My experience with the novel coronavirus: As doctor and patient

“She’s young,” I thought to myself one night as the intensive care physician on call in the hospital. I had been called to evaluate a patient in her thirties who had recently been confirmed as having contracted the (then) novel coronavirus. She possessed none of the attributes that medical school and residency teachings suggest are typical risk factors for the ravaging lung injury demonstrated on computed tomography and X-ray of her chest. © 2022 Elsevier Inc. All rights reserved.

Predictors of Persistent Fibrotic-Like Abnormalities in Survivors of Covid-19 Acute Respiratory Distress Syndrome (ARDS)

Rationale: A subset of COVID-19 patients will go on to have unremitting disease after recovering from the acute phase. Clinical parameters associated with the development and persistence of post-COVID sequela are largely unknown. We sought to determine the frequency of post-acute COVID lung sequelae and associated clinical factors in a subset of patients recovering from severe COVID-19. Methods: Of 88 COVID-19 ARDS subjects with no known prior lung disease who were hospitalized requiring mechanical ventilation between March-July 2020 and had a chest CT during their acute COVID-19 hospitalization, a subset of 19 patients who had post-discharge chest CTs were included. A thoracic radiologist visually scored the degree of opacity attributed to fibrotic-like changes, indicated by traction bronchiectasis and honeycombing, on the pre-discharge/inpatient CT (IPCT) and most recent outpatient CT (OPCT) for each patient. A significant difference was defined as a change in fibrosis score of >20%. Clinical data were collected and analyzed to evaluate for associations. Data represented as number of patients (percent of cohort) and mean ± standard deviation. Results: 17 of 19 patients were included in the analysis;the 2 excluded had no fibrosis on either CT. Mean time between IPCT and OPCT was 9 ± 6 months. 6 (35.3%) had either complete resolution or improvement of fibrosis (1 resolved, time to OPCT 14 months;5 improved, time to OPCT 10 ± 4 months), while 11 (64.7%) had either worsened or unchanged (2 worsened, time to OPCT 14 ± 5 months;9 unchanged, time to OPCT 7 ± 6 months). Compared with the worsened/unchanged group, the resolved/improved group had 73% higher fibrosis scores on IPCT, were more likely to have received Tocilizumab (66.7% vs 27.3%) and higher doses of steroids while hospitalized. The worsened/unchanged cohort had a higher prevalence of current or former smokers and longer hospital (76.3 ± 51.4 vs 63.8 ± 18.6 days) and ICU (61.2 ± 54.0 vs 55.7 ± 17.8 days) lengths of stay (LOS). Duration of mechanical ventilation and oxygen requirement at discharge were similar between groups. Conclusion: In this cohort of severe COVID-19 patients with radiologic evidence of fibrosis on IPCT, nearly two-thirds had persistent or increased fibroticlike changes on OPCT while over one-third improved or resolved over a mean follow-up of 9 months. Positive smoking history, longer hospital and ICU LOS, infrequent treatment with Tocilizumab, and lower total steroid doses were trends seen in subjects whose CT abnormalities persisted or increased.

Randomized, Double-Blind Trial of the Efficacy and Safety of Pirfenidone in Patients with Fibrotic Hypersensitivity Pneumonitis

Rationale: Fibrotic hypersensitivity pneumonitis (FHP) is an irreversible lung disease with high morbidity and mortality. We sought to evaluate the safety and effect of pirfenidone on disease progression in such patients.Methods: In a phase 2 double-blind, single-center trial, we randomly assigned, in a 2:1 ratio, adults with FHP to receive either oral pirfenidone (2403 mg/day) or placebo for 52 weeks. Patients had to have CT lung fibrotic abnormalities affecting ≥5%, worsening respiratory symptoms, and either an increase in the extent of fibrosis on CT or relative decline in the FVC% of ≥5% within the 24-months before screening. The primary endpoint was the mean change from baseline to week 52 in %FVC. Secondary endpoints included progression-free survival (PFS, time to the first occurrence of any one of the following: a relative decline of ≥10% in FVC and/or DLCO, acute exacerbation, a decrease of ≥50 m in the 6-minute walk distance, increase in background prednisone by ≥10 mg or introduction of corticosteroids and/or steroid-sparing drugs, or death), change from baseline to week 52 in FVC slope and mean %DLCO, all-cause hospitalizations, CT progression of lung fibrosis, and safety. Results: After 40 patients had been randomized (mean age 67.1 years, 42.5% males) the study was stopped due to slow recruitment due to the COVID-19 pandemic. At baseline, demographics, smoking and inciting antigen exposure history, lung function, 6-minute walk distance, extent of CT lung fibrosis, and immunosuppressive therapy were balanced in both groups. There was no significant difference between the pirfenidone and placebo groups after adjusting for baseline %FVC and concomitant immunosuppressive therapy (p=0.88) in mean change from baseline to week 52 in %FVC. Secondary endpoints showed no difference between groups in change from baseline to week 52 in FVC slope, mean %DLCO, all-cause hospitalization and CT progression of lung fibrosis. However, a decrease in PFS favored pirfenidone (Table). The percentages of patients with any adverse events (AE) were similar in both groups. Nausea and rash, respectively, led to transient dose reduction of study treatment in 2 patients in the pirfenidone group. There were no treatment-related serious AE or AE leading to discontinuation of study treatment. No death occurred in the pirfenidone group and one death (respiratory) occurred in the placebo group. Conclusions: The trial was under powered to detect a difference in the primary endpoint. Pirfenidone was found to be tolerable and safe and compared to placebo reduced PFS in patients with FHP.

Respiratory disease, and treatment / thematic poster session COVID-19 as a cause of pulmonary fibrosis

Rationale: Long term sequelae of COVID-19, especially pertaining to lung structure and function, are largely unknown. Patients with severe COVID-19 who develop acute respiratory distress syndrome (ARDS) requiring prolonged mechanical ventilation are likely at highest risk. We sought to determine the incidence of radiographic markers of lung fibrosis and associated risk factors in a cohort of patients with severe COVID-19. Methods: The Electronic Medical Record at New York University was queried for subjects without a history of interstitial lung disease who had a positive SARS-CoV-2 PCR, required mechanical ventilation, and had a chest computed tomography (CT) conducted during their hospitalization for COVID-19. Clinical and laboratory data was collected. CT scans were blindly read by a thoracic radiologist using a novel scoring system where fibrotic changes were defined as consolidation and/or ground glass with traction, and honeycombing. The prevalence of fibrosis was established and analyses were done to evaluate for clinical associations. Data is represented as number of patients (percent of cohort), and mean ± standard deviation). Results: 88 patients were included, 61 (69.3%) had fibrotic changes on CT done 50.3 ± 33.6 days after admission, while 27 (30.7%) had no fibrosis seen on CT done 41.5 ± 26.0 days after admission. There were no significant differences in demographics or medical history between the subgroups. The fibrotic subgroup required mechanical ventilation for a longer duration than the non-fibrotic subgroup (52.8 ± 33.2 vs 32.1 ± 18.8 days) and had higher plateau pressures 21 days after intubation (26.6 ± 6.0 vs 16.5 ± 5.4 cmH2O). P/F ratios were similar on day of intubation (145.4 ± 55.5 fibrotic vs 145.7 ± 64.1 non-fibrotic), however the fibrotic subgroup had lower P/F ratios 7 days after intubation (146.3 ± 57.0 vs 182.1 ± 63.3), 14 days after intubation (166.3 ± 83.7 vs 236.8 ± 84.3), and 21 days after intubation (170.8 ± 90.5 vs 249.5 ± 103.0). The fibrotic subgroup also had higher peak ferritin (8899.92 ± 11461.3 vs 6715.6 ± 9680.1 ng/mL) and LDH (1031.67 ± 628.9 vs 929.0 ± 493.3 U/L). Conclusion: In our cohort of severe COVID-19 patients, over two-thirds had fibrotic changes on CT chest. Longer duration of mechanical ventilation, higher plateau pressures 21 days after intubation, lower P/F ratios 7 days or more after intubation, and higher peak ferritin and LDH levels were associated with presence of fibrosis. .

Personal journey and perspective from psychiatric nurse and medical student to intern doctor during COVID-19.

COVID-19 or 'Coronavirus' has become a global pandemic since its initial report in Wuhan, China, on November 17, 2020. It is highly infectious and poses significant health risks for those in vulnerable populations. This article aims to provide perspective into an Irish experience, through the eyes of a practicing psychiatric nurse, who has recently graduated medical school and intends to work as an intern doctor.

Impact and mechanism of COVID-19 on mental health and wellbeing

The Covid-19 pandemic has brought unprecedented pressure to healthcare systems worldwide, resulting in significant and precipitous changes in demand, burden and method of delivery. The psychosocial impact of this crisis is likely to increase over the course of the pandemic, peak later than medical cases and endure for longer thereby significantly exceeding medical morbidity. It will have far reaching impact on the individual, their family and their care providers. Frontline healthcare workers and those with pre-existing mental health difficulties are recognised at increased risk. Now that the initial surge has been expertly curtailed, it is essential that urgent consideration is now directed towards the mental health implications of the current outbreak and ensure that we are as ready for the increased MH needs of the community as we were for the intensive medical care.