Neurological complications in a predominantly African American sample of COVID-19 predict worse outcomes during hospitalization
Neurological complications in a predominantly African American sample of COVID-19 predict worse outcomes during hospitalization
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DOI：
10.1016/j.clineuro.2020.106173
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发表时间：
2020-10-01
影响因子：
1.9
通讯作者：
Lovera, Jesus F.
中科院分区：
文献类型：
--
作者：
Chachkhiani, David;Soliman, Michael Y.;Lovera, Jesus F.
严重急性呼吸道综合征冠状病毒2型（SARS-CoV-2）感染者，COVID-19，可能会出现神经系统问题，包括头痛、嗅觉丧失、味觉障碍、精神状态改变（AMS）、伴有或不伴有大血管闭塞的缺血性中风和吉兰-巴雷综合征。路易斯安那州是受疫情影响最严重的州之一，截至2020年6月底，实验室确诊的COVID-19病例刚刚超过57，000例。记录在急诊室就诊的COVID-19患者中观察到的神经系统问题的类型和频率。次要目的是确定：1）住院期间神经系统主诉的频率; 2）就诊时存在任何神经系统主诉或入院时存在任何单独类型的神经系统主诉是否预示着三个独立的结局：死亡、住院时间或需要插管;以及3）是否存在任何神经系统疾病或住院期间发生的任何单独类型的神经系统疾病可预测前三种结局。非裔美国人，患有高血压（79%）。在250例患者中，56例（22%）患者死亡，72例（29%）患者需要插管。34例（14%）患者就诊时有神经系统主诉;整个样本中最常见的神经系统主诉为精神状态改变（AMS）（8%）、头痛（2%）和晕厥（2%）。我们使用竞争风险模型来确定在就诊时或住院期间的神经系统症状是否是延长住院时间和死亡的预测因子。为了确定神经系统症状是否与较高的插管几率相关，我们使用逻辑回归。年龄是死亡和住院时间的唯一重要人口统计学预测因素。年龄增加10年后继续住院的HR（95%CI）为1.2，（1.1，1.3，p < 0.0001），死亡的HR（95%CI）为1.3，（1.1，1.5，p < 0.01）。调整年龄后，与无任何神经系统疾病的患者相比，以神经系统疾病为主诉的患者住院风险显著增加，HR =1.7，（1.1，2.5，p = 0.0001），死亡风险显著增加，HR = 2.1（1.1，3.8，p = 0.02）。在个体入院投诉中，AMS与住院时间显著延长相关，HR = 1.8，（1.0-3.3，p = 0.05）。需要透析或插管或住院期间有AMS的患者住院时间更长。在调整年龄、透析和插管后，住院期间AMS患者留在医院的HR为1.6，（1.1，2.5，p = 0.01）。有神经系统主诉或头痛的患者需要插管的几率更高，OR = 2.8（1.3，5.8，p = 0.01），或头痛OR = 13.3（2.1，257.0，p = 0.008）。住院期间患有AMS的患者以及癫痫发作的患者更有可能需要插管。在多变量模型中，透析（OR = 4.9（2.6，9.4，p < 0.0001））和AMS（OR = 8.8（3.9，21.2，p < 0.0001））是插管的唯一独立预测因素。需要更多的工作来确定神经系统疾病的原因是病毒直接累及CNS还是病毒的其他全身并发症。
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.