ABSTRACT
Background and Aim: Patients receiving infliximab maintenance therapy for inflammatory bowel disease (IBD) now have the option to switch from intravenous (IV) to subcutaneous (SC) infusion. Self-administered SC infliximab has already shown comparable efficacy to IV infliximab in relation to maintaining clinical and endoscopic remission. Furthermore, in the COVID-19 era, safe hospital avoidance is important in this immunocompromised cohort. Any clinician or patient hesitancy to switch to SC administration may be in part due to concerns about reduced serum trough levels achieved when compared with IV administration. All patients with IBD in our center are given the choice to transition from IV to SC administration if adherence is considered likely. We aimed to compare the infliximab serum trough levels of patients before and 3 months after transitioning to SC infliximab. Method(s): We prospectively entered data as we transitioned a cohort of 11 patients from IV to SC infliximab. Data collected included trough infliximab levels before and >=3 months after transitioning to SC administration, IBD phenotype, biometric data, C-reactive protein level, infliximab antibody formation, peak disease severity, endoscopic remission rates, calprotectin levels before and after transition, remission maintenance, and flare rates in both cohorts. Result(s): We recorded data for 11 patients, and preliminary findings show no evidence of lower trough levels once patients transitioned to SC infliximab. We will present more detailed findings, including average change in infliximab trough levels, rate of antibody formation, and disease activity rates. Conclusion(s): We found that almost all patients who transitioned to SC infliximab had the same, if not higher, serum trough levels when compared with IV infliximab. This should help reassure clinicians and patients who are considering transitioning to SC administration. Given the established evidence that higher infliximab drug levels pertain to higher rates of disease remission in certain phenotypes, this may suggest SC infliximab could be more efficacious in some patients. Furthermore, as we move through the COVID-19 pandemic, safe hospital avoidance is clearly beneficial for this immunocompromised cohort.
ABSTRACT
Background: Known risk factors for child maltreatment, including parental unemployment and domestic violence (1, 2), were compounded by social isolation from school closures and restriction of home visitors during the COVID-19 lockdown. Data on the incidence of child maltreatment during the pandemic is limited. Aim: Our study aimed to compare the incidence of and characterize the types of child protection concerns among inpatients during the 2020 lockdown versus the same period in 2019. Methods: We carried out a retrospective chart review of inpatients at Children's Health Ireland (CHI) at Crumlin and CHI at Tallaght assessed for child protection concerns during the lockdown from March 13 to August 31, 2020, and the same timeframe in 2019. Results: Fewer patients with child protection concern were admitted in 2020 (n=86) compared to 2019 (n=163). Total admissions were also less in 2020 (n=4609) compared to 2019 (n=7728). Patients assessed for child protection concerns accounted for a smaller percentage of inpatients in 2020 (1.8% versus 2.1% in 2019 (p=0.35)). In 2020, there was a greater percentage of physical (52.3% versus 11% in 2019 (p<.001)) and emotional (6.9% versus 1.2% in 2019 (p=0.014)) abuse concern cases. There was also a greater percentage of neglect and sexual abuse concern cases and a lower percentage of welfare concern cases in 2020, but these differences were not statistically significant. The cases in 2020 were more complex, with 48.8% involving more than one concern type per case versus 13.4% in 2019 (p<.001). Child protection concerns increased steadily during the lockdown, peaking in July. In 2020, there were more unwitnessed injuries (34.8% versus 17.7% in 2019 (p=.002)) and parental use of physical discipline (6.9% versus 0.6% in 2019 (p=.003)). No statistically significant differences in delayed presentation and domestic violence were observed. Conclusions: While fewer inpatients were assessed for child protection concerns during the 2020 lockdown versus 2019, the 2020 cases were more complex. An increase in physical and emotional abuse concerns, unwitnessed injuries and physical disciplining highlights child protection issues specific to the pandemic.
ABSTRACT
Introduction: The COVID-19 pandemic increased the volume of critically ill patients in hospital. Healthcare professionals (HCPs), many of whom had limited experience of communicating bad news to relatives, needed to be able to do this and often by telephone. Aim: To design, deliver and evaluate a simulation based course to help HCPs communicate about death and dying by telephone during the pandemic. Methods: In March 2020 a multi-professional group of clinicians and educators developed a 2-hour, socially distanced communication skills course for HCPs in our Trust. Courses ran through March-June 2020, each course facilitated by 3-5 faculty. The course taught the 'SPIKES' structure for breaking bad news (BBN), using it to critique a pre-recorded conversation and role play of simulated scenarios, with faculty feedback. Participant confidence (using 1-5 scale) was assessed by pre and post course questionnaire, and analysed by descriptive statistics. Qualitative feedback was from participant questionnaires and thematic analysis of a faculty focus group. Ethical approval was gained. Results: 79 HCPs attended a course;55 gave feedback: nurses (24), doctors (21), allied health professionals (10). There was significant improvement in participant confidence in having a communication structure for BBN (mean change 1.69 (CI 1.94,1.44), p=0.03);applying SPIKES to BBN by telephone (mean change 1.82 (CI 2.05,1.59), p=0.005);giving and seeking feedback to improve communication (mean change 1.55 (CI 1.79,1.3), p=0.012). Qualitative data indicated excellent engagement and relevance beyond the pandemic. A faculty focus group identified key themes: applicability post COVID-19, greater openness to communication challenges, and awareness of emotionality in practice. Conclusion: An innovative course developed during the COVID-19 pandemic demonstrated improved HCP confidence in communicating bad news. Skills taught are applicable post pandemic and will inform further course development.
ABSTRACT
Background and Aim: The correlation between non-invasive fibrosis scores and histological liver fibrosis is well established. As the availability of FibroScan is limited in geographically isolated settings and those impacted by coronavirus disease 2019 (COVID-19), we aimed to demonstrate a correlation between FibroScan median liver stiffness readings of patients with metabolic-associated fatty liver disease (MAFLD) with aspartate aminotransferase (AST) to platelet ratio index (APRI), Fibrosis-4 (FIB-4) score, and Non-Alcoholic Fatty Liver Disease Fibrosis Score (NFS). Methods:We conducted a retrospective analysis over 2 years of patients referred to the hepatology service by primary care physicians with deranged liver function test results. Data were obtained from routine clinical investigations in electronic medical records at a single Australian tertiary referral center. Data collected included FibroScan liver stiffness measurements, age, body mass index, glycated hemoglobin level, albumin level, platelet count, AST level, and alanine aminotransferase (ALT) level. The APRI, FIB-4, and NFS scores were calculated. Results: We identified 65 patients, all of whom proceeded to FibroScan and exclusion of causes other than MAFLD. Of the 65 patients, we found correlation between FibroScan and all non-invasive scores. However, as expected, there was an indirect relationship only with multiple outliers beyond the commonly used cut-offs for excluding advanced fibrosis (APRI < 0.5, FIB-4 < 1.45, NFS < -1.45). Of the 48 patients with an APRI score < 0.5, 41 (85.4%) had a FibroScan result of <8.0 kPa. Of the 54 patients with a FIB-4 score < 1.45, 47 (87%) had a FibroScan result of <8 kPa. Of the 43 patients with an NFS score < -1.454, 41 (95%) had a FibroScan result of <8 kPa (Fig. 1). Conclusion: Use of non-invasive measures of fibrosis is accurate for excluding advanced fibrosis in the population with MAFLD. Individual previously published cut-off values all correlate well with a FibroScan reading of <8 kPa;so much so that, when used together, they may be relied upon when FibroScan is unavailable. This has obvious indications in the Australian setting with regional and remote communities that have limited access to FibroScan. This is of particular value in helping to avoid hospital attendance amid the COVID-19 pandemic and is also of value in risk stratification in primary care.
ABSTRACT
Background: The effects of the COVID-19 pandemic on people living with HIV (PWH) are unknown. Beyond SARS-CoV-2 co-infection, the pandemic may have devastating consequences for HIV care delivery. Understanding these is crucial as reduced antiretroviral therapy (ART) availability alone could lead to ≥500,000 AIDS-related deaths in 2020-2021. With Latin America now a focal point in the pandemic, we sought to describe the impact of COVID-19 on HIV care at Latin American clinical sites. Methods: Caribbean, Central and South America network for HIV epidemiology (CCASAnet) and additional Brazilian HIV care sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico, and Peru were included. An electronic survey of COVID-19 effects on HIV clinic operations was administered in Spanish or English via phone and email, April 28-June 2, 2020. We also compared national COVID-19 case, mortality, and policy data from public sources. Results: Brazil's and Mexico's epidemics appear most pronounced, with >10,000 confirmed COVID-19-related deaths (Figure 1);countries implemented “social distancing” policies at different times after initial cases, with Haiti earliest and Mexico latest (Figure 2). Nearly all 13 sites reported decreased hours and providers for HIV care. Twelve of 13 reported increased use of telehealth, suspension/postponements of routine HIV appointments, and/or suspension of HIV research. Eleven of 13 reported initiation of new COVID-19 research but suspension of community HIV testing, and nearly half provided additional ART supplies. Nearly 70% reported impacts on HIV viral load testing and nearly 40% reported personal protective equipment stock-outs (Table). All 13 sites experienced changes in resources/services in tandem with national policies;there was wide variation, however, in the number of economic and health supports implemented thus far (e.g., quarantines, tax deferrals, interest rate reductions, etc.), from 172 COVID-19-related policies in Brazil to only 30 in Mexico Conclusion: The COVID-19 pandemic has already had a substantial effect on daily operations of HIV clinics in Latin America. The downstream effects of these impacts on HIV outcomes in Latin America will need to be further studied. (Table Presented).