Post-ICU psychological morbidity in very long ICU stay patients with ARDS and delirium

Association of social support before ICU admission with postdischarge mental health symptoms in ICU patients: a single-centre prospective cohort study in Japan

OBJECTIVES

Mental health problems after discharge from the intensive care unit (ICU) interfere with physical recovery and seriously affect daily life. Social support has been suggested to be associated with mental health but has not been sufficiently characterised. This study aimed to evaluate the association of social support before ICU admission with mental health after ICU discharge.

DESIGN

Prospective cohort study.

SETTING

Medical-surgical ICU of a hospital in Japan.

PARTICIPANTS

Patients admitted to the ICU for more than 48 hours were surveyed on social support prior to ICU admission, and 3 months after discharge from the ICU, mental health questionnaires were mailed to the patient.

PRIMARY OUTCOME MEASURES

Post-traumatic stress disorder (PTSD)-related symptoms were measured using the Impact of Event Scale-Revised, and anxiety and depressive symptoms were measured using the Hospital Anxiety and Depression Scale.

RESULTS

A total of 153 patients were enrolled; the prevalence of PTSD-related symptoms, anxiety and depressive symptoms 3 months after discharge from the ICU was 11.3%, 14.0% and 24.6%, respectively. Multivariate analysis using linear regression models adjusted for age, sex and years of education for PTSD-related symptoms, anxiety and depressive symptoms revealed that social support (β=-0.018, 95% CI: -0.029 to 0.006, p=0.002) and female sex (β=0.268, 95% CI: 0.005 to 0.531, p=0.046) were independent factors associated with the severity of depressive symptoms. In addition, sex differences were observed in the association between depressive symptoms and social support (p for interaction=0.056).

CONCLUSIONS

Higher social support before ICU admission was not associated with PTSD symptoms after ICU discharge, although it may be associated with a lower prevalence depressive symptoms after ICU discharge. Therefore, it is important to provide necessary social support when needed.

Investigating the correlation of delirium after cardiac surgery with memories and posttraumatic stress disorder consequences of intensive care unit: A prospective cohort study

OBJECTIVES

To explore the differences in post-intensive care unit memory and posttraumatic stress disorder symptoms between patients with and without delirium, and assess the correlations between the two.

DESIGN

Prospective cohort observation study.

SETTING

A cardiac intensive care unit of a tertiary hospital in China. We enrolled 318 consecutive patients after cardiac surgery between December 2017 and March 2019.

MAIN OUTCOME MEASURES

Delirium was assessed using the Confusion Assessment Method for the ICU from intensive care unit admission to discharge. Intensive care unit memory was assessed using the ICU-Memory Tool through face-to-face interviews one week after discharge. Posttraumatic stress disorder was measured telephonically using the Impact of Events Scale-revised questionnaire at three months post-discharge.

RESULTS

Eighty patients each in the delirium and non-delirium groups were enrolled for follow-up interviews. Patients with delirium had vaguer memories of pre-intensive care unit admission and of their stay, and recollected more memories of feelings (vs. without delirium). Posttraumatic stress disorder was diagnosed in 14 patients with and in seven without delirium, with non-significant differences between groups. Delirium did not influence post-intensive care unit factual, feeling, and delusional memories, nor posttraumatic stress disorder and hyperarousal, intrusion, and avoidance. The memories of feelings were positively correlated with the last three (r = 0.285, r = 0.390 and r = 0.373, respectively).

CONCLUSION

Patients with delirium had vague intensive care unit memories. Memories of feelings were positively correlated with symptoms of hyperarousal, intrusion, and avoidance. Delirium did not influence factual, feeling, or delusional memories nor posttraumatic stress disorder incidence and symptoms.

IMPLICATIONS FOR CLINICAL PRACTICE

Interventions are needed to reduce the impact of vague memory in patients with post-intensive care unit delirium. Memories of feelings should be focused on because of their correlation with hyperarousal, intrusion, and avoidance. Delirium prevention and early recognition measures are suggested.

Patient characteristics associated with posttraumatic stress symptoms in intensive care unit survivors during a one-year follow-up: A multicenter study

BACKGROUND

Intensive care unit (ICU) patients are at risk of suffering from posttraumatic stress symptoms (PTSS) after ICU survival.

OBJECTIVES

To describe the prevalence of high levels of PTSS the first year after ICU admission. Further, to identify specific combinations of patient characteristics (latent classes based on pre-ICU data, demographics, and clinical characteristics), and to investigate possible associations among these classes and PTSS at 3, 6, and 12 months after ICU admission.

METHODS

Self-reported PTSS were measured with Impact of Event Scale-Revised (IES-R). PTSS and possible predictive factors (pre-ICU data, demographics, and clinical characteristics) were analyzed using descriptive statistics, latent class analysis, and linear mixed model for repeated measures.

RESULTS

High PTSS levels (IES-R ≥ 33) were reported by 14.9 % (95 % confidence interval [CI] [10.0; 21.1]), 16.7 % (95 % CI [11.5; 23.1]), and 18.4 % (95 % CI [12.9; 25.0]) of patients (sample 1, n = 174) at 3, 6, and 12 months, respectively. Three latent classes were identified (sample 2, n = 417). PTSS were significantly associated with class 2 (male with longer hospital stay) at 6 months and class 3 (age≥70, lower level of education, higher Simplified Acute Physiology Score, being mechanically ventilated) at all three measurement times.

CONCLUSIONS

The prevalence of high levels of PTSS is the greatest 12 months after ICU admission. Health professionals can use this information to be aware of specific groups of ICU patients reporting PTSS during the first year and follow up on these.

Dignity-related distress and recall among alert, non-delirious critically ill patients

OBJECTIVES

Critical illness is associated with multiple undesired impacts, including residual psychological distress, frequently associated with recollections of critical illness. Dignity-related distress is highly prevalent among the one-fifth of critically ill patients who are alert. The distress may be associated with unpleasant recollections of care. We examined whether patients at risk for dignity-related distress had recall of their reported distress approximately 1 week after assessment and whether this recall differed from another high-risk group, specifically patients undergoing dialysis for end-stage renal disease.

METHODS

The prospective cohort study included patients with critical illness and patients with end-stage renal disease enrolled from intensive care units (ICUs) and dialysis units at 1 academic center. Distress was assessed using the Patient Dignity Inventory (PDI). Participants received in-patient or telephonic follow-up 7-10 days after the initial interaction. Follow-up encounters focused on recollection of key aspects of the interpersonal interaction as well as the content of the PDI.

RESULTS

A total of 32 critically ill patients participated in initial assessment and follow-up. In total, 26 dialysis patients participated in both phases. The groups' demographics differed. Fifty percent (n = 16) of critically ill patients and 58% (n = 15) of dialysis patients reported a mean score per item of >1.6, corresponding with severe distress on the PDI. Among the ICU patients, the 95% upper 2-sided confidence interval for the median level of recall was commensurate with the participant having had no recall of the initial interview beyond remembering that there was an interview. The end-stage renal disease group did not demonstrate significantly better recall.

SIGNIFICANCE OF RESULTS

Dignity-related distress is high in both critically ill patients and those with end-stage renal disease; however, recollection of assessment is poor in both groups. Any intervention designed to mitigate dignity-related distress will need either to be immediately deployable or not to be reliant upon recollection for impact.

The Experiences of Post-ICU COVID-19 Survivors: An Existential Perspective using Interpretative Phenomenological Analysis

COVID-19 has highlighted the vulnerability of intensive care unit (ICU) patients and the negative sequelae associated with ICU treatment. While the potentially traumatic impact of ICU is well documented, less is known about the ICU survivor's subjective experience and how it influences life post-discharge. Existential psychology addresses the universal concerns of existence, including death, isolation, and meaninglessness, and offers a holistic view of human experience beyond diagnostic categories. An existential psychological understanding of ICU COVID-19 survivorship may therefore provide a rich account of what it means to be among the worst affected by a global existential crisis. This study employed interpretive phenomenological analysis of qualitative interviews with 10 post-ICU COVID-19 survivors (aged 18-78). Interviews were structured on existential psychology's 'Four Worlds' model that explores the physical, social, personal, and spiritual dimensions of human experience. The essential meaning of ICU COVID-19 survival was conceptualised as 'Trying to Reconnect with a Changed Reality' and consisted of four themes. The first, Between Shifting Realities in ICU, described the liminal nature of ICU and the need to ground oneself. The second, What it Means to Care and Be Cared For, captured the emotive nature of personal interdependence and reciprocity. The third, The Self is Different, described survivors' struggle to reconcile old and new selves. The fourth, A New Relationship with Life, outlined how survivors' experiences shaped their new worldviews. Findings evidence the value of holistic, existentially informed psychological support for ICU survivors.

Supervised deep learning with vision transformer predicts delirium using limited lead EEG

As many as 80% of critically ill patients develop delirium increasing the need for institutionalization and higher morbidity and mortality. Clinicians detect less than 40% of delirium when using a validated screening tool. EEG is the criterion standard but is resource intensive thus not feasible for widespread delirium monitoring. This study evaluated the use of limited-lead rapid-response EEG and supervised deep learning methods with vision transformer to predict delirium. This proof-of-concept study used a prospective design to evaluate use of supervised deep learning with vision transformer and a rapid-response EEG device for predicting delirium in mechanically ventilated critically ill older adults. Fifteen different models were analyzed. Using all available data, the vision transformer models provided 99.9%+ training and 97% testing accuracy across models. Vision transformer with rapid-response EEG is capable of predicting delirium. Such monitoring is feasible in critically ill older adults. Therefore, this method has strong potential for improving the accuracy of delirium detection, providing greater opportunity for individualized interventions. Such an approach may shorten hospital length of stay, increase discharge to home, decrease mortality, and reduce the financial burden associated with delirium.

Delirium-related psychiatric and neurocognitive impairment and the association with post-intensive care syndrome-A narrative review

INTRODUCTION

Delirium is common among patients admitted to the intensive care unit (ICU) and its impact on the neurocognitive and psychiatric state of survivors is of great interest. These new-onset or worsening conditions, together with physical alterations, are called post-intensive care syndrome (PICS). Our aim is to update on the latest screening and follow-up options for psychological and cognitive sequelae of PICS.

METHOD

This narrative review discusses the occurrence of delirium in ICU settings and the relatively new concept of PICS. Psychiatric and neurocognitive morbidities that may occur in survivors of critical illness following delirium are addressed. Future perspectives for practice and research are discussed.

RESULTS

There is no "gold standard" for diagnosing delirium in the ICU, but two extensively validated tools, the confusion assessment method for the ICU and the intensive care delirium screening checklist, are often used. PICS complaints are frequent in ICU survivors who have suffered delirium and have been recognized as an important public health and socio-economic problem worldwide. Depression, anxiety, post-traumatic stress disorder, and long-term cognitive impairment are recurrently exhibited. Screening tools for these deficits are discussed, as well as the suggestion of early assessment after discharge and at 3 and 12 months.

CONCLUSIONS

Delirium is a complex but common phenomenon in the ICU and a risk factor for PICS. Its diagnosis is challenging with potential long-term adverse outcomes, including psychiatric and cognitive difficulties. The implementation of screening and follow-up protocols for PICS sequelae is warranted to ensure early detection and appropriate management.

Scales to measure post intensive care syndrome, a scoping review

INTRODUCTION

Post Intensive Care Syndrome is a recently studied syndrome that affects between 50% and 70% of patients admitted to the ICU, its detection is complex due to the great variety of affected components.

OBJECTIVE

To determine the most widely used assessment instruments for the detection of post-intensive care syndrome, according to the evidence in the last 5 years.

METHODOLOGY

A scoping review was carried out in the databases: Academic Search, ScienceDirect, Scielo, Biblioteca Virtual en Salud, Medline, and Springer Link, with terms «Postintensive care syndrome» and «Post-intensive care syndrome». This review included 22 articles that met the criteria of: research or review typology, English, Spanish or Portuguese language, with access to the full text and published between 2015 and 2020.

CONCLUSIONS

Most of the instruments used to measure post-intensive care syndrome are divided according to the components of physical affectation (the Medical Research Council scale, the Katz index and the Barthel index); cognitive (Repeatable Battery for the Assessment of Neuropsychological Status, and the Montreal Cognitive Assessment test); and mental (Hospital Anxiety and Depression Scale, Beck's anxiety test, Depression Inventory Second Edition scale and Post Traumatic Stress Syndrome-14 scale). In addition, two tools were found that measure the event in its entirety with its three components, such as the Healthy Aging Brain Care Monitor and the Post-Intensive Care Syndrome Questionnaire.

The EMDR Recent Traumatic Episode Protocol With an Intensive Care Survivor: A Case Study

The intensive care survivor population is increasing. Critical illness can lead to long term psychological distress for a significant proportion of intensive care survivors. This situation has been brought into even starker focus with the impact of COVID-19. Critical illness can lead to long term psychological distress for a significant proportion of intensive care survivors. Risk factors for post-intensive care psychological distress include delirium experiences. This single case study describes the therapeutic process and utility of the Recent-Traumatic Episode Protocol (R-TEP), an eye movement Desensitization and reprocessing (EMDR) therapy protocol for early intervention, with an ICU survivor where therapy was conducted remotely. The treatment provision is unusual in terms of the use of the R-TEP protocol and therapy not being in person. Treatment response was assessed using three standardized measures pre-treatment, post-treatment and at 4-month follow-up, and through qualitative feedback. The advantages of the R-TEP structure are discussed and the need for further research with the ICU survivor population considered.

Recall of Intensive Care Unit Stay in Critical Illness Survivors in Southeast Iran

BACKGROUND

In survivors of critical illness, recall of an intensive care unit stay plays an important role in the development of post-intensive care unit syndrome, which includes psychological impairment after intensive care unit discharge.

OBJECTIVE

To investigate memories of the intensive care unit among survivors in southeast Iran.

METHODS

In this descriptive study, the intensive care unit memory tool was used to assess patients' memories of intensive care units.

RESULTS

All participants (N = 100) had 1 or more factual memories (89%), memories of feelings (66%), or delusional memories (34%) from the intensive care unit. Patients who received mechanical ventilation were 4 times as likely to have delusional memories as those who did not receive mechanical ventilation. Unmarried patients were 4.8 times as likely as married patients to have memories of feelings from the intensive care unit.

CONCLUSIONS

Steps should be taken to minimize distressing memories of an intensive care unit admission. Follow-up programs should take into account the psychological problems faced by intensive care unit survivors.

Assessment of 5-year outcomes of life satisfaction in survivors after rehabilitation programs: a multicenter clinical trial

Using a rehabilitation program for the survivors of acute respiratory distress syndrome (ARDS) could be one of the important and fundamental steps to improve the pulmonary function and health-related quality of life (HRQoL) of patients. This study was carried out to evaluate the effect of two rehabilitation techniques (Family-Based Empowerment Model (FECM)/Continuing Care Model (CCM), or both of them) on pulmonary function, and HRQoL in ARDS survivors. From December 2009 to June 2016, ARDS survivors from mixed medical-surgical ICUs at four academic teaching hospitals in Tehran, Iran, were randomly assigned to one of three intervention groups (A, B, or C) or a control group (D). Pre- and post-interventions, pulmonary functions and HRQoL status of patients in all groups were collected 48 times via clinical measurements and various questionnaires during 5 years of follow-up. Significantly improvement was seen in the intervention groups compared to the control group, and the greatest benefit was observed in patients who received mixed of FCEM and CCM rehabilitation techniques. Co-administration of FCEM and CCM can improve pulmonary function as well as the life satisfaction of ARDS survivors. As a result, the execution of the empowerment model by nurses is recommended for ARDS survivors and the participation of their families at the same time.Trial registration: NCT02787720 (ClinicalTrial.gov, 24/05/2016).

Incidence and Risk Factors of Ventilator-Associated Pneumonia among Patients with Delirium in the Intensive Care Unit: A Prospective Observational Study

INTRODUCTION

The incidence and risk factors for ventilator-related pneumonia (VAP) in patients with delirium are deficient, and there is a lack of in-depth knowledge of the impact of VAP on outcomes in this population. We investigated the incidence, risk factors, and outcomes of VAP in patients with delirium.

MATERIALS AND METHODS

This prospective observational study was performed in a surgical ICU at Be'sat Hospital in Hamadan, Iran, between 2018 and 2019. A total of 108 patients with delirium were identified using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC) and enrolled in this study. The association between VAP and delirium, risk factors, and outcomes (ICU length of stay and ICU mortality) for VAP were investigated using the Cox proportional hazards model and logistic and simple linear regression analyses with a 95% confidence interval.

RESULTS

Of 108 delirium patients, 86 patients (79.6%) underwent mechanical ventilation (MV) and 16 patients (18.6%) experienced VAP during ICU stay. The median onset of VAP was 6.5 (IQR 4.2-7.7) days after intubation. Delirium patients with VAP stayed longer in the ICU (21.68 ± 4.26 vs.12.93 ± 1.71, P < 0.001) and also had higher ICU mortality (31.25% vs. 0%, P < 0.001) than subjects without VAP. According to multivariate cox regression, the expected HR for VAP was 53.5% lower for patients with early-onset delirium than in patients with late-onset delirium (HR: 0.465, 95% CI: 0.241-0.894, P=0.022). However, the expected hazard for VAP was 1.854 times and 4.604 times higher in patients with longer ICU stay (HR: 1.854, 95% CI: 1.689-3.059, P=0.032) and in patients with a prolonged MV duration (HR: 4.604, 95%CI: 1.567-6.708, P=0.023).

CONCLUSION

According to the results, there seems to be an inverse relationship between early onset of delirium and VAP. This finding cannot be conclusively cited, and more studies in this filed should be conducted with a larger sample size. Furthermore, VAP in delirium patients is associated with increases in poor outcomes (higher ICU mortality) and the use of medical resources (longer stay in the ICU and MV duration).

Post-ICU Syndrome in a Cohort of COVID-19 Survivors in New York City

RATIONALE

The coronavirus disease 2019 (COVID-19) pandemic has led to a dramatic increase in the number of survivors of critical illness. These survivors are at increased risk of physical, psychological, and cognitive impairments known collectively as Post-Intensive Care Syndrome (PICS). Little is known about the prevalence of PICS in COVID-19 survivors.

OBJECTIVES

To report the prevalence of physical, psychological, and cognitive impairment among COVID-19 intensive care unit (ICU) survivors receiving follow-up care in an ICU recovery clinic, to assess for associations between PICS and ICU-related factors, and to compare the cohort of ICU survivors who attended post-ICU clinic to a cohort of ICU survivors who did not.

METHODS

We performed a retrospective cohort study of COVID-19 ICU survivors admitted from March to May 2020 who were subsequently seen in a post-ICU recovery clinic in New York City. We abstracted medical chart data on available clinical screening instruments for physical, psychological, and cognitive impairment. Associations between these outcomes and care-related variables were tested. Baseline characteristics and in-hospital treatments of the post-ICU clinic cohort were compared to COVID-19 ICU survivors from the same institution who were not seen in post-ICU clinic.

RESULTS

87 COVID-19 ICU survivors were seen in our post-ICU recovery clinic. The median age was 62 years and 74% were male. The median length of hospitalization was 51 days and the median length of ICU stay was 22 days. At the post-ICU follow-up visit, 29%, 21%, and 13% of patients reported clinically significant levels of depressive symptoms, anxiety, and post-traumatic stress disorder symptoms, respectively. 25% had cognitive impairment. The overall prevalence of PICS was 90%. There were no associations between length of ICU stay, delirium, exposure to benzodiazepines, steroids, or systemic paralytics with positive screens for physical, psychological, or cognitive impairment. Baseline characteristics and ICU-related factors were similar in the cohort of COVID-19 ICU survivors who attended ICU recovery clinic and those who did not.

CONCLUSION

PICS is common in COVID-19 survivors. We did not find any association with length of ICU stay, the use of benzodiazepines, steroids, or paralytics.

Identifying cues of distorted memories in intensive care by focus group interview of nurses

AIM

To determine cues to identify intensive care unit patients with distorted memories and related practices.

DESIGN

Qualitative descriptive study.

METHODS

Twenty nurses were included in semi-structured focus groups. Qualitative content analysis was conducted.

RESULTS

Cues and nursing practices related to distorted memories emerged under the following categories: "Get to know daily life before admission," "Facial expressions and behaviour are different from usual," "Pay close attention to the treatment outcome," "Notice it after the fact," "Sharing patients' intensive care unit experiences" and "Creates a new life." Nurses tried to detect distorted memories by observing the patients' facial expressions, medication effects and delirium presence during their normal lives and treatments, while trying to understand the patients' intensive care unit experiences and provide care that promotes autonomous living. This study emphasizes the importance of support for reconstructing ordinary life through communication and rehabilitation, in addition to support for medical care for distorted memories.

A Cognitive Behavioral Therapy-Informed Self-Management Program for Acute Respiratory Failure Survivors: A Feasibility Study

Background: The number of people surviving critical illness is rising rapidly around the globe. Survivorship comes at a cost, with approximately half of patients with acute respiratory failure (ARF) experiencing clinically significant symptoms of anxiety, and 32–40% of survivors having substantial anxiety symptoms in the months or years after hospitalization. Methods: This feasibility study reports on 11 consecutive ARF patients receiving up to six sessions of a psychological intervention for self-management of anxiety. Results: All 11 patients accepted and received the psychological intervention. Four patients did not fully complete all 6 sessions due to death (n = 1, 2 sessions completed), and early hospital discharge (n = 3, patients completed 2, 3 and 5 sessions). The median (IQR) score (range: 0–100; minimal clinically important difference: 13) for the Visual Analog Scale-Anxiety (VAS-A) pre-intervention was 70 (57, 75) points. During the intervention, all 11 patients had a decrease in VAS-A, with a median (IQR) decrease of 44 (19, 48) points. Conclusions: This self-management intervention appears acceptable and feasible to implement among ARF patients during and after an ICU stay.

Incidence and Risk Factors of Delirium in the Intensive Care Unit: A Prospective Cohort

Purpose

The purpose of this study was to determine the incidence, risk factors, and impact of delirium on outcomes in ICU patients. In addition, the scoring systems were measured consecutively to characterize how these scores changed with time in patients with and without delirium. Material and Methods. A prospective cohort study enrolling 400 consecutive patients admitted to the ICU between 2018 and 2019 due to trauma or surgery. Patients were followed up for the development of delirium over ICU days using the Confusion Assessment Method (CAM) for the ICU and Intensive Care Delirium Screening Checklist (ICDSC). Cox model logistic regression analysis was used to explore delirium risk factors.

Results

Delirium occurred in 108 (27%) patients during their ICU stay, and the median onset of delirium was 4 (IQR 3–4) days after admission. According to multivariate cox regression, the expected hazard for delirium was 1.523 times higher in patients who used mechanical ventilator as compared to those who did not (HR: 1.523, 95% CI: 1.197-2.388, P < 0.001).

Conclusion

Our findings suggest that an important opportunity for improving the care of critically ill patients may be the determination of modifiable risk factors for delirium in the ICU. In addition, the scoring systems (APACHE IV, SOFA, and RASS) are useful for the prediction of delirium in critically ill patients.

Functional independence and spirometry in adult post-intensive care unit patients

OBJECTIVE

To relate functional independence to the degree of pulmonary impairment in adult patients 3 months after discharge from the intensive care unit.

METHODS

This was a retrospective cohort study conducted in one adult intensive care unit and a multi-professional post-intensive care unit outpatient clinic of a single center. Patients admitted to the intensive care unit from January 2012 to December 2013 who underwent (3 months later) spirometry and answered the Functional Independence Measure Questionnaire were included.

RESULTS

Patients were divided into groups according to the classification of functional independence and spirometry. The study included 197 patients who were divided into greater dependence (n = 4), lower dependence (n = 12) and independent (n = 181) groups. Comparing the three groups, regarding the classification of the Functional Independence Measure, patients with greater dependence had higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment values at intensive care unit admission with more advanced age, more days on mechanical ventilation, and longer stay in the intensive care unit and hospital. The majority of patients presented with pulmonary impairment, which was the obstructive pattern observed most frequently. When comparing functional independence with pulmonary function, it was observed that the lower the functional status, the worse the pulmonary function, with a significant difference being observed in peak expiratory flow (p = 0.030).

CONCLUSION

The majority of patients who returned to the outpatient clinic 3 months after discharge had good functional status but did present with pulmonary impairment, which is related to the degree of functional dependence.

Distorted Memories and Related Factors in ICU Patients

This study aimed to examine the relationship between memory status of and factors related to patients in the intensive care unit (ICU) using a cross-sectional study design. Participants were adult patients who were admitted to the general ICUs for more than 48 hours. One week after ICU discharge, a survey on memory distortion was conducted. Overall, 133 patients were included, of whom 51.1% reported distorted memories. Among them, 15.0% had memory loss; 48.1% had unrealistic experiences; 27.8% recalled confusion, panic, anxiety, and discomfort during their ICU stay; and 9% had traumatic experiences. Multiple logistic regression analyses revealed that memory loss was associated with an operation, and a significant association was observed between traumatic memory and pain. Opioid use may have a protective effect against memory loss. These results suggest the importance of relieving pain and preserving true memories during ICU treatment.

Delayed Symptoms in Patients Recovered from COVID-19

Background:

COVID-19 is a new disease, so we don’t know what comes next. Since information on delayed symptoms is limited, this study was conducted to assess the frequency of delayed symptoms in patients with COVID-19.

Methods:

This follow-up cross-sectional study was conducted in a referral general hospital in Tehran, Iran from Feb to Apr 2020. Two hundred patients hospitalized for COVID-19 and were discharged were assessed for delayed symptoms 6 wk after discharge.

Results:

The mean age of the participants was 55.58±13.52, and 160 (80%) Of them were male. On admission to hospital, patients reported a mean of 5.63±2.88 symptoms per patient, range from 1 to 14 symptoms. Dyspnea was seen in 119 (59.5%) 0f them as the most frequent symptom. Then weakness, myalgia, and shivering were reported with a frequency of 111 (55.5%), 107 (53.5%), and 103 (51.5%), respectively. Six weeks after discharge reassessment was done. None of the patients was readmitted to the hospital. Ninety-four (42%) of them were symptom-free. Fatigue was the most frequent delayed symptom with a frequency of 39 (19.5%), and then dyspnea, weakness, and activity intolerance with a frequency of 37 (18.5%), 36 (18%), and 29 (14.5%) were reported, respectively.

Conclusion:

Fatigue, dyspnea, weakness, anxiety, and activity intolerance were most frequent delayed symptoms, respectively. Majority of patient was symptoms free and those with symptom, had mild to moderate symptoms. The importance of symptoms is not fully recognized. Follow up clinics and in some cases rehabilitation programs may be helpful.

Psychiatric Aspects of Chloroquine and Hydroxychloroquine Treatment in the Wake of Coronavirus Disease-2019: Psychopharmacological Interactions and Neuropsychiatric Sequelae

BACKGROUND

Chloroquine and hydroxychloroquine are among several experimental treatments being investigated in the urgent response to the coronavirus disease-2019. With increased use of these medications, physicians need to become knowledgeable of these drugs' neuropsychiatric side effects and interactions with psychiatric medications.

OBJECTIVE

Clarify evidence base regarding the psychiatric side effects and psychiatric drug interactions of chloroquine and hydroxychloroquine.

METHODS

A literature review was performed in PubMed from 1950 to 2020 regarding psychiatric topics and targeted pharmacological properties of chloroquine and hydroxychloroquine.

RESULTS

First, chloroquine and hydroxychloroquine may mildly inhibit CYP2D6 metabolism of psychiatric medications, and psychiatric medications that interfere with CYP2D6 or CYP3A4 activity could alter chloroquine and hydroxychloroquine levels. Second, they may prolong the QT interval, warranting caution with concomitant prescription of other QT prolonging agents. Finally, neuropsychiatric side effects are very uncommon but possible and include a potentially prolonged phenomenon of "psychosis after chloroquine." Hydroxychloroquine has less information available about its neuropsychiatric side effects than chloroquine, with psychosis literature limited to several case reports. Weak evidence suggests a possible association of hydroxychloroquine exposure and increased suicidal ideation. It is not clear whether patients with psychiatric illness are more vulnerable to neuropsychiatric sequela of these medications; however, overdose of these medications by suicidal patients has high risk of mortality.

CONCLUSION

The risk of neuropsychiatric side effects of chloroquine and hydroxychloroquine when used for coronavirus disease-2019 treatment is not known. Best practice may include suicide risk assessment for patients treated with hydroxychloroquine. However, delirium is expected to be a more likely etiology of neuropsychiatric symptoms in critically ill patients treated for coronavirus disease-2019, and adjustment disorder is a much more likely etiology of anxiety and depression symptoms than the side effects of chloroquine or hydroxychloroquine.

Feasibility of a Behavioral Intervention to Reduce Psychological Distress in Mechanically Ventilated Patients

Many survivors of acute respiratory failure suffer from mood disorders following discharge from the hospital. We investigated the feasibility of intensivists delivering psychological support based on positive suggestion (PSBPS) to 20 intubated patients to reduce their psychological distress. Thirteen patients completed follow-up surveys. Of those, 9 remembered the intensive care unit physician talking to them, and 7 described it as comforting. Five patients (38%) met criteria for anxiety, depression, and acute stress. In comparison to historical controls, intervention may be associated with lower estimated odds of anxiety. PSBPS can be performed with patients in parallel with medical treatment to potentially reduce psychological morbidity and to humanize critical care. A larger randomized study is warranted to assess the efficacy of PSBPS.

Cross mapping between clinical indicators for assistance in intensive care and nursing interventions

OBJECTIVE

Identify the main clinical indicators for assistance in the Intensive Care Unit (ICU) and map them in the nursing interventions described by the Nursing Interventions Classification (NIC).

METHODS

Integrative literature review study, followed by cross-mapping between clinical indicators for assistance in the ICU care and NIC nursing interventions and activities.

RESULTS

36 articles were identified, which resulted in 285 clinical indicators for ICU care, with mechanical ventilatory assistance, pain, sedation, psychomotor agitation, delirium, anxiety, altered heart rate, diet by naso tube / oroenteral and diarrhea the clinical indicators for assistance in the ICU the most prevalent. These were mapped in 12 Nursing Interventions Classification interventions and 130 nursing activities.

FINAL CONSIDERATIONS

It is concluded that the clinical indicators for ICU care associated with Nursing Interventions Classification are concrete data that assist intensive care nurses in their clinical practice.

Post-traumatic stress disorder: A differential diagnostic consideration for COVID-19 survivors

Objective: SARS-CoV-2 infection and its oft-associated illness COVID-19 may lead to neuropsychological deficits, either through direct mechanisms (i.e., neurovirulance) or indirect mechanisms, most notably complications caused by the virus (e.g., stroke) or medical procedures (e.g., intubation). The history of past human coronavirus outbreaks resulting in similar health emergencies suggests there will be a substantial prevalence of post-traumatic stress disorder (PTSD) among COVID-19 survivors. To prepare neuropsychologists for the difficult task of differentiating PTSD-related from neuropathology-related deficits in the oncoming wave of COVID-19 survivors, we integrate research across a spectrum of related areas.Methods: Several areas of literature were reviewed: psychiatric, neurologic, and neuropathological outcomes of SARS and MERS patients; neurological outcomes in COVID-19 survivors; PTSD associated with procedures common to COVID-19 patients; and differentiating neuropsychological deficits due to PTSD from those due to acquired brain injuries in other patient groups.Conclusions: Heightened risk of PTSD occurred in MERS and SARS survivors. While data concerning COVID-19 is lacking, PTSD is known to occur in patient groups who undergo similar hospital courses, including ICU survivors, patients who are intubated and mechanically ventilated, and those that experience delirium. Research with patients who develop PTSD in the context of mild traumatic brain injury further suggests that PTSD may account for some or all of a patient's subjective cognitive complaints and neuropsychological test performance. Recommendations are provided for assessing PTSD in the context of COVID-19.

Post-traumatic stress disorder in critical illness survivors and its relation to memories of ICU

BACKGROUND

Stressors in intensive care units (ICUs) are sometimes so severe that they result in Post-traumatic Stress Disorder (PTSD) in ICU survivors. The memories that survivors have from the ICU may play a role in developing PTSD.

AIM

This study aimed to determine the prevalence of PTSD-related symptoms in ICU survivors in Southeast Iran and its relationship with their memories of the ICU.

METHODS

In this descriptive correlational study, 100 people discharged from ICUs in southeastern Iran completed the Impact of Event Scale-Revised (IES-R) and ICU memory tool (ICU-MT).

RESULTS

Findings indicated that, from 100 participants who, on average, were assessed 3.19 ± 5.37 months after discharge, 13% were suffering from PTSD. The total mean IES-R score and the scores of "Intrusion," "Avoidance," and "Hyperarousal" subscales in patients with delusional memories were higher compared with the patients who did not have such memories. In the patients who were mechanically ventilated at the time of their stay in the ICU, the total mean IES-R score was 6.86 times higher (P = .03).

CONCLUSION

This research provided further evidence of the relationship between delusional memories and PTSD in patients who had been discharged from the ICU.

RELEVANCE TO CLINICAL PRACTICE

In the care of patients admitted to the ICU, preventive strategies should be used to minimize delusional memories and PTSD. It is necessary to detect post-ICU psychiatric morbidities and provide early psychological intervention in post-discharge follow-up programmes to improve psychological outcomes after critical illness.

A review of 17 years of application of partnership care model on the consequences of chronic diseases: Describing and assessing the quality of the methodology of papers

Background : Regarding the widespread prevalence of chronic diseases, nurses need to understand the choices, priorities, and abilities of patients in reality, their communication, and the social context in order to play their professional role and responsibility. This review study was conducted with two purposes: determining the effect of partnership-care-model (PCM) on the outcomes of chronic diseases, and describing and assessing the quality of methodology of published papers in the field. Methods : The systematic review was conducted from inception to the year 2019. A systematic search was conducted using PRISMA guidelines to retrieve all national and international PCM studies. To assess the quality of the methodology of studies, four instruments were used, including JADAD, Consort, New Castle-Ottawa, and Cochrane. Results : In the initial search, 11509 papers were retrieved, which according to the PRISMA guidelines, 23 relevant papers remained. The results of the reviewed papers indicated the effectiveness of the PCM. Describing and assessing the quality of the methodology of published papers of PCM was at an acceptable level. The final papers were classified and reviewed according to the authors, year, sampling characteristics, data collection methods, and final PCM conclusion. Conclusion : According to the review of the studies and their effectiveness in the different outcomes, also, the acceptable quality of the methodology of published papers, it can be concluded that the PCM is an effective, context-based, simple, efficient, and reliable model and has the ability to be used in promoting and improving the various dimensions of chronic diseases.

Preparing for the Behavioral Health Impact of COVID-19 in Michigan

PURPOSE OF REVIEW

As a global pandemic, COVID-19 has profoundly disrupted the lives of individuals, families, communities, and nations. This report summarizes the expected impact of COVID-19 on behavioral health, as well as strategies to address mental health needs during the COVID-19 pandemic and its aftermath. The state of Michigan in the USA is used to illustrate the complexity of the mental health issues and the critical gaps in the behavioral health infrastructure as they pertain to COVID-19. Scoping review was conducted to identify potential mental health needs and issues during the COVID-19 pandemic and its aftermath.

RECENT FINDINGS

The ramifications of COVID-19 on mental health are extensive, with the potential to negatively impact diverse populations including healthcare providers, children and adolescents, older adults, the LGBTQ community, and individuals with pre-existing mental illness. Suicide rates, alone, are expected to rise for Michiganders due to the economic downturn, isolation and quarantine, increased substance use, insomnia, and increased access to guns associated with the COVID-19 pandemic. This report promotes awareness of a behavioral health crisis due to COVID-19. Increasing access to behavioral health care should minimize COVID-19's negative influence on mental health in Michigan. We propose a three-prong approach to access: awareness, affordability, and technology. Addressing workforce development and fixing gaps in critical behavioral health infrastructure will also be essential. These actions need to be implemented immediately to prepare for the expected "surge" of behavioral health needs in the ensuing months.

Post-traumatic Stress Disorder Following Acute Delirium

Delirium is a significant medical condition that is common in hospitalized patients. Beyond the increased risk of mortality, patients who experience an episode of delirium often go on to develop long-term psychiatric disturbance, including symptoms of post-traumatic stress disorder (PTSD). While there is a growing interest in understanding the complex relationship between delirium and PTSD, the existing literature is sparse and lacking harmony. Thus, this review seeks to develop a unified and thorough description of the cognitive and psychiatric underpinnings of post-delirium PTSD with the aims of promoting awareness of this condition amongst clinicians in medical settings, improving patient care, and sparking further research on this topic. While specific underlying mechanisms are yet unclear, PTSD was found to be associated with delirium in that delirious patients may have decreased factual recall of hospital events and increased hallucinations/delusions of a traumatic nature. Several potential interventions were identified, as well as suggestions for future research and clinical practice.

Narrative review of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: updates and implications for practice

Human coronaviruses (HCoVs) comprise six subtypes of coronavirus that are associated with a number of respiratory diseases such as common cold, pneumonia, and bronchitis. Middle East respiratory syndrome coronavirus (MERS-CoV) is one of these six HCoV subtypes. HCoVs can result in life-threatening respiratory diseases, such as pneumonia and bronchiolitis, and may cause enteric and neurologic diseases, especially in immunocompromised patients. This narrative review aimed to enrich the knowledge of health care professional regarding MERS-CoV infection epidemiology, control, and management. This review discusses MERS-CoV prevalence, clinical manifestation, modes of transmission, control measures, and management, which we identified in a search of various databases, related journals, and the published literature. It has been shown that MERS-CoV infection is likely to be transmitted among countries. Therefore, countries with a high rate of MERS-CoV infection are urged to develop and implement guidelines to minimize the spread of infection. Countries must give careful consideration to raising public awareness in regions that are affected by MERS-CoV infection and the importance of reporting any disease signs and symptoms, to receive proper care.

Prevalence of post-traumatic stress disorder symptoms in adult critical care survivors: a systematic review and meta-analysis

Background

As more patients are surviving intensive care, mental health concerns in survivors have become a research priority. Among these, post-traumatic stress disorder (PTSD) can have an important impact on the quality of life of critical care survivors. However, data on its burden are conflicting. Therefore, this systematic review and meta-analysis aimed to evaluate the prevalence of PTSD symptoms in adult critical care patients after intensive care unit (ICU) discharge.

Methods

We searched MEDLINE, EMBASE, LILACS, Web of Science, PsycNET, and Scopus databases from inception to September 2018. We included observational studies assessing the prevalence of PTSD symptoms in adult critical care survivors. Two reviewers independently screened studies and extracted data. Studies were meta-analyzed using a random-effects model to estimate PTSD symptom prevalence at different time points, also estimating confidence and prediction intervals. Subgroup and meta-regression analyses were performed to explore heterogeneity. Risk of bias was assessed using the Joanna Briggs Institute tool and the GRADE approach.

Results

Of 13,267 studies retrieved, 48 were included in this review. Overall prevalence of PTSD symptoms was 19.83% (95% confidence interval [CI], 16.72–23.13; I² = 90%, low quality of evidence). Prevalence varied widely across studies, with a wide range of expected prevalence (from 3.70 to 43.73% in 95% of settings). Point prevalence estimates were 15.93% (95% CI, 11.15–21.35; I² = 90%; 17 studies), 16.80% (95% CI, 13.74–20.09; I² = 66%; 13 studies), 18.96% (95% CI, 14.28–24.12; I² = 92%; 13 studies), and 20.21% (95% CI, 13.79–27.44; I² = 58%; 7 studies) at 3, 6, 12, and > 12 months after discharge, respectively.

Conclusion

PTSD symptoms may affect 1 in every 5 adult critical care survivors, with a high expected prevalence 12 months after discharge. ICU survivors should be screened for PTSD symptoms and cared for accordingly, given the potential negative impact of PTSD on quality of life. In addition, action should be taken to further explore the causal relationship between ICU stay and PTSD, as well as to propose early measures to prevent PTSD in this population.

Trial registration

PROSPERO, CRD42017075124, Registered 6 December 2017.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2489-3) contains supplementary material, which is available to authorized users.

Prevalence of depression among Iranian patients with rheumatoid arthritis: a systematic review and meta-analysis

Patients with rheumatoid arthritis (RA) are prone to depression due to several factors related to their RA, including chronic and persistent pain, functional disability, economic constraints, and the side effects of RA medication. Previous Iranian studies showed conflicting and inconclusive findings regarding the prevalence of depression among RA patients. Therefore, this systematic review and meta-analysis was conducted to estimate the true prevalence of depression in Iranian patients with RA. Search for eligible articles was performed using the keywords of depression, depressive disorder, dysthymic disorder, major depressive disorder, RA, and Iran, and their possible combinations in the following databases: Scientific Information Database, MagIran, Web of Science/ISI, PubMed, and Scopus. The search was restricted to articles published in Persian and English languages. The meta-analysis was performed using the random effects model, and the data were analyzed using the STATA software version 12. Overall, six articles were selected; the overall prevalence of depression among the Iranian patients with RA was 65.58% (95% CI: 56.53%-74.62%). There were no significant relationships between the prevalence of depression and articles' methodological quality and year of publication, participants' age, sample size, and duration of disease. More than half of RA patients suffer from depression. The overlap between the physical symptoms of RA and depression in this group of patients makes it difficult to correctly diagnose depression; therefore, initiative and efforts are required to improve the identification of early depression symptoms in RA patients in order to effectively manage their depression.