Post-COVID-19 Syndrome: Theoretical Basis, Identification, and Management.

As COVID-19 continues to spread, with the United States surpassing 29 million cases, health care workers are beginning to see patients who have been infected with SARS-CoV-2 return seeking treatment for its longer-term physical and mental effects. The term long-haulers is used to identify patients who have not fully recovered from the illness after weeks or months. Although the acute symptoms of COVID-19 have been widely described, the longer-term effects are less well known because of the relatively short history of the pandemic. Symptoms may be due to persistent chronic inflammation (eg, fatigue), sequelae of organ damage (eg, pulmonary fibrosis, chronic kidney disease), and hospitalization and social isolation (eg, muscle wasting, malnutrition). Health care providers are instrumental in developing a comprehensive plan for identifying and managing post-COVID-19 complications. This article addresses the possible etiology of postviral syndromes and describes reported symptoms and suggested management of post-COVID syndrome.

Memory-Related Frontal Brainwaves Predict Transition to Mild Cognitive Impairment in Healthy Older Individuals Five Years Before Diagnosis.

BACKGROUND: Early prognosis of high-risk older adults for amnestic mild cognitive impairment (aMCI), using noninvasive and sensitive neuromarkers, is key for early prevention of Alzheimer's disease. We have developed individualized measures in electrophysiological brain signals during working memory that distinguish patients with aMCI from age-matched cognitively intact older individuals. OBJECTIVE: Here we test longitudinally the prognosis of the baseline neuromarkers for aMCI risk. We hypothesized that the older individuals diagnosed with incident aMCI already have aMCI-like brain signatures years before diagnosis. METHODS: Electroencephalogram (EEG) and memory performance were recorded during a working memory task at baseline. The individualized baseline neuromarkers, annual cognitive status, and longitudinal changes in memory recall scores up to 10 years were analyzed. RESULTS: Seven of the 19 cognitively normal older adults were diagnosed with incident aMCI for a median 5.2 years later. The seven converters' frontal brainwaves were statistically identical to those patients with diagnosed aMCI (n = 14) at baseline. Importantly, the converters' baseline memory-related brainwaves (reduced mean frontal responses to memory targets) were significantly different from those who remained normal. Furthermore, differentiation pattern of left frontal memory-related responses (targets versus nontargets) was associated with an increased risk hazard of aMCI (HR = 1.47, 95% CI 1.03, 2.08). CONCLUSION: The memory-related neuromarkers detect MCI-like brain signatures about five years before diagnosis. The individualized frontal neuromarkers index increased MCI risk at baseline. These noninvasive neuromarkers during our Bluegrass memory task have great potential to be used repeatedly for individualized prognosis of MCI risk and progression before clinical diagnosis.

COVID-19: An Immunopathologic Assault.

When caring for patients with coronavirus disease 2019 (COVID-19), clinicians have noticed some unusual clinical presentations not observed before, such as profound hypoxia and severe hypotension. Scientists are probing the evidence to explain these issues and many other unanswered questions. Severe acute respiratory syndrome associated with coronavirus 2 presents an unchartered acute and critical care dilemma. Some of the theories and proposed interventions that will improve outcomes for these critically ill patients are explored in this article. Various testing procedures for COVID-19 are described so valid results can be obtained. Clinical presentations are discussed but continue to evolve as the pandemic ravages our society. The psychological impact of this devastation is also addressed from multiple perspectives. The health care provider is faced with an unprecedented, harrowing situation that has become an internal war that also must be confronted. Professional dedication has provided a formidable response to this destructive virus.

Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM.

Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.

Immunology and Immunotherapy in Critical Care: An Overview.

Until recently, immunology was not a major focus of attention in the acute and critical care setting. With the evolution of immunotherapy, however-including the development of monoclonal antibodies, checkpoint inhibitors, and adoptive cellular therapies-an in-depth understanding of the immune system has become necessary to properly care for acutely ill patients. Lymphocytes (ie, T cells and B cells) play a major role in the daily functioning of the immune response. The interaction of these cells in protecting the body against infection and foreign substances is complicated and is the basis for many of the innovations in immunology and cancer treatment. This article explores basic immunology concepts, new drug categories, and adoptive cellular therapies that are at the forefront of cancer therapy.

Spared behavioral repetition effects in Alzheimer's disease linked to an altered neural mechanism at posterior cortex.

OBJECTIVE: Individuals with dementia of the Alzheimer type (AD) classically show disproportionate impairment in measures of working memory, but repetition learning effects are relatively preserved. As AD affects brain regions implicated in both working memory and repetition effects, the neural basis of this discrepancy is poorly understood. We hypothesized that the posterior repetition effect could account for this discrepancy due to the milder effects of AD at visual cortex. METHOD: Participants with early AD, amnestic mild cognitive impairment (MCI), and healthy controls performed a working memory task with superimposed repetition effects while electroencephalography was collected to identify possible neural mechanisms of preserved repetition effects. RESULTS: Participants with AD showed preserved behavioral repetition effects and a change in the posterior repetition effect. CONCLUSION: Visual cortex may play a role in maintained repetition effects in persons with early AD.

A cognitive electrophysiological signature differentiates amnestic mild cognitive impairment from normal aging.

BACKGROUND: Noninvasive and effective biomarkers for early detection of amnestic mild cognitive impairment (aMCI) before measurable changes in behavioral performance remain scarce. Cognitive event-related potentials (ERPs) measure synchronized synaptic neural activity associated with a cognitive event. Loss of synapses is a hallmark of the neuropathology of early Alzheimer's disease (AD). In the present study, we tested the hypothesis that ERP responses during working memory retrieval discriminate aMCI from cognitively normal controls (NC) matched in age and education. METHODS: Eighteen NC, 17 subjects with aMCI, and 13 subjects with AD performed a delayed match-to-sample task specially designed not only to be easy enough for impaired participants to complete but also to generate comparable performance between subjects with NC and those with aMCI. Scalp electroencephalography, memory accuracy, and reaction times were measured. RESULTS: Whereas memory performance separated the AD group from the others, the performance of NC and subjects with aMCI was similar. In contrast, left frontal cognitive ERP patterns differentiated subjects with aMCI from NC. Enhanced P3 responses at left frontal sites were associated with nonmatching relative to matching stimuli during working memory tasks in patients with aMCI and AD, but not in NC. The accuracy of discriminating aMCI from NC was 85% by using left frontal match/nonmatch effect combined with nonmatch reaction time. CONCLUSIONS: The left frontal cognitive ERP indicator holds promise as a sensitive, simple, affordable, and noninvasive biomarker for detection of early cognitive impairment.

Research in Review: Advancing Critical Care Practice.

Research published in 2016 identified strategies to enhance acute and critical care, initiated discussions on professional roles and responsibilities, clarified complex care issues, and led to robust debate. Some of this important work addressed strategies to prevent delirium and pressure ulcers, considerations for pain management within the context of the opioid abuse crisis, strategies to guide fluid resuscitation in patients with sepsis and heart failure, and ways to enhance care for family members of intensive care patients. The new sepsis definitions highlight the importance of detecting and providing care to patients with sepsis outside of critical care areas. Chimeric antigen receptor T-cell therapy is an example of the advancement of research in genomics and personalized medicine and of the need to understand the care implications of these therapies. Other research topics include interprofessional collaboration and shared decision-making as well as nurses' role in family conferences. Resources such as policies related to medical futility and inappropriate care and the American Association of Critical-Care Nurses' healthy work environment standards may inform conversations and provide strategies to address these complex issues.

Research in Review: Driving Critical Care Practice Change.

During the past year, studies were published that will lead to practice change, address challenges at the bedside, and introduce new care strategies. This article summarizes some of this important work and considers it in the context of previous research and practice. Examples of research-based practice changes include the performance and assessment of septic shock resuscitation, and the integration of tourniquets and massive transfusions in civilian trauma. Care challenges addressed include ethical considerations in light of the Ebola epidemic, infection prevention associated with chlorhexidine bathing, bedside alarm management, evidence to enhance moral courage, and interventions to mitigate thirst in critically ill patients. Research that portends future care includes a discussion of fecal microbiota transplant for patients with refractory infection with refractory infection with Clostridium difficile.

Antimicrobial Resistance: Thinking Outside the Box.

The health care system is challenged by another serious issue: antimicrobial resistance. Clostridium difficile is the most common infection in health care institutions and is becoming resistant to standard treatment. Carbapenem-resistant enterobacteriaceae can be found in almost every state in the United States. Confounding the antimicrobial resistance issue is the fact that few new antimicrobials are being developed by pharmaceutical companies. The situation is so critical that the White House issued a strategic plan in September 2014 to deal with antimicrobial resistance. One challenge in that plan is to better understand how microbes have become resistant. Microbes have developed defense mechanisms such as bacteriophages and bacteriocins to survive for thousands of years. If science can start to use these mechanisms to help combat resistant organisms in combination with antimicrobials and strong epidemiological interventions, the battle against antimicrobial resistance may succeed.

Discrimination of mild cognitive impairment and Alzheimer's disease using transfer entropy measures of scalp EEG.

Mild cognitive impairment (MCI) is a neurological condition related to early stages of dementia including Alzheimer's disease (AD). This study investigates the potential of measures of transfer entropy in scalp EEG for effectively discriminating between normal aging, MCI, and AD participants. Resting EEG records from 48 age-matched participants (mean age 75.7 years)-15 normal controls, 16 MCI, and 17 early AD-are examined. The mean temporal delays corresponding to peaks in inter-regional transfer entropy are computed and used as features to discriminate between the three groups of participants. Three-way classification schemes based on binary support vector machine models demonstrate overall discrimination accuracies of 91.7- 93.8%, depending on the protocol condition. These results demonstrate the potential for EEG transfer entropy measures as biomarkers in identifying early MCI and AD. Moreover, the analyses based on short data segments (two minutes) render the method practical for a primary care setting.

Sugihara causality analysis of scalp EEG for detection of early Alzheimer's disease.

Recently, Sugihara proposed an innovative causality concept, which, in contrast to statistical predictability in Granger sense, characterizes underlying deterministic causation of the system. This work exploits Sugihara causality analysis to develop novel EEG biomarkers for discriminating normal aging from mild cognitive impairment (MCI) and early Alzheimer's disease (AD). The hypothesis of this work is that scalp EEG based causality measurements have different distributions for different cognitive groups and hence the causality measurements can be used to distinguish between NC, MCI, and AD participants. The current results are based on 30-channel resting EEG records from 48 age-matched participants (mean age 75.7 years) - 15 normal controls (NCs), 16 MCI, and 17 early-stage AD. First, a reconstruction model is developed for each EEG channel, which predicts the signal in the current channel using data of the other 29 channels. The reconstruction model of the target channel is trained using NC, MCI, or AD records to generate an NC-, MCI-, or AD-specific model, respectively. To avoid over fitting, the training is based on the leave-one-out principle. Sugihara causality between the channels is described by a quality score based on comparison between the reconstructed signal and the original signal. The quality scores are studied for their potential as biomarkers to distinguish between the different cognitive groups. First, the dimension of the quality scores is reduced to two principal components. Then, a three-way classification based on the principal components is conducted. Accuracies of 95.8%, 95.8%, and 97.9% are achieved for resting eyes open, counting eyes closed, and resting eyes closed protocols, respectively. This work presents a novel application of Sugihara causality analysis to capture characteristic changes in EEG activity due to cognitive deficits. The developed method has excellent potential as individualized biomarkers in the detection of pathophysiological changes in early-stage AD.

Fever in acute and critical care: a diagnostic approach.

Determining the underlying cause of a fever can be a daunting task. Multiple reasons have been found for a patient to have a fever, but the use of an organized approach will assist clinicians in reaching a correct diagnosis. The first step in this process is a complete assessment, including a thorough physical assessment and an evaluation of the history of present illness as well as a detailed review of all the patient's medications. Infection should always be a primary consideration for the cause of a fever. Evaluating each body system can match symptoms with a possible cause for fever, and proper testing and imaging can be pursued. Noninfectious causes of fever need to be included in the differential diagnostic process. This article provides an analytic approach to fever in adult patients in the acute and critical care environment.

Ventilator-associated pneumonia bundle: reconstruction for best care.

The ventilator-associated pneumonia (VAP) bundle is a focus of many health care institutions. Many hospitals are conducting process-improvement projects in an attempt to improve VAP rates by implementing the bundle. However, this bundle is controversial in the literature, because the evidence supporting the VAP interventions is weak. In addition, definitions used for surveillance are interpreted differently than definitions used for clinical diagnosis. The variance in definitions has led to lower reported VAP rates, which may not be accurate. Because of the variance in definitions, the Centers for Disease Control and Prevention developed a ventilator-associated event algorithm. Health care institutions are under pressure to reduce the VAP infection rate, but correctly identifying VAP can be very challenging. This article reviews the current evidence related to VAP and provides insight into implementing a suggested revision of the care of patients being treated with mechanical ventilation.

Spectral and complexity analysis of scalp EEG characteristics for mild cognitive impairment and early Alzheimer's disease.

Amnestic mild cognitive impairment (aMCI) often is an early stage of Alzheimer's disease (AD). MCI is characterized by cognitive decline departing from normal cognitive aging but that does not significantly interfere with daily activities. This study explores the potential of scalp EEG for early detection of alterations from cognitively normal status of older adults signifying MCI and AD. Resting 32-channel EEG records from 48 age-matched participants (mean age 75.7 years)-15 normal controls (NC), 16 early MCI, and 17 early stage AD-are examined. Regional spectral and complexity features are computed and used in a support vector machine model to discriminate between groups. Analyses based on three-way classifications demonstrate overall discrimination accuracies of 83.3%, 85.4%, and 79.2% for resting eyes open, counting eyes closed, and resting eyes closed protocols, respectively. These results demonstrate the great promise for scalp EEG spectral and complexity features as noninvasive biomarkers for detection of MCI and early AD.

What an acute care nurse practitioner should know about reimbursement.

How to apply for reimbursement for ACNP services should be a carefully considered decision.It can be a complicated process and should be well understood before embarking on the"billing experience." The ACNP can expect that this course of action may be challenging,but if successful, the NP can further pursue the quantification of patient outcomes that can enhance the NP role in the acute and critical care environment.

Resting EEG discrimination of early stage Alzheimer's disease from normal aging using inter-channel coherence network graphs.

Amnestic mild cognitive impairment (MCI) is a degenerative neurological disorder at the early stage of Alzheimer's disease (AD). This work is a pilot study aimed at developing a simple scalp-EEG-based method for screening and monitoring MCI and AD. Specifically, the use of graphical analysis of inter-channel coherence of resting EEG for the detection of MCI and AD at early stages is explored. Resting EEG records from 48 age-matched subjects (mean age 75.7 years)--15 normal controls (NC), 16 with early-stage MCI, and 17 with early-stage AD--are examined. Network graphs are constructed using pairwise inter-channel coherence measures for delta-theta, alpha, beta, and gamma band frequencies. Network features are computed and used in a support vector machine model to discriminate among the three groups. Leave-one-out cross-validation discrimination accuracies of 93.6% for MCI vs. NC (p < 0.0003), 93.8% for AD vs. NC (p < 0.0003), and 97.0% for MCI vs. AD (p < 0.0003) are achieved. These results suggest the potential for graphical analysis of resting EEG inter-channel coherence as an efficacious method for noninvasive screening for MCI and early AD.

Hematologic complications of critical illness: anemia, neutropenia, thrombocytopenia, and more.

All critically ill patients are at risk for hematological complications during their hospitalization. It is essential that critical care nurses understand the hematological system and common complications. The purpose of this article is to briefly review some basic hematologic concepts involving each of the 3 cell lines: the white blood cell, the red blood cell, and platelets. The content focuses on how to assess these cell lines when there is dysfunction. Examples of disease processes involving the increased and decreased production of each cell line as well as destruction processes are discussed from a critical care perspective. The critical care nurse needs to continually incorporate this information into practice as research continues to formulate critical care practice.