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Key Points: Question: Does vitamin C administered intravenously to patients hospitalized with COVID-19 improve organ support–free days (composite outcome of in-hospital mortality and days alive and free of intensive care unit–based respiratory and cardiovascular support) up to day 21? Findings: In 2 prospectively harmonized randomized clinical trials, the use of vitamin C vs control (placebo or no vitamin C) yielded posterior probabilities for efficacy of 8.6% among 1568 critically ill patients and 2.9% among 1022 patients who were not critically ill regarding the odds of improvement for organ support–free days. Meaning: Among hospitalized patients with COVID-19, there was a low probability that vitamin C improved organ support–free days. Importance: The efficacy of vitamin C for hospitalized patients with COVID-19 is uncertain. Objective: To determine whether vitamin C improves outcomes for patients with COVID-19. Design, Setting, and Participants: Two prospectively harmonized randomized clinical trials enrolled critically ill patients receiving organ support in intensive care units (90 sites) and patients who were not critically ill (40 sites) between July 23, 2020, and July 15, 2022, on 4 continents. Interventions: Patients were randomized to receive vitamin C administered intravenously or control (placebo or no vitamin C) every 6 hours for 96 hours (maximum of 16 doses). Main Outcomes and Measures: The primary outcome was a composite of organ support–free days defined as days alive and free of respiratory and cardiovascular organ support in the intensive care unit up to day 21 and survival to hospital discharge. Values ranged from –1 organ support–free days for patients experiencing in-hospital death to 22 organ support–free days for those who survived without needing organ support. The primary analysis used a bayesian cumulative logistic model. An odds ratio (OR) greater than 1 represented efficacy (improved survival, more organ support–free days, or both), an OR less than 1 represented harm, and an OR less than 1.2 represented futility. Results: Enrollment was terminated after statistical triggers for harm and futility were met. The trials had primary outcome data for 1568 critically ill patients (1037 in the vitamin C group and 531 in the control group; median age, 60 years [IQR, 50-70 years]; 35.9% were female) and 1022 patients who were not critically ill (456 in the vitamin C group and 566 in the control group; median age, 62 years [IQR, 51-72 years]; 39.6% were female). Among critically ill patients, the median number of organ support–free days was 7 (IQR, −1 to 17 days) for the vitamin C group vs 10 (IQR, −1 to 17 days) for the control group (adjusted proportional OR, 0.88 [95% credible interval {CrI}, 0.73 to 1.06]) and the posterior probabilities were 8.6% (efficacy), 91.4% (harm), and 99.9% (futility). Among patients who were not critically ill, the median number of organ support–free days was 22 (IQR, 18 to 22 days) for the vitamin C group vs 22 (IQR, 21 to 22 days) for the control group (adjusted proportional OR, 0.80 [95% CrI, 0.60 to 1.01]) and the posterior probabilities were 2.9% (efficacy), 97.1% (harm), and greater than 99.9% (futility). Among critically ill patients, survival to hospital discharge was 61.9% (642/1037) for the vitamin C group vs 64.6% (343/531) for the control group (adjusted OR, 0.92 [95% CrI, 0.73 to 1.17]) and the posterior probability was 24.0% for efficacy. Among patients who were not critically ill, survival to hospital discharge was 85.1% (388/456) for the vitamin C group vs 86.6% (490/566) for the control group (adjusted OR, 0.86 [95% CrI, 0.61 to 1.17]) and the posterior probability was 17.8% for efficacy. Conclusions and Relevance: In hospitalized patients with COVID-19, vitamin C had low probability of improving the primary composite outcome of organ support–free days and hospital survival. Trial Registration: ClinicalTrials.gov Identifiers: NCT04401150 (LOVIT-COVID) and NCT02735707 (REMAP-CAP) Two randomized clinical trials were harmonized to compare the effect of vitamin C vs control on outcomes in hospitalized patients with COVID-19 who were critically ill or who were not critically ill. [ABSTRACT FROM AUTHOR]

A study was conducted to investigate the characteristics, treatment methodologies and outcomes of critically ill patients with 2009 influenza A (H1N1) in Mexico. Results indicated that the critically ill cases were those of young adults who had severe respiratory distress syndrome and a high mortality rate.

The study aims to investigate the characteristics, treatment methodologies and outcomes of critically ill patients with 2009 Influenza A (H1N1) infection in Canada. The results indicate that critical illness in such cases occurred after admission to hospital and was found among young adults and needed prolonged mechanical ventilation and other rescue therapies.

Importance: Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.Objective: To identify risk factors and physical findings that predict difficult intubation.Data Sources: The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.Study Selection: Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.Data Extraction and Synthesis: Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.Results: Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of <3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring <9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).Conclusions and Relevance: Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient. [ABSTRACT FROM AUTHOR]

Importance: People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care.Objective: To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life.Design, Setting, and Participants: This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts.Exposures: All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care.Main Outcomes and Measures: Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities.Results: Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia.Conclusions and Relevance: Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association. [ABSTRACT FROM AUTHOR]

IMPORTANCE Venous thromboembolism (VTE) is a common complication of acute illness, and its prevention is a ubiquitous aspect of inpatient care. A multicenter blinded, randomized trial compared the effectiveness of the most common pharmocoprevention strategies, unfractionated heparin (UFH) and the low-molecular-weight heparin (LMWH) dalteparin, finding no difference in the primary end point of leg deep-vein thrombosis but a reduced rate of pulmonary embolus and heparin-induced thrombocytopenia among critically ill medical-surgical patients who received dalteparin. OBJECTIVE To evaluate the comparative cost-effectiveness of LMWH vs UFH for prophylaxis against VTE in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS Prospective economic evaluation concurrent with the Prophylaxis for Thromboembolism in Critical Care Randomized Trial (May 2006 to June 2010). The economic evaluation adopted a health care payer perspective and in-hospital time horizon; derived baseline characteristics and probabilities of intensive care unit and in-hospital events; and measured costs among 2344 patients in 23 centers in 5 countries and applied these costs to measured resource use and effects of all enrolled patients. MAIN OUTCOMES AND MEASURES Costs, effects, incremental cost-effectiveness of LMWH vs UFH during the period of hospitalization, and sensitivity analyses across cost ranges. RESULTS Hospital costs per patient were $39 508 (interquartile range [IQR], $24 676 to $71 431) for 1862 patients who received LMWH compared with $40 805 (IQR, $24 393 to $76 139) for 1862 patients who received UFH (incremental cost, -$1297 [IQR, -$4398 to $1404]; P = .41). In 78%of simulations, a strategy using LMWH was most effective and least costly. In sensitivity analyses, a strategy using LMWH remained least costly unless the drug acquisition cost of dalteparin increased from $8 to $179 per dose and was consistent among higher- and lower-spending health care systems. There was no threshold at which lowering the acquisition cost of UFH favored prophylaxis with UFH. CONCLUSIONS AND RELEVANCE From a health care payer perspective, the use of the LMWH dalteparin for VTE prophylaxis among critically ill medical-surgical patients was more effective and had similar or lower costs than the use of UFH. These findings were driven by lower rates of pulmonary embolus and heparin-induced thrombocytopenia and corresponding lower overall use of resources with LMWH. [ABSTRACT FROM AUTHOR]

The article focuses on a cluster randomized trial that aimed to assess the effectiveness of a multicenter quality improvement program to increase delivery of six evidence-based intensive care unit (ICU) practices. The study involved 15 community hospital ICU in Ontario which were randomized into two groups that received the intervention. The videoconference-based forum implemented by the researchers included audit and feedback, expert-led educational sessions and dissemination of algorithms to sequentially improve delivery of the targeted practices. Results indicate greater adoption of the targeted practices in intervention ICU than in controls.

The article discusses a study which described the baseline characteristics, treatment and outcomes of consecutive critically ill patients in Mexican hospitals that treated the majority of such patients with confirmed, probable, or suspected 2009 influenza A(H1N1) infections. The study used 58 critically ill patients with A(H1N1) infections between March 24 and June 1, 2009 at six hospitals. A piloted case report form was used in collecting demographic data, symptoms, comorbid conditions, illness progressions, treatments and clinical outcomes. The study observed the occurrence of critical illness in 58 of 899 patients admitted to the hospital with the virus.

The article discusses a study which described the characteristics, treatment and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection. The study used 168 critically ill patients with 2009 influenza A(H1N1) infection in various Canadian adult and pediatric intensive care units (ICUs) during the period April 16-August 12, 2009. Primary outcome measures for the study were 28-day and 90-day mortality, while secondary measures included frequency and duration of mechanical ventilation and duration of stay in the ICU. Occurrence of critical illness in 215 patients with community-acquired 2009 influenza A(H1N1) infection was observed in the study. It also concluded that critical illness due to the virus has occurred rapidly after hospital admission.

Objective: To assess the hemodynamic and hemostatic effects of 2 different concentrations of epinephrine in local anesthetic used during functional endoscopic sinus surgery (FESS). Injection of local anesthetic containing epinephrine during endoscopic sinus surgery, while providing hemostasis, has been associated with cardiac adverse effects such as tachycardia, hypertension, as well as arrhythmias., Design: Double-blind, randomized clinical trial., Setting: Tertiary referral center., Patients: A total of 140 patients undergoing FESS randomly divided into 2 groups, with group 1 receiving lidocaine hydrochloride, 2%, with 1:100 000 epinephrine and group 2, lidocaine, 2%, with 1:200 000 epinephrine., Main Outcome Measures: Baseline and postinjection hemodynamic parameters were recorded at 1-minute intervals for 5 minutes. Patient demographics, the extent of surgery, and the presence of polyps were recorded in both groups. Hemodynamic and hemostatic parameters and intraoperative blood loss were compared., Results: Significant hemodynamic fluctuations were noted following injection of lidocaine, 2%, with 1:100 000 epinephrine (group 1). Increases in heart rate and systolic, diastolic, and mean arterial blood pressure were noted in group 1 patients. The increase was found to be significant (P < .001) in the first and second minutes after injection and decreased to baseline level by the fifth minute. This fluctuation was not noted in group 2 patients, who received lidocaine, 2%, with 1:200 000 epinephrine. Using a standardized scale to assess surgical bleeding, no statistical difference in the 2 groups was observed (P > .05)., Conclusion: Submucosal injection of lidocaine, 2%, with 1:200 000 epinephrine during FESS does not lead to hemodynamic fluctuations or increased intraoperative bleeding compared with lidocaine, 2%, with 1:100 000 epinephrine., Trial Registration: clinicaltrials.gov Identifier: NCT00852410.