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Hi, everyone. Welcome to medical primary care. Joining us today is Doctor Kathleen mccann who is a distinguished medical professional affiliated with Saint Vincent's University Hospital and University College. Dublin. Her clinical interests are complemented by a strong commitment to research, particularly in the realm of COVID-19, which has contributed valuable insights into the pandemic's impact on healthcare systems and patient outcomes. Today, Doctor mccann will be teaching us about long COVID. We have around 45 minutes for the presentation and there'll be some time for questions. So do put your questions in the chat as we go along and they'll be answered at the end, at the end of the event, there'll be a feedback form, email to you and once you complete that your attendance certificate will be on your Meadow account. That's all from me. I'll let doctor mccann take it away. Hi, thank you so much. Um So what I'm gonna do is just uh let everybody know cause I know we have an international audience here um about uh where the experience that I'll be talking about today is from, that's from Saint Vincent's University Hospital and that's located in Dublin Ireland. It's one of the largest hospitals in the country. Um There's a population of around 1.5 million and that's in the context of a country that has a population of just over 5 million um with 614 inpatient beds. And our outpatient department sees about 100 and 75 visits each year. So that gives you a context of where, where we're from. And, and then the research is done in conjunction with University College Dublin and, and a center called SR which is a center for experimental pathogen host research, which also looks at other infectious diseases such as HIV. Um So how our clinic started was uh we originally set up a post COVID clinic in May 2020 at that time. Um It was to all patients who were being discharged from um primary care COVID hubs or for patients who are being discharged from the hospital. Within 2 to 3 months. It became evident that um patients with initial mild COVID-19 were not making good recoveries. And we set up a dedicated once a week clinic and by May June 2020 this was um established in a dedicated assessment hub. Um It's now evolved into a once a week uh in person clinic and a second virtual clinic um to put it in context for people who are outside of Ireland. It is a, it is a, a public health service. So patients do not pay to attend the clinic. Or for their, the investigations for care with us. Um So that's who we are. Um, so I'm gonna move on to the patients and so let's talk a little about our post COVID condition. And so really we're talking about is the people who have had, um, infection with COVID-19 and have sustained a post infection que patients may call it long COVID long haul COVID. Um You also see the um, acronym PAC S in the literature. It's been there has its own ICD 10 classification now since September 2020. However, we one of these limitations which is very, very difficult is we still do not have a globally standardized and agreed upon definition of exactly what this is. Um the occurrence is variable in expression and impact. We're gonna be unpacking all of that today and there is not yet an accepted characterization of the epidemiology. So what causes it? I'm gonna uh I'm gonna say be saying this a lot throughout today's talk, we don't know lots and lots of theories and there are multiple potentially overlapping causes of long COVID. There are several hypothesis out there. Um And she and there's probably some evidence for all of this but, but nothing's definitive. So um one theory is there's persisting reservoirs of the virus at some point in the body. Another is immune regulation. Um endothelial dysfunction, autonomic dysfunction, impacts on the microbiota. And all of this um has been put forward as a theory there's some evidence for some of it. Um, but we really don't know what causes it, who gets it. Um If we look at the breakdown of who attends post COVID clinics or who identify having symptoms, um we do see it is women more than men. We do see a predominant distribution, middle age. But however, we do know that we see, we see it in Children, it also seen in older people as well. And those with more symptoms initially do seem to be more likely to have more persistent symptoms. And the only people who don't get long COVID or have zero risk of lung COVID are people who never get COVID. Other than that, in theory, as we know is that anyone would be at risk of having long COVID after having a COVID-19 infection. Um we are still working off of the clinical case definition that was established by Delphi consensus from October 2021 and that's a good working definition. Um And we identify it identifies post COVID-19 condition as an condition that occurs in individuals with a history of probable or confirmed SARS SARS COVID con in two infection within three months of the onset of COVID-19 with symptoms that last for at least two months and cannot be explained by an alternative diagnosis. Um, common symptoms include fatigue, shortness of breath and, and brain fog. However, I'd like to point out here that over 200 symptoms have been attributed to COVID-19. At this point, symptoms may be new onset following an initial recovery or persist from the initial injury or illness. Um, symptoms may fluctuate or relapse over time. Um, most common symptoms that we would see in our clinic, um and we do track this would be um brain fog, which is a type of subjective expre experience of cognitive dysfunction. Um However, with this als also can be objectively measured, fatigue, shortness of breath, um tachycardia or palpitations and headache. However, there'll be m multiple symptoms, post COVID conditions is some way to think of it because it does seem to be not a single entity. This graph is from our work uh published in 2022 looking at phenotypes. So we clustered the symptoms of our patients together um and just laying the groundwork with, you know, like other centers, we're starting to wonder, is there really one long COVID or is this really a a kind of a group of different related conditions? They might have separate etiologies, they might have se slightly separate epidemiologies. But we have started clustering and seeing if the symptoms cluster together. The lack of a clinical definition and lack of established diagnostic criteria is a challenge across research. Um that but also makes the epidemiology diff difficult, but there is an estimate um at the low end that up to 8% of patients recover from COVID-19 may have lingering symptoms. Um In some studies have suggested that may be as high as 20%. And I think some of this variation depends on how we're defining um post COVID condition. Um And, and the criteria being applied. Uh We extrapolate that Ireland. We would, we would expect that there'd be at least 100,000 people in the Republic of Ireland suffering from COVID-19. Um There are lots of things we don't know, we don't know how well vaccines protect against developing lung COVID. Um There's increasing research that seems that it takes at least two doses of the vaccine to reduce your risk of lung COVID. The real, the real answer is that if you don't get COVID-19, you're not gonna get lung COVID. But it does seem to have a lower incidence in people who have had at least two doses of the vaccine. And we again, we're still not sure what causes the post COVID condition. We don't know what the most effective treatment for post COVID condition is. We don't know how long symptoms are going to last. And we don't know those things we always wanna know in medicine, which is what are the, what is a five year, 10 year outcome gonna look like for these patients. So this and we talk a little bit more of how we do it. And I think throughout the talk today, we should really put this in context of, I am talking about how we do it. I'm not saying we have the answers um there'll be differing opinions out there on how to approach um, the care of these patients. Um, but I'm gonna tell you a little more about um, our experience and, and, and how we've, how we've developed the service um, over the last couple of years. Um So in our research, we, we've um been including our patients, something called the alli Infectious Disease cohort. Right now, the study is, um, recruiting from 11 centers throughout Ireland. Um It doesn't, it's not limited to COVID-19 patients, but they are, they have their own um set of data. Um It's been collecting from the beginning of the pandemic. So we start with a good history and I cannot uh emphasize this enough. Um We do start with a, with a good past medical history. Um There have been more than a few patients referred to us that have been unwell since 2018 or 2019. Um It does mean that we look at them a little bit differently than someone who was perfectly well got COVID and then is um and then is now unwell. Uh We do take a history of their medications um especially in long COVID patients. We ask specifically about vitamins, herbals supplements or other treatments they've tried before coming into us. Um social history. We talked, we, we asked specifically about smoking vaping um and alcohol use. We also ask a lot, we ask a lot about their baseline activities when they say they can't do things they used to do anymore. What was that level of activity? We do try to get a whole person approach. Many patients give um give it uh or, or express symptoms that are sometimes hard to quantify and such as fatigue. So we do use validated clinical tools such as the FS 36. Um We have a clinical psychologist with our team who's developed a psychological screening tool that includes um G A D2 and P HQ two questionnaires. We use the DePaul sim questionnaire that um evaluates post exertional malaise. Um And we've also adopted the modified COVID-19, Yorkshire Rehabilitation screen. Um in regards to COVID, we always um mark down the date they were diagnosed with COVID-19. Um and we make a list of all subsequent infections. Uh We do, we get a symptom list. Uh We ask them where possible to recall their acute symptoms in the 1st 14 days of the illness and then to um list their persistent symptoms. Um the patients who have a shortness of breath, we do uh quantify that with MRC score. Um and we know that patients often have some cognitive dysfunction. So we cue patients from a set list of symptoms and, and in their history of COVID, we do mark down whether or not they were hospitalized, um severity of the treatments, emergency department visits, GP assessment or treatments and the vaccine status. We do record the date and type of all um COVID vaccines because of pre or post infection. Um It used to be really easy when everyone had their um vaccination records on their app on their phone. It has become more challenging now that patients can't quite remember. Um, the dates of their, even if they have been recently boosted, they may be on uh vaccine number five, they can't quite remember um the sequence of vaccines. Um uh We find the social and lifestyle history really important for our patients. Um It gives you a better, much better idea and feel of dysfunction um or disability that they're experiencing. What can they not do now that they could do pre COVID. Um what is work like and specifically, we're very focused, what is the barriers to them returning to work COVID like other conditions? We always know that the longer patient is out of work, the poorer the prognosis for returning to work. So this is something we wanna consider from the outset. Um We also consider living situations and we ask very specifically about sleep. Um Many of our patients complain about uh fatigue, they simply do not sleep. And there's an emerging evidence of disordered sleep in patients who recover from COVID-19. Um Some of our patients do end up testing uh um uh with um polysomnography and end up having um obstructive sleep apnea. Um Other patients do not, but it's definitely worth taking a, a decent sleep history off of your patient. Um targeted physical examination, this is essential. Um And I'm gonna sound very old and old fashioned here. But um between um 2020 early 2022 there was a mo increasing move to online um medicine and it was not uncommon for a period for us to end up being the first physicians to actually put a hand on the patient in those clinics. And we have found clinical signs that not, not necessarily diagnostic COVID-19, but more point to the picture, there might be something else going on. Um For example, um we have these are the signs that we found in our clinic. We we found associated wheeze and cough, um flattened or tearful affects. Um It basic neurology patients would be giving a story and actually have, you know, uh word finding difficulty on dysarthrias, dys stags. Um There's some classic rheumatology findings in patients who are complaining of um joint pain, stiffness or swelling, um tachycardia, um alopecia, goiter, um acanthosis nigricans. This is all found in our clinics. It's worth, it's worth looking at the patients carefully doing a proper clinical examination. Um What next all of our patients, we do get demographics on them and observations. So we get a height and weight lying and standing observations. We're really screening for pots there and new hypertension. Both of which um when we started this clinic, we were surprised how often we found it. I think now the evidence from around the world as well. As our own with support that new pots and new hypertension are something you will find in in post COVID patients. Um ECG again, we're looking for a postviral sinus tachycardia. Uh rarely do we find any signs of pericarditis and we don't really see any a any of that in our clinic as much as the literature would suggest we should to be honest and we do get routine bloods. Um patients completed a, a self assessment score because patients um are suffering from fatigue, cognitive, fatigue, cognitive dysfunction. We actually post these out to the patients um in days before the clinic so they can complete them um at their own pace without being feeling pressured in the clinic. Um And then targeted further investigations. Again, there's no accepted algorithm for this. We've kind of found our way with this. Um the pulmonary function tests. We're really looking for um post viral asthma uh or no CO PD. Uh basically looking for something that's, that's a better explanation for shortness of breath wheeze or cough. Um Cardiac MRI echo again, targeted, often we talk to cardiology con uh colleagues. If he feels truly indicated, holter can be very, very helpful um especially with tachycardia and palpitations and 24 hour ambulatory BP monitors. Um It can help distinguish the white coat hypertension from true hypertension or find early hypertension again, your early loss of nocturnal dipping. For example, we don't know. And I think that's, that's one of the things. We are very open and honest with our patients in clinic. We don't know, we don't know when or when or if we'll have definitive guidelines about uh w what is it safe to ignore or when can we um skip what would be an otherwise indicated in best test? I think what I was I think about is, you know, prior to COVID-19. If a patient came in with new and persistent hoarseness, laryngoscopy, definitely a a standard of care. Um And yet it's so prevalent in our clinic, we do send most of our patients with persistent hoarseness, hoarseness to our ent colleagues for an outpatient laryngoscopy, most of the time it comes back normal. Um and getting those guidelines established about, you know, when we can kind of safely ignore things without, without um extra investigation. I think it will be incredible step forward for patients. One of the things that we found in the clinic that I think is worth um spending time on is that it's not always long COVID and that has to be one of the things that we are most anxious to find in clinic and it sounds um counterintuitive, but it's really important when L call was diagnosis of exclusion, other diagnosis do have to be reasonably excluded. Um And we have found some remarkably uh uncommon diagnosis just because they just ended up through our pathway of care. And I think it's just because of the linear relationship where patients um got, uh, became unwell after a pandemic or during a pandemic, um they became unwell COVID-19 and never got better. But new diagnosis of lupus rheumatoid arthritis, hypothyroidism, new diabetes, um exacerbations or worsenings of underlying conditions. Um A ch uh either new migraine or a or a change in the character of their migraine. Um We've had patients with multiple sclerosis so much asthma, um significant mental health comorbidities as well. New or severe anxiety. We've had several patients with profound agoraphobia. Um New diagnosis of CO PD. Again, a lot of these patients would have some background risk factors. Um prior to COVID, it was, is there a role in the virus in precipitating the onset of this disease at this point in time? I actually think that's a fascinating question to ask. But the question I'm really asking clinic is, is there something else that we might be missing that should be on a different and more standard pathway of care? And then we call COVID in our clinic. Informally, we often refer to it as the UN masker, which means patients present with multiple risk factors, they have other diseases. Um you know, depending on their age and BMI I lifestyle, family history, genetics and, but they had no previous medical history, there were risk factors there once you look at back retrospectively. Uh but what was the connection to COVID precipitating the onset of these problems? Um So this is if we had to pick everything that's referred into our lung COVID clinic. This is what it looks like. We have, um, postviral complications. We would think of that as a, your, uh, myocarditis, your postviral thyroiditis. These are things that if we go back prior to the pandemic, if you were doing a general medicine clinic, patients who had influenza, it came in postviral complications. These are the ones we would know about exacerbations of underlying conditions. Um Again, patients had borderline hypertension, they had prediabetes and now they have actual hypertension. They have, they have type two diabetes and we have unrelated new diagnoses that we end up e ending up getting to. Um, we also have patients who come in who are just vaguely, not quite themselves. There does seem to be a bit of deconditioning um after a severe prolonged illness and recovery. Um And then again, we have a separate ar area, the post COVID condition, which means none of those apply. This is where we focus a lot of our attention and trying to build a pathway for is in this group of patients. And I think this is a takeaway. If there's nothing else today, there's still insufficient evidence to suggest an optimal treatment for post COVID condition. There's not uh we're not gonna be able to come to the end of this talk to him and say this, this is what is gonna really help your patients. We simply don't know. Um So all the treatments we're gonna talk about today, we're gonna be balancing against the evidence has to be balanced against the risk of harm. And that if there's ever been a role in medicine for shared decision making, um It's in post COVID condition, um Your patient needs to be informed that whatever treatments we're offering that we're not sure they're gonna work and having those discussions about discussions about risk and harm is really important. Um So what next uh we do know is that a rehabilitation approach does seem to help some patients. Not all, I think a lot of the important research that we're doing in many centers around the world is going to say, can we get a better idea of which patients would benefit from a, from a rehabilitation approach? And which ones wouldn't? Um multidisciplinary team that we try to involve in our patients, clinical psychology, dietician physiotherapy, um therapy, looking at energy management strategies that can either be physiotherapy. We often have an occupational therapist uh who has experienced with fatigue management strategies. Um And lifestyle medicine approaches um regard regarding things such as um sleep hygiene, um smoking of su of substance sensation, uh positive psychology approaches, these can help support recovery, medical management. Um at the moment includes amitriptyline. Um This does have a role as um for years, has been used in multiple clinics from migraine clinic to Rheumatology Clinic and there's no evidence for a season on COVID. But patients with headache or uh poly or mild polyarthralgias may benefit from a trial of it. Melatonin. Again. Um for short term use may help alongside um evidence-based sleep hygiene techniques and or uh CBT reestablish um restorative sleep patterns. Um SSRI S have been trialed and lung COVID, but the evidence is best used for associated anxiety or depression. Uh Proco lot of beta blockers for patients who have established um postviral sinus tachycardia, uh inhalers, shortness of breath or cough, um anti-inflammatories for joint or muscle pain. So, where we know things work um based on evidence, these are probably worth trialing with patients. Um Our goal is to try and get patients to participate if at all possible in a rehabilitation program. So this is um so this is uh internal data. We haven't published this. Um We did two pilots of six weeks uh rehabilitation. Our findings though um do uh do line up with other published uh rehabilitation programs um that after um participating in a six week physical rehabilitation, which also did include input from clinical psychology and dietetics that patient that um that substantial amount of patients were ready to return to work full time. Um And that there was measurable changes in overall health. What we don't know is the impact of deconditioning. And this is really important because this message often gets twisted um by patients where they get frustrated with us and long COVID is not deconditioning. However, we are very concerned that patients with long COVID are becoming deconditioned. Um And that then becomes an obstacle to recovery. Um I'd like to point out to patients that when we look around the inpatient wards, we have patients on hospital wards for a long time, whether it's an orthopedic ward or oncology ward, or hematology ward or respiratory ward. We know that's not good for them to sit in bed all day or sit in a chair all day. Um Nurses, physios doctors were all getting those patients out and telling them to walk up and down the wards, getting physios working with them. We try and keep them as active as they can within the limits of their illness or injury. Um and that approach is sometimes lost in long COVID patients become go from being very active to completely sedentary. Um and while exercise is not a treatment for long COVID, um attention to avoiding deconditioning is something that, that we should, you know, at least extrapolate from what we do know about good medicine into Long COVID approach. So here's the fundamental role of MDT in recoveries. Um Clinical psychology as a real role. We do find patients who have um depression or a low mood. Some of this may be related to the changes in uh health. They have um new anxiety, insomnia, PTSD occupational therapy for cognition pacing approach, for fatigue management, physiotherapy is excellent for physical uh reconditioning and especially for dysfunctional breathing pattern um which is associated with autonomic dysfunction in pots. Um And then we involve other specialties on o on as needed. So that includes neurology, psychiatry, respiratory cardiology, endocrinology, rheumatology, um and pain services are among the most common referral pathways. The prognosis for recovery is unknown. And I think that is one of the most frustrating things for patients prior to COVID-19. In most diseases, we had a good amount of clinical evidence to tell patients based on statics what we would expect for clinical journey to be like. And we don't have that. Um We do know that patients do recover, we have patients who do recover um they do get better. Um But who recovers and and what that clinical picture looked like, what that profile is like, we don't have the future directions is that while long COVID doesn't seem to phenotypically be a single entity, is it really a single entity or is it not? That's something that really needs a lot more research. It does seem to be at the moment that needs a personalized approach. There's a real importance to um exclude other medical conditions. Um but there has to be balanced against protecting patients from unnecessary and unjustified investigations um or unproven and potentially harmful expensive treatments. So it really sums up that we don't know the pathophysiology, you know what causes long COVID. Uh we don't really have an internationally established diagnostic criteria. We're not sure of the real incident, which makes it challenging. That's based on lack of diagnostic criteria, the risk factors, the optimal treatment and the overall prognosis. Ok. The one thing that I think is always w we always talk with our patients about is the marketed cures. Um Patients are bombarded at the moment with misinformation, some unethical practitioners and predatory, you know, which boils on to basically snake oil. Um and this is, is bound against things that may have a benefit that have been rushed into clinical practice without the evidence. Um One of the questions, we get a lot in our clinic is whether or not they should get hyperbaric oxygen therapy. Um In short, we don't know we are following the hot local trial based in the Karolinska Institute which is doing a double blind randomized controlled trial of hyperbaric oxygen. There's a spectrum out there of what patients are offered. Some patients are, are offered medical grade hyperbaric oxygen therapy, others are given um unregulated hyperbaric oxygen, a treatment in a pod that's associated with a say a medical aesthetics clinic which would be completely different experiences um supplements. Um We don't use supplements in our clinic. There's no evidence um for its use unless there's a specific evidence-based indication or deficiency such as vitamin B12 or vitamin de. Um The role of LDN has been, has been discussed a lot at the moment, there's no evidence for its use. We are keeping our eye on the upcoming randomized controlled trial coming out of um University of British Columbia in Canada. Um that's under this to get underway this year. Um There's been an interesting work on Metformin um in preventing long COVID in patients with acute COVID. But um no trial has ever been done on its use as a treatment for long COVID. Um and then evidence-based symptom management strategies such as plan based prioritize approach. Um CBT for anxiety insomnia um and established and established approaches to chronic um headache management guidelines, for example, and, and patients are also marketed um treatments in medical tourism. Um We usually tell patients that they shouldn't be paying um excessive amounts of money for treatments that aren't established. And I think one of the takeaways here is that good medicine and, and a good therapeutic relationship cannot um be underestimated and many patients feel that they were dismissed and uh regarding their symptoms. So, um I think it's very important to believe patients if patients have a symptom, they have it. Um and being frank and honest that we don't have all the answers, but we will work with patients and we are very frank that our approach is to balance um benefit and harm. We wanna make sure that we're recommending a treatment for a patient that we can expect them to have more benefit and harm. And we are very transparent that we don't have the answers with them and all that, the very basics of taking a thorough history, a physical examination and targeting investigations does pay dividends, um, in, in making progress here, remembering that this is a diagnosis of exclusion is difficult, um, especially when you're working in a clinic where everything is tactically long COVID. It is a frame of mind that we try and keep in mind that we don't wanna miss something, uh, for a patient. So we do take it. So everything, uh, I always tell patients that it's, uh, in their best interest that I always start from a place of skepticism. Um I'll end up back on lung COVID. But I never wanna miss new di di new diabetes. I never wanna miss new asthma. I never wanna miss, um, you know, uh, a new rheumatoid arthritis that might have a better and more traditional pathway of care educating patients on expected recovery time of 12 weeks is important, especially, um, for patients who may get reinfection. I regularly get phone calls from patients who are on their third or fourth infection of COVID-19. There's advice I can give them now, I couldn't give them in 2021 or 2020 which is that I know that reinfection, the setback is usually around 12 weeks on their path recovery, but sometimes, um, reassuring them that that's what we expect to be. It can help. We sometimes get early referrals, um, from, from other centers or from, from primary care, um, or patients are only 4 to 6 weeks out from an infection. We often just give the patient a phone call, reassure them and then set up another phone call around the 12 to 13 week mark. Most patients at that point no longer need our services. Um but we do encourage patients to do their own research. Um but we always, we always ask them to let to talk to us about it. And this is just, we're very conscious that patients unfortunately are vulnerable to exploitation or predatory marketing. And I can, oh I think it would not surprise anyone that yes, this is a really challenging environment. Um So we do, we are doing an observational longitudinal prospective cohort study and we are not doing an interventional clinical trial at present, but we are and we are following um a number of trials um among the most interesting would be the recovery studies. Um These are based um through the National Institute of Health in us. Two are underway right now in Duke University. The vital store study is using Paxlovid to target um viral reservoirs. That one is um is interesting because it assumes that those viral reservoirs are gonna be there and if they are there um that this antiviral will be the best way to treat it. Um But it's an interesting one to watch the neuro trial, I think is much more promising. It's using uh online um rehabilitation techniques um to target patients with cognitive dysfunction. I think this one has a huge amount of, of real potential in the shorter term for patients because it's, it really is a targeted treatment. It's based on on therapies that have been effective in acquired brain injury. And the online medium, it means this is something that might be able to be rolled out to more resource limited uh environments more quickly. So the recovery neuro is one that I'm very interested in following. Again, I already mentioned the hot local one in Carolin Institute, which is hyperbaric oxygen and lung COVID. Um That, that is still ongoing. Uh Again, the LDN is going to be um starting this year in um University of British Columbia in Canada. Um And then I think one of the interesting areas of research is immuno profiling. Um There's a recent page for in, in nature that's starting helps shed some light on some of the pathophysiology. Um um What I'm gonna do is I'm just gonna highlight before I take questions and the last 15 minutes, I'm actually gonna highlight just some of um because it's look, it's my job to, to read all the research. Um And that everyone else is so what I'm gonna do is I'm gonna give you kind of a, a round up or a highlight of um of some of, of some avoid things more promising areas of research and that have been published in the last, in the last few months. And, and that I'm gonna, I'll open it up to questions. And so this is one thing II think is really worth doing it. This nod, a so new onset diabetes after COVID and the overlap with the epidemiology of people who are more likely to suffer with long COVID may be a confounding variable here. But it definitely, if you're seeing a patient complaining of post COVID symptoms, no harm, just checking an HBA1C and, and a fasting glucose. It's, it's, it's an easy check because if your HBA1C, we've had patients HBA1C S come to 9177 um getting their blood glucose under control and you know, they feel loads better. Um This is really interesting. So there's been a lot of work done on rehabilitation for patients in the recovery period and we're getting um we're starting to get a picture of what might work, what might not work. And so this is looking at things, makes a huge difference that where a lot of these um programs are in, in included rely a lot on self management techniques. However, patients are struggling a lot of them because their cognitive dysfunction, their men, mental fatigue. So having supervision um may make, may make a difference the outcome. Um again, rehab works, figuring out exactly the best practice as opposed to just standard physiotherapy exercise based training versus breathing training may make a difference to patients. And again, this is where the research is so important, which patients would benefit from this. Um This one is actually the most terrifying area of research is what is the actual cost of this pandemic and what is the burden of health care long term? Um what, what is gonna be the five year picture? And so some of these papers have started projecting um of what this burden is really going to be. Um Again, vaccination does seem to reduce your risk of lung COVID. This just goes along with the um logical um thought that if you are the more likely you are to be vaccinated, less likely you are to have COVID-19 infection, less likely you are to have COVID-19 A sequela. And, and this is, this was um verifying what many centers have found the new onset hypertension. This is why in person assessing your patients are is so important. Uh The basics work, basic observations um looking for um hypertension is really important. Um And again, this was very interesting about Metformin and I think I've seen a lot of uh centers have jumped, did a kind of a jump from this paper to just giving Metformin prolonged COVID. And I think the role of postviral insulin resistance personally is really, really uh fascinating. We don't have the evidence yet to use it as a treatment. Um and then the fatigue outcomes. So, what I'm gonna do is I'm just gonna go ahead and I'll start going through some of the questions there. Um And see, um let's start at the top here. Um, pots. Ok. So pots is one thing. We find a lot in our clinic and I think if you don't have a tilt table doing a lying and standing, um, observations is a easy bedside test to do. And it's high yield. Uh We use the standard except the definition of a sustained 30 beat per minute jump. We have our patients lie, um Supine for five minutes, we have them standing, we take observations at 13 and five minutes. Um And then we tend to refer our patients to Pot uk.org. Um And we tend to have, I think the website is excellent, has A L has wonderful uh resources for patients. So we tend to uh so I think if you're looking for helpful guidelines at uk.org website is the one we actually recommend for our own patients. Um um how to differentiate between fibromyalgia, lung COVID. Um We get rheumatology to help. So um we do use the um like the WPI and SS score in clinic. If we do feel that's fibromyalgia, we will ask uh rheumatology for an opinion on that. And we do have a number of patients who have received a diagnosis of fibromyalgia. The micro thrombi is really interesting and, but again, it's one of those, it's like everything, you know, there's so many theories about long COVID that there's low serotonin or there's micro clots or there's cortisol or it's gut microbiome or it's autonomic dysfunction, there's a little bit of evidence for all of these and we don't really have a good picture yet. Um But there's no consensus um regarding thrombotic tendency in long COVID again, acute COVID that's well established. And in this talk, I'm sticking straight to sequela ob that would be more than 12 weeks out from acute infection. Um The apheresis approach, I haven't seen good evidence published on that. Um The center that I would have most experience with clinically was a for profit center um that was selling treatments to my patients. But as far as I never had any patients involved in any um um any approved research, do we wear masks in clinic? At the moment, we follow the HSE, which is the Irish health guidelines regarding our pp use in clinic um patients who reported hair loss to reduce hair growth. And so basically, when it comes to a hair loss, yes, we've seen it generally, it seems to be most of our patients, we follow them out. It seems to be like with other patients who have had severe illness or injury, it seems to be a little hair loss, it does seem to be self-limiting. Um We do do the uh due diligence uh for example of making sure that we check um thyroid function tests, for example, you know, exclude anything else that might be going on if it's persistent. Um And it's only been a couple, I think I only two or three out of, out of the last four, almost four years. Um, it's been persistent or problematic. We've actually asked dermatology for an opinion. Uh, the COVID-19 related long term chronic anosmia. No. Um, we have a few patients that were doing observational, uh, follow up that were, that have had persistent anosmia today. I only have two that haven't gotten their smell back. They all tend to get their smell back. It just takes a lot longer and it can take as much as 18 months. Um The one thing we do tend to do is if it's really, really um lasting a long time is to get an ent opinion, to make sure there's nothing sinus wise that might be contributing or a barrier to recovery. I don't know regarding Children. I am an adult doctor only when I work in an adult service, so I couldn't speak about Children. I'm really sorry. Um Our service is limited to age of 16 and up if a pa if a patient had long COVID complains of joint pain and sleep disturbances, what is the management? So sleep disturbances versus take a sleep history, a proper sleep history. Um You know, what is it, is it delayed onset of sleep? Is it frequent night wakening? Is it waking unrefreshed? Um Is it disordered sleep or there's the daytime somnolence? Get a picture of what the, the sleep disturbance means and joint pain. I mean, there's usually linked to one of the things I would think to immediately is is there pain affecting your ability to sleep? In that case, we approach the joint pain, same as we uh we would with any joint pain to patients. You know, is there is this, you know, start looking for evidence uh of problems, inflammatory markers, autoimmune disease, uh joint examination, deep pigmentation is being seen more frequently now, not something we're seeing, but um ii obviously, definitely could be one thing about um working in a center like ours is that and we have very homogenous population. Um And that does limit our research any increase in migraine. Yes, we, we think there is the other interesting thing is there's a change in migraine. So patients who have a history of one type of migraine have noticed a change in their character of their migraine. Um Does anyone else have any questions? So I think as I said, but one of the things that we find really interesting is obviously and the fact that the patient presentations are so different, uh we've been trying to cluster symptoms, we've been trying to establish um trends but it, it it it can be very, very difficult and I think the role of a multidisciplinary team cannot be um be overestimated. Um I don't think there's many Irish doctors in here on the chance that there's any Irish primary care. And oh, how long after symptoms? Um do we call it long COVID? So 12 weeks I think there's a huge misunderstanding out there in the po patient population, um that insulation period equals recovery period. So depending on your local guidelines and you know, of uh you know, you're, you're isolating between five and 10 days after testing positive, that's your infectious period or where your risk to other people, that's not your recovery period. Um up to 12 weeks um is what I tell my patients. Now again, if there's something, you know, much, uh, acute in that period they should be seen. So we would encourage patients, you know, if their asthma is out of control, get it controlled. If they have shortness of breath, they have chest pains, they're gonna need to be seen. But if the symptoms are more vague, such as I'm just tired all the time, got the brain fog. You know, it's not, it's not myself. We usually would tell patients to stick it out around 12 weeks. Um, and the vast majority of them actually will be much, much better when we're coming into week 13. Week 14. Yeah. There, there's a l, there's a lot of questions about the relationship or overlap with me or C FS is, is a whole area of research. I don't work in that area of research but there is definitely a question about whether or not this is related to em e or, or C FS. Um, I think that's, there are centers that are researching on that. Um, uh, let's see. Yeah, they, I don't think there's a proper long COVID clinic here and I'm really concerned that not long COVID is missed. Yeah, that is actually my biggest concern. That is actually one of the things I'm very, very concerned. Um, we tend to triage our patients who refer from primary care if the primary care referral is very short and doesn't have a lot of details. We tend to call the patient within two weeks of referral and check to see whether or not they've physically seen a person physically examined, had recent bloods. Um And we'll try and take steps to, for example, get him in for bloods sooner rather than later rather than putting him on a routine waiting list. And, and no, we don't see any Children. Unfortunately, our this is um Saint Vincent's University Hospital is an adult hospital. Um Our clinic sees patients aged eight or 16 and up. And for research purposes, we consent and enroll from research from ages 18 and up. Let's see. I did I get all the questions here. Um I think I got all the questions. Any other questions? There's just one about menopausal symptoms. I being, oh, I missed that one. Ok. Yeah, that menopause is that is really, really important. So because in our epidemiology evidence and a lot of others is that uh one of the the populations most affected by long COVID are kind of women in their fifth decade. Um And So the overlap of menopause is something we have seen. Um And that can be a bit challenging. It's sometimes helpful depending on the patient, we tend to work with our primary care physician and try to address menopause and see if that helps. Um But yes, there is sometimes an overlap. Um And quite honestly, it usually ends up being the worst case. You can imagine. You actually, they actually have both. Um But uh generally speaking, if we can address the menopause, whether it's lifestyle interventions or whether it's HRT or whether it's, again, I'm not a menopause expert, but again, a lot of our patients, for example, um a low dose venlafaxine for night sweats. Um some of these things might have, have a real impact on um overall quality of life. Um do routinely check for iron deficiency. Yeah, we have a routine panel of bloods. We get a full blood count on patients. We get um a renal panel, uh a liver panel, thyroid function test, vitamin b12, Vitamin D HBA1C. Um And then we will expand from there based on clinical um indication, but definitely we would definitely be looking for anemia. A patient who's shortness of breath tired all the time and headaches. Yeah, you gotta, you gotta make sure you're not missing something, um, something big and yeah, I, I've had more than a few patients with hemoglobin of nine or 10 in clinic. Um, and they need a, a good work up for anemia rather than being labeled as long COVID. So we, we don't routinely do um do iron studies. We do do them by generally speaking, a patient with normal hemoglobin. Um and no symptoms suggest of iron deficiency anemia. And if the, if the, if the full blood count um is, is, is normal, uh we wouldn't pursue um iron function tests. Again, we're also looking at Ireland the the other side. Um And statistically, we would have uh increased risk of um hemochromatosis in Ireland. So also look at the other side for iron studies with long COVID muscle pain, be considered as chronic secondary pain in his analgesia advice how to use it before considering it's not effective. And we try to avoid prescribing long term analgesia. Uh If we think the patient is going to need long term analgesia, we involve pain management services for a whole person approach which involves both physiotherapy, um uh a pain informed movement therapies. Um you know, psychology and we'd be a whole person approach to pain management. Um We do not as uh as a clinic prescribe um long term uh analgesia non anemia. Iron deficiency is an issue there. No, I'm not, not something that we come across in our population um too much. And I think it's always have five more minutes. I'll talk about uh one of my areas of research that the um the uh it's a, it's a paper in progress. We've been working on it for the last two years. Um, and associated with pots is obviously autonomic dysfunction. Um, and it's something that we've been researching here since um, the summer 2020. And what we have found is like patients who fell short of the diagnosis of pots. Um, some patients still dis still have been found to have the dysfunctional breathing pattern. And some patients have a, have a chronic or acute hyperventilation syndrome and it's kind of a dysfunctional breathing pattern that you'd see after patients who've had, for example, um spells of um poorly controlled asthma, for example, um and breath retraining has made a difference to them. Um We've tried different approaches in the clinic to try and quantify it or diagnose it. Um the, the nead score with for hyperventilation syndrome or hypocapnia um which is a, which gives you a score out of 30 which has been used for a good number of years and mm can be helpful. Um And the symptoms with the dysfunctional breathing um comes secondary from the hypocapnia. So with this functional breathing, patients are taking in more breath than they need as they breathe in, they breathe out, the uh carbon dioxide goes down and they get the associated symptoms that vary from patient to patient, from tingling in their, their, their fingers or around their lips to blurred vision, headaches, chest pain or fatigue. Um So that has been really helpful for some patients where we can identify that. Um We do have an ent tidal capnograph um that we use in our clinic and we suspect that we actually can just um pop that on the patient. Get an idea of, of ental um CO2. Uh we stick to um evidence based pots and treatment at the moment. And uh we would usually um be advocates of self management technique where it's very debilitating. Um we would, we would involve um cardiologists who are experienced with pops and the evidence obviously is not great for um you know, for rapid IV fluid infusion. Uh I can't see how that would help a patient whose symptoms are going on month. Most of my patients um are really good about getting adequate fluid. Um Occasionally my patients would be on slow sodium and, and there's uh there's sometimes a role um for, you know, mineral corticoids um in, in, in some patients. But these would be ones, for example, usually with more abdominal symptoms um that are secondary to pooling, for example, uh we'd be slow to prescribe it. Um Most of our patients with pots are actually quite mild and it's in, it's remarkable those on, on more examined and um history. But pots many patients actually have a risk factor such as um previous diagnosis by loss or other joint hypermobility symptoms, family history or previous uh diagnosis of pots uh from a prepa viral infection. So a lot of times there's a risk factor in the background for it, which is really interesting when we go back. Um I think you missed the treatment part. How do you treat clinic, treat these patients? Uh It's a challenge and um so um the the the short is, is, is, is the treatment has to fit the patient. Um And there is no treatment for long COVID per se. Um but trying to do our best to address the symptoms and, and staying on the side of evidence and on staying on the benefit of, of not putting the patient at te for at potential risk or harm. Um are some of the guidelines I think are really important to keep in mind. Um But again, as I said, in the beginning of this, this is how our clinic does it. Um we definitely don't, not sure that we are the ones that have it, right. Um And I think this is um part of me is, is a morbidly fascinated and emerging disease where it's constantly more evidence every day and supposedly figured out that uh that the doctor to me is, it's quite, it's quite frustrated because I have clinic after clinic of people and I don't have answers to them and they deserve answers. Um And it's a challenge I think, and you know, the patients that are, that are being exploited or misled uh by people promising cures. II think it's, it's, it's, I think it's um II think it's, it's quite a challenge to, to deal with as a medical community. Any other questions at all? Thank you so much, Doctor mccann. That was a really, really informed session and lots and lots of questions as well. Uh We really appreciate you running the session. Thank you everyone to uh who joined. Uh you'll be set a feedback form shortly. Please fill in the form and you will get your certificate added to your meal account. And please do, let us know what other topics you want to learn about in the feedback form. And we'll try and arrange teaching sessions on those topics. We also have more free events coming up. Uh The next one is on the 15th of February and it's on mental health risk assessment and I'll pop a link in the chat now. All right. Thanks so much.