Predictors of admission to intensive care unit among systemic lupus erythematosus patients: prospective study

Background Through the disease course, different prognostic factors have been addressed in patients with SLE admitted to intensive care unit. For instance, higher disease activity on admission, recent immunosuppressive therapy, infections, renal disease, and central nervous system involvement, all had negative effects on the outcome of the disease. It is still a clinical challenge for the physicians to manage this disease which has many aspects regarding its pathogenesis, clinical presentation, and its outcome remains to be explained. The aim of our study was determining the course, outcome, and determinants of admission to intensive care unit in patients with systemic lupus erythematosus. Results Patients with systemic lupus erythematosus admitted to the intensive care unit in the study sample was 21.4%, and the death rate among them is 18.2%. In our study, the main causes of intensive care admission were cardiovascular causes followed by renal failure then infections. Holding the other covariates constant, a higher value of CRP, SLEDAI, and damage index value is associated with intensive care admission among lupus patients. Conclusion Our study showed that systemic lupus erythematosus patients with a higher value of CRP, SLEDAI, and damage index value were liable for intensive care unit admission. Good control of disease activity of SLE which in turn reduces damage of different body systems is mandatory. Periodic screening for functions of renal and cardiac systems is of great value. Proper screening and prophylaxis is recommended against variable causes of infections. Rheumatologists should be careful in controlling SLE active disease and to balance the doses of immunosuppressive especially in the presence of infection. They should focus the research on finding more accurate infection predictive index parameters to early predict the onset of infection.

Incidence Rate of ALI in COVID-19 Patients

Background: With the outbreak of COVID19, acute lung injury has been detected as the main etiology for intensive care admission and high mortality rate. Among the infected population, there is some percentage of those who tend to develop acute respiratory distress syndrome and respiratory failure. Thus, the intensivist and anesthesiologist must be aware of the of incidence rate of ARDS, risk factors, and try to take measures to reduce its incidence. To define the rate of incidence of acute lung injury and ARDS among COVID 19 patient. Methods: We performed a narrative review via searching in three databases PubMed, Google Scholar and Embase for all studies that mentioned the incidence of acute lung injury among infected patients with COVID19, manual searching also completed. All the selected reviews were limited to the English language and data also. Results: Five searches referred to the exact number of patients and the percentage rate of incidence of ARDS related to COVID 19 infection, other articles are merely reviews and case reports. Conclusion: Incidence of acute lung injury among COVID19 patient was highly reported, and some percentage of these cases tend to develop ARDS especially in those who have preexisting diseases and obesity.

Outpatient endoscopic resection of large calcified thoracic disc herniation with caudal displacement

Thoracic disc herniations can cause radiculopathy and myelopathy from neural compression. Surgical resection may require complex, morbid approaches. To avoid spinal cord retraction, wide exposures requiring extensive tissue, muscle, and bony disruption are needed, which may require instrumentation. Anterior approaches may require vascular surgeons, chest tube placement, and intensive care admission. Large, calcified discs or migrated fragments can pose additional challenges. Previous literature has noted the endoscopic approach to be contraindicated for calcified thoracic discs. The authors describe an ultra–minimally invasive, ambulatory endoscopic approach to resect a large calcified thoracic disc with caudal migration and avoidance of conventional approaches. The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID2112

Increased Risk of Poor Clinical Outcome in COVID-19 Patients with Diabetes Mellitus and in-hospital Mortality Predictors: A Retrospective Cohort from a Tertiary Hospital in Indonesia

Aim: To determine association between diabetes in confirmed cases of COVID-19 and intensive care admission and in-hospital mortality, evaluate several laboratory parameters as mortality predictor, and develop predictors of in-hospital mortality among diabetics with COVID-19. Methods: This retrospective cohort recruited all cases of COVID-19 hospitalized in Fatmawati General Hospital during March to October 2020. Inclusion criteria was RT-PCR confirmed cases of COVID-19 who aged 18 years and older while exclusion criteria were incomplete medical record or cannot be found and pregnant women. Results: We enrolled 506 participants to this study with median age of 51 years (IQR:22), female (56.32%), and diabetes (28.46%). Diabetes increased intensive care admission (adjusted OR:6.07;95%CI:3.52-10,43) and in-hospital mortality (adjusted OR:50;95%CI:1.61-3.89). In predicting in-hospital mortality, ferritin and lactate dehydrogenase offered an acceptable discrimination, AUC:0.71 (95%CI: 0.62-0.79) and AUC:0.70 (95%CI: 0.61-0.78), respectively. The optimal cut-off of predicting mortality for ferritin was 786 g/mL and for LDH was 514.94 u/L. Factors include age above 70 years old, RBGs level on admission above 250 mg/dL or below 140 mg/dL, ferritin level above 786 ng/mL, and presence of ARDS increased the odds of mortality among individuals with diabetes. Conclusions: Diabetes increases risk intensive care admission and in hospital mortality in COVID-19. Multivariate analysis showed that older age, RBG on admission, high ferritin level, presence of ARDS increased the odds of mortality among individuals with diabetes.

Risk of SARS-CoV-2 reinfections in children: prospective national surveillance, January 2020 to July 2021, England

BackgroundReinfection after primary SARS-CoV-2 infection is uncommon in adults, but little is known about the risks, characteristics, severity or outcomes of reinfection in children.MethodsWe used national SARS-CoV-2 testing data in England to estimate the risk of reinfection ≥90 days after primary infection from 01 January 2020 to 31 July 2021, which encompassed both the Alpha and Delta waves in England. Disease severity was assessed by linking reinfection cases to national hospitalisation, intensive care admission and death registrations datasets.FindingsReinfection rates closely followed community infection rates, with a small peak during the Alpha wave and a larger peak during the Delta wave. In children aged ≤16 years, there were 688,418 primary infections and 2,343 reinfections. The overall reinfection rate was 66·88/100,000 population, being higher in adults (72.53/100,000) than in children (21·53/100,000). Reinfection rates after primary infection were 0·68% overall, 0·73% in adults and 0·34% in children. Of the 109 reinfections in children admitted to hospital, 78 (72%) had underlying comorbidities. Hospitalisation rates were similar for the first (64/2343, 2·73%) and second episode (57/2343, 2·43%). Intensive care admission was rare after primary infection (n=7) or reinfection (n=4), mainly in children with comorbidities. 44 deaths occurred after primary infection within 28 days of diagnosis (44/688,418, 0·01%), none after possible reinfections.InterpretationThe risk of SARS-CoV-2 reinfection is strongly related to exposure due to community infection rates, especially during the Delta variant wave. Children had a lower risk of reinfection than adults, but reinfections were not associated with more severe disease or fatal outcomes.FundingPHE/UKHSAResearch in ContextEvidence Before this studyWe searched PubMed with the terms “COVID-19” or “SARS-CoV-2” with “reinfection” to identify publications relating to SARS-CoV-2 reinfections from 01 January until 15 November 2021. There were few publications relating to SARS-CoV-2 reinfections, and these primarily related to adults. Published studies reported very low rates of reinfection during the first few months after primary infection in adults. COVID-19 vaccines provide effective immune protection against SARS-CoV-2 infection, but recent studies have reported increasing risk of breakthrough infection with time since primary vaccination due to waning immunity. Several SARS-CoV-2 variants, including the beta, gamma and delta variants have been shown to partially evade immunity after natural infection and vaccination, potentially increasing the risk of reinfections and breakthrough infections, respectively. Data on reinfections in children are lacking and restricted mainly to case reports in immunocompromised children.Added Value of This StudyWe used national SARS-CoV-2 testing data during the first 19 months of the pandemic to estimate the risk of reinfection in children compared to adults during a period that encompassed both the Alpha and the Delta variant waves in England. We found that the risk of reinfection correlated with the risk of SARS-CoV-2 exposure and therefore, closely reflected community infection rates, with most reinfections occurring during the Delta variant wave. Whilst acknowledging the limitation of using national testing data, we found that children had a lower risk of reinfection compared to adults and that the risk of reinfection in children increased with age. Reinfections were not associated with severe disease in terms of hospitalization or intensive care admission and there were no fatalities within 28 days of the reinfection episode in children.Implications of all the Available EvidenceSARS-CoV-2 reinfections are rare in children, especially younger children, and occurred mainly during the Delta wave in England. Reinfections were not associated with more severe disease or fatal outcomes in children. COVID-19 vaccination will provide further protection against primary infections and reinfections in children.

Caregiving for Persons Living With Dementia in the New Normal: Family Caregiver’s Perspective

Persons living with dementia (PLWD) are at increased risk for COVID-19 and associated poor outcomes, including: incident delirium, hospitalization, severe symptoms, intensive care admission, and even death. PLWD are likely to rely on family caregivers to maintain their health and well-being in the community. Under normal circumstances, caregiving can be stressful and complex, and the COVID-19 pandemic has the potential to change and exacerbate the stresses of family caregiving. As a part of a larger study using descriptive qualitative methodology to explore the family caregiver understanding and experiences related to delirium in caring for a person with dementia, 14 participants (age x̄ =67, SD= 13.8) were asked about the impact of COVID-19 on their caregiving for PLWD. Thematic analysis of the transcribed interviews using Dedoose generated four overarching themes associated with the family caregiver’s perspective of changes in caregiving during the COVID-19 pandemic: 1) Cautious of COVID-19 exposure, 2) We can’t go in, 3) Feeling of isolation for both the PLWD and caregiver, and 4) Six-feet distance. The current study highlights the importance of understanding the needs of PLWD during a pandemic based upon the perspective of their family caregivers and will inform the development of ways to safely incorporate family caregivers in the interdisciplinary care team. Caregivers are integral to the care of PLWD across settings of care and should be partners even during a pandemic. Solutions for care include integrating technology for individualized approaches. Finally, future areas for research will be discussed.

Critical Care, Psychology, and Rehabilitation

This chapter discusses the integration of psychological and rehabilitative interventions into critical care practice and indicates how it can have a positive impact on desired outcomes, both short and long term. While there is a specific focus on postintensive care syndrome, the author also outlines overlapping issues relevant to caring for those with critical injuries and physical trauma. The chapter reviews barriers to developing truly interdisciplinary teams and how to address factors that interfere with the coordination of care. The importance of psychology and rehabilitation involvement across the critical care continuum is emphasized while also providing a summary of the literature supporting the efficacy of rehabilitation on and after the intensive care admission.