Impact of early rehabilitation on the functional quality of life of the critically ill at one year

Introduction: ICU-acquired weakness (ICUAW) is a long-recognised phenomenon, featuring a prevalence of 25-80%. Early mobilisation is anaccepted intervention that may attenuate ICUAW and improve outcomes [1, 2]. Method(s): Prospective observational study in polyvalent ICU analysing the effect of early rehabilitation (eRHB) on quality of life one year after discharge (D/C).Patients who required invasive mechanical ventilation > 24 h and survived SARS-CoV2 respiratory infection between 5/3/2020 and 12/01/2022 were included. Patients were classified into two groups: eRHB or not eRHB. Demographic and clinical data were collected, and a telephone survey was conducted one year after D/C. Clinical Frailty Scale at ICU admission (T1) and one year after D/C (T5);Medical Research Council (MRC) at the start of rehabilitation (T2) and hospital D/C (T4);Barthel Index at ICU D/C (T3), T4 and T5;and the SF-36 health questionnaire at T5 were also collected. Statistical analysis was performed between subgroups: Pearson's Chi-square test or Mann-Whitney U test to find significant differences. ART-ANOVA was used to analyse the survey results. Result(s): Of 99 patients, 64.6% belonged to the eRHB group. There were no statistically significant differences in the analysis of clinicdemographic variables. We observed a significant improvement of the MRC, a better Barthel Index in the eRHB group, and a statistically significant positive impact on several components of the SF-36 in the eRHB group (physical functioning, vitality, social functioning, bodily pain, general health, and self-reported health transition). Conclusion(s): Patients who received eRHB had better physical functioning and higher vitality recovery. In addition, they suffered less impact on their social life, had better pain control, and reported improved general health. All this emphasises the need for eRHB protocols in the ICU, promoting multidisciplinary care of our patients.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd

Intradermal skin test with mRNA vaccines as a surrogate marker of T cell immunity in immunosuppressed patients

Background: The role of T cell immunity in protection against COVID-19 in immunosuppressed patients who failed to mount serological responses remains ill defined. Hypothesis: Vaccine-based intradermal skin test (IDT) serves as a surrogate marker of T cell responses in seronegative immunosuppressed patients. Methods: We compared anti-SARS-CoV-2 antibodies and cellular responses in vaccinated immunosuppressed (IS) patients (n = 58), healthy unvaccinated naive controls (NC, n = 8) and healthy vaccinated controls (VC, n = 32) by Luminex, IFN-γ ELIPSOT and IDT 3 to 6 months after vaccination. In 3 VC we performed a skin biopsy 24h after IDT and performed single-cell RNAseq of the skin-infiltrating CD45+ cells Results: Seronegative NC had no detectable T cell responses and negative IDR, whereas VC had anti-SARS-CoV-2 antibodies (100%), positive ELIPSOT (90%) and IDR (90%). Overall IS patients had significantly less antibodies up to 39 weeks after vaccination compared to VC but similar ELIPSOT responses. ELISPOT was positive in 33.3 % and 66.6 % and IDR in 62.5% and 90.5% of seronegative vs seropositive IS patients respectively. Conversely, patients with negative IDR had significantly lower T cell responses and IgG titers than those with positive IDR. Importantly, the TCR repertoire of infiltrating skin lymphocytes revealed 18/1064 clonotypes with known specificities against SARS-CoV-2. Conclusion: Our results indicate that local reaction to IDR is partially composed of SARS-CoV-2-specific T cells. IDR represents a promising tool to cost-effectively monitor SARS-CoV-2 specific T cell immunity in IS patients.

A machine learning-based predictive model for outcome of COVID-19 in kidney transplant recipients

Purpose: Health systems need tools to deal with COVID-19, especially for high-risk population,such as transplant recipients. Predictive models are necessary to improve management of patients and optimize resources. Methods: A retrospective study of hospitalized transplant patients due to COVID-19 was evaluated(March 3-April 24,2020). Admission data were integrated to develop a prediction model to evaluate a composite-event defined as Intensive Care Unit admission or intensification treatment with antiinflamatory agents. Predictions were made using a Data Envelopment Analysis(DEA)-Artificial Neural Network(ANN) hybrid, whose accuracy relative to several alternative configurations has been validated through a battery of clustering techniques. Results: Of 1006 recipients with a planned or an unscheduled visit during the observation period, thirty-eight were admitted due to COVID-19. Twenty-five patients(63.2%) exhibited poor clinical course(mortality rate:13.2%), within a mean of 12 days of admission stay. Cough as a presenting symptom(P=0.000), pneumonia(P=0.011), and levels of LDH(P=0.031) were admission factors associated with poor outcomes. The prediction hybrid model working with a set of 17 input variables displays an accuracy of 96.3%, outperforming any competing model, such as logistic regression(65.5%) and Random forest(denoted by Bagged Trees,44.8%). Moreover, the prediction model allows us to categorize the evolution of patients through the values at hospital admission. Conclusions: The prediction model based in Data Envelopment Analysis-Artificial Neural Network hybrid forecasts the progression towards severe COVID-19 disease with an accuracy of 96.3%, and may help to guide COVID-19 management by identification of key predictors that permit a sustainable distribution of resources in a patient-centered model. Improving efficiency and patient parformance in the AAN with DEA, we can get high accurancy even with no-big cohorts. (Table Presented).

Advance care planning as a preventive strategy for ethical conflicts in emergencies during and after COVID-19

The events of the present CoVID-19 pandemic are causing serious threats to Public Health worldwide, specifically at the most vulnerable population groups. Emergency professionals have served as the first responders for the most serious cases of this disease. At the same time, they have made decisions in highly complex contexts where the prioritization of allocated care resources has generated ethically conflictive situations. The aim of this article is to analyze the importance of implementing the ACP as a tool in the emergency services to solve ethical problems that have arisen during the COVID-19 pandemic, particularly in the care of complex chronic patients or those with advanced chronic disease. Copyright © 2020 Silvia Poveda-Moral, Alejandro Bosch-Alcaraz, Anna Falcó-Pegueroles.