COVID Clinic Research Articles

8.H. Scientific session: Coordinated actions to improve our response to Long COVID at EU and national levels

Abstract The COVID-19 pandemic still has very real and far-reaching consequences for European citizens, healthcare systems and economies. It has been estimated that approximately 10%-20% of people that were infected by SARS-CoV-2, develop Long COVID. Countries within the European Union and elsewhere have been responding to Long COVID in various ways. Some countries initiated a more extensive response to Long COVID, including the creation of multidisciplinary Long COVID clinics. In other counties, Long COVID should be addressed within existing infrastructures within the health care system, which can be hampered by the siloed approach of how services for people with chronic conditions is organised. Moreover, a coordinated and uniform response to Long COVID is complicated by the fact that there is a large variety of terms and definitions of Long COVID and the fact that long COVID symptom are often similar to symptoms of other diseases, thus hampering specific characterisation of patients. While substantial progress has been made in understanding Long COVID we still need more answers about its causes and the most effective treatments. It is also important to understand the impact that Long COVID has on individual lives of those who are being affected - and their families - as well as on societies as a whole. The session aims to take stock of a number of recent insights relating to Long COVID, also with the purpose to identify opportunities for a more coordinated and harmonized approach towards Long COVID at national and international levels. The session will provide room for discussions and engagement with the audience, allowing to help inform future policy agendas. As such, better ways to understand and address Long COVID can also be beneficial for health systems as a whole, given the parallels with how services are provided and policies are set up to address other chronic (non-communicable) diseases. Key messages • Long COVID is still poorly understood, in part relating to the complexity of the condition, also having considerable impacts on individuals and societies. • A more harmonised response can help improve the manners to address it, this to support those still suffering from this long term impact of the COVID-19 pandemic.

5164 Long COVID patients with menstrual symptoms: a retrospective study in Japan

Abstract Disclosure: F. Otsuka: None. Y. Sakurada: None. Y. Matsuda: None. T. Hasegawa: None. Y. Otsuka: None. Y. Nakano: None. K. Tokumasu: None. K. Yamamoto: None. N. Sunada: None. H. Honda: None. H. Hagiya: None. K. Ueda: None. It has been recognized that about one third of patients may suffer from prolonged illness after surviving from the acute phase of COVID-19. Various symptoms of the prolonged illness have been evaluated by many institutions including WHO. However, the mechanisms of the prolonged symptoms have yet to be elucidated. Long COVID is a complicated illness that develops after SARS-CoV-2 infection, independent of the severity of COVID-19. Long COVID is defined as symptoms that occur within 3 months after the initial infection and persist for at least 2 months. The major symptoms of long COVID include general fatigue, post-exertional malaise, headache, insomnia, dyspnea, cognitive dysfunction, low-grade fever, and muscle pain. Proposed pathophysiological mechanisms of long COVID include pathogen persistence and viral reactivation, immune dysregulation and autoimmunity, neurological abnormalities, tissue damage due to hypoperfusion and/or microclots, autonomic and endocrine dysfunctions, and dysregulation of microbiomes. In the present study, we aimed to elucidate the impact of long COVID on female reproductive health. In this retrospective study, medical records of patients who visited our long COVID clinic and clinical trends of their menstrual symptoms were evaluated. In our study, of 349 female patients who visited our clinic between Feb 2021 and Mar 2023, 223 patients with long COVID (18-50 years) were included. It was revealed that 44 females (19.7%) had menstrual symptoms associated with long COVID. The patients with menstrual symptoms were significantly older than those without menstrual symptoms (42.5 vs. 38 years). The percentage of patients with menstrual symptoms was higher during the Omicron phase (24%) than during the Preceding (13%) and Delta (12%) phases. Cycle irregularity (63.6%) was the most frequent menstrual symptom, followed by severe pain (25%), heavy bleeding (20.5%), perimenopausal symptoms (18.2%), and premenstrual syndrome (15.9%). Fatigue and depression were the most frequent complications with menstrual complaints. Scores indicating fatigue and QOL were significantly worse in long COVID patients with menstrual symptoms. Endocrine examinations showed significantly increased cortisol levels in patients with menstrual complaints although plasma adrenocorticotropin levels were not altered. Hence, long COVID has an impact on women’s reproductive and mental health. Presentation: 6/1/2024

5164 Long COVID patients with menstrual symptoms: a retrospective study in Japan

Abstract Disclosure: F. Otsuka: None. Y. Sakurada: None. Y. Matsuda: None. T. Hasegawa: None. Y. Otsuka: None. Y. Nakano: None. K. Tokumasu: None. K. Yamamoto: None. N. Sunada: None. H. Honda: None. H. Hagiya: None. K. Ueda: None. It has been recognized that about one third of patients may suffer from prolonged illness after surviving from the acute phase of COVID-19. Various symptoms of the prolonged illness have been evaluated by many institutions including WHO. However, the mechanisms of the prolonged symptoms have yet to be elucidated. Long COVID is a complicated illness that develops after SARS-CoV-2 infection, independent of the severity of COVID-19. Long COVID is defined as symptoms that occur within 3 months after the initial infection and persist for at least 2 months. The major symptoms of long COVID include general fatigue, post-exertional malaise, headache, insomnia, dyspnea, cognitive dysfunction, low-grade fever, and muscle pain. Proposed pathophysiological mechanisms of long COVID include pathogen persistence and viral reactivation, immune dysregulation and autoimmunity, neurological abnormalities, tissue damage due to hypoperfusion and/or microclots, autonomic and endocrine dysfunctions, and dysregulation of microbiomes. In the present study, we aimed to elucidate the impact of long COVID on female reproductive health. In this retrospective study, medical records of patients who visited our long COVID clinic and clinical trends of their menstrual symptoms were evaluated. In our study, of 349 female patients who visited our clinic between Feb 2021 and Mar 2023, 223 patients with long COVID (18-50 years) were included. It was revealed that 44 females (19.7%) had menstrual symptoms associated with long COVID. The patients with menstrual symptoms were significantly older than those without menstrual symptoms (42.5 vs. 38 years). The percentage of patients with menstrual symptoms was higher during the Omicron phase (24%) than during the Preceding (13%) and Delta (12%) phases. Cycle irregularity (63.6%) was the most frequent menstrual symptom, followed by severe pain (25%), heavy bleeding (20.5%), perimenopausal symptoms (18.2%), and premenstrual syndrome (15.9%). Fatigue and depression were the most frequent complications with menstrual complaints. Scores indicating fatigue and QOL were significantly worse in long COVID patients with menstrual symptoms. Endocrine examinations showed significantly increased cortisol levels in patients with menstrual complaints although plasma adrenocorticotropin levels were not altered. Hence, long COVID has an impact on women’s reproductive and mental health. Presentation: 6/1/2024

Improving quality in adult long covid services: Findings from the LOCOMOTION quality improvement collaborative

The protracted form of COVID-19 known as ‘long covid’ was first described in 2020. Its symptoms, course and prognosis vary widely; some patients have a multi-system, disabling and prolonged illness. In 2021, ring-fenced funding was provided to establish 90 long covid clinics in England; some clinics were also established in Scotland and Wales. The NIHR-funded LOCOMOTION project implemented a UK-wide quality improvement collaborative involving ten of these clinics, which ran from 2021 to 2023. At regular online meetings held approximately 8-weekly, participants prioritised topics, discussed research evidence and guidelines, and presented exemplar case histories and clinic audits. A patient advisory group also held a priority-setting exercise, participated in quality meetings and undertook a service evaluation audit. The goal of successive quality improvement cycles aimed at changing practice to align with evidence was sometimes hard to achieve because definitive evidence did not yet exist in this new condition; many patients had comorbidities; and clinics were practically constrained in various ways. Nevertheless, much progress was made and a series of ‘best practice’ guides was produced, covering general assessment and management; breathing difficulties; orthostatic tachycardia and other autonomic symptoms; fatigue and cognitive impairment; and vocational rehabilitation. This paper summarises key findings with the frontline clinician in mind.

The Impact of the COVID-19 Pandemic on Nursing: A SWOT Analysis

Abstract Aim: The research was conducted descriptively using the SWOT analysis method to determine the impact of the COVID-19 pandemic on nursing. Material and method: The research was completed with 300 volunteers working in COVID intensive care units and clinics in a city hospital in Turkey. A survey form consisting of two parts, evaluating sociodemographic characteristics and SWOT categories, was used as a data collection tool in the study. Nurses who agreed to participate in the research and whose written permission/verbal consent was obtained were asked to fill out the questionnaire in the nurse's room, accompanied by the researcher, under the conditions permitted by the institution, taking into account the COVID-19 pandemic process and infection rules. The dataset was evaluated with the SPSS program. Results: In the research, when the impact of the COVID-19 epidemic on nursing was evaluated according to SWOT analysis, 34% of the nurses had professional factors under the strengths category (21.7%); 81.7% had psychological factors under the weakness category (59%); It was determined that 29.3% identified occupational factors (19.3%) under the opportunity category and 79% identified occupational factors (64%) under the threat category (p

Personalized Exercise Prescription in Long COVID: A Practical Toolbox for a Multidisciplinary Approach.

To describe our methodology and share the practical tools we have developed to operationalize a multidisciplinary Long COVID clinic that incorporates progressive, personalized exercise prescription as a cornerstone feature. There is a lack of evidence-based guidance regarding optimal rehabilitation strategies for people with Long COVID. Existing guidelines lack precision regarding exercise dosage. As one of Australia's few established multidisciplinary Long COVID clinics, we describe our novel approach to safely incorporating exercise of both peripheral and respiratory muscles, with essential monitoring and management of post-exertional symptom exacerbation. Working closely with primary health-care providers, our multidisciplinary team screens referrals for people aged 16 and older with Long COVID. Staff apply a three tier model of triage, dependent on the consumer's presenting problems. Exercise-based interventions necessitate detailed monitoring for post-exertional symptom exacerbation both in the clinic and at home. Personalized exercise prescription includes resistance training at a submaximal threshold (4-6 exercises, 3 days/week); whole-body endurance exercise titrated to the individual's progress, at an intensity 4-6/10 (Rate of Perceived Exertion); and for those limited by dyspnoea, high-intensity inspiratory muscle training using a threshold-based handheld device (30 repetitions per day, ≥50% of their maximum inspiratory pressure). We have used these approaches for the past 2 years in 250 consumers with no serious adverse events and promising consumer feedback. Our exercise prescription is less conservative than the methods advocated in international guidelines for people with Long COVID, and these more progressive tools may be valuable in other contexts. In our experience, a multidisciplinary clinic-based approach to safely prescribing progressive exercise in Long COVID is feasible. Both peripheral and inspiratory muscle exercise can be effectively titrated to each individual's symptoms, and careful monitoring for post-exertional symptom exacerbation is crucial.

Working knowledge, uncertainty and ontological politics: An ethnography of UK long covid clinics.

Long covid (persistent COVID-19) is a new disease with contested aetiology and variable prognosis. We report a 2-year ethnography of UK long covid clinics. Using a preformative lens, we show that multidisciplinary teams (MDTs) built working knowledge based on shared practices, mutual trust, distributed cognition (e.g. emails, record entries), relational knowledge of what was at stake for the patient, and harnessing uncertainty to open new discursive spaces. Most long covid MDTs performed the working knowledge of 'rehabilitation', a linked set of practices oriented to ensuring that the patient understood and strove to 'correct' maladaptive physiological responses (e.g. through breathing exercises) and pursued recovery goals, supported by physiotherapists, psychologists and generalist clinicians. Some MDTs with a higher proportion of doctors (e.g. cardiologists, neurologists, immunologists) enacted the working knowledge of 'microscopic damage', seeking to elucidate and rectify long covid's underlying molecular and cellular pathology. They justified non-standard investigations and medication in selected patients by co-constructing an evidentiary narrative based on biological mechanisms. Working knowledge was ontologically concordant within MDTs but sometimes discordant between MDTs. Overt ontological conflict occurred mostly when patients attending 'rehabilitation' clinics invoked the working knowledge of microscopic damage that had been generated and circulated in online support communities.

Changes in Working Situations of Employed Long COVID Patients: Retrospective Study in Japanese Outpatient Clinic.

Purpose: The present study aimed to uncover the impact of long COVID on the working situations of Japanese patients. Methods: Changes in the working situations of the patients who visited our long COVID clinic were evaluated from medical records for the aspects of physical status, quality of life (QOL), and mental conditions. Results: Of 846 long COVID patients who visited our clinic from February 2021 to December 2023, 545 employed patients aged between 18 and 65 years were included in this study. A total of 295 patients (54.1%) with long COVID (median age: 43 years, female: 55.6%) experienced changes in their working status. Those patients included 220 patients (40.4%) who took a leave of absence, 53 patients (9.7%) who retired, and 22 patients (4%) with reduced working hours. Most of the patients (93.2%) with changes in working conditions had mild disease severity in the acute phase of COVID-19. The majority of those patients with mild disease severity (58.8%) were infected in the Omicron-variant phase and included 65.3% of the female patients. The major symptoms in long COVID patients who had changes in their working situations were fatigue, insomnia, headache, and dyspnea. Scores indicating fatigue and QOL were worsened in long COVID patients who had changes in their working situations. In addition, 63.7% of the long COVID patients with changes in their working situations had decreases in their incomes. Conclusions: Changes in the working situation of long COVID patients who were employed had a negative impact on the maintenance of their QOL.

“The dream is that there’s one place you go”: a qualitative study of women’s experiences seeking care from Long COVID clinics in the USA

BackgroundSeeking and obtaining effective health care for Long COVID remains a challenge in the USA. Women have particularly been impacted, as they are both at higher risk of developing Long COVID and of facing gendered barriers to having symptoms acknowledged. Long COVID clinics, which provide multidisciplinary and coordinated care, have emerged as a potential solution. To date, however, there has been little examination of U.S. patient experiences with Long COVID clinics and how patients may or may not have come to access care at a Long COVID clinic.MethodsWe conducted semi-structured interviews with 30 U.S. women aged 18 or older who had experienced Long COVID symptoms for at least 3 months, who had not been hospitalized for acute COVID-19, and who had seen at least one medical provider about their symptoms. Participants were asked about experiences seeking medical care for Long COVID. Long COVID clinic-related responses were analyzed using qualitative framework analysis to identify key themes in experiences with Long COVID clinics.ResultsOf the 30 women, 43.3% (n = 13) had been seen at a Long COVID clinic or by a provider affiliated with a Long COVID clinic and 30.0% (n = 9) had explored or attempted to see a Long COVID clinic but had not been seen at time of interview. Participants expressed five key themes concerning their experiences with seeking care from Long COVID clinics: (1) Access to clinics remains an issue, (2) Clinics are not a one stop shop, (3) Not all clinic providers have sufficient Long COVID knowledge, (4) Clinics can offer validation and care, and (5) Treatment options are critical and urgent.ConclusionsWhile the potential for Long COVID clinics is significant, findings indicate that ongoing barriers to care and challenges related to quality and coordination of care hamper that potential and contribute to distress among women seeking Long COVID care. Since Long COVID clinics are uniquely positioned and framed as being the place to go to manage complex symptoms, it is critical to patient wellbeing that they be properly resourced to provide a level of care that complies with emerging best practices.

Long COVID clinics and services offered by top US hospitals: an empirical analysis of clinical options as of May 2023

BackgroundThe economic and health burden of COVID-19 has transformed the healthcare system in the US. Hospitals have adapted to the heterogeneity in long COVID symptoms, and the sheer number of people affected by this condition, by building long COVID centers and programs.ObjectiveWe sought to describe characteristics, services, and clinical trials of long COVID centers at top US hospitals.DesignCross-sectional analysis.ParticipantsLong COVID treatment programs or centers at top US hospitals.ExposuresFrequency of long COVID centers, eligibility for being treated, the services they provide, specialist to whom the patients may be referred, and the long COVID clinical trials in which these hospitals participate.FindingsMost top hospitals in the US (n = 43/50; 86%) offer long COVID services. 65% (28/43) did not describe the services provided. 12 (28%) required a referral from a primary care physician. The most common services were meeting with a team member (n = 20; 47%), ordering lab and/or radiology services (n = 8; 18.6%), and administering a physical exam (n = 7; 16%). 7 (16%) centers/programs treated only adults; 5 (12%) treated both adults and children, and 31 (72%) did not specify. The most common specialists described were psychology (n = 25; 58%), neurology (n = 25; 58%), and pulmonary (n = 24; 56%). Sixty-three trials (of 134 long COVID clinical trials) had at least one top hospital listed as a study site. The median number of clinical trials that each hospital sponsored or was a study site was 2 (interquartile range: 1, 3).Conclusions and relevanceWe find that services offered at long COVID clinics at top hospitals in the US often include meeting with a team member and referrals to a wide range of specialists. The diversity in long COVID services offered parallels the diversity in long COVID symptoms, suggesting a need for better consensus in developing and delivering treatment.

Lessons Learned in Implementing a Multidisciplinary Long COVID Clinic

The diagnosis and treatment of long COVID patients is challenging. Our aim is to share lessons learned using a multidisciplinary approach within the Veterans Affairs system. Our long COVID clinic is based in primary care but has imbedded rehabilitation specialists, nutrition, whole health, and different specialists within internal medicine. We conducted an extensive work-up to evaluate the presence of end-organ damage, ongoing inflammation, and dysautonomia. Our treatments are based on the prior experience that the Veterans Affairs system has on chronic fatigue syndrome and gulf war illness.

Time to re-define ‘normal’ in the context of Post-Acute COVID-19 biomarkers in the assessment of patient outcomes?

Introduction: Post-acute COVID-19 or Long COVID (LC) is a threat to health and well-being, and 1 in 10 infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) will develop persistent symptoms. LC is associated with >200 symptoms that impact quality of life and functional status. Many LC patients are being dismissed from care due to returning ‘normal’ results on ‘routine’ clinical investigations. Accordingly, the objective of the study was to explore the relationship between potential diagnostic biomarkers, symptom profile severity and functional status. Method: Participants with a confirmed history of COVID-19 were recruited from Long COVID clinics in the United Kingdom, as part of a 16-week cohort observation study. Venous blood samples were taken from 35 individuals [24 female] and assessed for standard clinical chemistry markers of inflammatory and metabolic status, including full blood count (white blood cells [WBC], red blood cells [RBC], platelets, haemoglobin, hematocrit, ferritin, mean corpuscular volume [MCV] mean corpuscular haemoglobin [MCH], mean corpuscular haemoglobin concentration [MCHC], red cell distribution width [RDW], basophils, neutrophils, lymphocytes, eosinophils, monocytes), CRP, d dimers, interleukin 6 (IL-6), and lactate dehydrogenase [LDH]. Patient-reported outcomes and symptoms were assessed by validated self-report methods including fatigue, dyspnoea, cognitive deficit, quality of life and symptom frequency and severity. Functional status was assessed via 6-Minute-Walk (6MWT). Results: Sixty-three percent of participants [17 female] had one or more values outside of expected reference ranges (WBC n=3, RBC n=6, haemoglobin n=3, haematocrit n=2, MCV n=3, MCH n=3, MCHC n= 1, RDW n=4, neutrophils n=3, lymphocytes n=5, monocytes n=1, basophils n=2, CRP n=3, ferritin n=3, d-dimer n=9). These changes were not linked to changes in function status or patient-reported outcomes ( p=>0.05), but there was a significant between-group difference with those outside of expected reference ranges completing less on the 6MWT on their final visit ( p=<0.05). Discussion: The pathophysiology of LC is complex and patients report broad symptoms across multiple organ systems, such as respiratory, gastrointestinal, cardiovascular, and the autonomic nervous system. Routine clinical investigations of biomarkers are vital, but assessments often return results within a pre-determined ‘normal’ range. Whilst routine testing is important, condition-specific investigations should also be explored. Further inspection of the data in reference to the symptom profile and reduced functional status demonstrates a need for more holistic approaches. Conclusion: The complex pathophysiology of LC requires further understanding and development of investigative approaches to LC diagnoses and treatment. Routine investigations of people with LC demonstrate abnormal responses, and even those that return ‘normal’ results experience debilitating symptom profiles and reduced quality of life. Due to the complex underlying mechanistic issues of LC, more specific biochemical profiling is required during clinical investigations. This study was supported by an unrestricted investigator-sponsored research grant from Gilead Sciences (#IN-UK-983-6080). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Modified streptavidin–biotin based lateral flow test strip for rapid detection of SARS-CoV-2 S1 antigen in saliva samples

Compared to other infectious diseases, for which LFT development can take years, SARS-CoV-2 antigen LFTS were developed and deployed within months. LFTS for antigen detection were adopted on an unprecedented scale during the COVID-19 pandemic, but many of them lack the sensitivity especially for samples with low viral load. In our previous work, we developed an enhanced signal strip for detection of SARS CoV-2 SI antigens in saliva. Here we introduce some modification to improve the sensitivity, and specificity, and to lower the cost of the strip, by using biotin streptavidin (BS) system. In the modified BS strip, gold-streptavidin and biotinylated Nanobodies (Nbs) against S1 antigen were externally mixed with the tested samples (saliva or nasopharyngeal swab) before their application on the sample pad of the test strip containing angiotensin converting enzyme (ACE-2), as the capturing probe. The study included 320 individuals, with 180 being positively confirmed by RT-PCR and 140 confirmed negative, as well as, 45 health care workers, who were responsible for screening and handling of surgical cases in General Surgery Department and COVID clinic of TBRI. Our results proved that modified BS strip improved the overall sensitivity and specificity of S1antigen detection in saliva samples (95.21% and 99.29% respectively) compared to our previously developed enhanced LFTS (91.66% and 98.57% respectively). Also, the sensitivity of cases with Ct ≤ 30, Ct ≤\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\le$$\\end{document} 35, and Ct ≤\\documentclass[12pt]{minimal} \\usepackage{amsmath} \\usepackage{wasysym} \\usepackage{amsfonts} \\usepackage{amssymb} \\usepackage{amsbsy} \\usepackage{mathrsfs} \\usepackage{upgreek} \\setlength{\\oddsidemargin}{-69pt} \\begin{document}$$\\le$$\\end{document} 40 using the modified BS strip showed higher values (98.54%, 95.38%, and 88.89% respectively), compared to the corresponding results of our previously developed enhanced LFTS (95.86%, 92.31%, and 82.22% respectively). There were no cross-reactions with either Middle East respiratory syndrome corona virus MERS-CoV or SARS-CoV antigens. Furthermore, we found that the lower viral detection limit (LVD) of BS strip was obviously lower than our previous LVD limit of the enhanced LFTS (0.2 × 104 copies/ml vs. 0.4 × 104 copies/ml, respectively). Our developed BS strip showed that saliva samples gave better results than nasopharyngeal swabs of the same patients. The fact of using smaller amounts of Nbs, and ACE2, as well as the dispensing off of conjugate pad when applying BS strip modifications, justified the expected reduction in the costs of the strip. The implementation of BS strips on saliva samples of 45 health co-workers, who were tested 4 and 6 days after exposure to infection, showed an increase in the sensitivity, starting from the 4th day and reaching its highest level on the 6th day in both high risk and paramedic groups (90.9%, and 80.0%, respectively). This study provides evidence that employment of the modified BS system could increase the sensitivity of the strips, lower their cost, and render them an effective screening tool for early detection of the virus in saliva of suspected Covid-19 patients.

Vaccine communication training using the Brief Motivational Interviewing for Maternal Immunization intervention: A PRISM implementation evaluation.

Improving clinician-patient communication can increase uptake of recommended vaccinations during pregnancy. To evaluate adaptations to and pragmatism of the brief Motivational Interviewing for Maternal Immunizations (MI4MI) intervention and to use the Practical Robust Implementation and Sustainability Model (PRISM) to describe context and implementation outcomes among clinician and staff participants. We incorporated data from study team members, clinicians and staff participants, pregnant patients at participating clinics, and patient medical records. Quantitative and qualitative data were collected using surveys, chart reviews, study team notes, interviews, and focus groups. Adaptations were evaluated using the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and pragmatism was measured with PRagmatic Explanatory Continuum Indicator Summary (PRECIS-2). MI4MI was effective at improving participants' vaccine communication experiences. Adoption was limited by our recruitment approach. MI4MI implementation was shaped by contextual factors and associated adaptations related to the COVID pandemic and clinic and participant characteristics. Virtual asynchronous intervention delivery had mixed effects on adoption and implementation that varied across clinics and participants. Participants expressed interest in maintaining the MI4MI intervention moving forward; however, identification of sustainability infrastructure was limited. MI4MI was evaluated to be relatively pragmatic. Contextual factors strongly shaped implementation of MI4MI. Future iterations of MI4MI should include training delivery modes and incentives that accommodate a range of participants across job roles and organizational settings. Future studies including control clinics are needed to measure effectiveness for increasing vaccination and comparing virtual versus hybrid implementation strategies.

Mechanisms underlying exercise intolerance in long COVID: An accumulation of multisystem dysfunction.

The pathogenesis of exercise intolerance and persistent fatigue which can follow an infection with the SARS-CoV-2 virus ("long COVID") is not fully understood. Cases were recruited from a long COVID clinic (N = 32; 44 ± 12 years; 10 (31%) men), and age-/sex-matched healthy controls (HC) (N = 19; 40 ± 13 years; 6 (32%) men) from University College London staff and students. We assessed exercise performance, lung and cardiac function, vascular health, skeletal muscle oxidative capacity, and autonomic nervous system (ANS) function. Key outcome measures for each physiological system were compared between groups using potential outcome means (95% confidence intervals) adjusted for potential confounders. Long COVID participant outcomes were compared to normative values. When compared to HC, cases exhibited reduced oxygen uptake efficiency slope (1847 (1679, 2016) vs. 2176 (1978, 2373) mL/min, p = 0.002) and anaerobic threshold (13.2 (12.2, 14.3) vs. 15.6 (14.4, 17.2) mL/kg/min, p < 0.001), and lower oxidative capacity, measured using near infrared spectroscopy (τ: 38.7 (31.9, 45.6) vs. 24.6 (19.1, 30.1) s, p = 0.001). In cases, ANS measures fell below normal limits in 39%. Long COVID is associated with reduced measures of exercise performance and skeletal muscle oxidative capacity in the absence of evidence of microvascular dysfunction, suggesting mitochondrial pathology. There was evidence of attendant ANS dysregulation in a significant proportion. These multisystem factors might contribute to impaired exercise tolerance in long COVID sufferers.

"I Had to Know About It, I Had to Find It, I Had to Know How to Access it": Experiences of Access to Rehabilitation Services Among People Living with Long COVID.

The aim of this qualitative study is to understand the need for, access to, and quality of rehabilitation services for people living with Long COVID. Little is known about the experiences of people living with Long COVID accessing rehabilitation services. Therefore, we explored health concerns leading people living with Long COVID to seek help to address functional concerns and their experiences with accessing and participating in rehabilitation. Interpretive description guided exploration of participants' experiences with Long COVID rehabilitation in Alberta, Canada. Semi-structured interviews were completed with 56 participants recruited from: three publicly funded Long COVID clinics, a specialized private physiotherapy clinic, a telephone-based rehabilitation advice line, and a Workers' Compensation Board-funded Long COVID rehabilitation program. Recruitment through mass media coverage allowed us to include people who did not access rehabilitation services. Data analysis was informed by Braun and Clarke's reflexive thematic analysis. Four themes were identified: (1) the burden of searching for guidance to address challenges with functioning and disability; (2) supportive relationships promote engagement in rehabilitation; (3) conditions for participation in safe rehabilitation; and (4) looking forward - provision of appropriate interventions at the right time. Our findings highlight the experiences of accessing rehabilitation services for people living with Long COVID. Results suggest approaches to Long COVID rehabilitation should be accessible, multi-disciplinary, flexible, and person-centred.

Upotreba antibiotika i antivirotika u lečenju pacijenata obolelih od COVID-19 u Kovid ambulanti Doma zdravlja Golubac

Introduction: There were 13 protocols for the COVID-19 infection treatment in Serbia. All protocols emphasize the importance of not giving antibiotics routinely, especially in patients who were treated at the primary healthcare level. Use of antibiotics was widely spread in the treatment of COVID-19 patients, all around the world. Objective. We aimed at examining the incidence, type, and combination of used antibiotics and antivirals in COVID-19 patients. Method: Observational retrospective cross-sectional study on the prescription of antibiotics and antivirals in patients who were treated in the COVID clinic of the Golubac Primary Healthcare Center in the period from 7/17/2020. until 10/31/2022. The data were obtained from the electronic health records of the participants. The sample consisted of 2709 respondents. The variables we used were sex and age. We used the statistical package SPSS17 for data processing. For statistical methods, we used descriptive statistics frequency (%) and, the X2 test. Results: The research included 2,709 patients. In total, 1590 people were prescribed antibiotics. Concerning the total number of patients, examined in the COVID clinic, this represents 58.7%. The highest percentage of patients who were prescribed an antibiotic was in the period November 2020 - May 2021. Depending on the study period, cephalosporin and azithromycin are the most frequently prescribed antibiotics (70-89% of the total number of prescribed antibiotics). The most commonly prescribed antibiotic combination is a cephalosporin-fluoroquinolone. Conclusion. The use of antibiotics in the treatment of COVID-19 patients was higher than recommended in the protocols and guidelines.

The Comparison Of Chest X-Ray Changes Between Post-Covid-19-Infection Patients With Mild-Moderate Severity And Severe-Critical Severity At Ugm Academic Hospital

Introduction: Post-COVID-19 syndrome can be seen from the radiological findings on the chest X-ray (CXR). However, limited studies compared CXR changes in post-COVID-19 patients based on their severity. Methods: Thirty-three post-hospitalized COVID-19 patients who came to the Long COVID Clinic at UGM Academic Hospital were divided into mild-moderate and severe-critical groups. The CXR were taken during hospital admission, in the 4th week, and in the 8th week. CXR images were assessed with the Brixia Score method. Results: The Brixia score in the mild-moderate group (n = 17) and severe-critical (n = 16) group showed a trend of change, which increased in the 4th week and decreased in the 8th week. However, there were no significant changes between the two groups during hospital admission, in the 4th week, and in the 8th week. The Brixia score during hospital admission and in the 8th-week follow-up in the mild-moderate group was significantly lower than that of the severe-critical group. Clinically, the mean Brixia score in the mild-moderate group ranges from mild pneumonia, while the severe-critical group ranges from moderate pneumonia. Conclusion: There is no significant resolution of the CXR until the 8th-week follow-up in post-COVID-19 infection patients with mild-moderate and severe-critical severity. However, the CXR during hospital admission and the 8th week is better in post-COVID-19 infection patients with mild-moderate severity. Keywords: chest X-ray, COVID-19, infectious disease, post-COVID-19 syndrome, severity,

The effect of general anesthesia applied during cesarean section on newborn bilirubin

Aims: Today, delivery is often performed as normal spontaneous vaginal delivery (NSVD) and cesarean section operations. Deliveries with NSVD mostly take place in the delivery room without the need for additional anesthetic agents. General anesthesia and regional anesthesia techniques are applied in cesarean section operations. In this study; The aim of this study was to examine the effect of general anesthesia on newborn bilirubin and to compare it with the bilirubin level of babies born without general anesthesia with NSVD method. Methods: Between March 2022 and September 2022, 152 patients over the age of 18 with term pregnancy NSVD and elective cesarean section without complications were randomly included in the study. Cases diagnosed with liver and biliary tract disease, systemic liver and biliary tract effective drug use, DCOOMBS( +) and Covid (+) clinics were excluded. Results: Of the patients included in our study, 75 (49.3%) were given general anesthesia and 77 (50.7%) delivered with NSVD without general anesthesia. It was determined that the first hour bilirubin and the fourth hour bilirubin values were significantly higher (p &lt;0.05) in the general anesthesia group compared to the group that did not receive general anesthesia. In the group that did not receive general anesthesia, the APGAR 5th min score was found to be significantly (p &lt;0.05) higher than the general anesthesia group. APGAR 1 min value did not differ significantly (p &gt; 0.05) between the anesthesia-free and general anesthesia groups. Neonatal weight, head circumference, and infant height did not differ significantly between the groups that did not receive general anesthesia and those who did not receive general anesthesia (p&gt; 0.05). Conclusion: Among the groups that did not receive general anesthesia and anesthesia; Bilirubin value was found to be higher among babies born by cesarean section under general anesthesia. It seems that it is more beneficial to avoid systemic effects as much as possible and to disseminate NSVD.

Unmasking Pandemic Echoes: An In-Depth Review of Long COVID's Unabated Cardiovascular Consequences beyond 2020.

At the beginning of 2020, coronavirus disease 2019 (COVID-19) emerged as a new pandemic, leading to a worldwide health crisis and overwhelming healthcare systems due to high numbers of hospital admissions, insufficient resources, and a lack of standardized therapeutic protocols. Multiple genetic variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been detected since its first public declaration in 2020, some of them being considered variants of concern (VOCs) corresponding to several pandemic waves. Nevertheless, a growing number of COVID-19 patients are continuously discharged from hospitals, remaining symptomatic even months after their first episode of COVID-19 infection. Long COVID-19 or 'post-acute COVID-19 syndrome' emerged as the new pandemic, being characterized by a high variability of clinical manifestations ranging from cardiorespiratory and neurological symptoms such as chest pain, exertional dyspnoea or cognitive disturbance to psychological disturbances, e.g., depression, anxiety or sleep disturbance with a crucial impact on patients' quality of life. Moreover, Long COVID is viewed as a new cardiovascular risk factor capable of modifying the trajectory of current and future cardiovascular diseases, altering the patients' prognosis. Therefore, in this review we address the current definitions of Long COVID and its pathophysiology, with a focus on cardiovascular manifestations. Furthermore, we aim to review the mechanisms of acute and chronic cardiac injury and the variety of cardiovascular sequelae observed in recovered COVID-19 patients, in addition to the potential role of Long COVID clinics in the medical management of this new condition. We will further address the role of future research for a better understanding of the actual impact of Long COVID and future therapeutic directions.