Risks and benefits of animal-assisted interventions for critically ill patients admitted to intensive care units

Background Pets offer significant health benefits, from decreased cardiovascular risks to anxiety and post-traumatic stress improvements. Animal-assisted interventions (AAI) are not frequently practiced in the intensive care unit (ICU) for fear of health risk for critical patients because there is a hypothetical risk of zoonoses. Objectives This systematic review aimed to collect and summarize available evidence about AAI in the ICU. The Review questions were “Do AAI improve the clinical outcome of Critically Ill Patients admitted to ICUs?” and “Are the zoonotic infections the cause of negative prognosis?”. Methods The following databases were searched on 5 January 2023: Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, and PubMed. All controlled studies (randomized controlled, quasi-experimental, and observational studies) were included. The systematic review protocol has been registered on the International Prospective Register of Systematic Review (CRD42022344539). Results A total of 1302 papers were retrieved, 1262 after the duplicate remotion. Of these, only 34 were assessed for eligibility and only 6 were included in the qualitative synthesis. In all the studies included the dog was the animal used for the AAI with a total of 118 cases and 128 controls. Studies have high variability, and no one has used increased survival or zoonotic risk as outcomes. Conclusions The evidence on the effectiveness of AAIs in ICU settings is scarce and no data are available on their safety. AAIs use in the ICU must be considered experimental and follow the related regulation until further data will be available. Given the potential positive impact on patient-centered outcomes, a research effort for high-quality studies seems to be justified

Clinical Utility of a Structured Program to Reduce the Risk of Health-Related Quality of Life Impairment after Discharge from Intensive Care Unit: A Real-World Experience

Background. Postdischarge deterioration in health-related quality of life (HRQoL) is a major clinical issue for patients after an intensive care unit (ICU) hospitalization. A significant proportion of these patients is known to develop a progressive worsening of mental and physical performance—the so-called post-intensive care syndrome (PICS). Aim. We aimed at exploring the effects of a structured program for the management of ICU patients, aimed at improving postdischarge HRQoL and reducing the risk of PICS. Methods. A total of 159 patients hospitalized in our ICU with a length of stay >72 hours were enrolled in an institutional management protocol including specific recommendations: adequate sedation and analgesia protocols, to ensure a valid delirium prevention strategy, and to provide a planned midterm after discharge. The main endpoint was the occurrence of PICS at the 6-month follow-up visitation, defined as an abnormal physical or mental score in the SF-12 questionnaire in the presence of clinical evidence of new or worsening impairment in physical, cognitive, or mental health status. An additional questionnaire was administered, to assess the effects of ICU-related memories. Results. Most patients positively rated their health at the 6-month follow-up and had no significant impairment in physical or mental health status. The mean normalized values of the physical and mental component of the SF-12 score were 46 ± 11 and 48 ± 14, suggesting a normal physical and mental health status in most patients. Twenty-nine patients (18.2%) showed evidence of PICS. Similar good results were found by the questionnaire of memories. In multivariable analysis, no variable was found to predict the risk of PICS in our population. Conclusion. In this real-world analysis that lacks a control group, patients who used a program aimed at minimizing the risk of HRQoL deterioration and PICS reported a good perception of their state of health with a relatively low prevalence of PICS

Severe encephalopathy associated with reactivated human herpesvirus 6 in a six year-old immunocompetent child.

When a six year-old immunocompetent child affected by encephalitis was subjected to virological studies, human herpesvirus 6 variant B2 resulted to be the cause of illness. Laboratory diagnosis based on the finding of human herpesvirus 6 genome in the cerebrospinal fluid of the patient both at the beginning of the disease and on the occasion of a relapse which occurred forty days after the patient's hospital discharge. The presence of high-avidity IgG to human herpesvirus 6 detected in the patient's serum at the time of the first hospital admission proved that he had suffered from a past infection by human herpesvirus 6. In the consequence of this, the human herpesvirus 6 DNA finding in the patient's cerebrospinal fluid was to ascribed to virus reactivation. In the light of virological and serological results, the clinical case described underlines the ability of human herpesvirus 6 to cause neurological disorders not only during primary infections but also during infections supported by rescued virus

Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial

BackgroundTocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients.MethodsA multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival.ResultsIn the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6-24.0, P=0.52) and 22.4% (97.5% CI: 17.2-28.3, P<0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline.ConclusionsTocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline.Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092)

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease