RESUMO
At least one in three women experience intimate partner violence (IPV) in their lifetime. The most commonly sustained IPV-related brain injuries include strangulation-related alterations in consciousness (S-AICs) and traumatic brain injuries (TBIs). Moreover, survivors of IPV-related S-AICs and/or TBIs often demonstrate psychological distress such as depression, anxiety, and post-traumatic stress. However, the co-occurrence of S-AICs and TBIs, and whether such TBIs may be moderate to severe, has not been systematically examined, and most data have been collected from women in North America. The purpose of this study was to examine the co-occurrence of IPV-related S-AICs and TBIs across a range of geographical locations and to determine the extent to which these S-AICs are related to psychological distress. Women who had experienced physical IPV (n = 213) were included in this secondary analysis of retrospectively collected data across four countries (Canada, the United States, Spain, and Colombia). The Brain Injury Severity Assessment (BISA) was used to assess IPV-related BI across all sites. Because various questionnaires were employed to assess levels of depression, anxiety, and post-traumatic stress disorder at each site, we created a standardized composite score by converting raw scores into Z-scores for analysis. Mann-Whitney U tests and chi-square tests were conducted to examine differences between women with and without experience of S-AICs and to discover if there was a relationship between the occurrence of S-AICs and TBIs. Analysis of variance and analysis of covariance (to control for the potential confounding effects of age, education, and non IPV-related TBI) were used to compare levels of psychological distress in women who had or had not experienced S-AICs. Approximately, 67% of women sustained at least one IPV-related BI (i.e., TBI and/or S-AIC). In a subsample of women who sustained at least one IPV-related BI, approximately 37% sustained both S-AICs and TBIs, 2% sustained only S-AICs (with no TBIs), and 61% sustained TBIs exclusively (with no S-AICs). Furthermore, women who had sustained S-AICs (with or without a TBI) were more likely to have experienced a moderate-to-severe BI than those who had not sustained an S-AIC (BISA severity subscale: U = 3939, p = 0.006). In addition, women who experienced S-AICs (with or without a TBI) reported higher levels of psychological distress compared with women who never experienced S-AICs, irrespective of whether they occurred once or multiple times. These data underscore the importance of assessing for S-AIC in women who have experienced IPV and when present, to also assess for TBIs and the presence of psychological distress. Unfortunately, there were methodological differences across sites precluding cross-site comparisons. Nonetheless, data were collected across four culturally and geographically diverse countries and, therefore, highlight IPV-related BIs as a global issue that needs to be aggressively studied with policies established and then implemented to address findings.
Assuntos
Lesões Encefálicas Traumáticas , Violência por Parceiro Íntimo , Angústia Psicológica , Humanos , Feminino , Adulto , Lesões Encefálicas Traumáticas/psicologia , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/epidemiologia , Violência por Parceiro Íntimo/psicologia , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Colômbia/epidemiologia , Canadá/epidemiologia , Espanha/epidemiologia , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/etiologia , Transtornos da Consciência/psicologia , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: A few studies specifically addressed medical comorbidities (MCs) in patients with severe acquired traumatic or non-traumatic brain injury and prolonged disorders of consciousness (pDoC; i.e., patients in vegetative state/unresponsive wakefulness syndrome, VS/UWS, or in minimally conscious state, MCS). OBJECTIVE: To provide an overview on incidence of MCs in patients with pDoC. METHODS: Narrative review on most impacting MCs in patients with pDoC, both those directly related to brain damage (epilepsy, neurosurgical complications, spasticity, paroxysmal sympathetic hyperactivity, PSH), and those related to severe disability and prolonged immobility (respiratory comorbidities, endocrine disorders, metabolic abnormalities, heterotopic ossifications). RESULTS: Patients with pDoC are at high risk to develop at least one MC. Moderate or severe respiratory and musculoskeletal comorbidities are the most common MCs. Epilepsy and PSH seem to be more frequent in patients in VS/UWS compared to patients in MCS, likely because of higher severity in the brain damage in VS. Endocrine metabolic, PSH and respiratory complications are less frequent in traumatic etiology, whereas neurogenic heterotopic ossifications are more frequent in traumatic etiology. Spasticity did not significantly differ between VS/UWS and MCS and in the three etiologies. MCs are associated with higher mortality rates, worse clinical improvement and can impact accuracy in the clinical diagnosis. CONCLUSIONS: The frequent occurrence of several MCs requires a specialized rehabilitative setting with high level of multidisciplinary medical expertise to prevent, appropriately recognize and treat them. Comprehensive rehabilitation could avoid possible progression to more serious complications that can negatively impact clinical outcomes.
Assuntos
Lesões Encefálicas , Epilepsia , Humanos , Lesões Encefálicas/reabilitação , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/etiologia , Estado Vegetativo Persistente/reabilitação , Estado de Consciência , Epilepsia/epidemiologia , Epilepsia/etiologiaRESUMO
OBJECTIVE: This study aimed to demonstrate the incidence of altered level of consciousness after hemorrhagic stroke and identify factors associated with altered level of consciousness at 3 mos after stroke. DESIGN: This study used data from a prospective multicenter cohort study conducted in nine hospitals in Korea and included 1677 patients with first-ever hemorrhagic stroke. Patients were dichotomized into those with and without altered level of consciousness at 3 mos after stroke. Multivariate logistic regression analysis was performed to identify factors associated with subacute to chronic stage altered level of consciousness. RESULTS: Among patients with hemorrhagic stroke (age: 20-99 yrs, female 50.21%), the prevalence of altered level of consciousness at admission was 38.58% (25.4% [drowsy], 6.38% [stupor], and 6.8% [coma]) and 17.29% 3 mos after stroke. Multivariate logistic regression analysis revealed that independent factors associated with altered level of consciousness at 3 mos after stroke included late seizure (odds ratio [95% confidence interval], 5.93 [1.78-20.00]), stroke progression (3.84 [1.48-9.64]), craniectomy (2.19 [1.19-4.00]), history of complications (1.74 [1.18-2.55]), age at stroke onset (1.08 [1.07-1.10]), and initial Glasgow Coma Scale score category (0.36 [0.30-0.44]). CONCLUSIONS: The factors associated with altered level of consciousness at 3 mos after stroke should be considered when explaining long-term consciousness status and focused management of modifiable factors in acute care hospitals could help ameliorate altered level of consciousness and promote recovery after stroke.
Assuntos
Acidente Vascular Cerebral Hemorrágico , Acidente Vascular Cerebral , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Pessoa de Meia-Idade , Adulto Jovem , Estudos de Coortes , Estado de Consciência , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/etiologia , Escala de Coma de Glasgow , Incidência , Estudos Prospectivos , República da Coreia/epidemiologia , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/epidemiologiaRESUMO
OBJECTIVE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is protean in its manifestations, affecting nearly every organ system. However, nervous system involvement and its effect on disease outcome are poorly characterized. The objective of this study was to determine whether neurologic syndromes are associated with increased risk of inpatient mortality. METHODS: A total of 581 hospitalized patients with confirmed SARS-CoV-2 infection, neurologic involvement, and brain imaging were compared to hospitalized non-neurologic patients with coronavirus disease 2019 (COVID-19). Four patterns of neurologic manifestations were identified: acute stroke, new or recrudescent seizures, altered mentation with normal imaging, and neuro-COVID-19 complex. Factors present on admission were analyzed as potential predictors of in-hospital mortality, including sociodemographic variables, preexisting comorbidities, vital signs, laboratory values, and pattern of neurologic manifestations. Significant predictors were incorporated into a disease severity score. Patients with neurologic manifestations were matched with patients of the same age and disease severity to assess the risk of death. RESULTS: A total of 4,711 patients with confirmed SARS-CoV-2 infection were admitted to one medical system in New York City during a 6-week period. Of these, 581 (12%) had neurologic issues of sufficient concern to warrant neuroimaging. These patients were compared to 1,743 non-neurologic patients with COVID-19 matched for age and disease severity admitted during the same period. Patients with altered mentation (n = 258, p = 0.04, odds ratio [OR] 1.39, confidence interval [CI] 1.04-1.86) or radiologically confirmed stroke (n = 55, p = 0.001, OR 3.1, CI 1.65-5.92) had a higher risk of mortality than age- and severity-matched controls. CONCLUSIONS: The incidence of altered mentation or stroke on admission predicts a modest but significantly higher risk of in-hospital mortality independent of disease severity. While other biomarker factors also predict mortality, measures to identify and treat such patients may be important in reducing overall mortality of COVID-19.
Assuntos
COVID-19/mortalidade , Confusão/fisiopatologia , Transtornos da Consciência/fisiopatologia , Mortalidade Hospitalar , Acidente Vascular Cerebral/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Ageusia/epidemiologia , Ageusia/fisiopatologia , Anosmia/epidemiologia , Anosmia/fisiopatologia , Ataxia/epidemiologia , Ataxia/fisiopatologia , COVID-19/fisiopatologia , Confusão/epidemiologia , Transtornos da Consciência/epidemiologia , Doenças dos Nervos Cranianos/epidemiologia , Doenças dos Nervos Cranianos/fisiopatologia , Delírio/epidemiologia , Delírio/fisiopatologia , Feminino , Cefaleia/epidemiologia , Cefaleia/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Parestesia/epidemiologia , Parestesia/fisiopatologia , Disautonomias Primárias/epidemiologia , Disautonomias Primárias/fisiopatologia , Recidiva , SARS-CoV-2 , Convulsões/epidemiologia , Convulsões/fisiopatologia , Acidente Vascular Cerebral/epidemiologia , Vertigem/epidemiologia , Vertigem/fisiopatologiaAssuntos
COVID-19/diagnóstico , Síndrome , Adulto , Idoso de 80 Anos ou mais , Ageusia/epidemiologia , Ageusia/etiologia , Agnosia/epidemiologia , Agnosia/etiologia , COVID-19/classificação , COVID-19/epidemiologia , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/etiologia , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/etiologia , Serviço Hospitalar de Emergência/organização & administração , Feminino , Febre/epidemiologia , Febre/etiologia , Humanos , Itália/epidemiologia , Doenças Pulmonares Intersticiais/complicações , Doenças Pulmonares Intersticiais/diagnóstico por imagem , Programas de Rastreamento/métodos , Programas de Rastreamento/estatística & dados numéricos , Convulsões/epidemiologia , Convulsões/etiologiaRESUMO
Information about Parkinson's disease (PD) patients with severe COVID-19 is scarce. We aimed to analyze the clinical characteristics, outcomes, and risk factors affecting the prognosis of PD patients with severe COVID-19 infection. Clinical data of severe COVID-19 patients admitted at the Union Hospital, Wuhan between 28th January and 29th February 2020 were collected and analyzed. 10 patients (1.96%) had a medical history of PD with a mean (SD) age of 72.10 (± 11.46) years. The clinical characteristics and outcomes of severe COVID-19 with and without PD patients were then compared. There was no significant difference in overall mortality between the PD and non-PD patients with severe COVID-19 (p > 0.05). In PD patients with severe COVID-19, the proportion of patients with critical type, disturbance of consciousness, incidence of complications, white blood cells count and neutrophils counts on admission seem higher in the non-survivors. PD patients with older age, longer PD duration, and late stage PD may be highly susceptible to critical COVID-19 infection and bad outcome. The PD patients with consciousness disorders and complications that progressed rapidly are at increased risk of death.
Assuntos
COVID-19/epidemiologia , Transtornos da Consciência/epidemiologia , Doença de Parkinson/epidemiologia , Idoso , Idoso de 80 Anos ou mais , COVID-19/complicações , COVID-19/mortalidade , China/epidemiologia , Comorbidade , Transtornos da Consciência/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/mortalidade , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: Frailty is associated with postoperative morbidity in multiple surgical disciplines. We evaluated the association between frailty and early postoperative outcomes for brain tumor patients using a national database. METHODS: We reviewed the Nationwide Readmissions Database from 2010 to 2014. International Classification of Diseases, ninth revision, codes were used to identify benign and malignant brain tumors treated with surgical resection. Pituitary tumors were excluded. Frailty was assessed using the Johns Hopkins Adjusted Clinical Groups frailty indicator tool. Multivariable exact logistic regression was used to conduct analyses assessing the association between frailty and the outcome variables. Statistical significance was defined as P < 0.001. RESULTS: The criteria for frailty were met for 7209 of 87,835 patients (8.2%). After adjustment for patient and hospital factors, frailty was independently associated with in-hospital surgical complications (odds ratio [OR], 1.48; 95% confidence interval [CI] 1.37-1.59; P < 0.0001), mental status changes (OR, 1.9; 95% CI, 1.72-2.09; P < 0.0001), and pulmonary insufficiency (OR, 1.75; 95% CI, 1.55-1.96; P < 0.0001). Frailty was associated with an increased length of stay (incident rate ratio, 1.92; 95% CI, 1.87-1.98; P < 0.0001) and nonroutine disposition (OR, 1.84; 95% CI, 1.72-1.97; P < 0.0001). In-hospital mortality was greater for frail patients (2.2% vs. 1.4%; P < 0.0001), but the difference did not achieve significance on multivariate analysis. Frail patients were not more likely to be readmitted. CONCLUSION: Frailty is associated with in-hospital complications and nonroutine disposition after craniotomy for benign and malignant brain tumors. Additional work is needed to identify prehabilitation or in-hospital strategies to improve the care and outcomes of these at-risk patients.
Assuntos
Neoplasias Encefálicas/cirurgia , Transtornos da Consciência/epidemiologia , Craniotomia , Fragilidade/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Insuficiência Respiratória/epidemiologia , Adulto , Idoso , Neoplasias Encefálicas/epidemiologia , Vazamento de Líquido Cefalorraquidiano/epidemiologia , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Hemorragia Pós-Operatória/epidemiologia , Náusea e Vômito Pós-Operatórios/epidemiologia , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologiaRESUMO
AIMS/INTRODUCTION: The aim of the present study was to clarify the pathophysiologies of hyperglycemic crises in Japanese patients. MATERIALS AND METHODS: This was a retrospective study of patients with hyperglycemic crises admitted to Kumamoto Medical Center, Kumamoto, Japan, between 2012 and 2019. Patients were classified as having diabetic ketoacidosis (DKA), hyperglycemic hyperosmotic syndrome (HHS) or a mixed state of the two conditions (MIX), and laboratory data and levels of consciousness at hospital admission, as well as the rates of mortality and coagulation disorders, were compared. RESULTS: The diagnostic criteria for hyperglycemic crisis were met in 144 cases, comprising 87 (60.4%), 38 (26.4%) and 19 (13.2%) cases of DKA, HHS and MIX, respectively. Type 1 diabetes was noted in 46.0 and 26.3% of patients in the DKA and MIX groups, respectively. Fibrin degradation product and D-dimer levels were significantly higher in the HHS group than in the DKA group (DKA and HHS groups: fibrin degradation product 7.94 ± 8.43 and 35.54 ± 51.80 µg/mL, respectively, P < 0.01; D-dimer 2.830 ± 2.745 and 14.846 ± 21.430 µg/mL, respectively, P < 0.01). Mortality rates were 5.7, 13.2 and 5.3% in the DKA, HHS and MIX groups, respectively. Seven patients (4.9%), four of whom were in the MIX group, had acute arterial occlusive diseases. CONCLUSIONS: The low frequency of type 1 diabetes in DKA and MIX might be responsible for reduced insulin secretion in Japanese populations. Patients with hyperglycemic crises have increased coagulability, and acute arterial occlusion needs to be considered, particularly in MIX.
Assuntos
Hiperglicemia/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/complicações , Transtornos da Coagulação Sanguínea/epidemiologia , Glicemia/análise , Transtornos da Consciência/epidemiologia , Diabetes Mellitus Tipo 1/complicações , Cetoacidose Diabética/epidemiologia , Cetoacidose Diabética/mortalidade , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Humanos , Hiperglicemia/classificação , Hiperglicemia/mortalidade , Coma Hiperglicêmico Hiperosmolar não Cetótico , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
Impaired consciousness (IC) at stroke onset in large hemispheric infarctions (LHI) patients is common in clinical practice. However, little is known about the incidence and risk factors of IC at stroke onset in LHI. Besides, stroke-related complications and clinical outcomes in relation to the development of IC has not been systematically examined. Data of 256 consecutive patients with LHI were collected. IC at stroke onset was retrospectively collected from the initial emergency department and/or admission records. Of the 256 LHI patients enrolled, 93 (36.3%) had IC at stroke onset. LHI patients with IC at stroke onset were older (median age 66 vs. 61, p = 0.041), had shorter prehospital delay (24 vs. 26 h, p < 0.001and higher baseline National Institutes of Health Stroke Scale (NIHSS) score (19 vs. 12, p < 0.001). Independent risk factors of IC at stroke onset were high NIHSS score (odds ratio, OR 1.17, 95% confidence interval [CI] 1.12 to 1.23) and atrial fibrillation (OR 1.93, 95% CI 1.07 to 3.47). Dyslipidemia appeared to protect against IC at stroke onset (adjusted OR 0.416, 95% CI 0.175 to 0.988). IC at stroke onset was associated with higher frequency of stroke-related complications (90.32% vs. 67.48%, p < 0.001), especially brain edema (45.16% vs. 23.31%, p < 0.001) and pneumonia (63.44% vs. 47.82%, p = 0.019). The IC group had higher rates of in-hospital death (23.66% vs. 11.66%, p = 0.012), 3-month mortality (49.46% vs. 24.87%, p = 0.002), and 3-month unfavorable outcome (64.51% vs. 49.07%, p = 0.017). However, after adjusting for age, baseline NIHSS score and other confounders, IC at stroke onset was not an independent predictor of in-hospital death (adjusted OR 0.56, 95% CI 0.22 to 1.47), 3-month mortality (adjusted OR 0.54, 95% CI 0.25 to 1.14) and 3-month unfavorable outcome (adjusted OR 0.64, 95% CI 0.31 to 1.33) in LHI patients (all p > 0.05). Our results suggested that IC occur in 1 out of every 3 LHI patients at stroke onset and was associated with initial stroke severity and atrial fibrillation. LHI patients with IC at stroke onset more frequently had stroke-related complications, 3-month mortality and unfavorable outcome, whereas IC was not an independent predictor of poor outcomes.
Assuntos
Infarto Encefálico/complicações , Transtornos da Consciência/diagnóstico por imagem , Transtornos da Consciência/epidemiologia , Adolescente , Adulto , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial , Infarto Encefálico/diagnóstico por imagem , Transtornos da Consciência/etiologia , Feminino , Humanos , Incidência , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Tomografia Computadorizada por Raios X , Adulto JovemRESUMO
BACKGROUND: Disturbance of consciousness (DOC) may develop in acute pancreatitis (AP). In clinical practice, it is known that DOC may worsen the patient's condition, but we have no exact data on how DOC affects the outcome of AP. METHODS: From the Hungarian Pancreatic Study Groups' AP registry, 1220 prospectively collected cases were analyzed, which contained exact data on DOC, included patients with confusion, delirium, convulsion, and alcohol withdrawal, answering a post hoc defined research question. Patients were separated to Non-DOC and DOC, whereas DOC was further divided into non-alcohol related DOC (Non-ALC DOC) and ALC DOC groups. For statistical analysis, independent sample t-test, Mann-Whitney, Chi-squared, or Fisher exact test were used. RESULTS: From the 1220 patients, 47 (3.9%) developed DOC, 23 (48.9%) cases were ALC DOC vs. 24 (51.1%) Non-ALC DOC. Analysis between the DOC and Non-DOC groups showed a higher incidence of severe AP (19.2% vs. 5.3%, p < 0.001), higher mortality (14.9% vs. 1.7%, p < 0.001), and a longer length of hospitalization (LOH) (Me = 11; IQR: 8-17 days vs. Me = 9; IQR: 6-13 days, p = 0.049) respectively. Patients with ALC DOC developed more frequently moderate AP vs. Non-ALC DOC (43.5% vs. 12.5%), while the incidence of severe AP was higher in Non-ALC vs. ALC DOC group (33.3% vs. 4.4%) (p < 0.001). LOH showed a tendency to be longer in Non-ALC DOC compared to ALC DOC, respectively (Me:13; IQR:7-20 days vs. Me:9.5; IQR:8-15.5 days, p = 0.119). CONCLUSION: DOC during AP is associated with a higher rate of moderate and severe AP and increases the risk of mortality.
Assuntos
Transtornos da Consciência/etiologia , Pancreatite/complicações , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Convulsões por Abstinência de Álcool/complicações , Estudos de Coortes , Transtornos da Consciência/epidemiologia , Delírio/epidemiologia , Delírio/etiologia , Feminino , Humanos , Hungria , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pancreatite/epidemiologia , Pancreatite/mortalidade , Prognóstico , Estudos Prospectivos , Adulto JovemRESUMO
Background: Birth asphyxia accounts for a third of global newborn deaths and 95 percent of these occur in low-resource settings. A key to reducing asphyxia-related deaths in these settings is improving care of these newborns and this requires an understanding of factors associated with adverse outcomes. Objectives: In this study, we report outcomes and risk factors for mortality among newborn infants with birth asphyxia admitted to a typical low-resource hospital setting. Methods: We prospectively followed up 191 asphyxiated newborn infants admitted to a referral tertiary hospital in North-central Nigeria. At baseline, care-givers completed a structured questionnaire. Using univariable analysis, we compared baseline characteristics between participants who died and those who survived till discharge. We also fitted a multivariable logistic regression model to identify risk factors for mortality among the cohort. Results: Majority (60.7%) of the study participants presented to the hospital within the first six hours of life. Despite this, mortality among the cohort was 14.7% with a third dying within the first 24 hours of admission. The presence of respiratory distress at admission increased the risk for mortality (AOR = 3.73, 95% CI 1.22 to 11.35) while higher participant weight at admission decreased the risk (AOR = 0.11, 95% CI 0.03 to 0.40). Intrapartum factors such as duration of labour and maternal age, although significant on univariable analysis, were not significant on multivariable analysis. Conclusions: Hospital mortality among newborns with birth asphyxia is high in North-central Nigeria and majority of deaths occur during acute care. Respiratory distress at presentation and admission weights were identified as key risk factors for asphyxia mortality. Intrapartum factors on the other hand might have indirect effects on mortality through an increased risk for neonatal complications.
Assuntos
Asfixia Neonatal/mortalidade , Peso ao Nascer , Mortalidade Hospitalar , Hipóxia-Isquemia Encefálica/epidemiologia , Idade Materna , Síndrome do Desconforto Respiratório do Recém-Nascido/epidemiologia , Adolescente , Adulto , Entorno do Parto/estatística & dados numéricos , Estudos de Coortes , Transtornos da Consciência/epidemiologia , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Trabalho de Parto , Masculino , Nigéria/epidemiologia , Gravidez , Estudos Prospectivos , Reflexo Anormal , Fatores de Risco , Convulsões/epidemiologia , Centros de Atenção Terciária , Tempo para o Tratamento , Adulto JovemRESUMO
As a severe and highly contagious infectious disease, coronavirus disease 2019 (COVID-19) has caused a global pandemic. Several case reports have demonstrated that the respiratory system is the main target in patients with COVID-19, but the disease is not limited to the respiratory system. Case analysis indicated that the nervous system can be invaded by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and that 36.4% of COVID-19 patients had neurological symptoms. Importantly, the involvement of the CNS may be associated with poor prognosis and disease worsening. Here, we discussed the symptoms and evidence of nervous system involvement (directly and indirectly) caused by SARS-CoV-2 infection and possible mechanisms. CNS symptoms could be a potential indicator of poor prognosis; therefore, the prevention and treatment of CNS symptoms are also crucial for the recovery of COVID-19 patients.
Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/complicações , Doenças do Sistema Nervoso/etiologia , Pneumonia Viral/complicações , Enzima de Conversão de Angiotensina 2 , COVID-19 , Transtornos Cerebrovasculares/epidemiologia , Transtornos Cerebrovasculares/etiologia , Terapia Combinada , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/etiologia , Infecções por Coronavirus/psicologia , Infecções por Coronavirus/virologia , Tontura/epidemiologia , Tontura/etiologia , Encefalite Viral/epidemiologia , Encefalite Viral/etiologia , Células Endoteliais/metabolismo , Células Endoteliais/virologia , Fadiga/epidemiologia , Fadiga/etiologia , Cefaleia/epidemiologia , Cefaleia/etiologia , Humanos , Hipertensão Intracraniana/epidemiologia , Hipertensão Intracraniana/etiologia , Transtornos Mentais/tratamento farmacológico , Transtornos Mentais/epidemiologia , Transtornos Mentais/etiologia , Transtornos Mentais/terapia , Transtornos do Humor/tratamento farmacológico , Transtornos do Humor/epidemiologia , Transtornos do Humor/etiologia , Transtornos do Humor/terapia , Doenças do Sistema Nervoso/epidemiologia , Neurônios/metabolismo , Neurônios/virologia , Nervo Olfatório/virologia , Pandemias , Peptidil Dipeptidase A/metabolismo , Pneumonia Viral/psicologia , Pneumonia Viral/virologia , Prevalência , Prognóstico , Psicoterapia , Psicotrópicos/uso terapêutico , Receptores Virais/metabolismo , Estudos Retrospectivos , SARS-CoV-2 , Transtornos de Sensação/epidemiologia , Transtornos de Sensação/etiologia , Glicoproteína da Espícula de Coronavírus/metabolismoRESUMO
A child presenting with decreased level of conscious (dLOC) is of great concern due to the wide range of possible causes, and potential for death or serious long-term sequelae. It is therefore vital that health professionals can recognise a child with dLOC quickly, intervene appropriately and escalate for senior review as a matter of urgency. This article provides an explanation for the mechanisms of decreased consciousness, outlines the different causative pathologies, and provides a simple and logical approach to the first-line recognition and management that a health professional may apply when faced with such a patient. Illustrative case studies have been included, to demonstrate how children with dLOC may present in clinical practice.
Assuntos
Transtornos da Consciência/enfermagem , Diagnóstico de Enfermagem , Criança , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/fisiopatologia , Diagnóstico Diferencial , Enfermagem em Emergência , Feminino , Humanos , Lactente , Masculino , Papel do Profissional de Enfermagem , Exame Físico/enfermagemRESUMO
The development of combination antiretroviral therapies (cARTs) in the mid-1990s has dramatically modified the clinical presentation of critically ill, HIV-infected patients. Most cART-treated patients aging with controlled HIV replication are currently admitted to the ICU for non-AIDS-related events, mostly bacterial pneumonia and exacerbation of comorbidities, variably affected by chronic HIV infection (COPD, cardiovascular diseases, or solid neoplasms). Today, Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis, TB, and other severe opportunistic infections only occur in patients with unknown viral status, limited access to cART, viral resistance, or compliance issues. Acute respiratory failure, neurological disorders, and sepsis remain the main conditions that lead HIV-infected patients to the ICU, although admissions for liver diseases or acute kidney injury are increasing. Case fatality dropped substantially over the past decades, reaching figures of HIV-uninfected critically ill patients with similar demographic characteristics, comorbidities, and level of organ dysfunctions. Several other facets of critical care management have evolved in this population, including diagnostic procedures, cART management at the acute phase of critical illness, and ethical considerations. The goal of this narrative review was to depict the current evidence and emerging challenges for the management of critically ill, HIV-infected patients, almost 40 years following the onset of the AIDS epidemic.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/epidemiologia , Antirretrovirais/uso terapêutico , Transtornos da Consciência/epidemiologia , Infecções por HIV/tratamento farmacológico , Insuficiência Respiratória/epidemiologia , Sepse/epidemiologia , Infecções Oportunistas Relacionadas com a AIDS/prevenção & controle , Infecções Oportunistas Relacionadas com a AIDS/terapia , Contagem de Linfócito CD4 , Transtornos da Consciência/terapia , Doença da Artéria Coronariana/epidemiologia , Cuidados Críticos , Estado Terminal , Oxigenação por Membrana Extracorpórea , Infecções por HIV/epidemiologia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Mortalidade , Neoplasias/epidemiologia , Pneumonia por Pneumocystis/epidemiologia , Pneumonia por Pneumocystis/prevenção & controle , Pneumonia por Pneumocystis/terapia , Prognóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Respiração Artificial , Síndrome do Desconforto Respiratório/epidemiologia , Síndrome do Desconforto Respiratório/terapia , Insuficiência Respiratória/terapia , Sepse/terapiaRESUMO
Primary Objective: The aim of this study was to demonstrate the clinical outcomes of long-term multidisciplinary attentive treatment (MAT) in patients with chronic disorders of consciousness (DOC) due to severe traumatic brain injury (TBI) following automotive accidents.Research Design: Five hundred and ten patients (mean age: 40.4 years) were enrolled in this retrospective study.Methods and Procedures: Patients were provided MAT for one to several years in the eight medical facilities of the National Agency for Automotive Safety and Victims' Aid (NASVA) in Japan. Clinical status for consciousness, communication, and activities of daily living were evaluated using the NASVA grading system.Outcomes and results: Following MAT, NASVA scores at discharge were significantly improved compared to those at admission in every patient subgroup including sex, age, NASVA score, and association with/without hypoxic encephalopathy at admission. Younger age, shorter interval between injury and admission, and better neurocognitive function at admission were found to be significant and independent factors for a good prognosis.Conclusions: MAT can partially improve the cognitive and physical abilities of patients with chronic DOC. From the perspective of not only restoring a patient's daily life, but also reducing the caregiver's burden, this type of treatment program warrants more public attention.
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Condução de Veículo/normas , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/reabilitação , Transtornos da Consciência/epidemiologia , Transtornos da Consciência/reabilitação , Equipe de Assistência ao Paciente/normas , Adolescente , Adulto , Condução de Veículo/educação , Condução de Veículo/psicologia , Lesões Encefálicas Traumáticas/psicologia , Doença Crônica , Transtornos da Consciência/psicologia , Feminino , Escala de Coma de Glasgow/normas , Humanos , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto JovemRESUMO
AIM: Systemic lupus erythematosus (SLE) is an unusual risk factor for cerebral venous sinus thrombosis (CVST). As few CVST patients with SLE have been reported, little is known regarding its frequency as an underlying etiology, clinical characteristics, or long-term outcome. We evaluated a large cohort of CVST patients with SLE in a multicenter study of cerebral venous thrombosis, the VENOST study, and their clinical characteristics. MATERIAL AND METHOD: Among the 1144 CVST patients in the VENOST cohort, patients diagnosed with SLE were studied. Their demographic and clinical characteristics, etiological risk factors, venous involvement status, and outcomes were recorded. RESULTS: In total, 15 (1.31%) of 1144 CVST patients had SLE. The mean age of these patients was 39.9 ± 12.1 years and 13 (86.7%) were female. Presenting symptoms included headache (73.3%), visual field defects (40.0%), and altered consciousness (26.7%). The main sinuses involved were the transverse (60.0%), sagittal (40.0%), and sigmoid (20.0%) sinuses. Parenchymal involvement was not seen in 73.3% of the patients. On the modified Rankin scale, 92.9% of the patients scored 0-1 at the 1-month follow-up and 90.9% scored 0-1 at the 1-year follow-up. CONCLUSIONS: SLE was found in 1.31% of the CVST patients, most frequently in young women. Headache was the most common symptom and the CVST onset was chronic in the majority of cases. The patient outcomes were favorable. CVST should be suspected in SLE patients, even in those with isolated chronic headache symptoms with or without other neurological findings.
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Lúpus Eritematoso Sistêmico/epidemiologia , Trombose dos Seios Intracranianos/epidemiologia , Adulto , Distribuição por Idade , Transtornos da Consciência/diagnóstico , Transtornos da Consciência/epidemiologia , Feminino , Transtornos da Cefaleia/diagnóstico , Transtornos da Cefaleia/epidemiologia , Humanos , Lúpus Eritematoso Sistêmico/diagnóstico , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Distribuição por Sexo , Trombose dos Seios Intracranianos/diagnóstico , Fatores de Tempo , Turquia/epidemiologia , Transtornos da Visão/diagnóstico , Transtornos da Visão/epidemiologiaRESUMO
BACKGROUND: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening complications of diabetes mellitus which require prompt treatment with large volume crystalloid fluid administration. A variety of crystalloid fluids is currently available for use and differs in their composition and ion concentrations. While there are potential pros and cons for different crystalloid fluids, it remains unknown if any particular fluid confers a clinical outcome benefit over others in the treatment of hyperglycemic emergencies. METHODS: A systematic search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews will be conducted to identify eligible studies, which will include observational and interventional studies involving adult and pediatric patients admitted to the hospital with either DKA or HHS. The interventions will include intravenous treatment with 0.9% saline versus other buffered (Ringer's lactate, Hartmann's, etc.), and non-buffered (0.45% saline) crystalloid fluids. The primary outcome is mortality at the latest follow-up time point. Secondary outcomes will include mortality at specific time points, length of hospital stay, development of acute kidney injury, requirement for renal replacement therapy, altered level of consciousness, and the time to normalization of several serum biochemical parameters. Where appropriate, meta-analyses will be performed for the outcomes and conducted separately for adult and pediatric patient populations. DISCUSSION: DKA and HHS are dangerous complications of diabetes mellitus and account for significant morbidity and mortality. Given the importance of crystalloid fluid administration in the management of these conditions, a systematic synthesis of the existing evidence base will identify potential evidence gaps and may help guide future clinical practice.
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Soluções Cristaloides/uso terapêutico , Cetoacidose Diabética/terapia , Hidratação/métodos , Coma Hiperglicêmico Hiperosmolar não Cetótico/terapia , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/terapia , Transtornos da Consciência/epidemiologia , Humanos , Tempo de Internação , Mortalidade , Terapia de Substituição Renal/estatística & dados numéricos , Lactato de Ringer/uso terapêutico , Solução Salina/uso terapêutico , Revisões Sistemáticas como AssuntoRESUMO
PURPOSE: This study presents a medication-associated altered mental status (AMS) risk model for real-time implementation in inpatient electronic health record (EHR) systems. METHODS: We utilized a retrospective cohort of patients admitted to 2 large hospitals between January 2012 and October 2013. The study population included admitted patients aged ≥18 years with exposure to an AMS risk-inducing medication within the first 5 hospitalization days. AMS events were identified by a measurable mental status change documented in the EHR in conjunction with the administration of an atypical antipsychotic or haloperidol. AMS risk factors and AMS risk-inducing medications were identified from the literature, drug information databases, and expert opinion. We used multivariate logistic regression with a full and backward eliminated set of risk factors to predict AMS. The final model was validated with 100 bootstrap samples. RESULTS: During 194,156 at-risk days for 66,875 admissions, 262 medication-associated AMS events occurred (an event rate of 0.13%). The strongest predictors included a history of AMS (odds ratio [OR], 9.55; 95% confidence interval [CI], 5.64-16.17), alcohol withdrawal (OR, 3.34; 95% CI, 2.18-5.13), history of delirium or psychosis (OR, 3.25; 95% CI, 2.39-4.40), presence in the intensive care unit (OR, 2.53; 95% CI, 1.89-3.39), and hypernatremia (OR, 2.40; 95% CI, 1.61-3.56). With a C statistic of 0.85, among patients scoring in the 90th percentile, our model captured 159 AMS events (60.7%). CONCLUSION: The risk model was demonstrated to have good predictive ability, with all risk factors operationalized from discrete EHR fields. The real-time identification of higher-risk patients would allow pharmacists to prioritize surveillance, thus allowing early management of precipitating factors.
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Transtornos da Consciência/epidemiologia , Transtornos Mentais/epidemiologia , Adulto , Idoso , Comorbidade , Transtornos da Consciência/induzido quimicamente , Transtornos da Consciência/prevenção & controle , Registros Eletrônicos de Saúde/estatística & dados numéricos , Feminino , Florida , Hospitalização , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Transtornos Mentais/induzido quimicamente , Transtornos Mentais/prevenção & controle , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de RiscoRESUMO
To date, no international guidelines or recommendations for diagnosis or prognosis of patients with disorders of consciousness (DoC) have been established. The International Brain Injury Association's (IBIA) Special Interest Group on Disorders of Consciousness (DoC-SIG) launched an international multicenter survey to compare diagnostic and prognostic procedures across countries and clinical settings. Objectives: To explore which specific diagnostic protocols and prognostic indices were utilized in the care for persons with DoC in different countries and to determine the usage, if any, of national guidelines in the care of such patients. Methods: The questionnaire included 17 questions in two distinct sections (I - clinical and instrumental tools and involvement of caregivers and II - clinical, anamnestic and instrumental markers). Results: Physicians composed 50% of the survey respondents (120) and were all involved in post-acute rehabilitation care. In the majority of countries, respondents reported that there were no national guidelines or recommendations for DoC care. The Glasgow Coma Scale (GCS) and the Coma Recovery Scale-Revised (CRS-R) were the most frequently used clinical scales for diagnostic purposes. The majority of respondents reported the involvement of caregivers in the evaluation of behavioral responsiveness of patient with DoC. The survey indicated that only a few centers performed neurophysiological investigations routinely as diagnostic instrumental procedures. Our results suggest that international guidelines and recommendations for the care of persons with DoC still need to be formulated and ideally agreed to by consensus.
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Transtornos da Consciência/diagnóstico , Transtornos da Consciência/epidemiologia , Pessoal de Saúde , Internacionalidade , Inquéritos e Questionários , Adulto , Feminino , Escala de Coma de Glasgow/normas , Pessoal de Saúde/normas , Humanos , Masculino , Guias de Prática Clínica como Assunto/normas , PrognósticoRESUMO
OBJECTIVE: The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. STUDY DESIGN: The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries. RESULTS: Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P = 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score <7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation. CONCLUSION: Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor.