Real-Life Impact of Glucocorticoid Treatment in COVID-19 Mortality: A Multicenter Retrospective Study

We aimed to determine the impact of steroid use in COVID-19 in-hospital mortality, in a retrospective cohort study of the SEMICOVID19 database of admitted patients with SARS-CoV-2 laboratory-confirmed pneumonia from 131 Spanish hospitals. Patients treated with corticosteroids were compared to patients not treated with corticosteroids; and adjusted using a propensity-score for steroid treatment. From March–July 2020, 5.262 (35.26%) were treated with corticosteroids and 9.659 (64.73%) were not. In-hospital mortality overall was 20.50%; it was higher in patients treated with corticosteroids than in controls (28.5% versus 16.2%, OR 2.068 [95% confidence interval; 1.908 to 2.242]; p = 0.0001); however, when adjusting by occurrence of ARDS, mortality was significantly lower in the steroid group (43.4% versus 57.6%; OR 0.564 [95% confidence interval; 0.503 to 0.633]; p = 0.0001). Moreover, the greater the respiratory failure, the greater the impact on mortality of the steroid treatment. When adjusting these results including the propensity score as a covariate, in-hospital mortality remained significantly lower in the steroid group (OR 0.774 [0.660 to 0.907], p = 0.002). Steroid treatment reduced mortality by 24% relative to no steroid treatment (RRR 0.24). These results support the use of glucocorticoids in COVID-19 in this subgroup of patients.

Steroids in severe COVID-19 patients: A retrospective analysis on the first pandemics in Lombardy

The pathogenesis of COVID-19 appears to be characterized by a dysregulated immune response. During the first pandemic wave in Lombardy, we started to administer glucocorticoids to some patients with severe respiratory failure requiring support with Continuous Positive Airway Pressure (CPAP) therapy. We retrospectively collected data to identify the effect of glucocorticoids in this COVID-19 particular population. With a multidisciplinary consensus, we administered to selected patients with severe COVID-19 disease (PaO2/FiO2 159±71 mmHg) 0,91 mg/kg/die of methylprednisolone equivalent dose after a median of 8 days of hospitalization. In our study we compared 57 patients from the steroid group with 123 from the control group: the event of invasive mechanical ventilation or death was reduced by 43% between steroid group and control group (19.3 % vs. 34.1 % respectively, p=0.001) and mortality was reduced by about 31% between steroid and usual care alone (15.8 % vs. 22.8 % respectively, p=0.011). Corticosteroids in selected COVID-19 patients may have a relevant impact on outcome, better profiling of the heterogeneity of this disease may be essential to guarantee the best treatment choices.

474 Effectiveness of Platelet Rich Plasma in the Treatment of Recalcitrant Shoulder Pathology

Aim To assess the outcome of platelet rich plasma injections (PRP) in patients with recalcitrant shoulder pathology using steroid injections as a control. Method This was a pragmatic retrospective analysis of patients treated for recalcitrant shoulder pathology between October 2018 to March 2019 with either PRP or steroid injection. Results In the PRP group 10 patients (n = 15) had previous steroid injections and 7 had previous surgery. 2 progressed to shoulder replacement. 5 have progressed to arthropathy. 4 patients were discharged due to improving symptoms. In the steroid group 2 patients (n = 15) were lost to follow up, 0 had previous surgery and 1 had a previous steroid injection. 6 were discharged due to improving symptoms. The average time to discharge post procedure was 241 days for PRP and 173 days for the steroid group. No complications were noted in either group. Conclusions Our findings show that PRP injections are a safe and effective treatment for cases of recalcitrant shoulder pathology leading to a 27% success rate for patients who have required steroid injections or arthroscopy in the past. In patients with arthropathy, PRP only has a short effect and should only be offered to patients that are unable to have surgery either due to high risk or patient choice. PRP requires a centrifuge machine and an operating theatre, thus incurring higher costs compared to steroid injections which may be given in clinic. Steroid injections should therefore remain the first line of treatment for recalcitrant shoulder pathology.

Effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure: a cohort study

Background: Tuberculosis (TB) remains an important and evolving health problem worldwide. Acute respiratory failure, the most severe form of pulmonary tuberculosis, is associated with a high mortality rate. Adjunctive corticosteroid therapy has been reported as an effective treatment in extrapulmonary TB. The aim of this study was to investigate the effect of adjunctive corticosteroid therapy on outcomes in pulmonary tuberculosis patients with acute respiratory failure. Methods: This retrospective cohort study enrolled newly diagnosed pulmonary tuberculosis patients with acute respiratory failure who were admitted to Siriraj Hospital (Bangkok, Thailand) during January 2011 to December 2013. Patients that received corticosteroid as an adjunctive treatment for pulmonary TB were assigned to the steroid group. The control group consisted of patients that did not receive corticosteroid. Collected data included age, gender, body mass index (BMI), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, sequential organ failure assessment (SOFA) scores, vital signs, PaO2/FiO2 ratio, chest X-ray abnormality pattern, and TB treatment strategies, including antituberculosis agents and adjunct corticosteroid treatment. The primary outcome was hospital mortality rate. The secondary outcomes were hospital length of stay and duration of mechanical ventilation. Results: Thirty-eight patients were included. There were 18 patients in the steroid group and 20 in the control group. No significant difference was observed between groups for age, gender, BMI, APACHE II score, vital signs, or PaO2/FiO2 ratio. Patients in the steroid group had a significantly higher mean SOFA score than controls (5.7±4.5 vs. 3.3±2.6, respectively; p=0.046). Almost all patients in this study (97.1%) had positive culture for M. tuberculosis from sputum. The mean corticosteroid dose was equivalent to hydrocortisone 329.7±146.0 mg/day. Patients in the steroid group had higher hospital mortality than control group patients, but the difference did not achieve statistical significance (66.7% vs. 45.0%, respectively; p=0.21). Adjunctive corticosteroid therapy did not significantly reduce hospital length of stay or duration of mechanical ventilation when compared between the steroid and control groups (12.0±13.3 vs. 14.6±19.3 days, respectively; p=0.636 and 7.2±10.6 vs. 8.0±8.3 days, respectively; p=0.801). Conclusion: Adjunctive corticosteroid therapy had no significant positive effect on outcomes in pulmonary tuberculosis patients with acute respiratory failure.

The Morphological and Dynamic Changes of Ultrasound in the Evaluation of Effects of Oral Steroids Treatment for Patients with Carpal Tunnel Syndrome

The role of oral steroids in carpal tunnel syndrome (CTS) remains elusive. This study aims to depict the ultrasound findings and conceivable mechanisms in relation to the efficacy of oral steroids for patients with CTS by measuring the morphological and motion changes in the median nerve. In this study, CTS patients were randomized to the oral steroid group (14 participants and 22 wrists) or nicergoline group (22 participants and 35 wrists) for 4 weeks. Both treatment arms were given global symptom score (GSS) measurements and completed an ultra-sound at baseline and at 2- and 4-weeks post-treatment. In the nerve conduction study (NCS), distal motor latency (DML) was used to assess the treatment response at baseline and 4 weeks post-treatment. The cross-sectional area (CSA) and amplitude (AMP) evaluated by the maximum lateral sliding displacement represented the morphological and dynamic changes in the median nerve, respectively. The results showed that AMP, CSA, GSS, and DML were significantly im-proved in the steroid group, as compared to the nicergoline group at weeks 2 and 4 (p < 0.05). The mean improvement in ultrasound parameters CSA (15.03% reduction) and AMP (466.09% increase) was better than the DML (7.88% reduction) parameter of NCS, and ultrasound changes were detectable as early as 2 weeks after oral steroid administration. Ultrasounds can serve as a tool for the quantitative measurement of treatment effects and can potentially elucidate the pathogenesis of CTS in a non-invasive and more effective manner.

Nationwide Population-Based Epidemiological Study for Outcomes of Adjunctive Steroid Therapy in Pediatric Patients with Bacterial Meningitis in Taiwan

Although corticosteroids can serve as an effective anti-inflammatory adjuvant therapy, the role of adjunctive steroid therapy in pediatric bacterial meningitis in Taiwan remains under-investigated. Cases of acute bacterial meningitis, aged between 1 month and 20 years, were divided into a steroid group (empirical antibiotics with adjunctive steroid therapy) and a non-steroid group (empirical antibiotics only). Data were identified from the annual hospitalization discharge claims of the National Health Insurance Research Database using the International Classification of Diseases, Ninth Revision codes. Of the 8083 episodes enrolled in this study, 26% (2122/8083) and 74% (5961/8083) were divided into the steroid and non-steroid groups, respectively. The fatality rates were 7.9% in the steroid group and 1.7% in the non-steroid group during hospitalization (p < 0.0001). In the steroid and non-steroid groups, the median length of hospital stay was 13 and 6 days, respectively (p < 0.0001). Medical costs (median (interquartile range)) of hospitalization were 77,941 (26,647–237,540) and 26,653 (14,287–53,421) New Taiwan dollars in the steroid and non-steroid groups, respectively (p < 0.0001). The steroid group had a more fulminant course at baseline, a higher fatality rate, length of hospital stay, and medical cost of hospitalization. Therefore, the beneficial effects of the adjunctive use of corticosteroids in pediatric bacterial meningitis are inconclusive, and additional prospective multicenter investigations are required to clarify this issue.

The effects of a single-dose subacromial injection of a nonsteroidal anti-inflammatory drug in geriatric patients with subacromial impingement syndrome: a randomized double-blind study

Background: As nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids have similar effects, steroids can be avoided to reduce adverse effects. This study aimed to compare the differences in symptom improvement after subacromial injection of steroids or NSAIDs.Methods: Sixty patients with rotator cuff syndrome for at least 3 months were enrolled and divided into steroid and NSAID groups. The steroid group received a mixture of 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of lidocaine hydrochloride 2%, while the NSAID group received a mixture of 1 mL of Ketorolac Tromethamine (30 mg/mL) and 1 mL of lidocaine hydrochloride 2%. The patients were assessed before and at 3, 6, and 12 weeks after the procedure. Shoulder scores from visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) were used for evaluation.Results: Both groups showed improvements in the clinical outcomes. Overall VAS, ASES, and UCLA scores improved from 6.9, 32.7, and 16.0 before the procedure to 2.0, 1.2, and 1.1; 81.5, 87.6, and 88.5; and 29.7, 31.8, and 32.0 at weeks 3, 6, and 12 weeks after the procedure, respectively. Twenty-six patients (86.7%) in the steroid group and 28 (93.3%) in the NSAID group reported satisfactory treatment outcomes. There were no significant differences in the outcomes between the two groups (p=0.671).Conclusions: Subacromial injection of NSAIDs for rotator cuff tendinitis with shoulder pain had equivalent outcomes with those of steroid injection at the 12-week follow-up.

The combined use of steroids and immune checkpoint inhibitors in brain metastasis patients: a systematic review and meta-analysis

Background Immune checkpoint inhibitors (ICI) have been a breakthrough for selected cancer patients, including those with brain metastases (BMs). Likewise, steroids have been an integral component of symptomatic management of BM patients. However, clinical evidence on the interaction between ICI and steroids in BM patients is conflicting and has not adequately been summarized thus far. Hence, the aim of this study was to perform a systematic literature review and meta-analysis on the association between steroid use and overall survival (OS) in BM patients receiving ICI. Methods A systematic literature search was performed. Pooled effect estimates were calculated using random-effects models across included studies. Results After screening 1145 abstracts, fifteen observational studies were included. Fourteen studies reported sufficient data for meta-analysis, comprising 1102 BM patients of which 32.1% received steroids. In the steroid group, median OS ranged from 2.9-10.2 months. In the non-steroid group, median OS ranged from 4.9-25.1 months. Pooled results demonstrated significantly worse OS (HR 1.84, 95% CI 1.22-2.77) and systemic progression free survival (PFS; HR 2.00, 95% CI 1.37-2.91) in the steroid group. Stratified analysis showed a consistent effect across the melanoma subgroup; not in the lung cancer subgroup. No significant association was shown between steroid use and intracranial PFS (HR 1.31, 95% CI 0.42-4.07). Conclusions Administration of steroids was associated with significantly worse OS and PFS in BM patients receiving ICI. Further research on dose, timing, and duration of steroids is needed to elucidate the cause of this association and optimize outcomes in BM patients receiving ICI.

Febrile reaction after hematopoietic stem cell infusion is more frequent if no steroid premedicaton is given which results in more frequent use of antibiotics in early post-transplant phase

Background: There is no consensus as to the need for steroid premedication before fresh product hematopoietic stem cell (HSC) infusion. In case of febrile reaction post-HSC infusion, on-call staff frequently prescribe antibiotics empirically. Considering the recent data on the value of microbiota and its influence on GVHD incidence, we analysed the frequency of febrile reactions and the use of antibiotic after HSC infusion in 149 consecutive patients. Methods: In the time period between 1/2018 and 10/2019, 149 patients were subject to transplantation in our institution. Per institutional standard operating procedure (SOP), all the patients received premedication before hematopoietic stem cell infusion consisting of 20 mg chloropyramine-chlorid iv, and in case of ABO incompatible graft 1 mg/kg methylprednisolone iv. Retrospective data was collected by using patient charts. Survival probability was calculated by applying Kaplan-Meier method. Results: Fifty-two patients received steroids, 12 patients (23%) developing fever after graft infusion, 46 patients received no steroids, 26 of them (57%) developed fever (p&lt;0.001). There was no difference in the number of patients having positive blood cultures. Nine (17%) and 16 (35%) patients received IV antibiotics in the “steroid” and no-steroid” group, respectively (p&lt;0.05). There was no difference in survival between “steroid” and “no-steroid” group. Conclusions: Even with no difference in the frequency of febrile episodes caused by systemic infection, a significantly more patients not receiving steroid premedication develop fever and are treated with IV antibiotics, which could potentially have further implications on transplantation outcomes due to its influence on microbiota early post-transplant.

The Immediate Effects of Pulse Steroid versus Common Steroid therapy in Patients with SSNHL

Introduction: In this study we aimed to review immediate effects of pulse steroid therapy versus common steroid therapy in patients with idiopathic Sudden Sensory- Neural Hearing Loss. Materials and Methods: In this clinical trial study 50 patients with SSNHL in less than 24 hours before referral were involved. The causes of hearing loss should be rejected and if the cause was identified, the patient would be excluded. Pulse therapy group received Methyl Prednisolone 10 mg /kg for three days and then continued by prednisolone 1 mg /kg for ten days and common therapy group received prednisolone 1 mg /kg for ten days. Average hearing threshold of the patients in frequencies of 500, 1000, and 2000 Htz, average SDS of patients and patient recovery was compared between two groups based on hearing tests and guidelines. Results: Fifty patients with average of 46 ±15.69 years were studied. There was no significant difference in average of hearing threshold in different frequencies and SDS between two groups. Mean hearing recovery was 10.69 db in common steroid group and it was 13.51 db in pulse steroid group. Although the mean of hearing recovery was higher in the pulse steroid group compare the common steroid group, there was no significant difference in hearing recovery after the treatment between two groups. Conclusion: According to the results pulse steroid is not preferable rather than common steroid therapy in terms of immediate therapeutic effects on SSNHL.