Um, so thanks everybody for joining me today. We will go through this um, based on the different syndromes that we're seeing the most often. So overall, our definition of long haulers is that patients have to have persistent symptoms beyond 30 days from their initial covid symptoms. So, you know, the 1st 10 or 14 days is going to be the acute covid phase. So this would be an additional 15 to 20 days after their acute covid. If they are still having some symptoms, then that would start to be called long hauler and the symptoms need to be new to the patient since they got covid. So if they already had COPD before and they had some shortness of breath, this would not be considered long hauler. That would be just considered their COPD. And we break it down into a variety of syndromes based on their clinical presentations. All long haulers don't have the same symptoms. Some have some, but not the others. And this is what we're seeing the most commonly. The chronic fatigue syndrome is by far the most common than some neurologic and psychiatric syndromes, then pulmonary cardiac etcetera, and we'll go through each of these. So For chronic fatigue again, this is about 85% of the patients that we're seeing so far are having chronic fatigue syndrome as part of their long hauler and it's presenting very similar as you would expect after other infectious diseases. Um, Mono being the really, really classic one that we all hear about. Even, you know, young healthy athletes who are in great shape, they get mono and then they have this chronic fatigue syndrome afterwards for months and months. This is, you know, really well described event after infections. We also see it after lime. We see it with sarcoidosis. So it's this is presenting with the same kind of syndrome. And what we're doing is um we recommend that the primary care doctors can order these these panel of tests. And the point is really to make sure that there's not something else that has been uncovered during covid um that we could treat. So thyroid and am cortisol C. B C. B 12 cmp for written stop being to look for sleep apnea. P. H. Q nine for depression screening. Or you could use the P. H. Q two as an initial screening test. Um and then a six minute walk test. So obviously if you find any of those then you would treat them specifically for you know whichever abnormality that you find if you find that all of that comes back normal, then you're really treating chronic fatigue syndrome post viral fatigue syndrome without other you know metabolic abnormalities. And so what we are recommending for the primary care docks to treat with is an ss ri of your choice. We're using flu oxytocin because it does have the side effect of being slightly activating. We use it also for our depressed geriatric patients for the same reason because we want them to have a little bit of boost of energy. Um So we're using the flu oxytocin then we have them come back in eight weeks. If they're still not improved, then for some of them were adding Provigil. And that actually comes from guidelines from sarcoidosis that sarcoidosis patients also get a type of chronic fatigue syndrome. And they treat them with S. S. Sorry if it's not effective, they add Provigil to it. And so we're copying that algorithm. So this is 85% of the long colors. This is what we're doing for work up and for treatment of that the next most common our two neurologic symptoms. So we'll do one and then the other. The first slightly more common one is this this description of brain fog patients may say they have trouble concentrating. They're unable to do things that require multiple steps, even though they used to be able to do it before. Like we have some young 30 something professionals, lawyers, they can't figure out how to get their kids ready off the bus to school and then get themselves to work on time anymore. They're discombobulated, they're getting all the steps of that in the wrong order where they didn't have a problem with it before. Um So this is they're describing it very similar to the way that people describe a post concussion syndrome. Um And so we're treating it the same idea as a post concussion syndrome. So we're doing a mOCA test to look for underlying dementia, um thyroid B 12 cmp because abnormalities in any of those can cause a toxic metabolic encephalopathy, sleep apnea screening, depression, screening treat for anything that you find abnormal. But again, if all of that comes back normal, then it's some non specific post concussion like illness. And we treat them with occupational therapy For brain exercises or a lot of the kind of millennial age patients who are getting this like their 20's and 30s. You know, it's very inconvenient for them to go in person. They'd rather do something on an app anyway because that's how millennials are. So for them, there are some home programs that have popped up over the past couple of years, not specific to covid, but they are recommended by occupational therapy for other um post concussion type symptoms. And so they can use luminosity. It's an app crosswords and Sudoku to start retraining some of their executive functioning. We do find that flew oxytocin does help this syndrome as well. So we're still using flu oxytocin And then if our screening test for Mocha is 26 or less, then we can recommend occupational therapy and the apps. But we still also try to convince the patient to go to neuro psych to get further testing. Um sometimes were not successful, they don't want to go, but we're at least giving that a track. So this is very common. The second neurologic one that's common is more of kind of migrating paris. These asia's might be stinging pains, electrical pains or numbness is and they moved to different Dermot Holmes. It's not always the same one, it's like, it's not always my right arm. When this symptom comes today, it might be my right arm tomorrow, my left leg the next day it will be the corner of my mouth. It's all over the place, it doesn't stay. It comes and goes by itself um Without doing anything and it's not in a single Dermot. O. So what we order for that is basically just screen for some of the electrolytes and vitamins that can affect nerve functioning um and treat them if they come abnormal. But otherwise we're actually just trying to convince patients that um use melatonin to make sure they're sleeping well to get their vitamin D. Up. Um We have sent a lot of these patients to neurology um and they've had consultations um for both the brain fog stuff and the paris these asia's. And then we've had multiple discussions with some of the neurology attendings. And really what it comes down to is that they do not have a good explanation for why some patients have either of these two neurologic syndromes that they hang around with. But they have done a bunch of mris at the beginning of the pandemic on these long haulers with neurologic symptoms. The memories are not coming back as helpful. So they recommend against getting mris. They are doing nerve conduction studies that's not coming back is very diagnostic either. And they are just recommending rather than referring. They're recommending to follow those two algorithms that we did mostly focusing on, look for underlying causes, treat and use occupational therapy for the majority of these um Some patients do have stroke associated with their covid but that will be very classic stroke like symptoms. So if you find stroke like symptoms and that's usually pretty early too. So stroke like symptoms, Fine for sure. Get the MRI sent him to the hospital, the normal work up. But if they're having this brain fog or the paris, these asia's, then really it's more in the occupational therapy and rule out underlying causes. So that's neurologic. Now, we'll talk about psychiatric. Um, so psychiatric is At least in the top three, potentially it's the the most prevalent of all, because this one tends to be co morbid with any of the other long hauler symptoms. And there's two varieties of psychiatric manifestations. There's just straight insomnia, or there's other um diagnosable psychiatric illnesses, such as anxiety that's new for them. Depression, that's new for them. PTSD is really, really common and this doesn't have to be only in patients who were very, very sick. From covid, we're seeing this even in patients who were only manifesting mild covid symptoms at the beginning, they're still getting a large burden of anxiety, depression, or PTSD because of the isolation, the job insecurity, the housing insecurity, um worrying about their other family members during this time, couldn't access healthcare or any of their infrastructure in the way they normally do. It was very disruptive to normal functioning and coping mechanisms that people have when something is happening to them when they're sick or a family member is sick. And because of that it's really destabilized mental health in a huge, huge way. So we're getting ph canines and God sevens so that we get our baseline level on all these patients were doing to stop being screening for sleep apnea on all of them because if they also have sleep apnea is going to make everything else worse. Again, we're using the flu oxytocin for any kind of psychiatric symptoms that we can melatonin for sleep. If that's not strong enough, you can add traZODone, you can add zolpidem, try to help them get some sleep. Um and then we're referring them to again, oftentimes these are younger people who prefer to have home therapy programs or apps. So we're giving them this list. There's others out there. But Savella calm or headspace together with the flu oxytocin. If they do want to talk to a psychiatrist, we can certainly refer them to the psychiatry teams. Um And that is even more helpful. They can combine that with the apps obviously. So the more resources they have the better. Um, but truly psychiatric symptoms are a really common part of any of the other syndromes, or they may be the only thing um that patients are having as long hauler symptoms at the end. So moving to some pulmonary symptoms. So, a common pulmonary, there's Kind of two. there's persistent Disney and then there's chronic or persistent cough. So we'll do Disney A first. So, um Disney on exertion, continued shortness of breath for this. We're ordering a ct a chest to look for pe because there is a higher burden of pE Dvt stroke and clots from covid. So we're looking for a PE with the C. T. A. Chest. Then we're getting complete PFT S. And a six minute walk test because that combined with the C. T. A. Would help us to know if the patients have developed any kind of fibrosis and then we're getting an echo um to look for any signs that their pulmonary disease is actually from a missed M. I. Or decreased DF. And pulmonary oedema. So of course then we treat depending on what we find from that. If you find a P. E. Then we give them an anti coagulant. Our choice um is a pig span. It could be river rocks and whatever you prefer. We use the provoked clot algorithm because this would be a provoked clot from an acute illness. So it's a three month treatment. Um If their P. F. T. S. And their six minute walk test and their cT scan all come back showing evidence of fibrosis or lung destruction. Then we're referring to the lung transplant clinic and the order for that an epic is the ambulatory referral to lung transplant and it will show up there. Um And then if they're Eco is coming back with depressed DF, then we're referring to cardiology because there's a new diagnosis of heart failure. Um And some of those patients are going on to get cats and they're finding that they have ischemic heart disease as the reason for their new heart failure. But if all of those come back normal. And so just for kind of reference, we've ordered about 45 of these workups for patients with long hauler shortness of breath and only about 15 have come back as having any of them abnormal. So the majority are normal on all these testing. So if they come back normal for the pulmonary testing, then we send them to pulmonary rehab with RPT and rehab colleagues and they start them on a graded exercise um pathway. And a lot of them get much much better with that. Then the second pulmonary thing that is pretty common is cough. So you know, obviously cough is one of the main acute symptoms of covid and then some people tend to continue on and have ongoing persistent cough that they did not have before. So for these patients, we're getting a pft with pre and post bronchodilator to see if they have reactive airway disease or asthma that maybe we just didn't really know about before. Um And then we're getting a high res ct chest again to look for fibrosis. So we treat each of those as you would normally you you treat their asthma is normal. And then if you find fibrosis or honey combing and sent a lung transplant, but if both of those are normal then what we're doing is um what we can do either stepwise or just hit them all at once. I'm finding now that I'm kind of just hitting them all at once. So I put them on a P. P. I. And inhaled or a nut inhale. But a nasal steroid and then a gavel Penton The id for 30 days. So I treat their post-asal drip, their guard and you're a genic cough All at once for 30 days. That has not failed. It has gotten every single one of them to stop coughing. Then I take it away one x 1 and I see which one is the one that is really treating them the most. But first you have to like get them to believe that you can control this. And so that's why I treat with all and then I take away one x one depending on which one seemed the least likely when I was doing my initial assessment of the patient. Um because you know, in primary care we could normally say, well it's probably post nasal trip. You have the allergic line or you have the shiners and you seem in an allergic person, let's do this nasal spray. But they, you know, they don't try it long enough or they don't spray it right. And so if you just hit him hard with all of it, then take everything else away and leave the nasal spray, they tend to believe you a little bit longer. So that's what I'm doing for them. So then moving on to their cardiac symptoms. So there's also two common cardiac symptoms but the work up is so similar. I just put them together on the same slide here. So some people are having palpitations and other people are having chest pain. And so the palpitations are really, there's no specific pattern. They can happen if you're just sitting down resting. That can happen if you're exercising it comes and goes on its own. Just no pattern can be identified by the patient. Then there's chest pain and that's usually a pluralistic type chest pain if you really sets it out with the patient. So nonetheless, we do make sure that their troops are negative. That they're not having any cute em high again because clotting during covid is more common. Um Then we get a D. Dime er or a C. T. A. For pe rollout. And I'm choosing C. T. A. More and more commonly because the D. Dime er um is really only good if it's stone cold normal but if it comes back borderline you still have to get the sea to anyway. So and these people have been acutely ill so they're di di Maria is likely to be elevated or at least borderline. So usually I'm just getting the C. T. A. On that. Then we get an echo and a zero patch if they're having palpitations. So depending what any of those show, we treat that specifically. If all of that comes back normal, then we're treating for muscular skeletal pain with you know uh Ibuprofen or diclofenac. Um We're doing an empirical PP. I. Trial and you know, any and then what kind of just following them to see if they continue to feel this? Maybe we repeat these tests again at six months. Um Some patients are very adamant that they want additional testing that they want an MRI um cardiac MRI. And so if they really want that, then we're referring them to cardiology to discuss it with cardiology. When we have had discussions with our cardiology attendings. Um They're finding that that's not often helpful but they have, you know, they have a few attendings who are willing to talk about that with patients. And um so but they would rather only get referrals if the zio patch is abnormal, if the echo is abnormal for example, rather than just patient would like to talk about it. So next um in the common now we're really getting to quite uncommon things. The last few are pretty uncommon, persistent fevers. We've had I think four or 5 patients among the long haulers who are having persistent fevers. And these could be intermittent or they could be every single night but they are more often at night than in the daytime. Um These patients, these few that we've had, they have continued elevation of the inflammatory markers of their autoimmune markers. Um and so we have sent them to rheumatology. Rheumatology is following along with us, but most of them are just borderline. They're not um That might be like a tighter of 1-80 for example, which is not really high enough for them to start a treatment with immuno suppressing agent. Um So they're they're not putting them on specific medicines for it. They're following along with us though. Um We're also getting some other tests to rule out other things. So we're checking HIV and RPR for syphilis a cBc, because maybe there's a new leukemia that has been uncovered. What kind of precipitated um d timer to look for clots in this case, this would be in the absence of having specific symptoms, in the absence of exertion, all chest pain or palpitations, um or shortness of breath or leg swelling, but just kind of looked for a clot anywhere. So in this case, I would use the timer to just point me towards maybe there's a clot and that's the cause of this fever. Um, If they were hospitalized, we're getting an echo to look for vegetation zones because if they were hospitalized, they probably had a line for a long time. Um, and then Quantum Fear on if they have any kind of exposure history that they could have had to be in any way we're getting. And basically, you know, we're following those rabbit holes. If we find anything on any of that testing. But if we find nothing except for some of these non specific SRS or low tighter atenas, Then we're doing a trial of pregnant zone 2.5 mg daily for 30 days. And then we stop that um room will follow along and they're not doing any different treatment than that though. Um and we are kind of seeing how they, how they go again. We have four. I think it's for that I know of, I think there might be one that I'm not following four or 5 patients And this is what we've done after the 30 days of predniSONE. They do get better. One is still having fevers after that. But we're just following, we're not changing anything. We're repeating the labs every couple of months and we are going to wait to see kind of what unfolds with the history and with the labs over time. So this one is one that's kind of frustrating. But this is the best algorithm that we could come up with by looking at other institutions by talking to our colleagues in different specialties. Um and we just have to kind of see how this evolves with time. After all, sooner we have a question. What is Zoo Patch? What is a Holter monitor? Yes. Okay. So Zio Patch and Holter monitor are basically the same thing, except Holter Monitor is usually for a shorter period of time. It will usually fall off in a cup in like one day or two days maximum. Whereas a a patch is a a patch that they can wear on their chest. It's maybe the size of like a nicotine patch and it tends to stay on the skin for 10 or 14 days before it falls off and then the patient's mail it back and the cardiologists read it. So both of them look for heart arrhythmias. But sour patch is just a little stickier so it stays on longer. Excellent thank you. We had a comment also you make mention of like psychiatry associated symptoms being the most common among post covid constellations. What is your advice if like for instance a typical wait time for USF psychiatry is many months out even if it's a serious condition. Mhm yep. USF psych has a very long wait list. I know that they're hiring new providers so hopefully they'll get that down soon. Um I think they've signed some that they're trying to on board. We've also been sending people to the T. G. H. Rehab in Brandon. They have some neuropsychiatry appointments there. Um And then if none of that works then we're advising them to follow their insurance and try to find a community psychiatrist that's covered by their insurance. Unfortunately. Thank you. That's all for now. Yeah. Great questions. Um So kind of like I was mentioning we're not sure what to do with these persistently elevated markers here. Um in one study there were up to 57 of patients who were hospitalized. So this was still during their acute illness um that had positive inflammatory markers, autoimmune disease markers and none of them they didn't treat them with immuno suppressants. This was an emery where they did this study. Um So you know more than half of people who covid end up getting some autoimmune markers that they never had before and they don't know why um they did not treat them and they're they're following them up at Emory and we'll kind of wait and see what we can find out from them about whether they you know, how long they stay positive or what treatments that they ended up giving them. But just to say that these are common and chasing this lab value does not seem to be the recommendation from any of the other centers that are treating long haulers nor from our rheumatology team here more. So follow the clinical picture. So the next thing that we have is hyper co availability as a syndrome. And this we've we've mentioned it, we've sprinkled it through but there is absolutely hypercritical ability as part of covid. We have increased rates of strokes and my pulmonary emboli lead and D. V. T. S. Usually this is going to be earlier on within the 1st 30 days during their acute illness. Um it's usually not gonna be after 30 days unless they have already had risk factors for this stuff. Um And for almost all of these, what you're going to do is treat them directly based on whichever one that you suspect, right, if it's stroke grandma, they're going to go to the hospital. Um like you would for anybody that you are suspecting a stroke or am I, if it's a pE or dVT, then you would order the test, then you would do the regular treatment, whichever one you prefer for provoked clot treatment. So this is these are just going to feed into your regular algorithms, but I put it in here to make sure that we're making everybody aware that this is something that's comin from kobane. Um And then the last thing that we're seeing and this has been very rare um is a few cases of new endocrine disorders after covid, Specifically adrenal insufficiency one case And hypothyroidism. one case. These are usually both of these cases. They were actually found when we were doing the work up for chronic fatigue syndrome and I thought we were just ruling out other stuff. But then we actually found these two situations. So you would do your good thorough work up to make sure you rule out other causes. Um And then if you find these two then refer to endure grain and treat them specifically um so that they can have, you know targeted treatment to help them get better. So this has been rare. A few other institutions are describing it also. Um Actually the adrenal insufficiency person that we had um did recover her adrenal function after a few months and she was able to taper off her her replacement therapy steroids so that her adrenal is working again. So that's good news. This may not be permanent, but that is something that we're looking for on these patients and that's all guys other questions. No other questions. Now I'll make a quick final announcement and while I do this, if you do have any other comments or questions, please use this time to type them into the chat box. Just a reminder if you're wanting to claim CMI or CPU credits. Within the next couple of days, I will email you with instructions on how to do that. Um, let me check our chat box. Oh yes, we do have a question. Doctor Ochsner, Can you explain the blood cultures for fevers? Yes. So that is really to look for um especially in patients who were hospitalized to look for endocarditis um as a cause for persistent fevers. Okay, another question organization, sorry. Organizations such as Integrative Medicine for the Underserved are promoting group counseling and bike oriented visit partially for economic and insurance reasons. But other reasons as well, like for example long wait times for services, does something of this nature exists in Tampa? So I think that's a great idea and I definitely am a proponent of it as far as I know there's no group sessions um specifically for covid long haulers in Tampa. Um there is a long hauler group called the Survivor Corps like C. O. R. P. S. That patients can find online and then they can subscribe to it and they can join. I mean nowadays everything is virtual anyway so they could join groups that are going on in Minnesota or whatever. Um so I think that's a good idea and I have sent some patients to the Survivor corps website to get involved in that group. Um therapy. Okay, great. I don't see anything else in the queue so we can use this time to close out. Thank you everyone for joining us and thank you Doctor Ochsner for your time this afternoon and everyone have a good rest of your day. Thanks guys.
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