Forming a consensus opinion to inform long COVID support mechanisms and interventions: a modified Delphi approach

All-cause healthcare resource utilization and costs among community-managed adults with long-COVID in France, 2020-2023

BACKGROUND

The clinical and economic burden of long COVID is poorly understood. We aim to assess all-cause healthcare resource utilization (HCRU) and costs in the primary care setting among adults with long COVID in France.

METHODS

A retrospective cohort study using the electronic healthcare records (EHRs) of confirmed and/or probable COVID-19 patients from The Health Improvement Network (THIN) data between March 2020 and December 2022 was conducted. Long COVID was identified per World Health Organization (WHO) definition as suggestive symptoms present ≥3 months following acute SARS-CoV-2 infection. Patients' characteristics, HCRU, direct healthcare and indirect costs (National Health Insurance-based prices) were summarized. Costs between patients with previous SARS-CoV-2 infection who developed long COVID, patients with previous SARS-CoV-2 infection who did not develop long COVID (COVID only), and contemporaneous controls without SARS-CoV-2 infection were compared (Non-COVID).

RESULTS

Long COVID developed among 30,122 (11.6%) adults; mean (SD) age was 50 (17) years, 63.6% were female and 27.5% had a Charlson Comorbidity Index score >2. During the post-infection follow-up (mean = 13 months), 97.3% of patients had general practitioner consultations (GP) and 62.4% had nursing care. Costs were highest during the first post-diagnosis year with per patient per year costs of €2,443 (total cost of €52 million), including costs for GP (€208) and specialist (€170) consultations, outpatient procedures (€413), retail pharmacy use (€595), biological testing (€147), and medical device usage (€172). Patients with long COVID had additional costs of €163 and €176 when compared to patients in the COVID only and Non-COVID cohorts, respectively.

LIMITATIONS

Since the THIN database is generated from GP EHRs, there is the possibility of measurement/documentation errors and missing values which could compromise the validity and accuracy of certain results.

CONCLUSION

Long COVID was associated with non-negligible HCRU, direct and indirect costs to the French healthcare system. These findings reinforce the importance of optimizing long-term resource allocation for patients infected with SARS-CoV-2.

Submaximal 2-day cardiopulmonary exercise testing to assess exercise capacity and post-exertional symptom exacerbation in people with long COVID

Long COVID has a complex pathology and a heterogeneous symptom profile that impacts quality of life and functional status. Post-exertional symptom exacerbation (PESE) affects one-third of people living with long COVID, but the physiological basis of impaired physical function remains poorly understood. Sixty-eight people (age (mean ± SD): 50 ± 11 years, 46 females (68%)) were screened for severity of PESE and completed two submaximal cardiopulmonary exercise tests separated by 24 h. Work rate was stratified relative to functional status and was set at 10, 20 or 30 W, increasing by 5 W/min for a maximum of 12 min. At the first ventilatory threshold (VT1),V ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ was 0.73 ± 0.16 L/min on Day 1 and decreased on Day 2 (0.68 ± 0.16 L/min; P = 0.003). Work rate at VT1 was lower on Day 2 (Day 1 vs. Day 2; 28 ± 13 vs. 24 ± 12 W; P = 0.004). Oxygen pulse on Day 1 at VT1 was 8.2 ± 2.2 mL/beat and was reduced on Day 2 (7.5 ± 1.8 mL/beat; P = 0.002). The partial pressure of end tidal carbon dioxide was reduced on Day 2 (Day 1 vs. Day 2; 38 ± 3.8 vs. 37 ± 3.2 mmHg; P = 0.010). ImpairedV ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ is indicative of reduced transport and/or utilisation of oxygen.V ̇ O 2 ${\dot V_{{{\mathrm{O}}_2}}}$ at VT1 was impaired on Day 2, highlighting worsened function in the 24 h after submaximal exercise. The data suggest multiple contributing physiological mechanisms across different systems and further research is needed to investigate these areas.

Trajectories of Health-Related Quality of Life 2 Years After Mild/Moderate Severe Acute Respiratory Syndrome Coronavirus 2 Infection in the Pre-Omicron Era

Background

Individuals with postacute sequelae of coronavirus disease 2019 (COVID-19), or long COVID, experience substantial burden of illness many months after initial infection. Few studies have comprehensively and longitudinally assessed health outcomes for people with long COVID following mild/moderate infection. We applied the Wilson-Cleary model of health-related quality of life (HRQOL) to describe the impact of long COVID on multiple health dimensions up to 24 months following mild/moderate COVID-19.

Methods

Participants within the ADAPT post-COVID study (N = 172, 86% mild/moderate infection) completed structured patient-reported outcome measures at 4, 8, 12, 18, and 24 months postinfection. Following the Wilson-Cleary model, questionnaires assessed symptoms (anxiety/depression, chronic fatigue, breathlessness), return to pre-COVID-19 functioning, perceived health status (EuroQol Visual Analogue Scale), and wellbeing (EuroQol EQ-5D-5L, Personal Wellbeing Index). Temporal trends were assessed using general estimating equations and ordinal logistic regression, including time × long COVID interactions.

Results

Thirty-seven percent of participants were diagnosed with long COVID (≥1 new/persisting symptoms of chest pain, breathlessness, or fatigue/malaise at least 12 weeks after infection). Long COVID was associated with poorer health outcomes across all domains at first assessment. Over 2 years, participants with long COVID reported improvement in return to pre-COVID-19 work and Somatic and Psychological Health Report chronic fatigue but sustained impairment was observed in all other health domains, compared to participants recovered from COVID-19.

Conclusions

Substantial long-term impairment in various health domains were observed for individuals with long COVID following mild/moderate initial infection, with little improvement over time in most. Multimodal interventions must address impairment in multiple domains of HRQOL in individuals with long COVID.

Psychotherapy in patients with long/post-COVID - A systematic review on the feasibility, acceptability, safety, and efficacy of available and emerging interventions

BACKGROUNDS

There is an urgent need for effective treatments for patients with long/post-COVID. Current recommendations for management favor a multimodal approach including psychotherapy and emphasize that interventions should also consider the mental health impact of living with long/post-COVID. This systematic review synthesizes psychotherapeutic interventions that currently target long/post-COVID complaints and summarizes data on the feasibility, acceptability, safety, and efficacy of psychotherapy for patients with long/post-COVID.

METHODS

This systematic review was conducted according to the PRISMA statement. Studies were retrieved from three databases (PubMed, PsycInfo, Web of Science) and independently assessed by two raters. Studies investigating patients of any age suffering from long/post-COVID were included if the intervention involved psychotherapeutic treatment and changes in long/post-COVID symptoms were reported. The review has been pre-registered on PROSPERO.

RESULTS

A total of 12 studies were included in the analysis. Of these, 10 were multimodal approaches with integrated psychotherapeutic interventions, and two were studies on stand-alone psychotherapy. The majority of studies were uncontrolled and demonstrate pre-post improvements in a range of long/post-COVID symptoms. Only one RCT could be identified, which supports the benefit of CBT for COVID-related fatigue. It was not possible to draw general conclusions regarding the efficacy of psychotherapy for long/post-COVID. However, data on feasibility, acceptability, and safety support the potential of psychotherapy as a treatment approach for long/post-COVID.

CONCLUSION

Future studies investigating the potential of psychotherapy approach for long/post-COVID which go beyond the pilot stage are needed to systematically assess feasibility, acceptability, safety, and efficacy in large-scale confirmatory trials.

Prevalence and determinant of long-term Post-COVID conditions among stroke survivors in the United States

BACKGROUND

Persistent post-COVID conditions (PCCs) have become inevitable challenges for individuals who have survived COVID. The National Research Plan on Long COVID-19 underscores the priority of addressing post-COVID conditions (PCCs) within specific subgroups of the United States (US) population. This study aimed to investigate the prevalence and factors associated with PCCs among stroke survivors in the US.

METHOD

In this retrospective cross-sectional study, we utilized the Behavioral Risk Factor Surveillance System (BRFSS) 2022 dataset. First, we identified respondents with a positive history of both COVID-19 and stroke. Subsequently, we categorized these respondents based on whether they experienced PCCs and conducted a comparative analysis of their characteristics. Additionally, our study included a comparison of our findings with those among individuals who have survived myocardial infarction (MI) and cancer.

RESULTS

A total of 3999 stroke, 5406 MI, and 10551 cancer survivors were included. The estimated prevalence of PCCs among stroke survivors was 30.6 %, compared to 22.4 %, 29.2 %, and 24.6 % among non-stroke (p < 0.001), MI, and cancer survivors, respectively. Fatigue, dyspnea, and taste/smell loss were the most common primary symptoms. In multivariate regression analysis, female sex (adjusted odds ratio (aOR):1.62, 95 %CI:[1.17-2.24]), stroke-belt residence (aOR:1.67, 95 %CI: [1.13-2.46]), pulmonary disease (aOR:2.12, 95 %CI:[1.53-2.92]), and depression (aOR:1.55, 95 %CI: [1.1-2.2]) were independent factors associated with higher odds of PCCs among stroke survivors. Additionally, age above 64 years was associated with lower odds of PCCs (aOR:0.6, 95 %CI: [0.41-0.86]).

CONCLUSION

Our study highlights a considerable prevalence of PCCs among stroke survivors, particularly among younger women and individuals with other chronic conditions.

Unveiling Post-COVID-19 syndrome: incidence, biomarkers, and clinical phenotypes in a Thai population

BACKGROUND

Post-COVID- 19 syndrome (PCS) significantly impacts the quality of life of survivors. There is, however, a lack of a standardized approach to PCS diagnosis and management. Our bidirectional cohort study aimed to estimate PCS incidence, identify risk factors and biomarkers, and classify clinical phenotypes for enhanced management to improve patient outcomes.

METHODS

A bidirectional prospective cohort study was conducted at five medical sites in Hatyai district in Songkhla Province, Thailand. Participants were randomly selected from among the survivors of COVID-19 aged≥18 years between May 15, 2022, and January 31, 2023. The selected participants underwent a scheduled outpatient visit for symptom and health assessments 12 to 16 weeks after the acute onset of infection, during which PCS was diagnosed and blood samples were collected for hematological, inflammatory, and serological tests. PCS was defined according to the World Health Organization criteria. Univariate and multiple logistic regression analyses were used to identify biomarkers associated with PCS. Moreover, three clustering methods (agglomerative hierarchical, divisive hierarchical, and K-means clustering) were applied, and internal validation metrics were used to determine clustering and similarities in phenotypes.

FINDINGS

A total of 300 survivors were enrolled in the study, 47% of whom developed PCS according to the World Health Organization (WHO) definition. In the sampled cohort, 66.3% were females, and 79.4% of them developed PCS (as compared to 54.7% of males, p-value <0.001). Comorbidities were present in 19% (57/300) of all patients, with 11% (18/159) in the group without PCS and 27.7% (39/141) in the group with PCS. The incidence of PCS varied depending on the criteria used and reached 13% when a quality of life indicator was added to the WHO definition. Common PCS symptoms were hair loss (22%) and fatigue (21%), while mental health symptoms were less frequent (insomnia 3%, depression 3%, anxiety 2%). According to our univariate analysis, we found significantly lower hematocrit and IgG levels and greater ALP levels in PCS patients than in patients who did not develop PCS (p-value < 0.05). According to our multivariable analysis, adjusted ALP levels remained a significant predictor of PCS (OR 1.02, p-value= 0.005). Clustering analysis revealed four groups characterized by severe clinical symptoms and mental health concerns (Cluster 1, 4%), moderate physical symptoms with predominant mental health issues (Cluster 2, 9%), moderate mental health issues with predominant physical symptoms (Cluster 3, 14%), and mild to no PCS (Cluster 4, 77%). The quality of life and ALP levels varied across the clusters.

INTERPRETATION

This study challenges the prevailing diagnostic criteria for PCS, emphasizing the need for a holistic approach that considers quality of life. The identification of ALP as a biomarker associated with PCS suggests that its monitoring could be used for early detection of the onset of PCS. Cluster analysis revealed four distinct clinical phenotypes characterized by different clinical symptoms and mental health concerns that 'exhibited varying impacts on quality of life. This finding suggested that accounting for the reduced quality of life in the definition of PCS could enhance its diagnosis and management and that moving toward personalized interventions could both improve patient outcomes and help reduce medicalization and optimally target the available resources.

FUNDING

The research publication received funding support from Medical Council of Thailand (Police General Dr. Jongjate Aojanepong Foundation), Hatyai Hospital Charity and Wellcome Trust.

Long COVID Clinical Severity Types Based on Symptoms and Functional Disability: A Longitudinal Evaluation

Background: Long COVID (LC) is a multisystem clinical syndrome with functional disability and compromised overall health. Information on LC clinical severity types is emerging in cross-sectional studies. This study explored the pattern and consistency of long COVID (LC) clinical severity types over time in a prospective sample. Methods: Participants with LC completed the condition-specific outcome measure C19-YRSm (Yorkshire Rehabilitation Scale modified version) at two assessment time points. A cluster analysis for clinical severity types was undertaken at both time points using the k-means partition method. Results: The study included cross-sectional data for 759 patients with a mean age of 46.8 years (SD = 12.7), 69.4% females, and a duration of symptoms of 360 days (IQR 217 to 703 days). The cluster analysis at first assessment revealed three distinct clinical severity type clusters: mild (n = 96), moderate (n = 422), and severe (n = 241). Longitudinal data on 356 patients revealed that the pattern of three clinical severity types remained consistent over time between the two assessments, with 51% of patients switching clinical severity types between the assessments. Conclusions: This study is the first of its kind to demonstrate that the pattern of three clinical severity types is consistent over time, with patients also switching between severity types, indicating the fluctuating nature of LC.

Adalimumab in the management of psoriasis and psoriatic arthritis: Results from a Delphi investigation

Background and Objectives

Psoriasis (PsO) and psoriatic arthritis (PsA) are often undertreated and require a multidisciplinary approach. In recent years, patent expiration has allowed the introduction of tumor necrosis factor inhibitor (anti-TNF) biosimilars, which have stimulated a significant increase in the use of biological therapies. This article reports the findings of a multidisciplinary approach to achieve a consensus on the use of adalimumab in patients with PsO or PsA.

Methods

A voting panel of 36 Italian dermatologists and rheumatologists were chosen by eight Italian clinicians (the Board), to provide a consensus on the real-world management of PsO and PsA with adalimumab using the Delphi Method, comprising three survey rounds. Twelve statements were defined by the Board and submitted to the panel (rating scale 1-7).

Results

Clinicians reached a wide consensus on the effectiveness (score 6-7: 67%) and long-term efficacy (6-7: 100%) of adalimumab in all clinical forms of PsO and PsA, including pediatric patients (6-7: 85%). Considering cost-effectiveness and safety, adalimumab is suggested as a first-line treatment in patients with enthesitis, predominant peripheral arthritis, axial involvement or associated inflammatory bowel disease (IBD) or uveitis. Adalimumab can be also considered after failure of etanercept (6-7: 94%).

Conclusion

Results from this Delphi study clearly show an overall consensus on the use of adalimumab in the management of PsO and PsA, particularly as first-choice for specific subpopulations (uveitis, IBD, hidradenitis suppurativa). Considering the cost-effectiveness of biosimilars within Italy, adalimumab may represent an effective and safe first-line treatment for patients with moderate-to-severe PsO or PsA, and a valid choice for switching after failure.

"Long COVID" and Its Impact on The Environment: Emerging Concerns and Perspectives

The COVID-19 pandemic has caused unprecedented global health and economic crises. The emergence of long COVID-19 has raised concerns about the interplay between SARS-CoV-2 infections, climate change, and the environment. In this context, a concise analysis of the potential long-term effects of the COVID-19 epidemic along with the awareness aboutenvironmental issues are realized. While COVID-19 effects in the short-term have reduced environmental air pollutants and pressures, CO2 emissions are projected to increase as the economy recovers and growth rates return to pre-COVID-19 levels. This review discusses the systematic effects of both the short-term and long-term effects of the pandemic on the clean energy revolution and environmental issues. This article also discusses opportunities to achieve long-term environmental benefits and emphasizes the importance of future policies in promoting global environmental sustainability. Future directions for growth and recovery are presented to cope with long COVID-19 epidemic along with the critical findings focussing on various aspects: waste management, air quality improvement.

Reaching out to Patients with Long COVID to Better Understand Their Life Experiences and How to Support Their Recovery: A Patient-Oriented Knowledge Sharing Session

This article reports on participants' experiences with long COVID-19 (LC) (symptoms, impact, healthcare use, and perceived needs) and satisfaction with a patient-oriented knowledge-sharing session organized by a multidisciplinary team of healthcare professionals, researchers, and a patient partner. Twenty-six participants completed a pre-session survey. On average, they were 21 months post-COVID-19 infection (SD 10.9); 81% of them were female, and 84% were 40+ years old. The main symptoms reported included fatigue (96%), cognitive problems (92%), and general pain or discomfort (40%). More than half of the participants reported that LC has had a significant impact on their health-related quality of life. Eighty-one percent of the participants reported seeking medical help for their LC symptoms and found the services provided by physical therapists, primary care providers, and acupuncturists to be helpful in managing their condition. Participants would like to have access to healthcare providers and clinics specializing in LC. They liked the session and found the information presented useful. This information helps to better understand the experiences of people living with LC and how to support their recovery.

Effects of a respiratory and neurological rehabilitation treatment plan in post Covid-19 affected university students. Randomized clinical study

BACKGROUND

COVID-19 demonstrated the possibility of neurological complications such as loss of sense of smell and taste, together with respiratory problems. Respiratory training and rehabilitation of neurological sequelae are essential to improve respiratory function and thus quality of life, and the aim of this study is to evaluate the efficacy of a pulmonary and neurological rehabilitation program.

OBJECTIVES

To apply a treatment to reduce dyspnea, increase exertional capacity, increase vital capacity and respiratory muscle strength, together with an increase in olfactory and gustatory sensitivity in post-SARS-CoV-2 patients.

METHODS

A randomised controlled experimental study was conducted in 220 patients with a medical diagnosis of COVID-19 and more than 5 months of evolution, dyspnoea or perceived fatigue, including olfactory and gustatory perception problems, of whom 200 patients completed the study. 100 patients were randomly assigned to the intervention group, consisting of an inspiratory training treatment plan (Powerbreathe Plus®) combined with aerobic exercise and olfactory gustatory treatment for 31 days, and 100 patients to the control group, for 31 days without any type of therapy.

RESULTS

The study was conducted in post-Covid-19 patients for 5 months. Two hundred patients were divided into an intervention group (n = 100) and a control group (n = 100). The comparison between the groups showed significant differences in spirometric variables; forced vital capacity (p < .001; Eta2 (0.439); Mean: 0,6135), the ratio between both FEV1/FVC (p < 0.01; Eta2 (0.728); Mean:9,313), peak inspiratory pressure (p < 0.01; Eta2 (0.906); Mean:4,526); changes were observed in dyspnoea measured with the modified Borg scale (p < 0.01; Eta2 (0.811); Mean:1,481) and the modified Medical Research Council scale (p < 0.01; Eta2 (0.881); Mean: 0.777); finally, changes were found in neurological variables, in the questions of the Singapore Smell and Taste Questionnaire, How was your sense of smell after treatment? (p < 0.01; Eta2 (0.813); Mean: 1,721) and How is your sense of taste after treatment? (p < 0.01; Eta2 (0.898); Mean: 1,088).

CONCLUSION

The implementation of a respiratory rehabilitation treatment plan with the Powerbreathe Plus® device, aerobic exercise and neurorehabilitation with olfactory and gustatory training, is a therapeutic option against respiratory and neurological sequelae in patients who have suffered such sequelae due to the SARS-CoV-2 virus. Clinicaltrials.gov: NCT05195099. First posted 18/01/2022; Last Update Posted 29/06/2022.