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.

Assessment of a point-of-care test for paracetamol and salicylate in blood.

BACKGROUND: Paracetamol and salicylate are commonly taken in acute overdose. Clinicians have a low threshold for excluding the presence of these two drugs, by ordering laboratory tests in any patient suspected of ingesting an overdose or with an altered mental state. AIM: To test the effectiveness of a new point of care test that qualitatively detects paracetamol and salicylate in blood and to examine the potential time saved by its use. DESIGN: Prospective multicentre trial. METHODS: The new test was compared with laboratory analysis in a routine blood sample taken from patients presenting to emergency departments with suspected overdose. RESULTS: The test had sensitivities of 98.5% and 88.5%, and specificities of 74.7% and 92%, for paracetamol and salicylate, respectively, at cut-off levels of 25 mg/l and 100 mg/l, respectively The point of care test results were available 2 h before the laboratory result. DISCUSSION: This point-of-care test could be used to rule out an overdose with either of these two drugs, and could thus lead to earlier clinical decisions for suspected overdose patients. Recommendations have been made following this trial that the cut-off value for paracetamol should be reduced from 25 mg/l to 12.5 mg/l in order to increase its usefulness. To prevent the test being misread, we also suggest that each device should be embossed to remind users that the presence of a line indicates there is no drug present.

Evaluation of the Simplify D-dimer assay as a screening test for the diagnosis of deep vein thrombosis in an emergency department.

OBJECTIVES: To evaluate the use in an emergency department of a new D-dimer assay (Simplify D-dimer) as a screening test for deep vein thrombosis (DVT). METHODS: 187 outpatients with clinical features suspicious of acute DVT were entered into this study. A Simplify D-dimer test was performed in the emergency department on all patients. A SimpliRED D-dimer test and a semi-automated latex agglutination assay (Auto-D-dimer 700 on a Thromboscreen 400C analyser) were performed in the haematology laboratory. All patients were investigated with contrast venography to confirm or exclude the diagnosis of DVT. RESULTS: The Simplify test had a sensitivity of 94.1% and a negative predictive value (NPV) of 94.8%. These results compared favourably with the SimpliRED test (sensitivity 74.5%, NPV 89.7%) and the latex agglutination assay (sensitivity 90.2%, NPV 92.2%). This increased sensitivity was at the cost of a lower specificity, the specificity of the three d-dimer tests being Simplify 40.4%, SimpliRED 83.1%, and latex agglutination 43.4%. CONCLUSIONS: Simplify proved to be a rapid and easy to use test and may be useful for use in the emergency department as part of a diagnostic algorithm for deep vein thrombosis. Further larger scale studies are needed.

Referral to the accident and emergency department following the use of community alarms.

OBJECTIVES: To assess the degree of appropriate referral to the accident and emergency (A&E) department following the use of a community alarm where a mobile warden works in conjunction with the community alarm control centre. METHODS: 611 consecutive calls using community alarms underwent assessment and the appropriateness of referral to the A&E department was considered. RESULTS: Of 542 requests for help 44 patients were transported to the A&E department (8.1%). Twenty nine patients were admitted (5.3%) and 15 patients (2.8%) discharged home from the A&E department after assessment or treatment, or both. Only three patients (0.55%) had been referred to the A&E department inappropriately. CONCLUSIONS: This study shows that where a mobile warden works in conjunction with the community alarm control centre the number of inappropriate referrals to the A&E department should be minimal.

Outpatient management of deep vein thrombosis.

OBJECTIVE: To assess whether patients with deep vein thrombosis (DVT) could be satisfactorily treated on an outpatient basis with low molecular weight (LMW) heparin and warfarin. DESIGN: A 22 month prospective study of adults attending St Peter's Hospital accident and emergency department with DVT. RESULTS: 1093 patients were referred and assessed; 160 were venogram positive, of which 159 patients between the ages of 22 and 89 years of age have now been treated with LMW heparin as outpatients. Direct liaison with community nurses has minimised the impact on general practitioner workload. CONCLUSIONS: 1272 bed days were saved during this period (an estimated 320,000 pounds). The outpatient treatment of thromboembolism has been shown to be effective and safe.

Apple II program to simulate the response-time profile of non-depolarising muscle relaxants.

We have developed a BASIC program for the Apple II microcomputer which can simulate the effect (degree of paralysis) time curve obtained following bolus intravenous administrations of pancuronium. The program is based on a combined pharmacokinetic/pharmacodynamic model and has practical application to the anaesthetist under operating room conditions. Knowing the disease state of the patient and the doses and times of administration of pancuronium the microcomputer can predict the degree of paralysis which exists at any time and so assists in the timing of the next dose of relaxant and in deciding when to effect reversal.

Plasma concentrations of lignocaine and its metabolites during fibreoptic bronchoscopy.

Lignocaine metabolites are known to have both antiarrhythmic and toxic effects. Large plasma concentrations of these metabolites have been reported following endotracheal instillation of lignocaine. We measured plasma lignocaine monoethylglycinexylidide (MEGX), and glycinexylidide (GX) concentrations for up to 4h after fibreoptic bronchoscopy. The total dose of lignocaine required to suppress coughing varied between 230 mg and 364 mg. Small therapeutic lignocaine concentrations occurred transiently in nine of 19 patients after the bronchoscopy examination had finished. Only one patient achieved a plasma lignocaine concentration in the range of minor toxicity. Metabolite peaks occurred later and were of much smaller magnitude. They were unlikely to contribute to prophylaxis of cardiac arrhythmia or to toxicity. It would seem to be safe to use topical lignocaine in doses greater than the currently recommended maximum (200 mg) in conscious patients during fibreoptic bronchoscopy.