Journal Article Annotations
2020, 2nd Quarter
Annotations by O. Joseph Bienvenu, MD, PhD and Jordan H. Rosen, MD
PUBLICATION #1 — Critical Care
The authors of this succinct report are a multidisciplinary group of French neuroradiologists, neurologists, intensivists, and infectious disease specialists. They screened 190 consecutive COVID-19-affected patients with neurologic symptoms who had brain MRIs and included 37 patients with confirmed brain MRI parenchymal signal abnormalities – not those with normal MRIs, ischemic infarcts, thrombi, or chronic lesions. The study partially addresses the nature of the apparent encephalitis in patients with severe COVID-19 infections, and the representative images are striking. The results are by no means definitive but favor an autoimmune phenomenon, as opposed to viral replication in glial and neuronal cells, as the cause of the clinical encephalopathy. As the authors note, though, a post-hypoxic leukoencephalopathy could also be a mechanism, as many of the patients had acute respiratory distress syndrome.
Strength and weaknesses
Strengths include the use of a variety of clinical and laboratory data to correlate with MRI findings. MRIs were apparently conducted as part of routine clinical care, and there is no data on the clinical or other laboratory findings in patients who had normal MRIs, ischemic infarcts, or venous thrombi.
The findings add to our growing knowledge base regarding how COVID-19 affects the brain.
Type of study
While previous studies have shown that delirium and severity are independently correlated with morbidity and mortality, this secondary analysis looked at a combination of the two factors and described five distinct delirium trajectories over time that predicted 30-day mortality. It also found independent risk factors for worse trajectories.
Strength and weaknesses: This is a secondary analysis 531 patients in a multi-site study using CAM-ICU and CAM-ICU7 for delirium and severity, respectively. It uses sophisticated statistical techniques to look trajectories for delirium as opposed to a more static view of psychomotor subtypes. The patients were all being treated in critical care units which decreases generalizability.
This study offers a novel way to subtype delirium in critical care settings which may allow us to both identify and target higher risk individuals for earlier intervention. Utilizing trajectories for a dynamic condition such as delirium is thoughtful. Assessment of interventions and biomarkers in specific trajectories may also lead to cleaner data in future studies.
Type of study
Secondary Analysis of a prospective cohort study
This is a “how-to” paper (described as “empirically grounded clinical guidance”). It does not present results of a study. The authors clearly have clinical experience treating critical illness survivors with PTSD phenomena. It is exciting to see well-established cognitive-behavioral therapists writing about treatment of a syndrome increasingly recognized in the critical care outcomes literature. The information provided should be of use to any mental health clinician who takes care of patients who have been critically ill. The paper also serves as a nice introduction to the phenomenology of post-ICU PTSD – i.e., what it is that survivors are frightened about and try to avoid.
Type of study
Empirically grounded clinical guidance