Year 2022 in Review - Intensive care medicine - Cardiovascular and general issues.

In 2022, intensive medicine all around the world gradually began to return to standard tracks, although we could still observe the effects of the pandemic waves of the disease COVID-19. In the literature, we could note the publication of research studies of "violently terminated" pandemics and new works. This review article presents a selection of the most interesting published articles in general intensive care medicine and those focusing on cardiovascular issues.Copyright © 2022, Czech Medical Association J.E. Purkyne. All rights reserved.

An Awareness Survey on COVID-19 among Japanese Patients with Fabry Disease

The purpose of this study was to clarify the effects of the coronavirus disease 2019 (COVID- 19) pandemic on the lives and medical care of Japanese patients with Fabry disease and how healthcare providers can support the continued treatment of these patients in the future. A questionnaire survey was conducted with members of the Japan Fabry Disease Patients and Family Association. The questionnaire was mailed to 156 patients and was returned by 87 (response rate, 56%);83 questionnaires were considered valid and were analyzed. The study found that most of patients with Fabry disease had already received or wanted to receive a vaccine and were "very worried" about COVID- 19. In addition, the COVID- 19 pandemic had changed the patients' lives and affected their physical and mental health. Although the percentage of patients who were able to continue treatment was higher than we expected and the percentage who wanted home infusion therapy was lower than we expected, some patients were anxious about coming to the hospital or had switched to oral pharmacological chaperone therapy. Therefore, to be prepared for pandemics, such as COVID- 19, a system of care at home for patients with Fabry disease should be developed.Copyright © 2022 Jikei University School of Medicine. All rights reserved.

Switching from natalizumab administration at the day hospital to administration at home. A 1 year prospective study of patient experience and quality of life in 30 consecutive patients with multiple sclerosis (TYSAD-35).

BACKGROUND: In the context of the COVID-19 pandemic, French health authorities allowed the home administration of natalizumab by a healthcare-at-home service. We evaluated the patients' perception of care quality following the transition from day-hospital to home natalizumab administration. METHODS: Thirty relapsing-remitting multiple sclerosis (MS) patients treated with natalizumab were prospectively evaluated for one year after changing onto a home treatment procedure, using MusiCare, the first MS-specific questionnaire to evaluate patient experience and MusiQol. A numerical rating scale score for satisfaction and a dedicated questionnaire concerning patient experience were completed after each infusion. The primary endpoint was the mean difference in MusiCare score between baseline and 12 months. RESULTS: From June 2020 to November 2021, 306 infusions were performed at home. Three patients withdrew from the study (one lost to follow-up and two preferred to return at the day hospital). No worsening of patient experience or quality of life was observed. The mean scores of the Musicare dimensions were higher at 12 months than at baseline, significantly for the "relationship with healthcare professionals" (p = 0.0203). The MusiQol global score remained stable but the coping and friendship dimensions were significantly better at M12 than at baseline (p = 0.0491 and p = 0.0478, respectively). The satisfaction questionnaire highlighted some pain during the infusions (21.8%) and contradictions between healthcare professionals (17.2%). The mean score for satisfaction with care was 9.1/10. No safety concerns were identified. CONCLUSION: The positive experience of patients with home natalizumab administration provides an important opportunity to improve the quality of patient care.

Pediatric Chemotherapy Infusions in Outpatient Examination Rooms: A Novel Patient Care Approach.

Background: Many health care organizations offer pediatric infusions in outpatient infusion centers or, as in our organization, in a hospital-based outpatient Pediatric Infusion Therapy Center (PITC). When restrictions related to the COVID-19 pandemic decreased our PITC appointment capacity by 40%, other patient and family satisfaction issues were exacerbated. We implemented a new approach to pediatric infusions with the aim of improving patient and family satisfaction and reducing the amount of time in an appointment itinerary without negatively affecting patient safety. Methods: Our team used a phased approach to pilot the administration of short chemotherapy infusions in the same outpatient clinic examination rooms where consultation and routine office visits were conducted. Patients saw their specialist for an examination and, if clinically indicated, their infusion was administered in the same room. Appointment itineraries were then completed. The team tracked efficiency, satisfaction, and safety metrics related to the new process. Results: All efficiency metrics improved. No harm came to the 49 unique patients who received a total of 184 infusions. Patient appointment itineraries were shortened by an average of 1.03 hr. Satisfaction survey responses indicated a clear preference (93%) for the new process. Discussion: The novel approach of offering short infusions in outpatient clinic examination rooms provides an opportunity to ease capacity constraints and further increase patient and family satisfaction. This method may be especially helpful for health care organizations when external influences (e.g., lack of physical space, challenging patient volumes, and pandemics) necessitate a change.

A case of post coronavirus disease 2019 (COVID-19) multisystem inflammatory syndrome in adults (MIS-A) presenting as fever and seizures

Background/Purpose: The coronavirus disease 2019 (COVID-19) pandemic has led to the emergence of a severe associated condition, multisystem inflammatory syndrome in adults (MIS-A). Initially identified in children as MIS-C, literature regarding the clinical manifestations, illness progression, and treatment of MIS-A are limited. Method(s): This study describes a case of MIS-A presenting as fever and seizures. She was initially given steroids and IVIG, and due to recurrence of fever, she was later treated with tocilizumab. Result(s): The patient was a 55-year- old Filipino female presenting to the emergency department with five days of fever, headache, and disorientation. Lumbar tap was done, which showed elevated opening pressure, normal leukocyte count, normal glucose, slightly elevated protein, and no microorganisms. She was admitted and managed as a case of viral encephalitis. On hospital day 6, she had sudden onset of head-jerking and further decrease in sensorium, hence she was transferred to the intensive care unit. Brain MRI was unremarkable, and subsequent immune-mediated encephalitis was considered. The patient underwent methylprednisolone pulse therapy and IVIG infusion, which provided immediate improvement of sensorium and resolution of fever episodes. Her condition stabilized, and she was transferred out of intensive care. She underwent physical and occupational rehabilitation as preparation for discharge. Two weeks after infusion therapy, on hospital day 26, patient had recurrence of fever episodes and persistence of elevated inflammatory markers. The patient had reported a previous COVID-19 infection 10 weeks prior to admission and received a booster dose of Moderna (Spikevax) COVID-19 vaccine three weeks prior. She tested positive for ANA (1:640, nuclear speckled), while the rest of the autoimmune antibody tests were negative. She was diagnosed as MIS-A based on the following: documented fever (>=38 degrees centigrade) for >=24 hours prior to hospitalization;new-onset neurologic signs and symptoms including seizures and encephalopathy in a patient without prior cognitive impairment;elevated CRP, ferritin, IL-6, and ESR;and a positive SARS-CoV- 2 test for recent infection by RT-PCR. Patient was treated with a locally available monoclonal antibody, tocilizumab, which was given on hospital day 43. Following infusion, she had lysis of fever and marked decrease in CRP, ferritin, IL-6, and ESR. Patient was discharged improved and without end-stage organ damage. Conclusion(s): Immunomodulators target hyperinflammation seen in MIS-A. There may be a role for the use of tocilizumab via blockage of IL-6. MIS-A remains a topic for research, particularly its disease characteristics, management, and relation to a dysregulated immune system.

Outcomes of AstraZeneca vaccine for relapse and Covid-19 infection in people with multiple sclerosis

Background: People with chronic diseases of the immune system, such as multiple sclerosis (MS), are at risk for Covid-19 disease. However, more research is needed with long-term follow-up. The aim of the study was to follow up people with MS (PwMS) for up to three months after AstraZeneca vaccination for the recurrence of MS and Covid-19 infection. Method(s): This study was a case study (descriptive-analytical) of follow-up type. The study population was PwMS over 18 years of age in Kermanshah province who received both doses of the AstraZeneca vaccine. This study was conducted from August to November 2021. Sampling was done with existing methods based on the National MS Registry of Iran (NMSRI). Demographic information of patients was extracted from NMSRI. A researcher-made form was used to collect information by telephone three months after vaccination about clinical characteristics, Covid-19 infection, and recurrence of MS. Data were analyzed using SPSS-25 software. Result(s): Study participants were 40 MS patients with a mean (SD) age of 39.27 (8.8) years, including 32 (80.0%) women. A mean of 9.39 (4.6) years had passed since The patients were diagnosed with MS, and 29 (76.4%) had RR type MS. Four patients (10%) relapsed between the second dose and three months later, of whom two (50%) had sensory symptoms, one (25%) had optic nerve involvement, and one (25%) had motor symptoms and pyramidal pathway involvement. The symptoms of Covid-19 were mild in three patients (10%), while severe symptoms developed in one patient (10%) who received rituximab. Among the patients, no cases of thrombosis were observed. Infusion therapy, a leg fracture, and kidney stones were the only hospitalized cases. Conclusion(s): Covid-19 and MS relapse prevalence did not differ significantly in the three months before and after vaccination. There is a need for further studies with a longer follow-up period. Copyright © 2022 Razazian et al. Published by Tehran University of Medical Sciences.

Home-hospital care for children with acute illnesses: A 2-year follow-up study.

AIM: Procedures normally performed in the hospital setting are increasingly delivered as part of hospital at home (HAH) programmes. The aim of this study is to describe the procedures and diseases treated during the first 2 years of a new paediatric HAH programme. METHODS: This is a retrospective, observational study conducted in the HAH programme of Niño Jesús Children's Hospital (Spain). We included demographic data, diagnosis and procedures delivered to patients admitted to the HAH programme from November 2018 to November 2020. RESULTS: There were 935 admissions of 833 patients. The median age was 5 years (interquartile range 2.3-9.5). Seventy-five percent of patients were previously healthy. The most frequent illnesses were acute infections (37%) (e.g. complicated appendicitis and ENT, genitourinary, skin and soft tissue infections) and acute respiratory diseases (17.3%) (e.g. asthma, bronchiolitis and pneumonia). Thirty-six percent of admissions underwent nocturnal polysomnography. The median length of stay was 4 days (SD 4.9 days). Eight percent of the episodes studied required care in the emergency department due to condition worsening (55.3%) and problems with devices (36.1%). Hospital readmission was required in 5.6% of cases, 42.4% of which later resumed care in the HAH. The estimated daily cost of HAH is 330.65 euros, while the hospital per-day costs of polysomnography, asthma and endovenous therapy are 1899.24, 1402.5, and 976.26 euros. Ninety percent of families reported a high level of satisfaction. CONCLUSIONS: Paediatric HAH programmes are a feasible, cost-effective alternative to hospital care. Further studies should compare the evolution of patients treated in the traditional hospital setting and those in HAH.

Home Delivery: Transfusion Services When and Where They Are Needed.

Home blood product transfusion has been utilized around the world in various forms over the past few decades. There is current interest in decentralizing hospital care to improve patient independence and convenience, minimize cost to the health service, and to prevent nosocomial infection, especially with the recent COVID-19 pandemic. The transition to "hospital in the home" is occurring across the healthcare sector driven by aims to improve patient outcomes and patient satisfaction, capacity pressures in the acute care sector, and most recently due to concerns regarding infectious disease transmission in hospital settings. This review explores the published literature on home red cell and platelet transfusions, and where the literature is limited, also considered data from subcutaneous immunoglobulin studies. Current published experience on red cell and platelet transfusion at home has identified benefits to the patient and health service, with further studies needed to quantify improvement in quality of life and health-related outcomes. Safety concerns may be a perceived barrier to implementation of home transfusion, however current published data suggests serious adverse reactions are rare. Cost-effectiveness data for home transfusion are very limited and a key area for future research. Home transfusion has the potential to benefit from newer technologies, such as portable/remote monitoring and electronic patient identifiers.

Declining the COVID-19 vaccination: An evaluation of why some high risk cancer patients decline vaccination

The COVID-19 pandemic has created many challenges and barriers to care for patients on active cancer treatments including increased risk for morbidity and mortality from COVID-19 infection and restricted access to care. Specific patient groups, such as the uninsured and patients of underrepresented minority communities, have experienced this burden disproportionately. The rapid development and emergency authorization of COVID-19 vaccinations present an opportunity to mitigate some of this increased risk and improve health outcomes for patients on active cancer treatments. However, little is known regarding the rate of vaccination in this patient group. We study the rate of COVID-19 vaccination in a single institution infusion therapy clinic for cancer patients at a large academic county hospital in San Antonio which serves a high-risk patient population with a high representation of minority patient and uninsured patients. Patients were surveyed on arrival to the University Health System outpatient infusion clinic between May 2021 and June 2021. COVID-19 vaccinations became available to this patient population in February 2021. Starting the survey process three months after the first vaccination availability allowed sufficient time for patients to become fully vaccinated. Of the 194 patients surveyed between May 3, 2001 and June 25, 2021, 56% reported receiving at least one dose of a COVID-19 vaccination which is lower than the community vaccination rate of 76%. Patients were given 6 options to choose from for declining the vaccination. They included: 1. I do not think it is safe for me because I have cancer 2. My doctor has not told me to get the vaccine 3. I want the vaccine but have not been able to schedule an appointment 4. I'm afraid of the side effects 5. I already had COVID, so I do not think I need the vaccine 6. Other The most common reason given for declining the vaccination was "My doctor has not told me to get the vaccine" by 30% of patients and the second most common was "I do not think it is safe for me because I have cancer" by 28% of patients. "I'm afraid of the side effects" was thethird most common response given by 23% of patients. Interestingly, access to the vaccine was not a common reason with only 10% of patients reporting this reason for not getting vaccinated. The three most common reasons cancer patients declined the COVD-19 vaccination can all be addressed by improvement in patient/physician communication regarding the known safety of the novel COVID-19 vaccinations and the recommendation for cancer patients to be vaccinated to help improve overall safety of giving immunosuppressive medications during the pandemic. This study shows the impact that healthcare works can make in increasing the COVID-19 vaccination rate in a high-risk population.

Will the screening of SARS-COV-2 infection in IBD infusion centers be useful?

Background: The global emergence of SARS-COV-2 virus and the COVID-19 pandemic increased the concerns about the vulnerability of inflammatory bowel disease (IBD) patients. Infusion centers are a crucial part in the management of IBD patients and safety for SARSCOV- 2 must be assured. Current recommendations of International Organization for the Study of Inflammatory Bowel Disease suggest that only patients exhibiting symptoms suggestive of COVID-19 should be tested for SARS-COV-2 before the biologic infusion therapy. We evaluated patients admitted at our infusion center, in which all had to be screened before treatment. Methods: We conducted an observational study, including all adult patients with IBD under biologic therapy infusion between April of 2020 and September of 2021. According to the local institutional protocol all patients were tested for SARS-COV-2 by a polymerase chain reaction (PCR) test in the previous 48-72 hours. Epidemiological, clinical and treatment data were collected. Results: A total of 105 patients were evaluated, with a mean age of 38,6±12,8 years and a predominance of male gender (61,9%). Crohn's disease was more prevalent, affecting 81,9% of the patients. The most common biologic infusion therapy was infliximab (93,3%), followed by vedolizumab (4,8%). A SARS-COV-2 infection were identified in five patients (4,8%), with age between 41 and 66 years, four asymptomatic and without a known risk contact. Four patients developed the infection before vaccination and one patient after the first dose. None of the patients required medical care or hospitalization. All cases were registered in February of 2021, which temporarily represented one of the most critical phases of the pandemic in our country and region, with one of the highest incidence of cases of SARS-COV-2 infection. In our cohort, most patients (85,7%) completed the vaccination schedule, with a minority (n=10) without any dose of vaccine. Conclusion: During this COVID-19 pandemic, health systems have to address unprecedented challenges. Our study support the current recommendation, since the universal screening of SARS-COV-2 infection in IBD patients, before the biological infusion therapy, detected just a few cases of infection. However this recommendation could be adapted locally, maybe when there is raising incidence of SARS-COV-2 in the general population. Our cohort also showed high compliance for the vaccination as general recommendation and even after the infection.

Functional viral neutralisation responses after SARS-CoV-2 infection in Inflammatory Bowel Disease patients receiving infusion therapies: Report from the ICARUS-IBD Consortium

Background: Recent data have highlighted adverse clinical outcomes in IBD patients treated with infliximab/thiopurines (IFX/ THIO) upon infection with SARS-CoV-2, as well as attenuated serological responses after infection and vaccination in patients treated with IFX. To provide mechanistic insight, we explored the serological and functional anti-viral response after infection in IBD patients treated with VDZ, IFX or IFX/THIO compared to healthy controls to guide clinical decision-making regarding treatment and vaccination strategies. Methods: Serum from 640 IBD patients attending routine infusions in Oxford and London in May to December 2020 was screened for anti-SARS-CoV-2 antibody responses by the Abbott assay. Serum from seropositive patients was compared to seropositive health care workers (Table 1). Antibody reactivity to the SARS-CoV-2 wild type strain receptor-binding domain (RBD), full-length spike, and nucleocapsid was assayed by IgG/IgA ELISA over time as well as by IgG high-throughput MSD V-PLEX ELISA at the time of seropositivity. A pseudotyped SARS-CoV-2 virus microneutralization assay was used to detect neutralising antibodies to the wild type, and an ELISA-based inhibition assay to compare differential inhibition of the wild type vs. delta variant SARS-CoV-2 RBD-ACE2 interaction. Results: All IBD patients showed significantly reduced IgG antibody responses compared to healthy controls for all SARS-CoV-2 antigens, using MSD V-PLEX ELISA (Figure 1). The greatest reduction in IgG response by ELISA was observed in individuals treated with IFX/THIO (p=0.00019), whereas IgG response over time declined significantly faster in the IFX treated group (p=0.019). IgA responses were significantly reduced in the IFX/THIO group compared to healthy controls (p=0.009), but not in the IFX or VDZ monotherapy group. The rate of decline in these monotherapy groups was also not significantly different to healthy controls. Functional SARS-CoV-2 neutralisation was significantly lower in all IBD patients compared to healthy controls, with the greatest reduction in patients receiving IFX/THIO (Figure 2A;p=0.00000091). The delta variant inhibition capacity was significantly reduced in 68.1% of IBD patients (30/44, Figure 2B;p=0.0005). Conclusion: IFX/THIO is associated with significantly lower IgA and IgG responses, and with impaired functional SARS-CoV-2 neutralising antibody capacity, compared to healthy individuals. Whilst IgG and neutralisation responses are reduced in each group of IBD patients, these findings were most pronounced in the combination treatment group. As neutralising antibody responses are associated with protection, this observation may impact on decision-making regarding treatment and vaccination/antiviral strategies.

CASE SERIES: RTPA INFUSION AS SALVAGE THERAPY FOR PROLONGED CRITICALLY ILL COVID-19 PATIENTS

RTPA regimen was approximated in each patient to receive a bolus of 0.5-1 mg/kg and a subsequent infusion rate of 1-5 mg/kg/hr actively titrated by the ICU Attending physician, guided by serial fibrinogen levels. B Methods: b Following IRB approval, retrospective data was collected from 5 patients with severe, prolonged (>10 days hypoxemia) COVID-19, from April to May, 2020 that received bolus and infusion rTPA followed by apixaban and clopidogrel at conclusion of rTPA infusion. B Results: b 2 of the 5 patients encountered bleeding at central lines within 6 hours of rTPA bolus, to prompt the Intensivist to pause the rTPA infusion and apply PRBC support. [Extracted from the article] Copyright of Critical Care Medicine is the property of Lippincott Williams & Wilkins and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Neutralizing monoclonal antibodies for outpatients with mild or moderate CoViD-19: our clinical experience

Background and Aim: Patients with mild to moderate CoViD-19 at high risk for progressing to severe CoViD-19 or hospitalization therapies. We describe our experience and outcomes of 19 pts who received MAB infusion therapy at CoViD Department (Internal Medicine of Jesi Hospital). Materials and Methods: This is a descriptive study of adult outpatients with a clinically and laboratory confirmed diagnosis of CoViD-19 who received MAB therapy between March 23 to May 10, 2021. The primary outcome was rate of hospitalization within 28 days;additional evaluations included the time of negativity of the molecular buffer and the safety. Results: During the study, 19 adult pts (58%M, 42%F) received MAB infusion. The hospitalization rate was 10,5% for pts who received MAB therapy within 0-7 days, 0% within ≥8-28 days of symptom onset. The negativity of molecular swab was observed in 47% of the pts within 7 days, and in 89% within 30 days. No adverse events were observed. During the study period, two pts were hospitalized: the first on day 7 due to dyspnea which required oxygen therapy for a few days and he was discharged after 7 days;the second for hyperpyrexia which arose on the same day of the infusion that did not require oxygen therapy and she was discharged after 5 days. Conclusions: While this therapy may be an important treatment option for early mild to moderate CoViD-19 in high-risk pts, further investigations are needed to define the optimal timing of MAB therapy in order to reduce hospitalization.

The role of anticoagulation in preventing myocardial infarction and improving the outcomes among covid-19 patients

COVID-19 has been associated with various cardiovascular complications including acute myocardial injury, myocarditis, arrhythmias, and venous thromboembolism. The infection is severe in patients with pre-existing cardiovascular disease, and in these cases the systemic inflammatory response due to a cytokine storm can lead to acute myocardial infarction. Hypercoagulation in COVID-19 can also predispose patients to fatal vascular events. Furthermore, these patients also have high hematocrit and platelet values, which, in their turn, contribute to the high risk of vascular events. We hypothesize that the use of anticoagulants and antiplatelets is decisive for prevention of acute coronary syndromes, especially in patients with pre-existing cardiovascular diseases. Prospective cohort study was conducted in patients with confirmed diagnosis of COVID-19 admitted to National Center for Infectious Diseases Ministry of Health of the Republic of Armenia. Clinical, laboratory data, total and cardiovascular mortality, the incidence of a myocardial infarction and treatment regimens were compared in two groups according to the time of the hospitalization: 40-day period in April-May (I Group) and October-November (II Group). Totally195 patients were enrolled in the study, which were divided into two groups. In I Group there were 93 patients with 36,5% of pre-existing cardiovascular diseases, in II Group 102 patients with 38,2% of pre-existing cardiovascular diseases. There was also drastic difference in laboratory test results between two groups. I Group was managed with minimal infusion therapy and only 10,7% received anticoagulation. In contrast, II Group was receiving preventive doses of anticoagulants and antiplatelet, and proper infusion therapy was administered. In I Group 7 cases of myocardial infarction were recorded, while patients in II Group, only 3 cases (1 of them with previous 1 of them with previous myocardial infarction). Statistical analysis revealed no significant difference in overall mortality (4.3% vs 6.86%, p = 0.441) and myocardial infarction incidence (7.5% vs 2.9%, p = 0.149) between two groups. In contrast there was significant difference in the incidence of severe and critically ill cases between two groups (69.9% and 7.5% vs 75.5% and 20.6%, p < .001).

Initial Experience of the Levodopa-Entacapone-Carbidopa Intestinal Gel in Clinical Practice.

Patients in fluctuating stages of Parkinson's disease (PD) require device-aided treatments. Continuous infusion of levodopa-carbidopa intestinal gel (LCIG) is a well-proven option in clinical practice. We now report the first clinical experience of levodopa-entacapone-carbidopa intestinal gel (LECIG) therapy. An observational study of the first patients to start LECIG in our clinic was performed. Twenty-four patients (11 females, 13 males) were included. The median age was 71.5 years, and the median duration since PD diagnosis was 15.5 years. The median treatment duration was 305 days. Median doses were: 6.0 mL as morning dose, 2.5 mL/h as infusion rate, and 1.0 mL as extra dose. Half of the patients were switched directly from LCIG. These patients express improvements in the size and weight of the pump. Furthermore, most of them considered the new pump to be improved regarding user-friendliness. Six patients discontinued LECIG, three due to diarrhea, one due to hallucinations and two deceased (one cardiac arrest and one COVID-19). LECIG has shown to be possible to use in patients with PD, efficacy and safety as expected. Patients are generally happy with the size and usability of the pump, but some technical improvements of the software are warranted, as well as larger, prospective studies.