Respiratory follow-up of patients with COVID-19 pneumonia

Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study

OBJECTIVE

To assess medium-term organ impairment in symptomatic individuals following recovery from acute SARS-CoV-2 infection.

DESIGN

Baseline findings from a prospective, observational cohort study.

SETTING

Community-based individuals from two UK centres between 1 April and 14 September 2020.

PARTICIPANTS

Individuals ≥18 years with persistent symptoms following recovery from acute SARS-CoV-2 infection and age-matched healthy controls.

INTERVENTION

Assessment of symptoms by standardised questionnaires (EQ-5D-5L, Dyspnoea-12) and organ-specific metrics by biochemical assessment and quantitative MRI.

MAIN OUTCOME MEASURES

Severe post-COVID-19 syndrome defined as ongoing respiratory symptoms and/or moderate functional impairment in activities of daily living; single-organ and multiorgan impairment (heart, lungs, kidneys, liver, pancreas, spleen) by consensus definitions at baseline investigation.

RESULTS

201 individuals (mean age 45, range 21-71 years, 71% female, 88% white, 32% healthcare workers) completed the baseline assessment (median of 141 days following SARS-CoV-2 infection, IQR 110-162). The study population was at low risk of COVID-19 mortality (obesity 20%, hypertension 7%, type 2 diabetes 2%, heart disease 5%), with only 19% hospitalised with COVID-19. 42% of individuals had 10 or more symptoms and 60% had severe post-COVID-19 syndrome. Fatigue (98%), muscle aches (87%), breathlessness (88%) and headaches (83%) were most frequently reported. Mild organ impairment was present in the heart (26%), lungs (11%), kidneys (4%), liver (28%), pancreas (40%) and spleen (4%), with single-organ and multiorgan impairment in 70% and 29%, respectively. Hospitalisation was associated with older age (p=0.001), non-white ethnicity (p=0.016), increased liver volume (p<0.0001), pancreatic inflammation (p<0.01), and fat accumulation in the liver (p<0.05) and pancreas (p<0.01). Severe post-COVID-19 syndrome was associated with radiological evidence of cardiac damage (myocarditis) (p<0.05).

CONCLUSIONS

In individuals at low risk of COVID-19 mortality with ongoing symptoms, 70% have impairment in one or more organs 4 months after initial COVID-19 symptoms, with implications for healthcare and public health, which have assumed low risk in young people with no comorbidities.

TRIAL REGISTRATION NUMBER

NCT04369807; Pre-results.

Alteration of Diffusion Capacity After SARS-CoV-2 Infection: A Pathophysiological Approach

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has affected millions of people worldwide, and pneumonia affects 90% of patients. This raises the possibility of millions of people with altered lung function. Few data exist to date on pulmonary function after SARS-CoV-2 infection, but alteration of diffusion capacity of CO (D LCO) is the most frequently described abnormality. First, we present original data on lung function at 3 months after SARS-CoV-2 infection and discuss the effect of using European Coal and Steel Community (ECSC) or Global Lung Function Initiative (GLI) reference equations to diagnose diffusion capacity. Second, we review existing data on D LCO alteration after SARS-CoV-2 infection and discuss the implication of restrictive disorder in D LCO alteration. Last, we discuss the pathophysiology of D LCO alteration and try to disentangle vascular damage and fibrosis.

Radiological and functional lung sequelae of COVID-19: a systematic review and meta-analysis

BACKGROUND

The coronavirus disease 2019 (COVID-19) causes a wide spectrum of lung manifestations ranging from mild asymptomatic disease to severe respiratory failure. We aimed to clarify the characteristics of radiological and functional lung sequelae of COVID-19 patients described in follow-up period.

METHOD

PubMed and EMBASE were searched on January 20th, 2021 to investigate characteristics of lung sequelae in COVID-19 patients. Chest computed tomography (CT) and pulmonary function test (PFT) data were collected and analyzed using one-group meta-analysis.

RESULTS

Our search identified 15 eligible studies with follow-up period in a range of 1-6 months. A total of 3066 discharged patients were included in these studies. Among them, 1232 and 1359 patients were evaluated by chest CT and PFT, respectively. The approximate follow-up timing on average was 90 days after either symptom onset or hospital discharge. The frequency of residual CT abnormalities after hospital discharge was 55.7% (95% confidential interval (CI) 41.2-70.1, I² = 96.2%). The most frequent chest CT abnormality was ground glass opacity in 44.1% (95% CI 30.5-57.8, I² = 96.2%), followed by parenchymal band or fibrous stripe in 33.9% (95% CI 18.4-49.4, I² = 95.0%). The frequency of abnormal pulmonary function test was 44.3% (95% CI 32.2-56.4, I² = 82.1%), and impaired diffusion capacity was the most frequently observed finding in 34.8% (95% CI 25.8-43.8, I² = 91.5%). Restrictive and obstructive patterns were observed in 16.4% (95% CI 8.9-23.9, I² = 89.8%) and 7.7% (95% CI 4.2-11.2, I² = 62.0%), respectively.

CONCLUSIONS

This systematic review suggested that about half of the patients with COVID-19 still had residual abnormalities on chest CT and PFT at about 3 months. Further studies with longer follow-up term are warranted.

Post-discharge chest CT findings and pulmonary function tests in severe COVID-19 patients

PURPOSE

To evaluate chest computed tomography (CT) and pulmonary function test (PFT) findings in severe COVID-19 patients after discharge and correlate CT pulmonary involvement with PFT results.

METHODS

COVID-19 patients admitted to our hospital between February 25 and May 2, 2020, were retrospectively included according to the following criteria: (a) COVID-19 defined as severe based on the WHO interim guidance (i.e., clinical signs of pneumonia plus respiratory rate > 30 breaths/min, severe respiratory distress, and/or SpO₂ < 90 % on room air); (b) chest radiograph in the acute setting; (c) post-discharge unenhanced chest CT; and (d) post-discharge comprehensive PFT. Imaging findings were retrospectively evaluated in consensus by two readers, and volume of abnormal lung was measured on CT using 3D Slicer software. Differences between demographics, comorbidities, acute radiographic findings, PFT, and post-discharge clinical and laboratory data of patients with normal and abnormal CT findings were assessed by Mann-Whitney or Fisher tests, and the compromised lung volume-PFT association by Pearson correlation after removing possible outliers.

RESULTS

At a median of 105 days from symptom onset, 74/91 (81 %) patients had CT abnormalities. The most common CT pattern was combined ground-glass opacity and reticular pattern (46/74, 62 %) along with architectural distortion (68/74, 92 %) and bronchial dilatation (66/74, 89 %). Compromised lung volume had a median value of 15 % [11-23], was higher in dyspneic patients, and negatively correlated with the percentage of predicted DLCO, VA, and FVC values (r = -0.39, -0.5, and -0.42, respectively). These PFT parameters were significantly lower in patients with CT abnormalities. Impairment of DLCO and KCO was found in 12 (13 %) cases, possibly implying an underlying pulmonary vasculopathy in this subgroup of patients.

CONCLUSIONS

Most severe COVID-19 survivors still had physiologically relevant CT abnormalities about three months after the disease onset, with an impairment of diffusion capacity on PFT. A pulmonary vasculopathy was suggested in a minor proportion of patients.

Post-acute COVID-19 syndrome. Incidence and risk factors: A Mediterranean cohort study

OBJECTIVES

This study aims to analyze the incidence of Post-acute COVID-19 syndrome (PCS) and its components, and to evaluate the acute infection phase associated risk factors.

METHODS

A prospective cohort study of adult patients who had recovered from COVID-19 (27th February to 29th April 2020) confirmed by PCR or subsequent seroconversion, with a systematic assessment 10-14 weeks after disease onset. PCS was defined as the persistence of at least one clinically relevant symptom, or abnormalities in spirometry or chest radiology. Outcome predictors were analyzed by multiple logistic regression (OR; 95%CI).

RESULTS

Two hundred seventy seven patients recovered from mild (34.3%) or severe (65.7%) forms of SARS-CoV-2 infection were evaluated 77 days (IQR 72-85) after disease onset. PCS was detected in 141 patients (50.9%; 95%CI 45.0-56.7%). Symptoms were mostly mild. Alterations in spirometry were noted in 25/269 (9.3%), while in radiographs in 51/277 (18.9%). No baseline clinical features behaved as independent predictors of PCS development.

CONCLUSIONS

A Post-acute COVID-19 syndrome was detected in a half of COVID19 survivors. Radiological and spirometric changes were mild and observed in less than 25% of patients. No baseline clinical features behaved as independent predictors of Post-acute COVID-19 syndrome development.

Medium-term chest computed tomography (CT) follow-up of COVID-19 pneumonia patients after recovery to assess the rate of resolution and determine the potential predictors of persistent lung changes

Background

The data on medium-term follow-up of coronavirus disease-19 (COVID-19) pneumonia survivors is scarce. Medium-term follow-up will generate knowledge and help in devising a structured follow-up plan and to facilitate enrolment in clinical trials assessing the role of antifibrotic drugs in modifying the course of disease in order to avert long-term pulmonary sequelae of disease. The study was aimed to evaluate the lung findings on a medium-term follow-up (3 months or more) chest computed tomography (CT) in COVID-19 pneumonia survivors, assess the rate of resolution or persistence of lung abnormalities and to identify the initial demographic, clinical, and imaging characteristics that could potentially predict the persistence of lung abnormalities on follow-up.

Results

Out of the total study cohort of 81 patients, 46 (56.8%) demonstrated complete resolution of lung findings and the remaining 35 (43.2%) had residual lung opacities on follow-up CT. The most common type of residual abnormality was ground glass opacity (GGO) (16/35; 45.7%), followed by parenchymal bands (9/35; 25.7%), mixed pattern of GGO and parenchymal bands (6/35; 17.2%), bronchiectasis (6/35; 17.2%), and interlobular septal thickening (4/35; 11.4%). Patients with residual abnormalities were older, had higher BMI, more comorbidities, lower SpO2, longer hospital stay, higher rate of intensive care unit (ICU) admission, higher WBC count, a higher CT severity score, and lower rate of steroid administration with all p values < 0.05.

Conclusion

Nearly half of post-COVID-19 survivors had residual lung abnormalities after ≥ 3 months of follow-up. Certain clinico-radiological characteristics have the potential to identify the individuals at risk of having residual lung abnormalities on medium-term follow-up.

Antimicrobial resistance and COVID-19: Intersections and implications

Before the coronavirus 2019 (COVID-19) pandemic began, antimicrobial resistance (AMR) was among the top priorities for global public health. Already a complex challenge, AMR now needs to be addressed in a changing healthcare landscape. Here, we analyse how changes due to COVID-19 in terms of antimicrobial usage, infection prevention, and health systems affect the emergence, transmission, and burden of AMR. Increased hand hygiene, decreased international travel, and decreased elective hospital procedures may reduce AMR pathogen selection and spread in the short term. However, the opposite effects may be seen if antibiotics are more widely used as standard healthcare pathways break down. Over 6 months into the COVID-19 pandemic, the dynamics of AMR remain uncertain. We call for the AMR community to keep a global perspective while designing finely tuned surveillance and research to continue to improve our preparedness and response to these intersecting public health challenges.

Atteintes pulmonaires liées à la COVID-19

Le SARS-CoV-2, responsable de la COVID-19, est un nouveau bêta-coronavirus.

Il engendre une réaction inflammatoire intense pouvant aller jusqu’à l’« orage cytokinique », avec des atteintes pulmonaires épithéliales sévères et un tableau de coagulopathie intravasculaire pulmonaire.

Le tableau clinique est polymorphe, avec possible survenue d’un syndrome de détresse respiratoire aigu (SDRA).

La ventilation non invasive et l’oxygénothérapie à haut débit permettent de traiter efficacement plus de la moitié des patients graves sans recours à l’intubation et sans risque pour le personnel soignant.

Le seul traitement actuellement validé est la dexaméthasone à dose modérée (6 mg/j pendant 10 jours).

Le haut risque thrombotique justifie en fonction des cas une anticoagulation préventive voire curative.

Cardiac involvement in consecutive elite athletes recovered from Covid-19: A magnetic resonance study

Magnetic resonance (MR) studies suggested cardiac involvement post-Covid-19 in a significant subset of affected individuals, including athletes. This brings serious clinical concerns regarding the potential need for in-depth cardiac screening in athletes after Covid-19 before return to play. The aim of this study was to gain further insight into the relation between Covid-19 and cardiac involvement in professional athletes. This was a retrospective cohort study, in which 26 consecutive elite athletes (national team, Olympians, top national league players; median age 24 years, interquartile range [IQR] 21-27, 81% female) were included. At 1.5 T including balanced steady-state free precession cine imaging, T1 and T2-mapping using Myomaps software (Siemens), dark-blood T2-weighted images with fat suppression, and late gadolinium enhancement (LGE) with phase-sensitive inversion recovery sequence were used. The athletes had mainly asymptomatic or mild course of the disease (77%). They were scanned after a median of 32 days (IQR 22-62 days) from the diagnosis. MR data were reviewed by three independent observers, each with >10 years cardiac MR experience. Native T1, T2, extracellular volume, and T2 signal intensity ratio were calculated. Diagnosis of acute myocarditis was based on modified Lake Louise criteria. Statistical analyses used were Pearson correlation and Bland-Altman repeatability analysis. At the time of MR the athletes had no pathologic electrocardiogram abnormalities or elevated troponin levels. MR did not reveal any case of acute myocarditis. Cardiac abnormalities were found in five (19%) athletes, including four athletes presenting borderline signs of isolated myocardial edema and one athlete showing nonischemic LGE with pleural and pericardial effusion. Another athlete had signs of persistent lung congestion without cardiac involvement. We have shown that in a small group of elite athletes with mainly asymptomatic to mild Covid-19, lack of electrocardiographic changes, and normal troponin concentration 1-2 months after the diagnosis, there were no signs of acute myocarditis, but 19% of athletes had some abnormalities as assessed by cardiac MR. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Implementation of Telemedicine in a Tertiary Hospital-Based Ambulatory Practice in Detroit During the COVID-19 Pandemic: Observational Study

Background

The COVID-19 pandemic, caused by SARS-CoV-2, has forced the health care delivery structure to change rapidly. The pandemic has further widened the disparities in health care and exposed vulnerable populations. Health care services caring for such populations must not only continue to operate but create innovative methods of care delivery without compromising safety. We present our experience of incorporating telemedicine in our university hospital–based outpatient clinic in one of the worst-hit areas in the world.

Objective

Our goal is to assess the adoption of a telemedicine service in the first month of its implementation in outpatient practice during the COVID-19 pandemic. We also want to assess the need for transitioning to telemedicine, the benefits and challenges in doing so, and ongoing solutions during the initial phase of the implementation of telemedicine services for our patients.

Methods

We conducted a prospective review of clinic operations data from the first month of a telemedicine rollout in the outpatient adult ambulatory clinic from April 1, 2020, to April 30, 2020. A telemedicine visit was defined as synchronous audio-video communication between the provider and patient for clinical care longer than 5 minutes or if the video visit converted to a telephone visit after 5 minutes due to technical problems. We recorded the number of telemedicine visits scheduled, visits completed, and the time for each visit. We also noted the most frequent billing codes used based on the time spent in the patient care and the number of clinical tasks (eg, activity suggested through diagnosis or procedural code) that were addressed remotely by the physicians.

Results

During the study period, we had 110 telemedicine visits scheduled, of which 94 (85.4%) visits were completed. The average duration of the video visit was 35 minutes, with the most prolonged visit lasting 120 minutes. Of 94 patients, 24 (25.54%) patients were recently discharged from the hospital, and 70 (74.46%) patients were seen for urgent care needs. There was a 50% increase from the baseline in the number of clinical tasks that were addressed by the physicians during the pandemic.

Conclusions

There was a high acceptance of telemedicine services by the patients, which was evident by a high show rate during the COVID-19 pandemic in Detroit. With limited staffing, restricted outpatient work hours, a shortage of providers, and increased outpatient needs, telemedicine was successfully implemented in our practice.

COVID-19: looking beyond the peak. Challenges and tips for radiologists in follow-up of a novel patient cohort

As the coronavirus pandemic evolves, the focus of radiology departments has begun to change. The acute phase of imaging a new disease entity whilst rationalising radiology services in the face of lockdown has passed. Radiologists are now becoming familiar with the complications of COVID-19, particularly the lung parenchymal and pulmonary vascular sequelae and are considering the impact follow-up imaging may have on departments already struggling with a backlog of suspended imaging in the face of reduced capacity. This review from the British Society of Thoracic Imaging explores both the thoracic and extra-thoracic complications of COVID-19, recognising the importance of a holistic approach to patient follow-up. The British Thoracic Society guidelines for respiratory follow-up of COVID-19 will be discussed, together with newly developed reporting templates, which aim to provide consistency for clinicians as well as an opportunity for longer-term data collection.

CUADRO CLÍNICO DEL COVID-19

El Coronavirus SARS-CoV-2 produce la enfermedad COVID-19, cuya manifestación más grave y potencialmente letal es la neumonía. En este artículo revisaremos las manifestaciones clínicas del COVID-19, la fisiopatología de la neumonía, el manejo intrahospitalario previo al ingreso a Unidades de Cuidados Intensivos, la embolia pulmonar que es una complicación muy frecuente de esta enfermedad y el seguimiento de los pacientes posterior al alta. Para esta publicación nos hemos basado en publicaciones médicas y en estudios que hemos hecho durante esta pandemia en nuestro Centro de Enfermedades Respiratorias.

COVID-19 and post-infectious myalgic encephalomyelitis/chronic fatigue syndrome: a narrative review

Coronavirus disease 2019 (COVID-19) is a viral infection which can cause a variety of respiratory, gastrointestinal, and vascular symptoms. The acute illness phase generally lasts no more than 2-3 weeks. However, there is increasing evidence that a proportion of COVID-19 patients experience a prolonged convalescence and continue to have symptoms lasting several months after the initial infection. A variety of chronic symptoms have been reported including fatigue, dyspnea, myalgia, exercise intolerance, sleep disturbances, difficulty concentrating, anxiety, fever, headache, malaise, and vertigo. These symptoms are similar to those seen in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a chronic multi-system illness characterized by profound fatigue, sleep disturbances, neurocognitive changes, orthostatic intolerance, and post-exertional malaise. ME/CFS symptoms are exacerbated by exercise or stress and occur in the absence of any significant clinical or laboratory findings. The pathology of ME/CFS is not known: it is thought to be multifactorial, resulting from the dysregulation of multiple systems in response to a particular trigger. Although not exclusively considered a post-infectious entity, ME/CFS has been associated with several infectious agents including Epstein-Barr Virus, Q fever, influenza, and other coronaviruses. There are important similarities between post-acute COVID-19 symptoms and ME/CFS. However, there is currently insufficient evidence to establish COVID-19 as an infectious trigger for ME/CFS. Further research is required to determine the natural history of this condition, as well as to define risk factors, prevalence, and possible interventional strategies.

Prevalence of potential respiratory symptoms in survivors of hospital admission after coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

Knowledge on the sequelae of Coronavirus Disease 2019 (COVID-19) remains limited due to the relatively recent onset of this pathology. However, the literature on other types of coronavirus infections prior to COVID-19 reports that patients may experience persistent symptoms after discharge. To determine the prevalence of respiratory symptoms in survivors of hospital admission after COVID-19 infection. A living systematic review of five databases was performed in order to identify studies which reported the persistence of respiratory symptoms in COVID-19 patients after discharge. Two independent researchers reviewed and analysed the available literature, and then extracted and assessed the quality of those articles. Of the 1,154 reports returned by the initial search nine articles were found, in which 1,816 patients were included in the data synthesis. In the pooled analysis, we found a prevalence of 0.52 (CI 0.38-0.66, p < 0.01, I2 = 97%), 0.37 (CI 0.28-0.48, p < 0.01, I2 = 93%), 0.16 (CI 0.10-0.23, p < 0.01, I2 = 90%) and 0.14 (CI 0.06-0.24, p < 0.01, I2 = 96%) for fatigue, dyspnoea, chest pain, and cough, respectively. Fatigue, dyspnoea, chest pain, and cough were the most prevalent respiratory symptoms found in 52%, 37%, 16% and 14% of patients between 3 weeks and 3 months, after discharge in survivors of hospital admission by COVID-19, respectively.

Outcomes Evaluated in Controlled Clinical Trials on the Management of COVID-19: A Methodological Systematic Review

It is crucial that randomized controlled trials (RCTs) on the management of coronavirus disease 2019 (COVID-19) evaluate the outcomes that are critical to patients and clinicians, to facilitate relevance, interpretability, and comparability. This methodological systematic review describes the outcomes evaluated in 415 RCTs on the management of COVID-19, that were registered with ClinicalTrials.gov, by 5 May 2020, and the instruments used to measure these outcomes. Significant heterogeneity was observed in the selection of outcomes and instruments. Mortality, adverse events and treatment success or failure are only evaluated in 64.4%, 48.4% and 43% of the included studies, respectively, while other outcomes are selected less often. Studies focusing on more severe presentations (hospitalized patients or requiring intensive care) most frequently evaluate mortality (72.5%) and adverse events (55.6%), while hospital admission (50.8%) and viral detection/load (55.6%) are most frequently assessed in the community setting. Outcome measurement instruments are poorly reported and heterogeneous. Follow-up does not exceed one month in 64.3% of these earlier trials, and long-term COVID-19 burden is rarely assessed. The methodological issues identified could delay the introduction of potentially life-saving treatments in clinical practice. Our findings demonstrate the need for greater consistency, to enable decision makers to compare and contrast studies.

Nanomedicine & Nanotoxicology Future Could Be Reshaped Post-COVID-19 Pandemic

Since its first emergence in December 2019, the coronavirus-2 infection has quickly spread around the world and the severity of the pandemic has already re-shaped our lives. This review highlights the role of nanotechnology in the fight against this pandemic with a focus on the design of effective nano-based prevention and treatment options that overcome the limitations associated with conventional vaccines and other therapies. How nanotechnology could be utilized to understand the pathology of the ongoing pandemic is also discussed as well as how our knowledge about SARS-CoV-2 cellular uptake and toxicity could influence future nanotoxicological considerations and nanomedicine design of safe yet effective nanomaterials.

Patient outcomes after hospitalisation with COVID-19 and implications for follow-up: results from a prospective UK cohort

The longer-term consequences of SARS-CoV-2 infection are uncertain. Consecutive patients hospitalised with COVID-19 were prospectively recruited to this observational study (n=163). At 8-12 weeks postadmission, survivors were invited to a systematic clinical follow-up. Of 131 participants, 110 attended the follow-up clinic. Most (74%) had persistent symptoms (notably breathlessness and excessive fatigue) and limitations in reported physical ability. However, clinically significant abnormalities in chest radiograph, exercise tests, blood tests and spirometry were less frequent (35%), especially in patients not requiring supplementary oxygen during their acute infection (7%). Results suggest that a holistic approach focusing on rehabilitation and general well-being is paramount.