The Pem/Pese Activity Questionnaire: A Novel Health-Related Quality of Life Measure for Post-Exertional Disablement

PURPOSE/HYPOTHESIS: Physical therapy practice depends on valid and reliable patient reported outcomes measures (PROMs). Post exertional malaise (PEM) and post exertional symptom exacerbation (PESE) are features of myalgic encephalomyelitis, Long Covid, and related conditions. They comprise a constellation of symptoms and signs including profound physical fatigue. Existing fatigue-specific instruments often are inappropriate to measure functional effects of accompanying symptoms and signs and demonstrate substantial floor effects. The purpose of this study was to determine the psychometric properties of a novel PROM for people living with PEM/PESE, the PEM/PESE Activity Questionnaire (PAQ). NUMBER OF SUBJECTS: 981 people living with PEM/PESE who completed a web-based questionnaire. MATERIALS AND METHODS: Respondents chose a function from a dropdown menu, consisting of the International Classification of Function core set for myalgic encephalomyelitis, and rated it on 2 different 0 to 10 scales. Each scale was anchored at 0 being Completely unable to perform, and 10 being Can perform at the same level as a time I have good energy and Can perform at the same level as before I became ill, respectively. Respondents also provided an estimate of effort intensiveness on a 0 to 10 scale, anchored at 0 being the activity took No time, effort, and resources at all and 10 being All of my time, effort, and resources. Respondents took the PAQ twice;they completed a demographic questionnaire after the first PAQ and before the second PAQ. Backward navigation was disabled so respondents could not view the first PAQ while completing the second PAQ. Descriptive statistics were calculated for the participants who completed versus did not complete the entire survey. Subgroup analyses by completion status and function were undertaken by chisquare analysis for binomial variables and one-way analysis of variance for continuous variables. Intraclass correlation coefficients were calculated for each scale to assess testretest reliability. Floor effects were the proportion of participants reporting the lowest score. RESULT(S): 981 surveys were available for analysis, including 675 complete surveys. All participants reported PEM/PESE. Respondents reported less frequent flu-like symptoms and pain, shorter recovery times after physical activity (i.e., less than 24 hours), and lower thresholds for physical and mental fatiguability than respondents who did not complete the survey (P< 001). Activities most frequently chosen for rating were Carry out my normal routine, Prepare meals, and Maintain employment for financial reward. Test-retest reliability was generally fair to excellent, depending on function and scale. Floor effects were noted in 9.2% to 24.7% of responses, also with notable variation based on function and scale. CONCLUSION(S): The PAQ provides valid, reliable, and sensitive outcome measure for people living with PEM/PESE. Survey completion may be limited by severity of PEM/PESE. CLINICAL RELEVANCE: Physical therapists could use the PAQ to assess illness severity and intervention efficacy for people living with PEM/PESE.

Evaluation of the impact of an oncology urgent care clinic on preventable emergency department visits

Background: OP-35 is a publicly reported quality metric aimed at reducing preventable emergency department (ED) visits and hospitalizations in patients with cancer on chemotherapy. During the COVID- 19 surge, one academic medical center opened the Respiratory Emergent Evaluation Service (REES) Unit, an urgent care clinic for patients with cancer and symptoms of COVID-19. In addition to preventing potential COVID-19 exposures in the clinic, this oncology-staffed urgent care evaluated patients who may have otherwise presented to the ED. We investigated the association between the REES urgent care clinic and patient ED evaluations for OP-35 diagnoses. Method(s): This single center retrospective analysis included patients with cancer receiving infusion and oral chemotherapy who presented to the ED within 30 days of treatment. ED visits occurred between 1/2019-12/2021, including when the REES unit was open (3/2020-6/2021). Preventable ED visits were defined as having one of ten primary diagnoses, which have been identified by OP-35. Of these, COVID-related diagnoses included fever, pneumonia, sepsis, neutropenia and diarrhea. Interrupted time series analyses were utilized to investigate the association between the REES unit opening and preventable ED visits. Result(s): 3,107 patients on chemotherapy were assessed in the ED from 1/2019-12/2021. Per week, there were 19.9 ED visits, 39.7% of which were for OP-35 diagnoses. When the REES unit opened, there was a 30% (95% CI -53% to -7%) reduction in preventable ED visits, corresponding to 2.62 (95% CI -4.61 to -0.63) fewer preventable ED evaluations per week. The primary driver of this reduction were presentations for COVID- related diagnoses, as there were 38% (95% CI -76% to -0.3%) fewer preventable ED visits weekly. During this period, there were approximately 6.9 patient visits per week to the REES unit. Conclusion(s): The introduction of an oncology urgent care clinic focusing on patients with symptoms of COVID-19 was associated with a reduction in potentially preventable ED visits. This analysis demonstrates the potential value of oncology urgent care clinics in reducing ED overcrowding and decreasing OP-35 related evaluations, which has patient experience, infection exposure and financial implications.

Trends in Patients at Risk for Prolonged Mechanical Ventilation, 2011-2019

Rationale Patients receiving what has been termed “prolonged acute mechanical ventilation” (PAMV, i.e. mechanical ventilation [MV] >96 hours) consume a disproportionate share of hospital and post-acute resources, and a third progress to prolonged mechanical ventilation (MV>14-21 days). Prior estimates (based on 2000-2008 annual growth rates) projected that the incidence of PAMV in 2020 could overwhelm healthcare systems. However, actual trends in incidence and outcomes of PAMV in the last decade, especially just preceding the COVID-19 pandemic, are unclear. Methods Using Medicare Provider Analysis and Review and Master Beneficiary Summary Files from the Center for Medicare and Medicaid Services, we conducted a retrospective cohort study of Medicare fee-for-service beneficiaries >65 years hospitalized between January 1, 2011- December 31, 2019 with admission to an intensive care unit (ICU) who received PAMV (MV>96 hours [ICD-9 96.72 or ICD-10 5A1955Z procedure codes]). We determined annual rates of PAMV out of total MV (ICD-9 96.7, 96.71, 96.72;ICD10 5A1935Z, 5A1945Z, 5A1955Z) and used US Census Bureau population estimates of adults >65 years to derive annual populationstandardized rates of PAMV. Among patients receiving PAMV, we determined annual rates of tracheostomies, median hospital and ICU length of stay, discharge destination, and 90-day and 1-year mortality. We tested for significant trends with Cochrane- Armitage (binary), Cochran-Mantel-Haenszel (categorical) and Jonckheere-Terpstra (continuous outcomes) tests. Results From 2011-2019, a total of 646,677 patients met inclusion criteria. Population-standardized incidence of PAMV decreased from 189 per 100,000 adults >65 years to 112 per 100,000 adults (78,504 to 60,625 individuals, p<0.001), concurrent with a decrease in the total MV population (210,791 to 189,414) and decrease in proportion of PAMV/MV (37% to 32%) (Figure 1). Tracheostomy rates among patients receiving PAMV declined from 21% to 17.5% (p<0.001). Median ICU and hospital length of stay declined from 13 to 12 days (p<0.001) and 16 to 15 days (p<0.001), respectively. Discharge to long-term acute care hospitals was stable at ∼17%;discharge to skilled nursing facilities decreased from 22% to 20% and discharge to hospice increased from 7% to 10% (p<0.001). 90-day mortality increased slightly (61.2% to 62.3% [p=0.01]);1-year mortality remained stable (∼72% [p=0.19]). Conclusions Contrary to prior estimates, the incidence of PAMV declined from 2011-2019. Furthermore, tracheostomy placement and skilled nursing facility use declined with a concurrent increase in hospice use, trends that may reflect improved alignment with patient goals of care. The impact of COVID-19 on incidence of PAMV is unclear. (Figure Presented).

Hospital-Level Availability of Prone Positioning, 2019 vs 2021

Rationale. Prone positioning (PP) of patients with moderate-severe acute respiratory distress syndrome (ARDS) is an evidence-based and guideline-recommended practice, but our 2019 survey found that fewer than half of Massachusetts ICUs could routinely offer PP. As studies have described rapid adoption of evidence- and nonevidence- based practices alike during COVID-19, we re-surveyed Massachusetts ICUs in 2021 to determine if institutional-level adoption of PP among intubated patients had changed during the COVID-19 pandemic;we additionally ascertained adoption of awake PP. Methods. In follow-up to our 2019 survey, we surveyed intensive care units (ICUs) at all acute-care hospitals in Massachusetts, June-October 2021. The survey asked: “Does your ICU have the ability to prone intubated patients?” (“Yes, routinely,” “Case-by-case,” or “No”). Follow-up questions inquired if ICUs had protocols/guidelines on intubated PP, trained nurses in intubated PP, and whether awake PP had been adopted. We collected descriptive hospital data (number of ICU and hospital beds, nonprofit status, teaching status, case-mix index) and tested for associations with chi-square tests. Results. Of the 57 acute care hospitals in Massachusetts with ICUs, 47 responded to the survey (82% response;compared to 54/60 [90%] in 2019;three hospitals surveyed in 2019 had closed ICUs in 2021). The number of hospitals able to routinely perform PP in intubated patients increased from 24 (44%) to 39 (83%);hospitals able to perform PP among intubated patients on a case-by-case basis or not at all decreased from 15 (28%) to 5 (11%) and 15 (28%) to 3 (6%), respectively (p<0.001) (Figure 1). ICUs with a protocol/guideline for intubated PP increased from 27 (50%) to 43 (92%) (p< 0.001);ICUs that had trained some or all nurses in intubated PP increased from 34 (63%) to 45 (96%) (p<0.001). In contrast to 2019, in 2021 there were no associations between availability of intubated PP and hospital/ICU bed number, teaching status, nonprofit status, or case-mix index. In 2021, 43 (92%) of Massachusetts ICUs had adopted awake PP, 19 of whom had not adopted routine PP of intubated patients in 2019, and 4 of whom had not adopted intubated PP in 2021. Conclusions. There was a significant increase in the proportion of Massachusetts ICUs that had adopted evidence-based, guideline-recommended PP in intubated patients by 2021. At the same time, almost all ICUs also adopted non-evidence-based PP in awake patients. Our results illustrate that factors other than available evidence play a large role in practice adoption.

Quantifying the impact of COVID-19 on cancer care: Pathology volume change in SEER cancer registries

The COVID-19 pandemic has interrupted oncology services including screening, diagnosis, and treatment. In this study pathology services were investigated as a proxy for cancer screening, diagnosis, and treatment delays to assess the effect of the pandemic on oncology services. In order to quantify the impact of COVID-19 we reviewed all pathology reports from January 1 through November 30 in 2018, 2019, and 2020 from 5 central registries in the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program. Using the SEER Data Management System and SAS, pathology reports were counted by cancer site (breast, lung, colorectal, prostate, other), patient age category (<50, 50-64, 65-74, >75 years), bi-weekly collection interval, and registry. Only pathology laboratories with monthly electronic reporting to their central registry throughout the study period were included. The reporting counts from 2020 were compared to those of the prior two years. In comparison to the 2019 baseline volume, March through November 2020 had an 11.2% decrease in pathology volume (48,779 fewer reports) in the 5 central registries. Over 75% of this decrease in volume occurred over a 10-week period, March through May 2020, with 30.2% fewer (37,127 reports) than expected pathology reports during this initial peak of the COVID-19 pandemic. The maximum bi-weekly decrease observed was 41.7% (>10,000 reports) from the 2019 baseline, which occurred in April 2020. During this 10-week period the decrease in volume by age category ranged 29.6-32.2%, cancer site ranged 27.5-39.1% and central registry ranged 26.1-36.8%. Two additional periods of volume decrease also occurred, both of shorter duration and magnitude, mid-July through August and mid-October through mid-November. Since the onset of the pandemic there remains a deficit (>11%) in the expected pathology volume compared to 2019, reflecting the continued impact of COVID-19 across oncology services. The majority of the pathology volume decrease in 2020 occurred during the initial peak of the COVID-19 pandemic. This period of decreased reporting volume along with two smaller decreases align with the 3 peaks of COVID-19 new cases reported by the CDC COVID Data Tracker. Prior to the onset of the pandemic the 2020 volume started at a bi-weekly rate greater than 2019, and the 2019 volume was consistently greater than 2018. Therefore, the 2020 expected values would be greater than those of the 2019 comparison year, i.e., the volume decreases reported would likely represent conservative estimates of the actual volume decrease. Continued longitudinal monitoring and the addition of more registries to this analysis are planned as well as pathology report type categorization (screening, surveillance, or treatment). This study also demonstrates the ability of the NCI SEER program to assist with near real time reporting of cancer data in quantifying the effect on the healthcare system of the COVID-19 pandemic.

Prioritized Access to COVID-19 Vaccines among Vulnerable Communities Increases Vaccination Rates

Background. Based on national recommendations,1 Beth Israel Lahey Health (BILH) in Eastern Massachusetts (MA) prioritized vulnerable communities in our distribution of COVID-19 vaccines. We hypothesized that creating prioritized access to appointments for patients in these communities would increase the likelihood vaccination. Methods. The BILH health system sent vaccine invitations first to patients of two clinics in vulnerable neighborhoods in Boston (Wave 1), followed by other patients from vulnerable communities (Wave 2) up to 1 day later, and then by all other patients (Wave 3) after up to 1 more day later. To identify whether early access/prioritization increased the likelihood of receipt of vaccine at any site or a vaccine at a BILH clinic, we compared patients in Wave 1 in a single community with high cumulative incidence of COVID-19 (Dorchester) to patients in Wave 2 during a period of limited vaccine access, 1/27/21-2/24/21. Each wave was modeled using logistic regression, adjusted for language and race. By taking the difference between these two differences, we are left with the impact of early vaccination invitation in Wave 1 for a subset of our most vulnerable patients (termed difference-in-differences;Stata SE 16.0). Results. In our study of Waves 1 and 2, we offered vaccinations to 24,410 patients. Of those, 6,712 (27.5%) scheduled the vaccine at BILH (Table 1). Patients in Wave 1 were much more likely to be vaccinated at BILH than patients in Wave 2. Patients offered the vaccine in Wave 1 and living in Dorchester were 1.7 percentage points more likely to be vaccinated at all (p=0.445) and 9.4 percentage points more likely to be vaccinated at BILH than another site in MA (p-value = 0.001), relative to patients living outside of Dorchester and offered the vaccine in Wave 2 (Table 2). The coefficient of interest is on Wave1∗Dorchester, 0.094. This indicates that residents of Dorchester who were offered the vaccine in Wave 1 were 9.4 percentage points more likely to receive the vaccine at BILH, given that they were vaccinated, relative to patients living outside of Dorchester and offered the vaccine in Wave 2. Conclusion. Patients residing in an urban community given prioritized access to vaccination had a higher likelihood of vaccination at our health system, given that they were vaccinated, than patients in other urban communities without prioritized access. We provide an example of a successful effort to move towards equity in access to COVID-19- vaccines, in contrast to larger national trends.2,3 Health systems can use a prioritization approach to improve vaccination equity.

Piezoelectric Nanofiber Membrane for Reusable, Stable, and Highly Functional Face Mask Filter with Long-Term Biodegradability

The emergence of the SARS-CoV-2 pandemic and airborne particulate matter (PM) pollution has led to remarkably high demand for face masks. However, conventional respirators are intended for single use and made from nondegradable materials, causing serious concern for a plastic-waste environmental crisis. Furthermore, these facemasks are weakened in humid conditions and difficult to decontaminate. Herein, a reusable, self-sustaining, highly effective, and humidity-resistant air filtration membrane with excellent particle-removal efficiency is reported, based on highly controllable and stable piezoelectric electrospun poly (l-lactic acid) (PLLA) nanofibers. The PLLA filter possesses a high filtration efficiency (>99% for PM 2.5 and >91% for PM 1.0) while providing a favorable pressure drop (≈91 Pa at normal breathing rate) for human breathing due to the piezoelectric charge naturally activated by respiration through the mask. The filter has a long, stable filtration performance and good humidity resistance, demonstrated by a minimal declination in the filtration performance of the nanofiber membrane after moisture exposure. The PLLA filter is reusable via common sterilization tools (i.e., an ultrasonic cleaning bath, autoclave, or microwave). Moreover, a prototype of a completely biodegradable PLLA nanofiber-based facemask is fabricated and shown to decompose within 5 weeks in an accelerated degradation environment. © 2022 Wiley-VCH GmbH

Angiotensin-converting enzyme-2(ACE2) expression in pediatric liver disease

Background: Angiotensin-converting enzyme-2 (ACE2) is a cell membrane protein that helps regulate blood pressure and inflammation. It has also gained recent notoriety as the receptor SARS-CoV-2 uses to invade human cells. While ACE2 has been shown to have moderate expression within the liver, prior research is mostly limited to animal models and the role of ACE2 in pediatric liver disease has not been discerned. Here we aim to analyze ACE2 expression in children with immune-mediated liver diseases, to better understand its evolving presence and utility in chronic liver disease as well as shed light on COVID-19's potential effects within the liver. Methods: Immunofluorescent staining of paraffin-fixed liver biopsy tissues of patients with autoimmune hepatitis and primary sclerosing cholangitis was done with ACE2-specific antibodies along with healthy controls. Cholangiocyte and nuclear antibody markers were concurrently added. ACE2 expression was analyzed by confocal microscopy. Computational deep learning-based segmentation models, StartDist and Cellpose, identified individual nuclei and cells within the tissue. Individual masks were generated for nuclei and cells using Fiji. Input from these masks in CellProfiler was used to quantify cellular, cytosolic, and nuclear mean IF intensity in samples. Additionally, state-of-the-art spatial transcriptomics technology was used to provide high throughput gene expression analysis in intact tissue section determining the cellular composition for ACE2 expression. Finally, an ACE2 enzyme-linked immunosorbent assay (ELISA) was used to quantify ACE2 serologic expression in patients and controls. Results: ACE2 showed clear and specific expression in all the liver biopsy specimens which were verified with nonspecific staining and negative controls. Computational deep machine learning effectively identified distinct cell and nuclear membranes, allowing for separate nuclear and cytosolic analysis. High ACE2 expression was evident at the apical surface of cholangiocytes for both patients and controls. Relatively lower expression was seen within the cytosol and nuclei of hepatocytes and hepatic lymphocytes. Children with immune-mediated liver diseases were found to have overall higher mean hepatic expression of ACE2 than controls (p<0.01). No significant differences were seen in serologic ACE2 expression. Spatial transcriptomics identified cell composition of ACE2 expressing spots containing antibody-secreting cells and was different as compared to the other spots. Conclusions: ACE2 expression is prevalent throughout the liver, with strong localization to cholangiocyte apical membranes as well as a presence within hepatocytes and immune cells. Machine learning can be used to rapidly identify hepatic cellular components for histologic analysis. ACE2 expression in the liver may be higher in pediatric immune-mediated liver disease. Future work will be directed to better understand the implications of hepatic ACE2 on COVID-19 presentation and clinical course.

Urine test predicts kidney injury and death in COVID-19

Background: Kidney injury is a common feature of COVID-19 infection, but serum creatinine (SCr) is not a sensitive or specific marker of kidney injury. We hypothesized that measurement of molecular markers of tubular injury can diagnose COVID-19 associated kidney injury and predict a poor prognosis. Methods: This is a prospective cohort study of 444 consecutive COVID-19 patients in a New York City Emergency Department recruited in March and April, 2020. Urine and blood were collected simultaneously at hospital admission (median time of day 0, IQR 0-2 days) and within 1 day of a positive SARS-CoV-2 test in 70% of patients. Urine NGAL and KIM-1 assays were blinded to clinical data. Primary outcomes included the diagnosis of Acute Kidney Injury (AKI) as defined by AKIN criteria, as well as its duration and severity. Secondary outcomes included death, dialysis, shock, respiratory failure, and length of hospital stay. Kidney biopsies from COVID-19 patients were examined for biomarker gene expression. Results: Elevated urinary NGAL (uNGAL) levels were associated with SCr based AKI (267±301 vs. 96±139 ng/mL, P=1.6x10-10). uNGAL level >150 ng/mL had 80% specificity and 75% sensitivity to diagnose AKIN stage 2 AKI or higher. Higher uNGAL levels were associated with sustained AKI [aOR per SD of uNGAL (95%CI): 2.67 (1.81-4.06), P=1.8x10-6], need for dialysis (aOR: 3.67 (1.89-7.57), P=2.2x10-4), shock (aOR: 1.64 (1.26-2.15), P=2.9x10-4), prolonged length of stay (aHR: 1.22 (1.09-1.36), P=4.8x10-4), and death [aOR=1.62 (1.19-2.24), P=2.5x10-3], independent of baseline SCr and pre-existing co-morbidities. These associations were also preserved after adjusting for proteinuria measured in the same urine sample. NGAL is typically transcribed by distal nephron segments but in COVID-19 kidney biopsies with widespread histopathologic acute tubular injury (ATI), NGAL mRNA expression included proximal tubules. Conclusions: Elevated uNGAL in patients admitted with acute COVID-19 was associated with the development of AKI, increased severity and duration of AKI, the degree of histopathological acute tubular injury, shock, prolonged hospitalization, need for dialysis, and death.

Association of the COVID-19 pandemic with patterns of cancer services

Background: The COVID-19 pandemic led to delays in medical care in the United States. We examined changes in patterns of cancer diagnosis and surgical treatment in 2020 using real-time electronic pathology report data from population-based SEER cancer registries in Georgia and Louisiana. Methods: Bi-weekly numbers, distributions, and patterns of pathology reports were compared between January 1 and December 31 in 2020 and the same period in 2019 by age group and cancer site. Results: During 2020, there were 29,905 fewer pathology reports than in 2019, representing a 10.2% decline. Absolute declines were greatest among adults aged ≥50 years (N=23,065);percentage declines were greatest among children and young adults ≤18 years (38.3%). By cancer site, percentage declines were greatest for lung cancer (17.4%), followed by colorectal (12.0%), breast (9.0%) and prostate (5.8%) cancers. Biweekly reports were statistically significantly lower in 2020 than in 2019 from late March through the end of December in most biweekly periods. The nadir was the month of April 2020 - the number of reports was at least 40% lower than in April 2019. The number of reports in 2020 compared with 2019 also declined sharply in early November (26.8%) and late December (32.0%). Numbers of reports in 2020 never consistently exceeded those in 2019 after the first decline. Patterns were similar by cancer site, with variation in magnitude and duration of declines. Conclusions: Significant declines in cancer pathology reports from population-based registries during 2020 suggest substantial delays in screening, evaluation of signs and symptoms, diagnosis, and treatment services for cancers with effective screening tests as well as in cancer sites and age groups without effective screening tests as an indirect result of the COVID-19 pandemic. Ongoing evaluation will be critical for informing public health efforts to minimize any lasting adverse effects of the pandemic on cancer screening, diagnosis, treatment, and survival.

Diabetic ketoacidosis and mortality in COVID-19 infection.

AIM: - Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients. METHODS: - Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19. RESULTS: - Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40-1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06-1.08) and need for pressors (HR 2.33, 95% CI 1.82-2.98). Glucocorticoid use was protective in patients with and without DKA. CONCLUSION: - The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

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.

Improving frequency of video-visits at a veterans affairs long term care facility: Value of the effort and lessons learned

Background During the COVID-19 pandemic, telemedicine has been used increasingly. Video visits are superior to phone visits through the addition of visual cues. Recent evidence highlights there are challenges associated with the use of this technology especially with older adults with physical or cognitive limitations. Hence, residents with comorbidities followed by subspecialists may have delays in care during the pandemic. This pilot study tested the feasibility of streamlining video visits for veterans in long term care facilities (LTCFs) Materials & Methods We surveyed appointments during the period of July-Sept 2020 for over 100 veterans in a Veterans Affairs LTCF. Barriers to telemedicine were identified by surveying staff and providers and a viable model for streamlining video visits for veterans was developed. Aiming to increase access to video visits, iPads were acquired through the VA. Staff were trained to set up and troubleshoot tele-visits. Subspecialists were notified of the video visit capability. The use of video visits is being tracked during the 2nd COVID surge. We will compare the number of video visits before and after our intervention and address challenges faced. Results During the first COVID surge in spring 2020 no video visits were conducted. Prior to our intervention and during the summer of 2020, we identified 121 in person visits to subspecialties, only 3 took place as video visits. After our intervention, we are assessing whether the number of video visits for nursing home residents is increasing. Detailed data will be presented during AGS 2021. Some of the challenges we are facing include suboptimal wi-fi reception, staff shortages and confidentiality issues. We are speculating that increasing the number of video visits will allow for decreased COVID exposure, decrease transportation expenses and improve appointment compliance. Conclusions Video visits are important during COVID surge to ensure veterans receive medical care in a safe and timely fashion. Results from this study will further inform the development of protocols for making video visits more accessible to this cohort.

COVID-19 outcomes among people with intellectual and developmental disability living in residential group homes in New York State.

BACKGROUND: People with intellectual and developmental disabilities (IDD) may be at higher risk of severe outcomes from COVID-19. OBJECTIVE: To describe COVID-19 outcomes among people with IDD living in residential groups homes in the state of New York and the general population of New York State. METHODS: Data for people with IDD are from a coalition of organizations providing over half of the residential services for the state of New York, and from the New York State Department of Health. Analysis describes COVID-19 case rates, case-fatality, and mortality among people with IDD living in residential group homes and New York State through May 28, 2020. RESULTS: People with IDD living in residential group homes were at greater risk of severe COVID-19 outcomes: case rates - 7,841 per 100,000 for people with IDD compared to 1,910 for New York State; case-fatality - 15.0% for people with IDD compared to 7.9% for New York State; and mortality rate - 1,175 per 100,000 for people with IDD compared to 151 per 100,000 for New York State. Differences in cases and mortality rate were confirmed across regions of the state, but case-fatality rate was only higher for people with IDD in and around the New York City region. CONCLUSIONS: COVID-19 appears to present a greater risk to people with IDD, especially those living in congregate settings. A full understanding of the severity of this risk will not be possible until US states begin publicly sharing all relevant data they have on COVID-19 outcomes among this population.