Effect of dexamethasone in patients with ARDS and COVID-19 (REMED trial)—study protocol for a prospective, multi-centre, open-label, parallel-group, randomized controlled trial

BACKGROUND: Since December 2019, SARS-CoV-2 virus has infected millions of people worldwide. In patients with COVID-19 pneumonia in need of oxygen therapy or mechanical ventilation, dexamethasone 6 mg per day is currently recommended. However, the dose of 6 mg of dexamethasone is currently being reappraised and may miss important therapeutic potential or may prevent potential deleterious effects of higher doses of corticosteroids. METHODS: REMED is a prospective, open-label, randomised controlled trial testing the superiority of dexamethasone 20 mg (dexamethasone 20 mg on days 1-5, followed by dexamethasone 10 mg on days 6-10) vs 6 mg administered once daily intravenously for 10 days in adult patients with moderate or severe ARDS due to confirmed COVID-19. Three hundred participants will be enrolled and followed up for 360 days after randomization. Patients will be randomised in a 1:1 ratio into one of the two treatment arms. The following stratification factors will be applied: age, Charlson Comorbidity Index, CRP levels and trial centre. The primary endpoint is the number of ventilator-free days (VFDs) at 28 days after randomisation. The secondary endpoints are mortality from any cause at 60 days after randomisation; dynamics of the inflammatory marker, change in WHO Clinical Progression Scale at day 14; and adverse events related to corticosteroids and independence at 90 days after randomisation assessed by the Barthel Index. The long-term outcomes of this study are to assess long-term consequences on mortality and quality of life at 180 and 360 days. The study will be conducted in the intensive care units (ICUs) of ten university hospitals in the Czech Republic. DISCUSSION: We aim to compare two different doses of dexamethasone in patients with moderate to severe ARDS undergoing mechanical ventilation regarding efficacy and safety. TRIAL REGISTRATION: EudraCT No. 2020-005887-70. ClinicalTrials.gov NCT04663555. Registered on December 11, 2020

Cryptococcal Pneumonia: An Unusual Complication in a COVID-19 Patient

Cryptococcal superinfection is a rare but potentially fatal complication, especially if its detection and subsequent treatment are delayed. Histopathological findings of pulmonary parenchyma from a deceased patient with these complications were acquired. Quite interestingly, only a minimal inflammatory reaction could be seen in an individual with no previously known immune suppression, indicating a disturbance of the immune system. This finding was well in concordance with the described changes in cellular immunity in COVID-19. We report the case of a 60 year old male with critical coronavirus disease 2019 (COVID-19) complicated by cryptococcal pneumonia and multiorgan failure. Both X-ray and CT scans revealed lung infiltrates corresponding with COVID-19 infection early after the onset of symptoms. Despite receiving standard treatment, the patient progressed into multiple organ failure, requiring mechanical ventilation, circulatory support, and haemodialysis. Cryptococcus neoformans was detected by subsequent BAL, and specific antifungal treatment was instituted. His clinical status deteriorated despite all treatment, and he died of refractory circulatory failure after 21 days from hospital admission. Histopathological findings confirmed severe diffuse alveolar damage (DAD) caused by COVID-19 and cryptococcal pneumonia. Timely diagnosis of cryptococcal superinfection may be challenging; therefore, PCR panels detecting even uncommon pathogens should be implemented while taking care of critical COVID-19 patients

Using a Rainfall Simulator to Define the Effect of Soil Conservation Techniques on Soil Loss and Water Retention

In the Czech Republic, the Universal Soil Loss Equation provides the basis for defining the soil protection strategy. Field rainfall simulators were used to define the actual cover-management factor values of the most extensively seeded crops in the Czech Republic. The second purpose was to assess rainfall-runoff ratio for different crops and management to contribute to the debate of water retention effectiveness during approaching climate change. The methodology focused on multi-seasonal measurements to cover the most important phenological phases. The rainfall intensity was 60 mm·h−1 for 30 min and a plot size of 16 m2. More than 380 rainfall simulation experiments provided data. Soil conservation techniques proved to have a significant effect on runoff reduction. Conventionally seeded maize can reduce the runoff ratio to around 50%. However, cover crops combined with reduced tillage or direct seeding can reduce the runoff ratio to 10–20% for ‘dry’ conditions and to 12–40% for ‘saturated’ conditions. Conventionally seeded maize on average loses 4.3 Mg·ha−1 per 30 min experiment. However, reduced tillage and direct seeding reduce soil loss to 0.6 and 0.16 Mg·ha−1, respectively. A comparison with the original USDA values for maize showed that it is desirable to redefine the crop cover factor

Using a Rainfall Simulator to Define the Effect of Soil Conservation Techniques on Soil Loss and Water Retention

In the Czech Republic, the Universal Soil Loss Equation provides the basis for defining the soil protection strategy. Field rainfall simulators were used to define the actual cover-management factor values of the most extensively seeded crops in the Czech Republic. The second purpose was to assess rainfall-runoff ratio for different crops and management to contribute to the debate of water retention effectiveness during approaching climate change. The methodology focused on multi-seasonal measurements to cover the most important phenological phases. The rainfall intensity was 60 mm·h−1 for 30 min and a plot size of 16 m2. More than 380 rainfall simulation experiments provided data. Soil conservation techniques proved to have a significant effect on runoff reduction. Conventionally seeded maize can reduce the runoff ratio to around 50%. However, cover crops combined with reduced tillage or direct seeding can reduce the runoff ratio to 10–20% for ‘dry’ conditions and to 12–40% for ‘saturated’ conditions. Conventionally seeded maize on average loses 4.3 Mg·ha−1 per 30 min experiment. However, reduced tillage and direct seeding reduce soil loss to 0.6 and 0.16 Mg·ha−1, respectively. A comparison with the original USDA values for maize showed that it is desirable to redefine the crop cover factor