ABSTRACT
OBJECTIVES: Stroke has been reported in observational series as a frequent complication of coronavirus disease 2019, but more information is needed regarding stroke prevalence and outcomes. We explored the prevalence and outcomes of acute stroke in an international cohort of patients with coronavirus disease 2019 who required ICU admission. DESIGN: Retrospective analysis of prospectively collected database. SETTING: A registry of coronavirus disease 2019 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with acute stroke during their stay. PATIENTS: Patients older than 18 years old with acute coronavirus disease 2019 infection in ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 2,699 patients identified (median age 59 yr; male 65%), 59 (2.2%) experienced acute stroke: 0.7% ischemic, 1.0% hemorrhagic, and 0.5% unspecified type. Systemic anticoagulant use was not associated with any stroke type. The frequency of diabetes, hypertension, and smoking was higher in patients with ischemic stroke than in stroke-free and hemorrhagic stroke patients. Extracorporeal membrane oxygenation support was more common among patients with hemorrhagic (56%) and ischemic stroke (16%) than in those without stroke (10%). Extracorporeal membrane oxygenation patients had higher cumulative 90-day probabilities of hemorrhagic (relative risk = 10.5) and ischemic stroke (relative risk = 1.7) versus nonextracorporeal membrane oxygenation patients. Hemorrhagic stroke increased the hazard of death (hazard ratio = 2.74), but ischemic stroke did not-similar to the effects of these stroke types seen in noncoronavirus disease 2019 ICU patients. CONCLUSIONS: In an international registry of ICU patients with coronavirus disease 2019, stroke was infrequent. Hemorrhagic stroke, but not ischemic stroke, was associated with increased mortality. Further, both hemorrhagic stroke and ischemic stroke were associated with traditional vascular risk factors. Extracorporeal membrane oxygenation use was strongly associated with both stroke and death.
Subject(s)
COVID-19/epidemiology , Stroke/epidemiology , Aged , Comorbidity , Critical Illness , Extracorporeal Membrane Oxygenation , Female , Hospital Mortality , Humans , Intensive Care Units , Male , Middle Aged , Respiration, Artificial , Retrospective Studies , Risk Factors , SARS-CoV-2ABSTRACT
The cytokine storm syndrome has been suggested as a mechanism in the pathophysiology of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2; COVID-19 [coronavirus disease 2019]) infection. Drugs such as tocilizumab, an interleukin-6 antagonist, have shown good results in other scenarios of hyperinflammatory state and might also be effective in COVID-19 disease. However, the best dosing regimen and the timing of infusion is currently unknown, specifically in obese patients. We report the first cases of tocilizumab administration in obese patients during the first days of COVID-19 worsening hypoxemia. This infusion was not adjusted by weight, following the manufacturer maximal dose limit. We kept a strict monitoring for possible infections, prior and during the treatment. All patients showed good improvements on chest-computed tomography images and oxygenation and were discharged from hospital shortly after, without complications or intubation. This case series highlights that tocilizumab seems to be effective to treat hyperinflammation of critical COVID-19 obese patients, even when the infusion of the ideal dose is not feasible to be administered. It also shows the importance of early timing in the decision to treat and the relevance of infections exclusion prior to the induction of immunosuppression by tocilizumab.
Subject(s)
Antibodies, Monoclonal, Humanized/therapeutic use , COVID-19 Drug Treatment , COVID-19/complications , Cytokine Release Syndrome/etiology , Obesity/complications , Adult , Female , Humans , Male , Middle Aged , Treatment OutcomeABSTRACT
Os avanços nas áreas de saúde e sociais contribuíram para o aumento da longevidade da população não somente nos países desenvolvidos, como também nos países emergentes. Estima-se que a população de idosos em 2025 atinja quase 2 bilhões de indivíduos.O idoso tem uma frequência aumentada de doenças infecciosas, crônicas, neoplásicas, processos inflamatórios exacerbados e alterações de autoimunidade. Todas estas morbidades são fortemente influenciadas por alterações no sistema imunológico. Este sistema é responsável pela proteção do indivíduo contra alterações de origem externa (infecções) ou interna (neoplasias). Composto por órgãos, células, moléculas e gene, atua de forma complexa interagindo com o meio ambiente e modificando-se ao longo da idade.Esta revisão visa mostrar alterações na imunidade do idoso (imunossenescência), sendo didaticamente dividida em imunidade inata e imunidade adaptativa. Na imunidade inata temos: alterações na atividade fagocitária de neutrófilos, menor atividade quimiotática dos macrófagos, aumento na quantidade de células NK e maior produção de IL-6 pelas células dendríticas, por exemplo. Na imunidade adaptativa temos: atrofia tímica, desequilíbrio entre o número de células T virgens e de memória, redução dos mecanismos efetores de imunidade celular e, além disso, as células B e seus produtos ? imunoglobulinas e anticorpos ? também são afetados com o envelhecimento. O aprofundamento do conhecimento sobre a imunossenescência se torna essencial para melhor entender o perfil imunitário do idoso, suas alterações e consequências. Com isso, poderemos intervir de forma mais eficiente nestes indivíduos, visando a prevenção de doenças e, consequentemente, melhorar a qualidade de vida dos idosos.