Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia (COVID STEROID) trial—Protocol and statistical analysis plan

Introduction

Severe acute respiratory syndrome coronavirus-2 has caused a pandemic of coronavirus disease (COVID-19) with many patients developing hypoxic respiratory failure. Corticosteroids reduce the time on mechanical ventilation, length of stay in the intensive care unit and potentially also mortality in similar patient populations. However, corticosteroids have undesirable effects, including longer time to viral clearance. Clinical equipoise on the use of corticosteroids for COVID-19 exists.

Methods

The COVID STEROID trial is an international, randomised, stratified, blinded clinical trial. We will allocate 1000 adult patients with COVID-19 receiving ≥10 L/min of oxygen or on mechanical ventilation to intravenous hydrocortisone 200 mg daily vs placebo (0.9% saline) for 7 days. The primary outcome is days alive without life support (ie mechanical ventilation, circulatory support, and renal replacement therapy) at day 28. Secondary outcomes are serious adverse reactions at day 14; days alive without life support at day 90; days alive and out of hospital at day 90; all-cause mortality at day 28, day 90, and 1 year; and health-related quality of life at 1 year. We will conduct the statistical analyses according to this protocol, including interim analyses for every 250 patients followed for 28 days. The primary outcome will be compared using the Kryger Jensen and Lange test in the intention to treat population and reported as differences in means and medians with 95% confidence intervals.

Discussion

The COVID STEROID trial will provide important evidence to guide the use of corticosteroids in COVID-19 and severe hypoxia.

     

Experiences of use of the cerebral palsy hemiplegic hand in young persons treated with upper extremity surgery.

The aim of this qualitative study was to explore the experiences of young persons using their hemiplegic hand in daily life activities following upper extremity surgery (UES). Ten persons, aged 12-24 years, were interviewed individually five to seven years after surgery. The analysis was guided by a comparative method. The findings show that the participants during this period had experienced changes which they related both to the treatment and to development. Data resolved into three main themes. Functional improvements are interwoven into daily life, the hand is easier to use and is used more, and changes in the appearance and in the internal feeling of the arm are of importance. This study reflects the patients' experiences of living with the outcome of UES and yields an important complement to objective, quantitative outcome studies.     

The effect of various thermal processes on the glycemic response to whole grain wheat products in humans and rats

The effects of different thermal processes used to produce ready-to-eat cereals on the glycemic response to whole grain wheat were investigated in rats. The metabolic response to drum dried flour, which constitutes the major component in instant gruel and porridge, was also studied in healthy human subjects. Boiled flour was used for comparison. The degree of starch gelatinization and rate of starch hydrolysis in vitro were also measured. Incompletely gelatinized steam flaked and dry autoclaved products were digested more slowly in vitro and elicited lower glucose responses in rats compared with completely gelatinized drum dried, extrusion cooked or boiled samples. The initial glycemic response in rats was closely related to the rate of starch hydrolysis in the pepsin/alpha-amylase assay (r = 0.91, P less than 0.04). When pepsin was omitted, no significant correlation was obtained. The peak glucose, insulin and C-peptide responses in humans after breakfast meals of porridge prepared from drum dried flour and from boiled flour were similar, whereas the rate of depression of the glucose curve was more rapid after consuming drum dried porridge. It is concluded that the glycemic response to wheat products is affected by the processing conditions used. The more severe the processing conditions, the more rapid the digestion of starch.     

Density dependence of maximal expiratory air flow in asthmatics with exacerbation of their disease

In an effort to evaluate the relationship between the site of air-flow obstruction and rate of improvement with therapy, we studied 20 asthmatics with spirometry, before and after bronchodilator, using air and 80% helium-20% oxygen (He-O2). Studies were obtained on 3 consecutive days after hospital admission and approximately 18 days after discharge. Greater He-O2 response ([Vmax50(He-O2)--Vmax50(air)]/predicted Vmax50) X 100, was associated with: less cigarette consumption (p less than 0.02), lesser frequency of chronic productive cough (p less than 0.02), more symptom-free intervals (p less than 0.02), and greater frequency of allergic rhinitis (p less than 0.03). Patients with greater He-O2 response (Group 1) reached maximal improvement in air flow by Hospital Day 2, whereas those with a lesser He-O2 response (Group 2) continued to improve throughout the observation period. The Group 1 mean peak expiratory flow rate (PEFR) improved by 24% of predicted per day to maximum, which was significantly greater (p less than 0.025) than the 11% per day rate of improvement of Group 2. The He-O2 response remained relatively stable throughout the course of the study except for 3 patients who dramatically improved their response with therapy. A highly significant correlation, adjusted for regression to the mean, (r = 0.95, p less than 0.0001) was found between mean baseline percent predicted Vmax50 and the mean He-O2 response. After adjustment for regression to the mean, there was no significant relationship between the degree of prebronchodilator He-O2 response and increase in He-O2 response with bronchodilator.(ABSTRACT TRUNCATED AT 250 WORDS)     

Metabolic alkalosis after pediatric cardiac surgery.

OBJECTIVE: To determine occurrence, causes and associated mortality of postoperative metabolic alkalosis in pediatric cardiac surgery. METHODS: We retrospectively analyzed clinical and biochemical variables of 186 consecutive cardiac operations other than ductal ligations on children less than 2 years old during the years 1999 and 2000. Metabolic alkalosis was defined as a pH>7.48 corrected for PCO2, with a base excess > or =5 on two or more consecutive measurements during an 8h period. RESULTS: Median age was 15 weeks [range 2 days-95 weeks] and median weight 4.5 kg [range 2.1-15.7 kg]. In 157 cases, cardiopulmonary bypass was used. In 92 [49%] procedures, metabolic alkalosis occurred with the highest corrected pH 24.3h after operation. Multivariate regression analysis associated age [P<0.001], cardiopulmonary bypass [P<0.001] and preoperative ductal dependency [P=0.04] with postoperative metabolic alkalosis. Of the surgical procedures the arterial switch for transposition of the great arteries [n=19] was strongly associated with metabolic alkalosis [100%, P<0.001]. Hemodilution appeared to enhance the development of alkalosis: those who experienced alkalosis had been hemodiluted to a greater extent [P=0.007]. Nearly 95% of patients experienced some increase in bicarbonate, but patients with metabolic alkalosis experienced more than those without [5.9 versus 3.5 mmol/l, P<0.001]. There were four postoperative deaths, only one coincidental with metabolic alkalosis. CONCLUSIONS: Metabolic alkalosis has a high incidence after pediatric cardiac surgery, strongly associated with younger age, cardiopulmonary bypass, preoperative ductal dependency and perioperative hemodilution. Early recognition allows for timely therapeutic intervention.     

The molecular basis of classic Ehlers-Danlos syndrome: a comprehensive study of biochemical and molecular findings in 48 unrelated patients

Classic Ehlers-Danlos syndrome (EDS) is characterized by fragile and hyperextensible skin, atrophic scarring, and joint hypermobility. Mutations in the COL5A1 and the COL5A2 gene encoding the alpha1(V) and the alpha2(V) chains, respectively, of type V collagen have been shown to cause the disorder, but it is unknown what proportion of classic EDS patients carries a mutation in these genes. We studied fibroblast cultures from 48 patients with classic EDS by SDS-PAGE for the presence of type V collagen defects. An abnormal collagen pattern was detected in only 2 out of 48 cell lines, making this a poor method for routine diagnostic evaluation. A total of 42 out of 48 (88%) patients were heterozygous for an expressed polymorphic variant in COL5A1. cDNA from 18 (43%) of them expressed only one COL5A1 allele. In 37 patients, the COL5A1/A2 genes were then analyzed by SSCP and conformation sensitive gel electrophoresis (CSGE). A total of 26 patients that were mutation-negative after SSCP/CSGE screening were reanalyzed by dHPLC. In addition, 11 other patients were analyzed by dHPLC only. In total, 17 mutations leading to a premature stop codon and five structural mutations were identified in the COL5A1 and the COL5A2 genes. In three patients with a positive COL5A1 null-allele test, no causal mutation was found. Overall, in 25 out of 48 patients (52%) with classic EDS, an abnormality in type V collagen was confirmed. Variability in severity of the phenotype was observed, but no significant genotype-phenotype correlations emerged. The relatively low mutation detection rate suggests that other genes are involved in classic EDS. We excluded the COL1A1, COL1A2, and DCN gene as major candidate genes for classic EDS, since no causal mutation in these genes was found in a number of patients who tested negative for COL5A1 and COL5A2.     

Isolation and characterization of two European strains of Ehrlichia phagocytophila of equine origin

We report the isolation and partial genetic characterization of two equine strains of granulocytic Ehrlichia of the genogroup Ehrlichia phagocytophila. Frozen whole-blood samples from two Swedish horses with laboratory-verified granulocytic ehrlichiosis were inoculated into HL-60 cell cultures. Granulocytic Ehrlichia was isolated and propagated from both horses. DNA extracts from the respective strains were amplified by PCR using primers directed towards the 16S rRNA gene, the groESL heat shock operon gene, and the ank gene. The amplified gene fragments were sequenced and compared to known sequences in the GenBank database. With respect to the 16S rRNA gene, the groESL gene, and the ank gene, the DNA sequences of the two equine Ehrlichia isolates were identical to sequences found in isolates from clinical cases of granulocytic ehrlichiosis in humans and domestic animals in Sweden. However, compared to amplified DNA from an American Ehrlichia strain of the E. phagocytophila genogroup, differences were found in the groESL gene and ank gene sequences.     

Adenoviral vectors expressing siRNAs for discovery and validation of gene function

RNA interference is a powerful tool for studying gene function and for drug target discovery in diverse organisms and cell types. In mammalian systems, small interfering RNAs (siRNAs), or DNA plasmids expressing these siRNAs, have been used to down-modulate gene expression. However, inefficient transfection protocols, in particular, for primary cell types, have hampered the use of these tools in disease-relevant cellular assays. To be able to use this technology for genome-wide function screening, a more robust transduction protocol, resulting in a longer duration of the knock-down effect, is required. Here, we describe the validation of adenoviral vectors that express hairpin RNAs that are further processed to siRNAs. Infection of cell lines, or primary human cells, with these viruses leads to an efficient, sequence-specific, and prolonged reduction of the corresponding target mRNA, resulting in a reduction of the encoded protein level in the cell. For knock-down of one of the targets, GalphaS, we have measured inhibition of ligand-dependent, G-protein-coupled signaling. It is expected that this technology will prove to be of great value in target validation and target discovery efforts.