REDUCED HEALTH-RELATED QUALITY OF LIFE USING PROMIS IN PATIENTS WITH SYSTEMIC SCLEROSIS: A CROSS-SECTIONAL ANALYSIS FROM THE INTERNATIONAL COVAD-2 E-SURVEY

BackgroundThe second COVID-19 vaccination in autoimmune disease (COVAD-2) study [1] is an international, multicentre, self-reported e-survey designed to evaluate several facets covering COVID-19 infection and vaccination as well as validated patient-reported outcome measures (PROMs) in a variety of autoimmune diseases (AIDs), including systemic sclerosis (SSc). Detailed assessment of the health-related quality of life (HRQOL) and its drivers in patients with SSc is lacking.ObjectivesTo assess physical and mental health in a global cohort of SSc patients in comparison with non-SSc autoimmune inflammatory rheumatic diseases (AIRDs), non-rheumatic AIDs (NRAIDs), and those without AIDs (controls) using Patient-Reported Outcome Measurement Information System (PROMIS) global health data from the COVAD-2 survey.MethodsThe COVAD-2 database was used to extract demographics, AID diagnosis, comorbidities, disease activity, current therapies, and PROMs. PROMIS global physical health (GPH), global mental health (GMH) scores, PROMIS physical function short form-10a (PROMIS PF-10a), pain visual analogue scale (VAS), and PROMIS Fatigue-4a scores were compared between SSc, non-SSc AIRDs, NRAIDs, and controls. Outcomes were also compared between diffuse cutaneous SSc (dcSSc) vs limited cutaneous SSc (lcSSc). Multivariable regression analysis was performed to identify factors influencing GPH and GMH scores in SSc.ResultsA total of 10,502 complete responses from 276 SSc, 6006 non-SSc AIRDs, 545 NRAIDs, and 3675 controls as of May 2022 were included in the analysis. Respondents with SSc were older [SSc vs. non-SSc AIRDs vs. NRAIDs vs. controls: 55 (14) vs. 51 (15) vs. 45 (14) vs. 40 (14) years old, mean (SD), p < 0.001]. Among patients with SSc, 129 (47%) had dcSSc and 147 (53%) had lcSSc. SSc patients reported a significantly higher prevalence of ILD [SSc vs. non-SSc AIRDs vs. NRAIDs vs. controls: 30.4% vs. 5.5% vs. 1.5% vs. 0.2%, p < 0.001], and treatment with MMF [SSc vs. non-SSc AIRDs vs. NRAIDs vs. controls: 26.4% vs. 9.5% vs. 1.1% vs. 0%, p < 0.001].Patients with SSc had lower GPH and PROMIS PF-10a scores [SSc vs. non-SSc AIRDs vs. NRAIDs vs. controls: 13 (11–15) vs. 13 (11–15) vs. 15 (13–17) vs. 17 (15–18), median (IQR), p < 0.001;39 (33–46) vs. 39 (32–45) vs. 47 (40–50) vs. 49 (45–50), p < 0.001, respectively] and higher Pain VAS and PROMIS Fatigue-4a scores compared to those with NRAIDs or controls [SSc vs. non-SSc AIRDs vs. NRAIDs vs. controls: 3 (2–5) vs. 3 (1–6) vs. 2 (0–4) vs. 0 (0–2), p < 0.001;11 (8–14) vs. 11 (8–14) vs. 9 (7–13) vs. 7 (4–10), p < 0.001, respectively]. Patients with AIDs including SSc had lower GMH scores compared to controls [SSc vs. non-SSc AIRDs vs. NRAIDs vs. controls: 12.5 (10–15) vs. 13 (10–15) vs. 13 (11–16) vs. 15 (13–17), p < 0.001].Among SSc patients, GPH, GMH, and PROMIS PF-10a scores were lower in dcSSc compared to lcSSc [dcSSc vs. lcSSc: 12 (10–14) vs. 14 (11–15), p < 0.001;12 (10-14) vs. 13 (10-15), p<0.001;38 (30–43) vs. 41 (34–47), p < 0.001, respectively]. Pain VAS and PROMIS Fatigue-4a scores were higher in dcSSc compared to lcSSc [4 (2–6) vs. 3 (1–5), p < 0.001;12 (8–15) vs. 9 (8–13), p < 0.001, respectively].The independent factors for lower GPH scores in SSc were older age, Asian ethnicity, glucocorticoid use, and higher pain and fatigue scales, while mental health disorders and higher pain and fatigue scales were independently associated with lower GMH scores.ConclusionIn a global cohort, patient-reported physical and mental health were significantly worse in patients with SSc in comparison to those with non-SSc AIDs and without AIDs. Our findings support the critical need for more attention to patient's subjective experiences including pain and fatigue to improve the HRQOL in patients with SSc.Reference[1]Fazal ZZ, Sen P, Joshi M, et al. COVAD survey 2 long-term outcomes: unmet need and protocol. Rheumatol Int. 2022;42: 2151–58.Acknowledgements:NIL.Disclosure of InterestsKeina Yomono: None declared, Yuan Li: None dec ared, Vahed Maroufy: None declared, Naveen Ravichandran: None declared, Akira Yoshida: None declared, Kshitij Jagtap: None declared, Tsvetelina Velikova Speakers bureau: Pfizer and AstraZeneca, Parikshit Sen: None declared, Lorenzo Cavagna: None declared, Vishwesh Agarwal: None declared, Johannes Knitza: None declared, Ashima Makol: None declared, Dey Dzifa: None declared, Carlos Enrique Toro Gutierrez: None declared, Tulika Chatterjee: None declared, Aarat Patel: None declared, Rohit Aggarwal Consultant of: Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, Abbvie, Janssen, Kyverna Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant, Merck, Galapagos, Actigraph, Scipher, Horizon Therepeutics, Teva, Beigene, ANI Pharmaceuticals, Biogen, Nuvig, Capella Bioscience, and CabalettaBio, Grant/research support from: Bristol Myers-Squibb, Pfizer, Genentech, Octapharma, CSL Behring, Mallinckrodt, AstraZeneca, Corbus, Kezar, Abbvie, Janssen, Kyverna Alexion, Argenx, Q32, EMD-Serono, Boehringer Ingelheim, Roivant, Merck, Galapagos, Actigraph, Scipher, Horizon Therepeutics, Teva, Beigene, ANI Pharmaceuticals, Biogen, Nuvig, Capella Bioscience, and CabalettaBio, Latika Gupta: None declared, Masataka Kuwana Speakers bureau: Abbvie, Asahi-Kasei, Astellas, Boehringer-Ingelheim, Chugai, Eisai, MBL, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Tanabe-Mitsubishi, Consultant of: Astra Zeneka, Boehringer-Ingelheim, Chugai, Corbus, GSK, Horizon, Tanabe-Mitsubishi, Grant/research support from: Boehringer-Ingelheim, Vikas Agarwal: None declared.

Drug Interaction between Paxlovid and Tacrolimus in an Adolescent with Inflammatory Bowel Disease

The coronavirus disease of 2019 (COVID-19) caused by SARS-CoV-2 virus led to a worldwide pandemic. Emergency use of an investigational medication, Paxlovid, was approved for patient 12 and older who tested positive for COVID-19 and at high risk for severe infection. Inflammatory Bowel Disease (IBD) is a chronic condition causing inflammation in the gastrointestinal tract. Ulcerative Colitis (UC) is a type of IBD centralized in colon and commonly treated with Immunosuppressive drugs. We present an adolescent with UC treated with paxlovid due to being on tacrolimus who developed with suspected tacrolimus toxicity. CASE REPORT: A 13-year-old female with UC presented to the ED with vomiting and fatigue after paxlovid ttreatment for COVID. The patient's UC treatment included tacrolimus along with ustekinumab. She had been diagnosed with SARS-CoV-2 and prescribed Paxlovid bid x 5 days due to immunosuppressive status. Tacrolimus was held during treatment. Once paxlovid completed, tacrolimus was restarted. Two days later, patient presented to ER for vomiting, fatigue, headaches and myalgia. Labs revealed a tacrolimus level of >60 ng/ml. Electrolytes and Creatinine were normal. Toxicology felt this was due to interaction between paxlovid and tacrolimus. Patient advised to hold tacrolimus for 48 hours and repeat levels were 15.8 ng/mL. Symptoms resolved and level repeated three days later and was 2.9 ng/mL. DISCUSSION: Tacrolimus is an immunosuppressant, commonly used for management of organ transplants but also been found effective in treatment of IBD. Tacrolimus requires close monitoring as toxicity may lead to acute or chronic kidney disease. The normal concentration is between 5-15 ng/mL. Due to rapid escalation of the COVID-19 pandemic, Paxlovid was approved for emergency use for treatment of high-risk patients. It is administered as a 5-day oral course consisting of nirmatrelvir and ritonavir. Our patient was prescribed Paxlovid due to risk secondary to immunosuppression. She was appropriately instructed to stop tacrolimus. Ritonavir is a cytochrome P450 3A inhibitor and can increase plasma concentration of tacrolimus. She restarted tacrolimus treatment 12 hours after her last dose of Paxlovid and presented with symptoms and a level consistent with toxicity. This level was concluded to be due to drug interaction between tacrolimus and Paxlovid. After further withholding of tacrolimus, symptoms improved, and levels normalized. Previous reports in transplant population stress importance of decreasing the dose of tacrolimus or withholding during the course of paxlovid treatment. This case demonstrates the importance of not only ceasing tacrolimus when administering paxlovid, but continuing discontinuation for longer period post completion of therapy to minimize interactions.Copyright © 2023

A study to determine Cardiopulmonary reserve and Vital capacity by Breath-holding test in Covid -19 patients in a Tertiary Care Hospital

Background & objectives: The most common clinical presentation of COVID 19 is acute respiratory distress syndrome. Due to its rapid and risky course of transmission and limited medical facilities, it is important to identify the patients with hampered lung function with minimal chance of aerosol spread. As conventional spirometry increases the chances of infection transmission, a breath-holding test can be used to determine vital capacity and cardiopulmonary reserve. Method(s): From May 11 to June 4, 2020, a randomly sampled study was conducted in a tertiary care hospital, Ahmedabad. Patients aged between 18-65 years with mild to moderate COVID 19 infection and who were vitally stable were included in the study. In all participants, the breath-holding test was performed and vital capacity and cardiopulmonary reserve were measured. Result(s): 16 females and 34 males, with a mean age of 45.82+/-12.08, were included in the study. Average Breath-holding time was 28.56 - 15.20 seconds, vital capacity was 3400+/-892.142 liters. Patients had 32%, 56% and 12% grade 0, 1 and 2 cardiopulmonary reserves respectively. Interpretation & conclusion: From our study, we concluded that vital capacity and cardiopulmonary reserve are compromised in patients with mild to moderate covid 19 infections. No Patients with more than two comorbidities had normal cardiopulmonary reserve and even vital capacity was lowest in them, when compared to patients with no comorbidities.Copyright © 2020 Ubiquity Press. All rights reserved.

Bedside naso-jejunal placement is more difficult, but successful in patients with COVID-19 in critical care: A retrospective service evaluation of a dietitian-led service

The COVID-19 pandemic presented clinical and logistical challenges in the delivery of adequate nutrition in the critical care setting. The use of neuromuscular-blocking drugs, presence of maxilla-facial oedema, strict infection control procedures, and patients placed in a prone position complicated feeding tube placement. We audited the outcomes of dietitian-led naso-jejunal tube (NJT) insertions using the IRIS (Kangaroo, USA) device, before and during the COVID-19 pandemic. NJT placement was successful in 78% of all cases (n = 50), and 87% of COVID-19 cases. Anaesthetic support was only required in COVID-19 patients (53%). NJT placement using IRIS was more difficult but achievable in patients with COVID-19.Copyright © The Intensive Care Society 2023.

Could virtual dermatology services widen healthcare inequity for patients with chronic skin conditions: are we READHY?

Advances in technology have resulted in increasing adoption of virtual dermatology services across the National Health Service. This has accelerated dramatically during the COVID-19 pandemic. Providing remote consultation alternatives empowers many patients to manage their health away from traditional in-person services. However, there is concern that universal implementation of such services may potentially widen healthcare inequalities for some patient groups. Reliably identifying at-risk groups is challenging. Co-design of health services has been proposed as a method to ensure equality and appropriateness of provision for all patients accessing a service by including them in the design process. In this study we profile the digital health literacy of patients with chronic skin conditions with the aim of using this information to redesign virtual services to support their long-term skin health. The Multidimensional Readiness and Enablement Index for Health Technology (READHY), comprising the eHealth Literacy Questionnaire (eHLQ), Health Literacy Questionnaire (HLQ) and Health Education Impact Questionnaire (heiQ), was used to assess patient skills, confidence and experience in using technology to manage their health. Consecutive patients under long-term follow-up in two specialist clinics supporting chronic skin conditions (organ transplant surveillance and biologics monitoring) completed questionnaires either in person or over the telephone. Between July and November 2021, 99 of 128 (77.3%) of patients invited to participate took part. Overall, these patients showed high levels of self-management skills, determination not to let health problems control their life and good support from family and healthcare professionals. In the domains related to digital skills, the responses were diverse. A cluster analysis identified multiple groups of patients with varying combinations of higher or lower level of digital health literacy, social and healthcare support, as well as capabilities in handling health condition and emotional responses. These preliminary data have provided important information for optimizing a co-design process aimed at tailoring services to support patients with chronic skin diseases. In particular, it has identified patient groups with distinct differences in terms of digital health literacy. Recognition of these groups and their differing profiles in terms of barriers to accessing virtual healthcare will be a key consideration in ensuring equitable representation in the service co-design process. It provides opportunities to target support to those patients with lower digital health literacy skills so that they may benefit from virtual services or adaptation of these services to address their specific needs. Alternatively, it allows recognition of patient groups who have higher digital health literacy and may safely benefit from alternative approaches to service provision such as patient-initiated follow-up.

Loss aversion or hand-to-mouth behaviour in private consumption models

This study empirically tests whether the loss aversion or hand-to-mouth theories of consumption behaviour is present in Fiji. The loss aversion hypothesis implies that consumers would maintain their consumption when income falls. To estimate this model, we apply the nonlinear autoregressive distributed lag model with annual data from 1981 to 2019. Our findings are in contrast to the predictions of the loss aversion hypothesis and support the hand-to-mouth hypothesis in Fiji. The results are robust to alternative measures of liquidity, and a sample that includes the COVID-19 pandemic. We contribute to the literature by providing evidence of nonlinearity's in the consumption-income association. The findings are useful for policymakers in developing countries for policies on economic growth and stabilization. © 2023 New Zealand Association of Economists Incorporated.

Effectiveness of Remote Cardiac Rehabilitation: A Meta-Analysis

Background Cardiac rehabilitation (CR) is a Class 1 indication for patients following acute coronary syndrome, coronary intervention and in patients with chronic, stable heart failure. However, rates of participation remain abysmal. Following the COVID-19 pandemic, interest in remote cardiac rehabilitation (R-CR) has increased. Efficacy of R-CR versus the current standard of care remains unclear. Methods A systematic review of the available literature was performed according to the PRISMA 2020 checklist. Of the identified studies, further screening was done to isolate randomized controlled trials (RCT) that measured objective markers of physical fitness such as peak oxygen consumption during exercise (VO2 max) and distance traveled during 6 minute walk test (6MWT). Results 20 RCTs were identified that compared R-CR versus either standard CR or usual care that did not include a component of CR. There is no difference in the change in exercise capacity achieved based on whether a patient underwent R-CR versus standard CR. There was a significant difference in the change in exercise capacity achieved in patients who underwent R-CR versus usual care. R-CR is associated with a significant change in VO2 max but not distance walked on 6MWT. Conclusion R-CR is not inferior to standard CR in improving VO2 max and distance walked on 6MWT. R-CR may be superior to usual care that does not include an element of CR. This is potentially beneficial as increased adoption of R-CR may improve participation in CR as a whole. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

An Unusual Case of Cardiogenic Shock in a Cardio-Oncologic Patient

Background Graft versus host disease (GVHD) most often occurs 100-365 days after hematopoietic stem cell transplant (HSCT). Manifestations most often are dermatologic, hepatic or pulmonic, and are rarely cardiac. We present a unique case of GVHD inducing cardiogenic shock necessitating advanced heart failure therapies. Case This is a 34 year-old male with a history of acute lymphoblastic leukemia who completed chemoradiation and HSCT from an HLA perfect sibling in 1992. In May 2020, he presented with dyspnea for 6 weeks. An echocardiogram at that time showed an EF of 10% and severe biventricular dilatation. He was originally hospitalized at an outside institution for hypoxia where a left heart catheterization showed normal coronaries and goal directed therapy was initiated. After 2 negative COVID tests, he was discharged with a LifeVest. One month later, despite medication compliance, he returned in cardiogenic shock after his LifeVest was activated for ventricular tachycardia (VT). Decision-making He was started on inotropic therapy and an intra-aortic balloon pump (IABP) was placed 1:1 prior to transfer to our tertiary center. After support was started, a right heart catheterization showed a right atrial pressure of 13 mmHg, a wedge of 17, and a cardiac index of 2.6. His course was complicated by VT storm. Differentials for his non-ischemic cardiomyopathy (NICMO) included myocarditis (viral vs. giant cell) with a possible component of chemotherapy/radiation induced NICMO. Immediate AHFT work-up was started. He was unable to be weaned off his IABP or inotropic support. The decision was made to pursue emergent left ventricular assist device placement (LVAD) and achieve a definitive diagnosis with a core biopsy. Pathology resulted with myocyte hypertrophy, chronic inflammation with eosinophils concerning for chronic GVHD. Conclusion There have only been a handful of case reports describing cardiac manifestations of GVHD, and none with NICMO and cardiogenic shock requiring an LVAD. Despite this, suspicion should remain present for GVHD in HSCT patients regardless of time frame from oncologic therapies or specificity of HLA match when presenting in cardiogenic shock.Copyright © 2023 American College of Cardiology Foundation

Impact of Donor Specific Antibodies in Cardiac Transplant Recipients after Acute Covid-19

Donor specific antibodies (DSA) are known to be associated with increased mortality following heart transplant (HT). Despite the high overall burden of disease from novel coronavirus (COVID-19) among HT recipients, little is known about the subsequent development of de novo or increased DSA (diDSA) in COVID-19 survivors. We performed a retrospective analysis at 8 large centers of HT recipients diagnosed with COVID-19 between 3/1/2020 and 3/31/2021. Acting on anecdotal reports, we began checking DSA approximately 3, 6, and 12 months after acute COVID-19 as standard of care. Incidence of diDSA, defined as an increase in MFI by >2500, was determined. Treatment of acute cellular rejection (ACR) and antibody mediated rejection was recorded. Of 380 HT patients who developed COVID-19, 191 (70% male) had DSA data available by study end-date. A total of 5% developed diDSA by 3 months (11/191), 10% by 6 months (17/172) and 18% by 12 months (24/131). The median time for development of diDSA was 144 days. Patients with pre-existing DSA had a significantly increased incidence of diDSA compared to those without pre-existing DSA (15/32 vs 9/159, p<0.001). There was no difference in diDSA between patients who had immunosuppression reduced during acute COVID-19 and those who did not (6/47 vs 17/107, p=0.890). Compared to those without diDSA, there was a significant increase in the incidence of ACR (ISHLT grade ≥2R) in the year following infection in those with diDSA (3/165 vs 4/24, p=0.006). This study demonstrates a high incidence of diDSA (18%) at 12 months among HT recipients after COVID-19. In addition, diDSA was more common among those with pre-existing DSA, and diDSA was associated with higher incidence of ACR. [ABSTRACT FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Emerging trends in the pharmaceutical waste generation and disposal after COVID-19

Every year, a million tonnes of pharmaceutical waste is generated around the globe. The major pharmaceutical products include syringes, masks, PPE kits, unused vaccines, antibiotics, etc. Its production was at a steady rate before the pandemic, but during the pandemic, the demand increased many-fold and so did the production. The widespread use of these pharmaceutical products during the COVID-19 pandemic has created an alarming situation around the world. All our landfills, oceans, and rivers are flooded with pharmaceutical waste. The unused antibiotics after unsafe disposal led to the presence of antibiotics in soil and water, which led to the antibiotic-resistant issue. In the current chapter, the authors suggest a drastic change in pharmacy waste before and after the pandemic and ways to minimize the environmental and health risks. © 2023 Nova Science Publishers, Inc. All rights reserved.

Prevalence and Pattern of Self Medication to Prevent Covid-19 Infection: Population-Based Survey

Objective: During COVID-19 pandemic, people have practiced one or more self-medication (SM) for prevention of the disease. This requires monitoring and evaluation to see the pattern of medicine used. Hence, in this study, we evaluated the prevalence and pattern of SM in various group of people. Method(s): A cross-sectional study was conducted as an online survey on individuals who were in contact through mobile phone from October 2020 to March 2021. A pre-structured questionnaire-based Google form that contain questions related to SM practiced was prepared and circulated on social media application and email. Submitted forms were analyzed using Microsoft excel. Result(s): Out of 779 forms, 775 (99.4%) filled completely were considered in result. Majority (52%) of participants were in the age group of 20-40 year. Six hundred and fifty-two (84%) participants had taken medication, out of which 40% were modern medicine users and rest 44% had used other than modern medicine. In modern medicine, Vitamin C was taken by 72% and in other group, lemon water was taken by 99% of participants. The prevalence of SM was highest among urban population (43%) with education up to postgraduation (53%). Health worker (57%) were highest among users. SM advice was received by doctors in 60% participants with belief of effectiveness against COVID-19 infection. Conclusion(s): SM was practiced by half of the participants that includes modern as well as other than modern medicine. It was mainly seen among people with higher education and who are associated with health-care system.Copyright © 2023 The Authors.

Pathogenesis, Clinical Manifestation, Diagnosis, Pathological Findings, Treatment Options, Preventive Measures, and Risk Factors of COVID-19

Background: COVID-19 is an infectious disease caused by SARS-CoV-2. The disease has hit hard around the globe and is now a pandemic. As of April 01, 2020, a total of 875,560 cases have been reported and the figures are increasing day by day. Currently, there is no treatment or vaccine available for curing COVID-19 and pharmaceutical companies are racing toward the common goal of achieving the cure. Method(s): Scientific databases, including Science direct, Pub med, Elsevier, Scopus, and Nature, were explored. Data has also been accessed from case reports, newspaper reports, internet data, World Health Organisation (WHO) reports, and Centre of Disease Control (CDCs) reports. The US National Library of Medicine, Clinicaltrials.gov, were accessed to get information about the ongoing clinical trials. The literature survey started in the first week of February 2020 and was completed in the first week of April 2020. Additional literature survey was done in the second week of June 2020. Result(s): The epicentre of COVID-19 is Wuhan City, Hubei Province, China. Coronavirus belongs to Order Nidovirale and is subdivided into four groups alpha, beta, gamma, and delta. Coronavirus 229E, NL63, HKU1, MERS-CoV and SARS-CoV are known to infect humans. It is an enveloped, non-segmented positive-sense RNA virus of size 30-32 kb with several structural and accessory proteins. The pathogenesis of COVID-19 involves attachment of Spike (S) protein of SARS-CoV-2 to the angio-tensin-converting enzyme 2(ACE2) receptor present on the host cell membrane. Clinical manifestation of COVID-19 include fever, cough, complicated dyspnoea, pneumonia, etc. Real-time-PCR is a sensi-tive test for the detection of SARS-CoV. Remdesivir, Bevacizumab, Darunavir and cobicistat, lopinavir-ritonavir, Oseltamavir, hydroxychloroquine, Sarilumab, mRNA-1273, Ad5-nCoV are some of the drugs under the clinical phase of the trial. People with A-positive blood group, with comorbidities like diabe-tes, hypertension, chronic pulmonary obstructive disease, substance abuse disorders, immunocom-promised individuals, health care workers, and older adults are at high risk of getting infected with SARS-CoV-2 Conclusion(s): This article gives insight into the occurrence of COVID-19, classification and structure of SARS-CoV-2, pathogenesis, pathological findings, clinical manifestation, diagnosis, potential treatment options and prevention, and people at risk of COVID-19.Copyright © 2021 Bentham Science Publishers.

Drug Interaction between Paxlovid and Tacrolimus in an Adolescent with Inflammatory Bowel Disease

The coronavirus disease of 2019 (COVID-19) caused by SARS-CoV-2 virus led to a worldwide pandemic. Emergency use of an investigational medication, Paxlovid, was approved for patient 12 and older who tested positive for COVID-19 and at high risk for severe infection. Inflammatory Bowel Disease (IBD) is a chronic condition causing inflammation in the gastrointestinal tract. Ulcerative Colitis (UC) is a type of IBD centralized in colon and commonly treated with Immunosuppressive drugs. We present an adolescent with UC treated with paxlovid due to being on tacrolimus who developed with suspected tacrolimus toxicity. CASE REPORT: A 13-year-old female with UC presented to the ED with vomiting and fatigue after paxlovid ttreatment for COVID. The patient's UC treatment included tacrolimus along with ustekinumab. She had been diagnosed with SARS-CoV-2 and prescribed Paxlovid bid x 5 days due to immunosuppressive status. Tacrolimus was held during treatment. Once paxlovid completed, tacrolimus was restarted. Two days later, patient presented to ER for vomiting, fatigue, headaches and myalgia. Labs revealed a tacrolimus level of >60 ng/ml . Electrolytes and Creatinine were normal. Toxicology felt this was due to interaction between paxlovid and tacrolimus. Patient advised to hold tacrolimus for 48 hours and repeat levels were 15.8 ng/ mL. Symptoms resolved and level repeated three days later and was 2.9 ng/mL DISCUSSION: Tacrolimus is an immunosuppressant, commonly used for management of organ transplants but also been found effective in treatment of IBD. Tacrolimus requires close monitoring as toxicity may lead to acute or chronic kidney disease. The normal concentration is between 5-15 ng/mL. Due to rapid escalation of the COVID-19 pandemic, Paxlovid was approved for emergency use for treatment of high-risk patients. It is administered as a 5-day oral course consisting of nirmatrelvir and ritonavir. Our patient was prescribed Paxlovid due to risk secondary to immunosuppression. She was appropriately instructed to stop tacrolimus. Ritonavir is a cytochrome P450 3A inhibitor and can increase plasma concentration of tacrolimus. She restarted tacrolimus treatment 12 hours after her last dose of Paxlovid and presented with symptoms and a level consistent with toxicity. This level was concluded to be due to drug interaction between tacrolimus and Paxlovid. After further withholding of tacrolimus, symptoms improved, and levels normalized. Previous reports in transplant population stress importance of decreasing the dose of tacrolimus or withholding during the course of paxlovid treatment. This case demonstrates the importance of not only ceasing tacrolimus when administering paxlovid, but continuing discontinuation for longer period post completion of therapy to minimize interactions.

Use of e-media among pediatric dental professionals and postgraduate students in pediatric dentistry during COVID-19

Background: Health-care providers, particularly pediatric dentists, highly depend on electronic media. This survey attempts to assess how they have taken to e-media to keep themselves abreast of the current situation and use it efficiently. Objectives: To determine attitudes, awareness, and practices of e-media usage among pediatric dental professionals and postgraduate students in pediatric dentistry during the COVID-19. Materials and Methods: A convenience sample of 958 pediatric dental practitioners and postgraduate students in pediatric dentistry from throughout India participated in a descriptive cross-sectional survey. An investigator-designed questionnaire comprising 23 close-ended questions related to the usage and various aspects of e-media before and during the COVID-19 pandemic. Results: Younger generations of pediatric dentistry are more active in the use of e-media. Dentists between the ages of 30 and 50 years are more likely to utilize social media in their profession than dentists above the age of 50 years. For academic purposes and patient communication, e-media was the most popular choice. Conclusion: The Indian pediatric dentistry profession has grown significantly with the use of e-media. © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

Fluid balance as an independent prognostic indicator of in-hospital mortality in heart failure patients with Covid19

Introduction: Fluid resuscitation confers protection against in-hospital mortality in heart failure (HF) patients with severe sepsis. SARS COV-2 infection leads to cytokine storm that is clinically similar to severe sepsis. We aim to evaluate if positive fluid balance is associated with in-hospital mortality in HF patients with Covid-19. Method(s): This single center retrospective cohort study was conducted in patients admitted in the ICU for Covid 19 from 10/2020 to 3/2021 in a community hospital in Newark. The primary outcome was survival to discharge. Clinical SAS 9.4 was used to obtain summary statistics, perform chi-squared test and multivariable logistic regression analysis. Result(s): We included 91 patients admitted in the ICU with covid 19, of which 33 were diagnosed with HF. Out of 33 people, majority were males. Most of the patients were hispanic. Diabetes and hypertension were the most common comorbidities. 60.61% of HF patients had multiple comorbidities. Odds of negative survival outcome in those with positive fluid balance after adjusting for HF as compared to those with negative fluid balance in patients of COVID 19 was 12.958 (P value= 0.0183). Conclusion(s): Positive fluid balance in HF patients admitted with Covid 19 may be associated with adverse outcomes. Larger, prospective studies are needed to investigate the correlation between covid 19 and fluid balance in HF patients.

Sidra Pharmacy's evidence-based approach to meet changing demands on the service: COVID-19

Background: From December 2019, the healthcare system as we know it changed, as the WHO declared a worldwide COVID-19 outbreak. Purpose(s): Evidenced-based review of pharmacy emergency major incident plan, alongside internationally recognised policies, with government updates (Ministry of Public Health;2019;ASHP, 2020;GPhC, 2020;Ministry of Public Health;2020);RPS, 2020). Method(s): Pharmacy leadership identified staff who could work remotely, split shifts;receive cross training. The clinical team worked closely with the infectious disease/antimicrobial stewardship team towards devising a clinical plan to manage those under our care. Result(s): Service changes included: team members resorted to online or telephone discussions;verification of medication orders took place from home;activation of automation systems;changes to the pharmacy homecare service;communication moved to digital virtual platforms;measures such as the addition of floor markings and medication deliveries to clinics were implemented. Patient education leaflets and social media platforms were utilised to inform patients. Introduction of a drive-through pharmacy collection service, home delivery services, online medication request services, along with expansion of the telephone request infrastructure. Tailored 'ABC' analysis were performed to identify 'valuable' medicine. Non-formulary stocks were distributed to all patients, to prevent any panic or assumption about shortage. All 2021 medication supply plan was booked with manufacturers. The Pharmacy Director was able to create new 'just-in time' delivery channels. Conclusion(s): It is important to reach out to approved evidenced-based guidance, and services must change in order to maintain high level patient care within a crisis. The question now arises-iIs there a need for further improvement?'.

Opportunities and barriers to implementing COVID-19 testing in community pharmacies

Background: The World Health Organisation sent a clear message to the world, to 'test, test, and test' for early identification, isolation, and limiting the spread of coronavirus disease 2019 (COVID-19). Dismal testing rates have been the biggest barrier to understanding the spread of this disease. Community pharmacists and pharmacies provide an accessible and reliable avenue to increase testing rates. Purpose(s): To identify opportunities and barriers to implementing COVID-19 testing in community pharmacies. Method(s): Review of worldwide literature from 2019 and onwards was completed to review guidance documents and expert opinions on COVID-19 testing by community pharmacists. Result(s): So far, only 32 states in the USA have provided community pharmacists with the independent ability to order and administer COVID-19 tests in community pharmacies. Opportunities are: fast and reliable access to testing;improved testing rate, data collection, and patient-pharmacists relationships;provide personalised follow-ups and new services;and leverage opportunity for future government collaboration. Barriers are: government buy-in, regulations and bylaw compliance, training, personal protective equipment, staffing needs, workflow optimisation, processes for collaboration with public health authorities, and pharmacists' willingness. Conclusion(s): COVID-19 testing in community pharmacies can improve testing rates, and provide new avenues to collaborate on public health initiatives. There is a scarcity of evidence and literature around this topic and future work should explore success of testing in community pharmacies, and pharmacists and public perceptions of provision of such services in community pharmacy setting.