A Survey to Assess Primary Care Physician Awareness of Complications Following Critical Illness.

Background: Survivors of critical illness are at risk for post-intensive care syndrome (PICS, comprised of physical dysfunction, cognitive impairment, and neuropsychiatric disorders including anxiety, depression, and post-traumatic stress). Their family members and caregivers are at risk for PICS-F (PICS-family, comprised of anxiety, depression, post-traumatic stress). PICS and PICS-F are increasingly recognized in critical care; however, the awareness among primary providers of the domains and the terms of PICS/PICS-F is unknown. Objectives: To determine current practice patterns and knowledge among primary care physicians in regards to patients recovering from critical illness; to determine barriers to care of post-critically ill patients. Methods: A paper and electronic survey were developed and randomly distributed to a subset of North Carolina primary care physicians. Survey questions consisted of the following domains: demographics, current practice, barriers to providing care, knowledge of common issues/complications following critical illness, and interest in changing care for survivors of critical illness. Results: One hundred and ninety-six surveys were delivered and 77 completed surveys (39% response rate) were analyzed. Respondents confirmed significant barriers to care of post-critically ill patients including lack of awareness of PICS/PICS-F terminology, insufficient time to spend with patients, and inadequate education of patients/families about recovery after critical illness. Fifty-seven percent of respondents thought a specialized transitional post-ICU clinic would be helpful. Sixty-two percent reported feeling comfortable caring for patients after a critical illness and 75% felt they were aware of common problems encountered after critical illness. However, 84% also thought more education about PICS/PICS-F would be helpful as would a list of common problems seen after critical illness (91%). Conclusions: Significant gaps and barriers to providing optimal post-ICU care by PCPs exist. Providers identified time constraints and educational gaps as domains needing attention. Dedicated post-ICU clinics might provide a bridge to transition care post-critical illness back to primary care providers.

Acute Thrombotic Microangiopathy and Cortical Necrosis Following Administration of Alemtuzumab: A Case Report.

Alemtuzumab, a humanized monoclonal antibody that targets CD52 antigens on lymphocytes and monocytes, has shown efficacy in preventing relapse in relapsing-remitting multiple sclerosis. Despite known severe (yet rare) renal side effects such as anti-glomerular basement membrane disease and membranous glomerulopathy, to our knowledge, alemtuzumab has never been documented to cause drug-induced thrombotic microangiopathy. We describe a 39-year-old woman with relapsing-remitting multiple sclerosis who developed acute kidney injury requiring renal replacement therapy after 1 dose of alemtuzumab, as well as microangiopathic hemolytic anemia and thrombocytopenia. Pathologic examination of a kidney biopsy specimen demonstrated extensive cortical necrosis and arteriolar fibrin thrombi with nonspecific immunofluorescence staining of immunoglobulin M and C3 and absence of immune deposits on electron microscopy. These findings were consistent with the diagnosis of acute thrombotic microangiopathy. She received dexamethasone and underwent plasmapheresis, which was unsuccessful at removing alemtuzumab. The patient received renal replacement therapy for approximately 7 weeks, followed by slow recovery of kidney function that returned close to her baseline.

The role of the RAPID score in surgical planning for empyema.

Background: The RAPID [Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)] score is a validated scoring system which allows risk stratification in patients with pleural infection at presentation. Surgical intervention plays a key role in managing pleural empyema. Methods: A retrospective study of patients with complicated pleural effusions and/or empyema undergoing thoracoscopic or open decortication admitted to multiple affiliated Texas hospitals from September 1, 2014 to September 30, 2018. The primary outcome was all-cause 90-day mortality. The secondary outcomes were organ failure, length of stay and 30-day readmission rate. The outcomes were compared between early surgery (≤3 days from diagnosis) and late surgery (>3 days from diagnosis) and low [0-3] vs. high [4-7] RAPID scores. Results: We enrolled 182 patients. Late surgery was associated with increased organ failure (64.0% vs. 45.6%, P=0.0197) and longer length of stay (16 vs. 10 days, P<0.0001). High RAPID scores were associated with a higher 90-day mortality (16.3% vs. 2.3%, P=0.0014), and organ failure (81.6% vs. 49.6%, P=0.0001). High RAPID scores with early surgery were associated with higher 90-day mortality (21.4% vs. 0%, P=0.0124), organ failure (78.6% vs. 34.9%, P=0.0044), 30-day readmission (50.0% vs. 16.3%, P=0.027) and length of stay (16 vs. 9 days, P=0.0064). High vs. low RAPID scores with late surgery was associated with a higher rate of organ failure (82.9% vs. 56.7%, P=0.0062), but there was not a significant association with mortality. Conclusions: We found a significant association between RAPID scores and surgical timing with new organ failure. Patients with complicated pleural effusions who had early surgery and low RAPID scores experienced better outcomes including decreased length of stay and organ failure compared with those who had late surgery and low RAPID scores. This suggests that using the RAPID score may help identify those who would benefit from early surgery.

Pleural tuberculosis.

A 35-year-old woman with previously untreated latent tuberculosis was admitted to the hospital for management of a right-sided empyema. After a prolonged hospitalization and several interventions, including chest tubes, bronchoscopy with bronchoalveolar lavage, and a video-assisted thoracoscopic surgery, positive acid-fast bacilli cultures on the initial thoracentesis ultimately led to the diagnosis of pleural tuberculosis. This case highlights the importance of utilizing a combination of diagnostic tests to diagnose pleural tuberculosis, especially in the setting of a negative pleural adenosine deaminase level.