AbstractObjectiveTo determine if inhaled and intranasal ciclesonide are superior to placebo at decreasing respiratory symptoms in adult outpatients with covid-19.DesignRandomised, double blind, ...placebo controlled trial.SettingThree Canadian provinces (Quebec, Ontario, and British Columbia).Participants203 adults aged 18 years and older with polymerase chain reaction confirmed covid-19, presenting with fever, cough, or dyspnoea.InterventionParticipants were randomised to receive either inhaled ciclesonide (600 μg twice daily) and intranasal ciclesonide (200 μg daily) or metered dose inhaler and nasal saline placebos for 14 days.Main outcome measuresThe primary outcome was symptom resolution at day 7. Analyses were conducted on the modified intention-to-treat population (participants who took at least one dose of study drug and completed one follow-up survey) and adjusted for stratified randomisation by sex.ResultsThe modified intention-to-treat population included 203 participants: 105 were randomly assigned to ciclesonide (excluding two dropouts and one loss to follow-up) and 98 to placebo (excluding three dropouts and six losses to follow-up). The median age was 35 years (interquartile range 27-47 years) and 54% were women. The proportion of participants with resolution of symptoms by day 7 did not differ significantly between the intervention group (42/105, 40%) and control group (34/98, 35%); absolute adjusted risk difference 5.5% (95% confidence interval −7.8% to 18.8%). Results might be limited to the population studied, which mainly included younger adults without comorbidities. The trial was stopped early, therefore could have been underpowered.ConclusionCompared with placebo, the combination of inhaled and intranasal ciclesonide did not show a statistically significant increase in resolution of symptoms among healthier young adults with covid-19 presenting with prominent respiratory symptoms. As evidence is insufficient to determine the benefit of inhaled and intranasal corticosteroids in the treatment of covid-19, further research is needed.Trial registrationClinicalTrials.gov NCT04435795.
Risk factors for nontuberculous mycobacteria (NTM) infections after solid organ transplant (SOT) are not well characterized. Here we aimed to describe these factors.
Retrospective, multinational, 1:2 ...matched case-control study that included SOT recipients ≥12 years old diagnosed with NTM infection from 1 January 2008 to 31 December 2018. Controls were matched on transplanted organ, NTM treatment center, and post-transplant survival greater than or equal to the time to NTM diagnosis. Logistic regression on matched pairs was used to assess associations between risk factors and NTM infections.
Analyses included 85 cases and 169 controls (59% male, 88% White, median age at time of SOT of 54 years interquartile range {IQR} 40-62). NTM infection occurred in kidney (42%), lung (35%), heart and liver (11% each), and pancreas transplant recipients (1%). Median time from transplant to infection was 21.6 months (IQR 5.3-55.2). Most underlying comorbidities were evenly distributed between groups; however, cases were older at the time of NTM diagnosis, more frequently on systemic corticosteroids and had a lower lymphocyte count (all P < .05). In the multivariable model, older age at transplant (adjusted odds ratio aOR 1.04; 95 confidence interval CI, 1.01-1.07), hospital admission within 90 days (aOR, 3.14; 95% CI, 1.41-6.98), receipt of antifungals (aOR, 5.35; 95% CI, 1.7-16.91), and lymphocyte-specific antibodies (aOR, 7.73; 95% CI, 1.07-56.14), were associated with NTM infection.
Risk of NTM infection in SOT recipients was associated with older age at SOT, prior hospital admission, receipt of antifungals or lymphocyte-specific antibodies. NTM infection should be considered in SOT patients with these risk factors.
Abstract Background Patient satisfaction and effective management of postoperative complaints are important factors in determining the success of outpatient surgery programs. Methods In September ...2013, a 24-hour postdischarge telephone follow-up (TFU) call was initiated by surgical day care nurses at the Royal Jubilee Hospital in Victoria, BC. The study group was contacted to evaluate the effectiveness of the TFU in identifying and addressing postoperative complaints and determining the level of satisfaction with discharge instructions and care. Results A total of 854 patients were contacted. Overall, 313 (36.7%) received TFU and 541 (63.3%) did not; these served as our control group. Independent sample t -tests revealed that patients who received TFU had significantly fewer postoperative complaints compared with the controls (.19 vs .28, respectively). Conclusions Day surgery patients receiving TFU reported fewer postoperative concerns. Results of this study suggest that a TFU call results in increased patient satisfaction with discharge care and is an appropriate tool to address patients' postoperative complaints and improve patient-reported outcomes.
A 21-year-old, previously healthy male presented to hospital following 1 week of bilateral asymmetric ascending paralysis, odynophagia, and dysphagia. Initial magnetic resonance imaging (MRI) of the ...spine revealed an abnormal increased T2 signal with predominant dorsal column involvement and sparing of white matter throughout the cervical cord and extending to T5. The initial presumptive diagnosis was an acute infectious, versus inflammatory, myelitis. On reviewing the history, family members recalled a bat scratch on the left hand, sustained months prior, for which the patient did not seek or receive post-exposure prophylaxis (PEP). Rabies virus (RABV) RNA was detected by quantitative reverse transcription polymerase chain reaction (RT-qPCR) in two saliva samples, while nuchal skin biopsy and cerebrospinal fluid (CSF) were negative. Serum was negative for RABV neutralizing antibody. Sequencing and phylogenetic analyses identified the infecting RABV as a variant associated with silver-haired bats. Following risk assessment of exposure, 67 health care workers and several family members were offered PEP.
Background. The management and outcomes of nontuberculous mycobacterial (NTM) infections in solid organ transplant (SOT) recipients are poorly characterized. We aimed to describe the management and ...1-y mortality of these patients. Methods. Retrospective, multinational, 1:2 matched case-control study included SOT recipients aged 12 y old or older diagnosed with NTM infection between January 1, 2008, and December 31, 2018. Controls were matched on transplanted organs, NTM treatment center, and posttransplant survival at least equal to the time to NTM diagnosis. The primary aim was 1-y mortality after NTM diagnosis. Differences between cases and controls were compared using the log-rank test, and Cox regression models were used to identify factors associated with mortality at 12 mo among cases. Results. In 85 patients and 169 controls, the median age at the time of SOT was 54 y (interquartile range, 40–62 y), 59% were men, and the lungs were the most common site of infection after SOT (57.6%). One-year mortality was significantly higher in cases than in controls (20% versus 3%; P < 0.001), and higher mortality was associated with lung transplantation (hazard ratio 3.27; 95% confidence interval 1.1-9.77; P = 0.034). Median time (interquartile range) from diagnosis to treatment initiation (20 4–42 versus 11 3–21 d) or the reduction of net immunosuppression (36% versus 45%, hazard ratio 1.35 95% CI, 0.41-4.43, P = 0.618) did not differ between survivors and those who died. Conclusions. NTM disease in SOT recipients is associated with a higher mortality risk, especially among lung transplant recipients. Time to NTM treatment and reduction in net immunosuppression were not associated with mortality.
Abstract
Background
Moderate to severe cellulitis is a common reason for presentation to the emergency department and administration of intravenous antibiotics. Misdiagnosis of cellulitis occurs ...frequently as the disease can masquerade as a wide variety of noninfectious and infectious problems. There are currently no studies evaluating the impact of infectious diseases physicians on the diagnostic accuracy and management of cellulitis referred to an outpatient parenteral antibiotic clinic from the emergency department. The objective of this study was to quantify the prevalence of misdiagnosed moderate to severe cellulitis through an evaluation by an infectious diseases specialist, characterize the alternative diagnoses, and assess variables associated with misdiagnosis.
Methods
A prospective cross-sectional study of adults referred from emergency departments with presumed moderate to severe cellulitis to an outpatient parenteral antibiotic clinic staffed by infectious diseases specialists.
Results
301 consecutive patients with presumed cellulitis were evaluated over a 6-month period. A concurring diagnosis of cellulitis was found in 170 patients (56.5%), for a misdiagnosis rate of 43.5% (131/301). Table 1 summarizes the alternative diagnoses. Infectious conditions other than cellulitis were the most common (63/301; 20.9%), with abscess being present in 23 (7.6%) of patients. Fifty-two of 301 (17.3%) of the diagnoses were noninfectious and 16/301 (5.3%) patients had a dual diagnosis where minor cellulitis was present, but secondary to another, predomintating condition. The presence of stasis dermatitis (OR 6.62, P = 0.013) and a history of physical trauma (OR 1.76, P = 0.046) were associated with a misdiagnosis. 31.9% (107/335) of antibiotic regimens prescribed by emergency physicians were inappropriate or sub-optimal compared with 7.9% (22/280) of those ordered by infectious disease doctors.
Conclusion
Moderate to severe cellulitis was incorrectly diagnosed in nearly half of the patients referred for intravenous antibiotics and resulted in a high rate of unstewardly antimicrobial use. Infectious diseases physicians at an outpatient antibiotic clinic improved the diagnostic accuracy and management of this complicated condition.
Disclosures
All authors: No reported disclosures.
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