Pulmonary Rehabilitation and Its Role in Long-Term COVID-19 Recovery

Coronavirus - 2019 (COVID-19)-a respiratory syndrome caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2)-is responsible for the world's latest pandemic unlike any seen since the 1980s HIV/AIDs pandemic. While significant effort has been made towards acute management, long-term management has received less attention. To address this, our study identified patients diagnosed with COVID-19 and recorded the time to enrollment into a formal pulmonary rehabilitation program at an academic center;the differences in time allowed us to assess whether earlier enrollment led to differences in physiologic and psychologic outcomes. First, we hypothesize that enrollment into a pulmonary rehabilitation program is essential to a patient's long term treatment and management of post-infectious, chronic COVID-19 symptoms. Second, we aim to demonstrate that early participation leads to improvements in dyspnea, anxiety and depression as supported by the UCSD SOBQ, GAD-7 and PHQ-9 scores respectively. Through chart review, we collected data from 24 patients enrolled in a post-COVID recovery program centered around pulmonary rehabilitation at an academic medical center in Texas. We administered: (1) pulmonary function test (PFT);(2) University of California - San Diego (UCSD) Dyspnea Questionnaire;and (3) six-minute walk (6MW) tests when a patient entered and completed the program. We used this data to assess for subjective and objective changes in respiratory function postrehabilitation. To analyze the indirect benefits of pulmonary rehabilitation on mental health effects of COVID-19, we used the Generalized Anxiety Disorder 7 (GAD7) and Patient Health Questionnaire (PHQ9) questionnaires to evaluate a patients' anxiety and depression respectively at the same time points. Our results showed that it took patients an average 67.8 days to initiate rehabilitation after initial diagnosis. 13 of 24 patients began rehab earlier than the average and had an average decrease in UCSD SOBQ score of 35.6 and 6MW increase of 64.5 m compared to the group averages of 17.8 and 74.7 m respectively. The average initial GAD7 and PHQ9 scores were 6.7 and 8.7, with an average decrease of 1.5 and 2.2 respectively. Through our study, we highlight the benefit of early initiation of pulmonary rehabilitation in the post-COVID 19 recovery period. Through both subjective and objective measurements of patient respiratory function and mental health, our study supports inclusion and standardization of early pulmonary rehabilitation as a component of COVID-19 recovery.

Late sequelae of COVID-19 infection in patients without comorbidities

Introduction: Since the appearance of SARS-CoV-2, more than 40 million patients worldwide have recovered from the infection. Co-morbidities have been linked with severity of disease and outcomes in patients infected with COVID-19. As the pandemic progresses, patients deemed “Long Haulers” are being recognized as more individuals recover. Currently, there is limited data on the late sequalae of the disease especially in the population of patients with no comorbidities. Objective: Evaluate the long-term sequalae of COVID-19 infection in healthy individuals. Methods: We identified 101 patients who presented to the University of Texas Medical Branch (UTMB) COVID-19 recovery clinic between July, 16, 2020 to October,8, 2020, and excluded all subjects with underlying comorbidities. Demographics and data regarding hospitalization history, persistent symptoms, patient health questionnaire score (PHQ-9), Generalized anxiety disorder score (GAD-7) and six-minute walk distance were collected. Results (Table 1): A total of 25 patients (24.7%) with no comorbidities were identified during the study period. Patients were predominantly female (80%), and older than 40 years (90%). More than half of subjects identified as white (52%), and 10 patients (40%) were hospitalized for COVID related symptoms. The mean duration from positive test to clinic visit was 66 days. Persistent fatigue, dyspnea on exertion and cough were reported by 96%, 84% and 68% of patients, respectively. Depression (PHQ-9 ≥ 5) and anxiety (GAD-7 ≥ 5) were present in 15 patients (60%), while 84% reported persistent gastrointestinal symptoms including abdominal pain, nausea, vomiting and diarrhea, and 76% reported persistent headache. The mean six-minute walk distance was 1084 feet. Conclusion: While comorbidities may be an indicator of COVID-19 disease severity, those without comorbidities are not spared from the prolonged recovery from illness.

Long-term health effects of COVID-19 in hospitalized and non-hospitalized patients

Introduction: On March 11, 2020, COVID-19 was declared a pandemic by the World Health Organization. The disease has had a major impact on public health and the global economy with more than 70 million people infected worldwide and more than 1.5 million mortalities. However, less is known about the long-term consequences of the disease. Objective: Evaluate the long-term health effects of COVID-19 on hospitalized and non-hospitalized subjects. Methods: We identified all patients who presented to the COVID-19 recovery clinic at the University of Texas Medical Branch (UTMB) in the period from March 16, 2020, to October 8, 2020. Data regarding persistent symptoms, patient health questionnaire (PHQ-9) score, generalized anxiety disorder (GAD- 7) questionnaire score and six-minute walk distance was collected. Comparisons between patients with a history of hospitalization for COVID-19 related symptoms and those who were not hospitalized were performed using Chi-square test or Fisher's exact test for categorical variables, and independent t-test for numeric values. Results: We identified a total of 93 patients who presented to the COVID-19 recovery clinic during the study period. Patients were predominantly females (69.9%), mean age was 52 years and the majority were white (58%). Obesity (body mass index ≥30) was present in 62% of subjects and 73% had at least one comorbidity. The most common noted comorbidities were hypertension (53.8%), asthma (29%) and diabetes (22.6%). The mean duration from positive COVID-19 test to clinic visit was 62 days (Table 1). Persistent fatigue, cough and dyspnea on exertion were reported by 60%, 57% and 56% of patients, respectively. The mean six-minute walk distance was 952 feet. Of the entire cohort, 46 (49.5%) were not hospitalized for COVID-19 related symptoms, these patients were younger (48 vs 56 years, P 0.006), and out of the comorbidities studied, obesity was less common (50% vs 74.4%, P 0.037) compared to those who were hospitalized. The mean six-minute walk distance was greater in the non-hospitalized cohort (1067 vs 841 feet, P 0.016) compared to those who were hospitalized. There was no difference between both groups in the prevalence of persistent symptoms, depression or anxiety. Conclusion: Persistent symptoms including fatigue, dyspnea, depression and anxiety were common in patients who recovered from COVID-19, regardless of their hospitalization history. Performance on the six-minute walk test was lower in patients who were hospitalized.

Characteristics and outcomes of patients with copd and COVID-19 in the united states

Rationale. Chronic obstructive Pulmonary Disease (COPD) has been associated with severe coronavirus disease 2019 (COVID-19) in Chinese and European cohorts. To date, no studies have evaluated the outcomes of COVID-19 in a selected cohort of patients with COPD in the United States (USA). We hypothesize that patients with COPD infected with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2) will have higher likelihood of 14-day hospitalization, mechanical ventilation use, and mortality compared to non-COPD SARS-CoV2 positive patients. Methods. We performed a retrospective analysis of electronic health records (EHR) from facilities across the 4 geographical regions of the USA (Optum Covid-19 Biweekly Data). We defined COVID-19 positive as having International Classification of Disease-10 (ICD-10) code of U07.1, or positive laboratory test results. COPD patients are defined by having at least 2-outpatient visits or 1- inpatient visit with any COPD diagnosis codes within a year prior to COVID-19 positive date. Results. We studied a cohort of 150,775 patients with COVID-19 between March and August 2020 in the United States. COPD was identified in 6,056 (4%) patients. The baseline characteristics of the cohort are presented in table 1. The percentage of patients with COPD and COVID-19 admitted to the hospital in 14-days for any cause was greater than that for non-COPD COVID-19 patients (28.7% vs 10.42%, p< 0.0001). The mean length of stay was longer for COPD with COVID-19 individuals than that for non-COPD COVID-19 patients (12.3 days vs 9.0 days, p<0.001). Amongst all hospitalized, the percentage of patients who required ICU was greater for COPD patients with COVID-19 than that for non-COPD patients (26.4% vs 16.11%, p<0.001). In addition, mechanical ventilation use was higher in COPD vs non-COPD COVID-19 patients (26.4% vs 16.11%, p<0.001) Moreover, the percentage of patients who died in 30 days was greater for COPD than that for non-COPD COVID-19 patients (13.6% vs 7.25%, p<0.0001). Discussion. Patients with COPD and COVID-19 have worse outcomes compared to non-COPD COVID-19 patients.

Determination of cause of death during COVID-19 pandemic

Introduction: The United States has reported 13 million patients infected with SARS-CoV-2 and more than 270,000 deaths. Currently, controversy exists regarding the cause of death due to SARS-CoV-2 that is directly related to the infection or to a co-existing condition. Objective: Assess the relationship of SARS-CoV-2 infection on the cause of death in hospitalized patients. Methods: We reviewed hospital discharge summaries of patients admitted to the University of Texas Medical Branch from 3/10/2020 to 10/22/2020, with positive nasopharyngeal SARS-CoV-2 nucleic acid assay test results that expired during their hospitalization. Deidentified discharge summaries were reviewed by 2 intensivists and classified as 1) COVID-19 related, 2) COVID-19 unrelated, or 3) indeterminate. COVID-19 related cause of death was defined as a patient with acute respiratory symptoms and radiographic findings of lower respiratory tract disease requiring oxygen or mechanical ventilation. Deaths not related to COVID-19 were defined as absence of acute respiratory symptoms and radiographic findings. An indeterminate cause of death was defined as acute respiratory failure symptoms without radiographic findings. For classification disagreement, a separate group of three intensivists arbitrated to determine the cause of death. Demographics, comorbidities, prescribed medications, and ventilatory support data were collected. Comparison between COVID-19 related death group and COVID-19 unrelated death group was performed with t-test and Chi-square test. Results: We identified 15,393 patients with positive polymerase chain reaction (PCR) results for SARS-CoV-2 nucleic acid. 1052 patients were admitted within 14 days of positive test results and 100 patients expired during hospitalization. Case fatality rate was 0.65% for the total cohort and 9.5% for the hospitalized group. Hospitalized patients were predominantly male and >65 years (Table 1). Obesity (BMI>30) was present in 38% and common comorbidities were hypertension (47%), diabetes (30%) and heart failure (20%). Cause of death was classified as COVID-19 related in 85% and not COVID-19 related in 5%. The cause of death was indeterminate in 10% due to insufficient information or atypical presentation. Dexamethasone was more frequently prescribed to the COVID-related death group (p=0.0009). No differences in supplemental oxygen or mechanical ventilation were observed between groups. Length of stay was significantly greater in the COVID-19 related death group compared to the COVID-19 unrelated death group (14.21 vs 8.2 days, p=0.005). Conclusion: In hospitalized patients with SARS-CoV-2 infection, a direct cause of death was attributed to COVID- 19 in 85% of patients while an additional 10% had an atypical presentation.

Association of smoking status with severe COVID-19

Rationale. The association between smoking status and severe Coronavirus Disease-2019 (COVID-19) remains controversial. To assess the risk of 14-day hospitalization, as a marker of severe COVID-19, in patients who are ever-smokers and tested positive for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) compared to those who are never smokers and tested positive for the virus in a single academic health system in the United States. Methods. We conducted a retrospective cohort study of patients who tested positive for SARS-CoV-2 in the University of Texas Medical Branch Health System between March 1st and October 30th 2020 to identify the risk of 14-day hospitalization in ever-smokers compared to non-smokers. Results. In our study period, we identified 5,738 patients who met the inclusion criteria and had documentation of smoking habits. Out of this group, 636 (11%) were consider to be ever-smokers. One hundred and ninety one patients were current smokers and 445 were former smokers. Of the 5,738 patients, 35.1% were male, average age was 43.8 (SD± 17.6), 37.4% were Caucasian, 51.5% were obese (BMI≥30), 3.19 % had vaping history, and 76.5% had at least one comorbidity. We identified 624 (10.8%) patients who were admitted in 14 days and 49(0.8%) who died in 14 days during hospitalization. The percentage of ever smokers admitted in 14 days was greater than that of never smokers (17.9% vs 10%, p<0.0001). In addition, the percentage of smokers who died in 14 days was greater than that of never smokers (2.8% vs 0.6%, p<0.0001). However, after adjusting for other covariates the odds for 14-day hospitalization among ever smokers with COVID-19 was not significant (OR 0.96, 95% CI 0.7-1.2). Conclusions. In our single center study, smoking status was not associated with severe COVID-19 infection.

Prevalence and factors associated with depression and anxiety among medical trainees in the united states during coronavirus disease 2019 (covid-19) pandemic

Rationale: Medical trainees are at risk of psychological and emotional distress during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to assess the prevalence and explore the factors associated with depression and anxiety among medical trainees taking care of patients with COVID-19 in the United States (US). Methods: The study is cross-sectional, anonymous, web-based survey of medical trainees distributed in the US via email and social media between April 14, 2020 and May 5, 2020. Participants were stratified based on whether they were in a residency or fellowship program. Practice settings were stratified based on hospital type (academic or community-based) and location. Study outcomes were prevalence and factors associated with depression and anxiety using the 9-item Patient Health Questionnaire (PHQ-9;range: 0- 27) and the 7-item Generalized Anxiety Disorder (GAD 7;range 0-21) questionnaires, respectively. Univariate analysis utilizing summary statistics and Chi-square test were performed to show the association of covariates with outcomes. We performed a multivariate analysis with logistic regression for each outcome. A p-value < 0.05 was considered significant. Results: In all, 239 trainee submitted surveys, predominantly females (51.9%), aged 31-40 (52.3%), and non-Hispanic White (59.8%). Overall, the prevalence for both depression and anxiety was 45.6%. Higher likelihood of depression and anxiety was observed among medical trainees who have COVID-19 exposure, those uncomfortable with infection control policies, and those not provided adequate PPE. Trainees who reported increased stress due to didactics, and those who had continued didactics once a week, also had a higher likelihood of depression and anxiety. Depression alone was more common in those who provided service in emergency department (ED).Multivariate analysis (Table 1) revealed greater odds of depression among females (odds ratio [OR] = 1.95;95% confidence interval [CI] = 1.01-3.74), and those who reported increased stress due to didactics (OR = 4.1;95% CI = 2-8.4). Similarly increased odds for anxiety were observed among medical trainees, and those who reported increased stress due to didactics (OR = 2.6;95% CI = 1.3-5.2). Conclusion: The majority of trainees surveyed had a high burden of depression and anxiety early in the COVID- 19 pandemic in the US, which was associated with increased stress due to didactics. Organizations and institutions will need to develop preventive and management strategies to optimize and sustain the mental health of medical trainees, particularly under pandemic conditions.

Smoking and risk of COVID-19 hospitalization

RATIONALE: The association between smoking status and severe Coronavirus Disease 2019 (COVID-19) remains controversial. OBJECTIVE: To assess the risk of hospitalization (as a marker of severe COVID-19) in patients by smoking status: former, current and never smokers, who tested positive for the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV2) at an academic medical center in the United States. METHODS: We conducted a retrospective cohort study in patients with SARS-COV2 between March-1-2020 and January-31-2021 to identify the risk of hospitalization due to COVID-19 by smoking status. RESULTS: We identified 10216 SARS-COV2-positive patients with complete documentation of smoking habits. Within 14 days of a SARS-COV2 positive test, 1150 (11.2%) patients were admitted and 188 (1.8%) died. Significantly more former smokers were hospitalized from COVID-19 than current or never smokers (21.2% former smokers;7.3% current smokers;10.4% never smokers, p<0.0001). In univariable analysis, former smokers had higher odds of hospitalization from COVID-19 than never smokers (OR 2.31;95% CI 1.94-2.74). This association remained significant when analysis was adjusted for age, race and gender (OR 1.28;95% CI 1.06-1.55), but became non-significant when analysis included Body Mass Index, previous hospitalization and number of comorbidities (OR 1.05;95% CI 0.86-1.29). In contrast, current smokers were less likely than never smokers to be hospitalized due to COVID-19. CONCLUSIONS: Significantly more former smokers were hospitalized and died from COVID-19 than current or never smokers. This effect is mediated via age and comorbidities in former smokers.