Characteristics and Outcomes of Mechanically Ventilated COVID-19 Patients-An Observational Cohort Study.

BACKGROUND: The United States currently has more confirmed cases of COVID-19 than any other country in the world. Given the variability in COVID-19 testing and prevention capability, identifying factors associated with mortality in patients requiring mechanical ventilation is critical. This study aimed to identify which demographics, comorbidities, markers of disease progression, and interventions are associated with 30-day mortality in COVID-19 patients requiring mechanical ventilation. METHODS: Adult patients with a confirmed diagnosis of COVID-19 admitted to one of the health system's intensive care units and requiring mechanical ventilation between March 9, 2020 and April 1, 2020, were included in this observational cohort study. We used Chi-Square and Mann-Whitney U tests to compare patient characteristics between deceased and living patients and multiple logistic regression to assess the association between independent variables and the likelihood of 30-day mortality. RESULTS: We included 85 patients, of which 20 died (23.5%) within 30 days of the first hospital admission. In the univariate analysis, deceased patients were more likely ≥60 years of age (p < 0.001), non-Hispanic (p = 0.026), and diagnosed with a solid malignant tumor (p = 0.003). Insurance status also differed between survivors and non-survivors (p = 0.019). Age ≥60 and malignancy had a 9.5-fold (95% confidence interval 1.4-62.3, p = 0.020) and 5.8-fold higher odds ratio (95% confidence interval 1.2-28.4, p = 0.032) for 30-day mortality after adjusted analysis using multivariable logistic regression, while other independent variables were no longer significant. CONCLUSIONS: In our observational cohort study of 85 mechanically ventilated COVID-19 patients, age, and a diagnosis of a solid malignant tumor were associated with 30-day mortality. Our findings validate concerns for the survival of elderly and cancer patients in the face of the COVID-19 pandemic in the United States, where testing capabilities and preventative measures have been inconsistent. Preventative efforts geared to patients at risk for intensive care unit mortality from COVID-19 should be explored.

Association between procalcitonin levels and duration of mechanical ventilation in COVID-19 patients.

BACKGROUND: Patients diagnosed with COVID-19 frequently require mechanical ventilation. Knowledge of laboratory tests associated with the prolonged need for mechanical ventilation may guide resource allocation. We hypothesized that an elevated plasma procalcitonin level (>0.1 ng/ml) would be associated with the duration of invasive mechanical ventilation. METHODS: Patients diagnosed with COVID-19, who were admitted to any of our health system's hospitals between March 9th-April 20th, 2020 and required invasive mechanical ventilation, were eligible for this observational cohort study. Demographics, comorbidities, components of the Sequential Organ Failure Assessment score, and procalcitonin levels on admission were obtained from the electronic health record. The primary outcome was the duration of mechanical ventilation; secondary outcomes included 28-day mortality and time to intubation. Outcomes were assessed within the first 28 days of admission. Baseline demographics and comorbidities were summarized by descriptive statistics. Univariate comparisons were made using Pearson's chi-square test for binary outcomes and Mann-Whitney U test for continuous outcomes. A multiple linear regression was fitted to assess the association between procalcitonin levels and the duration of mechanical ventilation. RESULTS: Patients with an initial procalcitonin level >0.1 ng/ml required a significantly longer duration of mechanical ventilation than patients with a level of ≤0.1 ng/ml (p = 0.021) in the univariate analysis. There was no significant difference in 28-day mortality or time to intubation between the two groups. After adjusted analysis using multivariable linear regression, the duration of mechanical ventilation was, on average, 5.6 (p = 0.016) days longer in patients with an initial procalcitonin level >0.1 ng/ml. CONCLUSION: In this cohort of 93 mechanically ventilated COVID-19 patients, we found an association between an initial plasma procalcitonin level >0.1 ng/ml and the duration of mechanical ventilation. These findings may help to identify patients at risk for prolonged mechanical ventilation upon admission.

Current Neurologic Assessment and Neuroprotective Strategies in Cardiac Anesthesia: A Survey to the Membership of the Society of Cardiovascular Anesthesiologists.

BACKGROUND: Neurologic injury and cognitive disorder after cardiac surgery are associated with morbidity and mortality. Variability in the application of neuroprotective strategies likely exists during cardiac surgery. The Society of Cardiovascular Anesthesiologists (SCA) conducted a survey among its members on common perioperative neuroprotective strategies: assessment of aortic atheromatous burden, management of intraoperative blood pressure, and use of cerebral oximetry. METHODS: A 15-item survey was developed by 3 members of the SCA Continuous Practice Improvement - Cerebral Protection Working Group. The questionnaire was then circulated among all working group members, adapted, and tested for face validity. On March 26, 2018, the survey was sent to members of the SCA via e-mail using the Research Electronic Data Capture system. Responses were recorded until April 16, 2018. RESULTS: Of the 3645 surveys e-mailed, 526 members responded (14.4%). Most responders worked in academic institutions (58.3%), followed by private practices (38.7%). Epiaortic ultrasound for the assessment of aortic atheromatous burden was most commonly utilized at the surgeon's request (46.5%). Cerebral oximetry was most commonly used in patients with increased perioperative risk of cerebral injury (41.4%). Epiaortic ultrasound (1.9%) and cerebral oximetry (5.2%) were rarely part of a standardized monitoring approach. A majority of respondents (52.0%) reported no standardized management strategies for neuroprotection during cardiac surgery at their institution. A total of 55.3% stated that no standardized institutional guidelines were in place for managing a patient's blood pressure intraoperatively or during cardiopulmonary bypass. When asked about patients at risk for postoperative cerebral injury, 41.3% targeted a blood pressure goal >65 mmHg during cardiopulmonary bypass. The majority of responders (60.4%) who had access to institutional rates of postoperative stroke/cerebral injury had standard neuroprotective strategies in place. CONCLUSIONS: Our data indicate that approximately half of the respondents to this SCA survey do not use standardized guidelines/standard operating procedures for perioperative cerebral protection. The lack of standardized neuroprotective strategies during cardiac surgery may impact postoperative neurologic outcomes. Further investigations are warranted and should assess the association of standardized neuroprotective approaches and postoperative neurological outcomes.

"In Safe Hands" - A costly integrated care program with limited benefits in stroke unit care.

Given reported favourable outcomes of accountable care unit models of health care delivery (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), the Clinical Excellence Commission of NSW has embraced "In Safe Hands" (ISH) to enhance coordination of care. ISH embraces the structured interdisciplinary bedside round (SIBR) component, for which reported outcomes include reduced length of stay (Taylor et al., 2017; Stein et al., 2015; Kara et al., 2015), possible reduction in overall costs of care (Kara et al., 2015), and enhanced patient and staff satisfaction (O'Leary et al., 2011). It is not yet clear whether the benefits of such a model are translatable to the Australian Health Care System (Hunyh et al., 2016) and/or established units with an already strong multi-disciplinary approach to patient care. The purpose of this prospective cohort study of 200 participants was to assess the effect(s) of implementation of ISH in a stroke unit of a tertiary hospital in Sydney, Australia. Data on length of stay, re-admission rates, adverse events, as well as patient and nursing satisfaction, were collected pre and post implementation. There was no significant difference in length of stay in median days (5 (IQR 2-7) versus 4 (IQR 2-6), P = 0.55) or incidence of adverse events (10% versus 12%, P = 0.82). Stroke outcome disability scores were not affected by the intervention. There were no significant differences overall in reported patient and nursing satisfaction. Implementation of the ISH program cost approximately AUD$ 1805/week (USD$ 1365) in wages. The ISH program was a costly intervention of limited benefit in a well-established acute stroke unit. We here discuss potential reasons for the failure of this intervention to achieve its primary aim in this setting.

Ultrastructural Alterations of Von Economo Neurons in the Anterior Cingulate Cortex in Schizophrenia.

Von Economo neurons (VENs) are large bipolar projection neurons mainly located in layer Vb of anterior cingulate cortex (ACC) and anterior insula. Both regions are involved in cognitive and emotional procedures and are functionally and anatomically altered in schizophrenia. Although the detailed function of VEN remains unclear, it has been suggested that these neurons are involved in the pathomechanism of schizophrenia. Here, we were interested in the question whether or not the VEN of schizophrenia patients would show abnormalities at the ultrastructural level. Accordingly, we examined the amount of lysosomal aggregations of the VEN in post-mortem tissue of patients with schizophrenia, bipolar disorder and psychologically unaffected individuals, and compared the findings with aggregations in adjacent pyramidal cells in layer Vb of the ACC. VEN of patients with schizophrenia, and to a lesser degree individuals with bipolar disorder contained significantly more lysosomal aggregations compared with tissue from unaffected controls. Specifically, the larger amount of lysosomal aggregations in schizophrenia seemed to be selective for VEN, with no differences occurring in pyramidal cells. These findings may indicate that the VEN of schizophrenia patients are selectively vulnerable to neuronal damage. Anat Rec, 2017. © 2017 Wiley Periodicals, Inc. Anat Rec, 300:2017-2024, 2017. © 2017 Wiley Periodicals, Inc.

Endovascular Thrombectomy for Ischemic Stroke Increases Disability-Free Survival, Quality of Life, and Life Expectancy and Reduces Cost.

BACKGROUND: Endovascular thrombectomy improves functional outcome in large vessel occlusion ischemic stroke. We examined disability, quality of life, survival and acute care costs in the EXTEND-IA trial, which used CT-perfusion imaging selection. METHODS: Large vessel ischemic stroke patients with favorable CT-perfusion were randomized to endovascular thrombectomy after alteplase versus alteplase-only. Clinical outcome was prospectively measured using 90-day modified Rankin scale (mRS). Individual patient expected survival and net difference in Disability/Quality-adjusted life years (DALY/QALY) up to 15 years from stroke were modeled using age, sex, 90-day mRS, and utility scores. Level of care within the first 90 days was prospectively measured and used to estimate procedure and inpatient care costs (US$ reference year 2014). RESULTS: There were 70 patients, 35 in each arm, mean age 69, median NIHSS 15 (IQR 12-19). The median (IQR) disability-weighted utility score at 90 days was 0.65 (0.00-0.91) in the alteplase-only versus 0.91 (0.65-1.00) in the endovascular group (p = 0.005). Modeled life expectancy was greater in the endovascular versus alteplase-only group (median 15.6 versus 11.2 years, p = 0.02). The endovascular thrombectomy group had fewer simulated DALYs lost over 15 years [median (IQR) 5.5 (3.2-8.7) versus 8.9 (4.7-13.8), p = 0.02] and more QALY gained [median (IQR) 9.3 (4.2-13.1) versus 4.9 (0.3-8.5), p = 0.03]. Endovascular patients spent less time in hospital [median (IQR) 5 (3-11) days versus 8 (5-14) days, p = 0.04] and rehabilitation [median (IQR) 0 (0-28) versus 27 (0-65) days, p = 0.03]. The estimated inpatient costs in the first 90 days were less in the thrombectomy group (average US$15,689 versus US$30,569, p = 0.008) offsetting the costs of interhospital transport and the thrombectomy procedure (average US$10,515). The average saving per patient treated with thrombectomy was US$4,365. CONCLUSION: Thrombectomy patients with large vessel occlusion and salvageable tissue on CT-perfusion had reduced length of stay and overall costs to 90 days. There was evidence of clinically relevant improvement in long-term survival and quality of life. CLINICAL TRIAL REGISTRATION: http://www.ClinicalTrials.gov NCT01492725 (registered 20/11/2011).

Predictive value of the Royal Melbourne Hospital Falls Risk Assessment Tool (RMH FRAT) for post-stroke patients.

Falls after stroke are common and carry a significant disease burden. Several scores aim to identify patients who are at risk of falls to implement primary prevention therapy. The aim of this study was to determine the validity of the commonly used Falls Risk Assessment Tool (FRAT) developed at the Royal Melbourne Hospital (RMH) in 1995 for predicting falls after a stroke. The RMH FRAT was administered within 2 weeks after discharge post-stroke. Occurrence of falls was recorded at 3 and 6 months post-stroke in 202 and 152 patients, respectively. In our study 90% of patients were placed in the RMH FRAT high risk or medium risk group. In these two groups the RMH FRAT did not provide sufficient predictive value.

Quality of care delivered by fee-for-service and DRG hospitals in Switzerland in patients with community-acquired pneumonia.

PRINCIPLES: Reimbursement for inpatient treatment in Switzerland is in transition. While hospitals in some cantons already use Diagnosis Related Groups (DRG) based systems for hospital financing, others use fee-for-service (FFS) based systems, a situation that provides the opportunity to perform a head-to-head comparison between the two reimbursement systems. The aim of this analysis was to compare reimbursement systems with regard to length of hospital stay (LOS) and patient outcomes in a cohort of community-acquired pneumonia patients from a previous prospective multicentre study in Switzerland. METHODS: This is a post-hoc analysis of 925 patients with community-acquired pneumonia from a previous randomised-controlled trial. We calculated multivariate regression models adjusted for age, gender, comorbidities and severity of illness (using the Pneumonia Severity Index) and accounting for clustering within hospitals to compare LOS and outcomes between FFS (n = 4) or DRG hospitals (n = 2). RESULTS: LOS in DRG hospitals was significantly shorter compared to FFS hospitals (8.4 vs 10.3 days, absolute difference 1.9 days [95%CI 0.8-3.1]). This was confirmed in multivariate adjusted Cox models (hazard ratio 1.2 [95% 1.1-1.3]). There were no differences in 30-day and 18-month mortality rates (adjusted odds ratio 1.7 [95% 0.9-3.2] and 1.3 [95% 0.9-1.9]) or recurrence rates within 30 days (adjusted odds ratio 0.8 [95% 0.4-1.7]). Also, no differences were found in the rate of still ongoing clinical symptoms at 30 days, satisfaction with the discharge process and quality of life measures at 30 days of follow-up. CONCLUSIONS: This study focusing on community-acquired pneumonia patients with different severities found a 20% shorter LOS in hospitals with DRG financing compared to FFS hospitals without apparent harmful effects on patient outcomes, satisfaction with care and different quality of life measures. Further studies are required to validate these findings for other medical and surgical patient populations.

El valor de las pruebas de elevación de la pierna con la rodilla extendida y de tensión de la extremidad superior en la evaluación de las disfunciones del movimiento / Value of leg raise test with extended knee and upper limb tension in the assessment of movement disfunctions

El presente trabajo efectúa una revisión de los mecanismos que explican la aplicación terapéutica de 2 maniobras de movilización neural. En extremidad superior, por medio del test de elevación de la pierna con la rodilla extendida, y en la superior a través del test de tensión de la extremidad superior. De esta forma se plantea el empleo de estos procedimientos para evaluar la presencia de alteraciones mecánicas (comprensión neural) o neurofisiológicas (inflamación neurogénica y espasmo muscular reflexógeno). La relación entre estos mecanismos y la aplicación de los procedimientos es discutida en profundidad