Guillain-Barré syndrome AMSAN variant in a 90-year-old woman after COVID-19: a case report.

BACKGROUND: Guillain-Barré syndrome (GBS) is an inflammatory disease of the peripheral nervous system characterized by rapidly evolving polyneuropathy caused by autoimmune demyelination and/or axonal degeneration. Since SARS-CoV-2 outbreak, several GBS cases following exposure to coronavirus disease-2019 (COVID-19) have been reported in literature, raising the concern of the latter being a potential trigger event for GBS. CASE PRESENTATION: We report the case of a 90-year-old Caucasian woman who was admitted to our hospital because of fatigue, worsening gait and leg strength, dysphonia, dysarthria and dysphagia, started 3 weeks after being exposed to COVID-19. Based on clinical presentation GBS was suspected, so she performed a lumbar puncture and electromyography, which confirmed the diagnosis of acute motor and sensory axonal neuropathy (AMSAN) variant. We administered high dose of intravenous immunoglobulin with slight neurological improvement. However, after 2 weeks of hospitalization with maximization of care, her physical condition worsen, manifesting severe frailty. The patient was discharged with home support services for managing parenteral nutrition and intense scheduled physiotherapy. A few days later, the patient experienced a further decline in her clinical condition and died at home. CONCLUSIONS: To the best of our knowledge, we report the oldest woman with GBS AMSAN variant after COVID-19 described in the existing literature. Our case supports further research aimed at improving recognition, characterization and prompt management of neurological diseases related to COVID-19 in older patients.

The effect of frailty on in-hospital and medium-term mortality of patients with COronaVIrus Disease-19: the FRACOVID study.

BACKGROUND: Older people hospitalized for COVID-19 are at highest risk of death. Frailty Assessment can detect heterogeneity in risk among people of the same chronological age. We investigated the association between frailty and in-hospital and medium-term mortality in middle-aged and older adults with COVID-19 during the first two pandemic waves. METHODS: This study is an observational multicenter study. We recorded sociodemographic factors (age, sex), smoking status, date of symptom onset, biological data, need for supplemental oxygen, comorbidities, cognitive and functional status, in-hospital mortality. We calculated a Frailty Index (FI) as the ratio between deficits presented and total deficits considered for each patient (theoretical range 0-1). We also assessed the Clinical Frailty Scale (CFS). Mortality at follow-up was ascertained from a regional registry. RESULTS: In total, 1344 patients were included; median age 68 years (Q1-Q3, 56-79); 857 (64%) were men. Median CFS score was 3 (Q1-Q3 2-5) and was lower in younger vs. older patients. Median FI was 0.06 (Q1-Q3 0.03-0.09) and increased with increasing age. Overall, 244 (18%) patients died in-hospital and 288 (22%) over a median follow-up of 253 days. FI and CFS were significantly associated with risk of death. In two different models using the same covariates, each increment of 0.1 in FI increased the overall hazard of death by 35% (HR=1.35, 95%CI 1.23-1.48), similar to the hazard for each increment of CFS (HR=1.37, 95%CI 1.25-1.50). CONCLUSIONS: Frailty, assessed with the FI or CFS, predicts in-hospital and medium-term mortality and may help estimate vulnerability in middle-aged and older COVID-19 patients.

Delirium in Patients with SARS-CoV-2 Infection: A Multicenter Study.

OBJECTIVES: The aims of this study are to report the prevalence of delirium on admission to the unit in patients hospitalized with SARS-CoV-2 infection, to identify the factors associated with delirium, and to evaluate the association between delirium and in-hospital mortality. DESIGN: Multicenter observational cohort study. SETTINGS: Acute medical units in four Italian hospitals. PARTICIPANTS: A total of 516 patients (median age 78 years) admitted to the participating centers with SARS-CoV-2 infection from February 22 to May 17, 2020. MEASUREMENTS: Comprehensive medical assessment with detailed history, physical examinations, functional status, laboratory and imaging procedures. On admission, delirium was determined by the Diagnostic and Statistical Manual of Mental Disorders (5th edition) criteria, 4AT, m-Richmond Agitation Sedation Scale, or clinical impression depending on the site. The primary outcomes were delirium rates and in-hospital mortality. RESULTS: Overall, 73 (14.1%, 95% confidence interval (CI) = 11.0-17.3%) patients presented delirium on admission. Factors significantly associated with delirium were dementia (odds ratio, OR = 4.66, 95% CI = 2.03-10.69), the number of chronic diseases (OR = 1.20, 95% CI = 1.03; 1.40), and chest X-ray or CT opacity (OR = 3.29, 95% CI = 1.12-9.64 and 3.35, 95% CI = 1.07-10.47, for multiple or bilateral opacities and single opacity vs no opacity, respectively). There were 148 (33.4%) in-hospital deaths in the no-delirium group and 43 (58.9%) in the delirium group (P-value assessed using the Gray test <.001). As assessed by a multivariable Cox model, patients with delirium on admission showed an almost twofold increased hazard ratio for in-hospital mortality with respect to patients without delirium (hazard ratio = 1.88, 95% CI = 1.25-2.83). CONCLUSION: Delirium is prevalent and associated with in-hospital mortality among older patients hospitalized with SARS-CoV-2 infection.

Delirium: A Marker of Vulnerability in Older People

Delirium is the clinical expression of an acute cerebral dysfunction caused by various noxious insults. Its prevalence is very high in the elderly, especially in the hospital setting, and in older patients it can be the presenting symptom of an acute underlying disease. Delirium is associated with several adverse clinical and functional outcomes, along with cognitive decline, institutionalization, and short- and long-term mortality. It is thus crucial to increase the attention on this geriatric syndrome, which has been demonstrated to be prevented in a large proportion of cases. Delirium is not only a marker of patient vulnerability and clinical instability, but also an index of the quality of care and the efficiency of its organization. By systematically assessing the presence of delirium during the whole length of hospital stay, physicians may closely monitor the patient’s clinical status. The aims of this chapter are to review the current clinical practice in delirium, focusing particularly on older and frail individuals. The topics covered include epidemiology and outcomes, causes, clinical features and diagnosis, prevention and treatment. Finally, implications for clinical practice are discussed.

Helmet CPAP to treat hypoxic pneumonia outside the ICU: an observational study during the COVID-19 outbreak.

BACKGROUND: Respiratory failure due to COVID-19 pneumonia is associated with high mortality and may overwhelm health care systems, due to the surge of patients requiring advanced respiratory support. Shortage of intensive care unit (ICU) beds required many patients to be treated outside the ICU despite severe gas exchange impairment. Helmet is an effective interface to provide continuous positive airway pressure (CPAP) noninvasively. We report data about the usefulness of helmet CPAP during pandemic, either as treatment, a bridge to intubation or a rescue therapy for patients with care limitations (DNI). METHODS: In this observational study we collected data regarding patients failing standard oxygen therapy (i.e., non-rebreathing mask) due to COVID-19 pneumonia treated with a free flow helmet CPAP system. Patients' data were recorded before, at initiation of CPAP treatment and once a day, thereafter. CPAP failure was defined as a composite outcome of intubation or death. RESULTS: A total of 306 patients were included; 42% were deemed as DNI. Helmet CPAP treatment was successful in 69% of the full treatment and 28% of the DNI patients (P < 0.001). With helmet CPAP, PaO2/FiO2 ratio doubled from about 100 to 200 mmHg (P < 0.001); respiratory rate decreased from 28 [22-32] to 24 [20-29] breaths per minute, P < 0.001). C-reactive protein, time to oxygen mask failure, age, PaO2/FiO2 during CPAP, number of comorbidities were independently associated with CPAP failure. Helmet CPAP was maintained for 6 [3-9] days, almost continuously during the first two days. None of the full treatment patients died before intubation in the wards. CONCLUSIONS: Helmet CPAP treatment is feasible for several days outside the ICU, despite persistent impairment in gas exchange. It was used, without escalating to intubation, in the majority of full treatment patients after standard oxygen therapy failed. DNI patients could benefit from helmet CPAP as rescue therapy to improve survival. TRIAL REGISTRATION: NCT04424992.