Use of Phenobarbitone for Palliative Sedation in Dyspneic Crises Due to COVID-19 Pneumonia - A Case Series.

Patients who suffer from dyspnea while dying from COVID-19 are treated with opioids and benzodiazepines. In some instances, patients may experience refractory dyspnea at the end of life. Palliative sedation can be prescribed to alleviate such patients' suffering. We describe two patients being treated for severe COVID-19 pneumonia in a tertiary hospital. Both developed intractable dyspneic crises despite high-dose opioids and benzodiazepines. This led to their requirement of palliative sedation in the general ward using subcutaneous phenobarbitone (phenobarbital). We outline clinical considerations for the use of palliative sedation in COVID-19 related dyspnea. In particular, we discuss the evidence for, benefits and limitations of using phenobarbitone for palliative sedation in COVID-19 patients.

Frontal subcortical ischemia is crucial for post stroke cognitive impairment.

BACKGROUND: The incidence of post stroke cognitive impairment (PSCI) and predictive factors for PSCI among patients with acute lacunar infarcts is unclear. OBJECTIVE: To study the impact of acute lacunar infarcts and chronic white matter disease in the development of PSCI. METHODS: Prospective cohort study of stroke patients attending a tertiary neurology center. Patients with MRI confirmed acute lacunar infarcts without pre-existing dementia were recruited. Logistic regression was used to determine risk factors for developing PSCI. RESULTS: 145 patients with a mean age of 55.8 years were studied of which 48 patients (33.1%) were identified to have PSCI. Patients with PSCI performed worse on the MMSE, MOCA and FAB and had significantly greater white matter hyperintensity (WMH) in the frontal subcortical (FSC) region (p = 0.006) and higher frontal subcortical acute infarct load (p = 0.002). Logistic regression demonstrated that deep subcortical WMH (odds ratio, OR = 1.45) and acute FSC infarcts (OR = 1.51) were associated with PSCI. High WMH load without acute FSC infarcts was associated with increased risk of PSCI (OR = 4.1). When patients developed acute FSC infarcts on pre-existing severe WMH, the risk of PSCI increased substantially (OR = 11.0). CONCLUSIONS: Patients with acute lacunar infarcts in the FSC region have 1.5 times risk of PSCI. This risk increases substantially to 11 times when there is pre-existing severe white matter disease.

White matter disease independently predicts progression from mild cognitive impairment to Alzheimer's disease in a clinic cohort.

BACKGROUND: The contribution of vascular pathology to the rate of progression from mild cognitive impairment (MCI) to Alzheimer's disease (AD) remains unclear. OBJECTIVE: To ascertain the relative roles of cerebral white matter disease and medial temporal atrophy (MTA) in predicting progression from MCI to AD. METHODS: MCI patients with baseline MRI and ≥18 months of longitudinal follow-up were evaluated. DSM-IV-TR criteria were used to diagnose conversion to dementia. MTA and white matter hyperintensity (WMH) were quantified using the Scheltens scale and modified Fazekas scale. RESULTS: Of a total of 171 MCI patients, 79 patients with baseline MRI and longitudinal follow-up were studied. Twenty-three MCI patients who progressed to dementia (MCI-P) were identified corresponding to a 19.4% annual risk of conversion. In MCI-P patients, the mean Mini-Mental State Examination and Montreal Cognitive Assessment decline was 1.3 and 2.9 points, respectively. MTA, periventricular WMH and deep subcortical WMH were significantly greater in the MCI-P cohort. WMH was found to predict MCI-P with an odds ratio of 7.69 (p = 0.03). CONCLUSION: MTA and deep subcortical WMH independently predict conversion from MCI to AD. Optimization of vascular risk factors among patients with MCI can potentially reduce the conversion from MCI to AD.