"Like before, but not exactly": the Qualy-REACT qualitative inquiry into the lived experience of long COVID.

BACKGROUND: Post-acute sequelae of SARS-CoV-2 infection (PASC) affect millions of individuals worldwide. Rehabilitation interventions could support individuals during the recovery phase of COVID-19, but a comprehensive understanding of this new disease and its associated needs is crucial. This qualitative study investigated the experience of individuals who had been hospitalized for COVID-19, focusing on those needs and difficulties they perceived as most urgent. METHODS: This naturalistic qualitative study was part of a single-center mix-method cross-sectional study (REACT) conducted in Italy during the first peak of the SARS-CoV-2 pandemic. The qualitative data collection took place through a telephone interview conducted 3 months after hospital discharge. The experience of individuals discharged after hospitalization for COVID-19 was investigated through the main research question - "Tell me, how has it been going since you were discharged?". Two secondary questions investigated symptoms, activities, and participation. Data were recorded and transcribed verbatim within 48 h. An empirical phenomenological approach was used by the researchers, who independently analyzed the data and, through consensus, developed an interpretative model to answer the research question. Translation occurred after data was analyzed. RESULTS: During the first peak of the COVID-19 pandemic, 784 individuals with COVID-19 were discharged from the hospitals of the Local Health Authority of the Province of Reggio Emilia (Italy); 446 were excluded due to the presence of acute or chronic conditions causing disability other than COVID-19 (n. 339), inability to participate in the study procedures (n. 56), insufficient medical documentation to allow for screening (n. 21), discharge to residential facilities (n. 25), and pregnancy (n. 5). Overall, 150 individuals consented to participate in the REACT study, and 56 individuals (60.7% male, average age 62.8 years ±11.8) were interviewed in June-July 2020, up to data saturation. Persistent symptoms, feelings of isolation, fear and stigma, emotional distress, a fatalistic attitude, and return to (adapted) life course were the key themes that characterized the participants' experience after hospital discharge. CONCLUSIONS: The experience as narrated by the participants in this study confirms the persistence of symptoms described in PASC and highlights the sense of isolation and psychological distress. These phenomena may trigger a vicious circle, but the participants also reported adaptation processes that allowed them to gradually return to their life course. Whether all individuals are able to rapidly activate these mechanisms and whether rehabilitation can help to break this vicious circle by improving residual symptoms remain to be seen. TRIAL REGISTRATION: ClinicalTrials.com NCT04438239.

"Challenging Professional Boundaries": A Grounded Theory Study of Health Professionals' First Experiences of End-of-Life Care in Hospital.

Little is known about health professionals first experiences of End-of-Life care in hospital. This study aims to understand the psycho-social process that occurs when hospital-based health professionals engage in caring for a dying patient for the first time. We conducted a Grounded Theory study, with 19 health professionals. Challenging professional boundaries is the core category which explains the overall process. The theoretical model we conceptualized evidenced three phases: 1) building a relationship between patient/family and professionals, 2) the disrupting impact and 3) the reaction phase. Our analysis highlighted the initial strong impact of this experience, which brought professionals to perceive emotional suffering and feelings of inadequacy. The new aspect our grounded theory revealed is that all the categories are pertinent to all the professionals involved, therefore they explain important aspects of interprofessional collaboration in End-of-Life care.

PUREAIR protocol: randomized controlled trial of intensive pulmonary rehabilitation versus standard care in patients undergoing surgical resection for lung cancer.

BACKGROUND: Non-small cell lung cancer is the most common type of lung cancer. Surgery is proven to be the most effective treatment in early stages, despite its potential impact on quality of life. Pulmonary rehabilitation, either before or after surgery, is associated with reduced morbidity related symptoms and improved exercise capacity, lung function and quality of life. METHODS: We describe the study protocol for the open-label randomized controlled trial we are conducting on patients affected by primary lung cancer (stages I-II) eligible for surgical treatment. The control group receives standard care consisting in one educational session before surgery and early inpatient postoperative physiotherapy. The treatment group receives, in addition to standard care, intensive rehabilitation involving 14 preoperative sessions (6 outpatient and 8 home-based) and 39 postoperative sessions (15 outpatient and 24 home-based) with aerobic, resistance and respiratory training, as well as scar massage and group bodyweight exercise training. Assessments are performed at baseline, the day before surgery and one month and six months after surgery. The main outcome is the long-term exercise capacity measured with the Six-Minute Walk Test; short-term exercise capacity, lung function, postoperative morbidity, length of hospital stay, quality of life (Short Form 12), mood disturbances (Hospital Anxiety and Depression Scale) and pain (Numeric Rating Scale) are also recorded and analysed. Patient compliance and treatment-related side effects are also collected. Statistical analyses will be performed according to the intention-to-treat approach. T-test for independent samples will be used for continuous variables after assessment of normality of distribution. Chi-square test will be used for categorical variables. Expecting a 10% dropout rate, assuming α of 5% and power of 80%, we planned to enrol 140 patients to demonstrate a statistically significant difference of 25 m at Six-Minute Walk Test. DISCUSSION: Pulmonary Resection and Intensive Rehabilitation study (PuReAIR) will contribute significantly in investigating the effects of perioperative rehabilitation on exercise capacity, symptoms, lung function and long-term outcomes in surgically treated lung cancer patients. This study protocol will facilitate interpretation of future results and wide application of evidence-based practice. TRIAL REGISTRATION: ClinicalTrials.gov Registry n. NCT02405273 [31.03.2015].

Sex differences and rehabilitation needs after hospital discharge for COVID-19: an Italian cross-sectional study.

OBJECTIVES: COVID-19 can result in persistent symptoms leaving potential rehabilitation needs unmet. This study aims to describe persistent symptoms and health status of individuals hospitalised for COVID-19 according to the International Classification of Functioning, Disability and Health domains of impairments, limitations in activity, and participation restrictions. DESIGN: Cross-sectional study consisting in a telephone interview 3 months after hospital discharge. SETTING: This study was conducted during the first peak of the COVID-19 pandemic by the Local Health Authority of Reggio Emilia (Italy). PARTICIPANTS: Adult individuals discharged from hospital between April and June 2020 after COVID-19. EXCLUSION CRITERIA: hospitalisation for reasons other than COVID-19, inability to participate in the study, concomitant acute or chronic conditions causing disability. PRIMARY AND SECONDARY OUTCOME MEASURES: We assessed: dyspnoea (Medical Research Council), fatigue (Fatigue Severity Scale), mood disturbances (Hospital Anxiety and Depression Scale), limitations in activity (Barthel Index) and participation restrictions (Reintegration to Normal Living Index). We also collected data on sociodemographic characteristics, health status prior to COVID-19, COVID-related clinical manifestations and hospital care pathway up to discharge, rehabilitation interventions, accidental falls and emergency room access. RESULTS: 149 participants (men, 62%; average age 62 (±11) years) were enrolled, 35 of which (23%) were admitted to the intensive care unit (ICU) while hospitalised. Three months after hospital discharge, nearly half of the participants still suffered from dyspnoea (44%) or fatigue (39%). Almost all individuals (91.2%) recovered a good level of independence in activity of daily living, but 76% still suffered participation restrictions. Female sex was significantly associated with worse outcomes for all symptoms. CONCLUSIONS: Individuals who had moderate or severe COVID-19 may perceive persistent symptoms which may result in reduced social participation. Sex differences should be monitored, as women may recover more slowly than men. TRIAL REGISTRATION NUMBER: NCT04438239.

Rehabilitation for lung cancer patients undergoing surgery: results of the PUREAIR randomized trial.

BACKGROUND: Surgery for non-small cell lung cancer is proven to be the most effective treatment in early stages, although concerns exist on its negative impact on patients' overall fitness. AIM: To establish whether intensive pulmonary rehabilitation, preoperative and postoperative, improves exercise capacity in patients undergoing lung resection. DESIGN: Single center, unblinded, designed for superiority, 1:1 randomized controlled trial with two parallel arms. SETTING: S. Maria Nuova Hospital of Reggio Emilia (Reggio Emilia, Italy). POPULATION: Patients referred from local lung cancer multidisciplinary team for lung resection. METHODS: Patients were randomized to either standard of care (SC) or SC + intensive perioperative pulmonary rehabilitation (SC+PR). The primary aim was to investigate the effectiveness of pulmonary rehabilitation in improving exercise capacity six months after surgery. Additionally, we wanted to investigate the same effect shortly after surgery (at one month), as well as the overall impact of rehabilitation on lung function, postoperative complications and length of stay, quality of life, mood disturbances and pain. Sample was sized based on the primary outcome assuming a minimal clinically significant difference of 25 meters in exercise tolerance, measured with 6 minutes walking test. RESULTS: The exercise tolerance at 6 months after surgery was significantly higher in patients undertaking PR compared to SC (+48.9 meters vs. -7.5 meters respectively, difference: +56.4 meters, 95% CI: 29.6-83.0, P<0.001) and it showed significantly lower impairment at 1 month after surgery in the intervention group (-3.0 meters vs. -30.1 meters difference: +27.1 meters, 95% CI: 3.4-50.8, P=0.025). No other significant differences between groups were found. CONCLUSIONS: Comparison between groups showed that pulmonary rehabilitation, administered pre and postoperatively, significantly improved exercise capacity at 6 months in patients undergoing lung resection; it also significantly reduced the decrease in exercise tolerance observed 1 month after surgery. CLINICAL REHABILITATION IMPACT: The PUREAIR trial highlights the importance of combined preoperative and postoperative rehabilitation in reducing physical deconditioning in lung cancer patients undergoing surgery. Comprehensive pulmonary rehabilitation improves exercise capacity at 1 and 6 months after surgery. The PUREAIR trial results increase knowledge on comprehensive rehabilitation's outcomes in the first six months after surgery.

Perioperative physical exercise interventions for patients undergoing lung cancer surgery: What is the evidence?

Surgical resection appears to be the most effective treatment for early-stage non-small cell lung cancer. Recent studies suggest that perioperative pulmonary rehabilitation improves functional capacity, reduces mortality and postoperative complications and enhances recovery and quality of life in operated patients. Our aim is to analyse and identify the most recent evidence-based physical exercise interventions, performed before or after surgery. We searched in MEDLINE, EMBASE, CINAHL, Cochrane Library and PsycINFO. We included randomised controlled trials aimed at assessing efficacy of exercise-training programmes; physical therapy interventions had to be described in detail in order to be reproducible. Characteristics of studies and programmes, results and outcome data were extracted. Six studies were included, one describing preoperative rehabilitation and three assessing postoperative intervention. It seems that the best preoperative physical therapy training should include aerobic and strength training with a duration of 2-4 weeks. Although results showed improvement in exercise performance after preoperative pulmonary rehabilitation, it was not possible to identify the best preoperative intervention due to paucity of clinical trials in this area. Physical training programmes differed in every postoperative study with conflicting results, so comparison is difficult. Current literature shows inconsistent results regarding preoperative or postoperative physical exercise in patients undergoing lung resection. Even though few randomised trials were retrieved, treatment protocols were difficult to compare due to variability in design and implementation. Further studies with larger samples and better methodological quality are urgently needed to assess efficacy of both preoperative and postoperative exercise programmes.