Free-living monitoring of ambulatory activity after treatments for lower extremity musculoskeletal cancers using an accelerometer-based wearable - a new paradigm to outcome assessment in musculoskeletal oncology?

PURPOSE: Ambulatory activity (walking) is affected after sarcoma surgery yet is not routinely assessed. Small inexpensive accelerometers could bridge the gap. Study objectives investigated, whether in patients with lower extremity musculoskeletal tumours: (A) it was feasible to conduct ambulatory activity assessments in patient's homes using an accelerometer-based wearable (AX3, Axivity). (B) AX3 assessments produced clinically useful data, distinguished tumour sub-groups and related to existing measures. METHODS: In a prospective cross-sectional pilot, 34 patients with musculoskeletal tumours in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) participated. Twenty-seven had limb-sparing surgery and seven amputation. Patients were assessed using a thigh-worn monitor. Summary measures of volume (total steps/day, total ambulatory bouts/day, mean bout length), pattern (alpha), and variability (S2) of ambulatory activity were derived. RESULTS: AX3 was well-tolerated and feasible to use. Outcomes compared to literature but did not distinguish tumour sub-groups. Alpha negatively correlated with disability (walking outside (r=-418, p = 0.042*), social life (r=-0.512, p = 0.010*)). Disability negatively predicted alpha (unstandardised co-efficient= -0.001, R2=0.186, p = 0.039*). CONCLUSIONS: A wearable can assess novel attributes of walking; volume, pattern, and variability after sarcoma surgery. Such outcomes provide valuable information about people's physical performance in their homes, which can guide rehabilitation. Implications for rehabilitationRoutine capture of ambulatory activity by sarcoma services in peoples' homes can provide important information about individuals "actual" physical activity levels and limitations after sarcoma surgery to inform personalised rehabilitation and care needs, including timely referral for support.Routine remote ambulatory monitoring about out of hospital activity can support personalised care for patients, including identifying high risk patients who need rapid intervention and care closer to home.Use of routine remote ambulatory monitoring could enhance delivery of evidence-based care closer to peoples' homes without disrupting their daily routine and therefore reducing patient and carer burden.Collection of data close to home using questionnaires and objective community assessment could be more cost effective and comprehensive than in-hospital assessment and could reduce the need for hospital attendance, which is of importance to vulnerable patients, particularly during the Covid-19 pandemic.

One year later: How outcomes of hip fractures treated during the "first wave" of the COVID-19 pandemic were affected.

The purpose of this study was to assess the impact of COVID-19 on long-term outcomes in the geriatric hip fracture population. We hypothesize that COVID + geriatric hip fracture patients had worse outcomes at 1-year follow-up. Between February and June 2020, 224 patients > 55 years old treated for a hip fracture were analyzed for demographics, COVID status on admission, hospital quality measures, 30- and 90-day readmission rates, 1-year functional outcomes (as measured by the EuroQol- 5 Dimension [EQ5D-3L] questionnaire), and inpatient, 30-day, and 1-year mortality rates with time to death. Comparative analyses were conducted between COVID + and COVID- patients. Twenty-four patients (11%) were COVID + on admission. No demographic differences were seen between cohorts. COVID + patients experienced a longer length of stay (8.58 ± 6.51 vs. 5.33 ± 3.09, p < 0.01) and higher rates of inpatient (20.83% vs. 1.00%, p < 0.01), 30-day (25.00% vs. 5.00%, p < 0.01), and 1-year mortality (58.33% vs. 18.50%, p < 0.01). There were no differences seen in 30- or 90-day readmission rates, or 1-year functional outcomes. While not significant, COVID + patients had a shorter average time to death post-hospital discharge (56.14 ± 54.31 vs 100.68 ± 62.12, p = 0.171). Pre-vaccine, COVID + geriatric hip fracture patients experienced significantly higher rates of mortality within 1 year post-hospital discharge. However, COVID + patients who did not die experienced a similar return of function by 1-year as the COVID- cohort.

COVID-19 independently predicts poor outcomes in Acute Ischemic Stroke- Insights from a multicenter study from Pakistan and United Arab Emirates.

BACKGROUND: Ischemic stroke associated with coronavirus 2019 (COVID-19) has been well recognized by now. Few studies have compared COVID related versus unrelated strokes. We intend to report on a large group of Asian patients from two countries and compare COVID with non-COVID strokes admitted during the same time period. METHODS: Consecutive cases of acute ischemic stroke either presenting or developing, between March 2020 and December 2021 in four tertiary care hospitals (1 in Dubai, UAE and 3 in Karachi, Pakistan) and testing positive for COVID-19 were included in the study. Patients admitted with ischemic stroke during the same time period and who tested negative for COVID-19 were also randomly selected from the four hospitals. All data was collected from the medical records of the patients and recorded on a standard questionnaire before it was entered in SPSS version 21 for analysis. RESULTS: There were 139 COVID positive and 271 COVID negative patients with acute ischemic stroke included in the current study. There were significantly more males (80.6% vs 64.9%, p=0.001) and more large vessel strokes in the COVID positive group (41% vs 21.8%, p<0.001). Being COVID positive was an independent predictor of poor outcome at discharge, defined as a modified Rankin score of 3-6 (OR 3.87, 95% CI 2.21-6.77) after adjusting for country, age, sex, vascular comorbid conditions and stroke subtype. CONCLUSIONS: In this largest series of patients with COVID related strokes from Asia, COVID-19 was an independent predictor of poor outcomes at discharge after adjusting for other variables.

Reliability of Machine Learning in Eliminating Data Redundancy of Radiomics and Reflecting Pathophysiology in COVID-19 Pneumonia: Impact of CT Reconstruction Kernels on Accuracy

Background: Radiomical data are redundant but they might serve as a tool for lung quantitative assessment reflecting disease severity and actual physiological status of COVID-19 patients. Objective: Test the effectiveness of machine learning in eliminating data redundancy of radiomics and reflecting pathophysiologic changes in patients with COVID-19 pneumonia. Methods: We analyzed 605 cases admitted to Al Ain Hospital from 24 February to 1 July, 2020. They met the following inclusion criteria: age $\geq 18$ years;inpatient admission;PCR positive for SARS-CoV-2;lung CT available at PACS. We categorized cases into 4 classes: mild < 5% of pulmonary parenchymal involvement, moderate - 5-24%, severe - 25-49%, and critical $\geq50$ %. We used CT scans to build regression models predicting the oxygenation level, respiratory and cardiovascular functioning. Results: Radiomical findings are a reliable source of information to assess the functional status of patients with COVID-19. Machine learning models can predict the oxygenation level, respiratory and cardiovascular functioning from a set of demographics and radiomics data regardless of the settings of reconstructionkernels. The regression models can be used for scoring lung impairment and comparing disease severity in followup studies. The most accurate prediction we achieved was 6.454 +/- 3.715% of mean absolute error/range for all thefeatures and 7.069 +/- 4.17% for radiomics.Conclusion:The models may contribute to the proper risk evaluation anddisease management especially when the oxygen therapy impacts the actual values of the functional findings. Still,the structural assessment of an acute lung injury reflects the severity of the disease.

Cloud Nine: A Population Study of Sleep During the COVID-19 Pandemic

Introduction: In this study, we aimed to evaluate how the COVID-19 pandemic has affect sleep patterns. To do this, we used the Functional Outcomes of Sleep Questionnaire (FOSQ10) tool among the general US population. Method(s): A Qualtrics survey containing the FOSQ10 questions and additional demographics was created for Amazon MTurk, a crowdsourcing platform. Respondents aged 18 years and older completed the survey anonymously in October 2021. Two-way analysis of variance and 2-tailed t tests were used for analyses. Result(s): A total of 2474 responses were included. The 3 most prevalent sleep disorders were snoring (48% of respondents), insomnia (11% of respondents), and sleep apnea/mild/ moderate/severe (6% of respondents). The 3 most common services and/or procedures that people indicated interest in were sleep study (32% of respondents), nasal appliance (28% of respondents), or oral appliance (22% of respondents). The 3 most common social media platforms used before bed were Facebook (48% of respondents), Instagram (47% of respondents), and YouTube (39% of respondents). Individuals who had COVID-19 had a lower average FOSQ10 score than those who did not (27.0+/-6.4 [SD] vs 29.2+/-7.2), P<.0001. Individuals who snore had a lower average FOSQ10 score than those who do not (27.6+/-6.6 vs 29.4+/-7.4), P<.0001. Individuals who had a romantic partner or family member complain about their sleeping pattern (restlessness, snoring, etc) had a lower average FOSQ10 score than those who do not (27.1+/-6.5 vs 30.0+/-7.3), P<.0001. Individuals who have seen an otolaryngologist about snoring or any other sleep-related problems had a lower average FOSQ10 score than those who have not (26.7+/-6.0 vs 29.4+/-7.4), P<.0001. Conclusion(s): A higher score on the FOSQ10 was found to be associated with better sleep outcomes. It is an appropriate tool for assessing functional outcomes of sleep in the US population and can be used by otolaryngologists to better understand and treat patients with impaired sleep.

Influence of vitamin D levels on outcomes and nosocomial COVID-19 infection in patients undergoing total knee arthroplasty- a cohort study.

Purpose: This study aimed to audit the effects of vitamin D3 on the early functional outcomes, the incidence of nosocomial COVID-19 infection and complications in patients undergoing elective Total Knee Arthroplasty (TKA). Methods: This was a retrospective study involving patients undergoing primary unilateral TKA between January 2020 to May 2021 operated by a single surgeon using a single implant. Participants were divided into two cohorts, Deficient-vitamin D3 level <20 ng/ml and Sufficient-vitamin D3 level ≥20 ng/ml. Assessment for Knee Society Score and Oxford Knee Score (OKS) was done preoperatively and one year after TKA. Nosocomial COVID-19 infection rate, 30-day re-admissions and complications were noted during the study. Results: 235 patients were divided into 2 cohorts matched by age, gender and ASA grades. 74 patients belonged to the deficient group and 161 belonged to the sufficient group. The mean preoperative scores in the sufficient group were higher than the deficient group (OKS = 15.74 vs 12.95; KSS = 88.91vs 85.62). Similarly, the one-year postoperative scores in the sufficient group were significantly higher (OKS = 36.54 vs 35.16; KSS = 164.01 vs 161.22). A linear correlation was present between preoperative score (r = 0.273) & post-operative scores (r = 0.141) with serum vitamin D3 levels. Vitamin D3 deficient individuals had higher nosocomial COVID-19 infection rate (10.81% vs 4.96%,p = 0.16). The incidence of complications like DVT, embolism, stroke, infection and fracture were not statistically different in the two groups. Conclusion: Vitamin D positively influences the outcomes of TKA and protects against nosocomial COVID-19 infection in patients undergoing elective TKA.

Surgical treatment for fragility hip fractures during the COVID-19 pandemic resulted in lower short-term postoperative functional outcome and a higher complication rate compared to the pre-pandemic period.

The COVID-19 pandemic adversely affected the functional outcomes of fragility hip fracture patients. This study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among patients treated during the pandemic. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods. INTRODUCTION: This study aims to investigate the in-hospital complication rate and short-term postoperative functional outcomes of fragility hip fracture (FHF) patients compared between during the COVID-19 pandemic and the same 14-month time period 1 year prior to the pandemic. METHODS: Using data from the Siriraj Fracture Liaison Service registry, FHF patients treated during the COVID-19 pandemic (1 March 2020 to 30 April 2021) were time-matched with FHF patients treated during the pre-pandemic period (1 March 2018 to 30 April 2019). We collected the rate of in-hospital postoperative complications and the postoperative functional outcomes at discharge and 3 months as measured by the Barthel Index (BI) and EuroQol visual analog scale (EQ-VAS). Functional outcome measures were compared between the pre-pandemic and pandemic periods. RESULTS: There were 197 and 287 patients in the pre-pandemic and pandemic groups, respectively. At the 3-month postoperative follow-up, the mean postoperative BI score and change in BI score were both significantly lower in the pandemic group indicating poorer postoperative function. Moreover, FHF patients treated during the pandemic had significantly more in-hospital complications (36.6% vs. 22.8%, p = 0.002). There was no significant difference in the 3-month EQ-VAS or change in the EQ-VAS between groups. CONCLUSION: The results of this study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among FHF patients treated during the COVID-19 pandemic compared to the pre-pandemic period. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.

Result of one-year, prospective follow-up of intensive care unit survivors after SARS-CoV-2 pneumonia.

INTRODUCTION: Survivors of viral ARDS are at risk of long-term physical, functional and neuropsychological complications resulting from the lung injury itself, but also from potential multiorgan dysfunction, and the long stay in the intensive care unit (ICU). Recovery profiles after severe SARS-CoV-2 pneumonia in intensive care unit survivors have yet to be clearly defined. MATERIAL AND METHODS: The goal of this single-center, prospective, observational study was to systematically evaluate pulmonary and extrapulmonary function at 12 months after a stay in the ICU, in a prospectively identified cohort of patients who survived SARS-CoV-2 pneumonia. Eligible patients were assessed at 3, 6 and 12 months after onset of SARS-CoV-2. Patients underwent physical examination, pulmonary function testing, chest computed tomography (CT) scan, a standardized six-minute walk test with continuous oximetry, overnight home respiratory polygraphy and have completed quality of life questionnaire. The primary endpoint was alteration of the alveolar-capillary barrier compared to reference values as measured by DLCO, at 12 months after onset of SARS-CoV-2 symptoms. RESULTS: In total, 85 patients (median age 68.4 years, (interquartile range [IQR] = 60.1-72.9 years), 78.8% male) participated in the trial. The median length of hospital stay was 44 days (IQR: 20-60) including 17 days in ICU (IQR: 11-26). Pulmonary function tests were completed at 3 months (n = 85), 6 months (n = 80), and 12 months (n = 73) after onset of symptoms. Most patients showed an improvement in DLCO at each timepoint (3, 6, and 12 months). All patients who normalized their DLCO did not subsequently deteriorate, except one. Chest CT scans were abnormal in 77 patients (96.3%) at 3 months and although the proportion was the same at 12 months, but patterns have changed. CONCLUSION: We report the results of a comprehensive evaluation of 85 patients admitted to the ICU for SARS-CoV-2, at one-year follow-up after symptom onset. We show that most patients had an improvement in DLCO at each timepoint. TRIAL REGISTRATION: Clinical trial registration number: NCT04519320.

The impact of the COVID-19 pandemic on functional and mental health outcomes after trauma.

BACKGROUND: The COVID-19 pandemic has led to decreased access to care and social isolation, which have the potential for negative psychophysical effects. We examine the impact of the pandemic on physical and mental health outcomes after trauma. METHODS: Patients in a prospective study were included. The cohort injured during the pandemic was compared to a cohort injured before the pandemic. We performed regression analyses to evaluate the association between the COVID-19 pandemic and physical and mental health outcomes. RESULTS: 1,398 patients were included. In adjusted analysis, patients injured during the pandemic scored significantly worse on the SF-12 physical composite score (OR 2.21; [95% CI 0.69-3.72]; P = 0.004) and were more likely to screen positive for depression (OR 1.46; [1.02-2.09]; P = 0.03) and anxiety (OR 1.56; [1.08-2.26]; P = 0.02). There was no significant difference in functional outcomes. CONCLUSIONS: Patients injured during the COVID-19 pandemic had worse mental health outcomes but not physical health outcomes.

Fatigue and cognitive impairment in Post-COVID-19 Syndrome: A systematic review and meta-analysis.

IMPORTANCE: COVID-19 is associated with clinically significant symptoms despite resolution of the acute infection (i.e., post-COVID-19 syndrome). Fatigue and cognitive impairment are amongst the most common and debilitating symptoms of post-COVID-19 syndrome. OBJECTIVE: To quantify the proportion of individuals experiencing fatigue and cognitive impairment 12 or more weeks following COVID-19 diagnosis, and to characterize the inflammatory correlates and functional consequences of post-COVID-19 syndrome. DATA SOURCES: Systematic searches were conducted without language restrictions from database inception to June 8, 2021 on PubMed/MEDLINE, The Cochrane Library, PsycInfo, Embase, Web of Science, Google/Google Scholar, and select reference lists. STUDY SELECTION: Primary research articles which evaluated individuals at least 12 weeks after confirmed COVID-19 diagnosis and specifically reported on fatigue, cognitive impairment, inflammatory parameters, and/or functional outcomes were selected. DATA EXTRACTION & SYNTHESIS: Two reviewers independently extracted published summary data and assessed methodological quality and risk of bias. A meta-analysis of proportions was conducted to pool Freeman-Tukey double arcsine transformed proportions using the random-effects restricted maximum-likelihood model. MAIN OUTCOMES & MEASURES: The co-primary outcomes were the proportions of individuals reporting fatigue and cognitive impairment, respectively, 12 or more weeks following COVID-19 infection. The secondary outcomes were inflammatory correlates and functional consequences associated with post-COVID-19 syndrome. RESULTS: The literature search yielded 10,979 studies, and 81 studies were selected for inclusion. The fatigue meta-analysis comprised 68 studies, the cognitive impairment meta-analysis comprised 43 studies, and 48 studies were included in the narrative synthesis. Meta-analysis revealed that the proportion of individuals experiencing fatigue 12 or more weeks following COVID-19 diagnosis was 0.32 (95% CI, 0.27, 0.37; p < 0.001; n = 25,268; I2 = 99.1%). The proportion of individuals exhibiting cognitive impairment was 0.22 (95% CI, 0.17, 0.28; p < 0.001; n = 13,232; I2 = 98.0). Moreover, narrative synthesis revealed elevations in proinflammatory markers and considerable functional impairment in a subset of individuals. CONCLUSIONS & RELEVANCE: A significant proportion of individuals experience persistent fatigue and/or cognitive impairment following resolution of acute COVID-19. The frequency and debilitating nature of the foregoing symptoms provides the impetus to characterize the underlying neurobiological substrates and how to best treat these phenomena. STUDY REGISTRATION: PROSPERO (CRD42021256965).

A structured methodology review showed analyses of functional outcomes are frequently limited to "survivors only" in trials enrolling patients at high risk of death.

OBJECTIVE: This structured methodology review evaluated statistical approaches used in randomized controlled trials (RCTs) enrolling patients at high risk of death and makes recommendations for reporting future RCTs. STUDY DESIGN AND SETTING: Using PubMed, we searched for RCTs published in five general medicine journals from January 2014 to August 2019 wherein mortality was ≥10% in at least one randomized group. We abstracted primary and secondary outcomes, statistical analysis methods, and patient samples evaluated (all randomized patients vs. "survivors only"). RESULTS: Of 1947 RCTs identified, 434 met eligibility criteria. Of the eligible RCTs, 91 (21%) and 351 (81%) had a primary or secondary functional outcome, respectively, of which 36 (40%) and 263 (75%) evaluated treatment effects among "survivors only". In RCTs that analyzed all randomized patients, the most common methods included use of ordinal outcomes (e.g., modified Rankin Scale) or creating composite outcomes (primary: 41 of 91 [45%]; secondary: 57 of 351 [16%]). CONCLUSION: In RCTs enrolling patients at high risk of death, statistical analyses of functional outcomes are frequently conducted among "survivors only," for which conclusions might be misleading. Given the growing number of RCTs conducted among patients hospitalized with COVID-19 and other critical illnesses, standards for reporting should be created.

Outcomes of seizures, status epilepticus, and EEG findings in critically ill patient with COVID-19.

OBJECTIVE: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has a myriad of neurological manifestations and its effects on the nervous system are increasingly recognized. Seizures and status epilepticus (SE) are reported in the novel coronavirus disease (COVID-19), both new onset and worsening of existing epilepsy; however, the exact prevalence is still unknown. The primary aim of this study was to correlate the presence of seizures, status epilepticus, and specific critical care EEG patterns with patient functional outcomes in those with COVID-19. METHODS: This is a retrospective, multicenter cohort of COVID-19-positive patients in Southeast Michigan who underwent electroencephalography (EEG) from March 12th through May 15th, 2020. All patients had confirmed nasopharyngeal PCR for COVID-19. EEG patterns were characterized per 2012 ACNS critical care EEG terminology. Clinical and demographic variables were collected by medical chart review. Outcomes were divided into recovered, recovered with disability, or deceased. RESULTS: Out of the total of 4100 patients hospitalized with COVID-19, 110 patients (2.68%) had EEG during their hospitalization; 64% were male, 67% were African American with mean age of 63 years (range 20-87). The majority (70%) had severe COVID-19, were intubated, or had multi-organ failure. The median length of hospitalization was 26.5 days (IQR = 15 to 44 days). During hospitalization, of the patients who had EEG, 21.8% had new-onset seizure including 7% with status epilepticus, majority (87.5%) with no prior epilepsy. Forty-nine (45%) patients died in the hospital, 46 (42%) recovered but maintained a disability and 15 (14%) recovered without a disability. The EEG findings associated with outcomes were background slowing/attenuation (recovered 60% vs recovered/disabled 96% vs died 96%, p < 0.001) and normal (recovered 27% vs recovered/disabled 0% vs died 1%, p < 0.001). However, these findings were no longer significant after adjusting for severity of COVID-19. CONCLUSION: In this large multicenter study from Southeast Michigan, one of the early COVID-19 epicenters in the US, none of the EEG findings were significantly correlated with outcomes in critically ill COVID-19 patients. Although seizures and status epilepticus could be encountered in COVID-19, the occurrence did not correlate with the patients' functional outcome.