ABSTRACT
L'assistanat spécialisé à temps partagé (ASTP) est un projet régional de santé piloté par l'Agence régionale de la santé (ARS). Il s'agit d'un partenariat entre un médecin en post-internat, thésé, et au moins deux établissements de santé (CH, CHRU ou structure ambulatoire en zone sous-dense). Ses objectifs sont de consolider les effectifs médicaux, soutenir les projets professionnels des jeunes médecins et parfaire leur formation post-internat. Ce dispositif est en expansion ces dernières années dans la Région Grand-Est. La neurologie y figure en 4e place des spécialités les plus représentées, avec 5 postes pourvus sur la campagne 2021/2023 et 12 postes en cours au 1er janvier 2022. La densité médicale est en flux tendu depuis plusieurs années et la pandémie COVID-19 a porté un coup supplémentaire au sein d'équipes déjà fragilisées. Ce fut notamment le cas du service de neurologie du CH de Mulhouse, suite à l'hospitalisation en réanimation de deux neurologues souffrant du SARS-CoV-2. En juin 2020, on ne comptait plus que 4 neurologues permanents pour assurer la continuité des soins et la gestion de 22 lits d'hospitalisation dont 4 de soins intensifs neurovasculaires, 8 lits d'hospitalisation de semaine et 6 d'hôpital de jour. Le dispositif d'ASTP a enrichi l'effectif d'1 praticien sur plusieurs semestres consécutifs. Les avantages pour le praticien sont multiples : – la poursuite de la formation en post-internat, le partage d'expérience d'équipes variées et surspécialisées et la possibilité d'encadrer des internes et des externes ;– un avantage financier avec la prime d'exercice multi-sites ;– l'alternance hebdomadaire permet un suivi plus prolongé des patients, ne se limitant plus à une seule période de 6 mois. Le principal inconvénient est la nécessité de déplacements inter-sites, impliquant un allongement du temps de trajet domicile–travail voire un changement de domicile. De plus, l'activité multi-site complexifie la gestion et le suivi des patients qui se fait simultanément sur plusieurs sites et donc parfois à distance. Enfin, l'ASTP est un contrat limité à 2 ans et ne solutionne pas les tensions d'effectifs sur le long cours. Pour conclure, l'ASTP est un dispositif bénéfique pour le praticien et les établissements partenaires, n'offrant néanmoins qu'un soutien transitoire des effectifs médicaux.
ABSTRACT
Various neurological complications have been described in COVID-19 patients, especially Guillain-Barre syndrome (GBS). The underlying mechanisms on the association between SARS-CoV-2 infection and GBS remain unclear, but several hypotheses have been proposed. It seems that post-SARS-CoV-2 GBS shares many characteristics with classic post-infectious GBS; however, it may occur in sedated and intubated patients hospitalized in the intensive care unit for SARS-CoV-2 acute respiratory distress syndrome, which presents challenges in the diagnosis and treatment of GBS. In this study, we describe three cases of post-SARS-CoV-2 GBS that were hospitalized in the intensive care unit.
Subject(s)
COVID-19 , Guillain-Barre Syndrome , COVID-19/complications , Guillain-Barre Syndrome/complications , Guillain-Barre Syndrome/diagnosis , Humans , Intensive Care Units , SARS-CoV-2ABSTRACT
Introduction: Thromboembolic events, including ischemic stroke, are major complications of coronavirus disease 2019 (COVID-19). The clinical characteristics of COVID-19-related stroke are not clearly defined, and few controlled studies assessed the underlying mechanisms of cerebrovascular complications of COVID-19. This single-center retrospective observational study compared stroke characteristics between patients with and without COVID-19. Methods: This study included all patients hospitalized between March 1, 2020, and April 30, 2020, in Colmar Hospital for ischemic stroke as confirmed by imaging. The characteristics of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection by real-time reverse transcriptase polymerase chain reaction or serology were compared with those without SARS-CoV-2 infection. Result: Among 772 patients, nine COVID-19 patients were compared with 50 patients without COVID-19. The following inflammatory and procoagulant marker levels were significantly higher in the COVID-19 group than those in the control group: C-reactive protein, 57.3 ± 43.4 vs. 15.0 ± 30.6 mg/L, p < 0.001; fibrinogen, 5.89 ± 1.75 vs. 4.03 ± 1.26 g/L, p < 0.001; and D-dimer, 4,833.9 ± 6,549.4 vs. 1,028.6 ± 942.6 ng/ml, p < 0.001. The rates of multifocal cerebral territory involvement (4 vs. 7, p = 0.05), microvascular involvement (4 vs. 6, p = 0.04), and thrombophilia (4 vs. 4, p = 0.014) were significantly higher in the COVID-19 group than in the control group, whereas no significant intergroup differences were found in the stroke mechanisms, i.e., cardio-embolic, atherosclerotic, small vessel disease, and cryptogenic. Conclusion: COVID-19-related stroke is characterized by hypercoagulability and hyperinflammation that may favor strokes via microvascular circulation abnormalities, microthrombus formation, and multifocal lesions.
ABSTRACT
Importance: Risk factors associated with the severity of coronavirus disease 2019 (COVID-19) in patients with multiple sclerosis (MS) are unknown. Disease-modifying therapies (DMTs) may modify the risk of developing a severe COVID-19 infection, beside identified risk factors such as age and comorbidities. Objective: To describe the clinical characteristics and outcomes in patients with MS and COVID-19 and identify factors associated with COVID-19 severity. Design, Setting, and Participants: The Covisep registry is a multicenter, retrospective, observational cohort study conducted in MS expert centers and general hospitals and with neurologists collaborating with MS expert centers and members of the Société Francophone de la Sclérose en Plaques. The study included patients with MS presenting with a confirmed or highly suspected diagnosis of COVID-19 between March 1, 2020, and May 21, 2020. Exposures: COVID-19 diagnosed with a polymerase chain reaction test on a nasopharyngeal swab, thoracic computed tomography, or typical symptoms. Main Outcomes and Measures: The main outcome was COVID-19 severity assessed on a 7-point ordinal scale (ranging from 1 [not hospitalized with no limitations on activities] to 7 [death]) with a cutoff at 3 (hospitalized and not requiring supplemental oxygen). We collected demographics, neurological history, Expanded Disability Severity Scale score (EDSS; ranging from 0 to 10, with cutoffs at 3 and 6), comorbidities, COVID-19 characteristics, and outcomes. Univariate and multivariate logistic regression models were used to estimate the association of collected variables with COVID-19 outcomes. Results: A total of 347 patients (mean [SD] age, 44.6 [12.8] years, 249 women; mean [SD] disease duration, 13.5 [10.0] years) were analyzed. Seventy-three patients (21.0%) had a COVID-19 severity score of 3 or more, and 12 patients (3.5%) died of COVID-19. The median EDSS was 2.0 (range, 0-9.5), and 284 patients (81.8%) were receiving DMT. There was a higher proportion of patients with a COVID-19 severity score of 3 or more among patients with no DMT relative to patients receiving DMTs (46.0% vs 15.5%; P < .001). Multivariate logistic regression models determined that age (odds ratio per 10 years: 1.9 [95% CI, 1.4-2.5]), EDSS (OR for EDSS ≥6, 6.3 [95% CI. 2.8-14.4]), and obesity (OR, 3.0 [95% CI, 1.0-8.7]) were independent risk factors for a COVID-19 severity score of 3 or more (indicating hospitalization or higher severity). The EDSS was associated with the highest variability of COVID-19 severe outcome (R2, 0.2), followed by age (R2, 0.06) and obesity (R2, 0.01). Conclusions and Relevance: In this registry-based cohort study of patients with MS, age, EDSS, and obesity were independent risk factors for severe COVID-19; there was no association found between DMTs exposure and COVID-19 severity. The identification of these risk factors should provide the rationale for an individual strategy regarding clinical management of patients with MS during the COVID-19 pandemic.
Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Coronavirus Infections/therapy , Multiple Sclerosis/epidemiology , Multiple Sclerosis/therapy , Pneumonia, Viral/epidemiology , Pneumonia, Viral/therapy , Adult , COVID-19 , Cohort Studies , Female , France/epidemiology , Humans , Male , Middle Aged , Pandemics , Registries , Retrospective Studies , SARS-CoV-2 , Treatment OutcomeABSTRACT
Résumé La Covid-19 peut comporter des troubles neurologiques qui se partagent en 5 grands groupes : Des encéphalopathies, souvent avec agitation, confusion, troubles psychotiques, dont la physiopathogénie est sans doute multiple (syndrome inflammatoire général lié au sepsis, hypoxie, insuffisance rénale, hypercoagulabilité, agression directe du virus). Des syndromes dysimmunitaires du système nerveux central (encéphalo-myélites aiguës disséminées, plus rarement syndrome de Miller Fisher, encéphalite aiguë nécrosante hémorragique…). Des AVC, majoritairement ischémiques, dont la Covid-19 est un facteur de risque indépendant, probablement par des phénomènes d’hypercoagulabilité. Des syndromes de Guillain-Barré. Des atteintes diverses de nerfs crâniens ou des nerfs périphériques. L’anosmie, qui est très fréquente est le plus souvent due à une atteinte de l’épithélium olfactif mais peut être due à une extension de l’agression virale au nerf et au cortex olfactifs. Des études complémentaires restent nécessaires pour mieux comprendre la physiopathogénie et donc la prévention et le traitement de ces complications neurologiques dues à la Covid-19. Summary Five major categories of Covid-19 related neurological disorders emerged : Encephalopathies, often with agitation, delirium and psychosis. Their physiopathology is probably mixed (general sepsis-induced inflammation, hypoxemia, renal failure, hypercoagulability, direct viral aggression). Dysimmune CNS disorders (acute disseminated encephalomyelitis, more rarely Miller Fisher syndrome, acute haemorrhagic necrotic encephalitis…). Ischaemic strokes associated with a prothrombotic state: Covid-19 appears to be an independant risk factor of stroke. Guillain-Barré syndrome. Various cranial nerves or peripheral nerves injuries. Anosmia, which is a key symptom, is most often the consequence of the olfactive epithelial insult, but may sometimes be due to the extension of viral aggression to the olfactive nerve and cortex. Prevention, early recognition and management of COVID-19-related neurological disorders are challenging and require a better understanding of their physiopathology.