Antibiotic Prophylaxis in Patients On Extracorporeal Membrane Oxygenation: A Systematic Review

Despite the frequent use of prophylactic antibiotics in hospitals for extracorporeal membrane oxygenation (ECMO) patients, the Extracorporeal Life Support Organization (ELSO) Infectious Disease Task Force does not recommend routine antibiotic prophylaxis due to a lack of compelling evidence. We assessed the effectiveness of prophylactic antibiotics in ECMO patients. We conducted a comprehensive search of multiple databases from their inception up to September 6, 2023, on various databases using keywords like "antibiotics," "prophylaxis," "extracorporeal membrane oxygenation," and "ECMO." Newcastle-Ottawa Scale (NOS) was used to assess the quality of the included research. We collected data using Microsoft Excel version 2016, mean and standard deviations were calculated for continuous data, while frequencies and percentages were calculated for binomial data. A total of three studies was included in the review with a total of 8,954 participants, of which 4,483 (50.06%) received antibiotic prophylaxis, and 1,131 (25.22%) were female. The administration of antibiotics prophylactically was associated with reduction in rate of mortality, the risk of infections, and complications like acute kidney injury and diarrhea. Although there have been some benefits on antibiotic prophylaxis, prospective research, and possibly the creation of tailored, ECMO-specific bundles will be needed to identify efficient ways to prevent ECMO infection.

Association between Impella device support and elevated rates of gout flares: a retrospective propensity-matched study

BACKGROUND

Impella is an advanced ventricular assist device frequently used as a bridge to heart transplantation. The association of Impella with increased rates of gout flares has not been studied. Our primary aim is to determine the rates of gout flares in patients on Impella support.

METHODOLOGY

A retrospective study was conducted between January 2017 and September 2022 involving all patients who underwent heart transplantation. The cohort was divided into two groups based on Impella support for statistical analysis. In patients receiving Impella support, outcome measures were compared based on the development of gout flares. 1:1 nearest neighbor propensity match, as well as inverse propensity of treatment weighted analyses, were performed to explore the causal relationship between impella use and gout flare in our study population.

RESULTS

Our analysis included 213 patients, among which 42 (19.71%) patients were supported by Impella. Impella and non-Impella groups had similar age, race, and BMI, but more males were in the Impella group. Gout and chronic kidney disease were more prevalent in Impella-supported patients, while coronary artery disease was less common. The prevalence of gout flare was significantly higher in Impella patients (30.9% vs. 5.3%). 42 Impella-supported patients were matched with 42 patients from the non-impella group upon performing a 1:1 propensity matching. Impella-supported patients were noted to have a significantly higher risk of gout flare (30.9% vs. 7.1%, SMD = 0.636), despite no significant difference in pre-existing gout history and use of anti-gout medications. Impella use was associated with a significantly increased risk of gout flare in unadjusted (OR 8.07), propensity-matched (OR 5.83), and the inverse propensity of treatment-weighted analysis (OR 4.21).

CONCLUSION

Our study is the first to identify the potential association between Impella support and increased rates of gout flares in hospitalized patients. Future studies are required to confirm this association and further elucidate the biological pathways. It is imperative to consider introducing appropriate measures to prevent and promptly manage gout flares in Impella-supported patients.

PROGNOSTIC PERFORMANCE OF SERIAL DETERMINATION OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY AND INTERVENTIONS SHOCK CLASSIFICATION IN ADULTS WITH CRITICAL ILLNESS

ABSTRACT

Purpose: The aim of the study is to evaluate whether serial assessment of shock severity can improve prognostication in intensive care unit (ICU) patients. Materials and Methods: This is a retrospective cohort of 21,461 ICU patient admissions from 2014 to 2018. We assigned the Society for Cardiovascular Angiography and Interventions (SCAI) Shock Stage in each 4-h block during the first 24 h of ICU admission; shock was defined as SCAI Shock stage C, D, or E. In-hospital mortality was evaluated using logistic regression. Results: The admission SCAI Shock stages were as follows: A, 39.0%; B, 27.0%; C, 28.9%; D, 2.6%; and E, 2.5%. The SCAI Shock stage subsequently increased in 30.6%, and late-onset shock developed in 30.4%. In-hospital mortality was higher in patients who had shock on admission (11.9%) or late-onset shock (7.3%) versus no shock (4.3%). Persistence of shock predicted higher mortality (adjusted OR = 1.09; 95% CI = 1.06-1.13, for each ICU block with shock). The mean SCAI Shock stage had higher discrimination for in-hospital mortality than the admission or maximum SCAI Shock stage. Dynamic modeling of the SCAI Shock classification improved discrimination for in-hospital mortality (C-statistic = 0.64-0.71). Conclusions: Serial application of the SCAI Shock classification provides improved mortality risk stratification compared with a single assessment on admission, facilitating dynamic prognostication.

Translating Policy to Practice: An Association Between Medicare Access and Children's Health Insurance Program Reauthorization Act Implementation and Palliative Care Consultations and Perioperative Mortality in Critical Care

OBJECTIVES

To evaluate the 30-day postoperative mortality and palliative care consultations in patients that underwent surgical procedures in the United States before and after Medicare Access and Children's Health Insurance Program Reauthorization Act (MACRA) implementation.

DESIGN

Retrospective, Observational cohort study.

SETTING

Secondary data were collected from the U.S. National Inpatient Sample, the largest hospital database in the country. The time span was from 2011 to 2019.

PATIENTS

Adult patients that electively underwent 1 of 19 major procedures.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was cumulative postoperative mortality in two study cohorts. The secondary outcome was palliative care use. We identified 4,900,451 patients and categorized them into two study cohorts: PreM: 2011-2014 ( n = 2,103,836) and PostM: 2016-2019 ( n = 2,796,615). Regression discontinuity estimates and multivariate analysis were used. Across all procedures, 149,372 patients (7.1%) and 156,610 patients (5%) died within 30 days of their index procedures in the PreM and PostM cohorts, respectively. There was no statistically significant increase in mortality rates around postoperative day (POD) 30 (POD 26-30 vs 31-35) for both cohorts. More patients had inpatient palliative consultations during POD 31-60 compared with POD 1-30 in PreM (8,533 of 2,081,207 patients [0.4%] vs 1,118 of 22,629 patients [4.9%]) and PostM (18,915 of 2,791,712 patients [0.7%] vs 417 of 4,903 patients [8.5%]). Patients were more likely to receive palliative care consultations during POD 31-60 compared with POD 1-30 in both the PreM (odds ratio [OR] 5.31; 95% CI, 2.22-8.68; p < 0.001) and the PostM (OR 7.84; 95% CI, 4.83-9.10; p < 0.001) cohorts.

CONCLUSIONS

We did not observe an increase in postoperative mortality after POD 30 before or after MACRA implementation. However, palliative care use markedly increased after POD 30. These findings should be considered hypothesis-generating because of several confounders.

Pneumothorax, pneumomediastinum, and subcutaneous emphysema in hospitalized COVID-19 patients: incidence, clinical characteristics, and outcomes

BACKGROUND

Limited data is available on the incidence and outcomes of pneumothorax (PTX), pneumomediastinum (PNM), and subcutaneous emphysema (SCE) in COVID-19 patients. This study aimed to investigate the characteristics of these complications in hospitalized COVID-19 patients.

RESEARCH DESIGN AND METHODS

A retrospective study was conducted, involving adult COVID-19 patients admitted to Mayo Clinic Florida from 03/2020-06/2022. Patients were divided into two groups based on the presence or absence of PTX/PNM/SCE.

RESULTS

1926 hospitalized patients with COVID-19 were included, of which 518 were admitted to the ICU. The incidence of PTX/PNM/SCE was 6.3%. Patients with these complications were more likely to be male, Asian, and unvaccinated. Conversely, they were less likely to have chronic obstructive pulmonary disease. Patients who developed PTX/PNM/SCE after 72 hours of admission were more likely to receive high-dose corticosteroids and for an extended duration. The affected group had an adjusted odds ratio for in-hospital mortality of 13.32 (95%CI, 8.19-21.59) and ICU admission of 9.14 (95%CI, 5.3-12.78) compared to the unaffected group.

CONCLUSION

Although the occurrence of PTX/PNM/SCE in hospitalized COVID-19 patients was rare, it was associated with worse outcomes. Corticosteroids may contribute to the pathogenesis of these complications; however, further studies are needed to investigate this relationship in more detail.

Life before Death in India: A Narrative Review

Palliative care is an ever-increasing need in India, with its large population and rising burden of chronic illness. India ranks 67th out of 80 countries in the quality of death index, which measures the availability and quality of palliative care. Community-led projects in Kerala have proven successful in improving palliative care access with modest resources and volunteer involvement. In India, the number of hospice facilities is increasing; however, <1% of the Indian population has access to palliative care. Financial and human resources limitations in the health-care system, poverty and high health-care expenditure, the lack of awareness among the public about end-of-life care, hesitance to seek care due to social stigma, strict laws regarding opiates that hinder adequate pain relief and the apparent conflict between traditional social values and western values regarding death are the major obstacles to improving palliative care. Significant efforts focused on public awareness of end-of-life care and locally-tailored programmes with family and community involvement are necessary to address this issue and integrate palliative care into the primary care system. Furthermore, we discuss the effects of the COVID-19 pandemic that has been managed effectively by palliative care involvement.

Updated Trends in Inferior Vena Cava Filter Use by Indication in the United States After Food and Drug Administration Safety Warnings: A Decade Analysis From 2010 to 2019

BACKGROUND

Overall inferior vena cava filter (IVCF) utilization has decreased in the United States since the 2010 US Food and Drug Administration (FDA) safety communication. The FDA renewed this safety warning in 2014 with additional mandates on reporting IVCF-related adverse events. We evaluated the impact of the FDA recommendations on IVCF placements for different indications from 2010 to 2019 and further assessed utilization trends by region and hospital teaching status.

METHODS

Inferior vena cava filter placements between 2010 and 2019 were identified in the Nationwide Inpatient Sample database using the associated International Classification of Diseases, Ninth Revision, Clinical Modification, and Tenth Revision codes. Inferior vena cava filter placements were categorized by indication for venous thromboembolism (VTE) "treatment" in patients with VTE diagnosis and contraindication to anticoagulation and "prophylaxis" in patients without VTE. Generalized linear regression was used to analyze utilization trends.

RESULTS

A total of 823 717 IVCFs were placed over the study period, of which 644 663 (78.3%) were for VTE treatment and 179 054 (21.7%) were for prophylaxis indications. The median age for both categories of patients was 68 years. The total number of IVCFs placed for all indications decreased from 129 616 in 2010 to 58 465 in 2019, with an aggregate decline rate of -8.4%. The decline rate was higher between 2014 and 2019 than between 2010 and 2014 (-11.6% vs -7.2%). From 2010 to 2019, IVCF placement for VTE treatment and prophylaxis trended downward at rates of -7.9% and -10.2%, respectively. Urban nonteaching hospitals saw the highest decline for both VTE treatment (-17.2%) and prophylactic indications (-18.0%). Hospitals located in the Northeast region had the highest decline rates for VTE treatment (-10.3%) and prophylactic indications (-12.5%).

CONCLUSION

The higher decline rate in IVCF placements between 2014 and 2019 compared with 2010 and 2014 suggests an additional impact of the renewed 2014 FDA safety indications on national IVCF utilization. Variations in IVCF use for VTE treatment and prophylactic indications existed across hospital teaching types, locations, and regions.

CLINICAL IMPACT

Inferior vena cava filters (IVCF) are associated with medical complications. The 2010 and 2014 FDA safety warnings appeared to have synergistically contributed to a significant decline in IVCF utilization rates from 2010 - 2019 in the US. IVC filter placements in patients without venous thromboembolism (VTE) declined at a higher rate than VTE. However, IVCF utilization varied across hospitals and geographical locations, likely due to the absence of universally accepted clinical guidelines on IVCF indications and use. Harmonization of IVCF placement guidelines is needed to standardize clinical practice, thereby reducing the observed regional and hospital variations and potential IVC filter overutilization.

Race affects adverse outcomes of deep vein thrombosis, pulmonary embolism, and acute kidney injury in coronavirus disease 2019 hospitalized patients

OBJECTIVE

The purpose of the present study was to explore the racial disparities in the incidence of deep vein thrombosis (DVT), pulmonary embolism (PE), and acute kidney injury (AKI) in hospitalized patients with coronavirus disease 2019 (COVID-19).

METHODS

A retrospective analysis was performed of prospectively collected data of consecutive COVID-19 patients hospitalized from March 11, 2020 to May 27, 2021. The primary outcome measures were the incidence of DVT/PE and mortality. The secondary outcome measures included differences in the length of hospitalization, need for intensive care unit care, readmission, and AKI. Multivariable regression models were used to assess for independent predictors of the primary and secondary outcome measures.

RESULTS

The present study included 876 hospitalized patients with COVID-19. The mean age was 64.4 ± 16.2 years, and 355 were women (40.5%). Of the 876 patients, 694 (79.2%) had identified as White, 111 (12.7%) as Black/African American, 48 (5.5%) as Asian, and 23 (2.6%) as other. The overall incidence of DVT/PE was 8.7%. The DVT/PE incidence rates differed across the race groups and was highest for Black/African American patients (n = 18; 16.2%), followed by Asian patients (n = 5; 10.4%), White patients (n = 52; 7.5%), and other (n = 1; 4.4%; P = .03). All but one of the hospitalization outcomes examined demonstrated no differences according to race, including the hospitalization stay (P = .33), need for intensive care unit care (P = .20), readmission rates (P = .52), and hospital all-cause mortality (P = .29). The AKI incidence differed among races, affecting a higher proportion of Black/African American patients (P=.003). On multivariable regression analysis, Black/African American race (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.0-4.0; P = .04) and higher D-dimer levels (OR, 1.1; 95% CI, 1.1-1.2; P < .0001) were predictors of DVT/PE. In addition, Black/African American race (OR, 2.3; 95% CI, 1.4-3.7; P = .001), lower hemoglobin levels (OR, 0.84; 95% CI, 0.8-0.9; P ≤ .0001), male sex (OR, 1.7; 95% CI, 1.2-2.4; P = .005), hypertension (OR, 2.1; 95% CI, 1.4-3.1; P = .0005), and older age (OR, 1.02; 95% CI, 1.006-1.03; P = .003) were predictors of AKI.

CONCLUSIONS

In our single-center case series, we found a higher incidence of DVT/PE and AKI among Black/African American patients with COVID-19. Black/African American race and D-dimer levels were independent predictors of DVT/PE, and Black/African American race, hemoglobin, and D-dimer levels were independent predictors of AKI.

Impact of colchicine on mortality and morbidity in COVID-19: a systematic review

INTRODUCTION

Colchicine, because of its anti-inflammatory and possible anti-viral properties, has been proposed as potential therapeutic option for COVID-19. The role of colchicine to mitigate "cytokine storm" and to decrease the severity and mortality associated with COVID-19 has been evaluated in many studies.

OBJECTIVE

To evaluate the role of colchicine on morbidity and mortality in COVID-19 patients.

METHODS

This systematic review was conducted in accordance with the PRISMA recommendations. The literature search was conducted in 6 medical databases from inception to February 17, 2021 to identify studies evaluating colchicine as a therapeutic agent in COVID-19. All included studies were evaluated for risk of bias (ROB) using the Revised Cochrane ROB tool for randomised controlled trials (RCTs) and Newcastle-Ottawa Scale (NOS) for case-control and cohort studies.

RESULTS

Four RCTs and four observational studies were included in the final analysis. One study evaluated colchicine in outpatients, while all others evaluated inpatient use of colchicine. There was significant variability in treatment protocols for colchicine and standard of care in all studies. A statistically significant decrease in all-cause mortality was observed in three observational studies. The risk of mechanical ventilation was significantly reduced only in one observational study. Length of hospitalisation was significantly reduced in two RCTs. Risk for hospitalisation was not significantly decreased in the study evaluating colchicine in outpatients. Very few studies had low risk of bias.

CONCLUSION

Based on the available data, colchicine shall not be recommended to treat COVID-19. Further high-quality and multi-center RCTs are required to assess the meaningful impact of this drug in COVID-19.KEY MESSAGESColchicine, an anti-inflammatory agent has demonstrated anti-viral properties in in-vitro studies by degrading the microtubules, as well as by inhibiting the production of pro-inflammatory cytokines.Colchicine has been studied as a potential therapeutic option for COVID-19, with variable results.Until further research can establish the efficacy of colchicine in COVID-19, the use of colchicine in COVID-19 shall be restricted to clinical trials.

Utilization trends and outcomes of catheter-directed thrombolysis for pulmonary embolism in the US by race/ethnicity

Contemporary data on catheter-directed thrombolysis (CDT) utilization trends and associated hospital outcomes in pulmonary embolism (PE) n the US is limited. Using the nationwide inpatient sample database, we identified patients hospitalized for acute PE treated with CDT from January 1, 2008, to December 31, 2018. Cochrane-Armitage test was used to evaluate the temporal trends in utilization, hospital mortality, and major bleeding rates. Multivariate logistic regression was used to compare differences in the outcomes across race/ethnicity, 4444 patients (unweighted hospitalizations) underwent CDT during the study period. The mean age ± standard deviation of the population was 58 ± 16 years and the majority were males (54%). 3269 (73.6%) patients were non-Hispanic White (NHW), 802 (18.0%) patients were non-Hispanic Black (NHB), and 373 (8.4%) patients were of 'other' races/ethnicities. There was a more than tenfold increase in CDT use in 2018 compared to 2008. The total mortality and bleeding rates were approximately 7 and 10% respectively. Hospital mortality rates trended down across all races/ethnicities during the study period. A similar downward trend in bleeding rates was noted in NHB only (28.6% vs 10.7%, p = 0.04). In-hospital mortality and major bleeding odds were comparable across all races/ethnicities were comparable. NHB patients and other races were more likely to require blood transfusion and incur higher hospitalization costs compared with NHW patients. CDT use increased significantly in the US during the study period with a corresponding downward trend in in-hospital mortality across all races, and bleeding rates in NHB.

Parents' perspective on COVID-19 vaccine in children 6 months through 4 years: a cross-sectional study from Northwest Wisconsin

Vaccination is critical to control the ongoing COVID-19 pandemic, but despite the availability of safe and effective vaccine in children over 5 years, vaccination rates remain low. There is paucity of data about vaccine acceptance and factors influencing parents' hesitancy about the COVID-19 vaccine for young children.

AIMS AND OBJECTIVES

To estimate vaccine acceptance by parents of children 6 months through 4 years, and to evaluate the factors influencing vaccine hesitancy.

METHODS

Electronic survey was sent to parents of children 6 months through 4 years through an online portal account at Mayo Clinic Health System, Northwest-Wisconsin. Data were captured via Research Electronic Data Capture secured data collection software. Bivariate and multivariate regression was used to determine most pertinent factors influencing parents' decisions against the outcome, 'Intent to Vaccinate'.

RESULTS

39.7% of the parents were 'very likely' or 'somewhat likely' to vaccinate their children once the vaccine became available, while 49.8% were not likely or highly unlikely to vaccinate. Routine childhood vaccination, receiving seasonal influenza vaccine, parents' perception of COVID-19 severity in children and safety and effectiveness of the vaccine were all associated with more vaccine acceptance. 71.4% of parents who will likely not vaccinate their children indicated that they are unlikely to change their decision. The need for more research on the vaccine and more information from the PCP office were the most common reasons behind the vaccine decision-making.

CONCLUSIONS

Vaccine hesitancy remains a major issue regarding uptake of the upcoming COVID-19 vaccine. Strong and clear evidence-based recommendations from primary care provider and more information from trusted websites such as Centers for Disease Control and Prevention can decrease vaccine hesitancy in parents. Further research targeted at understanding beliefs and perspectives of parents from different demographics can assist policy-makers in implementing measures to improve vaccination rates in children and tailor our dialogue to match the needs of our patients and families.

A Systematic Review and Meta-Analysis on Racial Disparities in Deep Venous Thrombosis and Pulmonary Embolism Events in COVID-19 Hospitalized Patients

Objective

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of venous thromboembolism (VTE). Recent studies have characterized racial disparities in the incidence of VTE. The aim of our study was to present a systematic review and meta-analysis to assess the association between race and VTE in patients hospitalized with COVID-19.

Methods

We performed a systematic literature review to evaluate the number of deep vein thrombosis (DVT) and pulmonary embolism (PE) events reported by racial groups in patients hospitalized with COVID-19. For the qualitative analysis, independent reviewers extracted the data from eligible studies, and we used the Newcastle-Ottawa scale to assess the quality of design and content for accurate interpretation. For the quantitative analysis, we pooled the odds ratios with Der Simonian and Laird random effects models.

Results

The qualitative analysis included 11 studies, with 6 included in the meta-analysis. All studies were observational, retrospective cohort studies, except for one retrospective case-control study. Six studies were eligible for the meta-analysis owing to the high interstudy heterogeneity; thus, the variable reports of racial groups reduced the cohort to Black/African American and White patients (n = 9723) in the analysis. The estimated proportion for DVT and PE events for Black/African American and White patients was 0.07 (95% confidence interval, 0.00-0.10) and 0.04 (95% confidence interval, 0.00-0.07), respectively. The P value of .13 suggested nonsignificant differences in the VTE rates between Black/African American and White patients.

Conclusions

In our study, the proportion of DVT and PE events between Black/African American and White patients with COVID-19 were comparable. Future COVID-19 studies should include systematic racial group reporting to identify any disparities in the setting of VTE events.

SARS-CoV-2 infection increases risk of acute kidney injury in a bimodal age distribution

BACKGROUND

Hospitalized patients with SARS-CoV2 develop acute kidney injury (AKI) frequently, yet gaps remain in understanding why adults seem to have higher rates compared to children. Our objectives were to evaluate the epidemiology of SARS-CoV2-related AKI across the age spectrum and determine if known risk factors such as illness severity contribute to its pattern.

METHODS

Secondary analysis of ongoing prospective international cohort registry. AKI was defined by KDIGO-creatinine only criteria. Log-linear, logistic and generalized estimating equations assessed odds ratios (OR), risk differences (RD), and 95% confidence intervals (CIs) for AKI and mortality adjusting for sex, pre-existing comorbidities, race/ethnicity, illness severity, and clustering within centers. Sensitivity analyses assessed different baseline creatinine estimators.

RESULTS

Overall, among 6874 hospitalized patients, 39.6% (n = 2719) developed AKI. There was a bimodal distribution of AKI by age with peaks in older age (≥60 years) and middle childhood (5-15 years), which persisted despite controlling for illness severity, pre-existing comorbidities, or different baseline creatinine estimators. For example, the adjusted OR of developing AKI among hospitalized patients with SARS-CoV2 was 2.74 (95% CI 1.66-4.56) for 10-15-year-olds compared to 30-35-year-olds and similarly was 2.31 (95% CI 1.71-3.12) for 70-75-year-olds, while adjusted OR dropped to 1.39 (95% CI 0.97-2.00) for 40-45-year-olds compared to 30-35-year-olds.

CONCLUSIONS

SARS-CoV2-related AKI is common with a bimodal age distribution that is not fully explained by known risk factors or confounders. As the pandemic turns to disproportionately impacting younger individuals, this deserves further investigation as the presence of AKI and SARS-CoV2 infection increases hospital mortality risk.

Resolution of Acute Pulmonary Embolism using anticoagulation therapy alone in Coronavirus Disease 2019

Objective

Methods

Results

Conclusions

Hydroxychloroquine: a comprehensive review and its controversial role in coronavirus disease 2019

Hydroxychloroquine, initially used as an antimalarial, is used as an immunomodulatory and anti-inflammatory agent for the management of autoimmune and rheumatic diseases such as systemic lupus erythematosus. Lately, there has been interest in its potential efficacy against severe acute respiratory syndrome coronavirus 2, with several speculated mechanisms. The purpose of this review is to elaborate on the mechanisms surrounding hydroxychloroquine. The review is an in-depth analysis of the antimalarial, immunomodulatory, and antiviral mechanisms of hydroxychloroquine, with detailed and novel pictorial explanations. The mechanisms of hydroxychloroquine are related to potential cardiotoxic manifestations and demonstrate potential adverse effects when used for coronavirus disease 2019 (COVID-19). Finally, current literature associated with hydroxychloroquine and COVID-19 has been analyzed to interrelate the mechanisms, adverse effects, and use of hydroxychloroquine in the current pandemic. Currently, there is insufficient evidence about the efficacy and safety of hydroxychloroquine in COVID-19. KEY MESSAGES HCQ, initially an antimalarial agent, is used as an immunomodulatory agent for managing several autoimmune diseases, for which its efficacy is linked to inhibiting lysosomal antigen processing, MHC-II antigen presentation, and TLR functions. HCQ is generally well-tolerated although severe life-threatening adverse effects including cardiomyopathy and conduction defects have been reported. HCQ use in COVID-19 should be discouraged outside clinical trials under strict medical supervision.

V.I.T.A.M. in COVID 19: A Systematic Approach to a Global Pandemic

Introduction

In the unprecedented era of COVID-19, ongoing research and evolution of evidence has led to ever-changing guidelines for clinical monitoring and therapeutic options. Formulating treatment protocols requires the understanding and application of the evolving research.

Objective

The primary objective of this study is to present a systematic evidence-based approach to synthesize the necessary data in order to optimize the management of COVID-19.

Methods

At Mayo Clinic Florida, we developed a multidisciplinary centralized COVID Treatment Review Panel (TRP) of expert pulmonologists, intensivists, infectious disease specialists, anesthesiologists, hematologists, rheumatologists, and hospitalists that in real-time reviews the latest evidence in peer-reviewed journals, the available clinical trials, and help guide the rapid application of therapeutics or interventions to the patient and the bedside provider.

Results/Conclusions

The multi-disciplinary team approach of synthesizing clinical data and coordinating care is effective in responding to rapidly evolving and changing evidence. Systematic data collection and evidence-based treatment algorithms enable physicians to rapidly translate the current literature to clinical practice, and improve care and outcomes of patients.

Novel repurposing of a Laerdal Airway trainer to simulate aerosolisation

COVID-19 has claimed over 200 000 lives in the USA and put healthcare workers at risk. Healthcare workers have an increased exposure risk from aerosol-generating procedures such as endotracheal intubation. New barrier designs such as the acrylic box and horizontal plastic drape have emerged to reduce exposure to airborne particles. Particle generating models are needed to test aerosol generating procedure (AGP) barrier designs. To achieve this, an aerosol model that generates a visible and measurable increase in particles which SARS-CoV-2 could travel on and that can also be intubated was created. The model was created using a Laerdal Airway Management Trainer (Laerdal Medical, Stavanger, Norway) combined with a nebuliser and Ambu bag-valve resuscitator (Ambu, Columbia, Maryland, USA). Nebulised Glo Germ (Glo Germ, Moab, Utah, USA) dissolved in saline solution was moved through the tubing and out of the mannequin’s mouth with compression of the Ambu bag. This nebulisation was visualised under ultraviolet light and the quantity of particles between 0.3 and 10.0 μm was measured with a particle counter. Nebulisation was visible exiting the mouth of the mannequin. Nebulised Glo Germ was visualised under ultraviolet light moving in the ambient air. Particles in the size range of 0.3–0.5 µm increased by 20-fold and 1–10 µm increased by 10 252%. SARS-CoV-2 can travel on aerosol and droplet particles and particle generating models are needed to visualise and measure exposure areas and the path particles take during AGPs. We used existing medical and simulation supplies to create a particle simulator.

Fixed-rate insulin for adult diabetic ketoacidosis is associated with more frequent hypoglycaemia than rate-reduction method: a retrospective cohort study

OBJECTIVE

To assess whether hypoglycaemia incidence during management of adult diabetic ketoacidosis (DKA) differed following transition from a fixed-rate insulin protocol to a protocol using an empiric insulin rate reduction after normoglycaemia.

METHODS

We retrospectively reviewed charts from adult patients managed with a DKA order set before and after order set revision. In cohort 1 (n = 77), insulin rate was 0.1 unit/kg/h with no adjustments and dextrose was infused at 12.5 g/h after glucose reached 250 mg/dl. In cohort 2 (n = 78), insulin was reduced to 0.05 unit/kg/h concurrent with dextrose initiation at 12.5 g/h after glucose reached 200 mg/dl. The primary outcome was hypoglycaemia (glucose < 70 mg/dl) within 24 h of the first order for insulin.

KEY FINDINGS

The 24-h incidence of hypoglycaemia was 19.2% in cohort 2 versus 32.5% in cohort 1; the adjusted odds ratio was 0.46 (95% confidence interval (CI) [0.21, 0.98]; P = 0.047). The 24-h use of dextrose 50% in water (D50W) was also reduced in cohort 2. No differences were seen in anion gap or bicarbonate normalization, rebound hyperglycaemia or ICU length of stay. In most patients who became hypoglycaemic, the preceding glucose value was below 100 mg/dl.

CONCLUSIONS

The insulin rate-reduction protocol was associated with less hypoglycaemia and no obvious disadvantage. Robust intervention for low-normal glucose values could plausibly achieve low hypoglycaemia rates with either approach.

Impact of Telemedicine Monitoring of Community ICUs on Interhospital Transfers

OBJECTIVES

To study the effects of tele-ICU monitoring on interhospital transfers from community-based ICUs to the quaternary care hospital at Mayo Clinic, Rochester, MN.

DESIGN

This is a retrospective review of data on interhospital transfers comparing trends prior to tele-ICU implementation to those following implementation.

SETTING

Tele-ICU programs are increasingly utilized to fill resource gaps in caring for critically ill patients. How such programs impact population and bed management within a healthcare system are not known. Mayo Clinic serves as quaternary referral care center for hospitals in the region within the Mayo Clinic Health System. In August 2013, we implemented tele-ICU monitoring at six Mayo Clinic Health System hospital ICUs.

SUBJECTS

All adult ICU admissions during the study period (preimplementation phase: January 1, 2012, to December 31, 2012; and postimplementation phase: January 1, 2014, to December 31, 2014) in any of the six specified community ICUs were included in the study.

MEASUREMENTS AND MAIN RESULTS

Interhospital transfers significantly increased post institution of tele-ICU (p = 0.040) and was attributed primarily to transfer from less specialized ICUs (p = 0.037) as compared with more resource-intensive ICUs (p = 0.88). However, for such patient transfers, there were no significant differences before and after severity of illness scores, ICU mortality, or inhospital mortality.

CONCLUSION

In a regional healthcare system, implementation of a tele-ICU program is associated with an increase in interhospital transfers from less resourced ICUs to the referral center, a trend that is not readily explained by increased severity of illness.

Recurrent nitrofurantoin-induced giant cell interstitial pneumonia: Case report and literature review

Giant cell interstitial pneumonia (GIP) is a rare form of chronic interstitial pneumonia typically associated with hard metal exposure. Only two cases of GIP induced by nitrofurantoin have been reported in the medical literature. We are reporting a case of recurrent nitrofurantoin-induced GIP. Although extremely rare, GIP needs to be included in the differential diagnosis in patients with chronic nitrofurantoin use who present with respiratory illness.

Acinetobacter baumannii bacteremia, a rare complication of endoscopic retrograde cholagiopancreatography!

Bacteremia is a severe and sometimes fatal complication following endoscopic retrograde cholagiopancreatography (ERCP). Several bacteria have been implicated, with Enterobacteriaceae being the most common. We report a case of post-ERCP multi-drug resistant Acinetobacter baumannii bacteremia.

Association of Holter-based measures including T-wave alternans with risk of sudden cardiac death in the community-dwelling elderly: the Cardiovascular Health Study

BACKGROUND

Sudden cardiac death (SCD) can be the first manifestation of cardiovascular disease. Development of screening methods for higher/lower risk is critical.

METHODS

The Cardiovascular Health Study is a population-based study of risk factors for coronary heart disease and stroke those 65 years or older. Forty-nine (of 1649) with usable Holters and in normal sinus rhythm had SCD during follow-up and were matched with 2 controls, alive at the time of death of the case and not experiencing SCD on follow-up. Univariate and multivariate conditional logistic regression determined the association of Holter-based information and SCD.

RESULTS

In univariate models, the upper half of ventricular premature contraction (VPC) counts, abnormal heart rate turbulence, decreased normalized low-frequency power, increased T-wave alternans (TWA), and decreased the short-term fractal scaling exponent (DFA(1)) were associated with SCD, but time domain heart rate variability was not. In multivariate models, the upper half of VPC counts (odds ratio [OR], 6.6) and having TWA of 37 muV or greater on channel 2 (OR, 4.8) were independently associated with SCD. Also, the upper half of VPC counts (OR, 6.9) and having a DFA(1) of less than 1.05 (OR, 5.0) were independently associated with SCD. When additive effects were explored, having both higher VPCs and higher TWA was associated with an OR of 8.2 for SCD compared with 2.6 for having either. Also, having both higher VPCs and lower DFA(1) was associated with an OR of 9.6 for SCD compared with 3.1 for having either.

CONCLUSIONS

Results support a potential role for 24-hour Holter recordings to identify older adults at increased or lower risk of SCD.