Nevin Manimala

N Engl J Med. 2021 Feb 25. doi: 10.1056/NEJMoa2100433. Online ahead of print.

ABSTRACT

BACKGROUND: The efficacy of interleukin-6 receptor antagonists in critically ill patients with coronavirus disease 2019 (Covid-19) is unclear.

METHODS: We evaluated tocilizumab and sarilumab in an ongoing international, multifactorial, adaptive platform trial. Adult patients with Covid-19, within 24 hours after starting organ support in the intensive care unit (ICU), were randomly assigned to receive tocilizumab (8 mg per kilogram of body weight), sarilumab (400 mg), or standard care (control). The primary outcome was respiratory and cardiovascular organ support-free days, on an ordinal scale combining in-hospital death (assigned a value of -1) and days free of organ support to day 21. The trial uses a Bayesian statistical model with predefined criteria for superiority, efficacy, equivalence, or futility. An odds ratio greater than 1 represented improved survival, more organ support-free days, or both.

RESULTS: Both tocilizumab and sarilumab met the predefined criteria for efficacy. At that time, 353 patients had been assigned to tocilizumab, 48 to sarilumab, and 402 to control. The median number of organ support-free days was 10 (interquartile range, -1 to 16) in the tocilizumab group, 11 (interquartile range, 0 to 16) in the sarilumab group, and 0 (interquartile range, -1 to 15) in the control group. The median adjusted cumulative odds ratios were 1.64 (95% credible interval, 1.25 to 2.14) for tocilizumab and 1.76 (95% credible interval, 1.17 to 2.91) for sarilumab as compared with control, yielding posterior probabilities of superiority to control of more than 99.9% and of 99.5%, respectively. An analysis of 90-day survival showed improved survival in the pooled interleukin-6 receptor antagonist groups, yielding a hazard ratio for the comparison with the control group of 1.61 (95% credible interval, 1.25 to 2.08) and a posterior probability of superiority of more than 99.9%. All secondary analyses supported efficacy of these interleukin-6 receptor antagonists.

CONCLUSIONS: In critically ill patients with Covid-19 receiving organ support in ICUs, treatment with the interleukin-6 receptor antagonists tocilizumab and sarilumab improved outcomes, including survival. (REMAP-CAP ClinicalTrials.gov number, NCT02735707.).

PMID:33631065 | DOI:10.1056/NEJMoa2100433

Pediatr Pulmonol. 2021 Feb 25. doi: 10.1002/ppul.25313. Online ahead of print.

ABSTRACT

PURPOSE: First, to investigate the added diagnostic value of chest computed tomography (CT) for evaluating COVID-19 in symptomatic children by comparing chest CT findings with chest radiographic findings, and second, to identify the imaging signs and patterns on CT associated with COVID-19 pneumonia in children.

MATERIALS AND METHODS: From March 2020 to December 2020, 56 consecutive children (33 males and 23 girls; mean age ± SD, 14.8 ± 5.0 years; range, 9 months-18 years) with mild to moderate symptom and laboratory confirmed COVID-19 (based on Centers for Disease Control criteria) underwent both chest radiography and chest CT on the same day within the first 2 days of initial presentation to the hospital. Two experienced radiologists independently evaluated chest radiographs and chest CT studies for thoracic abnormalities. The findings from chest radiography and chest CT were compared to evaluate the added diagnostic value of chest CT for affecting patient management. Interobserver agreement was measured with Cohen’s κ statistics.

RESULTS: Eleven (19.6%) of 56 patients had abnormal chest radiographic findings, including ground-glass opacity (GGO) in 5/11 (45.4%) and combined GGO and consolidation in 6/11 (54.5%). On chest CT, 26 (46.4%) of 56 patients had abnormal CT findings, including combined GGO and consolidation in 19/26 (73.1%), GGO in 6/26 (23.1%), and consolidation in 1/26 (3.8%). Chest CT detected all thoracic abnormalities seen on chest radiography in 11/26 (42.3%) cases. In 15/26 (57.7%), chest CT detected lung abnormalities that were not observed on chest radiography, which included GGO and consolidation in 9/15 (60%), GGO in 5/15 (33.3%), and consolidation in 1/15 (6.6%) cases. These additional CT findings did not affect patient management. In addition, chest CT detected radiological signs and patterns, including the halo sign, reversed halo sign, crazy paving pattern, and tree-in-bud pattern. There was almost perfect interobserver agreement between the two reviewers for detecting findings on both chest radiographs (κ, 0.89, p = .001) and chest CT (κ, 0.96, p = .001) studies.

CONCLUSION: Chest CT detected lung abnormalities, including GGO and/or consolidation, that were not observed on chest radiography in more than half of symptomatic pediatric patients with COVID-19 pneumonia. However, these additional CT findings did not affect patient management. Therefore, CT is not clinically indicated for the initial evaluation of mild to moderately symptomatic pediatric patients with COVID-19 pneumonia.

PMID:33631061 | DOI:10.1002/ppul.25313

J Contin Educ Nurs. 2021 Mar 1;52(3):118-122. doi: 10.3928/00220124-20210216-05.

ABSTRACT

BACKGROUND: Many people view escape rooms as challenging and fun. They require teams to communicate and work together effectively to solve puzzles to unlock the door to escape. Health care educators have recently used this dynamic format to provide teams with an engaging teaching modality. This article details the case study of combining an escape room with simulation-based education to form a dynamic teaching modality on proper cardiac arrest management.

METHOD: A group of nearly 70 nurses participated. This study uses a pretest-posttest to measure learning, a skills checklist to measure performance, and an evaluation to measure students’ reactions.

RESULTS: Results showed statistically significant increases in nurses’ code policy knowledge and response. Participants viewed this education as effective and fun.

CONCLUSION: This study provided evidence of the teaching effectiveness of escape rooms and is a solid springboard for future researchers to conduct additional simulation-based escape rooms with larger, broader populations. [J Contin Educ Nurs. 2021;52(3):118-122.].

PMID:33631021 | DOI:10.3928/00220124-20210216-05

Endocrinology. 2021 Feb 25:bqab043. doi: 10.1210/endocr/bqab043. Online ahead of print.

ABSTRACT

PURPOSE: The objectives of this study were to analyze the distribution of Dual oxidase (DUOX) system genes (containing DUOX2, DUOX1, DUOXA2 and DUOXA1) variants in children with congenital hypothyroidism and their phenotypes.

METHODS: Target region sequencing technology was performed on DUOX system genes among 606 congenital hypothyroidism (CH) subjects covering all the exon and intron regions. Detailed clinical data were collected for statistical analysis.

RESULTS: A total of 95 suspected pathogenic variants were detected in the DUOX system genes, showing a 39.11% rate in variant carrying (237/606). DUOX2 was with the highest rate in this study. There were statistical difference in maximum adjusted dose and current dose of L-T4 between the DUOX system genes non-mutated group with the mutated group (p<0.001; p<0.001). The cases in DUOX system genes mutated group were more likely to develop into transient CH (χ 2 = 23.155, p<0.001) and more likely to manifested as goiter or gland-in-situ (χ 2 = 66.139, p<0.001). In addition, there was no significant difference in clinical characteristics between DUOX system genes mono-allelic and non mono-allelic. Although 20% of the variants affected the functional domain regions (EF hand, and FAD and NADPH binding sites), there was no significant effect on the phenotype severity whether the variation is located in the functional domain regions.

CONCLUSIONS: Our results showed the high variation rate of DUOX2 in the DUOX system genes among the Chinese CH patients. And the complex genotype-phenotype relationship of DUOX system genes broadened the understanding of CH phenotype spectrum.

PMID:33631011 | DOI:10.1210/endocr/bqab043

Nicotine Tob Res. 2021 Feb 25:ntab033. doi: 10.1093/ntr/ntab033. Online ahead of print.

ABSTRACT

INTRODUCTION: There is limited research on the role of flavors in nicotine vaping products (NVPs) in relation to smoking. We examined patterns of flavor use in NVPs in relation to progression towards quitting.

METHODS: Data come from 886 concurrent users of NVPs (at least weekly) and cigarettes who were first surveyed in 2016 and then successfully recontacted in 2018 as part of the ITC 4CV Surveys conducted in Australia, Canada, England and the United States. Participants were asked about their main vaping flavor categorized as: 1) tobacco or unflavored, 2) menthol/mint flavored, and 3) “sweet” flavors (e.g., fruit/candy). We examined whether flavor was associated with progression towards quitting smoking between survey years.

RESULTS: Overall, 11.1% of baseline concurrent users quit smoking by 2018. Compared to users of tobacco flavors, those vaping “sweet” flavors were more likely to quit smoking between surveys (13.8% vs. 9.6%; adjusted OR=1.61, 95% CI 1.01-2.58, p<0.05), but those using menthol flavors were no more likely to quit smoking (8.3% vs. 9.6%, aOR=0.87, 95% CI 0.43-1.47, p=0.69). Among those who had quit smoking in 2018, 52.0% were still vaping, which was lower than the 65.8% among continuing smokers (aOR=0.60, 95% CI 0.39-0.92, p=0.02). Sweet flavor users were no more likely to continue vaping compared to tobacco flavor users, either for those continuing smoking or those having quit smoking by 2018. There was a net shift away from tobacco flavor among those who continued to vape at follow-up.

CONCLUSIONS: Use of fruit and other sweet flavored e-liquids is positively related to smokers’ transition away from cigarettes.

IMPLICATIONS: With multiple jurisdictions considering limiting or banning the sale of flavored NVPs, it is important to consider how such policies may impact smokers using NVPs to transition away from cigarette smoking. Our results indicate that vapers who used sweet flavors were more likely to transition away from cigarette smoking and quit cigarette use, at least in the short term, compared to those who used tobacco or unflavored NVPs. Randomized clinical trials are needed to establish if the observed association between use of flavored e-liquids and smoking cessation is due to self-selection or is truly causal.

PMID:33631007 | DOI:10.1093/ntr/ntab033

Neuro Oncol. 2021 Feb 25:noab049. doi: 10.1093/neuonc/noab049. Online ahead of print.

ABSTRACT

BACKGROUND: Gliomas manifest in a variety of histological phenotypes with varying aggressiveness. The etiology of glioma remains largely unknown. Taller stature in adulthood has been linked with glioma risk. The aim of this study was to discern whether this association can be detected in adolescence.

METHODS: The cohort included 2,223,168 adolescents between the ages of 16-19. Anthropometric measurements were collected at baseline. Incident cases of glioma were extracted from the Israel National Cancer Registry over a follow-up period spanning 47,635,745 person-years. Cox proportional hazard models were used to estimate the hazard ratio for glioma and glioma subtypes according to height, body mass index (BMI) and sex.

RESULTS: 1,195 patients were diagnosed with glioma during the study period. Mean(SD) age at diagnosis was 38.1 (11.7) years. Taller adolescent height (per 10cm increase) was positively associated with the risk for glioma of any type (HR 1.15; p=0.002). The association was retained in subgroup analyses for low-grade glioma (HR 1.17; p=0.031), high-grade glioma (HR 1.15; p=0.025), oligodendroglioma (HR 1.31; p=0.015), astrocytoma (HR 1.12; p=0.049), and a category of presumed IDH-mutated glioma (HR 1.17; p=0.013). There was a trend towards a positive association between height and glioblastoma, however this had borderline statistical significance (HR: 1.15; p=0.07). After stratification of the cohort by sex, height remained a risk factor for men, but not for women.

CONCLUSIONS: The previously – established association between taller stature in adulthood and glioma risk can be traced back to adolescence. The magnitude of association differs by glioma subtype.

PMID:33631004 | DOI:10.1093/neuonc/noab049

PLoS One. 2021 Feb 25;16(2):e0247459. doi: 10.1371/journal.pone.0247459. eCollection 2021.

ABSTRACT

BACKGROUND: Effective management of the vaccine cold chain system at all levels is one of the crucial factors for maintaining vaccine potency. Vaccines require more complex handling and storage requirements due to increased temperature sensitivity and complicated immunization schedules. This urges adequate knowledge, attitude, and practice. This study assessed the knowledge, attitude, and practice of vaccinators and vaccine handlers’ in public health facilities.

METHODOLOGY: An institutional-based cross-sectional study design was used to assess the knowledge, attitude, and practice of 127 vaccinators and vaccine handlers in public health facilities of Oromia Special Zone, from September 1 to 30, 2019. Data were collected using self-administered questionnaires and a structured observation checklist. Descriptive and inferential statistics were made using the statistical package for social sciences version 20. Variables with a p-value <0.05 were taken as statistically significant.

RESULT: The response rate was (96.94%). Sixty-eight (53.5%; 95% CI: 46.5%, 61.4%), 58 (45.7%; 95% CI: 37.8%, 53.5%) and 62 (48.8%: 95% CI; 41.7%, 56.7%) vaccinators and vaccine handlers had satisfactory knowledge, positive attitude and good practice respectively. Receiving training on cold chain management had a statistically significant association with the level of knowledge on cold chain management (AOR = 3.04, 95% CI: 1.04-8.88).

CONCLUSIONS: More than half of vaccinators and vaccine handlers had satisfactory knowledge, while below half of vaccinators and vaccine handlers had a positive attitude and good practice. The determinants of knowledge in cold chain management were receiving training on cold chain management. Providing regular technical support and on the job training on vaccine cold chain management will improve the knowledge, attitude, and practice of vaccinators and vaccine handlers.

PMID:33630946 | DOI:10.1371/journal.pone.0247459

PLoS One. 2021 Feb 25;16(2):e0247544. doi: 10.1371/journal.pone.0247544. eCollection 2021.

ABSTRACT

Six common beliefs about the usage of active learning in introductory STEM courses are investigated using survey data from 3769 instructors. Three beliefs focus on contextual factors: class size, classroom setup, and teaching evaluations; three focus on individual factors: security of employment, research activity, and prior exposure. The analysis indicates that instructors in all situations can and do employ active learning in their courses. However, with the exception of security of employment, trends in the data are consistent with beliefs about the impact of these factors on usage of active learning. We discuss implications of these results for institutional and departmental policies to facilitate the use of active learning.

PMID:33630945 | DOI:10.1371/journal.pone.0247544

PLoS One. 2021 Feb 25;16(2):e0247634. doi: 10.1371/journal.pone.0247634. eCollection 2021.

ABSTRACT

BACKGROUND: Diabetes is one of the most prevalent non-communicable diseases globally, which rapidly is increasing in developing countries. Ethiopia is also facing growing morbidity and mortality related to diabetes complications. Thus, dealing with glycemic control is essential for controlling the development of devastating acute and chronic complications related to diabetes. Therefore, this study aims to assess the magnitude and predictors of poor glycemic control among diabetic patients in western Ethiopia.

METHODS: The cross-sectional study design was employed on a sample of 423 diabetic patients. A systematic random sampling method was employed. An interviewer-administered structured questionnaire was used. The data entered into Epi data version 3.1 and exported into Statistical Package for the Social Sciences window version 24 for analysis. All variables significant at p-<0.25 in bivariate were entered into multivariate analysis. The multivariable logistic regressions were used to determine predictors’ poor glycemic control by considering the Adjusted Odds Ratio at CI 95% and the significance level was set at p <0.05.

RESULTS: The magnitude of poor glycemic control was 64.1%. Being females (AOR = 1.684,95%CI = 1.066,2.662), duration of diabetes >8years (AOR = 2.552,95%CI = 1.397, 4.665), presence of diabetes complication (AOR = 2.806,95%CI = 1.594,4.941), negligence of blood glucose test at home (AOR = 1.720, 95%CI = 1.078, 2.743), poor self-care behavior (AOR = 1.787, 95%CI = 1.083,2.959) and poor self-efficacy (AOR = 1.934, 95%CI = 1.078,3.469) were significant predictors of poor glycemic control.

CONCLUSION: The proportion of poor glycemic control was high which was nearly comparable to that reported from many countries. This could be due to factors that were significantly associated with poor glycemic control like lack of home blood glucose test, increased duration of diabetes, presence of diabetes complications, poor self-efficacy, and poor self-care behaviors. Each were significant independent predictors of poor glycemic control. Thus, we recommend patients with diabetes and health care providers enhancing self-monitoring practices, and preventing potential complications should be a priority concern to improve blood glucose levels. Further studies are also recommended to explore important factors which were not identified by the current study.

PMID:33630936 | DOI:10.1371/journal.pone.0247634

PLoS One. 2021 Feb 25;16(2):e0247499. doi: 10.1371/journal.pone.0247499. eCollection 2021.

ABSTRACT

INTRODUCTION: Medicines used at Danish public hospitals are purchased through tendering. Together with drug shortage, tendering result in drug changes, known to compromise patient safety, increase medicine errors and to be resource demanding for healthcare personnel. Details on actual resources required in the clinic setting to manage drug changes are unknown. The aim of the study is to explore time spend by hospital personnel in a drug change situation when dispensing medicine to in- and outpatients in a hospital setting in the Capital Region of Denmark.

METHOD: A time and motion study, using direct observation combined with time-registration tools, such as eye-tracking, video recording and manual time tracking. Data were obtained from observing nurses and social and health care assistants with dispensing authority while dispensing or extraditing medicine before and after the implementation of drug changes in two clinical setting; a cardiology ward and a rheumatology outpatient clinic.

RESULTS: Hospital personnel at the cardiology inpatient ward spent 20.5 seconds on dispensing a drug, which was increased up to 28.4 seconds by drug changes. At the rheumatology outpatient clinic, time to extradite medicine increased from 8 minutes and 6 seconds to 15 minutes and 36 seconds by drug changes due to tender. Similarly, drug changes due to drug shortage prolonged the extradition time to 16 minutes and 54 seconds. Statistical analysis reveal that drug changes impose a significant increase in time to dispense a drug for both in- and outpatients.

CONCLUSION: Clinical hospital personnel spent significantly longer time on drug change situations in the dispensing of medicine to in- and outpatients in a hospitals. This study emphasizes that implementing drug changes do require extra time, thus, the hospital management should encounter this and ensure that additional time is available for the hospital personnel to ensure a safe drug dispensing process.

PMID:33630933 | DOI:10.1371/journal.pone.0247499