Longitudinal Progression of Patients with Long COVID Treated in a Post-COVID Clinic: A Cross-Sectional Survey.

BACKGROUND: In addition to the morbidity and mortality associated with acute infection, COVID-19 has been associated with persistent symptoms (>30 days), often referred to as Long COVID (LC). LC symptoms often cluster into phenotypes, resembling conditions such as fibromyalgia, postural orthostatic tachycardiac syndrome (POTS), and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). LC clinics have been established to best address the needs of LC patients and continuity of care. We developed a cross-sectional survey to assess treatment response through our LC Clinic (LCC). METHODS: A 25-question survey (1-10 Likert scale) was expert- and content-validated by LCC clinicians, patients, and patient advocates. The survey assessed LC symptoms and the helpfulness of different interventions, including medications and supplements. A total of 852 LCC patients were asked to complete the survey, with 536 (62.9%) responding. RESULTS: The mean time from associated COVID-19 infection to survey completion was 23.2 ± 6.4 months. The mean age of responders was 52.3 ± 14.1 (63% females). Self-reported symptoms were all significantly improved (P < .001) from the initial visit to the LCC (baseline) to the time of the follow-up survey. However, only 4.5% (24/536) of patients rated all symptoms low (1-2) at the time of the survey, indicating low levels of full recovery in our cohort. The patients rated numerous interventions as being helpful, including low-dose naltrexone (45/77; 58%), vagal nerve stimulation (18/34; 53%), and fisetin (28/44; 64%). CONCLUSIONS: Patients report general improvements in symptoms following the initial LCC visit, but complete recovery rates remain low at 23.2 ± 6.4 months.

Pro Inflammatory Cytokines Profiles of Patients With Long COVID Differ Between Variant Epochs.

BACKGROUND: Over 30% of patients with COVID-19 have persistent symptoms that last beyond 30 days and referred to as Long COVID. Long COVID has been associated with a persistent elevation in peripheral cytokines including interleukin-6, interleukin-1ß, and tumor necrosis factor-α. This study reports cytokine profiles of patients in our clinic across SARS-COV-2 variant epochs. METHODS: The clinical cytokine panel was analyzed in patients with Long COVID during periods that were stratified according to variant epoch. The 4 variant epochs were defined as: (1) wild-type through alpha, (2) alpha/beta/gamma, (3) delta, and (4) omicron variants. RESULTS: A total of 390 patients had the clinical cytokine panel performed; the median age was 48 years (IQR 38-59) and 62% were female. Distribution by variant was wild-type and alpha, 50% (n = 196); alpha/beta/gamma, 7.9% (n = 31); delta, 18% (n = 72); and omicron, 23% (n = 91). Time to cytokine panel testing was significantly longer for the earlier epochs. Tumor necrosis factor-α (P < .001) and interleukin 1ß (P < .001) were significantly more elevated in the earlier epochs (median of 558 days in wild-type through Alpha epoch vs 263 days in omicron epoch, P < .001)). Nucleocapsid antibodies were consistently detected across epochs. DISCUSSION: When stratified by variant epoch, patients with early epoch Long COVID had persistently elevated peripheral pro-inflammatory cytokine levels when compared to later epoch Long COVID. Patients with Long COVID have similar clusters of symptoms across epochs, suggesting that the underlying pathology is independent of the peripheral cytokine signature.

Inflammatory Arthritis After COVID-19: A Case Series.

BACKGROUND Some patients who have recovered from acute infection with SARS-CoV-2 develop persistent symptoms that have been termed post-COVID syndrome (PoCoS). PoCoS can affect the musculoskeletal system, with arthralgia and myalgia being common. Preliminary evidence suggests that PoCoS is an immune-mediated condition that not only predisposes but also precipitates pre-existing inflammatory joint diseases such as rheumatoid arthritis and reactive arthritis. Here, we describe a series of patients who presented to our Post-COVID Clinic and were found to have inflammatory arthritis (reactive and rheumatoid arthritis). CASE REPORT We present 5 patients who developed joint pain several weeks after recovery from acute SARS-CoV-2 infection. These patients were seen in our Post-COVID Clinic and came from locations across the United States. All 5 patients were women, with age of diagnosis of COVID-19 disease between 19 and 61 years (mean 37.8 years). All patients presented with joint pain as the primary concern to the Post-COVID Clinic. Abnormal joint imaging was present in all patients. Treatments varied and included non-steroidal anti-inflammatory drugs, acetaminophen, corticosteroids, immunomodulators (golimumab), methotrexate, leflunomide, and hydroxychloroquine. CONCLUSIONS COVID-19 disease is a potential cause of inflammatory arthritis, with both rheumatoid arthritis and reactive arthritis demonstrated in our PoCoS population. Care must be taken to identify these conditions, as there are treatment ramifications.

Development of a Visit Facilitator Role to Assist Physicians in an Ambulatory Consultative Medical Practice.

Objective: To decrease the electronic health record (EHR) clerical burden and improve patient/clinician satisfaction, allied health staff were trained as visit facilitators (VFs) to assist the physician in clinical and administrative tasks. Patients and Methods: From December 7, 2020, to October 11, 2021, patients with complex medical conditions were evaluated by an internal medicine physician in an outpatient general internal medicine (GIM) consultative practice at a tertiary care institution. A VF assisted with specific tasks before, during, and after the clinical visit. Presurvey and postsurvey assessments were performed to understand the effect of the VF on clinical tasks as perceived by the physician. Results: A total of 57 GIM physicians used a VF, and 41 (82%) physicians and 39 (79%) physicians completed the pre-VF and post-VF surveys, respectively. Physicians reported a significant reduction in time reviewing outside materials, updating pertinent information, and creating/modifying EHR orders (P<.05). Clinicians reported improved interactions with patients and on-time completion of clinical documentation. In the pre-VF survey, "too much time spent" was the most common response for reviewing outside material, placing/modifying orders, completing documentation/clinical notes, resolving in-baskets, completing dismissal letters, and completing tasks outside of work hours. In the post-VF survey, "too much time spent" was not the most common answer to any question. Satisfaction improved in all areas (P<.05). Conclusion: VFs significantly reduced the EHR clinical burden and improved GIM physician practice satisfaction. This model can potentially be used in a wide range of medical practices.

The Female-Predominant Persistent Immune Dysregulation of the Post-COVID Syndrome.

OBJECTIVE: To describe the clinical data from the first 108 patients seen in the Mayo Clinic post-COVID-19 care clinic (PCOCC). METHODS: After Institutional Review Board approval, we reviewed the charts of the first 108 patients seen between January 19, 2021, and April 29, 2021, in the PCOCC and abstracted from the electronic medical record into a standardized database to facilitate analysis. Patients were grouped into phenotypes by expert review. RESULTS: Most of the patients seen in our clinic were female (75%; 81/108), and the median age at presentation was 46 years (interquartile range, 37 to 55 years). All had post-acute sequelae of SARS-CoV-2 infection, with 6 clinical phenotypes being identified: fatigue predominant (n=69), dyspnea predominant (n=23), myalgia predominant (n=6), orthostasis predominant (n=6), chest pain predominant (n=3), and headache predominant (n=1). The fatigue-predominant phenotype was more common in women, and the dyspnea-predominant phenotype was more common in men. Interleukin 6 (IL-6) was elevated in 61% of patients (69% of women; P=.0046), which was more common than elevation in C-reactive protein and erythrocyte sedimentation rate, identified in 17% and 20% of cases, respectively. CONCLUSION: In our PCOCC, we observed several distinct clinical phenotypes. Fatigue predominance was the most common presentation and was associated with elevated IL-6 levels and female sex. Dyspnea predominance was more common in men and was not associated with elevated IL-6 levels. IL-6 levels were more likely than erythrocyte sedimentation rate and C-reactive protein to be elevated in patients with post-acute sequelae of SARS-CoV-2 infection.

Use of the pause procedure in continuing medical education: A randomized controlled intervention study.

During lectures, a pause procedure (the presenter pauses so students can discuss content) can improve educational outcomes. We aimed to determine whether (1) continuing medical education (CME) presentations with a pause procedure were evaluated more favorably and (2) a pause procedure improved recall. In this randomized controlled intervention study of all participants (N = 214) at the Mayo Clinic Internal Medicine Board Review course, 48 lectures were randomly assigned to an intervention (pause procedure) or control (traditional lecture) group. The pause procedure was a 1-min pause at the middle and end of the presentation. Study outcomes were (1) presentation evaluation instrument scores and (2) number of recalled items per lecture. A total of 214 participants returned 145 surveys (response rate, 68%). Mean presentation evaluation scores were significantly higher for pause procedure than for traditional presentations (70.9% vs 65.8%; 95%CI for the difference, 3.5-6.7; p < .0001). Mean number of rapid recall items was higher for pause procedure presentations (0.68 vs 0.59; 95%CI for the difference, 0.02-0.14; p = .01). In a traditional CME course, presentations with a pause procedure had higher evaluation scores and more content was recalled. The pause procedure could arm CME presenters with an easy technique to improve educational content delivery.

Digital health interventions for the prevention of cardiovascular disease: a systematic review and meta-analysis.

OBJECTIVE: To assess the potential benefit of digital health interventions (DHIs) on cardiovascular disease (CVD) outcomes (CVD events, all-cause mortality, hospitalizations) and risk factors compared with non-DHIs. PATIENTS AND METHODS: We conducted a systematic search of PubMed, MEDLINE, EMBASE, Web of Science, Ovid, CINHAL, ERIC, PsychINFO, Cochrane, and Cochrane Central Register of Controlled Trials for articles published from January 1, 1990, through January 21, 2014. Included studies examined any element of DHI (telemedicine, Web-based strategies, e-mail, mobile phones, mobile applications, text messaging, and monitoring sensors) and CVD outcomes or risk factors. Two reviewers independently evaluated study quality utilizing a modified version of the Cochrane Collaboration risk assessment tool. Authors extracted CVD outcomes and risk factors for CVD such as weight, body mass index, blood pressure, and lipid levels from 51 full-text articles that met validity and inclusion criteria. RESULTS: Digital health interventions significantly reduced CVD outcomes (relative risk, 0.61; 95% CI, 0.46-0.80; P<.001; I(2)=22%). Concomitant reductions in weight (-2.77 lb [95% CI, -4.49 to -1.05 lb]; P<.002; I(2)=97%) and body mass index (-0.17 kg/m(2) [95% CI, -0.32 kg/m(2) to -0.01 kg/m(2)]; P=.03; I(2)=97%) but not blood pressure (-1.18 mm Hg [95% CI, -2.93 mm Hg to 0.57 mm Hg]; P=.19; I(2)=100%) were found in these DHI trials compared with usual care. In the 6 studies reporting Framingham risk score, 10-year risk percentages were also significantly improved (-1.24%; 95% CI, -1.73% to -0.76%; P<.001; I(2)=94%). Results were limited by heterogeneity not fully explained by study population (primary or secondary prevention) or DHI modality. CONCLUSION: Overall, these aggregations of data provide evidence that DHIs can reduce CVD outcomes and have a positive impact on risk factors for CVD.

The evolution of mindfulness-based physical interventions in breast cancer survivors.

Survivors of breast cancer are faced with a multitude of medical and psychological impairments during and after treatment and throughout their lifespan. Physical exercise has been shown to improve survival and recurrence in this population. Mind-body interventions combine a light-moderate intensity physical exercise with mindfulness, thus having the potential to improve both physical and psychological sequelae of breast cancer treatments. We conducted a review of mindfulness-based physical exercise interventions which included yoga, tai chi chuan, Pilates, and qigong, in breast cancer survivors. Among the mindfulness-based interventions, yoga was significantly more studied in this population as compared to tai chi chuan, Pilates, and qigong. The participants and the outcomes of the majority of the studies reviewed were heterogeneous, and the population included was generally not selected for symptoms. Yoga was shown to improve fatigue in a few methodologically strong studies, providing reasonable evidence for benefit in this population. Improvements were also seen in sleep, anxiety, depression, distress, quality of life, and postchemotherapy nausea and vomiting in the yoga studies. Tai chi chuan, Pilates, and qigong were not studied sufficiently in breast cancer survivors in order to be implemented in clinical practice.