Predicting which COVID patients will have a post-recovery problem – or what the problem will look like – is tricky. This guide, based on the data, helps doctors follow up in the optimal time frame and by asking the right questions. Included are common residual symptoms, the importance of assessing psychosocial needs, and red flags for patients recovering at home.
e hope to share with you what we've learned from our center and also give you sort of an update from the literature about how to care for these patients and give you some advice. And please do ask your questions. We're all learning about this together. I can't guarantee they'll have all the answers, but I'll share what we do know and we'll make sure toe start on time and end early for for optimal happiness and leave plenty of time for questions. Okay, so let's dive into it. I don't have any conflicts of interest to disclose, and we're really gonna chat about very briefly. Who are the folks getting Cove in? 19. What are the risk factors? Talk about the bulk of the time will be about the most common residual or persistent symptoms and defined strategies about how to manage these symptoms. So kind of the who, what and why and how of patients with persistent symptoms after Kobe 19 infection. So, first of all, who are the patients? And I just wanted Thio sort of acknowledge and reflect that Ah, lot of our patients don't really get tohave Um ah, proper remembrance. Proper goodbye and I know that many of you have cared for Cova 19 patients, and I think that all of our patients who pass away, we remember them in our hearts. And I think one of the biggest tragedies of this disease is that we're stripping away normal grief, normal processing for our patients, families. So it is. It is really sad. It's really heartbreaking. And because of that, I really want to anchor our talk in a case remembering one of my patients who had a good outcome overall. So we'll talk about Mrs L, who is a real life patient who I took care of in the I. C. U and who then saw me in clinic afterwards. So she is an 83 year old woman she Spanish speaking, and she was recently discharged from UCSF following hospitalization for Cova, 19 pneumonia. Her co morbidity is included diabetes, hypertension and hearing loss. And she lives with her daughter, who's her designated power of attorney, and she first went from the hospital to a sub acute rehab and ultimately a skilled nursing facility and then ultimately came home several weeks later, and during the hospitalization, she fortunately did not require intubation but was on high flow. Nasal cannula ultimately discharged home on room air but remained breathless, anxious and very, very socially isolated. I'm sure the story rings very familiar to many of you in the audience. And just to summarize are sobering statistics. You know, the U. S. The number of cases in the US makes over 10% of the world. Globally, we've had about a million deaths in the U. S. We are close to 9.4 million cases and globally. And in the US, we've had over 230,000 deaths. And what makes me extra sad is that every time I give a version of this talk and updating the number is seeing how quickly the numbers they're just rapidly rising. Unfortunately, in the Bay Area, we really have done a great job of flattening the curve somewhat. And, you know, I think all of our patients in the Bay Area for taking this seriously. So in the Bay Area, we've remarkably had. As of today, on Lee 7 1097 deaths. You see the California statistics here about 18,000 deaths and then, of course, the national statistics that I mentioned over 230,000 deaths. And there have been many articles talking about Why is the Bay Area doing so well and many hypotheses around that? What about who gets hospitalized and who remains outpatient? We're gonna focus more on this talk about kind of outpatient pearls. But nationally, about one out of five patients are still requiring hospitalization. And within that one out of five, you see there's a very high severity index. About 20% need. I see level of care. And you see here in this depiction, this is from an earlier article in JAMA that came out that about half of the cases are mild, but really about a quarter of cases are severe, with 5% really requiring critical care, and the asymptomatic folks are really the minority. The other thing to know about is that this pandemic is really highlighting further disparities in our care. It is disproportionately impacting our elderly population are geriatric population, and if you look at that sub population of older folks greater than 75 about 50% will be okay at home. 50% will require admission to the hospital and a full quarter will require ice. You care? This is from the 500 statistics. I think the other factor that's been well acknowledged that we still have a lot of work to Dio is talking about racial and ethnic disparities in Cova 19. And there are so many underlying reasons for these disparities. And this amazing graphic by Dr Nita Talker whose that sucker book, San Francisco General Hospital. Andi, who runs our post Covic clinic at the general that has a similar model to us. We help them set it up. She wrote this amazing article with this great graphic that shows about all the different kind of trying to disentangle what's behind these racial disparities in covet and really defining it as theirs pre disease conditions, conditions that increase the risk of poor outcomes and post disease conditions. So really, all the way from exposure. What a racial disparities and say the jobs that people are working all the way to long term hair care and access to long term care and things like that, and it really is all tied in with things like our sociopolitical context is inextricably linked to those things. So this is a great paper I encourage you all to check it out with this graphic. What about our patient level risk factors? I think one of the things that's been puzzling the pandemic is seeing who gets really sick and who doesn't. We know that there's some classic risk factors for which leading to poor outcomes chronic heart disease, COPD or interstitial lung disease, diabetes, a huge risk increase in folks with obesity, male sex as being more predominant and CKD. One of the interesting things that we've noted Aziz Pulmonary is that they're higher risk factors that appears in C o. P. D. As compared toa asthma. And why might that be? One theory is that it has to do with ACE to expression as we know that Ace two receptor is really important in the pathogenesis of Cove in 19. And so some people are saying that perhaps that could account for the disparity between COPD and asthma. We have seen that asthma certainly is a risk factor, but not as high as c o p d. When it comes to risk for intubation and risk for mortality. So that was just a brief review of statistics that you're already familiar with Let's talk about the persistence. Um, so this is something that we're really rapidly evolving. Our understanding of our early literature are early data coming out really was in China and Italy, so we'll go over those studies first. This was a good study that came out by Jew and colleagues of land set in early of this year, really looking at the proportion of symptoms in survivors versus non survivors. And this is a great graphic that really shows that early on you really see the symptoms in the first two weeks being fever and cough. Predominantly the Disney A, as you see, really kicks in around day seven or so and then I see you. Admission is very classically seen around day 10 to day 12. And that's why when we're in the hospital, we report, you know, on rounds right away what day of symptom onset they're at and what day post symptom onset there. Because we're noticing that people are following this very reliable, predictable trajectory trajectory. Interestingly, and that trajectory seems to match up for but survivors and non survivors. So it's not just that trajectory is only seen in people who end up dying so really interesting data that really informed how we thought about the trajectory in this pandemic. Early on. Another pivotal trial to be aware of is this trial coming out of car fee and colleagues in Italy. This is one of the first and biggest trials talking about persistent symptoms and outpatients with proven 19. And so this talked about At about, UM, it was a single center trial of about 180 patients, and they looked at what symptoms were seen acutely and what symptoms were seen in follow up at the one month post discharge visit. And they found that these symptoms of fatigue Disney a joint pain chest pain were often seen acutely and often persisted chronically, even at the time of follow up. About a month later. And I will say that several smaller, single center studies across the U. S. And across the world have replicated these findings of persistent symptoms. Subjective symptoms, particularly this triad of fatigue, Disney A and chest pain. Some people with persistent cough, some with joint pain and, um, when that matches our clinical experience at our Post Cove in clinic as well. You see here that some of the more unusual things. Like a Nadzmie, a sick of symptoms. Discuss Zia diarrhea. Some of that is seen a little bit more in the acute phase, and some people have those symptoms persisting, but not as many. And I like this figure because you get a quick snapshot of what symptoms Eircom and Post covert and what symptoms are a little bit less common again. One of the main critiques of this study was that it was a single center trial, certainly in Italy, but also that there was no control group. Um, that is this was not matched with, say, people who were hospitalized for substance from another cause from U T I or matched with another group of RDS survivors. And so a lot of what we're finding in our patient population is we're extrapolating. We're extrapolating from the really well known, well trodden field of research in post I see you outcomes or post step process or post aired s outcomes, particularly those that happened in the 4000 teens. And then extrapolating some of those lessons learned to now the cove in 19 pandemic and there are going to be similarities and differences. We'll talk about those we've seen, and we've experienced as treating clinicians that this is a multi organ system disease, especially acutely. So we've seen everything from, you know, cardiac arrhythmias. My party, my card itis myocardial injury, sudden cardiac death, even to you know, we've seen reports of p e hyper quagga ability, a k a i g. I issues renal failure. Some people have almost like an H l h human fag acidic type syndrome with septic shock and D. I. C. There have been impaired outcomes with fertility issues of pregnancy. There's been CNS infection, neurological outcomes, such a strokes and a lot of mental health impairments to anxiety, fear, PTSD. So these air all well described in the acute set. And now there's this increasing body of literature talking about longer term outcomes as well. So head to toe, just like that last five, we're seeing people with long term cognitive impairment long term issues with high poxy mia colliding long term taste and smell issues. With that disk you zia and in as Mia Paris, the Jha is profound Europa, thes cardiomyopathy and again, our mental health issues and one of the things that's really challenging is trying to see again. What if this is similar to our post Subsys post aired? Yes, population. And what if it is different? I think one of the things that are earmarked that is different, that you all are seeing is that we're seeing sure we've seen patients who been hospitalized with Subsys from another cause before, and they may have some persistent symptoms in these organ systems. However, one of the interesting things that we're seeing with co vid is that we're also seeing people who were not hospitalized were not in the I C. U and who are still having persistent, severe disabling symptoms. Sometimes, actually, I even see people who were, you know, paralyzed prone septic shock on death's door. Didn't think they would make it out of the hospital. And I see them a month later, and they're remarkably okay. And it's the people who I see who were not hospitalized, who maybe had one e d visit or urgent care visit. And they're the ones with these persistent severe chest pain. Disney A fatigue weeks to months afterwards, and so there's a lot of research going on right now about why that is. Why are people clearly having different sort of perhaps immunological responses or inflammatory responses to the same exposure of Cove in 19? So you've heard in the popular press about this long holler type phenotype of post Corbett syndrome? We've seen that some people have waxing and waning symptoms where they will report that they have kind of good days and bad days. Um, some people report this profound kind of post exertion all fatigue, where aerobic exercise or even gentle exercise makes things worse. Ah, lot of people report this brain fog or cognitive impairment. A lot of people report Disney A and Palpitations. So, um, it is really hard to disentangle all of these different symptoms and see, you know what is really decoded. What is not related to Kobe. So let's talk about some proposed mechanism. So there was this big study that came out talking about in Chicago, came out coming out of Chicago again, a single center trial, and I think the literature is always really hard to interpret because we're seeing a lot of single center trials without, like I mentioned historical controls to or even current control. So this trial got a lot of publicity, saying that one in five people would come in 19, has a neurological issues, and there's a bunch of different mechanisms ranging from the immunological to the non immunological people are talking about. Could there be adaptive auto immunity issues? Micro glial activation, some site, a kind, maladaptive profiles? Or are the neuro manifestations just related to simple things like unrecognized hypotension at home or even unrecognized hypoxia at home? Are there as we've seen on some autopsy studies, both micro and macro vascular thrombosis? There they are. They're tiny little blood clots that we're seeing. Is this just encephalopathies from substance that we're seeing? And in addition to the kind of cerebral vascular neural vascular complications, we also see the neuropsychiatric, um, symptoms and complications hand in hand. And you see here in this graphic that it really occurs across the spectrum of age distribution, where we see that younger people perhaps are less likely to have the cerebral vascular outcomes but still can have high rates of neuropsychiatric adverse outcomes. What about persistent pulmonary issues? There are a lot of trials coming out similar to this one from Huang and colleagues looking at different chest C T patterns after infection, ranging from here in a sort of a hint of ground glass throughout to be, which is largely unremarkable, with maybe some tiny little bits of ground glass and modules to see with kind of persistent fibrosis and D with more of an end stage scarring fibrosis, I think again, like I mentioned before, the question is compared to what? When we do studies on Post a RDS survivors, we're seeing similar CT patterns, and those patterns can persist months, even in some cases years after injury. And so more data are really needed toe. Look at longitudinal Lee and prospective Lee without sampling bias or observer ship bias. Thinking about what are the persistent chest CT abnormalities that maintain? I will say anecdotally, in our clinic, we have seen a lot of people actually have relatively unremarkable chest C. T s, and often you'll see that the physiologic testing the pft s the chest C. T s, that echoes are often actually discord it with symptom burden. So we're seeing a lot of people with persistent Disney a chest pain, etcetera with, you know, preserved or normal, even physiological testing, and that's really hard to disentangle as well. Pardon me. So how do we treat these folks? So at our clinic, the optimal clinic, we really use a picks framework of post intensive care syndrome framework. And for those of you new to the concept of picks, this came out really in the 4000 teens talking about how people who have survived intensive care units, intensive care unit stays or even hospitalizations often have profound consequences with respect to their mental health, their caregivers, mental health, their physical health and their cognitive health. And so we thought that this approach, the pics framework, is actually a really nice holistic approach to both caregivers and patients. That translates really well to cove it as well as our aging population. So what we do is we do kind of a very detailed, structured assessment. Some of you may have seen my notes before on our shared patients. Structured assessments on folks, mental help, cognitive dysfunction, physical impairments and pulmonary impact. This is not just limited to ice you patients. There's also similarly ah post hospital syndrome. And again it effects our elderly population more and so we kind of combine ah framework of geriatrics called the Four EMS Framework, which talks about mobility. What matters which is really your values or goals of care, medications and mente shin and thinking about assessing those four concepts in our elderly population is really critical for anyone who was hospitalized, not just in the I C. U. So a little word about our clinic. So were the optimal clinic. We focus on really post covert or post. I see you patients. It's multi disciplinary. It's a partnership between pulmonary geriatric psychiatry, psychology, integrative medicine, and we have kind of structured faculty partnerships with cardiology and neurology. We're very plugged into the broad and ever expanding research infrastructure of UCSF's well, so we can refer patients to the appropriate trials, and we first see patients about one month after discharge. That's a virtual visit, mostly because of infection control kind of issues and measures where our staff had concerns about infection control, because a lot of these patients have persistent positivity. So our first visit of virtual and our follow up visits are in person or virtual a, depending on patient preference. And so if you have a patient who was hospitalized, um, at any hospital in the Bay Area or beyond. Please do refer them so that they can take advantage of this service. I will say that in earlier, early in pandemic times we said, Please refer anybody who was admitted or who was kind of a long hauler type phenotype with persistent symptoms. Unfortunately, as you know, we thought this would. We all thought this would be a temporary thing, right? We thought Cove it would be here and gone. And as the pandemic has, um, persisted, especially in the absence of national leadership. Really, Because of that, our psychiatry, our mental health colleagues are really, really stretched. So I personally, you know, we would all love to see all patients with co vid. But because of our psychiatry, psychology colleagues who really have a lot more limited availability at this point where kind of limited to the our post hospitalization population. However, if you have patients who were not hospitalized who have persistent pulmonary issues like cough or shortness of breath, please do refer them to our general pulmonary clinic, and we're definitely happy to see patients in that situation. We've seen a lot of the one medical patients who are in that situation to and again. If there's any confusion or doubt, please don't hesitate to reach out and ask me. Our clinic has gotten a fair amount of attention, along with other clinics, about just this structured approach and the persistent symptoms. And how are we looking at the systematically and so diving into it a little bit in detail? So we have trained mental health research assistance or our psychologist, or are psychiatrists, both of who specialized in trauma and being impatient, being hospitalized in patient. And we kind of administered the structured instruments for anxiety, depression, PTSD. There's actually a short interview that's done about their hospitalization experience. We asked them about things like breathlessness, cough, sputum, production, a six minute walk. We asked them about their physical functioning. How, how much of the ability to transfer things like that? We do some screening for social determines of health, asking them about returned a work. Are they now unemployed? Are they, you know, uninsured, Unemployed? On disability, we have pharmacists embedded in our clinic who do a detailed med wreck. I'm sure you have all seen the post discharge Med wreck can be a mess, so we see patients who are on, say, Katia P. And Sarah quell forever, and they're totally fine. And so we do a lot of deep prescribing and mad wreck. We do a lot of counseling about safe activity. So I told you earlier that some patients have this post exertion ALS fatigue. But I think the majority of our of our patients, the standard kind of post hospitalization advice, applies for rehab of, you know, gradually, you know, get some fresh air, get aerobic exercise. Gradually, you may want to increase your activity. Take it slow, listen to your body and we see that for a subset of patients, there clearly is the subset where any amount of exertion really is depleting for them. That standard council of Push yourself a little bit day by day does not apply to the subset of population subset of the population of patients. And so, for those folks, we often will counsel them to limit their activity. I tell people to kind of find that threshold if walking for 10 minutes depletes you for the rest of the day, walk for seven minutes on Lee and stick with that seven minutes below that threshold, where it wipes you out and stick with that and for a while and Onley gradually increased. It's really tricky because often there's a vicious cycle of de conditioning dis mia, exercise intolerance. And so it can be really hard to disentangle all of those. We also do a lot of reassurance of people like I mentioned. Some people have a lot of normal physiological testing, and so that could be really reassuring, especially when there's a lot of scary media reports. It could be really assuring really reassuring to hear you don't have lung fibrosis or lung damage. You know you're testing is physiologically normal can be reassuring, and we do a lot of linkage to resource is and including mental health. Integrative medicine for the mind body connection pulmonary rehab, including virtual pulmonary rehab. So we kind of have this hub and spoke model where we have these collaborators or faculty champions and all of these clinics including, for example, with patients with a lot of persistent. You know, we've had some patients with almost concussion type symptoms, severe headaches afterwards. Neuropathy. We have a partner in the neuro recovery clinic. We haven't integrative medicine partner who specializes in kind of the mind body connection, especially for people who have a lot of mental health overlay to the symptoms as well. We're starting virtual support groups later this month, which will be great. Great question by anonymous about swallowing into Stasia. Really good question. We have I didn't put on the side. We have kind of a loose partnership with R O H and S E N T colleagues as well, thinking about particularly for folks with who have been intubated for a long time. So patients who have been intubated as we're seeing these folks for two weeks, three weeks, four weeks or people who needed a tracheostomy. We're seeing a lot of, um, persistent sputum production post nasal drip strider, hoarseness, swallowing dysfunction in people with prolonged intimations that was a little bit more severe early in the pandemic. Honestly, as compared to now as we're now trying for delaying intubation in the inpatient, setting shorter intimations, perhaps pushing for earlier tracheostomy things like that. So as our knowledge on the inpatient setting is evolving, it's interesting to see the kind of delays or lags and outpatient complications. So but yes, absolutely. Some patients, particularly with prolonged into patients have had issues with hoarseness, Strider swallowing Odin of Asia dysplasia for healthy outpatients. I haven't seen as much. This is just a This is a busy slide just to go to say that we're trying to analyze and this is now out of date. Already we've seen over 100 patients we're trying to analyze. Kind of. What are the differences between people who show up to clinic and people who don't drop to clinic? And so far we're seeing that actually, our patients are pretty representative of those who are admitted similar percentages of male and female, white and non white. We are actually seeing, interestingly, a little bit of an older population who comes to clinic as compared to everyone who is discharged. And that may just be because maybe the young, healthy person who is briefly admitted doesn't really feel the need to follow up, which is totally fine on DSO. More data on that to come. And yeah, I should update this that now we're up to over 100 patients and, you know, thinking about post discharge care. I want to dive into a little bit more. This is ah, kind of an example of our post UCSF dashboard, which really looks at things like, um, current hospitalizations, Kobe test positivity, things like that. And so I like thio kind of Compare this dashboard toe where we're at and see if discharged location impact Who follows up. Say, are people who are discharged to sniff or l tapped less likely to follow up. What about age? I should do a bit of that data. What about race? Ethnicity? Are there barriers and insurance? Things like that? Um, I think the other thing that we're seeing a lot of is delirium horrible, horrible delirium. And so Dr West Eli is a leading researcher in Post I see you syndrome and particularly thinking about the cognitive impacts and psychiatric impacts post I see you and he eloquently put it saying that Cove, it is a delirium factory and all the things that make I see patients still areas that is now on steroids pun intended, um, in the i c. U setting in cove it Now, patients don't really get to see their friends or family at all, except to resume. There's visitor restrictions. Everyone who comes into the room is in full PPE to convey, barely even see our eyes. You don't know how people are. The noise of the high flow nasal cannula blaring makes it hard. There's language barriers that are accentuated. So this is just making delirium so much worse. This is a New York Times article that came out by one of our patients who is discharged talking about the horrifying delirium that he experienced it. R i C U during Cove in 19. We've also partner with local sniff, such as the SF campus for Jewish Living, and had some of our geriatricians actually from our ace unit that you care for. Elders actually go and kind of travel to staff that Post Corbett rehab unit and what they're seeing is the sequel of the severe delirium they're seeing that are, elderly patients have severe isolation, limited ability to exercise. There's all these restrictions that they can't really leave their room because of infection control and nursing homes. I will give you for those of you who are a little bit more geriatric, Lee inclined. Um, there is this cove in 19 rapid response network for nursing homes by the H. I Institute for Healthcare Improvement, and they give a lot of great practical pearls is part of a daily huddle. Mhm. Other things that we do to help with recovery is that we have kind of standardized instructions for focus. For folks. Really giving them resource is particularly mental health. Resource is talking about coping, talking about pure support. There's a number of online peer support formats, you know. Nationally, there's there's groups like Survivor core body Politics. There's online peer support groups like such as one that we're going to be starting soon. Facebook, Flak, Twitter have long coveted support groups throughout. So I encourage that for our patients because in this time of social distancing and isolation, having this diagnosis of Cove, it can actually be very stigmatizing for folks in their community. And so reaching out to peer support has been very helpful to our patients. Um, and for those who need a little bit more than just peer support or mental health, resource is, you know, we are making referrals. Formally, the psychiatry, including for patients, were pregnant, too. Obese psychiatry, things like that for physical health. We're working on with one of our I see physical therapist working on developing kind of a home rehab guide for folks to kind of again get that counseling just right of how to push yourself without overly depleting yourself. And again, some of your patients are eligible for pulmonary rehab. The tricky thing about that is that Medicare will have pretty strict criteria for reimbursement of pulmonary rehab. So we, I will say, are still kind of learning the hard way and the easy way. What is Medicare covering for a pulmonary rehab diagnosis and what is not? I will say if you have somebody who has a lung condition already, and if they have covered, they could definitely qualified. So if they already have, say, C o P d interstitial lung disease, things like that and they get covet that will definitely be covered by pulmonary rehab. I think it's the people who are say, you know, the long holler type folks who don't have a primary pulmonary disease. It's harder to get that covered by Medicare or by insurance companies. We also talk in our instructions about you know, how toe stay connected the importance of avoiding loneliness and isolation, things like that. Safe isolation. What about national guidelines? So the U. S. Doesn't really have any clear guidelines yet, But the BMJ has this great article. I encourage you all to read it. It's called Govan 19 management for the primary care provider, and it talks a lot about what we know and what we don't know. There's a lot of uncertainty. So they talk about you know what? Lab tests might be good to order for people both acutely and chronically. They talk about how you should pay attention to focus co morbidity, ease social, financial and cultural support. Ideally, get a pulse, ox, heart rate and rhythm exam things like that. And they talk a lot about counseling and contingency planning. And so this is a lot of what we do in our clinic, too. Is telling people, If you have worse than high poxy Mia unexplained chest pain way worse, breathlessness, stroke like symptoms get back into care right away because we know, as I showed you in that earlier side that there is this tale around week to where people are at high risk for deterioration for, you know, worsening respiratory failure for PES or D. V. T. S for strokes. So in the outpatient setting, doing a lot of this anticipatory counseling and guidance of telling people when to call toe escalate. Their concern is really important, and you're lucky in one medical that you have a lot of sort of infrastructure and resource is to help guide patients how to navigate the system through that, um, we do a lot of talking about medical management about, you know, treating fevers. Optimizing co morbidity is a lot of listening and empathy. Thinking about when is the right time to use antibiotics for concern for secondary infections? Um, basics right of recovery, diet, sleep, quitting smoking and alcohol, limiting too much caffeine exercise as tolerated and thinking about linking people to mental health care in the community. How long should we follow these patients? It's a little bit of a black box. This is a great article that came out by Ragu and colleagues who's an interstitial lung disease expert and lancet who put forth this extremely ambitious proposal, saying we should follow people at one month, two months, three months, four months, six months, nine months. I will tell you practically in our clinic, you know, I showed you we have a big drop off from people were discharged to just come into clinic at the one month visit and then from the one month the three months following up. Similar. There's a big drop off and again, people self select out there feeling fine. They're not gonna follow up, which is fine. And then some people who are really sick or not gonna follow up. So it's really hard to know what is the optimal way to monitor people. I will tell you that there are some differences in opinion to at UCSF. Our faculty group is a little bit more minimalistic when it comes to invasive testing for chest C T. Things like that. What we tell people is based on the literature around surviving aired yes, and things like that that at the one month visit, based on all the literature we expect, people toe have a lot of those persistent symptoms like this via trust paint things like that so often at the one month visit will do counseling to say this is normal. This is expected. Let's see you back here soon and see if the symptoms persist, and then at the three month visit, If people are having persistent symptoms, then we do more testing, like particularly pulmonary function tests in the right patient population, you know, Do they need echocardiogram if there's concern for cardiac issues, things like that. So I would encourage you toe at the one month visit. Um, kind of resist the temptation towards all the tests that the one month visit because a lot of those symptoms will actually go away by the three month visit. And if the three month visit, if they're still having persistent symptoms, that's a good time toe start sending people for testing. What about, you know, what are the data around recommending Testing. This is the guidelines from this task force that came out by the 80 s American throughout society and the e. R. J European respiratory journal. And again they found more questions than answers. Sadly, they found that we don't know what is the best time to establish this testing schedule. What is the best time? How far out to look at pft six minute walk, CTS or echoes? We don't even know if routine screening for cognitive impairment, depression, anxiety or PTSD like we're doing in our clinic. We don't know if that's actually cost effective. Does that change outcome. We don't know about how long the continue sort of DVT prophylaxis. How long are people having infectivity afterward? How long you know what are the infection control issues about persistent anti joy and positivity? How quickly should be test people's household context? Is there even data for a robust, required or mandatory referral to a multi disciplinary clinic like ours? What is the role of pulmonary rehab and routine mental health counseling? So there's a lot more questions than answers.
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