Proposed Modifications in the 6-Minute Walk Test for Potential Application in Patients With Mild COVID-19: A Step to Optimize Triage Guidelines

Eight weeks of Pilates Method improves physical fitness and sleep quality of individuals with post-COVID-19 syndrome: A randomized clinical trial blinded

OBJECTIVES

To evaluate the impact of eight weeks of Pilates Method on physical fitness and sleep quality of individuals with post-COVID-19 syndrome.

METHODS

Randomized clinical trial blinded conducted with fifty-nine individuals with post-COVID-19 syndrome. The participants were randomly allocated to the Pilates group (PG; n = 20), supervised physical exercise group (SPEG; n = 20) and control group (CG; n = 19). The intervention occurred twice a week for eight weeks in a total of 16 sessions. The primary outcome was distance covered in the 6-min walk test and the secondary outcomes were the profile of the sample, post-exercise fatigue and sleep quality.

RESULTS

After the intervention, only the PG increased the distance covered in the 6-min walk test (p < 0.001; d = 0.762) and reduced the score on the modified BORG scale after exercise (p < 0.010; d = -0.835) and the Pittsburgh Sleep Quality Index (p < 0.005; d = -0.699). Furthermore, the PG covered a greater distance compared to the SPEG in the 6-min walk test [95%CI (26.129-179.770); p < 0.010; d = 1.021] and exhibited a greater reduction in fatigue levels compared to the CG [95%CI (-2.352 to -0.162); p < 0.050; d = 0.919].

CONCLUSION

Eight weeks of Pilates Method improve the physical fitness and sleep quality of individuals with post-COVID-19 syndrome.

Feasibility and Safety of Early Post-COVID-19 High-Intensity Gait Training: A Pilot Study

BACKGROUND

The feasibility and safety of rehabilitation interventions for individuals recovering from COVID-19 after the acute stage is not well understood. This pilot study aims to provide a preliminary investigation of the feasibility and safety of providing high-intensity gait training (HIT) with a targeted cardiovascular intensity of 70-85% of the age-predicted maximum heart rate (HRmax) for individuals undergoing rehabilitation post-COVID-19.

METHODS

Consecutive patients who were medically cleared for HIT were invited to participate in the study. Participants practiced walking in varied contexts (treadmill, overground, and stairs), aiming to spend as much time as possible within their target cardiovascular intensity zone during scheduled physical therapy (PT) sessions. Training characteristics and adverse events were collected to determine the feasibility and safety of HIT. The severity of adverse events was graded on a 1-5 scale according to the Common Terminology Criteria for Adverse Events.

RESULTS

The participants (n = 20) took a mean of 2093 (±619) steps per PT session. The average peak heart rate during PT sessions was 81.1% (±9.4) of HRmax, and 30.1% (±21.0) of the session time was spent at heart rates ≥ 70% HRmax. Mild adverse events (grade 1) occurred in <5% of the sessions, and no intervention-requiring or life-threatening adverse events (grade 2-5) occurred.

CONCLUSION

This pilot study provides preliminary evidence that HIT may be feasible and safe during inpatient rehabilitation for patients post-COVID-19 following medical clearance.

Predictive equation for six-minute walk test in Indian children, adolescents, and adults

Background

Post-COVID residual dysfunction has been observed in a majority of people, with reduction in cardiopulmonary endurance emerging as a primary symptom. The Six-Minute Walk Test is a simple, reliable, and valid test that is used routinely on people with chronic respiratory dysfunction. In the current COVID-19 pandemic situation, reference values and a predictive equation developed from a large sample across a large age group, from 6 to 75 years, will enable one to establish goals of treatment for post-COVID rehabilitation.

Methods

Following institutional ethical clearance, we recruited 1369 participants for the study (685 females and 684 males). Participants were classified according to biological age into group 1 (6-12 years), group 2 (13-17 years), group 3 (18-40 years), group 4 (41-65 years), and group 5 (>65 years). Informed consent was sought and participants were screened using a health history questionnaire. Demographic features, namely, age, height, weight, and body mass index (BMI) were noted. The Six-Minute Walk Test was administered as per ATS guidelines. Clinical parameters, namely, pulse rate, respiratory rate, systolic blood pressure, diastolic blood pressure, and rate of perceived exertion were recorded.

Results

The Six-Minute Walk Test (6MWT) was significantly influenced by age and gender (r = 0.257, P = 0.00 and r = 0.501, P = 0.00, respectively). Walking distance was longest in 13-17-year-old males, whereas females demonstrated a linear decline after 12 years. In each age group, males walked a greater distance than females. Stepwise linear regression analysis was used to derive the following predictive equation: 6MWT = 491.93 - (2.148 × age) + (107.07 × gender) (females = 0, males = 1).

Conclusion

The study confirmed variability of the Six-Minute Walk Test, with age and gender being predominant predictors. Reference values, equations, and percentile charts generated from the study can be utilised to guide clinical decision-making while exercise prescription for patients with post COVID dysfunction.

Breath-holding physiology, radiological severity and adverse outcomes in COVID-19 patients: A prospective validation study

BACKGROUND AND OBJECTIVE

COVID-19 remains a major cause of respiratory failure, and means to identify future deterioration is needed. We recently developed a prediction score based on breath-holding manoeuvres (desaturation and maximal duration) to predict incident adverse COVID-19 outcomes. Here we prospectively validated our breath-holding prediction score in COVID-19 patients, and assessed associations with radiological scores of pulmonary involvement.

METHODS

Hospitalized COVID-19 patients (N = 110, three recruitment centres) performed breath-holds at admission to provide a prediction score (Messineo et al.) based on mean desaturation (20-s breath-holds) and maximal breath-hold duration, plus baseline saturation, body mass index and cardiovascular disease. Odds ratios for incident adverse outcomes (composite of bi-level ventilatory support, ICU admission and death) were described for patients with versus without elevated scores (>0). Regression examined associations with chest x-ray (Brixia score) and computed tomography (CT; 3D-software quantification). Additional comparisons were made with the previously-validated '4C-score'.

RESULTS

Elevated prediction score was associated with adverse COVID-19 outcomes (N = 12/110), OR[95%CI] = 4.54[1.17-17.83], p = 0.030 (positive predictive value = 9/48, negative predictive value = 59/62). Results were diminished with removal of mean desaturation from the prediction score (OR = 3.30[0.93-11.72]). The prediction score rose linearly with Brixia score (β[95%CI] = 0.13[0.02-0.23], p = 0.026, N = 103) and CT-based quantification (β = 1.02[0.39-1.65], p = 0.002, N = 45). Mean desaturation was also associated with both radiological assessment. Elevated 4C-scores (≥high-risk category) had a weaker association with adverse outcomes (OR = 2.44[0.62-9.56]).

CONCLUSION

An elevated breath-holding prediction score is associated with almost five-fold increased adverse COVID-19 outcome risk, and with pulmonary deficits observed in chest imaging. Breath-holding may identify COVID-19 patients at risk of future respiratory failure.

New Therapeutic Options in Mild Moderate COVID-19 Outpatients

Background: In recent years, the therapeutic options for COVID have significantly improved; however, the therapies are expensive with restricted access to drugs, and expeditious and difficult to manage at home. We investigated the effect of pidotimod in preventing hospitalization in patients with mild-moderate COVID-19. Methods: A total of 1231 patients between January and June 2021 were screened. A total of 184 patients with mild-moderate COVID-19 were enrolled and divided into two groups: group-A (97) had undergone therapy with pidotimod 800 mg bid for 7−10 days and group-B (87) had other therapies. We excluded those who had undergone complete vaccination course, monoclonal anti-spike/antivirals or the co-administration of pidotimod-steroid. The primary outcome chosen was the emergency room, hospitalization, and deaths for COVID-related causes; the secondary outcome chosen was the duration of COVID-19 illness. Results: A total of 34 patients (18.5%) required hospital treatment, 11 in group-A and 23 in group-B (11.3% vs. 26.4%, p = 0.008). The median disease duration in group-A was 21 days (IQR 17−27) vs. 23 (IQR 20−31) in group-B (p = 0.005). Patients in the pidotimod group had higher SpO2 in the walking test (IQR 96−99% vs. IQR 93−98%, p = 0.01) and a lower need for steroid rescue therapy (11.5% vs. 60.9%, p < 0.001). Conclusions: In the first phase of disease, pidotimod can represent an effective, low-cost, weapon, without restrictions of use, that is able to prevent a second aggressive phase and promote faster virological recovery.

Effect of breathing intervention in patients with COVID and healthcare workers

Background

Regulated breathing facilitates ventilation and reduces breathlessness. However, the effect of Yogic breathing on patients with COVID remains unclear. We aimed to evaluate the efficacy of two breathing protocols, i.e., short breathing technique (SBT) and long duration breathing technique (LBDT).

Methods

Three groups including COVID-positive patients, COVID-recovered patients, and healthcare workers (HCWs) were included in the study and segregated into Yoga and control groups. SBT was administered to COVID-positive patients. Both SBT and LBDT were administered to COVID-recovered patients and HCWs. A total of 18 biochemical parameters, a 6-min walk test (6MWT), and a 1-min sit-stand test (1MSST) were assessed on 0th, 7th, and 15th days, where biochemical parameters were the primary outcome. Pre-post estimation of neuropsychological parameters (nine questionnaires) and heart rate variability (HRV) were carried out. The paired t-test or Wilcoxon rank test was applied for pre-post comparison and the Student's t-test or Mann-Whitney U test was used for group comparison. Repeated measures test was applied for data recorded at three time points.

Results

A significant elevation in white blood cell (WBC) count was observed in COVID-positive intervention (p < 0.001) and control groups (p = 0.003), indicating no role of intervention on change in WBC number. WBC count (p = 0.002) and D-dimer (p = 0.002) significantly decreased in the COVID-recovered intervention group. D-dimer was also reduced in HCWs practicing Yogic breathing as compared to controls (p = 0.01). D-dimer was the primary outcome, which remained below 0.50 μg/ml (a cutoff value to define severity) in the COVID-positive yoga group (CYG) and decreased in the COVID-recovered yoga group (RYG) and the HCW yoga group (HYG) after intervention. A 6-min walk test (6MWT) showed an increase in distance covered among the COVID-positive patients (p = 0.01) and HCWs (p = 0.002) after intervention. The high-frequency power (p = 0.01) was found to be reduced in the COVID-positive intervention group. No significant change in neuropsychological parameters was observed.

Conclusion

Yogic breathing lowered D-dimer, which is helpful in reducing thrombosis and venous thromboembolism in patients with COVID-19 besides lowering the chances of vaccine-induced thrombotic thrombocytopenia in vaccinated individuals. The breathing intervention improved exercise capacity in mild to moderate cases of COVID-19. Further studies can show if such breathing techniques can influence immunity-related genes, as reported recently in a study. We suggest that Yogic breathing may be considered an integrative approach for the management of patients with COVID.

Trial registration

http://ctri.nic.in/Clinicaltrials/login.php, identifier: CTRI/2020/10/028195.

COVID-19, cardiac involvement and cardiac rehabilitation: Insights from a rehabilitation perspective - State of the Art

Since the beginning of the pandemic, many novel coronavirus disease 2019 (COVID-19) patients have experienced multisystem involvement or become critically ill and treated in intensive care units, and even died. Among these systemic effects, cardiac involvement may have very important consequences for the patient’s prognosis and later life. Patients with COVID-19 may develop cardiac complications such as heart failure, myocarditis, pericarditis, vasculitis, acute coronary syndrome, and cardiac arrhythmias or trigger an accompanying cardiac disease. The ratio of COVID-19 cardiac involvement ranges between 7 and 28% in hospitalized patients with worse outcomes, longer stay in the intensive care unit, and a higher risk of death. Furthermore, deconditioning due to immobility and muscle involvement can be seen in post-COVID-19 patients and significant physical, cognitive and psychosocial impairments may be observed in some cases. Considering that the definition of health is “a state of complete physical, mental and social well-being”, individuals with heart involvement due to COVID-19 should be rehabilitated by evaluating all these aspects of the disease effect. In the light of the rehabilitation perspective and given the increasing number of patients with cardiac manifestations of COVID-19, in this review, we discuss the rehabilitation principles in this group of patients.

Assessment of Six-Minute Walk Test Among Discharge-Ready Severe COVID-19 Patients: A Cross-Sectional Study

Background

Among patients hospitalized for severe pneumonia due to coronavirus disease (COVID-19), clinical stability and normal resting peripheral oxygen saturation (SpO₂) levels are widely used as a discharge criterion after recovery. It is unknown whether a test to assess the functional exercise capacity, like a six-minute walk test (6MWT), can add to the appropriateness of discharge criteria.

Methods

A cross-sectional study was conducted at a tertiary care COVID-19 hospital in India from 01^st to 31^st May 2021. All patients considered fit for discharge after recovery from "severe" COVID-19 pneumonia were subjected to 6MWT. Fitness for discharge was assessed by clinical stability and resting SpO₂ above 93% for three consecutive days. Patients were considered to have failed the 6MWT if there was ≥4% fall in SpO₂ or if they could not complete the test. Serum samples were analyzed for levels of C-reactive protein (CRP), interleukin-6 (IL-6), and lactate dehydrogenase (LDH) at the time of discharge.

Results

Fifty-three discharge-ready patients with a mean age of 54.54 ± 14.35 years with a male preponderance (60.38%) were analyzed. Thirty-three (62.26%) patients failed the 6MWT with a median six-minute walk distance (6MWD) of 270 m (60-360). A total of 45 (84.91%) patients had a fall in SpO₂ during the test. The median change in SpO₂ (∆SpO₂) was 5% ranging from -6% to 8%. Serum LDH was significantly higher among patients who failed the 6MWT with a median LDH of 334 IU/L (38.96-2339) versus 261 IU/L (49.2-494) (p = 0.02). The difference was not significant for CRP or IL-6. There was no statistically significant correlation between the inflammatory markers with either 6MWD or (∆SpO₂).

Conclusion

Two-thirds of the patients considered fit for discharge after recovery from severe COVID-19 pneumonia failed 6MWT, implying reduced functional exercise capacity and exertional hypoxia. Serum LDH levels were higher in these patients but not in other inflammatory markers. None of the inflammatory markers at discharge correlated with 6MWD or ∆SpO₂ of 6MWT.

Neurological manifestations of long-COVID syndrome: a narrative review

Accumulating evidence points toward a very high prevalence of prolonged neurological symptoms among coronavirus disease 2019 (COVID-19) survivors. To date, there are no solidified criteria for 'long-COVID' diagnosis. Nevertheless, 'long-COVID' is conceptualized as a multi-organ disorder with a wide spectrum of clinical manifestations that may be indicative of underlying pulmonary, cardiovascular, endocrine, hematologic, renal, gastrointestinal, dermatologic, immunological, psychiatric, or neurological disease. Involvement of the central or peripheral nervous system is noted in more than one-third of patients with antecedent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, while an approximately threefold higher incidence of neurological symptoms is recorded in observational studies including patient-reported data. The most frequent neurological manifestations of 'long-COVID' encompass fatigue; 'brain fog'; headache; cognitive impairment; sleep, mood, smell, or taste disorders; myalgias; sensorimotor deficits; and dysautonomia. Although very limited evidence exists to date on the pathophysiological mechanisms implicated in the manifestation of 'long-COVID', neuroinflammatory and oxidative stress processes are thought to prevail in propagating neurological 'long-COVID' sequelae. In this narrative review, we sought to present a comprehensive overview of our current understanding of clinical features, risk factors, and pathophysiological processes of neurological 'long-COVID' sequelae. Moreover, we propose diagnostic and therapeutic algorithms that may aid in the prompt recognition and management of underlying causes of neurological symptoms that persist beyond the resolution of acute COVID-19. Furthermore, as causal treatments for 'long-COVID' are currently unavailable, we propose therapeutic approaches for symptom-oriented management of neurological 'long-COVID' symptoms. In addition, we emphasize that collaborative research initiatives are urgently needed to expedite the development of preventive and therapeutic strategies for neurological 'long-COVID' sequelae.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19

Introduction

There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.

Methods

A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round.

Results

Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs.

Conclusion

The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.

How to cite this article

How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19

INTRODUCTION

There is strong evidence for the use of corticosteroid in the management of severe coronavirus disease-2019 (COVID-19). However, there is still uncertainty about the timing of corticosteroids. We undertook a modified Delphi study to develop expert consensus statements on the early identification of a subset of patients from non-severe COVID-19 who may benefit from using corticosteroids.

METHODS

A modified Delphi was conducted with two anonymous surveys between April 30, 2021, and May 3, 2021. An expert panel of 35 experts was selected and invited to participate through e-mail. The consensus was defined as >70% votes in multiple-choice questions (MCQ) on Likert-scale type statements, while strong consensus as >90% votes in MCQ or >50% votes for "very important" on Likert-scale questions in the final round.

RESULTS

Twenty experts completed two rounds of the survey. There was strong consensus for the increased work of breathing (95%), a positive six-minute walk test (90%), thorax computed tomography severity score of >14/25 (85%), new-onset organ dysfunction (using clinical or biochemical criteria) (80%), and C-reactive protein >5 times the upper limit of normal (70%) as the criteria for patients' selection. The experts recommended using oral or intravenous (IV) low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days and monitoring of oxygen saturation, body temperature, clinical scoring system, blood sugar, and inflammatory markers for any "red-flag" signs.

CONCLUSION

The experts recommended against indiscriminate use of corticosteroids in mild to moderate COVID-19 without the signs of clinical worsening. Oral or IV low-dose corticosteroids (the equivalent of 6 mg/day dexamethasone) for 5-10 days are recommended for patients with features of disease progression based on clinical, biochemical, or radiological criteria after 5 days from symptom onset under close monitoring.

HOW TO CITE THIS ARTICLE

How to cite this article: Nasa P, Chaudhry D, Govil D, Daga MK, Jain R, Chhallani AA, et al. Expert Consensus Statements on the Use of Corticosteroids in Non-severe COVID-19. Indian J Crit Care Med 2021;25(11):1280-1285.

Predisease Physical Activity Level and Current Functional Capacity in Patients With COVID-19: Relationship With Pneumonia and Oxygen Requirement

BACKGROUND

During the COVID-19 pandemic, restrictive measures can reduce physical activity. The purpose of this study was to evaluate predisease physical activity and current functional capacity in patients with and without the presence of pneumonia and oxygen requirement in Turkish survivors of COVID-19.

METHODS

Among the COVID-19 patients admitted to the hospital, 100 patients were selected. Data about predisease physical activity (by short-form International Physical Activity Questionnaire), oxygen requirement and presence of pneumonia, and current functional capacity (by the 6-min walking test) were collected. Continuous and categorical variables were compared with the Mann-Whitney U and χ2 test, respectively (P < .05).

RESULTS

The predisease physical activity levels and current functional capacity of patients with pneumonia and oxygen requirement were significantly lower than patients without pneumonia and oxygen requirement (P < .05). However, there was no significant difference between males and females (P > 0.05). Pneumonia and oxygen requirement was more common in the older adults (P < .05). Also, a significant correlation was found between age with predisease physical activity (r = .530, P = .000) and current functional capacity (r = -.346, P = .000) and predisease physical activity level with current functional capacity (r = .523, P = .001).

CONCLUSION

The physical activity level may be related to the severity of COVID-19 disease.

One minute sit-to-stand test as a potential triage marker in COVID-19 patients: A pilot observational study

Background

The crisis of critical care resource allocation during the novel coronavirus infectious disease 2019 (COVID-19) pandemic has underscored the importance of triage. COVID-19 is associated with increased hypoxemia and desaturation on exertion. We hypothesized that desaturation after 1-min sit-to-stand test (1MSTS), a validated field exercise test can serve as a potential marker for triage of COVID 19 patients.

Methods

Subjects with proven COVID 19 without hypoxemia on ambient air at presentation underwent the 1MSTS. The demographic details, clinical profile, pre and post-test vitals and pulse oximetric saturation was recorded and they were followed up for outcome throughout the hospital stay and after discharge.

Results

55 mild cases of COVID-19 and 6 cases of recovering severe COVID-19 were included. The mild cohort had a median age of 35 years (IQR, 27-41.5) and a median hospital stay of 16 days (IQR 14,20). The severe cohort had a median age of 47.5 years (IQR, 42.3,54.3) and median intensive care and hospital stays of respectively 9 (IQR, 7.5,9) and 23.5 (IQR, 21.5,27) days. The two cohorts showed median desaturations of 0% (IQR, 0.5-1) and 5.5% (IQR, 4.3-6) respectively. No subjects in the mild cohort needed oxygen therapy or escalation of care to intensive care.

Conclusions

Significant desaturation after 1-MSTSin severe COVID 19 patients demonstrates the potential role of 1-MSTS both in triage for planning care and as a discharge criteria from intensive care unit. However, larger prospective studies are warranted for its evaluation and establishment of relevant cut-offs.

COVID-19: A New Challenge for Pulmonary Rehabilitation?

Coronavirus disease 2019 (COVID-19), currently one of the immense burdens for global healthcare, is often characterized by rapid progression and the occurrence of symptoms particularly affecting the respiratory system. Continuous refinement of treatment protocols improves prognosis; however, COVID-19 survivors are often left with the symptomatic burden of dyspnea and fatigue. Therefore, it is necessary to continue comprehensive treatment including pulmonary rehabilitation. This study aimed to review the available literature on pulmonary rehabilitation in patients diagnosed with COVID-19. The pulmonary rehabilitation programs implemented various forms, i.e., aerobic exercise, breathing exercises, effective cough exercises, diaphragmatic breathing, and respiratory muscle training. Based on the literature review, it was found that pulmonary rehabilitation programs result in an improvement of respiratory function, reduction of fatigue and dyspnea, and improvement in exercise endurance and quality of life after completing both short-term and long-term programs, but depression and anxiety problems did not improve. Pulmonary rehabilitation combined with psychological therapy is crucial for COVID-19 survivors and plays a substantial role in patients’ recovery.

The Neurological Manifestations of Post-Acute Sequelae of SARS-CoV-2 infection

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a global health challenge. This review aims to summarize the incidence, risk factors, possible pathophysiology, and proposed management of neurological manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC) or neuro-PASC based on the published literature.

RECENT FINDINGS

The National Institutes of Health has noted that PASC is a multi-organ disorder ranging from mild symptoms to an incapacitating state that can last for weeks or longer following recovery from initial infection with SARS-CoV-2. Various pathophysiological mechanisms have been proposed as the culprit for the development of PASC. These include, but are not limited to, direct or indirect invasion of the virus into the brain, immune dysregulation, hormonal disturbances, elevated cytokine levels due to immune reaction leading to chronic inflammation, direct tissue damage to other organs, and persistent low-grade infection. A multidisciplinary approach for the treatment of neuro-PASC will be required to diagnose and address these symptoms. Tailored rehabilitation and novel cognitive therapy protocols are as important as pharmacological treatments to treat neuro-PASC effectively. With recognizing the growing numbers of COVID-19 patients suffering from neuro-PASC, there is an urgent need to identify affected individuals early to provide the most appropriate and efficient treatments. Awareness among the general population and health care professionals about PASC is rising, and more efforts are needed to understand and treat this new emerging challenge. In this review, we summarize the relevant scientific literature about neuro-PASC.

Learning from the Italian experience during COVID-19 pandemic waves: be prepared and mind some crucial aspects

COVID-19 pandemic has rapidly spread worldwide causing a serious challenge to the global medical community. Italy was struck hard during the first wave earlier this year and several weaknesses as well as general unpreparedness of the national healthcare system were acknowledged. Learning essential lessons from the past, we realized how implementing contingency response measures, human resources and social dynamics could have changed the outcome if promptly adopted. This review translates the previous experience into strategic actions that has to be considered when developing appropriate national and regional operational plans to respond to a pandemic.

Computed tomography chest in COVID-19: When & why?

Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR-positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19-positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of <93 per cent at rest while breathing room air or de-saturate on six-minute walk test. Finally, CT chest plays a crucial role to rule out lung fibrosis in patients recovered from COVID-19 infection who present with hypoxia/impaired lung function on follow up. In conclusion, though CT chest is an indispensable diagnostic tool in COVID-19, it should be used judiciously and only when specifically indicated.

A COVID-19 Rehabilitation Prospective Surveillance Model for Use by Physiotherapists

The long-term sequelae of coronavirus disease 2019 (COVID-19) are only now beginning to be defined, but it is already known that the disease can have direct and indirect impacts mainly on the cardiorespiratory and neuromuscular systems and may affect mental health. A role for rehabilitation professionals from all disciplines in addressing COVID-19 sequelae is recognised, but it is essential that patient assessment be systematic if health complications are to be identified and treated and, if possible, prevented. The aim is to present a COVID-19 prospective surveillance model based on sensitive and easily used assessment tools, which is urgently required. Following the Oxford Centre for Evidence-Based Medicine Level of Evidence Tool, an expert team in cardiorespiratory, neuromuscular and mental health worked via telemeetings to establish a model that provides guidelines to rehabilitation professionals working with patients who require rehabilitation after suffering from COVID-19. A COVID-19 prospective surveillance model is proposed for use by rehabilitation professionals and includes both face-to-face and telematic monitoring components. This model should facilitate the early identification and management of long-term COVID-19 sequelae, thus responding to an arising need.

Direct and indirect evidence of efficacy and safety of rapid exercise tests for exertional desaturation in Covid-19: a rapid systematic review

BACKGROUND

Even when resting pulse oximetry is normal in the patient with acute Covid-19, hypoxia can manifest on exertion. We summarise the literature on the performance of different rapid tests for exertional desaturation and draw on this evidence base to provide guidance in the context of acute Covid-19.

MAIN RESEARCH QUESTIONS

1. What exercise tests have been used to assess exertional hypoxia at home or in an ambulatory setting in the context of Covid-19 and to what extent have they been validated? 2. What exercise tests have been used to assess exertional hypoxia in other lung conditions, to what extent have they been validated and what is the applicability of these studies to acute Covid-19?

METHOD

AMED, CINAHL, EMBASE MEDLINE, Cochrane and PubMed using LitCovid, Scholar and Google databases were searched to September 2020. Studies where participants had Covid-19 or another lung disease and underwent any form of exercise test which was compared to a reference standard were eligible. Risk of bias was assessed using QUADAS 2. A protocol for the review was published on the Medrxiv database.

RESULTS

Of 47 relevant papers, 15 were empirical studies, of which 11 described an attempt to validate one or more exercise desaturation tests in lung diseases other than Covid-19. In all but one of these, methodological quality was poor or impossible to fully assess. None had been designed as a formal validation study (most used simple tests of correlation). Only one validation study (comparing a 1-min sit-to-stand test [1MSTST] with reference to the 6-min walk test [6MWT] in 107 patients with interstitial lung disease) contained sufficient raw data for us to calculate the sensitivity (88%), specificity (81%) and positive and negative predictive value (79% and 89% respectively) of the 1MSTST. The other 4 empirical studies included two predictive studies on patients with Covid-19, and two on HIV-positive patients with suspected pneumocystis pneumonia. We found no studies on the 40-step walk test (a less demanding test that is widely used in clinical practice to assess Covid-19 patients). Heterogeneity of study design precluded meta-analysis.

DISCUSSION

Exertional desaturation tests have not yet been validated in patients with (or suspected of having) Covid-19. A stronger evidence base exists for the diagnostic accuracy of the 1MSTST in chronic long-term pulmonary disease; the relative intensity of this test may raise safety concerns in remote consultations or unstable patients. The less strenuous 40-step walk test should be urgently evaluated.

Post-exertion oxygen saturation as a prognostic factor for adverse outcome in patients attending the emergency department with suspected COVID-19: a substudy of the PRIEST observational cohort study

BACKGROUND

Measurement of post-exertion oxygen saturation has been proposed to assess illness severity in suspected COVID-19 infection. We aimed to determine the accuracy of post-exertional oxygen saturation for predicting adverse outcome in suspected COVID-19.

METHODS

We undertook a substudy of an observational cohort study across 70 emergency departments during the first wave of the COVID-19 pandemic in the UK. We collected data prospectively, using a standardised assessment form, and retrospectively, using hospital records, from patients with suspected COVID-19, and reviewed hospital records at 30 days for adverse outcome (death or receiving organ support). Patients with post-exertion oxygen saturation recorded were selected for this analysis. We constructed receiver-operating characteristic curves, calculated diagnostic parameters, and developed a multivariable model for predicting adverse outcome.

RESULTS

We analysed data from 817 patients with post-exertion oxygen saturation recorded after excluding 54 in whom measurement appeared unfeasible. The c-statistic for post-exertion change in oxygen saturation was 0.589 (95% CI 0.465 to 0.713), and the positive and negative likelihood ratios of a 3% or more desaturation were, respectively, 1.78 (1.25 to 2.53) and 0.67 (0.46 to 0.98). Multivariable analysis showed that post-exertion oxygen saturation was not a significant predictor of adverse outcome when baseline clinical assessment was taken into account (p=0.368). Secondary analysis excluding patients in whom post-exertion measurement appeared inappropriate resulted in a c-statistic of 0.699 (0.581 to 0.817), likelihood ratios of 1.98 (1.26 to 3.10) and 0.61 (0.35 to 1.07), and some evidence of additional prognostic value on multivariable analysis (p=0.019).

CONCLUSIONS

Post-exertion oxygen saturation provides modest prognostic information in the assessment of selected patients attending the emergency department with suspected COVID-19.

TRIAL REGISTRATION NUMBER

ISRCTN Registry (ISRCTN56149622) http://www.isrctn.com/ISRCTN28342533.