The Post-COVID-19 Functional Status scale: a tool to measure functional status over time after COVID-19

Short-term outpatient follow-up of COVID-19 patients: A multidisciplinary approach

BACKGROUND

Short-term follow-up of COVID-19 patients reveals pulmonary dysfunction, myocardial damage and severe psychological distress. Little is known of the burden of these sequelae, and there are no clear recommendations for follow-up of COVID-19 patients.In this multi-disciplinary evaluation, cardiopulmonary function and psychological impairment after hospitalization for COVID-19 are mapped.

METHODS

We evaluated patients at our outpatient clinic 6 weeks after discharge. Cardiopulmonary function was measured by echocardiography, 24-hours ECG monitoring and pulmonary function testing. Psychological adjustment was measured using questionnaires and semi-structured clinical interviews. A comparison was made between patients admitted to the general ward and Intensive care unit (ICU), and between patients with a high versus low functional status.

FINDINGS

Eighty-one patients were included of whom 34 (41%) had been admitted to the ICU. New York Heart Association class II-III was present in 62% of the patients. Left ventricular function was normal in 78% of patients. ICU patients had a lower diffusion capacity (mean difference 12,5% P = 0.01), lower forced expiratory volume in one second and forced vital capacity (mean difference 14.9%; P<0.001; 15.4%; P<0.001; respectively). Risk of depression, anxiety and PTSD were 17%, 5% and 10% respectively and similar for both ICU and non-ICU patients.

INTERPRETATION

Overall, most patients suffered from functional limitations. Dyspnea on exertion was most frequently reported, possibly related to decreased DLCOc. This could be caused by pulmonary fibrosis, which should be investigated in long-term follow-up. In addition, mechanical ventilation, deconditioning, or pulmonary embolism may play an important role.

Seguimiento de los pacientes con secuelas no respiratorias de la COVID-19

•La COVID-19 puede presentar síntomas prolongados no solo respiratorios, sino también extrapulmonares. •Las alteraciones hematológicas, cardiacas y neurológicas pueden llegar a ser las más graves, pero otras manifestaciones pueden también impactar sobre la calidad de vida. •El papel de atención primaria durante el seguimiento es fundamental, identificando problemas y orientando su tratamiento. •El trabajo multidisciplinar y en equipo es la base de una correcta atención a estos pacientes.

Caging the dragon: Research approach to COVID-19-related thrombosis

The incidence of venous thrombosis, mostly pulmonary embolism (PE), ranging from local immunothrombosis to central emboli, but also deep vein thrombosis (DVT) in people with coronavirus disease 2019 (COVID-19) is reported to be remarkably high. The relevance of better understanding, predicting, treating, and preventing COVID-19-associated venous thrombosis meets broad support, as can be concluded from the high number of research, review, and guideline papers that have been published on this topic. The Dutch COVID & Thrombosis Coalition (DCTC) is a multidisciplinary team involving a large number of Dutch experts in the broad area of venous thrombosis and hemostasis research, combined with experts on virology, critically ill patients, pulmonary diseases, and community medicine, across all university hospitals and many community hospitals in the Netherlands. Within the consortium, clinical data of at least 5000 admitted COVID-19-infected individuals are available, including substantial collections of biobanked materials in an estimated 3000 people. In addition to considerable experience in preclinical and clinical thrombosis research, the consortium embeds virology-hemostasis research models within unique biosafety facilities to address fundamental questions on the interaction of virus with epithelial and vascular cells, in relation to the coagulation and inflammatory system. The DCTC has initiated a comprehensive research program to answer many of the current questions on the pathophysiology and best anticoagulant treatment of COVID-19-associated thrombotic complications. The research program was funded by grants of the Netherlands Thrombosis Foundation and the Netherlands Organization for Health Research and Development. Here, we summarize the design and main aims of the research program.

Prevalence of Functional Limitation in COVID-19 Recovered Patients Using the Post COVID-19 Functional Status Scale

Introduction:

COVID-19 is an emerging global health pandemic causing tremendous morbidity and mortality worldwide. Chronic symptoms progressing to poor functional status have been reported in a substantial proportion of COVID-19 patients worldwide. This study aimed to determine the prevalence of functional limitation in COVID-19 recovered patients using the post-COVID-19 functional status scale.

Methods:

A descriptive cross-sectional study was conducted at Tribhuvan University Teaching Hospital. COVID-19 recovered patients with reverse transcription-polymerase chain reaction negative status were included and assessed using the post-COVID-19 functional status scale. Data entry and analysis was done in Statistical Package for the Social Sciences version 20.0. Descriptive statistics were performed.

Results:

A total of 106 patients were included for the final analysis. More than half of the patients (56.6%) reported having no functional limitation (grade 0), while the prevalence of some degree of functional limitation was observed in 46 (43.4%) patients (grade 1 to 4).

Conclusions:

Some form of functional limitation should be anticipated after COVID-19 infection. Post-COVID-19 functional status scale can be a valuable tool in determining the prevalence of functional limitation in COVID-19 recovered patients in acute health care settings. It can potentially guide in planning rehabilitative measures in post-acute care management of COVID-19 survivors.

COVID-19-induced sarcopenia and physical deconditioning may require reassessment of surgical risk for patients with cancer

Background

The long-term physiological consequences of SARS-CoV-2 (severe acute respiratory syndrome coronavirus) infection are not known. The ability of COVID-19 to cause chronic illness, sarcopenia, and physical deconditioning may be underestimated and go beyond the anticipated respiratory sequelae. Myalgia, lethargy, and anorexia are common symptoms even in mild to moderate cases and have the potential to exacerbate frailty. How this impacts on risk-stratification for patients requiring surgery for time-critical conditions, such as malignancy, requires further urgent investigation.

Main body

The deleterious effect of sarcopenia and poor physical capacity are well recognised in cancer surgery. This review commentary highlights current evidence which suggests skeletal muscle as an under recognised cause of COVID-19-related functional deconditioning. The mechanisms behind this are via direct (viral induced myositis, nutritional decline, cytokine-mediated myopathy) and indirect mechanisms (social isolation, inactivity, and psychological consequences).

Conclusion

Further mechanistic research is required to explore the processes behind the deconditioning effects of SARS-CoV-2 infection and how this impacts on treatment of malignant disease.

Clinical Nutrition Research and the COVID-19 Pandemic: A Scoping Review of the ASPEN COVID-19 Task Force on Nutrition Research

The purpose of this scoping review by the American Society for Parenteral and Enteral Nutrition (ASPEN) Coronavirus Disease 2019 (COVID-19) Nutrition Task Force was to examine nutrition research applicable to the COVID-19 pandemic. The rapid pace of emerging scientific information has prompted this activity to discover research/knowledge gaps. This methodology adhered with recommendations from the Joanna Briggs Institute. There were 2301 citations imported. Of these, there were 439 articles fully abstracted, with 23 main topic areas identified across 24 article types and sourced across 61 countries and 51 specialties in 8 settings and among 14 populations. Epidemiological/mechanistic relationships between nutrition and COVID-19 were reviewed and results mapped to the Population, Intervention, Comparator, Outcome, and Time (PICO-T) questions. The aggregated data were analyzed by clinical stage: pre-COVID-19, acute COVID-19, and chronic/post-COVID-19. Research gaps were discovered for all PICO-T questions. Nutrition topics meriting urgent research included food insecurity/societal infrastructure and transcultural factors (pre-COVID-19); cardiometabolic-based chronic disease, pediatrics, nutrition support, and hospital infrastructure (acute COVID-19); registered dietitian nutritionist counseling (chronic/post-COVID-19); and malnutrition and management (all stages). The paucity of randomized controlled trials (RCTs) was particularly glaring. Knowledge gaps were discovered for PICO-T questions on pediatrics, micronutrients, bariatric surgery, and transcultural factors (pre-COVID-19); enteral nutrition, protein-energy requirements, and glycemic control with nutrition (acute COVID-19); and home enteral and parenteral nutrition support (chronic/post-COVID-19). In conclusion, multiple critical areas for urgent nutrition research were identified, particularly using RCT design, to improve nutrition care for patients before, during, and after COVID-19.

Beyond the clot: perfusion imaging of the pulmonary vasculature after COVID-19

A compelling body of evidence points to pulmonary thrombosis and thromboembolism as a key feature of COVID-19. As the pandemic spread across the globe over the past few months, a timely call to arms was issued by a team of clinicians to consider the prospect of long-lasting pulmonary fibrotic damage and plan for structured follow-up. However, the component of post-thrombotic sequelae has been less widely considered. Although the long-term outcomes of COVID-19 are not known, should pulmonary vascular sequelae prove to be clinically significant, these have the potential to become a public health problem. In this Personal View, we propose a proactive follow-up strategy to evaluate residual clot burden, small vessel injury, and potential haemodynamic sequelae. A nuanced and physiological approach to follow-up imaging that looks beyond the clot, at the state of perfusion of lung tissue, is proposed as a key triage tool, with the potential to inform therapeutic strategies.

Effect of Synaid on cognitive functions and mood in elderly subjects with self-perceived loss of memory after COVID-19 infection

INTRODUCTION

There is growing attention towards the possible long-term effect of COVID-19 on neuropsychiatric disorders.

METHODS

We tested the effect of a combined nutraceutical (Synaid) with known nootropic effects in 40 elderly patients with self-perceived cognitive decline after SARS-CoV-2 infection, treated at home or in hospital.

RESULTS

After 3 months of treatment, Synaid significantly improved functional status, MMSE and the main psychological disorders associated with mild cognitive impairment, both in patients previously cared for at home and in hospital because of SARS-CoV-2 infection.

CONCLUSIONS

Synaid was well tolerated and effective in improving cognitive function and psychosocial parameters after SARS-CoV-2 infection.

Intermediate versus standard-dose prophylactic anticoagulation and statin therapy versus placebo in critically-ill patients with COVID-19: Rationale and design of the INSPIRATION/INSPIRATION-S studies

BACKGROUND

Microvascular and macrovascular thrombotic events are among the hallmarks of coronavirus disease 2019 (COVID-19). Furthermore, the exuberant immune response is considered an important driver of pulmonary and extrapulmonary manifestations of COVID-19. The optimal management strategy to prevent thrombosis in critically-ill patients with COVID-19 remains unknown.

METHODS

The Intermediate versus Standard-dose Prophylactic anticoagulation In cRitically-ill pATIents with COVID-19: An opeN label randomized controlled trial (INSPIRATION) and INSPIRATION-statin (INSPIRATION-S) studies test two independent hypotheses within a randomized controlled trial with 2 × 2 factorial design. Hospitalized critically-ill patients with reverse transcription polymerase chain reaction confirmed COVID-19 will be randomized to intermediate-dose versus standard dose prophylactic anticoagulation. The 600 patients undergoing this randomization will be screened and if meeting the eligibility criteria, will undergo an additional double-blind stratified randomization to atorvastatin 20 mg daily versus matching placebo. The primary endpoint, for both hypotheses will be tested for superiority and includes a composite of adjudicated acute arterial thrombosis, venous thromboembolism (VTE), use of extracorporeal membrane oxygenation, or all-cause death within 30 days from enrollment. Key secondary endpoints include all-cause mortality, adjudicated VTE, and ventilator-free days. Key safety endpoints include major bleeding according to the Bleeding Academic Research Consortium definition and severe thrombocytopenia (platelet count <20,000/fL) for the anticoagulation hypothesis. In a prespecified secondary analysis for non-inferiority, the study will test for the non-inferiority of intermediate intensity versus standard dose anticoagulation for major bleeding, considering a non-inferiority margin of 1.8 based on odds ratio. Key safety endpoints for the statin hypothesis include rise in liver enzymes >3 times upper normal limit and clinically-diagnosed myopathy. The primary analyses will be performed in the modified intention-to-treat population. Results will be tested in exploratory analyses across key subgroups and in the intention-to-treat and per-protocol cohorts.

CONCLUSIONS

INSPIRATION and INSPIRATON-S studies will help address clinically-relevant questions for antithrombotic therapy and thromboinflammatory therapy in critically-ill patients with COVID-19.

[What can pulmonary rehabilitation accomplish?]

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has stated that pulmonary rehabilitation (PR) is the most effective therapeutic intervention to reduce dyspnoea and to improve physical performance and quality of life for patients with obstructive lung disease.New innovative studies raised in the area of PR:1) Pulmonary fibrosis & asthma bronchiale - While PR is recommended for chronic respiratory diseases other than COPD (chronic obstructive pulmonary disease) in the respective disease-specific treatment guidelines, PR in some pathologies is underrated. For example, there is a growing body of evidence showing the effectiveness of structured and multidisciplinary PR programs in pulmonary fibrosis and asthma bronchial patients;2) Coronavirus SARS-CoV-2 - There is preliminary evidence that COVID-19 patients can benefit from a PR program. The current COVID-19 position paper of the German Respiratory Society e. V. (DGP) regarding PR recommendations suggests that early rehabilitative therapies are already indicated during hospitalisation on the normal or intensive care unit and that rehabilitative interventions should be continued after discharge as a follow-up treatment in PR centres in order to reduce long-term consequences of COVID-19 disease;3) Telehealth meets PR - To further improve the effectiveness of PR in COPD patients using recent technologies, a supplementary "digital exercise program" can contribute to greater benefits compared to PR alone.

Patient-reported outcome measures after COVID-19: a prospective cohort study

Patient reported outcome measures (PROMs) are standardised validated questionnaires completed by patients to provide information on their perceived functional well-being and health status [1]. These questionnaires can address various aspects of health including symptoms, quality of life, functionality, and physical, mental and social well-being. PROMs play an important role in increasing patient engagement, improving health systems, and ensuring that clinical care and research is person-centred.

Over 75% of patients admitted to hospital with COVID-19 have abnormal patient-reported outcome measures 3 months after symptom onset, with a third of patients reporting at least moderate impairment in major dimensions of quality of lifehttps://bit.ly/32QMMgw

Post-COVID-19 Functional Status: Relation to age, smoking, hospitalization and comorbidities.. [DOI: 10.1101/2020.08.26.20182618]

Rational

Recently, a new “Post-COVID-19 Functional Status (PCFS) scale” is recommended in the current COVID-19 pandemic. It is proposed that it could be used to display direct retrieval and the functional sequelae of COVID-19.

Aim of the study

To assess the Post COVID-19 functional status in Egypt and to evaluate if age, gender, comorbidities have any effect on functional limitations in recovered COVID-19 patients.

Patients and methods

A total of 444 registered confirmed COVID-19 patients were included. They were interviewed in our follow-up clinics or by calls and filled an Arabic translated PCFS scale in paper or online forms as well as their demographic and clinical data.

Results

80% of COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible (63.1%), slight (14.4%), moderate (2%) to severe (0.5%) based on PCFS. Furthermore, there was a substantial variance between the score of PCFS with age (P= 0.003), gender (P= 0.014), the duration since the onset of the symptoms of COVID-19 (P <0.001), need for oxygen supplementation (P<0.001), need for ICU admittance (P= 0.003), previous periodic influenza vaccination (P<0.001), smoking status (P < 0.001) and lastly the presence of any comorbid disorder (P <0.001).

Conclusions

Most of the COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible to severe based on PCFS. These restrictions were affected by age, gender, periodic influenza vaccination, smoking, duration since symptoms onset, need for oxygen or ICU admittance, and lastly the presence of coexisting comorbidity.

Systematic rapid living review on rehabilitation needs due to COVID-19: update to May 31st, 2020

INTRODUCTION

This paper adds to the series of systematic rapid living reviews, started in April 2020, to provide the rehabilitation community with updates on the latest scientific literature on rehabilitation needs due to the COVID-19 pandemic. The aim of this study was to present the results of a systematic search performed on papers published from May 1st to May 31st, 2020.

EVIDENCE ACQUISITION

An extensive search on the main medical literature databases for articles published (including Epub), in English, from May 1st to May 31st, 2020 was performed, according to the methodology already described in the previous 2 rapid reviews, with 2 important improvements: first, we made the search string more comprehensive; second, we relied on accredited terminologies to describe the study designs and report the rehabilitation settings.

EVIDENCE SYNTHESIS

Fifty-eight out of 618 articles were finally included for qualitative analysis. The number of primary studies has increased, with respect to the previous months, although still around 60% papers are just expert opinions. Six papers report on the prevalence and /or characteristics of emerging disability after COVID-19, 12 on rehabilitation approaches to COVID-19 patients, up to 25 on the organization of rehabilitation services after COVID-19, 13 papers on the impact of COVID-19 on health conditions of rehabilitative interest and only 2 on late complications due to COVID-19 that may be of rehabilitative interest.

CONCLUSIONS

Nowadays, all patients with disability, regardless of COVID-19 infection, are suffering because of restrictions imposed to rehabilitation service delivery. Neurological involvement is often present during acute and postacute stage, conveying the risk of a long-lasting disability. Accordingly, careful neurological monitoring should be granted. Although new therapies are under development, the main gap in the available scientific literature is the lack of high-quality primary studies, so experimental studies on the effects of rehabilitation are still warranted.

Prediction models for diagnosis and prognosis of covid-19: systematic review and critical appraisal

OBJECTIVE

To review and appraise the validity and usefulness of published and preprint reports of prediction models for diagnosing coronavirus disease 2019 (covid-19) in patients with suspected infection, for prognosis of patients with covid-19, and for detecting people in the general population at increased risk of covid-19 infection or being admitted to hospital with the disease.

DESIGN

Living systematic review and critical appraisal by the COVID-PRECISE (Precise Risk Estimation to optimise covid-19 Care for Infected or Suspected patients in diverse sEttings) group.

DATA SOURCES

PubMed and Embase through Ovid, up to 1 July 2020, supplemented with arXiv, medRxiv, and bioRxiv up to 5 May 2020.

STUDY SELECTION

Studies that developed or validated a multivariable covid-19 related prediction model.

DATA EXTRACTION

At least two authors independently extracted data using the CHARMS (critical appraisal and data extraction for systematic reviews of prediction modelling studies) checklist; risk of bias was assessed using PROBAST (prediction model risk of bias assessment tool).

RESULTS

37 421 titles were screened, and 169 studies describing 232 prediction models were included. The review identified seven models for identifying people at risk in the general population; 118 diagnostic models for detecting covid-19 (75 were based on medical imaging, 10 to diagnose disease severity); and 107 prognostic models for predicting mortality risk, progression to severe disease, intensive care unit admission, ventilation, intubation, or length of hospital stay. The most frequent types of predictors included in the covid-19 prediction models are vital signs, age, comorbidities, and image features. Flu-like symptoms are frequently predictive in diagnostic models, while sex, C reactive protein, and lymphocyte counts are frequent prognostic factors. Reported C index estimates from the strongest form of validation available per model ranged from 0.71 to 0.99 in prediction models for the general population, from 0.65 to more than 0.99 in diagnostic models, and from 0.54 to 0.99 in prognostic models. All models were rated at high or unclear risk of bias, mostly because of non-representative selection of control patients, exclusion of patients who had not experienced the event of interest by the end of the study, high risk of model overfitting, and unclear reporting. Many models did not include a description of the target population (n=27, 12%) or care setting (n=75, 32%), and only 11 (5%) were externally validated by a calibration plot. The Jehi diagnostic model and the 4C mortality score were identified as promising models.

CONCLUSION

Prediction models for covid-19 are quickly entering the academic literature to support medical decision making at a time when they are urgently needed. This review indicates that almost all pubished prediction models are poorly reported, and at high risk of bias such that their reported predictive performance is probably optimistic. However, we have identified two (one diagnostic and one prognostic) promising models that should soon be validated in multiple cohorts, preferably through collaborative efforts and data sharing to also allow an investigation of the stability and heterogeneity in their performance across populations and settings. Details on all reviewed models are publicly available at https://www.covprecise.org/. Methodological guidance as provided in this paper should be followed because unreliable predictions could cause more harm than benefit in guiding clinical decisions. Finally, prediction model authors should adhere to the TRIPOD (transparent reporting of a multivariable prediction model for individual prognosis or diagnosis) reporting guideline.

SYSTEMATIC REVIEW REGISTRATION

Protocol https://osf.io/ehc47/, registration https://osf.io/wy245.

READERS' NOTE

This article is a living systematic review that will be updated to reflect emerging evidence. Updates may occur for up to two years from the date of original publication. This version is update 3 of the original article published on 7 April 2020 (BMJ 2020;369:m1328). Previous updates can be found as data supplements (https://www.bmj.com/content/369/bmj.m1328/related#datasupp). When citing this paper please consider adding the update number and date of access for clarity.