Usefulness of modified distress thermometer in  screening adolescents with COVID-19 for psychological distress

Usefulness of modified distress thermometer in screening adolescents with COVID-19 for psychological distress | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Usefulness of modified distress thermometer in screening adolescents with COVID-19 for psychological distress Yasser Gamal, Sherif Mohamed, Yasser Abdel Raheem, Mohamed Abo Elela, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1481317/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Children and adolescents are more vulnerable than other age groups to the psychosocial effects of the COVID-19 pandemic. The modified DT (m-DT) was recently utilized for measuring the prevalence of psychological distress among adult COVID-19 patients. In the current study, we aimed to test the utilization of this m-DT in screening adolescent patients with COVID-19 for psychosocial distress. Methods: Egyptian adolescent subjects with suspected or confirmed cases of COVID-19 at a University Hospital were enrolled. Binary logistic regression tests were carried out to explore the association between the m-DT cut-off scores of 4 and the clinical variables. Results: Forty-eight percent (87/182) of the study subjects experienced significant (m-DT score ≥ 4) COVID-19 related distress. There were significant differences between those with and without significant distress with regards to length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders. Length of quarantine time, presence of chronic respiratory disease, worry, and fever were independent factors associated with significant distress in COVID-19 adolescent patients. Conclusions: Almost half of the enrolled Egyptian adolescents with COVID-19 experienced significant psychological distress. The m-DT was useful, as the current study had identified length of quarantine time, presence of chronic respiratory disease, worry, and fever as independent factors associated with significant distress in COVID-19 adolescents. Further studies are needed. COVID-19 distress adolescents utility screening psychology social thermometer Figures Figure 1 Introduction The coronavirus disease 2019 (COVID-19) affected virtually all countries and had posed a significant threat to the health of the population and creating a significant challenge for health systems. Unknown diseases with an uncertain prognosis and associated with a scarcity of medical and protective equipment have led to unwanted mental health consequences. The potential fallout of an economic downturn, as well as the consequences of quarantine and associated social and physical distancing measures, are additional risk factors for mental health problems [ 1 – 3 ]. Some groups may be more vulnerable than others to the psychosocial effects of pandemics. Because they are in a critical period of development, children and adolescents deserve special care to preserve and promote their mental health [ 4 ]. The presence of significant distress in certain groups of patients e.g. cancer patients, had motivated many international regulatory organizations and professional societies [( e.g ., International Psycho-Oncology Society (IPOS), National Institute for Health and Care Excellence (NICE) and National Comprehensive Cancer Network (NCCN)] to recommend the routine screening and management of distress as an integral aspect of whole-person cancer care in the same way that health-care teams monitor and respond to other vital signs [ 5 , 6 ]. Therefore, recently we have adopted a modified version of the NCCN distress thermometer (m-DT) and its PL for adults with of COVID-19 [ 7 ]. With the modified distress thermometer (m-DT), 60% of adult Egyptian COVID-19 patients experienced significant distress [ 7 ]. Being a vulnerable group for COVID-19-related stress, in the current study, we aimed to test the utilization of this m-DT in screening adolescent patients with COVID-19. Materials & Methods Study Population In this prospective study, Egyptian adolescent (10–18 years old) subjects who fulfilled the criteria of suspected or confirmed case of COVID-19 [ 8 ] and managed as outpatients (at the respiratory triage) or admitted at the Pediatric Department of a University Hospital at an isolation room with an adequate command of speaking and reading the Arabic language were enrolled. Subjects who had a history of or undergoing current treatment for psychiatric illness were excluded. Standard sociodemographic data were collected including age, gender, and education level. Medical records were reviewed for past medical history, vaccination history, history of recent travel, and history of quarantine. The study objectives and procedure were fully explained to eligible subjects and their sponsers. The essential infection control precautions for handling patients with COVID-19 were undertaken and the person who carried out the questionnaire wore full personal protective equipment (PPE) [ 8 ]. All methods of the study were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Institutional Review Board of the Faculty of Medicine of the University. A written consent was obtained from the study participants if they were ≥ 16 years old and from the participant’s parent and/or legal guardian for carrying out the study procedures. Modified distress thermometer (m-DT) As shown in our recent publication [ 7 ], we have utilized the m-DT (Fig. 1 ) to screen the enrolled adolescent subjects for psychological distress, with the use of a cutoff score of ≥ 4 for significant distress [ 7 , 9 ]. Screening was carried out for those patients at their first out-patient/Emegency Department visit or in-patient admission. Patients were asked to rate their distress in the past 3 days on an 11-point visual analog scale ranging from 0 (no distress) to 10 (extreme distress) (Fig. 1 ). Patients were then asked to fill in PL that accompanies the visual image of the m-DT to check, whether or not (yes/no) they have any of the problems listed during the previous 3 days. For illiterate patients, a research assistant helped them to rate their distress and fill in the PL. Correlation between the PL and m-DT was carried out to identify the nature of distress and related factors. Statistical analysis The following parameters were explored using descriptive statistical analysis; mean score, the standard deviation, the median score, and the frequency distribution of the m-DT. All p-values were two-tailed. A p < 0.05 was considered statistically significant. Binary logistic regression test was carried out to explore the association between the m-DT cutoff scores of 4 [ 7 , 9 ] and the demographic and clinical variables, while binary and multivariable logistic regression tests were used to analyze the association between the m-DT cut-off scores and individual items in the PL. The Statistical Package for Social Science; SPSS, version 24 (SPSS Inc., Chicago, IL, USA) has been used for data analysis. Results Sociodemographic and clinical characteristics A total of 182 patients were prospectively enrolled. The median age was 12.3 (range 10–18) years. Females constituted 45% of the participants. Forty-eight percent (87/182) of the study subjects experienced significant (m-DT score ≥ 4) COVID-19 related distress. Twenty-four percent (44/182) of patients had chronic underlying medical diseases, among which 30/44 (68%) had chronic respiratory diseases. The later included 24/30 (80%) patients with asthma, 4/30 (13.3%) with bronchiectasis, and 2/30 (6.7%) with interstitial lung disease (ILD), respectively. There were significant differences between those with and without significant distress with regards to length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders (p < 0.001 for each), respectively. Table 1 shows these data. Table 1 Sociodemographic characteristics of the study subjects (n = 182) and their association with m-DT score ≥ 4 * Characteristic Overall N = 182 (%) m-DT cut off ≥ 4 N = 87 (48%) m-DT cut off < 4 N = 95 (52%) P -value Age in years Median (range) 12.3 (10.0–18.0) Mean ± SD 13.1 ± 2.3 14.2 ± 1.8 13.8 ± 2.1 0.118 Age groups (years) 10 - < 14 129 (71) 56 (64) 73 (77) ≥ 14–18 53 (29) 31(36) 22 (23) 0.074 Gender Female 81(45) 38 (44) 43 (45) Male 101 (55) 49 (56) 52 (55) 0.882 Educational level Non-educated 16 (9) 11(13) 5 (5) Educated 166 (91) 76 (87) 90 (95) 0.115 Length of quarantine 3 months 103 (57) 70 (80) 33 (35) < 0.001 Underlying chronic disease Present 44 (24) 32 (37) 12 (13) Absent 138 (76) 55 (63) 83 (87) < 0.001 Type of chronic disease Respiratory 30/44 (68) 27/30 (90) 3/30 (10) Non-respiratory 14/44 (32) 4/14 (28) 10/14 (72) < 0.001 * m-DT; modified distress thermometer. For age, data are expressed in mean ± standard deviation and t-test with 95% confidence interval was carried out to compare age between the 2 groups of m-DT cut-off < 4 and ≥ 4. For other sociodemographic characteristics, data are expressed in numbers and percent and Chi-square tests was used to compare the significance of differences between the 2 groups of m-DT cut-off < 4 and ≥ 4. Data from m-DT and PL analysis The most frequent problems reported on the practical domain of the PL are shown in Table 2, in descending order, fatigue (64.3%), fever (63.2%), myalgia (56.6%), and cough (56.0%). Table 2: The most frequent problem list items among the studied subjects (n= 182) Problems List No. of patients % Fatigue 117 64.3 Fever 115 63.2 Myalgia 103 56.6 Cough 102 56.0 Worry 100 54.9 Fears 95 52.2 Shortness of breath 90 49.5 Anosmia 87 47.8 Headache 85 46.7 Association between m-DT and both the sociodemographics and PL items Table 3 details the association between m-DT and both the sociodemographic data and PL items. Table 3: Association between the m-DT score ≥ 4 and both the sociodemographic factors and PL items of COVID-19 patients Problem list Item Present (%) m-DT cut-off ≥ 4 N=87 (48%) m-DT cut-off < 4 N=95 (52%) OR (95% CI) Adjusted OR (95% CI) Sociodemographic factors Age groups (≥ 14 - 18) 53 53 (29) 31(36) 22 (23) 7.467(0.890-19.677) Gender (male) 101 (55) 49(56) 52 (55) 0.256 (0.019-2.448) Educational (non-educated) 16 (9) 11(13) 5 (5) 0.433(0.008-7.704) Length of quarantine (> 3 months) 103 (57) 70 (80) 33 (35) 25.581(3.856-92.952) ** 15.726( 4.453-55.542) ** Chronic disease (present) 44 (24) 32(37) 12 (13) 1.149(0.022-9.631) Respiratory disease 30 (16) 27(31) 3 (3) 29.140(0.844-88.967) ** 29.403(9.572-6.877) *** Emotional Problems Depression 67 (37) 29 (33) 38 (40) 2.418(0.200-22.203) Fears 95 (52) 53 (61) 42 (44) 0.011(0.000-0.914) Nervousness 66 (36) 33 (38) 33 (35) 0.328(0.036-3.030) Sadness 64 (35) 49 (56) 15 (16) 22.876(6.021-47.978) ** Worry 100 (55) 72 (83) 28 (29) 25.001(1.263- 49.715) ** 17.414(2.887-43.374) ** Loss of interest 32 (18) 20 (23) 12 (13) 2.793(0.127-11.319) Physical Problems Cough 102 (56) 63 (72) 39 (41) 1.384(0.160-12.000) Shortness of breath 90 (49) 66 (76) 24 (25) 2.275(0.213-19.323) Sore throat 45 (24) 35 (39) 10 (11) 0.918(0.386-8.185) Headache 85 (47) 40 (42) 45 (47) 0.151(0.010-2.282) Chest pain 45 (24) 26 (31) 19 (20) 0.478(0.041-5.586) Anosmia 87 (48) 50 (57) 37 (39) 3.566(0.282-25.014) Myalgia 103 (57) 60 (69) 43 (45) 2.533(0.309-20.768) Diarrhea 26 (14) 19 (22) 7 (7) 18.296(2.098- 34.609) ** Eating/anorexia 61 (33) 48 (55) 13 (14) 4.290(0.980-23.954) Fatigue 117 (64) 70 (80) 47 (49) 6.881(0.213-22.182) Fever 115 (63) 81 (93) 34 (36) 23.624(8.365-66.694) ** 26.727(10.108-72.715) *** Memory/concentration 16 (9) 10 (11) 6 (6) 2.793(0.069-11.271) Nausea/vomiting 18 (10) 12 (14) 4(4) 0.741(0.039-10.264) Nose dry/congested 49 (27) 24 (27) 25 (26) 1.602(0.164-11.628) Pain/body aches 44 (24) 29 (33) 15 (15) 0.148(0.009-2.305) Sleep 35 (19) 26 (28) 9 (9) 9.230(0.902-27.666) PL; Problem list, OR; Odds Ratio, CI; confidence interval, HC; * P-value <0.05, ** p <0.01, *** p<0.001. Binary logistic regression showed that m-DT score of 4 or more had statistically significant associations with 6 items: length of quarantine time, the presence of chronic respiratory disease, sadness, worry, diarrhea, and fever. After adjustment to the sociodemographic and clinical characteristics, the multivariable analysis confirmed that length of quarantine time, presence of chronic respiratory disease, worry, and fever were independent factors associated with significant distress in COVID-19 patients. The adjusted odds ratios (95% confidence interval) for these items were 15.726 (4.453–55.542), 29.403(9.572–86.877), 17.414(2.887–43.374), and 26.727(10.108–72.715), for length of quarantine time, presence of chronic respiratory disease, worry and fever, respectively. Discussion To the best of our knowledge, this is the first Egyptian study that evaluate the adolescents’ subjects with COVID-19 for psychological distress using the modified distress thermometer (m-DT). We had used this tool recently for screening adults with COVID-19 for distress [ 7 ] and observed that 60% of the screened subjects experienced significant distress. In the current study we found that 48% of Egyptian adolescents suffered from significant distress. By time, we have realized that the current COVID-19 pandemic has led to a substantial degree of mental health crisis along with other aspects of the quality of life [ 3 , 10 ]. So, it is not surprising that the World Health Organization (WHO) has issued brief messages related to psychological and mental health considerations and has emphasized the execution of psychological first aid [ 11 ]. Moreover, the International Psycho-oncology Society terms distress as the "sixth vital sign" [ 12 ] and major professional organizations [ 5 , 6 , 11 ] call for standards of care that include psychosocial screening. Screening is the brief first step in a logical process of identifying risks (and competencies), determining need for further evaluation, and developing an appropriate treatment plan [ 3,4,7,9]. The originally proposed DT for cancer patients is a single-item tool using a point Likert scale resembling a thermometer, where the patient rates his/her level of distress over the past week [ 5 , 9 ]. The NCCN original Problem List for cancer patients included a 39-item supplemental list of potential sources of distress that is incorporated as an essential part of the assessment to assist the provider in identifying distress. As this PL provides a comprehensive list of categories, it covers almost all aspects that might attribute to distress among cancer patients [ 5 , 9 ]. However, despite these advantages, we had speculated that modifying this DT and its PL into a more practical and less-time consuming list of only emotional and physical items directly related to the impacts of COVID-19 would be a reproducible tool for assessment of the rapidly growing global pandemic of COVID-19 [ 7 ]. Utilizing this modified DT, our results had revealed a high prevalence (60%) of distress among adults with COVID-19 disease. Some population groups are more vulnerable than others to the psychosocial effects of pandemics. Because this critical life stage includes physical, psychological, and social developmental changes; major transitions from school to work or further education; and growing independence from families, children and adolescents deserve special care to preserve and promote their mental health [ 13 , 14 ]. Logically, being a relatively novel global illness, no one is immune [ 15 – 17 ], several pathophysiologic aspects of this pandemic are still vague in the eye of the general population, affecting many body organs and systems [ 18 ], and still has no definitive therapy, COVID-19 represents a real stressful condition and explains the high prevalence of distress among the studied cohort. Our demographic data showed that length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders, were significantly related to significant distress among the study cohorts. For adolescents with chronic respiratory disorders and their parents, the development of COVID-19 related respiratory symptoms -even they were proved later to be an exacerbation of the underlying chronic respiratory disorder, and not COVID-19 disease- represents an exaggerated trigger for distress. The most frequent problems reported on the practical domain of the PL were, fatigue, fever, myalgia, and cough, in this descending order. It is of notice that these problems were a mix of emotional and COVID-19-related ones. Despite that these symptoms represent challenges to the clinician; their predominance reflects the practicality and reproducibility of the used modified DT [ 7 ]. Results of the current study had shown that length of quarantine time, presence of chronic respiratory disease, worry, and fever, were independent factors associated with significant distress in COVID-19 adolescent patients. The history of this pandemic has experienced unparalleled changes in recent world history. Among them, the drastic modification of children’s and adolescents’ routines. While aiming to suppress virus transmission, the preventive strategies of lockdowns and social distancing significantly decrease social interactions, with expected unwanted impacts on the adolescents’ mental health [ 7 , 10 , 11 ]. Mental distresses that are already common due to the pandemic, may be heavily exaggerated if less family support is available [ 14 ]. Remote schooling, potential sickness, and economic shutdown, play a fundamental role in the mental sufferings of children and adolescents [ 4 , 10 ]. Worry is highly expected in such global pandemics like COVID-19. Previous reports had highlighted that the presence of one or more of some behavioural and emotional changes should alarm the parents and healthcare givers for significant distress among children and adolescents [ 10 , 19 ]. These changes include sleep problems and nightmares, development of unfounded fears, increase drugs, alcohol, or tobacco use, tendency to be become isolated from others, lose interest in funny activities, to be angry or resentful easily, and to be disruptive or disrespectful or behave destructively [ 19 – 21 ]. Overall, the findings of the current study confirm the importance of screening of COVID-19 adolescent patients for emotional distress, using a simple and valid tool like m-DT. This could have important clinical implications. Despite that psychiatric management of COVID-19 adolescent patients with significant distress may be beyond the scope of this article, effective screening of those populations could protect against adverse mental health consequences s of COVID-19, the most important of which is the pandemic-associated suicidal behaviour [ 19 , 21 ]. Based upon studies that found previous viral epidemics were associated with increased rates of suicide deaths, COVID-19 pandemic may increase the risk of suicidal ideation and behaviour, including suicides that were reported as an adverse effect of quarantine [ 22 ]. Notably, suicidality related to COVID-19 may be due to the hardships imposed by the pandemic, including economic privation, social isolation, reduced access to general medical and mental health care, and the stigma of having COVID-19 [ 10 , 22 – 24 ]. As there is a paradigm shift in suicide nature and risk factors due to the ongoing pandemic; hence, exploring specific cohorts to understand suicide nature is warranted in adolescents. It was recently reported [ 25 ] that online schooling related problems led to mother and son suicide-pact in a Bangladeshi youth during the pandemic. Being the first prospective study utilizing a modified DT in a relatively good number of adolescents does not guarantee that it has no limitations. Possible limitations include being a single centre study, possible convenience sampling which may affect the generalizability of the study findings to all COVID-19 patients, and the study did not include patients admitted to the intensive care unit (ICU). Further studies are needed. Conclusions With the modified distress thermometer (m-DT), almost half the Egyptian COVID-19 adolescents experienced significant distress. This distress was significantly related to length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders. With m-DT, the current study had identified length of quarantine time, presence of chronic respiratory disease, worry, and fever, as independent factors associated with significant distress in COVID-19 adolescent patients. We recommend further larger studies implementing this m-DT for screening COVID-19 adolescents for psychological distress. Abbreviations DT; distress thermometer , ICU; intensive care unit, IPOS; International Psycho-Oncology Society, m-DT ; modified distress thermometer, NICE; National Institute for Health and Care Excellence, NCCN; National Comprehensive Cancer Network, PL ; problem list, PPE ; personal protective equipment, WHO ; World Health Organization Declarations Ethics approval and consent to participate All methods of the study were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Institutional Review Board of the Faculty of Medicine of the University. A written consent was obtained from the study participants if they were ≥ 16 years old and from the participant’s parent and/or legal guardian for carrying out the study procedures. Consent for publication A written consent was obtained from the study participants if they were ≥ 16 years old and from the participant’s parent and/or legal guardian for carrying out the study procedures. Availability of data and materials The dataset(s) supporting the conclusions of this article is(are) included within the article Competing interests Authors of this study have no conflicts of interest to disclose Funding No funding was secured for this study. Authors' contributions YG: conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. YA: shared in the design of the study. MA: shared in data collection and drafting of the manuscript. AB: designed the data collection instruments and collected data. SM: conceptualized and designed the study, carried out data analysis, wrote the manuscript and reviewed it. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Acknowledgements The authors thank Mr. Omar Sherif Mohamed ( [email protected] ), research assistant, for his great help in this manuscript. References [1] Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020; 3: e203976. [2] Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Int Med 2020; 180: 817-8. [3] Mohamed S, Elgohary G, Abd ElHaffez A, Kamel E, Abd El-Aziz N. Does distress thermometer have a utility in the era of COVID-19 pandemic? Open Access Libr J 2020; 7: e6643. [4] Marques de Miranda D, da Silva Athanasio B, Sena Oliveira AC, Simoes-E-Silva AC. How is COVID-19 pandemic impacting mental health of children and adolescents? Int J Disaster Risk Reduct 2020; 51: 101845. doi:10.1016 /j.ijdrr. 2020.101845. [5] Holland JC, Anderson B, Breibart WS, et al. Distress management: Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2013; 11: 190-209. [6] Pirl WF, Fann JR, Greer JA, et al. Recommendations for the implementation of distress screening programs in cancer centers: Report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) Joint Task Force. Cancer 2014; 120: 2946-54. [7] Mohamed SAA, AbdelHafeez A, Kamel E, Rashad A. Utility of a modified distress thermometer in screening COVID-19 patients for psychological distress: a prospective Egyptian study. Multidiscip Respir Med 2021; 16(1): 750. doi: 10.4081/mrm.2021.750. [8] Ministry of Health and Population, Egypt. Management protocol for COVID-19 Patients. Version 1.4 / November 2020. Available at; https://www.researchgate .net/publication/345813633. [9] Abd El-Aziz N, Khallaf S, Abozaid W, et al. Is it the time to implement the routine use of distress thermometer among Egyptian patients with newly diagnosed cancer? BMC Cancer 2020; 20: 1033 https://doi.org/10.1186/s12885-020-07451-7. [10] Imran N, Zeshan M, Pervaiz Z. Mental health considerations for children & adolescents in COVID-19 Pandemic. Pak J Med Sci 2020; 36 (COVID19-S4): COVID19-S67-S72. doi: https://doi.org/10.12669/pjms.36.COVID19-S4.2759. [11] World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak. Available online: https://apps.who.int/iris/ bitstream/handle /10665/331490/WHO-2019-nCoV-MentalHealth-2020.1-eng.pdf. [12] International Psycho-oncology Society. http://www.ipossociety.org. [13] Palmer S, Patterson P, Thompson K. A national approach to improving adolescent and young adult (AYA) oncology psychosocial care: the development of AYA-specific psychosocial assessment and care tools. Palliat Support Care. 2014; 12(3): 183–188. [14] Patton GC, Viner R. Pubertal transitions in health. Lancet. 2007; 369 (9567): 1130–1139. [15] Selim M, Mohamed S, Abdo M, Abdelhaffez A. Is COVID-19 similar in pregnant and non-pregnant women? Cureus 2020; 12: e8888. [16] Selim MF, Mohamed SAA, Abdo M, Abdelhaffez A, et al. A case of postpartum mortality due to COVID-19 infection. J Med Case Rep Case Series 2020;1. [17] Mohamed S, Abo El-Hassan O, Rizk M, Ismail JH, Baioumy A. Death due to cardiac arrest in a young female with highly suspected COVID-19: A case report. Cureus 2020; 12: e10127. [18] Mohamed S, Saad K, Elgohary G, Abd ElHaffez A, Abd El-Aziz N. Is COVID-19 a systemic disease? Coronaviruses 2020; 1: 1-5. [19] Jiao WY, Wang LN, Liu J, et al. Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic. J Pediatr 2020. doi: 10.1016/j.jpeds.2020.03.013. [20] Erbacher, T. Youth suicide risk during COVID-19: How parents can help. https://www.inquirer.com/health/expert-opinions/coronavirus-teen-suicide-risk-parentshelp-20200504.html. [21] National Institute of Mental Health Helping children and adolescents cope with disasters and other traumatic events: What parents, rescue workers, and the community can do. https://www.nimh.nih.gov/health/publications/helping-children-and-adolescentscope-with-disasters-and-other-traumatic-events/index.shtml. [22] Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. Lancet Psychiatry 2020; 7: 468-71. [23] Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019-A perfect storm? JAMA Psychiatry 2020. [24] Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395: 912-20. [25] Mamun MA, Chandrima RM, Griffiths MD. Mother and son suicide pact due to COVID-19-related online learning issues in Bangladesh: An unusual case report. Int. J. Ment. Health Addict. 2020. doi:10.1007/s11469-020-00362-5. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1481317","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":98023673,"identity":"fec3165d-f9c0-4c01-95a8-707aa2b46b65","order_by":0,"name":"Yasser Gamal","email":"","orcid":"","institution":"Assiut University Faculty of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"","lastName":"Gamal","suffix":""},{"id":98023674,"identity":"acb3de2c-fde5-4a5e-a9fb-8e76861b2a73","order_by":1,"name":"Sherif Mohamed","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA00lEQVRIiWNgGAWjYNCCChsefhCdUEC0ljNpcpINIC0GxOpgbDtsbHAAxCJGi3z74WdSN9iYEzefX5344YEBgzy/2AH8WgzOpJlJ5/CwJW678XazBNBhhjNnJxDQwpBgdjtHggeo5ewGkJYEg9sEtMj3P/92O8dAInHzjLObfxClheFGDtCWBANjA/7ebcTZYnDjTfnvnAMJchI3eLdZJBhIEPaLfH/6ZuPcf/95+PvPbr75o8JGnl+akMPgQAKsUoJY5SDAf4AU1aNgFIyCUTCSAACOTUbGsQWdxgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0001-9437-4799","institution":"Assiut University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sherif","middleName":"","lastName":"Mohamed","suffix":""},{"id":98023675,"identity":"c8b78824-6915-402a-9888-5cb5e8a77c75","order_by":2,"name":"Yasser Abdel Raheem","email":"","orcid":"","institution":"Assiut University Faculty of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"Abdel","lastName":"Raheem","suffix":""},{"id":98023676,"identity":"32106e8c-6ef5-48f2-981b-400bd00845bb","order_by":3,"name":"Mohamed Abo Elela","email":"","orcid":"","institution":"Assiut University Faculty of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Abo","lastName":"Elela","suffix":""},{"id":98023677,"identity":"fe051390-c952-4f13-8109-8f9ad55e2f44","order_by":4,"name":"Ahlam Badawy","email":"","orcid":"","institution":"Assiut University Faculty of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ahlam","middleName":"","lastName":"Badawy","suffix":""}],"badges":[],"createdAt":"2022-03-23 11:00:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1481317/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1481317/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":20354420,"identity":"a5c62cf2-09ba-4a53-bcc3-ebcde70630b0","added_by":"auto","created_at":"2022-04-14 16:45:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":266854,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eModified distress thermometer (with permission from[7])\u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Onlinefigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-1481317/v1/3f5b28d4775833d7ed555bad.png"},{"id":23356474,"identity":"40195e5a-0341-4be8-8e25-2fd805b787a4","added_by":"auto","created_at":"2022-07-02 08:01:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":875347,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1481317/v1/6cb28846-7b6c-44fa-8e0c-9d655d8f7182.pdf"}],"financialInterests":"","formattedTitle":"Usefulness of modified distress thermometer in screening adolescents with COVID-19 for psychological distress","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe coronavirus disease 2019 (COVID-19) affected virtually all countries and had posed a significant threat to the health of the population and creating a significant challenge for health systems. Unknown diseases with an uncertain prognosis and associated with a scarcity of medical and protective equipment have led to unwanted mental health consequences. The potential fallout of an economic downturn, as well as the consequences of quarantine and associated social and physical distancing measures, are additional risk factors for mental health problems [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSome groups may be more vulnerable than others to the psychosocial effects of pandemics. Because they are in a critical period of development, children and adolescents deserve special care to preserve and promote their mental health [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The presence of significant distress in certain groups of patients e.g. cancer patients, had motivated many international regulatory organizations and professional societies [(\u003cem\u003ee.g\u003c/em\u003e., International Psycho-Oncology Society (IPOS), National Institute for Health and Care Excellence (NICE) and National Comprehensive Cancer Network (NCCN)] to recommend the routine screening and management of distress as an integral aspect of whole-person cancer care in the same way that health-care teams monitor and respond to other vital signs [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTherefore, recently we have adopted a modified version of the NCCN distress thermometer (m-DT) and its PL for adults with of COVID-19 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. With the modified distress thermometer (m-DT), 60% of adult Egyptian COVID-19 patients experienced significant distress [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeing a vulnerable group for COVID-19-related stress, in the current study, we aimed to test the utilization of this m-DT in screening adolescent patients with COVID-19.\u003c/p\u003e"},{"header":"Materials \u0026 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Population\u003c/h2\u003e \u003cp\u003eIn this prospective study, Egyptian adolescent (10\u0026ndash;18 years old) subjects who fulfilled the criteria of suspected or confirmed case of COVID-19 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and managed as outpatients (at the respiratory triage) or admitted at the Pediatric Department of a University Hospital at an isolation room with an adequate command of speaking and reading the Arabic language were enrolled. Subjects who had a history of or undergoing current treatment for psychiatric illness were excluded. Standard sociodemographic data were collected including age, gender, and education level. Medical records were reviewed for past medical history, vaccination history, history of recent travel, and history of quarantine. The study objectives and procedure were fully explained to eligible subjects and their sponsers. The essential infection control precautions for handling patients with COVID-19 were undertaken and the person who carried out the questionnaire wore full personal protective equipment (PPE) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e All methods of the study were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Institutional Review Board of the Faculty of Medicine of the University. A written consent was obtained from the study participants if they were \u0026ge;\u0026thinsp;16 years old and from the participant\u0026rsquo;s parent and/or legal guardian for carrying out the study procedures.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eModified distress thermometer (m-DT)\u003c/h2\u003e \u003cp\u003eAs shown in our recent publication [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], we have utilized the m-DT (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) to screen the enrolled adolescent subjects for psychological distress, with the use of a cutoff score of \u0026ge;\u0026thinsp;4 for significant distress [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eScreening was carried out for those patients at their first out-patient/Emegency Department visit or in-patient admission. Patients were asked to rate their distress in the past 3 days on an 11-point visual analog scale ranging from 0 (no distress) to 10 (extreme distress) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patients were then asked to fill in PL that accompanies the visual image of the m-DT to check, whether or not (yes/no) they have any of the problems listed during the previous 3 days. For illiterate patients, a research assistant helped them to rate their distress and fill in the PL. Correlation between the PL\u003c/p\u003e \u003cp\u003eand m-DT was carried out to identify the nature of distress and related factors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe following parameters were explored using descriptive statistical analysis; mean score, the standard deviation, the median score, and the frequency distribution of the m-DT. All p-values were two-tailed. A p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Binary logistic regression test was carried out to explore the association between the m-DT cutoff scores of 4 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and the demographic and clinical variables, while binary and multivariable logistic regression tests were used to analyze the association between the m-DT cut-off scores and individual items in the PL. The Statistical Package for Social Science; SPSS, version 24 (SPSS Inc., Chicago, IL, USA) has been used for data analysis.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eSociodemographic and clinical characteristics\u003c/h2\u003e\n\u003cp\u003eA total of 182 patients were prospectively enrolled. The median age was 12.3 (range 10\u0026ndash;18) years. Females constituted 45% of the participants. Forty-eight percent (87/182) of the study subjects experienced significant (m-DT score\u0026thinsp;\u0026ge;\u0026thinsp;4) COVID-19 related distress. Twenty-four percent (44/182) of patients had chronic underlying medical diseases, among which 30/44 (68%) had chronic respiratory diseases. The later included 24/30 (80%) patients with asthma, 4/30 (13.3%) with bronchiectasis, and 2/30 (6.7%) with interstitial lung disease (ILD), respectively.\u003c/p\u003e\n\u003cp\u003eThere were significant differences between those with and without significant distress with regards to length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for each), respectively. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows these data.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSociodemographic characteristics of the study subjects (n\u0026thinsp;=\u0026thinsp;182) and their association with m-DT score\u0026thinsp;\u0026ge;\u0026thinsp;4\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCharacteristic\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;182 (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003em-DT cut\u003c/p\u003e\n\u003cp\u003eoff \u0026ge;\u0026thinsp;4\u003c/p\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;87 (48%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003em-DT cut\u003c/p\u003e\n\u003cp\u003eoff \u0026lt;\u0026thinsp;4\u003c/p\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;95 (52%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12.3 (10.0\u0026ndash;18.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.118\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge groups (years)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 - \u0026lt; 14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e129 (71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56 (64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e73 (77)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ge; 14\u0026ndash;18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31(36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.074\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81(45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e43 (45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e101 (55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 (56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e52 (55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.882\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEducational level\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-educated\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11(13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEducated\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e166 (91)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76 (87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e90 (95)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.115\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLength of quarantine\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt; 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e79 (43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62 (65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt; 3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e103 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e70 (80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eUnderlying\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003echronic disease\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePresent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 (37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbsent\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e138 (76)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55 (63)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e83 (87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eType of chronic disease\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRespiratory\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30/44 (68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27/30 (90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3/30 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-respiratory\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14/44 (32)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4/14 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10/14 (72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e* m-DT; modified distress thermometer. For age, data are expressed in mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and t-test with 95% confidence interval was carried out to compare age between the 2 groups of m-DT cut-off \u0026lt;\u0026thinsp;4 and \u0026ge;\u0026thinsp;4. For other sociodemographic characteristics, data are expressed in numbers and percent and Chi-square tests was used to compare the significance of differences between the 2 groups of m-DT cut-off \u0026lt;\u0026thinsp;4 and \u0026ge;\u0026thinsp;4.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003eData from m-DT and PL analysis\u003c/h2\u003e\n\u003cp\u003eThe most frequent problems reported on the practical domain of the PL are shown in Table\u0026nbsp;2, in descending order, fatigue (64.3%), fever (63.2%), myalgia (56.6%), and cough (56.0%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: \u003c/strong\u003e\u003cstrong\u003eThe most frequent problem list items among the studied \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;subjects\u003c/strong\u003e\u003cstrong\u003e (n= 182)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003e\u003cstrong\u003eProblems List\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e\u003cstrong\u003eNo. of patients\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eFatigue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e117\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e64.3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eFever\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e115\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e63.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eMyalgia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e103\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e56.6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eCough\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e102\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e56.0\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eWorry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e54.9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eFears\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e95\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e52.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eShortness of breath\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e49.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eAnosmia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e87\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e47.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"174\"\u003e\n\u003cp\u003eHeadache\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"132\"\u003e\n\u003cp\u003e85\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"108\"\u003e\n\u003cp\u003e46.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eAssociation between m-DT and both the sociodemographics and PL items\u003c/h2\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e details the association between m-DT and both the sociodemographic data and PL items.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\n\u003cp\u003e\u003cstrong\u003eTable 3: Association between the m-DT score \u0026ge; 4 and both the\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003esociodemographic\u003c/strong\u003e\u003cstrong\u003e factors and PL items of COVID-19 patients\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eProblem list \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; Item \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePresent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp; (%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;m-DT \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ecut-off \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026ge; 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=87 \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(48%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;m-DT \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ecut-off \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026lt; 4\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eN=95\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(52%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;OR \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; (95% CI)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; Adjusted\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;OR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"756\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Sociodemographic factors\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge groups \u003c/strong\u003e(\u0026ge; 14 - 18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e53\u0026nbsp;\u0026nbsp; 53 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; 31(36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; 22 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e\u0026nbsp;7.467(0.890-19.677)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender \u003c/strong\u003e(male)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp; 101 (55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; 49(56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp;52 (55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e\u0026nbsp;0.256 (0.019-2.448)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eEducational \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(non-educated)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp; 16 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e11(13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; 5 (5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e\u0026nbsp;0.433(0.008-7.704)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eLength of quarantine \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(\u0026gt; 3 months)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;103 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e70 (80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp; 33 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e\u0026nbsp; 25.581(3.856-92.952)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e15.726(\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 4.453-55.542)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eChronic disease \u003c/strong\u003e(present)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;44 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;32(37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp; 12 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; 1.149(0.022-9.631)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eRespiratory disease \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;30 (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;27(31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp; 3 (3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e29.140(0.844-88.967)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;29.403(9.572-6.877)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"756\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Emotional Problems\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eDepression\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e67 (37)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e29 (33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp;38 (40)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e2.418(0.200-22.203)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eFears\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e95 (52)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e53 (61)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e42 (44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.011(0.000-0.914)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eNervousness\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e66 (36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e33 (38)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e33 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.328(0.036-3.030)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eSadness\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e64 (35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e49 (56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e15 (16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e22.876(6.021-47.978)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eWorry\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e100 (55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;72 (83)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e28 (29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e25.001(1.263- 49.715)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e17.414(2.887-43.374)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eLoss of interest\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e32 (18)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;20 (23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e12 (13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e2.793(0.127-11.319)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" width=\"756\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;Physical Problems\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eCough\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e102 (56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;63 (72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e39 (41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e1.384(0.160-12.000)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eShortness of breath\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;90 (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;66 (76)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e24 (25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e2.275(0.213-19.323)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eSore throat\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;45 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; 35 (39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp;10 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.918(0.386-8.185)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eHeadache\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;85 (47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e40 (42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e45 (47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.151(0.010-2.282)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eChest pain\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;45 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e26 (31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e19 (20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.478(0.041-5.586)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eAnosmia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;87 (48)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e50 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e37 (39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e3.566(0.282-25.014)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eMyalgia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e103 (57)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e60 (69)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e43 (45)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e2.533(0.309-20.768)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eDiarrhea\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;26 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e19 (22)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp; 7 (7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e18.296(2.098- 34.609)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eEating/anorexia\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;61 (33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e48 (55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e13 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e4.290(0.980-23.954)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eFatigue\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e117 (64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e70 (80)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e47 (49)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e6.881(0.213-22.182)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eFever\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e115 (63)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e81 (93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e34 (36)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e23.624(8.365-66.694)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e26.727(10.108-72.715)\u003csup\u003e***\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eMemory/concentration\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;16 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e10 (11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp; 6 (6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e2.793(0.069-11.271)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eNausea/vomiting\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;18 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e12 (14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp; 4(4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.741(0.039-10.264)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eNose dry/congested\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp; 49 (27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e24 (27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e25 (26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e1.602(0.164-11.628)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003ePain/body aches\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;44 (24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e29 (33)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e15 (15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e0.148(0.009-2.305)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"190\"\u003e\n\u003cp\u003e\u003cstrong\u003eSleep\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"79\"\u003e\n\u003cp\u003e\u0026nbsp;35 (19)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"69\"\u003e\n\u003cp\u003e26 (28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"82\"\u003e\n\u003cp\u003e\u0026nbsp; 9 (9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"169\"\u003e\n\u003cp\u003e9.230(0.902-27.666)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"167\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ePL; Problem list, OR; Odds Ratio, CI; confidence interval, HC;\u0026nbsp; * P-value \u0026lt;0.05, ** p \u0026lt;0.01, *** p\u0026lt;0.001.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eBinary logistic regression showed that m-DT score of 4 or more had statistically significant associations with 6 items: length of quarantine time, the presence of chronic respiratory disease, sadness, worry, diarrhea, and fever. After adjustment to the sociodemographic and clinical characteristics, the multivariable analysis confirmed that length of quarantine time, presence of chronic respiratory disease, worry, and fever were independent factors associated with significant distress in COVID-19 patients. The adjusted odds ratios (95% confidence interval) for these items were 15.726 (4.453\u0026ndash;55.542), 29.403(9.572\u0026ndash;86.877), 17.414(2.887\u0026ndash;43.374), and 26.727(10.108\u0026ndash;72.715), for length of quarantine time, presence of chronic respiratory disease, worry and fever, respectively.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first Egyptian study that evaluate the adolescents\u0026rsquo; subjects with COVID-19 for psychological distress using the modified distress thermometer (m-DT). We had used this tool recently for screening adults with COVID-19 for distress [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and observed that 60% of the screened subjects experienced significant distress. In the current study we found that 48% of Egyptian adolescents suffered from significant distress. By time, we have realized that the current COVID-19 pandemic has led to a substantial degree of mental health crisis along with other aspects of the quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. So, it is not surprising that the World Health Organization (WHO) has issued brief messages related to psychological and mental health considerations and has emphasized the execution of psychological first aid [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Moreover, the International Psycho-oncology Society terms distress as the \"sixth vital sign\" [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and major professional organizations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] call for standards of care that include psychosocial screening. Screening is the brief first step in a logical process of identifying risks (and competencies), determining need for further evaluation, and developing an appropriate treatment plan [ 3,4,7,9].\u003c/p\u003e \u003cp\u003eThe originally proposed DT for cancer patients is a single-item tool using a point Likert scale resembling a thermometer, where the patient rates his/her level of distress over the past week [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The NCCN original Problem List for cancer patients included a 39-item supplemental list of potential sources of distress that is incorporated as an essential part of the assessment to assist the provider in identifying distress. As this PL provides a comprehensive list of categories, it covers almost all aspects that might attribute to distress among cancer patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, despite these advantages, we had speculated that modifying this DT and its PL into a more practical and less-time consuming list of only emotional and physical items directly related to the impacts of COVID-19 would be a reproducible tool for assessment of the rapidly growing global pandemic of COVID-19 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Utilizing this modified DT, our results had revealed a high prevalence (60%) of distress among adults with COVID-19 disease.\u003c/p\u003e \u003cp\u003eSome population groups are more vulnerable than others to the psychosocial effects of pandemics. Because this critical life stage includes physical, psychological, and social developmental changes; major transitions from school to work or further education; and growing independence from families, children and adolescents deserve special care to preserve and promote their mental health [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Logically, being a relatively novel global illness, no one is immune [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], several pathophysiologic aspects of this pandemic are still vague in the eye of the general population, affecting many body organs and systems [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and still has no definitive therapy, COVID-19 represents a real stressful condition and explains the high prevalence of distress among the studied cohort.\u003c/p\u003e \u003cp\u003eOur demographic data showed that length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders, were significantly related to significant distress among the study cohorts. For adolescents with chronic respiratory disorders and their parents, the development of COVID-19 related respiratory symptoms -even they were proved later to be an exacerbation of the underlying chronic respiratory disorder, and not COVID-19 disease- represents an exaggerated trigger for distress. The most frequent problems reported on the practical domain of the PL were, fatigue, fever, myalgia, and cough, in this descending order. It is of notice that these problems were a mix of emotional and COVID-19-related ones. Despite that these symptoms represent challenges to the clinician; their predominance reflects the practicality and reproducibility of the used modified DT [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eResults of the current study had shown that length of quarantine time, presence of chronic respiratory disease, worry, and fever, were independent factors associated with significant distress in COVID-19 adolescent patients. The history of this pandemic has experienced unparalleled changes in recent world history. Among them, the drastic modification of children\u0026rsquo;s and adolescents\u0026rsquo; routines. While aiming to suppress virus transmission, the preventive strategies of lockdowns and social distancing significantly decrease social interactions, with expected unwanted impacts on the adolescents\u0026rsquo; mental health [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Mental distresses that are already common due to the pandemic, may be heavily exaggerated if less family support is available [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Remote schooling, potential sickness, and economic shutdown, play a fundamental role in the mental sufferings of children and adolescents [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Worry is highly expected in such global pandemics like COVID-19. Previous reports had highlighted that the presence of one or more of some behavioural and emotional changes should alarm the parents and healthcare givers for significant distress among children and adolescents [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. These changes include sleep problems and nightmares, development of unfounded fears, increase drugs, alcohol, or tobacco use, tendency to be become isolated from others, lose interest in funny activities, to be angry or resentful easily, and to be disruptive or disrespectful or behave destructively [\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOverall, the findings of the current study confirm the importance of screening of COVID-19 adolescent patients for emotional distress, using a simple and valid tool like m-DT. This could have important clinical implications. Despite that psychiatric management of COVID-19 adolescent patients with significant distress may be beyond the scope of this article, effective screening of those populations could protect against adverse mental health consequences s of COVID-19, the most important of which is the pandemic-associated suicidal behaviour [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased upon studies that found previous viral epidemics were associated with increased rates of suicide deaths, COVID-19 pandemic may increase the risk of suicidal ideation and behaviour, including suicides that were reported as an adverse effect of quarantine [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Notably, suicidality related to COVID-19 may be due to the hardships imposed by the pandemic, including economic privation, social isolation, reduced access to general medical and mental health care, and the stigma of having COVID-19 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. As there is a paradigm shift in suicide nature and risk factors due to the ongoing pandemic; hence, exploring specific cohorts to understand suicide nature is warranted in adolescents. It was recently reported [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] that online schooling related\u003c/p\u003e \u003cp\u003eproblems led to mother and son suicide-pact in a Bangladeshi youth during the pandemic.\u003c/p\u003e \u003cp\u003eBeing the first prospective study utilizing a modified DT in a relatively good number of adolescents does not guarantee that it has no limitations. Possible limitations include being a single centre study, possible convenience sampling which may affect the generalizability of the study findings to all COVID-19 patients, and the study did not include patients admitted to the intensive care unit (ICU). Further studies are needed.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eWith the modified distress thermometer (m-DT), almost half the Egyptian COVID-19 adolescents experienced significant distress. This distress was significantly related to length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders. With m-DT, the current study had identified length of quarantine time, presence of chronic respiratory disease, worry, and fever, as independent factors associated with significant distress in COVID-19 adolescent patients. We recommend further larger studies implementing this m-DT for screening COVID-19 adolescents for psychological distress.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eDT;\u0026nbsp;\u003c/strong\u003edistress thermometer\u003cstrong\u003e, ICU;\u0026nbsp;\u003c/strong\u003eintensive care unit, \u003cstrong\u003eIPOS;\u0026nbsp;\u003c/strong\u003eInternational Psycho-Oncology Society, \u003cstrong\u003em-DT\u003c/strong\u003e; modified distress thermometer, \u003cstrong\u003eNICE;\u0026nbsp;\u003c/strong\u003eNational Institute for Health and Care Excellence, \u003cstrong\u003eNCCN;\u0026nbsp;\u003c/strong\u003eNational Comprehensive Cancer Network, \u003cstrong\u003ePL\u003c/strong\u003e; problem list,\u0026nbsp;\u003cstrong\u003ePPE\u003c/strong\u003e; personal protective equipment,\u0026nbsp;\u003cstrong\u003eWHO\u003c/strong\u003e; World Health Organization\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll methods of the study were carried out in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments. Ethical approval was obtained from the Institutional Review Board of the Faculty of Medicine of the University. A written consent was obtained from the study participants if they were \u0026ge; 16 years old and from the participant\u0026rsquo;s \u0026nbsp; parent and/or legal guardian for carrying out the study procedures.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eA written consent was obtained from the study participants if they were \u0026ge; 16 years old and from the participant\u0026rsquo;s \u0026nbsp;parent and/or legal guardian for carrying out the study procedures.\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe dataset(s) supporting the conclusions of this article is(are) included within the article\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp; Authors of this study have no conflicts of interest to disclose\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; No funding was secured for this study.\u0026nbsp;\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eYG: conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eYA: shared in the design of the study.\u003c/p\u003e\n\u003cp\u003eMA: shared in data collection and drafting of the manuscript.\u003c/p\u003e\n\u003cp\u003eAB: designed the data collection instruments and collected data.\u003c/p\u003e\n\u003cp\u003eSM: conceptualized and designed the study, carried out data analysis, wrote the manuscript and reviewed it.\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe authors thank Mr. Omar Sherif Mohamed ([email protected]), research assistant, for his great help in this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e[1] Lai J, Ma S, Wang Y, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. \u003cem\u003eJAMA Netw Open\u003c/em\u003e 2020; 3: e203976.\u003c/p\u003e\n\u003cp\u003e[2] Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. \u003cem\u003eJAMA Int Med\u0026nbsp;\u003c/em\u003e2020; 180: 817-8.\u003c/p\u003e\n\u003cp\u003e[3] Mohamed S, Elgohary G, Abd ElHaffez A, Kamel E, Abd El-Aziz N. Does distress thermometer have a utility in the era of COVID-19 pandemic? \u003cem\u003eOpen Access Libr J\u003c/em\u003e 2020; 7: e6643.\u003c/p\u003e\n\u003cp\u003e[4] Marques de Miranda D, da Silva Athanasio B, Sena Oliveira AC, Simoes-E-Silva AC. How is COVID-19 pandemic impacting mental health of children and adolescents?\u0026nbsp; \u003cem\u003eInt J Disaster Risk Reduct\u003c/em\u003e 2020; 51: 101845. doi:10.1016 /j.ijdrr. 2020.101845.\u003c/p\u003e\n\u003cp\u003e[5] Holland JC, Anderson B, Breibart WS, et al. Distress management: Clinical practice guidelines in oncology. \u003cem\u003eJ Natl Compr Canc Netw\u003c/em\u003e 2013; 11: 190-209.\u003c/p\u003e\n\u003cp\u003e[6] Pirl WF, Fann JR, Greer JA, et al. Recommendations for the implementation of distress screening programs in cancer centers: Report from the American Psychosocial Oncology Society (APOS), Association of Oncology Social Work (AOSW), and Oncology Nursing Society (ONS) Joint Task Force. \u003cem\u003eCancer \u003c/em\u003e2014; 120: 2946-54.\u003c/p\u003e\n\u003cp\u003e[7] Mohamed SAA, AbdelHafeez A, Kamel E, Rashad A. Utility of a modified distress thermometer in screening COVID-19 patients for psychological distress: a prospective Egyptian study. \u003cem\u003eMultidiscip Respir Med\u003c/em\u003e 2021; 16(1): 750. doi: 10.4081/mrm.2021.750.\u003c/p\u003e\n\u003cp\u003e[8] Ministry of Health and Population, Egypt. Management protocol for COVID-19\u0026nbsp; Patients. Version 1.4 / November 2020. Available at; https://www.researchgate .net/publication/345813633.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e[9] Abd El-Aziz N, Khallaf S, Abozaid W, et al. Is it the time to implement the routine use of distress thermometer among Egyptian patients with newly diagnosed cancer?\u0026nbsp;\u003cem\u003eBMC Cancer\u003c/em\u003e 2020; 20: 1033 https://doi.org/10.1186/s12885-020-07451-7.\u003c/p\u003e\n\u003cp\u003e[10] Imran N, Zeshan M, Pervaiz Z.\u0026nbsp; Mental health considerations for children \u0026amp; adolescents in COVID-19 Pandemic. \u003cem\u003ePak J Med Sci \u003c/em\u003e2020; 36 (COVID19-S4): COVID19-S67-S72. doi: https://doi.org/10.12669/pjms.36.COVID19-S4.2759.\u003c/p\u003e\n\u003cp\u003e[11] World Health Organization. Mental health and psychosocial considerations during the COVID-19 outbreak. Available online: https://apps.who.int/iris/ bitstream/handle /10665/331490/WHO-2019-nCoV-MentalHealth-2020.1-eng.pdf.\u003c/p\u003e\n\u003cp\u003e[12] International Psycho-oncology Society. http://www.ipossociety.org.\u003c/p\u003e\n\u003cp\u003e[13] Palmer S, Patterson P, Thompson K. A national approach to improving adolescent and young adult (AYA) oncology psychosocial care: the development of AYA-specific psychosocial assessment and care tools. \u003cem\u003ePalliat Support Care. \u003c/em\u003e2014; 12(3): 183\u0026ndash;188.\u003c/p\u003e\n\u003cp\u003e[14] Patton GC, Viner R. Pubertal transitions in health. \u003cem\u003eLancet. \u003c/em\u003e2007; 369 (9567): 1130\u0026ndash;1139.\u003c/p\u003e\n\u003cp\u003e[15] Selim M, Mohamed S, Abdo M, Abdelhaffez A. Is COVID-19 similar in pregnant and non-pregnant women? \u003cem\u003eCureus \u003c/em\u003e2020; 12: e8888.\u003c/p\u003e\n\u003cp\u003e[16] Selim MF, Mohamed SAA, Abdo M, Abdelhaffez A, et al. A case of postpartum mortality due to COVID-19 infection. \u003cem\u003eJ Med Case Rep Case Series\u003c/em\u003e 2020;1.\u003c/p\u003e\n\u003cp\u003e[17] Mohamed S, Abo El-Hassan O, Rizk M, Ismail JH, Baioumy A. Death due to cardiac arrest in a young female with highly suspected COVID-19: A case report. \u003cem\u003eCureus\u003c/em\u003e 2020; 12: e10127.\u003c/p\u003e\n\u003cp\u003e[18] Mohamed S, Saad K, Elgohary G, Abd ElHaffez A, Abd El-Aziz N. Is COVID-19 a systemic disease? \u003cem\u003eCoronaviruses \u003c/em\u003e2020; 1: 1-5.\u003c/p\u003e\n\u003cp\u003e[19] Jiao WY, Wang LN, Liu J, et al. Behavioral and Emotional Disorders in Children during the COVID-19 Epidemic. \u003cem\u003eJ Pediatr\u003c/em\u003e 2020. doi: 10.1016/j.jpeds.2020.03.013.\u003c/p\u003e\n\u003cp\u003e[20] Erbacher, T. Youth suicide risk during COVID-19: How parents can help. https://www.inquirer.com/health/expert-opinions/coronavirus-teen-suicide-risk-parentshelp-20200504.html.\u003c/p\u003e\n\u003cp\u003e[21] National Institute of Mental Health Helping children and adolescents cope with disasters and other traumatic events: What parents, rescue workers, and the community can do. https://www.nimh.nih.gov/health/publications/helping-children-and-adolescentscope-with-disasters-and-other-traumatic-events/index.shtml.\u003c/p\u003e\n\u003cp\u003e[22] Gunnell D, Appleby L, Arensman E, et al. Suicide risk and prevention during the COVID-19 pandemic. \u003cem\u003eLancet Psychiatry\u003c/em\u003e 2020; 7: 468-71.\u003c/p\u003e\n\u003cp\u003e[23] Reger MA, Stanley IH, Joiner TE. Suicide mortality and coronavirus disease 2019-A perfect storm? \u003cem\u003eJAMA Psychiatry\u003c/em\u003e 2020.\u003c/p\u003e\n\u003cp\u003e[24] Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. \u003cem\u003eLancet\u003c/em\u003e 2020; 395: 912-20.\u003c/p\u003e\n\u003cp\u003e[25] Mamun MA, Chandrima RM, Griffiths MD. Mother and son suicide pact due to COVID-19-related online learning issues in Bangladesh: An unusual case report. \u003cem\u003eInt. J. Ment. Health Addict. \u003c/em\u003e2020. doi:10.1007/s11469-020-00362-5.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, distress, adolescents, utility, screening, psychology, social, thermometer ","lastPublishedDoi":"10.21203/rs.3.rs-1481317/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1481317/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Children and adolescents are more vulnerable than other age groups to the psychosocial effects of the COVID-19 pandemic. The modified DT (m-DT) was recently utilized for measuring the prevalence of psychological distress among adult COVID-19 patients. In the current study, we aimed to test the utilization of this m-DT in screening adolescent patients with COVID-19 for psychosocial distress.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eEgyptian adolescent subjects with suspected or confirmed cases of COVID-19 at a University Hospital were enrolled. Binary logistic regression tests were carried out to explore the association between the m-DT cut-off scores of 4 and the clinical variables.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eForty-eight percent (87/182) of the study subjects experienced significant (m-DT score ≥ 4) COVID-19 related distress. There were significant differences between those with and without significant distress with regards to length of quarantine, presence of underlying medical disorder, and presence of chronic respiratory disorders. Length of quarantine time, presence of chronic respiratory disease, worry, and fever were independent factors associated with significant distress in COVID-19 adolescent patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Almost half of the enrolled Egyptian adolescents with COVID-19 experienced significant psychological distress. The m-DT was useful, as the current study had identified length of quarantine time, presence of chronic respiratory disease, worry, and fever as independent factors associated with significant distress in COVID-19 adolescents. Further studies are needed.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Usefulness of modified distress thermometer in screening adolescents with COVID-19 for psychological distress","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-04-14 16:45:52","doi":"10.21203/rs.3.rs-1481317/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8d236c74-b95a-40ec-8ac9-fdb7f04ef09c","owner":[],"postedDate":"April 14th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-07-02T08:01:24+00:00","versionOfRecord":[],"versionCreatedAt":"2022-04-14 16:45:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1481317","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1481317","identity":"rs-1481317","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}