Defence Medical Rehabilitation Centre (DMRC) COVID-19 Recovery Service.

Coronavirus disease 2019 (COVID-19) causes significant mortality and morbidity, with an unknown impact in the medium to long term. Evidence from previous coronavirus epidemics indicates that there is likely to be a substantial burden of disease, potentially even in those with a mild acute illness. The clinical and occupational effects of COVID-19 are likely to impact on the operational effectiveness of the Armed Forces. Collaboration between Defence Primary Healthcare, Defence Secondary Healthcare, Defence Rehabilitation and Defence Occupational Medicine resulted in the Defence Medical Rehabilitation Centre COVID-19 Recovery Service (DCRS). This integrated clinical and occupational pathway uses cardiopulmonary assessment as a cornerstone to identify, diagnose and manage post-COVID-19 pathology.

Factors influencing medium- and long-term occupational impact following COVID-19.

BACKGROUND: Significant numbers of individuals struggle to return to work following acute coronavirus disease 2019 (COVID-19). The UK Military developed an integrated medical and occupational pathway (Defence COVID-19 Recovery Service, DCRS) to ensure safe return to work for those with initially severe disease or persistent COVID-19 sequalae. Medical deployment status (MDS) is used to determine ability to perform job role without restriction ('fully deployable', FD) or with limitations ('medically downgraded', MDG). AIMS: To identify which variables differ between those who are FD and MDG 6 months after acute COVID-19. Within the downgraded cohort, a secondary aim is to understand which early factors are associated with persistent downgrading at 12 and 18 months. METHODS: Individuals undergoing DCRS had comprehensive clinical assessment. Following this, their electronic medical records were reviewed and MDS extracted at 6, 12 and 18 months. Fifty-seven predictors taken from DCRS were analysed. Associations were sought between initial and prolonged MDG. RESULTS: Three hundred and twenty-five participants were screened, with 222 included in the initial analysis. Those who were initially downgraded were more likely to have post-acute shortness of breath (SoB), fatigue and exercise intolerance (objective and subjective), cognitive impairment and report mental health symptoms. The presence of fatigue and SoB, cognitive impairment and mental health symptoms was associated with MDG at 12 months, and the latter two, at 18 months. There were also modest associations between cardiopulmonary function and sustained downgrading. CONCLUSIONS: Understanding the factors that are associated with initial and sustained inability to return to work allows individualized, targeted interventions to be utilized.

Development, design and experience of the UK Military's return to diving pathway following SARS-CoV-2 infection.

After the emergence of the SARS-CoV-2 virus in early 2020, it quickly became clear that symptomatic or asymptomatic infection had the potential to negatively impact on an individual's fitness to dive through effects on the respiratory, cardiovascular or neurological systems. The significance of these effects in the military diving environment was initially unclear due to an absence of data concerning incidence, chronology or severity. In order to safely return divers to the water and maintain operational capability, the UK Military developed a pathway for SARS-CoV-2 positive divers that stratified risk of sequelae and extent of required clinical investigation, while minimising reliance on viral testing and hospital-based investigations. We present this process, provide rationale and support for its design and detail the number of SARS-CoV-2 positive divers who have been returned to full diving fitness following infection of varying degrees of severity.

Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19.

OBJECTIVE: Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings. METHODS: 113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease. RESULTS: 7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O2 26.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2 slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar-arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease. CONCLUSIONS: In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

A balancing act: changing the referral pathway following remote consultations for dizziness during the coronavirus disease 2019 pandemic.

BACKGROUND: This paper reports our experience in managing dizzy patients remotely during the coronavirus disease 2019 pandemic, and explored its safety as an alternative to face-to-face consultations. METHODS: Dizzy patients referred by their general practitioner were contacted to answer a validated questionnaire. Clinicians recorded the time needed for consultations, and the diagnosis at each of the following assessment stages: after review of the electronic general practitioner letter; following completion of the questionnaire; following the telephone consultation; and/or at follow up. Patients were telephoned no earlier than three months later to determine satisfaction with the service and symptom resolution. Electronic patient records were checked for presentation to hospital because of dizziness. RESULTS: Seventy patients had telephone consultations. None presented to the emergency department or were admitted. The majority of consultations took 15-30 minutes. The most diagnosed condition was benign positional paroxysmal vertigo. Seventy-nine per cent of patients were satisfied with the service. The questionnaire and telephone consultations demonstrated the greatest diagnosis agreement (κ = 0.40). CONCLUSION: Validated questionnaire and telephone consultations are a safe alternative to face-to-face consultations. Our patient referral pathway has now changed to include elements of the questionnaire.

PILOT OF AN INDEPENDENT DOMESTIC AND SEXUAL VIOLENCE ADVOCATE (IDSVA) INTEGRATED WITHIN A CENTRAL LONDON SEXUAL HEALTH (SH) AND HIV SERVICE DURING COVID-19: 15 MONTHS OF DATA

Introduction During the COVID-19 pandemic and lockdowns, large increases in domestic abuse (DA) were reported1. A pilot project to evaluate the utility of a dedicated sexual health IDSVA was undertaken in a larger inner-city SH/HIV service. Methods Commissioners were approached with data highlighting high numbers of high-risk DA identified within SH. Funding to pilot an integrated Sexual health IDSVA was obtained. The pilot ran between August 2020 - November 2021. Referrals were made to the IDSVA by clinic staff who identified DA victim/survivors during routine enquiry. Results 121 referrals were received, of which 118 were accepted and 82% risk-assessed. Majority were cis-female (80%), heterosexual (81%) and aged 25-34yrs (37%). Five patients were aged under 18. 40% were for DA, 28% for SA, 22% for both DA/SA. 32% were assessed as high risk of harm. 44% was from ex-partner and 14% acquaintances. 21 cases involved child safeguarding considerations. IDSVA roles included face-to-face and telephone assessments, safety planning, arranging refuge, social care/safeguarding referrals, signposting and training/support for SH staff. Discussion Significant numbers of patients with complex safeguarding needs, at high risk of harm were identified within sexual health, engaged with, and were supported by the SH IDSVA. Patient acceptability was reflected by the high uptake of IDSVA support (88%). IDSVA expertise and support freed up clinic staff time and resources.

Prior sars-cov-2 infection is associated with subclinical changes in the cardiovascular morphology, function, energetics and exercise capacity

Background: COVID-19 has documented multisystem effects. Whether clinically significant cardiac involvement is related to severity of disease in a working age military population remains unknown, but has implications for occupational grading and ability to deploy. Aims: To determine in the military population 1) whether prior SARS-CoV-2 infection causes clinically significant cardiac disease and 2) whether changes are related to disease severity. Methods: 105 military personnel were recruited, 85 with prior SARS-CoV-2 infection (39±10 years, 87% male;50 mild (community), 35 severe (hospitalized) and 20 healthy volunteers (mean age 39 ±8.4 years, 90% male) underwent comprehensive cardiopulmonary investigations including;cardiopulmonary exercise test, exercise echocardiography, cardiac31MRI and P-MR spectroscopy (rest and dobutamine stress). Results: Prior SARS-CoV-2 infection was related to lower VO2max (110±18.2 vs 133±6.7% predicted, p<0.05), anaerobic threshold (45±10 vs 56±14% of peak VO2, p<0.05), VO2/HR (102±21 vs 128±24% predicted, p<0.05) and VE/VCO2 slope (28.3±5.0 vs 25.8±2.7, p<0.05) and an increase in average E/e' change from rest to exercise stress (+1.49±2.4 vs-0.16±3.6, p<0.05). Whilst resting myocardial energetics were similar, prior SARS-CoV-2 infection was associated with a fall in PCr/ATP during stress (by 8%, p=<0.01) which was not seen in healthy controls. When groups were ordered normal> mild> severe disease, RVEDVi, RV stroke volume, VO2peak, VO2pulse and VE/VCO slope were reduced (Jonckheere-Terpstra, all p<0.05). Conclusion: In a young military population, prior SARS-CoV-2 infection is associated with subclinical cardiovascular changes including;lower right ventricular volumes, reduced markers of exercise capacity and reduced myocardial energetics during stress.

COVID-19 and agriculture for development - calls for action

This article is about the calls for coordinated international efforts in response to COVID-19, particularly in relation to agriculture. An early (March 2020) open letter addressed to leaders of G20 countries called on the G20 to act "now" on two fronts, public health and economic policy, by: (1) ensuring that the World Health Organization (WHO) has sufficient resources to lead the global response;(2) shoring up domestic institutions managing the healthcare response, and to guarantee logistics and supply chains for health and other essential goods;(3) accelerating the global effort to find vaccines and therapeutics, and manufacture and distribute them fairly across the world;and (4) providing emergency resources to countries facing devastating fiscal outlays and massive capital outflows. Other calls for action related to COVID-19 followed, often focusing on particular aspects of agriculture for development. Three of these calls for action, focused on food security and nutrition, women, and livestock, are briefly considered. Two actions in response to these calls are also discussed, focusing on international research and a COVID-19 rural poor fund.

The impact of implementing the SNIS recommendations for the care of COVID-19 patients undergoing emergent mechanical thrombectomy

Objective: To determine how implementation of Society for Neurointerventional Surgery (SNIS) guidelines affected outcomes for ischemic stroke patients. Background: SNIS issued guidelines for patient management during the coronavirus disease 2019 (COVID-19) pandemic. Recommendations include intubating COVID-19 positive and unknown COVID-19 status patients prior to endovascular thrombectomy, cohorting by COVID-19 status, early discharge, and postponing elective cases. Design/Methods: This was a retrospective cohort study comparing ischemic stroke patients treated with thrombectomy during the COVID-19 pandemic peak (4/1/20-6/30/20) to those treated in 2019 (4/1/19-6/30/19). Statistical tests used for analysis included Kruskal-Wallis, chisquared and Fisher's exact test. Results: There were 112 ischemic stroke patients treated with thrombectomy: 55 (49%) in 2019 and 57 (51%) during the COVID-19 peak. There were no differences in thrombectomy among all ischemic stroke admissions in 2019 vs. the COVID-19 peak (22% vs. 24%, p=0.67). COVID- 19 testing was performed in 29 (51%) patients;none were positive. The median age was 68 in 2019 and 69 during the COVID-19 peak, p=0.28;other characteristics were similar. Compared to 2019, a significantly higher proportion of patients were intubated during the COVID-19 peak (96% vs. 45%, p<0.0001). The median days to extubation was 2 days for both groups, p=0.31. The proportion of patients re-intubated was 2% in 2019 vs. 5% during the COVID-19 peak, p=0.95. The median time to groin puncture was significantly shorter in 2019 than during the COVID-19 peak, 38 vs 43 minutes, p=0.002. The TICI score and mRS were similar between groups, p=0.26 and p=0.84, respectively. Conclusions: After implementing SNIS guidelines, including pre-treatment intubation, we observed a statistically significant but not clinically meaningful increased time to groin puncture, which did not negatively impact outcomes. These results suggest hospitals who manage patients efficiently can implement safe management practices in response to COVID-19 without impacting outcomes. We recommend following SNIS guidelines to prevent the spread of COVID-19.

The impact of COVID-19 on the volume of stroke admissions at a comprehensive stroke center

Objective: To determine how coronavirus disease 2019 (COVID-19) impacted stroke patient admission volumes. Background: To prevent the spread of COVID-19 social distancing guidelines were implemented and many institutions postponed elective procedures. Delayed hospital admission has been reported due to fear of infection. Design/Methods: This retrospective cohort study compared stroke patients admitted to a comprehensive stroke center during the COVID-19 pandemic 4/1/20-6/30/20 "COVID-19 peak" to patients admitted 4/1/19-6/30/19 "2019". Characteristics and outcomes were compared using chi-squared, Fisher's exact, and the Kruskal-Wallis test. Results: There were 651 stroke admissions: 341 (52%) in 2019, 310 (48%) during the COVID-19 peak;overall a 9% decrease. The median number of admissions per day was 4 in 2019 and 3 during the COVID-19 peak, p=0.21. The proportion of patients by stroke type was not significantly different in 2019 compared to the COVID-19 peak: Ischemic stroke (75% vs. 76%, p=0.69);hemorrhagic stroke (16% vs. 18%, p=0.39);transient ischemic attacks (11% vs. 7%, p=0.10). The median age was 70 years in both 2019 and during the COVID-19 peak, p=0.64;other demographic characteristics were comparable. The time from onset to arrival was 273 minutes in 2019 vs. 263 minutes during COVID-19 peak, p=0.46;24% were transfers in 2019 vs. 23% during the COVID-19 peak (p=0.72). The median length of stay (4 days, p=0.52) and the median discharge mRS (3, p=0.31) was identical in 2019 compared to the COVID-19 peak. Of the 113 patients tested for COVID-19, 4% were positive. Conclusions: Although many centers have reported a significant decrease in stroke patient admissions, the COVID-19 pandemic did not significantly affect patient volume or the time from onset to arrival at our institution. As the pandemic continues, it is important for hospitals to be informed that COVID-19 may not impact stroke volume, so providers are prepared to manage both stroke and COVID-19 patients efficiently.

A comparison of persistence of SARS-CoV-2 variants on stainless steel.

The survival of newer variants of SARS-CoV-2 on a representative surface has been compared to the established UK circulating isolate to determine whether enhanced environmental stability could play a part in their increased transmissibility. Stainless steel coupons were inoculated with liquid cultures of the three variants, with coupons recovered over seven days and processed for recoverable viable virus using plaque assay. After drying, there was no significant difference in inactivation rates between variants, indicating that there is no increased environmental persistence from the new variants.

TAKIN' CARE OF SMALL BUSINESS: THE RISE OF STAKEHOLDER INFLUENCE

In this Exchange, we consider three crucial boundary conditions that Barnett, Henriques, and Husted (2020) overlooked in theirmodel of diminished stakeholder influence. Although we agree that socialmedia platforms haveweakened stakeholder influence in certain conditions, such is not the case for all firms, all stakeholders, or all situations. Drawing from sociocognitive and self-determination theories, we contend that (a) independent, owner-managed small firms present a context wherein information overload is rendered less of an issue because the information about the firmismore salient to locals;(b) stakeholders can bemotivated to influence firms via social media platforms, which facilitate the collective engagement of local community members;and (c) uncertain economic circumstances (e.g., COVID-19) activate stakeholder information searches, which often occur through social media. Together, these three conditions enhance stakeholder power and influence. We also contemplate how, even under these conditions, stakeholder influence may change over time vis-a-vis the issue-attention cycle and societalization. We conclude our Exchange with a call formore research on stakeholder influence over independent, owner-manager small businesses.

The impact of implementing the snis recommendations for the care of emergent neurointerventional patients in the setting of COVID-19 on patients undergoing mechanical thrombectomy

Introduction: As a result of the novel coronavirus 2019 (COVID-19) pandemic, the Society for Neurointerventional Surgery (SNIS) issued guidelines for patient management during COVID-19. Specifically, they suggested intubating COVID-19 positive or those with unknown COVID-19 status prior to emergent endovascular thrombectomy, cohorting by COVID-19 status, early ICU discharge, and postponing elective cases. We sought to determine how the implementation of SNIS guidelines affected outcomes for patients with ischemic stroke. Methods: This was a retrospective cohort study comparing ischemic stroke patients who were treated with thrombectomy admitted during the COVID-19 pandemic 4/1/20-6/30/20 “COVID-19 peak” to patients admitted 4/1/19-6/30/19 “2019”. Statistical tests used for analysis included Kruskal- Wallis, chi-squared and Fisher's exact test. Results: The proportion of patients treated with thrombectomy was not significantly different, 23% in 2019 vs. 24% during the COVID-19 peak, p=0.67. There were 112 patients treated with thrombectomy: 57 (51%) in 2019, 55 (49%) during the COVID-19 peak. No patients treated with thrombectomy were positive for COVID-19, but 27 (49%) were tested. The median age was 69 for those treated in 2019 and 69 for those during the COVID-19 peak, p=0.44. Patients were similar in sex, race, and comorbidities. The time from onset to arrival was also statistically similar, p=0.19. In 2019, 16% received tPA compared to 9% during the COVID-19 peak, p=0.28. The median time to groin puncture was significantly shorter in 2019, 38 minutes, than during the COVID-19 peak, 44 minutes, p=0.01. The recanalization rate and mRS were similar between groups, p=0.06, and p=0.91, respectively. Conclusions: After implementing the SNIS guidelines, including pre-treatment intubation, we observed a significantly longer time to groin puncture. Anecdotally, the increased observed was remarkably small given the changes to care and did not negatively impact patient outcomes. This suggests that hospitals managing patients efficiently can implement changes in response to COVID- 19 and continue high level of care without impacting outcomes. Therefore, we recommend following the SNIS guidelines to prevent the spread of COVID-19.

Detection of SARS-CoV-2 within the healthcare environment: a multi-centre study conducted during the first wave of the COVID-19 outbreak in England.

BACKGROUND: Understanding how severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is spread within the hospital setting is essential in order to protect staff, implement effective infection control measures, and prevent nosocomial transmission. METHODS: The presence of SARS-CoV-2 in the air and on environmental surfaces around hospitalized patients, with and without respiratory symptoms, was investigated. Environmental sampling was undertaken within eight hospitals in England during the first wave of the coronavirus disease 2019 outbreak. Samples were analysed using reverse transcription polymerase chain reaction (PCR) and virus isolation assays. FINDINGS: SARS-CoV-2 RNA was detected on 30 (8.9%) of 336 environmental surfaces. Cycle threshold values ranged from 28.8 to 39.1, equating to 2.2 x 105 to 59 genomic copies/swab. Concomitant bacterial counts were low, suggesting that the cleaning performed by nursing and domestic staff across all eight hospitals was effective. SARS-CoV-2 RNA was detected in four of 55 air samples taken <1 m from four different patients. In all cases, the concentration of viral RNA was low and ranged from <10 to 460 genomic copies/m3 air. Infectious virus was not recovered from any of the PCR-positive samples analysed. CONCLUSIONS: Effective cleaning can reduce the risk of fomite (contact) transmission, but some surface types may facilitate the survival, persistence and/or dispersal of SARS-CoV-2. The presence of low or undetectable concentrations of viral RNA in the air supports current guidance on the use of specific personal protective equipment for aerosol-generating and non-aerosol-generating procedures.