26.05.2020

Clinical characteristics and outcomes of inpatients with neurologic disease and COVID-19 in Brescia, Lombardy, Italy

Epidemiological Neurology
Benussi A et al
Neurology

Main result

  • 214 adult patients were hospitalised in the neurology and vascular neurology unit of the ASST Spedali Civili di Brescia Hospital from 21 February to 5 April 2020.
  • Exclusion of 41 patients who were still hospitalized on April 5, 2020 and inclusion of 173 patients who were ultimately hospitalized. Of these, 56 (32.4%) tested positive for COVID-19 and were admitted to the neuro-COVID unit.
  • Compared to non-COVID-19 patients, patients with COVID-19 were older (77.0, IQR 67.0-83.8 vs. 70.1, IQR 52.9-78.6, p = 0.006), had a different distribution regarding admission diagnoses, particularly for cerebrovascular disorders (n = 43, 76.8% vs. n = 68, 58.1%, p = 0.035), and had a higher rapid SOFA score at admission (0.5, IQR 0.4-0.6 vs. 0.9, IQR 0.7-1.1, p = 0.006). No significant differences were observed for co-morbidities including diabetes, high cholesterol, hypertension, coronary heart disease, chronic kidney disease, immunodeficiency or malignancy (all p>0.050). COVID-19 patients had higher in-hospital mortality (n = 21, 37.5% vs. n = 5, 4.3%, p < 0.0 01), a higher incidence of delirium (n = 15, 26.8% vs. n = 9, 7.7%, p = 0.003) and fever (n = 27, 48.2% vs. n = 14, 12.0%, p < 0.001), while the days of hospitalization were similar (n = 6.0 IQR 3.3-10.0 vs. 5.0, IQR 4.0-8.0, p = 0.4 24). Among patients who were discharged (excluding in-hospital deaths), the days of hospitalization increased for COVID-19 patients (8.0, IQR 5.0-11.0 vs. 5.0, IQR 4.0-8.0, p = 0.005).
  • Treatments were different between the two groups, with greater use of high-flow oxygenation (n = 43, 76.8% vs. n = 11, 9.4%, p < 0.001), antibiotic therapy (n = 36, 67.9% vs. n = 19, 16.2%, p < 0.001) and antiviral therapy (n = 38, 67.9% vs. n = 2, 1.7%, p < 0.001) in the COVID-19 group.
  • Patients with COVID-19 had poorer functional outcomes as measured by SRM (5.0, IQR 2.3-6.0 vs. 2.0, IQR 1.0-3.0, p <0.001), with similar premorbid SRM scores (1.0, IQR 1.0-2.0 vs. 1.0, IQR 0.0-2.0, p = 0.9 03). Significant increase in rates of cerebrovascular disease in the COVID-19 group (n = 43, 76.8% vs. n = 68, 58.1%, p = 0.018), with a similar distribution among transient ischemic attacks (n = 5, 11.6% vs. n = 8, 11.9%), ischemic stroke (n = 35, 81.4% vs. n = 50, 74.6%) and hemorrhagic stroke (n = 3, 7.0% vs. n = 9, 13.4%) within the groups, p = 0.560.
  • Univariate analysis, increased age, elevated rapid-read SOFA score, thrombocytopenia, elevated C-reactive protein and lactate dehydrogenase were associated with in-hospital death in the COVID-19 group. In the multivariate logistic regression model, we found that higher rapid SOFA scores (odds ratio 4.47, 95% CI 1.21-16.50; p = 0.0 25), lower platelets (0.98, 0.97-0.99; p = 0.0 05) and higher lactate dehydrogenase (1.01, 1.00-1.03; p = 0.009) at admission were all associated with an increased risk of death in COVID-19 patients.

Takeaways

  • The authors observed a significant increase in stroke rates in patients with COVID-19, with poorer outcomes compared to the non-COVID-19 group, including higher SRI scores at discharge and significantly fewer patients with good outcomes.
  • COVID-19 patients admitted for neurological disease, including stroke, have significantly higher in-hospital mortality, risk of delirium and disability than non-COVID-19 patients .
  • Large retrospective cohort study among patients with neurological disorders and COVID-19 with a definitive outcome.

Strength of evidence Moderate

- Large retrospective cohort study.
- Due to the retrospective nature of the study, not all laboratory tests were performed on all patients.
- Several factors were not taken into account due to the retrospective design (stroke subtypes, infarction volume, and recanalization rates).
- Selection bias due to the reluctance of patients with COVID-related symptoms or infection to come forward for neurological assessment in hospital unless extremely necessary, such as stroke, epilepsy, or other major neurological disorders.

Objectives

Clinical and biological characteristics, treatment and clinical outcomes of patients admitted for neurological diseases with and without COVID-19

Method

  • Retrospective cohort study including hospitalized patients over 18 years of age, initially admitted for neurological disease from February 21 to April 5, 2020.
  • Epidemiological, demographic, clinical, laboratory, treatment and outcome data were extracted from printed and electronic medical records using standardized anonymous data collection forms. All data were imputed and edited by four physicians
  • Demographic and clinical data were acquired for all patients present at admission: age, sex, smoking, co-morbidities (diabetes, high cholesterol, hypertension, coronary artery disease, malignancies, chronic kidney disease, immunodeficiency), Sequential Organ Failure Assessment (SOFA) score, modified Rankin score (MRS), National Institute of Health Stroke Scale (NIHSS) score (for cerebrovascular disease only); during hospitalization: antibiotic, antiviral or high flow oxygen therapy, inpatient mortality, delirium, fever during hospitalization, number of diagnostic tests, acute phase therapies such as intravenous fibrinolysis, endovascular therapy or transition therapy (for ischemic stroke only).
  • Detection of SARS-Cov-2 was performed by RT-PCR on nasopharyngeal and oropharyngeal swabs in all patients.
  • Antiviral therapy included: lopinavir/ritonavir 200/50 mg 2 cp 1x/day, darunavir 800 mg 1 cp 1x/day + ritonavir 100 mg 1 cp 1x/day, or darunavir/cobicistat 800/150 mg 1 cp 1x/day.
  • Differences between patients with and without COVID-19 were compared by the Mann-Whitney U test, X² test or the Fisher exact test. To explore the risk factors associated with in-hospital deaths, univariate and multivariate logistic regret models were implemented. For the multivariate analysis, in order to avoid over-fitting the model, variables were selected based on past outcomes and clinical constraints. Previous studies showed age, qSOFA scores and several laboratory findings were associated with hospital mortality. Therefore, we selected age, qSOFA scores, platelet count, C-reactive protein and lactate dehydrogenase for our multivariate logistic regression model.
  • A bilateral p-value of <0.05 was considered significant and corrected for multiple comparisons using the Benjamini-Hochberg False Discovery Rate (FDR).
  • Exit criteria for patients with COVID-19 were absence of fever for at least 24 hours, respiratory rate <22/min and substantial improvement on chest X-ray or CT scan.

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