Neurologic manifestations of COVID-19 in a diverse population in chicago, Illinois

Objective: NA Background: We aimed to further characterize the neurologic manifestations observed in patients hospitalized with Coronavirus disease 2019 (COVID-19), particularly ischemic stroke in a diverse population. Design/Methods: We retrospectively reviewed data records of 50 patients with COVID-19 (48% African American and 24% Latino) who were evaluated by the neurology services in 2020. Patients were categorized into 2 groups based on timing of developing neurological manifestations: the "Neuro first" group had neurological manifestations upon initial assessment, and the "COVID first" group developed neurological symptoms greater than 24 hours after hospitalization. The demographics, comorbidities, disease severity and neurological symptoms of both groups were analyzed. Statistical analysis was performed to compare the two groups. We further analyzed acute ischemic stroke patients by comparing with historic patients with AIS without COVID-19 admitted in the same time frame in 2019 and 2020. Results: Most common neurological manifestations observed were encephalopathy (n = 30), cerebrovascular disease (n = 20), cognitive impairment (n = 13), seizures (n = 13), hypoxic brain injury (n = 7), dysgeusia (n = 5), and extraocular movement abnormalities (n = 5). The "COVID- 19 first" group had more severe/critical disease course (83.3% vs 53.8%, p 0.025). Out of 13 patients with AIS and COVID-19, Latinos and African Americans compromised the majority of our cohort (76.8%). Most strokes were cortical (84.6%) and more than 50% had no identifiable source. COVID-19 was associated with discharge to mRS>2 (p 0.046, OR 3.82, CI 1.02-14.3). Conclusions: Neurologic manifestations of COVID-19 are highly variable and can occur prior to the diagnosis of or as a complication of the viral infection. The COVID-19 patients who developed neurologic symptoms later in hospitalization had more severe disease courses. We noted a high percentage of African American and Latino individuals in both groups. Concurrent AIS and COVID-19 was associated with worse outcomes.

Admission serum ferritin levels and effect of methylprednisolone in nonintubated patients with severe COVID-19 pneumonia

Rationale: Systemic corticosteroids control the inflammatory overresponse to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in coronavirus disease 2019 (COVID- 19). Ferritin, an acute phase reactant which can also protect the host cell from oxidative stress and has in previous studies increased the cell tolerability to infection and sepsis, could be a marker of response to corticosteroids. We sought to examine whether response to methylprednisolone differed according to admission ferritin levels in severe COVID-19. Methods: Retrospective cohort study of consecutive adults with severe COVID-19 pneumonia on high-flow oxygen (FiO2 ≥50%) admitted to an academic center from March 1 to April 15, 2020, i.e., before incorporation of corticosteroids in the guidelines for severe COVID-19. We used inverse probability of treatment weights to balance patient characteristics according to methylprednisolone use and Cox proportional hazards models to examine for significant interaction of admission serum ferritin levels with methylprednisolone for outcomes. The outcomes of interest were mortality and the composite of death or mechanical ventilation. Results: Ferritin was available in 380 of 447 (85.0%) patients (age, 60±17 years;34.2% female;13.4% Black;34.5% Hispanic;body mass index, 30.4±6.4 kg/m2;O2 saturation, 89±7%;respiratory rate, 24±8 breaths/min). Of these, 142/380 (37.4%) received methylprednisolone (median dose, 160mg/day). Ferritin did not differ between patients who received methylprednisolone vs. those who did not (median [25th-75th percentile], 992 μg/L [509, 1610] vs. 893 μg/L [474, 1467];P=0.32). Patients with elevated (>1000 μg/L) ferritin had higher procalcitonin, creatinine, and transaminase, but lower Creactive protein on admission. At 28 days, 80 patients (21.1%) had died and 102 (26.8%) were intubated. Ferritin was not associated with mortality or the composite endpoint. However, in weighted analyses, methylprednisolone use was associated with significantly lower mortality in patients with ferritin >1000 μg/L (HR 0.29;95%CI 0.12-0.67;P=0.004) and significantly higher mortality in patients with ferritin ≤1000 μg/L (HR 2.88;95%CI 1.59-5.20;P<0.001);P<0.001 for interaction (Figure 1A). The composite endpoint rates were lower with methylprednisolone in patients with ferritin >1000 μg/L (HR 0.47;95%CI 0.30-0.74;P=0.001) but not in patients with ferritin ≤1000 μg/L (HR 1.09;95%CI 0.72-1.63;P=0.69);P=0.006 for interaction (Figure 1B). Conclusions: In nonintubated patients with severe COVID-19, methylprednisolone use was associated with reduced mortality and intubation only in patients with elevated admission ferritin levels. In contrast, there was a strong signal for higher mortality with methylprednisolone in patients with low baseline ferritin. These findings need prospective validation.

Characteristics of a diverse cohort of stroke patients with sars-cov-2 and outcome by sex

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. We describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease, and investigate the role of sex on outcome. Methods: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers from Chicago metropolitan area. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. Results: The study included 83 patients. Median age was 64 years and the majority were Blacks (47%) followed by Hispanics (28%) and whites (16%). Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Higher proportions of male experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%;p=0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%).Compared to female, males had higher mortality (38% vs. 13%;p=0.02) and were less likely to bedischarged home (12% vs. 33%;p=0.04). After adjustment for age, race/ethnicity, and number ofVRFs, mRS was higher in males than in females (OR=1.47, 95% CI=1.03-2.09) Conclusion: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence ofcoronavirus infection on admission and preexisting VRFs. Severe in-hospital complications andworse outcomes after ischemic strokes were higher in males, than females.

Incidence of hospital-acquired and ventilator-associated pneumonia in patients with severe covid 19 on high flow oxygen

Background: Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) can be serious complications of coronavirus disease 19 (COVID-19). Co-infections may worsen outcomes and prolong hospitalization. This risk may be exacerbated by systemic corticosteroids (steroids) and other adjunctive therapies. Methods: We reviewed the records of all adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with severe COVID-19 pneumonia, requiring high-flow O2 (non-rebreather mask, Venturi mask with FiO2 >50%, or high-flow nasal cannula). We excluded patients who received mechanical ventilation (MV) or died within 24h. Patients were followed until death or hospital discharge. We reviewed positive sputum cultures (PSC) for pathogenic microorganisms and calculated the incidence of HAP and VAP (nosocomial pneumonia, [NP]), rates of MV and impact on mortality. Fungi isolated from sputum, were considered colonization unless associated with fungemia. We also examined the impact of adjunctive therapies with immunosuppressive potential (steroids and tocilizumab), on HAP or VAP. Results: A total of 469 patients were included (Table 1). Of these, 199 (42.4%) required intensive care and 172 (36.7%) MV. Median length of stay was 13 days (8-22) and 105 (22.4%) had PSC. Of these, 59 were considered true pathogens (HAP: 11, VAP: 48), with predominance of S. aureus (MSSA) 38.9%, Enterobacteriaceae 33.8% and Pseudomonas species 18.6%. 39 isolates were considered colonization (Table 2);Patients with PSC < 48h (N=7) from admission, were not considered NP. The incidence of NP was 7.0 per 1000 patient-days (95%CI 5.5-8.5). Of 11 patients with HAP, 9 needed MV. NP was more frequent among patients receiving steroids (9.0 vs 5.7 per 1000 patient-days;P=0.023). Use of tocilizumab was not associated with NP (6.2 vs 8.4 per 1000 patient-days;P=0.11). Mortality was nonsignificantly higher in patients with (20/59, 33.9%) vs. without (103/410, 25.1%) NP (P=0.16). Intubation and length of stay were the strongest predictors of NP in multivariable models. Cohort Characteristics of Patients with Severe COVID -19 Pneumonia on High Flow Oxygen (N= 469) Conclusion: Among high risk COVID-19 patients, NP is a common complication. MSSA and Enterobacteriaceae were the most frequent isolates. The risk increases with intubation, longer hospital stay and use of steroids but not tocilizumab.

Effect of early administration of systemic corticosteroids on outcomes in patients with COVID-19 pneumonia

Background: Systemic corticosteroids (steroids) have been empirically used in acute respiratory distress syndrome, an entity also present in coronavirus disease 19 (COVID-19). Early steroids administration could accelerate resolution of symptoms and reduce intensive care unit (ICU) stay in these patients, but practice varies widely as evidence is scant. Methods: We reviewed the records of 498 adults admitted to Stony Brook University Hospital, NY, from 3/1 to 4/15, 2020 with COVID-19 requiring high-flow O2 (non-rebreather mask, Venturi mask with FiO2 >50%, or high-flow nasal cannula). We excluded those (N=29) who received mechanical ventilation (MV) or died within 24h of admission. We followed patients until death or discharge. We compared outcomes between patients who received early steroids (i.e. prior to MV) and those who did not. We used adjusted Cox models to evaluate the composite of death or need for MV. We also evaluated healthcare resources utilization. Results: Of 469 patients, 175 (37.3%) received steroids while on high flow O2. Table 1 summarizes the baseline characteristics. Patients who received steroids were more likely to have asthma, had slightly longer duration of symptoms, lower O2 saturation, higher NT-proBNP and lower IL-6 levels at baseline. In total, 228 patients (48.6%) reached the composite endpoint (123 died and 105 received MV). By 7 days, 32.5% of patients who received steroids died or were intubated vs. 44.8% of those who did not (log-rank P=0.008), Figure 1. In models adjusted for race, age, sex, comorbidities, baseline O2 saturation and procalcitonin, steroids reduced risk for death or MV by 44% (hazard ratio [HR] 0.56;95%CI 0.42-0.76;P< 0.001). The effect was time-dependent with initial HR 0.34 (95%CI 0.21-0.56;P< 0.001) and daily attenuation by 10.2% (95%CI 1.7%-19.4%;P=0.017). Mortality at 7 and 14 days did not differ between groups (8.1% vs. 8.3% and 19.1% vs. 21.0%, respectively, log-rank P=0.75). Among discharged patients, length of hospital stay was longer, but ICU stay was shorter with steroids, Table 2. Conclusion: Early administration of steroids reduced primarily the need for MV in our high-risk COVID-19 patients, with shorter ICU utilization, at the expense of longer hospital stay. Further studies are needed to optimize the use of steroids in these patients. (Table Presented).

Incidence of bloodstream infections and outcomes in patients with severe COVID-19 pneumonia

Background: Coronavirus disease 19 (COVID-19) leading to acute respiratory distress syndrome is associated with need for intensive care (IC), mechanical ventilation (MV), and prolonged recovery. These patients are thus predisposed to blood stream infections which can worsen outcomes. This risk may be aggravated by adjunctive therapies. Methods: We reviewed the medical records of all adults admitted to Stony Brook University Hospital, NY, from March 1 to April 15, 2020 with severe COVID- 19 pneumonia (requiring high-flow O2). Patients who received MV or died within 24h were excluded. Patients were followed until death or hospital discharge. We reviewed positive blood cultures (PBC) for pathogenic microorganisms, and calculated the incidence of bacteremia, rates of infective endocarditis (IE), and impact on mortality. Microbes isolated only once and belonging to groups defined as commensal skin microbiota were labelled as contaminants. We also examined the impact of adjunctive therapies with immunosuppressive potential (steroids and tocilizumab), on bacteremia. Results: A total of 469 patients with severe COVID-19 pneumonia were included (Table 1). Of these, 199 (42.4%) required IC and 172 (36.7%) MV. Median length of stay was 13 days (8-22) and 94 (20.0%) had PBC. Of these, 43 were considered true pathogens (bacteremia), with predominance of E. faecalis and S. epidermidis, and 51 were considered contaminants (Table 2). The incidence of bacteremia (43/469, 9.2%) was 5.1 per 1000 patient-days (95%CI 3.8-6.4). An echocardiogram was performed in 21 patients, 1 had an aortic valve vegetation (IE) by methicillin sensitive S. aureus. Bacteremia rates were nonsignificantly higher with steroids (5.9 vs 3.7 per 1000 patient-days;P=0.057). Use of tocilizumab was not associated with bacteremia (5.8 vs 4.8 per 1000 patient-days;P=0.28). Mortality was nonsignificantly higher in patients with (15/43, 34.9%) vs. without (108/426, 25.4%) bacteremia (P=0.20). Length of stay was the strongest predictor of bacteremia, with risk increasing by 7% (95%CI 6%-9%, P< 0.001) per additional day. Conclusion: The incidence of bacteremia was relatively low and IE was uncommon in this study of severe COVID-19 patients. Risk of bacteremia increased with longer hospital stay and with steroids use, but not with tocilizumab. (Table Presented).

Characteristics of a Diverse Cohort of Stroke Patients with SARS-CoV-2 and Outcome by Sex.

BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection is associated with stroke. The role of sex on stroke outcome has not been investigated. To objective of this paper is to describe the characteristics of a diverse cohort of acute stroke patients with COVID-19 disease and determine the role of sex on outcome. METHODS: This is a retrospective study of patients with acute stroke and SARS-CoV-2 infection admitted between March 15 to May 15, 2020 to one of the six participating comprehensive stroke centers. Baseline characteristics, stroke subtype, workup, treatment and outcome are presented as total number and percentage or median and interquartile range. Outcome at discharge was determined by the modified Rankin Scale Score (mRS). Variables and outcomes were compared for males and females using univariate and multivariate analysis. RESULTS: The study included 83 patients, 47% of which were Black, 28% Hispanics/Latinos, and 16% whites. Median age was 64 years. Approximately 89% had at least one preexisting vascular risk factor (VRF). The most common complications were respiratory failure (59%) and septic shock (34%). Compared with females, a higher proportion of males experienced severe SARS-CoV-2 symptoms requiring ICU hospitalization (73% vs. 49%; p = 0.04). When divided by stroke subtype, there were 77% ischemic, 19% intracerebral hemorrhage and 3% subarachnoid hemorrhage. The most common ischemic stroke etiologies were cryptogenic (39%) and cardioembolic (27%). Compared with females, males had higher mortality (38% vs. 13%; p = 0.02) and were less likely to be discharged home (12% vs. 33%; p = 0.04). After adjustment for age, race/ethnicity, and number of VRFs, mRS was higher in males than in females (OR = 1.47, 95% CI = 1.03-2.09). CONCLUSION: In this cohort of SARS-CoV-2 stroke patients, most had clinical evidence of coronavirus infection on admission and preexisting VRFs. Severe in-hospital complications and worse outcomes after ischemic strokes were higher in males, than females.