The impact of the COVID-19 pandemic on critically ill patients with acute stroke and diabetic ketoacidosis

Introduction and aim. This study aimed to compare the hospitalization rate, mortality rate and morbidity status of patients hospitalized with stroke and diabetic ketoacidosis (DKA) before and during the COVID-19 pandemic. Material and methods. The data of 2522 patients who applied to the emergency department (ED) before and during the pandemic were evaluated. A Poisson regression analysis was used to examine the number of presentations between two different periods. Results. Stroke cases during the pandemic era were compared to those during the pre-pandemic period, and it was shown that the mortality rate for stroke patients during the pandemic period was much higher. Treatment-related ED presentations decreased significantly during the pandemic period, particularly among patients aged 75-84 years. Rates of ED presentation decreased by 84 percent (IRR: 0.14, 95 percent CI: 0.03-0.59) in those with DKA and by 37 percent (IRR: 0.67, 95 percent CI: 0.53-0.75) in those with stroke during the pandemic period. Conclusion. Conclusion: Stroke and DKA admissions decreased during the pandemic, but the rate of stroke mortality increased statistically 3.375 times. Getting emergency medical care increases their chances of survival. Even in a COVID-19 outbreak, treatment is critical. © 2022 Publishing Office of the University of Rzeszow. All Rights Reserved.

Changing Higher Education in the United Kingdom: Examining Three Trends through a Neoliberal Lens

Perry discusses how neoliberalism has had a dramatic impact on higher education in the UK. She traces the history of neoliberalism in broad strokes from the pre-Thatcher years to the post-Thatcher years and identifies three key trends in higher education: widening participation and the politics of aspiration, the emergence of the student entrepreneur-consumer, and the marketization of higher education. With specific reference to the third trend, she discusses the use of Internet-based education by higher education institutions and its potential impact on students. The coronavirus pandemic has posed major challenges for student recruitment and increased the precariousness of students in the instructional process.

This work was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under award number P50NS108676 and Moore Foundation

The increasingly remote workforce resulting from the global coronavirus pandemic has caused unprecedented cybersecurity concerns to organizations. Considerable evidence has shown that one-pass authentication fails to meet security needs when the workforce work from home. The recent advent of continuous authentication (CA) has shown the potential to solve this predicament. In this paper, we propose NF-Heart, a physiological-based CA system utilizing a ballistocardiogram (BCG). The key insight is that the BCG measures the body's micro-movements produced by the recoil force of the body in reaction to the cardiac ejection of blood, and we can infer cardiac biometrics from BCG signals. To measure BCG, we deploy a lightweight accelerometer on an office chair, turning the common chair into a smart continuous identity "scanner". We design multiple stages of signal processing to decompose and transform the distorted BCG signals so that the effects of motion artifacts and dynamic variations are eliminated. User-specific fiducial features are then extracted from the processed BCG signals for authentication. We conduct comprehensive experiments on 105 subjects in terms of verification accuracy, security, robustness, and long-term availability. The results demonstrate that NF-Heart achieves a mean balanced accuracy of 96.45% and a median equal error rate of 3.83% for CA. The proposed signal processing pipeline is effective in addressing various practical disturbances. © 2023 ACM.

COVID-19 direct effects on the central nervous system

This chapter focuses on the direct and observable effects of COVID-19 on Central Nervous System (CNS) structures and functions. It includes a review of the persistent symptoms caused by CNS damage during the acute infection by the viral infection, the immune/inflammatory response, and brain hypoxia. Viruses or bacteria can directly infect cells within the brain or spinal cord, infect the membranes surrounding the brain, or by establishing abscesses within the brain. There is strong evidence that COVID-19 causes several forms of long-term brain disease. Nasal obstruction during upper respiratory infections, when the nasal passages are substantially blocked, by seasonal allergies, or as a result of COVID-19, can also cause a temporary loss of smell. Strokes that increased during acute COVID-19 were primarily related to the hypercoagulable state of blood and an inflammatory effect on brain blood vessels that interfered with normal brain oxygenation. © 2023 John Wiley & Sons Ltd. All rights reserved.

Mortality Prediction in ICU Patients Suffering from Stroke

Ischemic stroke is a medical emergency that requires hospitalization and occasionally, specialized care at the Intensive Care Unit. Mortality prediction in the ICUs has been a challenge for intensivists, since prompt identification could impact medical clinical practices and allow efficient allocation of health resources in the ICUs, which are extremely restricted, especially in the era of COVID-19 pandemic. Clinical decision support systems based on machine learning algorithms are taking advantage of the vast amount of information available in the ICUs and are becoming popular in the medical predictive analysis. This study aims to explore the feasibility of interpretable machine learning models to predict mortality in critically-ill patients suffering from stroke. To do so, a vast variety of clinical and laboratory information stored in the electronic health record, are pre-processed to allow taking into account the temporal characteristics of a patient's stay. An 8-hour sliding observation window was utilized. For the experimental evaluation we used the Medical Information Mart for Intensive Care Database (MIMIC-IV). Results indicate sufficient ability to predict mortality at the end of a given day during the patient's stay. Moreover, attribute evaluation highlights the important indicators to consider when following up with a patient. © 2022 ACM.

A REVIEW OF FAST DATA IN TALLAGHT UNIVERSITY HOSPITAL, AND THE IMPACT OF COVID ON TREATMENT

Introduction Stroke is a leading cause of morbidity. Current guidelines advise maximum of 4.5 hours post symptom onset for thrombolysis, and 24 hours for thrombectomy. (1) Delay between symptom onset and treatment is associated with an inferior outcome. Thrombolysis is available in 27 Irish centers. Average rate of thrombolysis is 11%. (3) Fewer than half of stroke patients arrived in hospital within three hours of symptom onset in 2019. (4) Median door-to-needle time is 48 minutes. Method FAST calls in Tallaght University Hospital, from 2/7/19–1/7/21, were included in this analysis (n = 594). Results 160 FAST calls took place pre-Covid (20/month), and 434 post-Covid (27.12/month). Time of symptom onset was recorded in 390 cases. Time patients last seen well was known in 185 cases, unknown time of onset in 19. After review by the stroke clinician, FAST imaging was obtained in 78% of cases (n = 464). Of these, 34 cases of FAST imaging were performed for inpatients. Average time from registration to CT was 35:24 minutes pre covid, and 45:52 minutes post. 9.7% of patients were thrombolysed. The median door-to-needle time was 41 minutes pre-Covid(n = 21, 2.625/month), and 54 minutes after (n = 37, 2.3/month). Thrombectomy was performed in 46 cases. 222 patients were diagnosed with an ischaemic stroke, 50 had TIA and 48 had haemorrhagic strokes. Other diagnoses included migraine (6.7%, n = 40), seizures (6.7%, n = 40) and Bells Palsy (3.7%, n = 22). 55% (n = 330) of cases were registered to ED with FAST call between the hours of 9 am-5 pm. 27% (n = 161) of cases occurred during the night shift. Conclusion The median door-to-needle times were below national median pre-Covid, and longer post-pandemic, with an increase in the rate of presentation in the same time-frame. This report highlights the effect of the pandemic on time-critical patient interventions in stroke and the need to stratify services to respond to structural challenges.

Clinical particularities regarding rehabilitation treatment of a young patient with right pontine ischemic stroke, resulting in dysarthria and left side brachial and crural hemiparesis, and quite recent COVID-19 history

Introduction. Cerebrovascular attacks are one of the leading causes of mortality and morbidity in the world. The most severe are considered to be pontine strokes, because of the high risk of vital functions impairment. The clinical presentation of a pontine stroke can vary from the classical crossed syndrome (ipsilateral cranial nerve palsy and contralateral motor and/or sensory impairment) to pure motor hemiplegia or pure sensory stroke, which are less common.(1) Materials and methods. This presentation describes the case of a 39-year-old patient with a recent history of untreated SARS-COV 2 infection that was followed in the next month by a sudden onset of facial paralysis, dysarthria and a progressive left hemiplegia. The patient's functional status was assessed in our Neuromuscular Clinical Division and he underwent a rehabilitation program consisting of physical, occupational and speech therapies. Multidisciplinary efforts were made in order to find the underlying cause of the pontine ischemic stroke. Results. The patient had a personal history of cardiovascular disease risk factors (essential hypertension and hyperlipidaemia), without other pathological brain imagining outcomes and normal bleeding tests. The suspicion of an interatrial communication was raised. The patient managed to rapidly maintain the standing posture and to practice walking with unilateral support. At discharge, the facial paralysis and dysarthria were almost completely remitted. The left brachial extremity also showed signs of improvement, as the patient was able to perform flexion and extension movements of the fingers, wrist and forearm. Conclusion. To conclude, the patient's evolution was favourable, although the certain cause of the underlying stroke has not been clarified. The neurological complications of COVID-19 include ischemic strokes, and cases were reported in young adults too(2,3). If this were the case, prevention of further cerebrovascular attacks and their complications is necessary(1). Caution in terms of medium/long-term prophylactic anticoagulant therapy and careful control of associated cardiovascular disease risk factors has been proposed and discussed in the multidisciplinary team: rehabilitation physician, neurologist, cardiologist.

Attached to technology: Exploring identity and human relating in a virtual and corporeal world

Technology seems to be everywhere and anywhere in our daily lives. We have devices that allow us to communicate and interact with our work, our social circles, and the world at all times. This article explores and reflects on our attachment to technology and its impact on how we identify and relate to ourselves and others given the advent of sensory-based interactions such as touch, face, and voice recognition. Through the lens of intrapsychic, interpersonal, and systemic processes, the author reflects on the implications of these developments for script theory. He seeks to question, describe, and better understand how these processes affect our sense of reality so that our discourse as a community of practitioners shifts to a curious and accounting process. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Acute Cerebral Ischemic Infarct in a 34-Year-Old Patient After an Asymptomatic COVID-19 Infection: A Case Report.

COVID-19 is an infectious disease induced by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), an enveloped RNA coronavirus that primarily has a tropism for the respiratory tract. Respiratory tract symptoms are frequently encountered, but many complications of this disease are still under study, including cardiovascular and neurological syndromes. The latter was linked to a severe disease presentation, but there are no reports on asymptomatic disease presentations.  A thirty-four-year-old lady presented to the emergency division for acute right-sided weakness. She was previously healthy, with no history of miscarriages. She had no previous signs or symptoms of any respiratory tract infection or other symptoms suggestive of COVID-19 infection. The physical exam revealed a complete right-sided hemiparesis with no other findings. Her initial blood workup was normal. The echocardiography and a carotid duplex ultrasound were performed and did not show any abnormality. A real-time polymerase chain reaction (PCR) for COVID-19 was negative; however, serology testing including IgM and IgG were positive, suggesting a recent COVID-19 infection. Cardiovascular complications have been reported in COVID-19 patients; however, ischemic stroke in asymptomatic COVID-19 patients has not been previously reported. Our case highlights the risk of thrombotic complications due to SARS-CoV-2 infection even in asymptomatic COVID-19 infected patients.

Hyperthrombotic Milieu in COVID-19 Patients.

COVID-19 infection has protean systemic manifestations. Experience from previous coronavirus outbreaks, including the current SARS-CoV-2, has shown an augmented risk of thrombosis of both macrovasculature and microvasculature. The former involves both arterial and venous beds manifesting as stroke, acute coronary syndrome and venous thromboembolic events. The microvascular thrombosis is an underappreciated complication of SARS-CoV-2 infection with profound implications on the development of multisystem organ failure. The telltale signs of perpetual on-going coagulation and fibrinolytic cascades underscore the presence of diffuse endothelial damage in the patients with COVID-19. These parameters serve as strong predictors of mortality. While summarizing the alterations of various components of thrombosis in patients with COVID-19, this review points to the emerging evidence that implicates the prominent role of the extrinsic coagulation cascade in COVID-19-related coagulopathy. These mechanisms are triggered by widespread endothelial cell damage (endotheliopathy), the dominant driver of macro- and micro-vascular thrombosis in these patients. We also summarize other mediators of thrombosis, clinically relevant nuances such as the occurrence of thromboembolic events despite thromboprophylaxis (breakthrough thrombosis), current understanding of systemic anticoagulation therapy and its risk-benefit ratio. We conclude by emphasizing a need to probe COVID-19-specific mechanisms of thrombosis to develop better risk markers and safer therapeutic targets.

Etiologic Subtypes of Ischemic Stroke in SARS-CoV-2 Patients in a Cohort of New York City Hospitals.

Objective: To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis. Background: Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Methods: Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected. Results: The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59-82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis. Conclusion: COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.

Neurovascular complications that can be seen in COVID-19 patients.

Coronavirus disease 2019 (COVID-19), a clinical manifestation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), was declared a global pandemic by the World Health Organization on March 11, 2020. Hypercoagulable state has been described as one of the hallmarks of SARS-CoV-2 infection and has been reported to manifest as pulmonary embolisms, deep vein thrombosis, and arterial thrombosis of the abdominal small vessels. Here we present cases of arterial and venous thrombosis pertaining to the head and neck in COVID-19 patients.

Acutely altered mental status as the main clinical presentation of multiple strokes in critically ill patients with COVID-19.

BACKGROUND AND AIMS: Cerebral infarction in COVID-19 patients might be associated with a hypercoagulable state related to a systemic inflammatory response. Its diagnosis might be challenging. We present two critically ill patients with COVID-19 who presented acutely altered mental status as the main manifestation of multiple strokes. METHODS: Clinical presentation and diagnostic work-up of the patients. RESULTS: Two patients in their sixties were hospitalized with a bilateral pneumonia COVID-19. They developed respiratory failure and were admitted to ICU for mechanical ventilation and intense medical treatment. They were started on low-molecular-weight heparin since admission. Their laboratory results showed lymphopenia and increased levels of C-reactive protein and D-dimer. Case 1 developed hypofibrinogenemia and presented several cutaneous lesions with biopsy features of thrombotic vasculopathy. Case 2 was performed a CT pulmonary angiogram at ICU showing a bilateral pulmonary embolism. When waking up, both patients were conscious but with a remarkable global altered mental status without focal neurological deficits. A brain MRI revealed multiple acute bilateral ischemic lesions with areas of hemorrhagic transformation in both patients (case 1: affecting the left frontal and temporal lobes and both occipital lobes; case 2: affecting both frontal and left occipital lobes). Cardioembolic source and acquired antiphospholipid syndrome were ruled out. COVID-19-associated coagulopathy was suspected as the possible main etiology of the strokes. CONCLUSION: Acutely altered mental status might be the main manifestation of multiple brain infarctions in critically ill COVID-19 patients. It should be specially considered in those with suspected COVID-19-associated coagulopathy. Full-dose anticoagulation and clinical-radiological monitoring might reduce their neurological consequences.

Association of Coronavirus Disease (COVID-19) With Large Vessel Occlusion Strokes: A Case-Control Study.

BACKGROUND. An increase in frequency of acute ischemic strokes has been observed among patients presenting with acute neurologic symptoms during the coronavirus disease (COVID-19) pandemic. OBJECTIVE. The purpose of this study was to investigate the association between COVID-19 and stroke subtypes in patients presenting with acute neurologic symptoms. METHODS. This retrospective case-control study included patients for whom a code for stroke was activated from March 16 to April 30, 2020, at any of six New York City hospitals that are part of a single health system. Demographic data (age, sex, and race or ethnicity), COVID-19 status, stroke-related risk factors, and clinical and imaging findings pertaining to stroke were collected. Univariate and multivariate analyses were conducted to evaluate the association between COVID-19 and stroke subtypes. RESULTS. The study sample consisted of 329 patients for whom a code for stroke was activated (175 [53.2%] men, 154 [46.8%] women; mean age, 66.9 ± 14.9 [SD] years). Among the 329 patients, 35.3% (116) had acute ischemic stroke confirmed with imaging; 21.6% (71) had large vessel occlusion (LVO) stroke; and 14.6% (48) had small vessel occlusion (SVO) stroke. Among LVO strokes, the most common location was middle cerebral artery segments M1 and M2 (62.0% [44/71]). Multifocal LVOs were present in 9.9% (7/71) of LVO strokes. COVID-19 was present in 38.3% (126/329) of the patients. The 61.7% (203/329) of patients without COVID-19 formed the negative control group. Among individual stroke-related risk factors, only Hispanic ethnicity was significantly associated with COVID-19 (38.1% of patients with COVID-19 vs 20.7% of patients without COVID-19; p = 0.001). LVO was present in 31.7% of patients with COVID-19 compared with 15.3% of patients without COVID-19 (p = 0.001). SVO was present in 15.9% of patients with COVID-19 and 13.8% of patients without COVID-19 (p = 0.632). In multivariate analysis controlled for race and ethnicity, presence of COVID-19 had a significant independent association with LVO stroke (odds ratio, 2.4) compared with absence of COVID-19 (p = 0.011). CONCLUSION. COVID-19 is associated with LVO strokes but not with SVO strokes. CLINICAL IMPACT. Patients with COVID-19 presenting with acute neurologic symptoms warrant a lower threshold for suspicion of large vessel stroke, and prompt workup for large vessel stroke is recommended.