Palliative care in Hospitalized Middle-Aged and Older Adults With COVID-19.

CONTEXT: As COVID-19 overwhelms health systems worldwide, palliative care strategies may ensure rational use of resources while safeguarding patient comfort and dignity. OBJECTIVE: To describe palliative care practices in hospitalized middle-aged and older adults in two of the largest COVID-19 treatment centers in Sao Paulo, Brazil. METHODS: Retrospective cohort. Eligible patients were those aged 50 years or older hospitalized between March and May 2020 with a laboratory confirmation of SARS-CoV-2 infection. Palliative care implementation was defined as present if medical notes indicated a decision to limit escalation of life support measures, or when opioids or sedatives were prescribed for palliative management of symptoms. RESULTS: We included 1162 participants (57% male, median 65 years). Overall, 21% were frail and 54% were treated in intensive care units, but only 17% received palliative care. Stepwise logistic regression demonstrated that age ≥80 years, dementia, history of stroke or cancer, frailty, having a PaO2/FiO2<200 or a C-reactive protein ≥150mg/dL at admission predicted palliative care implementation. Patients placed under palliative care stayed longer (13 vs.11 days) and were more likely to die in hospital (86 vs.27%). They also spent more days in ICU and received vasoactive drugs, hemodialysis, and invasive ventilation more frequently. CONCLUSIONS: One in five middle-aged and older adults hospitalized with COVID-19 received palliative care in our cohort. Patients who were very old, multimorbid, frail, and had severe COVID-19 were more likely to receive palliative care. However, it was often delayed until advanced and invasive life support measures had already been implemented.

Hypercaloric high-lipid diet and brain development: effects on cortical spreading depression in adult rats.

UNLABELLED: Nutritional conditions early in life constitute one of the environmental factors that can influence brain electrophysiology, as evaluated through the phenomenon denominated as cortical spreading depression (CSD). OBJECTIVE: To evaluate the effects of hypercaloric diet intake in different phases of life on CSD features in adult rats. METHODS: Newborn Wistar rats were suckled by dams fed a high-lipid (cafeteria) hypercaloric diet during the lactation period. After suckling, part of the pups remained in the high-lipid diet until the end of the experiment in adulthood (group 'full-life' FL), and the other part received the control (lab chow) diet (group L). A third group received the hypercaloric diet only at adulthood (group Ad). When the animals reached 90-93 days of life, CSD was recorded. RESULTS: CSD propagation velocities (in mm/minute) and CSD amplitudes (in mV) were reduced (P < 0.05) in the groups L (2.77 ± 0.07 and 7.1 ± 2.0 for velocity and amplitude, respectively) and FL (3.05 ± 0.17 and 8.5 ± 1.9), but not in the group Ad (3.36 ± 0.11 and 10.7 ± 2.0), in comparison with a control group (C), fed the lab chow diet during the entire life (3.52 ± 0.18 and 10.8 ± 2.2). DISCUSSION: CSD velocity changes observed in adulthood were associated with the hypercaloric dietary treatment during brain development, constituting evidence in favor of permanent or at least long-lasting electrophysiological effects related to the prevailing nutritional status during the period of brain growth spurt.

Differential effects of physical exercise and L-arginine on cortical spreading depression in developing rats.

OBJECTIVE: We investigated the effect of early-in-life administration of L-arginine, combined with physical exercise, on cortical spreading depression (CSD) in young and adult rats. METHODS: L-arginine (300 mg/kg/day, n = 40) or distilled water (vehicle, n = 40) was given to the rats during postnatal days 7-35 by gavage. Physical exercise (treadmill) was carried out during postnatal days 15-35 in half of the animals in each gavage condition described above. The other half (non-exercised) was used for comparison. When the animals reached 35-45 days (young groups) or 90-120 days of age (adult) CSD was recorded on two cortical points during 4 hours and CSD propagation velocity was calculated. RESULTS: L-arginine-treated + exercised rats had increased body weight, but not brain weight, in adult age compared to L-arginine + non-exercised ones (P < 0.05). In both young and adult animals, L-arginine increased, whereas exercise decreased the CSD propagation velocity. Analysis of variance revealed a significant interaction between gavage treatment and age (P < 0.001), and also between gavage treatment and exercise (P = 0.004), but not between age and exercise. An additional control group of young rats, treated with 300 mg/kg of L-histidine, presented CSD velocities comparable to the corresponding water-treated controls, suggesting that the CSD acceleration seen in the L-arginine group was an L-arginine-specific effect, rather than an effect due to a non-specific amino acid imbalance. DISCUSSION: L-arginine and exercise affect CSD differentially (L-arginine accelerated, while exercise decelerated CSD), and both effects did interact. Probably, they depend on developmental plasticity changes associated with the treatments.