Psychological Attachment Orientation and Long-Term Posttraumatic Stress Symptoms Among Family Members of ICU Patients.

To determine the degree to which an ICU patient's family member having an "anxious" psychologic attachment orientation is a risk factor for developing long-term posttraumatic stress disorder (PTSD) symptoms following patient ICU discharge or death. DESIGN: Prospective cohort study. SETTING: Single academic neuroscience ICU from November 2017 to September 2020. PARTICIPANTS: Consecutively enrolled sample of family members, one for each ICU patient with a minimum length of stay of 24 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Near time of ICU discharge or patient death, we determined each participant's psychologic attachment orientation as anxious versus nonanxious via a brief standard survey tool, the Relationship Questionnaire, and measured other participant and patient characteristics as potential covariates. Six months after discharge or death, each participant completed the Impact of Events Scale-Revised (IES-R) to measure PTSD symptoms, with a score of greater than 24 indicative of clinically significant symptoms. Among 162 total participants, 10 of 27 participants (37.0%) with an anxious attachment orientation reported 6-month PTSD symptoms, compared with 24 of 135 nonanxious participants (17.8%) (relative risk, 2.08; 95% CI, 1.13-3.84; p = 0.02; risk difference 19.2%). In a subsequent univariate analysis of participant and patient covariates, anxious attachment orientation, participant Hispanic ethnicity, prior experience as a care partner of a patient with a disability, and participation in 3 or more formal ICU family meetings were all associated with 6-month PTSD symptoms. In a multiple logistic regression, anxious attachment remained an independent predictor of 6-month PTSD symptoms (odds ratio [OR], 3.64; 95% CI, 1.35-9.77; p = 0.01), as did Hispanic ethnicity (OR, 4.72; 95% CI, 1.34-16.6; p = 0.01) and participation in three or more ICU family meetings (odds ratio, 2.97; 95% CI, 1.14-7.68; p = 0.02). CONCLUSIONS: An anxious psychologic attachment orientation is associated with double the risk of long-term PTSD symptoms among family members of ICU patients. Future interventions designed to decrease risk of adverse psychologic outcomes among ICU families could be initially tested for efficacy amongst those who fall into this high-risk category.

Systemic Oxygen Utilization in Severe COVID-19 Respiratory Failure: A Case Series.

BACKGROUND: Management of hypoxemia in patients with severe COVID-19 respiratory failure is based on the guideline recommendations for specific SpO2 targets. However, limited data exist on systemic O2 utilization. The objective of this study was to examine systemic O2 utilization in a case series of patients with this disease. PATIENTS AND METHODS: Between March 24, and April 9, 2020, 8 patients intubated for severe COVID-19 respiratory failure had near-simultaneous drawing of arterial blood gas (ABG), central venous blood gas (cVBG), and central venous oxygen saturation (ScvO2) at a mean of 6.1 days into hospitalization. Three patients were managed with indirect cardiac output (CO) monitoring by FloTrac sensor and Vigileo monitor (Edwards Lifesciences, Irvine, CA). The oxygen extraction index (OEI; SaO2-ScvO2/SaO2) and oxygen extraction fraction (OEF; CaO2-CvO2/CaO2 ≥ 100) were calculated. Values for hyperoxia (ScvO2 ≥ 90%), normoxia (ScvO2 71-89%), and hypoxia (ScvO2 ≤ 70%) were based on the literature. Mean values were calculated. RESULTS: The mean partial pressure of oxygen (PaO2) was 102 with a mean fraction of inspired O2 (FiO2) of 44%. One patient was hyperoxic with a reduced OEI (17%). Five patients were normoxic, but 2 had a reduced OEF (mean 15.9%). Two patients were hypoxic but had increased systemic O2 utilization based on OEF or OEI. CONCLUSION: In select patients with severe COVID-19 respiratory failure, O2 delivery (DO2) was found to exceed O2 utilization. SpO2 targets based on systemic O2 utilization may help in reducing oxygen toxicity, especially in the absence of anaerobic metabolism. Further data are needed on the prevalence of systemic O2 utilization in COVID-19. HOW TO CITE THIS ARTICLE: Garg RK, Kimbrough T, Lodhi W, DaSilva I. Systemic Oxygen Utilization in Severe COVID-19 Respiratory Failure: A Case Series. Indian J Crit Care Med 2021;25(2):215-218.

Antiepileptic Drug Management in Acute Ischemic Stroke: Are Vascular Neurologists Utilizing Electroencephalograms? An Observational Cohort Study.

INTRODUCTION: This study examines the utility of electroencephalography (EEG) in clinical decision making in acute ischemic stroke (AIS) patients in regards to the prescription of antiseizure medications. METHODS: Patients were grouped as having positive EEG (+) for epileptiform activity or negative EEG (-). These studies were no more than 30 minutes in length. Patients' charts were retrospectively reviewed for antiepileptic drug (AED) use before, during, and on discharge from AIS hospitalization. RESULTS: Of the 509 patients meeting inclusion criteria, 24 (4.7%) had a positive EEG. Patients did not significantly differ with respect to any demographic or baseline characteristics with the exception of prior history of seizure. In the EEG- group, AEDs were discontinued in only 3.5% of patients. In the EEG+ group, only 37.5% of patients had an initiation or change to their AED regimen within 36 hours of the study. 62.5% of the EEG+ group had a cortical stroke. Significance. Our results indicate that vascular neurologists are not using spot EEGs to routinely guide inpatient AED management. EEGs may have greater utility in those with a prior history of seizures and cortical strokes. Longer or continuous EEG monitoring may have better utility in the AIS population if there is clinical suspicion of seizure.

Somatic PRKAR1A mutation in sporadic atrial myxoma with cerebral parenchymal metastases: a case report.

BACKGROUND: Atrial myxomas are generally considered benign neoplasms. The majority of tumors are sporadic and less than 10% are associated with an autosomal dominant condition known as the Carney complex, which is most often caused by germline mutation in the gene PRKAR1A. Whether this gene plays a role in the development of sporadic myxomas has been an area of debate, although recent studies have suggested that some fraction of sporadic tumors also carry mutations in PRKARIA. Extra-cardiac complications of atrial myxoma include dissemination of tumor to the brain; however, the dissemination of viable invasive tumor cells is exceedingly rare. CASE PRESENTATION: We present here a 48-year-old white woman who developed multiple intracranial hemorrhagic lesions secondary to tumor embolism that progressed to 'false' aneurysm formation and invasion through the vascular wall into brain parenchyma 7 months after resection of an atrial myxoma. Whole exome sequencing of her tumor revealed multiple mutations in PRKAR1A not found in her germline deoxyribonucleic acid (DNA), suggesting that the myxoma in this patient was sporadic. CONCLUSIONS: Our patient illustrates that mutations in PRKAR1A may be found in sporadic lesions. Whether the presence of this mutation affects the clinical behavior of sporadic tumors and increases risk for metastasis is not clear. Regardless, the protein kinase A pathway which is regulated by PRKAR1A represents a possible target for treatment in patients with metastatic cardiac myxomas harboring mutations in the PRKARIA gene.

Intravenous Tissue Plasminogen Activator for Wake-Up Stroke: A Propensity Score-Matched Analysis.

GOAL: To evaluate the safety and efficacy of intravenous (IV) tissue plasminogen activator (tPA) in the treatment of wake-up stroke (WUS) using propensity score (PS) analysis. MATERIALS AND METHODS: Consecutive acute ischemic stroke patients meeting inclusion criteria were retrospectively identified from our stroke registry between July 2008 and May 2014, and classified as stroke onset less than or equal to 4.5 hours treated with tPA (control; n = 369), tPA-treated WUS (n = 46), or nontreated WUS (n = 154). The primary outcome of interest for safety was symptomatic intracerebral hemorrhage (sICH), defined as parenchymal hemorrhage associated with a greater than or equal to 4-point increase in National Institutes of Health Stroke Scale (NIHSS) score. Multivariate logistic regression with adjustment for confounders and PS for receiving IV tPA assessed outcomes, along with PS-matched average treatment effect on the treated (ATT). FINDINGS: No significant difference was found in rates of sICH between tPA-treated WUS, nontreated WUS, and controls (2.2%, .7%, and 3%, respectively), or in the odds of sICH between tPA-treated WUS and controls (OR = .53, 95% CI = .06-4.60, P = .568). Among WUS patients, tPA treatment was significantly associated with higher odds of good functional outcome in fully adjusted analyses (OR = 7.22, 95% CI = 2.28-22.88, P = .001). The ATT of tPA for WUS patients demonstrated a significantly greater decrease in NIHSS score at discharge when compared to nontreated WUS patients (-4.32 versus -.34, P = .032). CONCLUSIONS: Comparable rates of sICH between treated WUS and stroke onset less than or equal to 4.5 hours treated with tPA suggest that tPA may be safely used to treat WUS. Superior outcomes for tPA-treated versus nontreated WUS subjects may suggest clinical efficacy of the treatment.

Polydactyly of the hand.

Polydactyly is considered either the most or second most (after syndactyly) common congenital hand abnormality. Polydactyly is not simply a duplication; the anatomy is abnormal with hypoplastic structures, abnormally contoured joints, and anomalous tendon and ligament insertions. There are many ways to classify polydactyly, and surgical options range from simple excision to complicated bone, ligament, and tendon realignments. The prevalence of polydactyly makes it important for orthopedic surgeons to understand the basic tenets of the abnormality.