MALAYSIA SPONDYLARTHRITIS ACCELERATED MANAGEMENT (SAM) MODEL: EXPEDITING AXSPA PATIENT JOURNEY from EARLY REFERRAL, DIAGNOSIS and ACCESS to OPTIMAL CARE

Background: Axial spondyloarthritis (axSpA) is an important cause of infam-matory back pain (IBP). It is under-recognized, leading to signifcant delays in diagnosis. Early recognition and diagnosis are crucial to achieve the best outcomes for patients and in Malaysia, signifcant gaps in the clinical management of axSpA remain. Therefore, we sought to implement a strategy to improve the time to diagnosis and management of axSpA in Malaysia by collaborating and adopting guidance from an international axSpA expert. Objectives: The objectives were to improve disease recognition among healthcare practitioners (HCPs), reducing time to specialist referral and diagnosis whilst improving disease management by developing and implementing a new patient care model called the Spondyloarthritis Accelerated Management (SAM) and measure its effectiveness in 3 Rheumatology centers in Malaysia. Methods: The SAM initiative was developed by the Malaysian SpA Consortium Working Group involving 8 Malaysian rheumatologists from 3 local centers and 1 international axSpA expert from the UK as part of the steering committee. Selections were based on clinical expertise. The frst local alignment meeting on model structure was held in July 2020 with subsequent meetings held to address key barriers to early axSpA diagnosis and timely access to quality care. A care model with feasible key performance indicators (KPIs) was established, adapted and tracked monthly in the 3 rheumatology centers (Figure 1). Referral tools were developed to facilitate early referrals to rheumatologists. These included a QR-coded '3-R' referral guide1 and a patient self-screening tool with a patient self-referral letter all hosted on the Malaysian Society of Rheumatology (MSR) website, educational talks to HCPs and public awareness forums on IBP and axSpA. Data were collected on referral source, duration of referrals, knowledge on IBP in HCPs by surveys and imaging accessibility at baseline and at 1 year after the initiative was launched. Baseline data collected were from August to October 2020 and 1 year data were from November 2020 to November 2021. Results: At 1 year, the SAM initiative showed a 44.4% (Median: 1.33 [IQR 1-1.7] vs 1.92 [IQR 1.6-2.1]) increase in IBP referrals, a reducing trend from 9.5 (IQR 8-11.1) to 5.9 (IQR 5.1-6.8) weeks of waiting time to a frst Rheumatology visit and an increase of 37.2% (34% vs 71%) in IBP patients who were seen at the rheumatology clinic within 6 weeks. All patients with IBP had X-rays (sacroiliac joints or pelvis). MRI requests in X-ray negative patients suspected of axSpA was increased by 13.9% (77.8% vs 91.7%) and waiting time for MRI was reduced by 3.1 weeks (12 vs 8.9 weeks). The IBP knowledge among 224 HCPs improved by 40.6% (45.7% vs 86.3%). The number of patients newly diagnosed with axSpA increased by 40% (Median: 5 [IQR 4-9.5] vs 7 [IQR 6.5-7]) despite the COVID-19 pandemic. Conclusion: The SAM initiative has shown promising initial results in improving referrals of patients with IBP, promoting earlier diagnosis and establishing the importance of having timely access to optimal care. A nationwide implementation is being planned to improve the recognition of the axSpA in Malaysia.

Lessons learned from the COVID-19 control strategy of the XXXII Tokyo Summer Olympics and the XXIV Beijing Winter Olympics.

Coronavirus disease 2019 (COVID-19) has caused more than 500 million infections and 6.2 million deaths globally, resulting in numerous sporting events being cancelled or postponed. Therefore, effective control strategies are urgently needed to prevent COVID-19 transmission at these local and global events. This article introduced the strategies utilized at the Tokyo and Beijing Olympics and proposed several measures for future reference.

Clinical features and risk factors associated with severe COVID-19 patients in China.

BACKGROUND: Coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread throughout the world. In this study, we aimed to identify the risk factors for severe COVID-19 to improve treatment guidelines. METHODS: A multicenter, cross-sectional study was conducted on 313 patients hospitalized with COVID-19. Patients were classified into two groups based on disease severity (nonsevere and severe) according to initial clinical presentation. Laboratory test results and epidemiological and clinical characteristics were analyzed using descriptive statistics. Univariate and multivariate logistic regression models were used to detect potential risk factors associated with severe COVID-19. RESULTS: A total of 289 patients (197 nonsevere and 92 severe cases) with a median age of 45.0 (33.0, 61.0) years were included in this study, and 53.3% (154/289) were male. Fever (192/286, 67.1%) and cough (170/289, 58.8%) were commonly observed, followed by sore throat (49/289, 17.0%). Multivariate logistic regression analysis suggested that patients who were aged ≥ 65 years (OR: 2.725, 95% confidence interval [CI]: 1.317-5.636; P = 0.007), were male (OR: 1.878, 95% CI: 1.002-3.520, P = 0.049), had comorbid diabetes (OR: 3.314, 95% CI: 1.126-9.758, P = 0.030), cough (OR: 3.427, 95% CI: 1.752-6.706, P < 0.001), and/or diarrhea (OR: 2.629, 95% CI: 1.109-6.231, P = 0.028) on admission had a higher risk of severe disease. Moreover, stratification analysis indicated that male patients with diabetes were more likely to have severe COVID-19 (71.4% vs. 28.6%, χ2 = 8.183, P = 0.004). CONCLUSIONS: The clinical characteristics of those with severe and nonsevere COVID-19 were significantly different. The elderly, male patients with COVID-19, diabetes, and presenting with cough and/or diarrhea on admission may require close monitoring to prevent deterioration.

Clinical characteristics of 312 hospitalized older patients with COVID-19 in Wuhan, China.

OBJECTIVES: Much of the previous research on COVID-19 was based on all population. But substantial numbers of severe episodes occur in older patients. There is a lack of data about COVID-19 in older adults. The aims of this study were to analyze the clinical characteristics of older adult patients with COVID-19. METHODS: Retrospective study of older patients hospitalized with COVID-19 from February 1 st to March 31 st, 2020 was conducted in the Sino-French New City Branch of Tongjing Hospital in Wuhan, China. According to the degree of severity of COVID-19 during hospitalization, 312 older patients were divided into non-severe and severe cases. RESULTS: the mean age of the patients was 69.2 ± 7.3 years, and 47.4 % of patients had exposure history. 77.2 % of patients had a co-morbidity, with hypertension being the most common (57.1 %), followed by diabetes (38.8 %) and cardiovascular disease (29.8 %). Multivariable regression showed increasing odds of severe COVID-19 associated with age(OR 1.59, 95 %CI 1.13-2.08), SOFA score(OR 5.89, 95 %CI 3.48-7.96), APACHEⅡ score(OR 3.13, 95 %CI 1.85-5.62), platelet count＜125 × 109/L(OR 2.36, 95 %CI 1.03-4.14), d-dimer (OR 4.37, 95 %CI 2.58-7.16), creatinine＞133 µmol/L(OR 1.85, 95 %CI 1.12-3.04), interleukin-6(OR 4.32, 95 %CI 2.07-7.13), and lung consolidation(OR 1.94, 95 %CI 1.45-4.27) on admission. The most common complication was acute respiratory distress syndrome (35.6 %), followed by acute cardiac injury (33.0 %) and coagulation disorders (30.8 %). 91.7 % of patients were prescribed antiviral therapy, followed by immune globulin (52.9 %) and systemic glucocorticoids (43.6 %). 21.8 % of patients received invasive ventilation, 1.92 % for extracorporeal membrane oxygenation. The overall mortality was 6.73 %, and mortality of severe patients was 17.1 %, which was higher than non-severe patients (0.962 %). CONCLUSIONS: Older patients with COVID-19 had much more co-morbidity, complications and mortality. More attention should be paid to older patients with COVID-19.

Role of angiotensin-converting enzyme 2 (ACE2) in COVID-19.

An outbreak of pneumonia caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that started in Wuhan, China, at the end of 2019 has become a global pandemic. Both SARS-CoV-2 and SARS-CoV enter host cells via the angiotensin-converting enzyme 2 (ACE2) receptor, which is expressed in various human organs. We have reviewed previously published studies on SARS and recent studies on SARS-CoV-2 infection, named coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO), confirming that many other organs besides the lungs are vulnerable to the virus. ACE2 catalyzes angiotensin II conversion to angiotensin-(1-7), and the ACE2/angiotensin-(1-7)/MAS axis counteracts the negative effects of the renin-angiotensin system (RAS), which plays important roles in maintaining the physiological and pathophysiological balance of the body. In addition to the direct viral effects and inflammatory and immune factors associated with COVID-19 pathogenesis, ACE2 downregulation and the imbalance between the RAS and ACE2/angiotensin-(1-7)/MAS after infection may also contribute to multiple organ injury in COVID-19. The SARS-CoV-2 spike glycoprotein, which binds to ACE2, is a potential target for developing specific drugs, antibodies, and vaccines. Restoring the balance between the RAS and ACE2/angiotensin-(1-7)/MAS may help attenuate organ injuries. SARS-CoV-2 enters lung cells via the ACE2 receptor. The cell-free and macrophage-phagocytosed virus can spread to other organs and infect ACE2-expressing cells at local sites, causing multi-organ injury.