Long-Term Neurologic Sequelae Among Patients with Varying COVID-19 Severity: An Administrative Claims Database Analysis

Objectives: Examine the long-term incident neurologic sequelae post COVID recovery and assess relationship with COVID severity using real-world data. Method(s): This retrospective cohort study was conducted using Optum Research Database between 01July2019 to 30Sep2022. Patients included were >=18 years with COVID diagnosis (index date) between 01Jan2020 and 31Oct2020, with continuous enrollment 6 months before and >=12 months after index date, known demographics, not pregnant, and with no baseline neurologic conditions. Patients were stratified into COVID severity cohorts as mild (index diagnosis), moderate (inpatient visit within 15 days of index), or severe (evidence of acute respiratory distress) and followed for a minimum of 12-months post-index. Neurologic sequelae examined were persistent headache, migraine, anosmia, sleep disturbance, cognitive dysfunction, post-traumatic stress disorder, suicidality, anxiety, depression, attention deficit hyperactivity disorder, cerebrovascular disease (CVD), fatigue/myalgia and tremors. Descriptive statistics and incidence rate ratios (IRR) were calculated to assess outcomes. Result(s): Of 534,843 patients, 107,656 (Mild 96,637;Moderate 3,371;Severe 7,648) met the study inclusion criteria. Median follow up time was 750, 774 and 768 days in the mild, moderate and severe cohorts, respectively. About 20% of patients in the mild, 32% in moderate and 35% in the severe cohort experienced >=3 neurologic sequelae during the follow-up period. A significantly higher incidence of any neurologic sequelae was observed in moderate and severe cohorts compared with the mild cohort (IRR 3.1 and 3.0, respectively;p<0.001). Cognitive dysfunction (moderate IRR 5.4, severe IRR 5.7;p<0.001), and CVD (moderate IRR 4.8, severe IRR 4.0;p<0.001) were the most commonly occurring manifestations in moderate and severe cohorts compared with the mild cohort. Conclusion(s): These results highlight the need for long-term monitoring and preventative strategies for neurologic conditions post COVID recovery that might impair quality of life and increase overall healthcare burden in the U.S.Copyright © 2023

Cerebrovascular disease in COVID-19: a systematic review and meta-analysis.

Background: The association between COVID-19 and acute cerebrovascular disease (CVD) has not been explored extensively. New data has come to light which may change previous results. Methods: We queried the PubMed electronic database from its inception until February 2022 for studies evaluating the incidence of stroke in COVID-19 patients. Results of the analysis were pooled using a random-effects model and presented as odds ratios (ORs) with 95% confidence intervals (95% CIs). Results: 37 studies consisting of 294,249 patients were included in our analysis. Pooled results show that the incidence of acute CVD events in COVID-19 positive patients is 2.6% (95% CI: 2.0-3.3; P<0.001). Cardioembolic (OR=14.15, 95% CI: 11.01 to 18.19, P<0.00001) and cryptogenic (OR=2.87, 95% CI: 1.91 to 4.32, P<0.00001) etiologies were associated with COVID-19 positivity. Risk factors for CVD events in patients with COVID-19 were atrial fibrillation (OR=2.60, 95% CI: 1.15 to 5.87, P=0.02), coronary artery disease (OR=2.24, 95% CI: 1.38 to 3.61, P=0.0010), diabetes (OR=2.46, 95% CI: 1.36 to 4.44, P=0.003) and hypertension (OR=3.65, 95% CI: 1.69 to 7.90, P=0.005). Conclusion: COVID-19 infection is associated with an increased risk for acute CVD and is associated with cardioembolic and cryptogenic etiologies and the risk factors of atrial fibrillation, coronary artery disease, diabetes and hypertension in COVID-19 positive patients.

Inflammatory and Infectious Vasculopathies

Inflammatory and infectious disorders have been important, if uncommon, causes of stroke. Primary and secondary vasculitides may cause stroke affecting large and small blood vessels of the central nervous system. The pathology may include granulomatous, lymphocytic, and necrotizing lesions. The underlying antigens leading to vasculitis may include amyloid deposition from amyloid angiopathy, or even from infectious agents, although the mechanisms for these disorders remain poorly understood. Many of these conditions have a poor prognosis, although steroid and other immunosuppressive therapies may improve outcomes. Further research, including well-designed clinical trials, are needed. Although infections, such as syphilis, have been associated with stroke risk for more than a century, understanding the relationship between infection and stroke has taken on even greater urgency in the era of the coronavirus disease 19 pandemic. A multitude of pathogens, including bacteria, viruses, parasites, and fungi, have been associated with specific stroke syndromes, through a number of different mechanisms, including large vessel vasculopathy, aneurysmal dilatation, thrombophilia, and cardioembolism. Some infections may also contribute to the atherosclerotic process. This chapter will cover the clinical features, pathophysiology, and potential treatment (where available) for inflammatory and infectious causes and contributors to stroke risk. © 2022 Elsevier Inc.

COVID-19 and stroke: A review.

COVID-19 patients have presented with a wide range of neurological disorders, among which stroke is the most devastating. We have reviewed current studies, case series, and case reports with a focus on COVID-19 patients complicated with stroke, and presented the current understanding of stroke in this patient population. As evidenced by increased D-dimer, fibrinogen, factor VIII and von Willebrand factor, SARS-CoV-2 infection induces coagulopathy, disrupts endothelial function, and promotes hypercoagulative state. Collectively, it predisposes patients to cerebrovascular events. Additionally, due to the unprecedented strain on the healthcare system, stroke care has been inevitably compromised. The underlying mechanism between COVID-19 and stroke warrants further study, so does the development of an effective therapeutic or preventive intervention.

Functional outcome in patients with ischemic stroke and COVID-19 in Lima, Peru

Introduction: COVID-19 seems to induce ischemic stroke by several potential mechanisms including promoting hypercoagulability, and worse functional outcomes have been reported in patients with stroke and the infection with SARS-CoV-2. Objective(s): Determine the association between functional outcome and COVID-19 in patients with stroke. Patients and Methods: We performed a case control study comparing patients admitted to a neurological reference center in Peru with a diagnosis of stroke before (controls) and after (cases) the onset of the COVID-19 pandemic. There were 31 cases diagnosed with COVID-19 and 62 controls without COVID-19. Bivariate analysis and conditional fixed-effects Poisson regression analysis were used to evaluate the association between the functional outcome of the stroke and COVID-19. Result(s): Cases had higher baseline serum glucose (133.5, IQR: 117.5-174 versus 117, IQR: 101-130, p = 0.033) than controls, higher neutrophil counts (7.91, IQR: 5.93-9.57 versus 5.96, IQR: 4.41-7.79, p = 0.008), lower lymphocyte counts (1.48, IQR: 1.04-1.8 versus 1.83, IQR: 1.26-2.32, p = 0.025), higher neutrophil/lymphocyte ratios (5.44, IQR: 4.0-8.1 versus 3.29, IQR: 2.25-6.02, p = 0.011), higher NIH stroke scale/score (NIHSS) (14, IQR: 9-18 versus 7 IQR: 5-11, p = 0.000), and higher modified Rankin scores at discharge (4, IQR: 4-5 versus 2, IQR: 1-4), p = 0.001). Seven (21.88%) participants died in the group of cases versus 1 (1.56%) in the controls (p = 0.014). The odds ratio of having a bad functional outcome at discharge was 1.344 (CI: 1.079-4.039;p = 0.029), adjusted by NIHSS at admission. Conclusion(s): Our findings suggest that ischemic strokes associated with COVID-19 are more severe, have worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.Copyright © 2023 Sociedad Neurologica Argentina

Management of patients with cognitive impairment.

The management of patients with cognitive impairment (CI) is one of the urgent problems of modern medicine. Issues of diagnostics and therapy of patients with CI and their high mortality during the period of coronavirus infection are discussed. A wide prevalence of patients with mild CI (MCI), an important role of neuropsychological research in establishing CI, and frequent diagnosis of CI only at the stage of dementia were noted. In our country, CI is poorly diagnosed, the most common cause of CI in the elderly - Alzheimer's disease (AD) - is rarely established, patients are observed for a long time with a diagnosis of cerebrovascular disease (CVD). Some non-drug and drug methods can reduce the manifestations of CI, improve the quality of life of both the patients themselves and those around them. In severe CI, socio-psychological methods, stimulating patients to feasible household and social, physical and mental activity, and avoiding prolonged hospitalization are of primary importance. In addition to lifestyle changes, much attention in CI is given to the prevention of stroke, the treatment of arterial hypertension and diabetes mellitus. At the stage of dementia, cholinomimetic drugs (acetylcholinesterase inhibitors, donepezil, rivastigmine, galantamine) and the glutamate receptor blocker memantine are used. The use of choline alfoscerate in CI and the results of the multicenter, placebo-controlled ASCOMALVA study are discussed, in which, in patients with AD and CVD, the addition of choline alfoscerate to donepezil reduced the severity of CI, manifestations of depression, anxiety, and apathy. A new oral form of choline alfoscerate (Cerpechol) is reported that may improve patient compliance and be used in patients with swallowing disorders.Copyright © 2023 Ima-Press Publishing House. All rights reserved.

Ai-Based Prediction of Lung Tissue Involvement Is Predicitive of Covid-19 Severity

Background: During COVID-19 epidemics several artificial-intelligence neural networks (ANN) systems were developed classify the risk of disease progression to respiratory failure and death, providing aid for clinical decision. However, for optimal results these models should link multiple medical data in a simple model. In this study we analyse the in-hospital mortality and mechanical ventilation risk using combination ANN based rapid computed tomography assessment tool and selected clinical variables. Method(s): Data of 4317 COVID-19 hospitalized patients including 266 cases required mechanical ventilation were analysed using newly constructed and locally trained ANN algorithm. Demographic, clinical, laboratory, and ANNbased lung inflammation data were analysed using proportional Cox Hazards model and estimate in-hospital mortality and intensive care admission risk. Result(s): Overall in-hospital mortality associated with ANN-assigned percentage of the lung involvement (HR 5.72 (95%CI: 4.4-7.43), p< 0.001 for the patients with >50% of lung tissue affected by COVID-19 pneumonia), age category (HR 5.34 (95%CI: 3.32-8.59) for cases >80 years, p< 0.001), procalcitonin > 2 (HR: 2.1 (95%CI: 1.59-2.76) ng/ml p< 0.001, C-reactive protein level category (max. HR 2.11 (95%CI: 1.25-3.56) for CRP >100 mg/dL, p=0.004), estimated glomerular filtration rate (max HR 1.82 (95%CI: 1,37-2,42), p< 0.001 for eGFR < 30 ml/min) and troponin increase above upper limit normal level (HR: 2.14 (95%: 1.69-2.72, p< 0.001) (Figure 1). Furthermore, risk of mechanical ventilation also associated with ANN-based percentage of lung inflammation (HR 13.2 (8.65-20.4), p< 0.001 for patients with >50% involvement), age, procalcitonin > 2 ng/ml (HR: 1.91 (95%CI: 1.14-3.2), p=0.14 estimated glomerular filtration rate (HR 1.82 (1.2-2.74), p=0.004 for eGFR < 30 ml/min) but also clinical variables, including (HR: 2.5 (95%CI: 1.91-3.27), p< 0.001), cardiovascular and cerebrovascular disease (HR: 3.16 (95%CI: 2.38-4.2), p< 0.001), and chronic pulmonary disease (HR: 2.31 (95%CI: 1.44-3.7), p< 0.001). Conclusion(s): ANN-based lung tissue involvement was the strongest predictor of unfavorable outcomes in COVID-19, and represent valuable support tools for clinical decisions. (Figure Presented).

Cause-of-death statistics in 2020 in the Republic of Korea.

Background: This study analyzed the causes of death in the Korean population in 2020. Method(s): Cause-of-death data for 2020 from Statistics Korea were examined based on the Korean Standard Classification of Diseases and Causes of Death, 7th revision and the International Statistical Classification of Diseases and Related Health Problems, 10th revision. Result(s): In total, 304,948 deaths occurred, reflecting an increase of 9,838 (3.3%) from 2019. The crude death rate (the number of deaths per 100,000 people) was 593.9, corresponding to an increase of 19.0 (3.3%) from 2019. The 10 leading causes of death, in descending order, were malignant neoplasms, heart diseases, pneumonia, cerebrovascular diseases, intentional self-harm, diabetes mellitus, Alzheimer disease, liver diseases, hypertensive diseases, and sepsis. Cancer accounted for 27.0% of deaths. Within the category of malignant neoplasms, the top 5 leading organs of involvement were the lung, liver, colon, stomach, and pancreas. Sepsis was included in the 10 leading causes of death for the first time. Mortality due to pneumonia decreased to 43.3 (per 100,000 people) from 45.1 in 2019. The number of deaths due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was 950, of which 54.5% were in people aged 80 or older. Conclusion(s): These changes reflect the continuing increase in deaths due to diseases of old age, including sepsis. The decrease in deaths due to pneumonia may have been due to protective measures against SARS-CoV-2. With the concomitant decrease in fertility, 2020 became the first year in which Korea's natural total population decreased.Copyright © Korean Medical Association.

The effect of CT-based cardiothoracic ratio on survival of COVID-19 patients

Objectives: We aimed to investigate the relationship between computed tomography (CT)- based cardiothoracic ratio (CTR) with mortality rates of COVID-19 patients. Method(s): Our study was a single-center retrospective analysis of 484 patients (aged >= 18) who were admitted to our hospital's emergency department. We included only laboratory-confirmed COVID-19 patients who underwent chest CT. Data of demographic information, laboratory findings, survivals, and chest CT imaging findings were recorded. The radiologist calculated CTR by dividing the greatest transverse cardiac diameter by the greatest transverse thoracic diameter on the initial chest CT. Cardiomegaly was defined if "CTR > 0.5". Result(s): Thirty (6.2%) patients were treated as outpatients, and 135/484 (%27.9) patients were treated in the intensive care unit (ICU). A total of 147 /484 (30.4%) patients died. We found a statistical association between cardiomegaly with mortality rates (p < 0.001) and ICU admission (p = 0.008). In multivariate analysis, older age was 1.07-fold (p < 0.001), cardiomegaly 1.75-fold (p = 0.015), history of cerebrovascular diseases 2.929-fold (p = 0.018), and elevated serum LDH level 1.003-fold (p = 0.011) associated with higher risks of mortality. Conclusion(s): Since the presence of cardiomegaly on chest CT is associated with a worse prognosis for COVID-19 patients, more caution should be exercised in the evaluation, follow-up, and treatment of COVID-19 patients with cardiomegaly.Copyright © 2023 by Prusa Medical Publishing.

Resultado funcional en pacientes con infarto cerebral y COVID-19 en Lima, Perú

Resumen Introducción El COVID-19 puede desencadenar un infarto cerebral por varios mecanismos potenciales, entre ellas, la hipercoagulabilidad. Se han reportado peores resultados funcionales en pacientes con infarto cerebral y COVID-19. Objetivo Determinar la asociación entre resultado funcional y COVID-19 en pacientes con infarto cerebral isquémico. Pacientes y métodos Se realizó un estudio de casos y controles comparando a pacientes ingresados a un centro de referencia neurológico en Perú con diagnóstico de infarto cerebral, antes (controles) y después (casos) del inicio de la pandemia por COVID-19. Hubo 31 casos diagnosticados con COVID-19 y 62 controles. Se utilizaron análisis bivariado y análisis de regresión de Poisson de efectos fijos condicionales. Resultados Los casos tenían glucemia basal más alta (133,5, RIQ: 117,5-174 vs 117, RIQ: 101-130, p=0,033) que los controles, recuentos de neutrófilos más altos (7,91, RIQ: 5,93-9,57 vs. 5,96, RIQ: 4,41-7,79, p=0,008), menor recuento de linfocitos (1,48, RIQ: 1,04-1,8 frente a 1,83, RIQ: 1,26-2,32, p=0,025), mayor relación neutrófilos/linfocitos (5,44, RIQ: 4,0-8,1 frente a 3,29, RIQ: 2,25-6,02, p=0,011), mayor NIH scale/score (NIHSS) (14, RIQ: 9-18 vs. 7, RIQ: 5-11, p=0,000) y mayores puntuaciones de Rankin modificadas al alta (4, RIQ: 4-5 vs. 2, RIQ: 1-4) p=0,001). Siete (21,88%) participantes fallecieron en el grupo de casos vs. 1 (1,56%) en los controles (p=0,014). La odds ratio de un mal resultado funcional al alta fue de 1,344 (IC: 1,079-4,039;p=0,029), ajustada por NIHSS al ingreso. Conclusiones Nuestros hallazgos sugieren que los infartos cerebrales asociados a COVID-19 son más graves, tienen un peor resultado funcional y una mayor mortalidad que los infartos cerebrales no relacionados a COVID-19. Introduction COVID-19 seems to induce ischemic stroke by several potential mechanisms including promoting hypercoagulability, and worse functional outcomes have been reported in patients with stroke and the infection with SARS-CoV-2. Objective Determine the association between functional outcome and COVID-19 in patients with stroke. Patients and methods We performed a case control study comparing patients admitted to a neurological reference center in Peru with a diagnosis of stroke before (controls) and after (cases) the onset of the COVID-19 pandemic. There were 31 cases diagnosed with COVID-19 and 62 controls without COVID-19. Bivariate analysis and conditional fixed-effects Poisson regression analysis were used to evaluate the association between the functional outcome of the stroke and COVID-19. Results Cases had higher baseline serum glucose (133.5, IQR: 117.5-174 versus 117, IQR: 101-130, p=0.033) than controls, higher neutrophil counts (7.91, IQR: 5.93-9.57 versus 5.96, IQR: 4.41-7.79, p=0.008), lower lymphocyte counts (1.48, IQR: 1.04-1.8 versus 1.83, IQR: 1.26-2.32, p=0.025), higher neutrophil/lymphocyte ratios (5.44, IQR: 4.0-8.1 versus 3.29, IQR: 2.25-6.02, p=0.011), higher NIH stroke scale/score (NIHSS) (14, IQR: 9-18 versus 7 IQR: 5-11, p=0.000), and higher modified Rankin scores at discharge (4, IQR: 4-5 versus 2, IQR: 1-4), p=0.001). Seven (21.88%) participants died in the group of cases versus 1 (1.56%) in the controls (p=0.014). The odds ratio of having a bad functional outcome at discharge was 1.344 (CI: 1.079-4.039;p=0.029), adjusted by NIHSS at admission. Conclusions Our findings suggest that ischemic strokes associated with COVID-19 are more severe, have worse functional outcome and higher mortality than non-COVID-19 ischemic strokes.

Covid-19 vaccine (covishield) heralding Moyamoya angiopathy

Indroduction: Thrombotic complications leading to cerebrovascular events occuring in conjunction with Covid-19 vaccination though rare, is well-documented. Moyamoya Angiopathy is a progressive intracranial vasculopathy leading to recurrent strokes. Case presentation: We present two index cases of young patient presenting with stroke and TIA following Covid-19 vaccination (COVISHIELD) leading to unmasking of Moyamoya Angiopathy. Conclusion(s): Arterial stroke following Covid-19 vaccination is documented, but uncommon. However, in the background of a vasculopathy, it may not be so rare. Moyamoya Angiopathy has been closely studied in the model of inflammatory pathophysiology in genetically predisposed patients leading to progressive vaso-occlusive disease. Few reports of Covid-19 infection potentiating Moyamoya Angiopathy symptoms are also documented. Thus, as an extrapolation of the inflammatory etiopathogenesis of Moyamoya Angiopathy, Covid-19 vaccination can similarly affect the Moyamoya symptomatology. These two index cases open new lines of enquiry regarding the interplay of Covid-19 vaccination and neurological destabilization in patients with underlying vasculopathy of inflammatory pathophysiology.Copyright © 2022

Prognostic value of brain natriuretic peptide in COVID-19 with or without acute heart failure

Background: Although Brain Natriuretic Peptide (BNP) provides strong prognostic information of an unfavorable outcome in patients with acute heart failure (AHF), there is little information of its relevance as a biomarker for outcomes in COVID-19 and its complications Purpose: To evaluate the association of increased BNP levels with complications and in-hospital mortality in a cohort of hospitalized COVID-19 patients. Method(s): The study included COVID-19 patients with data on BNP levels included in the ISACS COVID-19 registry. The population was categorized according to the presence of peak BNP levels >=100 pg/mL during hospitalization. Primary outcomes included in-hospital mortality, AHF or acute respiratory failure (ARF, defined as PiO2/FiO2<300 mmHg or need for mechanical ventilation). Calculations were conducted using age and sex-adjusted multivariable logistic regression analyses. Results were also stratified according to presence or absence of cardiovascular disease (CVD) history. Differences between subgroups were verified for statistical significance using test for interaction. Result(s): Of the 1152 patients included in the study, 615 (53.4%) had elevated BNP levels. These subjects were older (69.9+/-13.8 vs 59.1+/-16.8, p-value<0.001), had higher rates of cardiovascular risk factors (82.9% vs 57.7%, p-value<0.001) and presented more frequently with a prior history of CVD (either ischemic heart disease, cerebrovascular disease, venous thromboembolism, atrial fibrillation or a history of revascularization) (50.1% vs 27.5%, p-value<0.001). No sex differences were observed. When considering outcomes, BNP levels >=100 pg/mL were associated with increased rates of in-hospital mortality (32.9% vs 4.9%, p-value<0.001), even after adjustment for demographic characteristics (OR: 7.35;95% CI: 4.75-11.40;p-value<0.001). High BNP levels were also strongly associated with an increased risk of AHF (OR 19.9;95% CI 8.6-45.9;pvalue< 0.001), a correlation that persisted both in patients with and without a prior CVD history (p for interaction=0.29). Of note, patients with elevated BNP also had a higher likelihood of developing ARF (OR 2.7;95% CI 2.1- 3.6;p-value<0.001), even in absence of AHF (OR 3.00;95% CI 2.20-4.1;p-value<0.001). Conclusion(s): In COVID-19, blood BNP level not only appears to be predictor of in-hospital mortality and AHF but was also independently associated with an increased risk of ARF. This finding supports the routine use of BNP in all patients admitted to hospital for COVID-19, regardless of a prior history of CVD.

Comorbidities Associated With Myocarditis In Hospitalized COVID-19 Patients

Introduction: While COVID-19 is predominantly a lung infection, it can cause systemic viremia in susceptible patients and lead to cardiac involvement and myocarditis (MC);an inflammation of the myocardium characterized by arrhythmias, cardiogenic shock, acute heart failure, and death. Although rare, there is evidence of a surge in MC-related admissions during the COVID-19 pandemic, implying a correlation. However, the risk factors associated with MC susceptibility in these patients remain unclear. This study aims to assess the comorbidities and demographic features associated with the development of MC in adult patients with COVID-19. Method(s): Data were obtained from the PearlDiver database (PearlDiver Technologies, Fort Wayne, IN). The database provides all-payers administrative claims data on the patient level. Using ICD-10-CM codes, a cohort of patients hospitalized with a primary diagnosis of COVID-19 was identified. The study included only patients admitted to the hospital between January and October 2020 to minimize bias associated with vaccine-related MC. Within this cohort, patients diagnosed with MC during and up to one month after admission were identified and their demographic features and comorbidities to were compared to those without MC. We calculated Risk Ratios with their respective 95% CI. A p-value <0.05 was deemed significant. Result(s): We found 627,465 admissions due to COVID-19 from January to October 2020, with 506 (0.08 %) diagnosis of MC. Patients with MC were more likely to be males (60%), younger (mean age 48, SD= 23 vs. 60, SD =17 - p<0.01), and they had more comorbidities (mean Elixhauser Comorbidity Index: 7.52, SD= 5 vs. 6.9, SD = 5 - p<0.001). The development of MC was significantly associated with a history of coagulopathies [0.55(0.46-0.66);p<0.0001], asthma [1.20 (1.06-1.23);p= 0.01], deep venous thrombosis [1.54(1.38-1.68);p<0.0001], renal disease[1.15 (1.02-1.27);p= 0.03], congestive heart failure [1.24 (1.12-1.34);p=0.006], ischemic heart disease [1.25 (1.14-1.35);p=0.0001], and arrhythmias [1.24 (1.14-1.32);p< 0.0001]. However, a history of diabetes [0.89 (0.67-0.99);p=0.02], hypertension [0.71 (0.62-0.80);<0.000.1], depression [0.71(0.52-0.88);p=0.0001], and hypothyroidism [0.42(0.08-0.69);p<0.0001] was associated with lower risk of MC-related hospitalization. Other preexistent conditions including, psychosis, rheumatoid arthritis, cerebrovascular disease, obesity, tobacco use, alcohol abuse, HIV, anemia, peripheral vascular disease, and non-metastatic solid tumor were not significantly correlated with MC. Discussion(s): MC is a rare yet serious complication of COVID-19. Therefore, a better knowledge of the pathophysiology of COVID-19 and the patient factors associated with development to MC is crucial for prognostication and providing risk-adjusted treatment. Conclusion(s): Patients with a history of cardiovascular disease, renal and pulmonary disease were more likely to develop MC as a result of COVID-19. However, hypertension and diabetes were associated with lower risk of MC, which warrants further investigation.Copyright © 2022

Neurological Symptoms Common in Covid-19 Patients: A Retrospective Observational Study

In December 2019, a novel coronavirus outbreak spread rapidly all over the world. The virus is known to be neuroinvasive, but much is still unknown. In this study, we aimed to pres-ent the main neurologic symptoms in patients who were diagnosed with coronavirus disease 2019 (COVID-19). The study was conducted retrospectively by phoning 156 patients in Turkey diagnosed with COVID-19 through real-time polymerase chain reaction;only 100 patients could be reached. Data about their demographics, initial symptoms, neurological symptoms, and sleeping habits were collected. During the disease process, 66% had at least one neurological symptom, 55% had central nervous system symptoms, 42% had peripheral nervous system symptoms, and 64% had sleep disturbances and myalgia. Impaired consciousness, smell and taste impairments, and sleep disturbances were significantly higher in patients with positive chest computed tomography imaging (p < 0.05). Neurological symptoms were observed in COVID-19, as in other coronaviruses. Headache in particular was the most common symptom in our population. In patients with respiratory system findings, the detec-tion of certain neurological symptoms such as smell-taste impairments, impaired consciousness, and sleep disorders were more common. We concluded that COVID-19 patients should be approached in a more holistic way, taking the nervous system into account.Copyright © 2022, Dr. Mladen Stojanovic University Hospital. All rights reserved.

Management of patients with cognitive impairment.

The management of patients with cognitive impairment (CI) is one of the urgent problems of modern medicine. Issues of diagnostics and therapy of patients with CI and their high mortality during the period of coronavirus infection are discussed. A wide prevalence of patients with mild CI (MCI), an important role of neuropsychological research in establishing CI, and frequent diagnosis of CI only at the stage of dementia were noted. In our country, CI is poorly diagnosed, the most common cause of CI in the elderly - Alzheimer's disease (AD) - is rarely established, patients are observed for a long time with a diagnosis of cerebrovascular disease (CVD). Some non-drug and drug methods can reduce the manifestations of CI, improve the quality of life of both the patients themselves and those around them. In severe CI, socio-psychological methods, stimulating patients to feasible household and social, physical and mental activity, and avoiding prolonged hospitalization are of primary importance. In addition to lifestyle changes, much attention in CI is given to the prevention of stroke, the treatment of arterial hypertension and diabetes mellitus. At the stage of dementia, cholinomimetic drugs (acetylcholinesterase inhibitors, donepezil, rivastigmine, galantamine) and the glutamate receptor blocker memantine are used. The use of choline alfoscerate in CI and the results of the multicenter, placebo-controlled ASCOMALVA study are discussed, in which, in patients with AD and CVD, the addition of choline alfoscerate to donepezil reduced the severity of CI, manifestations of depression, anxiety, and apathy. A new oral form of choline alfoscerate (Cerpechol) is reported that may improve patient compliance and be used in patients with swallowing disorders.Copyright © 2023 Ima-Press Publishing House. All rights reserved.

USE OF ANGIOTENSIN-CONVERTING ENZYME INHIBITORS (ACEIs) AND ANGIOTENSIN-RECEPTOR BLOCKERS (ARBs) AND INCIDENCE OF PNEUMONIA OR INFLUENZA OR COVID-19: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: The respiratory tract infections (RTIs), including pneumonia, influenza and Coronavirus Disease 2019 (COVID-19), are the leading cause of hospitalization and mortality worldwide, contributing to elevated healthcare and societal costs. There is conflicting evidences about the effects of angiotensin converting enzyme inhibitor (ACEIs) or angiotensin II receptor blockers (ARBs) on the susceptibility of RTIs. Method(s): Systematic review of interventional and observational studies that reported use of ACEI or/and ARB on incidence of pneumonia or influenza or COVID-19. Searching was conducted in the databases of PubMed, Excerpta Medica Database (Embase), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), including the Cochrane Library until April 2022, and references of retrieved relevant articles. We assessed the quality of included studies by using Cochrane Collaboration Risk of Bias tool for Randomized Controlled Trials and Newcastle-Ottawa Scale for observational studies. DerSimonian Laird random-effects meta-analysis was conducted to pool effects for the incidence of pneumonia, influenza and COVID-19. Subgroup analyses were carried according to baseline morbidities (hypertension or cardiovascular diseases, cerebrovascular diseases, chronic kidney disease (CKD) and other non-communicable diseases). Pooled estimates of odds ratios (OR) and corresponding 95% confidence intervals (95% CI) were computed, and heterogeneity among studies was assessed using Cochran's Q test and the I2 metrics, with two tailed P values. Result(s): 73 studies met the inclusion criteria, of which 38 studies assessed the odds of pneumonia, 32 studies assessed Covid-19 and 3 studies assessed influenza. The quality of included studies was moderate. Use of ACEIs was associated with a significantly reduced odds of pneumonia (23 studies: OR 0.74, 95% CI 0.64 to 0.85;I2=76.8%), of COVID-19 (24 studies: OR 0.87, 95% CI 0.82 to 0.92;I2=81.9%) and influenza (3 studies: OR 0.75, 95% CI 0.57 to 0.98, I2=97.7%), compared with control treatment. Use of ARBs was also associated with reduced odds of COVID-19 (25 studies: OR 0.90, 95% CI 0.83 to 0.97;I2=91.9%), but not with odds of pneumonia or influenza. These findings remain consistent in the community population, patients with history of cerebrovascular diseases or cardiovascular diseases, but not in those with CKD, diabetes and chronic obstructive pulmonary diseases. Conclusion(s): The current evidence favours a putative protective role of ACEIs, not ARB in odds of pneumonia, COVID-19 and influenza. Patient populations that may benefit most are those within the community, history of cerebrovascular diseases and cardiovascular diseases. No conflict of interestCopyright © 2023

Causes of COVID-19's Mortality and Prognostic Effect of Neutrophile-Lymphocyte Ratio

Objectives: In this study, we aimed to investigate the prognostic value of the neutrophile-lymphocyte ratio and the effects of age, gender, and comorbidities on mortality. Method(s): In our study, 100 patients who had a ground-glass opacification on computed thorax tomography and who had a positive polymerase chain reaction test were included in our study. Demographic data, laboratory data and comorbidities of the patients were recorded. Result(s): Sixty-five (65%) of the patients participating in the study were male. The mean age of the patients was 66 (21.5). The mortality rate was found to be 27% (n=27) High neutrophile-lymphocyte ratio, low lymphocyte count, high urea, and creatin levels were significant in terms of mortality. In addition, advanced age, diabetes mellitus, and hypertension are other factors that have an impact on mortality. Conclusion(s): The neutrophile-lymphocyte ratio can solely be used as a prognostic marker because it is simple and economical.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

The roles of bun/d-dimer and bun/lactate ratios in indicating mortality in intensive care patients with COVID-19

Aim: Coronavirus disease 2019 (COVID-19) is an epidemic disease with variable symptoms and high mortality rates. Therefore, patient follow-up is very significant. We aimed to investigate whether blood urea nitrogen (BUN), D-dimer and lactate parameters, which are laboratory tests used in follow-up, predict mortality. Material(s) and Method(s): The study included 173 COVID-19 patients hospitalized in the pandemic intensive care unit from March 2020 to June 2020. We retrospectively recorded patient age, gender, comorbidity, radiological involvement, oxygen demand, APACHE scores, in-hospital mortality status, BUN, lactate, and D-dimer levels, BUN/D-dimer ratio (BDR), BUN/lactate ratio (BLR). Then we made the statistical comparison between the groups by grouping the patients as discharged and deceased. Result(s): Among the patients included in the study, 107 (61.8%) were male and 66 (38.2%) were female. The mean ages between those discharged and those who died in the hospital were 73 and 67.5 years, respectively, and there was a statistically significant difference. The median BUN, d-dimer, lactate and BDR, BLR values of the patients in the non-survivor group were significantly higher than those in the survivor group. BLR had the highest diagnostic ratio (25.03) for estimating in-hospital COVID-19 mortality. Discussion(s): We found that BUN, BDR, and BLR levels were reliable predictors of in-hospital mortality in COVID-19 patients. However, BLR was a potent risk assessment tool, especially in defining the risk of in-hospital death.Copyright © 2022, Derman Medical Publishing. All rights reserved.

Temporal Trend in Mortality from Covid-19 Associated with Cardiovascular Disease

Background Coronavirus disease 2019 (COVID-19) mortality remains high in those with cardiovascular disease (CVD). The temporal trend in higher COVID-19 mortality due to CVD has public health implications. We assessed the association between CVD and COVID-19 mortality throughout the COVID-19 pandemic. Methods We retrospectively studied all patients who received care for COVID-19 at Rush University System for Health during the pandemic (divided into 7 waves based on predominant virus variants and vaccine rollouts). CVD was defined as congestive heart failure (CHF), myocardial infarction (MI), cerebrovascular or peripheral vascular disease (ascertained by ICD codes). Using multivariable logistic regression, we assessed independent associations of COVID-19 mortality with age, sex, race, and 17 comorbidities in the Charlson comorbidity index, overall and stratified by pandemic waves. Results Of 43876 patients (mean age 40, 56% female, 14% with CVD), 1032 (2%) died from COVID-19 between March 2020 and August 2022. Adjusted for covariables, mortality was 3.2 times as likely in those with CVD as those without (OR=3.2, 95%CI 2.7-3.9;p<0.001). There was a trend toward increasing mortality associated with co-existing CVD as pandemic progressed to later waves (where Delta and Omicron were predominant), particularly in those with CHF or MI (Figure). Conclusion We found that COVID-19 mortality associated with co-existing CVD (particularly CHF and MI) increased temporally throughout the pandemic. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Delirium in patients with acute cerebrovascular disease during visitation restrictions due to COVID-19 pandemic: A stroke-unit perspective

Background and aims: Hospitals around the world introduced considerable visitation restrictions to reduce the risk of infection during epidemic spread of SARS-CoV2. Understanding the negative impacts of visitation restrictions on subgroups of patients may help to balance and adjust policies accordingly or introduce further measures to mitigate their impact. Patients with acute cerebrovascular disease are at high risk of delirium. Lack of family visitation is discussed as a risk factor for development of delirium. We aimed to investigate the association of visitation restrictions with delirium incidence in patients with acute cerebrovascular disease treated in a stroke-unit. Method(s): Data from all stroke-unit cases with transient ischemic attack or stroke (ischemic/hemorrhagic) admitted between January 2017 and November 2021 to an over-regional university hospital stroke center were compared between three groups depending on visitation policy implemented at time of admission: pandemic-associated absolute visitation restriction (no visitors unless medical reasons or in palliative settings;n = 1087), limited visitation policy (one visitor per patient for one hour per day between 3 and 6 pm;n = 862) and pre-pandemic visitation policy (two visitors per patient at any time between 2.30 and -6.30 pm + 10 and -12 am on weekends;n = 3830). ICD-10 diagnosis of delirium and potentially relevant confounders were extracted (age, sex, acute infection (pneumonia, urinary tract infection, sepsis), SARS-CoV2 status (regardless of symptoms), history of dementia and duration of hospital stay). Univariate comparison and multiple logistic regression analyses were conducted to evaluate association of delirium with visitation restrictions. Result(s): 5779 cases were included in our analysis (median age 75 years [IQR: 64-83], 45.5% female). We observed delirium incidences of 6.3% during pandemic-associated absolute visitation restriction, 5.8% with limited visitation policy and 5.1% with pre-pandemic visitation policy (p = 0.239). In multiple logistic regression analyses adjusting for clinically relevant variables, we found any pandemic-associated visitation restriction (OR: 1.353, 95%CI: 1.059-1.730, p = 0.016) and, differentiating between scope of visitation restriction, specifically absolute visitation restriction (OR: 1.351, 95%CI: 1.005-1.817, p = 0.046) independently associated with delirium. Other factors associated with delirium were older age (OR:1.051, 95%CI: 1.039-1.064, p < 0.001), male sex (OR: 2.197, 95%CI: 1.705-2.831, p < 0.001), stroke versus TIA (OR: 1.886, 95%CI: 1.209-2.943, p = 0.005), acute infection (OR: 2.111, 95%CI: 1.624-2.743, p < 0.001), history of dementia (OR: 1.787, 95%CI: 1.221-2.615, p = 0.003) and longer duration of hospitalization (OR: 2.988, 95%CI: 2.281-3.914, p < 0.001). Positive SARS-CoV2-PCR status did not significantly predict delirium in our cohort. Conclusion(s): Pandemic-associated visitation restrictions and specifically absolute visitation restrictions were found to be associated with a higher incidence of delirium among stroke-unit patients with acute cerebrovascular disease. Benefit and harm of visitation restrictions even bevond the current pandemic should be carefully weighed and adjusted for patients otherwise at increased risk for delirium.Copyright © 2023