ImportanceHelmet noninvasive ventilation has been used in patients with COVID-19 with the premise that helmet interface is more effective than mask interface in delivering prolonged treatments with high positive airway pressure, but data about its effectiveness are limited.ObjectiveTo evaluate whether helmet noninvasive ventilation compared with usual respiratory support reduces mortality in patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia.Design, Setting, and ParticipantsThis was a multicenter, pragmatic, randomized clinical trial that was conducted in 8 sites in Saudi Arabia and Kuwait between February 8, 2021, and November 16, 2021. Adult patients with acute hypoxemic respiratory failure (n = 320) due to suspected or confirmed COVID-19 were included. The final follow-up date for the primary outcome was December 14, 2021.InterventionsPatients were randomized to receive helmet noninvasive ventilation (n = 159) or usual respiratory support (n = 161), which included mask noninvasive ventilation, high-flow nasal oxygen, and standard oxygen.Main Outcomes and MeasuresThe primary outcome was 28-day all-cause mortality. There were 12 prespecified secondary outcomes, including endotracheal intubation, barotrauma, skin pressure injury, and serious adverse events.ResultsAmong 322 patients who were randomized, 320 were included in the primary analysis, all of whom completed the trial. Median age was 58 years, and 187 were men (58.4%). Within 28 days, 43 of 159 patients (27.0%) died in the helmet noninvasive ventilation group compared with 42 of 161 (26.1%) in the usual respiratory support group (risk difference, 1.0% [95% CI, −8.7% to 10.6%]; relative risk, 1.04 [95% CI, 0.72-1.49]; P = .85). Within 28 days, 75 of 159 patients (47.2%) required endotracheal intubation in the helmet noninvasive ventilation group compared with 81 of 161 (50.3%) in the usual respiratory support group (risk difference, −3.1% [95% CI, −14.1% to 7.8%]; relative risk, 0.94 [95% CI, 0.75-1.17]). There were no significant differences between the 2 groups in any of the prespecified secondary end points. Barotrauma occurred in 30 of 159 patients (18.9%) in the helmet noninvasive ventilation group and 25 of 161 (15.5%) in the usual respiratory support group. Skin pressure injury occurred in 5 of 159 patients (3.1%) in the helmet noninvasive ventilation group and 10 of 161 (6.2%) in the usual respiratory support group. There were 2 serious adverse events in the helmet noninvasive ventilation group and 1 in the usual respiratory support group.Conclusions and RelevanceResults of this study suggest that helmet noninvasive ventilation did not significantly reduce 28-day mortality compared with usual respiratory support among patients with acute hypoxemic respiratory failure due to COVID-19 pneumonia. However, interpretation of the findings is limited by imprecision in the effect estimate, which does not exclude potentially clinically important benefit or harm.Trial RegistrationClinicalTrials.gov Identifier: NCT04477668
Background: Intensive care unit (ICU) patients with neurological impairments often require neuroimaging. However, the relative sensitivity of various imaging modalities of the brain has not yet been explored in this population. Methods: In this study, we compare the findings of CT and MRI scans in ICU patients to (1) identify the number and rate of clinically relevant lesion detected by MRI while missed by CT and vice versa and (2) determine specific lesion types for which CT versus MRI discrepancies exist. A review of medical records included CT and MRI reports of patients who underwent these procedures while they were patients in our ICUs between July 2004 and July 2009. MRI and CT were compared regarding their ability to detect clinically relevant abnormalities. Odds ratios with 95% confidence limits were calculated to compare diagnostic categories regarding the rate of discrepant MRI versus CT findings, followed by power analyses to estimate sample sizes necessary to allow for further testing in a larger trial. Results: MRI revealed clinically relevant additional abnormalities over CT in 129 of 136 patients (95%) that included the detection of additional finding for 15/27 hemorrhagic lesions (55.6%), 33/36 (92%) ischemic strokes, 19/27 (70%) traumatic lesions, 8/14 (57%) infections, 15/24 (62.5%) metabolic abnormalities, and all seven neoplasms. Odds ratio analysis revealed the added sensitivity of MRI to be greater for ischemic and neoplastic lesions than for trauma, metabolic-related abnormalities, infection, or hemorrhage. Conclusions: MRI is more sensitive than CT in identifying clinically meaningful lesions in at least a subset of ICU patients, regardless of pathology.RÉSUMÉ: Valeur ajoutée de l'IRM par rapport au CT du cerveau chez les patients hospitalisés à l'unité de soins intensifs. Contexte : Chez les patients présentant une atteinte neurologique, hospitalisés à l'unité de soins intensifs (USI), il est souvent nécessaire d'avoir recours à la neuroimagerie. Cependant, la sensibilité relative de différentes modalités d'imagerie du cerveau n'a encore jamais été explorée dans cette population de patients. Résultats : L'IRM a révélé des anomalies additionnelles significatives par rapport au CT chez 129/136 (95%) patients incluant la détection de constatations additionnelles chez 15/27 (55,6%) cas de lésions hémorragiques, 33/36 (92%) cas d'accidents vasculaires cérébraux ischémiques, 19/27 (70%) cas de lésions traumatiques, 8/14 (57%) cas d'infections, 15/24 (62,5%) cas d'anomalies métaboliques et chacun des 7 cas de néoplasies. L'analyse des rapports de cotes a montré que la plus grande sensibilité de l'IRM en faisait un examen supérieur pour les lésions ischémiques et les lésions néoplasiques que pour les lésions traumatiques, les anomalies métaboliques, les infections ou les hémorragies. Conclusions : L'IRM est plus sensible que le CT pour identifier des lésions significatives au point de vue clinique chez au moins un sous-groupe de patients de l'USI, quelle que soit la pathologie en cause.
Background: Recent attempts were made to identify early indicators of acute kidney injury (AKI) in order to accelerate treatment and hopefully improve outcomes. This study aims to assess the value of urinary neutrophil gelatinase-associated lipocalin (uNGAL) as a predictor of AKI, severe AKI, and the need for renal replacement therapy (RRT). Methods: We conducted a prospective study and included adults admitted to our intensive care unit (ICU) at King Abdulaziz University Hospital (KAUH), between May 2012 and June 2013, who had at least 1 major risk factor for AKI. They were followed up throughout their hospital stay to identify which potential characteristics predicted any of the above 3 outcomes. We collected information on patients’ age and gender, the Acute Physiology And Chronic Health Evaluation, version II (APACHE II) score, the Sepsis-Related Organ Failure Assessment (SOFA) score, serum creatinine and cystatin C levels, and uNGAL. We compared ICU patients who presented with any of the 3 outcomes with others who did not. Results: We included 75 patients, and among those 21 developed AKI, 18 severe AKI, and 17 required RRT. Bivariate analysis revealed intergroup differences for almost all clinical variables (e.g., patients with AKI vs. patients without AKI); while multivariate analysis identified mean arterial pressure as the only predictor for AKI (p < 0.001) and the SOFA score (p = 0.04) as the only predictor for severe AKI. For RRT, day 1 maximum uNGAL was the stronger predictor (p < 0.001) when compared to admission diagnosis (p = 0.014). Day 1 and day 2 maximum uNGAL levels were good and excellent predictors for future RRT, but only fair to good predictors for AKI and severe AKI. Conclusions: Maximum urine levels of uNGAL measured over the first and second 24 h of an ICU admission were highly accurate predictors of the future need for RRT, however less accurate at detecting early and severe AKI.
The COVID-19 pandemic emerged in late 2019. Previous research has shown a significant prevalence of burnout among physician trainees, with concern that the pandemic will increase burnout. We aimed to assess this risk among trainees at a large academic hospital. We performed a cross-sectional study during the pandemic using a survey that included the Maslach Burnout Inventory. The response rate was 94.7%. Among trainees, 58.5% changed their living arrangements to protect family. Psychological well-being was negatively affected in 81.7% and clinical performance in 64.3%; 13.8% were at high risk of burnout. Emotional exhaustion (EE) scores were high in 50% and depersonalization (DP) scores in 28.8%; a sense of personal accomplishment was low in 41.9%. Increased risk of burnout was associated with male gender and increased exposure to suspected COVID-19 cases. Risk of high EE correlated with an increased number of children and risk of high DP with male gender. High EE and DP score correlated with increased exposure to suspected and confirmed COVID-19 patients. Trainees who self-isolated to protect family were more likely to experience high DP and burnout. Trainees in surgical specialties were more likely to feel their clinical performance was negatively affected. The results suggest that a significant percentage of trainees are at high risk of burnout during the pandemic especially those that attempted self-isolation. Training programs should incorporate methods to maintain well-being and coping, including adequate time off between shifts. Future research should evaluate other aspects of trainee well-being in relation to self-isolation and/or changed living arrangements. Key words: Burnout, Medical education, pandemic, coronavirus, psychological wellbeing, medical residents
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