Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study

OBJECTIVE

To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients.

DESIGN

Retrospective, single-center observational study.

SETTING

Intensive Care Medicine.

PATIENTS

AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC).

INTERVENTIONS

Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated.

MAIN VARIABLES OF INTEREST

Reasons for switching, NIRS failure and mortality rates.

RESULTS

A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2-8] vs. 12 [8-30] days, p = 0.001).

CONCLUSIONS

NIRS combination is used in real life and both switches' strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.

ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumonia

BACKGROUND

Severe community-acquired pneumonia (sCAP) is associated with high morbidity and mortality, and while European and non-European guidelines are available for community-acquired pneumonia, there are no specific guidelines for sCAP.

MATERIALS AND METHODOLOGY

The European Respiratory Society (ERS), European Society of Intensive Care Medicine (ESICM), European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and Latin American Thoracic Association (ALAT) launched a task force to develop the first international guidelines for sCAP. The panel comprised a total of 18 European and four non-European experts, as well as two methodologists. Eight clinical questions for sCAP diagnosis and treatment were chosen to be addressed. Systematic literature searches were performed in several databases. Meta-analyses were performed for evidence synthesis, whenever possible. The quality of evidence was assessed with GRADE (Grading of Recommendations, Assessment, Development and Evaluation). Evidence to Decision frameworks were used to decide on the direction and strength of recommendations.

RESULTS

Recommendations issued were related to diagnosis, antibiotics, organ support, biomarkers and co-adjuvant therapy. After considering the confidence in effect estimates, the importance of outcomes studied, desirable and undesirable consequences of treatment, cost, feasibility, acceptability of the intervention and implications to health equity, recommendations were made for or against specific treatment interventions.

CONCLUSIONS

In these international guidelines, ERS, ESICM, ESCMID and ALAT provide evidence-based clinical practice recommendations for diagnosis, empirical treatment and antibiotic therapy for sCAP, following the GRADE approach. Furthermore, current knowledge gaps have been highlighted and recommendations for future research have been made.

Molar-incisor hypomineralisation: an updated view for aetiology 20 years later

BACKGROUND

The term Molar-Incisor Hypomineralisation (MIH) was introduced in 2001 by Weerheijm, Jälevik and Alaluusua, and describes a defect of systemic origin that affects one to four first permanent molars, often associated with permanent incisors. In the past 20 years, this definition dictated the work regarding MIH prevalence, associated risk factors, association with dental caries, impact on quality of life, and therapeutic options.

PURPOSE

In this report, we offer an updated and comprehensive view of MIH centred on the patient and the tooth.

CONCLUSION

MIH today is globally recognized as a potential public health problem and it is not a defect of purely systemic origin but rather a condition with complex aetiology that in some instances may be the result of gene-environmental interactions.

Early Documentation of Life-Sustaining Treatment Orders Prior to Diagnosis of COVID-19 in Nursing Home Residents

Public health guidelines to prevent spreading COVID-19 place older adults at risk of loneliness and social isolation. Evidence suggests that participation protects older adults from such detrimental outcomes, therefore we aimed to identify the factors associated with participation in life roles among older adults living in the community during the COVID-19 pandemic. We conducted a telesurvey on a random sample of community-dwelling older adults living in Hamilton, Ontario, Canada, between May and July 2020. Outcome measures included participation in life roles, physical function, physical activity, mobility, mental health, nutrition, and demographics. We conducted two multivariate regression analyses with the Late Life Disability Instrument’s (LLDI) frequency and limitations scales as the dependent variables. Candidate factors were organized by International Classification of Functioning, Disability, and Health (ICF) framework domains; personal factors, body functions and structures, activities, and environmental factors. A total of 272 older adults completed the telesurvey (mean age 78 ±7.3 yrs, 70% female). Age, using walking aids, driving status, household income, education, mental health, nutrition, physical function, and dwelling type explained 47.1% (p<0.001) of the variance observed in LLDI frequency scores. Using walking aids, driving status, receiving health assistance, mental health, and physical function explained 33.9% (p<0.001) of the variance observed in LLDI limitation scores. These findings highlight factors from multiple ICF domains that are associated with participation limitation and frequency among older adults during the pandemic. Our findings have implications for developing public health initiatives to mitigate the effects of the pandemic on the participation of older adults.

Hospital in Home COVID-19 Monitoring: A Novel Approach to Keeping a Watchful Eye on Older Adults

Older adults suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are at increased risk of death and hospitalization-related complications. The coronavirus disease 2019 (COVID-19) pandemic has forced adaptations in Telehealth, allowing COVID-19 patients to be managed at home. Traditionally, Hospital in Home (HIH) patients have better clinical outcomes and lower mortality compared to similar hospitalized patients. However, effectiveness of HIH for COVID-19 older adults remains unknown. This study examines the effect of age on rates of hospital readmission and overall mortality for patients enrolled in HIH after initial COVID-19 hospital discharge. A HIH COVID-19 monitoring program was developed to facilitate earlier hospital discharge and monitoring. Retrospective data between March 2020 and January 2021 were analyzed. Of the 402 subjects (age:26-99; mean:61.8), 13 (6.1%) subjects <65 years old vs 19 (10%) subjects □65 years old were readmitted to the hospital at least once. Two (0.94%) subjects <65 years old and 12 (6.3%) subjects □65 years old died. Older adults were 1.719 times more likely to be re-hospitalized (p=0.005) and 7.153 times more likely to die (p=0.017) compared to younger adults. Age remains a significant predictor of hospital readmission and mortality in subjects previously hospitalized for COVID-19 even when followed by monitoring programs like HIH. Further studies are needed to determine the best way to reduce hospital readmission and mortality rates for older adults after initial COVID-19 hospital discharge.

Urban versus Rural Prevalence of Intestinal Parasites Using Multi-Parallel qPCR in Colombia

Stool samples from 122 children living in an urban slum (n = 72) and rural (n = 50) areas were analyzed using multi-parallel real-time quantitative PCR to determine intestinal prevalence parasites from two communities in Colombia. Findings indicated a prevalence of 86.1% Blastocystis spp., 62.5% Giardia intestinalis, 19.4% Cryptosporidium spp., 19.4% Ascaris lumbricoides, and 5.6% Trichuris trichiura in an urban slum; and 76% Blastocystis spp., 68% G. intestinalis, 20% Entamoeba histolytica, 50% A. lumbricoides, 46% T. trichiura, and 2% Strongyloides stercoralis in rural areas. Polyparasitism was higher in rural (58%) than urban (25%) areas (P = 0.001). Trichuris trichiura burden was higher in the rural area (P = 0.002). Over 40% of helminthic infections in rural areas had a heavy parasite burden by WHO classification. Over half of urban and rural children were infected with G. intestinalis and Blastocystis spp. Our data provide accurate epidemiologic surveillance for public health interventions.

Aesthetic perception in children with molar incisor hypomineralization

PURPOSE

To investigate the relationship between aesthetic perception and molar incisor hypomineralization (MIH) in schoolchildren aged 8-12 years.

METHODS

The study included 467 pupils enrolled in elementary schools. Once authorization was received, the students were examined for DMFT and dmft indexes (WHO criteria), and for MIH (EAPD criteria). The aesthetic perceptions were verified by the Child Perceptions Questionnaire About Tooth Appearance (CQATA), a questionnaire divided into several items, including physical, psychological and social domains; perception about tooth pleasantness, tooth alignment, tooth discoloration and tooth health; and reported pleasant colour. Data analysis was carried out using descriptive statistics, the Chi-square, the Mann-Whitney and the Kruskal-Wallis tests, and linear regression at a significance level of 0.05.

RESULTS

The tooth health perception was worse when the child had MIH, and the tooth alignment and tooth discoloration perceptions, when MIH affected the incisors. The number of teeth affected by MIH was associated with higher averages in the tooth discoloration perception.

CONCLUSIONS

Children with MIH showed more negative perceptions toward tooth health, tooth alignment and tooth discoloration. However, none of the clinically investigated variables negatively impacted the reported pleasant colour question.

Increasing Prevalence of Chronic Lung Disease in Veterans of the Wars in Iraq and Afghanistan

Research from the wars in Afghanistan and Iraq have focused on traumatic brain injury (TBI) and mental health conditions; however, it is becoming clear that other health concerns, such as respiratory illnesses, warrant further scientific inquiry. Early reports from theater and postdeployment health assessments suggested an association with deployment-related exposures (e.g., sand, burn pits, chemical, etc.) and new-onset respiratory symptoms. We used data from Veterans Affairs medical encounters between fiscal years 2003 and 2011 to identify trends in chronic obstructive pulmonary disease, asthma, and interstitial lung disease in veterans. We used data from Veterans Affairs and Department of Defense sources to identify sociodemographic (age, sex, race), military (e.g., service branch, multiple deployments) and clinical characteristics (TBI, smoking) of individuals with and without chronic lung diseases. Generalized estimating equations found significant increases over time for chronic obstructive pulmonary disease and asthma in both unadjusted and adjusted analyses. Trends for interstitial lung disease were significant only in adjusted analyses. Age, smoking, and TBI were also significantly associated with chronic lung diseases; however, multiple deployments were not associated. Research is needed to identify which characteristics of deployment-related exposures are linked with chronic lung disease.

Tools for outcome prediction in patients with community acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is one of the most common causes of mortality world-wide. The mortality rate of patients with CAP is influenced by the severity of the disease, treatment failure and the requirement for hospitalization and/or intensive care unit (ICU) management, all of which may be predicted by biomarkers and clinical scoring systems. Areas covered: We review the recent literature examining the efficacy of established and newly-developed clinical scores, biological and inflammatory markers such as C-Reactive protein (CRP), procalcitonin (PCT) and Interleukin-6 (IL-6), whether used alone or in conjunction with clinical severity scores to assess the severity of CAP, predict treatment failure, guide acute in-hospital or ICU admission and predict mortality. Expert commentary: The early prediction of treatment failure using clinical scores and biomarkers plays a developing role in improving survival of patients with CAP by identifying high-risk patients requiring hospitalization or ICU admission; and may enable more efficient allocation of resources. However, it is likely that combinations of scoring systems and biomarkers will be of greater use than individual markers. Further larger studies are needed to corroborate the additive value of these markers to clinical prediction scores to provide a safer and more effective assessment tool for clinicians.

Tripanosomiasis americana, una mirada desde el tratamiento

La tripanosomiasis americana o enfermedad de Chagas es una infección parasitaria causada por el parásito flagelado Trypanosoma cruzi, cuyo principal vector es un insecto de la clase hemíptera conocido como triatomino. La quimioterapia, adicional a un control oportuno de vectores y rigurosidad en el control de las transfusiones, son los elementos más importantes para el manejo de esta parasitosis. En la actualidad, el mercado farmacéutico solo ofrece nifurtimox y benznidazol como opciones terapéuticas, y a pesar de que se han obtenido resultados satisfactorios con el uso de estos medicamentos en fases agudas de la enfermedad, tripanosomiasis congénita y accidentes de laboratorio, la efectividad en las fases crónicas es notoriamente menor. Además, ambos fármacos generan ciertos efectos adversos que deben ser tenidos en cuenta por el personal de la salud, antes de iniciar el debido manejo de esta enfermedad. El objetivo del presente artículo es revisar el estado actual del tratamiento farmacológico de la tripanosomiasis americana, buscando resumir los nuevos avances terapéuticos y dar a conocer las limitaciones de los mismos debido a sus efectos adversos.