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IntroductionAcute respiratory distress syndrome (ARDS) is the major cause of mortality in patients with SARS-CoV-2 pneumonia. It appears that development of ‘cytokine storm’ in patients with SARS-CoV-2 pneumonia precipitates progression to ARDS. However, severity scores on admission do not predict severity or mortality in patients with SARS-CoV-2 pneumonia. Our objective was to determine whether patients with SARS-CoV-2 ARDS are clinically distinct, therefore requiring alternative management strategies, compared with other patients with ARDS. We report a single-centre retrospective study comparing the characteristics and outcomes of patients with ARDS with and without SARS-CoV-2.MethodsTwo intensive care unit (ICU) cohorts of patients at the Queen Elizabeth Hospital Birmingham were analysed: SARS-CoV-2 patients admitted between 11 March and 21 April 2020 and all patients with community-acquired pneumonia (CAP) from bacterial or viral infection who developed ARDS between 1 January 2017 and 1 November 2019. All data were routinely collected on the hospital’s electronic patient records.ResultsA greater proportion of SARS-CoV-2 patients were from an Asian ethnic group (p=0.002). SARS-CoV-2 patients had lower circulating leucocytes, neutrophils and monocytes (p<0.0001), but higher CRP (p=0.016) on ICU admission. SARS-CoV-2 patients required a longer duration of mechanical ventilation (p=0.01), but had lower vasopressor requirements (p=0.016).DiscussionThe clinical syndromes and respiratory mechanics of SARS-CoV-2 and CAP-ARDS are broadly similar. However, SARS-CoV-2 patients initially have a lower requirement for vasopressor support, fewer circulating leukocytes and require prolonged ventilation support. Further studies are required to determine whether the dysregulated inflammation observed in SARS-CoV-2 ARDS may contribute to the increased duration of respiratory failure.

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Objective Preoperative education empowers children to approach surgery with positive expectations, and providers need efficient, child-focused resources. This study aimed to evaluate an interactive pop-up book as a tool for explaining surgery, managing preoperative anxiety, and strengthening coping strategies. Study Design Prospective randomized controlled trial. Setting Pediatric outpatient surgery center. Methods Patients ages 5 to 12 undergoing outpatient surgery read a pop-up book about anesthesia (intervention) or received standard care (control). Patients self-reported their preoperative fear, pain expectations, views of the procedure and preoperative explanations, and coping strategies. Outcomes also included observer-rated behavioral anxiety and caregiver satisfaction. Results In total, 148 patients completed the study. The pop-up book had a significant, large effect in reducing patients’ fear of anesthesia induction (Cohen’s d effect size = 0.94; P < .001). Intervention patients also expected less pain than control patients from the anesthesia mask and during surgery ( d = 0.60-0.80; P < .001). The book encouraged more positive views of the procedure and preoperative explanations ( P < .005). Furthermore, the book prepared patients to cope adaptively: intervention patients were significantly more likely to generate positive active coping strategies, distraction strategies, and support-seeking strategies ( P < .001). Observer-rated behavioral anxiety at anesthesia induction did not differ between groups ( P = .75). Caregivers in the intervention group were significantly more satisfied with each aspect of the surgical experience ( P≤ .02). Conclusion The educational pop-up book offers a child-focused resource that helps alleviate children’s preoperative fears, encourages positive coping, and improves caregivers’ perceptions of the experience. This study was registered at ClinicalTrials.gov (NCT04796077).

The SARS-CoV-2 pandemic has resulted in the development of various therapeutics to treat and prevent major complications related to the virus; pregnant patients are vulnerable to acquiring SARS-CoV-2 due to frequent contact with the healthcare setting. Despite publication of a plethora of case series and randomized control trials of SARS- CoV-2 therapeutics, few have addressed treatment in the pregnant population. To date, there have been no published review of therapeutics in the pregnant patient infected with SARS-CoV-2. We provide the first review of available treatments for SARS-CoV-2, various trials with inclusion and exclusion of the pregnant patients, and potential side effects of each treatment in the pregnant patient.

Current guidelines recommend triple antithrombotic therapy (TT) consisting of warfarin, aspirin, and a P2Y12 inhibitor following an anterior ST elevation myocardial infarction (STEMI) complicated by extensive wall motion abnormalities. This recommendation, however, is based on data collected before percutaneous coronary intervention (PCI) became the standard of care for the treatment of STEMI. We designed a retrospective study of patients who received PCI for anterior STEMI over an 8-year period to compare rates of thromboembolic and bleeding events between patients receiving dual antiplatelet therapy (DAPT) and those receiving TT, including warfarin. Patients were included if the predischarge echocardiogram showed extensive wall motion abnormality and an ejection fraction ≤35%. Patients with known left ventricular thrombus were excluded. A total of 124 patients met the criteria, with 80 patients in the DAPT group and 44 in the TT group. The median age was 58 years in the TT group and 64 years in the DAPT group (P < 0.04), with an average ejection fraction of 31%. Thromboembolic events occurred in 4 patients (5%) in the DAPT group compared with 3 patients (6.8%) in the TT group (P = 0.70). Bleeding occurred in 2 patients in the DAPT group and 4 patients in the TT group (2.5% in DAPT vs. 9.1% in TT group, P = 0.18). No differences in rates of clinical embolism or left ventricular thrombus were found. Our data support recent findings that warfarin may not be indicated for patients following PCI for anterior STEMI, even when significant wall motion abnormalities and reduced ejection fraction ≤35% are present.A cute thromboembolic events due to left ventricular thrombus (LVT) formation, particularly in patients with reduced ejection fraction (EF), remain a risk for patients surviving an anterior ST elevation myocardial infarction (STEMI) (1). Th e reported incidence of LVT formation and subsequent embolization varies based on the timing of the echocardiographic examination and the diagnostic, anticoagulation, and reperfusion strategies utilized in managing the initial presentation but is noted to range from 0 to as high as 86% (1-9). Warfarin as a prophylactic strategy is therefore utilized and suggested in guidelines based on data derived from pooled results of studies done before catheter-based treatment of STEMI was prominent (10, 11). A recent report by Le May et al has suggested that warfarin treatment might be unnecessary in patients managed by primary PCI and dual antiplatelet therapy (DAPT) (12). Th e potential adequacy of DAPT alone was also shown in a small study that showed no advantage to a triple therapy (TT) regimen involving aspirin, a P2Y12 inhibitor, and warfarin when compared with DAPT with aspirin and a P2Y12 inhibitor in preventing LVT and systemic embolism (13). Given the uncertain benefi t and known bleeding risk associated with TT (14), we conducted a retrospective analysis spanning 8 years to compare the rates of LVT formation and thromboembolic events in patients with STEMI with EF ≤35% mana...

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ARDS is the major cause of mortality in patients with SARS-CoV-2 pneumonia. We report a single-centre study comparing the characteristics of ARDS patients with and without SARS-CoV-2. A greater proportion of SARS-CoV-2 patients were from an Asian ethnic group (p=0.002). SARS-CoV-2 patients had lower circulating leukocytes, neutrophils and monocytes (p<0.0001), but higher CRP (p=0.016) on ICU admission. SARS-CoV-2 patients required a longer duration of mechanical ventilation (p=0.01), but had lower vasopressor requirements (p=0.016). While the clinical syndromes of SARS-CoV-2 and CAP-ARDS are similar, the dysregulated inflammation observed in SARS-CoV-2 may contribute to the increased duration of respiratory failure.