Frequently Asked Questions in Patients With Adrenal Insufficiency in the Time of COVID-19

Adrenal insufficiency (AI) is a life-threatening disorder, with increased morbidity and mortality, especially in case of an acute illness that can increase the requirement of cortisol. A novel infectious disease, termed Coronavirus Disease 2019 (COVID-19), appeared in 2020. Therefore, AI patients are experiencing a novel challenge: the risk of infection. In our experience, a prompt contact to the Endocrine center (with a telemedicine consultation) and a full awareness of diseases (cortisol deficiency, COVID-19 and the self-management of an adrenal crisis) are important to motivate patients. Vaccine is an effective treatment to prevent hospitalization and aggressive course of COVID-19. Some patients manifest challenges due to inequitable access and vaccine hesitancy, resulting in a delay in the acceptance of vaccines despite the availability of vaccination services. Therefore, an effort of all physicians must be conducted in order to advise patients with AI. In this short review, we try to answer some frequently asked questions regarding the management of patients with AI.

What you need to know about: delirium in older adults in hospital

Delirium is a clinical syndrome characterised by a disturbance of perception, consciousness and/or cognitive function, with an acute onset, fluctuating course and a severe deterioration arising over hours or days. Delirium is usually triggered by a combination of influences including acute illness, surgery, drugs and environmental factors. It is commonly seen in older people presenting to hospital, but can also develop during hospitalisation. There are three types of delirium: hypoactive, hyperactive and mixed. All patients over 65 years old presenting to hospital should be screened for delirium using the ‘4AT’ tool. An alternate method for diagnosing hospital-acquired delirium is described. This article outlines a 10-stage method for diagnosing, managing and preventing delirium, with emphasis on which areas of the history and examination should be prioritised, what the salient investigations are and both non-pharmacological and pharmacological approaches to preventing and treating delirium. Finally, this article explores which patients require specialist referrals or investigations and how to best follow up patients with delirium.

What a difference a year makes: A snapshot of the trends in vaccinations, hospitalizations, and mortality rates for SARS- CoV-2 across the state of Indiana

Background: Many efforts both scientifically and politically helped reduced the spread of SARS-CoV-2. In December of 2020, vaccinations were authorized for distribution. It is important to understand demographical correlations to COVID-19 acute illness rates and whether COVID-19 vaccinations significantly reduced these rates. Project Methods: This study focused on data from seventeen counties in Indiana. This information was used to determine if there were correlations between demographics and COVID-19 illness rates. County demographics were obtained from the United States Census Bureau. COVID-19 hospitalization and mortality were collected from the Regenstrief Institute and the Indiana State Department of Health respectively. Linear regression analyses were performed to determine if there were significant correlations between demographics and rates COVID-19 illness. T-test analyses assuming unequal variances were performed in order to determine if there has been a significant reduction in COVID-19 illness. Results: The results of this study revealed that the percentage of the population over the age of 65, with a bachelor’s degree, disabled under age 65, and the median income (r values: 0.729, 0.701, 0.661, and 0.533 respectively) are significantly correlated to the mortality rate. The percentage of the population over the age of 65 and with a bachelor’s degree (r values: 0.565 and 0.524 respectively) are significantly correlated to the hospitalization rate. When comparing the COVID-19 acute illness rates for each county from 07/27/20 until 02/01/21 to the rates after 02/01/21 until late- June of 2021, each county had significant decrease in the hospitalization and mortality rate after February 1, 2021. Potential Impact: The result of this study suggests that vaccinating residents was a significant factor in the 50% or higher reduction in COVID-19 hospitalization and mortality rates. These findings emphasize the importance of COVID-19 vaccinations to protect Americans from COVID-19 severe illness.

Predictors of the Development of Protracted Bacterial Bronchitis following Presentation to Healthcare for an Acute Respiratory Illness with Cough: Analysis of Three Cohort Studies

We describe the prevalence and risk factors for protracted bacterial bronchitis (PBB) following healthcare presentation for an acute cough illness in children. Data from three studies of the development of chronic cough (CC) in children were combined. PBB was defined as a wet cough of at least 4-weeks duration with no identified specific cause of cough that resolved following 2–4 weeks of appropriate antibiotics. Anterior nasal swabs were tested for 17 viruses and bacteria by polymerase chain reaction. The study included 903 children. Childcare attendance (adjusted relative risk (aRR) = 2.32, 95% CI 1.48–3.63), prior history of chronic cough (aRR = 2.63, 95% CI 1.72–4.01) and age <2-years (<12-months: aRR = 4.31, 95% CI 1.42–13.10; 12-<24 months: aRR = 2.00, 95% CI 1.35–2.96) increased risk of PBB. Baseline diagnoses of asthma/reactive airways disease (aRR = 0.30, 95% CI 0.26–0.35) or bronchiolitis (aRR = 0.15, 95% CI 0.06–0.38) decreased risk. M. catarrhalis was the most common organism (52.4%) identified in all children (PBB = 72.1%; no PBB = 50.2%, p < 0.001). We provide the first data on risks for PBB in children following acute illness and a hypothesis for studies to further investigate the relationship with wheeze-related illnesses. Clinicians and parents/guardians should be aware of these risks and seek early review if a wet cough lasting more than 4-weeks develops the post-acute illness.

Reliability and Validity of the Neuropsychiatric Inventory Questionnaire in Dyads With Dementia at Hospitalization

This study expanded on the limited psychometric testing of the Neuropsychiatric Inventory-Questionnaire (NPI-Q), and extended testing to include hospitalized persons with dementia upon admission to the hospital, with reports from family caregivers. Using data from 318 dyads in the ongoing Fam-FFC trial, a Rasch analysis was conducted. Most patients were female (62%), non-Hispanic (98%), and Black (50%) with a mean age of 81.62 (SD=8.43). There was evidence of internal consistency for all subscales (behavior, severity, caregiver distress); a DIF analysis showed invariance across race and gender. The items on the NPI-Q fit with each subscale. Hypothesis testing showed a significant association between the AD8 (F=30.04, p=.001) and MoCA (F= 5.05, p=.03) with behaviors; the AD8 (F =27.91, p=.001) and MoCA (F = 6.65, p=.01) with severity; and the AD8 (F = 29.23, p=.001) with caregiver distress. Findings provide support for the NPI-Q use in persons with dementia during acute illness.

Childhood mortality during and after acute illness in sub-Saharan Africa and South Asia - The CHAIN cohort study

Objectives Mortality during acute illness among children in low- and middle-income settings remain unacceptably high and there is increasing recognition of the importance of post-discharge mortality. A comprehensive understanding of pathways underlying mortality among acutely ill children is needed to develop interventions and improve guidelines. We aimed to determine the incidence, timing and contributions of proximal and underlying exposures for mortality among acutely ill young children from admission to hospital until 6 months after discharge in sub-Saharan Africa and South Asia in the context of guideline-based care. Design A prospective stratified cohort study recruiting acutely ill children at admission to hospital with follow up until 180 days after discharge from hospital (November 2016-July 2019). Setting Nine urban and rural hospitals in sub-Saharan Africa and South Asia across a range of facility levels, and local prevalences of HIV and malaria. Participants Inclusion criteria were age 2-23 months, admission to hospital with acute, non-traumatic medical illness and stratified into three groups by anthropometry. Children were excluded if currently receiving pulmonary resuscitation, had a known condition requiring surgery within 6 months or known terminal illness with death expected within 6 months. Main outcome measures Acute mortality occurring within 30-days from admission; post-discharge mortality within 180-days from discharge; characteristics with direct and indirect associations with mortality within a multi-level a priori framework including demographic, clinical, anthropometric characteristics at admission and discharge from hospital, and pre-existing child-, caregiver- and household-level characteristics. Results Of 3101 participants (median age 11 months), 1218 were severely wasted/kwashiorkor, 763 moderately wasted and 1120 were not wasted. Of 350 deaths, 182 (52%) occurred during index admission, 234 (67%) within 30-days of admission and 168 (48%) within 180-days post-discharge. Ninety (54%) post-discharge deaths occurred at home. The ratio of inpatient to post-discharge mortality was consistent across anthropometric strata and sites. Large high and low risk groups could be disaggregated for both early and post-discharge mortality. Structural equation models identified direct pathways to mortality and multiple socioeconomic, clinical and nutritional domains acting indirectly through anthropometric status. Conclusions Among diverse sites in Africa and South Asia, almost half of mortality occurs post-discharge. Despite being highly predictable, these deaths are not addressed in current guidelines. A fundamental shift to a risk-based approach to inpatient and post-discharge management is needed to further reduce childhood mortality and clinical trials of these approaches with outcomes of mortality, readmission and cost are warranted. Trial Registration ClinicalTrials.gov: NCT03208725

Risk factors and characterization of post-COVID-19 syndrome in patients from Colombia v1

Introduction: A high percentage of people who have suffered from COVID-19 present clinical manifestations that persist long after recovery from the acute phase. Objective: To determine the proportion of patients who presented post-COVID-19 syndrome, its clinical picture, and its risk factors in a group of patients from Colombia. Methods: This was an observational, longitudinal study of patients with SARS-CoV-2 treated in a network of clinics in Colombia. Over the telephone, after they gave prior informed consent, we evaluated whether the patients had post-COVID-19 syndrome and other clinical variables. Descriptive, bivariate, and multivariate analyses were performed. Results: A total of 311 patients (50.2% women) from 19 different cities were identified, with a median age of 47.0 years. In 63.0% of cases, symptoms persisted more than 3 months after recovery from the acute phase of the disease. Most common were dyspnea (54.1%), fatigue (42.9%), and muscle pain (36.2%). Greater age (30-59 vs. <30 years: OR: 2.67; 95% CI: 1.33-5.34; and ≥60 years vs. <30 years: OR: 3.23; 95% CI: 1.28-8.15), use of bronchodilators or inhaled corticosteroids (OR: 1.78; 95% CI: 1.02-3.10), and presenting cough at the time of diagnosis of COVID-19 (OR: 2, 39; 95% CI 1.23-4.65) increased the probability of prolonged clinical manifestations. Conclusions:Post-COVID-19 syndrome is a frequent condition characterized by heterogeneous symptoms. Older patients, those who present cough during the acute illness, and those who are managed with bronchodilators or inhaled corticosteroids have a higher risk of presenting it.

Long-term sequelae are highly prevalent one year after hospitalization for severe COVID-19

Many coronavirus disease 2019 (Covid-19) survivors show symptoms months after acute illness. The aim of this work is to describe the clinical evolution of Covid-19, one year after discharge. We performed a prospective cohort study on 238 patients previously hospitalized for Covid-19 pneumonia in 2020 who already underwent clinical follow-up 4 months post-Covid-19. 200 consented to participate to a 12-months clinical assessment, including: pulmonary function tests with diffusing lung capacity for carbon monoxide (DLCO); post-traumatic stress (PTS) symptoms evaluation by the Impact of Event Scale (IES); motor function evaluation (by Short Physical Performance Battery and 2 min walking test); chest Computed Tomography (CT). After 366 [363–369] days, 79 patients (39.5%) reported at least one symptom. A DLCO < 80% was observed in 96 patients (49.0%). Severe DLCO impairment (< 60%) was reported in 20 patients (10.2%), related to extent of CT scan abnormalities. Some degree of motor impairment was observed in 25.8% of subjects. 37/200 patients (18.5%) showed moderate-to-severe PTS symptoms. In the time elapsed from 4 to 12 months after hospital discharge, motor function improves, while respiratory function does not, being accompanied by evidence of lung structural damage. Symptoms remain highly prevalent one year after acute illness.