One-year outcomes following rehabilitation for chronic hip-related groin pain: ancillary analysis of a pilot randomized clinical trial

Purpose: Rehabilitation to address modifiable factors associated with chronic hip-related groin pain (CHRGP) may lead to reduced pain and improved function, yet little is known about its effectiveness. We assessed the preliminary effects of two interventions that target two distinct mechanisms, sensory disturbances and abnormal movement patterns. Sensory disturbances such as peripheral and central sensitization may contribute to pain persistence long after initial injury. Joint mobilization (JtMob) may impart a neurophysiological response within the nervous system that results in pain reduction and improved mobility. Abnormal movement patterns may create altered mechanical stresses on hip joint structures, resulting in pain and activity limitations. Movement pattern training (MoveTrain) may improve movement patterns and thus patient function. Method(s): Patients with CHRGP, 18-40, were enrolled. Assessments included self-report questionnaires, clinical exam, and quantitative sensory testing. Outcomes included the Hip disability and Osteoarthritis Outcome Score (HOOS), a patient-reported outcome;frontal plane kinematics of hip, pelvis, and trunk during single leg squat;and pain pressure threshold (PPT) assessed at the anterior groin of the most bothersome hip and dominant thenar eminence (local and generalized pressure hypersensitivity, respectively). Patients were randomized to JtMob or MoveTrain in a 1:1 ratio stratified by sex and HOOS Symptoms. Treatment for both groups included 10 individualized visits over 12 weeks with a trained physical therapist (PT);assessment of patient goals and education which focused on patient-specific tasks reported by the patient to be symptom-producing;instruction in a home exercise program (HEP);and handouts that provided education, description and benefits of assigned treatment and instructions for HEP. The key element of JtMob was PT-provided manual techniques using specific criteria to determine the joint mobilization techniques and parameters used for each patient. The patient's symptom report to each technique was monitored and if indicated, the technique modified according to our outlined procedures. The HEP included flexibility exercises. The key element of MoveTrain was task-specific instruction to correct abnormal movement patterns displayed during daily and patient-specific tasks. For example, hip adduction was minimized during a step descent. The HEP included repeated practice of modified tasks. Task difficulty was progressed based on each patient's performance. Immediately after treatment completion, patients returned for follow up assessment. To assess treatment sustainability after the active treatment phase, we collected HOOS at 6 and 12 months (extended follow-up), and kinematics and PPT at 12 months. Data from patients who provided any data after baseline were analyzed with a repeated measures analysis of variance (RM-ANOVA) with baseline value as a covariate, patient as a random effect, and an autoregressive covariance structure. After adjusting for baseline, the between-group difference in change from post-treatment to each extended follow-up results from pre-planned statistical contrasts in a RM-ANOVA that includes main effects for treatment group, visit and the group by visit interaction. The within-group treatment effect at each extended follow-up was calculated by subtracting the earlier time point from the later follow-up within each treatment group. Dependent samples t-tests were used to assess the degree of within-group change. Result(s): Demographics and outcome data are provided in Tables 1 and 2, respectively. Thirty-three patients with CHRGP were randomized and 29 (88%) provided post-treatment data. Four patients did not complete treatment or post-treatment testing (3 due to COVID pandemic, 1 lost to follow up);6 patients did not complete 12 month laboratory testing (due to pandemic), but did complete 12 month questionnaires. Previously, we reported that both groups reported clinically important improvements in HOOS subscales and MoveTrain group improved hip and pelvis kinematics immediately after treatment compared to baseline. After adjusting for baseline, there were no between-group differences in change in outcomes between post-treatment and extended follow-up when comparing JtMob and MoveTrain, indicating that treatment effects immediately post-treatment were maintained at 12 months after treatment completion. Conclusion(s): Our preliminary findings suggest that 12 weeks of JtMob or MoveTrain, may result in improvements in patient-reported pain and function and these effects may persist 12 months after treatment completion. A future, larger trial to definitively assess the efficacy of JtMob and MoveTrain and identify factors associated with long-term outcomes will improve our ability to develop treatment strategies for people with CHRGP. [Formula presented] [Formula presented]Copyright © 2023

COVID-19 and Professional Athletes

It could be argued that the sport stakeholders most negatively impacted by COVID-19 over the past two years have been the athletes. In this chapter the authors explore the impact of the cancellation and postponement of sport across 2020 and 2021 on professional athletes. Specifically, the chapter examines how athletes have been impacted socially, psychologically and economically. Furthermore, the isolation suffered by athletes through their participation in bio-secure ‘bubble' environments as well as taking part in various forms of quarantining are also examined. © 2023 selection and editorial matter, Stephen Frawley and Nico Schulenkorf;individual chapters, the contributors.

Training assessment of clinical knowledge and skills in the use of negative pressure wound dressings in cardiac patients

Funding Acknowledgements Type of funding sources: None. Objective An assessment was conducted to analyse the level of improvement impact one can have on clinical knowledge and skills in the use of a novel negative pressure wound dressings in high-risk cardiac patients along with their years of experience following a training program conducted among our cardiac staff. Methods In a prospective study involving twenty cardiac nursing staff from December 2020 to June 2021 who voluntarily participated in the study. Their pre and post training assessment of clinical knowledge and skills were assessed using twenty questionnaires. The pre and post training educational knowledge and skills scores were analysed along with their years of clinical experience. Results In the six-month period n=20 (100 %) were compliant to the training despite the covid-19 pandemic. The study group showed an average pre-training score of 10.5% (Knowledge 5.25% and Skills 5.25%) The average post-training score of84.75% (Knowledge 42.25% and Skills 42.25%) While comparing the years of clinical experience against the pre and post training scoresSeventeen (n=17/20, 85%) had five to ten years experience compared to three (n-3/20, 15%) with more than 20 years of experience. Conclusion Both clinical knowledge and skills can be augmented through regular training members with more than ten years of clinical experience might have an added benefit and their experience could be important to train younger staff members with less clinical experience.

Unpacking BMI Significance: Prevalence of Metabolically Healthy Obesity and Metabolic Profile Predictors Among Adolescents Enrolled in a Weight Management Program

Purpose: Adolescent obesity continues to rise, with body mass index (BMI) commonly used as an adiposity surrogate. While obesity correlates with metabolic syndrome risk, individuals with the same BMI do not have equivalent health risks. In 2018, the first pediatric consensus definition for metabolically healthy obesity (MHO) was proposed. Identifying MHO patients is clinically relevant for personalizing interventions by cardiometabolic phenotype. The objective of this study was to examine baseline MHO and metabolically unhealthy obesity (MUO) prevalence and identify metabolic and anthropomorphic predictors among adolescents enrolled in weight management. Methods: This study uses baseline data from 1,316 patients ≥ 11 years of age enrolled in a weight management program for obese adolescents in Baltimore, Maryland between 2005-2018. Anthropometric measures (including body fat by bioimpedance (%fat)), vital signs, and fasting labs were performed at intake. MHO definition was: glucose <100, HDL > 40, triglycerides < 150, systolic blood pressure < 120, diastolic blood pressure < 80. MUO was defined as ≥ 1 abnormal value among MHO variables. Independent samples t-tests were used to compare mean %fat and BMI z-score of MHO and MUO groups. Bivariate logistic regression was performed to determine effects of age, sex, %fat, BMI, and BMI z-score on likelihood of MHO. Results: Mean age in the MHO group was 13.48 years (SD 1.88);mean age in the MUO group was 13.98 years (SD 2.03). 444 (33.7%) patients met criteria for MHO;872 patients had MUO. MHO teens had statistically significantly lower mean %fat (46.7% +/- 8.0% SD) vs. MUO (47.8% +/- 8.2% SD) (p = 0.034) and lower BMI z-score (2.37 +/- 0.33 SD vs 2.51 +/- 0.34 SD;p < 0.001) vs MUO. The MHO group was 66.9% female vs 54.5% females in MUO, with 38.9% lower odds of MHO for males vs. females (OR 0.611;CI 0.467 - 0.800). For every 1% increase in %fat, odds of MHO increased by 3.1%, (OR 1.031;CI 1.008 - 1.053). Each 1-year age increase led to 10.9% decrease in MHO odds (OR 0.891;CI 0.823 - 0.965). In addition, each 1 unit increase in BMI z-score was associated with a 64.5% decrease in odds of MHO (OR 0.355;CI 0.166 - 0.759). BMI change did not significantly change MHO odds. Conclusions: Among this cohort of obese adolescents enrolled in weight management, one-third had MHO. Factors associated with higher likelihood of MHO include: female sex, younger age, and lower BMI z-score. Notably, BMI was not predictive of metabolic phenotype. These findings suggest potential for risk prediction for MUO profile to tailor interventions and resources accordingly. Next, we will evaluate metabolic profiles of patients enrolled during the COVID-19 pandemic. Sources of Support: NICHD T32HD052459 (PI: Trent), The Mount Washington Foundation.

HEALTH SUPPORT FOR AUSTRALIAN BREAST CANCER SURVIVORS VIA TEXT MESSAGES DURING COVID19 LOCKDOWNS: RESULTS OF A NATIONAL PRE-POST STUDY

Introduction COVID19 cancelled in-person breast cancer support in Australia. Text messages are effective at providing health support. Aim: Evaluate cost, uptake, reach and utility of a 3-month co-designed (consumers/clinicians/ researchers) lifestyle-focused text message program 'EMPOWER-SMS'. Methods Participants were recruited (Apr'20-Feb'21) via breast cancer organisations' social media and emails. Inclusion: Adults, finished active breast cancer treatment (surgery/chemotherapy/radiotherapy), lived in Australia, owned a mobile phone, sufficient English for e-consent. Exclusion: metastatic breast cancer. Online survey at baseline: Demographics and postcode (coded to Index of Relative Socio-economic Advantage and Disadvantage [IRSAD];1 least to 5 most advantaged). At 3-months: program feedback for ease-of-understanding, utility, perceived health management (5-Point Likert Scale;strongly [dis]agree), open-text feedback (coded thematically). Results Ads cost $2641. Participants' (N=845) mean age: 59±10yrs (range 30-87yrs), 48% resided in less advantaged areas (IRSAD 1-3). Survey participants (n=452) agreed/strongly agreed EMPOWERSMS was easy-to-understand (99%), useful (83%), helpful for managing health (69%), exercise (70%), healthy diet (70%). Key themes: 'feeling supported/less lonely', 'friendly reminders', 'sad it ended', 'some messages too simple'. Conclusions With low cost ($3.1/enrolment), 845 diverse participants enrolled and found it useful, overcoming support barriers during COVID19.

Creation and Evaluation of a Mixed Service Intermediate Care Unit with Obligate Critical Care Consultation to Improve ICU Capacity

Rationale: Significant capacity constraints brought on by the COVID-19 pandemic have underscored the need for novel staffing models that offload ICUs while still providing appropriate standard of care for high acuity patients. Intermediate Care Units (IMCs) provide one such outlet that have not been extensively examined, particularly during the COVID-19 era. Here we describe a quality improvement project focused on the creation of a mixed IMC with critical care support at our institution during the COVID-19 pandemic. Methods: With the support of institutional leadership, an interprofessional working group spanning critical care, surgery, hospital medicine, nursing, and respiratory therapy was convened to establish the staffing model, determine inclusion/exclusion criteria, and track IMC progress. The initial model entailed a medical-surgical service unit staffed by intermediate care-trained nurses, primary teams comprised of hospitalists or surgical teams, and an intensivist who rounded daily. All medical patients received an automatic critical care support consult;all surgical patients had the option of this consult. The maximum census was three. A retrospective chart review was conducted at the end of the initial phase to evaluate process, outcome, and balancing measures. Data were reported using simple descriptive statistics. Results: From August 9th to October 15th 2021, 36 patients - 21 medical and 15 surgical - were admitted to the IMC. The average age was 62.4, 17 (47.2%) were female, and 11 (30.5%) were admitted for COVID-19. The most frequent indications were hypoxemia (15, 71.4%) for medical patients and post-operative monitoring (12, 80%) for surgical patients. The average length of stay was 2.5 days. Most patients stepped down from an ICU or PACU rather than stepping up from a general ward or emergency department. A total of 577 ICU bed-hours were made available by admitting patients to the IMC who would have otherwise occupied an ICU bed. Seven medical patients (33.3%) required transfer back to an ICU and one medical patient (4.8%) transitioned to hospice. The remaining 13 (61.1%) medical and 14 (93.3%) surgical patients were discharged to a general ward. One patient was intubated within 48 hours of triage to the IMC, and zero patients expired while admitted to the IMC.Conclusions: Creation of an IMC provided a means to care for high acuity patients while creating ICU capacity. Subsequent phases will expand on inclusion criteria and maximum census while assessing the effect of critical care support consults on patient safety and hospitalist and intensivist workloads.

Social media and inspiring physical activity during COVID-19 and beyond. (Special Issue: Managing sport and leisure in the era of Covid-19.)

The COVID-19 pandemic has impacted sport and events greatly with a shutdown of leagues and the postponement of events like the 2020 Tokyo Olympic Games. However, new media technologies, such as social media platforms, have provided an avenue for sport organisations and athletes to continue to engage with their consumers and promote physical activity during the absence of live sport. New media technologies allow organisations and individuals to share user-generated content and facilitate interactivity. This commentary intends to stimulate discussion, interest and research on whether social media could be used as a platform to inspire physical activity and sport participation and what strategies may be successful in engaging with consumers. Olympic sport and the campaigns National Olympic Committees have engaged in during lockdown are the focus of this piece. It is hoped that this piece provides a starting point for future research focusing on the adoption of new media technologies, like social media, to engage with and inspire people to become more active and involved in sport.

COMPARISON OF MOVEMENT PATTERN TRAINING AND JOINT MOBILIZATION FOR CHRONIC PREARTHRITIC HIP DISORDERS: A PILOT RANDOMIZED CLINICAL TRIAL

Purpose: A clear need exists to rigorously assess treatment strategies for chronic prearthritic hip disorders (PAHD). We assessed the preliminary effects of two physical therapist-led interventions that target two distinct mechanisms, abnormal movement patterns and sensory disturbances. Abnormal movement patterns, such as excessive hip adduction, may create altered mechanical stresses on hip joint structures, resulting in subsequent injury, pain and activity limitations. Movement pattern training (MoveTrain) may improve movement patterns and patient-reported outcomes, however further investigation is needed to be definitive. Sensory disturbances such as peripheral sensitization and central sensitization (aka nociplastic pain) may also contribute to pain persistence long after an initial injury. Joint mobilization (JtMob) is proposed to impart a neurophysiological response within the peripheral and central nervous system that results in pain reduction and improved mobility, yet the investigation of JtMob for the treatment of PAHD is limited. Methods: Patients, 18-40 years, with chronic PAHD were recruited. Baseline assessment included self-report questionnaire completion, clinical examination and quantitative sensory testing. The primary outcome was the Hip disability and Osteoarthritis Outcome Score (HOOS), a hip-specific, patient-reported outcome measure. Secondary outcomes included movement evoked pain assessed with a repetitive step down task and a repetitive deep squat task, and pain pressure threshold assessed at the anterior groin of the most bothersome hip (local pressure hypersensitivity) and the dominant thenar eminence (generalized pressure hypersensitivity). After baseline assessment, patients were randomized into 1 of 2 treatment groups, MoveTrain or JtMob. Randomization was stratified by sex and HOOS Symptoms quartile, as determined from data collected during previous study. Treatment was provided by 4 experienced physical therapists (2 in each treatment arm) who were trained in standardized procedures. Treatment for both groups included 10 supervised sessions over 12 weeks and incorporated assessment of patient goals, patient education and instruction in a home program. Patient education focused on patient-specific tasks, such as work or fitness activities, identified by each patient to be symptom-producing. The goal of MoveTrain was to reduce stresses on the hip joint by optimizing the biomechanics of daily and patient-specific tasks. The key element of MoveTrain was task-specific instruction to correct abnormal movement patterns demonstrated during daily tasks and patient-specific tasks. For example, hip adduction and femoral internal rotation were minimized during step-down tasks. The home program included repeated practice of the modified tasks. Difficulty of the tasks were progressed based on each patient’s performance. The goal of JtMob was to reduce pain and improve pain-free motion of the hip. The key element of JtMob was manual techniques provided by the physical therapist. Specific criteria were used to determine the joint mobilization techniques and parameters used for each patient. The patient’s symptom report to each technique was monitored and if indicated, the technique modified according to our outlined procedures. The home program included flexibility exercises. Immediately after treatment completion, patients returned for follow up assessment. Data collected at baseline and post-treatment were analyzed with analysis of covariance (ANCOVA) using a generalized linear model where change is the dependent variable and baseline is the covariate. The adjusted immediate treatment effect was calculated by subtracting the least squares mean change between baseline and post for MoveTrain minus JtMob from the ANCOVA, and assesses the between-group difference in change after adjusting for baseline. Results: Thirty-three patients with PAHD were randomized. Demographics are provided in Table 1. Four patients did not complete treatment or post-treatment testing (3 due to COVID pandemic, 1 lost t follow up);7 patients did not complete post-treatment laboratory testing (due to COVID), but did complete post-treatment questionnaires. Both groups demonstrated clinically important within-group improvements in the HOOS subscales and movement evoked pain ratings after treatment (Table 2). No changes were noted in pain pressure threshold for either group. After adjusting for baseline, there were no between-group differences in change in outcomes when comparing MoveTrain and JtMob. Conclusions: Our preliminary findings suggest that 12 weeks of physical therapist-led intervention, including either MoveTrain or JtMob, may result in improvements in patient-reported pain and activities limitations. Further investigation is needed to determine the sustained effects of each treatment and to determine if specific patient factors are associated with treatment prognosis. [Formula presented] [Formula presented]

Online Social Listening Surveillance for Earlier Insights About Loperamide Abuse/Misuse, 2015-2021

Study Objectives: Loperamide (LOP) is a safe, effective antidiarrheal medication available over-the-counter (OTC) for over 30 years with a maximum dose of 8 mg/day for adults. Intentional LOP abuse/misuse (ingesting 70-200 mg/day to self-treat opioid withdrawal symptoms or achieve euphoria) was first reported in online forums in 2005. Following a 2016 US Food and Drug Administration (FDA) Drug Safety Communication on the potential risk of cardiovascular adverse events with high doses of LOP, the OTC industry initiated a communications campaign (www.LoperamideSafety.org) to educate health professionals, including emergency medicine specialists, about LOP abuse/misuse awareness and prevention. Retrospective surveillance (eg, FDA Adverse Event Reporting System database and National Poison Data System) has traditionally been employed to track reports of drug abuse/misuse. We utilized modern online social listening technology to observe and analyze comments/conversations (posts) about LOP abuse/misuse on various websites and online social media platforms to gain earlier insight into potential LOP abuse/misuse. Methods: Utilizing the software tools Crimson Hexagon and Synthesio, we scanned thousands of publicly accessible user posts in online blogs, forums, and social networks – including major platforms such as Twitter, Facebook, YouTube, Reddit, and Forums – from January 2015 to March 2021 to observe posts about LOP abuse/misuse. Listening consisted of keyword-based scrapes of user-generated content using search terms including loperamide, Imodium, overdose, OD, get high, getting high, withdrawal, and related terms/phrases. Findings were analyzed and reported quarterly. Results: From January 2015 to March 2021, there were 27,213 user posts regarding LOP abuse/misuse among all observed online platforms. Annual post volume peaked in 2016 before declining in 2019/2020, consistent with the pattern of annual intentional exposure cases reported by the American Association of Poison Control Centers. Over 2015-2021, there was an average of 390 posts per month. Since May 2018, Reddit contained the majority of posts (70%), followed by Twitter (18%), YouTube (6%), Forums (4%), Facebook (<1%), and other sites (<1%). Reddit and Forums accounted for an increasing percentage of posts over time with a decrease for all other platforms. Posts primarily addressed the use of high-dose LOP for easing withdrawal symptoms (73%) or seeking euphoria (17%). Posts about risks and dangers of misuse/abuse were 16% of Reddit posts from Q2 2020 to Q1 2021, with a peak of 22% in Q2 2020. Spikes in posts coincided with key events, including journal article publications regarding effects of high doses (2,499 posts in May 2016 and 830 posts in January 2017) and FDA Drug Safety Communications regarding abuse/misuse of LOP (650 posts in June 2016 and 1,400 posts in January 2018). Post volume also appeared to increase in relation to US COVID-19 infection rates in 2020/2021 slightly. Conclusion: Online chatter about LOP abuse/misuse rose from 2015 to a peak in 2016 before declining in 2019/2020, consistent with the pattern of reported annual intentional exposure cases. While not a substitute for epidemiological surveillance, online social media listening is a useful adjunct surveillance strategy for earlier insight into potential LOP abuse/misuse by observing and analyzing online comments/conversations, sentiments and contexts. [Formula presented]

Implementation of a remote rapid access chest pain service during the COVID-19 pandemic

Background: Rapid Access Chest Pain Clinic (RACPC) is a vital service in many hospitals in the UK, providing early specialist input for patients with suspected coronary artery disease referred via the Emergency Department (ED) or primary care (1). When the COVID-19 pandemic forced hospitals to refine their outpatient systems (2), our Trust continued the RACPC service remotely via telephone consultations. Purpose: To examine the long-term viability of this service, we designed a study to compare the outcomes of patients seen remotely during the pandemic to patients seen face to face. Methods: We performed a retrospective cohort study. The remote group (n=217) were patients seen over 4 weeks in April 2020, all having telephone consultations. The control group (n=368) were patients assessed face to face in the same 4-week period in 2019. Outcomes being analysed included: mode of investigation;interventions performed;and a 12 month combined safety endpoint of ED attendance with chest pain, re-referral to cardiology and hospitalisation for cardiac issue. Subgroup analysis was performed based on typicality of symptoms defined by NICE (3). Results: Baseline characteristics were similar between groups. In both 2019 and 2020, the largest subgroup of patients were those with nonanginal chest pain (64%, 71%). There were significant differences in investigation and management between the two cohorts (Figure 1). In 2020, a higher proportion of patients were discharged with no investigation (57% vs 23%, p<0.0001). This was driven primarily by changes in management of patients with non-anginal chest pain. There were significantly higher rates of investigation of this subgroup in 2019 by either CT Coronary Angiography (25% versus 4.5%, p<0.001) or functional testing (25% versus 6.5%, p<0.001), with a much higher rate of reassurance and discharge in 2020 (81% versus 36%, p<0.0001). More patients received coronary intervention in 2019 than in 2020 (2.4% vs 0%, p=0.02). In 2020, higher proportions of patients were commenced on medical therapy without further investigation when presenting with atypical (28% versus 1%, p<0.0001) or typical angina (63% versus 11.4%, p<0.0001) (Figure 2). There was no significant difference in the 12 month combined safety endpoint (1.3% in 2019 versus 2.3% in 2020, p=0.39), and no reported cardiac deaths. Conclusions: During the pandemic, as expected, fewer patients were investigated for coronary artery disease, with the preference being to commence medical therapy initially. This did not have a significant effect on safety endpoints. Importantly, clinicians felt comfortable with assessing and discharging patients with non-anginal chest pain remotely in 2020. This is key to the viability of a remote RACPC model, as this subgroup forms the majority of the referrals. We suggest that RACPC is appropriate for a remote model in the long term, in view of the relatively low-risk population and clear management guidelines.

A Covid-19 viral transmission prevention system for embedded devices utilising deep learning

The coronavirus pandemic (COVID-19) has created an urgent need for different monitoring systems to prevent viral transmission because of its severity and contagious aspect. This paper proposes design and implementation of a hardware-software solution that uses supervised machine learning algorithms to examine an individual and determine if he/she poses a viral transmission danger. The solution proposed was developed utilising an ARM embedded device along with different sensors to detect and monitor COVID-19 symptoms and, at the same time, to enforce wearing of a mask by using deep learning computer vision. © 2021 IEEE.

Persistent dyspnea and accompanying negative emotions after COVID-19 associated respiratory failure

INTRODUCTION: Dyspnea is common and distressing in patients with acute critical illness who require mechanical ventilation (MV), and is often a presenting symptom for COVID-19. However, little is known about the long-term persistence of dyspnea or its impact on patients recovering from mechanical ventilation. This study sought to evaluate early and persistent dyspnea, and its emotional impact, among survivors of respiratory failure due to COVID-19. METHODS: We conducted a prospective observational cohort study at Beth Israel Deaconess Medical Center. We identified ICU survivors who underwent at least 48 hours of MV for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. We assessed the presence and severity of dyspnea throughout their illness (ICU, hospital floor, hospital discharge, 6 months post-discharge) using components of the Multidimensional Dyspnea Profile (MDP), a validated instrument. Additionally, we asked patients with persistent dyspnea at the time of follow up whether dyspnea triggered specific emotional responses, using the MDP. Data are means + standard deviation or number (percent). RESULTS: Forty of 43 patients contacted by telephone completed interviews and 3 declined. Twenty-three patients (58%) were male, 7 (18%) had COPD, 9 (22%) had obstructive sleep apnea, and 11 (28%) had active tobacco use. The duration of invasive MV was 14+7.1 days and hospital length of stay was 24.7+9.6 days. Six-month post-discharge data revealed 25 patients (62.5%) with any dyspnea, and 10 (25%) with moderate to severe dyspnea (10-point severity scale score > 4). Among patients with persistent dyspnea at 6 months, the majority reported fear (60%), anxiety (57.5%), or frustration (52.5%). Depression was the most common severe emotional response accompanying dyspnea (10-point severity scale score of 7-10), reported by 9 patients (22.5%). CONCLUSIONS: Six months after COVID-19-associated respiratory failure, dyspnea was persistent in the majority of patients and commonly associated with negative emotions. Fear and anxiety were most commonly reported. Prior to COVID-19, long-term dyspnea had been described in up to 40% of patients after respiratory failure, though data are limited. Thus dyspnea appears as, or more, common after COVID-19. In addition to the typical components of post-intensive care syndrome (PICS), dyspnea and the negative emotional states it evokes may impair quality-of-life for COVID-19 survivors and should be specifically assessed during post-hospital care visits.

Long-term impairment in cognition, mental health, and physical function following covid-19-associated respiratory failure

RATIONALE: Prior to the emergence of coronavirus disease 2019 (COVID-19), critical illness survivors were known to suffer long-term impairments in physical function, mental health, and cognition. These deficits, collectively termed the post-intensive care syndrome (PICS), impact health-related quality-of-life. Survivors of COVID-19-associated respiratory failure may be at particularly high risk of PICS due to delirium and prolonged mechanical ventilation, and factors unique to the pandemic, including physical isolation from medical staff, lack of in-hospital family presence, limited post-acute care rehabilitation, and widespread economic recession. Given this context, we describe the prevalence of PICS 6 months following hospital discharge among survivors of COVID-19-associated respiratory failure. METHODS: We conducted a multicenter prospective cohort study from March to December 2020 at Beth Israel Deaconess Medical Center and the Hospital of the University of Pennsylvania. We identified ICU survivors who underwent at least 48 hours of mechanical ventilation for COVID-19. We contacted eligible patients via telephone at 6 months post-hospital discharge. Sample size was determined by thematic saturation of interviews within a concurrent qualitative assessment. We used the Society of Critical Care Medicine international consensus recommendations for PICS assessment. We assessed anxiety, depression, and post-traumatic stress disorder (PTSD) using the Hospital Anxiety and Depression Scale and Impact-of-Events Scale, respectively. We assessed physical impairment with the EQ-5D questionnaire, and cognitive impairment using the Montreal Cognitive Assessment-Blind. Data are means + standard deviation or number (percent). RESULTS: We completed telephone interviews with 50 of 173 eligible patients (53 contacted, 3 declined). Age was 57+13 years, duration of invasive mechanical ventilation was 14+8.2 days and PaO2:FiO2 ratio at intubation was 174±46. Delirium developed in 35 patients (70%). Six months post-discharge, 38 patients (76%) met criteria for PICS, with 1 or more domains impaired. Among patients with PICS, 22 (44%) were impaired in at least 2 domains, and 9 (18%) impaired in all 3 domains. PTSD was present in 17 patients (34%), anxiety in 19 (38%), and depression in 20 (40%). Twenty-four patients (48%) had impairments in activities of daily living. Nineteen patients (37%) demonstrated cognitive impairment. CONCLUSIONS Over three quarters of COVID-19-associated respiratory failure survivors demonstrated PICS 6 months after hospital discharge. Patients were commonly impaired in at least two domains. These estimates of PICS prevalence appear broadly similar to those reported in the pre-COVID-19 literature and should drive focused efforts to identify COVID-19 survivors at high risk for PICS prior to discharge.

Improved covid-19 survival in acute hospital settings following implementation of a realtime clinical decision support tool

Introduction COVID-19 mortality rates are high, particularly in patients requiring invasive ventilatory support, developing a cytokine storm, or experiencing thromboembolic disease. Our goal was to determine if traffic-light driven, personalised care was associated with improved survival in acute hospital settings. Methods Outcomes were evaluated during two implementation phases of a real-time clinical decision support tool that had been developed as part of a Trust's COVID-19 response, using a reporting and bioinformatics team to support Clinical and Operational teams. Following optimisation, the tool defined patients' clinical status in terms of risk of preventable complications based on blood test results (Ddimer, C reactive protein and ferritin). Feedback to wardbased clinicians enabled rapid modification of care pathways, in the first phase following a daily review, and in the second phase, in real-time (dashboard updated every 10 minutes). Results 1039 COVID-19 positive patients were admitted by 21/05/2020. Focusing on the first 939 completed encounters to death or home discharge (median age 69ys;60% [563/939] male), 568/939 (60.4%) received thromboembolism risk flags, and 212/939 (22.5%) cytokine storm flags. The maximum thromboembolism flag discriminated completed encounter mortality between no flag (9.97% [37/371]);medium-risk (28.5% [68/239]);high-risk (51.2% [105/205]);and suspected thromboembolism (52.4% [65/124]), Kruskal Wallis p<0.0001. 173 of 535 consecutive COVID-19 positive patients whose hospital encounter completed before real-time introduction died (32.3% [95% confidence intervals 28.0, 36.0]), compared to 46 of 200 (23.0% [95% CI 17.1, 28.9]) admitted after implementation of real-time traffic light flags (p=0.013). The realtime cohort were older (median age 72ys compared to 67ys, p=0.037), and were more likely to flag at risk of thromboembolism on admission. However, adjusted for age/sex, the probability of death was 0.33 (95% confidence intervals 0.30, 0.37) before real-time implementation, and 0.22 (0.17, 0.27) after real-time implementation (p<0.001). In subgroup analyses, older patients, males, and patients with hypertension (p£0.01) and/or diabetes (p=0.05) derived the greatest benefit from admission under the real-time traffic light system. Conclusion Personalised early interventions were associated with a reduction in mortality. We suggest benefit predominantly resulted from early triggers to review/enhance anticoagulation management, without exposing lower-risk patients to potential risks of full anticoagulation therapy.

Inflammatory markers in gynecologic oncology patients hospitalized with covid-19

Introduction Elevated inflammatory markers in COVID-19 infection are predictive of disease severity and mortality. It is unclear if these markers are associated with severe disease in patients with cancer due to underlying tumor related inflammation. We sought to further understand the inflammatory response related to COVID-19 in gynecologic cancer patients. Methods Patients with history of gynecologic cancer hospitalized for COVID-19 infection with available laboratory data were identified. Laboratory values at the time of hospital admission and clinical outcomes were abstracted from electronic medical records. Severe infection was defined as infection requiring ICU admission or resulting in death. Results 86 patients with gynecologic cancer were hospitalized with COVID-19 infection with median age of 68.5 years (interquartile range (IQR), 59.0 to 74.8 years). Of the 86 patients, 29 (33.7%) patients required ICU admission and 25 (29.1%) patients died of COVID-19 complications. There were 36 (41.9%) patients in remission and 50 (58.1%) had active disease. Patients with severe infection had significantly higher ferritin (median 1163.0, IQR 640.0-1967.0) and Creactive protein (CRP) (median 142.0, IQR 62.5-217.1) levels than those with non-severe disease (median 624.0, IQR 269.7-954.0, P=0.01;median 62.3, IQR 13.0-159.1, P=0.02 respectively) (table 1). White blood cell count, absolute neutrophil count, and lactate were also associated with severe disease. Procalcitonin and D-Dimer levels were not significantly associated with severe disease (P=0.2;P=0.7 respectively). Conclusion/Implications Inflammatory markers (ferritin and CRP) in gynecologic cancer patients are associated with COVID-19 severity and can be used as prognostic markers at the time of admission.