COVID-19 Continuous-EEG Case Series: A Descriptive Study.

PURPOSE: Corona virus disease 2019 (COVID-19) refers to coronavirus disease secondary to SARS-CoV2 infection mainly affecting the human respiratory system. The SARS-CoV2 has been reported to have neurotropic and neuroinvasive features and neurological sequalae with wide range of reported neurological manifestations, including cerebrovascular disease, skeletal muscle injury, meningitis, encephalitis, and demyelination, as well as seizures and focal status epilepticus. In this case series, we analyzed the continuous video-EEGs of patients with COVID-19 infection to determine the presence of specific EEG features or epileptogenicity. METHODS: All continuous video-EEG tracings done on SARS-CoV2-positive patients during a 2-week period from April 5, 2020, to April 19, 2020, were reviewed. The demographics, clinical characteristics, imaging, and EEG features were analyzed and presented. RESULTS: Of 23 patients undergoing continuous video-EEG, 16 were COVID positive and were included. Continuous video-EEG monitoring was ordered for "altered mental status" in 11 of 16 patients and for "clinical seizure" in 5 of 16 patients. None of the patients had seizures or status epilepticus as a presenting symptom of COVID-19 infection. Instead, witnessed clinical seizures developed as results of COVID-19-related medical illness(es): anoxic brain injury, stroke/hemorrhage, lithium (Li) toxicity (because of kidney failure), hypertension, and renal disease. Three patients required therapeutic burst suppression because of focal nonconvulsive status epilepticus, status epilepticus/myoclonus secondary to anoxic injury from cardiac arrest, and one for sedation (and with concomitant EEG abnormalities secondary to Li toxicity). CONCLUSIONS: In this observational case series of 16 patients with COVID-19 who were monitored with continuous video-EEG, most patients experienced a nonspecific encephalopathy. Clinical seizures and electrographic status epilepticus were the second most commonly observed neurological problem.

Incidence of Electrographic Seizures in Patients With COVID-19.

Critical illness and sepsis are commonly associated with subclinical seizures. COVID-19 frequently causes severe critical illness, but the incidence of electrographic seizures in patients with COVID-19 has been reported to be low. This retrospective case series assessed the incidence of and risks for electrographic seizures in patients hospitalized with COVID-19 who underwent continuous video electroencephalography monitoring (cvEEG) between March 1st, 2020 and June 30th, 2020. One hundred and twenty-two patients were initially identified who resulted SARS-CoV-2 nasopharyngeal RT-PCR swab positivity with any electroencephalography order placed in the EMR. Seventy-nine patients met study inclusion criteria: age ≥18 years, >1 h of cvEEG monitoring, and positive SARS-CoV-2 nasopharyngeal swab PCR. Six (8%) of the 79 patients suffered electrographic seizures (ES), three of whom suffered non-convulsive status epilepticus. Acute hyperkinetic movements were the most common reason for cvEEG in patients with ES (84%). None of the patients undergoing cvEEG for persistent coma (29% of all patients) had ES. Focal slowing (67 vs. 10%), sporadic interictal epileptiform discharges (EDs; 33 vs. 6%), and periodic/rhythmic EDs (67 vs. 1%) were proportionally more frequent among patients with electrographic seizures than those without these seizures. While 15% of patients without ES had generalized periodic discharges (GPDs) with triphasic morphology on EEG, none of the patients with ES had this pattern. Further study is required to assess the predictive values of these risk factors on electrographic seizure incidence and subsequent outcomes.

Coronavirus disease 2019 (COVID-19) can predispose young to Intracerebral hemorrhage: a retrospective observational study.

BACKGROUND: The respiratory system involvement is the most common presentation of Coronavirus disease 2019 (COVID-19). However, other organs including the central nervous system (CNS) could be affected by the virus. Strokes, seizures, change in mental status, and encephalitis have been reported as the neurological manifestation of the disease. We hypothesized that COVID-19 could predispose younger patients to spontaneous intracerebral hemorrhage (ICH). The present study aimed to investigate whether COVID-19 has any relationship with the occurrence of spontaneous ICH in young or not. METHODS: We retrospectively evaluated all the patients with spontaneous ICH who were referred to our center between 20 Feb and 1 Sep 2020. The demographic, clinical, radiological, and laboratory test data were evaluated. Patients were divided into two groups. The COVID-19 positive patients and COVID-19 negative ones. All the variables including age, sex, history of hypertension, diabetes mellitus, smoking, Glasgow Coma Scale (GCS), hematoma volume and location, the presence of intraventricular hemorrhage and hydrocephalus on admission, the length of hospital stay, the lab test results and the clinical outcome at last visit or discharge as Glasgow Outcome Scale (GOS) were compared between the two groups. RESULTS: There were 22 COVID-19 positive patients (20.8%) and 84 COVID-19 negative ones (79.2%). The mean age of the patients in the case group (54.27 ± 4.67) was significantly lower than that in the control group (69.88 ± 4.47) (p < 0.05). Meanwhile, our results showed a significant difference between the two groups based on the presence of chronic arterial hypertension (p < 0.05). There were no significant differences between the two groups based on gender, diabetes mellitus, smoking, Glasgow Coma Scale (GCS), hematoma volume, need for surgery, the presence of intraventricular hemorrhage and hydrocephalus on admission, White Blood Cell (WBC) count, platelet count, Prothrombin Time (PT), and Partial Thromboplastin Time (PTT) (p > 0.05). CONCLUSIONS: Our results show that COVID positive patients with ICH are younger and with less predisposing factors than COVID negative subjects with ICH.

Effect of the COVID-19 pandemic on drug compliance and stigmatization in patients with epilepsy.

OBJECTIVE: Pandemics like coronavirus disease 2019 (COVID-19) bring along many individual and social problems. We aimed to investigate what changes the COVID-19 pandemic can cause in patients with epilepsy on drug compliance and stigmatization. MATERIAL AND METHOD: Modified Morisky Scale (MMS) and stigmatization scales were used between October and November 2019 to assess drug compliance and stigmatization in epilepsy patients. These scales were renewed in June and July 2020 in the same patient group to assess the impact of the epidemic on drug compliance and stigmatization in patients with epilepsy. Statistical analysis was performed using the statistical software SPSS 17.0 for Windows (SPSS, Inc). Demographic and clinical characteristics of the patients were recorded in SPSS. The interviews were conducted during the interictal period. Paired-samples t-test was used to compare the stigma scale results of epilepsy patients before and during COVID-19. The Wilcoxon test was used to compare MMS groups before and during COVID-19. RESULTS: A total of 110 patients were included in the study. There was no significant difference between the pre-pandemic and pandemic period in epilepsy stigma scale used to evaluate stigmatization levels in patients. During the pandemic period, it was observed that patients had higher motivation and higher knowledge than before the pandemic (p = 0.048). There were seven patients (6.4%) whose seizure frequency increased during the pandemic period. There were two patients (1.8%) who had difficulty in accessing drugs during the pandemic period. In multivariate analysis, only parameter that predicted an increase in seizure frequency was the number of drugs used In the of COVID-19 period. In correlation analysis, a negative correlation was found between the stigma total score during COVID-19 period and education level. CONCLUSION: A slight increase in the frequency of seizures was observed in our patients during the pandemic period, and no significant problem was experienced in accessing drugs. The COVID-19 pandemic made patients more motivated and informed in drug compliance in the patient group and had no effect on stigmatization.

Impact of COVID-19 pandemic on epilepsy practice in India: A tripartite survey.

OBJECTIVE: To assess the impact of ongoing COVID-19 pandemic on epilepsy care in India. METHODS: We conducted a three-part survey comprising neurologists, people with epilepsy (PWE), and 11 specialized epilepsy centers across India. We sent two separate online survey questionnaires to Indian neurologists and PWE to assess the epilepsy practice, seizures control, and access to care during the COVID-19 pandemic. We collected and compared the data concerning the number of PWE cared for and epilepsy procedures performed during the 6 months periods preceding and following COVID-19 lockdown from epilepsy centers. RESULTS: The survey was completed by 453 neurologists and 325 PWE. One third of the neurologist reported >50 % decline in outdoor visits by PWE and EEG recordings. The cumulative data from 11 centers showed 65-70 % decline in the number of outdoor patients, video-EEG monitoring, and epilepsy surgery. Working in a hospital admitting COVID-19 patients and use of teleconsultation correlated with this decline. Half of PWE had postponed their planned outpatient visits and EEG. Less than 10 % of PWE missed their antiseizure medicines (ASM) or had seizures due to the nonavailability of ASM. Seizure control remained unchanged or improved in 92 % PWE. Half of the neurologists started using teleconsultation during the pandemic. Only 4% of PWE were afflicted with COVID-19 infection. CONCLUSIONS: Despite significant decline in the number of PWE visiting hospitals, their seizure control and access to ASMs were not affected during the COVID-19 pandemic in India. Risk of COVID-19 infection in PWE is similar to general population.

The neurological manifestations of COVID-19 - A case series.

Severe acute respiratory syndrome (SARS) is a fatal respiratory illness caused by the coronavirus (CoV). The first known case was reported in 2002, later coined as SARS-CoV. Over the last two decades, the CoV has periodically emerged in the general population, causing a varying degree of pneumonia. The most recent outbreak, now known as coronavirus disease of 2019 (COVID-19), has been on an exponential rise. Similar to its predecessors, COVID-19 causes a fatal form of pneumonia; however, in a small percentage of patients, COVID-19 has shown to cause neurological symptoms. Given that SARS-CoV and the new CoV strain share similar viral structures, COVID-19 may have the capability to invade the neurological system. We present a series of patients with COVID-19, the first of which presented with a seizure, whereas our second patient developed seizures during their hospital course. Neither patient had a previous history of epilepsy. RELEVANCE FOR PATIENTS: COVID-19 has rapidly evolved since it was first reported and has proven to be a fatal infective process. The last several months have been challenging for the medical community as we try to understand the complexities of this virus. Clinicians have attempted to assess the most common presenting symptoms based on reported cases. The purpose of this study was to help understand how COVID-19 presents itself when the neurological system is involved. This case series describes the common and uncommon neurological manifestations of COVID-19. By doing so, we hope to provide clinicians with additional information to help diagnose COVID-19 in this unprecedented time and to also be wary of the uncommon presenting features.

Neurologic manifestations in patients with COVID-19: A case report.

BACKGROUND: There are very few reports about the neurological complications of COVID-19. We describe two COVID-19 patients with neurologic presentations. CASE PRESENTATION: Herein we present neurological manifestations in 2 hospitalized patients with COVID-19. The patients showed most common symptoms of COVID-19 along with common conflicts in CT scans of lung such as ground-glass opacities (GGOs). First case revealed two episodes of generalized tonic-clonic seizures; brain CT scan in second patients revealed an extensive hypodense lesion in the left cerebellar hemisphere. All cases received supportive care, antibiotics, and antiviral medications. All cases were discharged with a good general condition. CONCLUSION: The current case series report the association between neurological involvements and COVID-19. Clinicians should be aware of neurologic symptoms in the setting of COVID-19, which might even be the first presentations of this infection.

COVID-19, de novo seizures, and epilepsy: a systematic review.

OBJECTIVE: We discuss the evidence on the occurrence of de novo seizures in patients with COVID-19, the consequences of this catastrophic disease in people with epilepsy (PWE), and the electroencephalographic (EEG) findings in patients with COVID-19. METHODS: This systematic review was prepared according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. MEDLINE, Scopus, and Embase from inception to August 15, 2020 were systematically searched. These key words were used: "COVID" AND "seizure" OR "epilepsy" OR "EEG" OR "status epilepticus" OR "electroencephalography". RESULTS: We could identify 62 related manuscripts. Many studies were case reports or case series of patients with COVID-19 and seizures. PWE showed more psychological distress than healthy controls. Many cases with new-onset focal seizures, serial seizures, and status epilepticus have been reported in the literature. EEG studies have been significantly ignored and underused globally. CONCLUSION: Many PWE perceived significant disruption in the quality of care to them, and some people reported increase in their seizure frequency since the onset of the pandemic. Telemedicine is a helpful technology that may improve access to the needed care for PWE in these difficult times. De novo seizures may occur in people with COVID-19 and they may happen in a variety of forms. In addition to prolonged EEG monitoring, performing a through metabolic investigation, electrocardiogram, brain imaging, and a careful review of all medications are necessary steps. The susceptibility of PWE to contracting COVID-19 should be investigated further.

Acute Seizures Occurring in Association With SARS-CoV-2.

Seizures are an infrequent and serious neurological complication of SARS-CoV-2 infection, with limited data describing the etiology and the clinical context in which these occur or the associated electrographic and imaging findings. This series details four cases of seizures occurring in patients with COVID-19 with distinct time points, underlying pathology, and proposed physiological mechanisms. An enhanced understanding of seizure manifestations in COVID-19 and their clinical course may allow for earlier detection and improved patient management.

Use of Thin Dressings Under N95 Respirators: Exploring Their Effect on Quantitative Fit Testing Results to Guide Hospital Practice During the COVID-19 Pandemic.

At the beginning of the coronavirus disease-19 pandemic, health care staff at a level 1 trauma center in the state of New York experienced facial irritation and skin breakdown under their N95 respirators due to increased and prolonged use. PURPOSE: Members of the Certified Wound and Ostomy Nurse, Nurse Practitioners staff were charged with developing recommendations within 48 hours to help prevent and manage facial skin issues using available products that would not compromise the seal of the respirators. METHOD: With the assistance of a health care safety specialist from the Environmental Health and Safety Department of the hospital, an ambient particle counting device was used to measure the N95 fit factor following application of a liquid skin barrier, transparent film dressing, light silicone-based adhesive dressing, or an extra-thin hydrocolloid dressing on the bridge of the nose and the cheekbones underneath an N95 respirator of 2 hospital staff members who volunteered to test the dressings. RESULTS: All thin dressings tested showed a fit factor over 100, reflecting an effective seal. The highest fit factors were seen with the liquid skin barrier in the 2 volunteers (200 and 198, respectively). Thin dressing usage information was included in the hospital guidelines for N95 respirators and shared with staff. Subsequent feedback suggests that the light silicone-based adhesive dressing and the extra-thin hydrocolloid dressing were preferred. CONCLUSION: Thin dressing use may help reduce skin complications among hospital staff during periods of extended N95 respirator wear time. Because use of the dressings did not result in failure of the quantitative fit test, they were permitted for use by health care staff under their N95 respirators. Studies are needed to help health care facilities optimize N95 respirator use to protect staff from coronavirus disease-19 and respirator-related skin complications while supply shortages remain.

Clinical characteristics of 10 children with a pediatric inflammatory multisystem syndrome associated with COVID-19 in Iran.

BACKGROUND: Although symptoms and signs of COVID-19 (Coronavirus disease 2019) in children are milder than adults, there are reports of more severe cases which were defined as pediatric inflammatory multisystem syndrome (PIMS). The purpose of this report was to describe the possible association between COVID-19 and PIMS in children. METHODS: From 28 March to 24 June 2020, 10 febrile children were admitted with COVID-19 infection showing characteristics of PIMS in Buali tertiary hospital of Sari, in Mazandaran province, northern Iran. Demographic and clinical characteristics, laboratory and imaging findings, and therapeutic modalities were recorded and analyzed. RESULTS: The mean age of the patients was 5.37 ± 3.9 years (13 months to 12 years). Six of them were boys. Kawasaki disease, myocarditis, toxic shock syndrome, appendicitis, sepsis, urosepsis, prolonged febrile seizure, acute hemorrhagic edema of infancy, and COVID-19-related pneumonia were their first presentation. All of them had increased C-reactive protein levels, and most of them had elevated erythrocyte sedimentation rate, lymphopenia, anemia, and hypoalbuminemia. Three of them had thrombocytopenia(PLT < 106). Six of them were serologically or polymerase chain reaction positive for COVID-19, and 4 of them were diagnosed as COVID-19 just by chest computed tomography scan. Most of the patients improved without a residual sequel, except one who died with multiorgan failure and another case was discharged with a giant coronary aneurysm. CONCLUSIONS: Children with COVID-19 may present symptoms similar to Kawasaki disease and inflammatory syndromes. PIMS should be considered in children with fever, rash, seizure, cough, tachypnea, and gastrointestinal symptoms such as vomiting, diarrhea, and abdominal pain.

Visual Field Artifacts in Glaucoma With Face Mask Use During the COVID-19 Pandemic.

PURPOSE: The coronavirus (COVID-19) pandemic has changed how outpatient care is delivered in ophthalmology clinics, particularly with glaucoma care. This case series highlights the need for awareness of fogging and improper face mask fit as causes of standard automated perimetry artifacts in patients with ocular hypertension and glaucoma. CLINICAL PRESENTATIONS: Six patients with the diagnosis of ocular hypertension, glaucoma suspect, or glaucoma underwent standard automated perimetry (24-2 or 10-2 SITA, Humphrey Field Analyzer) while wearing ear-loop surgical face masks. Due to patient complaints of fogging during the testing, low test reliability, and unexpected results, the tests were repeated after taping securely the mask to the bridge of the nose. CLINICAL FINDINGS: Fogging may reduce visual field (VF) test reliability and induce artifacts that mimic glaucomatous defects. VF test reliability can be improved and artifacts minimized following mask taping. In 1 case there was worsening of VF defects after mask taping. This suggests that fogging may also disguise true VF defects. CONCLUSIONS: Fogging can result in unreliable VF testing with glaucoma-like artifacts. Secure taping of the face mask to the nose bridge may minimize this problem and reduce unnecessary additional testing and follow-up visits.

Central Nervous System Manifestations Associated with COVID-19.

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID-19) has become a global health crisis of our time. The disease arises from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that binds to angiotensin-converting enzyme 2 (ACE2) receptors on host cells for its internalization. COVID-19 has a wide range of respiratory symptoms from mild to severe and affects several other organs, increasing the complexity of the treatment. There is accumulating evidence to suggest that SARS-CoV-2 can target the nervous system. In this review, we provide an account of the COVID-19 central nervous system (CNS) manifestations. RECENT FINDINGS: A broad spectrum of the CNS manifestations including headache, impaired consciousness, delirium, loss of smell and taste, encephalitis, seizures, strokes, myelitis, acute disseminated encephalomyelitis, neurogenic respiratory failure, encephalopathy, silent hypoxemia, generalized myoclonus, neuroleptic malignant syndrome and Kawasaki syndrome has been reported in patients with COVID-19. CNS manifestations associated with COVID-19 should be considered in clinical practice. There is a need for modification of current protocols and standing orders to provide better care for COVID-19 patients presenting with neurological symptoms.

Seizures and Epilepsy in Times of Corona Virus Disease 2019 Pandemic.

The end of the year 2019 was marked by novel coronavirus (severe acute respiratory syndrome coronavirus-2, SARS-CoV-2) outbreak in China that rapidly spread to the rest of the world. While the involvement of the lower respiratory system causing pneumonia is identified as the primary target of the virus, extra-pulmonary manifestations, especially of the central nervous system, are also being increasingly reported. Previous research on Middle East respiratory syndrome coronavirus and SARS-CoV have shown neurological involvement in human coronavirus infections. While several cases of seizures have been reported in patients with coronavirus disease 2019 (COVID-19) patients, there is no specific data to suggest an association of COVID-19 with epilepsy. Epilepsy patients on immunosuppressive medications may have a higher risk of contracting the viral infection. There can be an indirect relation of COVID-19 to epilepsy as the viral infection is associated with fever in most COVID-19 cases, which can lower seizure threshold. Additionally, inadequate sleep and stress due to ongoing pandemic of coronavirus can be another trigger for seizure precipitation in epilepsy patients. Drug compliance, availability of antiepileptic drugs, and drug interactions with COVID-19 experimental drugs are major concerns in epilepsy patients. Adopting telemedicine services and the use of epilepsy helplines may be important in assisting epilepsy patients and ensuring that treatment continues uninterrupted.

Fahr's syndrome presenting with seizures in SARS-CoV-2 (COVID-19) pneumonia-a case report.

BACKGROUND: Fahr's syndrome (or Fahr's disease) is a rare, neurological disorder characterized by bilateral calcification in the cerebellum, thalamus, basal ganglia, and cerebral cortex as a result of calcium and phosphorus metabolism disorder. The patients may be asymptomatic and clinical symptoms represent a wide range of neurologic manifestations and nonspecific neuropsychiatric disorders. We report an unusual case of Fahr's syndrome which was asymptomatic and incidentally diagnosed by generalized tonic-clonic seizure in a patient with SARS-CoV-2 (COVID-19) pneumonia. CASE PRESENTATION: The patient was a 68-year-old female and admitted to our emergency department suffering from cough and fatigue. After thorax computed tomography (CT) and SARS-CoV-2 PCR test, she was diagnosed as COVID-19 pneumonia. In the intensive care unit, the patient had a tonic-clonic convulsion starting from the left arm and spreading to the whole body. Fahr's syndrome was diagnosed after a cranial CT scan and blood metabolic panel test. CONCLUSIONS: As a result of the clinical, radiological, and biochemical evaluations, the patient was diagnosed incidentally as Fahr's syndrome associated with hypoparathyroidism. Seizures could be induced by hydroxychloroquine that was in the COVID-19 treatment or the inflammation caused by COVID-19 pneumonia. The association between the mortality of COVID-19 pneumonia and Fahr's syndrome is unknown which needs further research.

Seizure in patients with COVID-19.

OBJECTIVE: The purpose of the current study was to collect the data on the occurrence of seizures in patients with COVID-19 and to clarify the circumstances of the occurrence of seizures in these patients. METHODS: All consecutive patients who referred to healthcare facilities anywhere in Fars province (located in South Iran with a population of 4.851 million people) from February 19 until June 2, 2020, and had confirmed COVID-19 by positive result on polymerase chain reaction testing and seizure were included. RESULTS: During the study period, 6,147 people had confirmed COVID-19 in Fars province, Iran; 110 people died from the illness (case fatality rate 1.79%). During this time period, five people had seizures (seizure rate 0.08%). In four patients, seizure was one of the presenting manifestations, and in one person, it happened during the course of hospital admission. Two patients had status epilepticus. All patients experienced hypoxemia and four of them needed respirator. Two patients had related metabolic derangements and one had cerebrospinal fluid (CSF) lymphocytic pleocytosis. Brain imaging was abnormal in three patients. Four patients died. CONCLUSION: New-onset seizures in critically ill patients with COVID-19 should be considered as acute symptomatic seizures and the treating physician should try to determine the etiology of the seizure and manage the cause immediately and appropriately. Detailed clinical, neurological, imaging, and electrophysiological investigations and attempts to isolate SARS-CoV-2 from CSF may clarify the role played by this virus in causing seizures in these patients.

Neurological complications in a predominantly African American sample of COVID-19 predict worse outcomes during hospitalization.

People with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection, COVID-19, can have neurological problems including headache, anosmia, dysgeusia, altered mental status (AMS), ischemic stroke with or without large vessel occlusion, and Guillen-Barre Syndrome. Louisiana was one of the states hit hardest by the pandemic with just over 57,000 laboratory-confirmed cases of COVID-19 by the end of June 2020. We reviewed the electronic medical records (EMR) of patients hospitalized during the peak of the pandemic, March 1st through March 31st, to document the type and frequency of neurological problems seen in patients with COVID-19 at presentation to the emergency room. Secondary aims were to determine: 1) the frequency of neurological complaints during the hospital stay; 2) whether the presence of any neurological complaint at presentation or any of the individual types of neurological complaints at admission predicted three separate outcomes: death, length of hospital stay, or the need for intubation; and 3) if the presence of any neurological complaint or any of the individual types of neurological complaints developed during hospital stay predicted the previous three outcomes. A large proportion of our sample (80 %) was African American and had hypertension (79 %). Out of 250 patients, 56 (22 %) patients died, and 72 (29 %) patients required intubation. Thirty-four (14 %) had a neurological chief complaint at presentation; the most common neurological chief complaints in the entire sample were altered mental status (AMS) (8 %), headache (2 %), and syncope (2 %). We used a competing risk model to determine whether neurological symptoms at presentation or during hospital stay were predictors of prolonged hospital stay and death. To establish whether neurological symptoms were associated with higher odds of intubation, we used logistic regression. Age was the only significant demographic predictor of death and hospital stay. The HR (95 %CI) for remaining in the hospital for a ten-year increase in age was 1.2, (1.1, 1.3, p < 0.0001), and for death was 1.3, (1.1, 1.5, p < 0.01). There were no demographic characteristics, including age or comorbidities predictive of intubation. Adjusting for age, patients who at presentation had neurological issues as their chief complaint were at significantly increased risk for remaining in the hospital, HR = 1.7, (1.1,2.5, p = 0.0001), and dying, HR = 2.1(1.1,3.8, p = 0.02), compared to patients without any neurological complaint. Of the individual admission complaints, AMS was associated with a significantly prolonged hospital stay, HR = 1.8, (1.0-3.3, p = 0.05). Patients that required dialysis or intubation or had AMS during hospitalization had more extended hospital stays. After adjusting for age, dialysis, and intubation, patients with AMS during hospital stay had a HR of 1.6, (1.1, 2.5, p = 0.01) for remaining in the hospital. Patients who had statistically significant higher odds of requiring intubation were those who presented with any neurological chief complaint, OR = 2.8 (1.3,5.8, p = 0.01), or with headaches OR = 13.3 (2.1,257.0, p = 0.008). Patients with AMS during the hospital stay, as well as those who had seizures, were more likely to need intubation. In the multivariate model, dialysis, OR = 4.9 (2.6,9.4, p < 0.0001), and AMS, OR = 8.8 (3.9,21.2, p < 0.0001), were the only independent predictors of intubation. Neurological complaints at presentation and during the hospital stay are associated with a higher risk of death, prolonged hospital stay, and intubation. More work is needed to determine whether the cause of the neurological complaints was direct CNS involvement by the virus or the other systemic complications of the virus.

Neurological reasons for consultation and hospitalization during the COVID-19 pandemic.

BACKGROUND: COVID-19 disease affects the nervous system and led to an increase in neurological consults for patients at admission and through the period of hospitalization during the peak of the pandemic. METHODS: Patients with clinical and laboratory diagnosis of COVID-19 that required a neurologic consultation or those who presented with neurological problems on admission that led to a diagnosis of SARS-CoV-2 infection during a 2-month period at the peak of the pandemic were included in this study. Demographic and clinical variables were analyzed. RESULTS: Thirty-five patients were included. The presenting neurologic manifestations on admission led to the diagnosis of COVID-19 in 14 patients (40%). The most common reasons for consultation during the hospitalization period were stroke (11), encephalopathy (7), seizures (6), and neuropathies (5) followed by a miscellaneous of syncope (2), migraine (1), anosmia (1), critical illness myopathy (1), and exacerbation of residual dysarthria (1). The most common neurological disturbances were associated with severe disease except for neuropathies. Patients with encephalopathies and seizures had markedly increased D-dimer and ferritin values, even higher than stroke patients. RT-PCR was performed in 8 CSF samples and was negative in all of them. CONCLUSION: Neurological disturbances represent a significant and severe burden in COVID-19 patients, and they can be the presenting condition that leads to the diagnosis of the viral infection in a high percentage of patients. Evidence of direct viral mechanisms was scarce, but the pathogenesis of the diverse manifestations remains enigmatic.

The role of fit testing N95/FFP2/FFP3 masks: a narrative review.

For healthcare workers performing aerosol-generating procedures during the COVID-19 pandemic, well fitted filtering facepiece respirators, for example, N95/FFP2 or N99/FFP3 masks, are recommended as part of personal protective equipment. In this review, we evaluate the role of fit checking and fit testing of respirators, in addition to airborne protection provided by respirators. Filtering facepiece respirators are made of material with sufficient high filter capacity to protect against airborne respiratory viruses. Adequate viral protection can only be provided by respirators that properly fit the wearer's facial characteristics. Initial fit pass rates vary between 40% and 90% and are especially low in female and in Asian healthcare workers. Fit testing is recommended to ensure a proper fit of respirators for the individual healthcare worker so that alternative respirators can be selected if required. Although fit testing is required to comply with respirator standards, it is not performed consistently within all healthcare settings. Fit checking (a self-test) is recommended every time a healthcare worker dons a respirator, but is unreliable in detecting proper fit or leak. Additionally, fit testing has a high educational value and as such is best performed as part of a hospital respiratory protection programme. Whether fit checking alone, as opposed to fit tested and fit checked respirators, provides adequate airborne protection against aerosols containing the SARS-CoV-2 virus and other respiratory viruses remains unknown. While fit testing undoubtedly incurs additional costs, it is still recommended, not only to protect healthcare workers but also as it may reduce overall healthcare cost when considering the potential costs of sickness leave and the associated legal costs of compensation.

Neurological Complications of SARS-CoV-2 Infection in Children: A Systematic Review and Meta-Analysis.

BACKGROUND: Knowledge about neurological complications of COVID-19 in children is limited due to the paucity of data in the existing literature. Some systematic reviews are available describing overall clinical features of COVID-19 in children and neurological complications of COVID-19 in adults. But to the best of our knowledge, no systematic review has been performed to determine neurological manifestations of COVID-19. METHODS: Six different electronic databases (MEDLINE, EMBASE, Web of Science, CENTRAL, medRxiv and bioRxiv) were searched for articles related to COVID-19 and neurological complications in children. Studies/case series reporting neurological manifestations of COVID-19 in patients aged ≤18 years, as well as case reports, as neurological complications appear to be rare. The pooled estimate of various non-specific and specific neurological manifestations was performed using a random effect meta-analysis. RESULTS: Twenty-one studies/case series and five case reports (3707 patients) fulfilled the eligibility criteria and were included in this systematic review, from a total of 460 records. Headache, myalgia and fatigue were predominant non-specific neurological manifestations, presenting altogether in 16.7% cases. Total of 42 children (1%) were found to have been reported with definite neurological complications, more in those suffering from a severe illness (encephalopathy-25, seizure-12, meningeal signs-17). Rare neurological complications were intracranial hemorrhage, cranial nerve palsy, Guillain-Barré syndrome and vision problems. All children with acute symptomatic seizures survived suggesting a favorable short-term prognosis. CONCLUSION: Neurological complications are rare in children suffering from COVID-19. Still, these children are at risk of developing seizures and encephalopathy, more in those suffering from severe illness.