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SESSION TITLE: Post-COVID-19 Outcomes SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: The World Health Organization defines post-acute sequelae of SARS-COV-2 infection (Long-COVID) as persistent symptoms after COVID-19 for more than two months. Although many studies show associations of comorbidities with prolonged COVID-19 symptoms, to our knowledge, there is no study with a comparison group for Long-COVID. We performed a retrospective study looking at risk factors for the development of Long-COVID. METHODS: We retrospectively reviewed 2,234 records of patients with a history of COVID-19 diagnosed by RT-PCR who followed up as outpatients at multiple pulmonary clinics in Hartford, Connecticut, USA, from March 2020 to December 2021. Data included the patient's age, sex, comorbidities, oxygen device including FiO2 level, and duration of symptoms. We evaluated patient characteristics, duration of symptoms, comorbidities, and disease severity. Analyses comprised the Mann-Whitney U test, χ2 test, or Fisher's exact test Using SPSS v. 26 at an alpha of 0.05. RESULTS: Of the 2,234 patients evaluated, 471 patients were included. The mean age was 56 ± 15 years (± SD), and 62.6% were female. 212 (45%) required hospital admission, and 23 (4.9%) required mechanical ventilation. Of those patients, 351 had symptoms for more than two months (Long-COVID) and 121 for two months or less (no Long-COVID). Both groups had similar characteristics. Hospitalization was more common in the Long-COVID group (51.6% vs. 21.8%, p<0.001). Increased FiO2 requirement was associated with prolonged symptoms (p<0.001), and patients requiring high-flow, non-invasive and invasive ventilation were more likely to develop Long-COVID (p=0.002). The mean duration of symptoms in patients with long-COVID was 7.9 ± 3.9 months versus 0.5 ± 0.8 months in the comparison group (p<0.001). Obesity, asthma, COPD, heart failure, interstitial lung disease, pulmonary hypertension, and immunosuppression were not found to be associated with Long-COVID. Regarding vaccination status, our analysis was limited since only 15 patients were vaccinated prior to developing COVID-19. CONCLUSIONS: Current data on Long-COVID suggests that prolonged symptoms are associated with older age, comorbidities, duration of hospitalization, and ICU stay. Our results, however, suggest that infection severity is the most important factor related to prolonged COVID-19 symptoms rather than comorbidities and age. Our study did contain limitations due to its retrospective nature, subjective duration of symptoms rather than objective 6-minute walk test, and lastly, patients may have been affected by different SARS-COV2 variants and received different treatments. CLINICAL IMPLICATIONS: Our results suggest that patients with severe COVID-19 are more predisposed to develop prolonged symptoms. Based on disease severity, this knowledge can inform providers and patients about prognosis and anticipated duration of symptoms post COVID-19 infection. DISCLOSURES: No relevant relationships by Brian Bustos No relevant relationships by Christopher Dipollina No relevant relationships by David O'Sullivan No relevant relationships by Eduardo Padrao No relevant relationships by Ravneet Randhawa No relevant relationships by Tejal Shah No relevant relationships by Pooja Shekar
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SESSION TITLE: Long COVID: It Can Take Your Breath Away SESSION TYPE: Original Investigations PRESENTED ON: 10/16/2022 10:30 am - 11:30 am PURPOSE: The World Health Organization has defined post-acute sequelae of SARS-CoV-2 infection, or Long-COVID, as prolonged symptomatology after initial recovery lasting more than 2 months. Changes in respiratory function associated with this syndrome are not fully understood. Therefore, we performed a retrospective analysis of patients with pulmonary function tests (PFT) after COVID-19. METHODS: We retrospectively reviewed records of 2,234 patients with a history of COVID-19 diagnosed by RT-PCR who followed up in pulmonary clinics in Hartford, Connecticut from March 2020 to December 2021. Data included the patients’ age, sex, comorbidities, PFT results, and the maximum oxygen requirement during acute illness: room air (RA), low-flow oxygen (LF), high-flow nasal cannula (HFNC), non-invasive ventilation (NIV) or mechanical ventilation (MV). We performed an adjusted logistic regression analysis to evaluate if the disease severity (defined by oxygen requirement) was associated with the presence of obstructive and restrictive disease during follow-up. SPSS 26.0 was used with an alpha level of 0.05. RESULTS: Of the 2,234 records, 471 (21.1%) had available PFTs. Only PFTs done between 2 and 12 months post COVID-19 were included. The mean age (± SD) of the sample was 56 ± 15 years;62.6% were female. Twenty three (4.9%) patients required MV, 17 (3.6%) NIV, 45 (9.5%) HFNC, 111 (23.6%) LF and 275 (58.4%) remained on RA. Obstructive disease was seen in 106 (22.5%), and bronchodilator response was seen in 34 (9.1%). Restrictive disease was seen in 129 (27.4%) and was associated with use of HFNC, NIV and MV (OR: 2.44, 3.67, 3.26;p<0.01). The presence of obstruction did not correlate with disease severity, however use of HFNC did correlate with the absence of obstruction (OR: 0.24;p=0.019). CONCLUSIONS: Our results show a significant association between disease severity and restrictive disease during follow up. This is compatible with smaller studies and is likely related to the fibrotic stage of Acute Respiratory Distress Syndrome. There was an association of HFNC use with the absence of obstruction. Perhaps, patients with the pre-existing obstruction and severe COVID were less likely to tolerate HFNC and required higher support for recovery. Bronchodilator responsiveness was only present in a small portion of patients. Severe disease did not appear to predispose patients to the development of obstructive disease during the follow up period. Studies including pre- and post-COVID PFTs would further strengthen this assertion. CLINICAL IMPLICATIONS: We did find an association between severity of COVID-19 and restrictive disease during follow up. Conversely, disease severity did not correlate with obstruction. These data will help to define the typical course of progression in patients suffering from Long-COVID and may imply that management should mirror strategies employed in other pulmonary conditions that cause restriction. DISCLOSURES: No relevant relationships by Brian Bustos No relevant relationships by Christopher Dipollina No relevant relationships by David O'Sullivan No relevant relationships by Eduardo Padrao No relevant relationships by Ravneet Randhawa No relevant relationships by Tejal Shah No relevant relationships by Pooja Shekar
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CASE: A 57-year-old man with a history of hypertension presented with shortness of breath, dry cough, and subjective fever. He tested positive for SARS-CoV-2 upon presentation. He denied tobacco use or occupational hazards. He had an initial respiratory rate of 31 and oxygen saturation of 84% on room air. On exam, he was tachycardiac, and his lungs revealed bibasilar rales. His blood work revealed elevated inflammatory markers. His CTA was negative for pulmonary embolism but revealed bilateral groundglass infiltrates. He was admitted and started on dexamethasone, remdesivir, and enoxaparin. He developed worsening oxygen requirements during his stay and was transitioned to high flow nasal cannula and subsequently to BiPAP with IPAP of 20 cm H2O and EPAP of 10 cm H2O with FiO2 100%. His chest x-ray revealed a right-sided pneumothorax and pneumo-mediastinum with extensive subcutaneous emphysema [Fig 1]. Subsequently, he developed worsening acidosis, lethargy, hypotension, and tachycardia, prompting a chest tube placement and intubation [Fig 2]. While in the intensive care unit, he developed another right-sided pneumothorax, prompting a 2nd chest tube placement. IMPACT/DISCUSSION: The COVID-19 pandemic has created uncertainty about patient care, especially respiratory management. The increasing need for ventilators led to a nationwide shortage, and noninvasive ventilation (NIV) techniques needed to be employed despite the potential for aerosolization of the virus associated with their use. Barotrauma is a dreaded complication when using invasive ventilation. Increased volume can result in hyperinflated alveoli and air leaks into the surrounding tissues and spaces. There has been a limited number of cases reported of pneumothorax in COVID-19 infection from NIV. NIV can also produce high tidal volumes, high transpulmonary pressure, and high intrinsic positive expiratory pressure. Consider pneumothorax as a differential when a COVID-19 patient is clinically deteriorating on NIV. Radiographic imaging and ultrasound are cost-effective tools for the diagnosis of pneumothorax. CONCLUSION: Barotrauma-induced pneumothorax is a well-known complication of invasive ventilation. In an attempt to decrease invasive ventilation complications and save limited resources, our focus has shifted to NIV. We should, however, be mindful that COVID-19 patients managed with NIV are also at risk of pneumothorax from increased tidal volumes, the risk of which is compounded by severe lung injury. The best practice to prevent barotrauma is to ensure the patient's tidal volume does not exceed 6mL/kg ideal body weight. This application is an easy and effective prophylactic approach that should be taught to all providers to prevent iatrogenic injuries in these patients who are already at increased risk of lung injury.
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Rationale: Over 350,000,000 people have had SARS-CoV-2 infection worldwide. COVID-19 poses many challenges in the management of patients causing a long-term and significant burden on the healthcare system. Understanding the long-term complications is a challenge that the healthcare community and patients will face. To our knowledge, this is one of the largest retrospective analyses with the aim to understand the functional lung sequelae of the disease. Methods: We retrospectively reviewed 782 survivors who had COVID-19 diagnosed by RT-PCR and followed up at an outpatient pulmonary clinic in Hartford, Connecticut, USA, from March 2020 to June 2021. Data included patient's age, sex, comorbidities, pulmonary function tests (PFT), the maximal requirement of low-flow oxygen (LF), high-flow nasal cannula (HFNC), non-invasive ventilation (NIV) and mechanical ventilation (MV). We performed an adjusted logistic regression model to evaluate if severity of disease according to maximal oxygen support is associated with DLCO<80% in follow-up. SPSS IBM was used for the statistical modeling. Results: Of the 782 patients evaluated, 314 patients had PFT results available post COVID-19 for analysis. The mean age was 58.9±14.5 years, and of the total number of patients, 200 were female (63.7%). Other demographics are as follows: 156 (49.7%) were obese, 129 (41.2%) had asthma, 48 (15.3%) had COPD, 5 (1.6%) had Interstitial Lung Disease, 35 (11.1%) had anemia, 70 (22.3%) had diabetes mellitus, 164 (52.2%) had hypertension, 26 (8.3%) had heart failure. Only 14 (4.4%) required MV, 14 (4.5%) NIV, 29 (9.2%) HFNC, 94 (29.9%) LF and 153 (51.9%) remained on room air. Altered DLCO was seen in 107 patients (34.1%), 189 (60.1%) had normal DLCO, and 18 (5.7%) did not have DLCO, of which the latter were excluded from the analysis. Maximal oxygen support was associated with DLCO<80% on unadjusted analysis (p=0.003). However, it was not associated with DLCO<80% (p=0.2) when adjusted. Other variables associated with a higher risk of DLCO<80% were age (p<0.001) and COPD (p<0.028). Asthma was associated with lower risk of developing DLCO<80% (p<0.001). Conclusion: Patients with post-acute sequelae of SARS-CoV-2 infection can develop DLCO<80%, which may contribute to long-term symptoms. Altered DLCO was not associated with maximal oxygen support in the adjusted logistic regression analysis. However, this may be due to the low number of cases requiring MV or NIV, resulting in selection bias, given there was a higher mortality rate in patients requiring positive pressure ventilation. Additionally, age and COPD were correlated with DLCO<80%.
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Information products provide agents with additional information that can be used to update actions. In many situations, access to such products can be quite limited. For instance, in epidemics, there tends to be a limited supply of medical testing kits, or tests. These tests are information products because their output of a positive or a negative answer informs individuals and authorities on the underlying state and the appropriate course of action. In this paper, using an analytical model, we show how the accuracy of a test in detecting the underlying state affects the demand for the information product differentially across heterogeneous agents. Correspondingly, the test accuracy can serve as a rationing device to ensure that the limited supply of information products is appropriately allocated to the heterogeneous agents. When test availability is low and the social planner is unable to allocate tests in a targeted manner to the agents, we find that moderately good tests can outperform perfect tests in terms of social outcome.
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Background: Diabetes mellitus has been considered a significant risk factor for morbidity and mortality for COVID-19.1 HbA1c levels are often used as a marker of poor glycaemic control and are one way of diagnosing pre-diabetes as well as diabetes.2,3 We tried to explore whether HbA1c levels could be an independent risk factor for mortality and morbidity in patients with positive coronavirus (SARS-COv-2) swabs. Methods: This was a retrospective multicentre study of coronavirus swab positive patients who had a recent HbA1c test. Their demographic data, medical history, COVID-19 swab and laboratory results, and final outcomes were analysed. Patients were divided into three groups;HbA1c in normal (group 1), pre-diabetic (group 2) and diabetic (group 3) ranges. Data were analysed using JASP and statistical computation using a χ2 test. Results: A total of 1,226 patients had SARS-CoV-2 RNA identification swabs between 10 February 2020 and 1 May 2020. A cohort of 120 of these patients had positive swab results and recent HbA1c results. Mortality rates for group 1 (normal HbA1c) and 3 (diabetic HbA1c) were relatively higher than group 2 (pre-diabetic HbA1c). Among group 2, female patients had greater mortality, perhaps because of fewer male patients, although overall co-morbidity was less (4/120 (3.33%) in group 2 compared with 18/120 (15%) in group 1 and 14/120 (11.66%) in group 3. Overall, 36/120 (30%) patients died and 84/120 (70%) survived. Survival curves after analysis of data showed that increasing HbA1c levels were associated with poorer outcomes across all groups. Analysis was significant with p=0.003. Conclusions: HbA1c levels in this study were an independent marker of increased risk of mortality in COVID-19 swab positive patients. The findings are statistically significant (p=0.003). Increased co-morbidities at normal HbA1c seem to have a contributing role in enhanced mortality.
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Introduction: Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has been declared a global pandemic.1 A national lock-down was announced in the UK from 23rd March 2020, with a public health campaign encouraging patients to stay home. Healthcare services, including the NHS, had to urgently adapt to the demands of COVID-19, with changes in primary and secondary care. At our hospital trust we have reviewed the referrals to our lung cancer services during the pandemic. Suspected lung cancers in the community are referred using the cancer 2-week pathway. Survival estimates for lung cancer are poor compared to most other primary cancers and NICE advocates for quick referral to a specialist for patients whom lung cancer is suspected 2. We have looked at the impact of the pandemic on the referrals to our services. Method: We have reviewed the referrals to lung cancer services, via the lung cancer 2-week pathway at our hosptial trust, between the same periods in 2019 and 2020. Results: There has been a noticeable reduction in the number of referrals to the lung cancer services from the 23rd March, in comparison to same period in 2019 (see graph 1). Between weeks 13 and 19 of 2020 there was a 56.85% reduction in the number of referrals made compared to 2019. Conclusion: There are several likely reasons for the reduction in referral rate shown, including the nationwide advice to 'stay home to protect the NHS', changes to service provision and alterations to clinical set-ups. Timely referral of patients to lung cancer services and prompt diagnosis are essential, directly relating to lung cancer outcomes. We all, therfore, have a responsibility to ensure we learn from the COVID-19 pandemic, to help develop robust services, on top of appropriate clinical awareness, ensuring essential medical services can be provided irrespective of other pressures on the NHS.