Real-World Single-Centre Experience of Jak Inhibitor Use in Ra

Background/Aims The use of Janus Kinase Inhibitors (JAKi) has been gradually increasing overtime in the management of rheumatoid arthritis (RA) and other inflammatory arthritis and these appeal to patients. being oral agents. Nevertheless, rheumatologists have become cautious about their use since recent trials have shown safety concerns about VTEs, MACE and malignancies. Methods We decided to study use of JAKi at our centre in Princess of Wales Hospital Bridgend. The aim was to assess whether appropriate patients were selected (considering cautions about MACE, VTEs and malignancies). We also wanted to see whether all patients had required pretreatment safety testing and post-treatment monitoring performed. Results These were 70 patients;59 were females and 11 were males. All of them were diagnosed as RA. Average age was 61.1 years (20-85), average duration of disease 129.9 months (16-340) and average duration of treatment was 58.1 weeks. The most common JAKi being used was baricitinib (84%) followed by tofacitinib (12%) and upadacitinib (4%). 50% patient were on concomitant csDMARDs among whom two-thirds were on methotrexate. Looking at previous biologic use, 9 patients were biologic naive, 22 had one biologic, 15 had two biologics used in the past. All patients were appropriately selected (severe RA and no significant risk factors for MACE, VTEs and malignancies). All patients had pre-treatment Hepatitis B, Hepatitis C, latent TB, FBC and LFTs checked. All patients had FBC and LFTs monitored post treatment. No patient developed VTE, MACE or cancer on treatment. 84.2% patients had lipids tested before starting JAKi. 22.8% patients had abnormal lipids before Rx initiation and 62.5% of these were on lipid lowering Rx. All patients had lipids tested post treatment, but the timing was quite variable and only 62.5% of patients had lipids tested on the recommended time. There were 2 deaths recorded in this cohort. One of those was an 80-year-old RA patient on baricitinib 2mg OD, who died due to chest infection on the background of ILD. He was not on steroids or csDMARDs. The second patient was 63 years' old (on baricitinib 4mg OD), and died due to respiratory sepsis, and was also on azathioprine. She had RA with advanced ILD. The reasons for discontinuing JAKi were inefficacy (46%), side effects (39%) and both inefficacy and side effects (15%). 41.4%of patient experienced side effects due to JAKi. These included infection 28%, deranged lipids 17%, cytopenia 14%, deranged LFTs 14%, GI side effects 10%, skin rash 7% and varicella zoster 3%. Conclusion There has been steady increase in the use of tsDMARDs for RA and other rheumatic conditions. Due to short half-life, these drugs became a popular choice during COVID-19 pandemic but on the other hand safety monitoring became extremely challenging during this time.

'Forgotten issue': Living and caring for people with chronic breathlessness

Introduction: Breathlessness is a common symptom in clinical practice and in many prevalent diseases including chronic obstructive lung disease (COPD), asthma, heart failure, lung cancers and post COVID-19 syndrome. Understanding patients' experience of living with breathlessness, their expectations of care and self-management needs is essential to support development of health services and resources that meet their needs. Aim(s): To explore the perspectives of patients and their careers, on living with chronic breathlessness, provision and quality of medical care, and accessing information and resources to assist self-management. The study also explored their views on three evidence-based breathlessness patient education materials (PEMs). Method(s): Qualitative study involving in-depth semi-structured interviews with 16 patients living with chronic breathlessness (>=2 weeks) and their careers. Topics explored included: (1) experience living with breathlessness;(2) current medical care experience and their expectations;and (3) self-management resources, needs and views on some current publicly available PEMs. Result(s): Fourteen patients (cardiac, respiratory, and non-cardiorespiratory) and two carers (50% female) were interviewed (mean age 57 years). Twelve main themes were identified - (1) Breathlessness controls their lives, (2) Breathlessness avoidance and the vicious cycle, (3) Coping vs Fatalism, (4) Feeling misunderstood by their surroundings and health providers, (5) Diagnostic delays, misdiagnosis, and knowledge gaps, (6) Discontinuity of care, (7) Focus on pharmacologic management of breathlessness, (8) Demand for choice, non-pharmacologic options and support, (9) Beyond curing disease: symptom relief and improving quality of life as a goal, (10) Being more aware and in control of their disease, (11) Self-management and limited support for it, and (12) Resources they would value. Conclusion(s): Breathlessness remains a neglected condition in Australia. Patients suffer from lack of clinician and community awareness, discontinuity of care, and too few clinical and self-management options.

Perceptions of telemedicine in specialist outpatient services

Introduction/Aim: COVID-19 has fast-tracked changes to healthcare delivery, including the introduction of a broad range of telehealth services. Work is needed to assess the ongoing suitability of telemedicine for the post-pandemic era. We sought to explore perceptions of telemedicine amongst patients and providers (clinicians and health administrators) who had appointments in cardiology, respiratory, neurology, rheumatology and gastroenterology services in hospital specialist outpatient clinics in Sydney Local Health District. Method(s): Semi-structured interviews explored perceptions of consultations undertaken virtually compared to in-person, seeking perspectives on the benefits, limitations and risks of outpatient telemedicine consultations. The 37 participants comprised 16 patients, 14 specialists, 3 Clinical Nurse Consultants and 4 administrators. Result(s): Patients indicated satisfaction with telemedicine consultations, especially during the pandemic. They valued saving on travel time and costs, and being able to access care from their homes, thereby minimising risk of COVID exposure. The chief disadvantage perceived by patients was inability to receive a physical examination. They noted greater challenges for people with hearing and visual impairments, limited digital skills and/or computer access. Providers' perceptions were more ambivalent. Although telehealth was understood to help meet demands during the pandemic, mis- and under-diagnoses were considered major concerns arising from the inability to perform physical examination. Most regarded telemedicine as an effective tool for review appointments but mentioned an associated increased workload. All participants mentioned the need for relevant education and training, better integration of telemedicine platforms into existing infrastructure and the need for a hybrid model of care. Conclusion(s): Telemedicine played a unique role in meeting patients' needs during the pandemic and its convenience was valued by patients. Clinicians expressed concerns about missed diagnoses, uncertain clinical outcomes, lack of administrative and technological infrastructure. The ultimate test of telemedicine will be its impact on clinical outcomes versus longstanding models of in person care.

Impact of breathlessness on quality of life and healthcare use in Australia

Background and Aim: This study aimed to understand the impact of breathlessness on quality of life, productivity loss and healthcare use of Australian adults. Method(s): The National Breathlessness Survey was a nationwide cross-sectional web-based survey in Oct 2019, recruiting Australians aged >=18 years stratified by age-group, gender and state of residence. Severity of breathlessness using the modified Medical Research Council (mMRC) dyspnoea scale (0-5), quality of life (QoL) using EQ-VAS and EQ-5D-5L, and healthcare use (HCU) and productivity loss associated with having a "breathing problem" in the past 12 months were analysed. Quintile regression was conducted to analyse QoL and binary logistic regression for HCU and productivity loss outcomes. Effect sizes were adjusted for age, gender, Indigenous background, self-reported heart and lung disease, high PHQ-4 score, multimorbidity and smoking. Result(s): 10,072 adults completed the survey. The prevalence of clinically important breathlessness (mMRC>=2) was 9.54%. mMRC>=2 was associated with worse QoL, and greater healthcare use and productivity loss compared with mMRC=1 (Table). Despite COVID-19 impacts, similar prevalence (8.15%) and associations were seen in a repeat cross-sectional survey in December 2020 (n=10,024). Conclusion(s): Breathlessness carries a significant burden for patients, the healthcare system, and the economy.

Zoom or Gloom: The Challenges of a Virtual Internship Experience

The rise of the Covid-19 pandemic changed many facets of life for college students. College students were sent home in the middle of a semester, forced to quickly figure out how to learn virtually and take classes online that had been in-person. This change also resulted in a proliferation of virtual internships. The existing scholarship on virtual internships is sparse, leaving many questions, specifically, what makes a virtual internship "successful?” We examine this question by analyzing feedback of interns collected via a novel survey of students completing a virtual internship during Spring 2020, Fall 2020, and Spring 2021. We explore the effect of remote interning on a student's overall satisfaction with the internship experience, duties performed, technical difficulties faced while interning virtually, as well as specific factors that may improve the virtual internship experience for students. Results suggest that virtual internships can be highly successful component of student learning. We close by providing recommendations for internship coordinators interested in supporting virtual internship experiences. © 2022 Taylor & Francis Group, LLC.

Microbiological Quality of Ready-to-Eat Salad Products Collected from Retail and Catering Settings in England during 2020 to 2021.

ABSTRACT: Salad and other fresh produce were collected in England from retail and catering businesses during 2020 to 2021 and were tested for Salmonella, Shiga toxin-producing Escherichia coli (STEC), Listeria, Bacillus cereus, and E. coli. Of the 604 samples collected, 57% were from retail settings and 43% were from catering settings; 61% were either salad leaves or salad leaves mixed with other products. Equal numbers of samples were prepacked or loose, and 50% were refrigerated at the time of sampling. Combining results for all microbiological parameters, 84% were interpreted as satisfactory, 12% were interpreted as borderline, and 4% were interpreted as unsatisfactory. One sample (prepacked leaves, cucumber, and tomato from a caterer) was categorized as unacceptable and potentially injurious because of detection of STEC O76; no STEC from human infections in the United Kingdom matched this isolate. No Salmonella enterica was detected, but Listeria monocytogenes was recovered from 11 samples: 1 at 20 CFU/g and the remainder at <20 CFU/g. B. cereus was detected at borderline levels (103 to ≤105 CFU/g) in 9% of samples and at an unsatisfactory level (>105 CFU/g) in one sample. E. coli was detected in 3% of samples at borderline levels (20 to ≤102 CFU/g) and in 4% at unsatisfactory levels (>102 CFU/g). There was a significant association between detection of L. monocytogenes and borderline or unsatisfactory levels of E. coli. There were no specific risk profiles associated with products with the higher levels of B. cereus, STEC, or Listeria, but elevated levels of E. coli were predominantly confined to loose products from the United Kingdom collected from caterers in summer or autumn 2021 and may have resulted from relaxation of COVID-19 restrictions. Among the L. monocytogenes isolates, only one matched those from human cases and was recovered from a prepacked mixed salad from a catering business in 2021. This isolate was the same strain as that responsible for a multicountry outbreak (2015 to 2018) associated with Hungarian-produced frozen sweet corn; no link to the outbreak food chain was established.

Improving provider, patient and health systems outcomes: a qualitative analysis of Project ECHO

Background Project ECHO (Extension for Community Healthcare Outcomes) is an internationally recognised tele-mentoring intervention that has been implemented in over 40 countries. The model connects specialist healthcare providers (hubs) with providers in primary and community practice (spokes), often in rural and isolated areas. Objectives Project ECHO aims to improve healthcare provider's skills, confidence and knowledge, and to create a community of practitioners using the hub and spoke model. Analysing interview data from 27 Project ECHO network leads and participants in Northern Ireland, this study sought to assess the impact of Project ECHO on improving provider, patient and health system outcomes. Results Having access to a specialist, a space to share experiences, and being able to disseminate up-to-date best practice were all cited as improving provider knowledge. Providers described improved outcomes for patients such as receiving a new treatment or an efficient referral. Providers reported being more confident in managing patients and thus were less likely to refer unnecessarily, and links between providers at primary and secondary levels being improved. ECHO was deemed an acceptable methodology in terms of format and in improving access to education and training by removing geographic barriers and reducing time barriers. Conclusions This is one of the first studies to qualitatively analyse outcomes across a number of different ECHO networks, and involving both health and social care networks. The results indicate the benefit of ECHO in improving provider, patient and healthcare outcomes. This has implications for future resourcing decisions, particularly within the context of COVID-19 in which virtual and online training is necessitated by social distancing requirements. This study has implications for wider international contexts in which ECHO may be piloted to address similar challenges. Key messages Participants across our study described Project ECHO as having a positive impact on provider, patient and health systems outcomes. Project ECHO was described as an acceptable approach to training and education that improved access through removing geographic barriers.

Comparison of a roche total antispike semiquantitative assay against both a SARS-CoV-2 plaque reduction neutralization assay and a surrogate neutralization assay

Background/Case Studies: Several commercial and laboratory-developed approaches are available to quantify the level of antibodies to the spike glycoprotein of SARSCoV- 2. Plaque reduction neutralization test (PRNT)50 titers can also be used to quantify the neutralizing capacity of anti- SARS-CoV-2 antibodies in plasma. Here we describe the ability of the Elecsys anti-SARS-CoV-2 S assay (Roche, Mississauga, ON, Canada) to quantitatively determine the level of total antibodies to SARS-CoV-2 spike glycoprotein receptor binding domain in plasma specimens previously assessed by PRNT50 as well as the GenScript SARS-CoV-2 Surrogate Virus Neutralization Test (sVNT) Kit (Piscataway, NJ). Study Design/Methods: Plasma specimens were collected from blood donors that self-identified with a COVID-19 diagnosis (either SARS-CoV-2-positive nucleic acid test [NAT], or risk factors and signs/symptoms of COVID-19 disease, ≥2 weeks after cessation of clinical symptoms). 18 specimens that were previously tested by both the sVNT assay as well as by PRNT50 (National Microbiology Laboratory, Winnipeg, MB, Canada) were included in this analysis. 40 plasma specimens collected prior to November 2019 were also included in the analysis as a negative control. Specimens were analyzed using the Elecsys anti-SARS-CoV-2 S assay on the Cobas e801 analyzer (Roche, Mississauga, ON, Canada). If individual specimens were analyzed multiple times during a run, the median result in Units/ml was calculated. If specimens were further analyzed between runs, then the median between runs was calculated as the result in Units/ml. Data was stored (Microsoft Excel;Redmond, WA) and statistically analyzed (GraphPad Prism 5;San Diego, CA). Results/Findings: Of the 40 pre-pandemic specimens analyzed, all were negative for anti-SARS-CoV-2 S antibodies (<0.8 U/ml) on the Elecsys anti-SARS-CoV-2 S assay. These specimens were not orthogonally tested by other assays. Results from the other specimens tested were: Elecsys anti-SARS-CoV-2 S assay (median 63 U/ml;range 1-456 U/ml), PRNT50 (median 1:60;range 0-1:640), sVNT (median 62% neutralizing capacity;range 16-87% neutralizing capacity), PRNT50 (median 1:80;range 0-1:640). There was no correlation between the Elecsys anti-SARS-CoV-2 S assay and sVNT assays (Spearman r=0.4, p=0.1, Gaussian approximation). There was a correlation between the Elecsys anti-SARS-CoV-2 S assay and PRNT50 (Spearman r=0.8, p<0.0001, Gaussian approximation). Conclusions: This preliminary data suggests that the Elecsys anti-SARS-CoV-2 S assay may be able to act as a proxy for the quantification of neutralizing capacity in plasma specimens from individuals who have been previously infected with SARS-CoV-2.