Mechanical ventilation and prone positioning in pregnant patients with severe COVID-19 pneumonia: experience at a quaternary referral center

BackgroundWe present the care of 17 consecutive pregnant patients who required mechanical ventilation for Coronavirus Disease 2019 (COVID-19) pneumonia at a quaternary referral center in the United States. We retrospectively describe the management of these patients, maternal and fetal outcomes, as well as the feasibility of prone positioning and delivery.MethodsBetween March 2020 and June 2021, all pregnant and postpartum patients who were mechanically ventilated for COVID-19 pneumonia were identified. Details of their management including prone positioning, maternal and neonatal outcomes, and complications were noted.ResultsSeventeen pregnant patients required mechanical ventilation for COVID-19. Thirteen patients received prone positioning, with a total of 49 prone sessions. One patient required extracorporeal membrane oxygenation. All patients in this series survived until at least discharge. Nine patients delivered while mechanically ventilated, and all neonates survived, subsequently testing negative for SARS-CoV-2. There was one spontaneous abortion. Four emergent cesarean deliveries were prompted by refractory maternal hypoxemia or non-reassuring fetal heart rate after maternal intubation.ConclusionsOverall, maternal and neonatal survival were favorable even in the setting of severe COVID-19 pneumonia requiring mechanical ventilation. Prone positioning was well tolerated although the impact of prone positioning or fetal delivery on maternal oxygenation and ventilation are unclear.     

Debate: Lessons learned in lockdown – a one-day remotely delivered training on low-intensity psychological interventions for common mental health conditions

The coronavirus pandemic has highlighted the need for remote technologies to be used in child and adolescent mental health services. With the UK being placed in lockdown one week before a scheduled ‘face-to-face’ low-intensity CBT training day due to COVID-19, there was a need for rapid adaptations to be made to the content, structure and format of a training day for practitioners in mental health services, to suit the online environment. The content covered the core areas of low-intensity CBT in children and adolescents. Findings showed that the one-day low-intensity training day increased knowledge and understanding in all key areas measured, and was positively received, providing further evidence for the effectiveness and acceptability of remote delivery. Given discussed benefits of remote delivery, as well as rapid developments in technologies helping to address some of the challenges raised, going forward, remote delivery could continue to be beneficial for increasing access to much needed evidence-based interventions.     

Continuous electroencephalography characteristics and acute symptomatic seizures in COVID-19 patients

ObjectiveAs concerns regarding neurological manifestations in COVID-19 (coronavirus disease 2019) patients increase, limited data exists on continuous electroencephalography (cEEG) findings in these patients. We present a retrospective cohort study of cEEG monitoring in COVID-19 patients to better explore this knowledge gap.MethodsAmong 22 COVID-19 patients, 19 underwent cEEGs, and 3 underwent routine EEGs (<1 h). Demographic and clinical variables, including comorbid conditions, discharge disposition, survival and cEEG findings, were collected.ResultscEEG was performed for evaluation of altered mental status (n = 17) or seizure-like events (n = 5). Five patients, including 2 with epilepsy, had epileptiform abnormalities on cEEG. Two patients had electrographic seizures without a prior epilepsy history. There were no acute neuroimaging findings. Periodic discharges were noted in one-third of patients and encephalopathic EEG findings were not associated with IV anesthetic use.ConclusionsInterictal epileptiform abnormalities in the absence of prior epilepsy history were rare. However, the discovery of asymptomatic seizures in two of twenty-two patients was higher than previously reported and is therefore of concern.SignificancecEEG monitoring in COVID-19 patients may aid in better understanding an epileptogenic potential of SARS-CoV2 infection. Nevertheless, larger studies utilizing cEEG are required to better examine acute epileptic risk in COVID-19 patients.     

Validation of randomized controlled trial-derived models for the prediction of postintervention outcomes in chronic limb-threatening ischemia

BackgroundChronic limb-threatening ischemia (CLTI) represents the most severe form of peripheral artery disease and has a large impact on quality of life, morbidity, and mortality. Interventions are aimed at improving tissue perfusion and averting amputation and secondary cardiovascular complications with an optimal risk-benefit ratio. Several prediction models regarding postprocedural outcomes in CLTI patients have been developed on the basis of randomized controlled trials to improve clinical decision-making. We aimed to determine model performance in predicting clinical outcomes in selected CLTI cohorts.MethodsThis study validated the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL), Finland National Vascular registry (FINNVASC), and Prevention of Infrainguinal Vein Graft Failure (PREVENT III) models in data sets from a peripheral artery disease registry study (Athero-Express) and two randomized controlled trials of CLTI in The Netherlands, Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-arterial Supplementation (JUVENTAS) and Percutaneous Transluminal Angioplasty and Drug-eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia (PADI). Receiver operating characteristic (ROC) curve analysis was used to calculate their predictive capacity. The primary outcome was amputation-free survival (AFS); secondary outcomes were all-cause mortality and amputation at 12 months after intervention.ResultsThe BASIL and PREVENT III models showed predictive values regarding postintervention mortality in the JUVENTAS cohort with an area under the ROC curve (AUC) of 81% and 70%, respectively. Prediction of AFS was poor to fair (AUC, 0.60-0.71) for all models in each population, with the highest predictive value of 71% for the BASIL model in the JUVENTAS population. The FINNVASC model showed the highest predictive value regarding amputation risk in the PADI population with AUC of 78% at 12 months.ConclusionsIn general, all models performed poor to fair in predicting mortality and amputation. Because the BASIL model performed best in predicting AFS, we propose use of the BASIL model to aid in the clinical decision-making process in CLTI. However, improvements in performance have to be made for any of these models to be of real additional value in clinical practice.