The decline in air quality from wildfires is known to have detrimental health impacts locally, but less is known about the effects far from the source. To address this gap, we analyzed visits to the University of Virginia Emergency Department from 2017 to 2023 by examining the impact of elevated PM2.5 levels on respiratory visits. For this analysis, high exposure days were defined as those with PM2.5 levels 2 or more standard deviations above the 2017–2023 average, specifically during the summer of 2023 when the Québec wildfires plume was advected over central Virginia. The results showed higher odds ratios on high PM2.5 days compared to dates with normal exposure (1.190 [1.026,1.380]). This result was observed in males (1.388, [1.122,1.716]) and in white individuals (1.220 [1.009, 1.475]). Additionally, a comparison of mean ED visit departures (detrended and deseasoned) revealed that same day respiratory visits were significantly elevated on high exposure days (mean departure difference = + 1.886, p = 0.027). These findings indicate that wildfires can have measurable health impacts in areas far from their origin.

Many difficult-to-understand clinical features characterize COVID-19 and post-acute sequelae of COVID-19 (PASC or long COVID [LC]). These can include blood pressure instability, hyperinflammation, coagulopathies, and neuropsychiatric complaints. The pathogenesis of these features remains unclear. The SARS-CoV-2 Spike protein receptor-binding domain (RBD) binds angiotensin converting enzyme 2 (ACE2) on the surface of host cells to initiate infection. We hypothesized that some people convalescing from COVID-19 may produce anti-RBD antibodies that resemble ACE2 sufficiently to have ACE2-like catalytic activity, that is, they are ACE2-like proteolytic abzymes that may help mediate the pathogenesis of COVID-19 and LC. In previous work, we showed that some people with acute COVID-19 had immunoglobulin-associated ACE2-like proteolytic activity, suggesting that some people with COVID-19 indeed produced ACE2-like abzymes. However, it remained unknown whether ACE2-like abzymes were seen only in acute COVID-19 or whether ACE2-like abzymes could also be identified in people convalescing from COVID-19. Here, we show that some people convalescing from COVID-19 attending a clinic for people with persistent pulmonary symptoms also have ACE2-like abzymes and that the presence of ACE2-like catalytic activity correlates with alterations in blood pressure in an exercise test.IMPORTANCEPatients who have had COVID-19 can sometimes have troublesome symptoms, termed post-acute sequelae of COVID-19 (PASC) or long COVID (LC), which can include problems with blood pressure regulation, gastrointestinal problems, inflammation, blood clotting, and symptoms like "brain fog." The proximate causes for these problems are not known, which makes these problems difficult to treat definitively. We previously found that some acute COVID-19 patients make antibodies against SARS-CoV-2, the virus that causes COVID-19, that act like an enzyme, angiotensin converting enzyme 2 (ACE2). ACE2 normally helps regulate blood pressure and serves as the receptor for SARS-CoV-2 in the body. We show that patients convalescing from COVID-19 also make antibodies that act like ACE2 and that the presence of those antibodies correlates with problems in blood pressure regulation. The findings provide a new opening to potentially understanding the causes of LC, and so provide direction for the development of new treatments.

Sleep disturbances in “long COVID” are common, but the associations between the severity of sleep problems and the severity of COVID infection are unclear. We evaluated the prevalence, persistence, comorbidities, and clinical effects of insomnia following recovery from acute COVID-19 infection in a COVID-specific clinic. Inpatients discharged after COVID infection and outpatients referred for persistent post-COVID symptoms were surveyed on insomnia severity (Insomnia Severity Index), other neuropsychological symptoms, cardiopulmonary symptoms and physiological functions (6-minute walk distance and others), and functional outcome and quality of life. Multivariable regression models evaluated the severity of Insomnia Severity Index against independent variables. A total of 280 patients met criteria at the initial visit. The prevalence of significant insomnia at the initial visit was 50

The variable origins of persistent breathlessness after coronavirus disease 2019 (COVID-19) have hindered efforts to decipher the immunopathology of lung sequelae. Here we analyzed hundreds of cellular and molecular features in the context of discrete pulmonary phenotypes to define the systemic immune landscape of post-COVID lung disease. Cluster analysis of lung physiology measures highlighted two phenotypes of restrictive lung disease that differed according to their impaired diffusion and severity of fibrosis. Machine learning revealed marked CCR5+CD95+CD8+ T cell perturbations in milder lung disease but attenuated T cell responses hallmarked by elevated CXCL13 in more severe disease. Distinct sets of cells, mediators and autoantibodies distinguished each restrictive phenotype and differed from those of patients without substantial lung involvement. These differences were reflected in divergent T cell-based type 1 networks according to the severity of lung disease. Our findings, which provide an immunological basis for active lung injury versus advanced disease after COVID-19, might offer new targets for treatment.

Objective: We sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring venovenous extracorporeal membrane oxygenation. Methods: Six academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. Results: The cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1 % of patients who received extracorporeal membrane oxygenation and 27.4 % of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5 % of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non - extracorporeal membrane oxygenation cohorts strati fi ed by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7 % vs 24.4 % , P < .001), bleeding complications (77.1 % vs 53.8 % , P = .015), and worse survival independent of left ventricular dysfunction (39.6 % vs 64.1 % , P = .012). There was no signi fi cant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically signi fi cant differences in in -hospital outcomes. Conclusions: The presence of right ventricular dysfunction in patients with COVID-19 - related acute respiratory distress syndrome supported with venovenous extracorporeal membrane oxygenation was associated with increased in -hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality. (J Thorac Cardiovasc Surg 2024;167:1833-41)

Williams, Abigail; Davis, Claire; Bjoring, Margot; Blevins, Cheri; Enfield, Kyle; Barros, Andrew Author Information

Background:Cognitive overload is prevalent among intensive care unit (ICU) clinicians. Data visualization may decrease cognitive load by assisting with data interpretation and task prioritization. We developed the Bundle Board to display real-time data from the electronic medical record (EMR), highlighting opportunities for action in standardized ICU patient care. This study evaluates the practical usability of this data visualization tool among nurses in the ICU. Methods:The tool is offered as an application separate from the EMR and was available in the medical ICU for eight months before we surveyed unit nursing staff. To evaluate usability of the tool, we adapted the Health-Information Technology Usability Scale (Health-ITUES) and included an option to provide open-ended feedback. Survey data was analyzed using quantitative and qualitative methods. Results:ICU nurses were invited to participate through email and verbal announcements. Of the potential participants, 38% (N=47) responded. The survey demonstrated that the tool was perceived as usable. For each subscale, mean scores were as follows: Perceived Ease of Use 4.40, Impact 4.14, User Control 4.07, and Perceived Usefulness 3.61. There were no significant differences between core and contracted nurses or after stratifying by duration of Bundle Board use. Fifteen respondents completed the optional free-text portion of the survey. Qualitative analysis revealed six subthemes focusing on perceived impacts on quality and safety, cognitive burden and workload, and emotional impact of the Bundle Board. Conclusions:The Bundle Board demonstrated good usability among ICU Nurses, who provided substantive feedback for its improvement. These observations may be generalizable to other comparable interventions. Iterative feedback from end-users is vital to developing and implementing a digital health intervention. Our study provides a framework for performing a usability analysis within a specific clinician population and environment.

Background Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon. Objectives We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection. Methods We developed and implemented a data visualization tool called the “Bundle Board” to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release. Results After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027). Conclusion We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.

Digital twin technology has been increasingly applied in healthcare and patient well-being in recent years. This paper provides an overview of the current methods and applications of digital twins in the healthcare field. One such application is digital twins in precision healthcare, where digital twins are used to create patient-specific models to assist in diagnosis and treatment planning. Digital twins are also used in hospital/clinic management, where they help to optimize resource allocation and workflow processes. In response to the COVID-19 pandemic, digital twins have been utilized to detect outbreaks and predict disease spread. In addition, digital twins have been applied in bio-manufacturing and pharmaceutical industry to improve manufacturing processes. Another application area is machine learning and modeling, where digital twins are used in machine learning, data generation, and system modeling for applications in healthcare and disease prediction. Security and ethical issues related to digital twins are also discussed in this paper, as privacy concerns and data protection remain important considerations in the application of digital twin technology in healthcare. Finally, the paper concludes by discussing the future challenges and directions of future work in this field. These include the need to develop more accurate and sophisticated digital twin models, addressing interoperability and integration issues, and further exploring the potential of digital twin technology in emerging areas such as telemedicine and personalized medicine.

OBJECTIVE:We summarize the existing data on the occurrence of physical, emotional, and cognitive dysfunction associated with postintensive care syndrome (PICS) in adult survivors of venoarterial extracorporeal membrane oxygenation (VA-ECMO). DATA SOURCES:MEDLINE, Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched. STUDY SELECTION:Peer-reviewed studies of adults receiving VA-ECMO for any reason with at least one measure of health-related quality of life outcomes or PICS at long-term follow-up of at least 6 months were included. DATA EXTRACTION:The participant demographics and baseline characteristics, in-hospital outcomes, long-term health outcomes, quality of life outcome measures, and prevalence of PICS were extracted. DATA SYNTHESIS:Twenty-seven studies met inclusion criteria encompassing 3,271 patients who were treated with VA-ECMO. The studies were limited to single- or two-center studies. Outcomes variables and follow-up time points evaluated were widely heterogeneous which limits comprehensive analysis of PICS after VA-ECMO. In general, the longer-term PICS-related outcomes of survivors of VA-ECMO were worse than the general population, and approaching that of patients with chronic disease. Available studies identified high rates of abnormal 6-minute walk distance, depression, anxiety, and posttraumatic stress disorder that persisted for years. Half or fewer survivors return to work years after discharge. Only 2 of 27 studies examined cognitive outcomes and no studies evaluated cognitive dysfunction within the first year of recovery. No studies evaluated the impact of targeted interventions on these outcomes. CONCLUSIONS:Survivors of VA-ECMO represent a population of critically ill patients at high risk for deficits in physical, emotional, and cognitive function related to PICS. This systematic review highlights the alarming reality that PICS and in particular, neurocognitive outcomes, in survivors of VA-ECMO are understudied, underrecognized, and thus likely undertreated. These results underscore the imperative that we look beyond survival to focus on understanding the burden of survivorship with the goal of optimizing recovery and outcomes after these life-saving interventions. Future prospective, multicenter, longitudinal studies in recovery after VA-ECMO are justified.

Introduction: Despite the extensive use of vasopressors in critically ill patients, clinical guidelines surrounding use and discontinuation of vasopressors are based on sparse evidence. There is no literature guiding clinicians on the risk for recurrent hypoperfusion after discontinuation of vasopressors. Our goal was to describe frequency and timing for vasopressor re-initiation, among patients whose vasopressors were discontinued, across a cohort of patients in an intensive care unit (ICU). Methods: We extracted data from the eICU Collaborative Research Database. Patients were included if they received vasopressors (norepinephrine, epinephrine, phenylephrine, vasopressin, and dopamine) for less than 7 days, did not have code status change within 3 hours of discontinuation, had at least 4 hours of ICU follow-up time after discontinuation, and had an ICU length of stay greater than 8 hours. We performed a time to event analysis to identify the length of time until a vasopressor was re-started while accounting for competing risks. Results: The analysis cohort included 19,576 infusion episodes from 14,442 patients across 137 U.S. hospitals; 11 hospitals were academic medical centers. The most common vasopressor used was norepinephrine (78.5%) followed by phenylephrine (23.5%), vasopressin (16.2%), dopamine (15.4%), and epinephrine (10.7%) but 32.5% of episodes involved multiple vasopressors. Vasopressors were re-initiated in 4,855 (24.8%) of episodes. After controlling for center, shorter duration of vasopressor therapy (HR 1.22 for 10-hour duration versus 20-hour duration) and treatment with multiple vasopressors (HR 2.07) was associated with increased hazard of vasopressor re-initiation. When evaluating centers with at least 100 infusion episodes, 10% of all centers’ episodes has vasopressor re-initiation at median 12.5 hours. There was substantial variation across hospitals (IQR 7-27 hours). Conclusions: This is the first description of timing for vasopressor re-initiation. We demonstrate hospital-level variation in vasopressor re-initiation among patients admitted to an ICU. Prospective studies should identify hospital-level and patient care factors that contribute to successful vasopressor discontinuation.

OBJECTIVE: To investigate temporal trends and outcomes associated with early antibiotic prescribing in patients hospitalized with COVID-19. DESIGN: Retrospective propensity-matched cohort study using the National COVID Cohort Collaborative (N3C) database. SETTING: Sixty-six health systems throughout the United States that were contributing to the N3C database. Centers that had fewer than 500 admissions in their dataset were excluded. PATIENTS: Patients hospitalized with COVID-19 were included. Patients were defined to have early antibiotic use if they received at least 3 calendar days of intravenous antibiotics within the first 5 days of admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 322,867 qualifying first hospitalizations, 43,089 patients received early empiric antibiotics. Antibiotic use declined across all centers in the data collection period, from March 2020 (23%) to June 2022 (9.6%). Average rates of early empiric antibiotic use (EEAU) also varied significantly between centers (deviance explained 7.33% vs 20.0%, p < 0.001). Antibiotic use decreased slightly by day 2 of hospitalization and was significantly reduced by day 5. Mechanical ventilation before day 2 (odds ratio [OR] 3.57; 95% CI, 3.42–3.72), extracorporeal membrane oxygenation before day 2 (OR 2.14; 95% CI, 1.75–2.61), and early vasopressor use (OR 1.85; 95% CI, 1.78–1.93) but not region of residence was associated with EEAU. After propensity matching, EEAU was associated with an increased risk for in-hospital mortality (OR 1.27; 95% CI, 1.23–1.33), prolonged mechanical ventilation (OR 1.65; 95% CI, 1.50–1.82), late broad-spectrum antibiotic exposure (OR 3.24; 95% CI, 2.99–3.52), and late Clostridium difficile infection (OR 1.60; 95% CI, 1.37–1.87). CONCLUSIONS: Although treatment of COVID-19 patients with empiric antibiotics has declined during the pandemic, the frequency of use remains high. There is significant inter-center variation in antibiotic prescribing practices and evidence of potential harm. Our findings are hypothesis-generating and future work should prospectively compare outcomes and adverse events.

Introduction: The appropriate use of empiric antibiotics for patients with severe COVID-19 presents a clinical challenge. Bacterial coinfection can be difficult to exclude, sometimes resulting in empiric antibiotic therapy. However, antibiotics alter the respiratory tract microbiome and these changes in the lung microbiome have been associated with prolonged ARDS in COVID-19. We hypothesized that early antibiotic use increase the risk of prolonged mechanical ventilation in patients hospitalized with COVID-19. Methods: We used the National Covid Cohort Collaborative (N3C) to identify a retrospective cohort of patients admitted between March 2020 and May 2022 with a positive COVID-19 PCR or antigen test 15 days prior or within 48 hours of admission. We collected demographics, Charlson comorbidity index, month of hospitalization, antibiotics received, surgical procedures, details of mechanical ventilation, and diagnoses. We defined early empiric antibiotic use (EEAU) as administration of IV antibiotics for at least three calendar days before the sixth hospital day. Prolonged mechanical ventilation was defined as 14 consecutive days of mechanical ventilation. Our primary analysis used logistic regression after propensity score matching (PSM) with multiple imputation via chained equations for missing data. Sensitivity analyses included varying the required days of antibiotic exposure, using PSM with complete cases only, and using inverse probability of treatment weighting. Results: Our final cohort included 283,314 admissions. Prolonged mechanical ventilation and EEAU was observed in 1.4% and 13.9% of cases, respectively. In the unadjusted cohort, patients who received EEAU were more likely to be older, obese, and have more comorbidities. These patients were also more likely to have had mechanical ventilation, ECMO, major surgery, or a traumatic diagnosis during the first days of their hospitalization. After PSM, the standardized mean difference for all variables was less than 0.05. Early antibiotic use was associated with an increased risk of prolonged mechanical ventilation (OR 1.86, 95% CI 1.71 – 2.03). This finding was robust to all approaches in our sensitivity analysis. Conclusions: In our retrospective cohort, EEAU is independently associated with increased risk of prolonged mechanical ventilation.

Neuropsychological symptoms associated with post-COVID-19 conditions may prevent patients from resuming normal activities at home or work. We report a retrospective, cross-sectional evaluation of neuropsychological and cardiopulmonary outcomes in 2 groups of patients: outpatients with mild enough infection to be spared from hospitalization and those who required inpatient admission. We hypothesized a dose-response model of post-COVID symptom severity in which persistent consequences would be more severe in those who experienced worse acute infections. In a dedicated COVID clinic, 321 patients were seen (33% outpatient, 67% inpatient). Outpatients skewed female, White, non-Hispanic, and younger. Outpatients had worse insomnia (measured with insomnia severity index) and were less able to resume their usual activities (EQ-5D-5L usual activities scale), despite inpatients experiencing worse cognition (Montreal Cognitive Assessment), having greater obesity (body mass index), decreased exercise tolerance (6-minute-walk distance), and more exertional oxygen desaturation. In both groups, insomnia worsened while cognition improved significantly with time from infection to testing while controlling for patient age; other variables did not. In logistic regression, female sex, higher MoCA score, EQ-5D-5L "usual activities" subscore, less oxygen desaturation with exertion, and longer time from infection remained as significant associations with outpatient status. Our study demonstrated that the functional sequelae of post-COVID-19 conditions in patients with mild acute disease have the potential to be as severe as that in patients who have recovered from severe illness.

This article reviews the epidemiology and management of in-hospital cardiac arrest.

Catecholamine-resistant postoperative vasoplegic syndrome (PVS) lacks effective treatment modalities. Synthetic angiotensin II was recently approved for the treatment of vasodilatory shock; however, its use in PVS is not well described. We report outcomes in six patients receiving angiotensin II for the treatment of isolated PVS. All patients achieved their MAP goal and the majority showed improvement in lactate and background catecholamine dose; however, variables of perfusion changed discordantly. Three of six patients survived to hospital discharge.