Healthcare-acquired coronavirus disease 2019 (COVID-19) is less symptomatic than community-acquired disease among healthcare workers.

OBJECTIVE: We hypothesized that healthcare workers (HCWs) with high-risk exposures outside the healthcare system would have less asymptomatic coronavirus 2019 (COVID-19) disease and more symptoms than those without such exposures. DESIGN: A longitudinal point prevalence study was conducted during August 17-September 4, 2020 (period 1) and during December 2-23, 2020 (period 2). SETTING: Community based teaching health system. PARTICIPANTS: All HCWs were invited to participate. Among HCWs who acquired COVID-19, logistic regression models were used to evaluate the adjusted odds of asymptomatic disease using high-risk exposure outside the healthcare system as the explanatory variable. The number of symptoms between exposure groups was evaluated with the Wilcoxon rank-sum test. The risk of seropositivity among all HCS by work exposure was evaluated during both periods. INTERVENTIONS: Survey and serological testing. RESULT: Seroprevalence increased from 1.9% (95% confidence interval [CI], 1.2%-2.6%) to 13.7% (95% CI, 11.9%-15.5%) during the study. Only during period 2 did HCWs with the highest work exposure (versus low exposure) have an increased risk of seropositivity (risk difference [RD], 7%; 95% CI, 1%-13%). Participants who had a high-risk exposure outside of work (compared to those without) had a decreased probability of asymptomatic disease (odds ratio [OR], 0.38; 95% CI, 0.16-0.86) and demonstrated more symptoms (median 3 [IQR, 2-6] vs 1 [IQR, 0-4]; P = .001). CONCLUSIONS: Healthcare-acquired COVID-19 increases the probability of asymptomatic or mild COVID-19 disease compared to community-acquired disease. This finding suggests that infection prevention strategies (including masks and eye protection) may be mitigating inoculum and supports the variolation theory in COVID-19.

Continuous renal replacement therapy for refractory intracranial hypertension?

BACKGROUND: Continuous renal replacement therapy (CRRT) is the preferred mode of renal replacement therapy in patients with acute brain injury (ABI). There are limited data available describing the effects of CRRT on intracranial pressure (ICP). This study aims to evaluate changes in ICP during CRRT in patients after ABI. METHODS: This is a retrospective observational cohort study of patients with ABI, who had ICP monitoring as part of routine management and also underwent CRRT. Hourly ICP and fluid balance, type and indication for CRRT, ICP management, and patient demographics were extracted from the medical record. Wilcoxon signed-rank test was used to evaluate changes in ICP and volume during the 12 hours before and after the initiation of CRRT. RESULTS: Two patients with severe traumatic brain injury, one patient with moderate traumatic brain injury and one patient with subarachnoid hemorrhage were identified. Three patients were diagnosed with refractory intracranial hypertension (RIH) before the initiation of therapy and had a nonsignificant trend toward reduction of ICP during CRRT (p = 0.1810). One patient with chronic renal failure, who developed elevated ICP during conventional intermittent hemodialysis, demonstrated stability of ICP when switched to CRRT. CONCLUSIONS: CRRT may have beneficial effects in patients with RIH. Given the high mortality rate and poor neurological outcome associated with RIH, further research may be warranted.

Early onset probable linezolid-induced encephalopathy.

Linezolid is increasingly being utilized for the treatment of gram-positive pathogens. While neurological complications with linezolid are rare, long-term exposure can be associated with neurotoxic effects. Patients with pre-existing neurologic sequelae or risk factors, such as alcohol abuse, diabetes, or concomitant administration of chemotherapeutic agents and/or antiretroviral therapy, may be more susceptible to the development of linezolid-induced neurotoxicity. We describe a 41-year-old male who developed early onset encephalopathy after a day and a half of linezolid therapy. Our patient had at least one significant risk factor (alcoholism), making linezolid-induced encephalopathy probable based upon the Naranjo probability scale. Clinicians should be aware of the potential for early onset linezolid-induced neurotoxicity, particularly in patients with concomitant risk factors.

Expedited admission of patients decreases duration of mechanical ventilation and shortens ICU stay.

BACKGROUND: To determine if expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the emergency department (ED) to the intensive care unit (ICU) decreases ICU and hospital length of stay. METHODS: Patients with respiratory failure that required intubation and mechanical ventilation who were admitted to the hospital between June 2004 and May 2006 were retrospectively identified from the Project IMPACT database. Patients were divided into 2 groups based on ED length of stay: expedited (<2 hours) or nonexpedited (>2 hours). RESULTS: The expedited (n = 12) and nonexpedited (n = 66) groups were comparable in demographics, medical conditions, and disease severity. Mean duration of mechanical ventilation was significantly shorter in the expedited group (28.4 hours vs 67.9 hours; P = .0431), as was mean ICU length of stay (2.4 days vs 4.9 days; P = .0209). Length of hospital stay tended to be shorter for the patients in the expedited group (6.8 days vs 8.9 days; P = .0609). CONCLUSIONS: Expedited admission (<2 hours) of critically ill patients requiring intubation and mechanical ventilation from the ED to the ICU was associated with shorter durations of mechanical ventilation and ICU length of stay, suggesting that prompt ICU admission results in improved use of resources.

Methamphetamine production is hazardous to your health.

BACKGROUND: To describe the thermal injuries related to methamphetamine (METH) production, characterize patients' courses, and compare patients with matched controls and to the previously published series. METHODS: Trauma registry data from January 2001 to November 2005 was retrospectively reviewed. METH patients were compared with other burn patients of similar age and total body surface area burn size for toxicology, injury extent, therapies, hospital course, outcomes, and hospital charges. The METH group was compared with the other published series of METH-related burn patients. RESULTS: Twenty-nine patients (86.2% male) had METH-related burns. METH and control groups were similar in age, gender, predicted resuscitation fluid volume, and total body surface area. Mortality, mean length of stay, surgical procedures, and mean hospital charges did not differ significantly between the groups. Endotracheal intubation was required more frequently in METH patients (55.2% vs. 24.1%, p = 0.020). METH patients mean resuscitation volume was greater than controls (9,638 mL vs. 6,633 mL, p = 0.011), but neither group exceeded the volume predicted by the Parkland formula. More METH patients had inhalation injury (41.4% vs. 13.8%, p = 0.019). A METH patient was more likely to have a complication than his matched control (p = 0.049), and pneumonia was more frequent in the METH group (p = 0.005). Private insurance was less common in METH patients (10.3% vs. 58.6%, p < 0.001). CONCLUSIONS: METH patients suffer more frequent inhalation injuries, need greater initial fluid resuscitation volume, require endotracheal intubation more frequently, and are more likely to have complications than matched controls. This does not translate to greater mortality, longer length of stay, more surgical procedures, or significantly greater hospital charges. Few METH patients hold private insurance.

Continuous renal replacement therapy for refractory intracranial hypertension.

INTRODUCTION: Little is known about the effects of hemodialysis on the injured brain, however; concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy. Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety. Furthermore, exacerbations of cerebral edema have been reported. CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance. We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension. METHODS: A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma. He required significant volume resuscitation. Intensive care unit course was complicated by shock, acute respiratory distress syndrome, ventilator associated pneumonia, and development of intracranial hypertension (IH). Data were collected by retrospective chart review. RESULTS: Continuous hemofiltration was initiated for IH refractory to medical therapy. Within hours of initiation increase, ICP improved and normalized. Hemofiltration was safely discontinued after 48 h. Modified Rankin Score was 2 at 90 days. CONCLUSION: Though unproven, CRRT may be beneficial in patients with IH due to gentle removal of fluid, solutes, and inflammatory cytokines. Given the limited data on safety of CRRT in patients with ABI, we encourage further reports.