Biomarker-Concordant Steroid Administration in Severe Coronavirus Disease-2019

BACKGROUND

Although corticosteroids have become the standard of care for patients with coronavirus disease-2019 (COVID-19) on supplemental oxygen, there is growing evidence of differential treatment response. This study aimed to evaluate if there was an association between biomarker-concordant corticosteroid treatment and COVID-19 outcomes.

METHODS

This registry-based cohort study included adult COVID-19 hospitalized patients between January 2020 and December 2021 from 109 institutions. Patients with available C-reactive protein (CRP) levels within 48 h of admission were evaluated. Those on steroids before admission, stayed in the hospital for <48 h, or were not on oxygen support were excluded. Corticosteroid treatment was biomarker-concordant if given with high baseline CRP ≥150 mg/L or withheld with low CRP (<150 mg/L) and vice-versa was considered discordant (low CRP with steroids, high CRP without steroids). Hospital mortality was the primary outcome. Sensitivity analyses were conducted using varying CRP level thresholds. The model interaction was tested to determine steroid effectiveness with increasing CRP levels.

RESULTS

Corticosteroid treatment was biomarker-concordant in 1778 (49%) patients and discordant in 1835 (51%). The concordant group consisted of higher-risk patients than the discordant group. After adjusting for covariates, the odds of in-hospital mortality were significantly lower in the concordant group than the discordant (odds ratio [95% confidence interval (C.I.)] = 0.71 [0.51, 0.98]). Similarly, adjusted mortality difference was significant at the CRP thresholds of 100 and 200 mg/L (odds ratio [95% C.I.] = 0.70 [0.52, 0.95] and 0.57 [0.38, 0.85], respectively), and concordant steroid use was associated with lower need for invasive ventilation for 200 mg/L threshold (odds ratio [95% C.I.] = 0.52 [0.30, 0.91]). In contrast, no outcome benefit was observed at CRP threshold of 50. When the model interaction was tested, steroids were more effective at reducing mortality as CRP levels increased.

CONCLUSION

Biomarker-concordant corticosteroid treatment was associated with lower odds of in-hospital mortality in severe COVID-19.

Validation of automated data abstraction for SCCM discovery VIRUS COVID-19 registry: practical EHR export pathways (VIRUS-PEEP)

Background

The gold standard for gathering data from electronic health records (EHR) has been manual data extraction; however, this requires vast resources and personnel. Automation of this process reduces resource burdens and expands research opportunities.

Objective

This study aimed to determine the feasibility and reliability of automated data extraction in a large registry of adult COVID-19 patients.

Materials and methods

This observational study included data from sites participating in the SCCM Discovery VIRUS COVID-19 registry. Important demographic, comorbidity, and outcome variables were chosen for manual and automated extraction for the feasibility dataset. We quantified the degree of agreement with Cohen's kappa statistics for categorical variables. The sensitivity and specificity were also assessed. Correlations for continuous variables were assessed with Pearson's correlation coefficient and Bland-Altman plots. The strength of agreement was defined as almost perfect (0.81-1.00), substantial (0.61-0.80), and moderate (0.41-0.60) based on kappa statistics. Pearson correlations were classified as trivial (0.00-0.30), low (0.30-0.50), moderate (0.50-0.70), high (0.70-0.90), and extremely high (0.90-1.00).

Measurements and main results

The cohort included 652 patients from 11 sites. The agreement between manual and automated extraction for categorical variables was almost perfect in 13 (72.2%) variables (Race, Ethnicity, Sex, Coronary Artery Disease, Hypertension, Congestive Heart Failure, Asthma, Diabetes Mellitus, ICU admission rate, IMV rate, HFNC rate, ICU and Hospital Discharge Status), and substantial in five (27.8%) (COPD, CKD, Dyslipidemia/Hyperlipidemia, NIMV, and ECMO rate). The correlations were extremely high in three (42.9%) variables (age, weight, and hospital LOS) and high in four (57.1%) of the continuous variables (Height, Days to ICU admission, ICU LOS, and IMV days). The average sensitivity and specificity for the categorical data were 90.7 and 96.9%.

Conclusion and relevance

Our study confirms the feasibility and validity of an automated process to gather data from the EHR.

Facilitators and Barriers to Interacting With Clinical Decision Support in the ICU: A Mixed-Methods Approach

OBJECTIVES

Clinical decision support systems (CDSSs) are used in various aspects of healthcare to improve clinical decision-making, including in the ICU. However, there is growing evidence that CDSS are not used to their full potential, often resulting in alert fatigue which has been associated with patient harm. Clinicians in the ICU may be more vulnerable to desensitization of alerts than clinicians in less urgent parts of the hospital. We evaluated facilitators and barriers to appropriate CDSS interaction and provide methods to improve currently available CDSS in the ICU.

DESIGN

Sequential explanatory mixed-methods study design, using the BEhavior and Acceptance fRamework.

SETTING

International survey study.

PATIENT/SUBJECTS

Clinicians (pharmacists, physicians) identified via survey, with recent experience with clinical decision support.

INTERVENTIONS

An initial survey was developed to evaluate clinician perspectives on their interactions with CDSS. A subsequent in-depth interview was developed to further evaluate clinician (pharmacist, physician) beliefs and behaviors about CDSS. These interviews were then qualitatively analyzed to determine themes of facilitators and barriers with CDSS interactions.

MEASUREMENTS AND MAIN RESULTS

A total of 48 respondents completed the initial survey (estimated response rate 15.5%). The majority believed that responding to CDSS alerts was part of their job (75%) but felt they experienced alert fatigue (56.5%). In the qualitative analysis, a total of five facilitators (patient safety, ease of response, specificity, prioritization, and feedback) and four barriers (excess quantity, work environment, difficulty in response, and irrelevance) were identified from the in-depth interviews.

CONCLUSIONS

In this mixed-methods survey, we identified areas that institutions should focus on to improve appropriate clinician interactions with CDSS, specific to the ICU. Tailoring of CDSS to the ICU may lead to improvement in CDSS and subsequent improved patient safety outcomes.

Caring for Critically Ill Children With the ICU Liberation Bundle (ABCDEF): Results of the Pediatric Collaborative

OBJECTIVES

Assess clinical outcomes following PICU Liberation ABCDEF Bundle utilization.

DESIGN

Prospective, multicenter, cohort study.

SETTING

Eight academic PICUs.

PATIENTS

Children greater than 2 months with expected PICU stay greater than 2 days and need for mechanical ventilation (MV).

INTERVENTIONS

ABCDEF Bundle implementation.

MEASUREMENT AND MAIN RESULTS

Over an 11-month period (3-mo baseline, 8-mo implementation), Bundle utilization was measured for 622 patients totaling 5,017 PICU days. Risk of mortality was quantified for 532 patients (4,275 PICU days) for correlation between Bundle utilization and MV duration, PICU length of stay (LOS), delirium incidence, and mortality. Utilization was analyzed as subject-specific (entire PICU stay) and day-specific (single PICU day). Median overall subject-specific utilization increased from 50% during the 3-month baseline to 63.9% during the last four implementation months (p < 0.001). Subject-specific utilization for elements A and C did not change; utilization improved for B (0-12.5%; p = 0.007), D (22.2-61.1%; p < 0.001), E (17.7-50%; p = 0.003), and F (50-79.2%; p = 0.001). We observed no association between Bundle utilization and MV duration, PICU LOS, or delirium incidence. In contrast, on adjusted analysis, every 10% increase in subject-specific utilization correlated with mortality odds ratio (OR) reduction of 34%, p < 0.001; every 10% increase in day-specific utilization correlated with a mortality OR reduction of 1.4% (p = 0.006).

CONCLUSIONS

ABCDEF Bundle is applicable to children. Although enhanced Bundle utilization correlated with decreased mortality, increased utilization did not correlate with duration of MV, PICU LOS, or delirium incidence. Additional research in the domains of comparative effectiveness, implementation science, and human factors engineering is required to understand this clinical inconsistency and optimize PICU Liberation concept integration into clinical practice.

A Path to Real-World Evidence in Critical Care Using Open-Source Data Harmonization Tools

COVID-19 highlighted the need for use of real-world data (RWD) in critical care as a near real-time resource for clinical, research, and policy efforts. Analysis of RWD is gaining momentum and can generate important evidence for policy makers and regulators. Extracting high quality RWD from electronic health records (EHRs) requires sophisticated infrastructure and dedicated resources. We sought to customize freely available public tools, supporting all phases of data harmonization, from data quality assessments to de-identification procedures, and generation of robust, data science ready RWD from EHRs. These data are made available to clinicians and researchers through CURE ID, a free platform which facilitates access to case reports of challenging clinical cases and repurposed treatments hosted by the National Center for Advancing Translational Sciences/National Institutes of Health in partnership with the Food and Drug Administration. This commentary describes the partnership, rationale, process, use case, impact in critical care, and future directions for this collaborative effort.

Perceived Hospital Stress, Severe Acute Respiratory Syndrome Coronavirus 2 Activity, and Care Process Temporal Variance During the COVID-19 Pandemic

OBJECTIVES

The COVID-19 pandemic threatened standard hospital operations. We sought to understand how this stress was perceived and manifested within individual hospitals and in relation to local viral activity.

DESIGN

Prospective weekly hospital stress survey, November 2020-June 2022.

SETTING

Society of Critical Care Medicine's Discovery Severe Acute Respiratory Infection-Preparedness multicenter cohort study.

SUBJECTS

Thirteen hospitals across seven U.S. health systems.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed 839 hospital-weeks of data over 85 pandemic weeks and five viral surges. Perceived overall hospital, ICU, and emergency department (ED) stress due to severe acute respiratory infection patients during the pandemic were reported by a mean of 43% ( sd , 36%), 32% (30%), and 14% (22%) of hospitals per week, respectively, and perceived care deviations in a mean of 36% (33%). Overall hospital stress was highly correlated with ICU stress (ρ = 0.82; p < 0.0001) but only moderately correlated with ED stress (ρ = 0.52; p < 0.0001). A county increase in 10 severe acute respiratory syndrome coronavirus 2 cases per 100,000 residents was associated with an increase in the odds of overall hospital, ICU, and ED stress by 9% (95% CI, 5-12%), 7% (3-10%), and 4% (2-6%), respectively. During the Delta variant surge, overall hospital stress persisted for a median of 11.5 weeks (interquartile range, 9-14 wk) after local case peak. ICU stress had a similar pattern of resolution (median 11 wk [6-14 wk] after local case peak; p = 0.59) while the resolution of ED stress (median 6 wk [5-6 wk] after local case peak; p = 0.003) was earlier. There was a similar but attenuated pattern during the Omicron BA.1 subvariant surge.

CONCLUSIONS

During the COVID-19 pandemic, perceived care deviations were common and potentially avoidable patient harm was rare. Perceived hospital stress persisted for weeks after surges peaked.

Facilitators and barriers to the implementation of new critical care practices during COVID-19: a multicenter qualitative study using the Consolidated Framework for Implementation Research (CFIR)

BACKGROUND

The COVID-19 pandemic produced unprecedented demands and rapidly changing evidence and practices within critical care settings. The purpose of this study was to identify factors and strategies that hindered and facilitated effective implementation of new critical care practices and policies in response to the pandemic.

METHODS

We used a cross-sectional, qualitative study design to conduct semi-structured in-depth interviews with critical care leaders across the United States. The interviews were audio-taped and professionally transcribed verbatim. Guided by the Consolidated Framework for Implementation Research (CFIR), three qualitative researchers used rapid analysis methods to develop relevant codes and identify salient themes.

RESULTS

Among the 17 hospitals that agreed to participate in this study, 31 clinical leaders were interviewed. The CFIR-driven rapid analysis of the interview transcripts generated 12 major themes, which included six implementation facilitators (i.e., factors that promoted the implementation of new critical care practices) and six implementation barriers (i.e., factors that hindered the implementation of new critical care practices). These themes spanned the five CFIR domains (Intervention Characteristics, Outer Setting, Inner Setting, Characteristics of Individuals, and Process) and 11 distinct CFIR constructs. Salient facilitators to implementation efforts included staff resilience, commitment, and innovation, which were supported through collaborative feedback and decision-making mechanisms between leadership and frontline staff. Major identified barriers included lack of access to reliable and transferable information, available resources, uncollaborative leadership and communication styles.

CONCLUSIONS

Through applying the CFIR to organize and synthesize our qualitative data, this study revealed important insights into implementation determinants that influenced the uptake of new critical care practices during COVID-19. As the pandemic continues to burden critical care units, clinical leaders should consider emulating the effective change management strategies identified. The cultivation of streamlined, engaging, and collaborative leadership and communication mechanisms not only supported implementation of new care practices across sites, but it also helped reduce salient implementation barriers, particularly resource and staffing shortages. Future critical care implementation studies should seek to capitalize on identified facilitators and reduce barriers.

Angiopoietin-Like4 Is a Novel Marker of COVID-19 Severity

Vascular dysfunction and capillary leak are common in critically ill COVID-19 patients, but identification of endothelial pathways involved in COVID-19 pathogenesis has been limited. Angiopoietin-like 4 (ANGPTL4) is a protein secreted in response to hypoxic and nutrient-poor conditions that has a variety of biological effects including vascular injury and capillary leak.

OBJECTIVES

To assess the role of ANGPTL4 in COVID-19-related outcomes.

DESIGN SETTING AND PARTICIPANTS

Two hundred twenty-five COVID-19 ICU patients were enrolled from April 2020 to May 2021 in a prospective, multicenter cohort study from three different medical centers, University of Washington, University of Southern California and New York University.

MAIN OUTCOMES AND MEASURES

Plasma ANGPTL4 was measured on days 1, 7, and 14 after ICU admission. We used previously published tissue proteomic data and lung single nucleus RNA (snRNA) sequencing data from specimens collected from COVID-19 patients to determine the tissues and cells that produce ANGPTL4.

RESULTS

Higher plasma ANGPTL4 concentrations were significantly associated with worse hospital mortality (adjusted odds ratio per log2 increase, 1.53; 95% CI, 1.17-2.00; p = 0.002). Higher ANGPTL4 concentrations were also associated with higher proportions of venous thromboembolism and acute respiratory distress syndrome. Longitudinal ANGPTL4 concentrations were significantly different during the first 2 weeks of hospitalization in patients who subsequently died compared with survivors (p for interaction = 8.1 × 10-5). Proteomics analysis demonstrated abundance of ANGPTL4 in lung tissue compared with other organs in COVID-19. ANGPTL4 single-nuclear RNA gene expression was significantly increased in pulmonary alveolar type 2 epithelial cells and fibroblasts in COVID-19 lung tissue compared with controls.

CONCLUSIONS AND RELEVANCE

ANGPTL4 is expressed in pulmonary epithelial cells and fibroblasts and is associated with clinical prognosis in critically ill COVID-19 patients.

Severe Acute Respiratory Infection-Preparedness: Protocol for a Multicenter Prospective Cohort Study of Viral Respiratory Infections

Respiratory virus infections cause significant morbidity and mortality ranging from mild uncomplicated acute respiratory illness to severe complications, such as acute respiratory distress syndrome, multiple organ failure, and death during epidemics and pandemics. We present a protocol to systematically study patients with severe acute respiratory infection (SARI), including severe acute respiratory syndrome coronavirus 2, due to respiratory viral pathogens to evaluate the natural history, prognostic biomarkers, and characteristics, including hospital stress, associated with clinical outcomes and severity.

DESIGN

Prospective cohort study.

SETTING

Multicenter cohort of patients admitted to an acute care ward or ICU from at least 15 hospitals representing diverse geographic regions across the United States.

PATIENTS

Patients with SARI caused by infection with respiratory viruses that can cause outbreaks, epidemics, and pandemics.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measurements include patient demographics, signs, symptoms, and medications; microbiology, imaging, and associated tests; mechanical ventilation, hospital procedures, and other interventions; and clinical outcomes and hospital stress, with specimens collected on days 0, 3, and 7-14 after enrollment and at discharge. The primary outcome measure is the number of consecutive days alive and free of mechanical ventilation (VFD) in the first 30 days after hospital admission. Important secondary outcomes include organ failure-free days before acute kidney injury, shock, hepatic failure, disseminated intravascular coagulation, 28-day mortality, adaptive immunity, as well as immunologic and microbiologic outcomes.

CONCLUSIONS

SARI-Preparedness is a multicenter study under the collaboration of the Society of Critical Care Medicine Discovery, Resilience Intelligence Network, and National Emerging Special Pathogen Training and Education Center, which seeks to improve understanding of prognostic factors associated with worse outcomes and increased resource utilization. This can lead to interventions to mitigate the clinical impact of respiratory virus infections associated with SARI.

Association of Early Steroid Administration With Outcomes of Children Hospitalized for COVID-19 Without Multisystem Inflammatory Syndrome in Children

Importance

There is limited evidence for therapeutic options for pediatric COVID-19 outside of multisystem inflammatory syndrome in children (MIS-C).

Objective

To determine whether the use of steroids within 2 days of admission for non-MIS-C COVID-19 in children is associated with hospital length of stay (LOS). The secondary objective was to determine their association with intensive care unit (ICU) LOS, inflammation, and fever defervescence.

Design, Setting, and Participants

This cohort study analyzed data retrospectively for children (<18 years) who required hospitalization for non-MIS-C COVID-19. Data from March 2020 through September 2021 were provided by 58 hospitals in 7 countries who participate in the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 registry.

Exposure

Administration of steroids within 2 days of admission.

Main Outcomes and Measures

Length of stay in the hospital and ICU. Adjustment for confounders was done by mixed linear regression and propensity score matching.

Results

A total of 1163 patients met inclusion criteria and had a median (IQR) age of 7 years (0.9-14.3). Almost half of all patients (601/1163, 51.7%) were male, 33.8% (392/1163) were non-Hispanic White, and 27.9% (324/1163) were Hispanic. Of the study population, 184 patients (15.8%) received steroids within 2 days of admission, and 979 (84.2%) did not receive steroids within the first 2 days. Among 1163 patients, 658 (56.5%) required respiratory support during hospitalization. Overall, patients in the steroids group were older and had greater severity of illness, and a larger proportion required respiratory and vasoactive support. On multivariable linear regression, after controlling for treatment with remdesivir within 2 days, country, race and ethnicity, obesity and comorbidity, number of abnormal inflammatory mediators, age, bacterial or viral coinfection, and disease severity according to ICU admission within first 2 days or World Health Organization ordinal scale of 4 or higher on admission, with a random intercept for the site, early steroid treatment was not significantly associated with hospital LOS (exponentiated coefficient, 0.94; 95% CI, 0.81-1.09; P = .42). Separate analyses for patients with an LOS of 2 days or longer (n = 729), those receiving respiratory support at admission (n = 286), and propensity score-matched patients also showed no significant association between steroids and LOS. Early steroid treatment was not associated with ICU LOS, fever defervescence by day 3, or normalization of inflammatory mediators.

Conclusions and Relevance

Steroid treatment within 2 days of hospital admission in a heterogeneous cohort of pediatric patients hospitalized for COVID-19 without MIS-C did not have a statistically significant association with hospital LOS.

Association of Renin Angiotensin Aldosterone System Inhibitors and Outcomes of Hospitalized Patients With COVID-19

OBJECTIVES

To determine the association of prior use of renin-angiotensin-aldosterone system inhibitors (RAASIs) with mortality and outcomes in hospitalized patients with COVID-19.

DESIGN

Retrospective observational study.

SETTING

Multicenter, international COVID-19 registry.

SUBJECTS

Adult hospitalized COVID-19 patients on antihypertensive agents (AHAs) prior to admission, admitted from March 31, 2020, to March 10, 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were compared between three groups: patients on RAASIs only, other AHAs only, and those on both medications. Multivariable logistic and linear regressions were performed after controlling for prehospitalization characteristics to estimate the effect of RAASIs on mortality and other outcomes during hospitalization. Of 26,652 patients, 7,975 patients were on AHAs prior to hospitalization. Of these, 1,542 patients (19.3%) were on RAASIs only, 3,765 patients (47.2%) were on other AHAs only, and 2,668 (33.5%) patients were on both medications. Compared with those taking other AHAs only, patients on RAASIs only were younger (mean age 63.3 vs 66.9 yr; p < 0.0001), more often male (58.2% vs 52.4%; p = 0.0001) and more often White (55.1% vs 47.2%; p < 0.0001). After adjusting for age, gender, race, location, and comorbidities, patients on combination of RAASIs and other AHAs had higher in-hospital mortality than those on RAASIs only (odds ratio [OR] = 1.28; 95% CI [1.19-1.38]; p < 0.0001) and higher mortality than those on other AHAs only (OR = 1.09; 95% CI [1.03-1.15]; p = 0.0017). Patients on RAASIs only had lower mortality than those on other AHAs only (OR = 0.87; 95% CI [0.81-0.94]; p = 0.0003). Patients on ACEIs only had higher mortality compared with those on ARBs only (OR = 1.37; 95% CI [1.20-1.56]; p < 0.0001).

CONCLUSIONS

Among patients hospitalized for COVID-19 who were taking AHAs, prior use of a combination of RAASIs and other AHAs was associated with higher in-hospital mortality than the use of RAASIs alone. When compared with ARBs, ACEIs were associated with significantly higher mortality in hospitalized COVID-19 patients.

Gastrointestinal Manifestations in Hospitalized Children With Acute SARS-CoV-2 Infection and Multisystem Inflammatory Condition: An Analysis of the VIRUS COVID-19 Registry

BACKGROUND

Describe the incidence and associated outcomes of gastrointestinal (GI) manifestations of acute coronavirus disease 2019 (COVID-19) and multisystem inflammatory syndrome in hospitalized children (MIS-C).

METHODS

Retrospective review of the Viral Infection and Respiratory Illness Universal Study registry, a prospective observational, multicenter international cohort study of hospitalized children with acute COVID-19 or MIS-C from March 2020 to November 2020. The primary outcome measure was critical COVID-19 illness. Multivariable models were performed to assess for associations of GI involvement with the primary composite outcome in the entire cohort and a subpopulation of patients with MIS-C. Secondary outcomes included prolonged hospital length of stay defined as being >75th percentile and mortality.

RESULTS

Of the 789 patients, GI involvement was present in 500 (63.3%). Critical illness occurred in 392 (49.6%), and 18 (2.3%) died. Those with GI involvement were older (median age of 8 yr), and 18.2% had an underlying GI comorbidity. GI symptoms and liver derangements were more common among patients with MIS-C. In the adjusted multivariable models, acute COVID-19 was no associated with the primary or secondary outcomes. Similarly, despite the preponderance of GI involvement in patients with MIS-C, it was also not associated with the primary or secondary outcomes.

CONCLUSIONS

GI involvement is common in hospitalized children with acute COVID-19 and MIS-C. GI involvement is not associated with critical illness, hospital length of stay or mortality in acute COVID-19 or MIS-C.

The Association of Latitude and Altitude with COVID-19 Symptoms: A VIRUS: COVID-19 Registry Analysis

Background:

Better delineation of COVID-19 presentations in different climatological conditions might assist with prompt diagnosis and isolation of patients.

Objectives:

To study the association of latitude and altitude with COVID-19 symptomatology.

Methods:

This observational cohort study included 12267 adult COVID-19 patients hospitalized between 03/2020 and 01/2021 at 181 hospitals in 24 countries within the SCCM Discovery VIRUS: COVID-19 Registry. The outcome was symptoms at admission, categorized as respiratory, gastrointestinal, neurological, mucocutaneous, cardiovascular, and constitutional. Other symptoms were grouped as atypical. Multivariable regression modeling was performed, adjusting for baseline characteristics. Models were fitted using generalized estimating equations to account for the clustering.

Results:

The median age was 62 years, with 57% males. The median age and percentage of patients with comorbidities increased with higher latitude. Conversely, patients with comorbidities decreased with elevated altitudes. The most common symptoms were respiratory (80%), followed by constitutional (75%). Presentation with respiratory symptoms was not associated with the location. After adjustment, at lower latitudes (<30º), patients presented less commonly with gastrointestinal symptoms (p<.001, odds ratios for 15º, 25º, and 30º: 0.32, 0.81, and 0.98, respectively). Atypical symptoms were present in 21% of the patients and showed an association with altitude (p=.026, odds ratios for 75, 125, 400, and 600 meters above sea level: 0.44, 0.60, 0.84, and 0.77, respectively).

Conclusions:

We observed geographic variability in symptoms of COVID-19 patients. Respiratory symptoms were most common but were not associated with the location. Gastrointestinal symptoms were less frequent in lower latitudes. Atypical symptoms were associated with higher altitude.

How do frontline healthcare workers learn from COVID-19 webinars during a pandemic? An online survey study

OBJECTIVES

The COVID-19 pandemic severely restricted in-person learning. As a result, many educational institutions switched to online platforms to continue teaching. COVID-19 webinars have been useful for rapidly disseminating information to frontline healthcare workers. While conducting COVID-19 webinars through online platforms is a popular method to train medical professionals, their effectiveness has never been investigated. Our aim was to ascertain the usefulness of COVID-19 webinars during the pandemic.

METHODS

We conducted an online survey of about 400 frontline healthcare workers. 112 people responded to the survey (response rate = 28%). In it, we asked several questions to determine whether webinars had been a useful resource to help deal with COVID-19 patients.

RESULTS

We found that a majority of healthcare worker respondents had favourable opinions of online education during the pandemic as around 78% of respondents either agreed or highly agreed that webinars are a useful source of knowledge. A significant proportion (34%) did not participate in webinars and gave time constraints as their main reason for not participating.

CONCLUSION

Our results indicated that while online education is a great way to disseminate information quickly to a large amount of people, it also comes with its disadvantages. As we transition into a post-pandemic world, we need to make sure that online teaching is designed with the best interests of the healthcare workers in mind to ensure that we get the most out of it.

Variation in Use of High-Flow Nasal Cannula and Noninvasive Ventilation Among Patients With COVID-19

BACKGROUND

The use of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) for hypoxemic respiratory failure secondary to COVID-19 are recommended by critical-care guidelines; however, apprehension about viral particle aerosolization and patient self-inflicted lung injury may have limited use. We aimed to describe hospital variation in the use and clinical outcomes of HFNC and NIV for the management of COVID-19.

METHODS

This was a retrospective observational study of adults hospitalized with COVID-19 who received supplemental oxygen between February 15, 2020, and April 12, 2021, across 102 international and United States hospitals by using the COVID-19 Registry. Associations of HFNC and NIV use with clinical outcomes were evaluated by using multivariable adjusted hierarchical random-effects logistic regression models. Hospital variation was characterized by using intraclass correlation and the median odds ratio.

RESULTS

Among 13,454 adults with COVID-19 who received supplemental oxygen, 8,143 (60%) received nasal cannula/face mask only, 2,859 (21%) received HFNC, 878 (7%) received NIV, 1,574 (12%) received both HFNC and NIV, with 3,640 subjects (27%) progressing to invasive ventilation. The hospital of admission contributed to 24% of the risk-adjusted variation in HFNC and 30% of the risk-adjusted variation in NIV. The median odds ratio for hospital variation of HFNC was 2.6 (95% CI 1.4-4.9) and of NIV was 3.1 (95% CI 1.2-8.1). Among 5,311 subjects who received HFNC and/or NIV, 2,772 (52%) did not receive invasive ventilation and survived to hospital discharge. Hospital-level use of HFNC or NIV were not associated with the rates of invasive ventilation or mortality.

CONCLUSIONS

Hospital variation in the use of HFNC and NIV for acute respiratory failure secondary to COVID-19 was great but was not associated with intubation or mortality. The wide variation and relatively low use of HFNC/NIV observed within our study signaled that implementation of increased HFNC/NIV use in patients with COVID-19 will require changes to current care delivery practices. (ClinicalTrials.gov registration NCT04323787.).

Neurologic Manifestations of Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Hospitalized Patients During the First Year of the COVID-19 Pandemic

To describe the prevalence, associated risk factors, and outcomes of serious neurologic manifestations (encephalopathy, stroke, seizure, and meningitis/encephalitis) among patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

DESIGN

Prospective observational study.

SETTING

One hundred seventy-nine hospitals in 24 countries within the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 Registry.

PATIENTS

Hospitalized adults with laboratory-confirmed SARS-CoV-2 infection.

INTERVENTIONS

None.

RESULTS

Of 16,225 patients enrolled in the registry with hospital discharge status available, 2,092 (12.9%) developed serious neurologic manifestations including 1,656 (10.2%) with encephalopathy at admission, 331 (2.0%) with stroke, 243 (1.5%) with seizure, and 73 (0.5%) with meningitis/encephalitis at admission or during hospitalization. Patients with serious neurologic manifestations of COVID-19 were older with median (interquartile range) age 72 years (61.0-81.0 yr) versus 61 years (48.0-72.0 yr) and had higher prevalence of chronic medical conditions, including vascular risk factors. Adjusting for age, sex, and time since the onset of the pandemic, serious neurologic manifestations were associated with more severe disease (odds ratio [OR], 1.49; p < 0.001) as defined by the World Health Organization ordinal disease severity scale for COVID-19 infection. Patients with neurologic manifestations were more likely to be admitted to the ICU (OR, 1.45; p < 0.001) and require critical care interventions (extracorporeal membrane oxygenation: OR, 1.78; p = 0.009 and renal replacement therapy: OR, 1.99; p < 0.001). Hospital, ICU, and 28-day mortality for patients with neurologic manifestations was higher (OR, 1.51, 1.37, and 1.58; p < 0.001), and patients had fewer ICU-free, hospital-free, and ventilator-free days (estimated difference in days, -0.84, -1.34, and -0.84; p < 0.001).

CONCLUSIONS

Encephalopathy at admission is common in hospitalized patients with SARS-CoV-2 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.

Association of latitude and altitude with adverse outcomes in patients with COVID-19: The VIRUS registry

BACKGROUND

The coronavirus disease 2019 (COVID-19) course may be affected by environmental factors. Ecological studies previously suggested a link between climatological factors and COVID-19 fatality rates. However, individual-level impact of these factors has not been thoroughly evaluated yet.

AIM

To study the association of climatological factors related to patient location with unfavorable outcomes in patients.

METHODS

In this observational analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study: COVID-19 Registry cohort, the latitudes and altitudes of hospitals were examined as a covariate for mortality within 28 d of admission and the length of hospital stay. Adjusting for baseline parameters and admission date, multivariable regression modeling was utilized. Generalized estimating equations were used to fit the models.

RESULTS

Twenty-two thousand one hundred eight patients from over 20 countries were evaluated. The median age was 62 (interquartile range: 49-74) years, and 54% of the included patients were males. The median age increased with increasing latitude as well as the frequency of comorbidities. Contrarily, the percentage of comorbidities was lower in elevated altitudes. Mortality within 28 d of hospital admission was found to be 25%. The median hospital-free days among all included patients was 20 d. Despite the significant linear relationship between mortality and hospital-free days (adjusted odds ratio (aOR) = 1.39 (1.04, 1.86), P = 0.025 for mortality within 28 d of admission; aOR = -1.47 (-2.60, -0.33), P = 0.011 for hospital-free days), suggesting that adverse patient outcomes were more common in locations further away from the Equator; the results were no longer significant when adjusted for baseline differences (aOR = 1.32 (1.00, 1.74), P = 0.051 for 28-day mortality; aOR = -1.07 (-2.13, -0.01), P = 0.050 for hospital-free days). When we looked at the altitude’s effect, we discovered that it demonstrated a non-linear association with mortality within 28 d of hospital admission (aOR = 0.96 (0.62, 1.47), 1.04 (0.92, 1.19), 0.49 (0.22, 0.90), and 0.51 (0.27, 0.98), for the altitude points of 75 MASL, 125 MASL, 400 MASL, and 600 MASL, in comparison to the reference altitude of 148 m.a.s.l, respectively. P = 0.001). We detected an association between latitude and 28-day mortality as well as hospital-free days in this worldwide study. When the baseline features were taken into account, however, this did not stay significant.

CONCLUSION

Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.

Association of hypothyroidism with outcomes in hospitalized adults with COVID-19: Results from the International SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS): COVID-19 Registry

INTRODUCTION

Coronavirus disease 2019 (COVID-19) is associated with high rates of morbidity and mortality. Primary hypothyroidism is a common comorbid condition, but little is known about its association with COVID-19 severity and outcomes. This study aims to identify the frequency of hypothyroidism in hospitalized patients with COVID-19 as well as describe the differences in outcomes between patients with and without pre-existing hypothyroidism using an observational, multinational registry.

METHODS

In an observational cohort study we enrolled patients 18 years or older, with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection between March 2020 and February 2021. The primary outcomes were (1) the disease severity defined as per the World Health Organization Scale for Clinical Improvement, which is an ordinal outcome corresponding with the highest severity level recorded during a patient's index COVID-19 hospitalization, (2) in-hospital mortality and (3) hospital-free days. Secondary outcomes were the rate of intensive care unit (ICU) admission and ICU mortality.

RESULTS

Among the 20,366 adult patients included in the study, pre-existing hypothyroidism was identified in 1616 (7.9%). The median age for the Hypothyroidism group was 70 (interquartile range: 59-80) years, and 65% were female and 67% were White. The most common comorbidities were hypertension (68%), diabetes (42%), dyslipidemia (37%) and obesity (28%). After adjusting for age, body mass index, sex, admission date in the quarter year since March 2020, race, smoking history and other comorbid conditions (coronary artery disease, hypertension, diabetes and dyslipidemia), pre-existing hypothyroidism was not associated with higher odds of severe disease using the World Health Organization disease severity index (odds ratio [OR]: 1.02; 95% confidence interval [CI]: 0.92, 1.13; p = .69), in-hospital mortality (OR: 1.03; 95% CI: 0.92, 1.15; p = .58) or differences in hospital-free days (estimated difference 0.01 days; 95% CI: -0.45, 0.47; p = .97). Pre-existing hypothyroidism was not associated with ICU admission or ICU mortality in unadjusted as well as in adjusted analysis.

CONCLUSIONS

In an international registry, hypothyroidism was identified in around 1 of every 12 adult hospitalized patients with COVID-19. Pre-existing hypothyroidism in hospitalized patients with COVID-19 was not associated with higher disease severity or increased risk of mortality or ICU admissions. However, more research on the possible effects of COVID-19 on the thyroid gland and its function is needed in the future.

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.

Palliative care consultation and end-of-life outcomes in hospitalized COVID-19 patients

Rationale

The impact of palliative care consultation on end-of-life care has not previously been evaluated in a multi-center study.

Objectives

To evaluate the impact of palliative care consultation on the incidence of cardiopulmonary resuscitation (CPR) performed and comfort care received at the end-of-life in hospitalized patients with COVID-19.

Methods

We used the Society of Critical Care Medicine’s COVID-19 registry to extract clinical data on patients hospitalized with COVID-19 between March 31st, 2020 to March 17th, 2021 and died during their hospitalization. The proportion of patients who received palliative care consultation was assessed in patients who did and did not receive CPR (primary outcome) and comfort care (secondary outcome). Propensity matching was used to account for potential confounding variables.

Measurements and Main Results

3,227 patients were included in the analysis. There was no significant difference in the incidence of palliative care consultation between the CPR and no-CPR groups (19.9% vs. 19.4%, p = 0.8334). Patients who received comfort care at the end-of-life were significantly more likely to have received palliative care consultation (43.3% vs. 7.7%, p < 0.0001). After propensity matching for comfort care on demographic characteristics and comorbidities, this relationship was still significant (43.2% vs. 8.5%; p < 0.0001).

Conclusion

Palliative care consultation was not associated with CPR performed at the end-of-life but was associated with increased incidence of comfort care being utilized. These results suggest that utilizing palliative care consultation at the end-of-life may better align the needs and values of patients with the care they receive.

Metabolic Syndrome and Acute Respiratory Distress Syndrome in Hospitalized Patients With COVID-19

IMPORTANCE

Obesity, diabetes, and hypertension are common comorbidities in patients with severe COVID-19, yet little is known about the risk of acute respiratory distress syndrome (ARDS) or death in patients with COVID-19 and metabolic syndrome.

OBJECTIVE

To determine whether metabolic syndrome is associated with an increased risk of ARDS and death from COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter cohort study used data from the Society of Critical Care Medicine Discovery Viral Respiratory Illness Universal Study collected from 181 hospitals across 26 countries from February 15, 2020, to February 18, 2021. Outcomes were compared between patients with metabolic syndrome (defined as ≥3 of the following criteria: obesity, prediabetes or diabetes, hypertension, and dyslipidemia) and a control population without metabolic syndrome. Participants included adult patients hospitalized for COVID-19 during the study period who had a completed discharge status. Data were analyzed from February 22 to October 5, 2021.

EXPOSURES

Exposures were SARS-CoV-2 infection, metabolic syndrome, obesity, prediabetes or diabetes, hypertension, and/or dyslipidemia.

MAIN OUTCOMES AND MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included ARDS, intensive care unit (ICU) admission, need for invasive mechanical ventilation, and length of stay (LOS).

RESULTS

Among 46 441 patients hospitalized with COVID-19, 29 040 patients (mean [SD] age, 61.2 [17.8] years; 13 059 [45.0%] women and 15713 [54.1%] men; 6797 Black patients [23.4%], 5325 Hispanic patients [18.3%], and 16 507 White patients [57.8%]) met inclusion criteria. A total of 5069 patients (17.5%) with metabolic syndrome were compared with 23 971 control patients (82.5%) without metabolic syndrome. In adjusted analyses, metabolic syndrome was associated with increased risk of ICU admission (adjusted odds ratio [aOR], 1.32 [95% CI, 1.14-1.53]), invasive mechanical ventilation (aOR, 1.45 [95% CI, 1.28-1.65]), ARDS (aOR, 1.36 [95% CI, 1.12-1.66]), and mortality (aOR, 1.19 [95% CI, 1.08-1.31]) and prolonged hospital LOS (median [IQR], 8.0 [4.2-15.8] days vs 6.8 [3.4-13.0] days; P < .001) and ICU LOS (median [IQR], 7.0 [2.8-15.0] days vs 6.4 [2.7-13.0] days; P < .001). Each additional metabolic syndrome criterion was associated with increased risk of ARDS in an additive fashion (1 criterion: 1147 patients with ARDS [10.4%]; P = .83; 2 criteria: 1191 patients with ARDS [15.3%]; P < .001; 3 criteria: 817 patients with ARDS [19.3%]; P < .001; 4 criteria: 203 patients with ARDS [24.3%]; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that metabolic syndrome was associated with increased risks of ARDS and death in patients hospitalized with COVID-19. The association with ARDS was cumulative for each metabolic syndrome criteria present.

Clinical characteristics and outcomes of critically ill mechanically ventilated COVID-19 patients receiving interleukin-6 receptor antagonists and corticosteroid therapy: a preliminary report from a multinational registry

BACKGROUND

Interleukin-6 receptor antagonists (IL-6RAs) and steroids are emerging immunomodulatory therapies for severe and critical coronavirus disease (COVID-19). In this preliminary report, we aim to describe the epidemiology, clinical characteristics, and outcomes of adult critically ill COVID-19 patients, requiring invasive mechanical ventilation (iMV), and receiving IL-6RA and steroids therapy over the last 11 months.

MATERIALS AND METHODS

International, multicenter, cohort study derived from Viral Infection and Respiratory Illness University Study registry and conducted through Discovery Network, Society of Critical Care Medicine. Data were collected between March 01, 2020, and January 10, 2021.

RESULTS

Of 860 patients who met eligibility criteria, 589 received steroids, 170 IL-6RAs, and 101 combinations. Patients who received IL-6RAs were younger (median age of 57.5 years vs. 61.1 and 61.8 years in the steroids and combination groups, respectively). The median C-reactive protein level was > 75 mg/L, indicating a hyperinflammatory phenotype. The median daily steroid dose was 7.5 mg dexamethasone or equivalent (interquartile range: 6-14 mg); 80.8% and 19.2% received low-dose and high-dose steroids, respectively. Of the patients who received IL-6RAs, the majority received one dose of tocilizumab and sarilumab (dose range of 600-800 mg for tocilizumab and 200-400 mg for sarilumab). Regarding the timing of administration, we observed that steroid and IL-6RA administration on day 0 of ICU admission was only 55.6% and 39.5%, respectively. By day 28, when compared with steroid use alone, IL-6RA use was associated with an adjusted incidence rate ratio (aIRR) of 1.12 (95% confidence interval [CI] 0.88, 1.4) for ventilator-free days, while combination therapy was associated with an aIRR of 0.83 (95% CI 0.6, 1.14). IL-6RA use was associated with an adjusted odds ratio (aOR) of 0.68 (95% CI 0.44, 1.07) for the 28-day mortality rate, while combination therapy was associated with an aOR of 1.07 (95% CI 0.67, 1.70). Liver dysfunction was higher in IL-6RA group (p = 0.04), while the bacteremia rate did not differ among groups.

CONCLUSIONS

Discordance was observed between the registry utilization patterns (i.e., timing of steroids and IL-6RA administration) and new evidence from the recent randomized controlled trials and guideline recommendations. These data will help us to identify areas of improvement in prescribing patterns and enhance our understanding of IL-6RA safety with different steroid regimens. Further studies are needed to evaluate the drivers of hospital-level variation and their impact on clinical outcomes. Trial registration ClinicalTrials.gov: NCT04486521. Registered on July 2020.

Risk Factors for Critical Coronavirus Disease 2019 and Mortality in Hospitalized Young Adults: An Analysis of the Society of Critical Care Medicine Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) Coronavirus Disease 2019 Registry

IMPORTANCE

Even with its proclivity for older age, coronavirus disease 2019 has been shown to affect all age groups. However, there remains a lack of research focused primarily on the young adult population.

OBJECTIVES

To describe the epidemiology and outcomes of coronavirus disease 2019 and identify the risk factors associated with critical illness and mortality in hospitalized young adults.

DESIGN SETTINGS AND PARTICIPANTS

A retrospective cohort study of the Society of Critical Care Medicine's Viral Infection and Respiratory Illness Universal Study registry. Patients 18-40 years old, hospitalized from coronavirus disease 2019 from March 2020 to April 2021, were included in the analysis.

MAIN OUTCOMES AND MEASURES

Critical illness was defined as a composite of mortality and 21 predefined interventions and complications. Multivariable logistic regression was used to assess associations with critical illness and mortality.

RESULTS

Data from 4,005 patients (152 centers, 19 countries, 18.6% non-U.S. patients) were analyzed. The median age was 32 years (interquartile range, 27-37 yr); 51% were female, 29.4% Hispanic, and 42.9% had obesity. Most patients (63.2%) had comorbidities, the most common being hypertension (14.5%) and diabetes (13.7%). Hospital and ICU mortality were 3.2% (129/4,005) and 8.3% (109/1,313), respectively. Critical illness occurred in 25% (n = 996), and 34.3% (n = 1,376) were admitted to the ICU. Older age (p = 0.03), male sex (adjusted odds ratio, 1.83 [95% CI, 1.2-2.6]), and obesity (adjusted odds ratio, 1.6 [95% CI, 1.1-2.4]) were associated with hospital mortality. In addition to the above factors, the presence of any comorbidity was associated with critical illness from coronavirus disease 2019. Multiple sensitivity analyses, including analysis with U.S. patients only and patients admitted to high-volume sites, showed similar risk factors.

CONCLUSIONS

Among hospitalized young adults, obese males with comorbidities are at higher risk of developing critical illness or dying from coronavirus disease 2019.

Coronavirus Disease 2019-Associated PICU Admissions: A Report From the Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study Registry

OBJECTIVES

To compare clinical characteristics and outcomes of children admitted to the PICU for severe acute respiratory syndrome coronavirus 2-related illness with or without multisystem inflammatory syndrome in children. The secondary objective was to identify explanatory factors associated with outcome of critical illness defined by a composite index of in-hospital mortality and organ system support requirement.

DESIGN

Retrospective cohort study.

SETTING

Thirty-eight PICUs within the Viral Infection and Respiratory Illness Universal Study registry from March 2020 to January 2021.

PATIENTS

Children less than 18 years with severe acute respiratory syndrome coronavirus 2-related illness with or without multisystem inflammatory syndrome in children.

MEASUREMENTS AND MAIN RESULTS

Of 394 patients, 171 (43.4%) had multisystem inflammatory syndrome in children. Children with multisystem inflammatory syndrome in children were more likely younger (2-12 yr vs adolescents; p < 0.01), Black (35.6% vs 21.9%; p < 0.01), present with fever/abdominal pain than cough/dyspnea (p < 0.01), and less likely to have comorbidities (33.3% vs 61.9%; p < 0.01) compared with those without multisystem inflammatory syndrome in children. Inflammatory marker levels, use of inotropes/vasopressors, corticosteroids, and anticoagulants were higher in multisystem inflammatory syndrome in children patients (p < 0.01). Overall mortality was 3.8% (15/394), with no difference in the two groups. Diagnosis of multisystem inflammatory syndrome in children was associated with longer duration of hospitalization as compared to nonmultisystem inflammatory syndrome in children (7.5 d[interquartile range, 5-11] vs 5.3 d [interquartile range, 3-11 d]; p < 0.01). Critical illness occurred in 164 patients (41.6%) and was more common in patients with multisystem inflammatory syndrome in children compared with those without (55.6% vs 30.9%; p < 0.01). Multivariable analysis failed to show an association between critical illness and age, race, sex, greater than or equal to three signs and symptoms, or greater than or equal to two comorbidities among the multisystem inflammatory syndrome in children cohort. Among nonmultisystem inflammatory syndrome in children patients, the presence of greater than or equal to two comorbidities was associated with greater odds of critical illness (odds ratio 2.95 [95% CI, 1.61-5.40]; p < 0.01).

CONCLUSIONS

This study delineates significant clinically relevant differences in presentation, explanatory factors, and outcomes among children admitted to PICU with severe acute respiratory syndrome coronavirus 2-related illness stratified by multisystem inflammatory syndrome in children.

Outcomes of Patients With Coronavirus Disease 2019 Receiving Organ Support Therapies: The International Viral Infection and Respiratory Illness Universal Study Registry

OBJECTIVES

To describe the outcomes of hospitalized patients in a multicenter, international coronavirus disease 2019 registry.

DESIGN

Cross-sectional observational study including coronavirus disease 2019 patients hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 infection between February 15, 2020, and November 30, 2020, according to age and type of organ support therapies.

SETTING

About 168 hospitals in 16 countries within the Society of Critical Care Medicine's Discovery Viral Infection and Respiratory Illness University Study coronavirus disease 2019 registry.

PATIENTS

Adult hospitalized coronavirus disease 2019 patients who did and did not require various types and combinations of organ support (mechanical ventilation, renal replacement therapy, vasopressors, and extracorporeal membrane oxygenation).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was hospital mortality. Secondary outcomes were discharge home with or without assistance and hospital length of stay. Risk-adjusted variation in hospital mortality for patients receiving invasive mechanical ventilation was assessed by using multilevel models with hospitals as a random effect, adjusted for age, race/ethnicity, sex, and comorbidities. Among 20,608 patients with coronavirus disease 2019, the mean (± sd) age was 60.5 (±17), 11,1887 (54.3%) were men, 8,745 (42.4%) were admitted to the ICU, and 3,906 (19%) died in the hospital. Hospital mortality was 8.2% for patients receiving no organ support (n = 15,001). The most common organ support therapy was invasive mechanical ventilation (n = 5,005; 24.3%), with a hospital mortality of 49.8%. Mortality ranged from 40.8% among patients receiving only invasive mechanical ventilation (n =1,749) to 71.6% for patients receiving invasive mechanical ventilation, vasoactive drugs, and new renal replacement therapy (n = 655). Mortality was 39% for patients receiving extracorporeal membrane oxygenation (n = 389). Rates of discharge home ranged from 73.5% for patients who did not require organ support therapies to 29.8% for patients who only received invasive mechanical ventilation, and 8.8% for invasive mechanical ventilation, vasoactive drugs, and renal replacement; 10.8% of patients older than 74 years who received invasive mechanical ventilation were discharged home. Median hospital length of stay for patients on mechanical ventilation was 17.1 days (9.7-28 d). Adjusted interhospital variation in mortality among patients receiving invasive mechanical ventilation was large (median odds ratio 1.69).

CONCLUSIONS

Coronavirus disease 2019 prognosis varies by age and level of organ support. Interhospital variation in mortality of mechanically ventilated patients was not explained by patient characteristics and requires further evaluation.

Cultural Dimensions of Diabetes Management: a Qualitative Study of Middle Eastern Immigrants in the U.S

This study examined how aspects of culture, social support, isolation, and loneliness are perceived as influences in chronic illness management by pre-diabetic (Glycated hemoglobin A_1c levels between 5.7 and 6.4) or Type 2 diabetic patients (A_1c levels between 6.4 and 8). Twenty-eight Middle Eastern immigrants in the greater Philadelphia area were interviewed using a semi-structured approach. Results were consistent with other research which suggests that patients benefit from family and community support in the management of their illness. However, findings also suggest that even in the presence of strong family and social support, patients report increased feelings of isolation and loneliness because they have to manage a complex illness that requires many lifestyle changes. For immigrant suffering from chronic illnesses, social gatherings, especially those that center on the consumption of traditional ethnic food, can be highly stressful because they need to avoid such foods as part of their daily treatment regimen. The results of this study have significant implications for patients, physicians, and psychologists who can benefit from an increased sensitivity to patients' challenges in illness management by understanding how cultural factors affect compliance in diabetes treatment regimens.

The Viral Infection and Respiratory Illness Universal Study (VIRUS): An International Registry of Coronavirus 2019-Related Critical Illness

The coronavirus disease 2019 pandemic has disproportionally strained intensive care services worldwide. Large areas of uncertainly regarding epidemiology, physiology, practice patterns, and resource demands for patients with coronavirus disease 2019 require rapid collection and dissemination of data. We describe the conception and implementation of an intensive care database rapidly developed and designed to meet data analytic needs in response to the coronavirus disease 2019 pandemic-the multicenter, international Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study.

DESIGN

Prospective cohort study and disease registry.

SETTING

Multinational cohort of ICUs.

PATIENTS

Critically ill patients with a diagnosis of coronavirus disease 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Within 2 weeks of conception of the Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study, study leadership was convened, registry case report forms were designed, electronic data entry set up, and more than 250 centers had submitted the protocol for institutional review board approval, with more than 100 cases entered.

CONCLUSIONS

The Society of Critical Care Medicine Discovery Network Viral Infection and Respiratory Illness Universal Study provides an example of a rapidly deployed, international, pandemic registry that seeks to provide near real-time analytics and information regarding intensive care treatments and outcomes for patients with coronavirus disease 2019.

The effectiveness of collaborative story building and telling in facilitating group cohesion in a college classroom setting

This study tested the notion that the construction and telling of a collaborative group story would facilitate the development of group cohesion within the context of an actual classroom setting over the duration of the course. Participants were 125 students in 8 classes (4 experimental, 4 control) of a group psychotherapy course that focused on the principles and techniques of cognitive behavior therapy in conjunction with psychodrama techniques. Results showed significantly higher cohesion scores in the experimental condition compared to the control condition, suggesting that collaborative story building and telling is a viable strategy for improving group cohesion.

Toxicity of Low-Dose Intermittent Isotretinoin in Recalcitrant Acne

BACKGROUND

Isotretinoin, an oral retinoid, has been utilized to achieve long term remissions in cases of recalcitrant acne. In the conventional dosage schedule, the use of oral isotretinoin has been limited by the occurrence of biochemical abnormalities such as hypertriglyceridaemia and impaired liver function tests and radiological changes consistent with diffuse idiopathic skeletal hyperostosis. Low-dose intermittent regimen of oral isotretinoin has been evolved as a cost effective alternative to the conventional dosage regimen in cases of acne. This study addresses the issue of adverse effects of low-dose intermittent isotretinoin and the safety of this regimen.

METHODS

A total of 60 cases of recalcitrant acne were included in the study. Baseline haematological, biochemical and radiological investigations were carried out. Low-dose intermittent isotretinoin was instituted in a dose of 0.5 mg/kg/day for one week in every four weeks for six months. The investigations were repeated at the end of six months therapy.

RESULT

High triglyceride levels occurred in 5% of cases whereas impaired liver function tests and skeletal hyperostosis of the spine were not observed in any case after low-dose intermittent isotretinoin.

CONCLUSION

The low-dose intermittent regimen in cases of acne may be utilized to limit the systemic toxicity of oral isotretinoin.

Immunophenotypic Characterization of Benign and Malignant Prostatic Lesions

BACKGROUND

Biopsy diagnosis is the gold standard for differentiating benign and malignant prostatic enlargements. This study was aimed at supplementing biopsy diagnosis with immunophenotypic characters of prostatic lesions.

METHODS

Twenty five cases each of nodular hyperplasia and adenocarcinoma prostate were compared for their morphologic appearances and immunophenotyping, by studying antibodies to prostate specific antigen (PSA), transglutaminase, chromogranin and high molecular weight keratin, proliferating cell nuclear antigen, cell death (apoptosis) and neovascularisation (CD 34).

RESULTS

Markers of differentiation (PSA and transglutaminase) aided recognition of higher-grade tumours. PSA negativity avoided metaplasia being overcalled as carcinoma. Loss of basal cells around malignant prostatic acini as determined by high molecular weight keratin (HMWK), was useful in foci of atypical small acinar proliferation and in prostatic intraepithelial neoplasia. Assessment of proliferation indices identified subsets of tumours, within conventional morphologic Gleason's grades, with a higher growth fraction. Cell death determination and study of tumour vessels did not offer any improvement on morphology.

CONCLUSION

Immunophenotypic assessment helps in refining morphologic diagnosis of prostatic lesions. Differentiation and proliferation markers objectively assess tumour characteristics with their biologic growth potential and are recommended for diagnostic use. They also help in assessement of response to therapy.

Personality, drug preference, drug use, and drug availability

This study examined the relationship between drug preference, drug use, drug availability, and personality among individuals (n = 100) in treatment for substance abuse in an effort to replicate the results of an earlier study (Feldman, Kumar, Angelini, Pekala, & Porter, 2007) designed to test prediction derived from Eysenck's (1957, 1967) theories. Drug preference was measured by the method of paired-comparison and personality was measured with the Zuckerman-Kuhlman Personality Questionnaire-50 CC. Contrary to expectations, high compared with low scorers on Sociability and Impulsive-Sensation Seeking preferred depressants. Surprisingly, low compared with high scorers on neuroticism did not differ in preference for alcohol. As in the previous study, drug preference, use, and availability were highly correlated, although ease of availability was slightly more predictive of drug use than drug preference. Clinical and theoretical implications are discussed.

Trance state effects and imagery vividness before and during a hypnotic assessment: a preliminary study

This preliminary study explored the relationship between imagery vividness before and during a hypnotic phenomenological assessment procedure, the Phenomenology of Consciousness Inventory-Hypnotic Assessment Procedure (PCI-HAP), while also assessing trance (hypnoidal) state effects and several other variables. The PCI-HAP allows the assessment of trance state effects associated with hypnotism to be quantified and statistically assessed. The 102 subjects completed the PCI-HAP along with several other questionnaire items. Correlational and regression analyses suggested that imagery vividness during hypnotism (hypnotic imagoic suggestibility) was predicted by combined imagery vividness before hypnotism and trance (altered) state effects during hypnotism. When measuring several additional variables, imagery vividness during hypnotism was found to be a function of self-reported hypnotic depth and additional other variables. The usefulness of these results for better understanding imagery vividness before and during hypnotism is discussed.

Measurement of Intimacy Attitudes: The Intimacy Attitude Scale-Revisited

The study evaluated the reliability and validity of a revised version of the Intimacy Attitude Scale originally developed by Amidon. The Cronbach alpha measure of internal consistency showed alpha values between .78 and .86 in five different groups. The test-retest correlation was .57 which improved to .84 after exclusion of three extreme scores. Validity was examined by correlating with several variables. It was concluded that the revised Intimacy Attitude Scale is a reliable instrument with Some degree of Validity for use in research, diagnosis, and training.

Structural aspects of three hypnotizability scales: smallest space analysis

Smallest space analysis (SSA) was used to examine structural aspects of the Creative Imagination Scale (CIS), Harvard Group Scale of Hypnotic Susceptibility, Form:A (HGSHS:A), and Stanford Scale of Hypnotic Susceptibility, Form C (SHSS:C). Correlation matrices for each of the instruments came from published studies of other investigators. The SSA on the CIS suggested the presence of 1 facet, focus of processing, with 2 subsets of items: somato-sensory and imagination sensory. The combined 22-item matrix SSA showed that the CIS and HGSHS:A items regionalized separately. The item configuration suggested 1 facet, nature of suggestions including 3 subsets: direct motor items of the HGSHS:A, challenge-inhibition items of the HGSHS:A, and the cognitive items of the CIS. The SSA for the SHSS:C suggested 2 facets, containing 2 elements each: processing focus of suggestions (cognitive-sensory and motor-sensory) and nature of suggestions (direct and challenge-inhibition). A general mapping sentence is offered with possible implications.

Positive affect, negative affect, and negative effects during a phenomenological hypnotic assessment within a substance abuse population

Positive and negative affect generated while using the Phenomenology of Consciousness--Hypnotic Assessment Procedure (PCI-HAP) on a sample of drug and alcohol users were predicted using several variables. The results were then cross-validated on a second, smaller sample. The results suggest that, although some negative affect was reported, the PCI-HAP was more likely to generate positive, rather than negative, affect. Positive affect was related to the vividness of a suggested hypnotic dream during hypnosis and also hypnotic depth; these findings were replicated upon cross-validation. Although negative affect correlated with the Dissociative Experiences Scale scores and falling asleep, these results did not replicate upon cross-validation. Mild transient negative effects (e.g., headache) were reported by about 10% of the participants in a smaller, second sample. Implications of the results are discussed.

Cytomorphology of tumoral calcinosis: a case report

This paper describes the clinical, radiological and cytomorphological findings of tumoral calcinosis in a twelve-year old boy with normal serum calcium levels and simultaneous involvement of the right shoulder and the left hip. The aim of presentation is to highlights the fact that clinicoradiological correlation and correct interpretation of cytologic findings can alleviate patients' anxiety and avoid unnecessary mutilating surgery in this uncommon but completely benign condition.

"How deeply hypnotized did i get?" Predicting self-reported hypnotic depth from a phenomenological assessment instrument

Procedures for estimating hypnotic depth have been used for more than 70 years. This study predicted self-reported hypnotic depth from the phenomenological and behavioral variables of the Phenomenology of Consciousness Inventory-Hypnotic Assessment Procedure (PCI-HAP). Participants were divided into 2 groups; 1 was used to generate regression equations, and the other group was used for cross-validation. Both imagery vividness during hypnosis (imagoic suggestibility) and the PCI pHGS measure of hypnotic depth (hypnoidal state) accounted for most of the variance in self-reported hypnotic depth. The above results, further supported by correlational and 3-D visual analyses, are consistent with other researchers' observations that ratings of hypnotic depth are a function of: (a) alterations in subjective experience, and (b) the perception of responsiveness to suggestions. The findings are also congruent with J. Holroyd's hypothesis that suggestibility and altered-state effects interact to produce hypnotic effects.

Direct and indirect scales of hypnotic susceptibility: resistance to therapy and psychometric comparability

Groups of participants were randomly assigned to receive either direct hypnotic procedure using the Harvard Group Scale of Hypnotic Susceptibility: Form A (HGSHS:A) or its indirect counterpart, the Alman-Wexler Indirect Hypnotic Susceptibility Scale (AWIHSS). Prior to hypnosis, participants completed the Inventory of Childhood Memories and Imaginings (a measure of fantasy proneness) and the Therapeutic Reactance Scale (TRS, a measure of resistance to therapeutic directives). The Phenomenology of Consciousness Inventory was completed in reference to a 2-minute sitting-quietly period embedded in the hypnotic procedure. Although results generally suggest that the two scales are alternate measures of hypnotizability, some differences were observed: (a) item difficulty levels differed on 4 of the 12 items; (b) subjects reported greater altered awareness with the direct method; and (c) contrary to the results of previous research, the more resistant subjects showed a tendency toward higher hypnotizability scores with the HGSHS:A, while the less resistant subjects responded better with the AWIHSS.

Proliferative myositis--a case report

Proliferative myositis is a recently recognized and unusual reactive fibroproliferative lesion of striated muscle. It shows a bizarre cytological and histological appearance that can mimic a soft tissue sarcoma. It is important to recognize this pseudosarcomatous lesion so as to spare the patient anxiety and unnecessary surgery.

Self-hypnosis relapse prevention training with chronic drug/alcohol users: effects on self-esteem, affect, and relapse

This study evaluated the effectiveness of a self-hypnosis protocol with chronic drug and alcohol patients in increasing self-esteem, improving affect, and preventing relapse against a control, a transtheoretical cognitive-behavioral (TCB), and a stress management (attention-placebo) group. Participants were 261 veterans admitted to Substance Abuse Residential Rehabilitation Treatment Programs (SARRTPs). Participants were assessed pre- and postintervention, and at 7-week follow-up. Relapse rates did not significantly differ across the 4 groups at follow-up; 87% of those contacted reported abstinence. At follow-up, the participants in the 3 treatment conditions were asked how often they practiced the intervention materials provided them. Practicing and minimal-practicing participants were compared against the control group for each of the 3 interventions via MANOVAs/ANOVAs. Results revealed a significant Time by Groups interaction for the hypnosis intervention, with individuals who played the self-hypnosis audiotapes "at least 3 to 5 times a week" at 7-week follow-up reporting the highest levels of self-esteem and serenity, and the least anger/impulsivity, in comparison to the minimal-practice and control groups. No significant effects were found for the transtheoretical or stress management interventions. Regression analyses predicted almost two-thirds of the variance of who relapsed and who did not in the hypnosis intervention group. Hypnotic susceptibility predicted who practiced the self-hypnosis audiotapes. The results suggest that hypnosis can be a useful adjunct in helping chronic substance abuse individuals with their reported self-esteem, serenity, and anger/impulsivity.

Fantasy proneness, creative capacity, and styles of creativity

The Creativity Styles Questionnaire-Revised was used to measure graduate psychology students' (N=173) self-perceptions of creative capacity and styles of creativity (beliefs about and strategies for going about being creative). Participants also completed the Inventory of Childhood Memories and Imaginings, a self-report measure of Fantasy Proneness. The Self-perceived Creative Capacity and Fantasy Proneness scores were significantly correlated (r=.36, p<.001), and these scores were positively correlated with the styles subscale scores of Belief in Unconscious Processes. Use of Techniques, Use of Senses, and negatively correlated with Final Product Orientation. Also, the Fantasy Proneness scores were positively correlated with the Superstition scores and the Environmental Control and Behavioral Self-regulation scores.

Phenomenological experiences associated with hypnotic susceptibility

Following the administration of a Hungarian translation of the Stanford Hypnotic Susceptibility Scale, Form C (SHSS:C), 104 Hungarian subjects completed the Hungarian translation of the Phenomenology of Consciousness Inventory (PCI). Subjects had also been administered the Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A) about 1 week to 2 months before the SHSS:C. The pattern of correlations between hypnotizability (as measured by the HGSHS:A and the SHSS:C) and the 5 factors of the PCI was quite similar to that of previous work carried out using the English language versions on subjects in the United States. SHSS:C and HGSHS:A scores correlated significantly with the PCI factors of dissociated control, positive affect, and attention to internal processes factors. In addition, the SHSS:C score correlated significantly with the visual imagery factor, as found in previous work.

Operationalizing "trance". I: Rationale and research using a psychophenomenological approach

Despite the popularity of the term "trance" among clinicians to describe the subjective effects associated with being hypnotized, heretofore there has been no means to operationalize that definition. The authors present a rationale and psychophenomenological method to operationalize the term "trance" in terms of (a) hypnotic depth, a quantitative measure of subjective trance assessed via a pHGS (predicted Harvard Group Scale) score, derived from regression analysis, and (b) "trance typology profiles," a qualitative differentiation of empirically derived (via cluster and discriminant analyses) categories of subjective trance experiences. The authors then discuss theoretical and clinical implications of this psychophenomenological approach for developing an operational definition of the concept of trance.

The Harvard Group Scale of Hypnotic Susceptibility and related instruments: individual and group administrations

The Harvard Group Scale of Hypnotic Susceptibility, Form A (HGSHS:A), Tellegen's Absorption Scale (TAS); Dissociative Experiences Scale (DES); and Phenomenology of Consciousness Inventory (PCI) were administered either individually or in groups. Eighty students from undergraduate Introduction to Psychology classes were randomly assigned to 1 of the 2 administration conditions with 40 students each. Although there was a general trend of differential item difficulty levels across the 2 administration conditions, a variety of results (descriptive characteristics, reliability, and validity) point to the similarity of behavioral and subjective responses to hypnosis in the 2 conditions. The TAS, DES, and PCI also produced similar results across both conditions of administration.

State and trait depression, physical and social anhedonia, hypnotizability and subjective experiences during hypnosis

This study (n = 465) examined if (a) hypnotic susceptibility (assessed by the Harvard Group Scale, Form A) was related to state and trait depression, and physical and social anhedonia, and (b) phenomenological experiences (assessed by the Phenomenology of Consciousness Inventory [PCI]) varied with depression, anhedonia,and hypnotizability during hypnosis, compared with a sitting quietly condition. Only physical anhedonia showed a weak, but significant, negative correlation with hypnotizability. Hypnosis, compared with the sitting quietly condition, facilitated lowering of feelings of sadness especially for the chronically depressed. Other results pertaining to phenomenological experiences suggest that in future studies, instead of only correlating individual difference variables with hypnotizability, it may be more fruitful to explore their relationships with what happens during hypnosis in terms of reported phenomenological experiences.

Phenomenological experience in response to monotonous drumming and hypnotizability

Participants (N = 206) experienced 15-min of monotonous drumming either before or after hypnosis (Harvard scale). Participants completed the Phenomenology of Consciousness Inventory (PCI) in reference to the last 4-min of drumming. Stimulus order did not affect the objective trance levels as measured by the Harvard scores. The subjective trance level as measured by hypnoidal scores (predicted Harvard scores from the PCI) was significantly higher when drumming preceded hypnosis. Participants' estimated average trance level achieved during drumming fell in the medium range of susceptibility (5-8) (Pekala, 1995). Participants who achieved higher hypnoidal and Harvard scores were more likely to report relaxed feelings and shamanic-type experiences in narratives about their subjective experiences during drumming.