Neurological complications in COVID-19: a single case study of rehabilitation treatment

Background/aims:

COVID-19 is a global pandemic, which has seen over 198 million cases as of August 2021. This case study highlights the rehabilitation of a young patient with respiratory and neurologic sequalae of COVID-19 across the continuum of care, from the intensive care unit to the inpatient rehabilitation unit.

Case description:

A 45-year-old woman, with past medical history of fibromyalgia and morbid obesity, presented with complaints of shortness of breath. She tested positive for SARS-CoV-2, was transferred to the intensive care unit, and was intubated for 17 days. The day after extubation, she experienced worsened mental status; computed tomography and magnetic resonance imaging scans revealed bilateral strokes. On hospital day 21, she was transferred to the stroke step-down unit. On hospital day 24, she recovered some cognitive ability and movement of her lower extremities. On hospital day 30, she was admitted to the inpatient rehabilitation unit. Examination by occupational and physiotherapists found motor and sensory impairments of multiple peripheral nerves, including musculocutaneous, axillary and radial nerves. Interventions included passive range of motion, sitting balance, transfer training, rigid taping, upper extremity strengthening and functional training (gait, stair, activities of daily living). Her activities of daily living performance was limited by upper extremity weakness, sensory loss and pain.

Conclusions

This case highlights the medical, neurological and functional implications of COVID-19 on patients after prolonged hospitalisation. The plan of care was informed by collaboration between rehabilitation disciplines. Causes of her injuries are unclear but could include positioning, brachial plexus injuries, or post-critical illness syndrome. Further research on the evaluation and care of patients with COVID-19 that result in profound neurological impairments is warranted.

Replication of a managed health care initiative for people with mental retardation living in the community

To improve understanding of the cost-effectiveness of a managed health care program for individuals with mental retardation, we have described financing, utilization, and outcomes of the Developmental Disabilities Center at Morristown Memorial Hospital. The costs and benefits of health care coordination, a key feature of this program, were discussed. Under this model, annual, unreimbursed costs of health care coordination in 1989 averaged $668 for people with severe mental retardation. However, the total reimbursable costs of inpatient care were reduced. In addition, medical outcome data from ongoing research projects suggest that the program has been an important vehicle for improving the health of people with mental retardation in the community. The costs, revenues, and financing of this program were presented in order to assist candidate sites in the replication of this model. The role of this type of program in health care reform was discussed.

Managed health care services for people with mental retardation: impact on inpatient utilization

All admissions of people with mental retardation to a community hospital during one year were examined to determine the effects of a managed-care model on selected outcome variables. Hospitalization outcomes for patients receiving health care services through the program (care coordination group) were compared to those not enrolled (usual care group). Patients in the care coordination group were found to have shorter hospital stays, when adjusted for diagnosis-related groups; fewer readmissions; and were less severely ill upon admission. Cost data were extrapolated to show that costs of care coordination activities were partially offset by reductions in inpatient utilization.

Mortality among individuals with mental retardation living in the community

Mortality in a population of more than 1,300 people with mental retardation who live in the community was studied utilizing a case-by-case review and sentinel health event methodology. Death was noted in 14 people over a 4-year period. Cause of death was identified as avoidable (3 patients), potentially avoidable (3), unavoidable (3), sudden unexplained death with a history of epilepsy (3), or other unexplained deaths (2). Factors influencing mortality and the delivery of health care services were described. The sentinel health event methodology and case-by-case mortality reviews are recommended for monitoring avoidable deaths in community residential settings for people with mental retardation.

Children's testimony and their perceptions of stress in and out of the courtroom

Modifications of the courtroom environment have been proposed to reduce stress and enhance truth-telling of child witnesses. The present study examines the premise that courtroom environment affects the quality of children's evidence and children's perceptions of their own stress. Thirty-four 8- to 10-year-olds participated in an activity and 2 weeks later, their memory for the activity was tested. Half the children were questioned in a mock courtroom in the law school of a major university, and half at their school, both by the same interviewer. Children questioned at court showed impaired memory performance when compared with agemates questioned at school. They also rated certain court-related experiences as more stressful than peers interviewed at school. Furthermore, children's perceptions of courtroom stress were negatively correlated with completeness of accurate free recall, suggesting a relation between court-related stress and eyewitness memory worthy of further study.

A statewide public and professional education program on fragile X syndrome

Fragile X syndrome is reported to be the most common inherited cause of mental retardation known, but the majority of affected individuals are as yet undiagnosed. The project described in this paper was developed to increase the public and professional awareness of fragile X syndrome in the state of New Jersey. As a result there were increased efforts at diagnostic screening, provision of client and family support services, and prevention. This educational program proved to be a cost-effective method for increasing community awareness of a genetic disease on a statewide level.

Pertussis immunization patterns in special care nursery graduates

Controversy exists regarding immunization with pertussis vaccine of high-risk special care nursery graduates. Our study compared the immunization status of 38 high-risk, 30 low-risk, and 57 normal infants utilizing an immunization response form. Comparison of the three infant groups revealed that complete or incomplete immunization varies, depending on group status. Of 38 infants at high risk for developmental delay, 22 (57.9%) were not immunized against pertussis by age one. Physicians cited concerns related to previous neurologic injury and increased liability for vaccine-related injury as major reasons for deferring vaccination. Recommendations for improving current guidelines and practice are outlined.

HIV infection and developmental services for adults

The achievement of community living and greater personal independence has placed adults with developmental disabilities in a potentially vulnerable position regarding acquisition of HIV infection. Early surveys have identified a limited number of individuals who have become infected. Few states have undertaken planning for assurance of appropriate services. Program managers must consider the diverse educational and ethical issues involved; advisory committees can be of assistance. Strong antidiscrimination measures will be required for the protection of adults with developmental disabilities and HIV infection.