Variation in therapeutic strategies for the management of severe COVID-19 in India: A nationwide cross-sectional survey.

AIM: During the pandemic of coronavirus disease 2019 (COVID-19), the physicians are using various off-label therapeutics to manage COVID-19. We undertook a cross-sectional survey to study the current variation in therapeutic strategies for managing severe COVID-19 in India. METHODS: From January 4 to January 18, 2021, an online cross-sectional survey was conducted among physicians involved in the management of severe COVID-19. The survey had three sections: 1. Antiviral agents, 2. Immunomodulators, and 3. Adjuvant therapies. RESULTS: 1055 respondents (from 24 states and five union territories), of which 64.2% were consultants, 54.3% working in private hospitals, and 39.1% were from critical care medicine completed the survey. Remdesivir (95.2%), antithrombotics (94.2%), corticosteroids (90.3%), vitamins (89.7%) and empirical antibiotics (85.6%) were the commonly used therapeutics. Ivermectin (33%), convalescent plasma (28.6%) and favipiravir (17.6%) were other antiviral agents used. Methylprednisolone (50.2%) and dexamethasone (44.1%) were preferred corticosteroids and at a dose equivalent of 8 mg of dexamethasone phosphate (70.2%). There was significant variation among physicians from different medical specialities in the use of favipiravir, corticosteroids, empirical antibiotics and vitamins. CONCLUSION: There is a considerable variation in the physicians' choice of therapeutic strategies for the management of severe COVID-19 in India, as compared with the available evidence.

In COVID-19, adding lopinavir-ritonavir to usual care did not shorten time to clinical improvement.

SOURCE CITATION: Cao B, Wang Y, Wen D, et al. A trial of lopinavir-ritonavir in adults hospitalized with severe Covid-19. N Engl J Med. 2020;382:1787-99. 32187464.

Impact of COVID-19 Pandemic on the Emotional Well-being of Healthcare Workers: A Multinational Cross-sectional Survey.

BACKGROUND: Coronavirus disease-2019 (COVID-19) in the last few months has disrupted the healthcare system globally. The objective of this study is to assess the impact of the COVID-19 pandemic on the psychological and emotional well-being of healthcare workers (HCWs). MATERIALS AND METHODS: We conducted an online, cross-sectional, multinational survey, assessing the anxiety (using Generalized Anxiety Disorder [GAD-2] and GAD-7), depression (using Center for Epidemiologic Studies Depression), and insomnia (using Insomnia Severity Index), among HCWs across India, the Middle East, and North America. We used univariate and bivariate logistic regression to identify risk factors for psychological distress. RESULTS: The prevalence of clinically significant anxiety, depression, and insomnia were 41.4, 48.0, and 31.3%, respectively. On bivariate logistic regression, lack of social or emotional support to HCWs was independently associated with anxiety [odds ratio (OR), 3.81 (2.84-3.90)], depression [OR, 6.29 (4.50-8.79)], and insomnia [OR, 3.79 (2.81-5.110)]. Female gender and self-COVID-19 were independent risk factors for anxiety [OR, 3.71 (1.53-9.03) and 1.71 (1.23-2.38)] and depression [OR, 1.72 (1.27-2.31) and 1.62 (1.14-2.30)], respectively. Frontliners were independently associated with insomnia [OR, 1.68 (1.23-2.29)]. CONCLUSION: COVID-19 pandemic has a high prevalence of anxiety, depression, and insomnia among HCWs. Female gender, frontliners, self-COVID-19, and absence of social or emotional support are the independent risk factors for psychological distress. HOW TO CITE THIS ARTICLE: Jagiasi BG, Chanchalani G, Nasa P, Tekwani S. Impact of COVID-19 Pandemic on the Emotional Well-being of Healthcare Workers: A Multinational Cross-sectional Survey. Indian J Crit Care Med 2021;25(5):499-506.

Incidence and Etiology of Potentially Preventable ICU Readmissions.

OBJECTIVES: The rate of unplanned ICU readmissions is often considered a measure of hospital performance. However, the degree to which these readmissions are preventable and the causes of preventable readmissions are unknown, creating uncertainty about the feasibility and value of reducing ICU readmission rates. To inform this issue, we sought to determine the frequency and underlying causes of potentially preventable ICU readmissions. DESIGN: Retrospective cohort study. SETTING: Urban, academic medical center in the mid-Atlantic United States. PATIENTS: Adult patients discharged alive from their first ICU admission with an unplanned readmission within 48 hours of discharge. MEASUREMENTS AND MAIN RESULTS: Each patient's medical chart was reviewed by two independent investigators who rated each readmission's preventability according to standardized scale and assessed the etiology of both preventable and nonpreventable readmissions. We assessed concordance between raters using the κ statistic and resolved disagreements through iterative discussion. Of 136 readmissions in the final analysis, 16 (11.8%; 95% CI, 6.9-18.4) were considered preventable and 120 (88.2%; 95% CI, 81.5-93.1) were considered nonpreventable. Of nonpreventable readmissions, 67 were due to a new clinical problem and 53 were due to an existing clinical problem. Among preventable readmissions, six were attributable to system errors, six were attributable to management errors, two were attributable to procedural events, one was attributable to a diagnostic error, and one was attributable to a medication error. Compared to nonpreventable readmissions, preventable readmissions tended to have shorter index ICU lengths of stay (2 vs 3 d; p = 0.05) and a shorter duration of time on the ward prior to readmission (16.6 vs 23.6 hr; p = 0.05). CONCLUSIONS: The majority of early ICU readmissions are nonpreventable, raising important concerns about ICU readmission rates as a measure of hospital performance.

Mild antecedent COVID-19 associated with symptom-specific post-acute sequelae.

BACKGROUND: The impact of COVID-19 severity on development of long-term sequelae remains unclear, and symptom courses are not well defined. METHODS: This ambidirectional cohort study recruited adults with new or worsening symptoms lasting ≥3 weeks from confirmed SARS-CoV-2 infection between August 2020-December 2021. COVID-19 severity was defined as severe for those requiring hospitalization and mild for those not. Symptoms were collected using standardized questionnaires. Multivariable logistical regression estimated odds ratios (OR) and 95% confidence intervals (CI) for associations between clinical variables and symptoms. RESULTS: Of 332 participants enrolled, median age was 52 years (IQR 42-62), 233 (70%) were female, and 172 (52%) were African American. Antecedent COVID-19 was mild in 171 (52%) and severe in 161 (48%). In adjusted models relative to severe cases, mild COVID-19 was associated with greater odds of fatigue (OR:1.83, CI:1.01-3.31), subjective cognitive impairment (OR:2.76, CI:1.53-5.00), headaches (OR:2.15, CI:1.05-4.44), and dizziness (OR:2.41, CI:1.18-4.92). Remdesivir treatment was associated with less fatigue (OR:0.47, CI:0.26-0.86) and fewer participants scoring >1.5 SD on PROMIS Cognitive scales (OR:0.43, CI:0.20-0.92). Fatigue and subjective cognitive impairment prevalence was higher 3-6 months after COVID-19 and persisted (fatigue OR:3.29, CI:2.08-5.20; cognitive OR:2.62, CI:1.67-4.11). Headache was highest at 9-12 months (OR:5.80, CI:1.94-17.3). CONCLUSIONS: Mild antecedent COVID-19 was associated with highly prevalent symptoms, and those treated with remdesivir developed less fatigue and cognitive impairment. Sequelae had a delayed peak, ranging 3-12 months post infection, and many did not improve over time, underscoring the importance of targeted preventative measures.

Sepsis-induced cardiomyopathy is associated with higher mortality rates in patients with sepsis.

BACKGROUND: Patients with sepsis are at risk for developing sepsis-induced cardiomyopathy (SIC). Previous studies offer inconsistent results regarding the association of SIC and mortality. This study sought to assess whether SIC is linked to mortality in patients with sepsis and to evaluate predictors of the development of SIC. METHODS: In this retrospective study, patients admitted to the medical intensive care unit with a diagnosis of sepsis in the absence of acute coronary syndrome were included. SIC was identified using transthoracic echo and was defined by a new onset decline in left ventricular ejection fraction (LVEF) ≤50%, or ≥10% decline in LVEF compared to baseline in patients with a history of heart failure with reduced ejection fraction. Multivariable logistic regression analysis was performed using the R software program. RESULTS: Of the 359 patients in the final analysis, 19 (5.3%) had SIC. Eight (42.1%) of the 19 patients in the SIC group and 60 (17.6%) of the 340 patients in the non-SIC group died during hospitalization. SIC was associated with an increased risk for all-cause in-hospital mortality (odds ratio [OR], 4.46; 95% confidence interval [CI], 1.15-18.69; P=0.03). Independent predictors for the development of SIC were albumin level (OR, 0.47; 95% CI, 0.23-0.93; P=0.03) and culture positivity (OR, 8.47; 95% CI, 2.24-55.61; P=0.006). Concomitant right ventricular hypokinesis was noted in 13 (68.4%) of the 19 SIC patients. CONCLUSIONS: SIC was associated with an increased risk for all-cause in-hospital mortality. Low albumin level and culture positivity were independent predictors of SIC.

Remote Continuous Glucose Monitoring With a Computerized Insulin Infusion Protocol for Critically Ill Patients in a COVID-19 Medical ICU: Proof of Concept.

OBJECTIVE: The use of remote real-time continuous glucose monitoring (CGM) in the hospital has rapidly emerged to preserve personal protective equipment and reduce potential exposures during coronavirus disease 2019 (COVID-19). RESEARCH DESIGN AND METHODS: We linked a hybrid CGM and point-of-care (POC) glucose testing protocol to a computerized decision support system for continuous insulin infusion and integrated a validation system for sensor glucose values into the electronic health record. We report our proof-of-concept experience in a COVID-19 intensive care unit. RESULTS: All nine patients required mechanical ventilation and corticosteroids. During the protocol, 75.7% of sensor values were within 20% of the reference POC glucose with an associated average reduction in POC of 63%. Mean time in range (70-180 mg/dL) was 71.4 ± 13.9%. Sensor accuracy was impacted by mechanical interferences in four patients. CONCLUSIONS: A hybrid protocol integrating real-time CGM and POC is helpful for managing critically ill patients with COVID-19 requiring insulin infusion.

Attenuation of endocrine-exocrine pancreatic communication in type 2 diabetes: pancreatic extracellular matrix ultrastructural abnormalities.

Ultrastructural observations reveal a continuous interstitial matrix connection between the endocrine and exocrine pancreas, which is lost due to fibrosis in rodent models and humans with type 2 diabetes mellitus (T2DM). Widening of the islet-exocrine interface appears to result in loss of desmosomes and adherens junctions between islet and acinar cells and is associated with hypercellularity consisting of pericytes and inflammatory cells in T2DM pancreatic tissue. Organized fibrillar collagen was closely associated with pericytes, which are known to differentiate into myofibroblasts-pancreatic stellate cells. Of importance, some pericyte cellular processes traverse both the connecting islet-exocrine interface and the endoacinar interstitium of the exocrine pancreas. Loss of cellular paracrine communication and extracellular matrix remodeling fibrosis in young animal models and humans may result in a dysfunctional insulino-acinar-ductal-incretin gut hormone axis, resulting in pancreatic insufficiency and glucagon-like peptide deficiency, which are known to exist in prediabetes and overt T2DM in humans.