COVID-19: A Perspective from Clinical Neurology and Neuroscience

Healthcare Utilization Among Patients Diagnosed with COVID-19 in a Large Integrated Health System

Background

The demands for healthcare resources following a COVID-19 diagnosis are substantial, but not currently quantified.

Objective

To describe trends in healthcare utilization within 180 days for patients diagnosed with COVID-19 and identify patient factors associated with increased healthcare use.

Design

Observational cohort study.

Patients

A total of 64,011 patients with a test-confirmed COVID-19 diagnosis from March to September 2020 in a large integrated healthcare system in Southern California.

Main Measures

Overall healthcare utilization during the 180 days following COVID-19 diagnosis, as well as encounter types and reasons for visits during the first 30 days. Poisson regression was used to identify patient factors associated with higher utilization. Analyses were performed separately for patients who were and were not hospitalized for COVID-19.

Key Results

Healthcare utilization was about twice as high for hospitalized patients compared to non-hospitalized patients in all time periods. The average number of visits was highest in the first 30 days (hospitalized: 12.3 visits/30 person-days; non-hospitalized: 6.6) and gradually decreased over time. In the first 30 days, the majority of healthcare visits were telehealth encounters (hospitalized: 9.0 visits; non-hospitalized: 5.6 visits), and the most prevalent reasons for visits were COVID-related diagnoses, COVID-related symptoms, and respiratory-related conditions. For hospitalized patients, older age (≥65: RR 1.27, 95% CI 1.15–1.41), female gender (RR 1.07, 95% CI 1.05–1.09), and higher BMI (≥40: RR 1.07, 95% CI 1.03–1.10) were associated with higher total utilization. For non-hospitalized patients, older age, female gender, higher BMI, non-white race/ethnicity, former smoking, and greater number of pre-existing comorbidities were all associated with increased utilization.

Conclusions

Patients with COVID-19 seek healthcare frequently within 30 days of diagnosis, placing high demands on health systems. Identifying ways to support patients diagnosed with COVID-19 while adequately providing the usual recommended care to our communities will be important as we recover from the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-021-07139-z.

COVID-19 and Micronutrient Deficiency symptoms – is there some overlap?

Background & aims

COVID-19 is highly inflammatory and when it affects the elderly who have multiple comorbidities, the risk of malnutrition is high. The aim of this review is to highlight the evidence for COVID-19 and risk for malnutrition (macro- and micro-nutrient deficiency) sharing two case reports.

Methods

We report two cases of patients with COVID-19. The first case includes a 75-year-old male with increasing confusion, delirium and malnutrition once he had clinically resolved from his COVID-19 diagnosis. The patient had a number of comorbidities and was treated with diuretics before and after his hospital admission. He was treated with intravenous thiamine and enteral nutrition. The second case includes a 77-year-old male with diabetes who presented with suspected vitamin C deficiency likely due to chronic aspirin use nearly two weeks prior to being diagnosed with pneumonia and COVID-19. The patient recovered from his COVID-19 diagnosis but continued to decline nutritionally and was readmitted sixty days later with failure to thrive.

Results

The first case had significant improvements in his appetite and neurological conditions following thiamine infusion and enteral nutrition and was discharged to home after a 19-day hospital stay. The second case presented with a vitamin C deficiency before testing positive for COVID-19. Although he did recover from COVID-19 he struggled to meet nutritional needs post-COVID and passed away 60 days after his COVID-19 diagnosis with pneumonia and failure to thrive.

Conclusion

Elderly patients with chronic diseases who use nutrient depleting medications are particularly high risk for micronutrient deficiency when they also experience the inflammatory insult of COVID-19. Patients who continue to have poor nutrition intake even after they appear to be clinically resolved from the virus should be closely monitored.

Mitochondrial Dynamics in SARS-COV2 Spike Protein Treated Human Microglia: Implications for Neuro-COVID

Emerging clinical data from the current COVID-19 pandemic suggests that ~ 40% of COVID-19 patients develop neurological symptoms attributed to viral encephalitis while in COVID long haulers chronic neuro-inflammation and neuronal damage result in a syndrome described as Neuro-COVID. We hypothesize that SAR-COV2 induces mitochondrial dysfunction and activation of the mitochondrial-dependent intrinsic apoptotic pathway, resulting in microglial and neuronal apoptosis. The goal of our study was to determine the effect of SARS-COV2 on mitochondrial biogenesis and to monitor cell apoptosis in human microglia non-invasively in real time using Raman spectroscopy, providing a unique spatio-temporal information on mitochondrial function in live cells. We treated human microglia with SARS-COV2 spike protein and examined the levels of cytokines and reactive oxygen species (ROS) production, determined the effect of SARS-COV2 on mitochondrial biogenesis and examined the changes in molecular composition of phospholipids. Our results show that SARS- COV2 spike protein increases the levels of pro-inflammatory cytokines and ROS production, increases apoptosis and increases the oxygen consumption rate (OCR) in microglial cells. Increases in OCR are indicative of increased ROS production and oxidative stress suggesting that SARS-COV2 induced cell death. Raman spectroscopy yielded significant differences in phospholipids such as Phosphatidylinositol (PI), phosphatidylserine (PS), phosphatidylethanolamine (PE) and phosphatidylcholine (PC), which account for ~ 80% of mitochondrial membrane lipids between SARS-COV2 treated and untreated microglial cells. These data provide important mechanistic insights into SARS-COV2 induced mitochondrial dysfunction which underlies neuropathology associated with Neuro-COVID.

COVID-19 outbreak, herd immunity formation, and future public health strategies

In Korea, where the successful control of the coronavirus disease 2019 (COVID-19) epidemic have been implemented by the follow-up survey management (containment) of COVID-19-infected persons, the number of infected persons has increased rapidly, and a re-epidemic trend is emerging. The Korean government is strengthening epidemic prevention activities, such as increasing the social distance in the metropolitan area to four levels and increasing the vaccination rate. The public has been complaining of dissatisfaction with the atrophy of socioeconomic activities and of distrust of epidemic prevention policies. Australia started with an incidence similar to that of Korea, but its social activities are more flexible than those of Korea, where the incidence is maintained at approximately 0.1 per 100,000 people. In comparing the differences between both countries in terms of the Oxford COVID-19 Government Response Tracker Stringency Index, it was found that Australia effectively regulates the number of infected cases by high-intensity intermittent mitigation and the subsequent allowance of social activities. Korea has also recommended a high-intensity intermittent mitigation policy as in Australia until community herd immunity via vaccination is formed.

Refining "Long-COVID" by a Prospective Multimodal Evaluation of Patients with Long-Term Symptoms Attributed to SARS-CoV-2 Infection

Introduction

COVID-19 long-haulers, also decribed as having “long-COVID” or post-acute COVID-19 syndrome, represent 10% of COVID-19 patients and remain understudied.

Methods

In this prospective study, we recruited 30 consecutive patients seeking medical help for persistent symptoms (> 30 days) attributed to COVID-19. All reported a viral illness compatible with COVID-19. The patients underwent a multi-modal evaluation, including clinical, psychologic, virologic and specific immunologic assays and were followed longitudinally. A group of 17 convalescent COVID-19 individuals without persistent symptoms were included as a comparison group.

Results

The median age was 40 [interquartile range: 35–54] years and 18 (60%) were female. At a median time of 152 [102–164] days after symptom onset, fever, cough and dyspnea were less frequently reported compared with the initial presentation, but paresthesia and burning pain emerged in 18 (60%) and 13 (43%) patients, respectively. The clinical examination was unremarkable in all patients, although the median fatigue and pain visual analog scales were 7 [5–8] and 5 [2–6], respectively. Extensive biologic studies were unremarkable, and multiplex cytokines and ultra-sensitive interferon-α2 measurements were similar between long-haulers and convalescent COVID-19 individuals without persistent symptoms. Using SARS-CoV-2 serology and IFN-γ ELISPOT, we found evidence of a previous SARS-CoV-2 infection in 50% (15/30) of patients, with evidence of a lack of immune response, or a waning immune response, in two patients. Finally, psychiatric evaluation showed that 11 (36.7%), 13 (43.3%) and 9 (30%) patients had a positive screening for anxiety, depression and post-traumatic stress disorder, respectively.

Conclusions

Half of patients seeking medical help for post-acute COVID-19 syndrome lack SARS-CoV-2 immunity. The presence of SARS-CoV-2 immunity, or not, had no consequence on the clinical or biologic characteristics of post-acute COVID-19 syndrome patients, all of whom reported severe fatigue, altered quality of life and psychologic distress.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00484-w.

Retrospective and prospective monitoring in post COVID-19 complications and an approach for vigilance in Post-recovery period

COVID-19 is a Severe acute respiratory syndrome (SARS-CoV-2). It threatened the whole world and considered as pandemic recently, emergencies and quarantine has been declared all over the world. Many published reviews and research articles, discussed analysis, symptoms, diagnosis, and possible ways of treatments. However, nowadays, more focus is inclined on recovered patients and the possible events faced by these patients in postrecovery period. Specialists, medical care workers are looking for unmistakable approaches to defend their life later on. It is important to have a full background on their physical and psychological status after their recovery with certain guidelines to follow-up. There is more concern, care for family and society as they might suffer from stress, depression, and stigmatization from society. Awareness programs and counseling should be recommended to bring the recovered patients to their normalcy. Surveys and cohort studies will be helpful for prognosis of the disease as well as to be ready to face the second stage of COVID-19. This article will focus on recovered COVID-19 patients, their complications, precautionary methods, and post care.

Investigation of Genetic Variations of IL6 and IL6R as Potential Prognostic and Pharmacogenetics Biomarkers: Implications for COVID-19 and Neuroinflammatory Disorders

In the present study, we investigated the distribution of genetic variations in IL6 and IL6R genes, which may be employed as prognostic and pharmacogenetic biomarkers for COVID-19 and neurodegenerative diseases. The study was performed on 271 samples representative of the Italian general population and identified seven variants (rs140764737, rs142164099, rs2069849, rs142759801, rs190436077, rs148171375, rs13306435) in IL6 and five variants (rs2228144, rs2229237, rs2228145, rs28730735, rs143810642) within IL6R, respectively. These variants have been predicted to affect the expression and binding ability of IL6 and IL6R. Ingenuity Pathway Analysis (IPA) showed that IL6 and IL6R appeared to be implicated in several pathogenetic mechanisms associated with COVID-19 severity and mortality as well as with neurodegenerative diseases mediated by neuroinflammation. Thus, the availability of IL6-IL6R-related biomarkers for COVID-19 may be helpful to counteract harmful complications and prevent multiorgan failure. At the same time, IL6-IL6R-related biomarkers could also be useful for assessing the susceptibility and progression of neuroinflammatory disorders and undertake the most suitable treatment strategies to improve patients' prognosis and quality of life. In conclusion, this study showed how IL6 pleiotropic activity could be exploited to meet different clinical needs and realize personalized medicine protocols for chronic, age-related and modern public health emergencies.

Neuropathobiology of COVID-19: The Role for Glia

SARS-CoV-2, which causes the Coronavirus Disease 2019 (COVID-19) pandemic, has a brain neurotropism through binding to the receptor angiotensin-converting enzyme 2 expressed by neurones and glial cells, including astrocytes and microglia. Systemic infection which accompanies severe cases of COVID-19 also triggers substantial increase in circulating levels of chemokines and interleukins that compromise the blood-brain barrier, enter the brain parenchyma and affect its defensive systems, astrocytes and microglia. Brain areas devoid of a blood-brain barrier such as the circumventricular organs are particularly vulnerable to circulating inflammatory mediators. The performance of astrocytes and microglia, as well as of immune cells required for brain health, is considered critical in defining the neurological damage and neurological outcome of COVID-19. In this review, we discuss the neurotropism of SARS-CoV-2, the implication of neuroinflammation, adaptive and innate immunity, autoimmunity, as well as astrocytic and microglial immune and homeostatic functions in the neurological and psychiatric aspects of COVID-19. The consequences of SARS-CoV-2 infection during ageing, in the presence of systemic comorbidities, and for the exposed pregnant mother and foetus are also covered.