Treatment effect modifiers in hospitalised patients with COVID-19 receiving remdesivir and dexamethasone

BACKGROUND

The combined effectiveness of remdesivir and dexamethasone in subgroups of hospitalised patients with COVID-19 is poorly investigated.

METHODS

In this nationwide retrospective cohort study, we included 3826 patients with COVID-19 hospitalised between February 2020 and April 2021. The primary outcomes were use of invasive mechanical ventilation and 30-day mortality, comparing a cohort treated with remdesivir and dexamethasone with a previous cohort treated without remdesivir and dexamethasone. We used inverse probability of treatment weighting logistic regression to assess associations with progression to invasive mechanical ventilation and 30-day mortality between the two cohorts. The analyses were conducted overall and by subgroups based on patient characteristics.

RESULTS

Odds ratio for progression to invasive mechanical ventilation and 30-day mortality in individuals treated with remdesivir and dexamethasone compared to treatment with standard of care alone was 0.46 (95% confidence interval, 0.37-0.57) and 0.47 (95% confidence interval, 0.39-0.56), respectively. The reduced risk of mortality was observed in elderly patients, overweight patients and in patients requiring supplemental oxygen at admission, regardless of sex, comorbidities and symptom duration.

CONCLUSIONS

Patients treated with remdesivir and dexamethasone had significantly improved outcomes compared to patients treated with standard of care alone. These effects were observed in most patient subgroups.

Comparison of ionised calcium measured using a portable analyser to a reference method in healthy dogs

OBJECTIVES

To compare the ionised calcium measured on a portable analyser (iSTAT, Abbott) to a reference method.

MATERIALS AND METHODS

Blood samples from 39 apparently healthy dogs were analysed in duplicate using a portable analyser and a reference method (Radiometer ABL800 FLEX). Bland-Altman plots and Passing-Bablok regression were used to assess constant and proportional bias between the two instruments. A within-assay percentage coefficient of variation and total error (TE) was calculated for both analysers. The reference interval was calculated for the portable analyser using the robust method with confidence interval bootstrapping.

RESULTS

The Bland-Altman plot showed a -0.036 mmol/L difference between the two instruments (95% confidence limit -0.08 to 0.01 mmol/L; limits of agreement -0.07 to 0.006 mmol/L). Neither the Bland-Altman plot nor the Passing-Bablock regression (slope -0.03; 95% confidence interval -0.08 to 0.19 and intercept 1; 95% confidence interval 0.83 to 1.2) showed significant proportional bias. The coefficient of variation for the portable analyser was 1.08%, compared to 0.78% for the reference method with a total error of 3.5% for the portable analyser. The estimated population-based reference interval for ionised calcium using the portable analyser is 1.23 to 1.42 mmol/L.

CLINICAL SIGNIFICANCE

For the healthy dogs in this study, compared to the reference method, the portable analyser showed no significant bias for measurement of ionised calcium. Further studies including hyper and hypocalcaemic dogs are required to determine clinical impact of the use of this analyser.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Improved survival among hospitalized patients with COVID-19 treated with remdesivir and dexamethasone. A nationwide population-based cohort study

Background

There are limited data on outcomes of moderate to severe coronavirus disease 2019 (COVID-19) among patients treated with remdesivir and dexamethasone in a real-world setting. We sought to compare the effectiveness of standard of care (SOC) alone versus SOC plus remdesivir and dexamethasone.

Methods

Two population-based nationwide cohorts of individuals hospitalized with COVID-19 during February through December 2020 were studied. Death within 30 days and need of mechanical ventilation (MV) were compared by inverse probability of treatment weighted (ITPW) logistic regression analysis and shown as odds ratio (OR) with 95% confidence interval (CI).

Results

The 30-days mortality rate of 1694 individuals treated with remdesivir and dexamethasone in addition to SOC was 12.6% compared to 19.7% for 1053 individuals receiving SOC alone. This corresponded to a weighted OR of 30-day mortality of 0.47 (95% CI: .38–.57) for patients treated with remdesivir and dexamethasone compared to patients receiving SOC alone. Similarly, progression to MV was reduced (OR 0.36; 95% CI: .29–.46).

Conclusions

Treatment of moderate to severe COVID-19 during June through December that included remdesivir and dexamethasone was associated with reduced 30-day mortality and need of MV compared to treatment in February through May.

Effectiveness, safety and acceptability of no-test medical abortion (termination of pregnancy) provided via telemedicine: a national cohort study

OBJECTIVE

To compare outcomes before and after implementation of medical abortion (termination of pregnancy) without ultrasound via telemedicine.

DESIGN

Cohort analysis.

SETTING

The three main abortion providers.

POPULATION OR SAMPLE

Medical abortions at home at ≤69 days' gestation in two cohorts: traditional model (in-person with ultrasound, n = 22 158) from January to March 2020 versus telemedicine-hybrid model (either in person or via telemedicine without ultrasound, n = 29 984, of whom 18 435 had no-test telemedicine) between April and June 2020. Sample (n = 52 142) comprises 85% of all medical abortions provided nationally.

METHODS

Data from electronic records and incident databases were used to compare outcomes between cohorts, adjusted for baseline differences.

MAIN OUTCOME MEASURES

Treatment success, serious adverse events, waiting times, gestation at treatment, acceptability.

RESULTS

Mean waiting time from referral to treatment was 4.2 days shorter in the telemedicine-hybrid model and more abortions were provided at ≤6 weeks' gestation (40% versus 25%, P < 0.001). Treatment success (98.8% versus 98.2%, P > 0.999), serious adverse events (0.02% versus 0.04%, P = 0.557) and incidence of ectopic pregnancy (0.2% versus 0.2%, P = 0.796) were not different between models. In the telemedicine-hybrid model, 0.04% were estimated to be over 10 weeks' gestation at the time of the abortion; all were completed safely at home. Within the telemedicine-hybrid model, effectiveness was higher with telemedicine than in-person care (99.2% versus 98.1%, P < 0.001). Acceptability of telemedicine was high (96% satisfied) and 80% reported a future preference for telemedicine.

CONCLUSIONS

A telemedicine-hybrid model for medical abortion that includes no-test telemedicine and treatment without an ultrasound is effective, safe, acceptable and improves access to care.

TWEETABLE ABSTRACT

Compelling evidence from 52 142 women shows no-test telemedicine abortion is safe, effective and improves care.

An example of psychological adjustment in chronic illness: Hirschsprung's disease

The aim of this study was to investigate the outcomes after definitive surgical correction for children with Hirschsprung's disease (HD) and the psychosocial impact of HD on the child and family. The total sample comprised 72 children with HD along with their families. The development of a condition-specific questionnaire measured the functional and psychosocial outcomes for children with HD with parental perception of their child's condition. Psychiatric measures were also examined to assess psychiatric morbidity. The greatest functional problem after definitive surgery for HD was faecal soiling (76%). The principle findings of the study were that (1) HD did not have a significant impact on the child's rate of psychiatric morbidity and levels of hopefulness in comparison to the normal population, (2) surgical and psychosocial functioning improved with increasing age and, (3) families remain troubled about their future with HD and dealing with psychosocial difficulties related to the condition (such as distress because of faecal soiling). Specifically, faecal soiling was found to be physically, emotionally and psychosocially distressing complication. Bowel functioning and psychosocial distress improves with increasing age and parental and medical professional support. Despite the significant impairment of faecal continence, we found that children/young adults with HD have minimal psychiatric morbidity, yet experience condition-specific psychosocial problems (e.g. embarrassment and distress/discomfort). HD does not increase the rate of clinical psychiatric morbidity in children and families with HD, but does determine the context of their daily distress and concern.

Life after Definitive Treatment for Children with Hirschsprung's Disease

PURPOSE

The aim of this study was to investigate the long-term outcomes after definitive surgical correction for children with Hirschsprung's Disease (HD) and the psychosocial impact HD has on the child and family.

METHODS

A clinical-based database of seventy-two children and young people aged between one to twenty-four years with HD, along with their families were investigated. This study involved the development of a condition-specific questionnaire in order to assess the functional and psychosocial outcomes for children with HD at different age groups, combined with parental perception of their child's condition in the long-term.

RESULTS

The greatest functional problem after definitive surgery for HD was faecal soiling (n = 29/38: 76.3%). Children < or = 12 years experienced more embarrassment, distress/discomfort and family difficulties (n = 53/72; 73.6%) due to bowel dysfunctioning (such as faecal soiling) in comparison to children 12 years (n = 19/72; 26.3%) (p < 0.05). Young adults with HD (> 12 years) remained confident and 62.5% hopeful about their future with HD. Nine (12.5%) of the parents reported that HD had a negative impact on their marital relationship due to the daily stressors. Yet, 58.3% (n = 42) families remain confident and 70.8% (n = 42) hopeful about their child's future with HD.

CONCLUSION

Bowel functioning and psychosocial distress improves with increasing age and parental and medical professional support. Psychosocial difficulties found in the child and family with HD are condition-specific--thus improving complications such as faecal soiling will further enhance better psychosocial adjustment.

Long-term evaluation of rectus fascial wrap in patients with spina bifida

PURPOSE

We evaluated patients with spina bifida to determine long-term results of the rectus fascial wrap, a modification of the rectus fascial sling

MATERIALS AND METHODS

We assessed patients with spina bifida 3 years after a rectus fascial wrap procedure using an outcome questionnaire, renal ultrasound and urodynamics.

RESULTS

The 15 patients who completed the outcome questionnaire indicated that significant improvement over preoperative status was maintained a mean of 58 months postoperatively. Ultrasound in 14 cases showed no postoperative increase in hydronephrosis. Urodynamic study in 13 patients revealed a mean bladder capacity of 583 cc and mean maximum detrusor pressure of 39 cm. water, while 11 had no urine leakage when Valsalva leak point pressure was measured.

CONCLUSIONS

Three years postoperatively the rectus fascial wrap provides dryness comparable to that of other bladder neck sling procedures in patients with spina bifida.

Carcinoid tumor of the cystic duct

A 69-year-old male was admitted to an outside institution for severe right abdominal pain radiating to the flank. An extensive work-up, including lower GI series, IVP, and ultrasound of the kidneys were normal. Ultrasound of the liver demonstrated a thickened gallbladder as well as cholelithiasis. Despite some improvement, his symptoms returned intermittently and cholecystectomy was performed. Pathologic examination of the gallbladder showed a carcinoid tumor, 5.4 mm in maximum diameter, in the cystic duct. A small metastatic focus was also found in the cystic duct lymph node. In this paper we compare the clinical presentation, pathological findings and outcome of this case to the previously reported six cases of cystic duct carcinoid. A comparison is also made between the general features of carcinoid at this rare location and the more common gastrointestinal carcinoid.

Minimally invasive therapies for the treatment of symptomatic benign prostatic hyperplasia: the University of Florida experience

OBJECTIVE

To describe the University of Florida experience with minimally invasive therapies in the surgical treatment of benign prostatic hyperplasia (BPH).

BACKGROUND DATA

Typically, the standard surgical treatment for symptomatic benign prostatic hyperplasia (BPH) has been transurethral resection of the prostate (TURP). Due to the morbidity associated with TURP, several minimally invasive therapies, such as laser, microwaves, high intensity focused ultrasound, and radiofrequency needle ablation, have been utilized to treat BPH.

METHODS

The authors review their experience, along with that of others, with various forms of heat therapy in the treatment of BPH.

RESULTS AND CONCLUSIONS

Although high intensity focused ultrasound (HIFU), interstitial laser, and microwaves procedures have been shown to be effective in the treatment of BPH, our experience has been with laser, VaporTrode, and TUNA. We found that VaporTrode and TUNA currently offer several advantages over many of the other modalities.

Experience, knowledge and attitudes of child psychiatrists regarding electroconvulsive therapy in the young

OBJECTIVE

To ascertain the experience, knowledge and attitudes of Australian and New Zealand child psychiatrists in relation to electroconvulsive therapy (ECT) in the young in order to determine whether they would be willing and able to provide an opinion if consulted about children or adolescents in whom ECT is proposed.

METHOD

A 28-item questionnaire was posted to all members of the Faculty of Child and Adolescent Psychiatry living in Australia or New Zealand.

RESULTS

Eighty-three percent (n = 206) answered the questionnaire. Forty percent rated their knowledge about ECT in the young as nil or negligible. Having had patients treated with ECT was the best predictor of possessing some knowledge. Thirty-nine percent believed that ECT was unsafe in children compared to 17% for adolescents and 3% for adults. Almost all (92%) respondents believed child psychiatrists should be consulted in all cases of persons under 19 in whom ECT was recommended. The vast majority believed the Faculty or College should have guidelines relating to ECT use in this group and that it would be useful to have a national register of young persons treated with ECT.

CONCLUSIONS

Child and adolescent psychiatrists wish to be involved in the process of ECT treatment in young people. At the same time, there are gaps in their knowledge. This will need to be remedied, particularly if formal guidelines advocating their involvement are introduced.

Human HLA-B27 gene enhances susceptibility of rats to oral infection by Listeria monocytogenes

Germfree rats transgenic for the human genes HLA-B27 and beta 2-microglobulin were colonized with hemolysin-positive (Hly+) or hemolysin-negative (Hly-) strains of Listeria monocytogenes. HLA-B27 rats were very susceptible to infection with Hly+ L monocytogenes none survived beyond 6 days. Conversely, nontransgenic control rats survived alimentary tract colonization with the Hly+ strain, and both transgenic and nontransgenic rats survived colonization with the Hly- strain of L monocytogenes. After colonization with Hly+ L monocytogenes, both transgenic and nontransgenic rats developed severe bowel inflammation which consisted histologically of microab scesses, granulomatous lesions, and ulcers; however, whereas the transgenic rats died within 6 days, only very mild intestinal lesions were seen in nontransgenic rats 10 to 42 days after colonization. Liver and splenic lesions were small and transient in nontransgenic rats. Transgenic and nontransgenic control rats infected with Hly- Listeria developed mild transient diarrhea but showed no histological changes in the intestine. This study thus documents an association between a particular bacterial product (hemolysin produced by L monocytogenes) and the induction of severe inflammatory disease and death in rats expressing HLA-B27 and beta 2-microglobulin.

Transurethral vaportrode electrovaporization of the prostate: physical principles, technique, and results

OBJECTIVES

This is a study to evaluate technique, efficacy, and safety of a new electrosurgical instrument (Vaportrode) in management of benign prostatic hyperplasia (BPH).

METHODS

Forty-two symptomatic BPH patients form the subject of this study. Preoperative and postoperative International Prostate Symptom Score (IPSS), peak flow rates (PFR), postvoid residual urine (PVR), operative details, and complications were recorded in each patient. Baseline, 1, 3, and 6 months follow-up data were used for analyses.

RESULTS

Results reveal that transurethral electrovaporization of the prostate (TUEVP) is a reasonable procedure to treat symptomatic BPH, and at 6 months, this procedure results in 68% reduction in IPSS, 128% improvement in PFR, and 58% reduction in PVR. Even in patients who are in retention prior to TUEVP, at 6 months the IPSS is 7.7, PFR is 20.4 cc/s, and PVR reduces to 130 cc. The procedure is well tolerated without any significant short-term complications.

CONCLUSIONS

The results of this modality in improving the symptoms and PFR in symptomatic BPH patients in the short term appear promising. Advantages over transurethral resection (TUR) of the prostate and laser prostatectomy include familiarity of the transurethral route, lack of need for high-cost laser equipment and fibers, excellent intraoperative hemostasis, lack of bleeding or fluid absorption, and ability to cause a predictable TUR-like prostate defect at the end of the procedure. Further studies involving larger numbers of patients and longer follow-up are warranted to assess further the utility of this procedure.

Inter-rater reliability of global assessment of functioning in a clinical setting

Four studies on the inter-rater reliability of a proposed Axis V version for DSM-IV and of the CGAS involving 162 child and adolescent patients and 20 clinicians showed moderate agreement (intraclass correlation: 0.53-0.66). This was comparable to previous versions of Axis V, but lower than that reported for the CGAS. More detailed description of anchor points did not increase reliability nor there were differences in agreement when rating current or previous functioning.

Oligonucleotide-primed in situ DNA synthesis (PRINS): a method for chromosome mapping, banding, and investigation of sequence organization

Oligonucleotides were annealed to complementary sequences in fixed human metaphase chromosomes and extended with DNA polymerase. The newly synthesized fragments were labeled by incorporating bio-11-dUTP instead of TTP, and the sites of synthesis were detected by immunocytochemistry, using fluorochromes as the reporter molecules. We have obtained clear localization with oligonucleotides from alphoid (centromeric sequences), simple sequence (satellite) DNAs, a variety of Alu-dispersed repeated sequences, and oligonucleotides derived from the Tetrahymena and Trypanosoma telomere-specific sequences. The simple sequence and alphoid oligonucleotides gave results at least comparable to those obtained using the whole molecule as a probe for in situ hybridization, whereas the Alu oligonucleotides produced a diversity of results which depended on the absolute length and location of the oligonucleotide within the Alu sequence. The telomere-specific oligomers also produced a variety of results. The G-rich Trypanosoma oligomer and its complementary C-rich sequence produced strong telomeric signals and some interstitial signals on mouse chromosomes, but only weak telomeric signals on human chromosomes. The G-rich Tetrahymena oligomer produced detectable telomeric signals on human chromosomes. The technique appears to be a valuable extension of present tools for mapping and examining the organization of DNA sequences within chromosomes.

Hepatitis B vaccines in patients with chronic renal failure before dialysis

Hepatitis B remains a significant risk to patients receiving chronic hemodialysis, but no certain method of prevention has been identified. We tested two vaccines, plasma-derived vaccine (40-micrograms dose) and recombinant-derived vaccine (40-micrograms and 20-micrograms doses), in 61 patients with chronic renal failure who were not yet dependent on dialysis. Patients were followed up clinically and with laboratory tests of kidney function and hepatitis B virus serology for one year. Significantly more recipients of plasma-derived vaccine responded to vaccination; they also achieved a higher titer of antibody to hepatitis B virus than did recipients of recombinant-derived vaccine when evaluated at 6, 7, 9, and 12 mo after vaccination. No serious side effects were observed with any vaccine preparation, nor were excessive adverse effects observed in any group. Compared with the dialysis patients previously studied, patients with renal failure who were not yet dependent on dialysis responded more favorably to the hepatitis B virus vaccine.

Diaphragmatic injuries following blunt trauma

Over the last 10 years, 26 patients have undergone repair of blunt traumatic diaphragmatic injury. Motor vehicle accidents were the cause in 77 per cent of these cases. The diagnosis was made immediately by chest x-ray in eight of 26 cases, and in ten cases, the diagnosis was made at celiotomy because of other suspected intraabdominal injury. The other eight cases fell into two categories; delayed (diagnosis made within same hospitalization) and late (diagnosis made at subsequent presentation). In many cases in which diaphragmatic injuries were missed or delays in diagnosis occurred, radiologic evidence for possible injury was present on the initial chest x-ray, but the diagnosis was not suspected. Seventy-seven per cent of patients (20 of 26) had associated major injuries (spleen, chest, extremities). The left hemidiaphragm was involved in 19 patients and right diaphragmatic injuries in seven patients. Repair was accomplished in 23 cases transabdominally with a thoracoabdominal extension required in three patients because of severe liver trauma. The three cases in which the diagnosis was delayed had diaphragmatic defects repaired by a transthoracic approach.

Spontaneous thrombosis of left spermatic vein: report of 2 cases

We report 2 cases of spontaneous thrombosis of the left internal spermatic vein causing acute development of a painful scrotoinguinal mass. Both patients were treated by surgical ligation and excision of the thrombosed vein. Venous congestion and testicular ischemia occurred in 1 patient who required orchiectomy for massive swelling and pain. Based on our recent experience, we recommend conservative management of spontaneous spermatic vein thrombosis with anticoagulation (and possibly antibiotics).

Treatment of chalazia with injectable triamcinolone

Twenty patients with a total of 22 chalazia unresponsive to conservative medical treatment were randomized for treatment with either intralesional triamcinolone acetonide or placebo. Eight of 12 lesions treated with triamcinolone acetonide resolved. In all ten of those treated with normal saline injection, treatment failed to achieve a clinical cure. Nine of the normal saline treatment failures were then injected with triamcinolone acetonide. Eight of nine in this group achieved clinical resolution. When the two treatment groups were combined, a total of 16 of 21 chalazia (76%) resolved with intralesional steroid therapy. Intralesional steroid therapy can be used successfully to treat chalazia, and its effect is not merely due to a mechanical disruption of the lesion. Pain and discomfort from intralesional injections is a common complaint.

Regulation of renal Na+-K+-ATPase in the rat by adrenal steroids

The effects of single and multiple injections of aldosterone and dexamethasone on renal Na+-K+-ATPase, in vitro renal gluconeogenesis, and urinary electrolyte excretion were examined in adrenalectomized rats in a dose-dependent manner. Single maximal and supramaximal doses of aldosterone (defined by the effect of electrolyte excretion) had no effect on Na+-K+-ATPase or gluconeogenesis. By contrast, a single administration of dexamethasone (in a dose range that increased fasting blood sugar, stimulated renal gluconeogenesis, and had no mineralocorticoid effects) yielded clear-cut activation of Na+-K+-ATPase. Multiple submaximal doses of dexamethasone produced quantitatively similar stimulation of Na+-K+-ATPase and gluconeogenesis. Multiple supramaximal doses of aldosterone stimulated Na+-K+-ATPase and gluconeogenesis, but maximal and submaximal doses of the hormone were without effect. Aldosterone had no effect on hepatic Na+-K+-ATPase or gluconeogenesis. These results suggest that activation of renal Na+-K+-ATPase can be considered a putative glucocorticoid (not mineralocorticoid) effect. Renal Na+-K+-ATPase activation by chronic aldosterone treatment may be mediated by glucocorticoid receptor sites and, hence, may not represent a genuine mineralocorticoid effect.

Update of ocular reticulum cell sarcoma

Reticulum cell sarcoma involving the vitreous and the brainstem occurred in a 45-year-old man. He initially was seen with diplopia from a partial left-sided third cranial nerve palsy, which is rare. Later, a typical uveitis developed in the right eye. An initial diagnosis of brainstem glioma, based primarily on the computed tomographic scan findings and clinical history, was ultimately proved erroneous when the correct diagnosis was shown by the results of a cytologic examination of vitreous aspirate. Excellent visual response to a moderately high oral dose of steroids occurred, which has not been usual in other reported cases. Definitive cobalt (gamma) radiation therapy (6,000 rad to the brainstem and 4,000 rad to the vitreous) has produced a one-year remission at this time.

Changes in plasma and lung lymph lysosomal enzymes after major thermal injury

Plasma and lung lymph beta-glucuronidase and aryl sulfatase A specific activity were measured before and for 48 hours after a 50% full-thickness burn in the adult sheep. We noted a significant increase in plasma activity of both enzymes with maximum increase occurring 3 hours postburn, with levels returning toward baseline at 48 hours. Increase in plasma activity correlated in time course with increases in pulmonary vascular resistance. Lung lymph specific activity increased to levels identical to that in plasma but the time course lagged behind by 1 to 3 hours.