Acute stroke in COVID-19 patients: A first year experience in a Colombian hospital.

Background: COVID-19 may be a new risk factor for stroke. Stroke in COVID-19 varies from 1.1 to 8.1%. Various pathophysiological pathways predispose SARS-CoV-2 infected patients to stroke. Aim: To describe COVID-19 patients with acute stroke in one Colombian Center. Methods: From March 6 2020 and March 6 2021 records of patients with acute stroke and in-hospital positive PCR (Polymerase Chain Reaction) test for Sars-CoV-2 infection were reviewed. Demographic, stroke and COVID-19 characteristics were extracted. Continuous variables were reported in means and ranges. Categorical variables were presented in frequencies and percentage. A descriptive narrative was performed. Results: Of 328 acute stroke patients 14 (4.2%) tested positive for PCR SARS-CoV-2. Mean age 56.4 years with 57% males. Five were (35.7%) without vascular risk factors but 9 (64.3%) overweight. Brain infarct diagnosed in 11 (78.5%), 53% with anterior circulation syndromes. Mean NIHSS score 11.8 and 7 (63%) received intravenous thrombolysis. Acute inflammatory blood biomarkers (D-dimer, ferritin, LDH elevated) were positive in all. 11 (78.5%) had symptomatic COVID-19 before stroke with a mean latency of 7 days. 12 (85.7%) had severe COVID-19 and 6 (42.8%) required mechanical ventilation. Outcome was unfavorable in 9 (64.3%) (The Modified Rankin Scale (mRS) > 2), mean hospital stay was 21.8 days and in-hospital case fatality rate was 14.2%. Conclusion: In susceptible individuals COVID-19 predisposes to stroke. Hypercoagulation and immune thrombosis may be at the culprit for this state. In Colombia, COVID-19 patients with stroke have similar characteristics to the described worldwide.

A case of acute hepatitis and morbilliform eruption after mRNA COVID-19 vaccination

Objectives: A 36-year-old Caucasian woman developed acute hepatitis and morbilliform eruption arising ten days after the first dose of the mRNA BNT162b2 SARS-CoV-2 vaccine. Materials and Methods: The patient was asymptomatic apart from the skin rash. Liver function tests showed predmoninantly severe transaminitis (AST 523 U/L, ALT 1550 U/L, GGT 151 U/L, ALP 128 U/L, bilirubin 12 umol/L). Only the ANA 1:160 was abnormal. Other serology for autoimmune and infectious diseases were negative. Multiphase computed tomography of the abdomen was unremarkable. The SARS-CoV-2 anti-spike IgG titre was 67.5 AU/mL (cut-off[15 AU/mL). The skin histology revealed spongiotic reaction pattern with focal interface lymphocytic inflammation. Multiple eosinophils and a few plasma cells were present. The epidermal lymphocytes were composed of CD2, CD3, C4, CD5, CD7 and CD8-positive T cells, with a CD4:CD8 ratio of 1:5. A small number stained positive with TIA1, PD1 and granzyme B. CD56 staining was negative. A liver biopsy was performed after 2 days of steroids. Liver histology showed mild steatosis and mild inflammatory portal infiltrate comprising mainly of small lymphocytes that were CD3 positive with retained staining for CD7 and CD8. Lobular architecture was preserved with inconspicuous interface hepatitis or piecemeal necrosis. Results: The patient was treated with intravenous hydrocortisone (400 mg/day) followed by prednisone (50 mg/day). There was rapid improvement in her liver function tests and cutaneous manifestations (Fig. 1). Conclusion: mRNA COVID-19 vaccine induced hepatitis is a rare phenomenon that is steroid-responsive and has associations with cutaneous eruptions. Our patient's lack of hepatic histological abnormalties is most likely due to early immunosuppression. She had epidermal lymphocytosis with predominance of CD8-positive T cells that were not of cytotoxic phenotype and we are uncertain as to their significance. There is limited guidance on the safety of SARS-CoV-2 vaccination in those who have had developed significant hepatic and cutaenous reactions. Further work is needed.

Practice Variation among Canadian Stroke Prevention Clinics: Pre, During, and Post-COVID-19.

BACKGROUND: Stroke is a common and serious disorder. With optimal care, 90-day recurrent stroke risk can be reduced from 10% to about 1%. Stroke prevention clinics (SPCs) can improve patient outcomes and resource allocation but lack standardization in patient management. The extent of variation in patient management among SPCs is unknown. Our aims were to assess baseline practice variation between Canadian SPCs and the impact of COVID-19 on SPC patient care. METHODS: We conducted an electronic survey of 80 SPCs across Canada from May to November 2021. SPC leads were contacted by email with up to five reminders. RESULTS: Of 80 SPCs contacted, 76 were eligible from which 38 (50.0%) responded. The majority (65.8%) of SPCs are open 5 or more days a week. Tests are more likely to be completed before the SPC visit if referrals were from clinic's own emergency department compared to other referring sources. COVID-19 had a negative impact on routine patient care including longer wait times (increased for 36.4% clinics) and higher number of patients without completed bloodwork prior to arriving for appointments (increased for 27.3% clinics). During COVID-19 pandemic, 87.9% of SPCs provided virtual care while 72.7% plan to continue with virtual care post-COVID-19 pandemic. CONCLUSION: Despite the time-sensitive nature of transient ischemic attack patient management, some SPCs in Canada are not able to see patients quickly. SPCs should endeavor to implement strategies so that they can see high-risk patients within the highest risk timeline and implement strategies to complete some tests while waiting for SPC appointment.

Role of Stress Granules in Suppressing Viral Replication by the Infectious Bronchitis Virus Endoribonuclease.

Infectious bronchitis virus (IBV), a γ-coronavirus, causes the economically important poultry disease infectious bronchitis. Cellular stress response is an effective antiviral strategy that leads to stress granule (SG) formation. Previous studies suggested that SGs were involved in the antiviral activity of host cells to limit viral propagation. Here, we aimed to delineate the molecular mechanisms regulating the SG response to pathogenic IBV strain infection. We found that most chicken embryo kidney (CEK) cells formed no SGs during IBV infection and IBV replication inhibited arsenite-induced SG formation. This inhibition was not caused by changes in the integrity or abundance of SG proteins during infection. IBV nonstructural protein 15 (Nsp15) endoribonuclease activity suppressed SG formation. Regardless of whether Nsp15 was expressed alone, with recombinant viral infection with Newcastle disease virus as a vector, or with EndoU-deficient IBV, the Nsp15 endoribonuclease activity was the main factor inhibiting SG formation. Importantly, uridine-specific endoribonuclease (EndoU)-deficient IBV infection induced colocalization of IBV N protein/dsRNA and SG-associated protein TIA1 in infected cells. Additionally, overexpressing TIA1 in CEK cells suppressed IBV replication and may be a potential antiviral factor for impairing viral replication. These data provide a novel foundation for future investigations of the mechanisms by which coronavirus endoribonuclease activity affects viral replication. IMPORTANCE Endoribonuclease is conserved in coronaviruses and affects viral replication and pathogenicity. Infectious bronchitis virus (IBV), a γ-coronavirus, infects respiratory, renal, and reproductive systems, causing millions of dollars in lost revenue to the poultry industry worldwide annually. Mutating the viral endoribonuclease poly(U) resulted in SG formation, and TIA1 protein colocalized with the viral N protein and dsRNA, thus damaging IBV replication. These results suggest a new antiviral target design strategy for coronaviruses.

State-of-the-Art Light to Digital Converter Circuits Applicable in Non-Invasive Health Monitoring Devices to Combat COVID-19 and Other Respiratory Illnesses: A Review.

In the past few years, a tremendous advancement in the outcome of biomedical circuits and systems has been reported. Unfortunately, at the time of the sudden outbreak of COVID-19, the electronic engineering researchers felt dearth on their side to combat the pandemic, as no such immediate cutting-edge solutions were ready to recognize the virus with some standard and smart electronic devices. Likely, in this paper, a detailed comparative and comprehensive study on circuit architectures of the biomedical devices is presented. Mostly, this study relates the industry standard circuit schemes applicable in non-invasive health monitoring to combat respiratory illnesses. The trending circuit architectural schemes casted-off to tapeout non-invasive health-care devices available in the past literature are meticulously and broadly discussed in this study. Further, the comprehensive comparison of the state of art of the device performance in terms of supply voltage, chip area, sensitivity, dynamic range, etc. is also shown in this paper. The inclusive design processes of the health monitoring devices from Lab to Industry is thoroughly discussed for the readers. The authors think, that this critical review summarising all the trending and most cited health-care devices in a single paper will alternately help the industrialists to adapt and modify the circuit architectures of the health monitoring devices more precisely and straightforwardly. Finally, the demand for health monitoring devices particularly responsible to detect respiratory illnesses, measuring blood pressure and heart-rate is growing widely in the market after the the incident of COVID-19 and other respiratory diseases.

Sex Differences in Clinical Characteristics, Management Strategies, and Outcomes of STEMI With COVID-19: NACMI Registry.

Background: Women with ST-segment elevation myocardial infarction (STEMI) had worse outcomes than men prior to the COVID-19 pandemic. Although concomitant COVID-19 infection increases mortality risk in STEMI patients, no studies have evaluated sex differences in this context. Methods: The North American COVID-19 STEMI registry is a prospective, multicenter registry of hospitalized STEMI patients with COVID-19 infection. We compared sex differences in clinical characteristics, presentation, management strategies, and in-hospital mortality. Results: Among 585 patients with STEMI and COVID-19 infection, 154 (26.3%) were women. Compared to men, women were significantly older, had a higher prevalence of diabetes and stroke/transient ischemic attack, and were more likely to be on statins on presentation. Men more frequently presented with chest pain, whereas women presented with dyspnea. Women more often had STEMI without an identified culprit lesion than men (33% vs 18%, P < .001). The use of percutaneous coronary intervention was significantly higher in men, whereas medical therapy was higher in women. In-hospital mortality was 33% for women and 27% for men (P = .22). Conclusions: In patients presenting with STEMI in the context of COVID-19, the in-hospital mortality rate was 30% and similar for men and women. Lack of an identifiable culprit lesion was common in the setting of COVID-19 for both sexes but more likely in women (1/3 of women vs 1/5 of men). Evaluation of specific underlying etiologies is underway to better define the full impact of COVID-19 on STEMI outcomes and better understand the observed sex differences.

Impact of COVID-19 pandemic in natural course of Moyamoya Angiopathy: an experience from tertiary-care-center in India.

BACKGROUND: COVID-19 mediated immune dysregulation and cytokine storm can precipitate and aggravate Moyamoya angiopathy (MMA), influencing its disease course. This index study was undertaken to prospectively evaluate the status of neurological symptoms of MMA in relation to COVID-19 affection. METHODOLOGY AND RESULTS: Follow-up MMA patients of institute's Stroke-clinic were telephonically interview from 24th March to 30th September, 2020. The first call familiarized them with COVID-19 symptoms and neurological manifestations of MMA, followed by monthly-calls with predesigned questionnaire. Patients with suggestion of COVID-19 underwent nasopharyngeal-swab-testing for COVID-19 Reverse transcription-polymerase chain reaction (RT-PCR) positive cases were subjected to antibody levels for COVID-19 Enzyme-linked immunoassay (ELISA) 8-12 weeks after recovery. During symptomatic phase till 14 days of asymptomatic, they were contacted daily/alternate day. Any new onset/worsening of neurological symptoms were noted. The baseline clinico-radiological details were obtained from stroke-clinic registery. Subsequently, all data were analyzed and compared using descriptive statistics. Seventy four of 104 MMA patients could be contacted and enrolled. The mean age, time since last follow-up and compliance to previously prescribed medication were 23.5 ± 16.1 years, 9.2 ± 1.7 months and 90.5% (n = 67), respectively. Aggravation/new onset neurological symptom were seen in 64.3% (n = 9) of COVID-19 positive MMA (n = 14), of which 8 were seen among the 11 pediatric COVID-19 positive MMA [(Transient ischemic attacks) TIA-4, TIA with headache-1, seizure-2, stroke causing mortality-1]. CONCLUSION: COVID-19 infection can potentiate MMA causing significant morbidity and mortality, especially in children. Providing optimal care for severe diseases (such as MMA) in developing countries during pandemic remains a challenge.

A rare presentation of undiagnosed multiple sclerosis after the COVID-19 vaccine.

Multiple sclerosis (MS) is an auto-immune mediated neurological disorder that affects the central nervous system and leads to myelin sheath destruction. The pathogenesis of MS involves T helper cells causing inflammation and eventual death of the oligodendrocytes. Etiologies for the development of MS include a combination of genetic, environmental, and immune factors. Vaccines have been proposed to increase the immune response and have reportedly activated some autoimmune disorders. Although certain vaccines such as hepatitis B have been associated with MS, studies have refuted these cases. We present a rare case of a 32-year-old patient who presented with symptoms and suggestive of MS a few days after receiving the COVID vaccine. Laboratory and imaging findings confirmed the diagnosis of MS, and she was started on steroids and discharged in a stable condition a few days after.

e-Health solution for home patient telemonitoring in early post-acute TIA/Minor stroke during COVID-19 pandemic.

BACKGROUND: When it comes to critical early post-acute TIA/stroke phase, there is a lack of a comprehensive multi-parametric telemonitoring system. The COVID-19 emergency, its related global mobility restrictions and fear of hospitalization further highlighted the need of a comprehensive solution. OBJECTIVE: We aimed to design and test a pragmatic e-Health system based on multiparametric telemonitoring to support of TIA/stroke patients in sub-acute phase during the COVID-19 pandemic. METHODS: We proposed a telemonitoring system and protocol for TIA/minor stroke patients during COVID-19 pandemic for patients at risk of stroke recurrence. This system involves the use of portable devices for BP/HR/SpO2/temperature sensing, panic-button, gateway, and a dedicated ICT platform. The protocol is a 14-day multiparametric telemonitoring, therapy, and emergency intervention based on vital sign alteration notifications. We conducted a proof-of-concept validation test on 8 TIA/minor stroke patients in the early post-acute phase (< 14 days from ischemic event). RESULTS: The proposed solution allowed to promptly and remotely identify vital sign alterations at home during the early post-acute phase, allowing therapy and behavioral intervention adjustments. Also, we observed a significant improvement of quality of life, as well as a significant reduction of anxiety and depression status. TUQ showed ease of use, good interface quality and high user satisfaction of the proposed solution. The 3-month follow-up showed total adherence of prescribed therapy and no stroke/TIA recurrence or other emergency department admissions. CONCLUSION: The proposed e-Health solution and telemonitoring protocol may be highly useful for early post-acute remote patient management, thus supporting constant monitoring and patient adherence to the treatment pathway, especially during the COVID-19 emergency.

Evaluation of Transient Ischemic Attack and Minor Stroke: A Rapid Outpatient Model for the COVID-19 Pandemic and Beyond.

The grim circumstances of the COVID-19 pandemic have highlighted the need to refine and adapt stroke systems of care. Patients' care-seeking behaviors have changed due to perceived risks of in-hospital treatment during the pandemic. In response to these challenges, we optimized a recently implemented, novel outpatient approach for the evaluation and management of minor stroke and transient ischemic attack, entitled RESCUE-TIA. This modified approach incorporated telemedicine visits and remote testing, and proved valuable during the pandemic. In this review article, we provide the evidence-based rationale for our approach, describe its operationalization, and provide data from our initial experience.

The Effect of the 2019 Novel Coronavirus Pandemic on Stroke and TIA Patient Admissions: Perspectives and Risk Factors.

BACKGROUND: The 2019 novel coronavirus pandemic has generated concern from stroke specialist centres across the globe. Reductions in stroke admissions have been reported, despite many expecting an increase due to the pro-thrombotic nature of 2019 novel coronavirus. AIMS: To assess the impact of the pandemic and subsequent lockdown on stroke admissions and transient ischaemic attack referrals at the Royal Victoria Infirmary, Newcastle-Upon-Tyne, and additionally on patient behaviours affecting modifiable risk factors or perspectives related to accessing healthcare. METHODS: A single-centre retrospective data analysis was carried out on a "lockdown" cohort of suspected stroke patients admitted between 11 March to 26 May 2020 and a "pre-lockdown" cohort admitted in 2019. Differences in weekly admissions, weekly referrals, onset-to-presentation time and weekly thrombolysis cases were examined. Further analysis interrogated these cohorts separated by Bamford classification and stroke mimics (such as seizure/hemiplegic migraine/functional neurology). A binary-format questionnaire was separately administered to admitted patients from 15 April to 5 June 2020. RESULTS: Significant reductions in weekly posterior circulation infarct (-43%, p = 0.017) and stroke-mimic (-47%, p < 0.001) admissions and weekly referrals diagnosed as non-transient ischaemic attack (-55%, p = 0.002) were observed in the lockdown cohort, with no differences in onset-to-presentation time. Over 25% of questionnaire respondents reported less physical activity, increased isolation and delaying their presentation due to the pandemic. CONCLUSIONS: This study provides evidence of reduced stroke-mimic and posterior circulation infarct admissions. Questionnaire findings suggest that patients need to be informed to ensure they appropriately seek medical advice. Significant communication at the stroke-primary care interface is needed to support referral pathways and management of modifiable risk factors.

Impact of Covid-19 on the Behavior of Community Residents With Suspected Transient Ischemic Attack.

Background and Purpose: To investigate the impact of the novel coronavirus disease 2019 (Covid-19) on the behavior of those seeking medical attention for community residents suspected of having had a transient ischemic attack (TIA) during the pandemic. Methods: This was a community-based cross-sectional study with residents living in two communities located in the suburb of Shanghai. A face-to-face interview was prospectively conducted from 20 May 2020 to 30 June 2020 between community physicians and the community residents. Suspected TIA that occurred during the pandemic was identified by symptoms recalled from the community residents. The behavior of seeking medical attention after the suspected TIA was investigated. Results: A total of 873 community residents (517 from the Wujing community and 356 from the Maqiao community) took part in face-to-face interviews. Among them, 143 (16.38%) suspected TIA cases were identified. Less than 20% of the community residents suspected of having a TIA went to the hospital during the Covid-19 pandemic. The most common reason for not seeking medical care during the pandemic was still that symptoms disappeared quickly (94.9%); however, the pandemic did have an impact on behavior. Fear of in-hospital infection (55.1%) and of complicated procedures involved in seeking medical attention during the pandemic (55.9%) made community residents hesitate to seek medical attention after the suspected TIA. Residents with a dual attack within 1 week or with aphasia or dysarthria were more likely to seek medical attention during the pandemic. Conclusion: Our study indicated that the Covid-19 pandemic negatively affected the behavior of those seeking medical attention among community residents with suspected TIA and this might explain part of the reduction in patients presenting with stroke or TIA observed from other reports.

Impact of the COVID-19 Pandemic on Emergency Department Use: Focus on Patients Requiring Urgent Revascularization.

BACKGROUND: The novel coronavirus (2019-nCOV) appeared in China and precipitously extended across the globe. As always, natural disasters or infectious disease outbreaks have the potential to cause emergency department (ED) volume changes. OBJECTIVE: We aimed to assess the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on ED visits and the impact on the handling of patients requiring urgent revascularization. METHODS: We reviewed the charts of all patients presenting to the ED of Hospital Sainte Anne (Toulon, France) from March 23 to April 5, 2020 and compared them with those of the same period in 2019. Then we analyzed complementary data on acute coronary syndrome (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) and neurovascular emergencies (strokes and transient ischemic attacks). RESULTS: The total number of visits decreased by 47%. The number of people assessed as triage level 2 was 8% lower in 2020. There were five fewer cases of NSTEMI in 2020, but the same number of STEMI. The number of neurovascular emergencies increased (27 cases in 2019 compared with 30 in 2020). We observed a reduction in the delay between arrival at the ED and the beginning of coronary angiography for STEMI cases (27 min in 2019 and 22 min in 2020). In 2020, 7 more stroke patients were admitted. CONCLUSION: The COVID-19 pandemic probably dissuaded "non-critical" patients from coming to the hospital, whereas the same number of patients with a critical illness attended the ED as attended prior to the pandemic. There does not seem to have been any effect of the pandemic on patients requiring reperfusion therapy (STEMI and stroke).

Environmental Factors and Hyperacute Stroke Care Activity During the COVID-19 Pandemic: An Interrupted Time-Series Analysis.

BACKGROUND AND AIMS: Concerns have arisen regarding patient access and delivery of acute stroke care during the COVID-19 pandemic. We investigated key population level events on activity of the three hyperacute stroke units (HASUs) within Greater Manchester and East Cheshire (GM & EC), whilst adjusting for environmental factors. METHODS: Weekly stroke admission & discharge counts in the three HASUs were collected locally from Emergency Department (ED) data and Sentinel Stroke National Audit Programme core dataset prior to, and during the emergence of the COVID-19 pandemic (Jan 2020 to May 2020). Whilst adjusting for local traffic-related air pollution and ambient measurement, an interrupted time-series analysis using a segmented generalised linear model investigated key population level events on the rate of stroke team ED assessments, admissions for stroke, referrals for transient ischaemic attack (TIA), and stroke discharges. RESULTS: The median total number of ED stroke assessments, admissions, TIA referrals, and discharges across the three HASU sites prior to the first UK COVID-19 death were 150, 114, 69, and 76 per week. The stable weekly trend in ED assessments and stroke admissions decreased by approximately 16% (and 21% for TIAs) between first UK hospital COVID-19 death (5th March) and the implementation of the Act-FAST campaign (6th April) where a modest 4% and 5% increase per week was observed. TIA referrals increased post Government intervention (23rd March), without fully returning to the numbers observed in January and February. Trends in discharges from stroke units appeared unaffected within the study period reported here. CONCLUSION: Despite adjustment for environmental factors stroke activity was temporarily modified by the COVID-19 pandemic. Underlying motivations within the population are still not clear. This raises concerns that patients may have avoided urgent health care risking poorer short and long-term health outcomes.

Collateral damage - Impact of a pandemic on stroke emergency services.

BACKGROUND: The COVID-19 pandemic's impact on stroke care is two-fold direct impact of the infection and indirect impact on non-COVID-19 diseases. Anecdotal evidence and clinical observation suggest that there is a decrease in the number of patients presenting with stroke during the pandemic. We aim to understand the impact of the COVID-19 pandemic on the utilization of stroke emergency services on a single comprehensive stroke center (CSC). METHODS: We performed a retrospective analysis of a prospectively maintained database and compared all emergency department (ED) encounters, acute stroke admissions (including TIA), and thrombectomy cases admitted in March 2017-2019 to patients admitted in March 2020 at a comprehensive stroke center. RESULTS: Number of total ED encounters (22%, p=0.005), acute ischemic strokes (40%, p=0.001), and TIAs (60%, p=0.163) decreased between March of 2017-2019 compared to March of 2020. The number of patients undergoing EVT in March 2020 was comparable to March 2017-2019 (p=0.430). CONCLUSION: A pandemic-related stay-at-home policy reduces the utilization of stroke emergency services at a CSC. This effect appears to be more prominent for ED encounters, all stroke admissions and TIAs, and less impactful for severe strokes. Given the relatively low prevalence of COVID-19 cases in our region, this decrement is likely related to healthcare seeking behavior rather than capacity saturation.