Phenotyping of acute and persistent COVID-19 features in the outpatient setting: exploratory analysis of an international cross-sectional online survey

BACKGROUND. Long COVID, defined as presence of COVID-19 related symptoms 28 days or more after the onset of acute SARS-CoV-2 infection, is an emerging challenge to healthcare systems. The objective of this study was to phenotype recovery trajectories of non-hospitalized COVID-19 individuals. METHODS. We performed an international, multi-center, exploratory online survey study on demographics, comorbidities, COVID-19 symptoms and recovery status of non-hospitalized SARS-CoV-2 infected adults (Austria: n=1157), and Italy: n= 893). RESULTS. Working age subjects (Austria median: 43 yrs (IQR: 31 - 53), Italy: 45 yrs (IQR: 35 - 55)) and females (65.1% and 68.3%) predominated the study cohorts. Course of acute COVID-19 was characterized by a high symptom burden (median 13 (IQR: 9 - 18) and 13 (7 - 18) out of 44 features queried), a 47.6 - 49.3% rate of symptom persistence beyond 28 days and 20.9 - 31.9% relapse rate. By cluster analysis, two acute symptom phenotypes could be discerned: the non-specific infection phenotype and the multi-organ phenotype (MOP), the latter encompassing multiple neurological, cardiopulmonary, gastrointestinal and dermatological features. Clustering of long COVID subjects yielded three distinct subgroups, with a subset of 48.7 - 55 % long COVID individuals particularly affected by post-acute MOP symptoms. The number and presence of specific acute MOP symptoms and pre-existing multi-morbidity was linked to elevated risk of long COVID. CONCLUSION. The consistent findings of two independent cohorts further delineate patterns of acute and post-acute COVID-19 and emphasize the importance of symptom phenotyping of home-isolated COVID-19 patients to predict protracted convalescence and to allocate medical resources.

What Is the Capacity of Individuals with Schizophrenia and Bipolar Disorder to Make Healthcare Decisions? An Exploratory Study of the Views of Patients, Psychiatrists, and Family Caregivers—A Survey on Decisional Capacity in Mental Health

Background: Research on the decisional capacity of schizophrenia and bipolar disorder patients mostly reflects the hospital context. Aim: To describe the views of patients, psychiatrists, and caregivers on the capacity of individuals with schizophrenia and bipolar disorder to make everyday decisions on their care related to their illness. Methods: A survey was conducted among schizophrenia and bipolar disorder patients, psychiatrists, and caregivers (June 2019 to January 2020; seven countries). A questionnaire was emailed to members of the Global Alliance of Mental Illness of Advocacy Network—Europe (GAMIAN; patients) and the European Federation of Families of People with Mental Illness (EUFAMI; caregivers) and to psychiatrists who voluntarily agreed to participate. Questions referred to patients’ involvement and capacity for healthcare decision making, and to barriers to and opportunities for autonomous decision making. Frequency, agreement, and importance were rated on Likert scales. Descriptive statistics were conducted. Results: 21 schizophrenia or bipolar disorder patients (52.3% female; mean age (years) ± SD: 50.71 ± 12.02), 11 psychiatrists (18.2% female), and 15 caregivers (86.6% female; 100% family related) participated in the survey. In total, 86% of patients felt frequently involved in decisions about everyday care and medications, and 91% of psychiatrists and 40% of caregivers perceived the same; 38% of patients felt frequently involved in decisions about the use of acute symptom medications, and 57% on care planning, and 55% and 82% of psychiatrists, and 40% and 53% of caregivers, respectively, believed the same; and 86% of patients, 91% of psychiatrists, and 47% of caregivers agreed on the capacity of schizophrenia or bipolar disorder patients to value the implications of taking medicines to prevent acute psychotic crises. Poor understanding and training are barriers, while advocacy and increasing interest in patients’ needs are opportunities for increasing autonomous decision making. Conclusions: Stakeholders concur that schizophrenia and bipolar disorder patients have the capacity to make everyday decisions around their care related to their illness, including acute symptom management. Barriers and opportunities exist to foster autonomous decisions among mental illness individuals.

Decomposing Acute Symptom Severity in Large Vessel Occlusion Stroke: Association With Multiparametric CT Imaging and Clinical Parameters

Background and Purpose: Acute ischemic stroke of the anterior circulation due to large vessel occlusion (LVO) is a multifactorial process, which causes neurologic symptoms of different degree. Our aim was to examine the impact of neuromorphologic and vascular correlates as well as clinical factors on acute symptom severity in LVO stroke.Methods: We selected LVO stroke patients with known onset time from a consecutive cohort which underwent multiparametric CT including non-contrast CT, CT angiography and CT perfusion (CTP) before thrombectomy. Software-based quantification was used to calculate CTP total ischemic and ischemic core volume. Symptom severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) upon admission. Multivariable regression analysis was performed to determine independent associations of admission NIHSS with imaging and clinical parameters. Receiver operating characteristics (ROC) analyses were used to examine performance of imaging parameters to classify symptom severity.Results: We included 142 patients. Linear and ordinal regression analyses for NIHSS and NIHSS severity groups identified significant associations for total ischemic volume [β = 0.31, p = 0.01; Odds ratio (OR) = 1.11, 95%-confidence-interval (CI): 1.02–1.19], clot burden score (β = −0.28, p = 0.01; OR = 0.76, 95%-CI: 0.64–0.90) and age (β = 0.17, p = 0.04). No association was found for ischemic core volume, stroke side, collaterals and time from onset. Stroke topography according to the Alberta Stroke Program CT Score template did not display significant influence after correction for multiple comparisons. AUC for classification of the NIHSS threshold ≥6 by total ischemic volume was 0.81 (p < 0.001).Conclusions: We determined total ischemic volume, clot burden and age as relevant drivers for baseline NIHSS in acute LVO stroke. This suggests that not only mere volume but also degree of occlusion influences symptom severity. Use of imaging parameters as surrogate for baseline NIHSS reached limited performance underlining the need for combined clinical and imaging assessment in acute stroke management.

Implementation of Symptom Care Clinic (SCC) for acute symptoms management at outpatient oncology ambulatory centers.

2030 Background: With improved overall cancer survival, increasing number of cancer patients are undergoing active treatment. This, in return, add burden in acute symptom management related to disease and treatment. This has resulted in increasing unplanned emergency room (ER) visits and negatively impacted patients experience and health cost. We establish Symptom Care Clinic (SCC) embedded in suburban ambulatory oncology centers to reduce unplanned ER lists and to improve patient experience. Methods: Together with all stakeholders, we developed six SCCs at regional ambulatory centers in NY and NJ. Clearly defined work flow and algorithm were developed to ensure appropriate patient referral. On-site radiology and laboratory services are available. The SCCs are staffed with combination of Advanced Practice Provided (APP) and physicians or APP alone supported by on site medical oncologist or remote central Urgent Care Center Attendings. We evaluated clinic volumes, reduction ins unplanned ER visits and patient experience. Results: From October 2017 to December 2019, total of 17,542 SCC visits were documented. Total of 17,479 lab and 5,355 radiology tests as well as 3,915 infusions were performed. The top five most common laboratory tests are CBC, blood cultures, CMP, respiratory panel and urine culture. The most common symptoms are fever, nausea/vomiting/dehydration, rash and pain. Among all SCC visits during this period, 83% were discharged home and 17% were transferred to ER or hospitals. During 2019, total 10,736 SCC visits were recored, APP evaluated 73.7% of visits and physicians 16.3% with comaprable recidivism rate, 2.52% and 2.75%, respectively. Conservatively, we estimated that approximately 40% of visits would have been Er visits based on numbers of CBC and other testes performed. Qualitative feedbacks from patients indicated positive experience in convenient access, cohesive care coordination and time saving from traveling to and waiting in ER. Conclusions: We successfully implemented an effective acute symptom management system in busy ambulatory oncology centers that is patient centric. Out data showed that SCC reduced unplanned ER visits and that APP/physician model has low recidivism rate.

Prevalence and Outcomes of Web-Based Health Information Seeking for Acute Symptoms: Cross-Sectional Study

Background The literature indicates that Web-based health information seeking is mostly used for seeking information on well-established diseases. However, only a few studies report health information seeking in the absence of a doctor’s visit and in the context of acute symptoms. Objective This survey aimed to estimate the prevalence of Web-based health information seeking for acute symptoms and the impact of such information on symptom management and health service utilization. Methods This was a cross-sectional study of a convenience sample of 287 Lebanese adults (with a response rate of 18.5% [54/291]) conducted between December 2016 and June 2017. The survey was answered by participants online or through phone-based interviews. Results A total of 64.3% of the participants (178/277) reported checking the internet for health information when they had an acute symptom. The rate of those who sought to use Web-based health information first when experiencing acute symptom(s) in the past 12 months was 19.2% (25/130). In addition, 50% (9/18) visited the doctor because of the obtained information, and the rest self-medicated or sought a pharmacist’s advice; the majority (18/24, 75%) improved within 3-4 days. Conclusions Higher education level and trust in Web-based medical information were two major predictors of Web-based health information seeking for acute symptoms. Seeking Web-based health information first for acute symptoms is common and may lead to self-management by avoiding a visit to the physician. Physicians should encourage their patients to discuss Web-based health information and guide them toward trusted online websites.

Azithromycin Prophylaxis in an Adolescent With PANDAS

Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) is a type of pediatric obsessive-compulsive disorder with an acute symptom onset and periodic recurrence that is triggered by streptococcal infection. Due in part to the multifaceted assessment involved in the diagnosis of PANDAS and lack of consensus on the best treatment, management of these cases is complex. A background and case of PANDAS exacerbation in an adolescent patient, who presented with visuomotor impairment and was treated with azithromycin (Zithromax, Pfizer, New York, NY) prophylaxis to prevent further clinical deterioration, is described here.

Mapping brain recovery after concussion

ObjectiveTo test the hypothesis that concussion-related brain alterations seen at symptomatic injury and medical clearance to return to play (RTP) will have dissipated by 1 year after RTP.MethodsFor this observational study, 24 athletes with concussion were scanned longitudinally within 1 week after injury, at RTP, and 1 year after RTP. A large control cohort of 122 athletes were also scanned before the season. Each imaging session assessed global functional connectivity (Gconn) and cerebral blood flow (CBF), along with white matter fractional anisotropy (FA) and mean diffusivity (MD). The main effects of concussion on MRI parameters were evaluated at each postinjury time point. In addition, covariation was assessed between MRI parameters and clinical measures of acute symptom severity and time to RTP.ResultsDifferent aspects of brain physiology showed different patterns of recovery over time. Both Gconn and FA displayed no significant effects at 1 year after RTP, whereas CBF and MD exhibited persistent long-term effects. The effects of concussion on MRI parameters were also dependent on acute symptom severity and time to RTP for all postinjury time points.ConclusionThis study provides the first longitudinal evaluation of concussion focused on time of RTP and 1 year after medical clearance, using multiple different MRI measures to assess brain structure and function. These findings significantly enhance our understanding of the natural course of brain recovery after a concussion.

Incidence of the Acute Symptom of Chronic Periodontal Disease in Patients Undergoing Supportive Periodontal Therapy: A 5-Year Study Evaluating Climate Variables

Although patients under supportive periodontal therapy (SPT) have a stable periodontal condition, the acute symptom of chronic periodontal disease occasionally occurs without a clear reason. Therefore, in the present study, to obtain a better understanding of this relationship in patients undergoing SPT, we hypothesized that the acute symptom of chronic periodontal disease might be affected by climate factors. We conducted a questionnaire study and carried out oral examinations on patients undergoing SPT who had been diagnosed as having the acute symptom of chronic periodontal disease. We collected climate data from the local climate office in Okayama city, Japan. We predicted parameters that affect the acute symptom of chronic periodontal disease with unidentified cause and divided patients into high and low groups in terms of climate predictors. Then we defined the cut-off values of parameters showing significant differences in the incidence of the acute symptom of chronic periodontal disease. The incidence of the acute symptom of chronic periodontal disease with unidentified cause was significantly different when the cases were classified according to the maximum hourly decrease in barometric pressure (1.5 and 1.9 hPa) (p = 0.04 and p = 0.03, respectively). This suggests that climate variables could be predictors of the acute symptom of chronic periodontal disease. Therefore, gaining a better understanding of these factors could help periodontal patients undergoing SPT prepare to avoid the acute symptom of chronic periodontal disease.

Prevalence and Outcomes of Web-Based Health Information Seeking for Acute Symptoms: Cross-Sectional Study (Preprint)

BACKGROUND The literature indicates that Web-based health information seeking is mostly used for seeking information on well-established diseases. However, only a few studies report health information seeking in the absence of a doctor’s visit and in the context of acute symptoms. OBJECTIVE This survey aimed to estimate the prevalence of Web-based health information seeking for acute symptoms and the impact of such information on symptom management and health service utilization. METHODS This was a cross-sectional study of a convenience sample of 287 Lebanese adults (with a response rate of 18.5% [54/291]) conducted between December 2016 and June 2017. The survey was answered by participants online or through phone-based interviews. RESULTS A total of 64.3% of the participants (178/277) reported checking the internet for health information when they had an acute symptom. The rate of those who sought to use Web-based health information first when experiencing acute symptom(s) in the past 12 months was 19.2% (25/130). In addition, 50% (9/18) visited the doctor because of the obtained information, and the rest self-medicated or sought a pharmacist’s advice; the majority (18/24, 75%) improved within 3-4 days. CONCLUSIONS Higher education level and trust in Web-based medical information were two major predictors of Web-based health information seeking for acute symptoms. Seeking Web-based health information first for acute symptoms is common and may lead to self-management by avoiding a visit to the physician. Physicians should encourage their patients to discuss Web-based health information and guide them toward trusted online websites.