Impact of the COVID-19 Pandemic on Incidence of Asthma Exacerbations and Hospitalizations in US Subspecialist-Treated Patients with Severe Asthma: Results from the CHRONICLE Study.

Purpose: Patients with severe asthma (SA) are at an increased risk of asthma-related hospitalizations and exacerbations. Despite concerns that COVID-19 circulation would increase exacerbations of SA, anecdotal reports suggest that social distancing and exposure avoidance may have led to reduced exacerbations. Patients and methods: CHRONICLE is an ongoing noninterventional observational study of 3100 subspecialist-treated patients with SA. Eligible adults (≥ 18 years of age) have (1) current use of monoclonal antibody (ie, biologic) therapy for SA, (2) use of maintenance systemic corticosteroids (mSCS) or other systemic immunosuppressants for ≥ 50% of the prior 12 months for SA, or (3) persistently uncontrolled asthma while treated with high-dosage inhaled corticosteroids with additional controllers. For enrolled patients, electronic medical records were reviewed to record all exacerbations and asthma-related hospitalizations. Descriptive analyses were conducted of the monthly incidence of exacerbations, exacerbation-related visits to the emergency department (ED), and asthma hospitalizations from July 2018 through July 2021. Results: Exacerbations, exacerbation-related ED visits, and hospitalizations decreased since April 2020. Exacerbations in 2020 were 20% to 52% lower in April through August relative to the same months in 2019. Exacerbations remained lower than the prior year through May 2021. Similar results were observed by United States (US) census region, with an earlier decrease in exacerbation rates in the western US versus other regions. Across all months, exacerbation rates were lower among biologic recipients. Conclusion: In a clinical cohort of subspecialist-treated patients with SA, there was a meaningful reduction in exacerbations, exacerbation-related ED visits, and asthma hospitalizations following COVID-19-related stay-at-home orders and social distancing recommendations. Reasons for these reductions are likely multifactorial, including reduced viral infections due to less social contact and altered patient behavior.

Patient Satisfaction and Recommendations for Delivering a Group-Based Intensive Outpatient Program via Telemental Health During the COVID-19 Pandemic: Cross-sectional Cohort Study.

BACKGROUND: Although group-based intensive outpatient programs (IOPs) are a level of care commonly utilized by adults with serious mental illness, few studies have examined the acceptability of group-based IOPs that required rapid transition to a telemental health (TMH) format during the COVID-19 pandemic. OBJECTIVE: The aim of this study was to evaluate patient satisfaction and future recommendations for a group-based IOP that was transitioned to a TMH format during the COVID-19 pandemic. METHODS: A 17-item patient satisfaction questionnaire was completed by patients at discharge and covered 3 areas: IOP TMH satisfaction, future recommendations, and video technology challenges. Descriptive and content analyses were conducted for the quantitative and open-ended questions, respectively. RESULTS: A total of 76 patients completed the program in 2020. A subset of patients (n=40, 53%) responded to the survey at program discharge. The results indicated that the patients were satisfied overall with the TMH program format; 50% (n=20) of the patients preferred the program continue offering the TMH format, and the rest preferred returning to in-person formats after the pandemic. The patients indicated the elements of the program that they found most valuable and provided recommendations for future program improvement. CONCLUSIONS: Overall, adults with serious mental illness reported high satisfaction with the group-based IOP delivered via TMH. Health care systems may want to consider offering both TMH and in-person formats regardless of the state of the pandemic. Patients' feedback on future improvements should be considered to help ensure long-term success.

Rapid Adoption and Implementation of Telehealth Group Psychotherapy During COVID 19: Practical Strategies and Recommendations.

Behavioral health services have been tasked with rapidly adopting and implementing teletherapy during the SARS-CoV-2/COVID-19 pandemic to assure patient and staff safety. Existing teletherapy guidelines were developed prior to the pandemic and do not capture the nuances of rapidly transitioning in-person individual and group-based treatments to a teletherapy format. In this paper, we describe our approach to quickly adapting to a teletherapy technology platform for an intensive outpatient program (IOP) guided by cognitive and behavioral modular principles for adults with serious mental illness. A review of existing guidelines was conducted and the staged approach for teletherapy implementation (Muir et al., 2020) was selected as the most appropriate model for our organizational context. We describe the most pertinent implementation strategies and report our preliminary findings detailing the feasibility of IOPs delivered via telehealth. This model of rapid teletherapy implementation offers practical clinical guidelines for administrators and clinicians seeking to transition traditional in-person behavioral health services to a teletherapy format.

Genetic and non-genetic factors affecting the expression of COVID-19-relevant genes in the large airway epithelium.

BACKGROUND: The large airway epithelial barrier provides one of the first lines of defense against respiratory viruses, including SARS-CoV-2 that causes COVID-19. Substantial inter-individual variability in individual disease courses is hypothesized to be partially mediated by the differential regulation of the genes that interact with the SARS-CoV-2 virus or are involved in the subsequent host response. Here, we comprehensively investigated non-genetic and genetic factors influencing COVID-19-relevant bronchial epithelial gene expression. METHODS: We analyzed RNA-sequencing data from bronchial epithelial brushings obtained from uninfected individuals. We related ACE2 gene expression to host and environmental factors in the SPIROMICS cohort of smokers with and without chronic obstructive pulmonary disease (COPD) and replicated these associations in two asthma cohorts, SARP and MAST. To identify airway biology beyond ACE2 binding that may contribute to increased susceptibility, we used gene set enrichment analyses to determine if gene expression changes indicative of a suppressed airway immune response observed early in SARS-CoV-2 infection are also observed in association with host factors. To identify host genetic variants affecting COVID-19 susceptibility in SPIROMICS, we performed expression quantitative trait (eQTL) mapping and investigated the phenotypic associations of the eQTL variants. RESULTS: We found that ACE2 expression was higher in relation to active smoking, obesity, and hypertension that are known risk factors of COVID-19 severity, while an association with interferon-related inflammation was driven by the truncated, non-binding ACE2 isoform. We discovered that expression patterns of a suppressed airway immune response to early SARS-CoV-2 infection, compared to other viruses, are similar to patterns associated with obesity, hypertension, and cardiovascular disease, which may thus contribute to a COVID-19-susceptible airway environment. eQTL mapping identified regulatory variants for genes implicated in COVID-19, some of which had pheWAS evidence for their potential role in respiratory infections. CONCLUSIONS: These data provide evidence that clinically relevant variation in the expression of COVID-19-related genes is associated with host factors, environmental exposures, and likely host genetic variation.

Feasibility and Initial Outcomes of a Group-Based Teletherapy Psychiatric Day Program for Adults With Serious Mental Illness: Open, Nonrandomized Trial in the Context of COVID-19.

BACKGROUND: In the context of the COVID-19 pandemic, many behavioral health services have transitioned to teletherapy to continue delivering care for patients with mental illness. Studies that evaluate the outcome of this rapid teletherapy adoption and implementation are pertinent. OBJECTIVE: This single-arm, nonrandomized pilot study aimed to assess the feasibility and initial patient-level outcomes of a psychiatric transitional day program that switched from an in-person group to a video teletherapy group during the COVID-19 pandemic. METHODS: Patients with transdiagnostic conditions who were at risk of psychiatric hospitalization were referred to the Adult Transitions Program (ATP) at a large academic medical center in the United States. ATP was a 3-week intensive outpatient program that implemented group teletherapy guided by cognitive and behavioral principles delivered daily for 3 hours per day. Feasibility was assessed via retention, attendance rate, and rate of securing aftercare appointments prior to ATP discharge. Patients completed standardized patient-reported outcome measures at admission and discharge to assess the effectiveness of the program for improving quality of mental health, depression, anxiety, and suicide risk. RESULTS: Patients (N=76) started the program between March and August of 2020. Feasibility was established, with 70 of the 76 patients (92%) completing the program and a mean attendance of 14.43 days (SD 1.22); also, 71 patients (95%) scheduled at least one behavioral health aftercare service prior to ATP discharge. All patient-level reported outcomes demonstrated significant improvements in depression (95% CI -3.6 to -6.2; Cohen d=0.77; P<.001), anxiety (95% CI -3.0 to -4.9; Cohen d=0.74; P<.001), overall suicide risk (95% CI -0.5 to -0.1; Cohen d=0.41; P=.02), wish to live (95% CI 0.3 to 1.0; Cohen d=0.39; P<.001), wish to die (95% CI -0.2 to -1.4; Cohen d=0.52; P=.01), and overall mental health (95% CI 1.5 to 4.5; Cohen d=0.39; P<.001) from admission to discharge. CONCLUSIONS: Rapid adoption and implementation of a group-based teletherapy day program for adults at risk of psychiatric hospitalization appeared to be feasible and effective. Patients demonstrated high completion and attendance rates and reported significant improvements in psychosocial outcomes. Larger trials should be conducted to further evaluate the efficacy and effectiveness of the program through randomized controlled trials.

COVID-19-related Genes in Sputum Cells in Asthma. Relationship to Demographic Features and Corticosteroids.

Rationale: Coronavirus disease (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). ACE2 (angiotensin-converting enzyme 2), and TMPRSS2 (transmembrane protease serine 2) mediate viral infection of host cells. We reasoned that differences in ACE2 or TMPRSS2 gene expression in sputum cells among patients with asthma may identify subgroups at risk for COVID-19 morbidity.Objectives: To determine the relationship between demographic features and sputum ACE2 and TMPRSS2 gene expression in asthma.Methods: We analyzed gene expression for ACE2 and TMPRSS2, and for ICAM-1 (intercellular adhesion molecule 1) (rhinovirus receptor as a comparator) in sputum cells from 330 participants in SARP-3 (Severe Asthma Research Program-3) and 79 healthy control subjects.Measurements and Main Results: Gene expression of ACE2 was lower than TMPRSS2, and expression levels of both genes were similar in asthma and health. Among patients with asthma, male sex, African American race, and history of diabetes mellitus were associated with higher expression of ACE2 and TMPRSS2. Use of inhaled corticosteroids (ICS) was associated with lower expression of ACE2 and TMPRSS2, but treatment with triamcinolone acetonide did not decrease expression of either gene. These findings differed from those for ICAM-1, where gene expression was increased in asthma and less consistent differences were observed related to sex, race, and use of ICS.Conclusions: Higher expression of ACE2 and TMPRSS2 in males, African Americans, and patients with diabetes mellitus provides rationale for monitoring these asthma subgroups for poor COVID-19 outcomes. The lower expression of ACE2 and TMPRSS2 with ICS use warrants prospective study of ICS use as a predictor of decreased susceptibility to SARS-CoV-2 infection and decreased COVID-19 morbidity.