Cardiopulmonary Symptoms Research Articles

Validation of the Chinese version bodily distress syndrome checklist in Chinese out-patients of general hospitals

ObjectiveThe 25-item Bodily Distress Syndromes (BDS) checklist was developed to assess BDS symptoms with high validity and reliability. The aim of this study was to reveal the psychometric properties of the Chinese version of the BDS checklist in Chinese outpatients of general hospitals. MethodA cross-sectional study was carried out in nine Chinese general hospitals, consisting of three different medicine settings: biomedicine, traditional medicine, and psychosomatic medicine. The 25-item BDS checklist was translated into the Chinese version and conducted on outpatients from all nine centers. We performed validity and reliability analyses, including test-retest reliability, construct validity, and internal consistency reliability, on the collected checklist data. The convergent validity of the BDS checklist was analyzed with Pearson's Coefficient vs. Patient Health Questionnaire-15 (PHQ-15). The discriminant validity of the BDS checklist was analyzed with Pearson's Coefficient vs. Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7) and Whiteley-8 (WI-8). ResultsA total of 699 patients were included in this study. The test-retest reliability, construct validity, and internal consistency reliability of the Chinese version of the BDS were satisfactory in our study. Factor analyses identified five distinct determining factors: cardiopulmonary, gastric, intestinal, musculoskeletal, and general symptoms. Pearson's coefficients were found to be high in both discriminant validity and convergent validity analyses. ConclusionThe results provide empirical support for the Chinese version of the BDS checklist in patients in general hospitals. The Chinese version of the BDS checklist is potentially valuable for case finding in both clinical practice and research in Chinese.

Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis

There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms. To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs. This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021. The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation. The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs. A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]). In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care. Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.

Changes in self-image after pectus carinatum brace treatment

Background/PurposePectus carinatum (PC) is a chest wall deformity resulting in anterior protrusion of the chest. PC does not typically result in significant physical or cardiopulmonary symptoms, but patients with this condition can experience a disturbed body image, lower self-esteem and reduced quality of life. The purpose of this study was to investigate the relationship between self-image and non-surgical correction of PC using a brace. MethodsThis study was a descriptive, pre-post survey design. The sample included children ages 11 to <18 years undergoing PC treatment with the dynamic compressor system. Subjects completed the modified Pectus Excavatum Evaluation Questionnaire (mPEEQ) at the onset of bracing and again once PC correction was completed. ResultsNinety-seven subjects were enrolled at the time of bracing, and 41 achieved correction and took the second survey. The mean age was 14 years and 80% were male. There was a statistically significant (p<0.001) improvement in body self-image between the first and second surveys. ConclusionsNon-surgical correction of PC with the dynamic compressor system resulted in an improvement in the self-image of children. Prognosis studyLevel of Evidence II

282 Follow-up of hospitalized COVID-19 survivors: assessment of short- and long-term cardiovascular sequelae after SARS-CoV-2 infection

AimsCardiovascular sequelae in COVID-19 survivors remain largely unclear and can potentially go unrecognized. Reports on follow-up focused on cardiovascular evaluation after hospital discharge are currently scarce. Aim of this prospective study was to assess cardiovascular sequelae in previously hospitalized COVID-19 survivors.Methods and resultsThe study was conducted at ‘Sapienza’ University of Rome—Policlinico ‘Umberto I’. After 2 months from discharge, n = 230 COVID-19 survivors underwent a follow-up visit at a dedicated ‘post-COVID Outpatient Clinic’. A cardiovascular evaluation including electrocardiogram (ECG), Troponin and echocardiography was performed. Further tests were requested when clinically indicated. Medical history, symptoms, arterial-blood gas, blood tests, chest computed tomography, and treatment of both in-hospital and follow-up evaluation were recorded. A 1-year telephone follow-up was performed. A total of 36 (16%) COVID-19 survivors showed persistence or delayed onset of cardiovascular disease at 2-months follow-up visit. Persistent condition was recorded in 62% of survivors who experienced an in-hospital cardiovascular disease. Delayed cardiovascular involvement included: myocarditis, pericarditis, ventricular disfunction, new onset of systemic hypertension and arrhythmias. At 1-year telephone follow-up, 105 (45%) survivors reported persistent symptoms, with dyspnoea and fatigue being the most frequent. 60% of survivors showed persistent chest CT abnormalities and among those 28% complained of persistent cardiopulmonary symptoms at long term follow-up.ConclusionsOur preliminary data showed persistent or delayed onset of cardiovascular involvement (16%) at short-term follow-up and persistent symptoms (45%) at long-term follow-up. These findings suggest the need for monitoring COVID-19 survivors.

Lipid peroxidation mediates the relationship between cardiopulmonary fitness and depressive symptoms in people with coronary artery disease

AbstractBackgroundEmerging evidence suggests that poor cardiorespiratory fitness levels are related to greater depressive symptoms. In those with coronary artery disease (CAD) depressive symptoms are common and are associated with an increased risk of mortality. Exercise intervention is suggested to have positive effects on depressive symptoms and counteract oxidative stress (OS) in the body. However, a mechanistic link between cardiorespiratory fitness (CRF) and depressive symptoms has not been identified in CAD individuals. We aim to investigate if OS explains the relationship between poor cardiorespiratory fitness and higher depressive symptoms in CAD individuals.MethodCAD participants were recruited and OS was measured via serum lipid peroxidation marker 8‐isoprostane (8‐ISO), lipid hydroperoxides (LPH), and 4‐hydroxyneoneal (4‐HNE). CRF was assessed by peak oxygen uptake (VO2peak) and depressive symptoms measured via Center for Epidemiological Studies‐Depression (CES‐D) scale. Analyses were controlled for age, hypertension, hypercholesterolemia, and antidepressant use. Mediation effects of OS markers on the relationship between CRF and depressive symptoms were tested. A bias‐corrected inferential bootstrapping with 10,000 permutations was used to obtain a 95% confidence interval (CI) for the indirect effect.ResultAmong CAD individuals (n=224), lower VO2peak was associated with higher 8‐ISO (β=0.31, p&lt;0.001) and greater depressive symptoms (β=‐0.143, p=0.038). LPH (B=‐0.172 p=0.017) was associated with greater CES‐D score, but not VO2peak levels (B=‐0.122, p=0.109), when controlling for the same covariates. 4‐HNE was not a significant predictor of CES‐D scores (B=0.059, p=0.372) or VO2peak levels (B=‐0.052, p=0.440). 8‐ISO mediated the relationship between VO2peak (β=0.02, p=0.01) and CES‐D (β=7.13, p=0.001), and LPH did not (‐0.0098, 95% CI [‐0.0314, 0.0042]). Bootstrapping produced a significant unstandardized indirect effect for 8‐ISO (β=‐0.20, SE=0.05, 95% CI=‐0.32, ‐0.01).ConclusionIn those with CAD, poor CRF and greater OS levels were associated with higher depressive symptoms, and this relationship was mediated by 8‐ISO, but not LPH or 4‐HNE. These findings provide greater understanding of the mechanistic reasoning for the link between poor CRF and depressive symptoms.

Phenotyping of Acute and Persistent Coronavirus Disease 2019 Features in the Outpatient Setting: Exploratory Analysis of an International Cross-sectional Online Survey.

BACKGROUNDLong COVID, defined as presence of COVID-19 symptoms 28 days or more after clinical onset, is an emerging challenge to healthcare systems. The objective of this study was to explore recovery phenotypes in non-hospitalized COVID-19 individuals.METHODSA dual cohort, online survey study was conducted between September 2020 and July 2021 in the neighboring European regions Tyrol (TY, Austria, n = 1157) and South Tyrol (STY, Italy, n = 893). Data on demographics, comorbidities, COVID-19 symptoms and recovery adult outpatients were collected. Phenotypes of acute COVID-19, post-acute sequelae and risk of protracted recovery were explored by semi-supervised clustering and multi-parameter LASSO modeling.RESULTSWorking age subjects (TY: 43 yrs (IQR: 31 – 53), STY: 45 yrs (IQR: 35 – 55)) and females (TY: 65.1%, STY: 68.3%) predominated the study cohorts. Nearly half of the participants (TY: 47.6%, STY: 49.3%) reported symptom persistence beyond 28 days. Two acute COVID-19 phenotypes were discerned: the non-specific infection phenotype and the multi-organ phenotype (MOP). Acute MOP symptoms encompassing multiple neurological, cardiopulmonary, gastrointestinal and dermatological complaints were linked to elevated risk of protracted recovery. The major subset of long COVID individuals (TY: 49.3%, STY: 55.6%) displayed no persistent hyposmia or hypogeusia but high counts of post-acute MOP symptoms and poor self-reported physical recovery.CONCLUSIONThe results of our two-cohort analysis delineated phenotypic diversity of acute and post-acute COVID-19 manifestations in home-isolated patients which needs to be considered for predicting protracted convalescence and allocation of medical resources.

Abstract 11639: Characteristics of Patients Referred to a Cardiovascular Disease Clinic for Post-Acute Sequelae of SARS-CoV-2 Infection

Introduction: There is limited literature on the cardiovascular manifestations of post-acute sequelae of SARS-CoV-2 infection (PASC). Methods: All consecutive adult patients presenting to the cardiology clinic at Yale-New Haven Hospital since July 2020, with positive COVID-19 serologic testing, were included. Results: Of 71 patients, average age was 46 years (range 19-74 years), 44 (62%) were female. 51 (72%) were White. 19 (27%) patients were hospitalized for COVID-19 ( Table ). Comorbidities included Hypertension (27%), hyperlipidemia (25%), diabetes (24%), and obesity (30%). On average, patients presented four months after COVID-19 diagnosis. The most common symptoms at presentation were dyspnea (45%, almost all exertional), palpitations (49%), and chest pain/pressure (49%). Patients also had memory impairment (20%), fatigue (39%), and headache (14%). There was no significant difference in cardiopulmonary symptoms (dyspnea, palpitations, and chest pain/pressure) by hospitalization status (p=0.70). TTE was abnormal in 13 of 62 patients and cardiac MRI was abnormal in 10 of 17 patients. Women experienced more cardiopulmonary symptoms (p=0.02) than men. Hospitalized patients were more likely to have ventricular dysfunction than non-hospitalized patients, although there were no significant differences in abnormal MRI findings (p=0.38). Diagnostic yield included: nonischemic cardiomyopathy (6%); new ischemia (3%); coronary vasospasm (1%); new atrial fibrillation (1%); possible myocarditis based on symptoms, MRI LGE (8%) or inflammation (3%). Two people met POTS criteria; majority of patients had evidence of sinus tachycardia and exertional fatigue consistent with orthostatic intolerance and deconditioning. Conclusions: In this cohort of patients referred to a cardiology clinic for PASC, cardiopulmonary symptoms did not differ by hospitalization status, however women were more likely to experience these symptoms than men.

Abstract 13671: Return to Play After COVID-19 Infection in Collegiate Competitive Athletes

Introduction: COVID-19 infection has placed significant healthcare and economic burdens on society. Recent studies of patients recovered from COVID-19 infection demonstrate highly variable rates of cardiac involvement. A German cohort reported 78% cardiac involvement as defined by abnormalities seen on cardiac magnetic resonance imaging (CMR) while more recent data suggests rates of cardiac involvement between 0.3% and 3%. Competitive athletes represent a unique population as they may pose greater risk for sudden cardiac death during competition due to myocarditis as a sequela of COVID-19 infection. Hypothesis: We hypothesize that among athletes with non-severe COVID-19 infection, a symptom driven clinical pathway would lead to a safe and cost-effective return to sports. Methods: A retrospective analysis was conducted in a cohort of collegiate athletes with non-severe COVID-19 infection returning to competitive sports. The primary outcomes were the prevalence of cardiac involvement based on symptoms and abnormalities with electrocardiograms (ECG), troponin, or transthoracic echocardiogram (TTE). CMR were performed for ongoing cardiopulmonary symptoms or abnormal cardiac test results. Evaluation for myocarditis using CMR was based on the updated Lake Louise criteria. Athletes without evidence of cardiac involvement were permitted to participate in a graduated protocol to return to play. Results: A sample size of 83 athletes (mean age 20 years; female athletes 34%) diagnosed with COVID-19 infection by PCR was analyzed. Abnormal findings suggestive of cardiac involvement were detected by symptoms [82%, Standard Error of Mean (SEM) 0.04], ECG (2.5%, SEM 0.04), troponin (0%, SEM 0), and TTE (0%, SEM 0). CMR was clinically indicated in 7 patients and there were no abnormal findings. No patients were hospitalized and during a clinical surveillance period (median follow up of 105 days), there were no adverse cardiac or non-cardiac events. Conclusions: There is a low prevalence of cardiac involvement among collegiate athletes with non-severe COVID-19 infection. In this cohort, safe progression to competitive athletics using a symptom driven clinical pathway was demonstrated in a cost-effective manner.

P044 Have we been missing cases of Juvenile Systemic Lupus Erythematosus in Nigeria? The experience of a paediatric rheumatology trainee in Lagos

Abstract Background Juvenile Systemic lupus erythematosus (JSLE) is a chronic multisystem autoimmune disease of childhood, which accounts for 10% to20% of systemic lupus erythematosus (SLE). It was initially thought that systemic lupus erythematosus (SLE), including JSLE, was rare in Blacks, this was eventually debunked with increasing reports from Africa. However, it is now known that SLE is more common among patients of African descent in western countries. While the estimated prevalence of JSLE in the developed countries is 0.36–2.5 per 100 000, data in Black Africans is scarce due to missed diagnosis, poor diagnostic capacity and under-reporting. JSLE has protean manifestations similar to common paediatric conditions such as severe malaria, overwhelming septicaemia, hyper-haemolytic crisis in sickle cell anaemia etc., which often cause delayed or missed diagnosis. The objective is to describe the demographic and clinical characteristics, including outcome of children with JSLE, thus raising awareness on their occurrence and management in Nigerian children. Methods Retrospective review of records of children diagnosed with SLE at the Adult/paediatric Rheumatology Clinic and Paediatric Wards of Lagos State University Teaching Hospital (LASUTH) from May 2018 to May 2021. Results Twenty-two children, nineteen (n = 19) girls and three (n = 3) boys, aged 5–17 years, fulfilled the American College of Rheumatology (ACR)’s diagnostic criteria for JSLE out of 45 children newly diagnosed with paediatric rheumatic diseases during this period. The duration of symptoms before diagnosis ranged from two weeks to three years. The presentations included recurrent severe anaemia (n = 16), arthritis (n = 17), arthralgia (n = 17), malar rash (n = 17), neurologic symptoms (n = 5) oral ulcers (n = 17), cardiopulmonary symptoms (n = 5), photosensitivity (n = 10) and renal disease (n = 14). Laboratory findings included elevated ESR with a mean (±SD) of 99.68 ± 44.44, positive ANA (n = 22), positive anti-dsDNA (n = 12), low C3 &amp; C4 (n = 2), positive anti-Smith antibody (n = 8) and massive proteinuria (n = 14). All patients were treated with steroids and disease modifying anti-rheumatic drugs (synthetics and biologics) based on disease severity and organ manifestations. Sepsis (n = 4) was the most common preliminary diagnosis before a final diagnosis of JSLE was made, other preliminary diagnosis were pulmonary tuberculosis (n = 1), dermatitis (n = 1), acute glomerulonephritis (n = 1), Typhoid fever (n = 1), malaria (n = 1), deep vein thrombosis (n = 1), seizure disorder (n = 1), leukaemia (n = 1), meningitis (n = 1), meningoencephalitis (n = 1), hyper-haemolytic crisis in sickle cell anaemia (n = 1), Steven Johnson syndrome (n = 1), Juvenile Idiopathic Arthritis (n = 2), Eczema (n = 1), unexplained anaemia (n = 1) and acute rheumatic fever (n = 1). One boy and three girls defaulted from clinic after commencement of treatment due to severe financial constraints of their parents and religious beliefs, however six girls died, four from an acute flare and two from end stage renal disease. Conclusion Our study has shown that JSLE has protean manifestations with a tendency to miss its diagnosis due to similarity of signs and symptoms with common childhood diseases in our environment. JSLE may not be as rare as commonly thought, thus its prompt diagnosis and treatment require a high index of clinical suspicion.

Underdiagnosis of cardiopulmonary involvement in patients with idiopathic inflammatory myopathies.

ObjectivesIn the course of idiopathic inflammatory myopathies internal organs, including heart and lungs, can be involved. Cardiopulmonary complications significantly alter the course of the disease, leading to poorer prognosis. A lack of clear guidelines on the assessment of internal organ involvement in the course of myositis increases the risk of underdiagnosis. The aim of the study was to evaluate the incidence of clinical symptoms indicative of cardiovascular and pulmonary involvement in patients with myositis, and the impact of these ailments on daily living.Material and methodsA self-designed online survey was distributed via online support groups and community forums for patients with idiopathic inflammatory myopathies. The questionnaire contained inquiries about demographical data, clinical symptoms, including symptoms indicative of cardiopulmonary involvement, as well as the standardised Health Assessment Questionnaire. Respondents were divided according to concomitant diseases into a subgroup diagnosed with cardiopulmonary diseases and a subgroup without such comorbidities. The prevalence of cardiopulmonary symptoms was compared between the subgroups. The impact of cardiopulmonary symptoms on the degree of disability and daily functioning was assessed.ResultsIn total, 370 patients were included in the study group. The most commonly symptoms included dyspnoea during exercise, palpitations and ankle oedema during daily activities. Cardiopulmonary symptoms were frequent in respondents diagnosed with cardiopulmonary diseases and in patients declaring no comorbidities of the heart and lungs. Intensity of chest pain, tolerance of physical activity, and fatigue were comparable in both of the study subgroups. The degree of disability was higher in respondents with concomitant cardiovascular and/or pulmonary comorbidities, but only dry cough and ankle oedema impacted the results.ConclusionsClinical symptoms indicative of heart and lung involvement occur frequently in patients with idiopathic inflammatory myopathies; however, cardiopulmonary complications seem to be relatively rarely detected. Active screening for cardiopulmonary involvement is recommended.

Clinical commentary: Atypia in lung and mediastinal lymph node fine-needle aspiration.

In patients with known or suspected lung cancer, pathologic reports of cytologic "atypia" in the mediastinal nodal fine-needle aspirate samples pose a diagnostic and therapeutic dilemma. For the patents with non-operable disease, should the radiation oncologist empirically include lymph nodes with atypical findings in the radiation field, or should they exclude these mediastinal lymph nodes from the treatment field? Inclusion of an atypical finding in the management decision or radiation target would mean that the treating physicians are interpreting a pathologic report of "atypia" as probably "positive" rather than probably "negative" disease. Empirically treating lymph nodes without cancer involvement in thoracic radiotherapy for non-small cell lung cancer, also known as elective nodal irradiation, is generally avoided given increased treatment-related toxicities including esophagitis, pneumonitis, and cardiotoxicity without a demonstrated survival benefit. However, in the case of potentially curative chemoradiation, the discretion is left to the treating radiation oncologist to estimate the likelihood of oncologic involvement based on available and often clinically indeterminate radiologic findings and known routes of cancer spread. Alternatively, physicians may consider repeat or invasive diagnostic measures. The risks and benefits of additional procedures must be taken into careful consideration in our older patient population who present with co-morbid cardiopulmonary disease and pulmonary symptoms from their cancer. If atypia is reported, written and verbal communication to relay pathologist's concern for oncologic involvement is critical as it may affect oncologic treatment recommendations and cancer outcomes.

Prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms following SARS-CoV-2 infection in 3597 collegiate athletes: a study from the Outcomes Registry for Cardiac Conditions in Athletes (ORCCA)

ObjectiveTo assess the prevalence and clinical implications of persistent or exertional cardiopulmonary symptoms in young competitive athletes following SARS-CoV-2 infection.MethodsThis observational cohort study from the Outcomes Registry for Cardiac Conditions...

Predictive usefulness of RT-PCR testing in different patterns of Covid-19 symptomatology: analysis of a French cohort of 12,810 outpatients

Reverse transcriptase polymerase chain reaction (RT-PCR) is a key tool to diagnose Covid-19. Yet it may not be the most efficient test in all patients. In this paper, we develop a clinical strategy for prescribing RT-PCR to patients based on data from COVIDOM, a French cohort of 54,000 patients with clinically suspected Covid-19, including 12,810 patients tested by RT-PCR. We use a machine-learning algorithm (decision tree) in order to predict RT-PCR results based on the clinical presentation. We show that symptoms alone are sufficient to predict RT-PCR outcome with a mean average precision of 86%. We identify combinations of symptoms that are predictive of RT-PCR positivity (90% for anosmia/ageusia) or negativity (only 30% of RT-PCR+ for a subgroup with cardiopulmonary symptoms): in both cases, RT-PCR provides little added diagnostic value. We propose a prescribing strategy based on clinical presentation that can improve the global efficiency of RT-PCR testing.

Symptom Persistence Despite Improvement in Cardiopulmonary Health - Insights from longitudinal CMR, CPET and lung function testing post-COVID-19.

BackgroundThe longitudinal trajectories of cardiopulmonary abnormalities and symptoms following infection with coronavirus disease (COVID-19) are unclear. We sought to describe their natural history in previously hospitalised patients, compare this with controls, and assess the relationship between symptoms and cardiopulmonary impairment at 6 months post-COVID-19.MethodsFifty-eight patients and thirty matched controls (single visit), recruited between 14th March - 25th May 2020, underwent symptom-questionnaires, cardiac and lung magnetic resonance imaging (CMR), cardiopulmonary exercise test (CPET), and spirometry at 3 months following COVID-19. Of them, forty-six patients returned for follow-up assessments at 6 months.FindingsAt 2-3 months, 83% of patients had at least one cardiopulmonary symptom versus 33% of controls. Patients and controls had comparable biventricular volumes and function. Native cardiac T1 (marker of fibroinflammation) and late gadolinium enhancement (LGE, marker of focal fibrosis) were increased in patients at 2-3 months. Sixty percent of patients had lung parenchymal abnormalities on CMR and 55% had reduced peak oxygen consumption (pV̇O2) on CPET. By 6 months, 52% of patients remained symptomatic. On CMR, indexed right ventricular (RV) end-diastolic volume (-4·3 mls/m2, P=0·005) decreased and RV ejection fraction (+3·2%, P=0·0003) increased. Native T1 and LGE improved and was comparable to controls. Lung parenchymal abnormalities and peak V̇O2, although better, were abnormal in patients versus controls. 31% had reduced pV̇O2 secondary to symptomatic limitation and muscular impairment. Cardiopulmonary symptoms in patients did not associate with CMR, lung function, or CPET measures.InterpretationIn patients, cardiopulmonary abnormalities improve over time, though some measures remain abnormal relative to controls. Persistent symptoms at 6 months post-COVID-19 did not associate with objective measures of cardiopulmonary health.FundingThe authors’ work was supported by the NIHR Oxford Biomedical Research Centre, Oxford British Heart Foundation (BHF) Centre of Research Excellence (RE/18/3/34214), United Kingdom Research Innovation and Wellcome Trust. This project is part of a tier 3 study (C-MORE) within the collaborative research programme entitled PHOSP-COVID Post-hospitalization COVID-19 study: a national consortium to understand and improve long-term health outcomes, funded by the Medical Research Council and Department of Health and Social Care/National Institute for Health Research Grant (MR/V027859/1) ISRCTN number 10980107.

Stress myocardial blood flow reduced after severe COVID-19, not related to symptoms

Abstract Introduction Persistent cardiopulmonary symptoms after COVID-19 are reported in a large number of patients and the underlying pathology is still poorly understood. (1) Histopathologic studies revealed myocardial macrophage infiltrates in deceased patients, likely an unspecific finding of severe illness, and increased prevalence of micro- and macrovascular thrombi. (2) We examined whether microvascular perfusion, measured by quantitative cardiac magnetic resonance under vasodilator stress, was altered post COVID-19. Methods Our population consisted of 12 patients from the Pa-COVID-19-Study of the Charité Berlin, which received a cardiac MRI as part of a systematic follow up post discharge, 10 patients that presented at the German Heart Center Berlin with persistent cardiac symptoms post COVID-19 and 12 patients from the Kings College London referred for stress MRI and previous COVID-19. The scan protocol included standard functional, edema and scar imaging and quantitative stress and rest perfusion to assess both macro- and microvascular coronary artery disease. The pharmacological stress agent was regadenosone in 20 and adenosine in 13 of the patients. To control for the higher heart rate increase under regadenosone compared to adenosine, we calculated the myocardial blood flow per heartbeat (MBF_HRi) under stress. Results The median time between first positive PCR for COVID-19 and the CMR exam was 2 months (Range 0 to 12). None of the 33 patients exhibited signs of myocardial edema. One patient with a previous history of myocarditis had focal fibrosis. Three patients with known coronary artery disease showed ischemic Late Enhancement. Five patients had a small pericardial effusion; one of these four patients showed slight focal pericardial edema and LGE, consistent with mild focal pericarditis. Five Patients had a stress-induced focal perfusion deficit. Mean Stress MBF_HRi was 32.5±6.5 μl/beat/g. Stress MBF_HRi was negatively correlated with COVID-19 severity (rho=−0.361, P=0.039) and age (r=−0.452, P=0.009). The correlation with COVID-19 severity remained significant after controlling for age (rho=−0.390, P=0.027). There was no apparent difference in stress MBF_HRi between patients with and without persistent chest pain (34.5 vs. 31.5 μl/beat/g, P=0.229) Conclusion While vasodilator-stress myocardial blood flow after COVID-19 was negatively correlated to COVID-19 severity, it was not correlated to the presence of chest pain. The etiology of persistent cardiac symptoms after COVID-19 remains unclear. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Philips Figure 1. A) Quantitative regadenosone stress myocardial blood flow (MBF) map, medial short axis slice, in a patient with persistent cardiac symptoms after COVID-19. B) Boxplot of stress MBF per heart beat by COVID-19 severity, showing decreasing MBF with increasing COVID-19 severity.

ENHANCING CARDIO-PULMONARY IMAGING ACCESS TO A FIRST NATIONS CARE SETTING USING POINT-OF-CARE ULTRASOUND AND REMOTE LIVE-STREAMING

BACKGROUND Point-of-care ultrasound (POCUS) has revolutionized the clinical examination by providing the ability to accurately assess the heart and lungs at the bedside. It is recommended by the American Society of Echocardiography (ASE) as the first-line imaging tool for patients with suspected COVID-19 and cardiopulmonary symptoms. However, physicians practicing in remote or low-resource settings often do not have access to training opportunities. These challenges have been exacerbated by the pandemic. Live-streaming technology offers a novel opportunity to reach physicians that otherwise would be precluded from these opportunities. Our objective was to implement a fully virtual, live-streamed ultrasound teaching and tele-consultation service for non-conventional users of cardiopulmonary ultrasound in an underserviced care setting. METHODS AND RESULTS Physicians with no prior POCUS training at the Kingston Health Sciences Centre and the Weeneebayko General Hospital in Moose Factory, Ontario, were recruited to participate in a 3-week virtual POCUS training program (Fig. 1). All learners completed three e-learning modules based on the ASE COVID-19 POCUS protocol for COVID-19 and participated in a live-streamed virtual workshop led by expert educators. They then received 6-10 individualized, live-streamed tele-POCUS mentorship sessions using novel technology (Philips Lumify ultrasound and audio/video streams via Reacts software), and were evaluated through expert-assessed virtual tests. The primary outcome used to assess learner competence and knowledge retention was the average change in pre- and post-training test scores. All testing components were scored on a 5-point Likert scale. 16 physicians have been enrolled to date, including five family physicians in Moose Factory. In total, 82 tele-POCUS mentorship sessions have been conducted and 9 participants have completed the program. The average improvement between pre- and post-tests among participants who have finished was statistically significant for both cardiac (Average Likert score improved 2.5 to 4.1, p < 0.001) and lung ultrasound (Average Likert score improved 3.1 to 4.3, p < 0.001) components. All novice, remote users demonstrated improvement in device operation, image optimization, and acquisition following the training program despite no face-to-face contact with instructors. CONCLUSION Introductory POCUS skills can be taught to remote users using an entirely virtual, live-streamed format. We have demonstrated that this technology can be used to train physicians regardless of location, and offers a novel method for distributing POCUS skills to remote and low resource settings in Canada. Point-of-care ultrasound (POCUS) has revolutionized the clinical examination by providing the ability to accurately assess the heart and lungs at the bedside. It is recommended by the American Society of Echocardiography (ASE) as the first-line imaging tool for patients with suspected COVID-19 and cardiopulmonary symptoms. However, physicians practicing in remote or low-resource settings often do not have access to training opportunities. These challenges have been exacerbated by the pandemic. Live-streaming technology offers a novel opportunity to reach physicians that otherwise would be precluded from these opportunities. Our objective was to implement a fully virtual, live-streamed ultrasound teaching and tele-consultation service for non-conventional users of cardiopulmonary ultrasound in an underserviced care setting. Physicians with no prior POCUS training at the Kingston Health Sciences Centre and the Weeneebayko General Hospital in Moose Factory, Ontario, were recruited to participate in a 3-week virtual POCUS training program (Fig. 1). All learners completed three e-learning modules based on the ASE COVID-19 POCUS protocol for COVID-19 and participated in a live-streamed virtual workshop led by expert educators. They then received 6-10 individualized, live-streamed tele-POCUS mentorship sessions using novel technology (Philips Lumify ultrasound and audio/video streams via Reacts software), and were evaluated through expert-assessed virtual tests. The primary outcome used to assess learner competence and knowledge retention was the average change in pre- and post-training test scores. All testing components were scored on a 5-point Likert scale. 16 physicians have been enrolled to date, including five family physicians in Moose Factory. In total, 82 tele-POCUS mentorship sessions have been conducted and 9 participants have completed the program. The average improvement between pre- and post-tests among participants who have finished was statistically significant for both cardiac (Average Likert score improved 2.5 to 4.1, p < 0.001) and lung ultrasound (Average Likert score improved 3.1 to 4.3, p < 0.001) components. All novice, remote users demonstrated improvement in device operation, image optimization, and acquisition following the training program despite no face-to-face contact with instructors. Introductory POCUS skills can be taught to remote users using an entirely virtual, live-streamed format. We have demonstrated that this technology can be used to train physicians regardless of location, and offers a novel method for distributing POCUS skills to remote and low resource settings in Canada.

COVID-19 Mortality Prediction From Deep Learning in a Large Multistate Electronic Health Record and Laboratory Information System Data Set: Algorithm Development and Validation.

BackgroundCOVID-19 is caused by the SARS-CoV-2 virus and has strikingly heterogeneous clinical manifestations, with most individuals contracting mild disease but a substantial minority experiencing fulminant cardiopulmonary symptoms or death. The clinical covariates and the laboratory tests performed on a patient provide robust statistics to guide clinical treatment. Deep learning approaches on a data set of this nature enable patient stratification and provide methods to guide clinical treatment.ObjectiveHere, we report on the development and prospective validation of a state-of-the-art machine learning model to provide mortality prediction shortly after confirmation of SARS-CoV-2 infection in the Mayo Clinic patient population.MethodsWe retrospectively constructed one of the largest reported and most geographically diverse laboratory information system and electronic health record of COVID-19 data sets in the published literature, which included 11,807 patients residing in 41 states of the United States of America and treated at medical sites across 5 states in 3 time zones. Traditional machine learning models were evaluated independently as well as in a stacked learner approach by using AutoGluon, and various recurrent neural network architectures were considered. The traditional machine learning models were implemented using the AutoGluon-Tabular framework, whereas the recurrent neural networks utilized the TensorFlow Keras framework. We trained these models to operate solely using routine laboratory measurements and clinical covariates available within 72 hours of a patient’s first positive COVID-19 nucleic acid test result.ResultsThe GRU-D recurrent neural network achieved peak cross-validation performance with 0.938 (SE 0.004) as the area under the receiver operating characteristic (AUROC) curve. This model retained strong performance by reducing the follow-up time to 12 hours (0.916 [SE 0.005] AUROC), and the leave-one-out feature importance analysis indicated that the most independently valuable features were age, Charlson comorbidity index, minimum oxygen saturation, fibrinogen level, and serum iron level. In the prospective testing cohort, this model provided an AUROC of 0.901 and a statistically significant difference in survival (P<.001, hazard ratio for those predicted to survive, 95% CI 0.043-0.106).ConclusionsOur deep learning approach using GRU-D provides an alert system to flag mortality for COVID-19–positive patients by using clinical covariates and laboratory values within a 72-hour window after the first positive nucleic acid test result.

Mediastinal Mass with Unusual Etiology.

Mediastinal Mass with Unusual Etiology.

Long COVID: Distinction between Organ Damage and Deconditioning.

(1) Background: Long COVID syndrome refers to long-term sequelae of the novel viral disease, which occur even in patients with initially mild disease courses. However, there is still little evidence of the actual organic consequences and their frequency, and there is no standardized workup to diagnose long COVID syndrome yet. In this study, we aim to determine the efficiency of a stepwise diagnostic approach for reconvalescent COVID-19 patients with cardiopulmonary symptoms. (2) Methods: The diagnostic workup for long COVID syndrome included three steps. In the first step, the focus was on broad applicability (e.g., blood tests and body plethysmography). In the second step, cardiopulmonary exercise testing (CPET) and cardiac MRI (CMR) were used. The third step was tailored to the individual needs of each patient. The observation period lasted from 22 February to 14 May 2021. (3) Results: We examined 231 patients in our long COVID unit (mean [SD] age, 47.8 [14.9], 132 [57.1%] women). Acute illness occurred a mean (SD) of 121 (77) days previously. Suspicious findings in the first visit were seen in 80 (34.6%) patients, prompting further diagnostics. Thirty-six patients were further examined with CPET and CMR. Of those, 16 (44.4%) had pathological findings. The rest had functional complaints without organ damage (“functional long COVID”). Cardiopulmonary sequelae were found in asymptomatic as well as severe courses of the initial COVID-19 disease. (4) Conclusions: A structured diagnostic pathway for the diagnosis of long COVID syndrome is practicable and rational in terms of resource allocation. With this approach, manifest organ damage can be accurately and comprehensively diagnosed and distinguished from functional complaints.

Return to Activity After SARS-CoV-2 Infection: Cardiac Clearance for Children and Adolescents.

Sedentary behavior and inability to participate in organized physical activity has negatively affected the physical and mental health of children and adolescents; however, cardiac injury and associated risk for sudden cardiac death with return to activity remains a major concern. Guidelines have been proposed for return to activities; however, these fail to address the needs of younger children and those participating in more casual activities. Guidance is needed for primary care providers to facilitate safe return to everyday activity and sports and to help direct appropriate laboratory, electrocardiographic, and anatomical assessment. Review of computerized databases of available literature on SARS-CoV-2 infection in children and postinfection sequelae, risk factors for sudden cardiac death, and previous return to play recommendations. Clinical guidelines based on available evidence and expert consensus. Level 4. In this report, we review the literature on return to activity after SARS-CoV-2 infection and propose recommendations for cardiac clearance for children and adolescents. Though severe disease and cardiac injury is less common in children than in adults, it can occur. Several diagnostic modalities such as electrocardiography, echocardiography, cardiac magnetic resonance imaging, and serologic testing may be useful in the cardiac evaluation of children after SARS-CoV-2 infection. Gradual return to activity is possible in most children and adolescents after SARS-CoV-2 infection and many of these patients can be cleared by their primary care providers. Providing education on surveillance for cardiopulmonary symptoms with return to sports can avoid unnecessary testing and delays in clearance.