Interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms: A systematic review

BACKGROUND

Levothyroxine (LT4) monotherapy is the standard treatment for hypothyroidism; however, 10-15% of patients have persistent hypothyroid symptoms despite normalizing thyroid hormone levels with LT4. This study aims to summarize the best available evidence on interventions to improve symptomatology in patients with hypothyroidism and persistent symptoms.

METHODS

A systematic search was conducted in March 2022 for randomized controlled trials and observational studies on interventions for adult patients with persistent hypothyroid symptoms despite biochemical euthyroidism on thyroid hormone replacement.

RESULTS

A total of 277 articles were reviewed and seven fulfilled the inclusion criteria. 455 participants were included. Most intervention participants were female (78.6%) with a mean age of 47.5 (±2.8) years. Five clinical trials evaluating ginger (vs. starch), L-carnitine (vs. placebo), combination LT4 and liothyronine (LT3) (vs. LT4 or placebo), and surgery for patients with serum antithyroid peroxidase (TPO Ab) titers greater than 1000 IU/ml (vs. LT4) found inconsistent improvement in hypothyroidism related symptoms and general health. The two clinical trials with the largest improvement in fatigue scores were the use of ginger and surgery. One observational study comparing thyroidectomy vs observation found no significant difference on general health. Lastly, another observational study evaluating combination LT4/LT3 (vs. LT4 monotherapy) found improvement in fatigue and quality of life. There were 31 (12%) adverse events in the intervention group and 18 (10.8%) in the comparator group.

CONCLUSIONS

There is no high-quality evidence supporting any intervention for persistent symptoms in hypothyroidism. Available evidence, limited by the risk of bias, inconsistency, and heterogeneity, suggests that some persistent symptoms, particularly fatigue, could improve with ginger and thyroidectomy.

Updated Clinical Practice Guidelines for the Diagnosis and Management of Long COVID

"Long COVID" is a term used to describe a condition when the symptoms and signs associated with coronavirus disease 2019 (COVID-19) persist for more than three months among patients infected with COVID-19; this condition has been reported globally and poses a serious public health issue. Long COVID can manifest in various forms, highlighting the need for appropriate evaluation and management by experts from various fields. However, due to the lack of clear clinical definitions, knowledge of pathophysiology, diagnostic methods, and treatment protocols, it is necessary to develop the best standard clinical guidelines based on the scientific evidence reported to date. We developed this clinical guideline for diagnosing and treating long COVID by analyzing the latest research data collected from the start of the COVID-19 pandemic until June 2023, along with the consensus of expert opinions. This guideline provides recommendations for diagnosis and treatment that can be applied in clinical practice, based on a total of 32 key questions related to patients with long COVID. The evaluation of patients with long COVID should be comprehensive, including medical history, physical examination, blood tests, imaging studies, and functional tests. To reduce the risk of developing long COVID, vaccination and antiviral treatment during the acute phase are recommended. This guideline will be revised when there is a reasonable need for updates based on the availability of new knowledge on the diagnosis and treatment of long COVID.

Persistence of aerodigestive symptoms after vascular ring repair

OBJECTIVE

Vascular rings are often associated with respiratory and swallowing difficulties due to tracheal or esophageal compression. While the results of a vascular ring repair are considered excellent, the long-term effect of tracheal and esophageal remodeling and the persistence of symptoms have scarcely been reported. Our study aims to evaluate the respiratory and swallowing outcomes of vascular ring repair.

STUDY DESIGN AND METHODS

A retrospective cohort study of children who underwent vascular ring repair between 2010 and 2022 in a tertiary-care children's hospital.

RESULTS

There were 108 patients enrolled: sixty-three patients (57.41 %) with a right aortic arch, 42 patients (38.89 %) with a double aortic arch, and 3 patients (2.78 %) with other vascular rings. Forty-three (39.81 %) patients were diagnosed prenatally. Of the 65 patients (60.19 %) diagnosed postnatally, 35/65 (53.85 %) had either respiratory or swallowing symptoms as the indication for diagnostic workup. Persistent respiratory and swallowing symptoms were noted in 34/108 (31.48 %) and 30/108 (27.78 %) patients, respectively, within a year of surgical repair. Fourteen patients underwent repeated laryngoscopy and bronchoscopy that demonstrated residual tracheomalacia; however, only 2/14 (1.9 %) patients required tracheostomy tube placement, and 6-out-of-7 patients were weaned off positive pressure airway support. Persistent respiratory symptoms were significantly more common in patients with a double aortic arch compared to a right aortic arch. No differences were noted in demographics, comorbidities, and preoperative aerodigestive symptoms between patients with residual symptoms and patients with no residual symptoms.

CONCLUSIONS

Persistent respiratory and swallowing symptoms after vascular ring repair are not uncommon. Postoperative evaluation should be pursued by a dedicated team, and treatment considered as appropriate.

Fatigue and symptom-based clusters in post COVID-19 patients: a multicentre, prospective, observational cohort study

BACKGROUND

In the Netherlands, the prevalence of post COVID-19 condition is estimated at 12.7% at 90-150 days after SARS-CoV-2 infection. This study aimed to determine the occurrence of fatigue and other symptoms, to assess how many patients meet the Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) criteria, to identify symptom-based clusters within the P4O2 COVID-19 cohort and to compare these clusters with clusters in a ME/CFS cohort.

METHODS

In this multicentre, prospective, observational cohort in the Netherlands, 95 post COVID-19 patients aged 40-65 years were included. Data collection at 3-6 months after infection included demographics, medical history, questionnaires, and a medical examination. Follow-up assessments occurred 9-12 months later, where the same data were collected. Fatigue was determined with the Fatigue Severity Scale (FSS), a score of ≥ 4 means moderate to high fatigue. The frequency and severity of other symptoms and the percentage of patients that meet the ME/CFS criteria were assessed using the DePaul Symptom Questionnaire-2 (DSQ-2). A self-organizing map was used to visualize the clustering of patients based on severity and frequency of 79 symptoms. In a previous study, 337 Dutch ME/CFS patients were clustered based on their symptom scores. The symptom scores of post COVID-19 patients were applied to these clusters to examine whether the same or different clusters were found.

RESULTS

According to the FSS, fatigue was reported by 75.9% of the patients at 3-6 months after infection and by 57.1% of the patients 9-12 months later. Post-exertional malaise, sleep disturbances, pain, and neurocognitive symptoms were also frequently reported, according to the DSQ-2. Over half of the patients (52.7%) met the Fukuda criteria for ME/CFS, while fewer patients met other ME/CFS definitions. Clustering revealed specific symptom patterns and showed that post COVID-19 patients occurred in 11 of the clusters that have been observed in the ME/CFS cohort, where 2 clusters had > 10 patients.

CONCLUSIONS

This study shows persistent fatigue and diverse symptomatology in post COVID-19 patients, up to 12-18 months after SARS-CoV-2 infection. Clustering showed that post COVID-19 patients occurred in 11 of the clusters that have been observed in the ME/CFS cohort.

Prevalence and trends in persistent symptoms following COVID-19 in Japan: A nationwide cross-sectional survey

INTRODUCTION

Even during the endemic phase of the COVID-19 pandemic, the impact of persistent symptoms on patients and healthcare systems remains significant. Thus, a more comprehensive understanding of these symptoms is essential.

METHODS

Using data from the Japan Society and New Tobacco Internet Survey conducted in February 2023, this cross-sectional study investigated the prevalence of, and changes in, persistent COVID-19 symptoms.

RESULTS

In total, 21,108 individuals responded to the survey. Of these, 29.1 % (6143) had a history of COVID-19. Our analysis found that arm/leg/joint pain (adjusted odds ratio [aOR]: 1.17; 95 % confidence interval [95 % CI]: 1.03-1.33), back pain (aOR: 1.13; 95 % CI: 1.01-1.27), chest pain (aOR: 1.53; 95 % CI: 1.20-1.96), malaise (aOR: 1.14; 95 % CI: 1.02-1.28), loss of taste (aOR: 2.55; 95 % CI: 1.75-3.72), loss of smell (aOR: 2.33; 95 % CI: 1.67-3.26), memory impairment (aOR: 1.27; 95 % CI: 1.04-1.56), and cough (aOR: 1.72; 95 % CI: 1.38-2.13) were independently associated with a history of COVID-19 contracted more than two months but less than six months previously. Further, back pain (aOR: 1.24; 95 % CI: 1.04-1.47) and loss of taste (aOR: 2.28; 95 % CI: 1.24-4.21) showed independent association with COVID-19 contracted more than 12 months previously.

CONCLUSIONS

Various symptoms were independently associated with a history of COVID-19. While most patients tend to recover within a year after contracting COVID-19, certain symptoms, such as back pain and loss of taste, persist longer than a year, underscoring public health concerns and emphasizing the need for health care services to support patients suffering from persistent symptoms.

Tracking Health Beyond Recovery: A Study on Identifying Post-COVID Syndrome Symptoms

Context

The COVID-19 pandemic had a profound global impact, leaving a lasting legacy in the form of post-COVID syndrome. This condition, experienced after recovering from the virus, manifests in symptoms, such as fatigue, cough, shortness of breath, joint pain, and brain fog, highlighting the virus's lingering influence on the human body.

Aim

To Identify post-COVID syndrome symptoms among COVID-19 recovered patients from Karad Taluka.

Materials and methods

A study involving 228 COVID-19-recovered individuals from a Karad tertiary care hospital used consecutive sampling. Data were collected via structured questionnaires, focused on post-COVID syndrome symptoms.

Statistical analysis used

Frequency and percentage were used to analyze the presence of post-COVID syndrome symptoms.

Results

A total of 228 COVID-19-recovered individuals were included in the study, of whom 53% were male and 47% were female. Most of the study subjects had 25 (10.9%) mild, 138 (60.5%) moderate, and 65 (28.5%) severe symptoms. Symptom-wise, the majority of the subjects experienced symptoms: fatigue 116 (50.8% moderate), shortness of breath 135 (58.3% moderate), cough 116 (50.8%), sore throat 115 (50.4% mild), chest pain (57% mild), joint pain 151 (66.2% severe), brain fog 103 (45% severe). Most (43%) experienced symptoms for 12 months, that is, 1 year.

Conclusion

The results depict the recovered individuals continue to experience symptoms. The most common symptoms are fatigue, shortness of breath, and cough in varied severity (from mild, moderate, and severe).

How to cite this article

Walvekar SS, Mohite VR. Tracking Health Beyond Recovery: A Study on Identifying Post-COVID Syndrome symptoms. Indian J Crit Care Med 2024;28(2):170-174.

Determinants of persistent symptoms after treatment for Lyme borreliosis: a prospective observational cohort study

BACKGROUND

Patients treated for Lyme borreliosis (LB) frequently report persistent symptoms. Little is known about risk factors and etiology.

METHODS

In a prospective observational cohort study with a follow-up of one year, we assessed a range of microbiological, immunological, genetic, clinical, functional, epidemiological, psychosocial and cognitive-behavioral variables as determinants of persistent symptoms after treatment for LB. Between 2015 and 2018 we included 1135 physician-confirmed LB patients at initiation of antibiotic therapy, through clinical LB centers and online self-registration. Two reference cohorts of individuals without LB (n = 4000 and n = 2405) served as a control. Prediction analyses and association studies were used to identify determinants, as collected from online questionnaires (three-monthly) and laboratory tests (twice).

FINDINGS

Main predictors of persistent symptoms were baseline poorer physical and social functioning, higher depression and anxiety scores, more negative illness perceptions, comorbidity, as well as fatigue, cognitive impairment, and pain in 295 patients with persistent symptoms. The primary prediction model correctly indicated persistent symptoms in 71.0% of predictions (AUC 0.79). In patients with symptoms at baseline, cognitive-behavioral responses to symptoms predicted symptom persistence. Of various microbiological, immunological and genetic factors, only lower IL-10 concentrations in ex vivo stimulation experiments were associated with persistent symptoms. Clinical LB characteristics did not contribute to the prediction of persistent symptoms.

INTERPRETATION

Determinants of persistent symptoms after LB were mainly generic, including baseline functioning, symptoms and cognitive-behavioral responses. A potential role of host immune responses remains to be investigated.

FUNDING

Netherlands Organisation for Health Research and Development (ZonMw); the Dutch Ministry of Health, Welfare and Sport (VWS).

Patients with persistent symptoms after COVID-19 attending a multidisciplinary evaluation: Characteristics, medical conclusions, and satisfaction

OBJECTIVE

Among patients attending a multidisciplinary day-hospital program for persistent symptoms after COVID-19, we aimed i) to describe their characteristics ii) to present the medical conclusions (diagnoses and recommendations) and iii) to assess the patients' satisfaction and its correlates.

METHODS

For this retrospective chart review study, frequent symptoms were systematically assessed. Standardized questionnaires explored fatigue (Pichot scale), physical activity (Ricci & Gagnon scale), health-related quality of life (Short-Form Health Survey), anxiety and depressive symptoms (Hospital Anxiety and Depression scale) and associated psychological burden (Somatic-Symptom-Disorder B criteria Scale). Medical record conclusions were collected and a satisfaction survey was performed at 3-months follow-up.

RESULTS

Among 286 consecutive patients (median age: 44 years; 70% women), the most frequent symptoms were fatigue (86%), breathlessness (65%), joint/muscular pain (61%) and cognitive dysfunction (58%), with a median duration of 429 days (Inter-quartile range (IqR): 216-624). Questionnaires revealed low levels of physical activity and quality of life, and high levels of fatigue, anxiety, depression, and psychological burden, with 32% and 23% meeting the diagnostic criteria for a depressive or anxiety disorder, respectively. Positive arguments for a functional somatic disorder were found in 76% of patients, including 96% with no abnormal clinical or test findings that may explain the symptoms. Physical activity rehabilitation was recommended for 91% of patients. Patients' median satisfaction was 8/10 (IqR: 6-9).

CONCLUSION

Most patients attending this program presented with long-lasting symptoms and severe quality of life impairment, received a diagnosis of functional somatic disorder, and reported high levels of satisfaction regarding the program.

The Impact of Chronic Pulmonary Aspergillosis Co-infection on the Health-Related Quality of Life of Patients with Pulmonary Tuberculosis in Uganda

BACKGROUND

Both pulmonary tuberculosis (PTB) and chronic pulmonary aspergillosis (CPA) significantly affect health-related quality of life (HR-QoL). We aimed to determine the impact of CPA co-infection on the HR-QoL of Ugandans with PTB.

METHODS

We conducted a prospective study as part of a larger study among participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020 and June 2021. HR-QoL was assessed using St. George Respiratory Questionnaire (SGRQ) at enrollment and at the end of PTB treatment (4 months apart). SGRQ scores range from 0 to 100, with higher score representing a poorer HR-QoL.

RESULTS

Of the 162 participants enrolled in the larger study, 32 (19.8%) had PTB + CPA and 130 (80.2%) had PTB. The baseline characteristics of the two groups were comparable. Regarding overall health, a higher proportion of the PTB group rated their HR-QoL as "very good" compared to those who had PTB + CPA (68 [54.0%] versus 8 [25.8%]). At enrollment, both groups had comparable median SGRQ scores. However, at follow up, the PTB group had statistically significantly better SGRQ scores (interquartile range); symptoms (0 [0-12.4] versus 14.4 [0-42.9], p < 0.001), activity ((0 [0-17.1] versus 12.2 [0-35.5], p = .03), impact (0 [0-4.0] versus 3.1 [0-22.5], p = 0.004), and total scores ((0 [0-8.5] versus 7.6[(0-27.4], p = 0.005).

CONCLUSION

CPA co-infection impairs HR-QoL of people with PTB. Active screening and management of CPA in patients with PTB is recommended to improve HR-QoL of these individuals.

Prevalence of Persisting and New Symptoms Following Recovery from COVID-19 in the Jordanian Population

Background

Many patients do not have a clear idea about the recovery from COVID-19 infection. This study focuses on the prevalence of persistent symptoms of COVID-19 infection as well as new symptoms that appear after recovery, and it aids in determining the relationships between these symptoms and a variety of variables.

Methods

An online observational study was conducted between April and June 2022. It consisted of a self-administered web-based questionnaire conducted using social media platforms. Inclusion criteria were residency in Jordan, being 18 years of age or older, having recovered from COVID-19 for at least 90 days, and giving consent to participate. Participants whose infection was not confirmed by a positive PCR were excluded.

Results

The most common persistent symptoms were loss of smell (34.7%), fatigue (34.6%), loss of taste (29.5%), myalgia (26.3%), and headache (25.9%), while the most common newly appearing symptoms after recovery were smell hallucinations (15.8%), fatigue (15.5%), taste hallucinations (14.9%), and focus impairment (12.9%) and smell impairment (12.8%). The symptoms persisted more in females, non-smokers, and those who needed medical care sor oxygesnation and with increased infection duration.

Conclusion

The study about persistent and new symptoms after COVID-19 among Jordanians found a greater prevalence of symptoms related to the sense of smell. There is no association between persistent and new symptoms after COVID-19 recovery with comorbidities or oxygen therapy during illness. We recommend studying the effect of COVID-19 mutants and vaccination on the persistence of symptoms after recovery.

The clinical course and outcomes of SARS-CoV-2 virus infection in children: a 24-week follow-up study in Sulaimaniyah, Iraq

Most children infected with the SARS-CoV-2 virus have asymptomatic or mild disease with a short clinical course and excellent outcome; meanwhile, some children experienced persisting symptoms lasting > 12 weeks from the COVID-19 infection diagnosis. This study aimed to define the acute clinical course of SARS-CoV-2 virus infection and outcomes in children after recovery. This prospective cohort study was conducted on 105 children (aged < 16 years) with confirmed COVID-19 infection at Jamal Ahmed Rashid Teaching Hospital, Sulaimaniyah, Iraq, from July to September 2021. The symptomatic and suspicious cases of COVID-19 infection in children were confirmed by real-time reverse transcriptase-polymerase chain reaction (RT-PCR) on nasopharyngeal swabs. About 85.6% of children fully recovered at ≤ 4 weeks from initial COVID-19 infection diagnosis, 42% were hospitalized, while 15.2% reported long COVID-19 infection symptoms. The most commonly reported symptoms were fatigue (7.1%), hair fall (4.0%), lack of concentration (3.0%), and abdominal pain (2.0%). Children aged 11-16 showed a greater risk of long-term COVID-19 infection symptoms. We also observed a higher risk of long COVID infection symptoms in those who reported ongoing symptoms at 4-6 weeks of follow-up assessment (p = 0.01). Despite mild disease and complete recovery in most children, many suffered from long COVID infection symptoms.

Trust in sources of information on COVID-19 at the beginning of the pandemic's first wave and incident persistent symptoms in the population-based CONSTANCES cohort: A prospective study

OBJECTIVE

To examine the association between trust in different sources of information on COVID-19 at the beginning of the pandemic and the burden of incident persistent symptoms.

METHODS

This prospective study used data from the SAPRIS and SAPRIS-Sérologie surveys nested in the French CONSTANCES population-based cohort. Trust in different information sources was measured between April 6 and May 4, 2020. Persistent symptoms that emerged afterwards were self-reported between December 2020 and January 2021. The associated psychological burden was measured with the somatic symptom disorder B criteria scale (SSD-12). The analyses were adjusted for gender, age, education, income, self-rated health, SARS-CoV-2 serology tests, and self-reported COVID-19.

RESULTS

Among 20,985 participants [mean age (SD), 49.0 years (12.7); 50.2% women], those with higher trust in government/journalists at baseline had fewer incident persistent symptoms at follow-up (estimate (SE) for one IQR increase: -0.21 (0.03), p < 0.001). Participants with higher trust in government/journalists and medical doctors/scientists were less likely to have ≥1 symptom (odds ratio (95% confidence interval) for one IQR increase: 0.87 (0.82-0.91) and 0.91 (0.85-0.98), respectively). Among 3372 participants (16.1%) who reported ≥1 symptom, higher trust in government/journalists and medical doctors/scientists predicted lower SSD-12 scores (-0.39 (0.17), p = 0.02 and - 0.85 (0.24), p < 0.001, respectively), whereas higher trust in social media predicted higher scores in those with lower trust in government/journalists (0.90 (0.34), p = 0.008). These associations did not depend upon surrogate markers of infection with SARS-CoV-2.

CONCLUSIONS

Trust in information sources on COVID-19 may be associated with incident persistent symptoms and associated psychological burden, regardless of infection with SARS-CoV-2.

Symptoms, the GerdQ score and patients' characteristics do not predict gastroesophageal reflux disease in patients with proton-pump-inhibitor-refractory reflux symptoms-results from a large prospective database

Background

The number of patients with proton pump inhibitor (PPI)-refractory reflux symptoms is underestimated since many patients resign after an unsuccessful therapy attempt. Thus, it would be useful having a non-invasive tool that can help identify true gastroesophageal reflux disease (GERD) patients in order to manage them early and properly. The GerdQ is a validated tool developed for this purpose but its applicability in PPI-refractory patients has not yet been investigated. Our aim was to investigate if reflux symptoms per se, the GerdQ and patients characteristics are suitable for non-invasive diagnosis of GERD in patients with PPI refractory reflux symptoms.

Methods

A total of 500 patients from a prospectively recorded data base with PPI-refractory reflux symptoms were retrospectively analyzed. All patients received comprehensive diagnostic workup including EGD, pH-impedance measurement and manometry. GERD was diagnosed according to the recent Lyon consensus.

Results

Of all patients enrolled in the study, 280 (56%) finally fulfilled the criteria for objectively verified GERD according to the Lyon consensus. There were no significant differences in age and gender between the patients with and without GERD, whereas the body mass index was significantly higher in the group with verified GERD, but the discriminative value was low (Welch-Test, p < .001, Cohen's d = 0.39). Furthermore, there were no significant differences in the GerdQ values between the two groups. A GerdQ cutoff value ≥ 9 resulted in a sensitivity of 43% and specificity of 57% with a positive predictive value of 56% and a negative predictive value of 44%.

Conclusion

Based on our study, neither symptoms and the GerdQ score nor patients' characteristics are appropriate tools to distinguish between GERD and other causes for reflux symptoms in patients with PPI-refractory reflux symptoms.

High Prevalence of Functional Gastrointestinal Disorders in Celiac Patients with Persistent Symptoms on a Gluten-Free Diet: A 20-Year Follow-Up Study

BACKGROUND

Ongoing symptoms in treated celiac disease (CD) are frequent and are commonly thought of as being due to infractions to a gluten-free diet (GFD) or complications.

AIMS

To study the etiology and natural history of clinically relevant events (CREs) throughout follow-up and identify predictors thereof to guide follow-up.

METHODS

CREs (symptoms/signs requiring diagnostic/therapeutic interventions) occurring in celiac patients between January-2000 and May-2021 were retrospectively collected between June and September 2021 and analysed.

RESULTS

One-hundred-and-eighty-nine adult patients (133 F, age at diagnosis 36 ± 13 years, median follow-up 103 months, IQR 54-156) were enrolled. CREs were very common (88/189, 47%), but hardly due to poor GFD adherence (4%) or complications (2%). Interestingly, leading etiologies were functional gastrointestinal disorders (30%), reflux disease (18%) and micronutrient deficiencies (10%). Age at diagnosis ≥ 45 years (HR 1.68, 95%CI 1.05-2.69, p = 0.03) and classical pattern of CD (HR 1.63, 95%CI 1.04-2.54, p = 0.03) were predictors of CREs on a multivariable Cox model. At 5 years, 46% of classical patients ≥ 45 years old at diagnosis were event-free, while this was 62% for non-classical/silent ≥ 45 years, 60% for classical < 45 years, and 80% for non-classical/silent < 45 years.

CONCLUSIONS

CREs occurred in almost half of CD patients during follow-up, with functional disorders being very common. New follow-up strategies for adult CD may be developed based on age and clinical pattern at diagnosis.

[Evolution and quality of life at three months after hospitalization for COVID pneumonia]

OBJECTIVE

Assess clinical evolution and health-related quality of life at three months after discharge in patients who were admitted and diagnosed with COVID-19 pneumonia, evaluated by the Rehabilitation Service and received physiotherapy in Fuenlabrada Hospital.

METHODS

Data were collected from 59 patients, separating those who were assessed in ICU (41 patients) from those assessed in the hospital ward (18). Data were obtained from their Electronic Medical Record, and a telephone interview was performed three months after their discharge. Data about their clinical progress during their hospitalization, after discharge, over the next months and their condition at the time of the interview is analyzed. Patients were asked to assess the quality of the physiotherapy received and to answer the SF-36 health-related quality of life questionnaire.

RESULTS

These patients had the worst progress of the COVID pneumonia among all patients hospitalized in our hospital, but they had a good functional recovery with the inpatient physiotherapy received, which was positively rated. After three months, 84% have persistent symptoms, with the most common being dyspnoea, fatigue and anxiety/depression, and score worse in the SF-36 questionnaire than the reference population.

CONCLUSIONS

Most patients who require rehabilitation during their COVID pneumonia admission have persistent symptoms and perceive a deterioration in their health-related quality of life after three months of discharge.

Persistent symptoms after the first wave of COVID-19 in relation to SARS-CoV-2 serology and experience of acute symptoms: A nested survey in a population-based cohort

BACKGROUND

Many patients report persistent symptoms after COVID-19. Our aim was to determine whether some of these symptoms were more associated with past SARS-CoV-2 infection compared to other conditions.

METHODS

This prospective survey was nested in CONSTANCES, a randomly selected French population-based cohort, started in 2012. All participants being followed-up by internet completed 2 questionnaires during the first wave of the pandemic focusing on the acute symptoms of their COVID-19-like illness. Serological tests for SARS-CoV-2 were then performed (May-Nov 2020). Between December 2020 and January 2021, participants completed a third questionnaire about symptoms that had lasted more than 2 months. Participants were classified into four groups according to both European Center for Diseases Control (ECDC) criteria for COVID-19 (ECDC+ or ECDC-) and serological SARS-CoV-2 test results (Sero+ or Sero-). To compare the risk of each persistent symptom among the groups, logistic regression models were adjusted for age, sex, educational level, comorbidities, and the number of acute symptoms declared during the first wave of the epidemic. A mediation analysis was performed to estimate the direct effect of the infection on persistent symptoms and its indirect effect via the initial clinical presentation.

FINDINGS

The analysis was performed in 25,910 participants. There was a higher risk of persistent dysgeusia/anosmia, dyspnea and asthenia in the ECDC+/Sero+ group than in the ECDC+/Sero- group (OR: 6.83 [4.47-10.42], 1.69 [1.07-2.6] and 1.48 [1.05-2.07], respectively). Abdominal pain, sensory symptoms or sleep disorders were at lower risk in the ECDC+/Sero+ group than in the ECDC+/Sero- group (0.51 [0.24-0.96], 0.40 [0.16-0.85], and 0.69 [0.49-0.95], respectively). The mediation analysis revealed that the association of the serological test results with each symptom was mainly mediated by ECDC symptoms (proportion mediated range 50-107%).

CONCLUSION

A greater risk of persistent dysgeusia/anosmia, dyspnea and asthenia was observed in SARS-CoV-2 infected people. The initial clinical presentation substantially drives the association of positive serological test results with persistent symptoms.

FUNDING

French National Research Agency.

Chronic pulmonary aspergillosis in patients with active pulmonary tuberculosis with persisting symptoms in Uganda

BACKGROUND

The occurrence of chronic pulmonary aspergillosis (CPA) among drug sensitive pulmonary tuberculosis (PTB) patients on optimal therapy with persistent symptoms was investigated.

METHODS

We consecutively enrolled participants with PTB with persistent pulmonary symptoms after 2 months of anti-TB treatment at Mulago Hospital, Kampala, Uganda between July 2020, and June 2021. CPA was defined as a positive Aspergillus-specific IgG/IgM immunochromatographic test (ICT), a cavity with or without a fungal ball on chest x-ray (CXR), and compatible symptoms >3 months.

RESULTS

We enrolled 162 participants (median age 30 years; IQR: 25 - 40), 97 (59.9%) were male, 48 (29.6%) were HIV-infected, and 15 (9.3%) had prior PTB. Thirty-eight (23.4%) sputum samples grew A. niger and 13 (8.0%) A. fumigatus species complexes. Six (3.7%) participants had intra-cavitary fungal balls, and 52 (32.1%) had cavities. Overall, 32 (19.8%) participants had CPA. CPA was associated with prior PTB (adjusted odds ratio (aOR): 6.61, 95% CI: 1.85 - 23.9, p=0.004), and far advanced CXR changes (aOR: 4.26, 95%CI: 1.72 - 10.52, p=0.002). The Aspergillus IgG/IgM ICT was positive in 10 (31.3%) participants with CPA.

CONCLUSIONS

CPA may cause persistent respiratory symptoms in up to one-fifth of patients after intensive treatment for PTB. The Aspergillus IgG/IgM ICT positivity rate was very low and may not be used alone for the diagnosis of CPA in Uganda.

Challenges and Management of Long COVID in Individuals with Hematological Illnesses

COVID-19 has impacted hundreds of millions of people globally, a relatively large proportion of whom continue to suffer from ongoing, sometime debilitating symptoms. This phenomenon, termed “long COVID,” is difficult to diagnose and manage because of a paucity of objective findings and despite the abundance of descriptive data published so far. In this review, we aimed to describe the common manifestations of long COVID, diagnostic and management challenges, and address specific aspects in hematologic patients.

Post-acute COVID-19 syndrome in patients after 12 months from COVID-19 infection in Korea

BACKGROUND

As the coronavirus disease 2019 (COVID-19) pandemic continues to progress, awareness about its long-term impacts has been growing. To date, studies on the long-term course of symptoms, factors associated with persistent symptoms, and quality of life after 12 months since recovery from acute COVID-19 have been limited.

METHODS

A prospective online survey (First: September 8, 2020-September 10, 2020; Second: May 26, 2021-June 1, 2021) was conducted on recovered patients who were previously diagnosed with COVID-19 between February 13, 2020 and March 13, 2020 at Kyungpook National University Hospital. Responders aged between 17 and 70 years were included in the study. Overall, 900 and 241 responders were followed up at 6 and 12 months after recovery from COVID-19 in the first and second surveys, respectively. Clinical characteristics, self-reported persistent symptoms, and EuroQol-5-dimension (EQ5D) index score were investigated for evaluating quality of life.

RESULTS

The median period from the date of the first symptom onset or COVID-19 diagnosis to the time of the survey was 454 (interquartile range [IQR] 451-458) days. The median age of the responders was 37 (IQR 26.0-51.0) years, and 164 (68.0%) responders were women. Altogether, 11 (4.6%) responders were asymptomatic, and 194 (80.5%), 30 (12.4%), and 6 (2.5%) responders had mild, moderate, and severe illness, respectively. Overall, 127 (52.7%) responders still experienced COVID-19-related persistent symptoms and 12 (5.0%) were receiving outpatient treatment for such symptoms. The main symptoms were difficulty in concentration, cognitive dysfunction, amnesia, depression, fatigue, and anxiety. Considering the EQ5D index scores, only 59.3% of the responders did not have anxiety or depression. Older age, female sex, and disease severity were identified as risk factors for persistent neuropsychiatric symptoms.

CONCLUSION

COVID-19-related persistent symptoms improved over time; however, neurological symptoms can last longer than other symptoms. Continuous careful observation of symptom improvement and multidisciplinary integrated research on recovered COVID-19 patients are required.

A cross-sectional analysis of post-acute COVID-19 symptoms

OBJECTIVES

The severe acute respiratory syndrome (COVID-19) due to SARS-CoV-2 was first reported in China in December 2019 and has generated a worldwide pandemic. The objective of the research is to examine and describe (a) the symptoms that persist after the end of the acute stage and (b) their relationship with the severity of the disease.

STUDY DESIGN

This study is a cross-sectional study conducted in the Kingdom of Bahrain on COVID-19 infected patients using an online survey questionnaire with a total number of 52 patient responses (29 females and 23 males).

METHOD

A scale (0 no symptoms to 10 very high symptoms intensity) was assessed in patients after 3 months to detect the relevance of specific symptoms post-COVID-19 such as emotional and physical health, headache, dyspnoea, pain (muscles/joints/chest), anosmia, vertigo, neurologic symptoms, sarcopenia, delirium.

RESULTS

The most common COVID-19 symptoms were reported to be fever (69.2%), headache (59.6%), and cough (50.0%). Data analysis showed that BMI was not correlated with any post-acute COVID-19 symptoms. Regarding the post-acute COVID-19 symptoms, this study showed that an increase of intensity of headache was associated with an increase of delirium; an increase of intensity of dyspnoea was associated with an increase of pulmonary dysfunction. The increase of anosmia and dysgeusia was associated with an increase in delirium. In addition, the increase of neurological symptoms and delirium were associated with the increase of sarcopenia. The most common persistent post-COVID-19 symptoms observed in this study were emotional stress, followed by loss of smell and taste, and neurological symptoms.

CONCLUSIONS

Therefore, follow-up and rehabilitation care for COVID-19 patients must be focused on addressing the needs of these people in the longer term.

Clinical Assessment of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion produces a variety of signs and symptoms. Most patients recover within 2-4 weeks, but a significant minority experiences persistent post-concussive symptoms (PPCS), some of which may be from associated cervical or persistent neurologic sub-system (e.g., vestibular) dysfunction. This review provides evidence-based information for a pertinent history and physical examination of patients with concussion.

RECENT FINDINGS

The differential diagnosis of PPCS is based on the mechanism of injury, a thorough medical history and concussion-pertinent neurological and cervical physical examinations. The concussion physical examination focuses on elements of autonomic function, oculomotor and vestibular function, and the cervical spine. Abnormalities identified on physical examination can inform specific forms of rehabilitation to help speed recovery. Emerging data show that there are specific symptom generators after concussion that can be identified by a thorough history, a pertinent physical examination, and adjunct tests when indicated.

Management of Concussion and Persistent Post-Concussive Symptoms for Neurologists

PURPOSE OF REVIEW

Concussion is a complex injury that may present as a variety of clinical profiles, which can overlap and reinforce one another. This review summarizes the medical management of patients with concussion and persistent post-concussive symptoms (PPCS).

RECENT FINDINGS

Management of concussion and PPCS relies on identifying underlying symptom generators. Treatment options include sub-symptom threshold aerobic exercise, cervical physical therapy, vestibular therapy, vision therapy, cognitive rehabilitation, cognitive behavioral therapy, pharmacological management, or a combination of treatments. Evidence-based treatments have emerged to treat post-concussion symptom generators for sport-related concussion and for patients with PPCS.

T4+T3 Combination Therapy: An Unsolved Problem of Increasing Magnitude and Complexity

Thyroxine (T4)+triiodothyronine (T3) combination therapy can be considered in case of persistent symptoms despite normal serum thyroid stimulating hormone in levothyroxine (LT4)-treated hypothyroid patients. Combination therapy has gained popularity in the last two decades, especially in countries with a relatively high gross domestic product. The prevalence of persistent symptoms has also increased; most frequent are complaints about energy levels and fatigue (80% to 90%), weight management (70% to 75%), memory (60% to 80%), and mood (40% to 50%). Pathophysiological explanations for persistent problems are unrealistic patient expectations, comorbidities, somatic symptoms, related disorders (Diagnostic and Statistical Manual of Mental Disorders [DSM-5]), autoimmune neuroinflammation, and low tissue T3. There is fair circumstantial evidence for the latter cause (tissue and specifically brain T3 content is normalized by T4+T3, not by T4 alone), but the other causes are viewed as more relevant in current practice. This might be related to the 'hype' that has emerged surrounding T4+T3 therapy. Although more and better-designed trials are needed to validate the efficacy of T4+T3 combination, the management of persistent symptoms should also be directed towards alternative causes. Improving the doctor-patient relationship and including more and better information is crucial. For example, dissatisfaction with the outcomes of T4 treatment for subclinical hypothyroidism can be anticipated as recent trials have demonstrated that LT4 is hardly effective in improving symptoms associated with subclinical hypothyroidism.

Prognostic factors for persistent symptoms in adults with mild traumatic brain injury: protocol for an overview of systematic reviews

BACKGROUND

Mild traumatic brain injury (mTBI) is an increasing public health problem that can lead to persistent symptoms that have several functional consequences. Understanding the prognosis of a condition is an important component of clinical decision-making and can help guide the prevention of long-term disabilities of patients with mTBI. Several studies and systematic reviews have been conducted in order to understand prognosis of chronic symptoms following mTBI. We aim to synthesize evidence from systematic reviews on factors that affect the risk of persistent symptoms in mTBI-affected adults.

METHODS

We will conduct an overview of systematic reviews following steps described in the Cochrane Handbook. We will search in Cochrane, Medline, CINAHL, Embase, PsycINFO, and Epistemonikos for systematic reviews about the prognosis of persistent symptoms following mTBI in the adult population. Two reviewers will independently screen all references and then select eligible reviews based on eligibility criteria. A data extraction grid will be used to extract relevant information. The risk of bias in the included reviews will be assessed using the ROBIS tool. Data will be synthesized into a comprehensive conceptual model in order to have a better understanding of the predictive factors of post-concussion symptoms following mTBI.

DISCUSSION

Results will help multiple stakeholders, such as clinicians and rehabilitation program managers, to understand the prognosis of long-term consequences following mTBI. It could guide stakeholders to recognize their patients' prognostic factors and to invest their time and resources in patients who need it the most.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020176676 .

Severity of self-reported symptoms and psychological burden 6-months after hospital admission for COVID-19: a prospective cohort study

Objectives

Few studies have reported clinical COVID-19 sequelae six months (M6) after hospital discharge, but none has studied symptom severity.

Methods

Prevalence and severity of 7 symptoms were estimated until M6 using the self-administered influenza severity scale in COVID-19 hospitalized patients enrolled in the French COVID cohort. Factors associated with severity were assessed by logistic regression. Anxiety, depression and health-related quality of life (HRQL) were also assessed.

Results

At M6, among the 324 patients (median age 61 years, 63% men, 19% admitted to intensive care during the acute phase), 187/324 (58%) reported at least one symptom, mostly fatigue (47%) and myalgia (23%). Symptom severity was scored, at most, mild in 125 (67%), moderate in 44 (23%) and severe in 18 (10%). Female gender was the sole factor associated with moderate/severe symptom reporting (OR = 1.98, 95%CI=1.13-3.47). Among the 225 patients with psychological assessment, 24 (11%) had anxiety, 18 (8%) depressive symptoms, and their physical HRQL was significantly poorer than the general population (p=0.0005).

Conclusion

Even if 58% of patients reported ≥1 symptom at M6, less than 7% rated any symptom as severe. Assessing symptoms severity could be helpful to identify patients requiring appropriate medical care. Women may require special attention.

Relationship between duodenal microbiota composition, clinical features at diagnosis, and persistent symptoms in adult Coeliac disease

BACKGROUND

Duodenal dysbiosis has been suggested to possibly influence the clinical manifestations of coeliac disease (CD), both at onset and when symptoms persist despite a gluten-free diet (GFD).

AIMS

To evaluate the relationship between duodenal microbiota composition and: i) clinical phenotype of untreated CD (UCD); ii) presence and type of persistent symptoms despite a satisfactory serological and histological response to a strict GFD.

METHODS

Duodenal microbiota was analyzed by 16S rRNA sequencing and compared with i) clinical features in 12 adult UCD patients; ii) presence/absence and type of persistent symptoms (diarrhea-predominant vs. non-diarrhea predominant) in 25 adult treated coeliac patients (TCD) on a strict GFD.

RESULTS

UCD with iron deficiency anemia (IDA) had a pro-inflammatory shift in their duodenal microbiota (reduction of Firmicutes, p = 0.03; increase of beta-Proteobacteria, p = 0.02) than those without IDA. TCD with persistent diarrhea showed a reduction of Actinobacteria (p = 0.03) and Rothia spp (p = 0.046) compared to TCD suffering from other type of persistent symptoms.

CONCLUSION

A distinctive duodenal microbiota profile is associated with IDA in UCD, and diarrhea-predominant persistent symptoms in TCD. Clinical interventions may include reconsidering patients presenting with IDA as a specific disease subtype, and dietary rebalancing if diarrhea persists despite histological response to a GFD.

Sequelae, persistent symptomatology and outcomes after COVID-19 hospitalization: the ANCOHVID multicentre 6-month follow-up study

BACKGROUND

Long-term effects of COVID-19, also called Long COVID, affect more than 10% of patients. The most severe cases (i.e. those requiring hospitalization) present a higher frequency of sequelae, but detailed information on these effects is still lacking. The objective of this study is to identify and quantify the frequency and outcomes associated with the presence of sequelae or persistent symptomatology (SPS) during the 6 months after discharge for COVID-19.

METHODS

Retrospective observational 6-month follow-up study conducted in four hospitals of Spain. A cohort of all 969 patients who were hospitalized with PCR-confirmed SARS-CoV-2 from March 1 to April 15, 2020, was included. We collected all the SPS during the 6 months after discharge reported by patients during follow-up from primary care records. Cluster analyses were performed to validate the measures. The main outcome measures were return to the Emergency Services, hospital readmission and post-discharge death. Surviving patients' outcomes were collected through clinical histories and primary care reports. Multiple logistic regression models were applied.

RESULTS

The 797 (82.2%) patients who survived constituted the sample followed, while the rest died from COVID-19. The mean age was 63.0 years, 53.7% of them were men and 509 (63.9%) reported some sequelae during the first 6 months after discharge. These sequelae were very diverse, but the most frequent were respiratory (42.0%), systemic (36.1%), neurological (20.8%), mental health (12.2%) and infectious (7.9%) SPS, with some differences by sex. Women presented higher frequencies of headache and mental health SPS, among others. A total of 160 (20.1%) patients returned to the Emergency Services, 35 (4.4%) required hospital readmission and 8 (1.0%) died during follow-up. The main factors independently associated with the return to Emergency Services were persistent fever, dermatological SPS, arrythmia or palpitations, thoracic pain and pneumonia.

CONCLUSIONS

COVID-19 cases requiring hospitalization during the first wave of the pandemic developed a significant range of mid- to long-term SPS. A detailed list of symptoms and outcomes is provided in this multicentre study. Identification of possible factors associated with these SPS could be useful to optimize preventive follow-up strategies in primary care for the coming months of the pandemic.

Prevalence and characteristics of persistent symptoms after non-severe COVID-19: a prospective cohort study

We performed a prospective cohort study of 311 outpatients with non-severe COVID-19 (187 women, median age 39 years). Of the 214 (68.8%) who completed the 6-week follow-up questionnaire, 115 (53.7%) had recovered. Others mostly reported dyspnea (n = 86, 40.2%), weight loss (n = 83, 38.8%), sleep disorders (n = 68, 31.8%), and anxiety (n = 56, 26.2%). Of those who developed ageusia and anosmia, these symptoms were still present at week 6 in, respectively, 11/111 (9.9%) and 19/114 (16.7%). Chest CT scan and lung function tests found no explanation in the most disabled patients (n = 23). This study confirms the high prevalence of persistent symptoms after non-severe COVID-19.

'Long COVID': persistent COVID-19 symptoms in survivors managed in Lagos State, Nigeria

BACKGROUND

Coronavirus disease once thought to be a respiratory infection is now recognised as a multi-system disease affecting the respiratory, cardiovascular, gastrointestinal, neurological, immune, and hematopoietic systems. An emerging body of evidence suggests the persistence of COVID-19 symptoms of varying patterns among some survivors. This study aimed to describe persistent symptoms in COVID-19 survivors and investigate possible risk factors for these persistent symptoms.

METHODS

The study used a retrospective study design. The study population comprised of discharged COVID-19 patients. Demographic information, days since discharge, comorbidities, and persistent COVID-19 like symptoms were assessed in patients attending the COVID-19 outpatient clinic in Lagos State. Statistical analysis was done using STATA 15.0 software (StataCorp Texas) with significance placed at p-value < 0.05.

RESULTS

A total of 274 patients were enrolled in the study. A majority were within the age group > 35 to ≤49 years (38.3%), and male (66.1%). More than one-third (40.9%) had persistent COVID-19 symptoms after discharge, and 19.7% had more than three persistent COVID-like symptoms. The most persistent COVID-like symptoms experienced were easy fatigability (12.8%), headaches (12.8%), and chest pain (9.8%). Symptomatic COVID-19 disease with moderate severity compared to mild severity was a predictor of persistent COVID-like symptoms after discharge (p < 0.05).

CONCLUSION

Findings from this study suggests that patients who recovered from COVID-19 disease may still experience COVID-19 like symptoms, particularly fatigue and headaches. Therefore, careful monitoring should be in place after discharge to help mitigate the effects of these symptoms and improve the quality of life of COVID-19 survivors.

Pulmonary function and functional capacity in COVID-19 survivors with persistent dyspnoea

The purpose of this study was to examine the physiological mechanisms of persistent dyspnoea in COVID-19 survivors. Non-critical patients (n = 186) with varying degrees of COVID-19 severity reported persistent symptoms using a standardized questionnaire and underwent pulmonary function and 6-minute walk testing between 30 and 90 days following the onset of acute COVID-19 symptoms. Patients were divided into those with (n = 70) and without (n = 116) persistent dyspnoea. Patients with persistent dyspnoea had significantly lower FVC (p = 0.03), FEV₁ (p = 0.04), D_LCO (p = 0.01), 6-minute walk distance (% predicted, p = 0.03), and end-exercise oxygen saturation (p < 0.001), and higher Borg 0-10 ratings of dyspnoea and fatigue (both p < 0.001) compared to patients without persistent dyspnoea. We have shown that dyspnoea is a common persistent symptom across varying degrees of initial COVID-19 severity. Patients with persistent dyspnoea had greater restriction on spirometry, lower D_LCO, reduced functional capacity, and increased exertional desaturation and symptoms. This suggests that there is a true physiological mechanism that may explain persistent dyspnoea after COVID-19.

Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19

OBJECTIVE

To assess post-discharge persistent symptoms and health-related quality of life (HRQoL) of patients hospitalized in a COVID-19 ward unit more than 100 days after their admission.

METHODS

All eligible patients were contacted by phone by trained physicians and were asked to answer to a dedicated questionnaire. Patients managed in hospital ward without needing intensive care were compared with those who were transferred in intensive care units (ICU).

RESULTS

We included 120 patients after a mean (±SD) of 110.9 (±11.1) days following admission. The most frequently reported persistent symptoms were fatigue (55%), dyspnoea (42%), loss of memory (34%), concentration and sleep disorders (28% and 30.8%, respectively). Comparisons between ward- and ICU patients led to no statistically significant differences regarding those symptoms. In both group, EQ-5D (mobility, self-care, pain, anxiety or depression, usual activity) was altered with a slight difference in pain in the ICU group.

CONCLUSION

Most patients requiring hospitalization for COVID-19 still have persistent symptoms. While there were few differences between HRQoL between ward and ICU patients, our findings must be confirmed in larger cohorts, including more severe patients.

Prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis: study protocol for an observational, prospective cohort study (LymeProspect)

Background

After antibiotic treatment of Lyme borreliosis, a subset of patients report persistent symptoms, also referred to as post-treatment Lyme disease syndrome. The reported prevalence of persistent symptoms varies considerably, and its pathophysiology is under debate. The LymeProspect study has been designed to investigate the prevalence, severity, and a wide range of hypotheses on the etiology of persistent symptoms among patients treated for Lyme borreliosis in the Netherlands.

Methods

LymeProspect is a prospective, observational cohort study among adults with proven or probable Lyme borreliosis, either erythema migrans or disseminated manifestations, included at the start of antibiotic treatment. During one year of follow-up, participants are subjected to questionnaires every three months and blood is collected repeatedly during the first three months. The primary outcome is the prevalence of persistent symptoms after treatment, assessed by questionnaires online focusing on fatigue (CIS, subscale fatigue severity), pain (SF-36, subscale pain) and neurocognitive dysfunction (CFQ). Potential microbiological, immunological, genetic, epidemiological and cognitive-behavioral determinants for persistent symptoms are secondary outcome measures. Control cohorts include patients with long-lasting symptoms and unconfirmed Lyme disease, population controls, and subjects having reported a tick bite not followed by Lyme borreliosis.

Discussion

This article describes the background and design of the LymeProspect study protocol. This study is characterized by a prospective, explorative and multifaceted design. The results of this study will provide insights into the prevalence and determinants of persistent symptoms after treatment for Lyme borreliosis, and may provide a rationale for preventive and treatment recommendations.

Trial registration

NTR4998 (Netherlands Trial Register). Date of registration: 13 February 2015.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-3949-8) contains supplementary material, which is available to authorized users.

Is it really the result of a concussion? Lessons from a case study

Background

Within the last two decades, attitudes have shifted from considering sports-related concussion as an insignificant minor injury with no long-term repercussions to a potentially serious brain injury garnering attention from media, clinicians, researchers, and the general public.

Objectives

To conduct a case study to determine the underlying cause of persistent issues suspected to be associated with a history of sports-related concussion.

Protocol

Participant A underwent neurophysiological testing following the Neary protocol (assessment of cerebrovascular and cardiovascular variables), comprehensive concussion assessment at a dedicated sports concussion clinic (history, neurological assessment, cervical spine screening, vestibulo-ocular screening, SCAT-5, and exercise testing), referral to a neurologist, structural MRI scan, and referral for specialised assessment at a dedicated dizziness and balance centre.

Results

Despite a history of multiple sports-related concussions, Participant A’s persistent symptom reports were associated with peripheral vestibular dysfunction and otolithic dysfunction seemingly unrelated to his concussion history.

Discussion

Lessons from Participant A’s case study showed that on-going symptoms that patients may associate with the effects of concussions may instead be due to unrelated causes that share similar symptomology.

Conclusion

This research exemplifies the importance of a multi-disciplinary assessment using a repeated testing protocol.

Experiences, attitudes, and perceptions of caregivers of individuals with treatment-resistant schizophrenia: a qualitative study

BACKGROUND

Treatment-resistant schizophrenia (TRS) affects about one-third of individuals with schizophrenia. People with TRS do not experience sustained symptom relief and at the same time have the most severe disease-related disability and associated costs among individuals with severe mental disorders. Like caregivers of people with treatment-responsive schizophrenia, caregivers of individuals with TRS experience the disease burden along with their care recipients; however, for those providing care for individuals with TRS, the stress of the burden is unrelenting due to uncontrolled symptoms and a lack of effective treatment options. The objective of this study is to better understand the burden of TRS from the caregiver perspective and to explore their perception of available treatments.

METHODS

Eight focus groups with non-professional, informal caregivers of individuals with TRS were conducted in 5 US locations. TRS was defined as failure of ≥2 antipsychotics and persistent moderate-to-severe positive symptoms of schizophrenia, per caregiver report.

RESULTS

The 27 caregivers reported an average of 37 h/week providing direct care, and 21 reported being on call "24/7." Caregivers commonly reported that their care recipients exhibited symptoms of auditory hallucinations (89%), agitation/irritability/hostility (81%), suspiciousness (78%), tangentiality (74%), and cognitive impairment (74%); 70% of caregivers ranked suspiciousness/persecution as the most challenging symptom category. Caring for an individual with TRS impacted many caregivers' finances, career prospects, social relationships, and sense of freedom. Additionally, multiple medication failures led to a sense of hopelessness for many caregivers.

CONCLUSIONS

Persistent positive symptoms caused significant perceived burden, feelings of being overwhelmed and having no relief, and substantial negative impacts on caregivers' emotional and physical health. To address these substantial unmet needs, policy makers should be aware of the need for practical, social, and emotional support for these caregivers and their families. Additionally, new treatment options for TRS should be developed.

Understanding individual variability in symptoms and recovery following mTBI: A role for TMS-EEG?

The pathophysiology associated with mild traumatic brain injury (mTBI) includes neurometabolic and cytoskeletal changes that have been shown to impair structural and functional connectivity. Evidence that persistent neuropsychological impairments post injury are linked to structural and functional connectivity changes is increasing. However, to date the relationship between connectivity changes, heterogeneity of persistent symptoms and recovery post mTBI has been poorly characterised. Recent innovations in neuroimaging provide new ways of exploring connectivity changes post mTBI. Namely, combined transcranial magnetic stimulation and electroencephalography (TMS-EEG) offers several advantages over traditional approaches for studying connectivity changes post TBI. Its ability to perturb neural function in a controlled manner allows for measurement of causal interactions or effective connectivity between brain regions. We review the current literature assessing structural and functional connectivity following mTBI and outline the rationale for the use of TMS-EEG as an ideal tool for investigating the neural substrates of connectivity dysfunction and reorganisation post mTBI. The diagnostic, prognostic and potential therapeutic implications will also be explored.

Posttreatment Lyme disease syndrome

The prognosis following appropriate antibiotic treatment of early or late Lyme disease is favorable but can be complicated by persistent symptoms of unknown cause termed posttreatment Lyme disease syndrome (PTLDS), characterized by fatigue, musculoskeletal pain, and cognitive complaints that persist for 6 months or longer after completion of antibiotic therapy. Risk factors include delayed diagnosis, increased severity of symptoms, and presence of neurologic symptoms at time of initial treatment. Two-tier serologic testing is neither sensitive nor specific for diagnosis of PTLDS because of variability in convalescent serologic responses after treatment of early Lyme disease. Optimal treatment of PTLDS awaits more precise understanding of the pathophysiologic mechanisms involved in this illness and future treatment trials.