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Venkatesh B, Cohen J. Corticosteroids in septic shock secondary to community acquired pneumonia: clarity mixed with uncertainty. Lancet Respir Med 2024; 12:338-339. [PMID: 38310916 DOI: 10.1016/s2213-2600(23)00470-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/07/2023] [Indexed: 02/06/2024]
Affiliation(s)
- Balasubramanian Venkatesh
- Department of Intensive Care, The Wesley Hospital, Brisbane, QLD, Australia; University of Queensland, Brisbane, QLD, Australia; University of New South Wales, Sydney, NSW, Australia; The George Institute of Global Health, Barangaroo, NSW 2000, Australia.
| | - Jeremy Cohen
- Department of Intensive Care, The Wesley Hospital, Brisbane, QLD, Australia; University of Queensland, Brisbane, QLD, Australia; Department of Intensive Care, Royal Brisbane Hospital, Herston, QLD, Australia
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Donaldson LH, Vlok R, Sakurai K, Burrows M, McDonald G, Venkatesh K, Bagshaw SM, Bellomo R, Delaney A, Myburgh J, Hammond NE, Venkatesh B. Quantifying the Impact of Alternative Definitions of Sepsis-Associated Acute Kidney Injury on its Incidence and Outcomes: A Systematic Review and Meta-Analysis. Crit Care Med 2024:00003246-990000000-00320. [PMID: 38557802 DOI: 10.1097/ccm.0000000000006284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVES To derive a pooled estimate of the incidence and outcomes of sepsis-associated acute kidney injury (SA-AKI) in ICU patients and to explore the impact of differing definitions of SA-AKI on these estimates. DATA SOURCES Medline, Medline Epub, EMBASE, and Cochrane CENTRAL between 1990 and 2023. STUDY SELECTION Randomized clinical trials and prospective cohort studies of adults admitted to the ICU with either sepsis and/or SA-AKI. DATA EXTRACTION Data were extracted in duplicate. Risk of bias was assessed using adapted standard tools. Data were pooled using a random-effects model. Heterogeneity was assessed by using a single covariate logistic regression model. The primary outcome was the proportion of participants in ICU with sepsis who developed AKI. DATA SYNTHESIS A total of 189 studies met inclusion criteria. One hundred fifty-four reported an incidence of SA-AKI, including 150,978 participants. The pooled proportion of patients who developed SA-AKI across all definitions was 0.40 (95% CI, 0.37-0.42) and 0.52 (95% CI, 0.48-0.56) when only the Risk Injury Failure Loss End-Stage, Acute Kidney Injury Network, and Improving Global Outcomes definitions were used to define SA-AKI. There was significant variation in the incidence of SA-AKI depending on the definition of AKI used and whether AKI defined by urine output criteria was included; the incidence was lowest when receipt of renal replacement therapy was used to define AKI (0.26; 95% CI, 0.24-0.28), and highest when the Acute Kidney Injury Network score was used (0.57; 95% CI, 0.45-0.69; p < 0.01). Sixty-seven studies including 29,455 participants reported at least one SA-AKI outcome. At final follow-up, the proportion of patients with SA-AKI who had died was 0.48 (95% CI, 0.43-0.53), and the proportion of surviving patients who remained on dialysis was 0.10 (95% CI, 0.04-0.17). CONCLUSIONS SA-AKI is common in ICU patients with sepsis and carries a high risk of death and persisting kidney impairment. The incidence and outcomes of SA-AKI vary significantly depending on the definition of AKI used.
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Affiliation(s)
- Lachlan H Donaldson
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Kensington, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ruan Vlok
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ken Sakurai
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Morgan Burrows
- Intensive Care Unit, North Shore Private Hospital, St Leonards, NSW, Australia
| | - Gabrielle McDonald
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Karthik Venkatesh
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Kensington, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Anthony Delaney
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Kensington, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Kensington, NSW, Australia
- Department of Intensive Care Medicine, St George Hospital, Sydney, NSW, Australia
| | - Naomi E Hammond
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Kensington, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Kensington, NSW, Australia
- Intensive Care Unit, Princess Alexandra and Wesley Hospitals, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Kiran A, Nagaraju C, Babu JC, Venkatesh B, Kumar A, Khan SB, Albuali A, Basheer S. Hybrid optimization algorithm for enhanced performance and security of counter-flow shell and tube heat exchangers. PLoS One 2024; 19:e0298731. [PMID: 38527047 PMCID: PMC10962831 DOI: 10.1371/journal.pone.0298731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/29/2024] [Indexed: 03/27/2024] Open
Abstract
A shell and tube heat exchanger (STHE) for heat recovery applications was studied to discover the intricacies of its optimization. To optimize performance, a hybrid optimization methodology was developed by combining the Neural Fitting Tool (NFTool), Particle Swarm Optimization (PSO), and Grey Relational Analysis (GRE). STHE heat exchangers were analyzed systematically using the Taguchi method to analyze the critical elements related to a particular response. To clarify the complex relationship between the heat exchanger efficiency and operational parameters, grey relational grades (GRGs) are first computed. A forecast of the grey relation coefficients was then conducted using NFTool to provide more insight into the complex dynamics. An optimized parameter with a grey coefficient was created after applying PSO analysis, resulting in a higher grey coefficient and improved performance of the heat exchanger. A major and far-reaching application of this study was based on heat recovery. A detailed comparison was conducted between the estimated values and the experimental results as a result of the hybrid optimization algorithm. In the current study, the results demonstrate that the proposed counter-flow shell and tube strategy is effective for optimizing performance.
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Affiliation(s)
- Ajmeera Kiran
- Department of Computer Science and Engineering, MLR Institute of Technology, Hyderabad, Telangana, India
| | - Ch Nagaraju
- Department of Electronics and Communication Engineering, Annamacharya Institute of Technology and Sciences, Rajampet, Andhra Pradesh, India
| | - J. Chinna Babu
- Department of Electronics and Communication Engineering, Annamacharya Institute of Technology and Sciences, Rajampet, Andhra Pradesh, India
| | - B Venkatesh
- Department of Mechanical Engineering, Annamacharya Institute of Technology and Sciences, Rajampet, Andhra Pradesh, India
| | - Adarsh Kumar
- School of Computer Science, University of Petroleum and Energy Studies, Dehradun, India
| | - Surbhi Bhatia Khan
- Department of Data Science, School of Science, Engineering and Environment, University of Salford, Salford, United Kingdom
- Department of Electrical and Computer Engineering, Lebanese American University, Byblos, Lebanon
| | - Abdullah Albuali
- Department of Computer Networks and Communications, College of Computer Sciences and Information Technology, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Shakila Basheer
- Department of Information Systems, College of Computer and Information Science, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
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Zampieri FG, Cavalcanti AB, Di Tanna GL, Damiani LP, Hammond NE, Machado FR, Micallef S, Myburgh J, Ramanan M, Venkatesh B, Rice TW, Semler MW, Young PJ, Finfer S. Balanced crystalloids versus saline for critically ill patients (BEST-Living): a systematic review and individual patient data meta-analysis. Lancet Respir Med 2024; 12:237-246. [PMID: 38043564 DOI: 10.1016/s2213-2600(23)00417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/16/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND The effect of balanced crystalloids compared with that of saline in critically ill patients overall and in specific subgroups is unclear. We aimed to assess whether use of balanced solutions, compared with 0·9% sodium chloride (saline), decreased in-hospital mortality in adult patients in intensive care units (ICUs). METHODS For this systematic review and individual patient data meta-analysis, we searched PubMed, Embase, and CENTRAL databases from inception until March 1, 2022 (updated Sept 1, 2023) for individually randomised and cluster-randomised trials comparing balanced solutions with saline for adult patients in the ICU. Eligible trials were those that allocated patients to receive balanced solutions or saline for fluid resuscitation and maintenance fluids, or for maintenance fluids only; and administered the allocated fluid throughout ICU admission or, for trials using landmark mortality as their primary outcome, until the timepoint at which mortality was assessed (if ≥28 days). Authors of eligible trials were contacted to request individual patient data. Data obtained from eligible trials were merged, checked for accuracy, and centrally analysed by use of Bayesian regression models. The primary outcome was in-hospital mortality. Prespecified subgroups included patients with traumatic brain injury. This study was registered with PROSPERO (CRD42022299282). FINDINGS Our search identified 5219 records, yielding six eligible randomised controlled trials. Data obtained for 34 685 participants from the six trials, 17 407 assigned to receive balanced crystalloids and 17 278 to receive saline, were included in the analysis. The mean age of participants was 58·8 years (SD 17·5). Of 34 653 participants with available data, 14 579 (42·1%) were female and 20 074 (57·9%) were male. Among patients who provided consent to report in-hospital mortality, 2907 (16·8%) of 17 313 assigned balanced solutions and 2975 (17·3%) of 17 166 assigned saline died in hospital (odds ratio [OR] 0·962 [95% CrI 0·909 to 1·019], absolute difference -0·4 percentage points [-1·5 to 0·2]). The posterior probability that balanced solutions reduced mortality was 0·895. In patients with traumatic brain injury, 191 (19·1%) of 999 assigned balanced and 141 (14·7%) of 962 assigned saline died (OR 1·424 [1·100 to 1·818], absolute difference 3·2 percentage points [0·7 to 8·7]). The probability that balanced solutions increased mortality in patients with traumatic brain injury was 0·975. In an independent risk of bias assessment, two trials were deemed to be at low risk of bias and four at high risk of bias. INTERPRETATION The probability that using balanced solutions in the ICU reduces in-hospital mortality is high, although the certainty of the evidence was moderate and the absolute risk reduction was small. In patients with traumatic brain injury, using balanced solutions was associated with increased in-hospital mortality. FUNDING HCor (Brazil) and The George Institute for Global Health (Australia).
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
| | - Gian Luca Di Tanna
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | | | - Naomi E Hammond
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW Australia
| | - Flavia R Machado
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil; Anesthaesiology, Pain and Intensive Care Department, Hospital São Paulo, Federal University of São Paulo, São Paulo, Brazil
| | - Sharon Micallef
- The George Institute for Global Health, Sydney, NSW, Australia
| | - John Myburgh
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; St George Hospital, Sydney, NSW, Australia
| | - Mahesh Ramanan
- The George Institute for Global Health, Sydney, NSW, Australia; Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Metro North Hospital and Health Services, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Woolloongabba, QLD, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand; Medical Research Institute of New Zealand, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Simon Finfer
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; School of Public Health, Imperial College London, London, UK.
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Ramanan M, Delaney A, Venkatesh B. Fluid therapy in diabetic ketoacidosis. Curr Opin Clin Nutr Metab Care 2024; 27:178-183. [PMID: 38126191 DOI: 10.1097/mco.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. RECENT FINDINGS Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials. SUMMARY Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.
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Affiliation(s)
- Mahesh Ramanan
- Caboolture and The Prince Charles Hospitals, Metro North Hospital and Health Services, Brisbane, Queensland
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- James Mayne Academy of Critical Care, The University of Queensland, St Lucia, Queensland
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Royal North Shore Hospital, St Leonards, New South Wales
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Wesley Hospital, Auchenflower, Queensland, Australia
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Hernández-Mitre MP, Morpeth SC, Venkatesh B, Hills TE, Davis J, Mahar RK, McPhee G, Jones M, Totterdell J, Tong SYC, Roberts JA. TMPRSS2 inhibitors for the treatment of COVID-19 in adults: a systematic review and meta-analysis of randomized clinical trials of nafamostat and camostat mesylate. Clin Microbiol Infect 2024:S1198-743X(24)00055-7. [PMID: 38331253 DOI: 10.1016/j.cmi.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Synthetic serine protease inhibitors block the cellular enzyme transmembrane protease serine 2, thus preventing SARS-CoV-2 cell entry. There are two relevant drugs in this class, namely, nafamostat (intravenous formulation) and camostat (oral formulation). OBJECTIVE To determine whether transmembrane protease serine 2 inhibition with nafamostat or camostat is associated with a reduced risk of 30-day all-cause mortality in adults with COVID-19. DATA SOURCES Scientific databases and clinical trial registry platforms. STUDY ELIGIBILITY CRITERIA, INTERVENTIONS, AND PARTICIPANTS Preprints or published randomized clinical trials (RCTs) of nafamostat or camostat vs. usual care or placebo in adults requiring treatment for COVID-19. METHODS OF DATA SYNTHESIS AND RISK-OF-BIAS ASSESSMENT The primary outcome of the meta-analysis was 30-day all-cause mortality. Secondary outcomes included time to recovery, adverse events, and serious adverse events. Risk of bias (RoB) was assessed using the revised Cochrane RoB 2 tool for individually randomized trials. Meta-analysis was conducted in the R package meta (v7.0-0) using inverse variance and random effects. Protocol registration number was INPLASY202320120. RESULTS Twelve RCTs were included. Overall, the number of available patients was small (nafamostat = 387; camostat = 1061), the number of enrolled patients meeting the primary outcome was low (nafamostat = 12; camostat = 13), and heterogeneity was high. In hospitalized adults, we did not identify differences in 30-day all-cause mortality (risk ratio [95% CI]: 0.58 [0.19, 1.80], p 0.34; I2 = 0%; n = 6) and time to recovery (mean difference [95% CI]: 0.08 days [-0.74, 0.89], p 0.86; n = 2) between nafamostat vs. usual care; and for 30-day all-cause mortality (risk ratio [95% CI]: 0.99 [0.31, 3.18], p 0.99; n = 2) between camostat vs. placebo. CONCLUSION The RCT evidence is inconclusive to determine whether there is a mortality reduction and safety with either nafamostat or camostat for the treatment of adults with COVID-19. There were high RoB, small sample size, and high heterogeneity between RCTs.
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Affiliation(s)
| | - Susan C Morpeth
- Departments of Microbiology and Infectious Diseases, Middlemore Hospital, Te Whatu Ora Counties Manukau, New Zealand; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Balasubramanian Venkatesh
- Intensive Care, Princess Alexandra Hospital, The University of Queensland, Brisbane, Queensland, Australia; Intensive Care, Wesley Hospital, Brisbane, Queensland, Australia; The George Institute for Global Health, UNSW Sydney, New South Wales, Australia
| | - Thomas E Hills
- Departments of Immunology and Infectious Diseases, Auckland District Health Board, Auckland, New Zealand; Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Joshua Davis
- Infection Research Program, Hunter Medical Research Institute, Univerity of Newcastle, Newcastle, New South Wales, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - Grace McPhee
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Mark Jones
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - James Totterdell
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia; Victorian Infectious Diseases Service, The Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia; Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France; Herston Infectious Diseases Institute (HeIDI), Metro North Health, Herston, Queensland, Australia.
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Adigbli D, Liu R, Meyer J, Cohen J, Di Tanna GL, Gianacas C, Bhattacharya A, Hammond N, Walsham J, Venkatesh B, Hotchkiss R, Finfer S. EARLY PERSISTENT LYMPHOPENIA AND RISK OF DEATH IN CRITICALLY ILL PATIENTS WITH AND WITHOUT SEPSIS. Shock 2024; 61:197-203. [PMID: 38151771 DOI: 10.1097/shk.0000000000002284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
ABSTRACT Purpose: To examine the relationship of early persistent lymphopenia with hospital survival in critically ill patients with and without sepsis to assess whether it can be considered a treatable trait. Methods: Retrospective database analysis of patients with nonelective admission to intensive care units (ICUs) during January 2015 to December 2018. Patients were classified as having sepsis if the Acute Physiology and Chronic Health Evaluation III admission diagnostic code included sepsis or coded for an infection combined with a Sequential Organ Failure Assessment score of ≥2. We defined early persistent lymphopenia at two thresholds (absolute lymphocyte count [ALC] <1.0 and <0.75 × 10 9 /L) based on two qualifying values recorded during the first 4 days in ICU. The main outcome measure was time to in-hospital death. Results: Of 8,507 eligible patients, 7,605 (89.4%) had two ALCs recorded during their first 4 days in ICU; of these, 1,482 (19.5%) had sepsis. Persistent lymphopenia (ALC <1.0) was present in 728 of 1,482 (49.1%) and 2,302 of 6,123 (37.6%) patients with and without sepsis, respectively. For ALC <0.75, the results were 487 of 1,482 (32.9%) and 1,125 of 6,123 (18.4%), respectively. Of 3,030 patients with persistent lymphopenia (ALC <1.0), 562 (18.5%) died compared with 439 of 4,575 (9.6%) without persistent lymphopenia. Persistent lymphopenia was an independent risk factor for in-hospital death in all patients. The hazard ratios for death at ALC <1.0 were 1.89 (95% confidence interval, 1.32-2.71; P = 0.0005) and 1.17 (95% confidence interval, 1.02-1.35; P = 0.0246) in patients with and without sepsis respectively. Conclusions: Early persistent lymphopenia is common in critically ill patients and associated with increased risk of death in patients with and without sepsis. Although the association is stronger in patients with sepsis, lymphopenia is a candidate to be considered a treatable trait; drugs that reverse lymphopenia should be trialed in critically ill patients.
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Affiliation(s)
| | - Rebecca Liu
- Department of Anaesthesiology, Washington University School of Medicine, St Louis, Missouri
| | - Jason Meyer
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | | | - Christopher Gianacas
- Biostatistics and Data Science Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Amritendu Bhattacharya
- Biostatistics and Data Science Division, The George Institute for Global Health, New Delhi, India
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - Richard Hotchkiss
- Department of Anaesthesiology, Washington University School of Medicine, St Louis, Missouri
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Munch MW, Granholm A, Maláska J, Stašek J, Rodriguez PO, Pitre T, Wilson R, Savović J, Rochwerg B, Svobodnik A, Kratochvíl M, Taboada M, Jha V, Vijayaraghavan BKT, Myatra SN, Venkatesh B, Perner A, Møller MH. Dexamethasone doses in patients with COVID-19 and hypoxia: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2024; 68:146-166. [PMID: 37881881 DOI: 10.1111/aas.14346] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/08/2023] [Accepted: 10/07/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The optimal dose of dexamethasone for severe/critical COVID-19 is uncertain. We compared higher versus standard doses of dexamethasone in adults with COVID-19 and hypoxia. METHODS We searched PubMed and trial registers until 23 June 2023 for randomised clinical trials comparing higher (>6 mg) versus standard doses (6 mg) of dexamethasone in adults with COVID-19 and hypoxia. The primary outcome was mortality at 1 month. Secondary outcomes were mortality closest to 90 days; days alive without life support; and the occurrence of serious adverse events/reactions (SAEs/SARs) closest to 1 month. We assessed the risk of bias using the Cochrane RoB2 tool, risk of random errors using trial sequential analysis, and certainty of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS We included eight trials (2478 participants), of which four (1293 participants) had low risk of bias. Higher doses of dexamethasone probably resulted in little to no difference in mortality at 1 month (relative risk [RR] 0.97, 95% CI: 0.79-1.19), mortality closest to Day 90 (RR 1.01, 95% CI: 0.86-1.20), and SAEs/SARs (RR 1.00, 95% CI: 0.97-1.02). Higher doses of dexamethasone probably increased the number of days alive without invasive mechanical ventilation and circulatory support but had no effect on days alive without renal replacement therapy. CONCLUSIONS Based on low to moderate certainty evidence, higher versus standard doses of dexamethasone probably result in little to no difference in mortality, SAEs/SARs, and days alive without renal replacement therapy, but probably increase the number of days alive without invasive mechanical ventilation and circulatory support.
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Affiliation(s)
- Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jan Maláska
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- 2nd Department of Anaesthesiology University Hospital Brno, Brno, Czech Republic
| | - Jan Stašek
- Department of Internal Medicine and Cardiology, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Pablo O Rodriguez
- Pulmonary and Critical Care Medicine, Instituto Universitario CEMIC (Centro de Educación Médica e Investigación Clínica), Buenos Aires, Argentina
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Rebecca Wilson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West (ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Jelena Savović
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
- NIHR Applied Research Collaboration West (ARC West), University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Adam Svobodnik
- Department of Pharmacology/CZECRIN, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Milan Kratochvíl
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Manuel Taboada
- Department of Anaesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | | | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Wesley Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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9
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Daubney ER, D'Urso S, Cuellar-Partida G, Rajbhandari D, Peach E, de Guzman E, McArthur C, Rhodes A, Meyer J, Finfer S, Myburgh J, Cohen J, Schirra HJ, Venkatesh B, Evans DM. A Genome-Wide Association Study of Serum Metabolite Profiles in Septic Shock Patients. Crit Care Explor 2024; 6:e1030. [PMID: 38239409 PMCID: PMC10796137 DOI: 10.1097/cce.0000000000001030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024] Open
Abstract
OBJECTIVES We sought to assess whether genetic associations with metabolite concentrations in septic shock patients could be used to identify pathways of potential importance for understanding sepsis pathophysiology. DESIGN Retrospective multicenter cohort studies of septic shock patients. SETTING All participants who were admitted to 27 participating hospital sites in three countries (Australia, New Zealand, and the United Kingdom) were eligible for inclusion. PATIENTS Adult, critically ill, mechanically ventilated patients with septic shock (n = 230) who were a subset of the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock trial (ClinicalTrials.gov number: NCT01448109). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A genome-wide association study was conducted for a range of serum metabolite levels for participants. Genome-wide significant associations (p ≤ 5 × 10-8) were found for the two major ketone bodies (3-hydroxybutyrate [rs2456680] and acetoacetate [rs2213037] and creatinine (rs6851961). One of these single-nucleotide polymorphisms (SNPs) (rs2213037) was located in the alcohol dehydrogenase cluster of genes, which code for enzymes related to the metabolism of acetoacetate and, therefore, presents a plausible association for this metabolite. None of the three SNPs showed strong associations with risk of sepsis, 28- or 90-day mortality, or Acute Physiology and Chronic Health Evaluation score (a measure of sepsis severity). CONCLUSIONS We suggest that the genetic associations with metabolites may reflect a starvation response rather than processes involved in sepsis pathophysiology. However, our results require further investigation and replication in both healthy and diseased cohorts including those of different ancestry.
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Affiliation(s)
- Emily R Daubney
- Institute for Molecular Bioscience, University of Queensland, Brisbane, QLD, Australia
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia
| | - Shannon D'Urso
- Institute for Molecular Bioscience, University of Queensland, Brisbane, QLD, Australia
| | | | | | - Elizabeth Peach
- Frazer Institute, University of Queensland, Brisbane, QLD, Australia
| | - Erika de Guzman
- Australian Translational Genomics Centre, Queensland University of Technology, Brisbane, QLD, Australia
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Rhodes
- Department of Adult Critical Care, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, United Kingdom
| | - Jason Meyer
- The George Institute for Global Health, Sydney, NSW, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Simon Finfer
- The George Institute for Global Health, Sydney, NSW, Australia
- School of Public Health, Imperial College London, London, United Kingdom
| | - John Myburgh
- The George Institute for Global Health, Sydney, NSW, Australia
- St George Hospital, Sydney, NSW, Australia
| | - Jeremy Cohen
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
- Intensive Care Unit, The Wesley Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Horst Joachim Schirra
- Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia
- Griffith School of Environment and Science-Chemical Sciences, Griffith University, Brisbane, QLD, Australia
- Griffith Institute for Drug Discovery, Griffith University, Brisbane, QLD, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, NSW, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, QLD, Australia
- Intensive Care Unit, The Wesley Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Faculty of Health, University of New South Wales, Sydney, NSW, Australia
| | - David M Evans
- Institute for Molecular Bioscience, University of Queensland, Brisbane, QLD, Australia
- Frazer Institute, University of Queensland, Brisbane, QLD, Australia
- Medical Research Council Integrative Epidemiology Unit at the University of Bristol, Bristol, United Kingdom
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10
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Tirupakuzhi Vijayaraghavan BK, Granholm A, Myatra SN, Jha V, Hammond N, Micallef S, Munch MW, Kjær MBN, Møller MH, Lange T, Perner A, Venkatesh B. Heterogeneity of treatment effect of higher dose dexamethasone by geographic region (Europe vs. India) in patients with COVID-19 and severe hypoxemia - a post hoc evaluation of the COVID STEROID 2 trial. Lancet Reg Health Southeast Asia 2024; 20:100293. [PMID: 38234702 PMCID: PMC10794101 DOI: 10.1016/j.lansea.2023.100293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/21/2023] [Accepted: 09/25/2023] [Indexed: 01/19/2024]
Abstract
Background In the COVID-STEROID 2 trial there was suggestion of heterogeneity of treatment effects (HTE) between patients enrolled from Europe vs. India on the primary outcome. Whether there was HTE for the remaining patient-centred outcomes is unclear. Methods In this post hoc analysis of the COVID-STEROID 2 trial, which compared 12 mg vs. 6 mg dexamethasone in adults with COVID-19 and severe hypoxemia, we evaluated HTE by geographical region (Europe vs. India) for secondary outcomes with analyses adjusted for stratification variables. Results are presented as risk differences (RDs) or mean differences (MDs) with 99% confidence intervals (CIs) and P-values from interaction tests. Findings There were differences in mortality at day 28 (RD for Europe -8.3% (99% CI: -17.7 to 1.0) vs. India 0.1% (99% CI: -10.0 to 10.0)), mortality at day 90 (RD for Europe -7.4% (99% CI: -17.1 to 2.0) vs. India -1.4% (99% CI: -12.8 to 9.8)), mortality at day 180 (RD for Europe -6.7% (99% CI: -16.4 to 2.9) vs. India -1.0% (99% CI: -12.3 to 10.3)), and number of days alive without life support at day 90 (MD for Europe 6.1 days (99% CI: -1.3 to 13.4) vs. India 1.7 days (99% CI: -8.4 to 11.8)). For serious adverse reactions, the direction was reversed (RD for Europe -1.0% (99% CI: -7.1 to 5.2) vs. India -5.3% (99% CI: -16.2 to 5.0). Interpretation Our analysis suggests higher dose dexamethasone may have less beneficial effects for patients in India as compared with those in Europe; however, the evidence is weak, and this could represent a chance finding. Funding None for this analysis. The COVID STEROID 2 trial was funded by The Novo Nordisk Foundation and supported by Rigshospitalet's Research Council.
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Affiliation(s)
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | - Sheila N. Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- School of Public Health, Imperial College London, United Kingdom
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sharon Micallef
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Australia
| | - Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | - Maj-Brit N. Kjær
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | | | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital – Rigshospitalet, Denmark
| | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Australia
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11
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Young PJ, Devaux A, Li Q, Billot L, Davis JS, Delaney A, Finfer SR, Hammond NE, Micallef S, Seppelt IM, Venkatesh B, Myburgh JA. Selective digestive tract decontamination in critically ill adults with acute brain injuries: a post hoc analysis of a randomized clinical trial. Intensive Care Med 2024; 50:56-67. [PMID: 37982826 DOI: 10.1007/s00134-023-07261-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/21/2023] [Indexed: 11/21/2023]
Abstract
PURPOSE The aim of this study was to determine whether selective decontamination of the digestive tract (SDD) reduces in-hospital mortality in mechanically ventilated critically ill adults admitted to the intensive care unit (ICU) with acute brain injuries or conditions. METHODS We carried out a post hoc analysis from a crossover, cluster randomized clinical trial. ICUs were randomly assigned to adopt or not to adopt a SDD strategy for two alternating 12-month periods, separated by a 3-month inter-period gap. Patients in the SDD group (n = 2791; 968 admitted to the ICU with an acute brain injury) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191; 1093 admitted to the ICU with an acute brain injury) received standard care. The primary outcome was in-hospital mortality within 90 days. There were four secondary clinical outcomes: death in ICU, ventilator-, ICU- and hospital-free days to day 90. RESULTS Of 2061 patients with acute brain injuries (mean age, 55.8 years; 36.4% women), all completed the trial. In patients with acute brain injuries, there were 313/968 (32.3%) and 415/1093 (38%) in-hospital deaths in the SDD and standard care groups (unadjusted odds ratio [OR], 0.76, 95% confidence interval [CI] 0.63-0.92; p = 0.004). The use of SDD was associated with statistically significant improvements in the four clinical secondary outcomes compared to standard care. There was no significant heterogeneity of treatment effect between patients with and without acute brain injuries (interaction p = 0.22). CONCLUSIONS In this post hoc analysis of a randomized clinical trial in critically ill patients with acute brain injuries receiving mechanical ventilation, the use of SDD significantly reduced in-hospital mortality in patients compared to standard care without SDD. These findings require confirmation.
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Affiliation(s)
- Paul J Young
- Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Anthony Devaux
- The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine University of New South Wales, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine University of New South Wales, Sydney, Australia
| | - Laurent Billot
- The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine University of New South Wales, Sydney, Australia
| | - Joshua S Davis
- John Hunter Hospital, Newcastle, Australia
- School of Medicine and Public Health University of Newcastle, Newcastle, Australia
- Menzies School of Heath Research, Newcastle, Australia
| | - Anthony Delaney
- The George Institute for Global Health, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Simon R Finfer
- The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine University of New South Wales, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Imperial College London, London, UK
| | - Naomi E Hammond
- The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine University of New South Wales, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | | | - Ian M Seppelt
- The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
- Nepean Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, Australia
- University of Queensland, Brisbane, Australia
- Wesley Hospital, Brisbane, Australia
| | - John A Myburgh
- The George Institute for Global Health, Sydney, Australia.
- Faculty of Medicine University of New South Wales, Sydney, Australia.
- St George Hospital, Sydney, Australia.
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia.
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12
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Deane AM, Alhazzani W, Guyatt G, Finfer S, Marshall JC, Myburgh J, Zytaruk N, Hardie M, Saunders L, Knowles S, Lauzier F, Chapman MJ, English S, Muscedere J, Arabi Y, Ostermann M, Venkatesh B, Young P, Thabane L, Billot L, Heels-Ansdell D, Al-Fares AA, Hammond NE, Hall R, Rajbhandari D, Poole A, Johnson D, Iqbal M, Reis G, Xie F, Cook DJ. REVISE: Re- Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol. BMJ Open 2023; 13:e075588. [PMID: 37968012 PMCID: PMC10660838 DOI: 10.1136/bmjopen-2023-075588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE. METHODS AND ANALYSIS REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial. ETHICS AND DISSEMINATION All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION NUMBER NCT03374800.
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Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Waleed Alhazzani
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - John C Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lois Saunders
- Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Francois Lauzier
- Departments of Anesthesiology, Medicine & Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, Laval, Quebec, Canada
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shane English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | | | - Paul Young
- Intensive Care Department, Wellington Hospital, London, UK
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Abdulrahman A Al-Fares
- Departments of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Naomi E Hammond
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - R Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dorrilyn Rajbhandari
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Alexis Poole
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Johnson
- Departments of Critical Care and Anesthesia, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mobeen Iqbal
- Intensive Care Department, Maroof International Hospital, Islamabad, Pakistan
| | - Gilmar Reis
- Cardresearch-Cardiologia Assistencial e de Pesquisa LTDA, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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13
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Morpeth SC, Venkatesh B, Totterdell JA, McPhee GM, Mahar RK, Jones M, Bandara M, Barina LA, Basnet BK, Bowen AC, Burke AJ, Cochrane B, Denholm JT, Dhungana A, Dore GJ, Dotel R, Duffy E, Dummer J, Foo H, Gilbey TL, Hammond NE, Hudson BJ, Jha V, Jevaji PR, John O, Joshi R, Kang G, Kaur B, Kim S, Das SK, Lau JSY, Littleford R, Marsh JA, Marschner IC, Matthews G, Maze MJ, McArthur CJ, McFadyen JD, McMahon JH, McQuilten ZK, Molton J, Mora JM, Mudaliar V, Nguyen V, O'Sullivan MVN, Pant S, Park JE, Paterson DL, Price DJ, Raymond N, Rees MA, Robinson JO, Rogers BA, Ryu WS, Sasadeusz J, Shum O, Snelling TL, Sommerville C, Trask N, Lewin SR, Hills TE, Davis JS, Roberts JA, Tong SYC. A Randomized Trial of Nafamostat for Covid-19. NEJM Evid 2023; 2:EVIDoa2300132. [PMID: 38320527 DOI: 10.1056/evidoa2300132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
A Randomized Trial of Nafamostat for Covid-19Nafamostat mesylate is a potent in vitro antiviral that inhibits the host transmembrane protease serine 2 enzyme used by SARS-CoV-2 for cell entry. Morpeth et al report the results of an open-label randomized clinical trial of nafamostat for noncritically ill patients with Covid-19.
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Affiliation(s)
- Susan C Morpeth
- Department of Microbiology and Infectious Diseases, Middlemore Hospital, Te Whatu Ora Counties Makukau, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Balasubramanian Venkatesh
- Department of Intensive Care Medicine, The University of Queensland at Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Department of Intensive Care Medicine, The University of Queensland at The Wesley Hospital, Toowong, QLD, Australia
- The George Institute for Global Health, Newtown, NSW, Australia
| | - James A Totterdell
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Sydney
| | - Grace M McPhee
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Robert K Mahar
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Mark Jones
- Department of Health and Clinical Analytics, The University of Sydney School of Public Health, Sydney
| | - Methma Bandara
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Lauren A Barina
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Bhupendra K Basnet
- Department of Medicine, Bir Hospital, Kathmandu, Nepal
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Asha C Bowen
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
| | - Andrew J Burke
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- Department of Infectious Diseases, Prince Charles Hospital, Merthyr Tydfil, United Kingdom
| | - Belinda Cochrane
- Department of Respiratory and Sleep Medicine, Campbelltown Hospital, Campbelltown, NSW, Australia
- Western Sydney University School of Medicine, Campbelltown, NSW, Australia
| | - Justin T Denholm
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Ashesh Dhungana
- Department of Medicine, National Academy of Medical Sciences at Bir Hospital, Kathmandu, Nepal
| | - Gregory J Dore
- Viral Hepatitis Clinical Research Program, Kirby Institute, University of New South Wales, Kensington, NSW, Australia
- Department of Infectious Diseases, St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Ravindra Dotel
- Department of Infectious Diseases, Blacktown Hospital, Blacktown, NSW, Australia
| | - Eamon Duffy
- Department of Infectious Diseases, Te Whatu Ora Health New Zealand at Auckland City Hospital, Auckland, New Zealand
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Jack Dummer
- Department of Medicine, University of Otago, Dunedin, New Zealand
- Respiratory Services, Dunedin Hospital, Dunedin, New Zealand
| | - Hong Foo
- Department of Microbiology and Infectious Diseases, NSW Health Pathology Liverpool, Liverpool, NSW, Australia
| | - Timothy L Gilbey
- Department of Medicine and Infectious Diseases, Wagga Wagga Base Hospital, Wagga Wagga, Australia
| | - Naomi E Hammond
- Critical Care Program, The George Institute for Global Health, New Town, NSW, Australia
- Critical Care Program, The University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Bernard J Hudson
- Department of Microbiology and Infectious Diseases, NSW Health Pathology, St. Leonards, St. Leonards, NSW, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, Newtown, NSW, Australia
| | - Purnima R Jevaji
- Department of Research, The George Institute for Global Health, Pune, Maharashta, India
| | - Oommen John
- Department of Research, The George Institute for Global Health, Vellore, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Karnataka, India
| | - Rajesh Joshi
- Department of Research, The George Institute for Global Health, Pune, Maharashta, India
| | - Gagandeep Kang
- Wellcome Trust Research Laboratory, Chartered Accountants Australia and New Zealand, Sydney
| | - Baldeep Kaur
- Critical Care Program, The George Institute for Global Health, New Town, NSW, Australia
| | - Seungtaek Kim
- Zoonotic Virus Laboratory, Institut Pasteur Korea, Bundang-gu, Gyeonggi-do, Republic of Korea
| | - Santa Kumar Das
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Nepal
| | - Jillian S Y Lau
- Department of Infectious Diseases, Eastern Health, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Roberta Littleford
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Queensland, QLD, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
- Centre for Child Health Research, University of Western Australia Medical School, Nedlands, WA, Australia
| | - Ian C Marschner
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney
| | - Gail Matthews
- Department of Infectious Diseases, St. Vincent's Hospital Sydney, Sydney
- Therapeutic and Vaccine Research Program, The Kirby Institute at The University of New South Wales, Kensington, NSW, Australia
| | - Michael J Maze
- Department of Medicine, University of Otago Christchurch, Christchurch, New England
| | - Colin J McArthur
- Department of Critical Care Medicine, Te Whatu Ora - Health New Zealand, Wellington, New Zealand
| | - James D McFadyen
- Department of Clinical Haematology, Alfred Hospital, Melbourne, VIC, Australia
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - James H McMahon
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, VIC, Australia
| | - Zoe K McQuilten
- Department of Haematology, Monash Health, Melbourne, VIC, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - James Molton
- Department of Infectious Diseases, Western Health, Footscray, VIC, Australia
| | - Jocelyn M Mora
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Vijaybabu Mudaliar
- Department of Research, The George Institute for Global Health, Pune, Maharashta, India
| | - Vi Nguyen
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Matthew V N O'Sullivan
- Department of Microbiology and Infectious Diseases, NSW Health Pathology Westmead Hospital, Newcastle, NSW, Australia
- Faculty of Medicine and Health, University of Sydney Westmead Clinical School, Sydney
| | - Suman Pant
- Department of Internal Medicine, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Nepal
| | - Jaha E Park
- Business Development Team, Chong Kun Dang Pharmaceutical Corp., Dongbaekjukjeon-daero, Giheung-gu Yongin, Kyeonggi-do, Republic of Korea
| | - David L Paterson
- Saw Swee Hock School of Public Health, National Institute of Singapore, Singapore
| | - David J Price
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Nigel Raymond
- Department of Medicine, Te Whatu Ora Health New Zealand Capital, Coast and Hutt Valley, Wellington, New Zealand
- Department of Medicine, Wellington School of Medicine, University of Otago, Wellington, New Zealand
| | - Megan A Rees
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - James O Robinson
- Department of Infectious Diseases, Royal Perth Hospital, Perth, WA, Australia
- Department of Microbiology, PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Benjamin A Rogers
- Centre for Inflammatory Diseases, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
- Department of Infectious Diseases, Monash Health, Clayton, VIC, Australia
| | - Wang-Shick Ryu
- Virology, Institute Pasteur Korea, Bundang-gu, Gyeonggi-do, Republic of Korea
| | - Joe Sasadeusz
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Omar Shum
- Department of Infectious Diseases, Wollongong Hospital, Kingoonya, NSW, Australia
- Graduate School of Medicine, University of Wollongong, Wollonngong, NSW, Australia
| | - Thomas L Snelling
- Faculty of Medicine and Health, The University of Sydney School of Public Health, Sydney
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia
| | - Christine Sommerville
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
| | - Nanette Trask
- Chartered Accountants Australia and New Zealand, Sydney
| | - Sharon R Lewin
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, VIC, Australia
| | - Thomas E Hills
- Department of Clinical Research, Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Infectious Diseases, Auckland City Hospital, Auckland, New Zealand
| | - Joshua S Davis
- School of Medicine and Public Health, The University of Newcastle, New Castle, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, NT, Australia
| | - Jason A Roberts
- Faculty of Medicine, The University of Queensland Centre for Clinical Research, Herston, QLD, Australia
- Metro North Health, Herston Infectious Diseases Institute, Herston, QLD, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
- Division of Anaesthesiology, Critical Care Emergency and Pain Medicine, Nîmes University Hospital at The University of Montpellier, Nîmes, France
| | - Steven Y C Tong
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, VIC, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, VIC, Australia
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14
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Tong SYC, Venkatesh B, McCreary EK. Acute Kidney Injury With Empirical Antibiotics for Sepsis. JAMA 2023; 330:1531-1533. [PMID: 37837650 DOI: 10.1001/jama.2023.18591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Affiliation(s)
- Steven Y C Tong
- Peter Doherty Institute for Infection and Immunity, Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Australia
- Peter Doherty Institute for Infection and Immunity, Department of Infectious Diseases, University of Melbourne, Melbourne, Australia
| | - Balasubramanian Venkatesh
- Department of Intensive Care, Wesley Hospital, Brisbane, Australia
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Erin K McCreary
- Division of Infectious Diseases, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Li W, Cornelius V, Finfer S, Venkatesh B, Billot L. Adaptive designs in critical care trials: a simulation study. BMC Med Res Methodol 2023; 23:236. [PMID: 37853343 PMCID: PMC10585789 DOI: 10.1186/s12874-023-02049-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/28/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND Adaptive clinical trials are growing in popularity as they are more flexible, efficient and ethical than traditional fixed designs. However, notwithstanding their increased use in assessing treatments for COVID-19, their use in critical care trials remains limited. A better understanding of the relative benefits of various adaptive designs may increase their use and interpretation. METHODS Using two large critical care trials (ADRENAL. CLINICALTRIALS gov number, NCT01448109. Updated 12-12-2017; NICE-SUGAR. CLINICALTRIALS gov number, NCT00220987. Updated 01-29-2009), we assessed the performance of three frequentist and two bayesian adaptive approaches. We retrospectively re-analysed the trials with one, two, four, and nine equally spaced interims. Using the original hypotheses, we conducted 10,000 simulations to derive error rates, probabilities of making an early correct and incorrect decision, expected sample size and treatment effect estimates under the null scenario (no treatment effect) and alternative scenario (a positive treatment effect). We used a logistic regression model with 90-day mortality as the outcome and the treatment arm as the covariate. The null hypothesis was tested using a two-sided significance level (α) at 0.05. RESULTS Across all approaches, increasing the number of interims led to a decreased expected sample size. Under the null scenario, group sequential approaches provided good control of the type-I error rate; however, the type I error rate inflation was an issue for the Bayesian approaches. The Bayesian Predictive Probability and O'Brien-Fleming approaches showed the highest probability of correctly stopping the trials (around 95%). Under the alternative scenario, the Bayesian approaches showed the highest overall probability of correctly stopping the ADRENAL trial for efficacy (around 91%), whereas the Haybittle-Peto approach achieved the greatest power for the NICE-SUGAR trial. Treatment effect estimates became increasingly underestimated as the number of interims increased. CONCLUSIONS This study confirms the right adaptive design can reach the same conclusion as a fixed design with a much-reduced sample size. The efficiency gain associated with an increased number of interims is highly relevant to late-phase critical care trials with large sample sizes and short follow-up times. Systematically exploring adaptive methods at the trial design stage will aid the choice of the most appropriate method.
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Affiliation(s)
- W Li
- MRC Biostatistics Unit, East Forvie Building, University of Cambridge, Cambridge, CB2 0QY, UK.
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, 90 High Holborn, 2nd Floor, London, WC1V 6LJ, UK.
| | - V Cornelius
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Woodlane, London, W12 7RH, UK
| | - S Finfer
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
- Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - B Venkatesh
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
| | - L Billot
- The George Institute for Global Health, 1 King Street, Newtown, NSW, 2042, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, 2052, Australia
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16
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Wilks K, Mason D, Rice M, Seaton R, Redpath L, Gibbons K, Ergetu E, Lane P, Venkatesh B. Impact of 1-hour and 3-hour sepsis time bundles on antibiotic use in emergency departments in Queensland, Australia: a before-and-after cohort study. BMJ Open 2023; 13:e072167. [PMID: 37669847 PMCID: PMC10481845 DOI: 10.1136/bmjopen-2023-072167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVE To determine if the introduction of an emergency department (ED) sepsis screening tool and management bundle affects antibiotic prescribing and use. DESIGN Multicentre, cohort, before-and-after study design. SETTING Three tertiary hospitals in Queensland, Australia (median bed size 543, range 520-742). PARTICIPANTS Adult patients, presenting to the ED with symptoms and signs suggestive of sepsis who had blood cultures collected. These participants were further assessed and stratified as having septic shock, sepsis or infection alone, using Sepsis-3 definitions. The study dates were 1 July 2017-31 March 2020. INTERVENTION The breakthrough series collaborative 'Could this be Sepsis?' Programme, aimed at embedding a sepsis screening tool and treatment bundle with weighted-incidence syndromic combined antibiogram-derived antibiotic guidelines in EDs. MAIN OUTCOME MEASURES The primary outcome was the rate of empirical prescriptions adherent to antibiotic guidelines during the ED encounter. Secondary outcomes included the empirical prescriptions considered appropriate, effective antibiotics administered within 3 hours and assessment of harm measures. RESULTS Of 2591 eligible patients, 721 were randomly selected: 241 in the baseline phase and 480 in the post-intervention phase. The rates of guideline adherence were 54.0% and 59.5%, respectively (adjusted OR (aOR) 1.41 (95% CI 1.00, 1.98)). As compared with baseline, there was an increase in the rates of appropriate antibiotic prescription after bundle implementation (69.9% vs 57.1%, aOR 1.92 (95% CI 1.37, 2.68)). There were no differences between the baseline and post-intervention groups with respect to time to effective antibiotics, adverse effects or ED rates of broad-spectrum antibiotic use. CONCLUSION AND RELEVANCE The use of an ED sepsis screening tool and management bundle was associated with an improvement in the rates of appropriate antibiotic prescription without evidence of adverse effects.
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Affiliation(s)
- Kathryn Wilks
- School of Public Health, The University of Queensland, Saint Lucia, Queensland, Australia
- Departrment of Infectious Diseases, Sunshine Coast Hospital and Health Service, Birtinya, Queensland, Australia
- Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Donna Mason
- Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Michael Rice
- Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Robert Seaton
- Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Lyndell Redpath
- Clinical Excellence Queensland, Queensland Health, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Child Health Research Centre, Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Endrias Ergetu
- Child Health Research Centre, Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Paul Lane
- Department of Medicine, The Prince Charles Hospital, Chermside, Queensland, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Newtown, New South Wales, Australia
- Department of Intensive Care, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Department of Intensive Care, The Wesley Hospital, Auchenflower, Queensland, Australia
- Faculty of Medicine and Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
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17
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Attokaran AG, Ramanan M, Hunt L, Chandra K, Sandha R, Watts S, Venkatesh B. Sodium chloride or plasmalyte-148 for patients presenting to emergency departments with diabetic ketoacidosis: A nested cohort study within a multicentre, cluster, crossover, randomised, controlled trial. Emerg Med Australas 2023; 35:657-663. [PMID: 36970972 DOI: 10.1111/1742-6723.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission. METHODS We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU. RESULTS Eighty-four patients were enrolled (SC n = 38, PL n = 46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01-7.21], PL: 7.17 [IQR 6.99-7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000-3200 mL; SC) and 2200 mL (IQR 2000-3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13-3.97, P = 0.71). CONCLUSION Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.
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Affiliation(s)
- Antony George Attokaran
- Rockhampton Hospital, Rockhampton, Queensland, Australia
- Rural Clinical School, The University of Queensland, Rockhampton, Queensland, Australia
| | - Mahesh Ramanan
- Caboolture Hospital, Caboolture, Queensland, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Hunt
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kavita Chandra
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Rajbir Sandha
- Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Stacey Watts
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Wesley Hospital, Brisbane, Queensland, Australia
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18
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Pirracchio R, Annane D, Waschka AK, Lamontagne F, Arabi YM, Bollaert PE, Billot L, Du B, Briegel J, Cohen J, Finfer S, Gordon A, Hammond N, Hyvernat H, Keh D, Li Y, Liu L, Meduri GU, Mirea L, Myburgh JA, Sprung CL, Tilouche N, Tongyoo S, Venkatesh B, Zheng R, Delaney A. Patient-Level Meta-Analysis of Low-Dose Hydrocortisone in Adults with Septic Shock. NEJM Evid 2023; 2:EVIDoa2300034. [PMID: 38320130 DOI: 10.1056/evidoa2300034] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Low-Dose Hydrocortisone and Septic ShockCorticosteroids have been evaluated as a therapy for septic shock for more than 50 years. However, uncertainty persists about their effects on mortality. Pirracchio and colleagues undertake a patient-level meta-analysis to answer this important question.
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Affiliation(s)
- Romain Pirracchio
- Department of Anesthesia and Perioperative Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco, San Francisco
| | - Djillali Annane
- General Intensive Care Unit, Raymond Poincaré Hospital (APHP), Garches, France
- School of Medicine Simone Veil, University Paris Saclay-Campus UVSQ, Paris
- FHU SEPSIS, U1173, University Paris Saclay, INSERM, Paris
| | - Andre K Waschka
- Department of Statistics, University of California Berkeley, Berkeley
- Department of Mathematics, Mercer University, Macon, Georgia
| | - François Lamontagne
- Département de médecine interne, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Yaseen M Arabi
- Intensive Care Department, Ministry of the National Guard-Health Affairs, King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Laurent Billot
- The George Institute for Global Health, University of New South Wales Sydney, Sydney
| | - Bin Du
- State Key Laboratory of Complex Severe and Rare Diseases, Medical ICU, Peking Union Medical College Hospital, Beijing
| | - Josef Briegel
- Department of Anesthesiology, University Hospital, LMU Munich, Munich, Germany
| | - Jeremy Cohen
- Intensive Care Unit, The Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales Sydney, Sydney
- School of Public Health, Imperial College London, London
| | - Anthony Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London
| | - Naomi Hammond
- The George Institute for Global Health, University of New South Wales Sydney, Sydney
- Newtown, NSW, Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St. Leonards, NSW, Australia
| | - Herve Hyvernat
- Intensive Care Unit, Hôpital ARCHET 1-CHU de Nice, Nice, France
| | - Didier Keh
- Klinik für Anästhsiologie m.S. Canpus Virchow-Klinikum, Charite University Berlin, Berlin
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing
- Chinese Academy of Medical Science and Peking Union Medical College, Beijing
| | - Ling Liu
- Department of Critical Medicine, Zhong-Da Hospital, and School of Clinical Medicine, Southeast University, Nanjing, China
| | | | - Liliana Mirea
- Anaesthesia and Intensive Care Clinic, Clinical Emergency Hospital of Bucharest, Carol Davila University of Medicine, Bucharest, Romania
| | - John A Myburgh
- The George Institute for Global Health, University of New South Wales Sydney, Sydney
| | - Charles L Sprung
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem
| | - Neijla Tilouche
- Intensive Care Unit, University Hospital Taher Sfar Mahdia, University of Monastir, Research Laboratory, Monastir, Tunisia
| | - Surat Tongyoo
- Division of Critical Care, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales Sydney, Sydney
- Wesley Hospital, George Institute for Global Health, University of New South Wales, Sydney
| | - Ruiqiang Zheng
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital; Clinical Medical College, Yangzhou University, Yangzhou, China
| | - Anthony Delaney
- The George Institute for Global Health, University of New South Wales Sydney, Sydney
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney
- Northern Clinical School, Sydney Medical School, University of Sydney, Sydney
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19
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Perner A, Venkatesh B. Higher-dose dexamethasone for patients with COVID-19 and hypoxaemia? Lancet 2023; 401:1474-1476. [PMID: 37060914 PMCID: PMC10097504 DOI: 10.1016/s0140-6736(23)00587-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 04/17/2023]
Affiliation(s)
- Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, 2100 Copenhagen, Denmark.
| | - Balasubramanian Venkatesh
- Department of Intensive Care, The Wesley Hospital, Brisbane, QLD, Australia; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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20
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Li JX, Wang X, Henry A, Anderson CS, Hammond N, Harris K, Liu H, Loffler K, Myburgh J, Pandian J, Smyth B, Venkatesh B, Carcel C, Woodward M. Sex differences in pain expressed by patients across diverse disease states: individual patient data meta-analysis of 33,957 participants in 10 randomized controlled trials. Pain 2023:00006396-990000000-00275. [PMID: 36972472 DOI: 10.1097/j.pain.0000000000002884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/28/2022] [Indexed: 03/29/2023]
Abstract
ABSTRACT The experience of pain is determined by many factors and has a significant impact on quality of life. This study aimed to determine sex differences in pain prevalence and intensity reported by participants with diverse disease states in several large international clinical trials. Individual participant data meta-analysis was conducted using EuroQol-5 Dimension (EQ-5D) questionnaire pain data from randomised controlled trials published between January 2000 and January 2020 and undertaken by investigators at the George Institute for Global Health. Proportional odds logistic regression models, comparing pain scores between females and males and fitted with adjustments for age and randomized treatment, were pooled in a random-effects meta-analysis. In 10 trials involving 33,957 participants (38% females) with EQ-5D pain score data, the mean age ranged between 50 and 74. Pain was reported more frequently by females than males (47% vs 37%; P < 0.001). Females also reported greater levels of pain than males (adjusted odds ratio 1.41, 95% CI 1.24-1.61; P < 0.001). In stratified analyses, there were differences in pain by disease group (P for heterogeneity <0.001), but not by age group or region of recruitment. Females were more likely to report pain, and at a higher level, compared with males across diverse diseases, all ages, and geographical regions. This study reinforces the importance of reporting sex-disaggregated analysis to identify similarities and differences between females and males that reflect variable biology and may affect disease profiles and have implications for management.
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21
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Granholm A, Munch MW, Andersen‐Ranberg N, Myatra SN, Vijayaraghavan BKT, Venkatesh B, Jha V, Wahlin RR, Jakob SM, Cioccari L, Møller MH, Perner A. Heterogeneous treatment effects of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia-Post hoc exploratory analyses of the COVID STEROID 2 trial. Acta Anaesthesiol Scand 2023; 67:195-205. [PMID: 36314057 PMCID: PMC9874464 DOI: 10.1111/aas.14167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 09/12/2022] [Accepted: 10/17/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Corticosteroids improve outcomes in patients with severe COVID-19. In the COVID STEROID 2 randomised clinical trial, we found high probabilities of benefit with dexamethasone 12 versus 6 mg daily. While no statistically significant heterogeneity in treatment effects (HTE) was found in the conventional, dichotomous subgroup analyses, these analyses have limitations, and HTE could still exist. METHODS We assessed whether HTE was present for days alive without life support and mortality at Day 90 in the trial according to baseline age, weight, number of comorbidities, category of respiratory failure (type of respiratory support system and oxygen requirements) and predicted risk of mortality using an internal prediction model. We used flexible models for continuous variables and logistic regressions for categorical variables without dichotomisation of the baseline variables of interest. HTE was assessed both visually and with p and S values from likelihood ratio tests. RESULTS There was no strong evidence for substantial HTE on either outcome according to any of the baseline variables assessed with all p values >.37 (and all S values <1.43) in the planned analyses and no convincingly strong visual indications of HTE. CONCLUSIONS We found no strong evidence for HTE with 12 versus 6 mg dexamethasone daily on days alive without life support or mortality at Day 90 in patients with COVID-19 and severe hypoxaemia, although these results cannot rule out HTE either.
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Affiliation(s)
- Anders Granholm
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Marie Warrer Munch
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Nina Andersen‐Ranberg
- Collaboration for Research in Intensive CareCopenhagenDenmark,Department of Anaesthesiology and Intensive Care MedicineZealand University HospitalKøgeDenmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and PainTata Memorial Hospital, Homi Bhabha National InstituteMumbaiIndia
| | | | | | - Vivekanand Jha
- Chennai Critical Care ConsultantsChennaiIndia,Prasanna School of Public HealthManipal Academy of Higher EducationManipalIndia,School of Public HealthImperial College LondonLondonUK
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, SödersjukhusetKarolinska InstitutetStockholmSweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, InselspitalBern University Hospital, University of BernBernSwitzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, InselspitalBern University Hospital, University of BernBernSwitzerland,Department of Intensive Care MedicineKantonsspital AarauAarauSwitzerland
| | - Morten Hylander Møller
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Anders Perner
- Department of Intensive CareRigshospitalet—Copenhagen University HospitalCopenhagenDenmark,Collaboration for Research in Intensive CareCopenhagenDenmark
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22
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McQuilten ZK, Venkatesh B, Jha V, Roberts J, Morpeth SC, Totterdell JA, McPhee GM, Abraham J, Bam N, Bandara M, Bangi AK, Barina LA, Basnet BK, Bhally H, Bhusal KR, Bogati U, Bowen AC, Burke AJ, Christopher DJ, Chunilal SD, Cochrane B, Curnow JL, Das SK, Dhungana A, Di Tanna GL, Dotel R, DSouza H, Dummer J, Dutta S, Foo H, Gilbey TL, Giles ML, Goli K, Gordon A, Gyanwali P, Haksar D, Hudson BJ, Jani MK, Jevaji PR, Jhawar S, Jindal A, John MJ, John M, John FB, John O, Jones M, Joshi RD, Kamath P, Kang G, Karki AR, Karmalkar AM, Kaur B, Koganti KC, Koshy JM, Krishnamurthy MS, Lau JS, Lewin SR, Lim LL, Marschner IC, Marsh JA, Maze MJ, McGree JM, McMahon JH, Medcalf RL, Merriman EG, Misal AP, Mora JM, Mudaliar VK, Nguyen V, O'Sullivan MV, Pant S, Pant P, Paterson DL, Price DJ, Rees MA, Robinson JO, Rogers BA, Samuel S, Sasadeusz J, Sharma D, Sharma PK, Shrestha R, Shrestha SK, Shrestha P, Shukla U, Shum O, Sommerville C, Spelman T, Sullivan RP, Thatavarthi U, Tran HA, Trask N, Whitehead CL, Mahar RK, Hammond NE, McFadyen JD, Snelling TL, Davis JS, Denholm JT, Tong SYC. Anticoagulation Strategies in Non-Critically Ill Patients with Covid-19. NEJM Evid 2023; 2:EVIDoa2200293. [PMID: 38320033 DOI: 10.1056/evidoa2200293] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Anticoagulation in Non-Critically Ill Covid-19 PatientsMcQuilten et al. conducted a randomized clinical trial comparing low-dose, intermediate-dose, low-dose plus aspirin, and therapeutic-dose anticoagulation in patients with Covid-19 of diverse ethnicities in high-, low-, and middle-income countries.
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Affiliation(s)
- Zoe K McQuilten
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | - Balasubramanian Venkatesh
- University of Queensland, Brisbane, Australia
- The George Institute for Global Health, Sydney, Australia
- The George Institute for Global Health, Delhi, Delhi, India
- The Wesley Hospital, Brisbane, Queensland, Australia
- University of New South Wales, Sydney, New South Wales, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, Delhi, Delhi, India
- Imperial College, London, England, United Kingdom
| | - Jason Roberts
- University of Queensland, Brisbane, Australia
- Metro North Health, Brisbane, Queensland, Australia
| | | | - James A Totterdell
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Grace M McPhee
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - John Abraham
- Christian Medical College, Ludhiana, Punjab, India
| | - Niraj Bam
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
| | - Methma Bandara
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Ashpak K Bangi
- Jivanrekha Multispeciality Hospital, Pune, Maharashtra, India
| | - Lauren A Barina
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Bhupendra K Basnet
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Hasan Bhally
- North Shore Hospital, Auckland, North Island, New Zealand
| | - Khema R Bhusal
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Umesh Bogati
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Asha C Bowen
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
- Perth Children's Hospital, Perth, Western Australia, Australia
| | - Andrew J Burke
- University of Queensland, Brisbane, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
| | | | - Sanjeev D Chunilal
- Monash University, Melbourne, Australia
- Monash Medical Centre, Melbourne, Victoria, Australia
| | - Belinda Cochrane
- Campbelltown Hospital, Campbelltown, New South Wales, Australia
- Western Sydney University, Sydney, New South Wales, Australia
| | - Jennifer L Curnow
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Santa Kumar Das
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Ashesh Dhungana
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | | | | | - Hyjel DSouza
- The George Institute for Global Health, Delhi, Delhi, India
| | - Jack Dummer
- University of Otago, Dunedin, Otago, New Zealand
- Dunedin Hospital, Dunedin, Otago, New Zealand
| | - Sourabh Dutta
- Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Hong Foo
- NSW Health Pathology, Sydney, New South Wales, Australia
| | - Timothy L Gilbey
- Wagga Wagga Base Hospital, Wagga Wagga, New South Wales, Australia
| | - Michelle L Giles
- Monash University, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Kasiram Goli
- Aditya Multi-speciality Hospital, Guntur, Andhra Pradesh, India
| | - Adrienne Gordon
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Royal Prince Alfred Hospital, Newborn Care, Melbourne, Victoria, Australia
| | - Pradip Gyanwali
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | | | | | | | | | | | - Aikaj Jindal
- Satguru Partap Singh Hospitals, Ludhiana, Punjab, India
| | | | - Mary John
- Christian Medical College, Ludhiana, Punjab, India
| | | | - Oommen John
- The George Institute for Global Health, Delhi, Delhi, India
- Manipal Academy of Higher Education, Udupi, Karnataka, India
| | - Mark Jones
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Rajesh D Joshi
- The George Institute for Global Health, Delhi, Delhi, India
| | | | | | - Achyut R Karki
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | | | - Baldeep Kaur
- The George Institute for Global Health, Sydney, Australia
| | | | - Jency M Koshy
- Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | | | - Jillian S Lau
- Eastern Health, Melbourne, Victoria, Australia
- The Alfred Hospital, Melbourne, Victoria, Australia
| | - Sharon R Lewin
- Monash Health, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Ian C Marschner
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Julie A Marsh
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | | | - James M McGree
- Queensland University of Technology, Brisbane, Queensland, Australia
| | | | | | | | | | - Jocelyn M Mora
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | | | - Vi Nguyen
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Matthew V O'Sullivan
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Westmead Hospital, Sydney, New South Wales, Australia
- NSW Health Pathology, Sydney, New South Wales, Australia
| | - Suman Pant
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Pankaj Pant
- Institute of Medicine, Maharajgunj Medical Campus, Kathmandu, Bagmati, Nepal
| | - David L Paterson
- National Institute of Singapore, Singapore, Singapore, Singapore
| | - David J Price
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Megan A Rees
- Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - James O Robinson
- College of Science, Health, Engineering and Education, Discipline of Health, Murdoch University, Perth, Western Australia, Australia
- PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Benjamin A Rogers
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | | | - Joe Sasadeusz
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Deepak Sharma
- Maharaja Agrasen Superspeciality Hospital, Delhi, Delhi, India
| | | | - Roshan Shrestha
- Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Bagmati, Nepal
| | - Sailesh K Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Prajowl Shrestha
- National Academy of Medical Sciences, Bir Hospital, Kathmandu, Bagmati, Nepal
| | - Urvi Shukla
- Symbiosis University Hospital & Research Centre, Pune, Maharashtra, India
| | - Omar Shum
- The Wollongong Hospital, Wollongong, New South Wales, Australia
- University of Wollongong, Wollongong, New South Wales, Australia
| | - Christine Sommerville
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Tim Spelman
- Karolinska Institute, Solna, Stockholm, Sweden
- Burnet Institute, Melbourne, Victoria, Australia
| | - Richard P Sullivan
- St. George Hospital, School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | | | - Huyen A Tran
- Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Victoria, Australia
| | - Nanette Trask
- Chartered Accountants Australia and New Zealand, Perth, Western Australia, Australia
| | - Clare L Whitehead
- The Royal Women's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Robert K Mahar
- Melbourne School of Population & Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Perth, Western Australia, Australia
| | - Naomi E Hammond
- The George Institute for Global Health, Sydney, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - James D McFadyen
- The Alfred Hospital, Melbourne, Victoria, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Thomas L Snelling
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Joshua S Davis
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
- University of Newcastle, Newcastle, New South Wales, Australia
| | - Justin T Denholm
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
| | - Steven Y C Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria, Australia
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23
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Veerabhadrannavar SA, Venkatesh B. Future Predictions of Precipitation and Discharge Using CMIP5 Models in the Western Ghats Region, India. Nat Env Poll Tech 2022. [DOI: 10.46488/nept.2022.v21i05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Climate change is expected to exacerbate the hydrological cycle globally and have a significant impact on water resources. The Intergovernmental Panel on Climate Change (IPCC) Fourth Assessment Report states that observed and projected increases in both temperature and precipitation variability are the main reasons for projected climate change impacts on natural water resources. The examination of meteorological variables of the region, especially when agriculture is rainfall dependent, is very essential to formulate feasible adaptation strategies. As a result, using CORDEX-SA (Coordinated Regional Downscaling Experiment-South Asia) rainfall data (2021 to 2050), trend analysis was used to examine variations in rainfall data in the Kokkarne catchment of the Seetha river basin. Regression analysis was used to identify the season-wise rainfall trend. Annual, Summer, Monsoon, and Winter rainfall have depicted increasing trends with a rate of 2.46, 1.21, 2.77, and 0.009 mm per year respectively. The post-monsoon rainfall has projected a declining trend with a rate of -1.54 mm per year. Hence it is recommended that the designed strategies in the agricultural sector have to take the increasing, decreasing, and erratic nature of the trend of rainfall into consideration. Further considering the use of a Multi-Model Ensemble (MME) is reducing the SD and CV of rainfall data by 862 mm and 48.5% respectively. 87% of annual rainfall is contributed by monsoon season only with a Standard deviation of 424.4 mm and CV of 12%.
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24
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Denholm JT, Venkatesh B, Davis J, Bowen AC, Hammond NE, Jha V, McPhee G, McQuilten Z, O’Sullivan MVN, Paterson D, Price D, Rees M, Roberts J, Jones M, Totterdell J, Snelling T, Trask N, Morpeth S, Tong SYC. ASCOT ADAPT study of COVID-19 therapeutics in hospitalised patients: an international multicentre adaptive platform trial. Trials 2022; 23:1014. [PMID: 36514143 PMCID: PMC9747535 DOI: 10.1186/s13063-022-06929-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND SARS-CoV-2 infection is associated with a significant risk of hospitalisation, death, and prolonged impact on quality of life. Evaluation of new treatment options and optimising therapeutic management of people hospitalised with SARS-CoV-2 infection remains essential, but rapid changes in pandemic conditions and potential therapies have limited the utility of traditional approaches to randomised controlled trials. METHODS ASCOT ADAPT is an international, investigator-initiated, adaptive platform, randomised controlled trial of therapeutics for non-critically ill patients hospitalised with COVID-19. The study design is open label and pragmatic. Potential participants are hospitalised adults with PCR confirmed, symptomatic, SARS-CoV-2 infection, within 14 days of symptom onset. Domains include antiviral, antibody and anticoagulant interventions, with a composite primary outcome of 28-day mortality or progression to intensive-care level respiratory or haemodynamic support. Initial interventions include intravenous nafamostat and variable dose anticoagulation. A range of secondary endpoints, and substudies for specific domains and interventions are outlined. DISCUSSION This paper presents the trial protocol and management structure, including international governance, remote site monitoring and biobanking activities and provides commentary on ethical and pragmatic considerations in establishing the ASCOT ADAPT trial under pandemic conditions. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ACTRN12620000445976) and ClinicalTrials.gov (NCT04483960).
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Affiliation(s)
- Justin T. Denholm
- grid.416153.40000 0004 0624 1200Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000 Australia
| | - Balasubramanian Venkatesh
- grid.415508.d0000 0001 1964 6010The George Institute for Global Health, Sydney, Australia ,grid.464831.c0000 0004 8496 8261The George Institute for Global Health, New Delhi, India ,grid.1005.40000 0004 4902 0432Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Joshua Davis
- grid.1043.60000 0001 2157 559XMenzies School of Health Research, Charles Darwin University, Darwin, Australia ,grid.414724.00000 0004 0577 6676Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW Australia
| | - Asha C. Bowen
- grid.1043.60000 0001 2157 559XMenzies School of Health Research, Charles Darwin University, Darwin, Australia ,grid.410667.20000 0004 0625 8600Department of Infectious Diseases, Perth Children’s Hospital, Perth, Australia ,grid.1012.20000 0004 1936 7910Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, Australia
| | - Naomi E. Hammond
- grid.415508.d0000 0001 1964 6010The George Institute for Global Health, Sydney, Australia ,grid.1005.40000 0004 4902 0432Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Vivekanand Jha
- grid.464831.c0000 0004 8496 8261The George Institute for Global Health, New Delhi, India ,grid.1005.40000 0004 4902 0432Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Grace McPhee
- grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000 Australia
| | - Zoe McQuilten
- grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Transfusion Research Unit, Monash University, Melbourne, Australia
| | - Matthew V. N. O’Sullivan
- grid.413252.30000 0001 0180 6477Department of Infectious Diseases Westmead Hospital, Westmead, Australia ,grid.416088.30000 0001 0753 1056NSW Health Pathology, Institute for Clinical Pathology and Medical Research, Westmead, Australia ,grid.1013.30000 0004 1936 834XSydney Institute for Infectious Diseases, University of Sydney, Sydney, Australia
| | - David Paterson
- grid.1003.20000 0000 9320 7537University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia ,grid.416100.20000 0001 0688 4634Department of Infectious Diseases, Royal Brisbane and Women’s Hospital, Brisbane, Queensland Australia
| | - David Price
- grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000 Australia
| | - Megan Rees
- grid.1008.90000 0001 2179 088XDepartment of Respiratory Medicine, The Royal Melbourne Hospital and Department of Medicine, University of Melbourne, Melbourne, Victoria Australia
| | - Jason Roberts
- grid.1003.20000 0000 9320 7537University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia ,grid.416100.20000 0001 0688 4634Department of Infectious Diseases, Royal Brisbane and Women’s Hospital, Brisbane, Queensland Australia ,grid.416100.20000 0001 0688 4634Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women’s Hospital, Brisbane, Australia ,grid.411165.60000 0004 0593 8241Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Mark Jones
- grid.1013.30000 0004 1936 834XSchool of Public Health, University of Sydney, Camperdown, Australia
| | - James Totterdell
- grid.1013.30000 0004 1936 834XSchool of Public Health, University of Sydney, Camperdown, Australia
| | - Thomas Snelling
- grid.414724.00000 0004 0577 6676Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW Australia ,grid.410667.20000 0004 0625 8600Department of Infectious Diseases, Perth Children’s Hospital, Perth, Australia ,grid.1013.30000 0004 1936 834XSchool of Public Health, University of Sydney, Camperdown, Australia
| | | | - Susan Morpeth
- grid.415534.20000 0004 0372 0644Middlemore Hospital, Counties Manukau District Health Board, Auckland, New Zealand
| | - Steven YC Tong
- grid.416153.40000 0004 0624 1200Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Victoria 3000 Australia
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25
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Finfer S, Venkatesh B, Hotchkiss RS, Sasson SC. Lymphopenia in sepsis—an acquired immunodeficiency? Immunol Cell Biol 2022. [DOI: 10.1111/imcb.12611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/27/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Affiliation(s)
- Simon Finfer
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
- School of Public Health Imperial College London London UK
| | - Balasubramanian Venkatesh
- The George Institute for Global Health University of New South Wales Sydney NSW Australia
- Princess Alexandria and Wesley Hospitals Brisbane QLD Australia
| | - Richard S Hotchkiss
- Departments of Anesthesiology, Medicine, and Surgery Washington University School of Medicine St Louis MO USA
| | - Sarah C Sasson
- Department of Clinical Immunology and Immunopathology, Westmead Hospital Sydney NSW Australia
- The Kirby Institute University of New South Wales Sydney NSW Australia
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26
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Veerabhadrannavar S, Venkatesh B. An Assessment of Future Predictions of Rainfall Using GCM Projections in the Western Ghats Region of India. Nat Env Poll Tech 2022. [DOI: 10.46488/nept.2022.v21i04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The present study has been taken up to quantify the possible impacts of climate change on the climate variables using the outputs of the global climate model dataset over the Sagar and Kokkarne catchments. The baseline period considered is 30 years (1991-2020), and the daily rainfall dataset is used. The rainfall dataset for the future period is derived from five selected GCMs (Global Circulation Model) datasets under the (Representative Concentration Pathway) RCP 4.5 scenario for the period (2021-2050). The mean, standard deviation, and coefficient of variation of yearly rainfall are determined to check the rainfall variability using statistical analysis. The ensemble rainfall mean values of the five GCMs suggest that the uncertainty in the projected results is reduced by considering the cluster of GCMs. The minimum rainfall for the future period has shown an increasing trend (42.3 % 10.5 %) whereas maximum rainfall has shown decreasing trend (52.44 %, 15.28 %) for Sagar and Kokkarne catchments respectively. The future predicted results show that the percentage change in Ensemble mean annual rainfall for the period 2021-2050 with reference to rainfall data of the baseline period (1991-2020) is depicting an increasing trend of 2.52 % and 4.12 % for Sagar and Kokkarne catchments respectively. Monsoon arrival is earlier in the Kokkarne catchment as compared to the Sagar catchment. The highest positive percentage change in mean annual rainfall of 24.89 %, 10.25 % is projected by MPI-ESM-LR GCM, and the Highest negative percentage change in mean annual rainfall of -28.49 %, -9.19 % is projected by ACCESS1.0 GCM for Sagar and Kokkarne catchments respectively. This analysis will provide useful information for water resources planning engineers, research scientists, and farmers to assess the water availability in the region and create storage if essential.
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Ramanan M, Kumar A, Billot L, Myburgh J, Venkatesh B. Recruitment characteristics of randomised trials in critical care: A systematic review. Clin Trials 2022; 19:673-680. [PMID: 36068946 DOI: 10.1177/17407745221123248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS To summarise the temporal trends of recruitment and methodological characteristics of critical care randomised controlled trials with the primary outcome of mortality. METHODS PubMed was searched for articles meeting inclusion and exclusion criteria. Randomised controlled trials, with primary outcome of mortality, of adult and paediatric critical care patients treated in an intensive care unit, were included. Neonatal intensive care unit trials, non-English publications and conference proceedings or abstracts without full-length publications were excluded. Duplicate literature search, article selection and quality assessment were performed by two reviewers with disputes resolved through discussion. Data were extracted into a custom-designed Research Electronic Data Capture database. RESULTS The search identified 67,199 records of which 230 were included. The annual number of critical care randomised controlled trials published increased gradually over a 30-year period from 0 in 1990 to 19 in 2014 with stabilisation at 8-11 between 2015 and 2020. Twenty-seven percent of randomised controlled trials were low risk in all categories using the Cochrane Risk of Bias tool. Methodological characteristics such as registration on clinical trials registries and data safety monitoring committee presence significantly (p < 0.001) increased over time. The median recruitment was 376 patients (interquartile range 125-895) with significant increase (p = 0.002) from 62 (interquartile range: 33-486) in 1991 to 725 (interquartile range: 537-2600) in 2020. This was accompanied by an increase in recruitment times. Thus overall, recruitment rates did not increase. Early cessation occurred in 23% (54/230) of randomised controlled trials with no temporal trend. CONCLUSION The number, size and some methodological qualities of critical randomised controlled trials with primary outcome of mortality have increased over time, but rates of recruitment and early cessation have been unchanged.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Meadowbrook, QLD, Australia
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Balasubramanian Venkatesh
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,Intensive Care Unit, Wesley Hospital, Auchenflower, QLD, Australia
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28
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Hammond NE, Myburgh J, Seppelt I, Garside T, Vlok R, Mahendran S, Adigbli D, Finfer S, Gao Y, Goodman F, Guyatt G, Santos JA, Venkatesh B, Yao L, Di Tanna GL, Delaney A. Association Between Selective Decontamination of the Digestive Tract and In-Hospital Mortality in Intensive Care Unit Patients Receiving Mechanical Ventilation: A Systematic Review and Meta-analysis. JAMA 2022; 328:1922-1934. [PMID: 36286098 PMCID: PMC9607997 DOI: 10.1001/jama.2022.19709] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 10/07/2022] [Indexed: 11/14/2022]
Abstract
Importance The effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain. Objective To determine whether SDD is associated with reduced risk of death in adults receiving mechanical ventilation in intensive care units (ICUs) compared with standard care. Data Sources The primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022. Study Selection Randomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo. Data Extraction and Synthesis Data extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework. Main Outcomes and Measures The primary outcome was hospital mortality. Subgroups included SDD with an intravenous agent compared with SDD without an intravenous agent. There were 8 secondary outcomes including the incidence of ventilator-associated pneumonia, ICU-acquired bacteremia, and the incidence of positive cultures of antimicrobial-resistant organisms. Results There were 32 randomized clinical trials including 24 389 participants in the analysis. The median age of participants in the included studies was 54 years (IQR, 44-60), and the median proportion of female trial participants was 33% (IQR, 25%-38%). Data from 30 trials including 24 034 participants contributed to the primary outcome. The pooled estimated risk ratio (RR) for mortality for SDD compared with standard care was 0.91 (95% credible interval [CrI], 0.82-0.99; I2 = 33.9%; moderate certainty) with a 99.3% posterior probability that SDD reduced hospital mortality. The beneficial association of SDD was evident in trials with an intravenous agent (RR, 0.84 [95% CrI, 0.74-0.94]), but not in trials without an intravenous agent (RR, 1.01 [95% CrI, 0.91-1.11]) (P value for the interaction between subgroups = .02). SDD was associated with reduced risk of ventilator-associated pneumonia (RR, 0.44 [95% CrI, 0.36-0.54]) and ICU-acquired bacteremia (RR, 0.68 [95% CrI, 0.57-0.81]). Available data regarding the incidence of positive cultures of antimicrobial-resistant organisms were not amenable to pooling and were of very low certainty. Conclusions and Relevance Among adults in the ICU treated with mechanical ventilation, the use of SDD compared with standard care or placebo was associated with lower hospital mortality. Evidence regarding the effect of SDD on antimicrobial resistance was of very low certainty.
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Affiliation(s)
- Naomi E. Hammond
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Department of Intensive Care, St George Hospital, Kogarah, New South Wales, Australia
| | - Ian Seppelt
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Penrith, New South Wales, Australia
| | - Tessa Garside
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ruan Vlok
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Sajeev Mahendran
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Derick Adigbli
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, School of Public Health, Imperial College, London, United Kingdom
| | - Ya Gao
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Fiona Goodman
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
| | - Gordon Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Alvin Santos
- Biostatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Queensland, Australia
| | - Liang Yao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gian Luca Di Tanna
- Biostatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Innovative Technologies, University of Applied Sciences and Arts of Southern Switzerland, Viganello-Lugano, Switzerland
| | - Anthony Delaney
- Critical Care Program, The George Institute for Global Health and University of New South Wales, Sydney, New South Wales, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Hernández-Mitre MP, Tong SYC, Denholm JT, Dore GJ, Bowen AC, Lewin SR, Venkatesh B, Hills TE, McQuilten Z, Paterson DL, Morpeth SC, Roberts JA. Nafamostat Mesylate for Treatment of COVID-19 in Hospitalised Patients: A Structured, Narrative Review. Clin Pharmacokinet 2022; 61:1331-1343. [PMID: 36040613 PMCID: PMC9425784 DOI: 10.1007/s40262-022-01170-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 01/06/2024]
Abstract
The search for clinically effective antivirals against the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is ongoing. Repurposing of drugs licensed for non–coronavirus disease 2019 (COVID-19) indications has been extensively investigated in laboratory models and in clinical studies with mixed results. Nafamostat mesylate (nafamostat) is a drug licensed in Japan and Korea for indications including acute pancreatitis and disseminated intravascular coagulation. It is available only for continuous intravenous infusion. In vitro human lung cell line studies with nafamostat demonstrate high antiviral potency against SARS-CoV-2 (half maximal inhibitory concentration [IC50] of 0.0022 µM [compared to remdesivir 1.3 µM]), ostensibly via inhibition of the cellular enzyme transmembrane protease serine 2 (TMPRSS2) preventing viral entry into human cells. In addition, the established antithrombotic activity is hypothesised to be advantageous given thrombosis-associated sequelae of COVID-19. Clinical reports to date are limited, but indicate a potential benefit of nafamostat in patients with moderate to severe COVID-19. In this review, we will explore the pre-clinical, pharmacokinetic and clinical outcome data presently available for nafamostat as a treatment for COVID-19. The recruitment to ongoing clinical trials is a priority to provide more robust data on the safety and efficacy of nafamostat as a treatment for COVID-19.
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Affiliation(s)
| | - Steven Y C Tong
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.,Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia
| | - Justin T Denholm
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia
| | - Gregory J Dore
- Kirby Institute, UNSW Sydney, New South Wales, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia.,Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia
| | - Sharon R Lewin
- Victorian Infectious Disease Service, Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, VIC, Australia.,Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Balasubramanian Venkatesh
- Intensive Care, Princess Alexandra, and Wesley Hospital, The University of Queensland, Brisbane, QLD, Australia.,The George Institute for Global Health, UNSW Sydney, New South Wales, Australia
| | - Thomas E Hills
- Departments of Immunology and Infectious Diseases, Auckland District Health Broad, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Australia.,Department of Haematology, Monash Health, Melbourne, Australia
| | - David L Paterson
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | | | - Jason A Roberts
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Departments of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
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30
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Tirupakuzhi Vijayaraghavan BK, Jha V, Rajbhandari D, Myatra SN, Ghosh A, Bhattacharya A, Arfin S, Bassi A, Donaldson LH, Hammond NE, John O, Joshi R, Kunigari M, Amrutha C, Husaini SHM, Ghosh S, Nag SK, Selvaraj HK, Kantroo V, Shah KD, Venkatesh B. Hydroxychloroquine plus personal protective equipment versus personal protective equipment alone for the prevention of laboratory-confirmed COVID-19 infections among healthcare workers: a multicentre, parallel-group randomised controlled trial from India. BMJ Open 2022; 12:e059540. [PMID: 35649613 PMCID: PMC9160584 DOI: 10.1136/bmjopen-2021-059540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To determine whether hydroxychloroquine when used with personal protective equipment reduces the proportion of laboratory-confirmed COVID-19 among healthcare workers in comparison to the use of personal protective equipment alone. DESIGN Multicentre, parallel-group, open-label randomised trial. Enrolment started on 29 June 2020 and stopped on 4 February 2021. Participants randomised in HydrOxychloroquine Prophylaxis Evaluation were followed for 6 months. SETTING 9 hospitals across India. PARTICIPANTS Healthcare workers in an environment with exposure to COVID-19 were randomised in a 1:1 ratio to hydroxychloroquine plus use of personal protective equipment or personal protective equipment alone. 886 participants were screened and 416 randomised (213 hydroxychloroquine arm and 203 personal protective equipment). INTERVENTION Participants in intervention arm received 800 mg of hydroxychloroquine on day of randomisation and then 400 mg once a week for 12 weeks in addition to the use of personal protective equipment. In the control arm, participants continued to use personal protective equipment alone. MAIN OUTCOME Proportion of laboratory-confirmed COVID-19 in the 6 months after randomisation. RESULTS Participants were young (mean age 32.1 years, SD 9.1 years) with low-comorbid burden. 47.4% were female. In the 6 months after randomisation (primary analysis population=413), 11 participants assigned to the hydroxychloroquine group and 12 participants assigned to the standard practice group met the primary endpoint (5.2% vs 5.9%; OR 0.85, 95% CI 0.35 to 2.07, p=0.72). There was no heterogeneity of treatment effect in any prespecified subgroup. There were no significant differences in the secondary outcomes. The adverse event rates were 9.9% and 6.9% in the hydroxychloroquine and standard practice arms, respectively. There were no serious adverse events in either group. CONCLUSIONS AND RELEVANCE Hydroxychloroquine along with personal protective equipment was not superior to personal protective equipment alone on the proportion of laboratory-confirmed COVID-19. Definitive conclusions are precluded as the trial stopped early for futility, and hence was underpowered. TRIAL REGISTRATION NUMBER CTRI/2020/05/025067.
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Affiliation(s)
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, Delhi, India
| | | | - Sheila Nainan Myatra
- Homi Bhabha National Institute, Mumbai, Maharashtra, India
- Anaesthesiology and Critical Care Medicine, Tata Memorial Hospital, Mumbai, India
| | - Arpita Ghosh
- The George Institute for Global Health, New Delhi, Delhi, India
| | | | - Sumaiya Arfin
- The George Institute for Global Health, New Delhi, Delhi, India
| | - Abhinav Bassi
- The George Institute for Global Health, New Delhi, Delhi, India
| | | | - Naomi E Hammond
- Critical Care, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Oommen John
- The George Institute for Global Health, New Delhi, Delhi, India
| | - Rohina Joshi
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | - Subir Ghosh
- Apollo Hospitals Ahmedabad, Ahmedabad, Gujarat, India
| | | | | | - Viny Kantroo
- Indraprastha Apollo Hospital, New Delhi, Delhi, India
| | - Kamal D Shah
- NephroPlus Health Services, Hyderabad, Telangana, India
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Newtown, New South Wales, Australia
- Wesley Hospital, Brisbane, Queensland, Australia
- Wesley Medical Research, Brisbane, Queensland, Australia
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31
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Anstey CM, Venkatesh B. A Comparison of the Commonly Used Surrogate Markers for Citrate Accumulation and Toxicity during Continuous Renal Replacement Therapy with Regional Citrate Anticoagulation. Blood Purif 2022; 51:997-1005. [PMID: 35443247 DOI: 10.1159/000524129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 03/16/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Continuous renal replacement therapy using regional citrate anticoagulation is commonly used as a modality of organ support in the critically ill population. Currently, citrate accumulation or toxicity is assessed using surrogate markers, notably the uncorrected total-to-ionized calcium ration. The accuracy and utility of this method have been questioned. OBJECTIVES/AIMS The aim of this study was to compare the surrogate markers used for assessing citrate accumulation or toxicity using the measurement of plasma citrate as the gold standard. METHODS Blood was sampled from 20 patients before, during, and after episodes of filtration with citrate concentration measured using spectrophotometry. Demographic and other clinical and biochemical data were also collected. According to protocol, a 15 mmol/L solution of trisodium citrate was used as the prefilter anticoagulant. Results were analyzed using STATA (v16.0) and presented as mean (SD), median (IQR), or simple proportion. Univariate linear regression using citrate concentration as the dependent variable was performed with all surrogate markers. RESULTS Twenty patients (17 males) were enrolled in the study with a mean (SD) age of 62.7 (9.9) years. The uncorrected calcium ratio had the best fit to the citrate data with an R2 value of 0.39. The albumin-corrected calcium ratio, pH, anion gap (AG), albumin-corrected AG, standard base excess, and strong ion gap all had R2 values less than 0.05. CONCLUSION(S) In the absence of direct measurement of citrate concentration, uncorrected total-to-ionized calcium ratio is superior to other surrogate markers, though not ideal, in assessing citrate accumulation or toxicity.
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Affiliation(s)
- Chris M Anstey
- School of Medicine, Sunshine Coast Campus, Griffith University, Birtinya, Queensland, Australia
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32
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Granholm A, Kjær MBN, Munch MW, Myatra SN, Vijayaraghavan BKT, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Vesterlund GK, Meyhoff TS, Helleberg M, Møller MH, Benfield T, Venkatesh B, Hammond NE, Micallef S, Bassi A, John O, Jha V, Kristiansen KT, Ulrik CS, Jørgensen VL, Smitt M, Bestle MH, Andreasen AS, Poulsen LM, Rasmussen BS, Brøchner AC, Strøm T, Møller A, Khan MS, Padmanaban A, Divatia JV, Saseedharan S, Borawake K, Kapadia F, Dixit S, Chawla R, Shukla U, Amin P, Chew MS, Wamberg CA, Bose N, Shah MS, Darfelt IS, Gluud C, Lange T, Perner A. Long-term outcomes of dexamethasone 12 mg versus 6 mg in patients with COVID-19 and severe hypoxaemia. Intensive Care Med 2022; 48:580-589. [PMID: 35359168 PMCID: PMC8970069 DOI: 10.1007/s00134-022-06677-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/10/2022] [Indexed: 12/24/2022]
Abstract
PURPOSE We assessed long-term outcomes of dexamethasone 12 mg versus 6 mg given daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia. METHODS We assessed 180-day mortality and health-related quality of life (HRQoL) using EuroQoL (EQ)-5D-5L index values and EQ visual analogue scale (VAS) in the international, stratified, blinded COVID STEROID 2 trial, which randomised 1000 adults with confirmed COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 26 hospitals in Europe and India. In the HRQoL analyses, higher values indicated better outcomes, and deceased patients were given a score of zero. RESULTS We obtained vital status at 180 days for 963 of 982 patients (98.1%) in the intention-to-treat population, EQ-5D-5L index value data for 922 (93.9%) and EQ VAS data for 924 (94.1%). At 180 days, 164 of 486 patients (33.7%) had died in the 12 mg group versus 184 of 477 (38.6%) in the 6 mg group [adjusted risk difference - 4.3%; 99% confidence interval (CI) - 11.7-3.0; relative risk 0.89; 0.72-1.09; P = 0.13]. The adjusted mean differences between the 12 mg and the 6 mg groups in EQ-5D-5L index values were 0.06 (99% CI - 0.01 to 0.12; P = 0.10) and in EQ VAS scores 4 (- 3 to 10; P = 0.22). CONCLUSION Among patients with COVID-19 and severe hypoxaemia, dexamethasone 12 mg compared with 6 mg did not result in statistically significant improvements in mortality or HRQoL at 180 days, but the results were most compatible with benefit from the higher dose.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Maj-Brit Nørregaard Kjær
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Bharath Kumar Tirupakuzhi Vijayaraghavan
- Department of Critical Care, Apollo Hospitals, Chennai, India.,Chennai Critical Care Consultants, Chennai, India.,The George Institute for Global Health, New Delhi, India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gitte Kingo Vesterlund
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Tine Sylvest Meyhoff
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Benfield
- Center of Research and Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | | | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Oommen John
- Chennai Critical Care Consultants, Chennai, India.,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Vivekanand Jha
- Chennai Critical Care Consultants, Chennai, India.,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India.,School of Public Health, Imperial College London, London, UK
| | - Klaus Tjelle Kristiansen
- Department of Anaesthesia and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Lind Jørgensen
- Department of Thoracic Anaesthesiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Margit Smitt
- Department of Neuroanaesthesiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Hillerød, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Herlev, Herlev, Denmark
| | | | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Craveiro Brøchner
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark.,Department of Anaesthesia and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine, Odense University Hospital, Odense, Denmark.,Department of Anaesthesia and Critical Care Medicine, Hospital Sønderjylland, University Hospital of Southern, Aabenraa, Denmark
| | - Anders Møller
- Department of Anaesthesia and Intensive Care, Næstved-Slagelse-Ringsted Hospital, Slagelse, Denmark
| | - Mohd Saif Khan
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Ajay Padmanaban
- Department of Critical Care, Apollo Hospitals, Chennai, India
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Sanjith Saseedharan
- Department of Intensive Care, SL Raheja Hospital, Mumbai, Maharashtra, India
| | - Kapil Borawake
- Department of Intensive Care, Vishwaraj Hospital, Pune, India
| | - Farhad Kapadia
- Section of Critical Care, Department of Medicine, Hinduja Hospital, Mahim, Mumbai, India
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan Hospital, Pune, Maharashtra, India
| | - Rajesh Chawla
- Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Urvi Shukla
- Intensive Care Unit and Emergency Services, Symbiosis University Hospital and Research Centre, Lavale, Pune, India
| | - Pravin Amin
- Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Michelle S Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Neeta Bose
- Gotri General Hospital, Vadodara, Gujarat, India
| | - Mehul S Shah
- Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Iben S Darfelt
- Department of Anaesthesia and Intensive Care, Herning Hospital, Herning, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, the Capital Region, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, the Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark. .,The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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Donaldson LH, Hammond NE, Agarwal S, Taylor S, Bompoint S, Coombes J, Bennett-Brook K, Bellomo R, Myburgh J, Venkatesh B. Outcomes following severe septic shock in a cohort of Aboriginal and Torres Strait Islander people: a nested cohort study from the ADRENAL trial. CRIT CARE RESUSC 2022; 24:20-28. [PMID: 38046842 PMCID: PMC10692597 DOI: 10.51893/2022.1.oa3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To describe the pattern of acute illness and 6-month mortality and health-related quality-of-life outcomes for a cohort of Aboriginal and Torres Strait Islander patients presenting with septic shock. Design: Nested cohort study of Aboriginal and Torres Strait Islander participants recruited to a large randomised controlled trial of corticosteroid treatment in patients with septic shock. Setting: Royal Darwin Hospital, Northern Territory. Participants: All Aboriginal and Torres Strait Islander patients recruited to the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial at Royal Darwin Hospital were compared with a non-Indigenous cohort drawn from the same site, and a cohort matched for age, sex and severity of disease. Main outcome measures: Mortality at 90 days and 6 months, time to shock resolution, mechanical ventilation requirement, renal replacement therapy requirement, and five-domain, five-level EuroQol questionnaire (EQ-5D-5L) score at 6 months. Results: Aboriginal and Torres Strait Islander patients had significantly reduced risk of death at 90 days when compared with non-Indigenous patients recruited to ADRENAL at Royal Darwin Hospital (12/60 v 23/62; adjusted odds ratio, 0.40 [95% CI, 0.17 to 0.94]) which was robust to additional adjustment for baseline covariates (odds ratio, 0.35 [95% CI, 0.14 to 0.90]). When compared with the matched population drawn from the broader ADRENAL cohort, there was no significant difference in 90-day mortality (12/60 v 16/61; adjusted odds ratio, 1.43 [95% CI, 0.60 to 3.39]; P = 0.42). Only nine Aboriginal and Torres Strait Islander patients provided 6-month health-related quality-of-life data. Conclusions: Aboriginal and Torres Strait Islander patients had reduced risk of death at 90 days when compared with non- Indigenous patients recruited to the ADRENAL trial at Royal Darwin Hospital, which was robust to adjustment for covariates, but similar outcomes when compared with a cohort matched for age, sex and severity of disease.
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Affiliation(s)
- Lachlan H Donaldson
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Naomi E Hammond
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sidharth Agarwal
- Intensive Care Unit, Royal Darwin Hospital, Casuarina, NT, Australia
| | - Sean Taylor
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Severine Bompoint
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Julieann Coombes
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Keziah Bennett-Brook
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - John Myburgh
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Department of Intensive Care Medicine, St George Hospital, Sydney, NSW, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Faculty of Medicine, UNSW, Sydney, NSW, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
- The Wesley Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Bassi A, Arfin S, Joshi R, Bathla N, Hammond NE, Rajbhandari D, Tirupakuzhi Vijayaraghavan BK, Venkatesh B, Jha V. Challenges in operationalising clinical trials in India during the COVID-19 pandemic. Lancet Glob Health 2022; 10:e317-e319. [PMID: 34953516 PMCID: PMC8694703 DOI: 10.1016/s2214-109x(21)00546-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/10/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Abhinav Bassi
- The George Institute for Global Health, New Delhi, India
| | - Sumaiya Arfin
- The George Institute for Global Health, New Delhi, India
| | - Rohina Joshi
- The George Institute for Global Health, New Delhi, India; Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Nikita Bathla
- The George Institute for Global Health, New Delhi, India
| | - Naomi E Hammond
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Dorrilyn Rajbhandari
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Department of Critical Care, Wesley Hospital, Brisbane, QLD, Australia; Department of Critical Care, University of Queensland, Brisbane, QLD, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India; School of Public Health, Imperial College London, London, UK; Manipal Academy of Higher Education, Manipal, India
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35
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Nasa P, Azoulay E, Chakrabarti A, Divatia JV, Jain R, Rodrigues C, Rosenthal VD, Alhazzani W, Arabi YM, Bakker J, Bassetti M, De Waele J, Dimopoulos G, Du B, Einav S, Evans L, Finfer S, Guérin C, Hammond NE, Jaber S, Kleinpell RM, Koh Y, Kollef M, Levy MM, Machado FR, Mancebo J, Martin-Loeches I, Mer M, Niederman MS, Pelosi P, Perner A, Peter JV, Phua J, Piquilloud L, Pletz MW, Rhodes A, Schultz MJ, Singer M, Timsit JF, Venkatesh B, Vincent JL, Welte T, Myatra SN. Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method. Lancet Infect Dis 2022; 22:e74-e87. [PMID: 34774188 PMCID: PMC8580499 DOI: 10.1016/s1473-3099(21)00626-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/16/2021] [Accepted: 09/16/2021] [Indexed: 02/07/2023]
Abstract
During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.
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Affiliation(s)
- Prashant Nasa
- NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis Teaching Hospital, APHP, University of Paris, Paris, France
| | | | | | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Camilla Rodrigues
- PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University Grossman School of Medicine, New York, NY, USA; Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Erasmus University Medical Center, Rotterdam, Netherlands; Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - George Dimopoulos
- Attikon University Hospital, Athens, Greece; National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Bin Du
- State Key Laboratory of Rare, Complex and Critical Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Sharon Einav
- Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Imperial College London, London, UK
| | - Claude Guérin
- University de Lyon, Lyon, France; Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Newton, Adelaide, SA, Australia
| | - Samir Jaber
- Hôpital Saint-Éloi, Montpellier University Hospital, Montpellier, France
| | - Ruth M Kleinpell
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Younsuck Koh
- College of Medicine, University of Ulsan College of Medicine, University of Ulsan, Seoul, South Korea
| | - Marin Kollef
- Washington University School of Medicine, Washington University, St Louis, MO, USA
| | - Mitchell M Levy
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Flavia R Machado
- Hospital Sao Paulo, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa; Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paolo Pelosi
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy; University of Genoa, Genoa, Italy
| | - Anders Perner
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jason Phua
- Alexandra Hospital, National University Health System, Singapore; National University Hospital, National University Health System, Singapore
| | - Lise Piquilloud
- University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marcus J Schultz
- Amsterdam University Medical Centers, Locatie AMC, Amsterdam, Netherlands; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | - Tobias Welte
- German Center of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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Hammond NE, Zampieri FG, Di Tanna GL, Garside T, Adigbli D, Cavalcanti AB, Machado FR, Micallef S, Myburgh J, Ramanan M, Rice TW, Semler MW, Young PJ, Venkatesh B, Finfer S, Delaney A. Balanced Crystalloids versus Saline in Critically Ill Adults - A Systematic Review with Meta-Analysis. NEJM Evid 2022; 1:EVIDoa2100010. [PMID: 38319180 DOI: 10.1056/evidoa2100010] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Balanced Crystalloids and Saline in Critical IllnessThis article presents a frequentist (showing no significant difference) and Bayesian (in which the posterior probability that balanced crystalloids reduced mortality was 89.5%) systematic review of randomized clinical trials comparing balanced crystalloids with saline in critically ill adults with the primary outcome of 90-day mortality.
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Affiliation(s)
- Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo
- D'Or Research and Education Institute, São Paulo
| | - Gian Luca Di Tanna
- BioStatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney
| | - Tessa Garside
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Derick Adigbli
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | | | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Department of Intensive Care, St. George Hospital, Sydney
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Queensland, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Queensland, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- School of Public Health, The George Institute for Global Health, Imperial College, London
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
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Abstract
This systematic review examines geographical representation of low- and middle-income countries in randomized clinical trials for COVID-19 compared with high-income countries.
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Affiliation(s)
- Mahesh Ramanan
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Steven Y. C. Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | | | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Granholm A, Munch MW, Myatra SN, Vijayaraghavan BKT, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Kjær MBN, Vesterlund GK, Meyhoff TS, Helleberg M, Møller MH, Benfield T, Venkatesh B, Hammond NE, Micallef S, Bassi A, John O, Jha V, Kristiansen KT, Ulrik CS, Jørgensen VL, Smitt M, Bestle MH, Andreasen AS, Poulsen LM, Rasmussen BS, Brøchner AC, Strøm T, Møller A, Khan MS, Padmanaban A, Divatia JV, Saseedharan S, Borawake K, Kapadia F, Dixit S, Chawla R, Shukla U, Amin P, Chew MS, Wamberg CA, Gluud C, Lange T, Perner A. Dexamethasone 12 mg versus 6 mg for patients with COVID-19 and severe hypoxaemia: a pre-planned, secondary Bayesian analysis of the COVID STEROID 2 trial. Intensive Care Med 2022; 48:45-55. [PMID: 34757439 PMCID: PMC8579417 DOI: 10.1007/s00134-021-06573-1] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/29/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE We compared dexamethasone 12 versus 6 mg daily for up to 10 days in patients with coronavirus disease 2019 (COVID-19) and severe hypoxaemia in the international, randomised, blinded COVID STEROID 2 trial. In the primary, conventional analyses, the predefined statistical significance thresholds were not reached. We conducted a pre-planned Bayesian analysis to facilitate probabilistic interpretation. METHODS We analysed outcome data within 90 days in the intention-to-treat population (data available in 967 to 982 patients) using Bayesian models with various sensitivity analyses. Results are presented as median posterior probabilities with 95% credible intervals (CrIs) and probabilities of different effect sizes with 12 mg dexamethasone. RESULTS The adjusted mean difference on days alive without life support at day 28 (primary outcome) was 1.3 days (95% CrI -0.3 to 2.9; 94.2% probability of benefit). Adjusted relative risks and probabilities of benefit on serious adverse reactions was 0.85 (0.63 to 1.16; 84.1%) and on mortality 0.87 (0.73 to 1.03; 94.8%) at day 28 and 0.88 (0.75 to 1.02; 95.1%) at day 90. Probabilities of benefit on days alive without life support and days alive out of hospital at day 90 were 85 and 95.7%, respectively. Results were largely consistent across sensitivity analyses, with relatively low probabilities of clinically important harm with 12 mg on all outcomes in all analyses. CONCLUSION We found high probabilities of benefit and low probabilities of clinically important harm with dexamethasone 12 mg versus 6 mg daily in patients with COVID-19 and severe hypoxaemia on all outcomes up to 90 days.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Bharath Kumar Tirupakuzhi Vijayaraghavan
- Department of Critical Care, Apollo Hospitals, Chennai, India ,Chennai Critical Care Consultants, Chennai, India ,The George Institute for Global Health, New Delhi, India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Rebecka Rubenson Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Maj-Brit Nørregaard Kjær
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Gitte Kingo Vesterlund
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Tine Sylvest Meyhoff
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Benfield
- Center of Research & Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, Hvidovre, Denmark
| | | | - Naomi E. Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, Australia ,Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abhinav Bassi
- The George Institute for Global Health, New Delhi, India
| | - Oommen John
- The George Institute for Global Health, New Delhi, India ,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India ,Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India ,School of Public Health, Imperial College London, London, UK
| | - Klaus Tjelle Kristiansen
- Department of Anaesthesia and Intensive Care, Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Lind Jørgensen
- Department of Thoracic Anaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Margit Smitt
- Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten H. Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital – North Zealand, Hillerød, Denmark ,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Herlev Hospital, University of Copenhagen, Herlev, Denmark
| | | | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark ,Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Anne Craveiro Brøchner
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark ,Department of Anaesthesia and Intensive Care, Kolding Hospital, University Hospital of Southern Denmark, Kolding, Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine, Odense University Hospital, Odense C, Denmark ,Department of Anaesthesia and Critical Care Medicine, Hospital Sønderjylland, University Hospital of Southern, Odense, Denmark
| | - Anders Møller
- Department of Anaesthesia and Intensive Care, Næstved-Slagelse-Ringsted Hospital, Slagelse, Denmark
| | - Mohd Saif Khan
- Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, India
| | - Ajay Padmanaban
- Department of Critical Care, Apollo Hospitals, Chennai, India
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | - Kapil Borawake
- Department of Intensive Care, Vishwaraj Hospital, Pune, India
| | - Farhad Kapadia
- Section of Critical Care, Department of Medicine, Hinduja Hospital, Mahim, Mumbai India
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan Hospital, Pune, Maharashtra India
| | - Rajesh Chawla
- Department of Respiratory and Critical Care Medicine, Indraprastha Apollo Hospital, New Delhi, India
| | - Urvi Shukla
- Intensive Care Unit and Emergency Services, Symbiosis University Hospital and Research Centre, Lavale, Pune, India
| | - Pravin Amin
- Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Michelle S. Chew
- Department of Anesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Christian Gluud
- Centre for Clinical Intervention Research, Copenhagen Trial Unit, Capital Region of Denmark, Copenhagen University Hospital –Rigshospitalet, Copenhagen, Denmark ,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet—Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark ,Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Axfors C, Janiaud P, Schmitt AM, Van't Hooft J, Smith ER, Haber NA, Abayomi A, Abduljalil M, Abdulrahman A, Acosta-Ampudia Y, Aguilar-Guisado M, Al-Beidh F, Alejandria MM, Alfonso RN, Ali M, AlQahtani M, AlZamrooni A, Anaya JM, Ang MAC, Aomar IF, Argumanis LE, Averyanov A, Baklaushev VP, Balionis O, Benfield T, Berry S, Birocco N, Bonifacio LB, Bowen AC, Bown A, Cabello-Gutierrez C, Camacho B, Camacho-Ortiz A, Campbell-Lee S, Cao DH, Cardesa A, Carnate JM, Castillo GJJ, Cavallo R, Chowdhury FR, Chowdhury FUH, Ciccone G, Cingolani A, Climacosa FMM, Compernolle V, Cortez CFN, Costa Neto A, D'Antico S, Daly J, Danielle F, Davis JS, De Rosa FG, Denholm JT, Denkinger CM, Desmecht D, Díaz-Coronado JC, Díaz Ponce-Medrano JA, Donneau AF, Dumagay TE, Dunachie S, Dungog CC, Erinoso O, Escasa IMS, Estcourt LJ, Evans A, Evasan ALM, Fareli CJ, Fernandez-Sanchez V, Galassi C, Gallo JE, Garcia PJ, Garcia PL, Garcia JA, Garigliany M, Garza-Gonzalez E, Gauiran DTV, Gaviria García PA, Giron-Gonzalez JA, Gómez-Almaguer D, Gordon AC, Gothot A, Grass Guaqueta JS, Green C, Grimaldi D, Hammond NE, Harvala H, Heralde FM, Herrick J, Higgins AM, Hills TE, Hines J, Holm K, Hoque A, Hoste E, Ignacio JM, Ivanov AV, Janssen M, Jennings JH, Jha V, King RAN, Kjeldsen-Kragh J, Klenerman P, Kotecha A, Krapp F, Labanca L, Laing E, Landin-Olsson M, Laterre PF, Lim LL, Lim J, Ljungquist O, Llaca-Díaz JM, López-Robles C, López-Cárdenas S, Lopez-Plaza I, Lucero JAC, Lundgren M, Macías J, Maganito SC, Malundo AFG, Manrique RD, Manzini PM, Marcos M, Marquez I, Martínez-Marcos FJ, Mata AM, McArthur CJ, McQuilten ZK, McVerry BJ, Menon DK, Meyfroidt G, Mirasol MAL, Misset B, Molton JS, Mondragon AV, Monsalve DM, Moradi Choghakabodi P, Morpeth SC, Mouncey PR, Moutschen M, Müller-Tidow C, Murphy E, Najdovski T, Nichol AD, Nielsen H, Novak RM, O'Sullivan MVN, Olalla J, Osibogun A, Osikomaiya B, Oyonarte S, Pardo-Oviedo JM, Patel MC, Paterson DL, Peña-Perez CA, Perez-Calatayud AA, Pérez-Alba E, Perkina A, Perry N, Pouladzadeh M, Poyato I, Price DJ, Quero AKH, Rahman MM, Rahman MS, Ramesh M, Ramírez-Santana C, Rasmussen M, Rees MA, Rego E, Roberts JA, Roberts DJ, Rodríguez Y, Rodríguez-Baño J, Rogers BA, Rojas M, Romero A, Rowan KM, Saccona F, Safdarian M, Santos MCM, Sasadeusz J, Scozzari G, Shankar-Hari M, Sharma G, Snelling T, Soto A, Tagayuna PY, Tang A, Tatem G, Teofili L, Tong SYC, Turgeon AF, Veloso JD, Venkatesh B, Ventura-Enriquez Y, Webb SA, Wiese L, Wikén C, Wood EM, Yusubalieva GM, Zacharowski K, Zarychanski R, Khanna N, Moher D, Goodman SN, Ioannidis JPA, Hemkens LG. Association between convalescent plasma treatment and mortality in COVID-19: a collaborative systematic review and meta-analysis of randomized clinical trials. BMC Infect Dis 2021; 21:1170. [PMID: 34800996 PMCID: PMC8605464 DOI: 10.1186/s12879-021-06829-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Convalescent plasma has been widely used to treat COVID-19 and is under investigation in numerous randomized clinical trials, but results are publicly available only for a small number of trials. The objective of this study was to assess the benefits of convalescent plasma treatment compared to placebo or no treatment and all-cause mortality in patients with COVID-19, using data from all available randomized clinical trials, including unpublished and ongoing trials (Open Science Framework, https://doi.org/10.17605/OSF.IO/GEHFX ). METHODS In this collaborative systematic review and meta-analysis, clinical trial registries (ClinicalTrials.gov, WHO International Clinical Trials Registry Platform), the Cochrane COVID-19 register, the LOVE database, and PubMed were searched until April 8, 2021. Investigators of trials registered by March 1, 2021, without published results were contacted via email. Eligible were ongoing, discontinued and completed randomized clinical trials that compared convalescent plasma with placebo or no treatment in COVID-19 patients, regardless of setting or treatment schedule. Aggregated mortality data were extracted from publications or provided by investigators of unpublished trials and combined using the Hartung-Knapp-Sidik-Jonkman random effects model. We investigated the contribution of unpublished trials to the overall evidence. RESULTS A total of 16,477 patients were included in 33 trials (20 unpublished with 3190 patients, 13 published with 13,287 patients). 32 trials enrolled only hospitalized patients (including 3 with only intensive care unit patients). Risk of bias was low for 29/33 trials. Of 8495 patients who received convalescent plasma, 1997 died (23%), and of 7982 control patients, 1952 died (24%). The combined risk ratio for all-cause mortality was 0.97 (95% confidence interval: 0.92; 1.02) with between-study heterogeneity not beyond chance (I2 = 0%). The RECOVERY trial had 69.8% and the unpublished evidence 25.3% of the weight in the meta-analysis. CONCLUSIONS Convalescent plasma treatment of patients with COVID-19 did not reduce all-cause mortality. These results provide strong evidence that convalescent plasma treatment for patients with COVID-19 should not be used outside of randomized trials. Evidence synthesis from collaborations among trial investigators can inform both evidence generation and evidence application in patient care.
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Affiliation(s)
- Cathrine Axfors
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, USA
- Department for Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Perrine Janiaud
- Department of Clinical Research, University Hospital Basel, University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Andreas M Schmitt
- Department of Clinical Research, University Hospital Basel, University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
- Department of Medical Oncology, University of Basel, Basel, Switzerland
| | - Janneke Van't Hooft
- Amsterdam University Medical Center, Amsterdam University, Amsterdam, The Netherlands
| | - Emily R Smith
- Department of Global Health, Milken Institute School of Public Health, The George Washington University, Washington, USA
| | - Noah A Haber
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, USA
| | | | - Manal Abduljalil
- Internal Medicine, Bahrain Defence Force Hospital, Riffa, Bahrain
| | - Abdulkarim Abdulrahman
- Medical Team, National Task Force for Combating the Coronavirus (COVID19), Riffa, Bahrain
- Mohammed Bin Khalifa Cardiac Centre, Awali, Bahrain
| | - Yeny Acosta-Ampudia
- Center for Autoimmune Diseases Research (CREA), Universidad del Rosario, Bogotá, Colombia
| | - Manuela Aguilar-Guisado
- Infectious Diseases, Microbiology and Preventive Medicine Unit, Hospital Universitario Virgen del Rocío, Seville, Spain
| | - Farah Al-Beidh
- Surgery and Cancer, Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
| | - Marissa M Alejandria
- Department of Medicine, Division of Infectious Diseases, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Rachelle N Alfonso
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Mohammad Ali
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Manaf AlQahtani
- Medical Team, National Task Force for Combating the Coronavirus (COVID19), Riffa, Bahrain
- Microbiology, Infectious Diseases, Bahrain Defence Force Hospital, Riffa, Bahrain
- Microbiology, Royal College of Surgeons in Ireland-Medical University in Bahrain, Riffa, Bahrain
| | - Alaa AlZamrooni
- Internal Medicine, Salmaniya Medical Complex, Manama, Bahrain
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), Universidad del Rosario, Bogotá, Colombia
| | - Mark Angelo C Ang
- Department of Laboratories, Division of Blood Bank, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Ismael F Aomar
- Department of Internal Medicine, Hospital Universitario San Cecilio, Granada, Spain
| | - Luis E Argumanis
- Banco de Sangre, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru
| | - Alexander Averyanov
- Pulmonary Division, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical and Biological Agency, Moscow, Russian Federation
- Fundamental Medicine Department, Pulmonology Scientific and Research Institute under Federal Medical and Biological Agency, Moscow, Russian Federation
| | - Vladimir P Baklaushev
- Fundamental Medicine Department, Pulmonology Scientific and Research Institute under Federal Medical and Biological Agency, Moscow, Russian Federation
- Cell Culture Laboratory, Biomedical Research, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical and Biological Agency, Moscow, Russian Federation
| | - Olga Balionis
- Pulmonary Division, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical and Biological Agency, Moscow, Russian Federation
- Laboratory of Personalized Medicine, Pulmonology Scientific and Research Institute under Federal Medical and Biological Agency, Moscow, Russian Federation
| | - Thomas Benfield
- Center for Research and Disruption of Infectious Diseases, Department of Infectious Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | | | - Nadia Birocco
- Department of Oncology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Lynn B Bonifacio
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Asha C Bowen
- Menzies School of Health Research, Casuarina, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia
- Department of Infectious Diseases, Perth Children's Hospital, Nedlands, Australia
| | - Abbie Bown
- Rare and Imported Pathogens Laboratory, Public Health England, Porton Down, UK
| | - Carlos Cabello-Gutierrez
- Department Research in Virology and Mycology, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Bernardo Camacho
- Instituto Distrital de Ciencia Biotecnología e Investigación en Salud (IDCBIS), Bogotá, Colombia
| | - Adrian Camacho-Ortiz
- Department of Infectious Diseases, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | | | - Damon H Cao
- Department of Medicine, Division of Nephrology, Henry Ford Hospital, Detroit, USA
| | - Ana Cardesa
- Clinical Department, Red Andaluza de Diseño y Traslacion de Terapias Avanzadas, Sevilla, Spain
| | - Jose M Carnate
- Department of Laboratories, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - German Jr J Castillo
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Rossana Cavallo
- Department of Laboratory Medicine, Unit of Microbiology and Virology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Fazle R Chowdhury
- Internal Medicine, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | - Giovannino Ciccone
- Department of Quality and Safety in Health Care, Unit of Clinical Epidemiology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Antonella Cingolani
- Infectious Disease, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Veerle Compernolle
- Blood Services, Belgian Red Cross-Flanders, Mechelen, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Carlo Francisco N Cortez
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Abel Costa Neto
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo, Brazil
| | - Sergio D'Antico
- Department of Laboratory Medicine, Unit of Transfusion Medicine, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - James Daly
- Australian Red Cross Lifeblood, Melbourne, Australia
| | - Franca Danielle
- Department of Laboratory Medicine, Blood Bank, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Francesco Giuseppe De Rosa
- Department of Medical Sciences, Unit of Infective Diseases, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Justin T Denholm
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Australia
- Doherty Department, University of Melbourne, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Claudia M Denkinger
- Center of Infectious Diseases, Division of Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | | | | | - Teresita E Dumagay
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Susanna Dunachie
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Cecile C Dungog
- Department of Laboratories, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | | | - Ivy Mae S Escasa
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Lise J Estcourt
- Clinical, Research and Development, NHS Blood and Transplant, Oxford, UK
- Radcliffe Department of Medicine and BRC Haematology Theme, University of Oxford, Oxford, UK
| | - Amy Evans
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Agnes L M Evasan
- Department of Medicine, Division of Infectious Diseases, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Christian J Fareli
- CENETEC (National Center for Health Technology Excellence), Mexico City, Mexico
| | | | - Claudia Galassi
- Department of Quality and Safety in Health Care, Unit of Clinical Epidemiology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | | | - Patricia J Garcia
- Facultad de Salud Pública y Administración, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Patricia L Garcia
- Servicio de Hemoterapia y Banco de Sangre, Instituto Nacional de Salud del Niño San Borja, Lima, Peru
| | - Jesus A Garcia
- Department of Haematology, Centro Transfusional Tejidos y Celulas de Granada, Granada, Spain
| | | | - Elvira Garza-Gonzalez
- Department of Infectious Diseases, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Deonne Thaddeus V Gauiran
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Paula A Gaviria García
- Instituto Distrital de Ciencia Biotecnología e Investigación en Salud (IDCBIS), Bogotá, Colombia
| | | | | | - Anthony C Gordon
- Surgery and Cancer, Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, London, UK
- Intensive Care, Imperial College Healthcare NHS Trust, London, UK
| | - André Gothot
- Immunohematology, Liège University Hospital, Liège, Belgium
| | | | - Cameron Green
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - David Grimaldi
- Intensive Care Medicine, Cliniques Universitaires de Bruxelles-Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Naomi E Hammond
- The George Institute for Global Health, Sydney and New Delhi, Sydney, Australia
| | - Heli Harvala
- Microbiology Services, NHS Blood and Transplant, London, UK
| | - Francisco M Heralde
- Department of Biochemistry and Molecular Biology, University of the Philippines, Manila, Philippines
| | - Jesica Herrick
- Medicine, Division of Infectious Diseases, Immunology, and International Medicine, University of Illinois at Chicago, Chicago, USA
| | - Alisa M Higgins
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Thomas E Hills
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Auckland City Hospital, Auckland, New Zealand
| | - Jennifer Hines
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
| | - Karin Holm
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
- Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Ashraful Hoque
- Blood Transfusion, Sheikh Hasina National Institute of Burn and Plastic Surgery, Dhaka, Bangladesh
| | - Eric Hoste
- Intensive Care Medicine, Gand University Hospital, Gent, Belgium
| | - Jose M Ignacio
- Department of Neumology and Pulmonology, Hospital Quiron de Marbella, Málaga, Spain
| | - Alexander V Ivanov
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Engelhardt Institute of Molecular Biology of the Russian Academy of Sciences, Moscow, Russian Federation
| | - Maike Janssen
- Department of Hematology, Oncology and Rheumatology, Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Jeffrey H Jennings
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
| | - Vivekanand Jha
- The George Institute for Global Health, Sydney and New Delhi, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Ruby Anne N King
- Department of Biochemistry and Molecular Biology, University of the Philippines, Manila, Philippines
| | - Jens Kjeldsen-Kragh
- Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Region Skåne, Lund, Sweden
| | - Paul Klenerman
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Aditya Kotecha
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
| | - Fiorella Krapp
- Facultad de Medicina, Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Luciana Labanca
- Department of Laboratory Medicine, Blood Bank, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Emma Laing
- Clinical Trials Unit, NHS Blood and Transplant, Cambridge, UK
| | - Mona Landin-Olsson
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Endocrinology, Skåne University Hospital, Lund, Sweden
| | | | | | - Jodor Lim
- Department of Medicine, Division of Infectious Diseases, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Oskar Ljungquist
- Clinical Sciences, Clinical Infection Medicine, Lund University, Malmo, Sweden
| | - Jorge M Llaca-Díaz
- Department of Clinical Pathology, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Concepción López-Robles
- Department of Infectious Diseases, Hospital Universitario Virgen de Las Nieves, Granada, Spain
| | - Salvador López-Cárdenas
- Department of Infectious Diseases, Hospital Universitario de Jerez de La Frontera, Jerez de la Frontera, Spain
| | - Ileana Lopez-Plaza
- Division of Transfusion Medicine, Department of Pathology, Henry Ford Hospital, Detroit, USA
| | - Josephine Anne C Lucero
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Maria Lundgren
- Clinical Immunology and Transfusion Medicine, University and Regional Laboratories, Region Skåne, Lund, Sweden
| | - Juan Macías
- Department of Infectious Diseases, Hospital Universitario de Valme, Sevilla, Spain
| | - Sandy C Maganito
- Department of Laboratories, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Anna Flor G Malundo
- Department of Medicine, Division of Infectious Diseases, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Rubén D Manrique
- Epidemiology and Biostatistics Research Group, Universidad CES, Medellín, Colombia
| | - Paola M Manzini
- Department of Laboratory Medicine, Unit of Transfusion Medicine, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Miguel Marcos
- Department of Internal Medicine, Hospital Quiron de Malaga, Málaga, Spain
| | - Ignacio Marquez
- Department of Infectious Diseases, Hospital Regional Universitario de Malaga, Málaga, Spain
| | | | - Ana M Mata
- Department of Internal Medicine, Hospital San Juan de Dios del Aljarafe, Bormujos, Spain
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Zoe K McQuilten
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Haematology, Monash Health, Melbourne, Australia
| | - Bryan J McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - David K Menon
- University Division of Anaesthesia, Addenbrooke's Hospital Cambridge, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Intensive Care Medicine, Leuven University Hospital, Leuven, Belgium
| | - Ma Angelina L Mirasol
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Benoît Misset
- Intensive Care Medicine, Liège University Hospital, Liège, Belgium
| | | | - Alric V Mondragon
- Department of Medicine, Division of Allergy and Immunology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Diana M Monsalve
- Center for Autoimmune Diseases Research (CREA), Universidad del Rosario, Bogotá, Colombia
| | - Parastoo Moradi Choghakabodi
- Thalassemia and Hemoglobinopathy Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Thalassemia and Hemoglobinopathy Research Center, Health Research Institute, Ahvaz, Iran
| | | | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Michel Moutschen
- Intensive Care Medicine, Liège University Hospital, Liège, Belgium
| | - Carsten Müller-Tidow
- Department of Hematology, Oncology and Rheumatology, Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Erin Murphy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
| | | | - Alistair D Nichol
- School of Medicine and Medical Sciences, University College Dublin-Clinical Research Centre, University College Dublin, Dublin, Ireland
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Intensive Care Medicine, Alfred Health, Melbourne, Australia
| | - Henrik Nielsen
- Department of Infectious Diseases, Aalborg University Hospital, Aalborg, Denmark
| | - Richard M Novak
- Medicine, Division of Infectious Diseases, Immunology, and International Medicine, University of Illinois at Chicago, Chicago, USA
| | - Matthew V N O'Sullivan
- Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead, Australia
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Westmead, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Julian Olalla
- Department of Internal Medicine, Hospital Costa del Sol, Málaga, Spain
| | - Akin Osibogun
- College of Medicine, University of Lagos, Lagos, Nigeria
| | | | - Salvador Oyonarte
- Department of Infectious Diseases, Centro Transfusional Tejidos y Celulas de Sevilla, Sevilla, Spain
| | - Juan M Pardo-Oviedo
- Hospital Universitario Mayor Méderi, Universidad del Rosario, Bogotá, Colombia
| | - Mahesh C Patel
- Medicine, Division of Infectious Diseases, Immunology, and International Medicine, University of Illinois at Chicago, Chicago, USA
| | - David L Paterson
- Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Herston, Australia
| | | | | | - Eduardo Pérez-Alba
- Department of Infectious Diseases, Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Anastasia Perkina
- Pulmonary Division, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical and Biological Agency, Moscow, Russian Federation
- Laboratory of Personalized Medicine, Pulmonology Scientific and Research Institute under Federal Medical and Biological Agency, Moscow, Russian Federation
| | - Naomi Perry
- Doherty Department, University of Melbourne, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Mandana Pouladzadeh
- Emergency Medicine Department, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Inmaculada Poyato
- Department of Internal Medicine, Hospital Universitario Torrecardenas, Almería, Spain
| | - David J Price
- Doherty Department, University of Melbourne, Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Anne Kristine H Quero
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Md M Rahman
- Internal Medicine, Dhaka Medical College, Dhaka, Bangladesh
| | - Md S Rahman
- Pharmacology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Mayur Ramesh
- Department of Internal Medicine, Division of Infectious Diseases, Henry Ford Hospital, Detroit, USA
| | | | - Magnus Rasmussen
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
- Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Megan A Rees
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Royal Melbourne Hospital, Melbourne Health, Melbourne, Australia
| | - Eduardo Rego
- Instituto D'Or de Pesquisa e Ensino (IDOR), São Paulo, Brazil
| | - Jason A Roberts
- Hospital Universitario Mayor Méderi, Universidad del Rosario, Bogotá, Colombia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - David J Roberts
- Radcliffe Department of Medicine and BRC Haematology Theme, University of Oxford, Oxford, UK
- Clinical and Research and Development, NHS Blood and Transplant, Oxford, UK
| | - Yhojan Rodríguez
- Center for Autoimmune Diseases Research (CREA), Universidad del Rosario, Bogotá, Colombia
- Clinica del Occidente, Bogotá, Colombia
| | - Jesús Rodríguez-Baño
- Infectious Diseases and Clinical Microbiology Unit, Hospital Universitario Virgen Macarena, Sevilla, Spain
- Department of Medicine, University of Sevilla-IBiS, Sevilla, Spain
| | - Benjamin A Rogers
- Monash University, Melbourne, Australia
- Monash Health, Melbourne, Australia
| | - Manuel Rojas
- Center for Autoimmune Diseases Research (CREA), Universidad del Rosario, Bogotá, Colombia
| | - Alberto Romero
- Department of Infectious Diseases, Hospital Universitario de Puerto Real, Cádiz, Spain
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Fabio Saccona
- Department of Quality and Safety in Health Care, Unit of Clinical Epidemiology, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mehdi Safdarian
- Nanotechnology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Maria Clariza M Santos
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Joe Sasadeusz
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, Melbourne, Australia
- Doherty Department, University of Melbourne, The Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Gitana Scozzari
- Department of Medical Hospital Direction, Unit of Medical Direction, University Hospital Città della Salute e della Scienza di Torino, Turin, Italy
| | - Manu Shankar-Hari
- St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
- School of Immunology and Microbial Sciences, Kings College London, London, UK
| | - Gorav Sharma
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
| | - Thomas Snelling
- Menzies School of Health Research, Casuarina, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Nedlands, Australia
- Sydney School of Public Health, University of Sydney, Camperdown, Australia
- Sydney Children's Hospital Network, Westmead, Australia
| | - Alonso Soto
- Facultad de Medicina Humana, Instituto de Investigación en Ciencias Biomédicas (INICIB), Universidad Ricardo Palma, Lima, Peru
- Department of Internal Medicine, Hospital Nacional Hipolito Unanue, Lima, Peru
| | - Pedrito Y Tagayuna
- Department of Laboratories, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Amy Tang
- Public Health Sciences, Henry Ford Hospital, Detroit, USA
| | - Geneva Tatem
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Henry Ford Hospital, Detroit, USA
| | - Luciana Teofili
- Transfusion Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Januario D Veloso
- Department of Medicine, Division of Hematology, University of the Philippines-Philippine General Hospital, Manila, Philippines
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney and New Delhi, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Wesley and Princess Alexandra Hospitals, University of Queensland, Brisbane, Australia
| | | | - Steve A Webb
- School of Medicine and Medical Sciences, University College Dublin-Clinical Research Centre, University College Dublin, Dublin, Ireland
- St John of God Hospital, Subiaco, Subiaco, Australia
| | - Lothar Wiese
- Department of Infectious Diseases, Zealand University Hospital, Roskilde, Denmark
| | - Christian Wikén
- Infectious Diseases, Skåne University Hospital, Lund, Sweden
| | - Erica M Wood
- Department of Clinical Haematology, Monash Health, Melbourne, Australia
| | - Gaukhar M Yusubalieva
- Cell Culture Laboratory, Biomedical Research, Federal Scientific and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical and Biological Agency, Moscow, Russian Federation
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Ryan Zarychanski
- Department of Internal Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Canada
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Hygiene and Infection Biology Laboratory, University Hospital Basel and University of Basel, Basel, Switzerland
| | - David Moher
- Centre for Journalology, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Steven N Goodman
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, USA
- Stanford University School of Medicine, Stanford, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, USA
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, USA
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, USA
- Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, USA
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Lars G Hemkens
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, USA.
- Department of Clinical Research, University Hospital Basel, University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.
- Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany.
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Nasa P, Azoulay E, Chakrabarti A, Divatia JV, Jain R, Rodrigues C, Rosenthal VD, Alhazzani W, Arabi YM, Bakker J, Bassetti M, De Waele J, Dimopoulos G, Du B, Einav S, Evans L, Finfer S, Guérin C, Hammond NE, Jaber S, Kleinpell RM, Koh Y, Kollef M, Levy MM, Machado FR, Mancebo J, Martin-Loeches I, Mer M, Niederman MS, Pelosi P, Perner A, Peter JV, Phua J, Piquilloud L, Pletz MW, Rhodes A, Schultz MJ, Singer M, Timsit JF, Venkatesh B, Vincent JL, Welte T, Myatra SN. Infection control in the intensive care unit: expert consensus statements for SARS-CoV-2 using a Delphi method. Lancet Infect Dis 2021. [PMID: 34774188 DOI: 10.1016/s1473-3099(21)00626-5.] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
During the current COVID-19 pandemic, health-care workers and uninfected patients in intensive care units (ICUs) are at risk of being infected with SARS-CoV-2 as a result of transmission from infected patients and health-care workers. In the absence of high-quality evidence on the transmission of SARS-CoV-2, clinical practice of infection control and prevention in ICUs varies widely. Using a Delphi process, international experts in intensive care, infectious diseases, and infection control developed consensus statements on infection control for SARS-CoV-2 in an ICU. Consensus was achieved for 31 (94%) of 33 statements, from which 25 clinical practice statements were issued. These statements include guidance on ICU design and engineering, health-care worker safety, visiting policy, personal protective equipment, patients and procedures, disinfection, and sterilisation. Consensus was not reached on optimal return to work criteria for health-care workers who were infected with SARS-CoV-2 or the acceptable disinfection strategy for heat-sensitive instruments used for airway management of patients with SARS-CoV-2 infection. Well designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.
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Affiliation(s)
- Prashant Nasa
- NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis Teaching Hospital, APHP, University of Paris, Paris, France
| | | | | | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Camilla Rodrigues
- PD Hinduja National Hospital and Medical Research Centre, Mumbai, India
| | | | | | - Yaseen M Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University Grossman School of Medicine, New York, NY, USA; Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA; Erasmus University Medical Center, Rotterdam, Netherlands; Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Matteo Bassetti
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | | | - George Dimopoulos
- Attikon University Hospital, Athens, Greece; National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Bin Du
- State Key Laboratory of Rare, Complex and Critical Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Sharon Einav
- Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | | | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Imperial College London, London, UK
| | - Claude Guérin
- University de Lyon, Lyon, France; Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Newton, Adelaide, SA, Australia
| | - Samir Jaber
- Hôpital Saint-Éloi, Montpellier University Hospital, Montpellier, France
| | - Ruth M Kleinpell
- Vanderbilt University School of Nursing, Vanderbilt University, Nashville, TN, USA
| | - Younsuck Koh
- College of Medicine, University of Ulsan College of Medicine, University of Ulsan, Seoul, South Korea
| | - Marin Kollef
- Washington University School of Medicine, Washington University, St Louis, MO, USA
| | - Mitchell M Levy
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Flavia R Machado
- Hospital Sao Paulo, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa; Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa
| | | | - Paolo Pelosi
- IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy; University of Genoa, Genoa, Italy
| | - Anders Perner
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jason Phua
- Alexandra Hospital, National University Health System, Singapore; National University Hospital, National University Health System, Singapore
| | - Lise Piquilloud
- University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathias W Pletz
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Andrew Rhodes
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marcus J Schultz
- Amsterdam University Medical Centers, Locatie AMC, Amsterdam, Netherlands; Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand; Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | | | | | - Tobias Welte
- German Center of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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Munch MW, Myatra SN, Vijayaraghavan BKT, Saseedharan S, Benfield T, Wahlin RR, Rasmussen BS, Andreasen AS, Poulsen LM, Cioccari L, Khan MS, Kapadia F, Divatia JV, Brøchner AC, Bestle MH, Helleberg M, Michelsen J, Padmanaban A, Bose N, Møller A, Borawake K, Kristiansen KT, Shukla U, Chew MS, Dixit S, Ulrik CS, Amin PR, Chawla R, Wamberg CA, Shah MS, Darfelt IS, Jørgensen VL, Smitt M, Granholm A, Kjær MBN, Møller MH, Meyhoff TS, Vesterlund GK, Hammond NE, Micallef S, Bassi A, John O, Jha A, Cronhjort M, Jakob SM, Gluud C, Lange T, Kadam V, Marcussen KV, Hollenberg J, Hedman A, Nielsen H, Schjørring OL, Jensen MQ, Leistner JW, Jonassen TB, Kristensen CM, Clapp EC, Hjortsø CJS, Jensen TS, Halstad LS, Bak ERB, Zaabalawi R, Metcalf-Clausen M, Abdi S, Hatley EV, Aksnes TS, Gleipner-Andersen E, Alarcón AF, Yamin G, Heymowski A, Berggren A, La Cour K, Weihe S, Pind AH, Engstrøm J, Jha V, Venkatesh B, Perner A. Effect of 12 mg vs 6 mg of Dexamethasone on the Number of Days Alive Without Life Support in Adults With COVID-19 and Severe Hypoxemia: The COVID STEROID 2 Randomized Trial. JAMA 2021; 326:1807-1817. [PMID: 34673895 PMCID: PMC8532039 DOI: 10.1001/jama.2021.18295] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease. OBJECTIVE To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021. INTERVENTIONS Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and ≥1 serious adverse reactions at 28 days). RESULTS Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29]). CONCLUSIONS AND RELEVANCE Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04509973 and ctri.nic.in Identifier: CTRI/2020/10/028731.
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Affiliation(s)
| | - Marie W Munch
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sheila N Myatra
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Rebecka R Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | | | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Lone M Poulsen
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Luca Cioccari
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mohd S Khan
- Rajendra Institute of Medical Sciences, Ranchi, India
| | | | | | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, Kolding Hospital, Kolding, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hilleroed, Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Michelsen
- Department of Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Anders Møller
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | | | - Klaus T Kristiansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Urvi Shukla
- Symbiosis University Hospital and Research Centre, Lavale, India
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Charlotte S Ulrik
- Department of Respiratory Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Pravin R Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Christian A Wamberg
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Mehul S Shah
- Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Iben S Darfelt
- Department of Anaesthesia and Intensive Care, Herning Hospital, Herning, Denmark
| | - Vibeke L Jørgensen
- Department of Thoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Margit Smitt
- Department of Neurointensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maj-Brit N Kjær
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tine S Meyhoff
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gitte K Vesterlund
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abhinav Bassi
- The George Institute for Global Health, New Delhi, India
| | - Oommen John
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Medical Sciences, Manipal, India
| | - Anubhuti Jha
- The George Institute for Global Health, New Delhi, India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M Jakob
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Klaus V Marcussen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Nielsen
- Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | | | - Marie Q Jensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens W Leistner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine B Jonassen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Camilla M Kristensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Esben C Clapp
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carl J S Hjortsø
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas S Jensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Liv S Halstad
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emilie R B Bak
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Reem Zaabalawi
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matias Metcalf-Clausen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Suhayb Abdi
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emma V Hatley
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tobias S Aksnes
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Gleipner-Andersen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Arif F Alarcón
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Yamin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Adam Heymowski
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anton Berggren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Kirstine La Cour
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Sarah Weihe
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Alison H Pind
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Janus Engstrøm
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Medical Sciences, Manipal, India
- School of Public Health, Imperial College, London, England
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Intensive Care, Wesley Hospital, Brisbane, Australia
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Tirupakuzhi Vijayaraghavan BK, Nainan Myatra S, Mathew M, Lodh N, Vasishtha Divatia J, Hammond N, Jha V, Venkatesh B. Challenges in the delivery of critical care in India during the COVID-19 pandemic. J Intensive Care Soc 2021; 22:342-348. [PMID: 35154373 PMCID: PMC8829772 DOI: 10.1177/1751143720952590] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Coronavirus disease 2019 cases in India continue to increase and are expected to peak over the next few weeks. Based on some projection models, India is expected to have more than 10 million cases by September 2020. The spectrum of disease can vary from mild upper respiratory tract symptoms to life-threatening acute respiratory distress syndrome and multi-organ failure requiring intensive care. Even if less than 5% of patients require critical care services, this will still rapidly overwhelm the healthcare system in a country, where intensive care services and resources are scarce and unevenly distributed. In this perspective article, we highlight the critical care preparedness of India for the pandemic and the associated challenges.
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Affiliation(s)
- Bharath Kumar Tirupakuzhi Vijayaraghavan
- Department of Critical Care, Apollo Hospitals, Chennai, India
- Asia Pacific Sepsis Alliance, Newton, New South Wales, Australia
- The George Institute for Global Health, New Delhi, India
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Meghena Mathew
- Department of Critical Care, Apollo Hospitals, Chennai, India
| | - Nirmalyo Lodh
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Jigeeshu Vasishtha Divatia
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Naomi Hammond
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, New South Wales, Australia
| | - Vivekanand Jha
- The George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Manipal Academy of Higher Education, Manipal, India
| | - Balasubramanian Venkatesh
- Division of Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Department of Critical Care Medicine, University of Queensland, St Lucia, QLD, Australia
- Wesley Hospital, Auchenflower, Brisbane, Australia
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Munch MW, Meyhoff TS, Helleberg M, Kjær MN, Granholm A, Hjortsø CJS, Jensen TS, Møller MH, Hjortrup PB, Wetterslev M, Vesterlund GK, Russell L, Jørgensen VL, Kristiansen KT, Benfield T, Ulrik CS, Andreasen AS, Bestle MH, Poulsen LM, Hildebrandt T, Knudsen LS, Møller A, Sølling CG, Brøchner AC, Rasmussen BS, Nielsen H, Christensen S, Strøm T, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Venkatesh B, Hammond N, Jha V, Myatra SN, Jensen MQ, Leistner JW, Mikkelsen VS, Svenningsen JS, Laursen SB, Hatley EV, Kristensen CM, Al‐Alak A, Clapp E, Jonassen TB, Bjerregaard CL, Østerby NCH, Jespersen MM, Abou‐Kassem D, Lassen ML, Zaabalawi R, Daoud MM, Abdi S, Meier N, Cour K, Derby CB, Damlund BR, Laigaard J, Andersen LL, Mikkelsen J, Jensen JLS, Rasmussen AH, Arnerlöv E, Lykke M, Holst‐Hansen MZB, Tøstesen BW, Schwab J, Madsen EK, Gluud C, Lange T, Perner A. Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia: The COVID STEROID randomised, placebo-controlled trial. Acta Anaesthesiol Scand 2021; 65:1421-1430. [PMID: 34138478 PMCID: PMC8441888 DOI: 10.1111/aas.13941] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/05/2021] [Indexed: 12/20/2022]
Abstract
Background In the early phase of the pandemic, some guidelines recommended the use of corticosteroids for critically ill patients with COVID‐19, whereas others recommended against the use despite lack of firm evidence of either benefit or harm. In the COVID STEROID trial, we aimed to assess the effects of low‐dose hydrocortisone on patient‐centred outcomes in adults with COVID‐19 and severe hypoxia. Methods In this multicentre, parallel‐group, placebo‐controlled, blinded, centrally randomised, stratified clinical trial, we randomly assigned adults with confirmed COVID‐19 and severe hypoxia (use of mechanical ventilation or supplementary oxygen with a flow of at least 10 L/min) to either hydrocortisone (200 mg/d) vs a matching placebo for 7 days or until hospital discharge. The primary outcome was the number of days alive without life support at day 28 after randomisation. Results The trial was terminated early when 30 out of 1000 participants had been enrolled because of external evidence indicating benefit from corticosteroids in severe COVID‐19. At day 28, the median number of days alive without life support in the hydrocortisone vs placebo group were 7 vs 10 (adjusted mean difference: −1.1 days, 95% CI −9.5 to 7.3, P = .79); mortality was 6/16 vs 2/14; and the number of serious adverse reactions 1/16 vs 0/14. Conclusions In this trial of adults with COVID‐19 and severe hypoxia, we were unable to provide precise estimates of the benefits and harms of hydrocortisone as compared with placebo as only 3% of the planned sample size were enrolled. Trial registration: ClinicalTrials.gov: NCT04348305. European Union Drug Regulation Authorities Clinical Trials (EudraCT) Database: 2020‐001395‐15.
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Shah FA, Meyer NJ, Angus DC, Awdish R, Azoulay É, Calfee CS, Clermont G, Gordon AC, Kwizera A, Leligdowicz A, Marshall JC, Mikacenic C, Sinha P, Venkatesh B, Wong HR, Zampieri FG, Yende S. A Research Agenda for Precision Medicine in Sepsis and Acute Respiratory Distress Syndrome: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med 2021; 204:891-901. [PMID: 34652268 PMCID: PMC8534611 DOI: 10.1164/rccm.202108-1908st] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: Precision medicine focuses on the identification of therapeutic strategies that are effective for a group of patients based on similar unifying characteristics. The recent success of precision medicine in non-critical care settings has resulted from the confluence of large clinical and biospecimen repositories, innovative bioinformatics, and novel trial designs. Similar advances for precision medicine in sepsis and in the acute respiratory distress syndrome (ARDS) are possible but will require further investigation and significant investment in infrastructure. Methods: This project was funded by the American Thoracic Society Board of Directors. A multidisciplinary and diverse working group reviewed the available literature, established a conceptual framework, and iteratively developed recommendations for the Precision Medicine Research Agenda for Sepsis and ARDS. Results: The following six priority recommendations were developed by the working group: 1) the creation of large richly phenotyped and harmonized knowledge networks of clinical, imaging, and multianalyte molecular data for sepsis and ARDS; 2) the implementation of novel trial designs, including adaptive designs, and embedding trial procedures in the electronic health record; 3) continued innovation in the data science and engineering methods required to identify heterogeneity of treatment effect; 4) further development of the tools necessary for the real-time application of precision medicine approaches; 5) work to ensure that precision medicine strategies are applicable and available to a broad range of patients varying across differing racial, ethnic, socioeconomic, and demographic groups; and 6) the securement and maintenance of adequate and sustainable funding for precision medicine efforts. Conclusions: Precision medicine approaches that incorporate variability in genomic, biologic, and environmental factors may provide a path forward for better individualizing the delivery of therapies and improving care for patients with sepsis and ARDS.
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Ramanan M, Attokaran A, Murray L, Bhadange N, Stewart D, Rajendran G, Pusapati R, Petty M, Garrett P, Kruger P, Peake S, Billot L, Venkatesh B. Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (SCOPE-DKA): a cluster, crossover, randomized, controlled trial. Intensive Care Med 2021; 47:1248-1257. [PMID: 34609547 DOI: 10.1007/s00134-021-06480-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine whether treatment with Plasmalyte-148 (PL) compared to sodium chloride 0.9% (SC) results in faster resolution of diabetic ketoacidosis (DKA) and whether the acetate in PL potentiates ketosis. METHODS We conducted a cluster, crossover, open-label, randomized, controlled Phase 2 trial at seven hospitals in adults admitted to intensive care unit (ICU) with severe DKA with hospital randomised to PL or SC as fluid therapy. The primary outcome, DKA resolution, was defined as a change in base excess to ≥ - 3 mEq/L at 48 h. RESULTS Ninety-three patients were enrolled with 90 patients included in the modified-intention-to-treat population (PL n = 48, SC n = 42). At 48 h, mean fluid administration was 6798 ± 4850 ml vs 6574 ± 3123 ml, median anion gap 6 mEq/L (IQR 5-7) vs 7 mEq/L (IQR 5-7) and median blood ketones 0.3 mmol/L (IQR 0.1-0.5) vs 0.3 (IQR 0.1-0.5) in the PL and SC groups. DKA resolution at 48 h occurred in 96% (PL) and 86% (SC) of patients; odds ratio 3.93 (95% CI 0.73-21.16, p = 0.111). At 24 h, DKA resolution occurred in 69% (PL) and 36% (SC) of patients; odds ratio 4.24 (95% CI 1.68-10.72, p = 0.002). The median ICU and hospital lengths of stay were 49 h (IQR 23-72) vs 55 h (IQR 41-80) and 81 h (IQR 58-137) vs 98 h (IQR 65-195) in the PL and SC groups. CONCLUSION Plasmalyte-148, compared to sodium chloride 0.9%, may lead to faster resolution of metabolic acidosis in patients with DKA without an increase in ketosis. These findings need confirmation in a large, Phase 3 trial.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, McKean Street, Caboolture, QLD, 4510, Australia. .,Adult Intensive Care Services, The Prince Charles Hospital, Rode Road, Chermside, QLD, 4032, Australia. .,The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia. .,School of Medicine, University of Queensland, Sir Fred Schonell Drive, St Lucia, QLD, 4072, Australia.
| | - Antony Attokaran
- Intensive Care Unit, Rockhampton Hospital, Canning Street, Rockhampton, QLD, 4700, Australia
| | - Lauren Murray
- Intensive Care Unit, Sunshine Coast University Hospital, Doherty Street, Birtinya, QLD, 4575, Australia
| | - Neeraj Bhadange
- Intensive Care Unit, Ipswich Hospital, Chelmsford Avenue, Ipswich, QLD, 4305, Australia
| | - David Stewart
- Intensive Care Unit, Queen Elizabeth-2 Jubilee Hospital, Kessels Road, Coopers Plains, QLD, 4108, Australia
| | - Gokulnath Rajendran
- Intensive Care Unit, Mackay Base Hospital, Bridge Road, Mackay, QLD, 4741, Australia
| | - Raju Pusapati
- Intensive Care Unit, Hervey Bay Hospital, Urraween Road, Pialba, QLD, 4655, Australia
| | - Melissa Petty
- Intensive Care Unit, Caboolture Hospital, McKean Street, Caboolture, QLD, 4510, Australia
| | - Peter Garrett
- Intensive Care Unit, Sunshine Coast University Hospital, Doherty Street, Birtinya, QLD, 4575, Australia
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD, 4102, Australia
| | - Sandra Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville Road, Woodville South, South Australia, 5011, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia.,Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Woolloongabba, QLD, Australia
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Sathishkumar VE, Hatamleh WA, Alnuaim AA, Abdelhady M, Venkatesh B, Santhoshkumar S. Secure Dynamic Group Data Sharing in Semi-trusted Third Party Cloud Environment. Arab J Sci Eng 2021. [DOI: 10.1007/s13369-021-06155-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ramanan M, Billot L, Rajbhandari D, Myburgh J, Venkatesh B. An evaluation of factors that may influence clinicians' decisions not to enroll eligible patients into randomized trials in critical care. PLoS One 2021; 16:e0255361. [PMID: 34314449 PMCID: PMC8315530 DOI: 10.1371/journal.pone.0255361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/14/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To determine the association between intensive care unit (ICU) characteristics and clinicians' decision to decline eligible patients for randomization into a multicentered pragmatic comparative-effectiveness controlled trial. METHODS Screening logs from the Adjunctive Glucocorticoid Therapy in Septic Shock Trial (ADRENAL) and site-level data from the College of Intensive Care Medicine and Australia New Zealand Intensive Care Society were examined. The effects of ICU characteristics such as tertiary academic status, research coordinator availability, number of admissions, and ICU affiliations on clinicians declining to randomize eligible patients were calculated using mixed effects logistic regression modelling. RESULTS There were 21,818 patients screened for inclusion in the ADRENAL trial at 69 sites across five countries, out of which 5,501 were eligible, 3,800 were randomized and 659 eligible patients were declined for randomization by the treating clinician. The proportion of eligible patients declined by clinicians at individual ICUs ranged from 0 to41%. In the multivariable model, none of the ICU characteristics were significantly associated with higher clinician decline rate. CONCLUSIONS Neither tertiary academic status, nor other site-level variables were significantly associated with increased rate of clinicians declining eligible patients.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Laurent Billot
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dorrilyn Rajbhandari
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
- Intensive Care Unit, Wesley Hospital, Auchenflower, Queensland, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Thompson KJ, Young PJ, Venkatesh B, Cohen J, Finfer SR, Grattan S, Hammond NE, Jan S, Li Q, Di Tanna GL, McArthur C, Myburgh J, Rajbhandari D, Taylor CB. Long-term costs and cost-effectiveness of adjunctive corticosteroids for patients with septic shock in New Zealand. Aust Crit Care 2021; 35:241-250. [PMID: 34325975 DOI: 10.1016/j.aucc.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 05/11/2021] [Accepted: 05/17/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of the study was to determine whether adjunctive hydrocortisone reduced healthcare expenditure and was cost-effective compared with placebo in New Zealand patients in the Adjunctive Glucocorticoid Therapy in Patients with Septic Shock (ADRENAL) trial. DESIGN This is a health economic analysis using data linkage to New Zealand Ministry of Health databases to determine resource use, costs, and cost-effectiveness for a 24-month period. SETTING The study was conducted in New Zealand. PARTICIPANTS AND INTERVENTION Patients with septic shock were randomised to receive a 7-day continuous infusion of 200 mg of hydrocortisone or placebo in the ADRENAL trial. MAIN OUTCOME MEASURES Healthcare expenditure was associated with all hospital admissions, emergency department presentations, outpatient visits, and pharmacy expenditure. Effectiveness outcomes included mortality at 6 months and 24 months and quality of life at 6 months. Cost-effectiveness outcomes were assessed with reference to quality-adjusted life years gained at 6 months and life years gained at 24 months. RESULTS Of 3800 patients in the ADRENAL trial, 419 (11.0%) were eligible, and 405 (96.7% of those eligible) were included. The mean total costs per patient over 24 months were $143,627 ± 100,890 and $143,772 ± 97,117 for the hydrocortisone and placebo groups, respectively (p = 0.99). Intensive care unit costs for the index admission were $50,492 and $62,288 per patient for the hydrocortisone and placebo groups, respectively (p = 0.09). The mean number of quality-adjusted life years gained at 6 months and mean number of life years gained at 24 months was not significantly different by treatment group, and the probability of hydrocortisone being cost-effective was 55% at 24 months. CONCLUSIONS In New Zealand, adjunctive hydrocortisone did not reduce total healthcare expenditure or improve outcomes compared with placebo in patients with septic shock.
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Affiliation(s)
- Kelly J Thompson
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand; Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia; The Princess Alexandra Hospital, University of Queensland, Brisbane, Australia; The Wesley Hospital, Brisbane, Australia
| | - Jeremy Cohen
- The George Institute for Global Health, Sydney, Australia
| | - Simon R Finfer
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia; Imperial College, London, UK; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Sarah Grattan
- The George Institute for Global Health, Sydney, Australia
| | - Naomi E Hammond
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Gian Luca Di Tanna
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand; Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - John Myburgh
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia; St George Clinical School, University of New South Wales, Sydney, Australia
| | | | - Colman B Taylor
- The George Institute for Global Health, Sydney, Australia; University of New South Wales, Sydney, Australia.
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Munch MW, Granholm A, Myatra SN, Vijayaraghavan BKT, Cronhjort M, Wahlin RR, Jakob SM, Cioccari L, Kjær MN, Vesterlund GK, Meyhoff TS, Helleberg M, Møller MH, Benfield T, Venkatesh B, Hammond N, Micallef S, Bassi A, John O, Jha V, Kristiansen KT, Ulrik CS, Jørgensen VL, Smitt M, Bestle MH, Andreasen AS, Poulsen LM, Rasmussen BS, Brøchner AC, Strøm T, Møller A, Khan MS, Padmanaban A, Divatia JV, Saseedharan S, Borawake K, Kapadia F, Dixit S, Chawla R, Shukla U, Amin P, Chew MS, Gluud C, Lange T, Perner A. Higher vs lower doses of dexamethasone in patients with COVID-19 and severe hypoxia (COVID STEROID 2) trial: Protocol and statistical analysis plan. Acta Anaesthesiol Scand 2021; 65:834-845. [PMID: 33583034 PMCID: PMC8014264 DOI: 10.1111/aas.13795] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/29/2022]
Abstract
Background The coronavirus disease 2019 (COVID‐19) pandemic has resulted in millions of deaths and overburdened healthcare systems worldwide. Systemic low‐dose corticosteroids have proven clinical benefit in patients with severe COVID‐19. Higher doses of corticosteroids are used in other inflammatory lung diseases and may offer additional clinical benefits in COVID‐19. At present, the balance between benefits and harms of higher vs. lower doses of corticosteroids for patients with COVID‐19 is unclear. Methods The COVID STEROID 2 trial is an investigator‐initiated, international, parallel‐grouped, blinded, centrally randomised and stratified clinical trial assessing higher (12 mg) vs. lower (6 mg) doses of dexamethasone for adults with COVID‐19 and severe hypoxia. We plan to enrol 1,000 patients in Denmark, Sweden, Switzerland and India. The primary outcome is days alive without life support (invasive mechanical ventilation, circulatory support or renal replacement therapy) at day 28. Secondary outcomes include serious adverse reactions at day 28; all‐cause mortality at day 28, 90 and 180; days alive without life support at day 90; days alive and out of hospital at day 90; and health‐related quality of life at day 180. The primary outcome will be analysed using the Kryger Jensen and Lange test adjusted for stratification variables and reported as adjusted mean differences and median differences. The full statistical analysis plan is outlined in this protocol. Discussion The COVID STEROID 2 trial will provide evidence on the optimal dosing of systemic corticosteroids for COVID‐19 patients with severe hypoxia with important implications for patients, their relatives and society.
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Affiliation(s)
- MW Munch
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - SN Myatra
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute Mumbai India
| | - BKT Vijayaraghavan
- Department of Critical Care Apollo Hospitals Chennai India
- Chennai Critical Care Consultants Chennai India
- The George Institute for Global Health, University of New South Wales New Delhi India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - RR Wahlin
- Department of Clinical Science and Education, Södersjukhuset Karolinska Institutet Stockholm Sweden
| | - Stephan M. Jakob
- Department of Intensive Care Medicine Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - Luca Cioccari
- Department of Intensive Care Medicine Inselspital, Bern University Hospital, University of Bern Bern Switzerland
| | - MN Kjær
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - GK Vesterlund
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - TS Meyhoff
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - MH Møller
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Center of Research & Disruption of Infectious Diseases Copenhagen University Hospital – Amager and Hvidovre Copenhagen Denmark
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales Sydney New South Wales Australia
| | - Naomi Hammond
- The George Institute for Global Health, University of New South Wales Sydney New South Wales Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales Sydney New South Wales Australia
| | - Abhinav Bassi
- The George Institute for Global Health, University of New South Wales New Delhi India
| | - Oommen John
- The George Institute for Global Health, University of New South Wales New Delhi India
- Prasanna School of Public Health Manipal Academy of Higher Education Manipal India
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales New Delhi India
- Prasanna School of Public Health Manipal Academy of Higher Education Manipal India
- School of Public Health Imperial College London London UK
| | - KT Kristiansen
- Department of Anaesthesia and Intensive Care Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - CS Ulrik
- Department of Respiratory Medicine Hvidovre Hospital, University of Copenhagen Copenhagen Denmark
| | - VL Jørgensen
- Department of Thoracic Anaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Margit Smitt
- Department of Neuroanaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Morten H. Bestle
- Department of Anaesthesiology and Intensive Care Copenhagen University Hospital Nordsjælland Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - AS Andreasen
- Department of Anaesthesia and Intensive Care Herlev Hospital, University of Copenhagen Copenhagen Denmark
| | - LM Poulsen
- Department of Anaesthesiology Zealand University Hospital Copenhagen Denmark
| | - BS Rasmussen
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Aalborg University Hospital Aalborg Denmark
| | - AC Brøchner
- Department of Anaesthesia and Intensive Care Kolding Hospital Kolding Denmark
| | - Thomas Strøm
- Department of Anaesthesia and Critical Care Medicine Odense University Hospital Odense C Denmark
- Department of Anaesthesia and Critical Care Medicine Hospital Sønderjylland, University Hospital of Southern Denmark Odense Denmark
| | - Anders Møller
- Department of Anaesthesia and Intensive Care Næstved‐Slagelse‐Ringsted Hospital Slagelse Denmark
| | - MS Khan
- Department of Critical Care Medicine Rajendra Institute of Medical Sciences Ranchi India
| | - Ajay Padmanaban
- Department of Critical Care Apollo Hospitals Chennai India
- Chennai Critical Care Consultants Chennai India
| | - JV Divatia
- Department of Anaesthesia Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute Mumbai India
| | | | - Kapil Borawake
- Department of Intensive Care Vishwaraj Hospital Pune India
| | - Farhad Kapadia
- Section of Critical Care, Department of Medicine Hinduja Hospital Mahim, Mumbai India
| | - Subhal Dixit
- Department of Critical Care Medicine Sanjeevan Hospital Pune Maharashtra India
| | - Rajesh Chawla
- Department of Respiratory and Critical Care Medicine Indraprastha Apollo Hospital New Delhi India
| | - Urvi Shukla
- Intensive Care Unit and Emergency Services Symbiosis University Hospital and Research Centre Lavale, Pune India
| | - Pravin Amin
- Department of Critical Care Medicine Bombay Hospital Institute of Medical Sciences Mumbai India
| | - Michelle S. Chew
- Department of Anesthesiology and Intensive Care, Biomedical and Clinical Sciences Linköping University Linköping Sweden
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research Capital Region of Denmark, Rigshospitalet, Copenhagen University Hospital Copenhagen Denmark
| | - Theis Lange
- Department of Public Health, Section of Biostatistics University of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Collaboration for Research in Intensive Care (CRIC) Copenhagen Denmark
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50
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Cohen J, Blumenthal A, Cuellar-Partida G, Evans DM, Finfer S, Li Q, Ljungberg J, Myburgh J, Peach E, Powell J, Rajbhandari D, Rhodes A, Senabouth A, Venkatesh B. The relationship between adrenocortical candidate gene expression and clinical response to hydrocortisone in patients with septic shock. Intensive Care Med 2021; 47:974-983. [PMID: 34185116 DOI: 10.1007/s00134-021-06464-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine if adrenocortical gene expression is associated with clinical outcomes or response to corticosteroid treatment in septic shock. METHODS A pre-specified nested cohort study of a randomised controlled trial of hydrocortisone compared to placebo in septic shock. Blood was collected for RNAseq analysis prior to treatment with hydrocortisone or placebo. The expression of adrenocortical candidate genes related to pituitary releasing hormones, mineralocorticoid and glucocorticoid receptors, intracellular glucocorticoid metabolism and transport proteins was measured. RESULTS From May 2014 to April 2017, 671 patients were enrolled in the nested cohort study, from which 494 samples were available for analysis. We found no evidence of an association between candidate gene expression levels and either 90-day mortality, 28-day mortality or time to shock reversal. We observed evidence of a significant interaction between expression and treatment group for time to shock reversal in two genes; GLCCI1 (HR 3.81, 95%CI 0.57-25.47 vs. HR 0.64, 95%CI 0.13-3.07 for hydrocortisone and placebo respectively, p for interaction 0.008) and BHSD1 (HR 0.55, 95%CI 0.28-1.09 vs. HR 1.32 95%CI 0.67-2.60, p for interaction 0.01). CONCLUSIONS In patients with septic shock, there is no association between adrenocortical candidate gene expression and mortality. Patients with higher expression of GLCCI1 who received hydrocortisone achieved shock resolution faster than those receiving placebo; conversely, patients who had higher expression of BHSD1 who received hydrocortisone achieved shock resolution slower than those who received placebo. Variation in gene expression may be a mechanism for heterogeneity of treatment response to corticosteroids in septic shock.
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Affiliation(s)
- Jeremy Cohen
- The George Institute for Global Health, Sydney, Australia. .,Royal Brisbane and Women's Hospital, University of Queensland, Brisbane, Australia. .,The Wesley Hospital, Brisbane, Australia. .,The University of Queensland, St Lucia, Australia.
| | - Antje Blumenthal
- University of Queensland Diamantina Institute, University of Queensland, St Lucia, Australia
| | - Gabriel Cuellar-Partida
- University of Queensland Diamantina Institute, University of Queensland, St Lucia, Australia
| | - David M Evans
- University of Queensland Diamantina Institute, University of Queensland, St Lucia, Australia.,Medical Research Council Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Simon Finfer
- The George Institute for Global Health, Sydney, Australia.,University of New South Wales, Sydney, Australia.,Northern Clinical School, University of Sydney, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Qiang Li
- The George Institute for Global Health, Sydney, Australia
| | - Johanna Ljungberg
- University of Queensland Diamantina Institute, University of Queensland, St Lucia, Australia
| | - John Myburgh
- The George Institute for Global Health, Sydney, Australia.,University of New South Wales, Sydney, Australia.,St. George Hospital, University of New South Wales, Sydney, Australia
| | - Elizabeth Peach
- University of Queensland Diamantina Institute, University of Queensland, St Lucia, Australia
| | - Joseph Powell
- Garvan-Weizmann Centre for Cellular Genomics, Garvan Institute, Sydney, Australia.,UNSW Cellular Genomics Futures Institute, University of New South Wales, Sydney, Australia
| | | | | | - Anne Senabouth
- Garvan-Weizmann Centre for Cellular Genomics, Garvan Institute, Sydney, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, Australia.,The Wesley Hospital, Brisbane, Australia.,University of New South Wales, Sydney, Australia.,The Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
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