ABSTRACT
BackgroundCOVID 19 infection could lead to different sequelae in survivors, known as post-COVID or long COVID 19 syndromes. Some of them are thought to be due to the thrombophylic changes observed in COVID 19 infection, but some are thought to be caused by the administrated (especially high dose) corticosteroid treatment. Avascular necrosis of the femoral head (AVNFH) is a multifactorial disease which leads to compromised vascular supply, ischemia and finally necrosis of the femoral head. As corticosteroids usage and thrombophylic states are among the main known risk factors for the development AVNFH [1], it could be presumed that the frequency of this disease will increase with the COVID 19 pandemic. The exact corticosteroid dose needed for the development of AVNFH is not clear, but it has been stated that a higher daily dose and a larger total cumulative dose increase substantially the risk for the development of osteonecrosis [2].ObjectivesTo describe in detail the characteristics of AVNFH diagnosed in patients after COVID 19 infection.MethodsThe study was done in a tertiary university rheumatological clinic. Data was extracted from the records of patients who have been referred to the clinic because of hip pain between June and December 2022. Inclusion criteria were: - a new onset of uni-or bilateral hip pain that started after a documented COVID 19 infection;and an MRI scan of the hip joints showing osteonecrosis of one or both femoral heads. Exclusion criteria were the presence of hip pain prior to the COVID 19 infection, anamnesis of traumatic injuries of the hips or pelvis, personal history of hypercoagulable states.ResultsNine patients (4 women and 5 men) with an average age 59.1 years (range 38-72) were included in the study. Four patients had been diagnosed with bilateral and five – with unilateral AVNFH, thus 13 hip joints were analysed in total (8 left and 5 right sided). The mean time lap between the COVID 19 infection and the start of the hip pain was 26.2 weeks (range 10-48 weeks). All patients had limited and painful movement in their symptomatic hip(s), especially internal rotation and four of the patients had also elevated CRP levels (mean 11.7 mg/L). The stage of the AVNFH was evaluated according to the Ficat-Arlet classification (0-IV stage). In four hips the AVNFH was stage I, five hips were classified as stage II and the remaining four joints - as stage III. All symptomatic hip joints exhibited effusion/synovitis on both ultrasound examination and the corresponding MRI scan. It should be noted that the presence of hip effusion was found to be related with a worse prognosis in AVNFH [1]. In three patients the amount of the effusion required arthrocentesis and fluid aspiration. The analysis of the joint fluid was consistent with a degenerative disease (i.e., low WBC count with predominant lymphocytes and no crystals). All patients included in our study had received corticosteroids during their COVID19 infection, while 6 of the patients had also been hospitalized due to more severe disease. According to the patients' documentation, the mean cumulative dose of the received corticosteroids was 936.2 mg prednisolone equivalent per patient (range 187-2272 mg).ConclusionAVNFH must not be overlooked in a new onset hip pain after COVID 19 infection. Our results show that corticosteroids administrated during the infection and the presence of hip joint effusion on ultrasound are especially suggestive for the development of osteonecrosis, as they were registered in all of our patients. The presence of these two factors necessitates patient referral for an MRI scan of the hips, in order that AVNFH be detected timely.References[1]Petek D, Hannouche D, Suva D. Osteonecrosis of the femoral head: pathophysiology and current concepts of treatment. EFORT Open Rev. 2019 Mar 15;4(3):85-97.[2]Kerachian MA, Séguin C, Harvey EJ. Glucocorticoids in osteonecrosis of the femoral head: a new understanding of the mechanisms of action. J Steroid Biochem Mol Biol. 2009 Apr;114(3-5):121-8.Acknowledgements:NIL.Disclosur of InterestsPLAMEN TODOROV Speakers bureau: speaker at national level for AbbVie, Novartis and UCB, Lily Mekenyan: None declared, Anastas Batalov Speakers bureau: Speaker at national level for AbbVie, Novartis, Pfizer, Stada, Elly Lilly.
ABSTRACT
BackgroundThe Covid-19 pandemic has put patients with rheumatic diseases in front of a number of obstacles that had to be solved together with Bulgarian rheumatologists. The lockdowns and restrictive measures have made it difficult for people with rheumatic diseases to have access to timely hospital and pre-hospital care. A number of digital solutions have been implemented to address these issues.ObjectivesTo highlight the problems that patients with rheumatic diseases had during the Covid-19 pandemic;access to rheumatologists and the effectiveness of hospital and pre-hospital care during the pandemic, access to treatment, changes of treatment;communication between physicians and patients, the impact of the pandemic on work, social contacts, hobbies.MethodsAn anonymous survey was conducted online and by telephone. The survey was developed by Medical university, Plovdiv, University hospital "Kaspela”:, Plovdiv, Bulgarian Association for Musculoskeletal Ultrasound, Bulgarian organization for people with rheumatic diseases;Association for patients with autoimmune diseases.Number of participants: 1205 patients with RMD's.Age range: 18-82ResultsFace to face meetings with doctors have been limited during the pandemic.Visits to the rheumatologist's office are significantly reduced and phone, email, text messaging, online consultations were preferred as communication channels.Before the pandemic, 76% of respondents most often communicated with their physicians by visiting their practice, during the pandemic their relative share decreased to 46%, with a significant difference of 30%Phone consultations: patients using this type of communication increasing from 38% before the pandemic to 56% during the pandemic, a significant difference of 18%The percentage of patients who communicated via text or email rises from 10% to 17 %.It has become apparent that Digital transformation is needed and patients and physicians should work together to achieve it and to be established in Bulgaria.245 patients reported a change in their treatment. Of these: (30%) reduced the dose of their medications, 119 (49%) increased the dose and the remaining 55 (21%) stopped their therapy.From the responses of the respondents, it is clear that 71% have not experienced a change in their work during the COVID-19 pandemic, 17% have worked from home.From the responses of the respondents, it is clear that 71% have not experienced a change in their work during the COVID-19 pandemic, 17% have worked from home, 4% have been fired, 3% have left their jobs due to the risk of their health and 5% left their jobs for other reasons.ConclusionThe Covid-19 pandemic has shown that the digital transformation in rheumatology care can be an efficient alternative to some of the services offered to patients with rheumatic diseases in Bulgaria (especially secondary examinations and therapy monitoring examinations). The results of the conducted survey could be used to support digitization in healthcare in Bulgaria.Very important was the collaboration between the patient organizations and the Bulgarian Association for Musculoskeletal Ultrasound, Medical University, Plovdiv and the rheumatologists from University hospital "Kaspela” Plovdiv.References[1]Gianfrancesco M, Hyrich KL, Al-Adely S, et al. Characteristics associated with hospitalisation for COVID-19 in people with rheumatic disease: data from the COVID-19 Global Rheumatology Alliance physician-reported registry. Ann Rheum Dis 2020;79: 859–66.[2]Monti S, Balduzzi S, Delvino P, Bellis E, Quadrelli VS, Montecucco C. Clinical course of COVID-19 in a series of patients with chronic arthritis treated with immunosuppressive targeted therapies. Ann Rheum Dis 2020;79: 667–68.[3]Dejaco, C.;Alunno, A.;Bijlsma, J.W.;Boonen, A.;Combe, B.;Finckh, A.;Machado, P.M.;Padjen, I.;Sivera, F.;Stamm, T.A.;et al. Influence of COVID-19 pandemic on decisions for the management of people with inflammatory rheumatic and musculoskeletal diseases: A survey among EULAR countries. Ann. Rheum. Dis. 2020AcknowledgementsBul arian organization for people with rheumatic diseases.Association for patients with autoimmune diseases.Bulgarian Association for Musculoskeletal Ultrasound.Disclosure of InterestsNone Declared.
ABSTRACT
Introduction: The COVID-19 pandemic has undoubtedly affected all aspects of the spiritual and material worlds' but it had a significant impact on the health and lives of people with chronic illnesses such as the rheumatological ones. The specific course of the rheumatological diseases' as well as medication used for them influence the course of all infections' including COVID-19 in this population. The data presented so far on the frequency of COVID-19 infection in patients with various rheumatological diseases are contradictory depending on the underlying rheumatological disease' the underlying basic therapy and the studied population. A study on the incidence of COVID-19 in patients with rheumatic diseases in Bulgaria has not been conducted so far and the data obtained would help to better monitor patients and optimize treatment algorithms in the context of the COVID-19 pandemic. Materials and methods: With the help of a specially created standardized questionnaire and electronic platform' an online survey was conducted for the period March-July 2021. 1205 patients with rheumatological diseases were interviewed' with a mean age of 47 ± 12.74 years' in the range of 18 to 82 years of age. The majority of respondents (93%) reside in Bulgaria and 7% abroad. Among the respondents' women significantly prevail (77.60%)' P < 0.001. Results: The results of the survey show 28.80% incidence of COVID-19 infection among respondents with a rheumatological diagnosis. The majority of patients (85.60%) were treated at home and only 1.20% were in intensive care units. Among the drugs for rheumatological diseases' the most commonly taken are corticosteroids (n = 345)' NSAIDs (n = 332)' methotrexate (n = 253)' antimalarial/hydroxychloroquine (n = 193) and biological drugs with JAK inhibitors (n = 537). People with mild or moderate infection accounted for 81% of patients' 13.50% had severe and 3.50% very severe form of the disease. These facts largely explain the lack of a significant relationship between the severity of COVID-19 disease' the types of rheumatological drugs' access to them' and the visit to a rheumatologist during the pandemic. Conclusion: From the conducted survey only the presence and number of concomitant diseases showed a significant association with the severity of COVID-19 infection. Ischemic heart disease' heart failure' lung disease and hypertension have emerged as the most common comorbidities in patients with very severe form of the COVID disease.