorly justified exclusion criteria, the most common were pregnancy (19 criteria [24.4%]), communication barriers (11 criteria [14.1%]), lactation (10 criteria [12.8%]), and lack of health insurance (10 criteria [12.8%]). Overall, 45 of 75 studies (60.0%) had at least 1 poorly justified exclusion criteria.

Conclusions and Relevance

Most exclusion criteria in critical care medicine RCTs were strongly justifiable. Across poorly justified criteria, the most common exclusions were pregnant or lactating persons, those with communication barriers, and individuals without health insurance. This highlights the need to carefully consider exclusion criteria when designing trials to minimize the inappropriate exclusion of participants and enhance generalizability.

Safety of steroids in severe community-acquired pneumonia

The systemic use of corticosteroids for patients with severe community-acquired pneumonia (sCAP) remains controversial in clinical practice, particularly in terms of the safety profile of these drugs. This narrative review aims to analyse the available literature data concerning the safety of short-term steroid use in the treatment of sCAP, while also highlighting potential future research directions. Several trials and meta-analyses have evaluated corticosteroid therapy as an adjuvant treatment for sCAP, yielding heterogeneous results regarding its efficacy and safety. Despite the wide variability in results, it is generally accepted that steroids are not associated with a significant risk of healthcare-associated infections, gastrointestinal bleeding or acute kidney injury in patients with sCAP in the short term. Nevertheless, such drugs are linked to hyperglycaemia, necessitating regular monitoring and appropriate management. The influence of steroids on long-term outcomes and their potential risks in viral sCAP still needs to be investigated.

COVID-19 in pregnancy: Perinatal outcomes and complications

BACKGROUND

The risk of severe coronavirus disease 2019 (COVID-19) in pregnant women is elevated.

AIM

To examine the outcomes of pregnant women with COVID-19 and report perinatal outcomes and complications, while providing a brief review of current literature.

METHODS

The study included pregnant women presenting from April 2020 to February 2022 to the emergency department (ED) of a tertiary hospital. We retrospectively recorded the maternal and perinatal files, including patient epidemiological and clinical characteristics, laboratory values, outcomes, treatment modalities and associations were explored.

RESULTS

Among the 60 pregnant women, 25% required hospitalization, all of whom were symptomatic. Preterm delivery occurred in 30% of cases. Ten percent of neonates required admission to the neonatal intensive care unit, and 5% were classified as small for their gestational age. All mothers survived COVID-19 and pregnancy, with 6.6% requiring invasive mechanical ventilation. Preterm delivery rates did not differ between hospitalized and non-hospitalized pregnant women; composite unfavorable perinatal outcomes, including stillbirth, small for gestational age, or neonatal intensive care unit (ICU) admission, did not significantly increase in the cases hospitalized for COVID-19 (P = 0.09). The odds of hospitalization increased 2.3-fold for each day of delayed ED presentation [adj. OR (95%CI: 1.46-3.624), P < 0.001]. Comorbidity status was an independent predictor of hospitalization, albeit with marginal significance [adj. OR = 16.13 (95%CI: 1.021-255.146), P = 0.048]. No independent predictors of adverse fetal outcome (composite) were identified, and eventual hospitalization failed to reach statistical significance by a slight margin (P = 0.054).

CONCLUSION

Delayed ED presentation and comorbidities increase hospitalization odds. This study highlights the importance of continuous and specific guidance for managing pregnant COVID-19 patients, including timely and appropriate interventions to minimize maternal and perinatal morbidity and mortality.

Cross-sectional evaluation of medical reversals among National Institute of Health guideline practices implemented during the COVID-19 pandemic: how often did experts err in a time of crisis?

OBJECTIVE

The COVID-19 pandemic required the rapid and often widespread implementation of medical practices without robust data. Many of these practices have since been tested in large, randomised trials and were found to be in error. We sought to identify incorrect recommendations, or reversals, among National Institute of Health COVID-19 guidelines and Food and Drug Administration (FDA) approvals and authorisations.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Recommended medical practices and FDA authorisations or approvals for COVID-19 prevention, treatment and/or management.

MAIN OUTCOME MEASURES

The frequency and characteristics of COVID-19 medical reversals, defined as practices that were implemented and/or recommended during the pandemic, but were later tested in randomised trials that failed to find benefit.

RESULTS

We found 332 COVID-19 recommendations. 85 (25.6%) opposed a medical practice, 23 (6.9%) were to continue a pre-COVID standard of care without deviation and 224 (67.5%) reccommended a new medical practice. We found randomised trials assessing 72 of these practices (32.1%), among which 25 (35%) were found to be in error and deemed medical reversals. Among medical reversals, 21 (84%) were prescription medications and 1 (4%) was convalescent plasma. 17 (68%) were repurposed medications. Two (8%) were procedures or mechanical interventions and one (4%) was a device. 16 (64%) reversals pertained to the hospital setting (4 to intensive care units), 4 (16%) were non-specific (ie, applicable to any setting), 4 (16%) pertained to a non-hospital setting and 1 pertained to healthcare workers.

CONCLUSION

When faced with a novel pandemic, policymakers rapidly made hundreds of specific medical recommendations. More than two out of three were never robustly tested. Among practices tested in a randomised fashion, one in three was made in error. Pandemic recommendation errors were substantial. Early and coordinated efforts to initiate randomised trials, even during dire situations, may mitigate the perpetuation of ineffective practices.

The Role of Inflammation in the Pathogenesis of Viral Respiratory Infections

Viral respiratory infections (VRIs) are a leading cause of morbidity and mortality worldwide, making them a significant public health concern. During infection, respiratory viruses, including Influenza virus, SARS-CoV-2, and respiratory syncytial virus (RSV), trigger an antiviral immune response, specifically boosting the inflammatory response that plays a critical role in their pathogenesis. The inflammatory response induced by respiratory viruses can be a double-edged sword since it can be initially induced to be antiviral and protective/reparative from virus-induced injuries. Still, it can also be detrimental to host cells and tissues. However, the mechanisms that differentiate the complex crosstalk between favorable host inflammatory responses and harmful inflammatory responses are poorly understood. This review explores the complex interplay between viral pathogens and the host immune response, mainly focusing on the role of inflammation in the pathogenesis of VRIs. We discuss how inflammation can both contain and exacerbate the progression of viral infections, highlighting potential therapeutic targets and emerging drugs for modulating the aberrant inflammatory responses during VRIs.

Efficacy of COVID-19 Treatments in Intensive Care Unit: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objectives: Examining the cumulative evidence from randomized controlled trials (RCTs), evaluating the use of pharmacological agents for the treatment of COVID-19 infections in patients with critical illness. Data Sources: Databases Medline, Embase, Web of Science, Scopus, CINAHL, and Cochrane. Study Selection: Inclusion criteria were RCTs that enrolled patients with confirmed or suspected COVID-19 infection who are critically ill. Only RCTs that examined therapeutic agents against one another or no intervention, placebo, or standard of care, were included. Data Extraction: Pairs of reviewers extracted data independently. Outcomes of interest included the overall reported mortality defined as either the ICU mortality, hospital mortality, mortality within 28 days or mortality within 90 days. Data Synthesis: A total of 40 studies (11,613 patients) evaluated 50 therapeutic intervention arms divided into five main therapy categories; steroids, antiviral medications, immunomodulators, plasma therapies [intravenous immunoglobulins (IVIG), convalescent plasma and/or, therapeutic plasma exchange], and therapeutic anticoagulation. Immunomodulators was the only group with possible mortality benefit, risk ratio (RR) 0.83 (95% CI 0.73; 0.95), with nonsignificant heterogeneity (I 2 = 8%, p=0.36). In contrast, the other therapy groups showed no significant impact on mortality, as indicated by their respective pooled RRs: steroids [RR 0.91 (95% CI 0.82; 1.01), I 2 = 31%], antiviral medications [RR 1.11 (95% CI 0.82; 1.49), I 2 = 57%], plasma therapies [RR 0.77 (95% CI 0.58; 1.01), I 2 = 36%], and anticoagulation [RR 1.06 (95% CI 0.95; 1.18), I 2 = 0%]. Conclusions: This meta-analysis highlights both the heterogeneity and a lack of benefit from therapies evaluated during the COVID-19 pandemic. Many of the RCTs were developed based on limited observational data. Future RCTs investigating pharmaceutical interventions in critically ill patients during pandemics need to be designed based on better evidence.

Examining Brain Structures and Cognitive Functions in Patients with Recovered COVID-19 Infection: A Multicenter Study Using 7T MRI

Importance

Emerging evidence suggests that severe acute respiratory syndrome, COVID-19, negatively impacts brain health, with clinical magnetic resonance imaging (MRI) showing a wide range of neurologic manifestations but no consistent pattern. Compared with 3 Tesla (3T) MRI, 7 Tesla (7T) MRI can detect more subtle injuries, including hippocampal subfield volume differences and additional standard biomarkers such as white matter lesions. 7T MRI could help with the interpretation of the various persistent post-acute and distal onset sequelae of COVID-19 infection.

Objective

To investigate the differences in white matter hyperintensity (WMH), hippocampal subfields volumes, and cognition between patients hospitalized with COVID-19 and non-hospitalized participants in a multi-site/multi-national cohort.

Design

Original investigation of patients hospitalized with COVID-19 between 5/2020 and 10/2022 in 3 USA and 1 UK medical centers with follow-up at hospital discharge.

Participants

A total of 179 participants without a history of dementia completed cognitive, mood and other assessments and MRI scans.

Exposure

COVID-19 severity, as measured by hospitalization vs no hospitalization.

Main Outcomes and Measures

7T MRI scans were acquired. All WMH and hippocampal subfield volumes were corrected for intracranial volumes to account for subject variability. Cognition was assessed using a comprehensive battery of tests. Pearson correlations and unpaired t-tests were performed to assess correlations and differences between hospitalized and non-hospitalized groups.

Results

We found similar WMH volume (4112 vs 3144mm³, p=0.2131), smaller hippocampal volume (11856 vs 12227mm³, p=0.0497) and lower cognitive and memory performance, especially the MoCA score (24.9 vs 26.4 pts, p=0.0084), duration completing trail making test B (97.6 vs 79.4 seconds, p=0.0285), Craft immediate recall (12.6 vs 16.4 pts, p<0.0001), Craft delay recall (12.0 vs 15.6 pts, p=0.0001), and Benson figure copy (15.2 vs 16.1 pts, p=0.0078) in 52 patients hospitalized for COVID-19 (19[37%] female; mean[SD] age, 61.1[7.4] years) compared with 111 age-matched non-hospitalized participants (66[59%] female; mean[SD] age, 61.5[8.4] years).

Conclusions and Relevance

Our results indicate that hospitalized COVID-19 cases show lower hippocampal volume when compared to non-hospitalized participants. We also show that WMH and hippocampal volumes correlate with worse cognitive scores in hospitalized patients compared with non-hospitalized participants, potentially indicating recent lesions and atrophy.

Key Points

Question: Do white matter hyperintensity burden, hippocampal whole and subfield volumes, and cognition differ between patients hospitalized with COVID-19 versus participants without hospitalization?Findings: We found no significant difference in white matter hyperintensity volume, but hippocampal volume was reduced, and cognitive and memory performance were worse in those hospitalized for COVID-19 compared with age-matched non-hospitalized group (either mild COVID-19 or no COVID-19 reported). In the hospitalized group, increased white matter hyperintensity and reduced hippocampal volumes are significantly higher correlated with worse cognitive and memory scores.Meaning: Adults hospitalized for COVID-19 had lower hippocampal volumes and worse cognitive performance than adults with COVID-19 that did not lead to hospitalization or without reported COVID-19 infection.

The Effectiveness of Mini-Pulse Methylprednisolone in the Treatment of Patients With COVID-19 in the Intensive Care Unit

OBJECTIVE

To investigate the effect of mini-pulse methylprednisolone in the treatment of patients with COVID-19 hospitalized in the intensive care units (ICU).

METHODS

This is a single-blind parallel non-randomized clinical trial that will be carried out on 60 hospitalized COVID-19 patients and conducted between February 2020 and December 2020 in Ardabil City Hospital, Ardabil, Iran. The t-test and chi-square test were used to compare the results of the two groups. A p-value of less than 0.05 was considered statistically significant. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 26 software.

RESULTS

The mean (±SD) age of patients was 57.53 ± 13.71 years. Thirty-five patients (58.3%) were male and 25 (14.7%) were female. Twenty-eight patients had fever. During admission, the mean (±SD) of the oxygen saturation was 80.73 ± 8.31. No significant relationship was observed between the study variables in the two groups at baseline.

CONCLUSION

The results of the present study showed that in patients treated with methylprednisolone, blood oxygen saturation increased and heart rate and breathing rate decreased significantly. Also, mini-pulse treatment with methylprednisolone significantly reduced the number of days of hospitalization and the incidence of mortality.

Clinical phenotyping uncovers heterogeneous associations between corticosteroid treatment and survival in critically ill COVID-19 patients

PURPOSE

Disease heterogeneity in coronavirus disease 2019 (COVID-19) may render the current one-size-fits-all treatment approach suboptimal. We aimed to identify and immunologically characterize clinical phenotypes among critically ill COVID-19 patients, and to assess heterogeneity of corticosteroid treatment effect.

METHODS

We applied consensus k-means clustering on 21 clinical parameters obtained within 24 h after admission to the intensive care unit (ICU) from 13,279 COVID-19 patients admitted to 82 Dutch ICUs from February 2020 to February 2022. Derived phenotypes were reproduced in 6225 COVID-19 ICU patients from Spain (February 2020 to December 2021). Longitudinal immunological characterization was performed in three COVID-19 ICU cohorts from the Netherlands and Germany, and associations between corticosteroid treatment and survival were assessed across phenotypes.

RESULTS

We derived three phenotypes: COVIDICU1 (43% of patients) consisted of younger patients with the lowest Acute Physiology And Chronic Health Evaluation (APACHE) scores, highest body mass index (BMI), lowest PaO2/FiO2 ratio, and a 90-day in-hospital mortality rate of 18%. COVIDICU2 patients (37%) had the lowest BMI, were older and had higher APACHE scores and mortality rate (24%) than COVIDICU1. Patients with COVIDICU3 (20%) were the eldest with the most comorbidities, the highest APACHE scores, acute kidney injury and metabolic dysregulations, and the highest mortality rate (47%). These patients also displayed the most pronounced inflammatory response. Corticosteroid therapy started at day 5 [2-9] after ICU admission and administered for 5 [3-7] days was associated with an increased risk for 90-day mortality in patients with the COVIDICU1 and COVIDICU2 phenotypes (hazard ratio [HR] 1.59 [1.09-2.31], p = 0.015 and HR 1.79 [1.42-2.26], p < 0.001, respectively), but not in patients with the COVIDICU3 phenotype (HR 1.08 [0.76-1.54], p = 0.654).

CONCLUSION

Our multinational study identified three distinct clinical COVID-19 phenotypes, each exhibiting marked differences in demographic, clinical, and immunological features, and in the response to late and short-term corticosteroid treatment.

How international guidelines recommend treating children who have severe COVID-19 or risk disease progression

AIM

This study reviewed the current knowledge and guidelines on managing COVID-19 in children and proposed a practical approach to drug treatment.

METHODS

We analysed international guidelines from four prominent scientific bodies on treating COVID-19 in children. These were the UK National Institute for Health and Care Excellence, the American National Institutes of Health, the Infectious Diseases Society of America and the Australian National Clinical Evidence Taskforce COVID-19.

RESULTS

Most paediatric patients with COVID-19 only require symptomatic treatment. There was limited evidence on treatment recommendations for children with severe COVID-19 or at risk of disease progression. However, several drugs are available for children and we have summarised the guidelines, in order to provide a concise, practical format for clinicians. All the guidelines agree that nirmatrelvir plus ritonavir or remdesivir can be used as prophylaxis for severe COVID-19 in high-risk patients. Remdesivir can also be used for severe COVID-19 cases. Glucocorticosteroids are recommended, particularly in patients requiring oxygen therapy. Tocilizumab or baricitinib should be reserved for patients with progressive disease and/or signs of systemic inflammation.

CONCLUSION

The guidelines provide useful advice and a degree of consensus on specific drug treatment for children with severe COVID-19 or at risk of progression.

Corticosteroids for hospitalized patients with severe/critical COVID-19: a retrospective study in Chongqing, China

Corticosteroids have always been recommended for severe cases of COVID-19. However, the efficacy of treatment with corticosteroids for COVID-19 during the SARS-CoV-2 omicron outbreak in China has not been reported. Clinical data from 406 patients hospitalized for severe/critical COVID-19 from December 2022 to January 2023 at six hospitals in Chongqing were retrospectively analyzed. The primary outcome was all-cause mortality at 28 days in the groups with and without corticosteroids treatment after propensity score matching (PSM). Secondary outcomes were to compare in-hospital mortality and length of survival time with corticosteroids and those without corticosteroids. This study included 406 patients with severe or critical COVID-19, divided into the corticosteroids group (231, 56.9%) and non-corticosteroids group (175, 43.1%). After PSM, the use of corticosteroids did not reduce all-cause mortality at 28 days (42.5% vs. 39.1%). Univariate analysis showed that corticosteroids were not associated with improved all-cause mortality at 28 days [hazard ratio (HR), 1.019; 95% confidence interval (CI), 0.639-1.623; p = 0.938]. Multivariate analysis showed similar results (HR, 1.047; 95% CI, 0.633-1.732; p = 0.858). Among non-survivors, the survival time was significantly larger in those who received corticosteroids compared with the non-corticosteroid users [median 13 (IQR 6.5-15.5) vs. 6 (4-11.25), p = 0.007]. The use of systemic corticosteroids in severe/critical COVID-19 may provide certain potential survival benefits but does not improve prognosis.

Impact of corticosteroid doses on prognosis of severe and critical COVID-19 patients with Omicron variant infection: a propensity score matching study

BACKGROUND

There is lack of research on corticosteroid use for severe and critical COVID-19 patients with Omicron variant infection.

METHODS

This multi-center retrospective cohort study involved 1167 patients from 59 ICUs across the mainland of China diagnosed with severe or critical SARS-CoV-2 Omicron variant infection between November 1, 2022, and February 11, 2023. Patients were segregated into two groups based on their corticosteroid treatment-usual dose (equivalent prednisone dose 30-50 mg/day) and higher dose (equivalent prednisone dose > 50 mg/day). The primary outcome was 28-day ICU mortality. Propensity score matching was used to compare outcomes between cohorts.

RESULTS

After propensity score matching, 520 patients in the usual dose corticosteroid group and 260 patients in the higher dose corticosteroid group were included in the analysis, respectively. The mortality was significantly higher in the higher dose corticosteroid group (67.3%, 175/260) compared to the usual dose group (56.0%, 291/520). Logistic regression showed that higher doses of corticosteroids were significantly associated with increased mortality at 28-day (OR = 1.62,95% CI 1.19-2.21, p = 0.002) and mortality in ICU stay (OR = 1.66,95% CI 1.21-2.28, p = 0.002). Different types of corticosteroids did not affect the effect.

CONCLUSIONS

The study suggests that higher-dose corticosteroids may lead to a poorer prognosis for severe and critical COVID-19 patients with Omicron variant infection in the ICU. Further research is needed to determine the appropriate corticosteroid dosage for these patients.

Glucocorticoid therapy for acute respiratory distress syndrome: Current concepts

Acute respiratory distress syndrome (ARDS), a fatal critical disease, is induced by various insults. ARDS represents a major global public health burden, and the management of ARDS continues to challenge healthcare systems globally, especially during the pandemic of the coronavirus disease 2019 (COVID-19). There remains no confirmed specific pharmacotherapy for ARDS, despite advances in understanding its pathophysiology. Debate continues about the potential role of glucocorticoids (GCs) as a promising ARDS clinical therapy. Questions regarding GC agent, dose, and duration in patients with ARDS need to be answered, because of substantial variations in GC administration regimens across studies. ARDS heterogeneity likely affects the therapeutic actions of exogenous GCs. This review includes progress in determining the GC mechanisms of action and clinical applications in ARDS, especially during the COVID-19 pandemic.

Using real-world data to accelerate the search for long COVID therapies

Long COVID, a spectrum of symptoms and syndromes that can develop after SARS-COV-2 infection, can significantly affect patients' health, quality of life and impact their ability to productively function in society. There is currently no approved therapy for Long COVID and there is an urgent need for rigorous clinical trials to find such treatments. Although research into the pathophysiology of Long COVID is advancing, investigations into treatment for patients remain underfunded and, as a result, understudied. Owing to the urgency of the Long COVID pandemic and as a research collaborative across a diversity of biomedical innovation value propositions, we are calling for a new approach that parallelizes pathophysiologic and therapeutic research into this condition, leveraging patient-centered research and real-world data to generate hypotheses to assess the effectiveness of existing FDA approved drugs. Accelerated discovery of therapeutics for Long COVID can then be confirmed through efficient and cost-effective adaptive platform clinical trials.

Heterogeneity, Bayesian thinking, and phenotyping in critical care: A primer

PURPOSE

To familiarize clinicians with the emerging concepts in critical care research of Bayesian thinking and personalized medicine through phenotyping and explain their clinical relevance by highlighting how they address the issues of frequent negative trials and heterogeneity of treatment effect.

SUMMARY

The past decades have seen many negative (effect-neutral) critical care trials of promising interventions, culminating in calls to improve the field's research through adopting Bayesian thinking and increasing personalization of critical care medicine through phenotyping. Bayesian analyses add interpretive power for clinicians as they summarize treatment effects based on probabilities of benefit or harm, contrasting with conventional frequentist statistics that either affirm or reject a null hypothesis. Critical care trials are beginning to include prospective Bayesian analyses, and many trials have undergone reanalysis with Bayesian methods. Phenotyping seeks to identify treatable traits to target interventions to patients expected to derive benefit. Phenotyping and subphenotyping have gained prominence in the most syndromic and heterogenous critical care disease states, acute respiratory distress syndrome and sepsis. Grouping of patients has been informative across a spectrum of clinically observable physiological parameters, biomarkers, and genomic data. Bayesian thinking and phenotyping are emerging as elements of adaptive clinical trials and predictive enrichment, paving the way for a new era of high-quality evidence. These concepts share a common goal, sifting through the noise of heterogeneity in critical care to increase the value of existing and future research.

CONCLUSION

The future of critical care medicine will inevitably involve modification of statistical methods through Bayesian analyses and targeted therapeutics via phenotyping. Clinicians must be familiar with these systems that support recommendations to improve decision-making in the gray areas of critical care practice.

Associations between corticosteroid dosage and clinical outcomes in patients with hypoxemic COVID-19 pneumonia: A retrospective cohort study

BACKGROUND

Corticosteroids are commonly used to treat COVID-19 patients with hypoxemia, and clinicians have adjusted the corticosteroid intensity on the basis of clinical needs. However, neither the optimal dose nor the duration of treatment has been recommended.

OBJECTIVE

To investigate whether cumulative doses of corticosteroids, measured as dexamethasone-equivalent doses over the first 14 days, impact outcomes in patients with COVID-19 pneumonia.

METHODS

We conducted a retrospective cohort study of COVID-19 pneumonia patients admitted between April 1st, 2020, and September 30th, 2021. The study focused on the type and dose of corticosteroid administered during the initial 14 days, clinical outcomes, and complications. The primary outcome was in-hospital mortality.

RESULTS

Among 271 patients, the mean cumulative dexamethasone-equivalent dose was 158 (119.9-197.25) mg in survivors and 185 (131.7-222.0) mg in nonsurvivors. Univariate analysis revealed that the cumulative dexamethasone-equivalent dose was a risk factor for in-hospital mortality. However, this association did not hold true in the multivariate analysis. After the cumulative dexamethasone-equivalent dose was categorized into quartiles, the moderate dosage (126.01-165.00 mg) in the second quartile was found to be associated with the lowest in-hospital mortality (16.2%). Higher cumulative dexamethasone-equivalent doses were associated with longer hospital and ICU stays and fewer ventilator-free days (p < 0.001). Doses exceeding 165 mg were associated with an increased risk of hospital-acquired infections (p < 0.001).

CONCLUSIONS

The cumulative dexamethasone-equivalent dose during the first 14 days is not associated with in-hospital mortality in hypoxemic COVID-19 patients. However, higher cumulative doses exceeding 165 mg are associated with an increased risk of in-hospital mortality and secondary hospital-acquired infections.

Understanding the Evolving Pathophysiology of Coronavirus Disease 2019 and Adult Nursing Management

Coronavirus disease 2019 (COVID-19) was first identified in December 2019 and quickly became a global pandemic. The understanding of the pathophysiology, treatment, and management of the disease has evolved since the beginning of the pandemic in 2020. COVID-19 can be complicated by immune system dysfunction, lung injury with hypoxemia, acute kidney injury, and coagulopathy. The treatment and management of COVID-19 is based on the severity of illness, ranging from asymptomatic to severe and often life-threatening disease. The 3 main recommended medication classes include antivirals, immunomodulators, and anticoagulants. Other supportive therapies include ensuring adequate oxygenation, mechanical ventilation, and prone positioning.

Evaluating the Risk-Benefit Profile of Corticosteroid Therapy for COVID-19 Patients: A Scoping Review

BACKGROUND

The 2019 coronavirus (COVID-19) outbreak was declared a global pandemic in March 2020. It quickly spread across all continents, causing significant social, environmental, health, and economic impacts. During the pandemic, there has been consideration of repurposing and repositioning of medications, such as corticosteroids, for the treatment of hospitalised COVID-19 patients.

OBJECTIVE

To assess and summarise corticosteroid regimens used for hospitalised COVID-19 patients, focusing on dosage, route of administration, and clinical outcome from clinical trials.

METHODS

PubMed and Embase databases and the grey literature were searched to identify randomised controlled trials (RCTs) that evaluated the efficacy of corticosteroids in hospitalised patients with COVID-19 between January 2020 and January 2023. This scoping review was conducted in line with the PRISMA extension for scoping reviews (PRISMA-ScR) checklist.

KEY FINDINGS

A total of 24 RCTs were eligible for inclusion. There was variation in the steroid regimens used for treatment across COVID-19 trials. Despite the heterogeneity of included RCTs, the overall results have shown the benefits of improving lung function and a lower all-cause mortality rate in hospitalised COVID-19 patients treated with systematic corticosteroids.

CONCLUSIONS

Corticosteroids have proven to be an effective treatment for COVID-19 patients in critical condition. However, comparative effectiveness studies should be conducted to assess the efficacy and safety of optimal corticosteroid treatment at the population level. Moreover, the global burden of long COVID is significant, affecting millions with persistent symptoms and long-term health complications. Thus, it is also necessary to evaluate the optimal steroid regimen for long COVID treatment.

Severe COVID-19 infection: An institutional review and literature overview

BACKGROUND

Our study aimed to describe the group of severe COVID-19 patients at an institutional level, and determine factors associated with different outcomes.

METHODS

A retrospective chart review of patients admitted with severe acute hypoxic respiratory failure due to COVID-19 infection. Based on outcomes, we categorized 3 groups of severe COVID-19: (1) Favorable outcome: progressive care unit admission and discharge (2) Intermediate outcome: ICU care (3) Poor outcome: in-hospital mortality.

RESULTS

Eighty-nine patients met our inclusion criteria; 42.7% were female. The average age was 59.7 (standard deviation (SD):13.7). Most of the population were Caucasian (95.5%) and non-Hispanic (91.0%). Age, sex, race, and ethnicity were similar between outcome groups. Medicare and Medicaid patients accounted for 62.9%. The average BMI was 33.5 (SD:8.2). Moderate comorbidity was observed, with an average Charlson Comorbidity index (CCI) of 3.8 (SD:2.6). There were no differences in the average CCI between groups(p = 0.291). Many patients (67.4%) had hypertension, diabetes (42.7%) and chronic lung disease (32.6%). A statistical difference was found when chronic lung disease was evaluated; p = 0.002. The prevalence of chronic lung disease was 19.6%, 27.8%, and 40% in the favorable, intermediate, and poor outcome groups, respectively. Smoking history was associated with poor outcomes (p = 0.04). Only 7.9% were fully vaccinated. Almost half (46.1%) were intubated and mechanically ventilated. Patients spent an average of 12.1 days ventilated (SD:8.5), with an average of 6.0 days from admission to ventilation (SD:5.1). The intermediate group had a shorter average interval from admission to ventilator (77.2 hours, SD:67.6), than the poor group (212.8 hours, SD:126.8); (p = 0.001). The presence of bacterial pneumonia was greatest in the intermediate group (72.2%), compared to the favorable group (17.4%), and the poor group (56%); this was significant (p<0.0001). In-hospital mortality was seen in 28.1%.

CONCLUSION

Most patients were male, obese, had moderate-level comorbidity, a history of tobacco abuse, and government-funded insurance. Nearly 50% required mechanical ventilation, and about 28% died during hospitalization. Bacterial pneumonia was most prevalent in intubated groups. Patients who were intubated with a good outcome were intubated earlier during their hospital course, with an average difference of 135.6 hours. A history of cigarette smoking and chronic lung disease were associated with poor outcomes.

Challenges of consolidating evidence collected during a pandemic and lessons for the future

OBJECTIVE

To illustrate the challenges encountered when gathering rapidly synthesized evidence in response to the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

In this article, we describe the challenges encountered when we performed a systematic literature review (SLR) of randomized controlled trials (RCTs) on the efficacy and safety of treatments for severe COVID-19. The methods of the SLR are described in full, to show the context of our objectives. Then we use the results of the SLR to demonstrate the problems of producing synthesized evidence in this setting.

RESULTS

Various challenges were identified during this SLR. These were primarily a result of heterogeneity in the study methodology of eligible studies. Definitions of the patient populations and outcome measurements were highly variable and the majority of studies demonstrated a high risk of bias, preventing quantitative synthesis of the collated evidence.

CONCLUSION

Consolidating evidence from RCTs evaluating COVID-19 interventions was problematic. Guidance is needed for scenarios with high rapid output in primary research.

Enhanced angiogenesis of human umbilical vein endothelial cells via THP-1-derived M2c-like macrophages and treatment with proteasome inhibitors 'bortezomib and ixazomib'

The leading cause of cancer-related death is lung cancer, with metastasis being the most common cause of death. To elucidate the role of macrophages in lung cancer and angiogenesis processes, we established an in vitro co-culture model of A549 or HUVEC with THP-1 cells that polarized to M2c macrophages with hydrocortisone. The proteasome inhibitors bortezomib and ixazomib were investigated for their effects on proliferation, invasion, migration, metastasis, and angiogenesis pathways. The effects of bortezomib and ixazomib on gene expression in gene panels, including crucial genes related to angiogenesis and proteasomes, were investigated after the co-culture model to determine these effects at the molecular level. In conclusion, bortezomib and ixazomib showed antiproliferative effects in both cells, as well as in M2c macrophage co-culture. M2c macrophages also increased invasion in A549 cells and both invasion and migration in HUVEC. mRNA expression upregulation, specifically in the NFKB and VEGF genes, supported the metastatic and angiogenic effects found in A549 and HUVEC with M2c macrophage co-culture. Additionally, bortezomib inhibited the VEGFB pathway in HUVEC and NFKB1 in A549 cells. The significant findings obtained as a result of this study will provide information regarding angiogenesis induced by M2 macrophages.

Corticosteroid Treatment for Leptospirosis: A Systematic Review and Meta-Analysis

Background: Leptospirosis, a zoonotic disease prevalent in tropical regions, often leads to severe complications such as Weil's disease and acute respiratory distress syndrome (ARDS). This pioneering meta-analysis investigated the role of corticosteroids in treating severe leptospirosis, addressing a critical gap in the current clinical knowledge. Methods: We systematically reviewed studies from PubMed and Scopus, focusing on randomized controlled trials and observational cohort studies involving adult patients diagnosed with leptospirosis. Five studies comprising 279 participants met the inclusion criteria. Results: Although some studies suggest potential benefits, particularly for pulmonary complications, the evidence remains inconclusive due to the limited number of studies and their methodological limitations. Notably, while four of the five reviewed studies indicated a possible positive role of corticosteroids, the single randomized controlled trial showed no significant benefit, highlighting the need for more robust research. Conclusions: While the current evidence provides a basis for potential benefits, it is not sufficient to make definitive clinical recommendations. Further research is essential to clarify the role of corticosteroids in the treatment of severe leptospirosis, with the aim of improving patient outcomes and guiding clinical practices effectively.

Low-Dose Corticosteroids for Critically Ill Adults With Severe Pulmonary Infections: A Review

Importance

Severe pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%.

Observations

Corticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections.

Conclusions and Relevance

Treatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both.

Comparative Efficacy of Inhaled and Intravenous Corticosteroids in Managing COVID-19-Related Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome (ARDS) is a life-threatening condition in which the lungs fail to provide sufficient oxygen to the body's vital organs. It is commonly associated with COVID-19 patients. Severe cases of COVID-19 can lead to lung damage and organ failure due to an immune response in the body. To mitigate these effects, corticosteroids, which are known for their anti-inflammatory properties, have been suggested as a potential treatment option. The primary focus of this study was to assess the impact of various corticosteroid administration methods on the outcomes of patients with COVID-19. Methods: The current study was conducted on COVID-19 patients divided into three groups. The first group was administered 6 mg of intravenous (IV) dexamethasone; the second group received 1 mg/kg of IV methylprednisolone (methylprednisolone); and the third group received budesonide respirable solution at a dosage of 1mg twice daily. The neubilizer used was a vibrating mesh nebulizer (VMN). All patients received standard care. We found that dexamethasone administered intravenously led to a significant reduction in C-reactive protein levels, surpassing the effectiveness of both IV methylprednisolone and inhaled budesonide. Oxygen saturation without mask change over time showed statistically significant differences (p = 0.004) in favor of the budesonide and dexamethasone groups for all days. Individuals who received methylprednisolone showed a significant decrease in mortality rate and an extended survival duration, with statistical significance observed at p = 0.024. The rest of the parameters, including ferritin, lymphocytes, total leukocyte count, platelets, hemoglobin, urea, serum potassium, serum sodium, serum creatinine, serum glutamic-pyruvic transaminase, serum glutamic-oxaloacetic transaminase, uric acid, albumin, globulin, erythrocyte sedimentation rate, international normalized ratio, oxygen saturation with flow, and oxygen flow, showed no statistically significant differences between the three drugs. In conclusion, treatment with IV methylprednisolone (1 mg/kg) resulted in a shorter hospital stay, decreased reliance on ventilation, and improved health outcomes for COVID-19 patients compared to using dexamethasone at a daily dosage of 6 mg or budesonide respirable solution at a dosage of 1mg twice daily.

The Integration of Clinical Trials With the Practice of Medicine: Repairing a House Divided

Importance

Optimal health care delivery, both now and in the future, requires a continuous loop of knowledge generation, dissemination, and uptake on how best to provide care, not just determining what interventions work but also how best to ensure they are provided to those who need them. The randomized clinical trial (RCT) is the most rigorous instrument to determine what works in health care. However, major issues with both the clinical trials enterprise and the lack of integration of clinical trials with health care delivery compromise medicine's ability to best serve society.

Observations

In most resource-rich countries, the clinical trials and health care delivery enterprises function as separate entities, with siloed goals, infrastructure, and incentives. Consequently, RCTs are often poorly relevant and responsive to the needs of patients and those responsible for care delivery. At the same time, health care delivery systems are often disengaged from clinical trials and fail to rapidly incorporate knowledge generated from RCTs into practice. Though longstanding, these issues are more pressing given the lessons learned from the COVID-19 pandemic, heightened awareness of the disproportionate impact of poor access to optimal care on vulnerable populations, and the unprecedented opportunity for improvement offered by the digital revolution in health care. Four major areas must be improved. First, especially in the US, greater clarity is required to ensure appropriate regulation and oversight of implementation science, quality improvement, embedded clinical trials, and learning health systems. Second, greater adoption is required of study designs that improve statistical and logistical efficiency and lower the burden on participants and clinicians, allowing trials to be smarter, safer, and faster. Third, RCTs could be considerably more responsive and efficient if they were better integrated with electronic health records. However, this advance first requires greater adoption of standards and processes designed to ensure health data are adequately reliable and accurate and capable of being transferred responsibly and efficiently across platforms and organizations. Fourth, tackling the problems described above requires alignment of stakeholders in the clinical trials and health care delivery enterprises through financial and nonfinancial incentives, which could be enabled by new legislation. Solutions exist for each of these problems, and there are examples of success for each, but there is a failure to implement at adequate scale.

Conclusions and Relevance

The gulf between current care and that which could be delivered has arguably never been wider. A key contributor is that the 2 limbs of knowledge generation and implementation-the clinical trials and health care delivery enterprises-operate as a house divided. Better integration of these 2 worlds is key to accelerated improvement in health care delivery.

SARS-CoV-2 clearance in term of Cycle Threshold (Ct) during first two waves of COVID-19 in Pakistan: a phenomenon of delayed viral clearance post-corticosteroid treatment

SARS-CoV-2 is recently emerged virus, which caused millions of deaths, all over the world. To tackle COVID-19 pandemic, there is an utmost need for in-depth analysis of viral replication. We aimed to examine viral load in SARS-CoV-2 patients during first two waves of COVID-19 in Pakistan. 225,615 suspected subjects from 75 different regions of Pakistan were selected in the study. SARS-CoV-2 RNAs were detected via real time PCR. During first wave (period of June-July, 2020) of COVID-19 the prevalence of SARS-CoV-2 was 20.38%. However, during second wave (period of November-December, 2020) of COVID-19, the rate of prevalence was 9.41%. During first wave of COVID-19 96.31% of participants remained PCR positive for 14 to 21 days, 3.39% of subjects showed positive results for 22 to 35 days, while delayed Ct values were observed among 0.26% of participants for 36 to 49 days. However, during second wave of COVID-19 89.31% of the subjects exhibited symptoms and showed real-time PCR positive results for 14 to 21 days, 9.42% showed positive results for 22 to 35 days, while significantly delayed Ct value results were observed among 1.026% of participants for 36 to 63 days (3.95 times higher than first wave). In contrast to first wave of COVID-19, the factors that were different in second wave were neither viral (different strains) nor host (same population). But treatment factors changed significantly. As during second wave besides azithromycin, corticosteroid dexamethasone consumption was increased consequently causing delayed Ct value negativity. This suggests that corticosteroid treatment might be linked with delayed Ct value or viral clearance. This study is crucial for re-considering effective therapeutic options against COVID-19.

Current role of pasireotide in the treatment of acromegaly

"First-generation" somatostatin receptor agonists (SSTRAs) octreotide and lanreotide are the most commonly used first-line pharmacological therapy for patients with acromegaly. A subset of patients respond only partially or not at all to the first-generation SSTRA, necessitating the use of additional pharmacological agents or other modes of therapy. Pasireotide is a "second-generation" SSTRA that has multi-receptor activity. Prospective studies have shown promise in the use of pasireotide in patients with poor response to first-generation SSTRA. Here we elucidate the molecular pathways of resistance to first-generation SSTRA, the mechanism of action, pre-clinical and clinical evidence of the use of pasireotide in patients having incomplete / lack of response to first-generation SSTRA. We also discuss the clinical, pathological, and radiological markers predicting response to pasireotide, and the difference in side-effect profiles of pasireotide, compared to first-generation SSTRA.

Corticosteroids in critically ill patients: A narrative review

Corticosteroids have been utilized in modern medicine for decades. Many indications have been investigated across various treatment settings with both benefit and harm observed. Given the instability of critically ill patients, the increased risk of corticosteroid-related complications, and the pervasive comorbidities, patients who receive corticosteroids must be carefully managed. Common critical care disease states in which corticosteroids have been studied and are routinely utilized include acute respiratory distress syndrome, adrenal insufficiency, angioedema, asthma, chronic obstructive pulmonary disease, community-acquired pneumonia, coronavirus disease 2019, septic shock, and spinal cord injury. Benefits of corticosteroids include an improvement in disease state-specific outcomes, decreased hospital length of stay, decreased mechanical ventilatory support, and decreased mortality. The harm of corticosteroids is well documented through adverse effects that include, but are not limited to, hyperglycemia, tachycardia, hypertension, agitation, delirium, anxiety, immunosuppression, gastrointestinal bleeding, fluid retention, and muscle weakness. Furthermore, corticosteroids are associated with increased health care costs through adverse effects as well as drug acquisition and administration costs. Given the assortment of agents, dosing, benefits, risks, and utilization in the critical care setting, there may be difficulty with identifying the appropriate places for use of corticosteroids in therapy. There currently exists no comprehensive report detailing the use of corticosteroids in the aforementioned disease states within the critical care setting. This narrative review sets out to describe these in detail.

Critical Illness Outside the Intensive Care Unit: Research Challenges in Emergency and Prehospital Settings

Patients with acute critical illness require prompt interventions, yet high-quality evidence supporting many investigations and treatments is lacking. Clinical research in this setting is challenging due to the need for immediate treatment and the inability of patients to provide informed consent. Attempts to obtain consent from surrogate decision-makers can be intrusive and lead to unacceptable delays to treatment. These problems may be overcome by pragmatic approaches to study design and the use of supervised waivers of consent, which is ethical and appropriate in situations where there is high risk of poor outcome and a paucity of proven effective treatment.

Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (September 2022)

There are many pharmacologic therapies that are being used or considered for treatment of coronavirus disease 2019 (COVID-19), with rapidly changing efficacy and safety evidence from trials. The objective was to develop evidence-based, rapid, living guidelines intended to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19. In March 2020, the Infectious Diseases Society of America (IDSA) formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise to regularly review the evidence and make recommendations about the treatment and management of persons with COVID-19. The process used a living guideline approach and followed a rapid recommendation development checklist. The panel prioritized questions and outcomes. A systematic review of the peer-reviewed and grey literature was conducted at regular intervals. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. Based on the most recent search conducted on 31 May 2022, the IDSA guideline panel has made 32 recommendations for the treatment and management of the following groups/populations: pre- and postexposure prophylaxis, ambulatory with mild-to-moderate disease, and hospitalized with mild-to-moderate, severe but not critical, and critical disease. As these are living guidelines, the most recent recommendations can be found online at: https://idsociety.org/COVID19guidelines. At the inception of its work, the panel has expressed the overarching goal that patients be recruited into ongoing trials. Since then, many trials were conducted that provided much-needed evidence for COVID-19 therapies. There still remain many unanswered questions as the pandemic evolved, which we hope future trials can answer.

Steroids in acute respiratory distress syndrome: A panacea or still a puzzle?

Acute respiratory distress syndrome (ARDS) is a unique entity marked by various etiologies and heterogenous pathophysiologies. There remain concerns regarding the efficacy of particular medications for each severity level apart from respiratory support. Among several pharmacotherapies which have been examined in the treatment of ARDS, corticosteroids, in particular, have demonstrated potential for improving the resolution of ARDS. Nevertheless, it is imperative to consider the potential adverse effects of hyperglycemia, susceptibility to hospital-acquired infections, and the development of intensive care unit acquired weakness when administering corticosteroids. Thus far, a multitude of trials spanning several decades have investigated the role of corticosteroids in ARDS. Further stringent trials are necessary to identify particular subgroups before implementing corticosteroids more widely in the treatment of ARDS. This review article provides a concise overview of the most recent evidence regarding the role and impact of corticosteroids in the management of ARDS.