Neurologic manifestations in hospitalized patients with COVID-19 in Mexico City

Background The coronavirus disease 2019 (COVID-19) is a systemic entity that frequently implies neurologic features at presentation and complications during the disease course. We aimed to describe the characteristics and predictors for developing in-hospital neurologic manifestations in a large cohort of hospitalized patients with COVID-19 in Mexico City. Methods We analyzed records from consecutive adult patients hospitalized from March 15 to June 30, 2020, with moderate to severe COVID-19 confirmed by reverse transcription real-time polymerase chain reaction (rtRT-PCR) for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Neurologic syndromes were actively searched by a standardized structured questionnaire and physical examination, confirmed by neuroimaging, neurophysiology of laboratory analyses, as applicable. Results We studied 1,072 cases (65% men, mean age 53.2±13 years), 71 patients had pre-existing neurologic diseases (diabetic neuropathy: 17, epilepsy: 15, history of ischemic stroke: eight, migraine: six, multiple sclerosis: one, Parkinson disease: one), and 163 (15.2%) developed a new neurologic complication. Headache (41.7%), myalgia (38.5%), dysgeusia (8%), and anosmia (7%) were the most common neurologic symptoms at hospital presentation. Delirium (13.1%), objective limb weakness (5.1%), and delayed recovery of mental status after sedation withdrawal (2.5%), were the most common new neurologic syndromes. Age, headache at presentation, preexisting neurologic disease, invasive mechanical ventilation, and neutrophil/lymphocyte ratio ≥9 were independent predictors of new in-hospital neurologic complications. Conclusions Even after excluding initial clinical features and pre-existing comorbidities, new neurologic complications in hospitalized patients with COVID-19 are frequent and can be predicted from clinical information at hospital admission.

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Clinical Characteristics and Outcomes in Hospitalized Patients with Proven and Probable Coccidioidomycosis at the National Institute of Respiratory Diseases in Mexico City

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.040 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S86-S87

Author(s):

Jose Arturo Martinez-Orozco ◽

Angelina Contreras-Cortez ◽

Fernando Morales-Villareal ◽

Eduardo Becerril Vargas

Keyword(s):

Mexico City ◽

Clinical Characteristics ◽

Respiratory Diseases ◽

Invasive Mechanical Ventilation ◽

Hospitalized Patients ◽

Dimorphic Fungi ◽

Lower Survival ◽

The North ◽

Health Report ◽

Disseminated Disease

Abstract Background Coccidioides spp. an endemic dimorphic fungi is present in the north and south of Mexico. The Ministry of Health report in Mexico between 1988 and 1994 0.5 to 1.3 cases per 100,000 habitants. The clinical picture ranges from asymptomatic to disseminated disease. They should be classified according to the EORTC/MSG criteria in proven and probable disease, in Mexico there is no study about clinical characteristics and outcomes in hospitalized patients according to this classification. Objective Evaluate the clinical characteristics and outcomes in hospitalized patients with proven and probable coccidioidomycosis according to EORTC/MSG criteria. Methods The National Institute of Respiratory Diseases in Mexico City is the national referral center for complicated pulmonary infectious diseases. This retrospective cohort from 2010 to 2016 included proven and probable Coccidioidomycosis hospitalized patients classified according to EORTC/MSG 2008 criteria. We collected data about clinical characteristics on admission and outcomes. Results Fifty-seven patients were evaluated, 26 proven and 31 probable, mean age was 43 years. The proven group was associated with DM2 OR 2.8 (IC95% 1.1–7, P = 0.014) and hemoptysis OR 3.2 (IC95% 1.1–9, P = 0.013), the probable group with dyspnea OR 3.5 (IC 95% 1.08–11, P = 0.024), high respiratory rate 27.2 ± 13 vs. 22 ± 3.3 (P = 0.05), and low O2 saturation 83.97% ± 11.1 vs. 91.8% ± 4.31 (P < 0.001). In the proven group, multiple cavities in CT scan were more frequent. The probable had association with severe ARDS (P 0.011), use of invasive mechanical ventilation (P 0.025), and increase in mortality 14% vs. 1.8% OR 1.2 (IC95% 1.03–1.6 P = 0.025) with lower survival in Kaplan–Meier (P < 0.02). In the proven group, there was more disseminated disease (P <0.001), HIV was associated with lower survival (P <0.001) and they received more days of antifungal treatment 109.5 ± 127 vs. 59.8 ± 93 days. Amphotericin B was the most prescribed in both groups. Conclusion At present, we do not use the EORTC/MSG criteria due to lack of tests in our country, in this study the probable group referred usually from community centers had worse outcome and clinical characteristics, that is why we cannot underestimate this group of patients. We need to have better diagnostic tests in order to identify promptly these patients and avoid a late disease presentation. Disclosures All authors: No reported disclosures.

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Z-line degradation and phagocytosis of sarcomeric fragments in myonecrosis

Proceedings, annual meeting, Electron Microscopy Society of America ◽

10.1017/s0424820100077529 ◽

1983 ◽

Vol 41 ◽

pp. 790-791

Author(s):

Melinda L. Estes ◽

Samuel M. Chou

Keyword(s):

Vastus Lateralis ◽

Inflammatory Myopathy ◽

Muscle Disease ◽

White Female ◽

Inflammatory Cell Infiltrate ◽

Limb Weakness ◽

Muscle Diseases ◽

History Of ◽

The Right ◽

Mononuclear Inflammatory Cell

Many muscle diseases show common pathological features although their etiology is different. In primary muscle diseases a characteristic finding is myofiber necrosis. The mechanism of myonecrosis is unknown. Polymyositis is a primary muscle disease characterized by acute and subacute degeneration as well as regeneration of muscle fibers coupled with an inflammatory infiltrate. We present a case of polymyositis with unusual ultrastructural features indicative of the basic pathogenetic process involved in myonecrosis.The patient is a 63-year-old white female with a one history of proximal limb weakness, weight loss and fatigue. Examination revealed mild proximal weakness and diminished deep tendon reflexes. Her creatine kinase was 1800 mU/ml (normal < 140 mU/ml) and electromyography was consistent with an inflammatory myopathy which was verified by light microscopy on biopsy muscle. Ultrastructural study of necrotizing myofiber, from the right vastus lateralis, showed: (1) degradation of the Z-lines with preservation of the adjacent Abands including M-lines and H-bands, (Fig. 1), (2) fracture of the sarcomeres at the I-bands with disappearance of the Z-lines, (Fig. 2), (3) fragmented sarcomeres without I-bands, engulfed by invading phagocytes, (Fig. 3, a & b ), and (4) mononuclear inflammatory cell infiltrate in the endomysium.

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Risk Factors for Undernutrition at Admission Among Adult Hospitalized Patients at a Referral Hospital in Indonesia

SAGE Open ◽

10.1177/2158244020983310 ◽

2021 ◽

Vol 11 (5) ◽

pp. 215824402098331

Author(s):

Nur Chandra Bunawan ◽

Dwi Suseno ◽

Drupadi H. S. Dillon ◽

Ikhwan Rinaldi ◽

Dyah Purnamasari

Keyword(s):

Associated Factors ◽

Multivariate Analyses ◽

Gastrointestinal Disease ◽

Cross Sectional Study ◽

Hospitalized Patients ◽

Bivariate Analysis ◽

Cross Sectional ◽

Neutrophil Lymphocyte Ratio ◽

Initial Hospital ◽

Comorbidity Index

Patients with undernutrition at admission have higher risks to worsen their nutritional status, which is linked to an increase in morbidity and mortality. This study investigated the prevalence of undernutrition at admission and its associated factors. A cross-sectional study was conducted on patients aged 18 to 59 years old in Internal Medicine ward at Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia, between July and September 2019. Factors that might be associated with undernutrition at admission, such as age, sex, marital status, Charlson Comorbidity Index (CCI) and type of comorbidity, depression, and neutrophil–lymphocyte ratio (NLR), were assessed. Bivariate and multivariate analyses were used to determine the associated factors. Sixty hospitalized patients with median age of 42 years and 76.7% with married status joined the study. The most common reason for hospitalization was acute gastrointestinal disease with gallstones as the most common comorbidity. Undernutrition exists in 26.7% of subjects. High CCI score was observed among 11.7% subjects and half of subjects had NLR category ≥5. Bivariate analysis revealed that unmarried status, age ≥40 years, and malignancy were associated with undernutrition at admission. Logistic regression analysis showed malignancy as an independent predictor of undernutrition during the initial hospital admission (odds ratio [OR] = 11.8; 95% confidence interval [CI]: [1.1, 125.7]). The prevalence of undernutrition at admission was 26.7%. Factors associated with an increased prevalence of undernutrition at admission were age <40 years, unmarried status, and malignancy. Malignancy was an independent factor of the prevalence of undernutrition at admission.

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Etiology, incidence, and outcomes of patient–ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation

Scientific Reports ◽

10.1038/s41598-021-90013-z ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Yongfang Zhou ◽

Steven R. Holets ◽

Man Li ◽

Gustavo A. Cortes-Puentes ◽

Todd J. Meyer ◽

...

Keyword(s):

Risk Factors ◽

Mechanical Ventilation ◽

Critically Ill ◽

Critically Ill Patients ◽

Invasive Mechanical Ventilation ◽

Surgical Intensive Care ◽

Mechanically Ventilated ◽

History Of ◽

Training Background ◽

The Relationship

AbstractPatient–ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.

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Empiric use of anticoagulation in hospitalized patients with COVID-19: a propensity score-matched study of risks and benefits

Biomarker Research ◽

10.1186/s40364-021-00283-y ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Bo Yu ◽

Victor Perez Gutierrez ◽

Alex Carlos ◽

Gregory Hoge ◽

Anjana Pillai ◽

...

Keyword(s):

Mechanical Ventilation ◽

Propensity Score ◽

Propensity Score Matching ◽

Major Bleeding ◽

Risk Estimation ◽

Large Population ◽

Invasive Mechanical Ventilation ◽

Bleeding Risk ◽

Hospitalized Patients ◽

Significant Difference

Abstract Background Hospitalized patients with COVID-19 demonstrate a higher risk of developing thromboembolism. Anticoagulation (AC) has been proposed for high-risk patients, even without confirmed thromboembolism. However, benefits and risks of AC are not well assessed due to insufficient clinical data. We performed a retrospective analysis of outcomes from AC in a large population of COVID-19 patients. Methods We retrospectively reviewed 1189 patients hospitalized for COVID-19 between March 5 and May 15, 2020, with primary outcomes of mortality, invasive mechanical ventilation, and major bleeding. Patients who received therapeutic AC for known indications were excluded. Propensity score matching of baseline characteristics and admission parameters was performed to minimize bias between cohorts. Results The analysis cohort included 973 patients. Forty-four patients who received therapeutic AC for confirmed thromboembolic events and atrial fibrillation were excluded. After propensity score matching, 133 patients received empiric therapeutic AC while 215 received low dose prophylactic AC. Overall, there was no difference in the rate of invasive mechanical ventilation (73.7% versus 65.6%, p = 0.133) or mortality (60.2% versus 60.9%, p = 0.885). However, among patients requiring invasive mechanical ventilation, empiric therapeutic AC was an independent predictor of lower mortality (hazard ratio [HR] 0.476, 95% confidence interval [CI] 0.345–0.657, p < 0.001) with longer median survival (14 days vs 8 days, p < 0.001), but these associations were not observed in the overall cohort (p = 0.063). Additionally, no significant difference in mortality was found between patients receiving empiric therapeutic AC versus prophylactic AC in various subgroups with different D-dimer level cutoffs. Patients who received therapeutic AC showed a higher incidence of major bleeding (13.8% vs 3.9%, p < 0.001). Furthermore, patients with a HAS-BLED score of ≥2 had a higher risk of mortality (HR 1.482, 95% CI 1.110–1.980, p = 0.008), while those with a score of ≥3 had a higher risk of major bleeding (Odds ratio: 1.883, CI: 1.114–3.729, p = 0.016). Conclusion Empiric use of therapeutic AC conferred survival benefit to patients requiring invasive mechanical ventilation, but did not show benefit in non-critically ill patients hospitalized for COVID-19. Careful bleeding risk estimation should be pursued before considering escalation of AC intensity.

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Dissociative disorder – unraveling the mystery

European Psychiatry ◽

10.1016/j.eurpsy.2016.01.1132 ◽

2016 ◽

Vol 33 (S1) ◽

pp. S327-S327

Author(s):

L. Sousa ◽

A. Antunes ◽

S. Oliveira

Keyword(s):

Romantic Relationship ◽

Clinical Information ◽

Dissociative Disorders ◽

Dissociative Disorder ◽

Clinical Interviews ◽

Medical Interventions ◽

Brazilian Woman ◽

History Of ◽

Competing Interest ◽

Car Accident

IntroductionDissociative disorders are among the most enigmatic and controversial psychiatric pathologies. In the last decades, great interest has emerged in understanding its pathophysiology, nonetheless, problems in recognition and management of these disorders are still challenging the psychiatric community.ObjectivesWe describe a paradigmatic case of a dissociative disorder illustrating the “choice” of dissociation as a strategy for coping with a traumatic reality.AimCall attention to problems that interfere with the recognition, diagnosis and management of dissociative disorders.MethodsBibliographic research was conducted through the PubMed in the Medline library and clinical information was obtained through medical records and clinical interviews with the patient.ResultsA 51-year-old Brazilian woman with no psychiatric history presented to the psychiatric outpatient care with apparent dissociative symptoms, these consisted of amnesia for episodes of agitation and aggressive behavior that occurred mainly at bed time. She had been previously on general practice and neurology consultations but none organic diagnose was made. Already in psychiatry, it was recognized that those symptoms developed together after a car accident and the beginning of a romantic relationship. It was also recognized that she has sexual dysfunction and a history of sexual abuse by a family member during her childhood, a known risk factor to dissociative disorders.ConclusionsSkepticism and lack of understanding might be the reason for late psychiatric referral after the realization of various expensive and time-consuming medical exams. Improving the recognition of dissociative disorders will conduce not only to better clinical outcomes but also improve cost effectivity of medical interventions.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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Abstract TP41: Prevalence and Factors Associated with Early Ischemic Changes on Non-contrast CT Obtained Less Than 90 Minutes After Symptom Onset

Stroke ◽

10.1161/str.48.suppl_1.tp41 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jared Noroozi ◽

David S Liebeskind ◽

Jeffrey L Saver ◽

Sidney Starkman ◽

Juan Pablo Villablanca ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Ischemia ◽

Symptom Onset ◽

Clinical Information ◽

Final Diagnosis ◽

Factors Associated ◽

History Of ◽

Artery Disease ◽

Initial Imaging ◽

Contrast Ct

Background: Usually early infarct signs on imaging take a few hours to develop in ischemic stroke. There may be a subset of patients manifesting early infarct signs on imaging hyperacutely. Objective: To determine the prevalence and factors associated with very early infarct signs on ASPECTS among patients with cerebral ischemia who were imaged <90 minutes after symptom onset. Methods: Subjects participating in the NIH Field Administration of Stroke Therapy- Magnesium (FAST-MAG) phase 3 clinical trial with a final diagnosis of cerebral ischemia (TIA or Stroke) and initial imaging performed <90 minutes from last known well time (LKWT) were included. ASPECTS was graded by a neuroradiologist (JPV) blinded to all clinical information. Individual subjects were characterized as having no early ischemic changes (ASPECTS 10) vs. early ischemic changes (ASPECTS 0-9). We describe the prevalence of early ischemic signs in this prospectively enrolled cohort, clinical factors associated with early ischemic changes as well as outcomes. Results: There were 566 cases imaged a mean of 71 (SD 11) minutes after LKWT. Mean age was 69 (SD 13), 43% women, 93% ischemic stroke, 7% TIA, median emergency department NIHSS 8 (IQR 3-16), median ASPECTS score of 10 (IQR 7-10, range 1-10). There were 200 cases with early ischemic findings (35%). Early ischemic changes were not related to age, blood pressure, history of hypertension, diabetes, dyslipidemia, coronary artery disease, or time to imaging (71 vs. 71 mins). Early ischemic changes were more commonly noted in women (50% vs. 39%, p=0.015) and associated higher presenting NIHSS (14 [IQR 7-20] vs 5 [IQR 2-11], p<0.001). The presence of any hyperacute ischemia change was associate with worse 90-day outcome (modified Rankin score 3 [IQR 1-5] vs 1 [IQR 0-3, p<0.001). Conclusions: Early ischemic changes were noted on about 1/3 rd of imaging obtained <90 minutes after symptom onset. The presence of hyperacute ischemic changes is associated with more severe stroke and poor clinical outcomes.

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Association Between the Diabetes mellitus Duration and the Severity of Diabetic Foot Disease in Hospitalized Patients in Latin America

The International Journal of Lower Extremity Wounds ◽

10.1177/15347346211063266 ◽

2021 ◽

pp. 153473462110632

Author(s):

Belissa Bedriñana-Marañón ◽

Maria Rubio-Rodríguez ◽

Marlon Yovera-Aldana ◽

Eilhart Garcia-Villasante ◽

Isabel Pinedo-Torres

Keyword(s):

Diabetes Mellitus ◽

Latin America ◽

Diabetic Foot ◽

Poisson Regression ◽

Hospitalized Patients ◽

Bivariate Analysis ◽

Severe Injuries ◽

History Of ◽

Diabetic Foot Disease ◽

Foot Disease

The objective was to determine the association between a diabetes mellitus duration greater than 10 years and the severity of diabetic foot in hospitalized patients in Latin America. Analytical, observational, and retrospective study based in secondary databases. Patients older than 18 years with diagnosis of diabetes mellitus (DM) and hospitalized for any causes were included. The independent and dependent variables were having more than 10 years of diagnosis of DM and the severity of the diabetic foot disease (Wagner> = 2), respectively. A crude Poisson regression analysis was performed to obtain prevalence rates adjusted to confounders. Male gender was 54.8% and the median age was 62 years. In the group with more than10 years of disease (n = 903) 18% (n = 162) had severe injuries. We performed two Poisson regression analyzes, one of which included the entire sample; and in the other, only patients with some degree of ulcer were included at the time of evaluation (Wagner > = 1). In the first analysis the PR was 1.95 ( p < 0.01) adjusted for the significant variables in the bivariate analysis and in the second analysis the PR was 1.18 ( p < 0.01) adding to the adjustment the days of injury prior to hospitalization and the location of the ulcer. We conclude that in patients with more than 10 years of diabetes mellitus, diabetic foot injuries are more severe, regardless type of diabetes, gender, age, history of amputation and days of injury prior to hospitalization for inpatients in Latin America.

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Do Hospital Doctors Screen for Diabetes?

Experimental and Clinical Endocrinology & Diabetes ◽

10.1055/a-0598-4682 ◽

2018 ◽

Vol 127 (08) ◽

pp. 511-516

Author(s):

Marie Méan ◽

Gérard Waeber ◽

Pedro Marques-Vidal

Keyword(s):

Previous History ◽

Hospitalized Patients ◽

Antidiabetic Drug ◽

Prediabetic State ◽

High Detection Rate ◽

High Detection ◽

Discharge Letter ◽

History Of ◽

Hospital Doctors ◽

Hba1c Measurement

Abstract Background One in five hospitalized patients presents with previously undetected diabetes mellitus (DM). We assessed whether hospital doctors measure HbA1c in hospitalized patients and act consequently. Methods Data from patients hospitalized between January 2013 and December 2014 in a Swiss teaching hospital was collected. We assessed the frequency of HbA1c measurements and the number of newly detected prediabetes or DM. We also examined whether HbA1c values were associated with the antidiabetic drugs prescription and reporting of DM in the discharge letter. Results Of the 2618 patients studied, 298 (11.4%) had HbA1c measured, of whom 136 (45.6%) had no previous history of DM. Of the 136 patients without history of DM, 51 (37.5%) had prediabetic state and 23 (16.9%) had DM. Newly detected prediabetes or DM were reported in 5.8% (3/51) and 65.8% of cases (15/23), respectively. Only half of patients (11/23, 47.8%) with newly detected DM received antidiabetic drug treatment at discharge. Patients with newly detected DM (n=23) had a longer length of stay (median and interquartile range: 16 [9–25] versus 10 [8–16] days, p=0.028) compared to patients without DM, while no such differences were found regarding in-hospital mortality. Conclusions Hospital doctors seldom prescribe HbA1c measurement in medical hospitalized patients. Prescription of HbA1c measurement leads to a high detection rate (53%) of (pre)DM among patients unaware of their status, but management and reporting of these conditions at discharge could be further improved.

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COVID-IRS: A novel predictive score for risk of invasive mechanical ventilation in patients with COVID-19

PLoS ONE ◽

10.1371/journal.pone.0248357 ◽

2021 ◽

Vol 16 (4) ◽

pp. e0248357

Author(s):

José Antonio Garcia-Gordillo ◽

Antonio Camiro-Zúñiga ◽

Mercedes Aguilar-Soto ◽

Dalia Cuenca ◽

Arturo Cadena-Fernández ◽

...

Keyword(s):

Mechanical Ventilation ◽

Systemic Disease ◽

Invasive Mechanical Ventilation ◽

Area Under The Curve ◽

Lactic Dehydrogenase ◽

Total Sample ◽

Adverse Outcomes ◽

Predictive Score ◽

Neutrophil Lymphocyte Ratio ◽

Predictive Variables

Background Coronavirus disease 2019 (COVID-19) is a systemic disease that can rapidly progress into acute respiratory failure and death. Timely identification of these patients is crucial for a proper administration of health-care resources. Objective To develop a predictive score that estimates the risk of invasive mechanical ventilation (IMV) among patients with COVID-19. Study design Retrospective cohort study of 401 COVID-19 patients diagnosed from March 12, to August 10, 2020. The score development cohort comprised 211 patients (52.62% of total sample) whereas the validation cohort included 190 patients (47.38% of total sample). We divided participants according to the need of invasive mechanical ventilation (IMV) and looked for potential predictive variables. Results We developed two predictive scores, one based on Interleukin-6 (IL-6) and the other one on the Neutrophil/Lymphocyte ratio (NLR), using the following variables: respiratory rate, SpO2/FiO2 ratio and lactic dehydrogenase (LDH). The area under the curve (AUC) in the development cohort was 0.877 (0.823–0.931) using the NLR based score and 0.891 (0.843–0.939) using the IL-6 based score. When compared with other similar scores developed for the prediction of adverse outcomes in COVID-19, the COVID-IRS scores proved to be superior in the prediction of IMV. Conclusion The COVID-IRS scores accurately predict the need for mechanical ventilation in COVID-19 patients using readily available variables taken upon admission. More studies testing the applicability of COVID-IRS in other centers and populations, as well as its performance as a triage tool for COVID-19 patients are needed.

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