The impact of ethnicity on the long-term sequelae of COVID-19: follow-up from the first and second waves in North London

P137 Table 1Demographics, admission severity and follow-up symptomsVariable White N = 603 Asian N = 252 Black N = 130 Other N = 122 p-value Age 65 ± 16.5 59 ± 15.4 59 ± 13.9 59 ± 14.7 <0.001 Male (%) 372 (62) 148 (59) 72 (55) 81 (66) 0.28 Index of deprivation* 6 (3–7) 6 (4–8) 5 (3–7) 5 (3–7) 0.03 Body mass index 27.1 (23.5–30.5) 26.0 (23.7 – 29.2) 28.9 (25.9 – 34.7) 26.7 (25.1 – 30.9) <0.001 Hypertension (%) 244/583 (42) 113/247 (46) 72/125 (58) 40/119 (34) 0.001 Cardiovascular disease (%) 133/415 (32) 45/166 (27) 15/86 (17) 16/73 (22) 0.02 Diabetes (%) 122/583 (21) 80/247 (32) 45/125 (36) 40/119 (34) <0.001 Respiratory disease (%) 124/416 (30) 39/167 (23) 21/91 (23) 16/70 (23) 0.25 Chronic kidney disease (%) 61/583 (11) 29/247 (12) 27/125 (22) 9/119 (8) 0.002 Any mental health (%) 77/583 (13) 23/247 (9) 8/125 (6) 17/119 (14) 0.08 Smoking history (%) 250/587 (43) 43/244 (18) 44/127 (35) 44/118 (37) <0.001 Clinical frailty score 3 (2–4) 2 (2–4) 3 (2–4) 3 (2–3) 0.11 NEWS2 4 (2–6) 4.5 (3–6) 5 (3–6) 5 (3–7) 0.3 Respiratory support 80/564 (14) 47/236 (20) 23/116 (20) 21/118 (18) 0.15 Follow-up symptoms MRC score* 2 (1–3) 2 (1–3) 2 (1–3) 2 (1–2) 0.61 Cough improved (%) 414/553 (75) 177/232 (76) 85/118 (72) 87/113 (77) 0.8 Fatigue improved (%) 451/552 (82) 193/228 (85) 109/122 (89) 88/115 (77) 0.05 Sleep improved (%) 342/536 (64) 155/228 (68) 76/117 (65) 68/112 (61) 0.57 Burden of symptoms* 1 (0–2) 1 (0–2) 1 (0–2) 1 (0–2) 0.78 Returned to work (%) 142/256 (56) 77/139 (55) 29/64 (45) 41/71 (58) 0.45 Felt back to normal (%) 256/439 (55) 112/186 (60) 62/103 (60) 43/78 (55) 0.87 Positive PHQ-2 (depression screening) 65/580 (11) 40/242 (17) 12/126 (10) 11/116 (10) 0.09 Positive TSQ (post-traumatic stress screening) 42/601 (7) 16/248 (7) 13/130 (10) 8/122 (7) 0.6 *Non-parametric data presented as median ± interquartile range, all other data presented as mean ± standard deviation.DiscussionOur data demonstrate that despite having more co-morbidities associated with worse outcomes, adults from BAME backgrounds who are discharged from hospital following COVID-19 are no more likely to experience symptoms consistent with ‘Long CO ID’. However, given the increased risk of infection among BAME communities, we must ensure that reducing health inequalities remain central to the UK health agenda.ReferenceSze, et al. EClinicalMedicine 2020. doi:10.1016/j.eclinm.2020.100630

Do persistent chest radiograph changes Correlate with ongoing respiratory symptoms in patients recovering from covid-19 Pneumonia?

Introduction and Objectives In May 2020, BTS published guidelines on radiological follow-up for patients with COVID-19 pneumonia, advising an initial repeat chest radiograph at 12 weeks to assess resolution.1 It is unclear whether persistent chest radiograph changes are clinically significant. Our aim was to assess whether there is a correlation between post-COVID chest radiograph appearances and ongoing respiratory symptoms. Methods Inpatients at two trust hospital sites diagnosed with COVID-19, either clinically or from a positive nasopharyngeal swab, were followed-up via telephone approximately 6-8 weeks post-discharge. Patients were offered a chest radiograph and blood tests if abnormal and a symptomatic assessment via a proforma. Patients subjectively rated their degree of breathlessness, cough and fatigue using a numerical rating scale. Chest radiograph reports were coded by consultant radiologists as per BSTI guidelines2 and grouped into 'improvers' (PCVCX0/1) and 'non-improvers' (PCVCX2/3 i.e. static or worsening appearances). Patients who had both an initial and follow-up chest radiograph, and who completed a proforma were included for retrospective analysis Introduction and Objectives In May 2020, BTS published guidelines on radiological follow-up for patients with COVID-19 pneumonia, advising an initial repeat chest radiograph at 12 weeks to assess resolution.1 It is unclear whether persistent chest radiograph changes are clinically significant. Our aim was to assess whether there is a correlation between post-COVID chest radiograph appearances and ongoing respiratory symptoms. Methods Inpatients at two trust hospital sites diagnosed with COVID-19, either clinically or from a positive nasopharyngeal swab, were followed-up via telephone approximately 6-8 weeks post-discharge. Patients were offered a chest radiograph and blood tests if abnormal and a symptomatic assessment via a proforma. Patients subjectively rated their degree of breathlessness, cough and fatigue using a numerical rating scale. Chest radiograph reports were coded by consultant radiologists as per BSTI guidelines2 and grouped into 'improvers' (PCVCX0/1) and 'non-improvers' (PCVCX2/3 i.e. static or worsening appearances). Patients who had both an initial and follow-up chest radiograph, and who completed a proforma were included for retrospective analysis.

What factors influence mental health burden in patients recovering from Covid-19?

Background Respiratory teams should perform a holistic assessment of patients recovering from COVID-19 to identify both physical and psychological needs.1Patients may develop psychological sequelae such as anxiety, dysfunctional breathing, depression and post-traumatic stress disorder (PTSD). We investigated the psychological burden at follow-up in people admitted with COVID-19 and the factors associated with this. Methods SARS-CoV-2 swab-positive patients from two hospital sites had telephone follow-up 8-10 weeks post discharge. We conducted screening questionnaires including the Patient Health Questionnaire 2-item (PHQ-2) for depression and Trauma Screening Questionnaire (TSQ) for PTSD. Demographic, admission, co-morbidity data and symptom burden at follow up (quantified by a numerical rating scale) were also collected. Results 782 patients completed both screening questionnaires. Patients' baseline characteristics are shown in table 1. 71 (9.1%) and 60 (7.7%) patients screened positive for depression and PTSD respectively. Patients with a background of depression and anxiety were more likely to have higher PHQ-2 scores (11.6% and 11.8%, p<0.001);those with anxiety had higher TSQ scores (8.5%, p=0.009). Patients who had a greater symptom burden both at admission and at follow-up were significantly more likely to have positive PHQ-2 and TSQ scores. No difference in scores was found in patients who received positive-airway pressure treatment (5.2%) or who were admitted to ITU (11.8%). Patients who returned to work (53.7%) were less likely to have positive TSQ scores (p=0.006). Discussion In this large cohort, patients with a higher physical symptom burden at admission and follow-up are more likely to also have psychological burden and this may impact their ability to return to work. Current guidelines1 highlight mental health screening only for patients who had more severe disease, but our data suggest any patient may be affected. Whilst more work in this field is required, we suggest clinicians who encounter patients still recovering from COVID-19 should proactively screen for psychological burden and liaise with local psychology services to ensure holistic care is offered.

'Long-COVID': The need for multi-disciplinary working

Background: Patients discharged from hospital following admission for COVID-19 may have on-going sequelae and require multidisciplinary input to ensure optimal recovery and early detection of complications. We evaluated our COVID-19 follow-up service to understand on-going patient needs. Methods: The respiratory team at Trust hospital sites established a virtual post-COVID-19 clinic. A bespoke questionnaire was developed to capture demographic data, symptom burden and mental health outcomes to identify those who needed further support. All patients were offered blood tests and a repeat chest radiograph (CXR) if abnormal pre-discharge. (Table presented) Results: Of patients admitted between March and August 2020 with COVID-19, 908 were eligible for follow-up. 643 (71%) have been assessed thus far. 133 (15%) declined or were unreachable. Patients' demographic data are summarised in table 1. All patients, including the 5.4% who received CPAP/NIV and 11.1% admitted to intensive care, were offered virtual follow-up. Median follow-up was 63 (54-79) days from discharge. Persistent symptoms (i.e. same or worse since admission) included cough (23.0%), breathlessness (16.5%), myalgia (15.7%) and fatigue (14.4%). Some patients developed new symptoms including 'fuzzy head' (12%), diarrhoea or abdominal pain (8%). 11% and 9.3% were at risk of depression and post-traumatic stress disorder respectively. Under half (44.5%) felt they had fully recovered. Of the 363 who were eligible to return to work, 31.4% felt able to do so. 57.9% were immediately discharged from secondary care after their follow-up assessment. 28% had further virtual follow-up arranged, while 20.8% were scheduled for face-to-face respiratory follow-up. 23.5% had a subsequent repeat CXR or CT scan arranged. Patients who scored highly on mental health questionnaires were offered referral to local psychology services and 49% (n=64) agreed. Discussion Our data demonstrates a significant proportion of hospital inpatients develop physical or psychological sequelae after COVID-19, 'Long-COVID'. A significant number felt unable to return to work 9 weeks after discharge. Our virtual clinic provided a structured way to identify patients' on-going symptoms and demonstrates the importance of establishing structured multi-disciplinary pathways, particularly with referrals to physiotherapy, cardiology and neurology. We strongly recommend the development of clear follow-up protocols prior to the next wave of disease.

COVID-19 and pneumothorax: a multicentre retrospective case series

Introduction: Pneumothorax and pneumomediastinum have both been noted to complicate cases of coronavirus disease 2019 (COVID-19) requiring hospital admission. We report the largest case series yet described of patients with both these pathologies (including nonventilated patients). Methods: Cases were collected retrospectively from UK hospitals with inclusion criteria limited to a diagnosis of COVID-19 and the presence of either pneumothorax or pneumomediastinum. Patients included in the study presented between March and June 2020. Details obtained from the medical record included demographics, radiology, laboratory investigations, clinical management and survival. Results: 71 patients from 16 centres were included in the study, of whom 60 had pneumothoraces (six with pneumomediastinum in addition) and 11 had pneumomediastinum alone. Two of these patients had two distinct episodes of pneumothorax, occurring bilaterally in sequential fashion, bringing the total number of pneumothoraces included to 62. Clinical scenarios included patients who had presented to hospital with pneumothorax, patients who had developed pneumothorax or pneumomediastinum during their inpatient admission with COVID-19 and patients who developed their complication while intubated and ventilated, either with or without concurrent extracorporeal membrane oxygenation. Survival at 28 days was not significantly different following pneumothorax (63.1 +/- 6.5%) or isolated pneumomediastinum (53.0 +/- 18.7%;p=0.854). The incidence of pneumothorax was higher in males. 28-day survival was not different between the sexes (males 62.5 +/- 7.7% versus females 68.4 +/- 10.7%;p=0.619). Patients aged >= 70 years had a significantly lower 28-day survival than younger individuals (>= 70 years 41.7 +/- 13.5% survival versus <70 years 70.9 +/- 6.8% survival;p=0.018 log-rank). Conclusion: These cases suggest that pneumothorax is a complication of COVID-19. Pneumothorax does not seem to be an independent marker of poor prognosis and we encourage continuation of active treatment where clinically possible.

S53 What factors influence mental health burden in patients recovering from COVID-19?

S53 Table 1Patient characteristics and outcomesVariablePHQ-2p - valueTSQp-valueNegativePositive NegativePositive N71171 72260 DemographicsAge *62.0 ± 16.660.5 ± 16.90.47162.2 ± 16.857.3 ± 14.20.028Sex – Male (%)429 (60.3)35 (49.3)0.071438 (60.7)26 (43.3)0.009Ethnicity – White (%)286/573 (49.9)37/70 (52.9)0.642290/585 (49.6)33/58 (56.9)0.287Co-morbiditiesTotal number of co-morbidities4 (3–5)5 (3–6)0.1701 (0–3)2 (1–3)0.239Depression (%)34/683 (5)11/68 (16.2)<0.00139/692 (5.6)6/59 (10.2)0.159Anxiety (%)14/683 (2)8/68 (11.8)<0.00117/692 (2.5)5/59 (8.5)0.009Admission dataDuration of symptoms at admission in days7 (5–11)7 (4.5–9)0.2877 (5–11)7 (5–10)0.357Total number of symptoms (out of 16)4 (3–5)5 (3–6)0.0144 (3–5)4 (3–6)0.001 Positive airway pressure (CPAP or NIV)39 (5.5)2 (2.8)0.33637 (5.1)4 (6.7)0.607Admission to intensive care unit (ITU)81/674 (12)11/69 (15.9)0.34682/683 (12)10/60 (16.7)0.293Follow up dataBreathlessness rating 0–100 (0–2)2 (0–5)0.0030 (0–3)2 (0–4)<0.001Cough rating 0–100 (0–0)0 (0–3)0.0120 (0–0.5)0 (0–2)0.023Fatigue rating 0–102 (0–4)5 (3–7)<0.0012 (0–4)5 (3–7)<0.001Sleep quality rating 0–100 (0–4)3 (2–6)<0.0010 (0–3)5 (3–8)<0.001Symptom burden at follow-up (out of 7)4 (3–5)5 (3–6)<0.0010 (0–1)2 (1–2)<0.001Back to work122/216 (56.5)10/30 (33.3)0.060121/213 (56.8)11/33 (33.3)0.006ReferenceBritish Thoracic Society ( 2020). Guidance on respiratory follow up of patients with a clinico-radiological diagnosis of COVID-19 pneumonia.

P9 Do persistent chest radiograph changes correlate with ongoing respiratory symptoms in patients recovering from COVID-19 pneumonia?

P9 Table 1Differences in symptom burden in patients with improved vs. non-improved chest radiographsDemographicChest radiograph appearancep-valueImprovers n=356 (93%)Non-improvers n=26 (7%)Age (years)58.9 ± 14.763.23 ± 12.70.103BMI (kg/m2)27.7 ± 5.4326.7 ± 4.500.331Male sex (n,%)224 (62.9)21 (80.8)0.154BAME (n,%)165 (46.3)10 (38.5)0.268Current or ex-smoker (n,%)112 (31.4)9 (34.6)0.008Underlying respiratory disease (n,%)62 (17.4)3 (11.5)0.737ITU admission (n,%)41 (11.5)10 (38.5)<0.001Symptoms Breathlessness*1 (0 – 3)2 (0 – 4)0.010Cough*0 (0 –1)0 (0 – 2.5)0.090Fatigue*2 (0 – 5)2 (0.5 – 4.5)0.773How close back to 100% of usual do you feel?*90 (80 – 100)85 (75 – 97.5)0.500MRC dyspnoea scale*1 (1 – 2)1 (1 – 3)0.021*non-parametric data presented as median and IQR, all other data are presented as mean ± standard deviationConclusionsIn our cohort, patients recovering from COVID-19 pneumonia with a ‘non-improver’ chest radiograph are more likely to have been admitted to ITU and remain breathless at follow-up. We conclude that ‘non-improver’ chest radiographs at follow-up are an indicator of who may have ongoing respiratory pathology. These patients can thus be prioritised for further respiratory investigation.ReferencesBritish Thoracic Society (2020). Guidance on Respiratory Follow Up of Patients with a Clinico-Radiological Diagnosis of COVID-19 Pneumonia. https://www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/resp-follow-up-guidance-post-covid-pneumonia/British Society of Thoracic Imaging (2020). Post-COVID-19 CXR Report Codes. https://www.bsti.org.uk/media/resources/files/BSTI_PostCOVIDCXRtemplatefinal.28.05.201.pdf