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Yehia A, Abulseoud OA. Melatonin: a ferroptosis inhibitor with potential therapeutic efficacy for the post-COVID-19 trajectory of accelerated brain aging and neurodegeneration. Mol Neurodegener 2024; 19:36. [PMID: 38641847 PMCID: PMC11031980 DOI: 10.1186/s13024-024-00728-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/15/2024] [Indexed: 04/21/2024] Open
Abstract
The unprecedented pandemic of COVID-19 swept millions of lives in a short period, yet its menace continues among its survivors in the form of post-COVID syndrome. An exponentially growing number of COVID-19 survivors suffer from cognitive impairment, with compelling evidence of a trajectory of accelerated aging and neurodegeneration. The novel and enigmatic nature of this yet-to-unfold pathology demands extensive research seeking answers for both the molecular underpinnings and potential therapeutic targets. Ferroptosis, an iron-dependent cell death, is a strongly proposed underlying mechanism in post-COVID-19 aging and neurodegeneration discourse. COVID-19 incites neuroinflammation, iron dysregulation, reactive oxygen species (ROS) accumulation, antioxidant system repression, renin-angiotensin system (RAS) disruption, and clock gene alteration. These events pave the way for ferroptosis, which shows its signature in COVID-19, premature aging, and neurodegenerative disorders. In the search for a treatment, melatonin shines as a promising ferroptosis inhibitor with its repeatedly reported safety and tolerability. According to various studies, melatonin has proven efficacy in attenuating the severity of certain COVID-19 manifestations, validating its reputation as an anti-viral compound. Melatonin has well-documented anti-aging properties and combating neurodegenerative-related pathologies. Melatonin can block the leading events of ferroptosis since it is an efficient anti-inflammatory, iron chelator, antioxidant, angiotensin II antagonist, and clock gene regulator. Therefore, we propose ferroptosis as the culprit behind the post-COVID-19 trajectory of aging and neurodegeneration and melatonin, a well-fitting ferroptosis inhibitor, as a potential treatment.
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Affiliation(s)
- Asmaa Yehia
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ, 58054, USA
- Department of Medical Physiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Osama A Abulseoud
- Department of Neuroscience, Graduate School of Biomedical Sciences, Mayo Clinic College of Medicine, Phoenix, AZ, 58054, USA.
- Department of Psychiatry and Psychology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
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Huang P, Tan YY, Chen B, Shang HF, Wang LJ, Liu CF, Chen L, Chang Y, Wang H, Wang XL, Lei XG, Yao LF, Yu Y, Ye Z, Chen HB, Chen SD. Life and disease status of patients with Parkinson's disease during and after zero-COVID in China: an online survey. Transl Neurodegener 2024; 13:8. [PMID: 38317265 PMCID: PMC10845503 DOI: 10.1186/s40035-024-00399-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/14/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Little is known about the impact of the COVID-19 pandemic on patients with Parkinson's disease (PD) at different stages of the pandemic. This study aims to assess the lives and disease status of PD patients during the zero-COVID policy period and after ending the zero-COVID policy. METHODS This multicenter cross-sectional study included two online surveys among PD patients in China, from May 30 to June 30 in 2022 and from January 1 to February 28 in 2023, respectively. The survey questionnaires contained four sections: (1) status of COVID-19 infection; (2) impact on motor and non-motor symptoms; (3) impact on daily and social lives; and (4) impact on PD disease management. RESULTS A total of 1764 PD patients participated in the first online survey, with 200 patients having lockdown experience and 3 being COVID-19-positive (0.17%). In addition, 537 patients participated in the second online survey, with 467 patients having COVID-19 infection (86.96%). (1) During zero-COVID, all of the COVID-19-positive patients had mild symptoms of COVID-19 and no death was reported. After zero-COVID, 83.51% of the COVID-19-positive patients had mild symptoms. The overall death rate and inpatient mortality rate of COVID-19-positive PD patients were 3.21% and 30.00%, respectively. (2) During zero-COVID, 49.43% of PD patients reported worsening of PD-related symptoms (lockdown vs. unlockdown, 60.50% vs. 48.02%, P = 0.0009). After zero-COVID, 54.93% of PD patients reported worsening of PD-related symptoms (COVID-19 positive vs. COVID-19 negative, 59.31% vs. 25.71%, P < 0.0001). (3) During zero-COVID, 62.36% of patients felt worried, and 'limited outdoor activities' (55.39%) was the top reason for mental health problems. After zero-COVID, 59.03% of patients felt worried, with 'poor health' (58.10%) being the top reason. The PD patients tended to change their daily activities from offline to online, and their economic and caregiver burdens increased both during and after zero-COVID. (4) Most PD patients would like to choose online rehabilitation during (69.56%) and after zero-COVID (69.27%). The demand for online medication purchasing also increased during (47.00%) and after zero-COVID (26.63%). CONCLUSIONS The COVID-19 pandemic aggravated the motor and non-motor symptoms of PD patients either during or after the zero-COVID policy period. The PD patients also experienced prominent mental health problems, changes in daily activities, and increases in economic and caregiver burdens. The COVID-19 pandemic has changed ways of PD management with increasing demands for online medication purchasing and rehabilitation.
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Affiliation(s)
- Pei Huang
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Yu-Yan Tan
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Biao Chen
- Department of Neurology, Xuan Wu Hospital Affiliated to Capital Medical University, Beijing, 100053, China
| | - Hui-Fang Shang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Li-Juan Wang
- Department of Neurology, Guangdong General Hospital, Guangzhou, 510080, China
| | - Chun-Feng Liu
- Department of Neurology, Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Ling Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, 510080, China
| | - Ying Chang
- Department of Neurology, China-Japan Union Hospital, Jilin University, Changchun, 130031, China
| | - Han Wang
- Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xue-Lian Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xiao-Guang Lei
- Department of Neurology, The First Affiliated Hospital of Kunming Medical University, Kunming, 650032, China
| | - Li-Fen Yao
- Department of Neurology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, China
| | - Yang Yu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, 300350, China
| | - Zheng Ye
- Institute of Neuroscience, Center for Excellence in Brain Science and Intelligence Technology, Chinese Academy of Sciences, Shanghai, 200031, China
| | - Hai-Bo Chen
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China.
| | - Sheng-Di Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
- Lab for Translational Research of Neurodegenerative Diseases, Shanghai Institute for Advanced Immunochemical Studies (SIAIS), Shanghai Tech University, Shanghai, 201210, China.
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Sandeep, Subba R, Mondal AC. Does COVID-19 Trigger the Risk for the Development of Parkinson's Disease? Therapeutic Potential of Vitamin C. Mol Neurobiol 2023:10.1007/s12035-023-03756-3. [PMID: 37957424 DOI: 10.1007/s12035-023-03756-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which was proclaimed a pandemic by the World Health Organization (WHO) in March 2020. There is mounting evidence that older patients with multimorbidity are more susceptible to COVID-19 complications than are younger, healthy people. Having neuroinvasive potential, SARS-CoV-2 infection may increase susceptibility toward the development of Parkinson's disease (PD), a progressive neurodegenerative disorder with extensive motor deficits. PD is characterized by the aggregation of α-synuclein in the form of Lewy bodies and the loss of dopaminergic neurons in the dorsal striatum and substantia nigra pars compacta (SNpc) of the nigrostriatal pathway in the brain. Increasing reports suggest that SARS-CoV-2 infection is linked with the worsening of motor and non-motor symptoms with high rates of hospitalization and mortality in PD patients. Common pathological changes in both diseases involve oxidative stress, mitochondrial dysfunction, neuroinflammation, and neurodegeneration. COVID-19 exacerbates the damage ensuing from the dysregulation of those processes, furthering neurological complications, and increasing the severity of PD symptomatology. Phytochemicals have antioxidant, anti-inflammatory, and anti-apoptotic properties. Vitamin C supplementation is found to ameliorate the common pathological changes in both diseases to some extent. This review aims to present the available evidence on the association between COVID-19 and PD, and discusses the therapeutic potential of vitamin C for its better management.
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Affiliation(s)
- Sandeep
- Laboratory of Cellular & Molecular Neurobiology, School of Life Sciences, Jawaharlal Nehru University, New Delhi, 110067, India
| | - Rhea Subba
- Laboratory of Cellular & Molecular Neurobiology, School of Life Sciences, Jawaharlal Nehru University, New Delhi, 110067, India
| | - Amal Chandra Mondal
- Laboratory of Cellular & Molecular Neurobiology, School of Life Sciences, Jawaharlal Nehru University, New Delhi, 110067, India.
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Fung WK, Fasano A, Fearon C. Movement Disorders and SARS-CoV-2. Mov Disord Clin Pract 2023; 10:S9-S17. [PMID: 37637980 PMCID: PMC10448146 DOI: 10.1002/mdc3.13615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 05/02/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Wilson K.W. Fung
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital – UHNUniversity of TorontoTorontoOntarioCanada
| | - Alfonso Fasano
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital – UHNUniversity of TorontoTorontoOntarioCanada
- Krembil Research InstituteTorontoOntarioCanada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA)TorontoOntarioCanada
- Department of Parkinson's Disease and Movement Disorders Rehabilitation‘Moriggia‐Pelascini’ Hospital – Gravedona ed UnitiComoItaly
| | - Conor Fearon
- Division of Neurology, Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital – UHNUniversity of TorontoTorontoOntarioCanada
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Sorrell L, Leta V, Barnett A, Stevens K, King A, Inches J, Kobylecki C, Walker R, Chaudhuri KR, Martin H, Rideout J, Sneyd JR, Campbell S, Carroll C. Clinical features and outcomes of hospitalised patients with COVID-19 and Parkinsonian disorders: A multicentre UK-based study. PLoS One 2023; 18:e0285349. [PMID: 37523365 PMCID: PMC10389727 DOI: 10.1371/journal.pone.0285349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/18/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Parkinson's disease has been identified as a risk factor for severe Coronavirus disease 2019 (COVID-19) outcomes. However, whether the significant high risk of death from COVID-19 in people with Parkinson's disease is specific to the disease itself or driven by other concomitant and known risk factors such as comorbidities, age, and frailty remains unclear. OBJECTIVE To investigate clinical profiles and outcomes of people with Parkinson's disease and atypical parkinsonian syndromes who tested positive for COVID-19 in the hospital setting in a multicentre UK-based study. METHODS A retrospective cohort study of Parkinson's disease patients with a positive SARS-CoV-2 test admitted to hospital between February 2020 and July 2021. An online survey was used to collect data from clinical care records, recording patient, Parkinson's disease and COVID-19 characteristics. Associations with time-to-mortality and severe outcomes were analysed using either the Cox proportional hazards model or logistic regression models, as appropriate. RESULTS Data from 552 admissions were collected: 365 (66%) male; median (inter-quartile range) age 80 (74-85) years. The 34-day all-cause mortality rate was 38.4%; male sex, increased age and frailty, Parkinson's dementia syndrome, requirement for respiratory support and no vaccination were associated with increased mortality risk. Community-acquired COVID-19 and co-morbid chronic neurological disorder were associated with increased odds of requiring respiratory support. Hospital-acquired COVID-19 and delirium were associated with requiring an increase in care level post-discharge. CONCLUSIONS This first, multicentre, UK-based study on people with Parkinson's disease or atypical parkinsonian syndromes, hospitalised with COVID-19, adds and expands previous findings on clinical profiles and outcomes in this population.
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Affiliation(s)
- Lexy Sorrell
- University of Plymouth, Plymouth, United Kingdom
| | - Valentina Leta
- Department of Basic and Clinical Neuroscience, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, United Kingdom
| | | | - Kara Stevens
- Exploristics Ltd, Belfast, Northern Ireland, United Kingdom
| | - Angela King
- University of Plymouth, Plymouth, United Kingdom
| | - Jemma Inches
- University of Plymouth, Plymouth, United Kingdom
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Christopher Kobylecki
- Division of Neuroscience and Experimental Psychology, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- Department of Neurology, Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Richard Walker
- Department of Medicine, North Tyneside Hospital, Northumbria Healthcare NHS Foundation Trust, North Shields, United Kingdom
- Population Health Science Institute, Newcastle University, Newcastle, United Kingdom
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neuroscience, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, United Kingdom
- Parkinson's Foundation Centre of Excellence, King's College Hospital, London, United Kingdom
| | - Hannah Martin
- University Hospitals Coventry and Warwickshire NHS Trust, Coventry, United Kingdom
| | | | | | | | - Camille Carroll
- University of Plymouth, Plymouth, United Kingdom
- University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
- Newcastle University, Newcastle, United Kingdom
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Georgakopoulou VE, Gkoufa A, Bougea A, Basoulis D, Tsakanikas A, Makrodimitri S, Karamanakos G, Spandidos DA, Angelopoulou E, Sipsas NV. Characteristics and outcomes of elderly patients with Parkinson's disease hospitalized due to COVID‑19‑associated pneumonia. MEDICINE INTERNATIONAL 2023; 3:34. [PMID: 37448768 PMCID: PMC10336924 DOI: 10.3892/mi.2023.94] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023]
Abstract
Patients with Parkinson's disease (PD) and coronavirus disease 2019 (COVID-19)-associated pneumonia present, according to the literature, high mortality rates due to the nature of the disease, advanced age, and underlying diseases. Most available studies, however, refer to the first waves of the pandemic. The aim of the present study was to investigate the clinical characteristics and outcomes of elderly patients (≥65 years old) with PD hospitalized with COVID-19-associated pneumonia during the period of prevalence of various severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants, as well as to determine possible prognostic factors for poor outcomes. During the period from February 15, 2021, to July 15, 2022, 1,144 elderly patients with COVID-19 pneumonia were hospitalized. Age, sex, Charlson comorbidity index, vaccination status against SARS-CoV-2, and admission laboratory parameters were recorded for all patients. A total of 36 (3.1%) patients with PD were hospitalized due to COVID-19-associated pneumonia (18 males, 50%). The mean age of the patients was 82.72±8.18 years. In total, 8 patients (22.2%) were hospitalized during the period of alpha variant predominance, 3 patients (8.3%) during the period of delta variant predominance, and 25 patients (69.4%) during the omicron variant predominance period. Of note, 16 patients (44.4%) were vaccinated with at least two doses. In addition, 17 (47.2%) patients succumbed to the disease. Between the patients who survived and those who succumbed, a statistically significant difference was only found in the mean value of albumin (37.48±6.02 vs. 31.97±5.34 g/l, P=0.019). In particular, as shown by receiver operating characteristic curve analysis, albumin exhibited a satisfactory predictive ability for mortality (area under the curve, 0.780; P=0.013) with an albumin value ≤37.7 g/l being able to predict mortality with 85.7% sensitivity and 54.8% specificity. Overall, the findings of the present study indicate that mortality among elderly patients with PD hospitalized with COVID-19-associated pneumonia was high in all phases of the pandemic. A low albumin value, not only as an indicator of the immune status, but also of the nutritional status, is a predictor of adverse outcomes.
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Affiliation(s)
- Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Pathophysiology, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Aikaterini Gkoufa
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Anastasia Bougea
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Dimitrios Basoulis
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Pathophysiology, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Aristeidis Tsakanikas
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sotiria Makrodimitri
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgios Karamanakos
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Efthalia Angelopoulou
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | - Nikolaos V. Sipsas
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Pathophysiology, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
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Huang P, Zhang LY, Tan YY, Chen SD. Links between COVID-19 and Parkinson's disease/Alzheimer's disease: reciprocal impacts, medical care strategies and underlying mechanisms. Transl Neurodegener 2023; 12:5. [PMID: 36717892 PMCID: PMC9885419 DOI: 10.1186/s40035-023-00337-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/12/2023] [Indexed: 01/31/2023] Open
Abstract
The impact of coronavirus disease 2019 (COVID-19) pandemic on patients with neurodegenerative diseases and the specific neurological manifestations of COVID-19 have aroused great interest. However, there are still many issues of concern to be clarified. Therefore, we review the current literature on the complex relationship between COVID-19 and neurodegenerative diseases with an emphasis on Parkinson's disease (PD) and Alzheimer's disease (AD). We summarize the impact of COVID-19 infection on symptom severity, disease progression, and mortality rate of PD and AD, and discuss whether COVID-19 infection could trigger PD and AD. In addition, the susceptibility to and the prognosis of COVID-19 in PD patients and AD patients are also included. In order to achieve better management of PD and AD patients, modifications of care strategies, specific drug therapies, and vaccines during the pandemic are also listed. At last, mechanisms underlying the link of COVID-19 with PD and AD are reviewed.
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Affiliation(s)
- Pei Huang
- grid.16821.3c0000 0004 0368 8293Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025 China
| | - Lin-Yuan Zhang
- grid.412478.c0000 0004 1760 4628Department of Neurology, Shanghai General Hospital, Shanghai, 200080 China
| | - Yu-Yan Tan
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Sheng-Di Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China. .,Lab for Translational Research of Neurodegenerative Diseases, Shanghai Institute for Advanced Immunochemical Studies (SIAIS), Shanghai Tech University, Shanghai, 201210, China.
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Rezayi S, Rahmani Katigari M, Shahmoradi L, Nilashi M. Vulnerability of Parkinson's Patients to COVID-19 and Its Consequences and Effects on Them: A Systematic Review. PARKINSON'S DISEASE 2023; 2023:6272982. [PMID: 37144210 PMCID: PMC10151717 DOI: 10.1155/2023/6272982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 02/08/2023] [Accepted: 04/09/2023] [Indexed: 05/06/2023]
Abstract
Introduction Parkinson's disease (PD) is the second most common neurological disorder. Patients with PD were affected by the COVID-19 pandemic in many different ways. This study's principal purpose is to assess PD patients' vulnerability to COVID-19 and its consequences. Method This systematic review was performed based on Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines. A thorough search was conducted in the Medline (through PubMed) and Scopus databases from inception to January 30, 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist was used to evaluate the studies. Results Most of the studies (38%) had been conducted in Italy. Of the total number of studies, 17 (58%) were cross-sectional, seven (22%) were cohort, four (12%) were quasiexperimental, two (6%) were case-control, and one (3%) was a qualitative study. The PD duration in patients ranged from 3.26 to 13.40 years (IQR1: 5.7 yrs., median: 3.688 yrs., and IQR3: 8.815 yrs.). Meanwhile, the sample size ranged from 12 to 30872 participants (IQR1: 46, median: 96, and IQR3: 211). Despite worsening PD symptoms in the targeted population (persons with COVID-19 and Parkinson's disease), some studies found PD to be a risk factor for more severe COVID-19 disease. There are many adverse effects during the pandemic period in PD patients such as abnormalities of motor, nonmotor functioning, clinical outcomes, activities of daily living, and other outcomes. Conclusion This study confirmed the negative effect of the COVID-19 pandemic on health-related quality of life and its determinants in patients with PD and their caregivers. Thus, due to the worsening symptoms of PD patients in the current pandemic, these people should be given more care and supervision to minimize their coronavirus exposure.
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Affiliation(s)
- Sorayya Rezayi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Leila Shahmoradi
- Health Information Management and Medical Informatics Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrbakhsh Nilashi
- UCSI Graduate Business School, UCSI University, No. 1 Jalan Menara Gading, UCSI Heights, 56000 Cheras, Kuala Lumpur, Malaysia
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Demleitner AF, Wolff AW, Erber J, Gebhardt F, Westenberg E, Winkler AS, Kolbe-Busch S, Chaberny IF, Lingor P. Best practice approaches to outpatient management of people living with Parkinson's disease during the COVID-19 pandemic. J Neural Transm (Vienna) 2022; 129:1377-1385. [PMID: 35244753 PMCID: PMC8895054 DOI: 10.1007/s00702-022-02484-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/24/2022] [Indexed: 11/26/2022]
Abstract
The prevalence of Parkinson's disease (PD) is rising, rendering it one of the most common neurodegenerative diseases. Treatment and monitoring of patients require regular specialized in- and outpatient care. Patients with PD are more likely to have a complicated disease course if they become infected with severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2). Regular in-hospital appointments place these patients at risk of exposure to SARS-CoV-2 due to travel and contact with other patients and staff. However, guidelines for the management of outpatients with PD during times of increased risk of infection are currently lacking. These are urgently needed to conduct risk-benefit evaluations to recommend the best medical treatment. This article discusses best practice approaches based on the current literature, as suggested by the multidisciplinary Network of University Medicine (NUM) in Germany. These include measures such as mask-wearing, hand hygiene, social distancing measures, and appropriate testing strategies in outpatient settings, which can minimize the risk of exposure. Furthermore, the urgency of appointments should be considered. Visits of low urgency may be conducted by general practitioners or via telemedicine consultations, whereas in-person presentation is required in case of moderate and high urgency visits. Classification of urgency should be carried out by skilled medical staff, and telemedicine (telephone or video consultations) may be a useful tool in this situation. The currently approved vaccines against SARS-CoV-2 are safe and effective for patients with PD and play a key role in minimizing infection risk for patients with PD.
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Affiliation(s)
- Antonia F Demleitner
- Department of Neurology, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas W Wolff
- Department of Neurology, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
| | - Johanna Erber
- Department of Internal Medicine II, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
| | - Friedemann Gebhardt
- Department of Hospital Hygiene, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
| | - Erica Westenberg
- Department of Neurology, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
- Center for Global Health, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andrea S Winkler
- Department of Neurology, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
- Center for Global Health, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany
- Centre for Global Health, Institute of Health and Society, School of Medicine, University of Oslo, Oslo, Norway
| | - Susanne Kolbe-Busch
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Iris F Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Paul Lingor
- Department of Neurology, School of Medicine, University Hospital München rechts der Isar, Technical University of Munich, Munich, Germany.
- DZNE, German Center for Neurodegenerative Diseases, Munich, Germany.
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.
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Zenesini C, Vignatelli L, Belotti LMB, Baccari F, Calandra‐Buonaura G, Cortelli P, Descovich C, Giannini G, Guaraldi P, Guarino M, Loddo G, Pantieri R, Perlangeli V, Scaglione C, Stivanello E, Trombetti S, D'Alessandro R, Baldin E, Nonino F. Risk of SARS-CoV-2 infection, hospitalization and death for COVID-19 in people with Parkinson's disease or parkinsonism over a 15-month period: a cohort study. Eur J Neurol 2022; 29:10.1111/ene.15505. [PMID: 35841385 PMCID: PMC9350080 DOI: 10.1111/ene.15505] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/30/2022] [Accepted: 07/13/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The patterns of long term risk of SARS-CoV-2 infection, hospitalization for COVID-19 and related death are uncertain in people with Parkinson's disease (PD) or parkinsonism (PS). The aim of the study was to quantify these risks compared to a control population cohort, during the period March 2020-May 2021, in Bologna, northern Italy. METHOD ParkLink Bologna cohort (759 PD; 192 PS) and controls (9,226) anonymously matched (ratio 1:10) for sex, age, district, comorbidity were included. Data were analysed in the whole period and in the two different pandemic waves (March-May 2020 and October 2020-May 2021). RESULTS Adjusted hazard ratio of SARS-CoV-2 infection was 1.3 (95% CI 1.04-1.7) in PD and 1.9 (1.3-2.8) in PS compared to the controls. The trend was detected in both the pandemic waves. Adjusted hazard ratio of hospitalization for COVID-19 was 1.1 (95% CI 0.8-1.7) in PD and 1.8 (95% CI 0.97-3.1) in PS. A higher risk of hospital admission was detected in PS only in the first wave. The 30-day mortality risk after hospitalization was higher (p=0.048) in PS (58%) than in PD (19%) and controls (26%). CONCLUSIONS Compared with controls, after adjustment for key covariates, people with PD and PS showed a higher risk of SARS-CoV-2 infection throughout the first 15 months of the pandemic. COVID-19 hospitalization risk was increased only in people with PS and only during the first wave. This group of patients was burdened by a very high risk of death after infection and hospitalization.
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Affiliation(s)
- Corrado Zenesini
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Luca Vignatelli
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | | | - Flavia Baccari
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Giovanna Calandra‐Buonaura
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
- Dipartimento di Scienze Biomediche e NeuroMotorieUniversità degli Studi di BolognaBolognaItaly
| | - Pietro Cortelli
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
- Dipartimento di Scienze Biomediche e NeuroMotorieUniversità degli Studi di BolognaBolognaItaly
| | | | - Giulia Giannini
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
- Dipartimento di Scienze Biomediche e NeuroMotorieUniversità degli Studi di BolognaBolognaItaly
| | - Pietro Guaraldi
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Maria Guarino
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Giuseppe Loddo
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
- Azienda USL di BolognaBolognaItaly
| | - Roberta Pantieri
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | | | - Cesa Scaglione
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | | | | | | | - Elisa Baldin
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di BolognaBolognaItaly
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Scherbaum R, Bartig D, Richter D, Kwon EH, Muhlack S, Gold R, Krogias C, Tönges L. COVID-19 outcomes in hospitalized Parkinson's disease patients in two pandemic waves in 2020: a nationwide cross-sectional study from Germany. Neurol Res Pract 2022; 4:27. [PMID: 35811323 PMCID: PMC9271552 DOI: 10.1186/s42466-022-00192-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 05/12/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The individualized clinical and public health management of the COVID-19 pandemic have changed over time, including care of people with PD. The objective was to investigate whether in-hospital COVID-19 outcomes and hospital care utilization of people with PD differed between the first two pandemic waves (W) 2020 in Germany. METHODS We conducted a nationwide cross-sectional study of inpatients with confirmed COVID-19 and PD between March 1 and May 31 (W1), and October 1 and December 31 (W2), 2020 and 2019, using an administrative database. Outcomes were in-hospital mortality, ICU admission rate, change in hospital care utilization, demographical data, PD clinical characteristics, and selected comorbidities. Differences were assessed between waves, PD/non-PD groups, and years. RESULTS We identified 2600 PD COVID-19 inpatients in W2 who in total showed higher in-hospital mortality rates and lower ICU admission rates, compared to both W1 (n = 775) and W1/W2 non-PD COVID-19 inpatients (n = 144,355). Compared to W1, W2 inpatients were more long-term care-dependent, older, more of female sex, and had less advanced disease. During both waves, PD inpatients were older, more frequently male and long-term care-dependent, and showed more risk comorbidities than non-PD COVID-19 inpatients. Decreases in hospital care utilization were stronger than average for PD inpatients but relatively weaker during W2. Non-COVID-19 PD inpatients showed poorer in-hospital outcomes in 2020 than in 2019 with better outcomes during W2. CONCLUSIONS In-hospital COVID-19 outcomes and hospital care utilization of PD patients in Germany differed between the two pandemic waves in 2020 with increased in-hospital mortality for PD COVID-19. Overall hospital care utilization for PD was increased during W2. TRIAL REGISTRATION No trial registration or ethical approval was required because data were publicly available, anonymized, and complied with the German data protection regulations.
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Affiliation(s)
- Raphael Scherbaum
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | | | - Daniel Richter
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Eun Hae Kwon
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Siegfried Muhlack
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Ralf Gold
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
- Neurodegeneration Research, Protein Research Unit Ruhr (PURE), Ruhr-University Bochum, 44801 Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
| | - Lars Tönges
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, 44791 Bochum, Germany
- Neurodegeneration Research, Protein Research Unit Ruhr (PURE), Ruhr-University Bochum, 44801 Bochum, Germany
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12
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Khoshnood RJ, Zali A, Tafreshinejad A, Ghajarzadeh M, Ebrahimi N, Safari S, Mirmosayyeb O. Parkinson's disease and COVID-19: a systematic review and meta-analysis. Neurol Sci 2022; 43:775-783. [PMID: 34787753 PMCID: PMC8596358 DOI: 10.1007/s10072-021-05756-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 11/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with Parkinson's disease (PD) are at higher risk of COVID-19 infection as most of them are at older age. The goal of this study is to update the pooled prevalence of COVID-19 infection in patients with PD. METHODS Two researchers systematically searched PubMed, Scopus, EMBASE, Web of Science, Google Scholar, and also gray literature including references of the included studies which were published before September 2021. We extracted data regarding the total number of participants, first author, publication year, the country of origin, mean age, number with COVID-19, symptoms, hospitalization, and death. RESULTS We found 1693 articles by literature search; after deleting duplicates, 798 remained. Thirty articles remained for meta-analysis. The pooled prevalence of COVID-19 infection in PD cases was 5% (95%CI: 4-6%) (I2 = 98.1%, P < 0.001). The pooled prevalence of fever in cases with PD was 4% (95%CI: 2-6%) (I2 = 96%, P < 0.001). The pooled prevalence of cough in cases with PD was 3% (95%CI: 2-4%) (I2 = 95.9%, P < 0.001). The pooled prevalence of hospitalization in cases with COVID-19 infection was 49% (95%CI: 29-52%) (I2: 93.5%, P < 0.001). The pooled prevalence of mortality in COVID-19 cases was 12% (95%CI: 10-14%) (I2 = 97.6%, P < 0.001). CONCLUSION The results of this systematic review and meta-analysis show that the pooled prevalence of COVID-19 infection in PD cases is 5% besides hospitalization and mortality rates which are 49% and 12%.
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Affiliation(s)
- Reza Jalili Khoshnood
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Zali
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Tafreshinejad
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Ghajarzadeh
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
- Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Narges Ebrahimi
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Saeid Safari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Omid Mirmosayyeb
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
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Rukavina K, McConvey V, Ray Chaudhuri K, Miyasaki J. Parkinson's disease and Covid-19: Is there an impact of ethnicity and the need for palliative care. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 165:229-249. [PMID: 36208902 PMCID: PMC9042419 DOI: 10.1016/bs.irn.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Under the traditional models of care for People with Parkinson's Disease (PD, PwP), many of their needs remain unmet and a substantial burden of motor and non-motor symptoms they experience may not be tackled sufficiently. An introduction of palliative care (PC) interventions early in the course of PD offers profound benefits: it may improve quality of life of patients, their families and caregivers through the prevention and relief of medical symptoms, while, at the same time, emphasizing their emotional needs and spiritual wellbeing, establishing goals of care, and engaging in the advance care planning (ACP). The ongoing Coronavirus Disease 2019 (Covid-19) pandemic poses an unprecedented set of challenges for PwP and has in many ways (both directly and indirectly) magnified their suffering, thus rapidly raising the demand for PC interventions. Covid-19, as well as the repercussions of prolonged mobility restrictions and limited health-care access might exacerbate the severity of PD motor symptoms and interact negatively with a range of non-motor symptoms, with a detrimental effect on quality of life. Greater motor disability, higher amount of levodopa-induced motor fluctuations with an increased daily off-time, fatigue, anxiety, depression, sleep disturbances, pain and worsening of cognitive complaints might dominate the clinical presentation in PwP during the Covid-19 pandemic, alongside raising psychological and spiritual concerns and anticipatory grief. Here, we aim to provide a foundation for pragmatic and clinically orientated PC approach to improve quality of life and relieve suffering of PwP in the context of the current, ongoing Covid-19 pandemic.
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Fearon C, Fasano A. Prevalence and outcomes of Covid-19 in Parkinson's disease: Acute settings and hospital. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 165:35-62. [PMID: 36208906 PMCID: PMC9020798 DOI: 10.1016/bs.irn.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The global explosion of COVID-19 necessitated the rapid dissemination of information regarding SARS-CoV-2. Hence, COVID-19 prevalence and outcome data in Parkinson's disease patients were disseminated at a time when we only had part of the picture. In this chapter we firstly discuss the current literature on the prevalence of COVID-19 in people with PD. We then discuss outcomes from COVID-19 in people with PD, specifically risk of hospitalization and mortality. Finally, we discuss specific contributing and confounding factors which may put PD patients at higher or lower risk from COVID-19.
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Affiliation(s)
- Conor Fearon
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital-UHN, Division of Neurology, University of Toronto, Toronto, ON, Canada; Krembil Research Institute, Toronto, ON, Canada; Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada.
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15
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Salari M, Etemadifar M, Ashrafi F, Ommi D, Aminzade Z, Tehrani Fateh S. Parkinson's disease patients may have higher rates of Covid-19 mortality in Iran. Parkinsonism Relat Disord 2021; 89:90-92. [PMID: 34256334 PMCID: PMC8264275 DOI: 10.1016/j.parkreldis.2021.07.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/11/2021] [Accepted: 07/05/2021] [Indexed: 12/04/2022]
Abstract
Background Parkinson's disease (PD) patients may be at increased risk of Covid-19 mortality due to the nature of their disease or underlying conditions. Method The information of 12,909 Covid-19 patients who were hospitalized during the last eleven months were collected from the data depository of two referral university hospitals. Eighty-seven of these patients were diagnosed with PD, and thirty-one of these PD patients died because of Covid-19. 2132 other deaths occurred in these centers, related to Covid-19 of non-PD patients. Fisher exact test, Chi-square test, and Principle component analysis were used for statistical analysis. Results The mortality among PD patients and other hospitalized patients was 35.6% and 19.8%, respectively, and the difference between the mortality of these two groups was found to be statistically significant (p-value<0.01). The mean age of PD patients who passed away was 77.06 ± 7.46, and it was not significantly different from that of alive PD patients (p-value>0.05). Alzheimer's disease as an underlying condition was more frequent in deceased PD patients in comparison to survived PD patients, and this difference was found to be statistically significant (p-value<0.01). Conclusion PD patients possess a higher rate of Covid-19 mortality in comparison with other patients hospitalized for Covid-19. PD pathophysiology, advanced age, underlying conditions, and health systems’ efficacy may play an essential role in such an outcome.
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Affiliation(s)
- Mehri Salari
- Functional Neurosurgery Research Center, Shohada-e Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Masoud Etemadifar
- Department of Functional Neurosurgery, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farzad Ashrafi
- Functional Neurosurgery Research Center, Shohada-e Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Ommi
- Functional Neurosurgery Research Center, Shohada-e Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Zahra Aminzade
- Functional Neurosurgery Research Center, Shohada-e Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sepand Tehrani Fateh
- Functional Neurosurgery Research Center, Shohada-e Tajrish Comprehensive Neurosurgical Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran; School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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