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Objective To determine whether disrupting the renin angiotensin system with angiotensin receptor blockers will improve clinical outcomes in people with covid-19. Design CLARITY was a pragmatic, adaptive, multicentre, phase 3, randomised controlled trial. Setting 17 hospital sites in India and Australia. Participants Participants were at least 18 years old, previously untreated with angiotensin receptor blockers, with a laboratory confirmed diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection who had been admitted to hospital for management of covid-19. Intervention Oral angiotensin receptor blockers (telmisartan in India) or placebo (1:1) for 28 days. Main outcome measures The primary endpoint was covid-19 disease severity using a modified World Health Organization Clinical Progression Scale (WHO scale) at day 14. Secondary outcomes were WHO scale scores at day 28, mortality, intensive care unit admission, and respiratory failure. Analyses were evaluated on an ordinal scale in the intention-to-treat population. Results Between 3 May 2020 and 13 November 2021, 2930 people were screened for eligibility, with 393 randomly assigned to angiotensin receptor blockers (of which 388 (98.7%) to telmisartan 40 mg/day) and 394 to the control group. 787 participants were randomised: 778 (98.9%) from India and nine (1.1%) from Australia. The median WHO scale score at day 14 was 1 (interquartile range 1-1) in 384 participants assigned angiotensin receptor blockers and 1 (1-1) in 382 participants assigned placebo (adjusted odds ratio 1.51 (95% credible interval 1.02 to 2.23), probability of an odds ratio of >1 (Pr(OR>1)=0.98). WHO scale scores at day 28 showed little evidence of difference between groups (1.02 (0.55 to 1.87), Pr(OR>1)=0.53). The trial was stopped when a prespecified futility rule was met. Conclusions In patients admitted to hospital for covid-19, mostly with mild disease, not requiring oxygen, no evidence of benefit, based on disease severity score, was found for treatment with angiotensin receptor blockers, using predominantly 40 mg/day of telmisartan. Trial registration ClinicalTrials.gov NCT04394117 .

Background:Recurrent shoulder dislocation and anterior instability are most commonly attributed to pathology of the capsulolabral complex with the presence of bony loss at the humeral and glenoid surfaces. Unassessed bone loss has been a cause of failure of primary soft tissue procedures or recurrence of symptoms, despite adequate address of soft tissue pathology.Purpose:To study the anthropometric and radiologic dimensions of the coracoid in relation to glenoid bone loss, its adequacy in filling glenoid defects in an Indian population, and whether the choice of surgical technique (congruent arc vs classical) and graft positioning alters the surgical results. This study also intended to establish whether computed tomography measurements correlate with actual anthropometric measurements.Study Design:Cross-sectional study; Level of evidence, 3.Methods:A total of 64 participants with 108 healthy shoulders were included in this study. Additionally, 100 skeletally mature bone specimens of the scapula were measured to assess glenoid diameter as well as coracoid width and length in 2 perpendicular planes with a humeral subtraction 3-dimensional en face glenoid view.Results:Specimen and participant measurements proved that the congruent arc technique was able to fill up to 50% more glenoid bone loss than the classical technique in an Indian population (mean ± SD, 13.45 ± 6.97 vs 7.96 ± 4.89 mm, respectively), with computed tomography being the best and most accurate modality to study it. The mean difference in the bone block length restoration of the glenoid bony arc was 5.41 ± 2.08 mm. Radii of curvature were congruent in populations of the Indian subcontinent.Conclusion:The congruent arc technique can be performed in an Indian population but with caution and careful presurgical assessment of bone loss. However, adequate coracoid dimension to accommodate the implant for fixation without failure must be ensured, as anthropometry suggests the existence of a subset of the population in whom the graft may have compromised width for accommodating standard implants for fixation.

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High-flow nasal oxygen therapy warms and humidifies gases, allows better clearance of secretions, along with providing added benefits like preventing dehydration of airway surface, while decreasing atelectasis and thereby, offering comfort to the patient. While its effect on critically ill patients is still in its pioneering phase, there is lack of substantial evidence on the use of high-flow nasal cannula in cardiac patients with type I respiratory failure. We found it worthwhile to share our experience of its use in elderly and postpartum patients with moderate-to-severe pulmonary hypertension, with associated comorbidities and type I respiratory failure, with do-not-intubate or defer intubation status. In patients with pulmonary hypertension (PHT) and respiratory failure, endotracheal intubation followed by initiation of mechanical ventilation may have detrimental hemodynamic effects. Increase in lung volumes and decrease in functional residual capacity lead to increase in pulmonary hypertension and right ventricle afterload. If a patient has right heart failure, lung hyperinflation can fatally reduce cardiac output. High-flow nasal oxygen therapy may be of an advantage in these scenarios.How to cite this article: Gupta B, Kerai S, Kakkar K, Gupta L. Role of High-flow Nasal Oxygen Therapy in Cases with Pulmonary Hypertension in an Intensive Care Unit Setting. Indian J Crit Care Med 2019;23(10):458–461.

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