Prophylactic Intra-Aortic Balloon Counterpulsation in High Risk Cardiac Surgery: The PINBALL Pilot Multicentre, Registry-Linked, Randomised, Controlled Feasibility Trial

Background: Prophylactic intra-aortic balloon counterpulsation (IABC) is commonly used in selected patients undergoing coronary artery bypass graft (CABG) surgery, but definitive evidence is lacking. The aim of the multicentre PINBALL Pilot randomised controlled trial (RCT) was to assess the feasibility of performing a definitive trial to address this question. Methods: Patients listed for CABG surgery with impaired left ventricular function and at least one additional risk factor for postoperative low cardiac output syndrome were eligible for inclusion if the treating surgical team was uncertain as to the benefit of prophylactic IABC. The primary outcome of feasibility was based on exceeding a pre-specified recruitment rate, protocol compliance and follow-up. Results: The recruitment rate of 0.5 participants per site per month did not meet the feasibility threshold of two participants per site per month and the study was stopped early after enrolment of 24 out of the planned sample size of 40 participants. For 20/24 (83%) participants, preoperative IABC use occurred according to study assignment. Six (6)-month follow-up was available for all enrolled participants, [IABC 1 death (8%) vs. control 1 death (9%), p = 0.95]. Conclusion: The PINBALL Pilot recruitment rate was insufficient to demonstrate feasibility of a multicentre RCT of prophylactic IABC in high risk patients undergoing CABG surgery

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Cognitive impairment in intensive care unit patients: A pilot mixed-methods feasibility study exploring incidence and experiences for recovering patients

© 2018 Australian College of Critical Care Nurses Ltd Background: Despite improvements in survival after critical illness and intensive care unit (ICU) treatment, some recovering patients still face ongoing challenges. There are few investigations exploring the incidence, risk factors, and trajectory for cognitive impairment (CI) in former ICU patients in Australia. Objectives: To test the feasibility of a study protocol designed to ascertain the incidence and impact of CI during recovery from a critical illness. Methods: We conducted a mixed-methods longitudinal single-centre pilot study. Participants were adult patients mechanically ventilated for ≥48 h. Cognitive function was assessed during hospitalisation and at 1 week, 2 months, and 6 months after hospital discharge, using the Montreal Cognitive Assessment instrument. Factors potentially affecting cognitive function were also collected, including demographic and clinical variables and fatigue, frailty, and muscle strength. Semistructured interviews were conducted to further explore participants’ experiences during recovery. Results: We screened 2068 patients (10% met the inclusion criteria). Participants (n = 20) were mostly male with a mean age 61.9 years and a median of 4 days of mechanical ventilation. Data collection was complete for 14 and 11 participants at 2 months and 6 months, respectively. Pre-illness patients were not cognitively impaired; one patient had delirium in ICU. The proportion of patients with CI ranged from 80% (17/18) while in hospital to 35% (5/14) at 6 months. Participants were challenged by fatigue and sleep disruption during recovery but were not particularly concerned about CI. Conclusions: Recruitment in ICU was challenging as few patients received prolonged mechanical ventilation. The protocol was feasible, but some attrition was noted. A significant proportion of patients had mild CI, largely confined to recall, and language cognitive domains; quantitative findings were supported by interview findings. Further investigations are required to ascertain the most appropriate inclusion criteria to enable identification of those at highest risk of CI

Historia de la normativa reguladora de la Protección de Datos de carácter personal en distintos países Latinoamericanos

La Declaración universal de los derechos humanos fue firmada en Nueva York el 10 de diciembre de 1948, otros derechos de los ciudadanos se han ido sumando a estos primeros derechos de 1948, en este sentido se habla de los derechos humanos de segunda y tercera generación.  Entre los derechos humanos de tercera generación se encuentra el derecho a la protección de datos de carácter personal. Los ordenamientos de gran parte de los países de América Latina han ido introduciendo la regulación del derecho a la protección de datos de carácter personal. Sin embargo, Ecuador todavía no se ha sumado al grupo de países innovadores en materia de protección de los derechos humanos en este tema. Mediante el presente artículo se va a realizar un análisis de la evolución histórica de la normativa regulatoria de la protección de datos en Latinoamérica, la cual fundamentará los aportes que pueden integrarse en el borrador del anteproyecto de la Ley orgánica de protección de datos personales, que se está elaborando por la Dirección Nacional de Registro de Datos Públicos (DINARDAP) en el momento actual

Seroconversion and Abundance of IgG Antibodies against S1-RBD of SARS-CoV-2 and Neutralizing Activity in the Chilean Population

COVID-19 is a pandemic caused by SARS-CoV-2. In Chile, half a million people have been infected and more than 16,000 have died from COVID-19. As part of the clinical trial NCT04384588, we quantified IgG against S1-RBD of SARS-CoV-2 (anti-RBD) in recovered people in Santiago and evaluated their suitability as COVID-19 convalescent plasma donors. ELISA and a luminescent SARS-CoV-2 pseudotype were used for IgG and neutralizing antibody quantification. 72.9% of the convalescent population (468 of 639) showed seroconversion (5-55 μg/mL anti-RBD IgG) and were suitable candidates for plasma donation. Analysis by gender, age, and days after symptom offset did not show significant differences. Neutralizing activity correlated with an increased concentration of anti-RBD IgG (p<0.0001) and showed a high variability between donors. We confirmed that the majority of the Chilean patients have developed anti-SARS-CoV-2 antibodies. The quantification of anti-RBD IgG in convalescent plasma donors is necessary to increase the detection of neutralizing antibodies

How much do we throw away in the intensive care unit? : an observational point prevalence study of Australian and New Zealand ICUs

Objective: During the current COVID pandemic, waste generation has been more evident with increased use of single use masks, gowns and other personal protective equipment. We aimed to understand the scale of waste generation, recycling rates and participation in Australian and New Zealand (ANZ) ICUs. Design: This is a prospective cross-sectional point prevalence study, as part of the 2021 ANZICS Point Prevalence Program. Specific questions related to waste and sustainability practices were asked at the site and patient level. Setting and participants: ANZ adult ICUs and their patients on the day of the study. Main outcome measures: Amount of single use items disposed of per shift, as well as the engagement of the site with sustainability and recycling practices. Results: In total, 712 patients (median number of patients per ICU = 17, IQR 11–30) from 51 ICUs across ANZ were included in our study; 55% of hospitals had a sustainability officer, and recycling paper (86%) and plastics (65%) were frequent, but metal recycling was limited (27%). Per patient bed space per 12-h shift there was recycling of less than 40% paper, glass, intravenous fluid bags, medication cups and metal instruments. A median of 10 gowns (IQR 3–19.5), 10 syringes (4.5–18) and gloves 30 (18–49) were disposed of per bed space, per 12-h shift. These numbers increased significantly when comparing patients with and without infection control precautions in place. Conclusions: In ANZ ICUs, we found utilisation of common ICU consumables to be high and associated with low recycling rates. Interventions to abate resource utilisation and augment recycling are required to improve environmental sustainability in intensive care units

Statistical analysis plan for the Pneumatic CompREssion for PreVENting Venous Thromboembolism (PREVENT) trial: A study protocol for a randomized controlled trial

Background: The Pneumatic CompREssion for Preventing VENous Thromboembolism (PREVENT) trial evaluates the effect of adjunctive intermittent pneumatic compression (IPC) with pharmacologic thromboprophylaxis compared to pharmacologic thromboprophylaxis alone on venous thromboembolism (VTE) in critically ill adults. Methods/design: In this multicenter randomized trial, critically ill patients receiving pharmacologic thromboprophylaxis will be randomized to an IPC or a no IPC (control) group. The primary outcome is "incident" proximal lower-extremity deep vein thrombosis (DVT) within 28 days after randomization. Radiologists interpreting the lower-extremity ultrasonography will be blinded to intervention allocation, whereas the patients and treating team will be unblinded. The trial has 80% power to detect a 3% absolute risk reduction in the rate of proximal DVT from 7% to 4%. Discussion: Consistent with international guidelines, we have developed a detailed plan to guide the analysis of the PREVENT trial. This plan specifies the statistical methods for the evaluation of primary and secondary outcomes, and defines covariates for adjusted analyses a priori. Application of this statistical analysis plan to the PREVENT trial will facilitate unbiased analyses of clinical data