Use of a Data Repository to Identify Delirium as a Presenting Symptom of COVID-19 Infection in Hospitalized Adults: Cross-Sectional Cohort Pilot Study.

BACKGROUND: Delirium, an acute confusional state highlighted by inattention, has been reported to occur in 10% to 50% of patients with COVID-19. People hospitalized with COVID-19 have been noted to present with or develop delirium and neurocognitive disorders. Caring for patients with delirium is associated with more burden for nurses, clinicians, and caregivers. Using information in electronic health record data to recognize delirium and possibly COVID-19 could lead to earlier treatment of the underlying viral infection and improve outcomes in clinical and health care systems cost per patient. Clinical data repositories can further support rapid discovery through cohort identification tools, such as the Informatics for Integrating Biology and the Bedside tool. OBJECTIVE: The specific aim of this research was to investigate delirium in hospitalized older adults as a possible presenting symptom in COVID-19 using a data repository to identify neurocognitive disorders with a novel group of International Classification of Diseases, Tenth Revision (ICD-10) codes. METHODS: We analyzed data from 2 catchment areas with different demographics. The first catchment area (7 counties in the North-Central Florida) is predominantly rural while the second (1 county in North Florida) is predominantly urban. The Integrating Biology and the Bedside data repository was queried for patients with COVID-19 admitted to inpatient units via the emergency department (ED) within the health center from April 1, 2020, and April 1, 2022. Patients with COVID-19 were identified by having a positive COVID-19 laboratory test or a diagnosis code of U07.1. We identified neurocognitive disorders as delirium or encephalopathy, using ICD-10 codes. RESULTS: Less than one-third (1437/4828, 29.8%) of patients with COVID-19 were diagnosed with a co-occurring neurocognitive disorder. A neurocognitive disorder was present on admission for 15.8% (762/4828) of all patients with COVID-19 admitted through the ED. Among patients with both COVID-19 and a neurocognitive disorder, 56.9% (817/1437) were aged ≥65 years, a significantly higher proportion than those with no neurocognitive disorder (P<.001). The proportion of patients aged <65 years was significantly higher among patients diagnosed with encephalopathy only than patients diagnosed with delirium only and both delirium and encephalopathy (P<.001). Most (1272/4828, 26.3%) patients with COVID-19 admitted through the ED during our study period were admitted during the Delta variant peak. CONCLUSIONS: The data collected demonstrated that an increased number of older patients with neurocognitive disorder present on admission were infected with COVID-19. Knowing that delirium increases the staffing, nursing care needs, hospital resources used, and the length of stay as previously noted, identifying delirium early may benefit hospital administration when planning for newly anticipated COVID-19 surges. A robust and accessible data repository, such as the one used in this study, can provide invaluable support to clinicians and clinical administrators in such resource reallocation and clinical decision-making.

Effect of beta2-agonist treatment and spirometry on exhaled nitric oxide in healthy children and children with asthma.

We set out to determine the effect of spirometry and bronchodilator therapy on exhaled nitric oxide (FE(NO)) values in children. We hypothesized that there will be no difference on FE(NO) values pre- and postspirometry and following bronchodilator therapy. Sixteen children [(mean = 14.4 +/- 1.2 years; range, 12-18 years; healthy controls (n = 6); asthmatics on inhaled steroids (n = 5); and asthmatics on no steroids (n = 5)] had exhaled nitric oxide (FE(NO)) measurements on 4 consecutive days as follows: pre- and postspirometry (day 1); pre- and postalbuterol metered dose inhaler (MDI) therapy (day 2); pre- and postspirometry and albuterol MDI therapy (day 3); and pre- and postspirometry and placebo MDI (day 4). FE(NO) was measured with a chemiluminescence analyzer, using the single vital capacity exhalation technique at an exhalation flow of 50 mL/sec. There were no statistically significant differences in FE(NO) values pre- and poststudy maneuvers under all experimental conditions in healthy children. However, in healthy children, clinically relevant (>10%) differences from baseline were observed on day 1 (3-18 min) and day 4 at 18 min. In children with asthma, FE(NO) values increased significantly by 11-19% from pretreatment levels at 8 and 18 min, postbronchodilator on day 2, and 12-17% at 8 and 18 min post bronchodilator and spirometry on day 3. Spirometry and treatment with a placebo (day 4) resulted in a decrease in FE(NO) values by 11% at 3 min postbaseline in patients on inhaled steroids. The changes observed were similar in children on vs. off inhaled steroids, and also in well-controlled vs. poorly controlled asthma. We conclude that FE(NO) values should be obtained consistently either pre- and at a specific time postalbuterol treatment or spirometry. Alternatively, changes in FE(NO) values should be interpreted in relationship to the timing of these maneuvers.

Effect of montelukast on time-course of exhaled nitric oxide in asthma: influence of LTC4 synthase A(-444)C polymorphism.

Leukotrienes (LT) mediate inflammation in asthma. The fraction of exhaled nitric oxide (FE(NO)) is thought to be a sensitive and reproducible method for assessing airway inflammation in asthmatics and the anti-inflammatory effects of drugs. A number of factors are known to contribute to intrapatient variation in FE(NO) which can confound interpretation. The aims of this study were to characterize the time-course of FE(NO), determine the effect of montelukast on the time-course of FE(NO), and evaluate the influence of the LTC(4) synthase A(-444)C polymorphism on montelukast-evoked changes in FE(NO). Following a 2-week run-in, 7 males and 5 females with asthma, 10-16 years old, received 5 or 10 mg of montelukast or an identical placebo at bedtime for 7 days in double-blind, crossover fashion, followed by a 7-day washout. FE(NO)was quantified every 30 min for 3 or 6 hr at baseline and on days 1, 2, 3, and 7 of treatment. A time-averaged value for FE(NO) was calculated (FE(NO)*), and % changes in FE(NO)* relative to baseline vs. time following placebo and montelukast were compared. The genotype of the A(-444)C polymorphism was determined by PCR and RFLP. FE(NO) varied markedly as a function of time in each patient. Time-averaged values of FE(NO) (FE(NO)*) during placebo and montelukast treatment were similar. Montelukast significantly reduced the slope of the % change in FE(NO)* vs. time curve in heterozygotes (n = 4), but not in A/A homozygotes (n = 8). These data suggest that heterozygotes respond better to montelukast compared to A/A homozygotes, at least with respect to changes in FE(NO). We conclude that assessment of inflammation or the anti-inflammatory effects of drugs in asthma based on single determinations of FE(NO) can be misleading. We further conclude that the A(-444)C polymorphism in the LTC(4) synthase gene probably contributes to interpatient variability in montelukast-evoked changes in FE(NO)* and warrants further study.

Exhaled nitric oxide concentrations: online versus offline values in healthy children.

Exhaled nitric oxide (FE(NO)) is a noninvasive and practical method to assess airway inflammation. We conducted this investigation to determine the most appropriate flow rate to measure FE(NO) and to obtain reference values for FE(NO) in children. FE(NO) was measured in 112 healthy 6-18 year olds (60 males) at 4 expiratory flow rates (46, 31, 23, and 15 mL/sec) using a chemiluminescent nitric oxide analyzer. Offline and online analyses were done to determine FE(NO) intraclass correlation coefficients, the relationship between FE(NO) and expiratory flow rates, and the effects of age and gender on these measurements. The major findings were: 1) intraclass correlation coefficients for FE(NO) and flow rates ranged from 0.92-0.99 for offline values, and 0.99 for all online values; 2) variation at an expiratory flow rate of 46 mL/sec (SD, 9.39) was considerably less than at other flows, especially at 15 mL/sec (SD, 26.55); 3) FE(NO) increased as flow rates decreased for both offline and online values; 4) there were no significant differences and good agreement between offline bag and online FE(NO) values at 31 and 46 mL/sec expiratory flows; and 5) using multiple regression, significant predictors of FE(NO) were flow, body surface area, age, and FEF(25-75). We have provided FE(NO) values in healthy children and propose that the ideal expiratory flow rate for FE(NO) measurements in children using the single breath technique is between 30-50 mL/sec.

Exhaled nitric oxide reflects asthma severity and asthma control.

INTRODUCTION: This study was undertaken to a) evaluate whether exhaled nitric oxide (fraction of exhaled nitric oxide [FENO]) levels are reflective of asthma severity in concordance with the National Asthma Education and Prevention Program categorization and b) determine the usefulness of FENO using the single-breath exhalation technique for monitoring asthma control and compliance with steroid treatment. METHODS: Thirty patients with asthma (7-17 yrs old; 14 males and 16 females) that was mild (n=8), moderate (n=17), or severe (n=5) were included in the study. Fifteen patients were seen on more than one occasion for a total of 53 visits. Information obtained at each visit included asthma symptoms, beta-agonists and corticosteroids use, compliance to steroids, and forced expiratory volume in 1 sec (FEV1) and FENO measurements. Asthma control was judged by a pulmonologist based on overall evaluation of symptoms, FEV1 measurements, and the frequency of beta-agonists use at each visit. RESULTS: The mean +/- SD FENO was significantly different in the mild, moderate, and severe asthma categories (30 +/- 12, 65 +/- 48, 104 +/- 68, respectively; F(2,52)=6.02 p=.005). FENO was significantly correlated with asthma severity (r=.44, p=.001), compliance (r=-.75, p=.001), and control (r=-.51, p=.001). There were no statistically significant differences between asthma severity and compliance or FEV1. DISCUSSION: Our data suggest that a) FENO may be a practical tool to evaluate asthma severity and asthma control over time and b) FENO may be used as a marker of compliance with steroids even when FEV1 has not decreased significantly.

Relevance of type of catheters for central venous pressure measurement.

OBJECTIVE: To compare simultaneous central venous pressure measurements from rigid polyurethane and soft tunneled silicone elastomere catheters. HYPOTHESIS: There will be no significant difference in central venous pressure readings between polyurethane and silastic catheters. SETTING: Bone Marrow Transplant Unit in a tertiary care children's hospital. PATIENTS: Five children undergoing bone marrow transplantation with preexisting polyurethane and silastic catheters. METHODS: Simultaneous central venous pressure readings were obtained by 2 observers blinded to the other readings and to the type of catheter. Readings were done in triplicate (total of 690 readings). Each triplicate was averaged to 1 data point yielding 115 paired central venous pressure measurements. RESULTS: No significant difference was demonstrated between polyurethane and silicone catheters (-1 +/- 3 cm H20). Using Bland and Altman method revealed no significant bias (mean = -1 cm H2O) and acceptable agreement between catheter types. CONCLUSION: Silicone and polyurethane catheters yield similar values of central venous pressures. Permanently implanted silicone elastomere catheters can be used to measure central venous pressure in the emergency setting.