PURPOSE: Prone positioning (PP) in awake patients has been recently proposed as an adjunctive treatment for spontaneously breathing non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to reduce the risk of intubation.However, the magnitude of the effect of PP on clinical outcomes (e.g., the risk of endotracheal intubation, intensive care unit [ICU] admission, or mortality) in these patients remains uncertain.Therefore, we performed a systematic review and metaanalysis to evaluate the effectiveness of PP to improve the clinical outcomes in non-intubated patients with COVID-19. METHODS:We performed a comprehensive literature search using PubMed, Embase, and Cochrane Library databases from inception through February 24, 2020 for all the studies all studies that all compared PP versus no PP in non-intubated patients with COVID-19.The primary outcome of interest was the rate of endotracheal intubation.The secondary outcomes were inhospital mortality and intensive care unit (ICU) rates.Pooled odds risk (OR) and 95% confidence intervals (CIs) were obtained by the Mantel-Haenszel method within a random-effect model. RESULTS:A total of five studies (two randomized controlled trials and three observational studies), involving 470 non-intubated patients with COVID-19 (185 patients received PP and 285 did not) were included.The mean age was 59.82 years, and males represented 67% of total patients.The follow-up period ranged from 14 to 30 days.The endotracheal intubation rate was similar between PP and control groups (OR 0.75, 95% CI 0.41-1.35,P = 0.33, I2 = 20%).There was no difference in the in-hospital mortality rate between the two groups (OR 0.68, 95% CI 0.16-2.85,P = 0.60, I2 = 60%).Four studies reported the risk of ICU admission and demonstrated no difference between the two groups (OR 0.77, 95% CI 0.30-1.95,P = 0.58, I2 = 37%). CONCLUSIONS:Our meta-analysis demonstrated that prone positioning in non-intubated COVID-19 patients did not reduce the risk of endotracheal intubation.Furthermore, PP failed to reduce in-hospital mortality and ICU admission rates.CLINICAL IMPLICATIONS: Although our meta-analysis showed that prone positioning might not reduce the risks of intubation, in-hospital mortality, or ICU admission rate in spontaneously breathing non-intubated COVID-19 patients, more large-scale trials with a standardized protocol for prone positioning are needed to better evaluate the effectiveness of prone positioning in this select population.
Abstract Introduction: Autoimmune polyglandular syndrome (APS) is a multiorgan genetic autoimmune disease. APS-3B subtype is autoimmune thyroiditis with pernicious anemia. In this case, we will discuss an elderly female patient diagnosed with APS-3B. Case Presentation: A 69-year-old Caucasian female patient with a past medical history of autoimmune thyroiditis presented to the emergency department with a two-month history of generalized weakness and nausea. Associated symptoms included shortness of breath and diarrhea. Review of systems was otherwise unremarkable. Physical exam was positive for depigmented skin macules over the upper extremities. Lab results showed hemoglobin 8.2 [11.7 - 15.5 g/dL], MCV 121[80 - 100 fL], platelets 144,000 [150 - 450 X10E9/L], WBC 1.9 [4.0 - 11.0 X10E9/L], LDH 1153[100 - 235 U/L], TSH 0.28[0.49 - 4.67 uIU/mL], free T4 1.7 [0.61 - 1.60 ng/dL], direct Coombs test negative. Iron saturation 55%, vitamin B12 level <50 [180 - 914 pg/mL], folate >25[>5.8 ng/mL], total bilirubin 2.3 [0.3 - 1.2 mg/dL], haptoglobin <30 [32 - 228 mg/dL], AST 43 [0 - 41 U/L], reticulocyte 1.4%. Blood smear showed absolute neutropenia with flow cytometry unremarkable. Chest x-ray and urinalysis were negative. Immunofixation showed low IgM 44 [45 - 281 mg/dL], low IgG 619 [635 - 1,741 mg/dL]. Intrinsic factor antibodies (IF-Ab) were positive. Hematology reported that hemolytic anemia is less likely given Coombs test was negative. About 1.5% of Vitamin B12 deficiency present with a hemolytic picture due to ineffective erythropoiesis while Coombs test help to differentiate it from autoimmune hemolytic anemia. Diagnosis of pernicious anemia was made and the patient started on vitamin B12 injections. The combination of pernicious anemia, autoimmune thyroiditis, and vitiligo supported the diagnosis of autoimmune APS-3B. There was a normalization of vitamin B12 level and symptomatic improvement on a one-week follow-up. Discussion: The patient was diagnosed with autoimmune thyroiditis in 2014 with positive anti-TPO antibodies and elevated TSH; she required levothyroxine supplementation since diagnosis. Hypothyroidism causes macrocytic anemia, which may delay pernicious anemia diagnosis. APS-3B is associated with HLA-B8 and/or DR3 and DR5. Many studies reported that autoantibodies can be detected before developing symptoms of organ involvement. Thorough family history provides support for autoantibody testing to detect cases of APS-3B earlier. Active surveillance and early diagnosis will help minimize invasive testing such as bone marrow biopsy, so proper history taking is a key factor to early diagnose these conditions. Conclusion: APS-3B is a rare disorder. Diagnosis is difficult hypothyroidism causes macrocytic anemia. Early detection of APS-3B may help to prevent complications that increase the risk of mortality and morbidity, particularly in the elderly population.
Abstract Disclosure: H. Ayesh: None. A.B. Bradley: None. Introduction: Cardiovascular diseases (CVD) are associated with significant mortality and morbidity. Early identification of at-risk individuals plays an essential role in the treatment and management of CVD. There are multiple reports in the literature that Visceral Adiposity Index (VAI), has been associated with CVD. In this study, we will investigate the association of VAI with CVD, independent of body mass index (BMI), age, and diabetes status. Methods: A sample of 6587 individuals were selected from the NHANES study population (2011-2020). The sample included all individuals in the NHANES population (2011-2020) who are above 18 years and have waist circumference (WC), serum high-density lipoprotein (HDL) level, and serum triglyceride level (TG) available to calculate VAI. CVD status was assigned based on the question “Ever told you had coronary heart disease” from the NHANES survey. VAI for men was calculated using the formula “(WC/(39,68+(1.88*BMI) *(TG/1.03) *(1.31/HDL)”. VAI for women was calculated using the formula “(WC/(36,58+(BMI *1.89) *(TG/0.81) *(1.52/ HDL)” .VAI values were divided into 4 quartiles as follows: 1st(<1.81), 2nd (< 3.03), 3rd(< 5.09), 4th(> 5.09). Logistic regression analysis was performed to study the association between VAI and CVD. Statistical analysis was adjusted for age, BMI, and diabetes status. Results: Statistical analysis showed a statistically significant association between CVD and VAI independent of age, BMI and diabetes status. The odds of CVD were higher in the VAI 4th quartile group compared to the 1st quartile group with an odds ratio of 1.44 (95% CI 1.05-1.98), P value 0.02. Discussion/Conclusion: These results indicate that VAI can serve as a screening tool to identify individuals at risk for cardiovascular diseases. Waist circumference measurements, serum triglyceride levels, and high-density lipoproteins serum levels values are often easily accessible in clinical practice. Implementation of auto-calculation of VAI in electronic health records will provide robust screening and monitoring tools to identify individuals at risk for CVD, especially those with normal BMI. Future high-quality prospective studies will be helpful to further understand the association. Presentation: Friday, June 16, 2023
Introduction: Insulin therapy (IT) and plasmapheresis are used to treat hypertriglyceridemia-associated pancreatitis (HTAP). However, the optimal treatment modality for lowering the triglyceride level in patients with HTAP remains unclear. Therefore, we evaluated the efficacy and safety of IT and plasmapheresis in managing HTAP. Methods: We performed a comprehensive literature search using PubMed, Embase, and Web of Science databases through May 30, 2022, for all studies that compared IT vs. plasmapheresis in patients with HTAP. The primary outcomes were effectiveness (reduction in triglycerides within 24-hours of admission) and clinical outcomes, including hospital length-of-stay (LOS), mortality, acute renal failure (ARF), hypotension, and need for invasive mechanical ventilation (IMV). The secondary outcome was the overall treatment-related adverse events (AEs). Random-effects meta-analysis was conducted, and risk ratio (RR) and mean difference (MD) or standardized mean difference (SMD) for proportional and continuous variables were computed, respectively. For each outcome, forest plot, 95% confidence interval (CI), P-value (< 0.05 considered statistically significant), and I2 statistic ( > 50% considered as significant heterogeneity) were generated. Results: Six studies (1 randomized controlled trial [RCT] and 5 cohort studies) with 302 patients with HTAP (167 on IT vs. 135 on plasmapheresis) were included. Plasmapheresis was more effective than IT in reduction of triglycerides within 24-hours (SMD -0.57; 95% CI -1.02, -0.13; P=0.01, I2=56.8%, Figure 1A). However, LOS (MD -1.96; 95% CI -4.45, 0.54; P=0.12; I2=0%, Figure 1B), mortality (RR 0.68, 95% CI 0.28-1.64, P=0.39, I2=0%, Figure 1C), ARF (RR 0.44, 95% CI 0.06-3.05, P=0.41, I2=84%), hypotension (RR 0.63, 95% CI 0.16-2.52, P=0.51, I2=79%), and need for IMV (RR 0.52, 95% CI 0.12-12.35, P=0.40, I2=80%) were similar between two groups. The treatment-related AEs were significantly lower in IT than plasmapheresis (RR 0.14, 95% CI 0.04-0.51, P=0.003, I2=0%, Figure 1D). Conclusion: Our meta-analysis demonstrated that despite the greater reduction of triglycerides with plasmapheresis compared to insulin therapy, the clinical outcomes, including LOS, mortality, ARF, hypotension, and need for IMV, were comparable with lower treatment-related adverse events with insulin therapy. Future large-scale RCTs are necessary to validate our findings.Figure 1.: Forest plots comparing between insulin therapy and plasmapheresis regarding: (A) the reduction of triglyceride within 24 hours, (B) length of hospital stay, (C) mortality, and (D) treatment-related adverse events.
Micronutrient supplements such as vitamin D, vitamin C, and zinc have been used in managing viral illnesses. However, the clinical significance of these individual micronutrients in patients with Coronavirus disease 2019 (COVID-19) remains unclear. We conducted this meta-analysis to provide a quantitative assessment of the clinical significance of these individual micronutrients in COVID-19.
Awake prone positioning (APP) has been recently proposed as an adjunctive treatment for non-intubated coronavirus disease 2019 (COVID-19) patients requiring oxygen therapy to improve oxygenation and reduce the risk of intubation. However, the magnitude of the effect of APP on clinical outcomes in these patients remains uncertain. We performed a comparative systematic review and meta-analysis to evaluate the effectiveness of APP to improve the clinical outcomes in non-intubated subjects with COVID-19.
METHODS:
The primary outcomes were the need for endotracheal intubation and mortality. The secondary outcome was hospital length of stay. Pooled risk ratio (RR) and mean difference with the corresponding 95% CI were obtained by the Mantel-Haenszel method within a random-effect model.
RESULTS:
A total of 14 studies (5 randomized controlled trials [RCTs] and 9 observational studies) involving 3,324 subjects (1,495 received APP and 1,829 did not) were included. There was a significant reduction in the mortality rate in APP group compared to control (RR 0.68 [95% CI 0.51–0.90]; P = .008, I2 = 52%) with no significant effect on intubation (RR 0.85 [95% CI 0.66–1.08]; P = .17, I2 = 63%) or hospital length of stay (mean difference −3.09 d [95% CI−10.14–3.96]; P = .39, I2 = 97%). Subgroup analysis of RCTs showed significant reduction in intubation rate (RR 0.83 [95% CI 0.72–0.97]; P = .02, I2 = 0%).
CONCLUSIONS:
APP has the potential to reduce the in-hospital mortality rate in COVID-19 subjects with hypoxemia without a significant effect on the need for intubation or length of hospital stay. However, there was a significant decrease in the need for intubation on subgroup analysis of RCTs. More large-scale trials with a standardized protocol for prone positioning are needed to better evaluate its effectiveness in this select population.
