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Introduction: We report a case of a 67 year old lady with an acute drop in conscious level whilst on a transatlantic flight. She had a background history of TII DM and recent mild COVID. Past surgical history of a gastric bypass, at which time a CXR had incidentally shown a bulla, with no underlying respiratory symptoms, or history of COPD. Method(s): On arrival in the emergency department, her GCS was 7/15, and she required immediate intubation. Non-contrast CT head showed multiple tiny gas locules in keeping with air emboli. CT Chest, Abdo, Pelvis showed an 88mm bulla within the left lung lingula with a bronchus and many large pulmonary vessels running on its edge. Result(s): It was thought the change in air pressure during the flight caused a communication to open between the bulla and the pulmonary circulation resulting in the release of air emboli. Conclusion(s): She required ITU admission for 8 days. After initial stabilisation she was stepped down to HASU. Neurologically she was dysphagic, dysarthric, quadriplegic and GCS 14 due to confusion. MRI whole spine ruled out spinal cord pathology. Repeat CT head showed air initially present had completely resorbed leaving multifocal, small areas of cortical and subcortical ischaemia in both cerebral hemispheres. MRI head confirmed innumerable small early subacute embolic ischaemic infarcts across multiple vascular distributions.
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The first centenarian study in Hong Kong was conducted in 2011 and examined the multidimensional health of adults aged 95 or older. The 2011 study found that, among a population of about 3,000 centenarians, a significant proportion enjoyed a high degree of autonomy in their daily functions in relatively good health. The study has been repeated in 2021/22 (i.e., born in 1926 or before) when the city had more than 11,000 centenarians. Comparison of the two samples (2011: Nf77;2021/22: Nf120) who lived with their family shows a significant difference in functional health, but not as much for physical health, favouring the 2011 cohort. More than 75% of the 2011 cohort demonstrated autonomy in activities of daily living (Bathing: 77.9%, dressing: 85.7%, toileting: 90.9%, indoor transfer: 89.6%;continence:75.3% and feeding: 94.8%). Only about half of the 2021/22 cohort were autonomous in these areas (40.0%, 44.3%, 54.7%, 42.5%, 63.2%, 46.7%, respectively). The number of chronic illnesses between the two cohorts were comparable (Mean(SD): 2011: 2.7 (1.6);2021: 3.26 (1.60), yet dementia and frailty were more prevalent in the 2021 cohort (dementia: 44%;frailty: 9.1%) then the 2011 cohort (41.0%;23.4%). Our findings alert metropolitans worldwide to the fast-increasing population of adults of advanced age with significant personal care and health needs in the community. Existing care for older adults has to be reframed and overhauled to provide comprehensive home- and personal-care support which will be essential for realizing ageing-in-place for adults in advanced age, especially after social distancing policies in COVID-19.
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Successful aging (SA) was proposed by Robert J Havighurst in 1961 to capture how older adults add "lives onto (their) years.” While there is a consensus regarding the multidimensionality of the concept, the set of criteria that should be applied to older adults of advanced age remain controversial. Notwithstanding their inevitable decline in physical health, adults of advanced age may still enjoy good psychosocial well-being. In this light, we compared the proportion of "successful agers” in two cohorts of adults aged 95 or above who lived with their families in 2011 (Nf77) and 2021/22 (Nf120) in Hong Kong using two models – Model A: i: Good subjective health, ii: more well-off than average, iii: as happy as young (Cho et al., 2012) and Model B: i: Weekly social activities, ii: absence of dementia, iii: intact sight and hearing ability, iv: intact mobility (Nosraty et al, 2012). Both models have been applied in adults aged 90 or above. In the 2011 cohort, 13.0% and 16.9% of our sample fulfilled the SA criteria of Model A & B respectively. The percentages fell to 1.7% and 13.7% respectively in the 2021/22 cohort. The decrease is due to less participants fulfilling the financial criterion of Model A, as well as the criteria on intact sight and hearing ability and the absence of dementia of Model B. COVID presents multidimensional challenges for adults of advanced age. Examining the dimensions that are most impacted will help orient recovery works along the direction of SA.
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Background and aims: Optimal management of carotid artery freefloating thrombus (CAFFT) and CAFFT-related strokes remains unclear. We sought to examine the clinical characteristics, treatment strategies and patient outcomes for CAFFT-related ischaemic strokes. Methods: We conducted a single-centre retrospective observational study by extracting data from electronic patient records. We included consecutive patients admitted between 2016-2021 with ischaemic stroke and CAFFT on initial CT/MR angiogram. Results: We included 59 patients (mean age 63, 66% male). Vascular risk factors included hypertension (42%), diabetes (19%), dyslipidaemia (27%), previous stroke (10%), smoking history (56%) and alcohol excess (14%). 6 patients (10%) were COVID-19 positive. Median modified Rankin score was 0 and mean NIHSS was 11. On admission, 42% were taking antiplatelet agents, 10% were on anticoagulant, 34% had CRP >10mg/L, and 14% had eGFR <50 ml/min/1.73m2. On arrival, 27% received IV thrombolysis and 19% underwent mechanical thrombectomy. Acute antithrombotic strategies included IV heparin (49%), low molecular weight heparin (47%), oral anticoagulation (15%), and antiplatelet agents (63%). 24 patients (41%) were referred to vascular surgery, of whom 9 (38%, 15% of total) received emergency carotid endarterectomy. Neurological deterioration (<7 days) occurred in 14%. In-hospital mortality was 8% overall, but 67% for COVID-positive patients. At 6 months, recurrent stroke occurred in 12% and mortality was 3%. Conclusions: CAFFT-related ischaemic stroke is associated with significant mortality and neurological morbidity. The use of different acute antithrombotic strategies and emergency carotid endarterectomy varied significantly between patients. These major treatment options should be subjects of future clinical trials.
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Background: Paediatric Cov-2 infections have been less severe than in adults, however some have developed a newly defined syndrome, Paediatric Inflammatory Multisystem Syndrome associated with CoV-2 (PIMS -TS). Its presentation is variable and can cause multi-system involvement. It belongs to the common spectrum of pathogen-triggered hyperinflammatory states, including atypical Kawasaki disease. Case summary: 17 year old male of Ghanaian origin, with no significant past medical history, presented with a one-week history of general malaise, fevers and sore throat. He developed severe chest pain and cardiogenic shock, with a CRP of 200, raised troponin and global hypokinesia on echocardiogram with an ejection fraction of 20%. He was positive for SARS-CoV-2 antibodies (though PCR-antigen negative at admission) and fit the criteria for myocarditis secondary to PIMS-TS. He was treated for sepsis, commenced on IV methylprednisolone and needed intubation, sedation and cardiothoracic ICU level care. On weaning sedation after 3 days, he was found to have left middle cerebral artery syndrome with NIHSS 16. CT head and CT angiogram showed a left MCA ischaemic stroke, and a thrombus in the Sylvian MCA branch. This was treated with antiplatelets. His disease markers and motor deficits improved significantly, however he has cognitive impairment and low mood. Conclusion: PIMS-TS related LVO anterior circulation infarct is rare. It necessitates urgent recognition and multi-specialty involvement as currently management is not standardised. Axial DWI (A), ADC (B) MRI demonstrate large left MCA territory infarct. Axial MRA (C) shows occlusion of the left M2 branches, signal drop-out on SWI (D).
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Objective: The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods. Background: The COVID-19 pandemic led to widespread repercussions on the delivery of health care worldwide. Design/Methods: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by ICD-10 codes and/or classifications in stroke center databases. Results: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI,-11.7 to-11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI,-13.8 to-12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI,-13.7 to-10.3, p=0.001). There were greater declines in primary compared to comprehensive stroke centers (CSC) for stroke hospitalizations (-17.3% vs-10.3%, p<0.0001) and IVT (-15.5% vs-12.6%, p=0.0001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) months of the pandemic, with greater recovery in hospitals with lower COVID-19 hospitalization volume, high volume stroke center, and CSC. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions. Conclusions: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months, with greater recovery in hospitals with lower COVID-19 hospitalizations, high volume stroke centers, and CSCs.
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The COVID-19 pandemic has caused widespread devastation throughout the world. In addition to the health and economical impacts, there is an enormous emotional toll associated with the constant stress of daily life with the numerous restrictions in place to combat the pandemic. To better understand the impact of COVID-19, we proposed a framework that utilizes public tweets to derive the sentiments, emotions and discussion topics of the general public in various regions and across multiple timeframes. Using this framework, we study and discuss various research questions relating to COVID-19, namely: (i) how sentiments/emotions change during the pandemic? (ii) how sentiments/emotions change in relation to global events? and (iii) what are the common topics discussed during the pandemic?
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Interactions between the medical community, government, and the wider public during the COVID-19 pandemic have been an important consideration throughout the pandemic response. Attitudes towards vaccinations, in particular, have been especially complex. From the discordance of political and healthcare interests to vaccine hesitancy, there are an array of perspectives on both the delivery and administration of the vaccine. However, in a time of crisis, coherent voices need to prevail. Clinicians need to be encouraged to vocalize their expertise and lived experiences beyond the bedside. Gaps in clinician involvement with decision-making bodies have led to an erosion of trust between the public and healthcare authorities. In this commentary, we argue that it is important that medical professionals are supported in their advocacy, to act as a bridge between reliable and unbiased healthcare information and the wider community, to promote public trust, and to combat medical misinformation.
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Introduction: There are reports of changes in the numbers of stroke admissions and time intervals to receiving emergency treatments during the COVID-19 pandemic. We examined the impact of the COVID-19 pandemic on the stroke thrombolysis rate and delay to thrombolysis treatment in a regional stroke centre in London, UK. Methods: COVID-19 testing began at our hospital on 3 March 2020. Clinical data for all acute stroke admissions were routinely collected as part of a national Sentinel Stroke National Audit Programme (SSNAP) and all thrombolysis data were entered into our local thrombolysis database. We retrospectively extracted the relevant patient data for the period of March to May 2020 (COVID group) and compared to the same period in 2019 (pre-COVID group). Results: Compared with pre-COVID, there was a 17.5% fall in total stroke admissions (from 315 to 260) during COVID;but there were no significant differences in the demographics, stroke severity, proportions with known time of onset, or median onset-to-arrival time. The thrombolysis rates amongst ischemic strokes were not significantly different between the two groups (59/260=23% pre- COVID vs. 41/228=18% COVID, p=.19). For thrombolysis patients, their stroke severity and demographics were similar between the two both groups. Median onset-to-needle time was significantly longer by 22 minutes during COVID [127 (IQR 94-160) vs. 149 (IQR 110-124) minutes, p=.045];this delay to treatment was almost entirely due to a longer median onset-to-arrival time by 16 minutes during COVID (p=.029). Favorable early neurological outcomes post-thrombolysis (defined as an improvement in NIHSS by ≥4 points at 24 hours) were similar (45% vs. 46%, p=.86). Conclusion: COVID-19 pandemic had a negative impact on prehospital delays which in turn significantly increased onset-to-needle time, but without affecting the chance of a favorable early neurological outcome. Our data highlight the need to maintain public awareness of taking immediate action when stroke symptoms occur during the COVID-19 pandemic.
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The COVID-19 pandemic has created widespread health and economical impacts, affecting millions around the world. To better understand these impacts, we present the TweetCOVID system that offers the capability to understand the public reactions to the COVID-19 pandemic in terms of their sentiments, emotions, topics of interest and controversial discussions, over a range of time periods and locations, using public tweets. We also present three example use cases that illustrates the usefulness of our proposed TweetCOVID system. © 2021 Owner/Author.
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Background: The outcome of renal function and in COVID-19 positive patients is unclear. We studied the epidemiology of acute kidney injury (AKI) in the COVID-19 positive patients Methods: Between 9th March 2020 and 26th April 2020 data was prospectively collected on 253 adult COVID-19 positive inpatients about co-morbidity, s. creatinine, demographics and AKI from digital records at our secondary care hospital. AKI stages were defined as per KDIGO Criteria Results: Of the 253 patients, 58.9% were male with (mean ± stdev) age 71.9 ± 16.4 years. Common co-morbidities were Hypertension (54.1%), Cardiovascular Disease (34%), Diabetes Mellitus (28.3%), Chronic lung disease (23.3%), Dementia (20.5%), CKD (stage 3 - 5) 19.8% & 2 (0.8%) renal transplant. 2.8% (7) Patients on regular dialysis were excluded. 42.6% (105) patients had AKI. Of these 53.3% (56) had AKI 1, 20.9% (22) AKI 2 and 25.7% (25) had AKI 3. 2.4% (6) patient's needed acute haemofiltrated. The mean systolic BP at admission in non-AKI patients was 136 ± 22 mmHg (109 of 147 available) whilst in those with AKI it was 124 ± 25 mmHg (78 of 105 available). Thes, creatinine (median and range) in AKI patient at admission, peak and discharge or death was 126 (Range 30 - 1339), 173 (57 - 1339) and 113 (28 - 761) umol/L respectively. 52.4% (55) patients had recovered from AKI. The overall mortality rate in COVID-19 infected patient was 36.4% with mean age of 77.5 ± 12.4 years. Mortality in patients without AKI was 22% (31) & with AKI was 56.2% (59) with mean age of 77.7 ± 11.7 Years. The stagewise AKI mortality was AKI1 25.7% (27), AKI2 10.4% (11) and AKI3 20% (21). 66.6% haemofiltration patients. 23% (25) AKI patients died with normal creatinine. Mortality in CKD patients as co-morbidity was 64%. All renal transplant patients survived without having AKI. 7.7% {19} patients required continuous positive airway pressure, 42.1% (8) patients developed AKI of these 75% (6) patients with CPAP died. A further 24 (9.75%) required mechanical ventilation with 62.5% (15) of these developed AKI with mortality of 80% (12). Conclusions: Elderly patients were most commonly infected with COVID-19 infection. AKI was seen in 42.6% patients with COVID-19 infection. More than 60% COVID-19 infected patients died if they had AKI and were on any form of mechanical ventilatory support or had CKD as co-morbidity.