Characterization of telerehabilitation visits and patient satisfaction in outpatient physical medicine and rehabilitation clinics from March 2020 to November 2021.

OBJECTIVE: To explore the usability of and satisfaction with telerehabilitation services provided to rehabilitation patients with various diagnoses at two large urban medical facilities during the Covid-19 pandemic. DESIGN: This was a usability study and all patients that received telerehabilitation services from March 2020 to November 2021 were included. Of the 4,070 surveys sent via mail or email links to RedCap, 405 were completed (10% Response Rate). Participants completed demographic surveys, surveys on the telerehabilitation visit characteristics, telerehabilitation usability, and overall satisfaction with the visit. RESULTS: Patients were mostly women (64.4%), White, non-hispanic (74.3%) and English speaking (99%). Most patients were seen via telerehabilitation due to Covid-19 restrictions (37.1%). Patients were generally satisfied with their telerehabilitation visit (3.64 out of 4). Additionally, patients generally found telerehab to be useful (6.4 out of 7), easy to use (6.3 out of 7), effective (6.2 out of 7), satisfactory (6.3 out of 7) and comparable to in-person visits (6.5 out of 7). CONCLUSION: Patients generally reported feeling satisfied and comfortable with telerehabilitation visits, and felt they were comparable to in-person visits. Future research should examine the impact of socioeconomic factors on telerehabilitation use, with a focus on education level and non-English speakers.

Impact of Urine Culture Reflex Policy Implementation in a Large County Hospital Inpatient Rehabilitation Unit-A Pilot Study.

OBJECTIVE: To promote antimicrobial stewardship, many institutions have implemented a policy of reflexing to a urine culture based on a positive urinalysis result. The rehabilitation patient population, including individuals with brain and spinal cord injuries, may have atypical presentations of urinary tract infections. The study objective is to determine the effects of implementing a urine culture reflex policy in this specific patient population. DESIGN: In an inpatient rehabilitation unit, 348 urinalyses were analyzed from August 2019 to June 2021. Urinalysis with greater than or equal to 10 white blood cells per high power field was automatically reflexed to a urine culture in this prospective study. Primary outcome was return to acute care related to urinary tract infection. Secondary outcomes included adherence to reflex protocol, antibiotic utilization and appropriateness, adverse outcomes related to antibiotic use, and reduction in urine cultures processed and the associated reduction in healthcare costs. RESULTS: There was no statistically significant difference before and after intervention related to the primary outcome. Urine cultures processed were reduced by 58% after intervention. CONCLUSIONS: Urine culture reflex policy is likely an effective intervention to reduce the frequency of urine cultures without significantly affecting the need to transfer patients from inpatient rehabilitation back to the acute care setting.

Longitudinal assessment of mitochondrial dysfunction in acute traumatic brain injury using hyperpolarized [1-13 C]pyruvate.

PURPOSE: [13 C]Bicarbonate formation from hyperpolarized [1-13 C]pyruvate via pyruvate dehydrogenase, a key regulatory enzyme, represents the cerebral oxidation of pyruvate and the integrity of mitochondrial function. The present study is to characterize the chronology of cerebral mitochondrial metabolism during secondary injury associated with acute traumatic brain injury (TBI) by longitudinally monitoring [13 C]bicarbonate production from hyperpolarized [1-13 C]pyruvate in rodents. METHODS: Male Wistar rats were randomly assigned to undergo a controlled-cortical impact (CCI, n = 31) or sham surgery (n = 22). Seventeen of the CCI and 9 of the sham rats longitudinally underwent a 1 H/13 C-integrated MR protocol that includes a bolus injection of hyperpolarized [1-13 C]pyruvate at 0 (2 h), 1, 2, 5, and 10 days post-surgery. Separate CCI and sham rats were used for histological validation and enzyme assays. RESULTS: In addition to elevated lactate, we observed significantly reduced bicarbonate production in the injured site. Unlike the immediate appearance of hyperintensity on T2 -weighted MRI, the contrast of bicarbonate signals between the injured region and the contralateral brain peaked at 24 h post-injury, then fully recovered to the normal level at day 10. A subset of TBI rats demonstrated markedly increased bicarbonate in normal-appearing contralateral brain regions post-injury. CONCLUSION: This study demonstrates that aberrant mitochondrial metabolism occurring in acute TBI can be monitored by detecting [13 C]bicarbonate production from hyperpolarized [1-13 C]pyruvate, suggesting that [13 C]bicarbonate is a sensitive in-vivo biomarker of the secondary injury processes.

Integrated Care Models for Long Coronavirus Disease.

Professional or governmental agencies and organizations have developed guidelines to define the problem and evaluate and manage patients with Post-Acute Sequelae of SARS CoV-2 (PASC). Multidisciplinary models largely exist in academic centers and larger cities; however, most care for PASC patients is provided by the primary care providers. The American Academy of Physical Medicine and Rehabilitation has been in the forefront in releasing consensus statements as a part of the long COVID collaborative.

Cardiovascular and cerebral vascular health in females with postacute sequelae of COVID-19.

Many individuals who had coronavirus disease 2019 (COVID-19) develop detrimental persistent symptoms, a condition known as postacute sequelae of COVID-19 (PASC). Despite the elevated risk of cardiovascular disease following COVID-19, limited studies have examined vascular function in PASC with equivocal results reported. Moreover, the role of PASC symptom burden on vascular health has not been examined. We tested the hypothesis that peripheral and cerebral vascular function would be blunted and central arterial stiffness would be elevated in patients with PASC compared with age-matched controls. Furthermore, we hypothesized that impairments in vascular health would be greater in those with higher PASC symptom burden. Resting blood pressure (BP; brachial and central), brachial artery flow-mediated dilation (FMD), forearm reactive hyperemia, carotid-femoral pulse wave velocity (PWV), and cerebral vasodilator function were measured in 12 females with PASC and 11 age-matched female controls without PASC. The severity of persistent symptoms in those with PASC was reported on a scale of 1-10 (higher score: greater severity). Brachial BP (e.g., systolic BP, 126 ± 19 vs.109 ± 8 mmHg; P = 0.010), central BP (P < 0.050), and PWV (7.1 ± 1.2 vs. 6.0 ± 0.8 m/s; P = 0.015) were higher in PASC group compared with controls. However, FMD, reactive hyperemia, and cerebral vasodilator function were not different between groups (P > 0.050 for all). Total symptom burden was not correlated with any measure of cardiovascular health (P > 0.050 for all). Collectively, these findings indicate that BP and central arterial stiffness are elevated in females with PASC, whereas peripheral and cerebral vascular function appear to be unaffected, effects that appear independent of symptom burden.NEW & NOTEWORTHY We demonstrate for the first time that resting blood pressure (BP) and central arterial stiffness are higher in females with PASC compared with controls. In contrast, peripheral and cerebral vascular functions appear unaffected. Moreover, there was no relationship between total PASC symptom burden and measures of BP, arterial stiffness, or vascular function. Collectively, these findings suggest that females with PASC could be at greater risk of developing hypertension, which appears independent of symptom burden.

A survey of dedicated PASC clinics: Characteristics, barriers and spirit of collaboration.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can produce prolonged multi-organ system dysfunction and a worsened quality of life, a condition known as Post-Acute Sequelae of SARS-CoV-2 Infection (PASC). In response, clinics have emerged dedicated to the treatment of individuals with PASC. OBJECTIVE: To better understand the current characteristics of these clinics, the barriers they face, and the interest in collaboration between clinics. DESIGN: A cross-sectional survey study. PARTICIPANTS: Clinicians working within dedicated PASC centers (N = 94) identified primarily through the Survivor Corps database of Post-COVID Care Centers. Additional clinics were found through news articles, an American Academy of Physical Medicine and Rehabilitation Database, and word of mouth. METHODS: The branching logic electronic survey consisting of up to 39 questions was sent electronically to potential participants. RESULTS: Complete survey responses were obtained from 45 clinics. There was a wide variety of different clinical models and specialties involved. The majority of clinics were homed in physical medicine and rehabilitation (40%), pulmonology (22%), and internal medicine (16%). Most clinics (73%) reported experiencing obstacles in the treatment of their patients, the most common of which included needing more established protocols (45%) and more clinical resources (24%). Most clinics (76%) also reported an interest in participating in a collaborative clinical network. CONCLUSION: Despite wide variability in current clinical models of PASC clinics, there are common practices such as using telemedicine, having initial visits longer than 30 minutes, involving certain specialties in the treatment team, and having the ability for follow-up. Clinicians involved with PASC clinics have a strong interest in collaboration to improve patient care and overcome clinical obstacles, the most common of which is the lack of clear treatment protocols. More research is needed to identify which clinical models lead to better patient outcomes.

Heart Failure and Disability in Community-Dwelling Older Adults in the United States-1999 to 2018: Data From National Health and Nutrition Examination Survey.

To examine the associations of heart failure (HF) with five domains of disability while controlling for covariates. Subjects with HF and aged ≥ 50 years were selected from the 1999 to 2018 National Health and Nutrition Examination Survey data. Five domains of disability were measured with 19 physical tasks. Logistic regression with adjustment for covariates was conducted. The prevalence of HF in 27,185 adults aged ≥ 50 years was 6.37%. After controlling for demographics and smoking, logistic regression showed that HF was associated with 2.8 to 3.4 times increased odds of all domains of disability compared to adults without HF, but with additional adjustments of covariates, the association was attenuated indicating the mediating effects of covariates. The future study may examine the mediating effects of covariates when intervening difficulties with lower extremity mobility and activities of daily living while considering in community-dwelling older adults with HF.

Models of Care for Postacute COVID-19 Clinics: Experiences and a Practical Framework for Outpatient Physiatry Settings.

ABSTRACT: After surviving infection with the SARS-CoV-2 virus, individuals may have persistent symptoms and prolonged impairments that may last for weeks to months. The frequency and heterogeneity of persistent post-COVID conditions have created challenges in care. Specialty clinics are being established in response to an increasing need to care for patients with postacute sequelae of SARS-CoV-2 or long COVID syndrome. Although many post-COVID conditions can be bettered through a comprehensive rehabilitation plan, various clinical settings may benefit from differing models of coordinated care. We present five models of care in varying degrees of development and compare processes and adaptations to address the unique needs of each center and their unique patient populations. Forging a path to recovery will necessitate a multidisciplinary team with physiatry involvement to meet the distinctive needs of patients with postacute sequelae of SARS-CoV-2. Furthermore, it is imperative that there be equitable access to this care and commitment from healthcare institutions to provide resources for these programs.

Imaging Acute Metabolic Changes in Patients with Mild Traumatic Brain Injury Using Hyperpolarized [1-13C]Pyruvate.

Traumatic brain injury (TBI) involves complex secondary injury processes following the primary injury. The secondary injury is often associated with rapid metabolic shifts and impaired brain function immediately after the initial tissue damage. Magnetic resonance spectroscopic imaging (MRSI) coupled with hyperpolarization of 13C-labeled substrates provides a unique opportunity to map the metabolic changes in the brain after traumatic injury in real-time without invasive procedures. In this report, we investigated two patients with acute mild TBI (Glasgow coma scale 15) but no anatomical brain injury or hemorrhage. Patients were imaged with hyperpolarized [1-13C]pyruvate MRSI 1 or 6 days after head trauma. Both patients showed significantly reduced bicarbonate (HCO3 -) production, and one showed hyperintense lactate production at the injured sites. This study reports the feasibility of imaging altered metabolism using hyperpolarized pyruvate in patients with TBI, demonstrating the translatability and sensitivity of the technology to cerebral metabolic changes after mild TBI.

Sleep Disturbance After TBI.

PURPOSE OF REVIEW: Present relevant literature to update knowledge on sleep science, identify common sleep disturbances seen in TBI, discuss evidence for available treatment options, and illuminate future areas for research. RECENT FINDINGS: Sleep disturbances, including insomnia, circadian rhythm disturbances, and sleep apnea, are prevalent for all severities of traumatic brain injury (TBI), can be chronic, and affect both rehabilitation and recovery from the TBI. New knowledge of basic sleep mechanisms and neurochemistry has exploded in the last decade. In addition to known effects on mood and cognition from sleep deprivation in persons with TBI, new evidence indicates potential deleterious effects on neurorecovery and acceleration of long-term neurodegeneration.

Impact of evaluating antibiotic concentrations in abdominal abscesses percutaneously drained.

BACKGROUND: Appropriate antibiotic therapy and prompt drainage are essential for optimal results with abdominal abscesses. METHODS: In this prospective study, 47 abdominal abscesses from 42 patients over 2 years who had percutaneous drainage were evaluated. Antibiotic concentrations were evaluated from the abscess fluid and correlated with clinical and microbiologic cure. RESULTS: Only 23% of patients had appropriate antibiotic selection with optimal concentrations for the bacteria recovered. Piperacillin/tazobactam, cefepime, and metronidazole provided adequate concentrations in all except the largest abscesses, whereas fluconazole required higher doses in all abscesses. Vancomycin and ciprofloxacin levels were inadequate in most abscesses. With gram-negative aerobes, the use of appropriate antibiotics resulted in a relatively higher incidence of presumed eradication (100% [4 of 4] vs 75% [9 of 12], P = .26). With ≥ 3 organisms identified, clinical failure was significant (58% vs 13%, P = .01). CONCLUSIONS: For optimal treatment, abdominal abscesses require prompt drainage and properly selected antibiotics at adequate doses. Essential information can be obtained from abscess cultures and their antibiotic concentrations.