Study of Alteplase for Respiratory Failure in SARS-CoV-2 COVID-19: A Vanguard Multicenter, Rapidly Adaptive, Pragmatic, Randomized Controlled Trial

Background

Pulmonary vascular microthrombi are a proposed mechanism of COVID-19 respiratory failure. We hypothesized that early administration of tissue plasminogen activator (tPA) followed by therapeutic heparin would improve pulmonary function in these patients.

Research Question

Does tPA improve pulmonary function in severe COVID-19 respiratory failure, and is it safe?

Study Design and Methods

Adults with COVID-19-induced respiratory failure were randomized from May14, 2020 through March 3, 2021, in two phases. Phase 1 (n = 36) comprised a control group (standard-of-care treatment) vs a tPA bolus (50-mg tPA IV bolus followed by 7 days of heparin; goal activated partial thromboplastin time [aPTT], 60-80 s) group. Phase 2 (n = 14) comprised a control group vs a tPA drip (50-mg tPA IV bolus, followed by tPA drip 2 mg/h plus heparin 500 units/h over 24 h, then heparin to maintain aPTT of 60-80 s for 7 days) group. Patients were excluded from enrollment if they had not undergone a neurologic examination or cross-sectional brain imaging within the previous 4.5 h to rule out stroke and potential for hemorrhagic conversion. The primary outcome was Pao₂ to Fio₂ ratio improvement from baseline at 48 h after randomization. Secondary outcomes included Pao₂ to Fio₂ ratio improvement of > 50% or Pao₂ to Fio₂ ratio of ≥ 200 at 48 h (composite outcome), ventilator-free days (VFD), and mortality.

Results

Fifty patients were randomized: 17 in the control group and 19 in the tPA bolus group in phase 1 and eight in the control group and six in the tPA drip group in phase 2. No severe bleeding events occurred. In the tPA bolus group, the Pao₂ to Fio₂ ratio values were significantly (P < .017) higher than baseline at 6 through 168 h after randomization; the control group showed no significant improvements. Among patients receiving a tPA bolus, the percent change of Pao₂ to Fio₂ ratio at 48 h (16.9% control [interquartile range (IQR), –8.3% to 36.8%] vs 29.8% tPA bolus [IQR, 4.5%-88.7%]; P = .11), the composite outcome (11.8% vs 47.4%; P = .03), VFD (0.0 [IQR, 0.0-9.0] vs 12.0 [IQR, 0.0-19.0]; P = .11), and in-hospital mortality (41.2% vs 21.1%; P = .19) did not reach statistically significant differences when compared with those of control participants. The patients who received a tPA drip did not experience benefit.

Interpretation

The combination of tPA bolus plus heparin is safe in severe COVID-19 respiratory failure. A phase 3 study is warranted given the improvements in oxygenation and promising observations in VFD and mortality.

Trial Registry

ClinicalTrials.gov; No.: NCT04357730; URL: www.clinicaltrials.gov

Effects of Modified Atmospheric Packaging on Ground Chicken Color and Lipid Oxidation

The objective of the current study was to evaluate the color changes and lipid oxidation of ground chicken patties packaged in polyvinyl chloride (PVC) film, high-oxygen (HiOx)–modified atmospheric packaging (MAP; 80% oxygen + 20% carbon dioxide [CO2]), and carbon monoxide (CO)-MAP (0.4% CO + 19.6% CO2 + 80% nitrogen) and stored at 2°C. Surface color was measured using a HunterLab MiniScan spectrophotometer on days 0, 1, 2, and 4. Lipid oxidation, pH, and aerobic plate count were determined on days 0 and 4 of storage. Fatty acid profiles were determined on day 0 to characterize saturated and unsaturated fatty acids. Patties packaged in PVC had greater (P &lt; 0.05) pH than HiOx-MAP and CO-MAP. Gas chromatography analysis indicated that ground chicken has 72.8% unsaturated fatty acids and 27.2% saturated fatty acids (based on total lipids and fatty acid methyl ester). The formation of carboxymyoglobin on ground chicken patty surface was confirmed by peaks at 420 and 570 nm, whereas oxymyoglobin had peaks at 410 and 580 nm. Instrumental color analysis indicated both HiOx-MAP and CO-MAP had greater (P &lt; 0.05) redness (a* values) than PVC on day 4 of storage. Patties packaged in HiOx-MAP had greater (P &lt; 0.05) chroma values than CO-MAP and PVC on day 4 of storage. Visual panelists noted less (P &lt; 0.05) surface discoloration in CO-MAP than PVC and HiOx-MAP on day 4 of storage. Lipid oxidation was greater (P &lt; 0.05) in PVC and HiOx-MAP than CO-MAP. CO inclusion at 0.4% level effectively inhibited lipid oxidation and stabilized surface redness during refrigerated storage of ground chicken.

A 35-Year Systematic Mapping Review of Refereed Publications on Hippotherapy

Date Presented 4/8/2016

This systematic mapping review comprehensively mapped national, international, and refereed literature on hippotherapy between 1980 and 2014 as a guide for future occupational therapy practice, research, and education.

Primary Author and Speaker: Beth Hoesly

Additional Author and Speaker: Wendy Wood

Contributing Authors: E. Osmann, C. McDaniel, M. Rose, R. Finkstrom

Metabolic and hormonal responses of growing modern meat-type chickens to fasting

1. The present study compared the effects of fasting on circulating concentrations of glucose, insulin and glucagon in male and female modern meat-type chickens (Ross 708) at three ages (19 d, 33 d and 47 d). 2. Plasma concentrations of glucose were reduced by fasting with reductions of 24.9% (19-d-old), 22.6% (33-d-old) and 17.9% (47-d-old) in broiler chickens fasted for 12 h. 3. Plasma concentrations of insulin decreased with fasting. For instance, circulating concentrations of insulin declined after 6 h of fasting by 45.7%, 54.7% and 50.0%, respectively, in 19-d-old, 33-d-old and 47-d-old broiler chickens. 4. Plasma concentrations of glucagon were increased by fasting. Plasma concentrations of glucagon were elevated by 3.79% (19-d-old), 3.51% (33-d-old) and 3.79% (47-d-old) with 6 h of fasting and remained elevated with 12 h, 18 h and 24 h of fasting.

Reliability of nurses' neurological assessments in the cardiothoracic surgical intensive care unit

BACKGROUND: Alterations in mental status are common among patients in the cardiothoracic surgical intensive care unit. Changes in mental status can be caused by metabolic factors, medications, or brain injury. In this setting, reliable, serial neurological evaluations are critical for assessing the effectiveness of treatment and the need for additional studies. OBJECTIVES: To estimate the reliability of the Rancho Los Amigos Cognitive Scale and the newly developed Neurologic Intensive Care Evaluation as measures of cognitive function in the cardiothoracic surgical intensive care unit. METHODS: Nurses used 1 of the 2 scales as part of routine neurological assessments of patients in the cardiothoracic surgical intensive care unit. For each test, scores of different observers were correlated and a reliability estimate formed. RESULTS: Interrater reliability was high for both evaluations (Rancho scale, 0.91; Neurologic Intensive Care Evaluation, 0.94). Correlations between the scores of different pairs of observers were also high (mean rho values, 0.84 for the Rancho scale and 0.77 for the Neurologic Intensive Care Evaluation). CONCLUSIONS: Both scales are reliable indicators of the neurological state of patients in the cardiothoracic surgical intensive care unit. These scales measure different, although limited, aspects of cognitive function. Each test was simple to administer and did not take more time than the standard nursing neurological examination. Most of the variability in scoring was related to the different degrees of stimulation used by examiners when assessing patients, not to differences in the interpretation of patients' responses.

Reliability of nurses' neurological assessments in the cardiothoracic surgical intensive care unit

BACKGROUND

Alterations in mental status are common among patients in the cardiothoracic surgical intensive care unit. Changes in mental status can be caused by metabolic factors, medications, or brain injury. In this setting, reliable, serial neurological evaluations are critical for assessing the effectiveness of treatment and the need for additional studies.

OBJECTIVES

To estimate the reliability of the Rancho Los Amigos Cognitive Scale and the newly developed Neurologic Intensive Care Evaluation as measures of cognitive function in the cardiothoracic surgical intensive care unit.

METHODS

Nurses used 1 of the 2 scales as part of routine neurological assessments of patients in the cardiothoracic surgical intensive care unit. For each test, scores of different observers were correlated and a reliability estimate formed.

RESULTS

Interrater reliability was high for both evaluations (Rancho scale, 0.91; Neurologic Intensive Care Evaluation, 0.94). Correlations between the scores of different pairs of observers were also high (mean rho values, 0.84 for the Rancho scale and 0.77 for the Neurologic Intensive Care Evaluation).

CONCLUSIONS

Both scales are reliable indicators of the neurological state of patients in the cardiothoracic surgical intensive care unit. These scales measure different, although limited, aspects of cognitive function. Each test was simple to administer and did not take more time than the standard nursing neurological examination. Most of the variability in scoring was related to the different degrees of stimulation used by examiners when assessing patients, not to differences in the interpretation of patients' responses.

Hospital ethics committees and nurses' participation

The hospital ethics committee's mandates of patient care review, policy formation, and education make them central to nurses and healthcare delivery. In a study examining nurses' communication exchange frequency and perceived effectiveness as members of hospital ethics committees, nurses represented the largest proportion, were moderately active, and rated their participation effectiveness the highest: they are more involved in discussions regarding patients than policy formation and education. Nurse administrators can provide strategies and education for nurses that enhance nurses' participation in all three committee functions. Policies affect patient care; therefore, policy decisions, too, benefit from nurses' participation.

Ethical environment: reports of practicing nurses

Reports from the development of the Ethics Environment Questionnaire identify three critical features for ethical environments in health care settings of registered nurses. They are the ability of nurses to engage in discussions about patient care, support from administrators, and the development of policies-procedures that support their practice. Implications for clinical practicing nurses are explored.

Enhancing nurses' ethical practice: development of a clinical ethics program

There is increasing attention paid to ethics under managed care; however, few clinical-based ethics programs are reported. This paper reports the assessment and outcomes of one such program. A quasi-experimental research design with t-tests is used to assess the outcome differences between participants and control groups. There are twenty nurses in each; they are assessed for comparability. Differences are predicted on two outcomes using reliable and valid measures: nurses' time with their patients in ethics discussions, and nurses' opinions regarding their clinical ethics environments. Results reveal a statistically significant difference (p <.05) between the two groups, with modest positive change in the participants. Additional exploratory analyses are reported on variables influential in health care services.

Development and psychometric properties of the Ethics Environment Questionnaire

OBJECTIVES

The author reports on the development and the psychometric properties of the Ethics Environment Questionnaire (EEQ), an instrument by which to measure the opinions of health-care providers about ethics in their clinical practice organizations. The EEQ was developed to increase the number of valid and reliable measures pertaining to ethics in health-care delivery.

METHODS

The EEQ is a 20-item self-administered questionnaire using a Likert-type 5-point format, offering ease of administration. It is applicable to a cross-section of health-care practitioners and health-care facilities. The mean administration time is 10 minutes. The EEQ represents testing on 450 respondents in acute care settings among a cross-section of acute care facilities.

RESULTS

Internal consistency reliability using Cronbach's alpha coefficient is 0.93, and the test-retest reliability is 0.88. Construct, content, and criterion validity are established. The scale is unidimensional, with factor loadings exceeding the minimum preset criterion. Mean score is 3.1 out of 5.0, with scores of 3.5 and above interpreted as reflective of a positive ethics environment.

CONCLUSIONS

The EEQ provides a measure of ethics in health-care organizations among multi-practitioners in clinical practice on a valid, reliable, cost effective, and easily administered instrument that requires minimum investment of personnel time.

The Maryland mammoth allele reduces floral stimulus activity in stem piece explants of Nicotiana tabacum (Solanaceae)

The response of axillary buds to floral stimulus activity in stem pieces was examined in two near-isogenic cultivars of tobacco that differ in the recessive maryland mammoth (mm) allele, which confers short-day behavior. All axillary buds from day-neutral plants assayed on six-internode stem pieces made few nodes (less than 20) before flowering, while axillary buds from plants homozygous for mm assayed on six-internode stem pieces either did not flower in noninductive conditions or made many nodes before flowering in inductive conditions. About 80% of day-neutral axillary buds grafted onto day-neutral stem pieces did not respond to floral stimulus in stem pieces, indicating that the floral stimulus in stem pieces is ephemeral. In other graft combinations, the proportion of axillary buds that did respond to floral stimulus in stem pieces was substantially reduced from the 20% of day-neutral buds on day-neutral stem pieces that responded. These results indicate that the mm allele probably reduces both the amount of floral stimulus activity in stem pieces and the competence of axillary buds to respond.

Ethics and mental health service delivery under managed care

The delivery of mental health services under managed care takes on different dimensions affecting the ethical considerations of providers and patients. In this article, we explore five key issues that are especially relevant to the psychiatric population: conflict of interest, confidentiality, patients' rights, underserved patients and allocation, and levels of ethical analysis. Implications for nursing are also discussed.

Organizational culture and ethics work satisfaction

Nurse executives have opportunities for creating constructive organizational cultures and for supporting ethical healthcare practice. Because culture and ethics are so central to effective nursing practice, this study explored relationships between them, measuring ethics as work satisfaction pertaining to ethics. This article provides initial assessment of one dimension of ethics, ethics work satisfaction, and examines its relationship to organizational culture.

Phase I clinical and pharmacokinetic study of oral etoposide phosphate

PURPOSE

To determine the bioavailability (F) and the pharmacokinetic profile of both etoposide and its prodrug, etoposide phosphate, after oral and intravenous administration of etoposide phosphate, and to determine the maximum-tolerable dose (MTD) of oral etoposide phosphate administered daily for 5 consecutive days every 3 weeks. In addition, we sought to develop and validate two limited-sampling models (LSMs) to predict the etoposide area under the curve (AUC) 24 hours after administration of oral and intravenous etoposide phosphate.

PATIENTS AND METHODS

In the F part of the study, patients were assessed for pharmacokinetic studies after one oral and one intravenous administration of the same dose of etoposide phosphate. Etoposide phosphate and etoposide plasma concentrations were assayed by high-performance liquid chromatography (HPLC). To develop LSMs after oral and intravenous administration, patients were randomized between the training and validation data sets. In the phase I part of the study, which followed the F part, the dose of etoposide phosphate was escalated from 50 mg/m2/d for etoposide equivalents for 5 days to 220 mg/m2/d for 5 days.

RESULTS

Forty adult patients with solid tumors or lymphoma entered the study and 35 were assessable for toxicity. The MTDs were defined as 175 mg/m2 and 220 mg/m2 in previously treated and untreated patients, respectively. Neutropenia was dose-limiting, with high interpatient variability. Within 15 minutes after intravenous administration, etoposide phosphate was no longer detectable in plasma, and it was never detectable after oral administration. Plasma concentrations and pharmacokinetic parameters of etoposide following etoposide phosphate were comparable to those reported for etoposide. The relative F (mean +/- SD) of etoposide after oral etoposide phosphate was 76 +/- 27%, with a range of 37% to 144%.

CONCLUSION

The clinical and pharmacokinetic results of this study confirm the prodrug hypothesis of etoposide phosphate. Although firm conclusions cannot be drawn, the F of oral etoposide phosphate seems to be comparable to or only slightly better than that of oral etoposide.

Anonymous grading: an ethical teaching strategy

Increasing emphasis on student rights, as well as attention to ethics, has focused awareness on strategies that faculty can implement to ensure that the subject of ethics is illustrated in classroom teaching. The author discusses anonymous grading as one strategy to operationalize ethics in the classroom. As an ethical concept, justice is a primary concern in the implementation of impartial and fair evaluation of students' work.

Conflict of interest: its relationship to integrity in the academic setting

Conflict of interest is an issue not only for business leaders, government officials, and researchers, but also academicians. As an ethical issue, conflict of interest involves competing interests as well as raises questions related to an individual's integrity. A case is used to discuss these ethical issues in the academic setting. Recommendations are provided to prevent, reduce, or avoid these ethical tensions, with particular attention to the development of policies to support institutional and, thereby, personal and professional relationships among faculty and students.

Taxol: initial Israeli experience with a novel anticancer agent

Taxol is a novel taxane derivative obtained from the bark of the Pacific yew, Taxus brevifolia, which has demonstrated substantial antitumor activity in early clinical trials. Intensive research efforts were necessary to overcome both supply problems and hypersensitivity reactions to the drug and thus assure its widespread use. Taxol is active in a variety of neoplasias, including advanced breast and ovarian tumors resistant to drugs such as doxorubicin and cisplatin, respectively. We report here the initial experience with taxol in these two disease entities in Israel, at three institutions within the framework of large multinational trials. These studies compared a) the use of two dose levels of taxol, and b) short, 3-h administration vs. a longer 24-h infusion of the drug. A total of 107 Israeli patients, 38 with ovarian cancer and 69 with breast cancer, were given 706 courses of taxol. Our results show that the administration of taxol at doses ranging between 135 and 175 mg/m2 is indeed feasible and that 3-h infusions are as well tolerated as longer administration. The main hematological toxicity was leukopenia, which was promptly reversible and was more pronounced both at the higher dose level and with the more prolonged infusion. Of the nonhematological side effects, the most prominent were alopecia, mild nausea and vomiting, limb paresthesias, fatigue and myalgia. Allergic reactions following routine premedication were mild and infrequent, never necessitating discontinuation of the drug. Clinically significant cardiac events did not occur. Taxol is an important addition to the anticancer chemotherapy armamentarium.

Staffing solutions: an in-house agency

Cost-efficient, flexible labor and scheduling can be met within one's own organization through a professional staffing program. Conceptualization, implementation and evaluation of this in-house agency are detailed. In addition to meeting unit schedules, this program improved staff morale due to better coverage and compensation.

The organizational culture. Implications for nursing service

Research has established positive links between a constructive culture, the morale and retention of employees, and the decreased mortality of patients. Given these important variables and their ties to organizational culture, it is important to understand the culture of nursing service. Even more important are the implications that the culture provides for development of strategies to enhance the service. For these reasons, this study assessed the organizational culture of seven acute care hospitals to provide a background for discussion of the implications and strategies to enhance service.

Phase I clinical study of LL-D49194 alpha 1 with retrospective pharmacokinetic investigations in mice and humans. The EORTC ECTG

LL-D49194 alpha 1 is a new cytotoxic antibiotic selected for clinical phase I study because of its impressive pre-clinical anti-tumour activity and its low toxicity profile in experimental animals. A total of 15 patients were treated in centres in Glasgow and Amsterdam at doses ranging from 0.25 to 4 mg/m2. One minor response was noted in a patient with colonic carcinoma. The study was suspended following the discovery of unexpected cardiotoxicity. As this toxicity was not consistent with the standard (EORTC) European Organisation for Research and Treatment of Cancer toxicology profile, we chose to investigate the pharmacokinetics of LL-D49194 alpha 1 in mice and humans in more detail to try to explain this phenomenon. A major difference in plasma protein binding was discovered between mice and patients, with a suggestion of non-linear kinetics being noted at higher doses in humans. It is likely that these differences in drug handling account for the unexpected and serious toxicity encountered in this trial.

Who leaves the service area? Profiling the hospital outshopper

Rural hospitals are facing a crisis of major proportions. Declining patient loads, revenues, and profits are the norm. The authors find that in rural communities, the likelihood of going to the local hospital increases with age and may decrease with income.

Transformational leadership in nursing service. A test of theory

What are the leadership dimensions that result in low turnover or work satisfaction? Intellectual stimulation, charisma, and individual consideration constitute aspects of transformational leadership that are suggested to enhance retention and staff satisfaction. In this study, the authors tested transformational leadership theory in one nursing department with an executive, 11 midlevel administrators, and 77 staff registered nurses. Findings support the predictions. Composed of teachable components, transformational factors are similar to leadership qualities described in magnet hospitals, offering positive implications for nursing administration and professional nursing practice.

Ethical issues in restructuring of psychiatric services

The restructuring of health care services is occurring at an increasing rate. Among those most common are the types known as vertical integration, illustrated by the development of psychiatric services within acute care settings. These restructured psychiatric services have implications for psychiatric care and nursing. In some instances, they raise ethical issues. The purpose of this article is to explore ethical issues in restructuring of psychiatric services and to offer suggestions for retaining quality nursing care.

Phase I study of DABIS maleate given once every 3 weeks

DABIS maleate is an alkylating quaternary nitrogen. In a phase I study DABIS maleate was administered as a single intravenous infusion once every 3 weeks. 32 patients with solid tumours were studied, at least 3 per dose level (50-1400 mg/m2). Dose-limiting toxicity was severe paresthaesias in the face, around the mouth and in the tongue. Cerebellar ataxia developed at 750 mg/m2 or higher. Haematological toxicity was minimal. Nausea and vomiting were mild to moderate. No other non-haematological side-effects were noted. The recommended dose for phase II studies at once every 3 weeks is 750 mg/m2 intravenously as a 15 min infusion.

Compendium of instruments measuring patient satisfaction with nursing care

Recent changes in health care delivery have encouraged a search for comprehensive and established measures of patient satisfaction with nursing care (PSNC), which studies have found to be the most important predictor of overall satisfaction with hospital care and an important indicator of outcome. Twenty-one current PSNC instruments are described in a compendium, which provides information on the developer and the date of publication or first use, types of items and subscales, mode of administration, reliability and validity formulas, and availability.

Nursing administration research as a paradigm reflection

Nursing administration research: What has been done? What needs to be done? McDaniel analyzes the research completed in recent years, describing the extant research as atomistic, focused on the nurse provider, not on the organization, administration, or patient. She suggests directions for future nursing administration research: multisite and multivariate analyses of the complex and dynamic nature of health systems, including international perspectives.

Reorganization of community psychiatric services by professional nurses

This article describes the reorganization of one part of an individual, home visiting service for mentally dysfunctional women into a group intervention. Deinstitutionalization has been followed by escalating health care costs, cost containment, and restructuring of services, affecting the already constrained resources for community psychiatric services. Faced with these challenges, a nursing staff, under the administration of a clinical specialist psychiatric nurse, began reorganization of a home visiting service with one trial group. The model group used the prior success reports of groups that were adapted prospectively with a focus on immediate needs and led by nurses for women. The aims were to enhance social supports of the clients while reducing their relapse rates and to reduce the personnel time and cost. Evaluation found that these objectives were met. Thus, the involvement of nurses in the assessment, planning, implementation, and evaluation of its services demonstrates success in the redesign and reorganization of community psychiatric services.

The perception of biological motion by human infants

When a small number of lights are placed on the limbs and joints of a moving human (or animal), the motions of the lights (biological motion) are sufficient to enable adult observers to perceive immediately the activity of the human. This perception of biological motion has been hypothesized to be an intrinsic capacity of the visual system. The results of this experiment, which demonstrate that infants 4 to 6 months of age exhibit a preference for biological motion patterns, support that hypothesis.