Symptom Clusters Seen in Adult COVID-19 Recovery Clinic Care Seekers.

BACKGROUND: COVID-19 symptom reports describe varying levels of disease severity with differing periods of recovery and symptom trajectories. Thus, there are a multitude of disease and symptom characteristics clinicians must navigate and interpret to guide care. OBJECTIVE: To find natural groups of patients with similar constellations of post-acute sequelae of COVID-19 (PASC) symptoms. DESIGN: Cohort SETTING: Outpatient COVID-19 recovery clinic with patient referrals from 160 primary care clinics serving 36 counties in Texas. PATIENTS: Adult patients seeking COVID-19 recovery clinic care between November 15, 2020, and July 31, 2021, with laboratory-confirmed mild (not hospitalized), moderate (hospitalized), or severe (hospitalized with critical care) COVID-19. MAIN MEASURES: Demographics, COVID illness onset, and duration of persistent PASC symptoms via semi-structured medical assessments. KEY RESULTS: Four hundred forty-one patients (mean age 51.5 years; 295 [66.9%] women; 99 [22%] Hispanic, and 170 [38.5%] non-White, racial minority) met inclusion criteria. Using a k-medoids algorithm, we found that PASC symptoms cluster into two distinct groups: neuropsychiatric (N = 186) (e.g., subjective cognitive dysfunction) and pulmonary (N = 255) (e.g., dyspnea, cough). The neuropsychiatric cluster had significantly higher incidences of otolaryngologic (X2 = 14.3, p < 0.001), gastrointestinal (X2 = 6.90, p = 0.009), neurologic (X2 = 441, p < 0.001), and psychiatric sequelae (X2 = 40.6, p < 0.001) with more female (X2 = 5.44, p = 0.020) and younger age (t = 2.39, p = 0.017) patients experiencing longer durations of PASC symptoms before seeking care (t = 2.44, p = 0.015). Patients in the pulmonary cluster were more often hospitalized for COVID-19 (X2 = 3.98, p = 0.046) and had significantly higher comorbidity burden (U = 20800, p = 0.019) and pulmonary sequelae (X2 = 13.2, p < 0.001). CONCLUSIONS: Health services clinic data from a large integrated health system offers insights into the post-COVID symptoms associated with care seeking for sequelae that are not adequately managed by usual care pathways (self-management and primary care clinic visits). These findings can inform machine learning algorithms, primary care management, and selection of patients for earlier COVID-19 recovery referral. TRIAL REGISTRATION: N/A.

Post-acute sequelae of COVID-19 in adults referred to COVID recovery clinic services in an integrated health system in Texas.

The epidemiology and organ-specific sequelae following acute illness due to COVID-19 and prompting patients to seek COVID recovery care are not yet well characterized. This cross-sectional study reviewed data on 200 adult patients with prolonged symptoms of COVID-19 (>14 days after symptom onset) not resolved by usual primary care or specialist care who were referred for COVID-specific follow-up. Most patients sought COVID recovery clinic visits within the first 2 months of initial onset of symptoms (median 37 days), with some seeking care for sequelae persisting up to 10 months (median 82 days). At the time of telehealth evaluation, 13% of patients were using home oxygen, and 10% of patients had been unable to return to work due to persistent fatigue and/or subjective cognitive dysfunction ("brain fog"). The prominent specific symptom sequelae prompting patients to seek COVID-specific evaluation beyond usual primary care and specialist referrals were dyspnea, fatigue/weakness, and subjective cognitive dysfunction, irrespective of whether patients had required hospitalization or time since COVID-19 symptom onset.

Hypovitaminosis d: a contributor to psychiatric disorders in elderly?

BACKGROUND: Hypovitaminosis D is unrecognized and remarkably common in geriatric patients, with various clinical manifestations. The purpose of this study was to prospectively assess the vitamin D (VD) status in newly admitted psychogeriatric patients, and to study the correlation of VD status with indicators of calcium metabolism. METHODS: A valid VD sample, as measured by serum 25-hydroxyvitamin D (25-OHD), was obtained from nine consecutive psycogeriatric inpatients (66% women), during a one-month period in 2011. The Research Ethics Boards at St. Joseph's Healthcare Hamilton approved this project. RESULTS: All participants showed VD inadequacy (defined as 25-OHD ≤ 75 nmol/L) with a mean level of serum 25-OHD of 45.5 ± 14.6 (range 28.5-73.4) nmol/L. None of the patients in the sample met criteria for VD deficiency (currently defined by expert consensus as 25-OHD < 25 nmol/L). Mean serum VD levels were lower in females (38.8 ± 9.8 nmol/L) than in males (59.0 ± 14.3 nmol/L), p = .03. Magnesium and PTH were both higher in females (p = .03 and .02, respectively). Univariate linear regression analysis showed that VD levels were strongly negatively associated with magnesium (p = .001) and PTH (p = .02). CONCLUSION: Since research links VD deficiency to psychiatric conditions, high rates of insufficiency in this population is very common and routine supplements are strongly suggested, regardless of patients' living environment.

Lagtime in psychosomatic medicine consultations for cognitive-disorder patients: association with length of stay.

BACKGROUND: Utilization studies in inpatient psychosomatic medicine have focused on patterns of consultation requests, timing of consultation requests relative to date of hospital admission, and the association between time to initial psychiatric consultation and length of stay. OBJECTIVE: The authors studied the association of time to initial psychosomatic medicine consultation and length of stay for inpatients with cognitive disorders. METHOD: The authors reviewed 157 charts, analyzing effects of age, gender, days from admission until consultation (REFLAG), and length of stay (LOS). Two values were computed: referral lag divided by LOS (REFLAG/LOS) and log(REFLAG)/log(LOS). RESULTS: Mean REFLAG was 8.13; mean LOS was 18.6 days; mean REFLAG/LOS was 0.466; and mean log(REFLAG)/log (LOS) was 0.596. REFLAG and log (REFLAG)/log(LOS) correlated significantly with LOS. CONCLUSION: REFLAG is significantly associated with increased LOS. Referring services may need to consider earlier consultation requests.

Sleep in hospitalized medical patients, part 2: behavioral and pharmacological management of sleep disturbances.

BACKGROUND: As described in Part 1 of this article, multiple factors lead to disrupted sleep in hospitalized medical patients. Recognizing and addressing these factors can help clinicians more effectively manage patients' sleep complaints. METHODS: A PubMed search was conducted by cross-referencing the terms "sleep deprivation," "insomnia," and "sleep"; "hospitalized," "acutely ill," and "critically ill"; and "medication," "drugs," "hypnotics," "benzodiazepines," and "sedatives." The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search. RESULTS: Few articles addressed the topic of the assessment and management of sleep problems in hospitalized medical patients. In Part 2, we propose an evaluation and treatment algorithm that includes recommendations regarding the use of nonpharmacologic and pharmacologic therapies as clinicians consider relevant clinical data. The algorithm is accompanied by 5 tables that include pertinent and practical information to assist clinicians as they manage their inpatients' sleep complaints. CONCLUSIONS: Assessment of a sleep complaint should include a review of factors that could exacerbate patients' sleep. The treatment could then focus on ameliorating these factors, and the judicious use of nonpharmacologic strategies and psychopharmacologic agents.

A prospective observational study of decisional capacity determinations in an academic medical center.

OBJECTIVE: The main goals, of this observational study were to clarify and categorize decisional capacity assessments performed by a psychosomatic medicine (PSM) consult service at an academic medical center. Areas of investigation included types of decisional capacity requests, the relationship between Folstein Mini-Mental State Exam (MMSE) and PSM decisional capacity determination, psychiatric diagnoses of patients, and the agreement between primary clinician capacity assessment and that of the PSM clinician. METHOD: This was a prospective study of 100 consecutive decisional capacity consultations. Twelve requests were for second consultations for patients previously seen, for a net of 88 patients. RESULTS: In 77 cases, patients lacked decisional capacity. Assessments for capacity to leave against medical advice (AMA), capacity to accept medical/surgical procedures, capacity to refuse medical/surgical procedures, and capacity to participate in discharge planning were nearly equally frequent. An MMSE cutoff score of < 21 was found to be 100% specific and 69% sensitive for identifying the patients without capacity, while a cutoff of < 24 was found to be 83% sensitive and 90% specific for identifying patients without capacity. The primary psychiatric diagnosis was a cognitive disorder in 52 cases. In 38 of the 39 cases where the primary team believed the patient lacked capacity, the PSM service agreed. In only two of the seven cases where primary teams believed patients had capacity did the PSM team agree. CONCLUSIONS: The MMSE was a useful predictor of capacity determination by PSM personnel, but using MMSE alone results in a number of erroneous determinations. Cognitive disorders were the most common primary psychiatric diagnoses in decisional capacity cases. Primary teams tended to be more accurate when they found patients to lack capacity.

DNR versus DNT: clinical implications of a conceptual ambiguity: a case analysis.

Psychiatrists who practice psychosomatic medicine are routinely called upon to help resolve ethical dilemmas that arise in the care of patients near the end of their lives. Psychosomatic-medicine psychiatrists may be of unique value in these situations because of the clinical insights that we bring to the care of the dying patient. In particular, our subspecialty brings expertise related to the evaluation of decisional capacity of patients who are faced with accepting or declining end-of-life clinical interventions, such as resuscitation and intubation. In this first entry in a new bioethics case series in Psychosomatics, we will lay the groundwork for examining a complex patient case and provide an illustrative analysis of the end-of-life care issues that may be addressed by psychiatrists who practice psychosomatic medicine.

The role of psychosomatic-medicine psychiatrists in bioethics: a survey study of members of the academy of psychosomatic medicine.

The Bioethics Subcommittee of The Academy of Psychosomatic Medicine developed a survey to assess the involvement of psychosomatic-medicine psychiatrists in bioethics and the extent of their participation on bioethics committees and in the teaching of bioethics. Of 599 Academy members surveyed, 122 (20.4%) responded. The majority of respondents reported that the management of bioethical dilemmas had a significant impact on their work in psychosomatic medicine. Many respondents were involved in teaching bioethics and in serving on ethics committees. The majority of respondents reported psychiatry-resident involvement on ethics committees. Bioethics work is an integral part of the fabric of psychosomatic medicine.

Cognitive-disorder diagnoses in inpatient psychosomatic-medicine consultations: associations with age and length of stay.

Authors reviewed consecutive charts of 155 cognitive-disorder patients from a psychosomatic medicine service in 2001, analyzing factors of age, cognitive-disorder diagnosis, and length of stay. Mean length of stay for this cohort exceeded the typical hospital length of stay, and decreased with age. Increased age was associated with a decreased probability of a delirium-only diagnosis, and was strongly associated with an increased probability of a dementia diagnosis. Among those with dementia, the probability of having an additional diagnosis of delirium was unrelated to age. The case-mix of cognitive disorders differs with age, whereas cognitive disorders are associated with increased length of stay for adult patients of all ages.

Pharmacological intervention for cognitive deficits and aggression in frontal lobe injury.

We present a case that promotes early intervention and pharmacological treatment for the neuropsychiatric sequelae (frontal lobe syndrome, including cognitive impairment and aggressive behavior) associated with traumatic brain injury (TBI) and delirium. The patient, who sustained significant systemic complications related to his trauma, was previously diagnosed with alcohol and drug dependence and antisocial personality disorder. These antecedent conditions and prolonged systemic complications likely played a complicating role in his course of recovery.