RCSLT: Covid-19 Speech and language therapy rehabilitation pathway #covid19rftlks

COVID-19 Speech and language therapy rehabilitation pathway | July 2020| Covid-19 Speech and language therapy rehabilitation pathway

Data on the functional outcomes of patients surviving an intensive care unit (ICU)
admission for COVID-19 is sparse. However, anecdotal experience across a number of
London ICUs indicates that a high proportion has significant physical functional
impairment (more than 50 % of those discharged from ICU) and the range of
impairments is diverse. There is an immediate need to provide specialist, effective and
targeted rehabilitation for patients recovering from the disease to improve functional
outcomes and to ensure they make the best possible recovery.
The key role of Speech and Language Therapists within ICU is widely recognised
and is essential to providing rehabilitation of communication and upper airway functions following critical illness. This guidance informs models and pathways for speech and language therapy services in the provision of high-quality rehabilitation. [1, 2]. Guidance has already been produced, for example by the British Rehabilitation Society.
This speech and language therapy guidance has been developed as part of the
Intensive Care Society’s Rehabilitation Working Party’s work on a rehabilitation
framework for COVID-19 patients. This will inform what high quality rehabilitation
service models and pathways could look like for COVID-19. There is also an opportunity
in this time to design and mobilise improved multidisciplinary rehabilitation pathways
that will serve as a lasting legacy for all patients in years to come (Source: RCSLT)

COVID-19 Speech and language therapy rehabilitation pathway

Antithrombotic Therapies in COVID-19 Disease: a Systematic Review #covid19rftlks

Maldonado, Tao & Mackey (2020). Antithrombotic Therapies in COVID-19 Disease: a Systematic Review. Journal of General Internal Medicine. Jun 17 : 1–9.

Abstract
Background

Infection with coronavirus SARS-CoV-2, causing COVID-19 disease, leads to inflammation and a prothrombotic state.

Objective

This rapid systematic review aims to synthesize evidence on thromboembolism incidence and outcomes with antithrombotic therapies in COVID-19.

Data Sources

We searched MEDLINE (Ovid), Cochrane Rapid Reviews, PROSPERO, and the WHO COVID-19 Database from January 1, 2003, to April 22, 2020, for studies meeting pre-specified inclusion criteria.

Study Selection, Data Extraction, and Synthesis

One investigator identified articles for inclusion, abstracted data, and performed quality assessment, with second reviewer checking.

Results

Incidence of thromboembolism among hospitalized patients with COVID-19 ranged from 25 to 53% in 4 retrospective series. We identified 3 studies (1 retrospective cohort study, 1 prospective uncontrolled observational study, and 1 case series) examining outcomes among COVID-19 patients who received antithrombotic therapies. These studies all included different interventions (thromboprophylaxis with unfractionated heparin (UFH) or low molecular-weight heparin (LMWH); an intensive thromboprophylaxis protocol with LMWH, antithrombin, and clopidogrel; and salvage therapy with tissue plasminogen activator and heparin). These studies are overall poor quality due to methodological limitations including unclear patient selection protocols, lack of reporting or adjustment for patient baseline characteristics, inadequate duration of follow-up, and partial reporting of outcomes.

Conclusions

New evidence on thromboembolism in COVID-19 does not warrant a change in current guidance on thromboprophylaxis among hospitalized patients. Prospective trials of antithrombotic treatment strategies among patients with COVID-19 are urgently needed.

Full paper available from Journal of General Internal Medicine 

Antithrombotic Therapies in COVID-19 Disease: a Systematic Review

HQIP: National Audit of Breast Cancer in Older Patients – 2020 Annual Report

Health Quality Improvement Partnership | July 2020 | National Audit of Breast Cancer in Older Patients – 2020 Annual Report

This is the fourth annual report of the National Audit of Breast Cancer in Older Patients (NABCOP). It describes the process and outcomes of care for 185,648 patients, aged 50 years and over, diagnosed with breast cancer between 1 January 2014 and 31 December 2018 in England and Wales. Information from the English Cancer Patient Experience Survey (CPES), completed by patients diagnosed in England in 2015 to 2018 is included.

For the second year in a row, overall survival following a diagnosis of breast cancer is presented. In addition, the report presents short-term mortality following (adjuvant/palliative) chemotherapy along with investigating the reporting of recurrence within the routinely collected data used by NABCOP.

This image has an empty alt attribute; its file name is hqip.org_.uk_.png
Image source: hqip.org.uk

Infographic

National Audit of Breast Cancer in Older Patients

For patients, the public and professional users: a guide to COVID-19 tests and testing kits [updated 10 July] #covid19rftlks

Medicines & Healthcare products Regulatory Agency | July 2020 | For patients, the public and professional users: a guide to COVID-19 tests and testing kits

Updated 10 July: this guidance has been rewritten to include updated information for members of the public, patients, professionals and industry about COVID-19 tests and testing kits, including how they work, the different types of tests and the specifications manufacturers need to follow.

Tests are only reliable if used in the way intended by the manufacturer. It is always important to follow the manufacturer’s instructions for use.

In order for a test to be safe to use, the company that develops this test must comply with the In Vitro Diagnostic Medical Devices Directive as implemented in the UK by Part IV of the Medical Devices Regulations 2002. Once they do, they are allowed to print a ‘CE’ mark on their test. This CE mark represents a declaration by the company that the test meets all of the legal criteria.

Tests will only be as reliable as the manufacturer claims if used in the way intended by the manufacturer. It is always important to follow the manufacturer’s instructions for use.

There are different stages to the testing process. A ‘CE’ mark is only valid if the following events happen in the way intended by the manufacturer:

  • Collection of a sample (sometimes using a sampling kit)
  • Testing of that sample
  • Reading and interpretation of results; and
  • The provision of the result is accompanied by information to help you understand what they mean

These stages are different for COVID-19 virus testing and COVID-19 antibody testing.

Full details from Medicines & Healthcare products Regulatory Agency

Cochrane Library: Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: a living systematic review #covid19rftlks

Piechotta  V, et al. (2020). Convalescent plasma or hyperimmune immunoglobulin for people with COVID‐19: a living systematic review|Cochrane Database of Systematic Reviews 2020| Issue 7|Art. No.: CD013600| DOI: 10.1002/14651858.CD013600.pub2.

Abstract

Background: Convalescent plasma and hyperimmune immunoglobulin may reduce mortality in patients with viral respiratory diseases, and are currently being investigated in trials as potential therapy for coronavirus disease 2019 (COVID-19). A thorough understanding of the current body of evidence regarding the benefits and risks is required. OBJECTIVES: To continually assess, as more evidence becomes available, whether convalescent plasma or hyperimmune immunoglobulin transfusion is effective and safe in treatment of people with COVID-19.

Search methods: We searched the World Health Organization (WHO) COVID-19 Global Research Database, MEDLINE, Embase, Cochrane COVID-19 Study Register, Centers for Disease Control and Prevention COVID-19 Research Article Database and trial registries to identify completed and ongoing studies on 4 June 2020.

Selection criteria: We followed standard Cochrane methodology. We included studies evaluating convalescent plasma or hyperimmune immunoglobulin for people with COVID-19, irrespective of study design, disease severity, age, gender or ethnicity. We excluded studies including populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)) and studies evaluating standard immunoglobulin.

Data collection and analysis: We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane ‘Risk of bias’ tool for randomised controlled trials (RCTs), the Risk of Bias in Non-randomised Studies – of Interventions (ROBINS-I) tool for controlled non-randomised studies of interventions (NRSIs), and the assessment criteria for observational studies, provided by Cochrane Childhood Cancer for non-controlled NRSIs. MAIN RESULTS: This is the first living update of our review. We included 20 studies (1 RCT, 3 controlled NRSIs, 16 non-controlled NRSIs) with 5443 participants, of whom 5211 received convalescent plasma, and identified a further 98 ongoing studies evaluating convalescent plasma or hyperimmune immunoglobulin, of which 50 are randomised. We did not identify any completed studies evaluating hyperimmune immunoglobulin. Overall risk of bias of included studies was high, due to study design, type of participants, and other previous or concurrent treatments. Effectiveness of convalescent plasma for people with COVID-19 We included results from four controlled studies (1 RCT (stopped early) with 103 participants, of whom 52 received convalescent plasma; and 3 controlled NRSIs with 236 participants, of whom 55 received convalescent plasma) to assess effectiveness of convalescent plasma. Control groups received standard care at time of treatment without convalescent plasma. All-cause mortality at hospital discharge (1 controlled NRSI, 21 participants) We are very uncertain whether convalescent plasma has any effect on all-cause mortality at hospital discharge (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.61 to 1.31; very low-certainty evidence). Time to death (1 RCT, 103 participants; 1 controlled NRSI, 195 participants) We are very uncertain whether convalescent plasma prolongs time to death (RCT: hazard ratio (HR) 0.74, 95% CI 0.30 to 1.82; controlled NRSI: HR 0.46, 95% CI 0.22 to 0.96; very low-certainty evidence). Improvement of clinical symptoms, assessed by need for respiratory support (1 RCT, 103 participants; 1 controlled NRSI, 195 participants) We are very uncertain whether convalescent plasma has any effect on improvement of clinical symptoms at seven days (RCT: RR 0.98, 95% CI 0.30 to 3.19), 14 days (RCT: RR 1.85, 95% CI 0.91 to 3.77; controlled NRSI: RR 1.08, 95% CI 0.91 to 1.29), and 28 days (RCT: RR 1.20, 95% CI 0.80 to 1.81; very low-certainty evidence). Quality of life No studies reported this outcome. Safety of convalescent plasma for people with COVID-19 We included results from 1 RCT, 3 controlled NRSIs and 10 non-controlled NRSIs assessing safety of convalescent plasma. Reporting of adverse events and serious adverse events was variable. The controlled studies reported on adverse events and serious adverse events only in participants receiving convalescent plasma. The duration of follow-up varied. Some, but not all, studies included death as a serious adverse event. Grade 3 or 4 adverse events (13 studies, 201 participants) The studies did not report the grade of adverse events. Thirteen studies (201 participants) reported on adverse events of possible grade 3 or 4 severity. The majority of these adverse events were allergic or respiratory events. We are very uncertain whether or not convalescent plasma therapy affects the risk of moderate to severe adverse events (very low-certainty evidence). Serious adverse events (14 studies, 5201 participants) Fourteen studies (5201 participants) reported on serious adverse events. The majority of participants were from one non-controlled NRSI (5000 participants), which reported only on serious adverse events limited to the first four hours after convalescent plasma transfusion. This study included death as a serious adverse event; they reported 15 deaths, four of which they classified as potentially, probably or definitely related to transfusion. Other serious adverse events reported in all studies were predominantly allergic or respiratory in nature, including anaphylaxis, transfusion-associated dyspnoea, and transfusion-related acute lung injury (TRALI). We are very uncertain whether or not convalescent plasma affects the number of serious adverse events.

Authors’ conclusions: We are very uncertain whether convalescent plasma is beneficial for people admitted to hospital with COVID-19. For safety outcomes we also included non-controlled NRSIs. There was limited information regarding adverse events. Of the controlled studies, none reported on this outcome in the control group. There is only very low-certainty evidence for safety of convalescent plasma for COVID-19. While major efforts to conduct research on COVID-19 are being made, problems with recruiting the anticipated number of participants into these studies are conceivable. The early termination of the first RCT investigating convalescent plasma, and the multitude of studies registered in the past months illustrate this. It is therefore necessary to critically assess the design of these registered studies, and well-designed studies should be prioritised. Other considerations for these studies are the need to report outcomes for all study arms in the same way, and the importance of maintaining comparability in terms of co-interventions administered in all study arms. There are 98 ongoing studies evaluating convalescent plasma and hyperimmune immunoglobulin, of which 50 are RCTs. This is the first living update of the review, and we will continue to update this review periodically. These updates may show different results to those reported here.

Read the full review from Cochrane

One year on and one pandemic later: What’s happened to primary care networks and other forms of primary and community care collaboration?

NHS Providers, NHS Confederation| July 2020| One year on and one pandemic later:What’s happened to primary care networks and other forms of primary and community care collaboration?

One year has passed since the deadline for all GP practices to form PCNs. Described as the ‘building blocks’ of integrated care systems by NHS England and Improvement, these geographical networks were formed to work with NHS community health services and other local partners to deliver more joined-up care at neighbourhood level (patient populations of 30,000-50,000) and support the future sustainability of general practice.

But the interface between primary and community care has evolved over time and in different ways across the country. It has developed many forms and functions, of which PCNs are the latest incarnation. Our briefing Primary care networks: a quiet revolution (July, 2019) proposed ways for PCNs and NHS community health services to work effectively together, which remain relevant and – we hope – helpful one year later.

As we come out of the first wave of the pandemic, it is clear that COVID-19 has put a huge strain on all parts of the health and care system. The time will come for an in-depth analysis of the benefits of neighbourhood-level integration during the COVID-19 response, but the emerging picture is one of variation across the country. We thought that this would be a timely moment to revisit the range of partnerships that community service providers are forming with primary care colleagues, and the support that trusts can offer to PCNs specifically.

Key points

  • A year since the introduction of primary care networks (PCNs), it is timely to look back on how collaboration between secondary, community and primary care is evolving.
  • The Community Network briefing Primary care networks: a quiet revolution, published in July 2019, supported NHS community health services to navigate the new PCN landscape, often in conjunction with pre-existing partnerships with primary care. Given the challenges facing the primary and community care sectors, this briefing remains relevant today.
  • Although much of the national policy narrative understandably focuses on the creation of PCNs, we know that community service providers operate a number of partnership models with primary care, including partnerships with and support for individual practices and large scale providers of primary care services, such as super-practices and super-partnerships.
  • As a number of our case studies show, the coronavirus (COVID-19) pandemic has accelerated primary and community care collaboration in some areas, as services came together in creative ways to support shielded patients, care homes and more complex care needs in the community.
  • However, in other parts of the country, we still hear about the barriers to be overcome, including variable relationships and the levels of support required to establish nascent PCNs in some areas.
  • As the health and care sector moves to recover and reset after the first peak of the pandemic, community and primary care services are embedding innovative practice and learning from their recent experiences. This progress needs to be supported by appropriate resourcing and contractual mechanisms which facilitate local flexibilities and collaboration.

Full details from NHS Providers

One year on and one pandemic later: What’s happened to primary care networks and other forms of primary and community care collaboration?

JAMA: The Development of COVID-19 VaccinesSafeguards Needed #covid19rftlks

Lurie N, Sharfstein JM, Goodman JL. The Development of COVID-19 Vaccines: Safeguards Needed. JAMA. Published online July 06, 2020. doi:10.1001/jama.2020.12461

Asafe and effective vaccine against coronavirus disease 2019 (COVID-19) is the best way to control and ultimately end the pandemic. Vaccine development is moving at unprecedented speed, with more than 200 candidates, billions of dollars committed, and manufacturing often proceeding before even knowing whether a given vaccine candidate will succeed. To date, the US federal government has rapidly advanced 5 vaccine candidates through Operation Warp Speed.1 At the same time, a growing movement of skeptics has raised doubt about future COVID-19 vaccines.2 A poll of 1056 individuals in the US found that only 49% reported that they currently are planning to receive a COVID-19 vaccine, 31% are uncertain, and 20% are not, with safety a major concern.3

The best response to such concerns is a transparent and rigorous approach to vaccine development and regulation, including for licensure or any prelicensure use permitted by the US Food and Drug Administration (FDA). For this effort to be successful, it is critical that the independence of the agency be respected, standards maintained, and politicians kept from pronouncements that create the appearance of interference such as that engendered by the emergency use authorization of antimalarial drugs to treat COVID-19.4,5 To help ensure the best possible decision-making and increase public confidence, regulators should be transparent about plans for 4 needed safeguards in COVID-19 vaccine development (Source:JAMA)

Persistent Symptoms in Patients After Acute COVID-19 #covid19rftlks

Carfì A, Bernabei R, Landi F, for the Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. (2020)| JAMA| Published online July 09, 2020. doi:10.1001/jama.2020.12603

In Italy, a large proportion of patients with coronavirus disease 2019 (COVID-19) presented with symptoms (71.4% of 31 845 confirmed cases as of June 3, 2020). Common symptoms include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, and anosmia/dysgeusia. However, information is lacking on symptoms that persist after recovery. We assessed persistent symptoms in patients who were discharged from the hospital after recovery from COVID-19.

Methods

In the waning phase of the pandemic, beginning on April 21, 2020, the Fondazione Policlinico Universitario Agostino Gemelli IRCCS in Rome, Italy, established a postacute outpatient service for individuals discharged from the hospital after recovery from COVID-19. All patients who met World Health Organization criteria for discontinuation of quarantine (no fever for 3 consecutive days, improvement in other symptoms, and 2 negative test results for severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] 24 hours apart) were followed up. At enrollment in the study, real-time reverse transcriptase–polymerase chain reaction for SARS-CoV-2 was performed and patients with a negative test result were included.

Patients were offered a comprehensive medical assessment with detailed history and physical examination. Data on all clinical characteristics, including clinical and pharmacological history, lifestyle factors, vaccination status, and body measurements, were collected in a structured electronic data collection system. The COVID-19 postacute outpatient service is currently active, and further details about the patient evaluation protocol are described elsewhere.

In particular, data on specific symptoms potentially correlated with COVID-19 were obtained using a standardized questionnaire administered at enrollment. Patients were asked to retrospectively recount the presence or absence of symptoms during the acute phase of COVID-19 and whether each symptom persisted at the time of the visit. More than 1 symptom could be reported. The EuroQol visual analog scale was used to ask patients to score their quality of life from 0 (worst imaginable health) to 100 (best imaginable health) before COVID-19 and at the time of the visit. A difference of 10 points defined worsened quality of life. All analyses were performed using R version 3.6.3 (R Foundation).

This study was approved by the Università Cattolica and Fondazione Policlinico Gemelli IRCCS Institutional Ethics Committee. Written informed consent was obtained from all participants.Results

From April 21 to May 29, 2020, 179 patients were potentially eligible for the follow-up post–acute care assessment; 14 individuals (8%) refused to participate and 22 had a positive test result. Thus, 143 patients were included. The mean age was 56.5 (SD, 14.6) years (range, 19-84 years), and 53 (37%) were women. During hospitalization, 72.7% of participants had evidence of interstitial pneumonia. The mean length of hospital stay was 13.5 (SD, 9.7) days; 21 patients (15%) received noninvasive ventilation and 7 patients (5%) received invasive ventilation. The characteristics of the study population are summarized in the Table.

Patients were assessed a mean of 60.3 (SD, 13.6) days after onset of the first COVID-19 symptom; at the time of the evaluation, only 18 (12.6%) were completely free of any COVID-19–related symptom, while 32% had 1 or 2 symptoms and 55% had 3 or more. None of the patients had fever or any signs or symptoms of acute illness. Worsened quality of life was observed among 44.1% of patients. The Figure shows that a high proportion of individuals still reported fatigue (53.1%), dyspnea (43.4%), joint pain, (27.3%) and chest pain (21.7%).Discussion

This study found that in patients who had recovered from COVID-19, 87.4% reported persistence of at least 1 symptom, particularly fatigue and dyspnea. Limitations of the study include the lack of information on symptom history before acute COVID-19 illness and the lack of details on symptom severity. Furthermore, this is a single-center study with a relatively small number of patients and without a control group of patients discharged for other reasons. Patients with community-acquired pneumonia can also have persistent symptoms, suggesting that these findings may not be exclusive to COVID-19.

Clinicians and researchers have focused on the acute phase of COVID-19, but continued monitoring after discharge for long-lasting effects is needed (JAMA).

Full article from JAMA

Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom #covid19rftlks

Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom | Psychiatry Research | Volume 291, September 2020

Despite ample research on the prevalence of specific psychiatric disorders during COVID-19, we know little about the broader psychological impact of the pandemic on a wider population. The study investigates the prevalence and predictors of general psychiatric disorders measured by the 12-item General Health Questionnaire (GHQ-12) and frequency of loneliness during COVID-19 in the United Kingdom, a country heavily hit by the pandemic.

The study found:

  • Over one-fourth of British have general psychiatric disorders during COVID-19.
  • Over one-third of British sometimes or often feel lonely during COVID-19.
  • People with COVID-19 symptoms have more psychiatric disorders and are lonelier.
  • Women and young people are risky for psychiatric disorders and loneliness.
  • Employment and living with a partner reduce psychiatric disorders and loneliness.

Full paper: Prevalence and predictors of general psychiatric disorders and loneliness during COVID-19 in the United Kingdom