A differential therapeutic consideration for use of corticosteroids according to established COVID-19 clinical phenotypes in critically ill patients

OBJECTIVE

To determine if the use of corticosteroids was associated with Intensive Care Unit (ICU) mortality among whole population and pre-specified clinical phenotypes.

DESIGN

A secondary analysis derived from multicenter, observational study.

SETTING

Critical Care Units.

PATIENTS

Adult critically ill patients with confirmed COVID-19 disease admitted to 63 ICUs in Spain.

INTERVENTIONS

Corticosteroids vs. no corticosteroids.

MAIN VARIABLES OF INTEREST

Three phenotypes were derived by non-supervised clustering analysis from whole population and classified as (A: severe, B: critical and C: life-threatening). We performed a multivariate analysis after propensity optimal full matching (PS) for whole population and weighted Cox regression (HR) and Fine-Gray analysis (sHR) to assess the impact of corticosteroids on ICU mortality according to the whole population and distinctive patient clinical phenotypes.

RESULTS

A total of 2017 patients were analyzed, 1171 (58%) with corticosteroids. After PS, corticosteroids were shown not to be associated with ICU mortality (OR: 1.0; 95% CI: 0.98-1.15). Corticosteroids were administered in 298/537 (55.5%) patients of "A" phenotype and their use was not associated with ICU mortality (HR=0.85 [0.55-1.33]). A total of 338/623 (54.2%) patients in "B" phenotype received corticosteroids. No effect of corticosteroids on ICU mortality was observed when HR was performed (0.72 [0.49-1.05]). Finally, 535/857 (62.4%) patients in "C" phenotype received corticosteroids. In this phenotype HR (0.75 [0.58-0.98]) and sHR (0.79 [0.63-0.98]) suggest a protective effect of corticosteroids on ICU mortality.

CONCLUSION

Our finding warns against the widespread use of corticosteroids in all critically ill patients with COVID-19 at moderate dose. Only patients with the highest inflammatory levels could benefit from steroid treatment.

Searching for a job: Cardiac responses to acute stress and the mediating role of threat appraisal in young people

Being unemployed and looking for a job has become a source of stress for many people in several European countries. However, little attention has been paid to the impact of this stressful situation on the individuals' psychophysiological stress responses. The aim of this study was to investigate the effect of being an unemployed job seeker on cognitive threat appraisal and cardiac responses to a psychosocial stressor. We exposed a group of unemployed job seekers (N = 42) and a matched group of unemployed non-job seekers (N = 40) to a standardized social stressor in form of job interview, the Trier Social Stress Test. Our results showed that unemployed job seekers manifest lower cardiac responses, along with a lower cognitive threat appraisal, compared to non-job seekers. Moreover, we observed a full mediating role of cognitive threat appraisal on the relationship between being an unemployed job seeker and cardiac responses to stress. These findings reveal that being unemployed and looking for a job has an effect on physiological responses to acute stress, as well as the importance of psychological process related to the situation. These responses might lead to negative health and motivational consequences. Theoretical and practical implications are discussed.

Being an optimist or a pessimist and its relationship with morning cortisol release and past life review in healthy older people

OBJECTIVE

Investigate the relationship between optimism and pessimism and the cortisol awakening response (CAR) and past life review in healthy older people.

DESIGN

76 older volunteers summarised their lives, highlighting the most important events, impressions and experiences. Cortisol saliva samples were collected on two consecutive weekdays. High and low optimism and pessimism groups were computed by mean split.

MAIN OUTCOME MEASURES

Percentages of positive (PE) and negative events (NE) and positive (PCE) and negative cognitions and emotions (NCE) were obtained. Optimism and pessimism were measured with the Life Orientation Test Revised. The areas under the curve with respect to the ground and with respect to the increase were computed, with the latter understood as the CAR.

RESULTS

The high pessimism group reported more NE and NCE and less PE and PCE (p's < 0.041). No significant differences in CAR were found between high and low optimism and pessimism groups after removing suspected non-adherent participants (p's > 0.116). Higher CAR was related to lower PCE, but higher NCE (both p < 0.008).

CONCLUSION

Pessimism seems to increase the focus on negative aspects of the past, which may lead to a worse perception of life in ageing, whereas optimism contributes to a healthier CAR.

Noninvasive Mechanical Ventilation in Acute Respiratory Failure Patients: A Respiratory Therapist Perspective

Physiotherapist in Chile and Respiratory Therapist worldwide are the professionals who are experts in respiratory care, in mechanical ventilation (MV), pathophysiology and connection and disconnection criteria. They should be experts in every aspect of the acute respiratory failure and its management, they and are the ones who in medical units are able to resolve doubts about ventilation and the setting of the ventilator. Noninvasive mechanical ventilation should be the first-line of treatment in acute respiratory failure, and the standard of care in severe exacerbations of chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema, and in immunosuppressed patients with high levels of evidence that support the work of physiotherapist. Exist other considerations where most of the time, physicians and other professionals in the critical units do not take into account when checking the patient ventilator synchrony, such as the appropriate patient selection, ventilator selection, mask selection, mode selection, and the selection of a trained team in NIMV. The physiotherapist needs to evaluate bedside; if patients are properly connected to the ventilator and in a synchronously manner. In Chile, since 2004, the physioterapist are included in the guidelines as a professional resource in the ICU organization, with the same skills and obligations as those described in the literature for respiratory therapists.

Pathophysiological Basis of Acute Respiratory Failure on Non-Invasive Mechanical Ventilation

Noninvasive mechanical ventilation (NIMV) was created for patients who needed noninvasive ventilator support, this procedure decreases the complications associated with the use of endotracheal intubation (ETT). The application of NIMV has acquired major relevance in the last few years in the management of acute respiratory failure (ARF), in patients with hypoxemic and hypercapnic failure. The main advantage of NIMV as compared to invasive mechanical ventilation (IMV) is that it can be used earlier outside intensive care units (ICUs). The evidence strongly supports its use in patients with COPD exacerbation, support in weaning process in chronic obstructive pulmonary disease (COPD) patients, patients with acute cardiogenic pulmonary edema (ACPE), and Immunosuppressed patients. On the other hand, there is poor evidence that supports the use of NIMV in other pathologies such as pneumonia, acute respiratory distress syndrome (ARDS), and during procedures as bronchoscopy, where its use is still controversial because the results of these studies are inconclusive against the decrease in the rate of intubation or mortality.

Humidification on Ventilated Patients: Heated Humidifications or Heat and Moisture Exchangers?

The normal physiology of conditioning of inspired gases is altered when the patient requires an artificial airway access and an invasive mechanical ventilation (IMV). The endotracheal tube (ETT) removes the natural mechanisms of filtration, humidification and warming of inspired air. Despite the noninvasive ventilation (NIMV) in the upper airways, humidification of inspired gas may not be optimal mainly due to the high flow that is being created by the leakage compensation, among other aspects. Any moisture and heating deficit is compensated by the large airways of the tracheobronchial tree, these are poorly suited for this task, which alters mucociliary function, quality of secretions, and homeostasis gas exchange system. To avoid the occurrence of these events, external devices that provide humidification, heating and filtration have been developed, with different degrees of evidence that support their use.

Assessment and accreditation of Mexican medical schools

With the objective of evaluating and accrediting the quality of medical education in the country, the Mexican Association of Medical Schools initiated the National Programme for the Strengthening of the Quality of Medical Education (PNFCE). This programme led to the establishment of the National System of Accreditation. Medical school deans in Mexico determined the criteria for the evaluation of quality and its subsequent standards through a consensus process. The following 10 criteria resulted: general basis and educational objectives; government and institutional orientation; educational programme and academic structure; educational process assessment; students; teaching staff; institutional coherence; resources; clinical sites; and administration. Eighty-eight standards were developed in the instrument designed for the self-evaluation phase. The information resulting from the self-evaluation will be verified by a group of experts during a survey visit, which will be finalized with a report to serve as the basis for the decision to be made by the Accreditation Commission. The self-evaluation phase started in 1994. In 1996 four schools submitted their request for accreditation. As of July 1996, one survey visit has been completed and three more are programmed for the second half of the year.

Voluntary feed intake, acid-base balance and partitioning of urinary nitrogen in lambs fed corn silage with added sodium bicarbonate or sodium sesquicarbonate

An experiment with growing lambs was designed to test the hypothesis that alterations in blood acid-base status would influence intake of corn silage. Six wethers (29 kg) were fed a diet of corn silage (36% DM, 8% CP) supplemented with 1.25% urea and .2% sulfur. At feeding time, sodium bicarbonate (NaHCO3) and sodium sesquicarbonate (NaSC) were added to the silage at levels of 0, 2% or 4% of diet DM. The treatments were arranged as a 2 x 3 factorial, and the study was conducted as a 6 x 4 incomplete latin square with four 17-d periods. Voluntary intake of OM was not different (P greater than .05) between NaHCO3 (1,008 g/d) and NaSC (1,041 g/d). There was no significant interaction between type of buffer (NaHCO3 or NaSC) and level of buffer on any of the variables measured. The progressive increase in buffer load did not alter feed intake (P greater than .05), although there was a quadratic response (P less than .05) in urine pH and a linear increase (P less than .01) in blood HCO3- 2 h after feeding. There was no evidence that lambs fed corn silage experienced metabolic acid stress. Urinary excretion of ammonia and urea were indicative of changes, although not pronounced, in ammoniuria and ureapoiesis in response to bicarbonate loading. This study implies that corn silage imposes no "acid stress" on lambs and, consequently, that there is no nutritional benefit in adding buffers to corn silage for sheep.

Postoperative radical radiotherapy with concurrent weekly intra-arterial cis-platinum for treatment of malignant glioma: a pilot study

Twelve patients with histologically proven malignant glioma have been treated with a combination of intra-arterial (IA) cis-platinum (CDDP) and radical radiation therapy (RT). Chemotherapy consisted of intracarotid (IC) CDDP, 40-60 mg/m2, weekly, repeated for 3-5 treatments. Radiation therapy consisted of whole-brain irradiation 5000 cGy in 5 weeks, plus a cone-down boost (1000 cGy in one week) to the primary tumour lesion. Ocular toxicity derived from IC chemotherapy was observed in 3 out of 41 procedures analyzed (7%). Results in tumour response assessed by computed tomography (CT) showed 5 complete remissions, 6 partial remissions and one patient was not evaluable. The median survival time for the entire group was 10 months. Median survival time in patients with complete response is 17 months, and 10 months in patients with partial response. Four patients are still alive with a follow-up ranging from 6+ to 27+ months.

[Intra-arterial chemotherapy, using the hepatic artery, in metastases of colorectal carcinoma]

Hepatic metastasis is the major cause of death in advanced cancer of the colon and rectum. Various modes of therapy have been attempted with only partial success. Infusion of cytotoxic agents into the hepatic artery has allowed a higher concentration of drug into the tumor capillary bed than is achievable with intravenous administration. We review the data on therapeutic outcome, administration techniques and toxicity of hepatic arterial chemotherapy for colorectal cancer metastatic to the liver.

Simultaneous radiotherapy and cis-platinum for the treatment of brain metastases. A pilot study

Thirteen patients with the established diagnosis of brain metastases were treated with weekly intravenous or intra-arterial cis-platinum (40-60 mg/m2) during whole-brain irradiation (5,000 cGy over 5 weeks). Objective tumor response was observed in 12 patients (seven complete responses [CRs] and five partial responses [PRs]), and one patient showed stable disease (NC) following treatment. Chemotherapy- and radiation therapy-related toxicity was mild. There was no enhanced radiation therapy side effects on the normal tissues. Intracarotid cis-platinum with radiotherapy resulted in five CRs, two PRs, and one NC. Intravenous cis-platinum with conventional radiation therapy resulted in two CRs and three PRs. Responses according to tumor type were as follows: lung cancer (three adenocarcinoma, one mixed type, and one small-cell anaplastic carcinoma), two CRs and three PRs; breast cancer, one CR; thyroid cancer, one CR; unknown primary cancer, one CR; and melanoma, one NC. These results represent a relatively high CR rate (53.8%) for an otherwise barely manageable complication of malignant disease. Further controlled studies are recommended.