Corticosteroid therapy for critically ill patients with the Middle East Respiratory Syndrome.

Rationale Corticosteroid therapy is commonly used among critically ill patients with the Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients’ clinical condition at the time of corticosteroid therapy initiation. Objectives To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically ill patients with MERS. Methods MERS ICU patients were included from 14 Saudi Arabian centers between September 2012 and October 2015. We carried out marginal structural modeling to account for baseline and time-varying confounders. Measurements and Main Results Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (Quartile Q1, 3: 1.0, 7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141/151 [93.4%] vs. 121/158 [76.6%], p≤0.0001) and had higher 90-day crude mortality (112/151 [74.2%] vs. 91/158 [57.6%], p=0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio 0.75, 95% CI 0.52, 1.07, p=0.12), but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio 0.35, 95% CI: 0.17, 0.72, p=0.005). Conclusions Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders, but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.</p

Corticosteroid therapy for critically ill patients with the Middle East Respiratory Syndrome.

Rationale Corticosteroid therapy is commonly used among critically ill patients with the Middle East Respiratory Syndrome (MERS), but its impact on outcomes is uncertain. Analyses of observational studies often do not account for patients’ clinical condition at the time of corticosteroid therapy initiation. Objectives To investigate the association of corticosteroid therapy on mortality and on MERS coronavirus RNA clearance in critically ill patients with MERS. Methods MERS ICU patients were included from 14 Saudi Arabian centers between September 2012 and October 2015. We carried out marginal structural modeling to account for baseline and time-varying confounders. Measurements and Main Results Of 309 patients, 151 received corticosteroids. Corticosteroids were initiated at a median of 3.0 days (Quartile Q1, 3: 1.0, 7.0) from ICU admission. Patients who received corticosteroids were more likely to receive invasive ventilation (141/151 [93.4%] vs. 121/158 [76.6%], p≤0.0001) and had higher 90-day crude mortality (112/151 [74.2%] vs. 91/158 [57.6%], p=0.002). Using marginal structural modeling, corticosteroid therapy was not significantly associated with 90-day mortality (adjusted odds ratio 0.75, 95% CI 0.52, 1.07, p=0.12), but was associated with delay in MERS coronavirus RNA clearance (adjusted hazard ratio 0.35, 95% CI: 0.17, 0.72, p=0.005). Conclusions Corticosteroid therapy in patients with MERS was not associated with a difference in mortality after adjustment for time-varying confounders, but was associated with delayed MERS coronavirus RNA clearance. These findings highlight the challenges and importance of adjusting for baseline and time-varying confounders when estimating clinical effects of treatments using observational studies.</p

Critically Ill Patients With the Middle East Respiratory Syndrome: A Multicenter Retrospective Cohort Study

Objectives:andnbsp;To describe patient characteristics, clinical manifestations, disease course including viral replication patterns, and outcomes of critically ill patients with severe acute respiratory infection from the Middle East respiratory syndrome and to compare these features with patients with severe acute respiratory infection due to other etiologies. Design:andnbsp;Retrospective cohort study. Setting:andnbsp;Patients admitted to ICUs in 14 Saudi Arabian hospitals. Patients:andnbsp;Critically ill patients with laboratory-confirmed Middle East respiratory syndrome severe acute respiratory infection (nandnbsp;= 330) admitted between September 2012 and October 2015 were compared to consecutive critically ill patients with community-acquired severe acute respiratory infection of nonandndash;Middle East respiratory syndrome etiology (nonandndash;Middle East respiratory syndrome severe acute respiratory infection) (nandnbsp;= 222). Interventions:andnbsp;None. Measurements and Main Results:andnbsp;Although Middle East respiratory syndrome severe acute respiratory infection patients were younger than those with nonandndash;Middle East respiratory syndrome severe acute respiratory infection (median [quartile 1, quartile 3] 58 yr [44, 69] vs 70 [52, 78];andnbsp;pandnbsp;andlt; 0.001), clinical presentations and comorbidities overlapped substantially. Patients with Middle East respiratory syndrome severe acute respiratory infection had more severe hypoxemic respiratory failure (PaO2/FIO2: 106 [66, 160] vs 176 [104, 252];andnbsp;pandnbsp;andlt; 0.001) and more frequent nonrespiratory organ failure (nonrespiratory Sequential Organ Failure Assessment score: 6 [4, 9] vs 5 [3, 7];andnbsp;pandnbsp;= 0.002), thus required more frequently invasive mechanical ventilation (85.2% vs 73.0%;andnbsp;pandnbsp;andlt; 0.001), oxygen rescue therapies (extracorporeal membrane oxygenation 5.8% vs 0.9%;andnbsp;pandnbsp;= 0.003), vasopressor support (79.4% vs 55.0%;andnbsp;pandnbsp;andlt; 0.001), and renal replacement therapy (48.8% vs 22.1%;andnbsp;pandnbsp;andlt; 0.001). After adjustment for potential confounding factors, Middle East respiratory syndrome was independently associated with death compared to nonandndash;Middle East respiratory syndrome severe acute respiratory infection (adjusted odds ratio, 5.87; 95% CI, 4.02andndash;8.56;andnbsp;pandnbsp;andlt; 0.001). Conclusions:andnbsp;Substantial overlap exists in the clinical presentation and comorbidities among patients with Middle East respiratory syndrome severe acute respiratory infection from other etiologies; therefore, a high index of suspicion combined with diagnostic testing is essential component of severe acute respiratory infection investigation for at-risk patients. The lack of distinguishing clinical features, the need to rely on real-time reverse transcription polymerase chain reaction from respiratory samples, variability in viral shedding duration, lack of effective therapy, and high mortality represent substantial clinical challenges and help guide ongoing clinical research efforts.</p

The association of corticosteroid therapy and the outcome of critically ill patients with the Middle East Respiratory Syndrome

Systematic corticosteroids are commonly used among critically ill patients with the Middle East Respiratory Syndrome (MERS), but their impact on outcome is uncertain. Studies that adjust only for baseline characteristics do not account for the clinical condition at the time of corticosteroid initiation. The objective of this study is to investigate the association of corticosteroids on mortality accounting for time-dependent variables during critical illness up-to the time of corticosteroid initiation

Laser and Light-Based Therapies in the Treatment of Hair Loss

Laser and light-based therapies including low-level laser and light therapy, fractional, excimer, and other lasers are increasingly well-regarded treatment options for patients with hair loss. Lasers emit wavelengths of light specific to a chromophore in the tissue, causing a targeted thermal response with minimal damage to surrounding tissue. The cascade of events downstream of the initial injury is responsible for the clinical effects seen. Low-level laser or light therapy (LLLT) was accidentally discovered in the 1960s when Hungarian scientist Endre Mester attempted to repeat an experiment performed by American Paul McGuff, who had cured malignant tumors in rats using a ruby laser. Mester’s laser was much less powerful than McGuff’s, and while he did not successfully cure any tumors, he observed for the first time that a low-level laser induced hair growth and improved wound healing. The mechanism by which this occurs is described as photobiomodulation or the stimulation of biological processes in the target tissue. This accidental discovery is the basis for the huge variety of LLLT products available on the market today. In the last 2 years alone, the number of approved items classified as laser, comb, or hair products intended for the purpose of the growth of scalp hairs on the FDA’s 510(k) premarket notification list, meaning the device is demonstrated to be at least safe and effective, has nearly doubled to a total of 50. This chapter will summarize current knowledge regarding all laser and light devices for patients with various forms of alopecia and will outline treatment strategy, device parameters, and appropriate limitations of use to guide providers toward optimal patient management