RESILIENCE IN AN EMBODIED PERSPECTIVE: THE IMPACT OF INTEGRATED ARTS EDUCATION ON EXPERIENCES OF SOUTH AFRICAN PRIMARY SCHOOL CHILDREN POST COVID-19 LOCKDOWN

This article seeks to deepen knowledge about how education that integrates dance and visual arts has had an impact on supporting resilience among children in a primary school in the time of the COVID-19 pandemic in South Africa. The authors have for four years run a project in which the value of integrating dance and visual arts in different ways has been explored. The last workshop week took place in 2020 once schools had reopened after a long period of lockdown. The week included a focus on illuminating the children’s experiences of schooling during and after the lockdown. Through a hermeneutic phenomenological analysis of data collected using methods involving multi modal means of expression, it comes forth that the impact that this work has had, is that the children have learned to not just accept what is, but to question and be critical based on what they feel. They learned techniques to assist them to let go of tension and to feel and be aware of embodied sensations. They also had experiences of relating to their peers in new ways and used their imagination to create and express ideas. Based on this study it is concluded that when an embodied perspective is included in a theoretical understanding of the notion of resilience, and this perspective is implemented to guide educational practice, schools may be able to better promote environments that support resilience. © Latvian Academy of Culture, Charlotte Svendler Nielsen, Liesl Hartman, Fabian Hartzenberg, Gerard M. Samuel, All Rights Reserved.

FAVORABLE BALANCE of BENEFIT and HARM of LONG-TERM, LOW-DOSE PREDNISOLONE ADDED to STANDARD TREATMENT in RHEUMATOID ARTHRITIS PATIENTS AGED 65+: The PRAGMATIC, MULTICENTER, PLACEBO-CONTROLLED GLORIA TRIAL

Background: Low-dose glucocorticoid (GC) therapy is widely used in RA but the true balance of beneft and harm is still unknown. Objectives: We studied the effects of prednisolone (5 mg/day, 2 years) in RA patients aged 65+, requiring adjustment of antirheumatic therapy (DAS28≥2.60). Methods: Pragmatic double-blind placebo-controlled randomized trial;all co-treatments and changes therein were allowed during the trial except longterm open label GC;Ca/D supplementation was advised in all patients. Minimal exclusion criteria were tailored to seniors. Harm outcome: the number of patients with ≥1 serious adverse event (SAE), or ≥1 'other adverse event of special interest' (other AESI). Other AESI comprised any AE (except worsening of RA) causing study discontinuation, and GC-specifc events (Table 1). Beneft outcomes: improvement in disease activity (DAS28) and joint damage progression (Sharp/van der Heijde). Longitudinal mixed models analyzed the data. Given prior knowledge we report one-sided 95% confdence limit (95%CL) and statistical tests, performed only for the main outcomes. Results: We randomized 451 RA patients in 7 EU countries, 449 received the intervention;of these 63% prednisolone vs 61% placebo patients completed 2 years of follow up. Discontinuations were similar in both groups: for AE (14%) and active disease (4%);the remainder mostly for 'trial fatigue' and covid-related access issues (20%). Mean time on study drug was 19 (SD 8) months. 70% of patients were female, mean age was 72 (max 88) years, RA duration 11 years;67% were RF+, 56% ACPA+, 96% had joint damage on radiographs: mean score 20, median 8. Mean DAS28 was 4.5. Most patients (79%) were on current DMARD treatment, including 14% on biologics;47% had previously used GC, 14% changed DMARD therapy at baseline. Patients had mean 2.1 active comorbidities, and used median 7 drugs. Beneft: Disease activity rapidly declined to stabilize after 1 year (Figure 1), and was lower on prednisolone (adjusted mean difference in DAS28 over 2 years: 0.37, 95%CL 0.23, p<0.0001). The contrast in early (3-month) response was larger in 331 patients adherent to protocol on stable treatment: mean difference in DAS28 0.62 (95%CL 0.44), more responders on prednisolone (Figure 1). Sig-nifcant time-treatment interaction in secondary analyses suggested a decrease in contrast after the frst year, most likely caused by signifcantly more changes in DMARD treatment on placebo. Joint damage progression over 2 years was signifcantly lower on prednisolone: mean 0.6 (SD 1.9) v 1.8 (6.4) score points on placebo, difference 1.2 (95%CL 0.2, p=0.02). Harm: 60% prednisolone vs 49% placebo patients experienced the harm outcome: adjusted RR 1.24, 95%CL 1.04, p=0.02;number needed to harm 9.5 (Table 1). During the study 1 vs 2 patients died, and 3 vs 0 died within 5 months of discontinuation. Per 100 patient-years, AE totaled 278 in prednisolone vs 206 in placebo patients, and the difference was most marked for infections (Table 1);these were mostly mild or moderately severe. Other GC-specifc AESI were rare without relevant differences. Conclusion: Add-on low dose prednisolone has benefcial long-term effects on disease activity and damage progression in senior RA patients on standard treatment. The tradeoff is a 24% increase in patients with mostly mild to moderate AE, suggesting a favorable balance of beneft and harm.

Effect of non-alcoholic fatty liver disease on cognition in adolescents

Background: Nonalcoholic fatty liver disease (NAFLD) is characterized by macrovesicular hepatic steatosis occurring in the absence of significant alcohol consumption or identifiable secondary causes of hepatic lipid accumulation. Estimated prevalence of pediatric NAFLD in the United States has increased from 3.8% in 1988-1994 to 10% -12 % in 2007-2018. Pediatric obesity rates have also risen, with a prevalence among adolescents 12-19 years of 21% in 2018. Cognitively, recent studies have shown an association between NAFLD and deficits in executive functioning and visuospatial domains;the etiology is uncertain but may relate to increase in pro-inflammatory cytokines and microvascular changes altering neuronal functioning and cerebral perfusion. Studies associating NAFLD and decreased cerebral volume even after controlling for cardiometabolic risk factors suggest hepatic steatosis can influence brain development. Objective: To investigate the potential association between NAFLD and neurocognitive and social/emotional health in adolescents. Methods: Study of three groups comprised of a convenience-based sample of participants, 12 to 17 years of age, recruited from an outpatient pediatric gastroenterology clinic. NAFLD Group (n=15) included youth with BMI ≥ 95th% for age/sex, hepatic ultrasound with increased echogenicity compatible with hepatic steatosis, and ALT > 2 times upper limit of normal. Elevated BMI Group (n=16) included youth with BMI ≥ 95th% for age/sex and normal ALT. Non-obese Control Group (n=15) included youth with BMI <95th % for age/ and sex normal ALT. The study included subjects proficient in English and English or Spanish speaking parent/legal guardian available to participate in the consent process. Exclusion criteria included individuals with documented causes of liver disease (e.g., known hepatotoxic medications, autoimmune hepatitis, hemachromatosis, viral hepatitis, rheumatalogic diseases), or treatment with combined hormonal contraceptives, antipsychotic or diabetic medications. Using the NIH Toolbox iPad app, subjects were administered the Sadness, Emotional Support, & Anxiety self-report measures and three performance-based cognitive tasks: Picture Vocabulary Test, Flanker Inhibitory Control and Attention Test, and Dimensional Change Card Sort Test. Statistical analyses of primary outcome measures included one-way ANOVAs, unpaired Student's t-tests, and Pearson correlations to assess relationships between dependent and independent variables. Results: No significant group differences for demographics, social/emotional outcomes, vocabulary test, or dimensional card sort test were observed. ANOVA of the Flanker Test of Inhibition and Attention was significant (p= 0.047), and post-hoc t-tests revealed Elevated BMI group scored significantly lower than the non-obese controls (p=0.03). Pearson correlation analysis of the total study sample revealed a significant inverse relationship between BMI and Flanker Test (r= -0.38, p <0.001). Exploratory analysis revealed a significant increase in BMI of study subjects enrolled following onset of COVID-19 pandemic (n=22) compared to subjects enrolled pre-pandemic (n=23), p= 0.03. Conclusions: We found no significant difference in social/emotional health or cognitive functioning between adolescents with NAFLD and those without NAFLD from our pediatric GI clinic. However, adolescents with elevated BMI (without NAFLD) performed significantly below non-obese controls on a measure of attention and inhibition. We also found a significant inverse relationship between BMI and attentional processing and inhibition for our overall adolescent sample. These results are consistent with studies reporting lower cognitive function in obese adults and improved neurocognitive outcomes in adults following bariatric surgery. Studies with children and adolescents are limited but our data support findings from a previous adolescent study citing a negative correlation between elevated BMI and cognition. Our study adds to a growing body of research in pediatric populations. tudy limitations include potential impact of confounding variables, namely the environment in which the cognitive tests were administered -a busy outpatient GI clinic- as well as possible inclusion of undiagnosed NAFLD patients in the elevated BMI group, as our study included a mix of both newly referred patients and established patients. Interestingly, we must also consider and further explore the potential impact of COVID-19 pandemic, as across all three of our study groups, pre-pandemic patients had a lower BMI compared to patients enrolled during the pandemic.

Nurse and nurse practitioner-lead monoclonal antibody initiative for solid organ transplant (SOT) recipients with COVID-19

Purpose: Monoclonal antibody (mAB) infusion (bamlanivimab or casirivimab/ imdevimab) for symptomatic, non-hypoxemic, high-risk outpatients with COVID-19 infection, is an available early intervention for COVID-19+ SOT recipients. We aimed to assess efficiency in time from diagnosis to treatment, and outcomes in a retrospective cohort of SOT recipients with COVID-19 who received mAB. Methods: We developed a Nurse Coordinator-led initiative to screen, refer, and facilitate mAB infusion for COVID-19+ SOT recipients within 10 days of symptom onset. SOT recipients received electronic messaging to promptly report potential COVID-19 symptoms to the transplant team. Data were collected on time from symptom onset to diagnosis, mAB infusion, and follow-up > 21 days, and hospital admissions, disease severity, mortality, and rejection. Results: 34 out of 36 referred SOT recipients with symptomatic COVID-19 disease without hypoxia received mAB therapy (3 heart, 8 lung, 16 kidney, 2 Liver-Kidney, 2 Pancreas-Kidney, 3 Kidney-Heart). Median time from symptom onset to diagnosis was 2 days and from date of diagnosis to mAB infusion was 4 days. Of those 34, 88% did not require hospitalization and recovered uneventfully. 12% required hospitalization for COVID disease progression, two on the same day as mAB infusion, and the other 2, more than 26 days post infusion. Of these, 2 patients had mild-moderate hypoxia, and 2 had critical disease. Only 1 patient died from COVID-19 complications and no episodes of rejection or graft loss were observed. Conclusions: The Nurse Coordinator-led initiative efficiently facilitated mAB therapy for COVID-19+ SOT recipients and was associated with excellent outcomes. Compared to prior published COVID-19 outcomes in SOT recipients, patients who received mAB may have reduce hospitalization and low mortality. As mAB therapy may be underutilized in the general population, these results support efforts to educate transplant centers to implement efficient interventions for the screening and referral of COVID+ SOT recipients for mAB therapy.