COVID-19: ICU delirium management during SARS-CoV-2 pandemic

Augmentative and Alternative Communication Interventions in Critical and Acute Care With Mechanically Ventilated and Tracheostomy Patients: A Scoping Review

PURPOSE

Communication with nonspeaking patients is a critical challenge of person-centered care. This scoping review aimed to map the literature on augmentative and alternative communication (AAC) interventions for nonspeaking mechanically ventilated and tracheostomy patients in critical and acute care settings.

METHOD

Electronic database, ancestry, and forward citation searches were conducted using eligibility criteria established a priori. Data were extracted, synthesized, and summarized according to scoping review methodology. Studies were categorized by type of intervention and summarized in terms of purpose, participants, design, quality appraisal (including validity and reliability of selected efficacy measures), and efficacy.

RESULTS

Small-to-large treatment effect sizes indicated demonstrable impact on patient health and communication efficacy with high-tech and no-tech visual interface-based interventions and systematic nurse training interventions. Treatment effects primarily pertained to dependent variables of patient anxiety, communication satisfaction, comfort, symptom self-reporting, and nursing practice changes.

CONCLUSIONS

There is a paucity of high-quality AAC intervention research for mechanically ventilated and tracheostomy patients in critical and acute care settings. Emergent evidence suggests that select visual interface and nurse training interventions can impact efficacy of patient-provider communication and patients' overall health.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.26506102.

Predictors of 2-year mortality in geriatric patients hospitalized with COVID-19 in Türkiye: a retrospective cohort study

Aim: To reveal factors affecting 2-year mortality in geriatric patients hospitalized with COVID-19.Methods: Demographic characteristics, clinical and laboratory data, thorax computed tomography (CT) images, second-year survival status, and causes of death were analyzed.Results: The 2-year post-discharge mortality rate of 605 patients was 21.9%. Mean age of patients in the deceased group was 76.8 ± 8.1 years, which was shorter than the life expectancy at birth in Türkiye. Older age (≥85), delirium, some co-morbidities, and atypical thorax CT involvement were associated with a significant increase in 2-year mortality (p < 0.05).Conclusion: This is the first study to evaluate factors associated with 2-year mortality in older COVID-19 patients. Identifying risk factors for long-term mortality in geriatric COVID-19 patients is important.

A world-wide study on delirium assessments and presence of protocols

BACKGROUND

Delirium is a common complication of older people in hospitals, rehabilitation and long-term facilities.

OBJECTIVE

To assess the worldwide use of validated delirium assessment tools and the presence of delirium management protocols.

DESIGN

Secondary analysis of a worldwide one-day point prevalence study on World Delirium Awareness Day, 15 March 2023.

SETTING

Cross-sectional online survey including hospitals, rehabilitation and long-term facilities.

METHODS

Participating clinicians reported data on delirium, the presence of protocols, delirium assessments, delirium-awareness interventions, non-pharmacological and pharmacological interventions, and ward/unit-specific barriers.

RESULTS

Data from 44 countries, 1664 wards/units and 36 048 patients were analysed. Validated delirium assessments were used in 66.7% (n = 1110) of wards/units, 18.6% (n = 310) used personal judgement or no assessment, and 10% (n = 166) used other assessment methods. A delirium management protocol was reported in 66.8% (n = 1094) of wards/units. The presence of protocols for delirium management varied across continents, ranging from 21.6% (on 21/97 wards/units) in Africa to 90.4% (235/260) in Australia, similar to the use of validated delirium assessments with 29.6% (29/98) in Africa to 93.5% (116/124) in North America. Wards/units with a delirium management protocol [n = 1094/1664, 66.8%] were more likely to use a validated delirium test than those without a protocol [odds ratio 6.97 (95% confidence interval 5.289-9.185)]. The presence of a delirium protocol increased the chances for valid delirium assessment and, likely, evidence-based interventions.

CONCLUSION

Wards/units that reported the presence of delirium management protocols had a higher probability of using validated delirium assessments tools to assess for delirium.

In-Hospital Delirium and Disability and Cognitive Impairment After COVID-19 Hospitalization

Importance

Older adults who are hospitalized for COVID-19 are at risk of delirium. Little is known about the association of in-hospital delirium with functional and cognitive outcomes among older adults who have survived a COVID-19 hospitalization.

Objective

To evaluate the association of delirium with functional disability and cognitive impairment over the 6 months after discharge among older adults hospitalized with COVID-19.

Design, Setting, and Participants

This prospective cohort study involved patients aged 60 years or older who were hospitalized with COVID-19 between June 18, 2020, and June 30, 2021, at 5 hospitals in a major tertiary care system in the US. Follow-up occurred through January 11, 2022. Data analysis was performed from December 2022 to February 2024.

Exposure

Delirium during the COVID-19 hospitalization was assessed using the Chart-based Delirium Identification Instrument (CHART-DEL) and CHART-DEL-ICU.

Main Outcomes and Measures

Primary outcomes were disability in 15 functional activities and the presence of cognitive impairment (defined as Montreal Cognitive Assessment score <22) at 1, 3, and 6 months after hospital discharge. The associations of in-hospital delirium with functional disability and cognitive impairment were evaluated using zero-inflated negative binominal and logistic regression models, respectively, with adjustment for age, month of follow-up, and baseline (before COVID-19) measures of the respective outcome.

Results

The cohort included 311 older adults (mean [SD] age, 71.3 [8.5] years; 163 female [52.4%]) who survived COVID-19 hospitalization. In the functional disability sample of 311 participants, 49 participants (15.8%) experienced in-hospital delirium. In the cognition sample of 271 participants, 31 (11.4%) experienced in-hospital delirium. In-hospital delirium was associated with both increased functional disability (rate ratio, 1.32; 95% CI, 1.05-1.66) and increased cognitive impairment (odds ratio, 2.48; 95% CI, 1.38-4.82) over the 6 months after discharge from the COVID-19 hospitalization.

Conclusions and Relevance

In this cohort study of 311 hospitalized older adults with COVID-19, in-hospital delirium was associated with increased functional disability and cognitive impairment over the 6 months following discharge. Older survivors of a COVID-19 hospitalization who experience in-hospital delirium should be assessed for disability and cognitive impairment during postdischarge follow-up.

COVID-19 and the Impact on Delirium Care of Hospitalized Older Adults: A Qualitative Study

BACKGROUND

Older adult patients with COVID-19 and delirium experience higher rates of adverse outcomes. Early recognition of at-risk patients and implementation of management strategies improve outcomes, though understanding barriers to acute care nurses implementing these strategies is limited.

PURPOSE

This study's purpose was to understand the experiences of acute care nurses providing care to older adults with COVID-19 and delirium. Experiences explored included assessment, nursing management interventions, and barriers to care.

METHODS

Purposive sampling to recruit nurses for semistructured focus groups was performed, and thematic analysis was generated by 4 members of the research team.

RESULTS

Twenty-one nurses participated in focus groups. Thematic analysis revealed themes of increased patient social isolation, barriers to delirium assessment and prevention, increased staff demands, and stressful work environments.

CONCLUSION

Rich findings reveal the profound impact of the pandemic on assessment for delirium and implementation of strategies for prevention and management in older adult patients.

Experiential Learning with Ketamine: A Mixed-Methods Exploratory Study on Prescription and Perception

Background

Incorporating unfamiliar therapies into practice requires effective longitudinal learning and the optimal way to achieve this is debated. Though not a novel therapy, ketamine in critical care has a paucity of data and variable acceptance, with limited research describing intensivist perceptions and utilization. The Coronavirus-19 pandemic presented a particular crisis where providers rapidly adapted analgosedation strategies to achieve prolonged, deep sedation due to a surge of severe acute respiratory distress syndrome (ARDS).

Question

How does clinical experience with ketamine impact the perception and attitude of clinicians toward this therapy?

Methods

We conducted a mixed-methods study using quantitative ketamine prescription data and qualitative focus group data. We analyzed prescription patterns of ketamine in a tertiary academic ICU during two different time points: pre-COVID-19 (March 1-June 30, 2019) and during the COVID-19 surge (March 1-June 30, 2020). Two focus groups (FG) of critical care attendings were held, and data were analyzed using the Framework Method for content analysis.

Results

Four-hundred forty-six medical ICU patients were mechanically ventilated (195 pre-COVID-19 and 251 during COVID-19). The COVID-19 population was more likely to receive ketamine (81[32.3%] vs 4 [2.1%], p < 0.001). Thirteen respondents participated across two FG sessions (Pre-COVID = 8, Post-COVID=5). The most prevalent attitude among our respondents was discomfort, with three key themes identified as follows: 1) lack of evidence regarding ketamine, 2) lack of personal experience, and 3) desire for more education and protocols.

Conclusion

Despite a substantial increase in ketamine prescription during COVID-19, intensivists continued to feel discomfort with utilization. Factors contributing to this discomfort include a lack of evidence, a lack of experience, and a desire for more education and protocols. Increase in experience with ketamine alone was not sufficient to minimize provider discomfort. These findings should inform future curricula and call for process improvement to optimize continuing education.

Post intensive care syndrome: A review of clinical symptoms, evaluation, intervention

Post intensive care syndrome (PICS) is a typical complication of critically ill patients during or after their stay in intensive care unit (ICU), characterized by a high incidence and impairment rate. It significantly impacts the quality of life of patients and their families, as well as consumes a substantial amount of medical resources. Therefore, early intervention and assessment of PICS is crucial. This paper aims to provide clinical professionals with a reference base by focusing on the clinical symptoms, diagnostic assessment, and preventative measures of PICS.

Discovery of Delirium Biomarkers through Minimally Invasive Serum Molecular Fingerprinting

Delirium presents a significant clinical challenge, primarily due to its profound impact on patient outcomes and the limitations of the current diagnostic methods, which are largely subjective. During the COVID-19 pandemic, this challenge was intensified as the frequency of delirium assessments decreased in Intensive Care Units (ICUs), even as the prevalence of delirium among critically ill patients increased. The present study evaluated how the serum molecular fingerprint, as acquired by Fourier-Transform InfraRed (FTIR) spectroscopy, can enable the development of predictive models for delirium. A preliminary univariate analysis of serum FTIR spectra indicated significantly different bands between 26 ICU patients with delirium and 26 patients without, all of whom were admitted with COVID-19. However, these bands resulted in a poorly performing Naïve-Bayes predictive model. Considering the use of a Fast-Correlation-Based Filter for feature selection, it was possible to define a new set of spectral bands with a wider coverage of molecular functional groups. These bands ensured an excellent Naïve-Bayes predictive model, with an AUC, a sensitivity, and a specificity all exceeding 0.92. These spectral bands, acquired through a minimally invasive analysis and obtained rapidly, economically, and in a high-throughput mode, therefore offer significant potential for managing delirium in critically ill patients.

Tocilizumab is associated with reduced delirium and coma in critically ill patients with COVID-19

Recent preclinical studies demonstrate a direct pathological role for the interleukin-6 (IL-6) pathway in mediating structural and functional delirium-like phenotypes in animal models of acute lung injury. Tocilizumab, an IL-6 pathway inhibitor, has shown reduced duration of ventilator dependency and mortality in critically ill patients with COVID-19. In this study, we test the hypothesis that tocilizumab is associated with reduced delirium/coma prevalence in critically ill patients with COVID-19. 253 patients were included in the study cohort, 69 in the tocilizumab group and 184 in the historical control group who did not receive tocilizumab. Delirium was assessed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) with a positive score indicating delirium. Coma was defined as a Richmond Agitation-Sedation Scale score of - 4 or - 5. Tocilizumab was associated with significantly greater number of days alive without delirium/coma (tocilizumab [7 days (IQR: 3-9 days)] vs control [3 days (IQR: 1-8 days)]; p < 0.001). These results remained significant after adjusting for age, sex, sepsis, Charlson Comorbidity Index, Sequential Organ Failure Assessment score, and median daily dose of analgesics/sedatives ( β ^  = 0.671, p = 0.010). There were no significant differences in mortality ( β ^  = - 0.204, p = 0.561), ventilator duration ( β ^  = 0.016, p = 0.956), and ICU or hospital length of stay ( β ^  = - 0.134, p = 0.603; β ^  = 0.003, p = 0.991, respectively). Tocilizumab use was associated with significantly increased number of days without delirium/coma. Confirmation of these findings in randomized prospective studies may inform a novel paradigm of pharmacological amelioration of delirium/coma during critical illness.

New initiation of opioids, benzodiazepines and antipsychotics following hospitalization for COVID-19

BACKGROUND

Patients newly initiated on opioids (OP), benzodiazepines (BZD), and antipsychotics (AP) during hospitalization are often prescribed these on discharge. Implications of this practice on outcomes remains unexplored.

OBJECTIVE

To explore the prevalence and risk factors of new initiation of select OP, BZD and AP among patients requiring in-patient stays. Test the hypothesis that new prescriptions are associated with higher odds of readmission or death within 28 days of discharge.

DESIGN

Single center retrospective cohort study.

SETTING AND PARTICIPANTS

Patients admitted to a tertiary-level medical center with either a primary diagnosis of RT-PCR positive for COVID-19 or high index of clinical suspicion thereof.

INTERVENTION

None.

MAIN OUTCOME AND MEASURES

Exposure was the new initiation of select common OP, BZD, and AP which were continued on hospital discharge. Outcome was a composite of 28-day readmission or death following index admission. Multivariable logistic regression was used to assess patient mortality or readmission within 28 days of discharge associated with new prescriptions at discharge.

RESULTS

One thousand three hundred and nineteen patients were included in the analysis. 11.3% (149/1319) were discharged with a new prescription of select OP, BZD, or AP either alone or in combination. OP (110/149) were most prescribed followed by BZD (41/149) and AP (22/149). After adjusting for unbalanced confounders, new prescriptions (adjusted odds ratio: 2.44, 95% confidence interval: 1.42-4.12; p = .001) were associated with readmission or death within 28 days of discharge. One in nine patients admitted with a diagnosis of COVID-19 or high clinical suspicion thereof were discharged with a new prescription of either OP, BZD or AP. New prescriptions were associated with higher odds of 28-day readmission or death. Strengthening medication reconciliation processes focused on these classes may reduce avoidable harm.

High-Molecular-Weight Hyaluronic Acid Can Be Used as a Food Additive to Improve the Symptoms of Persistent Inflammation, Immunosuppression and Catabolism Syndrome (PICS)

Hyaluronic acid (HA) is a new functional food additive which has the potential to ameliorate persistent inflammation, immunosuppression and catabolism syndrome (PICS), but the biological effects of HA with various molecular weights differ dramatically. To systematically investigate the efficacy of HA in altering PICS symptoms, medium-molecular-weight (MMW) HA was specifically selected to test its intervention effect on a PICS mouse model induced by CLP through oral administration, with high-molecular-weight (HMW) and low-molecular-weight (LMW) HA also participating in the experimental validation process. The results of pathological observations and gut flora showed that MMW HA rapidly alleviated lung lesions and intestinal structural changes in PICS mice in the short term. However, although long-term MMW HA administration significantly reduced the proportions of harmful bacteria in gut flora, inflammatory responses in the intestines and lungs of PICS mice were significantly higher in the MMW HA group than in the HMW HA and LMW HA groups. The use of HMW HA not only rapidly reduced the mortality rate of PICS mice but also improved their grip strength and the recovery of spleen and thymus indices. Furthermore, it consistently promoted the recovery of lung and intestinal tissues in PICS mice, and it also assisted in the sustained restoration of their gut microbiota. These effects were superior to those of LMW HA and MMW HA. The experimental results indicate that HMW weight HA has the greatest potential to be an adjunct in alleviating PICS as a food additive, while the safety of other HAs requires further attention.

Lived Experiences of Critically Ill COVID-19 Patients About Death and Dying: A Descriptive Phenomenology

Thinking about death is one of the most common problems of critically ill patients with COVID-19 in ICUs. Therefore, this study aims to explore the experiences of critically ill patients with COVID-19 about death and dying. This is a descriptive phenomenology approach. Participants in this study had 12 participants who were purposefully selected. The data collection method was semi-structured through interviews. Data were analyzed based on Colaizzi's approach. Data analysis generated two main themes, including personal, and non-personal; challenge thinking about death, and eight sub-themes. Thinking about the death of critically ill COVID-19 patients is a significant challenge that affects the patient's health and prolongs the treatment process. Therefore, it should be careful in the patient's treatment and care program.

Cognitive performance of post-covid patients in mild, moderate, and severe clinical situations

BACKGROUND

Studying individuals with varying symptoms, from mild to severe, can provide valuable insights into the spectrum of cognitive outcomes after COVID-19. We investigated the cognitive performance of adults who recovered from the novel coronavirus disease (COVID-19) without prior cognitive complaints, considering mild (not hospitalized), moderate (ward), and severe (intensive care unit) symptoms.

METHODS

This cross-sectional study included 302 patients who recovered from COVID-19 (mild, n = 102; moderate, n = 102; severe, n = 98). We assessed intellectual quotient (IQ), attention, memory, processing speed, visual-constructive ability, as well as symptoms of depression, anxiety, and stress, at least eighteen months after infection. The mean length of hospitalization was Mdays=8.2 (SD = 3.9) and Mdays=14.4 (SD = 8.2) in the moderate and severe groups, respectively.

RESULTS

Cognitive difficulties were present in all three groups: mild (n = 12, 11.7%), moderate (n = 40, 39.2%), and severe (n = 48, 48.9%). Using Multinomial Logistic Regression and considering the odds ratio, our results indicated that a one-point increase in sustained attention, visual memory, and working memory might decrease the odds of being categorized in the severe group by 20%, 24%, and 77%, respectively, compared to the mild group.

CONCLUSIONS

Our findings provide empirical evidence regarding the long-term cognitive effects of COVID-19, particularly in individuals experiencing severe manifestations of the disease. We also highlighted the need for a comprehensive, multidimensional approach in rehabilitation programs to address the enduring cognitive impacts of COVID-19.

An exploratory study of the practical impact of the COVID-19 pandemic on nursing tasks in clinical settings

AIMS

To identify and compare new or increased nursing tasks in South Korea during the pandemic, categorized by hospital type and department.

BACKGROUND

Although COVID-19 is no longer considered a global public health emergency, the threat of novel infectious diseases remains. Reflecting on the COVID-19 pandemic is essential to prepare effectively for future outbreaks.

METHODS

This cross-sectional exploratory study, following the STROBE checklist, included 948 registered nurses with more than a year of clinical experience currently working in various hospitals. Questionnaires gathered demographic data, work characteristics, and the frequency of nursing task performance. Statistical analysis encompassed descriptive and inferential methods.

RESULTS

The most common new or increased nursing task across all hospital types was 'Access control for family caregivers.' General wards prioritized tasks related to family caregivers, while specialized units like ICU and ER focused on infection control.

CONCLUSION

Understanding how COVID-19 has impacted nursing tasks is crucial for gaining insights into efficient resource allocation, targeted education, and policy formulation during similar public health crises. The pandemic has given rise to new family caregiver-related tasks in the nursing profession. Consequently, continuous nursing research is essential for establishing guidelines and fostering a supportive work environment, which is crucial for the successful implementation of these tasks.

Examination of workload perception, burnout, and perceived organizational support in emergency healthcare professionals: A structural equation model

Job stress is one of the important factors affecting employee behavior. One of the most important factors in reducing burnout caused by stress is organizational support. In this context, the aim of this study is to identify the moderating role of perceived organizational support in the effect of workload perception on burnout within the emergency healthcare professionals' universe. The data for this study were collected from 703 health professionals working in emergency health services in three major cities of Turkey. The relationships and the model of the study is analyzed by the Structural Equation Model technique. The results indicate that perceived workload is a factor that causes employee burnout, and perceived organizational support is a factor that reduces employee burnout. This study contributes to researchers and health managers by revealing the importance of workload planning and organizational activities that support employees to reduce burnout in health workers.

Application of in-silico drug discovery techniques to discover a novel hit for target-specific inhibition of SARS-CoV-2 Mpro's revealed allosteric binding with MAO-B receptor: A theoretical study to find a cure for post-covid neurological disorder

Several studies have revealed that SARS-CoV-2 damages brain function and produces significant neurological disability. The SARS-CoV-2 coronavirus, which causes COVID-19, may infect the heart, kidneys, and brain. Recent research suggests that monoamine oxidase B (MAO-B) may be involved in metabolomics variations in delirium-prone individuals and severe SARS-CoV-2 infection. In light of this situation, we have employed a variety of computational to develop suitable QSAR model using PyDescriptor and genetic algorithm-multilinear regression (GA-MLR) models (R2 = 0.800-793, Q2LOO = 0.734-0.727, and so on) on the data set of 106 molecules whose anti-SARS-CoV-2 activity was empirically determined. QSAR models generated follow OECD standards and are predictive. QSAR model descriptors were also observed in x-ray-resolved structures. After developing a QSAR model, we did a QSAR-based virtual screening on an in-house database of 200 compounds and found a potential hit molecule. The new hit's docking score (-8.208 kcal/mol) and PIC50 (7.85 M) demonstrated a significant affinity for SARS-CoV-2's main protease. Based on post-covid neurodegenerative episodes in Alzheimer's and Parkinson's-like disorders and MAO-B's role in neurodegeneration, the initially disclosed hit for the SARS-CoV-2 main protease was repurposed against the MAO-B receptor using receptor-based molecular docking, which yielded a docking score of -12.0 kcal/mol. This shows that the compound that inhibits SARS-CoV-2's primary protease may bind allosterically to the MAO-B receptor. We then did molecular dynamic simulations and MMGBSA tests to confirm molecular docking analyses and quantify binding free energy. The drug-receptor complex was stable during the 150-ns MD simulation. The first computational effort to show in-silico inhibition of SARS-CoV-2 Mpro and allosteric interaction of novel inhibitors with MAO-B in post-covid neurodegenerative symptoms and other disorders. The current study seeks a novel compound that inhibits SAR's COV-2 Mpro and perhaps binds MAO-B allosterically. Thus, this study will enable scientists design a new SARS-CoV-2 Mpro that inhibits the MAO-B receptor to treat post-covid neurological illness.

"Who Takes Care of Carers?": Experiences of Intensive Care Unit Nurses in the Acute Phase of the COVID-19 Pandemic

Introduction: The COVID-19 pandemic caused an international health emergency situation where nursing took on a fundamental role. The high number of patients in hospital ICUs led to a shift in nurses' working conditions and workload. Objective: The objective of this study was to describe the experiences of nurses who worked in ICUs during the acute phase of the COVID-19 pandemic. Methodology: A qualitative, descriptive study was carried out, with the participation of 21 nurses who worked in the ICU during the pandemic. Data collection took place between May and July 2021 through 21 in-depth interviews. Results: Three main themes emerged: (1) COVID-19 in ICUs: nurses on the frontline. (2) United against adversity: teamwork. (3) New optics of critical care and the nursing profession. COVID-19 was perceived with harshness, and the lack of knowledge about the virus generated confusion, anxiety and fear due to the risk of transmission to family members and relatives. The pandemic marked a shift in the management of human, material and economic resources. Novice nurses learned critical care at an accelerated pace, with significant physical and psychological strain. Expert nurses carried the burden of training new nurses. Although there were tense situations, experiencing these adverse situations as a team led to feelings of increased belonging, togetherness and professional bonding for nurses. While the participants noted an increase in motivation to continue in their profession, they also had a feeling of not having been cared for as they deserve by healthcare institutions.

Nervous system-related tropism of SARS-CoV-2 and autoimmunity in COVID-19 infection

The effects of SARS-CoV-2 in COVID-19 on the nervous system are incompletely understood. SARS-CoV-2 can infect endothelial cells, neurons, astrocytes, and oligodendrocytes with consequences for the host. There are indications that infection of these CNS-resident cells may result in long-term effects, including emergence of neurodegenerative diseases. Indirect effects of infection with SARS-CoV-2 relate to the induction of autoimmune disease involving molecular mimicry or/and bystander activation of T- and B cells and emergence of autoantibodies against various self-antigens. Data obtained in preclinical models of coronavirus-induced disease gives important clues for the understanding of nervous system-related assault of SARS-CoV-2. The pathophysiology of long-COVID syndrome and post-COVID syndrome in which autoimmunity and immune dysregulation might be the driving forces are still incompletely understood. A better understanding of nervous-system-related immunity in COVID-19 might support the development of therapeutic approaches. In this review, the current understanding of SARS-CoV-2 tropism for the nervous system, the associated immune responses, and diseases are summarized. The data indicates that there is viral tropism of SARS-CoV-2 in the nervous system resulting in various disease conditions. Prevention of SARS-CoV-2 infection by means of vaccination is currently the best strategy for the prevention of subsequent tissue damage involving the nervous system.

Delirium in the Era of COVID-19

BACKGROUND

Delirium has been associated with poor outcomes in hospitalized older adults. Rates of delirium have increased in the context of coronavirus disease 2019 (COVID-19).

PURPOSE

To explore the prevalence of delirium in older adult patients hospitalized with COVID-19 as well as correlations with age, gender, length of stay (LOS), occurrence of an intensive care unit admission or transfer, and in-hospital mortality in 2 hospitals in the southeast United States.

METHODS

A retrospective study of 1502 patients admitted between 2020 and 2021 was completed.

RESULTS

Older adult patients hospitalized with delirium and COVID-19 demonstrated significantly prolonged LOS (14.1 days vs 7.1 days, P < .0001) and higher rates of in-hospital mortality (33.5% vs 12.8%, P < .0001).

CONCLUSIONS

Findings of this study add to the growing literature on delirium in hospitalized patients and support the need for future initiatives to create protocols for monitoring and nursing care management of delirium to improve care delivery.

The distorted memories of patients treated in the intensive care unit during the COVID-19 pandemic: A qualitative study

BACKGROUND

During the COVID-19 pandemic, patients cared for in the intensive care unit were exposed to many risk factors for developing delirium and subsequent distorted memories. Further, seeing healthcare professionals who have been dressed in personal protective equipment and face masks could have affected the patients' memories. Therefore, the aim of this study was to explore memories and how they are experienced and managed by former patients who have been treated for COVID-19 in an intensive care unit.

METHODS

Sixteen former patients treated for COVID-19 at a large emergency hospital in Sweden were interviewed 3-8 months after discharge from the intensive care unit. The data were interpreted using thematic analysis. The Consolidated Criteria for Reporting Qualitative Research checklist was followed in the reporting of the study.

FINDINGS

Participants' descriptions of their memories of treatment in the intensive care unit for COVID-19 generated three themes: 'Distorted truth' the content in the memories which implied facing death in an unreal distorted environment. 'Captive,' was the experience and feelings linked to memories with a feeling of being exposed and alone, and 'Coping with memories' explained how participants managed the implications of the memories using a mixture of strategies.

CONCLUSIONS

For former patients who were admitted to an intensive care unit after a diagnosis of COVID-19, memories caused considerable distress, which were similar to other intensive care patientś experiences, before the pandemic. Emotion-focused and problem-focused strategies could be used to cope with these memories. Healthcare professionals wearing protective equipment gave the patient a distant feeling, but more important was to be treated with attention/care and respect.

IMPLICATIONS FOR CLINICAL PRACTICE

Awareness of the impact of distorted memories on patients who are severely ill and their needs and strategies to cope with these memories can form the basis for early interventions that promotes well-being during care and recovery. Healthcare professionals have an important task to inform patients and their family members about the existence of distorted memories, and talk about the patients' experience of them, to facilitate their recovery.

The relation between vaccination status and referral to a consultation-liaison psychiatry service for hospitalized patients with COVID-19

BACKGROUND

Previous studies have shown that patients with Coronavirus Disease 2019 (COVID-19) are likely to be affected by delirium and other psychiatric complications. We aimed to evaluate the relation between COVID-19 vaccination status and referral of patients hospitalized with COVID-19 for consultation-liaison psychiatry services.

METHOD

From the medical records used for this retrospective, single hospital-based study, 576 patients were identified who were over 18 years-of-age and hospitalized with a diagnosis of COVID-19 between March 2020 and March 2022. The data of 531 for whom the vaccine history was obtained from the medical records were available for analysis: 455 without and 76 with referral to consultation-liaison psychiatry. A history of COVID-19 vaccination at least two times was used in the analysis of the odds for referral to liaison psychiatric consultation: 95% confidence interval (CI) in multivariable logistic regression. The adjustment factors included sex, age, body mass index (BMI), severity of COVID-19, C-reactive protein level, medical history, and therapeutic factors such as the use of remdesivir, steroids, or mechanical ventilation.

RESULTS

The prevalence of psychiatric consultation was 14.3%. Patients without vaccination had a 7-times greater OR (95%CI:2.08-23.58) than vaccinated patients for a referral for consultation-liaison psychiatry services after adjusting for confounding factors.

CONCLUSION

Non-vaccination was associated with a greater likelihood of referral for consultation-liaison psychiatry service among these hospitalized Japanese patients with COVID-19, even after adjusting for clinical and therapeutic factors. It is possible that vaccination greatly lessens the need for the referral of COVID-19 patients for consultation-liaison psychiatry services.

Depression, anxiety, and stress among COVID-19 patients in South Sinai, Egypt: prevalence and associated predictors

Infectious diseases trigger fear and anxiety among patients leading to disturbance in psychological health of patients. Psychological symptoms were found during SARS-COV-1 epidemic which raise the curiosity about their presence with SARS-COV-2 infection. The current study aimed to estimate the prevalence and severity of psychiatric disorders (depression, anxiety, and stress) among COVID-19 patients and their associated significant predictors. A cross-sectional study was conducted among 382 patients infected with COVID-19 in South Sinai governorate, Egypt, during the period June 2021 through January 2022. Patients with positive PCR test for COVID-19 were included if no more than 6 months have passed after being isolated in the hospital or at home. The patients were being contacted after being cured from COVID-19. The Arabic version of the Depression Anxiety Stress was used to assess the psychological status of patients. Multivariate linear regression analysis was done to detect the predictors of psychiatric symptoms among patients. A total of 382 participants with mean age of 41.5 ± 15.0 years old, of whom 72.5% were males were included in the study. 91.6% of participants had all the three studied psychological disorders; depression, anxiety and stress with most of participants had either severe or extremely severe conditions (13.9 and 75.7 for anxiety, 22.8 and 46.3% for depression, 38.5 and % 19.6 for stress, respectively). Healthcare workers had higher prevalence rates of depression, anxiety and stress. In bivariate analysis, educational level, HCWs and visiting healthcare facility were significantly affecting DASS scores. In linear regression analysis, hospital admission was the main predictor of the three psychological disorders. In Conclusion, majority of patients affected with COVID-19 suffered from symptoms of anxiety, depression and stress within six months after being infected. Hospital admission was found to be the main predictor of the presence of psychiatric disorders with prolonged recovery time from COVID-19 infection. More attention should be paid to COVID-19 patient's mental health as psychological care and presence of psychiatric in the isolation hospitals should be considered.

Long-term cognitive dysfunction after the COVID-19 pandemic: a narrative review

Introduction

SARS-CoV-2, the virus responsible for the COVID-19 pandemic, has brought a conglomerate of novel chronic disabling conditions described as 'Long COVID/Post-COVID-19 Syndrome'. Recent evidence suggests that the multifaceted nature of this syndrome results in both pulmonary and extrapulmonary sequelae,chronic dyspnoea, persistent fatigue, and cognitive dysfunction being the most common, debilitating symptoms. Several mechanisms engender or exacerbate cognitive impairment, including central nervous system and extra-central nervous system causes, although the exact mechanism remains unclear. Both hospitalized and non-hospitalized patients may suffer varying degrees of cognitive impairment, ranging from fatigue and brain fog to prolonged deficits in memory and attention, detrimental to the quality-of-life years post-recovery. The aim of this review is to understand the underlying mechanisms, associations, and attempts for prevention with early intervention of long-term cognitive impairment post-COVID-19.

Methodology

A systematic search was conducted through multiple databases such as Medline, National Library of Medicine, Ovid, Scopus database to retrieve all the articles on the long-term sequalae of cognitive dysfunction after SARS-CoV-2 infection. The inclusion criteria included all articles pertinent to this specific topic and exclusion criteria subtracted studies pertaining to other aetiologies of cognitive dysfunction. This search was carefully screened for duplicates and the relevant information was extracted and analysed.

Results/discussion

To date, the exact pathogenesis, and underlying mechanisms behind cognitive dysfunction in COVID-19, remain unclear, hindering the development of adequate management strategies. However, the proposed mechanisms suggested by various studies include direct damage to the blood-brain barrier, systemic inflammation, prolonged hypoxia, and extended intensive care admissions. However, no clear-cut guidelines for management are apparent.

Conclusion

This review of the COVID-19 pandemic has elucidated a new global challenge which is affecting individuals' quality of life by inducing long-term impaired cognitive function. The authors have found that comprehensive evaluations and interventions are crucial to address the cognitive sequelae in all COVID-19 patients, especially in patients with pre-existing cognitive impairment. Nevertheless, the authors recommend further research for the development of relevant, timely neurocognitive assessments and treatment plans.

No Visitors: Family Perceptions of Separation From Hospitalized Loved Ones

BACKGROUND/INTRODUCTION

Restrictions on visitors during the coronavirus disease 2019 (COVID-19) pandemic had major implications for both patients and families, impacting health care outcomes. Policies included mandatory closures, masking, and visiting restrictions both in acute and long-term care. Despite visiting restrictions in health care systems, little is known about its effects.

OBJECTIVES/AIMS

The objective of this study was to elicit perceptions of individuals who were separated from their loved ones during acute care hospitalization during the COVID pandemic.

METHODS

Individuals who experienced separation from hospitalized family members because of the "no-visitor policies" during the COVID-19 pandemic were asked to participate in a study to elicit their perceptions. After institutional review board approval, interviews were completed for those who had loved ones admitted to acute care facilities only. Audiotaped and transcribed interviews were conducted in person, via telephone, or virtually using a primary investigator-developed interview guide. Using the Colaizzi method of analysis, themes were derived.

RESULTS

Of the 11 completed interviews, 100% of participants were female, and all were residents of Texas. Themes derived from this pilot project were advocacy, communication, emotional upheaval, human factors, isolation, and abandonment.

CONCLUSIONS

Findings from patient interviews support previous published studies. Ideas for improved patient and family experience discussed by the authors include personal protective equipment for significant others, consideration of visitation policies for those patients without decision-making capabilities, and increased accessibility to communication aids for both patients and families.

Lessons Learned From a Systematic, Hospital-Wide Implementation of the ABCDEF Bundle: A Survey Evaluation

Objective

We recently reported the first part of a study testing the impact of data literacy training on "assessing pain, spontaneous awakening and breathing trials, choice of analgesia and sedation, delirium monitoring/management, early exercise/mobility, and family and patient empowerment" [ABCDEF [A-F]) compliance. The purpose of the current study, part 2, was to evaluate the effectiveness of the implementation approach by surveying clinical staff to examine staff knowledge, skill, motivation, and organizational resources.

DESIGN

The Clark and Estes Gap Analysis framework was used to study knowledge, motivation, and organization (KMO) influences. Assumed influences identified in the literature were used to design the A-F bundle implementation strategies. The influences were validated against a survey distributed to the ICU interprofessional team.

SETTING

Single-center study was conducted in eight adult ICUs in a quaternary academic medical center.

SUBJECTS

Interprofessional ICU clinical team.

INTERVENTIONS

A quantitative survey was sent to 386 participants to evaluate the implementation design postimplementation. An exploratory factor analysis was performed to understand the relationship between the KMO influences and the questions posed to validate the influence. Descriptive statistics were used to identify strengths needed to sustain performance and weaknesses that required improvement to increase A-F bundle adherence.

MEASUREMENT AND RESULTS

The survey received an 83% response rate. The exploratory factor analysis confirmed that 38 of 42 questions had a strong relationship to the KMO influences, validating the survey's utility in evaluating the effectiveness of implementation design. A total of 12 KMO influences were identified, 8 were categorized as a strength and 4 as a weakness of the implementation.

CONCLUSIONS

Our study used an evidence-based gap analysis framework to demonstrate key implementation approaches needed to increase A-F bundle compliance. The following drivers were recommended as essential methods required for successful protocol implementation: data literacy training and performance monitoring, organizational support, value proposition, multidisciplinary collaboration, and interprofessional teamwork activities. We believe the learning generated in this two-part study is applicable to implementation design beyond the A-F bundle.

Discharge Disposition and Loss of Independence Among Survivors of COVID-19 Admitted to Intensive Care: Results From the SCCM Discovery Viral Infection and Respiratory Illness Universal Study (VIRUS)

OBJECTIVES

To describe incidence and risk factors of loss of previous independent living through nonhome discharge or discharge home with health assistance in survivors of intensive care unit (ICU) admission for coronavirus disease 2019 (COVID-19).

DESIGN

Multicenter observational study including patients admitted to the ICU from January 2020 till June 30, 2021.

HYPOTHESIS

We hypothesized that there is a high risk of nonhome discharge in patients surviving ICU admission due to COVID-19.

SETTING

Data were included from 306 hospitals in 28 countries participating in the SCCM Discovery Viral Infection and Respiratory Illness Universal Study COVID-19 registry.

PATIENTS

Previously independently living adult ICU survivors of COVID-19.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was nonhome discharge. Secondary outcome was the requirement of health assistance among patients who were discharged home. Out of 10 820 patients, 7101 (66%) were discharged alive; 3791 (53%) of these survivors lost their previous independent living status, out of those 2071 (29%) through nonhome discharge, and 1720 (24%) through discharge home requiring health assistance. In adjusted analyses, loss of independence on discharge among survivors was predicted by patient age ≥ 65 years (adjusted odds ratio [aOR] 2.78, 95% confidence interval [CI] 2.47-3.14, P < .0001), former and current smoking status (aOR 1.25, 95% CI 1.08-1.46, P  =  .003 and 1.60 (95% CI 1.18-2.16), P  =  .003, respectively), substance use disorder (aOR 1.52, 95% CI 1.12-2.06, P  =  .007), requirement for mechanical ventilation (aOR 4.17, 95% CI 3.69-4.71, P < .0001), prone positioning (aOR 1.19, 95% CI 1.03-1.38, P  =  .02), and requirement for extracorporeal membrane oxygenation (aOR 2.28, 95% CI 1.55-3.34, P < .0001).

CONCLUSIONS

More than half of ICU survivors hospitalized for COVID-19 are unable to return to independent living status, thereby imposing a significant secondary strain on health care systems worldwide.

Compassionate Nursing Care for COVID-19 Patients in the ICU in the Western Region of Saudi Arabia: A Lived Experience Study

INTRODUCTION

The rapid spread and the severity of symptoms of COVID-19 led to an increasing number of critical cases that need to be admitted to intensive care units (ICUs) worldwide. Compassion is a principle of nursing practice and indicates the meaning of providing high-quality care in all units, especially in the ICU. It means that nurses know what is important to patients and when they should be there for them when it is needed. There is a paucity of literature from Saudi Arabia that explores how critical care nurses perceive compassionate care during COVID-19.

OBJECTIVES

The aim of this study was to investigate the lived experiences of critical care nurses providing compassionate care to COVID-19 patients at King Abdulaziz Medical City, Jeddah, Saudi Arabia.

METHODS

A prospective, cross-sectional, descriptive phenomenological approach was utilized in this study. Data were collected from 13 ICU nurses through interviews. Collected data were transcribed and analyzed using Colaizzi's data analysis method.

RESULTS

 Eleven out of the 13 ICU nurses hold a Bachelor of Science in Nursing (BSN) and have more than five years of experience. Despite all the challenges surrounding the care for critically ill COVID-19 patients, nurses provide compassion in different ways to show personal interest to the patients. Data analysis revealed five themes: (1) contemporary meaning and competencies for compassionate nursing care, including communication and the inability to freely use touch; (2) physical symptoms, including discomfort, body aches and headaches, and sleep disturbances; (3) emotional turmoil, where three sub-themes emerged, including fear and anxiety, uncertainty, and isolation and loneliness; (4) role changing, including frequent guidelines change, additional roles and responsibilities, and altruism; (5) professionalism, including cultural facets of care, teamwork, and support.

DISCUSSION

The COVID-19 pandemic has caused major changes in nurses' working environment and so their experience. The results of this study indicated that nurses working in the ICU experienced remarkable and massive physical, psychological, and emotional symptoms during the COVID-19 pandemic. The nurses extended the relationships to the patients' families as they are at high risk of stress, anxiety, and depression. In addition, they were able to support them in dealing with the fear associated with the uncertainty of COVID-19. Also, results revealed that remote therapeutic relationships and psychotherapy can be credible and trustworthy alternatives to in-person care.

CONCLUSIONS

The results of this study indicated that ICU nurses provide compassionate care despite experiencing unprecedented and immense physical, psychological, and emotional symptoms during the COVID-19 pandemic.

RECOMMENDATIONS

Further study is recommended using other research methodologies. It is also recommended to conduct the same study in different cities for better generalization.

Effect of famotidine on cognitive and behavioral dysfunctions induced in post-COVID-19 infection: A randomized, double-blind, and placebo-controlled study

OBJECTIVES

This is an investigation of the efficacy and safety of famotidine, a selective histamine H2 receptor antagonist, on improvement of cognitive impairment, depression and anxiety symptoms developing post-COVID-19, in a 12-week, randomized controlled trial.

METHODS

A total of 50 patients with a confirmed diagnosis of COVID-19 and a score ≤ 23 on the Mini-Mental State Examination (MMSE) test or a score ≤ 22 on the Montreal Cognitive Assessment (MoCA) were randomly assigned to either the famotidine (40 mg twice daily) or the placebo group. Changes in MMSE scores at weeks 6 and 12 were the primary outcome, while changes in other scales were the secondary outcomes. Participants and evaluators were blinded.

RESULTS

At weeks 6 and 12, patients in the famotidine group had significantly higher MMSE scores (p = 0.014, p < 0.001, respectively). Regarding the MoCA scale, the famotidine group had a significantly higher score at weeks 6 and 12 (p = 0.001, p < 0.001, respectively). Considering the HAM-D scale (Hamilton Depression Rating Scale), at weeks 6 and 12, the famotidine group experienced a larger reduction (p = 0.009, p = 0.02, respectively). Additionally, comparison of the HAM-A scale scores (Hamilton Anxiety Rating Scale) at weeks 6 and 12 showed a statistically significant larger reduction in the famotidine group (p = 0.04, p = 0.02, respectively). The two groups did not differ in the frequency of adverse effects.

CONCLUSION

Our study supports safety and efficacy of famotidine in treating cognitive impairment, depression and anxiety symptoms induced by COVID-19.

TRIAL REGISTRATION

This trial was registered at the Iranian registry of clinical trials (IRCT: www.irct.ir; registration number: IRCT20090117001556N138).

Perceived Difficulties and Learning Needs Among Acute Care Ward Nurses Providing End-of-Life Care During the COVID-19 Pandemic: Comparison by Years of Clinical Experience

Background

In the daily routine of acute care wards, where priority is given to patients with severe illnesses and those who require urgent care, working with and supporting the decision making of terminally ill patients can be challenging.

Methods

This study aimed to clarify the perceived difficulties of and learning needs among acute care ward nurses providing end-of-life care during the COVID-19 pandemic. In order to perform analyses by years of clinical experience, we conducted semi-structured interviews with both novice and experienced nurses. Participants were nurses working in the acute care ward of hospitals in the Kansai area.

Results

We interviewed 31 nurses who agreed to cooperate, including 18 novice/advanced beginner nurses and 13 proficient/expert nurses. Perceived difficulties were categorized into four main groups for novice/advanced beginner nurses: , , , and . Perceived difficulties were categorized into four main groups for proficient/expert nurses: , , , and . Perceived learning needs were categorized into three main groups for novice/advanced beginner nurses: , , and . Perceived learning needs were categorized into three main groups for proficient/expert nurses: , , and .

Conclusion

Novice/advanced beginner nurses felt anxiety and confusion, and were overwhelmed with how to care for terminal patients. Proficient/expert nurses were able to think about how to make patients and their families feel better, and were able to think specifically about post-mortem care. Many proficient/expert nurses were thinking not only about patient care but also about patients' room environment and how to spend time with their families. They sought learning opportunities regarding angel care, including methods of teaching it and basic techniques for performing it, and realized that information sharing within wards, chain of command within the hospital, information exchange with other hospitals, and inter-hospital collaboration were all important during COVID-19 pandemic.

Incidence of Delirium in Critically Ill Patients With and Without COVID-19

BACKGROUND

It is known that patients with COVID-19 are at high risk of developing delirium. The aim of the study was to compare the incidence of delirium between critically ill patients with and without a diagnosis of COVID-19.

METHODS

This is a retrospective study conducted in a southern Brazilian hospital from March 2020 to January 2021. Patients were divided into two groups: the COVID-19 group consisted of patients with a diagnosis of COVID-19 confirmed by reverse transcription-polymerase chain reaction (RT-PCR) or serological tests who were admitted to specific ICUs. The non-COVID-19 group consisted of patients with other surgical and medical diagnoses who were admitted to non-COVID ICUs. All patients were evaluated daily using the Intensive Care Delirium Screening Checklist (ICDSC). The two cohorts were compared in terms of the diagnosis of delirium.

RESULTS

Of the 649 patients who remained more than 48 h in the ICU, 523 were eligible for the study (COVID-19 group: 292, non-COVID-19 group: 231). There were 119 (22.7%) patients who had at least one episode of delirium, including 96 (32.9%) in the COVID-19 group and 23 (10.0%) in the non-COVID-19 group (odds ratio [OR] 4.42; 95% confidence interval [CI], 2.69 to 7.26; p < 0.001). Among patients mechanically ventilated for two days or more, the incidence of delirium did not differ between groups (COVID-19: 89/211, 42.1% vs non-COVID-19: 19/47, 40.4%; p  =  0.82). Logistic regression showed that the duration of mechanical ventilation was the only independent factor associated with delirium (p  =  0.001).

CONCLUSION

COVID-19 can be associated with a higher incidence of delirium among critically ill patients, but there was no difference in this incidence between groups when mechanical ventilation lasted two days or more.

ICU Delirium Is Associated with Cardiovascular Burden and Higher Mortality in Patients with Severe COVID-19 Pneumonia

BACKGROUND

COVID-19 can lead to functional disorders and complications, e.g., pulmonary, thromboembolic, and neurological. The neuro-invasive potential of SARS-CoV-2 may result in acute brain malfunction, which manifests as delirium as a symptom. Delirium is a risk factor for death among patients hospitalized due to critical illness. Taking the above into consideration, the authors investigated risk factors for delirium in COVID-19 patients and its influence on outcomes.

METHODS

A total of 335 patients hospitalized due to severe forms of COVID-19 were enrolled in the study. Data were collected from medical charts.

RESULTS

Delirium occurred among 21.5% of patients. In the delirium group, mortality was significantly higher compared to non-delirium patients (59.7% vs. 28.5%; p < 0.001). Delirium increased the risk of death, with an OR of 3.71 (95% CI 2.16-6.89; p < 0.001). Age, chronic atrial fibrillation, elevated INR, urea, and procalcitonin, as well as decreased phosphates, appeared to be the independent risk factors for delirium occurrence.

CONCLUSIONS

Delirium occurrence in patients with severe COVID-19 significantly increases the risk of death and is associated with a cardiovascular burden. Hypophosphatemia is a promising reversible factor to reduce mortality in this group of patients. However, larger studies are essential in this area.

COVID-19 delirium and encephalopathy: Pathophysiology assumed in the first 3 years of the ongoing pandemic

Background

The coronavirus disease (COVID-19) continues to spread worldwide. It has a high rate of delirium, even in young patients without comorbidities. Infected patients required isolation because of the high infectivity and virulence of COVID-19. The high prevalence of delirium in COVID-19 primarily results from encephalopathy and neuroinflammation caused by acute respiratory distress syndrome (ARDS)-associated cytokine storm. Acute respiratory distress syndrome has been linked to delirium and psychotic symptoms in the subacute phase (4 to 12 weeks), termed post-acute COVID-19 syndrome (PACS), and to brain fog, cognitive dysfunction, and fatigue, termed "long COVID," which persists beyond 12 weeks. However, no review article that mentions "COVID-19 delirium" have never been reported.

Basic Procedures

This narrative review summarizes data on delirium associated with acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and related neurological symptoms of persistent post-infection illness (PACS or long COVID) after persistence of cognitive dysfunction. Thus, we describe the pathophysiological hypothesis of COVID-19 delirium and its continuation as long COVID. This review also describes the treatment of delirium complicated by COVID-19 pneumonia.

Main Findings

SARS-CoV-2 infection is associated with encephalopathy and delirium. An association between COVID-19 infection and Alzheimer's disease has been suggested, and studies are being conducted from multiple facets including genetics, cytology, and postmortem study.

Principal Conclusions

This review suggests that COVID-19 has important short and long-term neuropsychiatric effects. Several hypotheses have been proposed that highlight potential neurobiological mechanisms as causal factors, including neuronal-inflammatory pathways by cytokine storm and cellular senescence, and chronic inflammation.

ACE-2, TMPRSS2, and Neuropilin-1 Receptor Expression on Human Brain Astrocytes and Pericytes and SARS-CoV-2 Infection Kinetics

Angiotensin Converting Enzyme 2 (ACE-2), Transmembrane Serine Protease 2 (TMPRSS-2) and Neuropilin-1 cellular receptors support the entry of SARS-CoV-2 into susceptible human target cells and are characterized at the molecular level. Some evidence on the expression of entry receptors at mRNA and protein levels in brain cells is available, but co-expression of these receptors and confirmatory evidence on brain cells is lacking. SARS-CoV-2 infects some brain cell types, but infection susceptibility, multiple entry receptor density, and infection kinetics are rarely reported in specific brain cell types. Highly sensitive Taqman ddPCR, flow-cytometry and immunocytochemistry assays were used to quantitate the expression of ACE-2, TMPRSS-2 and Neuropilin-1 at mRNA and protein levels on human brain-extracted pericytes and astrocytes, which are an integral part of the Blood-Brain-Barrier (BBB). Astrocytes showed moderate ACE-2 (15.9 ± 1.3%, Mean ± SD, n = 2) and TMPRSS-2 (17.6%) positive cells, and in contrast show high Neuropilin-1 (56.4 ± 39.8%, n = 4) protein expression. Whereas pericytes showed variable ACE-2 (23.1 ± 20.7%, n = 2), Neuropilin-1 (30.3 ± 7.5%, n = 4) protein expression and higher TMPRSS-2 mRNA (667.2 ± 232.3, n = 3) expression. Co-expression of multiple entry receptors on astrocytes and pericytes allows entry of SARS-CoV-2 and progression of infection. Astrocytes showed roughly four-fold more virus in culture supernatants than pericytes. SARS-CoV-2 cellular entry receptor expression and "in vitro" viral kinetics in astrocytes and pericytes may improve our understanding of viral infection "in vivo". In addition, this study may facilitate the development of novel strategies to counter the effects of SARS-CoV-2 and inhibit viral infection in brain tissues to prevent the spread and interference in neuronal functions.

Cognition and Mental Health in Pediatric Patients Following COVID-19

The global coronavirus pandemic has significantly impacted public health and has been a research subject since its emergence in 2019. The acute phase of the disease leads to pulmonary and non-pulmonary manifestations, which in some individuals may progress to long-lasting symptoms. In this article, we conducted a narrative review of the current literature to summarize current knowledge regarding long COVID syndrome in children, focusing on cognitive symptoms. The review included a search of three databases (PubMed, Embase, and Web of Science) using the key phrases "post COVID-19 cognitive pediatric", "long COVID pediatric", "mental health long COVID children", and "COVID-19 cognitive symptoms". A total of 102 studies were included. The review revealed that the main long-term cognitive symptoms following COVID-19 were memory and concentration deficits, sleep disturbances, and psychiatric states such as anxiety and stress. In addition to the direct physiological effects of a viral infection, there are psychological, behavioral, and social factors contributing to cognitive impairment, which should be addressed regarding the pediatric population. The high prevalence of neurocognitive symptoms in children following COVID-19 emphasizes the importance of understanding the mechanisms of nervous system involvement.

Unlicensed assistive personnel's care for persons with or at risk of delirium: a scoping review protocol

OBJECTIVE

The objective of this review is to describe the nature and extent of the literature regarding unlicensed assistive personnel's involvement in delivering care to persons with or at risk of delirium.

INTRODUCTION

Initiatives that promote the involvement of unlicensed assistive personnel in providing additional supervision and care to persons with or at risk of delirium have been developed. Since no standardized approach guides unlicensed assistive personnel's involvement with persons with or at risk of delirium, and since inconsistent training and expectations may pose a threat to the safety and quality of care, it is essential to clarify their role with persons with or at risk of delirium.

INCLUSION CRITERIA

This review will consider articles published in peer-reviewed journals, dissertations, theses, book chapters, and conference papers in French or English. Quantitative, qualitative, or mixed method studies that report on the development, implementation, or evaluation of the role of unlicensed assistive personnel in contexts of delirium will be included. We will consider editorials and opinion papers only if they report on the development, implementation, or evaluation of the role of unlicensed assistive personnel.

METHODS

Records will be identified via CINAHL, ProQuest Dissertations & Theses Global, Embase, MEDLINE, APA PsycINFO, and Web of Science. Two independent reviewers will select studies and extract data using a piloted form. Data will be synthesized narratively, using descriptive statistics and a tabular format. A consultation phase will include approximately 24 unlicensed assistive personnel and registered nurses who will be invited to comment on the review findings.

Nursing workload assessment in an intensive care unit: A retrospective observational study using the Nursing Activities Score

BACKGROUND

Nursing Activities Score (NAS) is a promising tool for calculating the nursing workload in intensive care units (ICU). However, data on intensive care nursing activities in Portugal are practically non-existent.

AIM

To assess the nursing workload in a Portuguese ICU using the NAS.

STUDY DESIGN

Retrospective cohort study developed throughout the analysis of the electronic health record database from 56 adult patients admitted to a six-bed Portuguese ICU between 1 June-31 August 2020. The nursing workload was assessed by the Portuguese version of the NAS. The study was approved by the Hospital Council Board and Ethics Committee. The study report followed the STROBE guidelines.

RESULTS

The average occupancy rate was 73.55% (±16.60%). The average nursing workload per participant was 67.52 (±10.91) points. There was a correlation between the occupancy rate and the nursing workload. In 35.78% of the days, the nursing workload was higher than the available human resources, overloading nurse staffing/team.

CONCLUSIONS

The nursing workload reported follows the trend of the international studies and the results reinforce the importance of adjusting the nursing staffing to the complexity of nursing care in this ICU. This study highlighted periods of nursing workload that could compromise patient safety.

RELEVANCE TO CLINICAL PRACTICE

This was one of the first studies carried out with the NAS after its cross-cultural adaptation and validation for the Portuguese population. The nursing workload at the patient level was higher in the first 24 h of ICU stays. Because of the 'administrative and management activities' related to the 'patient discharge procedures', the last 24 h of ICU stays also presented high levels of nursing workload. The implementation of a nurse-to-patient ratio of 1:1 may contribute to safer nurse staffing and to improve patient safety in this Tertiary (level 3) ICU.

Cognitive and psychological outcomes and follow-up in severely affected COVID-19 survivors admitted to a rehabilitation hospital

BACKGROUND

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) represents the most recent severe pandemic resulting in coronavirus disease 2019 (COVID-19). COVID-19 can damage the central nervous system, requiring admission to intensive care units (ICU) and aggressive treatments (long-term ventilatory assistance and sedation) to stabilize vitals. Most post-COVID-19 patients experience cognitive impairments and mood or stress disorders. We aimed to study the frequency of cognitive deficits in COVID-19 survivors, the relationship between clinical factors in the acute phase and cognitive outcomes, affective states, and quality of life. We explored cognitive reserve (CR) role, as a post-COVID-19 resilience factor.

METHODS

Twenty-nine COVID-19 inpatients were assessed using a neuropsychological battery, mood scales, quality of life, and social integration questionnaires. Twenty-five were retained through telephone follow-up to monitor cognitive sequelae, affective states, and reintegration levels roughly 8 months after hospital discharge. We administered the Cognitive Reserve Index questionnaire.

RESULTS

We found most patients display no cognitive deficits. When they did, multi-domain impairment occurred most frequently, especially involving executive functions. Results revealed a significant correlation between depression levels and the interval between ICU admission and tracheal tube removal. We found increased levels of depression and anxiety at follow-up, a significant relationship between resuming daily life activities, high CR, and executive functions.

CONCLUSIONS

These findings suggest the importance of psychological support in the long term and the modulating role of cognitive reserve in quality of life after infection.

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.

Short-term evaluation of motor and sensory nerve conduction parameters in COVID-19-associated peripheral neuropathy patients

Background

Severe acute respiratory syndrome coronavirus 2 (SARS‐COV‐2) is mostly associated with upper and lower respiratory tract manifestations. However, coronavirus disease 19 (COVID-19) can result in a wide range of other systemic symptomatology, including neuropsychiatric, psychological, and psychosocial impairments. Literature regarding neurological compromise, including neuropathy and sensory and motor affection associated with COVID-19, is still limited.

This study aims to evaluate the sensory, motor neuropathy, and secondary neurological impairment among patients with mild to moderate coronavirus disease associated with peripheral neuropathy within 1 month.

Methods

Forty participants, including 20 mild to moderate COVID-19 patients with peripheral neuropathy and 20 age and gender-matched healthy volunteers, were recruited in this case/control study. Laboratory evaluation focused on C-reactive protein (CRP) and D-dimer levels. Oxygen saturation for all participants was recorded. The neurophysiological study included motor nerve study, sensory nerve study, and F wave study for upper and lower limbs were done.

Results

The two groups were similar regarding baseline data. Neurological symptoms’ onset in the COVID-19 group ranged from 4 to 24 days. Levels of CRP and D-dimer levels were significantly higher in patients versus the control group. Motor nerve conduction (MNC) amplitude and latency for the median nerve were significantly compromised among the COVID-19 group. The MNC latency and F wave latency for the posterior tibial nerve were significantly higher in the COVID-19 group. The CRP and D-dimer levels were associated with a significant positive correlation with a latency of median nerve MNC, sensory nerve conduction (SNC), and f-wave; latency of MNC and F wave of the posterior tibial nerve; and SNC latency for sural nerve.

Conclusion

neurological involvement can occur in mild to moderate cases of SARS-COV-2 infection and add to the burden of the disease. Neurological symptoms in the course of COVID-19 disease should be interpreted cautiously, and appropriate diagnosis, including nerve conduction studies and management, should be considered.

Trial registration

ClinicalTrials.gov. NCT05721040.

Altered EEG, disrupted hippocampal long-term potentiation and neurobehavioral deficits implicate a delirium-like state in a mouse model of sepsis

Sepsis and systemic inflammation are often accompanied by severe encephalopathy, sleep disruption and delirium that strongly correlate with poor clinical outcomes including long-term cognitive deficits. The cardinal manifestations of delirium are fluctuating altered mental status and inattention, identified in critically ill patients by interactive bedside assessment. The lack of analogous assessments in mouse models or clear biomarkers is a challenge to preclinical studies of delirium. In this study, we utilized concurrent measures of telemetric EEG recordings and neurobehavioral tasks in mice to characterize inattention and persistent cognitive deficits following polymicrobial sepsis. During the 24-hour critical illness period for the mice, slow-wave EEG dominance, sleep disruption, and hypersensitivity to auditory stimuli in neurobehavioral tasks resembled clinical observations in delirious patients in which alterations in similar outcome measurements, although measured differently in mice and humans, are reported. Mice were tested for nest building ability 7 days after sepsis induction, when sickness behaviors and spontaneous activity had returned to baseline. Animals that showed persistent deficits determined by poor nest building at 7 days also exhibited molecular changes in hippocampal long-term potentiation compared to mice that returned to baseline cognitive performance. Together, these behavioral and electrophysiological biomarkers offer a robust mouse model with which to further probe molecular pathways underlying brain and behavioral changes during and after acute illness such as sepsis.

Demographic Features, Physical Examination Findings, and Medication Use in Hospitalized, Delirious Patients With and Without COVID-19 Infection: A Retrospective Study

BACKGROUND

Delirium is common in the setting of infection with severe acute respiratory syndrome coronavirus 2. Anecdotal evidence and case reports suggest that patients with delirium in the setting of Coronavirus 2019 (COVID-19) may exhibit specific features, including increased tone, abulia, and alogia.

OBJECTIVE

To determine whether differences exist in sociodemographic and medical characteristics, physical examination findings, and medication use in delirious patients with and without COVID-19 infection referred for psychiatric consultation.

METHODS

We undertook an exploratory, retrospective chart review of 486 patients seen by the psychiatry consultation service at a tertiary care hospital from March 10 to May 15, 2020. Delirious patients were diagnosed via clinical examination by a psychiatric consultant, and these patients were stratified by COVID-19 infection status. The strata were described and compared using bivariate analyses across sociodemographic, historical, objective, and treatment-related variables.

RESULTS

A total of 109 patients were diagnosed with delirium during the study period. Thirty-six were COVID-19+. Median age was 63 years and did not differ between groups. COVID-19+ patients with delirium were more likely to present from nursing facilities (39% vs 11%; Fisher's exact test; P = 0.001) and have a history of schizophrenia (11% vs 0%; Fisher's exact test; P = 0.011). Myoclonus (28% vs 4%; P = 0.002), hypertonia (36% vs 10%; P = 0.003), withdrawal (36% vs 15%; P = 0.011), akinesia (19% vs 6%; P = 0.034), abulia (19% vs 3%; P = 0.004), and alogia (25% vs 8%; P = 0.012) were more common in COVID-19+ patients. COVID-19+ delirious patients were significantly more likely to have received ketamine (28% vs 7%; P = 0.006), alpha-adrenergic agents besides dexmedetomidine (36% vs 14%; P = 0.014), and enteral antipsychotics (92% vs 66%; P = 0.007) at some point.

CONCLUSIONS

Patients with COVID-19 delirium referred for psychiatric consultation are more likely to reside in nursing facilities and have a history of schizophrenia than delirious patients without COVID-19. Patients with delirium in the setting of COVID-19 may exhibit features consistent with akinetic mutism. Psychiatrists must assess for such features, as they may influence management choices and the risk of side effects with agents commonly used in the setting of delirium.

Common Biomarkers Associated with Delirium in Hospitalized Patients with COVID-19 at the Epicentre of Turkish Coronavirus Outbreak: A Case-Control Study

Introduction

To investigate the differences in biochemical characteristics between Coronavirus Disease 2019 (COVID-19) patients with and without delirium in non-intensive care (IC) COVID-19 units was aimed.

Methods

This study was designed as an observational, single-centered, and case-control study consisting of 43 delirious patients and matched 45 non-delirious patients admitted to non-IC COVID-19 units. Delirium was diagnosed by a consultant psychiatrist according to the DSM-5 delirium diagnostic criteria. Independent variables such as laboratory tests at the time of admission, clinical features, and patient characteristics were obtained from electronic medical records by researchers. In the primary analyses, binomial logistic regression models were used to investigate the factors associated with delirium, which was identified as the outcome variable. Multivariate logistic models were then adjusted for potential confounding factors, including age, gender, history of neurocognitive disorders and Charlson Comorbidity Index (CCI).

Results

We observed higher levels of urea, d-dimer, troponin-T, proB-type natriuretic peptide, and CCI in patients with delirium compared to patients without delirium. We also observed lower levels of estimated glomerular filtration rate (eGFR), serum albumin, and O₂ saturation and a decrease in the length of stay at the hospital. After adjusting for confounding factors such as gender, age, and comorbidity, we found that urea (adjusted estimate=0.015; 95% Confidence Interval [CI]=0.058-0.032, P=0.039), urea/creatinine ratio (adjusted estimate=0.008; 95% CI=0.002-0.013, P=0.011), and troponin-T (adjusted estimate=0.066; 95% CI=0.014-0.118, P=0.014) were independent biomarkers associated with delirium.

Conclusion

Delirium is associated with higher urea levels and urea/creatinine ratios in COVID-19 patients. In addition, the relationship between troponin-T and delirium may help understand the potential link between the brain and the heart in COVID-19. Additional multi-centred studies with larger sample sizes are needed to generalise these results.

Delirium in hospitalized COVID-19 patients: Predictors and implications for patient outcome

INTRODUCTION

Delirium is recognized as a severe complication of coronavirus-disease-2019 (COVID-19). COVID-19-associated delirium has been linked to worse patient outcomes and is considered to be of multifactorial origin. Here we sought to evaluate the incidence and risk factors of delirium in hospitalized COVID-19 patients, along with its impact on clinical outcome.

METHODS

Consecutive adult COVID-19 patients admitted to a tertiary academic referral hospital between March 1st and December 31st, 2020 were included. Potential risk factors for delirium were evaluated, including: age, gender, disease severity (as per the highest WHO grading reached during admission), laboratory parameters for infection and renal function (as per their most extreme values), and presence of comorbidities. To assess the relative strength of risk factors for predicting the occurrence of delirium, we performed a random-forest survival analysis.

RESULTS

347 patients with positive COVID-19 PCR test and median age 68.2 [IQR 55.5, 80.5] years were included. Of those, 79 patients (22.8%) developed delirium, 81 (23.3%) were transferred to ICU, 58 (16.7%) died. 163 (73.8%) patients were discharged home, 13 (5.9%) to another hospital, 32 (14.5%) to nursing homes, 13 (5.9%) to rehabilitation with an overall median admission-to-discharge time of 53 [IQR 14, 195] days. The strongest predictors for the occurrence of delirium were blood urea nitrogen (minimal depth value (MD): 3.33), age (MD: 3.75), disease severity (as captured by WHO grading; MD: 3.93), leukocyte count (MD: 4.22), the presence of a neurodegenerative history (MD: 4.43), ferritin (MD: 4.46) and creatinine (MD: 4.59) levels.

CONCLUSION

The risk of delirium in COVID-19 can be stratified based on COVID-19 disease severity and-similar to delirium associated with other respiratory infections-the factors advanced age, neurodegenerative disease history, and presence of elevated infection and renal-retention parameters. Screening for these risk factors may facilitate early identification of patients at high-risk for COVID-19-associated delirium.

Post-Intensive Care Syndrome in Non-COVID-19 ICU Survivors during the COVID-19 Pandemic in South Korea: A Multicenter Prospective Cohort Study

A prospective observational cohort study investigated the prevalence of post-intensive care syndrome (PICS) among non-COVID-19 ICU survivors during the COVID-19 pandemic. Adults who had been admitted to the ICU for more than 24 h were enrolled, and followed-up at 3, 6, and 12 months post-discharge. PICS (mental health, cognitive, and physical domains) was measured using the Hospital Anxiety and Depression Scale, Posttraumatic Diagnosis Scale, Montreal Cognitive Assessment, and Korean Activities of Daily Living (ADL) scale. Data were analyzed from 237 participants who completed all three follow-up surveys. The prevalence of PICS was 44.7%, 38.4%, and 47.3%, at 3, 6, and 12 months of discharge, respectively. The prevalence of PICS in the mental health and cognitive domains decreased at 6 and increased at 12 months. The prevalence of PICS in the physical domain declined over time. Changes in PICS scores other than ADL differed significantly according to whether participants completed follow-up before or after December 2020, when COVID-19 rapidly spread in South Korea. In the recent group, anxiety, depression, post-traumatic stress disorder, and cognition scores were significantly worse at 12 months than at 6 months post-discharge. The COVID-19 pandemic may have adversely affected the recovery of non-COVID-19 ICU survivors.

Delirium in COVID-19 and post-liver transplant patients: an observational study

OBJECTIVE

Delirium is a major complication in hospitalised patients. This study aimed to compare the mortality trends of patients with delirium according to the underlying physical condition.

METHODS

Hospitalised patients diagnosed with delirium by the Modena Consultation-Liaison Psychiatry Service (Italy) during 2020 were enrolled. Three groups were identified: COVID; after orthotopic liver transplant (OLT); other conditions. The full medical records were screened to retrieve socio-demographic and clinical data. INTERMED score and Delirium Rating Scale were used to retrospectively rate bio-social-complexity and delirium severity. Early (20 days) and end of study (31^st January 2021) mortality were ascertained for each subject.

RESULTS

A total of 103 patients were enrolled. Patients hospitalised for COVID showed higher INTERMED scores (two-tailed t-test, p = 0.019) and higher 20-day mortality (HR = 3.68, p = 0.014). When considering a 1-year follow-up, the main predictor of mortality was patients' age in all three subgroups (HR = 1.06; p = 0.003).

CONCLUSION

Our results suggest that patients hospitalised for COVID-19 with delirium showed higher bio-psycho-social complexity and higher short-term mortality, regardless of the severity of delirium. OLT patients showed lower mortality and bio-psycho-social complexity, despite being still considered as 'complex', according to the INTERMED score. Future research should focus on understanding the underlying mechanisms in the relationship between delirium and mortality.Key pointsPatients hospitalised for COVID-19 with delirium were found at risk of higher short-term mortality and higher bio-psycho-social complexity.OLT patients showed lower overall mortality and lower bio-psycho-social complexity than the other two groups, despite being still in the 'complex' range according to the INTERMED score.Future research should assess the areas of impact of delirium in patients affected by COVID-19, considering short- and long-term outcomes.