Brain microvascular occlusive disorder in COVID-19: a case report.

We describe the case of a COVID-19 patient with severely impaired consciousness after sedation hold, showing magnetic resonance imaging (MRI) findings of (i) acute bilateral supratentorial ischemic lesions involving the fronto-parietal white matter and the corpus callosum and (ii) multiple diffuse susceptibility weighted imaging (SWI) hypointense foci, infra and supratentorial, predominantly bithalamic, suggestive of microhemorrhage or alternatively microthrombi. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) RNA was detected in the cerebrospinal fluid. Our findings suggest the occurrence of vascular damage, predominantly involving microvessels. The underlying mechanisms, which include direct and indirect penetration of the virus to the central nervous system and systemic cardiorespiratory complications, are yet to be elucidated, and a direct correlation with SARS-CoV-2 infection remains uncertain.

Return to Work and Participation in Society After Out-of-Hospital Cardiac Arrest.

BACKGROUND: The aim of this study was to describe out-of-hospital cardiac arrest (OHCA) survivors' ability to participate in activities of everyday life and society, including return to work. The specific aim was to evaluate potential effects of cognitive impairment. METHODS AND RESULTS: Two hundred eighty-seven OHCA survivors included in the TTM trial (Target Temperature Management) and 119 matched control patients with ST-segment-elevation myocardial infarction participated in a follow-up 180 days post-event that included assessments of participation, return to work, emotional problems, and cognitive impairment. On the Mayo-Portland Adaptability Inventory-4 Participation Index, OHCA survivors (n=270) reported more restricted participation In everyday life and in society (47% versus 30%; P<0.001) compared with ST-segment-elevation myocardial infarction controls (n=118). Furthermore, 27% (n=36) of pre-event working OHCA survivors (n=135) compared with 7% (n=3) of pre-event working ST-segment-elevation myocardial infarction controls (n=45) were on sick leave (odds ratio, 4.9; 95% confidence interval, 1.4-16.8; P=0.01). Among the OHCA survivors assumed to return to work (n=135), those with cognitive impairment (n=55) were 3× more likely (odds ratio, 3.3; 95% confidence interval, 1.2-9.3; P=0.02) to be on sick leave compared with those without cognitive impairment (n=40; 36%, n=20, versus 15%, n=6). For OHCA survivors, the variables that were found most predictive for a lower participation were depression, restricted mobility, memory impairment, novel problem-solving difficulties, fatigue, and slower processing speed. CONCLUSIONS: OHCA survivors reported a more restricted societal participation 6 months post-arrest, and their return to work was lower compared with ST-segment-elevation myocardial infarction controls. Cognitive impairment was significantly associated with lower participation, together with the closely related symptoms of fatigue, depression, and restricted mobility. These predictive variables may be used during follow-up to identify OHCA survivors at risk of a less successful recovery that may benefit from further support and rehabilitation. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01946932.

Mortality and long-term quality of life after percutaneous tracheotomy in Intensive Care Unit: a prospective observational study.

BACKGROUND: Quality of life and mortality after percutaneous dilatational tracheotomy (PDT) has been poorly investigated. The aims of this study were to evaluate the independent risk factors for Intensive Care Unit (ICU) mortality and investigate quality of life over the first year after PDT in critically ill patients. METHODS: This was a prospective, single-center, cohort study performed in a tertiary care University Hospital, enrolling consecutive ICU patients requiring elective PDT, collecting data during the tracheotomy procedure and the ICU stay. Follow-up was performed at three, six and twelve months after PDT. The medical interview included the Euro Quality of Life questionnaire comprising five dimensions (mobility, self-care, usual activities, pain/discomfort, anxiety/depression). RESULTS: A total of 137 patients were included in the study. In the multivariate analysis, ICU mortality was independently associated with age (OR 1.089; P=0.003) and SAPS II (OR 1.047; P=0.003), and inversely with neurologic disease (OR 0.162; P=0.004). Mortality increased over time (ICU mortality 26.7%; in-hospital mortality 43.1%; 3-months mortality 47.4%; 6-months mortality 61.3%; and 1-year mortality 70.8%; P=0.0001). Tracheostomized patients due to respiratory disease had a higher ICU mortality (50%) compared to those with neurological disease (13.6%). quality of life (QoL) of tracheostomized patients was severely compromised at 3-months (QoL: 17, 15-19), 6-months (QoL: 17; 16-19), while moderately compromised at 1-year (QoL: 13; 9-16). A subgroup analysis showed better QoL at 3-months, 6-months and 1-year in respiratory compared to neurological tracheostomized patients (P=0.01). CONCLUSIONS: Patients baseline characteristics and indication for PDT procedure are important determinants of in-ICU mortality and QoL in tracheostomized patients.

Antibacterial activity of standard and N-doped titanium dioxide-coated endotracheal tubes: an in vitro study. / Atividade antibacteriana de tubos endotraqueais revestidos com dióxido de titânio padrão e dopados com nitrogênio: um estudo in vitro.

OBJECTIVE:: The aim of this study was to assess the antibacterial activity against Staphylococcus aureus and Pseudomonas aeruginosa of two nanoparticle endotracheal tube coatings with visible light-induced photocatalysis. METHODS:: Two types of titanium dioxide nanoparticles were tested: standard anatase (TiO2) and N-doped TiO2 (N-TiO2). Nanoparticles were placed on the internal surface of a segment of commercial endotracheal tubes, which were loaded on a cellulose acetate filter; control endotracheal tubes were left without a nanoparticle coating. A bacterial inoculum of 150 colony forming units was placed in the endotracheal tubes and then exposed to a fluorescent light source (3700 lux, 300-700 nm wavelength) for 5, 10, 20, 40, 60 and 80 minutes. Colony forming units were counted after 24 hours of incubation at 37°C. Bacterial inactivation was calculated as the percentage reduction of bacterial growth compared to endotracheal tubes not exposed to light. RESULTS:: In the absence of light, no relevant antibacterial activity was shown against neither strain. For P. aeruginosa, both coatings had a higher bacterial inactivation than controls at any time point (p < 0.001), and no difference was observed between TiO2 and N-TiO2. For S. aureus, inactivation was higher than for controls starting at 5 minutes for N-TiO2 (p = 0.018) and 10 minutes for TiO2 (p = 0.014); inactivation with N-TiO2 was higher than that with TiO2 at 20 minutes (p < 0.001), 40 minutes (p < 0.001) and 60 minutes (p < 0.001). CONCLUSIONS:: Nanosized commercial and N-doped TiO2 inhibit bacterial growth under visible fluorescent light. N-TiO2 has higher antibacterial activity against S. aureus compared to TiO2.

Atividade antibacteriana de tubos endotraqueais revestidos com dióxido de titânio padrão e dopados com nitrogênio: um estudo in vitro / Antibacterial activity of standard and N-doped titanium dioxide-coated endotracheal tubes: an in vitro study

RESUMO Objetivo: Avaliar a atividade antibacteriana contra Staphylococcus aureus e Pseudomonas aeruginosa de dois revestimentos endotraqueais com nanopartículas e fotocatálise sob luz visível. Métodos: Testaram-se dois tipos de nanopartículas de titânio: anatase padrão (TiO2) e TiO2 nano-dopada (N-TiO2). As nanopartículas foram colocadas em superfície interna de segmentos de tubos endotraqueais comerciais, aplicadas sobre um filtro de acetato de celulose; os tubos endotraqueais controle foram deixados sem revestimento de nanopartículas. Em cada tubo endotraqueal foi inoculado um total de 150 unidades formadoras de colônia e, a seguir, estes foram expostos a uma fonte de luz fluorescente (3700 lux, comprimento de onda de 300 - 700nm) por 5, 10, 20, 40, 60 e 80 minutos. Contaram-se as Unidades Formadoras de Colônia após 24 horas de incubação a 37ºC. A inativação bacteriana foi calculada como a redução porcentual do crescimento bacteriano em comparação a tubos não expostos à luz. Resultados: Na ausência de luz, não se observou qualquer atividade antibacteriana relevante contra qualquer das cepas estudadas. Para P. aeruginosa, ambos os revestimentos tiveram inativação bacteriana mais elevada do que o controle em qualquer dos momentos de avaliação (p < 0,001), sendo que não se observaram diferenças entre o revestimento padrão e nano-dopado. Para S. aureus, a inativação foi maior que os controles, começando a partir de 5 minutos para nano-dopado (p = 0,018) e 10 minutos para o revestimento padrão (p = 0,014); a inativação com a forma nano-dopada foi maior do que com a forma padrão aos 20 minutos (p < 0,001), 40 minutos (p < 0,001) e 60 minutos (p < 0,001). Conclusões: O revestimento com nanopartículas de titânio comercial padrão e nano-dopado inibiu o crescimento bacteriano sob a luz fluorescente visível. o revestimento nano-dopado teve maior atividade antibacteriana contra S. aureus em comparação à atividade observada com o revestimento com anatase padrão.

ABSTRACT Objective: The aim of this study was to assess the antibacterial activity against Staphylococcus aureus and Pseudomonas aeruginosa of two nanoparticle endotracheal tube coatings with visible light-induced photocatalysis. Methods: Two types of titanium dioxide nanoparticles were tested: standard anatase (TiO2) and N-doped TiO2 (N-TiO2). Nanoparticles were placed on the internal surface of a segment of commercial endotracheal tubes, which were loaded on a cellulose acetate filter; control endotracheal tubes were left without a nanoparticle coating. A bacterial inoculum of 150 colony forming units was placed in the endotracheal tubes and then exposed to a fluorescent light source (3700 lux, 300-700 nm wavelength) for 5, 10, 20, 40, 60 and 80 minutes. Colony forming units were counted after 24 hours of incubation at 37°C. Bacterial inactivation was calculated as the percentage reduction of bacterial growth compared to endotracheal tubes not exposed to light. Results: In the absence of light, no relevant antibacterial activity was shown against neither strain. For P. aeruginosa, both coatings had a higher bacterial inactivation than controls at any time point (p < 0.001), and no difference was observed between TiO2 and N-TiO2. For S. aureus, inactivation was higher than for controls starting at 5 minutes for N-TiO2 (p = 0.018) and 10 minutes for TiO2 (p = 0.014); inactivation with N-TiO2 was higher than that with TiO2 at 20 minutes (p < 0.001), 40 minutes (p < 0.001) and 60 minutes (p < 0.001). Conclusions: Nanosized commercial and N-doped TiO2 inhibit bacterial growth under visible fluorescent light. N-TiO2 has higher antibacterial activity against S. aureus compared to TiO2.

Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome.

OBJECTIVE: Volutrauma and atelectrauma promote ventilator-induced lung injury, but their relative contribution to inflammation in ventilator-induced lung injury is not well established. The aim of this study was to determine the impact of volutrauma and atelectrauma on the distribution of lung inflammation in experimental acute respiratory distress syndrome. DESIGN: Laboratory investigation. SETTING: University-hospital research facility. SUBJECTS: Ten pigs (five per group; 34.7-49.9 kg) INTERVENTIONS: : Animals were anesthetized and intubated, and saline lung lavage was performed. Lungs were separated with a double-lumen tube. Following lung recruitment and decremental positive end-expiratory pressure trial, animals were randomly assigned to 4 hours of ventilation of the left (ventilator-induced lung injury) lung with tidal volume of approximately 3 mL/kg and 1) high positive end-expiratory pressure set above the level where dynamic compliance increased more than 5% during positive end-expiratory pressure trial (volutrauma); or 2) low positive end-expiratory pressure to achieve driving pressure comparable with volutrauma (atelectrauma). The right (control) lung was kept on continuous positive airway pressure of 20 cm H2O, and CO2 was partially removed extracorporeally. MEASUREMENTS AND MAIN RESULTS: Regional lung aeration, specific [F]fluorodeoxyglucose uptake rate, and perfusion were assessed using computed and positron emission tomography. Volutrauma yielded higher [F]fluorodeoxyglucose uptake rate in the ventilated lung compared with atelectrauma (median [interquartile range], 0.017 [0.014-0.025] vs 0.013 min [0.010-0.014 min]; p < 0.01), mainly in central lung regions. Volutrauma yielded higher [F]fluorodeoxyglucose uptake rate in ventilator-induced lung injury versus control lung (0.017 [0.014-0.025] vs 0.011 min [0.010-0.016 min]; p < 0.05), whereas atelectrauma did not. Volutrauma decreased blood fraction at similar perfusion and increased normally as well as hyperaerated lung compartments and tidal hyperaeration. Atelectrauma yielded higher poorly and nonaerated lung compartments, and tidal recruitment. Driving pressure increased in atelectrauma. CONCLUSIONS: In this model of acute respiratory distress syndrome, volutrauma promoted higher lung inflammation than atelectrauma at comparable low tidal volume and lower driving pressure, suggesting that static stress and strain are major determinants of ventilator-induced lung injury.

Cognitive function in survivors of out-of-hospital cardiac arrest after target temperature management at 33°C versus 36°C.

BACKGROUND: Target temperature management is recommended as a neuroprotective strategy after out-of-hospital cardiac arrest. Potential effects of different target temperatures on cognitive impairment commonly described in survivors have not been investigated sufficiently. The primary aim of this study was to evaluate whether a target temperature of 33°C compared with 36°C was favorable for cognitive function; the secondary aim was to describe cognitive impairment in cardiac arrest survivors in general. METHODS AND RESULTS: Study sites included 652 cardiac arrest survivors originally randomized and stratified for site to temperature control at 33°C or 36°C within the Target Temperature Management trial. Survival until 180 days after the arrest was 52% (33°C, n=178/328; 36°C, n=164/324). Survivors were invited to a face-to-face follow-up, and 287 cardiac arrest survivors (33°C, n=148/36°C, n=139) were assessed with tests for memory (Rivermead Behavioural Memory Test), executive functions (Frontal Assessment Battery), and attention/mental speed (Symbol Digit Modalities Test). A control group of 119 matched patients hospitalized for acute ST-segment-elevation myocardial infarction without cardiac arrest performed the same assessments. Half of the cardiac arrest survivors had cognitive impairment, which was mostly mild. Cognitive outcome did not differ (P>0.30) between the 2 temperature groups (33°C/36°C). Compared with control subjects with ST-segment-elevation myocardial infarction, attention/mental speed was more affected among cardiac arrest patients, but results for memory and executive functioning were similar. CONCLUSIONS: Cognitive function was comparable in survivors of out-of-hospital cardiac arrest when a temperature of 33°C and 36°C was targeted. Cognitive impairment detected in cardiac arrest survivors was also common in matched control subjects with ST-segment-elevation myocardial infarction not having had a cardiac arrest. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01946932.