Changing characteristics of post-COVID-19 syndrome: Cross-sectional findings from 458 consultations using the Stanford Hall remote rehabilitation assessment tool.

BACKGROUND: In the UK, there have been multiple waves of COVID-19, with a five-tier alert system created to describe the transmission rate and appropriate restrictions. While acute mortality decreased, there continued to be a significant morbidity, with individuals suffering from persistent, life-restricting symptoms for months to years afterwards. A remote rehabilitation tool was created at the Defence Medical Rehabilitation Centre (DMRC) Stanford Hall to assess post-COVID-19 symptoms and their impact on the UK military.This study aims to understand changes in post-COVID-19 syndrome between wave 1 and wave 2, identify interactions between alert level and symptoms and investigate any predictive nature of acute symptoms for postacute symptomology in a young, physically active population. METHODS: Cross-sectional study of 458 consecutive remote rehabilitation assessments performed at DMRC Stanford Hall between 2 April 2020 and 29 July 2021. Consultations were coded, anonymised, and statistical analysis was performed to determine associations between acute and postacute symptoms, and between symptoms, alert levels and waves. RESULTS: 435 assessments were eligible; 174 in wave 1 and 261 in wave 2. Post-COVID-19 syndrome prevalence reduced from 43% to 2% between the waves. Acutely, widespread pain was more prevalent in wave 2 (p<0.001). Postacutely, there was increased anxiety (p=0.10) in wave 1 and increased sleep disturbance (p<0.001), memory/concentration issues (p<0.001) and shortness of breath/cough (p=0.017) in wave 2. Increasing alert level was associated with increased postacute symptom prevalence (p=0.046), with sleep disturbance increasing at higher alert level (p=0.016). Acute symptoms, including fatigue, sleep disturbance and myalgia, were associated with multiple postacute symptoms. CONCLUSIONS: This study reports the overall prevalence and symptom burden in the UK military in the first two waves of COVID-19. By reporting differences in COVID-19 in different waves and alert level, this study highlights the importance of careful assessment and contextual understanding of acute and postacute illnesses for individual management plans.

Rehabilitation post-COVID-19: cross-sectional observations using the Stanford Hall remote assessment tool.

INTRODUCTION: The multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs. METHODS: Cross-sectional study of consecutive patients referred by general practitioners (April-November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology. RESULTS: 155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months. CONCLUSIONS: Rehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.

Cardiopulmonary exercise testing excludes significant disease in patients recovering from COVID-19.

OBJECTIVE: Post-COVID-19 syndrome presents a health and economic challenge affecting ~10% of patients recovering from COVID-19. Accurate assessment of patients with post-COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings. METHODS: 113 consecutive military patients were assessed in a comprehensive clinical pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CT pulmonary angiography and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease. RESULTS: 7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multidisciplinary team (MDT). These patients had reduced fitness (V̇O2 26.7 (±5.1) vs 34.6 (±7.0) mL/kg/min; p=0.002) and functional capacity (peak power 200 (±36) vs 247 (±55) W; p=0.026) compared with those without significant disease. Simple CPET criteria (oxygen uptake (V̇O2) >100% predicted and minute ventilation (VE)/carbon dioxide elimination (V̇CO2) slope <30.0 or VE/V̇CO2 slope <35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83%, respectively (area under the receiver operating characteristic curve (AUC) 0.89). The addition of capillary blood gases to estimate alveolar-arterial gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease. CONCLUSIONS: In a population recovering from SARS-CoV-2, there is reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, permit the exclusion of clinically significant disease.

Trauma-related amputations in war and at a civilian major trauma centre-comparison of care, outcome and the challenges ahead.

The Afghanistan conflict has resulted in a large number of service personnel sustaining amputations. Whilst obvious differences exist between military and civilian trauma-related amputations both settings result in life changing injuries. Comparisons offer the potential of advancement and protection of the knowledge gained during the last 12 years. This paper compares the military and civilian trauma-related amputee cohorts' demographics, management and rehabilitation outcomes measures. The UK military Joint Theatre Trauma Registry and a civilian major trauma centre database of trauma-related amputees were analysed. 255 military and 24 civilian amputees were identified. A significant difference (p>0.05) was seen in median age (24, range 18-43, vs. 48, range 24-87 years), mean number of amputations per casualty (1.6±SD 0.678 vs. 1±SD 0.0), mean ISS (22±SD 12.8 vs. 14.7±SD 15.7) and gender (99% males vs. 78%). Rehabilitation outcome measures recorded included the Special Interest Group in Amputee Medicine score where the military group demonstrated significantly better scores (91% Grade E+ compared to 19%). Differences in patients underlying physiology and psychology, the military trauma system and a huge sustained investment in rehabilitation are all contributing factors for these differing outcomes. However the authors also believe that the use of a consultant-led MDT and central rehabilitation have benefited the military cohort in the acute rehabilitation stage and is reflected in the good short-term outcomes.

Effect of fetal movement, ultrasound scans, and amniocentesis on maternal-fetal attachment.

The effects of fetal movement, ultrasound scans, and amniocentesis on maternal-fetal attachment and perception of fetal development in normal pregnancy were examined in 91 women during the second trimester. Women who reported feeling fetal movement early in pregnancy had higher maternal-fetal attachment scores and higher perception of fetal development scores. Ultrasound scans had no effect on either variable. Women who had genetic amniocentesis had lower attachment scores before the procedure, but one month later the attachment scores were not significantly different from those of other women. Both maternal-fetal attachment and perceptions of fetal development increased significantly from 16 to 20 weeks of gestation. There was a small but significant correlation between attachment scores and perception of fetal development.

Social support as a factor in the development of parents' attachment to their unborn.

Two studies are discussed which have investigated the association between aspects of social support and parents' attachment to their unborn children. The first study involved interviews of 30 women in the third trimester of pregnancy and utilized a broad conceptualization of social support measured by a questionnaire developed for the study. Overall social support was positively associated with the woman's attachment to her fetus; support from health care professionals was more highly correlated with attachment (.74) than was support from family and friends (.25). The second study utilized questionnaires from 326 couples to investigate the relationship between fetal attachment and satisfaction with the marital relationship. Results revealed a positive association between marital relationship and attachment to the fetus for both men and women. Implications for further research are discussed.

Perinatal risk.

Genetic inheritance, the embryonic-fetal environment, and the family and social milieu are factors that may place the fetus-newborn at an increased risk for premature birth, congenital malformations, or neonatal illness. Knowledge of these factors is crucial to providing optimum nursing care to newborns. These factors are discussed in detail, and appropriate nursing assessments and interventions are reviewed.

An exploration of paternal-fetal attachment behavior.

A 63-item questionnaire utilizing the modified Maternal-Fetal Attachment Scale (PFA) (Cranley, 1981), the Marital Relationship Scale (Wapner, 1976), and the Physical History Scale (Wapner, 1976) was tested on 100 expectant fathers who had wives in their third trimester of pregnancy. Scores on the PFA were positively correlated with the strength of the marital relationship as perceived by the expectant father during pregnancy. A positive but weak association was shown between paternal-fetal attachment and the incidence of physical symptoms resembling pregnancy in the expectant father. Further testing of the PFA and related variables is indicated.

Women's perceptions of vaginal and cesarean deliveries.

Three groups of women were compared to determine their perceptions of giving birth and the relationships between those perceptions and their degree of participation in decision making, the type of anesthesia for delivery, and the presence of their husbands at the births. Forty women had vaginal deliveries; 39 had emergency cesareans, and 43 had planned cesareans. All the women were interviewed and completed self-administered questionnaires two to four days after delivery. The three groups had significantly different perceptions of the birth experience with the emergency cesarean birth group having the most negative perception. Among women having cesareans, more positive perceptions were associated with regional anesthesia, presence of their husbands at delivery, and greater participation in decision making. Women in the cesarean groups were less likely to breast feed, and those having planned cesareans were least likely to attend childbirth classes. Many of the women were unaware of the options available to them that could influence the birth experiences.

Development of a tool for the measurement of maternal attachment during pregnancy.

A 24-item scale with five subscales was developed to measure the construct of maternal-fetal attachment during pregnancy and tested on 71 subjects in the third trimester of pregnancy. Content validity was built into the scale. A coefficient of reliability of .85 was demonstrated for the scale with the reliability of the subscales ranging from .52 to .73. Scores of the MFA scale were positively correlated with the amount of available social support reported by women and with their perceptions of babies three days after birth. There was a negative association between MFA scores and the amount of stress perceived by the women. Further refinement of the scale is indicated.