Four- and sixteen-month clinical status of a cohort of patients following hospitalization for COVID-19.

BACKGROUND AND OBJECTIVES: Although many symptoms of post-COVID syndrome have been described, a comprehensive evaluation of their prevalence is lacking. We aimed to describe symptoms at 16 months from hospitalization for COVID-19. METHODS: A telephone assessment was performed one year later in a cohort of COVID-19 survivors hospitalized between March and May 2020 and already evaluated four months after discharge. Patients with relevant symptoms at 16 months, patients who presented symptoms at four months, and all intensive care unit patients were invited for assessment at an outpatient facility. At telephone consultation, respiratory, cognitive, and functional symptoms were assessed. Patients underwent pulmonary function tests, lung CT scans, and psychometric and cognitive tests at the outpatient facility. RESULTS: Among 478 patients evaluated four months after discharge, 317 (67 %) were assessed at telephone consultation and 124 at ambulatory assessment. At telephone assessment, ≥1 new symptom was reported by 216 patients (68 %), mainly fatigue (53 %), dyspnea (37 %), and memory difficulties (24 %). Seventy-nine patients (25 %) were asymptomatic at four months but declared ≥1 symptom one year later. In patients evaluated twice, the prevalence of cognitive impairment was 45 % at four months and 40 % at 16 months. Depression and post-traumatic symptoms prevalence remained stable, and the prevalence of anxiety significantly decreased. Dysfunctional breathing was detected in 32 % of patients. At 16 months after discharge, lung CT-scan exhibited abnormalities in 30/80 patients (38 %), compared to 52/85 patients (61 %) at four months. CONCLUSION: At 16 months after hospitalization for COVID-19, 68 % of patients declared symptoms, including patients whose symptoms appeared between 4 and 16 months. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04704388.

Tocilizumab-treated convalescent COVID-19 patients retain the cross-neutralization potential against SARS-CoV-2 variants.

Although tocilizumab treatment in severe and critical coronavirus disease 2019 (COVID-19) patients has proven its efficacy at the clinical level, there is little evidence supporting the effect of short-term use of interleukin-6 receptor blocking therapy on the B cell sub-populations and the cross-neutralization of SARS-CoV-2 variants in convalescent COVID-19 patients. We performed immunological profiling of 69 tocilizumab-treated and non-treated convalescent COVID-19 patients in total. We observed that SARS-CoV-2-specific IgG1 titers depended on disease severity but not on tocilizumab treatment. The plasma of both treated and non-treated patients infected with the ancestral variant exhibit strong neutralizing activity against the ancestral virus and the Alpha, Beta, and Delta variants of SARS-CoV-2, whereas the Gamma and Omicron viruses were less sensitive to seroneutralization. Overall, we observed that, despite the clinical benefits of short-term tocilizumab therapy in modifying the cytokine storm associated with COVID-19 infections, there were no modifications in the robustness of B cell and IgG responses to Spike antigens.

Reperfusion therapy for acute ischemic stroke in older people: An observational real-life study.

BACKGROUND: While randomized clinical trials have shown the benefit of thrombolysis and endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS), we aimed to describe in a real-life study the differences between older (>80 years old) and younger patients treated for AIS. METHODS: Thousand patients treated with thrombolysis and/or EVT were consecutively included in a prospective monocentric database (admitted from December 2015 to May 2019 in our comprehensive stroke center). Demographic data with detailed history, baseline physical examinations and treatments, laboratory and imaging data, prestroke functional status, and outcome 3 months after stroke were analyzed. RESULTS: Older patients (n = 357) had more baseline comorbidities and lower levels of prestroke independence (modified Rankin scale ≤2; 67.2% vs. 96.1%) and more severe strokes (median National Institute of Health Stroke Score [NIHSS] 15 vs. 12; p < 0.001) than younger patients (n = 643). There was no difference in the reperfusion treatments used or treatment timelines. In older patients, good functional status at 3 months was less common (29.7% vs. 61.3%) and mortality was higher (37.1% vs. 11.4%) than in younger patients. Younger age was independently associated with better prognosis (odds ratio [OR] 0.37, 95% confidence interval [CI]: 0.20-0.67; p = 0.001) and lower mortality (OR 4.38, 95% CI: 2.11-9.09; p < 0.001). Among older adults, features associated with good outcome at 3 months were age (OR 0.89, 95% CI: 0.81-0.97; p = 0.01), initial NIHSS (OR 0.89, 95% CI: 0.83-0.94; p < 0.0001), and absence of severe leukoaraiosis, anticoagulant treatment, and symptomatic intracerebral hemorrhage following reperfusion therapy (respectively, OR 0.42, 95% CI: 0.19-0.93; p = 0.03; OR = 0.07, 95% CI: 0.01-0.70; p = 0.02; and OR = 0.07, 95% CI: 0.01-0.61; p = 0.02). CONCLUSION: Although reperfusion therapy was less successful in older patients, these patients may benefit from acute recanalization despite their age. With an increasing older adult population, high-quality prospective studies are still required to better predict functional outcome and clarify the criteria that would allow better selection of appropriate treatment.

Four-Month Clinical Status of a Cohort of Patients After Hospitalization for COVID-19.

Importance: Little is known about long-term sequelae of COVID-19. Objective: To describe the consequences at 4 months in patients hospitalized for COVID-19. Design, Setting, and Participants: In a prospective uncontrolled cohort study, survivors of COVID-19 who had been hospitalized in a university hospital in France between March 1 and May 29, 2020, underwent a telephone assessment 4 months after discharge, between July 15 and September 18, 2020. Patients with relevant symptoms and all patients hospitalized in an intensive care unit (ICU) were invited for further assessment at an ambulatory care visit. Exposures: Survival of hospitalization for COVID-19. Main Outcomes and Measures: Respiratory, cognitive, and functional symptoms were assessed by telephone with the Q3PC cognitive screening questionnaire and a checklist of symptoms. At the ambulatory care visit, patients underwent pulmonary function tests, lung computed tomographic scan, psychometric and cognitive tests (including the 36-Item Short-Form Health Survey and 20-item Multidimensional Fatigue Inventory), and, for patients who had been hospitalized in the ICU or reported ongoing symptoms, echocardiography. Results: Among 834 eligible patients, 478 were evaluated by telephone (mean age, 61 years [SD, 16 years]; 201 men, 277 women). During the telephone interview, 244 patients (51%) declared at least 1 symptom that did not exist before COVID-19: fatigue in 31%, cognitive symptoms in 21%, and new-onset dyspnea in 16%. There was further evaluation in 177 patients (37%), including 97 of 142 former ICU patients. The median 20-item Multidimensional Fatigue Inventory score (n = 130) was 4.5 (interquartile range, 3.0-5.0) for reduced motivation and 3.7 (interquartile range, 3.0-4.5) for mental fatigue (possible range, 1 [best] to 5 [worst]). The median 36-Item Short-Form Health Survey score (n = 145) was 25 (interquartile range, 25.0-75.0) for the subscale "role limited owing to physical problems" (possible range, 0 [best] to 100 [worst]). Computed tomographic lung-scan abnormalities were found in 108 of 171 patients (63%), mainly subtle ground-glass opacities. Fibrotic lesions were observed in 33 of 171 patients (19%), involving less than 25% of parenchyma in all but 1 patient. Fibrotic lesions were observed in 19 of 49 survivors (39%) with acute respiratory distress syndrome. Among 94 former ICU patients, anxiety, depression, and posttraumatic symptoms were observed in 23%, 18%, and 7%, respectively. The left ventricular ejection fraction was less than 50% in 8 of 83 ICU patients (10%). New-onset chronic kidney disease was observed in 2 ICU patients. Serology was positive in 172 of 177 outpatients (97%). Conclusions and Relevance: Four months after hospitalization for COVID-19, a cohort of patients frequently reported symptoms not previously present, and lung-scan abnormalities were common among those who were tested. These findings are limited by the absence of a control group and of pre-COVID assessments in this cohort. Further research is needed to understand longer-term outcomes and whether these findings reflect associations with the disease.

Cardiovascular Complications Over 5 Years and Their Association With Survival in the GERODIAB Cohort of Elderly French Patients With Type 2 Diabetes.

OBJECTIVE: The GERODIAB study is a multicenter prospective observational study performed over 5 years in French patients aged 70 years or above with type 2 diabetes. This report deals with their cardiovascular complications and their relationship with survival. RESEARCH DESIGN AND METHODS: Consecutive patients (n = 987, median age = 77 years) were included from 56 diabetes centers over 1 year. Individual characteristics, history and complications of diabetes, geriatric factors, and clinical and biological parameters were recorded. Survival was analyzed using the Kaplan-Meier method and proportional hazards regression models. RESULTS: The frequency of cardiovascular complications increased from 47% at inclusion to 67% at 5 years. The most frequent complications were coronary heart disease (increasing from 30% to 41%) and vascular disease of the lower limbs (25% to 35%) and of the cerebral vessels (15% to 26%). Heart failure was less common, but its frequency doubled during the follow-up (9% to 20%). It was strongly associated with poor survival (P < 0.0001), as was vascular disease of the lower limbs (P = 0.0004), whereas coronary heart disease (P = 0.0056) and vascular disease of cerebral vessels (P = 0.026) had mild associations. Amputation (P < 0.0001) and foot wounds (P < 0.0001) were strongly associated with survival. In multivariate models, heart failure was the strongest predictor of poor survival (hazard ratio [HR] 1.96 [95% CI 1.45-2.64]; P < 0.0001). It remained significant when other factors were considered simultaneously (HR 1.92 [95% CI 1.43-2.58]; P < 0.0001). CONCLUSIONS: Cardiovascular complications are associated with poor survival in elderly patients with type 2 diabetes, especially heart failure.

Monitoring of Potentially Inappropriate Prescriptions in Older Inpatients: A French Multicenter Study.

OBJECTIVES: To determine whether potentially inappropriate medications (PIMs) or potentially inappropriate associations (PIAs) prescribed knowingly are associated with patient monitoring. DESIGN: Prospective observational study. SETTING: Geriatric units (n = 56) in 28 hospitals. PARTICIPANTS: Inpatients aged 75 and older (N = 1,327). MEASUREMENTS: Potentially inappropriate prescriptions (PIP) were defined as a PIM or a PIA selected by an expert board from lists of explicit criteria (Beers, Priscus, Laroche, French Health Agency) using a Delphi process. They were considered to be prescribed knowingly if they were maintained after reassessment by the geriatrician and the clinical pharmacist. Primary outcome was the rate of PIPs maintained (prescribed knowingly) and for which a geriatrician declared that specific monitoring was performed. Secondary outcomes were the parameters monitored and the rate of participants receiving knowingly a PIP. RESULTS: One thousand sixty-three PIPs were detected in 607 participants (46%). After reassessment, 826 (78%) PIPs were maintained in 490 participants (37%), the main reasons being participant's regular treatment and lack of alternative. Psychotropic (36%), cardiovascular (including antithrombotics) (29%), and laxative or antiemetic drugs (16%) were the most-frequent classes prescribed knowingly. The geriatricians declared to perform clinical or biological monitoring for 69% (n = 570) of PIMs or PIAs prescribed knowingly. Three types of specific monitoring were identified: clinical, biological, and follow-up with a specialist. CONCLUSION: Approximately three-quarters of PIMs or PIAs were prescribed knowingly, of which 69% were monitored, with wide variations in occurrence and in quality according to drug classes. This underlines the need for accurate guidelines on PIP monitoring.

Medical treatments of elderly, French patients with type 2 diabetes: results at inclusion in the GERODIAB Cohort.

Prevalence of diabetes in the elderly increases, and half of the French diabetics are over the age of 75 years. The GERODIAB study is the first French multicentre, prospective, observational study designed to analyse over 5 years the influence of glycaemic control on morbidity-mortality in type 2 diabetics patients 70 years old and over. This study analysed the diabetic and geriatric factors associated with the treatment modalities, particularly insulin, at inclusion in the cohort. The cohort of 987 type 2 diabetics was divided into three groups according to the method of treatment. Slightly fewer than one-third of these patients (26.4%) were treated with insulin alone, 31% received insulin and oral antidiabetic drugs, and 42.7% oral antidiabetic drugs alone. The patients that received insulin alone were significantly older, had poorer glycaemic control (HbA1c = 7.9 ± 1.4, 7.8 ± 1.0 and 7.1 ± 1.2%, respectively; P < 0.001) and had greater alterations of glomerular filtration rate (GFR). HbA1c was below 6.5% in 15% of patients and 37.3% of patients had a GFR below 60 mL/min. The patients treated with insulin alone had significantly more hypoglycaemic episodes (respectively 53.3, 36.3 and 19.5%, P < 0.001), retinopathy, cardiovascular involvement and more specific geriatric complications, such as cognitive disorders (respectively 34.1, 31.4 and 23.6%, P = 0.006). In this specific population of elderly type 2 diabetic patients, diabetic and geriatric conditions significantly differed between the types of drug treatments. Considering low values of HbA1c and GFR, some patients seemed overtreated and other patients received inappropriate drugs.

[Treatment of frail or dependent elderly patients with type 2 diabetes]. / Traitement du diabète de type 2 chez les sujets âgés.

In elderly type 2 diabetes, treatment of hyperglycemia has to be integrated into global and individualized care, driven by geriatric assessment In addition to avoiding lethal complications of diabetes, the prevention of decrease in the level of functional independence is the most important goal of this care, and must be implemented by taking into account the type of patient, vigourous or frail. For the dependent patient, maintaining comfort becomes the priority goal. From this assessment ensue the therapeutic and glycemic goals. The choice of therapeutic tools is a function of fixed goals, of comorbidities, of the organization of care at home or in nursing homes, and of the atrogenic risk, in particular the undernutrition and the hypoglycemia.

Cardiovascular events and geriatric scale scores in elderly (70 years old and above) type 2 diabetic patients at inclusion in the GERODIAB cohort.

OBJECTIVE To analyze the relationships between cardiovascular complications and geriatric scale scores in French elderly (≥70 years of age) type 2 diabetic patients at inclusion in the GERODIAB cohort. RESEARCH DESIGN AND METHODS GERODIAB is the first French multicenter, prospective, observational survey designed to analyze the influence of glycemic control on morbidity/mortality in type 2 diabetic patients aged ≥70 years during a 5-year follow-up period. This study analyzed the relationships between classical macroangiopathic complications and geriatric scale scores in 987 patients at baseline, using bivariate and multivariate analyses. RESULTS Cardiac ischemia (31.2%) was significantly associated with impaired activities of daily living (ADL) scores (P < 0.001). Stepwise logistic regression included hypercholesterolemia, ADL, sex, and hypertension successively (70.3% concordance; P < 0.001). Heart failure (10.1%) was associated with impaired Mini Mental State Examination (MMSE), instrumental ADL (IADL) (P < 0.05), and ADL scores (P < 0.001). With the logistic model, waist circumference, age, and HDL cholesterol were significant factors (70.7% concordance; P < 0.001). Arterial disease of the lower limbs (25.6%) was associated with impaired IADL and ADL scores (P < 0.001). Significant factors using the logistic model were duration of diabetes, IADL score, hypertension, and sex (62.8% concordance; P < 0.001). Cerebral ischemia (15.8%) was associated with impaired MMSE, Mini Nutritional Assessment, ADL, and IADL scores (P < 0.01). IADL, sex, hypertension, and ADL were included in the logistic model successively (65.6% concordance; P < 0.001). CONCLUSIONS In this specific population, impaired geriatric scale scores were found to be associated with classical macrovascular complications, notably using multivariate analyses. This suggests the benefits of thorough screening and management of cognitive and functional decline in elderly type 2 diabetic patients.