The prevalence and predicting factors of pulmonary thromboembolism in patients with exacerbated chronic obstructive pulmonary disease

Introduction: The risk of pulmonary thromboembolism (PTE) in patients with exacerbated chronic obstructive pulmonary disease(e-COPD) is higher than in non-COPD states. The study aimed to evaluate the prevalence and the parameters that are critical forfinding the incidence of PTE in patients with e-COPD. Material and methods: This cross-sectional study was performed on 68 consecutive patients with the e-COPD, referred to thePulmonary Disease Department at the Shariati Hospital in Tehran between 2013 and 2014. In addition to collecting data on thehistory of disease and physical examination, arterial blood sampling, spirometry, electrocardiography and echocardiography wereperformed for all patients. All subjects underwent computed tomography pulmonary angiography (CT-PA) as a method of choicefor diagnosing PTE. Results: Out of 68 cases, five (7.4%) had CT angiography findings suggesting PTE. These patients were all male and had a highermean age (79 vs. 65 years), lower mean systolic blood pressure (88.36 vs. 118.33 mmHg), and a higher mean heart rate (133.12vs 90.33 beats/min), compared to e-COPD patients without PTE. Arterial blood gas analysis in individuals with PTE demonstrateda lower HCO3 (2.33 vs. 9.44 mEq/l) and PCO2 (44.35 vs. 51.43 mm Hg) levels. The mean left ventricular ejection fraction (LVEF)was lower in patients with PTE (34.14 ± 4.49% vs. 46.94 ± 8.27%). Conclusion: The prevalence of PTE in our series of patients with e-COPD was 7.4%. According to the study results, male gender,advanced age, hypotension, tachycardia, and respiratory alkalosis are factors indicating possible PTE among subjects with e-COPD

Comparison of Standard and Percutaneous Tracheostomy Complications in Shariati Hospital in Iran

Background: Tracheostomy is a procedure which aims at better managing patients’ airway. It can be done using two methods: standard and percutaneous. The percutaneous method is a favorable choice for critically illpatients because it is a less invasive procedure. This study compares the short-term complications of these two methods (during 7 days after the procedure).Methods: This study was a cross-sectional research performed on 50 ICU patients in need of tracheostomy.The patients were divided into two groups of percutaneous procedure (15 patients) and standard procedure(35 patients). The complications were registered in questionnaires and the data were analyzed using SPSS software (χ² test and t-test).Results: The two groups had no significant difference in age, sex, and vital signs. Average duration of the procedure was 24.4 minutes in the standard procedure (10-45 minutes) and 26.78 minutes (5-70 minutes) in the percutaneous procedure, and there was no significant difference between two groups (P = 0.814). Average bleeding during 7 days after the procedure was 44 cc (10-150 cc) in standard procedure and 24.7 cc (10-50 cc) in the percutaneous procedure, and the difference was significant (P = 0.012). The other variables were not significantly different in two groups.Conclusions: There was no difference in short-term complications between percutaneous and standard tracheostomy method should be selected considering other important factors

Występowanie i czynniki predykcyjne zatorowości płucnej u chorych na przewlekłą obturacyjną chorobę płuc w okresie zaostrzenia

WSTĘP: Ryzyko zatorowości płucnej (ZP) u chorych na przewlekłą obturacyjną chorobę płuc (POChP) w okresie zaostrzenia jest wyższe niż u osób niechorujących na POChP. Celem badania była ocena częstości występowania zatorowości oraz parametrów krytycznych związanych z ryzykiem ZP u chorych na POChP w okresie zaostrzenia. MATERIAŁ I METODY: Przeprowadzono badanie przekrojowe u 68 kolejnych chorych na zaostrzenie POChP, kierowanych na Oddział Chorób Płuc Szpitala Shariati w Teheranie w latach 2013–2014. U wszystkich chorych zebrano dane z wywiadu dotyczące przebiegu choroby oraz przeprowadzono badanie przedmiotowe, wykonano gazometrię krwi tętniczej, spirometrię, elektrokardiografię oraz echokardiografię. U wszystkich chorych przeprowadzono angiografię tomografii komputerowej jako metodę z wyboru w diagnostyce ZP. WYNIKI: Zmiany wskazujące na ZP w badaniu angio-TK stwierdzono u pięciu chorych (7,4%). Byli to wyłącznie mężczyźni, o wyższej średniej wieku (79 v. 65 lat), niższym średnim ciśnieniu skurczowym (88,36 v. 118,33 mm Hg), oraz wyższej średniej częstości pracy serca (133,12 v. 90,33 uderzeń/min), w porównaniu z chorymi na zaostrzenie POChP bez cech zatorowości płucnej. U chorych z zatorowością płucną wykazano niższe stężenia HCO3 (2,33 v. 9,44 mEq/l) i PCO2 (44.35 v. 51.43 mm Hg). Średnia wartość frakcji wyrzutowej lewej komory (LVEF, left ventricular ejection fraction) była niższa u chorych z cechami ZP (34,14 ± 4,49% v. 46,94 ± 8,27%). WNIOSKI: W badanej grupie chorych na zaostrzenie POChP zator płucny rozpoznano u 7,4% badanych. Uzyskane wyniki wskazują, że płeć męska, starszy wiek, niskie ciśnienie tętnicze, tachykardia, zasadowica oddechowa są czynnikami związanymi z ryzykiem zatorowości płucnej u chorych na POChP z cechami zaostrzenia.WSTĘP: Ryzyko zatorowości płucnej (ZP) u chorych na przewlekłą obturacyjną chorobę płuc (POChP) w okresie zaostrzenia jest wyższe niż u osób niechorujących na POChP. Celem badania była ocena częstości występowania zatorowości oraz parametrów krytycznych związanych z ryzykiem ZP u chorych na POChP w okresie zaostrzenia. MATERIAŁ I METODY: Przeprowadzono badanie przekrojowe u 68 kolejnych chorych na zaostrzenie POChP, kierowanych na Oddział Chorób Płuc Szpitala Shariati w Teheranie w latach 2013–2014. U wszystkich chorych zebrano dane z wywiadu dotyczące przebiegu choroby oraz przeprowadzono badanie przedmiotowe, wykonano gazometrię krwi tętniczej, spirometrię, elektrokardiografię oraz echokardiografię. U wszystkich chorych przeprowadzono angiografię tomografii komputerowej jako metodę z wyboru w diagnostyce ZP. WYNIKI: Zmiany wskazujące na ZP w badaniu angio-TK stwierdzono u pięciu chorych (7,4%). Byli to wyłącznie mężczyźni, o wyższej średniej wieku (79 v. 65 lat), niższym średnim ciśnieniu skurczowym (88,36 v. 118,33 mm Hg), oraz wyższej średniej częstości pracy serca (133,12 v. 90,33 uderzeń/min), w porównaniu z chorymi na zaostrzenie POChP bez cech zatorowości płucnej. U chorych z zatorowością płucną wykazano niższe stężenia HCO3 (2,33 v. 9,44 mEq/l) i PCO2 (44.35 v. 51.43 mm Hg). Średnia wartość frakcji wyrzutowej lewej komory (LVEF, left ventricular ejection fraction) była niższa u chorych z cechami ZP (34,14 ± 4,49% v. 46,94 ± 8,27%). WNIOSKI: W badanej grupie chorych na zaostrzenie POChP zator płucny rozpoznano u 7,4% badanych. Uzyskane wyniki wskazują, że płeć męska, starszy wiek, niskie ciśnienie tętnicze, tachykardia, zasadowica oddechowa są czynnikami związanymi z ryzykiem zatorowości płucnej u chorych na POChP z cechami zaostrzenia

Phantom Tumor of the Lung

Background: Localized interlobar effusions in congestive heart failure (phantom or vanishing lung tumor/s) are uncommon but well-known entities.Case Report: The patient is a 60-year-old male with a history of dyspnea and surgical removal of kidney stonein 1 year ago.Results: In chest-X-ray prior to the surgery an olive-shaped homogenous density, with a size of 30 mm × 20 mm in the right lung have been detected. Computed tomography (CT) scan has been performed, and a homogenous mass with a well-delineated border in major fissure of the right lung and mediastinal lymphadenopathy had been detected. Serial CT scans revealed mass enlargement. In Ct guided, Transthoracic biopsy fluid collection along the major fissure of the right lung had been detected. Biopsy of mediastinal lymph node silicoanthracotic changes with focal hyaline fibrosis had been shown.Conclusions: The diagnosis of the phantom tumor must be considered in any patient with congestive heart failure and lung mass. In this patient, there was no history of congestive heart failure which shows that phantom tumor could happen in non-chronic heart failure patients. Although the accurate diagnosis of the phantom tumor with imaging modalities in patients without congestive heart failure is very difficult but at least this diagnosis must be considered in a patient with a lung mass in the major fissure of the lungs

Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality among Patients with COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial

Importance: Thrombotic events are commonly reported in critically ill patients with COVID-19. Limited data exist to guide the intensity of antithrombotic prophylaxis. Objective: To evaluate the effects of intermediate-dose vs standard-dose prophylactic anticoagulation among patients with COVID-19 admitted to the intensive care unit (ICU). Design, Setting, and Participants: Multicenter randomized trial with a 2 � 2 factorial design performed in 10 academic centers in Iran comparing intermediate-dose vs standard-dose prophylactic anticoagulation (first hypothesis) and statin therapy vs matching placebo (second hypothesis; not reported in this article) among adult patients admitted to the ICU with COVID-19. Patients were recruited between July 29, 2020, and November 19, 2020. The final follow-up date for the 30-day primary outcome was December 19, 2020. Interventions: Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286), with modification according to body weight and creatinine clearance. The assigned treatments were planned to be continued until completion of 30-day follow-up. Main Outcomes and Measures: The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment. Prespecified safety outcomes included major bleeding according to the Bleeding Academic Research Consortium (type 3 or 5 definition), powered for noninferiority (a noninferiority margin of 1.8 based on odds ratio), and severe thrombocytopenia (platelet count <20 �103/µL). All outcomes were blindly adjudicated. Results: Among 600 randomized patients, 562 (93.7) were included in the primary analysis (median interquartile range age, 62 50-71 years; 237 42.2% women). The primary efficacy outcome occurred in 126 patients (45.7%) in the intermediate-dose group and 126 patients (44.1%) in the standard-dose prophylaxis group (absolute risk difference, 1.5% 95% CI,-6.6% to 9.8%; odds ratio, 1.06 95% CI, 0.76-1.48; P =.70). Major bleeding occurred in 7 patients (2.5%) in the intermediate-dose group and 4 patients (1.4%) in the standard-dose prophylaxis group (risk difference, 1.1% 1-sided 97.5% CI,-� to 3.4%; odds ratio, 1.83 1-sided 97.5% CI, 0.00-5.93), not meeting the noninferiority criteria (P for noninferiority >.99). Severe thrombocytopenia occurred only in patients assigned to the intermediate-dose group (6 vs 0 patients; risk difference, 2.2% 95% CI, 0.4%-3.8%; P =.01). Conclusions and Relevance: Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days. These results do not support the routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients admitted to the ICU with COVID-19. Trial Registration: ClinicalTrials.gov Identifier: NCT04486508. © 2021 American Medical Association. All rights reserved

A Modified Physical Disability Screening Model after Treatment in the Intensive Care Unit: A Nationwide Derivation-Validation Study

Background: Many of the survivors of critical illnesses in the intensive care unit (ICU) suffer from physical disability for months after the treatment in the ICU. Identifying patients who are susceptible to disability is essential. The purpose of the study was to modify a model for early in-ICU prediction of the patient's risk for physical disability two months after the treatment in the ICU. ------ Methods: A prospective multicenter derivation-validation study was conducted from 1 July 2015, to 31 August 2016. We modified a model consisting of three risk factors in the derivation group and tested the modified model in the validation group. They were asked for their physical abilities before being admitted, two months after discharge from the ICU by a binary ADL staircases questionnaire. The univariate and multivariate logistic regression was used to modify physical disability components in the derivation data set. Receiver operating characteristic curves were used to determine the sensitivity and specificity of the threshold values in the validation group. ----- Results: Five-hundred nineteen survivors were enrolled in the derivation group, and 271 in the validation. In multivariable analysis, the odds ratio (OR) of physical disability significantly increased with educational level ≤ elementary school (OR: 36.96, 95%CI: 18.14-75.29), inability to sit without support (OR: 15.16, 95%CI: 7.98-28.80), and having a fracture (OR: 12.74, 95%CI: 4.47-36.30). The multivariable validation model indicated that education level, inability to sit without support, and having a fracture simultaneously had sensitivity 71.3%, specificity 88.2%, LR+ 6.0, LR- 0.33, PPV 90.9, and NPV 64.9 to predict physical disability. Applying the coefficients derived from the multivariable logistic regression fitted on the derivation dataset in the validation dataset and computing diagnostic index sensitivity 100%, specificity 60.5%, LR+ 2.5, LR- 0.003, PPV 80.8, and NPV 100. The modified model had an excellent prediction ability for physical disability (AUC ± SE = 0.881 ± 0.016). ----- Conclusions: Low education level, inability to sit without support, and having a fracture in a modified model were associated with the development of physical disability after discharge from ICU. Therefore, these clinical variables should be considered when organizing follow-up care for ICU survivors

Effect of a Multistage Educational Skill-Based Program on Nurse’s Stress and Anxiety in the Intensive Care Setting: A Randomized Controlled Trial

Background. Psychological problems such as stress and anxiety are prevalent among working nurses in the intensive care units (ICUs). This study was aimed at investigating the effects of three skill-based educational programs on stress and anxiety among critical care nurses. Methods. Using a randomized controlled trial, 160 nurses were assigned to four groups including one control and three intervention groups. A standard skill-based educational program was delivered to three intervention groups using booklet, booklet+oral presentation, and booklet+oral presentation+clinical teaching over a period of one month to reduce different types of stress and anxiety. The control group received routine education only. Perceived stress, state anxiety, trait anxiety, and work-related stress were assessed at baseline and three times after the intervention (15 days, 3 months, and 21 months). Repeated-measure analysis of variance was used for data analysis. Results. There was no significant change in the control group in terms of study variables during follow-up assessments, whereas measures of stress and anxiety were reduced after intervention in the trial groups except trait anxiety. Nurses in the mixed-method group (booklet+oral presentation+clinical teaching) showed less stress and anxiety during follow-ups. Although the stress and anxiety scores decreased in the first and second follow-ups, there was no significant reduction in the third follow-up. Conclusions. To improve the mental health and performance of the intensive care unit nurses, knowledge-based and skill-based training programs seem useful. Continuous training may help to maintain the effectiveness of these programs over time

Effect of the Specific Training Course for Competency in Doing Arterial Blood Gas Sampling in the Intensive Care Unit: Developing a Standardized Learning Curve according to the Procedure’s Time and Socioprofessional Predictors

Background. Standardization of clinical practices is an essential part of continuing education of newly registered nurses in the intensive care unit (ICU). The development of educational standards based on evidence can help improve the quality of educational programs and ultimately clinical skills and practices. Objectives. The objectives of the study were to develop a standardized learning curve of arterial blood gas (ABG) sampling competency, to design a checklist for the assessment of competency, to assess the relative importance of predictors and learning patterns of competency, and to determine how many times it is essential to reach a specific level of ABG sampling competency according to the learning curve. Design. A quasi-experimental, nonrandomized, single-group trial with time series design. Participants. All newly registered nurses in the ICU of a teaching hospital of Tehran University of Medical Sciences were selected from July 2016 to April 2018. Altogether, 65 nurses participated in the study; however, at the end, only nine nurses had dropped out due to shift displacement. Methods. At first, the primary checklist was prepared to assess the nurses’ ABG sampling practices and it was finalized after three sessions of the expert panel. The checklist had three domains, including presampling, during sampling, and postsampling of ABG competency. Then, 56 nurses practiced ABG sampling step by step under the supervision of three observers who controlled the processes and they filled the checklists. The endpoint was considered reaching a 95 score on the learning curve. The Poisson regression model was used in order to verify the effective factors of ABG sampling competency. The importance of variables in the prediction of practice scores had been calculated in a linear regression of R software by using the relaimpo package. Results. According to the results, in order to reach a skill level of 55, 65, 75, 85, and 95, nurses, respectively, would need average ABG practice times of 6, 6, 7, 7, and 7. In the linear regression model, demographic variables predict 47.65 percent of changes related to scores in practices but the extent of prediction of these variables totally decreased till 7 practice times, and in each practice, nurses who had the higher primary skill levels gained 1 to 2 skill scores more than those with low primary skills. Conclusions. Utilization of the learning curve could be helpful in the standardization of clinical practices in nursing training and optimization of the frequency of skills training, thus improving the training quality in this field. This trial is registered with NCT02830971

Atorvastatin versus Placebo in ICU Patients with COVID-19: Ninety-day Results of the INSPIRATION-S Trial

BACKGROUND: In the INSPIRATION-S trial, atorvastatin versus placebo was associated with a nonsignificant 16% reduction in 30-day composite of venous/arterial thrombosis or death in intensive care unit (ICU) patients with COVID-19. Thrombo-inflammatory response in coronavirus disease 2019 (COVID-19) may last beyond the first 30 days. METHODS: This article reports the effects of atorvastatin 20 mg daily versus placebo on 90-day clinical and functional outcomes from INSPIRATION-S, a double-blind multicenter randomized trial of adult ICU patients with COVID-19. The main outcome for this prespecified study was a composite of adjudicated venous/arterial thrombosis, treatment with extracorporeal membrane oxygenation (ECMO), or all-cause mortality. Functional status was assessed with the Post-COVID-19 Functional Scale. RESULTS: In the primary analysis, 587 patients were included (age: 57 [Q1-Q3: 45-68] years; 44% women). By 90-day follow-up, the main outcome occurred in 96 (33.1%) patients assigned to atorvastatin and 113 (38.0%) assigned to placebo (hazard ratio [HR]: 0.80, 95% confidence interval [CI]: 0.60-1.05, p = 0.11). Atorvastatin in patients who presented within 7 days of symptom onset was associated with reduced 90-day hazard for the main outcome (HR: 0.60, 95% CI: 0.42-0.86, p $_{interaction}$ = 0.02). Atorvastatin use was associated with improved 90-day functional status, although the upper bound CI crossed 1.0 (OR$_{ordinal}$: 0.64, 95% CI: 0.41-1.01, p = 0.05). CONCLUSION: Atorvastatin 20 mg compared with placebo did not significantly reduce the 90-day composite of death, treatment with ECMO, or venous/arterial thrombosis. However, the point estimates do not exclude a potential clinically meaningful treatment effect, especially among patients who presented within 7 days of symptom onset (NCT04486508)