COVID-19 complications can include neurological, psychiatric, psychological, and psychosocial impairments. Little is known on the consequences of SARS-COV-2 on cognitive functions of patients in the sub-acute phase of the disease. We aimed to investigate the impact of COVID-19 on cognitive functions of patients admitted to the COVID-19 Rehabilitation Unit of the San Raffaele Hospital (Milan, Italy).
Material and methods
87 patients admitted to the COVID-19 Rehabilitation Unit from March 27th to June 20th 2020 were included. Patients underwent Mini Mental State Evaluation (MMSE), Montreal Cognitive Assessment (MoCA), Hamilton Rating Scale for Depression, and Functional Independence Measure (FIM). Data were divided in 4 groups according to the respiratory assistance in the acute phase: Group1 (orotracheal intubation), Group2 (non-invasive ventilation using Biphasic Positive Airway Pressure), Group3 (Venturi Masks), Group4 (no oxygen therapy). Follow-ups were performed at one month after home-discharge.
Out of the 87 patients (62 Male, mean age 67.23 ± 12.89 years), 80% had neuropsychological deficits (MoCA and MMSE) and 40% showed mild-to-moderate depression. Group1 had higher scores than Group3 for visuospatial/executive functions (p = 0.016), naming (p = 0.024), short- and long-term memory (p = 0.010, p = 0.005), abstraction (p = 0.024), and orientation (p = 0.034). Group1 was younger than Groups2 and 3. Cognitive impairments correlated with patients’ age. Only 18 patients presented with anosmia. Their data did not differ from the other patients. FIM (<100) did not differ between groups. Patients partly recovered at one-month follow-up and 43% showed signs of post-traumatic stress disorder.
Patients with severe functional impairments had important cognitive and emotional deficits which might have been influenced by the choice of ventilatory therapy, but mostly appeared to be related to aging, independently of FIM scores. These findings should be integrated for correct neuropsychiatric assistance of COVID-19 patients in the subacute phase of the disease, and show the need for long-term psychological support and treatment of post-COVID-19 patients.
This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm REHABILITATION OF COVID-19 PATIENTS The coronavirus-2 (SARS-CoV-2) pandemic has dramatically transformed the organization of public and private health organizations of the Lombardy region, the Italian region where the viral spread has been more quick and intense (1). According to the data available on the 8 th of April 2020 from the beginning of the epidemic at the end of February, 139,422 cases and 17,669 deaths have been reported in Italy, which may underestimate the real incidence. The rapid spread of the virus has upset all hospital organizations. The Rehabilitation Hospitals, as well as the rehabilitation units of multidisciplinary institutes, have considerably changed their activity. The need for medical assistance to an increasingly higher number of patients forced the hospitals to improve the volume of intensive care beds and to convert the rehabilitation departments in COVID-19 beds. San Raffaele Scientific Institute, a large tertiary hospital and research centre in Milan, Italy, was immediately involved in the management of the public health emergency (1). After the first COVID-19 case of San Raffaele Scientific Institute of Milan, dated back on 25 th February, the 3 Rehabilitation Units were merged to create dedicated beds for coronavirus cases in less than one week. Furthermore, regional laws relieved the outpatient activities of the Rehabilitation Departments to reduce the viral spread. The nurse staff have been sent to the new COVID-19 Rehabilitation Department created for those patients coming from the Intensive Care Units. At this moment, about 40 patients are hospitalized in the Rehabilitation Department at San Raffaele Hospital. The acute respiratory syndrome caused by SARS-CoV-2 syndrome may be characterized by mild respiratory diseases or moderate-to-severe pneumonia, which can cause Acute Respiratory Distress Syndrome (ARDS) and multi-organ failure. In SARS-CoV-2 pneumonia, bilateral interstitial infiltration with serious alteration of the ventilationperfusion ratio and probably shunt, cause hypoxic respiratory insufficiency (2). Acute hypoxemia may cause obstinate dyspnoea with the need of oxygen therapy administration through High-flow nasal oxygen (HFNO), or through the application of a non-invasive positive pressure, c-PAP or NIV (with oronasal or face masks, helmets) (2, 3). Unfortunately, in case of O 2 saturation worsening, orotracheal intubation and invasive mechanical ventilation are mandatory. The pulmonary parenchyma presents focal haemorrhages and necrosis, even up to a haemorrhagic infarction. The alveolar exudate can consolidate causing
Objective: To investigate the safety and efficacy of intermittent theta-burst stimulation (iTBS) in the treatment of motor symptoms in Parkinson disease (PD).Background: Progression of PD is characterized by the emergence of motor deficits, which even-
Human voluntary movement is associated with two changes in electroencephalography (EEG) that can be observed as early as 1.5 s prior to movement: slow DC potentials and frequency power shifts in the alpha and beta bands. Our goal was to determine whether and when we can reliably predict human natural movement BEFORE it occurs from EEG signals ONLINE IN REAL-TIME.
We developed a computational algorithm to support online prediction. Seven healthy volunteers participated in this study and performed wrist extensions at their own pace.
The average online prediction time was 0.62 ± 0.25 s before actual movement monitored by EMG signals. There were also predictions that occurred without subsequent actual movements, where subjects often reported that they were thinking about making a movement.
Human voluntary movement can be predicted before movement occurs.
The successful prediction of human movement intention will provide further insight into how the brain prepares for movement, as well as the potential for direct cortical control of a device which may be faster than normal physical control.
To investigate the safety and efficacy of 50Hz repetitive Transcranial Magnetic Stimulation(rTMS) in the treatment of motor symptoms in Parkinson’s disease(PD).
Progression of PD is characterized by the emergence of motor deficits, which eventually respond less to dopaminergic therapy and pose a therapeutic challenge. RTMS has shown promising results in improving gait, a major cause of disability, and may provide a therapeutic alternative. Controlled studies suggest increasing stimulation frequency might enhance therapeutic efficacy.
In this randomized, double blind, sham-controlled study, we investigated safety and efficacy of 50Hz-rTMS of the motor cortices in 8sessions over 2weeks. Assessment of safety and clinical efficacy over a 1-month period included timed tests of gait and bradykinesia, UPDRS and additional clinical, neurophysiological and neuropsychological parameters. In addition, safety of 50Hz-rTMS was tested with EMG-EEG-monitoring during and after stimulation.
We investigated 26 patients with mild to moderate PD: 13 received 50Hz-rTMS and 13 sham-stimulation. 50Hz-rTMS did not improve gait, bradykinesia, global and motor UPDRS, but there appeared a short-lived “on”-state improvement in activities of daily living (UPDRS II). 50Hz-rTMS lengthened the cortical silent period, but other neurophysiology and neuropsychological measures remained unchanged. EMG/EEG recorded no pathological increase of cortical excitability or epileptic activity. There were no adverse effects.
50Hz-rTMS of the motor cortices appears safe, but fails to improve motor performance and functional status in PD. Prolonged stimulation or other techniques with rTMS might be more efficacious, but need to be established in future research.
The rapid evolution of the health emergency linked to the spread of severe acute respiratory syndrome coronavirus 2 requires specifications for the rehabilitative management of patients with coronavirus disease 2019 . The symptomatic evolution of patients with COVID-19 is characterized by 2 phases: an acute phase in which respiratory symptoms prevail and a postacute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions, and to cognitive and emotional disorders. Thus, there is the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan and recommends the setup of specialized clinical pathways for the rehabilitation of patients with COVID-19. In this hospital, between February 1 and March 2, 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (intensive care/infectious diseases). In the following 30 days, from March 2 to mid-April, despite the presence of 60 daily arrivals to the emergency department, the organization of patient flow between different wards was modified, and several different units were created based on a more accurate integration of patients' needs. According to this new organization, patients were admitted first to acute care COVID-19 units and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units, and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists, and nutritionists.
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