Caring Advanced Cancer Patients at Home During COVID-19 Outbreak: Burnout and Psychological Morbidity Among Palliative Care Professionals in Italy

ContextProviding palliative care (PC) at home for patients with advanced cancer has become essential during the COVID-19 emergency. Nevertheless, the home PC professionals (PCPs) faced a challenging situation because of increased number of discharged patients, reduced availability of health-care facilities, and physical/relational barriers between them and patients.ObjectivesThis study aimed to investigate the impact of COVID-19 pandemic on burnout and psychological morbidity among home PCPs in Italy.MethodsOne hundred and ninety-eight PC physicians and nurses working in home assistance in Italy were invited to participate. The results obtained by the investigation conducted during the COVID-19 emergency (COVID2020) were compared with data collected in 2016 in the same setting (BURNOUT2016). The questionnaires (socio-demographics, Maslach Burnout Inventory and General Health Questionnaire-12) were the same for both the surveys. The PCPs participating in COVID2020 survey (n = 145) were mostly the same (70%) who participated in the BURNOUT2016 study (n = 179).ResultsOne hundred and forty-five PCPs participated in the study (response rate 73.2%). During the COVID-19 emergency, home PCPs presented a lower burnout frequency (P < .001) and higher level of personal accomplishment than in 2016 (P = .047). Conversely, the risk for psychological morbidity was significantly higher during the pandemic (P < .001).ConclusionsIn the age of COVID-19, the awareness of being at the forefront of containing the pandemic along with the sense of responsibility toward their high-risk patients may arouse PCPs' psychological distress, but, on the other hand, this condition may improve their sense of professional satisfaction and personal accomplishment.     

Use of Point-of-Care Ultrasound for the Diagnosis of Ovarian Hyperstimulation Syndrome

BackgroundOvarian hyperstimulation syndrome (OHSS) occurs when ovaries are overstimulated and enlarged due to fertility treatments resulting in a shift of serum from the intravascular space to the third space, mainly the abdominal cavity. It is the most serious complication of ovarian hyperstimulation for assisted reproduction.Case ReportWe present the case of a 40-year-old woman who presented with abdominal bloating and nausea 2 weeks after undergoing in vitro fertilization (IVF); she was diagnosed by an outside radiology ultrasound as having a ruptured ovarian cyst. A point-of-care emergency ultrasound performed by the emergency physician made the diagnosis of ovarian hyperstimulation syndrome. This led to more expedient management and obstetrical consultation.Why Should an Emergency Physician Be Aware of This?Abdominal bloating and nausea are common presenting complaints in pregnant women. OHSS is a rare but potentially fatal complication of IVF. Recognition and early diagnosis by the emergency physician can lead to appropriate intervention and consultation.     

Aortic Arch Thrombus and Pulmonary Embolism in a COVID-19 Patient

BackgroundCoronavirus disease 2019 (COVID-19) is associated with endothelial inflammation and a hypercoagulable state resulting in both venous and arterial thromboembolic complications. We present a case of COVID-19-associated aortic thrombus in an otherwise healthy patient.Case ReportA 53-year-old woman with no past medical history presented with a 10-day history of dyspnea, fever, and cough. Her pulse oximetry on room air was 84%. She tested positive for severe acute respiratory syndrome coronavirus 2 infection, and chest radiography revealed moderate patchy bilateral airspace opacities. Serology markers for cytokine storm were significantly elevated, with a serum D-dimer level of 8180 ng/mL (normal < 230 ng/mL). Computed tomography of the chest with i.v. contrast was positive for bilateral ground-glass opacities, scattered filling defects within the bilateral segmental and subsegmental pulmonary arteries, and a large thrombus was present at the aortic arch. The patient was admitted to the intensive care unit and successfully treated with unfractionated heparin, alteplase 50 mg, and argatroban 2 μg/kg/min.Why Should an Emergency Physician Be Aware of This?Mural aortic thrombus is a rare but serious cause of distal embolism and is typically discovered during an evaluation of cryptogenic arterial embolization to the viscera or extremities. Patients with suspected hypercoagulable states, such as that encountered with COVID-19, should be screened for thromboembolism, and when identified, aggressively anticoagulated.     

Prehospital management of acute respiratory distress in suspected COVID-19 patients

BackgroundIn December 2019, coronavirus disease (COVID-19) emerged in China and became a world-wide pandemic in March 2020. Emergency services and intensive care units (ICUs) were faced with a novel disease with unknown clinical characteristics and presentations. Acute respiratory distress (ARD) was often the chief complaint for an EMS call. This retrospective study evaluated prehospital ARD management and identified factors associated with the need of prehospital mechanical ventilation (PMV) for suspected COVID-19 patients.MethodsWe included 256 consecutive patients with suspected COVID-19-related ARD that received prehospital care from a Paris Fire Brigade BLS or ALS team, from March 08 to April 18, 2020. We performed multivariate regression to identify factors predisposing to PMV.ResultsOf 256 patients (mean age 60 ± 18 years; 82 (32%) males), 77 (30%) had previous hypertension, 31 (12%) were obese, and 49 (19%) had diabetes mellitus. Nineteen patients (7%) required PMV. Logistic regression observed that a low initial pulse oximetry was associated with prehospital PMV (ORa = 0.86, 95%CI: 0.73–0.92; p = 0.004).ConclusionsThis study showed that pulse oximetry might be a valuable marker for rapidly determining suspected COVID-19-patients requiring prehospital mechanical ventilation. Nevertheless, the impact of prehospital mechanical ventilation on COVID-19 patients outcome require further investigations.     

Lung Ultrasound vs. Chest X-Ray Study for the Radiographic Diagnosis of COVID-19 Pneumonia in a High-Prevalence Population

BackgroundThe viral illness severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), more commonly known as Coronavirus 2019 (COVID-19), has become a global pandemic, infecting over 100 million individuals worldwide.ObjectivesThe objective of this study was to compare the test characteristics of point-of-care lung ultrasound (LUS) with chest x-ray study (CXR) at radiographically detecting COVID-19 pneumonia.MethodsThis was a single-center, prospective, observational study at an urban university hospital with > 105,000 patient visits annually. Patients ≥ 18 years old, who presented to the Emergency Department with predefined signs and symptoms of COVID-19, were eligible for enrollment. Each patient received an LUS using a portable, handheld ultrasound followed by a single-view, portable anteroposterior CXR. Patients with an abnormal LUS or CXR underwent a non-contrast-enhanced computed tomography scan (NCCT). The primary outcome was the radiographic diagnosis of COVID-19 pneumonia on NCCT.ResultsOne hundred ten patients underwent LUS, CXR, and NCCT; 99 LUS and 73 CXRs were interpreted as positive; 81 NCCTs were interpreted as positive, providing a prevalence of COVID-19 pneumonia of 75% (95% confidence interval [CI] 66–83.2) in our study population. LUS sensitivity was 97.6% (95% CI 91.6–99.7) vs. 69.9% (95% CI 58.8–79.5) for CXR. LUS specificity was 33.3% (95% CI 16.5–54) vs. 44.4% (95% CI 25.5–64.7) for CXR. LUS positive predictive value and negative predictive value were 81.8% (95% CI 72.8–88.9) and 81.8% (95% CI 48.2–97.7), respectively, vs. 79.5% (95% CI 68.4–88), and 32.4% (95% CI 18–49.8), respectively, for CXR.ConclusionLUS was more sensitive than CXR at radiographically identifying COVID-19 pneumonia.     

MitraClip-Associated Endocarditis: Emergency Department Diagnosis With Point of Care Ultrasound

BackgroundManagement of mitral valve regurgitation in patients with multiple comorbidities is complicated because of poor surgical candidacy. Less invasive techniques for these patients include the MitraClip device, an endovascular repair option used to reduce mitral valve regurgitation symptoms. However, complications include leaflet damage, stenosis, and infectious endocarditis.Case ReportFour years after MitraClip placement, an 80-year-old man presented to the emergency department with progressive dyspnea. He was diagnosed with MitraClip-associated infectious endocarditis by the emergency physician using point-of-care ultrasound. There are 6 reported cases of infective endocarditis in patients with MitraClip devices, with this being the first case identified using point-of-care ultrasound. This is also the first reported case of MitraClip-associated Corynebacterium endocarditis.Why Should an Emergency Physician Be Aware of This?The use of the MitraClip device and its echocardiographic appearance is not widely described in the published emergency medicine literature. Knowledge of this device, its appearance, and the potential complications is essential for emergency physicians caring for these patients. Rapid diagnosis may lead to earlier initiation of treatment and optimal disposition for these complex patients.     

Thymosin as a possible therapeutic drug for COVID-19: A case report

BACKGROUNDThere are no effective antiviral therapies for coronavirus disease 2019 (COVID-19) at present. Although most patients with COVID-19 have a mild or moderate course of disease, up to 5%-10% of patients may have a serious and potentially life-threatening condition, indicating an urgent need for effective therapeutic drugs. The therapeutic effect of thymosin on COVID-19 has not been previously studied. In this paper, for the first time we report a case of thymosin treatment of COVID-19.CASE SUMMARYA 51-year-old man with imported COVID-19 was admitted with definite symptoms of chest tightness, chest pain, and fatigue. The polymerase chain reaction results for severe acute respiratory syndrome coronavirus 2 were negative. The antibody test was positive, confirming the diagnosis of COVID-19. As many orally administered drugs were not well tolerated due to gastrointestinal symptoms, an emergency use of thymosin, a polypeptide consisting of 28 amino acids, was administered by injection. Finally, after the implementation of the treatment program, symptoms and lung imaging improved significantly.CONCLUSIONIn this case report, it is confirmed that thymosin may help alleviate the severity of COVID-19 symptoms.     

Functional Limitations in Individuals With Long COVID

ObjectivesTo examine the extent of long-term functional deficits experienced by individuals hospitalized for coronavirus disease 2019 (COVID-19). Specific objectives were to (1) describe changes in perceived global health, mobility, participation in daily activities, and employment status from pre-COVID-19 to ≥2 months after infection and (2) evaluate factors associated with change in function.DesignWe conducted a telephone survey (at least 2 months postinfection).SettingPopulation-based study of adults living at home.ParticipantsAdult residents in Laval, Quebec (n=121), who were discharged home posthospitalization for COVID-19.InterventionsNot applicable.Main Outcome MeasuresParticipants responded to a standard questionnaire (COVID-19 Yorkshire Rehabilitation Screen) regarding persistent symptoms and limitations in daily functioning. We calculated the prevalence of changes in perceived global health, mobility, personal care, participation in daily activities, and employment, and evaluated associated factors using bivariate analysis and multivariable logistic regression.ResultsAlmost all participants (94%) were more fatigued and reported deterioration of their global health status (90%) at least 3 months after infection. The majority were more short of breath and experienced pain and anxiety. The change in outcomes indicates a substantial reduction in those reporting “good” health status, mobility, personal care, and daily activities and less employment. Time since diagnosis was significantly associated with global health, mobility, and participation in daily activities.ConclusionsThis population-based study suggests that individuals hospitalized for COVID-19 infection have symptoms that affect daily functional activities many months after infection. It is imperative that the effect of infection be better understood so that those affected long term can receive the needed services.     

Prone Positioning of Patients With Coronavirus Disease 2019 Who Are Nonintubated in Hypoxic Respiratory Distress: Single-Site Retrospective Health Records Review

IntroductionIn March and April 2020 of the coronavirus disease 2019 pandemic, site clinical practice guidelines were implemented for prone positioning of patients with suspected coronavirus disease 2019 in hypoxic respiratory distress who are awake, alert, and spontaneously breathing. The purpose of this pandemic disaster practice improvement project was to measure changes in pulse oximetry associated with prone positioning of patients with coronavirus disease 2019 infection in adult acute respiratory distress or adult respiratory distress syndrome, who are awake, alert, spontaneously breathing, and nonintubated.MethodsA retrospective chart review of patients who were coronavirus disease 2019 positive in the emergency department from March 30, 2020 to April 30, 2020 was conducted for patients with a room air pulse oximetry <90% and a preprone position pulse oximetry ≤94% who tolerated prone positioning for at least 30 minutes. The primary outcome was the change in pulse oximetry associated with prone positioning, measured on room air, with supplemental oxygen, and approximately 30 minutes after initiating prone positioning. Median and mean differences were compared with the Wilcoxon signed-rank test and paired t-test.ResultsOf the 440 patients with coronavirus disease 2019, 31 met inclusion criteria. Median pulse oximetry increased as 83% (interquartile range, 75%-86%) on room air, 90% (interquartile range, 89%-93%) with supplemental oxygen, and 96% (interquartile range, 94%-98%) with prone positioning (z = -4.48, P < .001). A total of 45% (n = 14) were intubated during their hospital stay, and 26% (n = 8) of the included patients died.DiscussionIn patients with coronavirus disease 2019 who are awake, alert, and spontaneously breathing, an initially low pulse oximetry reading improved with prone positioning. Future studies are needed to determine the association of prone positioning with subsequent endotracheal intubation and mortality.     

Emergency Department Use by Young Adults With Chronic Illness Before and During the COVID-19 Pandemic

IntroductionThere was a significant decrease in emergency department encounters during the COVID-19 pandemic. Our large urban emergency department observed decreased encounters and admissions by youths with chronic health conditions. This study aimed to compare the frequency of emergency department encounters for certain young adults before the pandemic and during the COVID-19 pandemic.MethodsA retrospective cohort study using medical records of patients ages 20 to 26 years from October 2018 to September 2019 and February 2020 to February 2021. Files set for inclusion were those with a primary diagnosis of human immunodeficiency virus, diabetes mellitus, epilepsy, cerebral palsy, sickle cell disease, asthma, and certain psychiatric disorders for potentially preventable health events.ResultsWe included 1203 total encounters (853 before the pandemic and 350 during the pandemic), with the total number of subjects included in the study 568 (293 before the pandemic to 239 during the pandemic). During the pandemic, young adults with mental health conditions (53.1%) accounted for most encounters. Encounters requiring hospital admissions increased from 27.4% to 52.5% during the pandemic, primarily among patients with diabetes (41.8% vs 61.1%) and mental health conditions (50% vs 73.3%).DiscussionThe number of young adults with certain chronic health conditions decreased during COVID-19, with encounters for subjects with mental health conditions increasing significantly. The proportion of admissions increased during the pandemic with increases for subjects with mental health disorders and diabetes. The number of frequent users decreased during COVID-19. Future research is needed to understand better the causes for these disparities in young adults with chronic conditions who use the emergency department as a source of care.     

Association of Sleep Quality Status With Worsening Low Back or Knee Pain During The COVID-19 State of Emergency Among Old-Old Adults

BackgroundPoor sleep quality has a negative effect on pain among older adults. During the coronavirus disease 2019 (COVID-19) state of emergency, lifestyle changes can cause psychologic stressors and lead to poor sleep quality.AimThis study examined whether sleep quality status was associated with low back or knee pain changes during the COVID-19 state of emergency among community-dwelling Japanese old-old adults.DesignCross-sectional investigation.MethodsIn July 2020, during the COVID-19 epidemic, we conducted a postal survey for old-old adults aged ≥77 years and collected data on 597 participants. For those who had low back or knee pain at the time of the survey (in July), characteristics such as low back pain, knee pain, changes in pain status, and sleep quality status during the COVID-19 state of emergency (in March) were assessed.ResultsData from 597 participants showed the prevalence of low back pain (50.6%) and knee pain (40.7%) in July. Of those with low back or knee pain, 374 had pain changes during the state of emergency, with 12.3% worsening. Of these, 23.9% had poor sleep quality in March compared to non-change (p = .008). In a multivariate logistic regression model adjusted for potential confounders, poor sleep quality was significantly associated with pain worsening (odds ratio 2.80, 95% confidence interval 1.26-6.22).ConclusionsDuring the COVID-19 state of emergency, poor sleep quality was associated with worsening low back or knee pain. This may indicate the need to pay attention to poor sleep quality to prevent the exacerbation of pain among old-old adults.     

Intensive care nurse-led point of care ultrasound in the assessment and management of the critically ill COVID-19 patient: A single centre case series

Focused ultrasound can be used to rapidly diagnose COVID-19 disease, assess disease severity, and inform management of COVID-19 and associated pathologies, reducing radiation exposure from other imaging modalities and minimizing spread of infection. Ultrasound examinations performed by trained nurses in the intensive care unit (ICU) enable more patients to receive these assessments. This case series evaluates the use of nurse-led focused cardiac and lung ultrasound for clinical management of ICU patients with COVID-19. We describe common pathophysiological findings and how findings were used to inform clinical decision-making. An ultrasound trained ICU nurse performed Focused Ultrasound in Intensive Care (FUSIC) cardiac and lung scans enabling calculation of a lung severity score on adult ICU patients with a confirmed COVID-19 diagnosis in a single-centre setting. Fifteen scans were performed on 15 patients. Thirteen (87%) patients had normal left ventricular function; 12 (80%) normal right ventricular function. All 15 (100%) scans identified abnormal lung findings including irregular thickened pleura, B-lines, sub-pleural consolidation and hepatization. Worse lung severity scores were correlated with higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores (r = 0.70; p = .003). Of the 15 scans, 10 (67%) identified abnormal pathology contributing to a change in clinical management. This included targeted fluid removal (4, 27%), change in respiratory management (3, 20%) and need for formal echocardiographic assessment (3, 20%). Findings from five (33%) scans required no intervention. This case series demonstrates nurse-led ultrasound could be a useful adjunct in the management of the COVID-19 patient.     

Factors associated with anti-SARS-CoV-2 IgG antibody production in patients convalescing from COVID-19

IntroductionAmong patients with coronavirus disease 2019 (COVID-19), the factors that affect anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody production remain unclear. This study aimed to identify such factors among patients convalescing from COVID-19.MethodsThis study comprised patients who had been diagnosed with COVID-19 between January 1 and June 30, 2020 and gave consent for anti-SARS-CoV-2 spike protein antibody measurement using enzyme-linked immunosorbent assay during their acute and/or convalescent phases. Factors related to elevated antibody titers and the relationship between the days from disease onset and the development of antibody titers were assessed.ResultsA total of 84 participants enrolled in the study. Nineteen participants had antibody titers measured during the convalescent phase only, and 65 participants had antibody titers measured during the acute and convalescent phases. The antibody titers peaked in weeks 5 and 6. The stepwise multivariate log-normal analysis revealed that male sex (P = 0.04), diabetes mellitus (P = 0.03), and high C-reactive protein levels during the disease course (P < 0.001) were associated with elevated IgG antibodies. Glucocorticoid use was not associated with antibody titers.ConclusionThe study found that high values of maximum CRP levels during the acute phase, male sex, and diabetes mellitus were associated with elevated antibody titers. Antibody titers tended to be highest in the first 5 or 6 weeks after the onset of symptoms.     

Lung ultrasound monitoring in patients with COVID-19 on home isolation

Many patients with COVID-19, the clinical illness caused by SARS-CoV-2 infection, exhibit mild symptoms and do not require hospitalization. Instead, these patients are often referred for 14-days of home isolation as symptoms resolve. Lung ultrasound is well-established as an important means of evaluating lung pathology in patients in the emergency department and in intensive care units. Ultrasound is also being used to assess admitted patients with COVID-19. However, data on the progression of sonographic findings in patients with COVID-19 on home isolation is lacking. Here we present a case series of a group of physician patients with COVID-19 who monitored themselves daily while in home isolation using lung point-of-care ultrasound (POCUS). Lung POCUS findings corresponded with symptom onset and resolution in all 3 patients with confirmed COVID-19 during the 14-day isolation period. Lung POCUS may offer a feasible means of monitoring patients with COVID-19 who are on home isolation. Further studies correlating sonographic findings to disease progression and prognosis will be valuable.     

Successful use of mild therapeutic hypothermia as compassionate treatment for severe refractory hypoxemia in COVID-19

BackgroundCOVID-19 is a disease associated with an intense systemic inflammation that could induce severe acute respiratory distress syndrome (ARDS), with life-threatening hypoxia and hypercapnia. We present a case where mild therapeutic hypothermia was associated with improved gas exchange, facing other therapies' unavailability due to the pandemic.Case reportA healthy 38-year-old male admitted for COVID-19 pneumonia developed extreme hypoxia (PaO₂/FiO₂ ratio 42 mmHg), respiratory acidosis, and hyperthermia, refractory to usual treatment (mechanical ventilation, neuromuscular blockade, and prone position), and advanced therapies were not available. Mild therapeutic hypothermia management (target 33–34 °C) was maintained for five days, with progressive gas exchange improvement, which allowed his recovery over the following weeks. He was discharged home after 68 days without significant ICU associated morbidity.ConclusionsMild hypothermia is a widely available therapy, that given some specific characteristics of COVID-19, may be explored as adjunctive therapy for life-threatening ARDS, especially during a shortage of other rescue therapies.     

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

ContextHome care programs in Italy.ObjectivesThe aim of this study was to assess a protocol for palliative sedation (PS) performed at home.MethodsA total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam.ResultsA total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P = 0.012). The principal reasons to start PS were agitated delirium (n = 20) and dyspnea (n = 4). Mean duration of PS was 42.2 ± 30.4 hours, and the mean doses of midazolam were 23–58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively.ConclusionThis protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies.     

Emergency Nurse Consensus on Most Effective and Accessible Support Strategies During COVID-19: A Delphi Study

IntroductionEmergency nurses face significant risk for stress-related complications while working during the COVID-19 pandemic. However, there is limited empirical evidence on the effectiveness and accessibility of support strategies for nurses in this novel situation. Expert consensus may help fill this knowledge gap. Therefore, the study objective was to gain expert consensus from emergency nurses on the most effective and accessible strategies during the COVID-19 pandemic.MethodsThis 2-round Delphi study recruited an online expert panel from emergency nurses practicing during the COVID-19 pandemic within a single Mountain West health system spanning 9 urban and rural emergency departments. Over 10 weeks in the summer of 2021, participants completed 2 sequential surveys to rate and rank employee-led and employer-led support strategies collated from a literature review.ResultsOf 327 recruitment emails sent, 28 nurses joined the expert panel. Emergency nurses reached a consensus on preference for employee-led self-care activities, including enhancing social well-being and strengthening emotional well-being. None of the employer-led strategies reached group consensus regarding high effectiveness, accessibility, and the likelihood of participation. Additionally, emergency nurses favored in-person support strategies over other delivery methods.DiscussionNumerous studies have explored the impact of the COVID-19 pandemic on health care workers. Although experts and researchers seek to determine the best support strategies, this study highlights how emergency nurses wish to be supported. Employers can tailor support strategies for maximum effect by understanding health care worker perceptions and preferences.     

Antibody responses induced by the BNT162b2 mRNA COVID-19 vaccine in healthcare workers in a single community hospital in Japan

IntroductionThe effectiveness of several vaccines against coronavirus disease (COVID-19) has been reported in the real-world setting. However, it is still unknown how long antibodies persist following vaccination and whether or not the persistence of antibodies has a protective effect against COVID-19.MethodsHealthcare workers who had received two doses of the BNT162b2 mRNA COVID-19 vaccine were enrolled, and a single-center study was conducted at the National Hospital Organization Hakodate National Hospital. Serum samples from all participants were collected 13–21 weeks (median: 20 weeks) after the second dose of vaccination. The antibody titers were measured using an electrochemiluminescence immunoassay (Elecsys® Anti-SARS-CoV-2 S). Data on characteristics of the participants were gathered from patient records and interview sheets.ResultsA total of 401 participants, among whom 70.1% were women and the median age was 42 years, were evaluated in this study. None of the participants had a definite COVID-19 history, and all participants who received complete vaccination showed positive antibody titers. The antibody titer was observed to be higher in participants with younger age (p < 0.001) and those who were females (p = 0.028). Despite the higher risk of infection than that of the general public, no vaccinated staff developed breakthrough infections.ConclusionsThis study demonstrates the significant contribution of the BNT162b2 vaccine in the acquisition of anti-SARS-CoV-2S antibodies; therefore, the general population should benefit from these two vaccine doses, which are expected to be protective for at least five months.