An educational mobile health application for pulmonary rehabilitation in patients with mild to moderate COVID-19 pneumonia

There is an urgent need for individuals with mild to moderate COVID-19 pneumonia to learn and apply the recommended interventions for pulmonary rehabilitation. In the health literature, various studies showed that mobile health (m-health) applications play an important support role in managing health and coping with diseases. However, there is no m-health application yet for pulmonary rehabilitation specifically designed for COVID-19 patients. This chapter reports the development of "Covid Breathe" and its evaluation in terms of feasibility, safety, and effectiveness. A hundred patients with mild to moderate pneumonia were randomly assigned to control and intervention groups. While 88% of the patients reported being very satisfied with the m-health application, no statistical difference in patient satisfaction between the groups was reported. Nevertheless, there was a statistically significant improvement in Modified Borg Scale, Dyspnea Score, and Hospital Anxiety and Depression Scale parameters. The usage of this m-health app is therefore recommended for pulmonary rehabilitation. © 2023, IGI Global. All rights reserved.

Hand hygiene habits and hand eczema prevalence of healthcare workers during the COVID-19 pandemic

Aim: Hand hygiene has become an important building block in the prevention of the spread of coronavirus disease 2019 (COVID-19). The current study was conducted to determine the hand hygiene habits of healthcare workers and possible risk factors for hand eczema during the COVID-19 pandemic. Materials and Methods: The hand hygiene habits of healthcare personnel working at a university hospital since COVID-19 pandemic started were questioned between December 2020 and February 2021 and they were dermatologically examined to screen for hand eczema.

Did Dermatological Hospital Referrals and Practice of Dermatologists Change in Between Pre-covid and Covid Era? A Short-term Preliminary Evaluation

Objective: In this descriptive study, we aimed to evaluate features of dermatology referrals before and after Covid-19 pandemic. Materials and Methods: The patients referred to dermatology outpatient clinics of Acibadem Group Hospitals in Istanbul between the time intervals 2019 March 1st and August 31st (Group G1) and 2020 March 1st and August 31st (Group G2) were included in this study. G1 and G2 groups were compared in terms of age, gender, mean duration of complaints, the most common five anatomic regions and the most common five dermatoses. Results: Referral rate after Covid-19 pandemic was decreased by 40%. Face (p=.0013, OR= 1.20, 95% CI=1.07-1.34), scalp (p=.02, OR=1.23, 95% CI=1.02-1.48) and hand (p=.04, 95% OR=1.24, 95% CI=1.00-1.54) were more common locations in 2020 (group G2) than in 2019 (G2 group). The most common five dermatoses were contact dermatitis (8.3%), acne (8,1%), wart (7,0%), seborrheic dermatitis (5,7%) and pyoderma (5,5%) in G1 (2019), while the order was contact dermatitis (10,6%), acne (7,5%), seborrheic dermatitis (6,5%), wart (6,4%) and pyoderma (4,9%) in G2 (2020). Contact dermatitis showed a significant increase after pandemic (p=.0017, OR=1.29, 95% CI=1.10-1.51). In 2020, psoriasis and lichen planus showed a two-fold increases (P <.001, OR=2.00, 95% CI=1.43-2.79 and p=.03, OR=1.92, 95% CI=1.09-3.38, respectively), whereas frequency of molluscum contagiosum decreased significantly (p=.03, OR=0.49, 95% CI=0.26-0.92). Conclusion: Although we found some remarkable results, relatively short-term period design with the limited patient population of this study needs to be verified in more comprehensive studies.

Clinical course of COVID-19 in children with rheumatic disease under biologic therapy from Turkey

Introduction: What a biological disease-modifying antirheumatic drugs (bDMARDs)? and/or underlying rheumatological diseases, which we frequently use in our pediatric rheumatology practice, affect the clinical course of COVID-19 has not been fully demonstrated. Objectives: Here, we aimed to reveal the course of COVID-19 infection in patients with rheumatic disease and receiving bDMARD treatment. Methods: This was a retrospective, multicenter study in patients with a biological treatment had been initiated. This real-life study is based on secondary data collection from medical records of patients evaluated at the 14 Pediatric Rheumatology Clinics in Turkey from April 2020 to April 2021. The diagnosis of COVID-19 was confirmed in 101 patients by nasal PCR and in 10 patients by antibody test. Results: The study population of 112 patients consisted of 70 females (63.6%). The mean age of patients was 12.87 ± 4.69 years. The primary diagnosis of patients was as follows;59 juvenile idiopathic arthritis, 33 systemic autoinflammatory diseases, 10 vasculitis, 8 connective tissue diseases. The mean duration of primary disease was 4.62±3.65 years. Nineteen patients had also additional comorbid diseases (hypertension, Chron's disease, hereditary spherocytosis, and chronic renal failure, astma, cardiomyopathy, adrenal insufficiency in individual patients). Prior to COVID-19 infection, 35 patients (31.8%) were using canakinumab, 10 were infliximab (9.1%), 25 were adalimumab (21.8%), 18 were etanercept (16.4%), 9 were tocilizumab (8.2%), 4 were anakinra (3.6%), 6 were rituximab (5.5%), 1 was abatacept (0.9%), and 3 was tofacitinib (2.7%). The median exposure time of a biologic drug was 13.5 months. Additionally, 66 patients were using DMARD, and 27 patients were also receiving corticosteroid. 70 (63.6%) patients had at least one COVID-19-related symptom (fever, cough, diarrhea, myalgia, anosmia and/or rash), while 40 (36.4%) patients were asymptomatic. Respiratory findings were seen in 26% of all patients, 7 patients also had pathology in computed tomography. Hospitalization was required in 25 patients (22.7%) at median of 6 days (IQR: 4-10). Five patients developed MIS-C and 2 of these patients were followed up in the pediatric intensive care unit. Laboratory tests revealed that fourteen patients had elevated acute phase reactants, ten had elevated D-dimer levels, 5 had lymphopenia (< 1000/mm3), and five had hyperferritinemia. Conclusion: In patients with underlying comorbidities, COVID-19 can have a severe course regardless of the use of bDMARD. In the light of these findings, it would not be correct to say that the currently used bDMARDs worsen the course of COVID-19 infection or to say whether they affect the severity of the disease, but still, the disease findings-modifying effects of these drugs, especially high fever and myalgia, have been observed.

Clinical course of COVID-19 in children with rheumatic disease under biologic therapy

Introduction: Comorbidities and immunosuppression are known as the risk factors for the worse course of COVID-19 infection. However, it has not been shown exactly how biological disease-modifying antirheumatic drug (bDMARD)s, used frequently in our pediatric rheumatology practice, and the underlying rheumatological diseases affect the clinical course of COVID-19. Emerge of serious infections have been reported in adults and children treated with bDMARDs. Objectives: Here, we aimed to reveal the outcome of COVID-19 infection in our patients with pediatric rheumatic disease and treated with bDMARDs. Methods: During the period between April 1, 2020, and December 1, 2020, the patients who received bDMARDs (N:436) were evaluated at the regular outpatient clinic follow-up or by telemedicine with a maximum of three-month intervals. Clinical and demographic characteristics, COVID-19 data, and outcomes of these patients were retrospectively collected. Results: Out of the 436 patients treated with bDMARDs, 39 children were infected with COVID-19. The diagnosis was confirmed in 37 patients by RT-PCR (nasalpharyngeal swab) and in twoby an antibody test. All patients were under biological treatment when they were diagnosed with COVID-19 or MIS-C. Twenty-two(56.4%) patients were female (17 male, %43.6) and the median age of patients were 12.3 years (min-max:1.2-20.9). The primary diagnosis of patients were as follows;20 juvenile idiopathic arthritis (JIA), 12 systemic autoinflammatory disease (SAID)s, three vasculitis, three chronic recurrent multifocal osteomyelitis (CRMO) and one Sjögren's syndrome. Prior to COVID-19 infection, 13 patients(33.3%) were using canakinumab, seven were on infliximab(18%), five were on adalimumab(12.8%), four were on etanercept (10.2%), four were on tocilizumab(10.2%), three were on anakinra(7.7%), two were on rituximab( 5.1%), and one was on tofacitinib(2.6%). Additionally, 14 patients were using conventional DMARD, 12 were colchicine, two were mycophenolate mofetil and one was cyclosporine. Of the 39 patients, 21 had at least one COVID-19-related symptom, while 18 patients were asymptomatic. Laboratory tests revealed that fourteen patients had elevated acute phase reactants, six had elevated D-dimer levels, three had lymphopenia (<1000/mm3), and three had hyperferritinemia. Viral pneumonia compatible findings were detected in three of nine patients who underwent computed tomography. Hospitalization was required in 20 patients(51.3%) at median of 7- days (min-max: 3-17) and pediatric intensive care unit admission in one. Five patients developed MIS-C and one of these patients was followed up in the pediatric intensive care unit. Myocardial dysfunction was developed in one patient and he died despite treatments. This patient had a previous case of macrophage activation syndrome (MAS) attack and was diagnosed with systemic JIA. The other four patients fully recovered with no remaining morbidity. Conclusion: Considering the literature data and the results of our study, it is not possible to say that currently used bDMARDs worsen the course of COVID-19 infection. Whether bDMARDs does not affect the severity of the disease, but it is still not true to say that these drugs are protective. Since the cessation of bDMARDs for COVID-risk may cause exacerbation of the primary rheumatic disease, continuing with current treatments seems an appropriate approach. In a patient treated with bDMARD during the active COVID-19 infection period, it may be considered to interrupt the biological treatment on a patient basis by the current biological agent, primary disease status, and clinical findings of COVID-19 infection, according to ACR and PReS recommendations.

Clinical course of COVID-19 in children with rheumatic disease under biologic therapy. (Special Issue: Letter to editor rheumatology: commentaries and controversies.)

This study aimed to reveal the outcome of COVID-19 infection in our patients with paediatric rheumatic disease and treated with bDMARDs in the Paediatric Rheumatology clinic, Umraniye Training and Research, Turkey. During the period between April 1, 2020, and December 1, 2020, the patients who received bDMARDs were evaluated at the regular outpatient clinic follow-up or by telemedicine with a maximum of three-month intervals. Out of the 436 patients treated with bDMARDs, 39 children were infected with COVID-19. When the patients were diagnosed with COVID-19, depending on the severity of the COVID-19 symptoms and the type of bDMARD being administered, the use of bDMARDs were ceased according to the ACR and PReS recommendations on a patient basis. There were COVID-19 positive patients in the families of our 30 patients. Looking at the distribution of underlying systemic disease and treatments in patients with MIS-C, one patient had CRMO with etanercept treatment, one had DADA-2 and was on infliximab, one had undefined SAID and was on tocilizumab, and two had system ic JIA and being treated with anakinra or canakinumab. There is a limited number of studies in the literature on the clinical course of COVID-19 infection in patients with paediatric rheumatic disease who re ceived bDMARDs. To the best of our knowledge, our study is the largest series of children with rheumatic disease in the literature who received bDMARDs and diagnosed with COVID-19 infection. COVID-19 infection related symptoms were not observed in nearly half of the 39 patients who were under bDMARD treatment. In patients with underlying risk factors for hyperinflammation, as in one of our patients, COVID-19 may cause mortality regardless of the use of bDMARDs.

Performances of the risk factors and pediatric vasculitis activity scores for disease severity in children with multisystem inflammatory syndrome

Background: Multisystem Inflammatory Syndrome in Children (MIS-C) is observed by hyperinflammation and cytokine storm. The spectrum of severity ranged from standard hospitalization to pediatric intensive care unit management. There is no specific activity score that predicts whether this hyperinflammatory state will be severe or result in mortality in pediatric patients. There are activity scores used in KD and other vasculitis such as Kobayashi score (KS) and Pediatric Vasculitis Activity Score (PVAS) that determine the severity of the disease in children. Objectives: Based on the clinical similarity of MIS-C to these disease groups, we wanted to evaluate the performance of these disease activity scores. Also, we aimed to identify the factors associated with the disease severity of patients with MISC Methods: We retrospectively enrolled a single-center cohort of 45 consecutive pediatric patients with MISC admitted to Umraniye Training and Resrach Hospital, Pediatric Rheumatology Clinic, Istanbul, Turkey, from April 20 to December 31, 2020. Medical information of each patient including demographic data, clinical characteristics, laboratory results, and outcomes was extracted retrospectively through review of electronic medical records. We analyzed all score systems including KS, PVAS, NLR, cHIS, and C-reactive protein/albumin ratio (CAR) as assessment factors for diagnosis for severe disease and evaluation of disease activity in MISC. All scores were compared between two groups and receiver operating characteristic (ROC) curve analysis was performed to evaluate diagnostic utility. Results: We reported 45 patients (10 female, 35male) with MISC. Their mean age was 9.65±4.93 years (7 months-18 years). All patients had fever (median 4 days), 71 % patients had acute gastrointestinal symptoms, 37.8 % of patient's conjunctivitis and only 5 patients had respiratory findings at admission. Twenty-four (46.7%) patients met criteria for classic KD. Macrophage activation syndrome and myocardial dysfunction with or without cardiogenic shock were seen 14 and 10 patients respectively. All the patients had positive serology for SARSCoV-2, abnormal complete blood counts and coagulation tests, and elevated inflammatory markers. We divided the disease severity into a moderate or severe group based on admission on intensive care unit (ICU). There were 15 patients with severe illness (33%). The median age of these patients was significantly older (11.3 years vs 9.16 years, p=0.05). The median hospital stay period was 10 days. The median need for intensive care was on the first day (1-14th days), and the median lasted 5 (1-9) days. The majority of MISC patients were on Intravenous immunoglobulin (IVIG) (89%), and corticosteroid (73.3%). A total of 12 patients received anakinra. In the severe group, all patients had higher values of KD, PVAS, NLR, cHIS, and CAR than the patients in moderate group. For severe MISC, the area under receiver operating characteristic curve (AUC) was 0.864 (95% confidence interval [CI], 0.729-1) for the PVAS, 0.911 (95% CI, 0.827-0.995) for the NLR, and 0.853 (95% CI, 0.744-0.963) for the CAR, with optimal cut-off values of 3.5, 9.05, and 4.86, respectively. Thirty-eight (84.4%) of the 45 patients met two or more cHIS criteria at the time of their hospitalization;39% of these patients were identified as severe group (OR 1.62, 95% CI 1.27-2.13, p=0.04). At the time of diagnosis, 29 patients with a Kobayashi score greater than 4 were detected, of which 15 required intensive care (OR 2.07, 95% CI 1.42-3.0, p=0.00). Conclusion: This study demonstrated that both inflammatory scores (CAR and NLR) and disease activity scores (KS, PVAS and cHIS) can be used to aid the assessment for severity of MISC.

Clinical course of COVID-19 in children with rheumatic disease under biologic therapy

Background: Since the beginning of the COVID-19 pandemic in our country, Turkey, more than two million people have been infected and more than 20,000 people have died. Although children infected less frequently and generally have a milder findings of COVID-19, the number of patients with a more severe clinical course as multisystem inflammatory syndrome in children (MIS-C) is increasing significantly. However, it has not been shown exactly how biological disease-modifying antirheumatic drug (bDMARD)s, which we frequently use in our pediatric rheumatology practice, and/or the underlying rheumatological diseases affect the clinical course of COVID-19. Objectives: Here, we aimed to reveal the outcome of COVID-19 infection in our patients with pediatric rheumatic disease and treated with bDMARDs. Methods: During the period between April 1, 2020 and December 1, 2020, the patients who received bDMARDs were evaluated at the regular outpatient clinic follow-up or by telemedicine with a maximum of 3 months interval. Clinical and demographic characteristics, COVID-19 data and outcome of these patients were retrospectively collected. Results: Out of the 436 patients treated with bDMARDs, 39 children were infected with COVID-19. The diagnosis was confirmed in 37 patients by RT-PCR (nasalpharyngeal swab) and in two by antibody test. Twenty-two (56.4%) patients were female (17 male, %43.6) and the median age of patients were 12.3 years (min-max: 1.2-20.9). The primary diagnosis of patients were as follows;20 juvenile idiopathic arthritis (six were systemic subtype), 12 systemic autoinflammatory diseases, three vasculitis, three chronic recurrent multifocal osteomyelitis and one Sjögren's syndrome. Prior to COVID-19 infection, 13 patients (33.3%) were using canakinumab, seven were infliximab (18%), five were adalimumab (12.8%), four were etanercept 10.2%), four were tocilizumab (10.2%), three were anakinra (7.7%), two were rituximab (5.1%), and one was tofacitinib (2.6%). Of the 39 patients, 21 had at least one COVID-19-related symptom, while 18 patients were asymptomatic. No laboratory or imaging tests was performed for asymptomatic patients and they were followed up without treatment at home isolation. Laboratory tests revealed that fourteen patients had elevated acute phase reactants, six had elevated D-dimer levels, three had lymphopenia (<1000/mm3), and three had hyperferritinemia. Hospitalization was required in 20 patients (51.3%) at median of 7-days (minmax: 3-17) and pediatric intensive care unit admission in one. Five patients developed MIS-C and one of these patients was followed up in the pediatric intensive care unit. Myocardial dysfunction was developed in this patient and he was died. The other four patients fully recovered with no remain morbidity. Conclusion: Considering the literature data and the results of our study, it is not possible to say that currently used bDMARDs worse the course of COVID-19 infection. In patients with underlying risk factors for hyperinflammation, as in one of our patients, COVID-19 may cause mortality regardless of the use of bDMARDs. Whether bDMARDs does not affect the severity of the disease, but it is still not true to say that these drugs are protective. Since cessation of bDMARDs for COVID-risk may cause exacerbation of the primary rheumatic disease, continuing with current treatments seems an appropriate approach.

SARS-CoV-2 infection in children with rheumatic disease: experience of a tertiary referral center

Background: Patients with rheumatic diseases are considered at risk for serious infections due to their immune-compromised-status set in their primary systemic disease and the usage of immune-modulating therapies. Although various results have been reported on the subject, it is still unknown whether patients with rheumatic disease, many of whom are on immune-suppression, are at higher risk of severe COVID-19. Objectives: We aim to share our clinical SARS-CoV-2 experience in patient with the childhood rheumatic disease during pandemic. Methods: We evaluated 4470 patients at our pediatric-rheumatology clinic during the pandemic, from 11-March to 15-October-2020. Demographic and clinical features, treatments, laboratory results, imaging findings, and clinical outcomes of patients diagnosed with COVID-19 and/or multisystem inflammatory syndrome (MIS-C) were review from the medical records. The data of all these patients were compared between groups and presented. A p-value <0.05 was considered statistically significant. Results: Among 4470 patients, 87 COVID-19 suspected patients were included in the study. Fifty six (64.4%) patients were hospitalized and 31 were followed without hospitalization. The most common rheumatic diseases among them were juvenile idiopathic arthritis and familial Mediterranean fever (35.6% and 34.5%). The primary disease status of these patients were;78 (89.6%) were in remission, while 9 (10.3%) had active disease at the time of COVID-19 diagnosis. Twenty six of these patients were treated with biologic DMARDs. SARS-CoV-2 infection (RT-PCR and/or antibody test) was found positive in 84 patients (96.5%). Also, fifty one (58.6%) patients had an epidemiologic contact to a person with COVID-19. Fifty six of 87 (64.3%) had a fever and 20 (23%) had a fever for five or more days. Gastrointestinal system involvement was in 11 (12.6%), the respiratory system was in 40 (46%) and fatigue was in 57 (65.5%) patients. Cutaneous involvement was seen in 5 patients including maculopapular rash in two, vasculitic rash in two, and chilblain in one patient. 63.2% of patients had increased C-reactive protein (CRP), 40.2% had lymphocytopenia (<1500/mm3) and 26.4 % had elevated D-dimer level. SARS-CoV-2 infection was confirmed in 84 patients (96.5%). The diagnosis was confirmed by RT-PCR in 74 patients and by antibody test in 10. 18 patients met the clinical criteria and diagnosed with MIS-C. Nine of them had also hypotension and seven patients admitted the intensive care unit because of shock and severe end-organ illness. COVID-19 outbreak also caused exacerbation of systemic disease in 56 children due to a discontinue of medication, postponed drug switch, or viral infection triggered. Conclusion: In conclusion, children with rheumatic disease do not appear to present a higher risk of severe COVID-19. Whether these patients receive biological treatment does not affect the severity of the disease, but it is still not true to say that these drugs are protective. The immunosuppressive treatments can be adjusted in case of infection, otherwise it is not recommended interrupt the treatments. Physicians should be cautious about the hyperinflammatory syndrome associated with COVID-19 in rheumatic children, which may be severe in this group of patients and may be confused with primary diseases.

Examining Teachers’ Opinions Related To Distance Education In The Covid-19 Process

In this study, it is aimed to examine the opinions of teachers regarding the distance education activities in primary school in Covid 19 process. The research is designed as a case study. In the research, an open-ended questionnaire form was used as a data collection tool. The data obtained were analyzed with content analysis. Typical case sampling method was used in the study. The study group of the research consists of 44 teachers working in different primary schools. According to the results of the research, teachers carried out educational activities such as preparing for distance education, sharing with students, giving online lessons, communicating with parents and students, and monitoring students during the Covid-19 process. Teachers carried out distance education activities by using computer, internet, communication tools and various messaging programs, communicating with parents and students, directing and following students, and using EBA and various online platforms. They evaluated the training activities in the Covid-19 process in three different ways: satisfactory, inconvenient and limited. They encountered problems related to infrastructure, participation, planning, communication, uncertainty and EBA platform in distance education activities. They made suggestions about the infrastructure of the EBA platform, preparation for the process, planning of the process, content used in education and implementation of the activities. © 2020. All Rights Reserved.