No abstract

The efficacy of convalescent plasma for coronavirus disease 2019 (COVID-19) is unclear. Although most randomized controlled trials have shown negative results, uncontrolled studies have suggested that the antibody content could influence patient outcomes. We conducted an open-label, randomized controlled trial of convalescent plasma for adults with COVID-19 receiving oxygen within 12 d of respiratory symptom onset (NCT04348656). Patients were allocated 2:1 to 500 ml of convalescent plasma or standard of care. The composite primary outcome was intubation or death by 30 d. Exploratory analyses of the effect of convalescent plasma antibodies on the primary outcome was assessed by logistic regression. The trial was terminated at 78% of planned enrollment after meeting stopping criteria for futility. In total, 940 patients were randomized, and 921 patients were included in the intention-to-treat analysis. Intubation or death occurred in 199/614 (32.4%) patients in the convalescent plasma arm and 86/307 (28.0%) patients in the standard of care arm—relative risk (RR) = 1.16 (95% confidence interval (CI) 0.94–1.43, P = 0.18). Patients in the convalescent plasma arm had more serious adverse events (33.4% versus 26.4%; RR = 1.27, 95% CI 1.02–1.57, P = 0.034). The antibody content significantly modulated the therapeutic effect of convalescent plasma. In multivariate analysis, each standardized log increase in neutralization or antibody-dependent cellular cytotoxicity independently reduced the potential harmful effect of plasma (odds ratio (OR) = 0.74, 95% CI 0.57–0.95 and OR = 0.66, 95% CI 0.50–0.87, respectively), whereas IgG against the full transmembrane spike protein increased it (OR = 1.53, 95% CI 1.14–2.05). Convalescent plasma did not reduce the risk of intubation or death at 30 d in hospitalized patients with COVID-19. Transfusion of convalescent plasma with unfavorable antibody profiles could be associated with worse clinical outcomes compared to standard care.

Educational initiatives incorporating systematic management protocols with nonpharmacologic measures and individualized titration of sedation, analgesia, and delirium therapies are associated with better outcomes.

No abstract

BackgroundTotal joint replacement procedures are increasing in number because of population aging and osteoarthritis development. Defined as a lack of physiological reserves and the inability to adequately respond to external stressors, frailty may be more common than expected in older patients with degenerative arthritis awaiting total joint replacements.The aim of the present study was to assess associations between frailty and adverse outcomes, frailty prevalence among elderly patients awaiting elective TJR, and agreement between 2 frailty screening instruments.MethodsWe undertook a prospective, observational, pilot study in our institution. We enrolled patients 65 years or older who were awaiting elective knee or hip replacement surgery and evaluated them in our preoperative clinic with planned postoperative hospital length of stay greater than 24 h. Patients were asked to grade their perceived well-being on the Clinical Frailty Scale and to answer questions on the FRAIL Scale.ResultsThe Clinical Frailty Scale classified 40 patients (45.9%) as robust, 43 patients (49.4%) as prefrail and 4 patients (4.5%) as frail, while the FRAIL Scale categorized 12 patients (13.7%) as robust, 54 patients (62.0%) as prefrail, and 20 patients (22.9%) as frail. Robustness, ascertained on the Clinical Frailty Scale was, while the FRAIL Scale was not, significantly associated with shorter hospital length of stay and fewer discharges to the rehabilitation center. Both scales showed moderate mutual agreement.ConclusionScreening for frailty identified between 5% and 10% of patients at risk of adverse outcomes. The Clinical Frailty Scale was, while the FRAIL scale was not, significantly associated with hospital length of stay and discharge to rehabilitation center in our cohort of total joint replacement patients.

These results indicate that cytoplasmic accumulation of MNDA facilitates progression of apoptosis and suggest that impaired cytoplasmic MNDA accumulation contributes to delayed neutrophil apoptosis in patients with severe sepsis.

Educational strategies aimed at changing residents' knowledge, skills and attitude should address the hidden curriculum for the patient EOL decision-making process that is part of the experienced culture of every day practice. Future studies of this experienced culture would inform specific educational interventions.

In order to improve the understanding of educational needs among residents caring for the critically ill, narrative accounts of 19 senior physician trainees participating in level of care decision-making were analyzed. In this multicentre qualitative study involving 9 university centers in Canada, in-depth interviews were conducted in either English or French, and the transcripts then underwent a hermeneutic phenomenological analysis. The resident was the central figure in the narrated incident, along with the patients' relatives and other attending physicians. The vast majority of interviews recounted negative experiences that involved delivering bad news to patients' families and managing difficult communications with them and with physician colleagues. Emotional distress and suffering were often part of their decision-making process. Narrating their experiences was viewed as a positive event. Data analysis uncovered 6 general themes that were organized into 2 categories, the first one grouping together themes related to interactions with the patients' families and the second comprising themes related to interactions with physician coworkers. The findings suggest that physician trainees' narratives are a rich source of data regarding what constitutes meaningful training experiences and what they learn from them. Educational approaches that incorporate the telling of stories would allow students to express their feelings, doubts, and opinions about their work experiences and could thus foster personal and emotional learning in critical care.