Anticipated Long-Term Neurobehavioral Outcomes Following COVID-19

First identified in December 2021, Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)-the virus causing COVID-19, is responsible for significant morbidity and mortality rates. Given the worldwide impact of COVID-19, there is much interest in the anticipated long-term effects for those with history of SARS-CoV-2 infection. While initially presumed as a respiratory infection, there is now evidence of a broader array of pathophysiological mechanisms which result in a wide spectrum of reported acute and chronic symptoms in patients with confirmed COVID-19. These include including memory and other neurocognitive changes as well as psychiatric and behavioral symptoms. These nonspecific, but often debilitating, sequalaeare complex and difficult to disentangle from more common causes of neurobehavioral change. The goal of this chapter is to discuss anticipated chronic neurocognitive and psychiatric outcomes of COVID-19 survivors based on emerging peer-reviewed literature, data from prior pandemics, and outcome studies from well-characterized, clinically similar syndromes. This unpacking of long-term complications from COVID-19 will seek to set expectations and provide guidance for clinicians who will undoubtably encounter increased volumes of patients with residual post-COVID-19 neurobehavioral changes. © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

From Strict Bedrest to Early Mobilization: A History of Physiotherapy in the Intensive Care Unit.

Critically ill patients are at risk of post-intensive care syndrome, including physical, cognitive, and psychological sequelae. Physiotherapists are rehabilitation experts who focus on restoring strength, physical function, and exercise capacity. Critical care has evolved from a culture of deep sedation and bed rest to one of awakening and early mobility; physiotherapeutic interventions have developed to address patients' rehabilitation needs. Physiotherapists are assuming more prominent roles in clinical and research leadership, with opportunities for wider interdisciplinary collaboration. This paper reviews the evolution of critical care from a rehabilitation perspective, highlights relevant research milestones, and proposes future opportunities for improving survivorship outcomes.

Key elements of an evidence-based clinical psychology service within adult critical care.

The COVID-19 pandemic has generated renewed interest in the psychological rehabilitation needs of patients admitted to intensive care units. While the availability of embedded practitioner psychologists within adult critical care teams remains inconsistent, post numbers have increased in response to the clinical needs of the pandemic. As psychology services within adult critical care become more widely established, models for service provision will be required. We describe our experience of developing a model for the delivery of a clinical psychology service within critical care in a District General Hospital with specialist tertiary surgical and cancer services. The current paper describes a service design that is firmly rooted in psychological theory and the broader clinical health psychology evidence base. We hope that our learning will be helpful to others.

Analysis of mortality and long-term prognosis in ventilated patients with COVID-19: a multicenter prospective observational study

Introduction: Long-term prognosis, especially for post-intensive care syndrome (PICS) is an emerging problem in critically ill patients. Prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). We aimed to investigate the prevalence and risks of mortality and PICS in ventilated patients with COVID-19. Method(s): A multicenter prospective study was conducted on ventilated patients with COVID-19 infection. The questionnaire for PICS evaluation was mailed within a median of 6 mo after hospital discharge, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. Result(s): 251 patients completed the PICS questionnaires with a prevalence of PICS of 58.6%, along with the highest percentages of cognitive impairment. Delirium (OR 2.34, p = 0.03) and the duration of mechanical ventilation (OR 1.29, p = 0.02) were identified as independent risks for PICS. In 297 patients who received mechanicalventilation for 7 day or longer, protein and energy delivery in day 4-7, especially for protein delivery, were independently and monotonically associated with in-hospital mortality, but not with PICS occurence. Conclusion(s): 60% of the ventilated patients with COVID-19 suffered from PICS. Delirium and longer mechanical ventilation were identified as risks for PICS. In the patents requiring longer mechanical ventilation, nutrition delivery in the late period of the acute phase might be imprtant to survive COVID-19.

A retrospective review of the functional status of patients post-severe COVID-19 disease

Introduction: The purpose of this study was to evaluate the functional status and ongoing respiratory symptoms of patients who have been discharged home, who were admitted to the intensive care unit (ICU) with severe COVID-19 disease. Long term complications post critical illness, such as post intensive care syndrome (PICS), are well-recognised [1], however, little data exists specific to COVID-19 ICU survivors. Method(s): Local ethics committee approval was secured. Participants were recruited using the electronic intensive care chart database. All patients, from March 2020 to November 2021, who survived Covid-19 were included. Researchers conducted phone interviews with participants and completed three questionnaires;Katz Index of Independent Living Questionnaire, Karnofsky Performance Status Scale and the American Thoracic Society (ATS) Respiratory Disease Questionnaire. Data was input and analysed using excel and stored on a password encrypted computer. Result(s): Database search revealed 61 patients available, 33 of 61 patients were included. 20 (61%) were male, 13 (39%) were female. Mean age was 58, with a range of 25-81. Mean length of ICU stay was 15 days, with a range of 1-74 days. 15 (45%) patients were intubated. Most common Katz score (range 1-6) was the highest score of 6 in 23 (70%) patients. Most common Karnofsky score (range 10-100) was 60 in 11 (33%) patients, with 31 (94%) scoring < 100. The most frequent ATS shortness of breath (SOB) grade (range 0-4) was 3 in 10 (9%) patients, with 23 (70%) patients scoring > 0. 14 (42%) patients had an ongoing cough, 11 (33%) patients had a wheeze and 0 (0%) patients were on home oxygen therapy. Conclusion(s): This study highlights in the majority of patients who survived severe Covid-19 disease to discharge home, there were serious ongoing limitations to their functional status and exercise tolerance, however, they remained independent of basic activities of daily living.

Survival ≠ Recovery: A Narrative Review of Post-Intensive Care Syndrome

: Surviving critical illness does not always equate to recovery, with its aftermath frequently complicated by post-intensive care syndrome (PICS). This syndrome consists of a collection of new or worsening impairments in the physical, psychological, or cognitive domains that develop after critical illness. In this review, we describe the clinical manifestations, evaluation, and management of PICS. We also examine the interplay between PICS and social determinants of health. Finally, we discuss how multidisciplinary PICS clinics can be utilized to care for intensive care unit (ICU) survivors and potentially improve care within the ICU.

Chronic critical illness in critically ill COVID-19 patients.

OBJECTIVES: To evaluate the presence of chronic critical illness (CCI) in COVID-19 patients and compare clinical characteristics and prognosis of patients with and without CCI admitted to intensive care unit (ICU). METHODS: It was a retrospective, observational study at a university hospital ICU. Patients were accepted as CCI if they had prolonged ICU stay (≥14 days) and got ≥1 score for cardiovascular sequential organ failure assessment (SOFA) score and ≥2 score in other parameters on day 14 of ICU admission which was described as persistent organ dysfunction. RESULTS: 131 of 397 (33%) patients met CCI criteria. CCI patients were older (p = 0.003) and frailer (p < 0.001). Their Acute Physiology and Chronic Health Evaluation (APACHE) II and SOFA scores were higher, PaO2/FiO2 ratio was lower (p < 0.001). Requirement of invasive mechanical ventilation (IMV), steroid use, and septic shock on admission were higher in the CCI group (p < 0.001). CCI patients had higher ICU and hospital mortality than other patients (54.2% vs. 19.9% and 55.7% vs. 22.6%, p < 0.001, respectively). Regression analysis revealed that IMV (OR: 8.40, [5.10-13.83], p < 0.001) and PaO2/FiO2 < 150 on admission (OR: 2.25, [1.36-3.71], p = 0.002) were independent predictors for CCI. DISCUSSION: One-third of the COVID-19 patients admitted to the ICU were considered as CCI with significantly higher ICU and hospital mortality.

Sepsis-Associated Delirium: A Narrative Review.

Delirium is characterized by an acutely altered mental status accompanied by reductions in cognitive function and attention. Delirium in septic patients, termed sepsis-associated delirium (SAD), differs in several specific aspects from the other types of delirium that are typically encountered in intensive care units. Since sepsis and delirium are both closely associated with increased morbidity and mortality, it is important to not only prevent but also promptly diagnose and treat SAD. We herein reviewed the etiology, pathogenesis, risk factors, prevention, diagnosis, treatment, and prognosis of SAD, including coronavirus disease 2019 (COVID-19)-related delirium. Delirium by itself not only worsens long-term prognosis, but it is also regarded as an important factor affecting the outcome of post-intensive care syndrome. In COVID-19 patients, the difficulties associated with adequately implementing the ABCDEF bundle (Assess, prevent, and manage pain; Both spontaneous awakening and breathing trials: Choice of analgesia and sedation; Delirium assess, prevent, and manage; Early mobility and exercise; Family engagement/empowerment) and the need for social isolation are issues that require the development of conventional care for SAD.

Physical, social, mental and spiritual functioning of COVID-19 intensive care unit-survivors and their family members one year after intensive care unit-discharge: A prospective cohort study.

OBJECTIVE: To describe the long-term functioning of patients who survived a COVID-19-related admission to the intensive care unit and their family members, in the physical, social, mental and spiritual domain. DESIGN: A single-centre, prospective cohort study with a mixed-methods design. SETTING: The intensive care unit of the University Medical Center Groningen in the Netherlands. MAIN OUTCOME MEASURES: To study functioning 12 months after intensive care discharge several measurements were used, including a standardised list of physical problems, the Clinical Frailty Scale, the Medical Outcomes Study Short-Form General Health Survey, the McMaster Family Assessment Device, the Hospital Anxiety and Depression Scale, and the Spiritual Needs Questionnaire, as well as open questions and interviews with survivors and their family members. RESULTS: A total of 56 survivors (77%) returned the 12-month questionnaire, whose median age was 62 (inter-quartile range [IQR]: 55.0-68.0). Moreover, 67 family members (66%) returned the 12-month questionnaire, whose median age was 58 (IQR: 43-66). At least one physical problem was reported by 93% of the survivors, with 22% reporting changes in their work-status. Both survivors (84%) and their family members (85%) reported at least one spiritual need. The need to feel connected with family was the strongest. The main theme was 'returning to normal' in the interviews with survivors and 'if the patient is well, I am well' in the interviews with family members. CONCLUSIONS: One year after discharge, both COVID-19 intensive care survivors and their family members positively evaluate their health-status. Survivors experience physical impairments, and their family members' well-being is strongly impacted by the health of the survivor.

Post-traumatic stress symptoms six months after ICU admission with COVID-19: Prospective observational study.

AIMS AND OBJECTIVES: The aim of this study was to investigate the prevalence of post-traumatic stress symptoms, and to identify possible predictive factors in Norwegian intensive care unit survivors, 6 months after admission to the intensive care unit with COVID-19. BACKGROUND: The SARS CoV-2 virus causing COVID-19 has spread worldwide since it was declared a pandemic in March 2020. The most severely ill patients have been treated in the intensive care due to acute respiratory failure and also acute respiratory distress syndrome. It is well documented that these severe conditions can lead to complex and long-lasting symptoms, such as psychological distress, and was, therefore, investigated for the specific COVID-19 population. DESIGN: Prospective observational study. METHODS: Clinical data and patient reported outcome measures were collected by the Norwegian Intensive Care and Pandemic Registry and by the study group 6 months after admission to an intensive care unit. RESULTS: Among 222 COVID-19 patients admitted to Norwegian intensive care units between 10 March and 6 July 2020, 175 survived. The study sample consisted of 131 patients who responded to at least one patient reported outcome measure at 6 months following admission. The primary outcome was self-reported post-traumatic stress symptoms, using the Impact of Event Scale-6 (n = 89). Of those, 22.5% reported post-traumatic stress symptoms 6 months after admission. Female gender, younger age and having a high respiratory rate at admission were statistically significant predictive factors for reporting post-traumatic stress symptoms. CONCLUSIONS: The result is in accordance with previously published research with comparable populations, suggesting that for many COVID-19 survivors psychological distress is a part of the post-acute sequelae. Results from the present study should be replicated in larger datasets. RELEVANCE TO CLINICAL PRACTICE: This project provides important insight to post-acute sequelae after COVID-19 that patients may experience after critical illness.

Health-related quality of life and stress-related disorders in COVID-19 ICU survivors: Are they worse than with other causes of ARDS?

Background: There are insufficient data regarding the impact of acute respiratory distress syndrome related to coronavirus disease 2019 (C-ARDS) - caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) - on health-related quality of life (HRQoL) and the occurrence of stress-related disorders in coronavirus disease 2019 (COVID-19) intensive care unit (ICU) survivors. The aim of this study is to assess HRQoL and the occurrence of stress-related disorders (acute stress disorder [ASD] and post-traumatic stress disorder [PTSD]) in C-ARDS ICU survivors at 1 and 6 months following hospital discharge. Methods: This prospective observational study included 90 patients treated for C-ARDS between March and May 2020 in the ICU and discharged alive from the hospital. All patients included in the study were contacted by telephone 1 month and 6 months post-hospital discharge to assess the presence of symptoms of stress-related disorders and HRQoL using the 8-item Treatment Outcome Post-traumatic Stress Disorder scale (TOP-8) and 36-item Short Form survey (SF-36). We performed univariate analyses to evaluate differences between patients who developed stress and those who did not. We also compared SF-36 scores in our sample with data from the general Spanish population and from cohorts of non-C-ARDS and severe acute respiratory syndrome coronavirus-1 (SARS-CoV-1) survivors. Results: There are 24.1% of patients showed symptoms of ASD; in 13.5% of cases the symptoms persisted 6 months later. Risk factors for the development of symptoms of ASD and PTSD are younger age, female sex, obesity, a previously diagnosed psychiatric disease and disease severity at ICU admission (P < 0.05). HRQoL was greatly affected by C-ARDS; however, there was improvement on all scales of the SF-36 at the 6-month follow-up (P < 0.05). The mean SF-36 score of our sample was higher than those previously reported in non-C-ARDS survivors (P < 0.05) for physical functioning (78.0 vs. 52.0), role functioning/physical (51.0 vs. 31.0), bodily pain (76.1 vs. 57.0), vitality (58.6 vs. 48.0), social function (72.6 vs. 63.0) and role emotional (77.4 vs. 55.0), except on the general health scale. C-ARDS survivors also scored better than SARS-CoV-1 survivors on all scales except for body pain (P < 0.05). Conclusions: The impact of C-ARDS on HRQoL is substantial, with frequent occurrence of PTSD symptoms. Patients are heavily affected in all areas of health in the first month of post-hospital discharge but show a dramatic improvement within 6 months, especially in terms of physical health.

Inpatient rehabilitation can improve functional outcomes of post-intensive care unit COVID-19 patients-a prospective study.

PURPOSE: To evaluate the impact of an inpatient multimodal and intensive rehabilitation program on neuromuscular, respiratory, and functional impairments of post-ICU COVID-19 patients. MATERIALS AND METHODS: Prospective study including post-ICU COVID-19 survivors consecutively admitted to a rehabilitation centre. Rehabilitation was conducted by an interdisciplinary team. Medical Research Council (MRC) score, maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP), peak cough flow (PCF), Functional Oral Intake Scale (FOIS), Brief Balance Evaluation Systems Test (Brief-BESTest), Timed Up and Go (TUG) test, 1 min Sit to Stand Test (1' STST), 6 min Walking Test (6MWT), Fatigue Assessment Scale (FAS), Functional Independence Measure (FIM) were assessed at admission (T0) and discharge (T1). RESULTS: A total of 42 patients were included. After 32.00;26.00 days of inpatient rehabilitation, there was a significant improvement in limb and respiratory muscle strength, cough effectiveness, fatigue, balance, exercise capacity, and in the ability to perform activities of daily living. Advanced age, longer acute care hospitalization, depressive symptoms, and cognitive deficits were associated with poorer functional outcomes. CONCLUSION: Post-ICU COVID-19 patients present multiple sequelae with detrimental functional impact. An adapted interdisciplinary rehabilitation program is essential for a thorough evaluation of these patients and results in significant functional gains.IMPLICATIONS FOR REHABILITATIONPost-ICU COVID-19 survivors present multiple sequelae and disabilities.An intensive and interdisciplinary inpatient rehabilitation results in significant improvement in limb and respiratory muscle strength, cough effectiveness, fatigue, balance, exercise capacity, and ability to perform activities of daily living.Timely referral from the acute care setting to rehabilitation services is crucial to minimize the functional impact of severe multisystemic disease and prolonged hospitalization.

Characteristics of Mid-Term Post-Intensive Care Syndrome in Patients Attending a Follow-Up Clinic: A Prospective Comparison Between COVID-19 and Non-COVID-19 Survivors.

At present, it is not clear if critically ill COVID-19 survivors have different needs in terms of follow-up compared with other critically ill survivors, and thus if duplicated post-ICU trajectories are mandatory. OBJECTIVES: To compare the post-intensive care syndrome (PICS) of COVID-19 acute respiratory distress syndrome and non-COVID-19 (NC) survivors referred to a follow-up clinic at 3 months (M3) after ICU discharge. DESIGN SETTING AND PARTICIPANTS: Adults who survived an ICU stay greater than or equal to 7 days and attended the M3 consultation were included in this observational study performed in a post-ICU follow-up clinic of a single tertiary hospital. MAIN OUTCOMES AND MEASURES: Patients underwent a standardized assessment, addressing health-related quality of life (3-level version of EQ-5D), sleep disorders (Pittsburgh Sleep Quality Index [PSQI]), physical status (Barthel index, handgrip and quadriceps strengths), mental health disorders (Hospital Anxiety and Depression Scale and Impact of Event Scale-Revised [IES-R]), and cognitive impairment (Montreal Cognitive Assessment [MoCA]). RESULTS: A total of 143 survivors (86 COVID and 57 NC) attended the M3 consultation. Their median age and severity scores were similar. NC patients had a shorter ICU stay (10 d [8-17.2 d]) compared with COVID group (18 d [10.8-30 d]) (p = 0.001). M3 outcomes were similar in the two groups, except for a higher PSQI (p = 0.038) in the COVID group (6 [3-9.5]) versus NC group (4 [2-7]), and a slightly lower Barthel index in the NC group (100 [100-100]) than in the COVID group (100 [85-100]) (p = 0.026). However, the proportion of patients with abnormal values at each score was similar in the two groups. Health-related quality of life was similar in the two groups. The three MoCA (≥ 26), IES-R (<33), and Barthel (=100) were normal in 58 of 143 patients (40.6%). In contrast, 68.5% (98/143) had not returned to their baseline level of daily activities. CONCLUSIONS AND RELEVANCE: In our follow-up clinic at 3 months after discharge, the proportion of patients presenting alterations in the main PICS domains was similar whether they survived a COVID-19 or another critical illness, despite longer ICU stay in COVID group. Cognition and sleep were the two most affected PICS domains.

The Intensive Care Unit diary - A significant complement in the recovery after intensive care. A focus group study.

OBJECTIVES: The aim of this study was to gain an increased understanding of the intensive care unit diary and how it affects patients' recovery after intensive care. METHODOLOGY/DESIGN: The study had a qualitative design and was conducted by two focus group interviews in October 2021 and was analysed with thematic analysis. SETTING: Ventilator treated intensive care patients with a length of stay ≥ 72 hours who had received a written diary were included. The study was conducted at two university hospitals in the south of Sweden. FINDINGS: The intensive care unit diary can be an important complement to the medical record and notes taken by family members by enhancing understanding of critical illness. The patients experience several prominent feelings from reading the diary such as guilt, fear, and anxiety as well as feelings of being cared for. The design and content of the diary can be important used as a tool in patients' recovery after intensive care. CONCLUSION: Understanding their critical illness and the time in intensive care seems important to former intensive care patients. In this respect, the intensive care unit diary on its own does not provide significant information and thus need to be complemented by information from the medical record and notes taken by family members. Therefore, the diary can be used as a complement that might increase patients' sense of coherence and facilitate recovery after intensive care.

Interdisciplinary Treatment for Survivors of Critical Illness due to COVID-19: Expanding the Post-Intensive Care Recovery Model and Impact on Psychiatric Outcomes.

BACKGROUND: Post-intensive care unit recovery programs for survivors of critical illness related to COVID-19 remain limited, ever-evolving, and under active investigation. Mental health professionals have an emerging role within this multidisciplinary care model. OBJECTIVE: This article explores the design and implementation of an intensive care unit follow-up clinic in New Orleans during the era of COVID-19. Survivors of a critical illness due to COVID-19 were offered multidisciplinary outpatient treatment and systematic psychological screening up to 6 months after the initial clinic visit. METHODS: We implemented a prospective, observational study at a post-intensive care syndrome (PICS) clinic for survivors of a critical illness related to COVID-19 embedded within an academic Veterans Affairs hospital. Our team identified patients at high risk of PICS and offered them a clinic consultation. Patients were provided the following interventions: review of the critical care course, medication reconciliation, primary care, psychopharmacotherapy, psychotherapy, and subspecialty referrals. Patients were followed up at 1- to 3-month intervals. Psychological symptom screening was conducted with Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, 9-question Patient Health Questionnaire, and 7-item Generalized Anxiety Disorder assessments. RESULTS: Seventy-seven total patients were identified to be at high risk of PICS from March to November 2020, and of this cohort, 44 (57.14%) survived their COVID-19 hospitalizations. Of the surviving 44 patients contacted, 21 patients established care in the PICS clinic and returned for at least 1 follow-up visit. At initial evaluation, 66.7% of patients demonstrated clinically meaningful symptoms of post-traumatic stress disorder. At 3-month follow-up, 9.5% of patients showed significant post-traumatic stress disorder symptoms. Moderate-to-severe symptoms of anxiety were present in 38.1% of patients at initial evaluation and in 4.8% of patients at 3 months. Moderate-to-severe symptoms of depression were present in 33.4% and 4.8% of patients at initial visit and at 3 months, respectively. CONCLUSIONS: A PICS clinic serves as a posthospitalization model of care for COVID-19 intensive care unit survivors. This type of health care infrastructure expands the continuum of care for patients enduring the consequences of a critical illness. We identified a high prevalence of post-traumatic stress, anxiety, and depression, along with other post- intensive care unit complications warranting an intervention. The prevalence of distressing psychological symptoms diminished across all domains by 3 months.

Post-Intensive Care Syndrome Among Survivors in a Safety Net Hospital in South Bronx: A Comparison of Patients With and Without Coronavirus Disease 2019.

Comparison of post-intensive care syndrome between critically ill survivors with or without coronavirus disease 2019 (CovP and CovN, respectively) showed that fewer CovP were able to return to work full time at >1 year and none at <1 year after discharge and that the majority of CovP survivors were able to work part time during both evaluation periods compared to CovN.

Symptoms of Anxiety, Depression, and Stress among Families of Critically Ill Patients with COVID-19: A Longitudinal Clinical Trial.

Rationale: Families of critically ill patients with coronavirus disease (COVID-19) may be at particularly high risk for anxiety, depression, and post-traumatic stress disorder after hospital discharge. Objectives: To assess symptoms of anxiety, depression, and stress among families of patients with COVID-19 during and after intensive care unit (ICU) admissions and to use qualitative methods to determine the sources of emotional distress. Methods: Families of patients with COVID-19 who participated in an ICU study were approached for participation in this post-hospital discharge study. Participants completed the Hospital Anxiety and Depression Scale (HADS) and the Impact of Events Scale-Revised (IES-R) at up to three points during the ICU stay and once after the ICU stay. Mixed-effects models were used to compare trajectories of HADS and IES-R scores over the ICU and post-ICU periods. Telephone interviews with participants were evaluated using thematic content analysis. Results: Among the 90 families that participated from September 2020 to April 2021, 47 respective patients were alive and 43 were deceased. Average HADS anxiety, HADS depression, and IES-R scores after hospital discharge were significantly higher (greater symptom burden) among families of deceased versus surviving patients: 9.2 (95% confidence interval [CI], 7.8-10.6) versus 6.3 (95% CI, 4.9-7.6) (P < 0.01), 7.1 (95% CI, 5.7-8.6) versus 3.2 (95% CI, 2.3-4.1) (P < 0.001), and 36.1 (95% CI, 31.0-41.2) versus 20.4 (95% CI, 16.1-24.8) (P < 0.001), respectively. HADS anxiety and HADS depression scores began to diverge during the ICU stay, whereas IES-R scores diverged after the stay for families of surviving versus deceased patients. Qualitative analysis confirmed a higher burden of psychological symptoms among families of deceased patients. Memories from the ICU stay became a focal point for participants who lost their loved ones, whereas families of surviving patients were able to look positively toward the future. In addition, families of deceased patients often viewed friends and family as sources of stress, whereas families of surviving patients typically viewed their community as a source of support. Conclusions: Patient death was associated with symptoms of anxiety, depression, and post-traumatic stress disorder among families of ICU patients with COVID-19. Psychological support interventions may be most beneficial for families of patients who died of COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04501445).

Features and management of acute and chronic neuro-COVID

This book underlines how COVID-19 is a multisystem inflammatory disease and how its pathophysiology can predispose to an increased risk of neurological issues. Several scientific pieces of evidence showes the mechanisms underlying the neuroinvasive capacity of the SARS-CoV-2 through direct viral damage and indirect processes entering the CNS by different routes including the vasculature, the olfactory and trigeminal nerves, the cerebrospinal fluid, and the lymphatic system inducing a direct neurotoxicity. Furthermore, the pro-inflammatory cytokine storm and oxidative stress can induce microglial activation and damage to the blood-brain barrier, culminating in widespread neuroinflammatory process. This acute neurotoxicity is clinically expressed as anosmia and ageusia, headache, nausea and vomiting, but other neurologic manifestations such as acute cerebrovascular diseases, consciousness impairment due to encephalitis, and meningitis are also described. The PNS can also be affected by infectious damage and clinical manifestations including Guillain-Barre syndrome, polyneuritis cranialis, and Miller Fisher Syndrome. A special issue concerns the neurocognitive dysfunction and altered consciousness manifested as delirium, agitation and confusion. Non-specific symptoms such as dizziness, seizures can accompany clinical pictures. Regardless of the admission diagnosis, a high percentage of patients discharged from ICUs develop disabilities affecting physical, cognitive and psychological activities. The symptoms such as asthenia, memory disturbances, depression, sleep disturbances, anxiety, and Post-traumatic stress disorder (PTSD), configure the so-called Post-intensive Care Syndrome (PICS). Multimodal management during the ICU stay and implementation of follow-up programs at patient discharge can reduce the incidence of this syndrome, improving the quality of life of surviving patients. In this complex scenario, a careful clinical approach through reliable diagnostic tools, and epidemiological studies aimed at evaluating the dimensions of the problem also in economic terms, is urgently needed. This book represents a valuable aid for all those healthcare professionals (intensivists, neurologist and psychiatrists, as well) involved in the management of these critically ill patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Post-intensive Care Unit COVID-19 Survivors: Functional Status and Respiratory Function Three Months After an Inpatient Rehabilitation Program.

Introduction and objectives Long-term coronavirus disease 2019 (COVID-19) sequelae have become an increasing concern, with persistent dyspnoea and fatigue being the most common and long-lasting symptoms reported. The aim of this study was to evaluate the functional status and respiratory function three months after discharge from an inpatient rehabilitation program. Materials and methods This was a prospective study including post-ICU COVID-19 survivors consecutively admitted to an inpatient and multimodal rehabilitation program in a rehabilitation center. Evaluation of functional status (brief balance evaluation systems test (brief-BESTEST), timed up and go (TUG) test, 1 min sit to stand test (1STST), 6 min walking test (6MWT)); respiratory muscle strength (maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP)); cough effectiveness (peak cough flow (PCF)); and fatigue (fatigue assessment scale (FAS)) were assessed at admission (T0), discharge (T1), and three months after discharge (T2). Results A total of 36 patients were included. Between T1 and T2, there was a significant improvement in MEP (84.47±20.89 vs 97.23±24.63 cmH2O, p<0.001), PCF (367.83±117.24 vs 441.33±132.90 L/min, p=0.003), functional capacity (1STST (19.90±6.37 vs 23.13±6.07, p=0.004), and 6MWT (459.25±153.70 vs 500.00±163.74 meters, p=0.003)). No differences were seen in MIP, brief-BESTEST, or TUG. Patients presented a higher median final FAS score at T2 compared to T1: 21.50±5 vs 18.60±2.65, p=0.002. Conclusions Post-ICU COVID-19 survivors admitted to an inpatient rehabilitation program maintained a good functional recovery at the three-month follow-up. Despite overall improvement, we found higher scores of FAS, suggesting worse fatigue levels.