CT Imaging Features of 2019 Novel Coronavirus (2019-nCoV)

Chung M, Bernheim A, Mei X, et al. Radiology. 2020 Feb 4:200230. [CrossRef] [PubMed]

In a retrospective case series, chest CT scans of 21 symptomatic patients from China infected with the 2019 novel coronavirus (2019-nCoV) were reviewed. Typical CT findings included bilateral pulmonary parenchymal ground-glass and consolidative pulmonary opacities, sometimes with a rounded morphology and a peripheral lung distribution. Notably, lung cavitation, discrete pulmonary nodules, pleural effusions, and lymphadenopathy were absent. Follow-up imaging in a subset of patients during the study time window often demonstrated mild or moderate progression of disease, as manifested by increasing extent and density of lung opacities. Although nonspecific, these manifestations are similar to many other viral pneumonias.

Effect of Obstructive Sleep Apnoea and Its Treatment with Continuous Positive Airway Pressure on the Prevalence of Cardiovascular Events in Patients with Acute Coronary Syndrome (ISAACC Study): A Randomised Controlled Trial

Sánchez-de-la-Torre M, Sánchez-de-la-Torre A, Bertran S, et al; on behalf of the Spanish Sleep Network. [published online December 12, 2019]. Lancet Respir Med. [CrossRef] [PubMed]

The authors evaluated the effect of obstructive sleep apnoea (OSA) and its treatment with continuous positive airway pressure (CPAP) on the clinical evolution of patients with acute coronary syndrome (ACS). A multicentre, open-label, parallel-group, randomised controlled trial of patients with ACS at 15 hospitals was conducted in Spain. Eligible non-sleepy patients were men and women aged 18 years and older, admitted to hospital for documented symptoms of ACS. All patients underwent respiratory polygraphy during the first 24–72 h after admission. OSA patients were randomly assigned (1:1) to CPAP treatment plus usual care (CPAP group) or usual care alone (UC group). The primary endpoint was the prevalence of a composite of cardiovascular events (cardiovascular death or non-fatal events [acute myocardial infarction, non-fatal stroke, hospital admission for heart failure, and new hospitalisations for unstable angina or transient ischaemic attack]) in patients followed up for a minimum of 1 year. A total of 2834 patients with ACS had respiratory polygraphy, of whom 2551 (90·01%) were recruited. The prevalence of cardiovascular events was similar in the CPAP and UC groups (98 events [16%] vs 108 events [17%]; hazard ratio [HR] 0·89 [95% CI 0·68–1·17]; p=0·40) during follow-up. The prevalence of cardiovascular events seems not to be related to CPAP compliance or OSA severity. The authors conclude that among non-sleepy patients with ACS, the presence of OSA was not associated with an increased prevalence of cardiovascular events and treatment with CPAP did not significantly reduce this prevalence. 

Changes in Quality of Care after Hospital Mergers and Acquisitions

Beaulieu ND, Dafny LS, Landon BE, Dalton JB, Kuye I, McWilliams JM. N Engl J Med. 2020 Jan 2;382(1):51-59. [CrossRef] [PubMed]

The hospital industry has consolidated substantially with multiple studies have shown that hospital mergers have led to higher prices for commercially insured patients, but research about effects on quality of care is limited. Using Medicare claims and Hospital Compare data from 2007 through 2016 on performance on four measures of quality of care (a composite of clinical-process measures, a composite of patient-experience measures, mortality, and the rate of readmission after discharge) and data on hospital mergers and acquisitions occurring from 2009 through 2013, we conducted difference-in-differences analyses comparing changes in the performance of acquired hospitals from the time before acquisition to the time after acquisition with concurrent changes for control hospitals that did not have a change in ownership. The study sample included 246 acquired hospitals and 1986 control hospitals. Being acquired was associated with a modest differential decline in performance on the patient-experience measure (adjusted differential change, −0.17 SD; 95% confidence interval [CI], −0.26 to −0.07; P=0.002; the change was analogous to a fall from the 50th to the 41st percentile) and no significant differential change in 30-day readmission rates (−0.10 percentage points; 95% CI, −0.53 to 0.34; P=0.72) or in 30-day mortality (−0.03 percentage points; 95% CI, −0.20 to 0.14; P=0.72). Acquired hospitals had a significant differential improvement in performance on the clinical-process measure (0.22 SD; 95% CI, 0.05 to 0.38; P=0.03), but this could not be attributed conclusively to a change in ownership because differential improvement occurred before acquisition. Hospital acquisition by another hospital or hospital system was associated with modestly worse patient experiences and no significant changes in readmission or mortality rates. Effects on process measures of quality were inconclusive.

Comparative Effectiveness of Combined Favipiravir A and Oseltamivir Therapy Versus Oseltamivir Monotherapy in Critically Ill Patients with Influenza Virus Infection

Wang Y, Fan G, Salam A, et al. J Infect Dis. 2019 Dec 11. pii: jiz656. [CrossRef] [PubMed]

A synergistic effect of combination therapy with favipiravir and oseltamivir has been reported in pre-clinical models of influenza. However, no data are available on the clinical effectiveness of combination therapy in severe influenza. Data from two separate prospective studies of influenza adults were used to compare outcomes between combination and oseltamivir monotherapy. Outcomes includes rate of clinical improvement, defined as a decrease of 2 categories on a 7-category ordinal scale, and viral RNA detectability over time. Forty patients were treated with combination therapy and 128 with oseltamivir alone. Clinical improvement on Day 14 occurred in the combination group was higher than in monotherapy group (62.5% vs 42.2%, p=0.0247). The proportion of undetectable viral RNA at day 10 was higher in the combination group than oseltamivir group (67.5% vs 21.9%, p<0.01). No significant differences were observed in mortality or other outcomes. The authors conclude that favipiravir and oseltamivir combination therapy may accelerate clinical recovery compared to oseltamivir monotherapy in severe influenza, and this strategy should be formally evaluated in a randomized controlled trial.

Balanced Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial

Brown RM, Wang L, Coston TD, et al. Am J Respir Crit Care Med. 2019 Aug 27. [CrossRef] [PubMed]

Administration of intravenous crystalloid solutions is a fundamental therapy for sepsis, but the effect of crystalloid composition on patient outcomes remains unknown. The authors compared the effect of balanced crystalloids versus saline on 30-day in-hospital mortality among critically ill adults with sepsis. Of 15,802 patients enrolled in SMART, 1,641 patients were admitted to the medical intensive care unit with a diagnosis of sepsis. A total of 217 patients (26.3%) in the balanced crystalloids group experienced 30-day in-hospital morality, compared with 255 patients (31.2%) in the saline group (adjusted odds ratio, 0.74; 95% confidence interval, 0.59 - 0.93; P = 0.01) but the 60-day mortality did not significantly differ (aOR 0.80 [0.64 to 1.01]). Patients in the balanced group experienced a lower incidence of major adverse kidney events within 30 days (35.4% vs 40.1%; aOR 0.78; 95% CI 0.63 - 0.97) and a greater number of vasopressor-free days (20 ± 12 vs 19 ± 13; aOR 1.25; 95% CI 1.02 - 1.54) and renal replacement therapy-free days (20 ± 12 vs 19 ± 13; aOR 1.35 [1.08 - 1.69]), compared to the saline group. The authors conclude that amongst patients with sepsis in a large randomized trial, use of balanced crystalloids was associated with a lower 30-day in-hospital mortality compared to use of saline. The article is accompanied by a thoughtful editorial authored by Paul Young.