Publications by authors named "Rahul Kashyap"

187 Publications

Probing the Incompressibility of Nuclear Matter at Ultrahigh Density through the Prompt Collapse of Asymmetric Neutron Star Binaries.

Phys Rev Lett 2022 Jul;129(3):032701

Institute for Gravitation and the Cosmos, Pennsylvania State University, University Park, Pennsylvania 16802, USA.

Using 250 neutron star merger simulations with microphysics, we explore for the first time the role of nuclear incompressibility in the prompt collapse threshold for binaries with different mass ratios. We demonstrate that observations of prompt collapse thresholds, either from binaries with two different mass ratios or with one mass ratio but combined with the knowledge of the maximum neutron star mass or compactness, will constrain the incompressibility at the maximum neutron star density K_{max} to within tens of percent. This otherwise inaccessible measure of K_{max} can potentially reveal the presence of hyperons or quarks inside neutron stars.
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http://dx.doi.org/10.1103/PhysRevLett.129.032701DOI Listing
July 2022

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

Crit Care Med 2022 Jul 27. Epub 2022 Jul 27.

Biomedical and Behavioral Methodology Core, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK.

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

Design: Retrospective observational study.

Setting: Multicenter, international COVID-19 registry.

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

Interventions: None.

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

Conclusions: Among patients hospitalized for COVID-19 who were taking AHAs, prior use of a combination of RAASIs and other AHAs was associated with higher in-hospital mortality than the use of RAASIs alone. When compared with ARBs, ACEIs were associated with significantly higher mortality in hospitalized COVID-19 patients.
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http://dx.doi.org/10.1097/CCM.0000000000005627DOI Listing
July 2022

Acute mania following COVID-19 in a woman with no past psychiatric history case report.

BMC Psychiatry 2022 07 20;22(1):486. Epub 2022 Jul 20.

Department of Psychiatry, Tristar Centennial Medical Center, HCA Healthcare, 2300 Patterson St, 37203, Nashville, TN, USA.

Background: The COVID-19 pandemic that began in late 2019 is caused by infection with the severe acute respiratory syndrome coronavirus-2. Since that time, many neuropsychiatric sequelae including psychosis, neurocognitive disorders, and mood disorders have been observed. The mechanism underlying these effects are currently unknown, however several mechanisms have been proposed.

Case Presentation: A 47-year-old woman with past medical history including hypertension and premenstrual syndrome but no psychiatric history presented to the psychiatric hospital with new onset mania. She had developed symptoms of COVID-19 and was later diagnosed with COVID pneumonia. During quarantine, she reported high levels of stress, grief, and anxiety. Seventeen days into her illness, she developed altered mental status, sleeplessness, elevated mood, talkativeness, and preoccupations. Her spouse was concerned for her safety and contacted emergency medical services who brought her to the psychiatric hospital. She had not slept for five days prior to her arrival and exhibited flight of ideas, talkativeness, and grandiose ideas. She reported a family history of bipolar disorder but no past manic or depressive episodes. She was diagnosed with acute mania and stabilized using antipsychotics, a mood stabilizer, and a short course of a benzodiazepine. Many of her symptoms improved, including her elevated mood, increased activity level, and flight of ideas though she continued to have decreased need for sleep as her benzodiazepine was tapered. She and her partner were agreeable to transitioning to outpatient care after her mood stabilized.

Conclusions: This report emphasizes the link between COVID-19 and neuropsychiatric symptoms. Acute mania has no recognized association with COVID-19, but similar presentations have been reported. The patient's age and time to onset of psychiatric symptoms is consistent with previous reports. Given the growing body of evidence, this association warrants further investigation. Severe acute respiratory syndrome coronavirus-2 causes systemic inflammation and has been shown to be neurotropic. In addition, patients undergoing quarantine experience anxiety related to the disease in addition to social isolation. Psychiatric practitioners should be aware of these effects and advocate for psychiatric evaluation following COVID-19 infection. Understanding the sequelae of infectious disease is crucial for responding to future pandemics.
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http://dx.doi.org/10.1186/s12888-022-04110-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9296893PMC
July 2022

Admission Code Status and End-of-life Care for Hospitalized Patients With COVID-19.

J Pain Symptom Manage 2022 Jun 25. Epub 2022 Jun 25.

Cambia Palliative Care Center of Excellence (WA.K., L.R.P., C.J.C., E.K.K., J.R.C., N.K.), University of Washington, Seattle, WA, USA; Department of Anesthesiology and Pain Medicine (N.K.), University of Washington, Seattle, WA, USA.

Context: The COVID-19 pandemic has highlighted variability in intensity of care. We aimed to characterize intensity of care among hospitalized patients with COVID-19.

Objectives: Examine the prevalence and predictors of admission code status, palliative care consultation, comfort-measures-only orders, and cardiopulmonary resuscitation (CPR) among patients hospitalized with COVID-19.

Methods: This cross-sectional study examined data from an international registry of hospitalized patients with COVID-19. A proportional odds model evaluated predictors of more aggressive code status (i.e., Full Code) vs. less (i.e., Do Not Resuscitate, DNR). Among decedents, logistic regression was used to identify predictors of palliative care consultation, comfort measures only, and CPR at time of death.

Results: We included 29,923 patients across 179 sites. Among those with admission code status documented, Full Code was selected by 90% (n = 15,273). Adjusting for site, Full Code was more likely for patients who were of Black or Asian race (ORs 1.82, 95% CIs 1.5-2.19; 1.78, 1.15-3.09 respectively, relative to White race), Hispanic ethnicity (OR 1.89, CI 1.35-2.32), and male sex (OR 1.16, CI 1.0-1.33). Of the 4951 decedents, 29% received palliative care consultation, 59% transitioned to comfort measures only, and 29% received CPR, with non-White racial and ethnic groups less likely to receive comfort measures only and more likely to receive CPR.

Conclusion: In this international cohort of patients with COVID-19, Full Code was the initial code status in the majority, and more likely among patients who were Black or Asian race, Hispanic ethnicity or male. These results provide direction for future studies to improve these disparities in care.
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http://dx.doi.org/10.1016/j.jpainsymman.2022.06.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9233554PMC
June 2022

Association of Obesity With COVID-19 Severity and Mortality: An Updated Systemic Review, Meta-Analysis, and Meta-Regression.

Front Endocrinol (Lausanne) 2022 3;13:780872. Epub 2022 Jun 3.

Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MI, United States.

Background: Obesity affects the course of critical illnesses. We aimed to estimate the association of obesity with the severity and mortality in coronavirus disease 2019 (COVID-19) patients.

Data Sources: A systematic search was conducted from the inception of the COVID-19 pandemic through to 13 October 2021, on databases including Medline (PubMed), Embase, Science Web, and Cochrane Central Controlled Trials Registry. Preprint servers such as BioRxiv, MedRxiv, ChemRxiv, and SSRN were also scanned.

Study Selection And Data Extraction: Full-length articles focusing on the association of obesity and outcome in COVID-19 patients were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were used for study selection and data extraction. Our Population of interest were COVID-19 positive patients, obesity is our Intervention/Exposure point, Comparators are Non-obese vs obese patients The chief outcome of the study was the severity of the confirmed COVID-19 positive hospitalized patients in terms of admission to the intensive care unit (ICU) or the requirement of invasive mechanical ventilation/intubation with obesity. All-cause mortality in COVID-19 positive hospitalized patients with obesity was the secondary outcome of the study.

Results: In total, 3,140,413 patients from 167 studies were included in the study. Obesity was associated with an increased risk of severe disease (RR=1.52, 95% CI 1.41-1.63, p<0.001, I = 97%). Similarly, high mortality was observed in obese patients (RR=1.09, 95% CI 1.02-1.16, p=0.006, I = 97%). In multivariate meta-regression on severity, the covariate of the female gender, pulmonary disease, diabetes, older age, cardiovascular diseases, and hypertension was found to be significant and explained R = 40% of the between-study heterogeneity for severity. The aforementioned covariates were found to be significant for mortality as well, and these covariates collectively explained R = 50% of the between-study variability for mortality.

Conclusions: Our findings suggest that obesity is significantly associated with increased severity and higher mortality among COVID-19 patients. Therefore, the inclusion of obesity or its surrogate body mass index in prognostic scores and improvement of guidelines for patient care management is recommended.
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http://dx.doi.org/10.3389/fendo.2022.780872DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9205425PMC
June 2022

The Well-Being of Healthcare Workers During the COVID-19 Pandemic: A Narrative Review.

Cureus 2022 May 17;14(5):e25065. Epub 2022 May 17.

Critical Care Medicine, TriStar Centennial Medical Center, TriStar Division, HCA Healthcare, Nashville, USA.

The coronavirus disease 2019 (COVID-19) pandemic has turned into a global healthcare challenge, causing significant morbidity and mortality.Healthcare workers (HCWs) who are on the frontline of the COVID-19 outbreak response face an increased risk of contracting the disease. Some common challenges encountered by HCWs include exposure to the pathogen, psychological distress, and long working hours. In addition, HCWs may be more prone to develop mental health issues such as anxiety, depression, suicidal thoughts, post-traumatic stress disorder (PTSD), sleep disorders, and drug addictions compared to the general population. These issues arise from increased job stress, fear of spreading the disease to loved ones, and potential discrimination or stigma associated with the disease. This study aims to review the current literature to explore the effects of COVID-19 on healthcare providers' physical and mental well-being and suggest interventional strategies to combat these issues. To that end, we performed a literature search on Google Scholar and PubMed databases using combinations of the following keywords and synonyms: "SARS-CoV-2", "Healthcare-worker", "COVID-19", "Well-being", "Wellness", "Depression", "Anxiety", and "PTSD."
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http://dx.doi.org/10.7759/cureus.25065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9201991PMC
May 2022

Use of peripherally inserted central catheters with a dedicated vascular access specialists team versus centrally inserted central catheters in the management of septic shock patients in the ICU.

J Vasc Access 2022 Jun 10:11297298221105323. Epub 2022 Jun 10.

Department of Critical Care Medicine, Mayo Clinic Arizona, Scottsdale, AZ, USA.

Objectives: Peripherally inserted central catheters (PICCs) are increasingly recognized as an alternative to centrally inserted central catheters (CICCs) in critical care, yet the data regarding the safety and feasibility of this choice in septic shock management is growing but still lacking. In this study, we aimed to determine the feasibility, safety, and impact on outcomes of using dedicated vascular access specialist (VAS) teams to insert PICCs versus CICCs on patients admitted to the ICU with septic shock.

Design: Retrospective cohort study.

Setting: Mayo Clinic Rochester Medical ICU and Mayo Clinic Arizona Multidisciplinary ICU from 2013 to 2016.

Patients: All adult patients hospitalized with diagnosis of septic shock excluding patients who declined authorization for review of their medical records, mixed shock states, and readmissions.

Interventions: None.

Measurement And Main Results: Comprehensive data regarding septic shock diagnosis and resuscitation were abstracted from electronic medical records. A total of 562 patients with septic shock were included in the study; 215 patients were resuscitated utilizing a PICC and 347 were resuscitated using a CICC. On univariate analysis, the time to central line insertion and time to vasopressor initiation were found to be reduced in those who received PICC at time of ICU admission versus CICC. Other favorable outcomes were also observed in those who received PICC versus CICC including shorter ICU length of stay and lower unadjusted hospital mortality. A multivariable analysis for hospital mortality showed that after adjusting for important covariates, neither the time to central line insertion nor the time to vasopressor initiation was associated with a lower hospital mortality.

Conclusions: Across two tertiary referral centers within the same enterprise, use of a dedicated VAS team for insertion of PICCs for initial resuscitation in patients with septic shock was feasible and associated with shorter time to central venous access and initiation of vasopressors; however, adjusted hospital mortality was not different between the two groups.
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http://dx.doi.org/10.1177/11297298221105323DOI Listing
June 2022

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

Respir Care 2022 08 7;67(8):929-938. Epub 2022 Jun 7.

The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.

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

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

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

Conclusions: Hospital variation in the use of HFNC and NIV for acute respiratory failure secondary to COVID-19 was great but was not associated with intubation or mortality. The wide variation and relatively low use of HFNC/NIV observed within our study signaled that implementation of increased HFNC/NIV use in patients with COVID-19 will require changes to current care delivery practices. (ClinicalTrials.gov registration NCT04323787.).
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http://dx.doi.org/10.4187/respcare.09672DOI Listing
August 2022

Early combination therapy with immunoglobulin and steroids is associated with shorter ICU length of stay in Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19: A retrospective cohort analysis from 28 U.S. Hospitals.

Pharmacotherapy 2022 Jul 27;42(7):529-539. Epub 2022 Jun 27.

Department of Pediatrics, University of Illinois College of Medicine Peoria, Peoria, Illinois, USA.

Objectives: Suggested therapeutic options for Multisystem Inflammatory Syndrome in Children (MIS-C) include intravenous immunoglobulins (IVIG) and steroids. Prior studies have shown the benefit of combination therapy with both agents on fever control or the resolution of organ dysfunction. The primary objective of this study was to analyze the impact of IVIG and steroids on hospital and ICU length of stay (LOS) in patients with MIS-C associated with Coronavirus Disease 2019 (COVID-19).

Study Design: This was a retrospective study on 356 hospitalized patients with MIS-C from March 2020 to September 2021 (28 sites in the United States) in the Society of Critical Care Medicine (SCCM) Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS) COVID-19 Registry. The effect of IVIG and steroids initiated in the first 2 days of admission, alone or in combination, on LOS was analyzed. Adjustment for confounders was made by multivariable mixed regression with a random intercept for the site.

Results: The median age of the study population was 8.8 (Interquartile range (IQR) 4.0, 13) years. 247/356 (69%) patients required intensive care unit (ICU) admission during hospitalization. Overall hospital mortality was 2% (7/356). Of the total patients, 153 (43%) received IVIG and steroids, 33 (9%) received IVIG only, 43 (12%) received steroids only, and 127 (36%) received neither within 2 days of admission. After adjustment of confounders, only combination therapy showed a significant decrease of ICU LOS by 1.6 days compared to no therapy (exponentiated coefficient 0.71 [95% confidence interval 0.51, 0.97, p = 0.03]). No significant difference was observed in hospital LOS or the secondary outcome variable of the normalization of inflammatory mediators by Day 3.

Conclusions: Combination therapy with IVIG and steroids initiated in the first 2 days of admission favorably impacts ICU but not the overall hospital LOS in children with MIS-C.
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http://dx.doi.org/10.1002/phar.2709DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9347960PMC
July 2022

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

Pediatr Infect Dis J 2022 Sep 27;41(9):751-758. Epub 2022 May 27.

From the Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora, Colorado.

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

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

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

Conclusions: GI involvement is common in hospitalized children with acute COVID-19 and MIS-C. GI involvement is not associated with critical illness, hospital length of stay or mortality in acute COVID-19 or MIS-C.
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http://dx.doi.org/10.1097/INF.0000000000003589DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9359679PMC
September 2022

Editorial: Clinical Application of Artificial Intelligence in Emergency and Critical Care Medicine, Volume II.

Front Med (Lausanne) 2022 6;9:910163. Epub 2022 May 6.

Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.

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http://dx.doi.org/10.3389/fmed.2022.910163DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9121731PMC
May 2022

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

Crit Care Explor 2022 Apr 25;4(4):e0686. Epub 2022 Apr 25.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.

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

Design: Prospective observational study.

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

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

Interventions: None.

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

Conclusions: Encephalopathy at admission is common in hospitalized patients with SARS-CoV-2 infection and is associated with worse outcomes. While serious neurologic manifestations including stroke, seizure, and meningitis/encephalitis were less common, all were associated with increased ICU support utilization, more severe disease, and worse outcomes.
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http://dx.doi.org/10.1097/CCE.0000000000000686DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9042584PMC
April 2022

International Virtual Simulation Education in Critical Care During COVID-19 Pandemic: Preliminary Description of the Virtual Checklist for Early Recognition and Treatment of Acute Illness and iNjury Program.

Simul Healthc 2022 Apr 13. Epub 2022 Apr 13.

From the Division of Clinical Microbiology (L.F.), Mayo Clinic, Rochester, MN; Critical Care Unit (L.F.), University Hospital of Guadeloupe, France; and Department of Anesthesiology and Perioperative Medicine (A.T., R.K., Y.D.), Division of Pulmonary and Critical Care (M.B., S.Z., Y.S., H.L., S.A., O.G., A.N.), and Department of Emergency Medicine (A.F.), Mayo Clinic, Rochester, MN.

Summary Statement: The Checklist for Early Recognition and Treatment of Acute Illness and iNjury program is a well-established, interactive, and simulation-based program designed to improve the quality of care delivered in intensive care units. The COVID-19 pandemic created an overwhelming surge of critically ill patients worldwide, and infection control concerns limited healthcare providers' access to in-person and hands-on simulation training when they needed it the most. Virtual simulation offers an alternative to in-person training but is often complex and expensive. We describe our successful development and initial implementation of an inexpensive, simulation-based virtual Checklist for Early Recognition and Treatment of Acute Illness and iNjury program to address the pressing need for effective critical care training in various resource-limited settings both within and outside of the United States. The overall satisfaction rate ("excellent" or "very good" responses) was 94.4% after the virtual simulation workshop. Our initial experience suggests that virtual interactions can be engaging and build strong relationships, like in-person continuing professional education, even using relatively simple technology. This knowledge-to-practice improvement platform can be readily adapted to other disciplines beyond critical care medicine.
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http://dx.doi.org/10.1097/SIH.0000000000000656DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9169605PMC
April 2022

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

World J Crit Care Med 2022 Mar 9;11(2):102-111. Epub 2022 Mar 9.

Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States.

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

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

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

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

Conclusion: Our findings suggest that differences observed in previous epidemiological studies may be due to ecological fallacy rather than implying a causal relationship at the patient level.
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http://dx.doi.org/10.5492/wjccm.v11.i2.102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8968480PMC
March 2022

Sequential organ failure assessment score improves survival prediction for left ventricular assist device recipients in intensive care.

Artif Organs 2022 Apr 11. Epub 2022 Apr 11.

Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minnesota, USA.

Background: Preoperative risk scores facilitate patient selection, but postoperative risk scores may offer valuable information for predicting outcomes. We hypothesized that the postoperative Sequential Organ Failure Assessment (SOFA) score would predict mortality after left ventricular assist device (LVAD) implantation.

Methods: We retrospectively reviewed data from 294 continuous-flow LVAD implantations performed at Mayo Clinic Rochester during 2007 to 2015. We calculated the EuroSCORE, HeartMate-II Risk Score, and RV Failure Risk Score from preoperative data and the APACHE III and Post Cardiac Surgery (POCAS) risk scores from postoperative data. Daily, maximum, and mean SOFA scores were calculated for the first 5 postoperative days. The area under receiver-operator characteristic curves (AUC) was calculated to compare the scoring systems' ability to predict 30-day, 90-day, and 1-year mortality.

Results: For the entire cohort, mortality was 5% at 30 days, 10% at 90 days, and 19% at 1 year. The Day 1 SOFA score had better discrimination for 30-day mortality (AUC 0.77) than the preoperative risk scores or the APACHE III and POCAS postoperative scores. The maximum SOFA score had the best discrimination for 30-day mortality (AUC 0.86), and the mean SOFA score had the best discrimination for 90-day mortality (AUC 0.82) and 1-year mortality (AUC 0.76).

Conclusions: We observed that postoperative mean and maximum SOFA scores in LVAD recipients predict short-term and intermediate-term mortality better than preoperative risk scores do. However, because preoperative and postoperative risk scores each contribute unique information, they are best used in concert to predict outcomes after LVAD implantation.
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http://dx.doi.org/10.1111/aor.14254DOI Listing
April 2022

Effectiveness of Mechanical Chest Compression Devices over Manual Cardiopulmonary Resuscitation: A Systematic Review with Meta-analysis and Trial Sequential Analysis.

West J Emerg Med 2021 Jul 19;22(4):810-819. Epub 2021 Jul 19.

Mayo Clinic, Department of Anesthesiology and Critical Care, Rochester, Minnesota.

Introduction: Our goal was to systematically review contemporary literature comparing the relative effectiveness of two mechanical compression devices (LUCAS and AutoPulse) to manual compression for achieving return of spontaneous circulation (ROSC) in patients undergoing cardiopulmonary resuscitation (CPR) after an out-of-hospital cardiac arrest (OHCA).

Methods: We searched medical databases systematically for randomized controlled trials (RCT) and observational studies published between January 1, 2000-October 1, 2020 that compared mechanical chest compression (using any device) with manual chest compression following OHCA. We only included studies in the English language that reported ROSC outcomes in adult patients in non-trauma settings to conduct random-effects metanalysis and trial sequence analysis (TSA). Multivariate meta-regression was performed using preselected covariates to account for heterogeneity. We assessed for risk of biases in randomization, allocation sequence concealment, blinding, incomplete outcome data, and selective outcome reporting.

Results: A total of 15 studies (n = 18474), including six RCTs, two cluster RCTs, five retrospective case-control, and two phased prospective cohort studies, were pooled for analysis. The pooled estimates' summary effect did not indicate a significant difference (Mantel-Haenszel odds ratio = 1.16, 95% confidence interval, 0.97 to 1.39, P = 0.11, I2 = 0.83) between mechanical and manual compressions during CPR for ROSC. The TSA showed firm evidence supporting the lack of improvement in ROSC using mechanical compression devices. The Z-curves successfully crossed the TSA futility boundary for ROSC, indicating sufficient evidence to draw firm conclusions regarding these outcomes. Multivariate meta-regression demonstrated that 100% of the between-study variation could be explained by differences in average age, the proportion of females, cardiac arrests with shockable rhythms, witnessed cardiac arrest, bystander CPR, and the average time for emergency medical services (EMS) arrival in the study samples, with the latter three attaining statistical significance.

Conclusion: Mechanical compression devices for resuscitation in cardiac arrests are not associated with improved rates of ROSC. Their use may be more beneficial in non-ideal situations such as lack of bystander CPR, unwitnessed arrest, and delayed EMS response times. Studies done to date have enough power to render further studies on this comparison futile.
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http://dx.doi.org/10.5811/westjem.2021.3.50932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328162PMC
July 2021

Reintubation Summation Calculation: A Predictive Score for Extubation Failure in Critically Ill Patients.

Front Med (Lausanne) 2021 17;8:789440. Epub 2022 Feb 17.

Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, United States.

Objective: To derive and validate a multivariate risk score for the prediction of respiratory failure after extubation.

Patients And Methods: We performed a retrospective cohort study of adult patients admitted to the intensive care unit from January 1, 2006, to December 31, 2015, who received mechanical ventilation for ≥48 h. Extubation failure was defined as the need for reintubation within 72 h after extubation. Multivariate logistic regression model coefficient estimates generated the e-ntubation ummation alculation (RISC) score.

Results: The 6,161 included patients were randomly divided into 2 sets: derivation ( = 3,080) and validation ( = 3,081). Predictors of extubation failure in the derivation set included body mass index <18.5 kg/m [odds ratio (OR), 1.91; 95% CI, 1.12-3.26; = 0.02], threshold of Glasgow Coma Scale of at least 10 (OR, 1.68; 95% CI, 1.31-2.16; < 0.001), mean airway pressure at 1 min of spontaneous breathing trial <10 cmHO (OR, 2.11; 95% CI, 1.68-2.66; < 0.001), fluid balance ≥1,500 mL 24 h preceding extubation (OR, 2.36; 95% CI, 1.87-2.96; < 0.001), and total mechanical ventilation days ≥5 (OR, 3.94; 95% CI 3.04-5.11; < 0.001). The C-index for the derivation and validation sets were 0.72 (95% CI, 0.70-0.75) and 0.72 (95% CI, 0.69-0.75). Multivariate logistic regression demonstrated that an increase of 1 in RISC score increased odds of extubation failure 1.6-fold (OR, 1.58; 95% CI, 1.47-1.69; < 0.001).

Conclusion: RISC predicts extubation failure in mechanically ventilated patients in the intensive care unit using several clinically relevant variables available in the electronic medical record but requires a larger validation cohort before widespread clinical implementation.
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http://dx.doi.org/10.3389/fmed.2021.789440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8891541PMC
February 2022

Hospital Variation in Management and Outcomes of Acute Respiratory Distress Syndrome Due to COVID-19.

Crit Care Explor 2022 Feb 18;10(2):e0638. Epub 2022 Feb 18.

The Pulmonary Center, Division of Pulmonary, Allergy, Sleep and Critical Care, Department of Medicine, Boston University School of Medicine, Boston, MA.

Objectives: To describe hospital variation in use of "guideline-based care" for acute respiratory distress syndrome (ARDS) due to COVID-19.

Design: Retrospective, observational study.

Setting: The Society of Critical Care Medicine's Discovery Viral Infection and

Patients: Adult patients with ARDS due to COVID-19 between February 15, 2020, and April 12, 2021.

Interventions: Hospital-level use of "guideline-based care" for ARDS including low-tidal-volume ventilation, plateau pressure less than 30 cm HO, and prone ventilation for a Pao/Fio ratio less than 100.

Measurements And Main Results: Among 1,495 adults with COVID-19 ARDS receiving care across 42 hospitals, 50.4% ever received care consistent with ARDS clinical practice guidelines. After adjusting for patient demographics and severity of illness, hospital characteristics, and pandemic timing, hospital of admission contributed to 14% of the risk-adjusted variation in "guideline-based care." A patient treated at a randomly selected hospital with higher use of guideline-based care had a median odds ratio of 2.0 (95% CI, 1.1-3.4) for receipt of "guideline-based care" compared with a patient receiving treatment at a randomly selected hospital with low use of recommended therapies. Median-adjusted inhospital mortality was 53% (interquartile range, 47-62%), with a nonsignificantly decreased risk of mortality for patients admitted to hospitals in the highest use "guideline-based care" quartile (49%) compared with the lowest use quartile (60%) (odds ratio, 0.7; 95% CI, 0.3-1.9; = 0.49).

Conclusions: During the first year of the COVID-19 pandemic, only half of patients received "guideline-based care" for ARDS management, with wide practice variation across hospitals. Strategies that improve adherence to recommended ARDS management strategies are needed.
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http://dx.doi.org/10.1097/CCE.0000000000000638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8860338PMC
February 2022

Bedside Clinicians' Perceptions on the Contributing Role of Diagnostic Errors in Acutely Ill Patient Presentation: A Survey of Academic and Community Practice.

J Patient Saf 2022 03;18(2):e454-e462

From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.

Objectives: This study aimed to explore clinicians' perceptions of the occurrence of and factors associated with diagnostic errors in patients evaluated during a rapid response team (RRT) activation or unplanned admission to the intensive care unit (ICU).

Methods: A multicenter prospective survey study was conducted among multiprofessional clinicians involved in the care of patients with RRT activations and/or unplanned ICU admissions (UIAs) at 2 academic hospitals and 1 community-based hospital between April 2019 and March 2020. A study investigator screened eligible patients every day. Within 24 hours of the event, a research coordinator administered the survey to clinicians, who were asked the following: whether diagnostic errors contributed to the reason for RRT/UIA, whether any new diagnosis was made after RRT/UIA, if there were any failures to communicate the diagnosis, and if involvement of specialists earlier would have benefited that patient. Patient clinical data were extracted from the electronic health record.

Results: A total of 1815 patients experienced RRT activations, and 1024 patients experienced UIA. Clinicians reported that 18.2% (95/522) of patients experienced diagnostic errors, 8.0% (42/522) experienced a failure of communication, and 16.7% (87/522) may have benefitted from earlier involvement of specialists. Compared with academic settings, clinicians in the community hospital were less likely to report diagnostic errors (7.0% versus 22.8%, P = 0.002).

Conclusions: Clinicians report a high rate of diagnostic errors in patients they evaluate during RRT or UIAs.
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http://dx.doi.org/10.1097/PTS.0000000000000840DOI Listing
March 2022

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

Clin Endocrinol (Oxf) 2022 Feb 18. Epub 2022 Feb 18.

Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.

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

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

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

Conclusions: In an international registry, hypothyroidism was identified in around 1 of every 12 adult hospitalized patients with COVID-19. Pre-existing hypothyroidism in hospitalized patients with COVID-19 was not associated with higher disease severity or increased risk of mortality or ICU admissions. However, more research on the possible effects of COVID-19 on the thyroid gland and its function is needed in the future.
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http://dx.doi.org/10.1111/cen.14699DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9111656PMC
February 2022

Infection risk with the use of interleukin inhibitors in hospitalized patients with COVID-19: A narrative review.

Infez Med 2021 10;29(4):495-503. Epub 2021 Dec 10.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA.

Introduction: To date, only corticosteroids and interleukin-6 (IL-6) inhibitors have been shown to reduce mortality of hospitalized patients with COVID-19. In this literature review, we aimed to summarize infection risk of IL inhibitors, with or without the use of corticosteroids, used to treat hospitalized patients with COVID-19.

Methods: A literature search was conducted using the following evidence-based medicine reviews: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Embase; Ovid Medline; and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions 1946 to April 28, 2021. All relevant articles were identified using the search terms or , , , , , and .

Results: We identified 36 studies of which 2 were meta-analyses, 5 were randomized controlled trials, 9 were prospective studies, and 20 were retrospective studies. When anakinra was compared with control, 2 studies reported an increased risk of infection, and 3 studies reported a similar or decreased incidence of infection. Canakinumab had a lower associated incidence of infection compared with placebo in one study. When sarilumab was compared with placebo, one study reported an increased risk of infection. Nine studies comparing tocilizumab with placebo reported decreased or no difference in infection risk (odds ratio [OR] for the studies ranged from 0.39-1.21). Fourteen studies comparing tocilizumab with placebo reported an increased risk of infection, ranging from 9.1% to 63.0% (OR for the studies ranged from 1.85-5.04). Infection most commonly presented as bacteremia. Of the 6 studies comparing tocilizumab and corticosteroid use with placebo, 4 reported a nonsignificant increase toward corticosteroids being associated with bacterial infections (OR ranged from 2.76-3.8), and 2 studies reported no increased association with a higher infection risk.

Conclusions: Our literature review showed mixed results with variable significance for the association of IL-6 inhibitors with risk of infections in patients with COVID-19.
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http://dx.doi.org/10.53854/liim-2904-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8805476PMC
December 2021

A narrative review of emergency use authorization versus full FDA approval and its effect on COVID-19 vaccination hesitancy.

Infez Med 2021 10;29(3):339-344. Epub 2021 Sep 10.

Department of Anesthesiology and Peri-operative Medicine, Mayo Clinic, Rochester, MN, USA.

COVID-19 pandemic affected the lives of many with its devastating mortality and morbidity. Acquisition of herd immunity is one way to mitigate the spread of infection. Many factors influence the acceptance of vaccination including the regulatory process of the vaccines. This review article will briefly summarize the Emergency Use Authorization, Full FDA Approval process and highlight how the key factors affecting the vaccination hesitancy, are being influenced by the lack of Full FDA Approval.
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http://dx.doi.org/10.53854/liim-2903-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8805497PMC
September 2021

SARS-CoV-2 infection increases risk of acute kidney injury in a bimodal age distribution.

BMC Nephrol 2022 02 11;23(1):63. Epub 2022 Feb 11.

University of Colorado Anschutz Medical Campus, Aurora, CO, USA.

Background: Hospitalized patients with SARS-CoV2 develop acute kidney injury (AKI) frequently, yet gaps remain in understanding why adults seem to have higher rates compared to children. Our objectives were to evaluate the epidemiology of SARS-CoV2-related AKI across the age spectrum and determine if known risk factors such as illness severity contribute to its pattern.

Methods: Secondary analysis of ongoing prospective international cohort registry. AKI was defined by KDIGO-creatinine only criteria. Log-linear, logistic and generalized estimating equations assessed odds ratios (OR), risk differences (RD), and 95% confidence intervals (CIs) for AKI and mortality adjusting for sex, pre-existing comorbidities, race/ethnicity, illness severity, and clustering within centers. Sensitivity analyses assessed different baseline creatinine estimators.

Results: Overall, among 6874 hospitalized patients, 39.6% (n = 2719) developed AKI. There was a bimodal distribution of AKI by age with peaks in older age (≥60 years) and middle childhood (5-15 years), which persisted despite controlling for illness severity, pre-existing comorbidities, or different baseline creatinine estimators. For example, the adjusted OR of developing AKI among hospitalized patients with SARS-CoV2 was 2.74 (95% CI 1.66-4.56) for 10-15-year-olds compared to 30-35-year-olds and similarly was 2.31 (95% CI 1.71-3.12) for 70-75-year-olds, while adjusted OR dropped to 1.39 (95% CI 0.97-2.00) for 40-45-year-olds compared to 30-35-year-olds.

Conclusions: SARS-CoV2-related AKI is common with a bimodal age distribution that is not fully explained by known risk factors or confounders. As the pandemic turns to disproportionately impacting younger individuals, this deserves further investigation as the presence of AKI and SARS-CoV2 infection increases hospital mortality risk.
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http://dx.doi.org/10.1186/s12882-022-02681-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8831033PMC
February 2022

Mortality and Severity in COVID-19 Patients on ACEIs and ARBs-A Systematic Review, Meta-Analysis, and Meta-Regression Analysis.

Front Med (Lausanne) 2021 10;8:703661. Epub 2022 Jan 10.

Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States.

The primary objective of this systematic review is to assess association of mortality in COVID-19 patients on Angiotensin-converting-enzyme inhibitors (ACEIs) and Angiotensin-II receptor blockers (ARBs). A secondary objective is to assess associations with higher severity of the disease in COVID-19 patients. We searched multiple COVID-19 databases (WHO, CDC, LIT-COVID) for longitudinal studies globally reporting mortality and severity published before January 18th, 2021. Meta-analyses were performed using 53 studies for mortality outcome and 43 for the severity outcome. Mantel-Haenszel odds ratios were generated to describe overall effect size using random effect models. To account for between study results variations, multivariate meta-regression was performed with preselected covariates using maximum likelihood method for both the mortality and severity models. Our findings showed that the use of ACEIs/ARBs did not significantly influence either mortality (OR = 1.16 95% CI 0.94-1.44, = 0.15, = 93.2%) or severity (OR = 1.18, 95% CI 0.94-1.48, = 0.15, = 91.1%) in comparison to not being on ACEIs/ARBs in COVID-19 positive patients. Multivariate meta-regression for the mortality model demonstrated that 36% of between study variations could be explained by differences in age, gender, and proportion of heart diseases in the study samples. Multivariate meta-regression for the severity model demonstrated that 8% of between study variations could be explained by differences in age, proportion of diabetes, heart disease and study country in the study samples. We found no association of mortality or severity in COVID-19 patients taking ACEIs/ARBs.
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http://dx.doi.org/10.3389/fmed.2021.703661DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8784609PMC
January 2022

Reducing 30-Day All-Cause Acute Exacerbation of Chronic Obstructive Pulmonary Disease Readmission Rate With a Multidisciplinary Quality Improvement Project.

Cureus 2021 Nov 26;13(11):e19917. Epub 2021 Nov 26.

Hospital Medicine, Mayo Clinic, Mankato, USA.

Our objective was to implement a comprehensive quality improvement project to decrease the 30-day readmission rate for all-cause acute exacerbation of chronic obstructive pulmonary disease (AECOPD) at a rural Midwestern community hospital in the United States. Prospective data were collected from January 1 to December 31, 2017. A total of 77 patients met the study criteria and were included for analysis. Baseline data analysis involved data for 72 patients from September 1, 2015, to October 1, 2016, and showed a 30.6% all-cause 30-day AECOPD readmission rate. The Define, Measure, Analyze, Improve, and Control (DMAIC) model was used for this quality improvement project. All aspects of this project were successfully implemented, and the resulting 30-day all-cause AECOPD readmission rate decreased to 16.9% during the study time frame. Through this comprehensive quality improvement project, the 30-day all-cause AECOPD readmission rate was reduced by 23.7%.
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http://dx.doi.org/10.7759/cureus.19917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8712235PMC
November 2021

Granulomatous Polyangiitis With Renal Involvement: A Case Report and Review of Literature.

Cureus 2021 Nov 22;13(11):e19814. Epub 2021 Nov 22.

Anesthesiology, Mayo Clinic, Rochester, USA.

Granulomatosis with polyangiitis (GPA), formerly named Wegner's granulomatosis is an antineutrophilic cytoplasmic antibody (ANCA) associated vasculitis of the small vessels. GPA can affect several organ systems even though predominantly affects respiratory and renal systems. Pathogenesis is initiated by activation of the immune system to produce ANCA, Cytoplasmic (C-ANCA) antibody, which thereby leads to widespread necrosis and granulomatous inflammation. Multisystem involvement with varied symptomatology makes GPA diagnosis more challenging. Early diagnosis and management are vital and can alter the prognosis of the disease. We present a literature review and a clinical scenario of a 26-year-old male with a history of chronic sinusitis, testicular carcinoma in remission, recent onset of worsening cough, epistaxis, hoarseness of voice, weight loss, and dark-colored urine. Workup revealed high titers of C-ANCA, C-reactive protein, procalcitonin, CT chest evidence of mass-like consolidation, and bronchoscopy findings of friable tissue that was not amenable for biopsy. Methylprednisolone and rituximab (RTX) were administered, which resulted in marked clinical improvement. Therefore, a keen eye for details is necessary to diagnose GPA early, which can improve disease outcomes dramatically.
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http://dx.doi.org/10.7759/cureus.19814DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8695666PMC
November 2021

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

JAMA Netw Open 2021 12 1;4(12):e2140568. Epub 2021 Dec 1.

Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.

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

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

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

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

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

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

Conclusions And Relevance: These findings suggest that metabolic syndrome was associated with increased risks of ARDS and death in patients hospitalized with COVID-19. The association with ARDS was cumulative for each metabolic syndrome criteria present.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.40568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8696573PMC
December 2021

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

Resuscitation 2022 01 14;170:230-237. Epub 2021 Dec 14.

Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX, United States; McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, United States.

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

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

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

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

Conclusion: Palliative care consultation was not associated with CPR performed at the end-of-life but was associated with increased incidence of comfort care being utilized. These results suggest that utilizing palliative care consultation at the end-of-life may better align the needs and values of patients with the care they receive.
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http://dx.doi.org/10.1016/j.resuscitation.2021.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8669976PMC
January 2022

A Review of the Quiz, as a New Dimension in Medical Education.

Cureus 2021 Oct 18;13(10):e18854. Epub 2021 Oct 18.

Department of Critical Care Medicine, Mayo Clinic Health System, Mankato, USA.

Over the years, medical education delivery has seen a change from teacher-centric to student-centric teaching-learning methods. Educators are constantly looking to develop interactive and innovative teaching-learning tools. One such supplementary tool is the use of the quiz for medical education. The Quiz has been used traditionally as a feedback assessment tool, but lately, it has found its way into the medical curriculum, mostly informally. The few available documented studies on the Quiz as a teaching and learning tool illustrate its acceptance and impact on the stakeholders. It could be one of the solutions to the endless search for a student-centric and engaging tool to deliver the medical curriculum. Commonly, the format for medical quiz is either on a case-based or image-based approach. Such an approach helps bridge the gap between traditional classroom teaching and clinical application. The Quiz is a readily acceptable tool that complements didactic lectures and improves students' learning and comprehension. Being an interactive student-centric tool, it enhances active student participation and encourages regular feedback mechanisms. It promotes healthy competition and peer-assisted learning by encouraging active discussion among students, hence improving student performance in standard examination techniques, along with teacher satisfaction. This literature review aims to enumerate the various formats of the Quiz, their role in improving the understanding and retention of knowledge among the students and assess their acceptability among the stakeholders.
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http://dx.doi.org/10.7759/cureus.18854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8597672PMC
October 2021
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