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PURPOSE: Special needs children presenting with dental problems were penalised during the Covid-19 pandemic due to the reduction of clinical activity and the risks of nosocomial infection. The aim of this study is to evaluate the impact of the pandemic on oral healthcare in paediatric special needs patients. METHODS: We retrospectively assessed and compared the outpatient clinic activity and dental procedures performed under general anaesthesia in children with special needs at Brescia Children's Hospital (Italy) in 2019, 2020, and 2021. Any delay between expected waiting time based on assigned priority and surgery was recorded. The efficacy of the protocol adopted to reduce the spread of Covid-19 was evaluated by reporting any infections in patients, parents, and health care providers. RESULTS: In 2020, 270 outpatient visits were performed, and 40 patients were treated under general anaesthesia, with a 26% and 65% reduction, respectively, compared to 2019. In 2021, 362 visits were performed (similar to 2019) and 48 patients were treated under general anaesthesia (58% compared to 2019). The mean delay in the planned treatment was 1.0 month in 2019 (pre-pandemic period), 2.1 months in 2020, and 1.1 month in 2021. No cases of Covid-19 infection were reported in the cohort of patients and parents or among the operators related to nosocomial infection. CONCLUSIONS: The Covid-19 pandemic has profoundly reduced the activity of general anaesthesia in paediatric special need patients during 2020, with a gradual return to normal pre-pandemic activity in 2021. The adopted protocol prevented the spread of COVID-19 during hospitalisation.
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The post-COVID syndrome is emerging as a new chronic condition, characterized by symptoms of breathlessness, fatigue, and decline of neurocognitive functions. Rehabilitation programs that include physical training seem to be beneficial to reduce such symptoms and improve patients’ quality of life. Given this, and considering the limitations imposed by the pandemic on rehabilitation services, it emerged the need to integrate telerehabilitation programs into clinical practice. Some telerehabilitation solutions, also based on virtual reality (VR), are available in the market. Still, they mainly focus on rehabilitation of upper limbs, balance, and cognitive training, while exercises like cycling or walking are usually not considered. The presented work aims to fill this gap by integrating a VR application to provide cardio-respiratory fitness training to post-COVID patients in an existing telerehabilitation platform. The ARTEDIA application allows patients to perform a cycling exercise and a concurrent cognitive task. Patients can cycle in a virtual park while performing a “go/no-go” task by selecting only specific targets appearing along the way. The difficulty of the practice can be adjusted by the therapists, while the physiological response is continuously monitored through wearable sensors to ensure safety. The application has been integrated into the VRRS system by Khymeia. In the next months, a study to assess the feasibility of a complete telerehabilitation program based on physical and cognitive training will take place. Such a program will combine the existing VRRS exercises and the cardio-respiratory fitness exercise provided by the ARTEDIA application. Feasibility, acceptance, and usability will be assessed from both the patients’ and the therapists’ sides. © 2022, Springer Nature Switzerland AG.
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Background: The determinants of the susceptibility to SARS-CoV-2 infection and severe Coronavirus Disease 19 (COVID-19) manifestations are yet not fully understood. Amino-bisphosphonates (N-BPs) have anti-infammatory properties and have been shown to reduce the incidence of lower respiratory infections, cardiovascular events and cancer. Objectives: We conducted a population-based retrospective observational case control study with the primary objective of determining if oral N-BPs treatment can play a role in thesusceptibility to the development of severe COVID-19. Methods: Administrative ICD-9-CM and AT C data, representative of Italian population (9% sample of the overallpopulation), were analyzed. Oral N-BPs (mainly alendronate and risedronate) were included in the analysis. Patients treated with bisphosphonates (cases) were randomly matched (1:1 ratio) for age, sex and for other clinically relevant variables (presence of treatments other than bisphosphonates and hospitalizations) with all the health-assisted population without this treatment (controls). Results: Incidence of Covid-19 hospitalization was 12.32 [95%CI 9.61-15.04] and 11.55 [95%CI 8.91-14.20], of ICU utilization due to COVID-19 was 1.25 [95%CI 0.38-2.11] and 1.42 [95%CI 0.49-2.36] and of all-cause death was4.06 [95%CI 2.50-5.61] and 3.96 [95%CI 2.41-5.51] for oral N-BPs users and non-users, respectively (Figure 1A). Figure 1B Incidence and 95% CI of COVID-19 related events in N-BPs treated and untreated subjects with anti-osteoporotic drugs and without corticos-teroids. C. Incidence and 95% CI of COVID-19 related events in N-BPs treated and untreated without previous vertebral or hip fragility fractures. D. Incidence of COVID-19related events in bisphosphonates treated and untreated patients without previous vertebral or hip fracture without corticosteroid prescriptions. Conclusion: In conclusion, we found that the incidence of COVID-19 hospi-talization, intensive care unit (ICU) utilization and COVID-19 potentially related mortality were similar in N-BPs treated and non-treated subjects. Similar results were found in N-BPs versus other anti-osteoporotic drugs. We provided real-life data on the safety of oral N-BPs in terms of severe COVID-19 risk on a population-based cohort. Our results strongly support national and international guidelines that advocate against the discontinuation of oral bisphosphonates only for the fear of COVID-19.
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Background: The best way to manage disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatic and musculoskeletal diseases (RMDs) undergoing the Coronavirus disease (Covid)-19 vaccination and the recommendations regarding the use and timing of immunomodulatory therapies around the time of vaccination are still a matter of debate, due to the difficulties in balancing the vaccination efficacy and safety. Objectives: To assess the impact of different strategies of antirheumatic treatment management on disease activity around the time of vaccination for Coronavirus disease (Covid)-19 in patients with psoriatic arthritis (PsA). Methods: We prospectively evaluated patients with PsA in remission or low-disease activity candidate to receive Covid-19 vaccination with mRNA vaccines. Methotrexate (MTX) and lefunomide were withheld 7 days after each dose, whilst biological DMARDs (bDMARDs), were either continued (46.8% of the patients) or withheld (53.2%) from the day of the frst dose until 7 days after the second dose. Patients were reassessed after 3 months from enrollment or in case of disease fare. Results: After the second dose of Covid-19 vaccination 7 patients (5.6%) (6 females) had an articular disease fare each (mean involved joints: 1.29), one patient presented a concomitant worsening of psoriasis, and four patients had an isolated worsening of their psoriasis. All patients received additional treatments with oral GC (n=2) or non-steroidal anti-infammatory drugs (n=5). Two fares lasted more than one week and required a modifcation of the ongoing bDMARD. Articular fare incidence (6.8% vs 3%, p=0.259), involved joints (1.4 vs 1.5, p=0.846), disease fare severity, and changes in antirheumatic therapies (1 vs 1, p=0.928) did not differ signifcantly between the two different bDMARD management strategy groups (continued vs temporary withheld). There was no signifcant difference in disease activity score for psoriatic arthritis (DAPSA) and C-reactive protein (CRP) after vaccination, but patients who fared up had a higher mean basal DAPSA (7.3 vs 4.1, p=0.046). On binomial logistic regression analysis, we did not fnd any signifcant association with gender, age, basal CRP, basal DAPSA, active psoriasis, conventional synthetic DMARDs, or bDMARDs and disease fare. Conclusion: Our fndings suggest that a temporary short halt of bDMARDs could be a viable option in patients with well-controlled PsA undergoing Covid-19 vaccination without increasing the risk of fares, which could be useful to increase T cell response and antibody titres after Covid-19 vaccination.
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Background: So far, few studies provided detailed data for the incidence of disease fare after the vaccination against Coronavirus (Covid)-19 in patients with psoriatic arthritis (PsA). Results from small cohorts report an incidence of fares after Covid-19 vaccination of 0-7.7% and disease activity does not seems to be influenced by Covid-19 vaccination in patients with PsA. However, since PsA is a highly fuctuating disease with prolonged remission and irregular reactivation, it is difficult to establish a causal relationship between the Covid-19 vaccination and disease fares. Objectives: To defne the impact of Covid-19 vaccination and disease activity on the incidence of disease fare in patients with psoriatic arthritis (PsA). Methods: We prospectively evaluated patients with PsA in remission or low-disease activity candidate to receive Covid-19 vaccination with mRNA vaccines, collecting demographic, clinical, and therapeutic data and assessing DAPSA 28, PCR before and after vaccination. We assessed fares using patients and clinician concordance. We retrospectively evaluated fare incidence in the same timeframe of the previous year. We performed statistical analysis to fnd possible predictors of fares after vaccination. Results: A total of 57 patients with PsA were prospectively evaluated, and retrospective analysis was possible for 53 of them. DAPSA 28 and CRP did not differ signifcantly before and after the vaccination. The incidence of fares in the two periods (2020 vs 2021) did not differ signifcantly (18.8% vs 8.8%, p=0.166). We found a higher basal mean DAPSA 28 in patients who fared up after vaccination (7.3 vs 4.1, p-value 0.046). Only having a fare in the previous year was associated with a higher chance of recurrence after Covid-19 vaccination (p=0.02) in the logistic regression analysis, while other predictors (age, gender, disease activity, ongoing DMARD therapy, ongoing bDMARD therapy) did not. Conclusion: Our fndings suggest that, in patients with PsA, disease activity could be the main driver of disease fares rather than Covid-19 vaccination.
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BACKGROUND AND AIMS: COVID-19 infection in solid organ transplant recipients (SOT) is associated with increased morbidity and mortality due to comorbidities and immunosuppression state (Chaudhry ZS et al, 2020). Although vaccines represent the greatest hope to control COVID-19 pandemic, several studies showed the low immunogenicity of a two-dose mRNA COVID-19 vaccine regimen in SOT as compared with general population (Boyarsky BJ et al, 2021). Based on this evidence, on September 2021, the Italian Medicine Agency (AIFA) authorized a third vaccine administration as additional primary dose to immunocompromised patients. The aim of this study is to evaluate the seroconversion rate after the third dose of BNT162b2 (Pfizer-BioNTech) SARS-CoV-2 mRNA vaccine in kidney transplant recipients (KTRs) and to investigate the baseline factors associated with the absence of the antibody response. METHOD: we performed a prospective and observational study on a monocentric cohort of 329 consecutive Caucasian KTRs given three doses of the BNT162b2 COVID-19 vaccine. Key exclusion criteria were a previous history of COVID-19 infection and transplantation or having underwent chemotherapy treatment within the last year. Antibody response against the spike protein was tested on blood sample collected before the administration of vaccine (T0), at 15 and 90 days after the second dose (T2 and T3, respectively) and one month after the third dose (T5). The level of antibodies was assessed using the Roche Elecsys anti-SARS-CoV-2 S enzyme immunoassay (positive cut-off ≥ 0.8 U/mL). A total of 22 patients were excluded from the analysis because categorized as SARS-CoV-2-pre-immunized according to the antibodies' baseline status (T0) above the positivity cut-off. The Local Ethics Committees approved the study protocol and written informed consent was obtained before enrolment. RESULTS: The study population of 307 KTRs was 57.10 ± 13.10 years, with a predominance of male sex (64.2%). Median time from transplantation to vaccine was 10 [IQR 5-17] years. Blood analysis at baseline revealed mean eGFR assessed by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to be 56.95 ± 23.04 mL/min/1.73 m2. The standard immunosuppressive regimen consisted of glucocorticoids in all patients, calcineurin inhibitors (88.6% of patients), antimetabolites (73.3% of patients) and mTOR inhibitors (in 15.6% of patients). The first two doses were administered 21 days apart, and the third dose was administrated 172 ± 4 days after the second dose. In our cohort, 43.3% patients (133/307) responded to the vaccine at T2. The proportion of responders increased to 68.4% (186/272) at T3 (median antibody level: 5.2 [0.40-74.07]). One month after the third dose, a positive antibody titer was detected in 251 of 307 patients (81.8%) (median antibody titre: 1137.50 [9.32- 4189.75]). The response curve starting at T2 and increasing at T3 makes apparent that there is a distinctive kinetic of humoral response in immunocompromised patients compared to immunocompetent individuals (Walsh EE et al., 2020). A multivariate analysis showed that the negative response to the third primary dose was associated with antimetabolite immunosuppressants (P = .001), lower estimated glomerular filtration rate (P < .001) and female sex (P = .04) (Figure 1). No serious adverse events were reported. Neither De novo DSAs nor change in proteinuria were reported after vaccination. The limitation of this study is the absence of assays for cellular immune response. CONCLUSION: Although the exact threshold of antibody titer for protection against SARS-CoV-2 infection remains unclear, the ability of the additional mRNA COVID- 19 vaccine dose to increase both immune response (Figure 2A) and the prevalence of seroconversion rate (Figure 2B) associated with the acceptable safety profile supports its use after an initial 2-dose mRNA COVID-19 primary vaccine series in immunocompromised patients. (Table Presented).
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Background: Vitamin D is a pleiotropic hormone and plays a major role in protecting the body against infection and regulating inflammation. Research suggests that kidney [K] recipients with low levels of 25 hydroxyvitamin D3 (25(OH)D3) have a higher incidence of infections and rejection. Furthermore, research indicates low dietary vitamin D intake is positively associated with a lowered 25(OH)D3 serum levels. However, no research exists examining vitamin D intake and length of stay in the hospital [LOS(H)] in the K and K-pancreas [KP] population. Objective: The objective was to determine the associations between dietary vitamin D intake and episodes of infection, rejection, and LOS(H) in K+KP transplant recipients. Methods: Methods: A prospective investigation of 110 K+KP transplant patients with follow-up at 3, 6, 9, and 12-months posttransplant was undertaken. Due to barriers encountered by the COVID-19 pandemic, data was collected at baseline and 3 months only. Dietary vitamin D intake was obtained through modified Automated Multi-pass Method 24-hour (24HR) dietary recall at baseline which were analyzed by ESHA Food Processor. Vitamin D intake amounts did not include intake from supplementation. Episodes of infection, rejection and LOS(H) were recorded at 3 months post-transplant. Demographic data was determined using frequencies and means ± SD. Associations were determined using Spearman's correlations. Statistical analysis was preformed using SPSS v27 and statistical significance was determined using p < 0.05. Results: Results/Discussion: 100K and 10KP were available for evaluation. Participants were 64% male and 36% female, mean age: 50.5 ± 13.9 years, and BMI: 28.6 ± 5.5kg/m2. 99% of our patient population did not meet their recommended dietary allowance [RDA] for vitamin D intake by food alone, thus, it is possible that a portion of our patient population would have deficient serum 25(OH)D3 levels. No significant associations were found between vitamin D intake and episodes of infection, rejection, or LOS(H) at 3 months. We report 25% vitamin D intake from dairy products and only 2% from margarine. Lower intake of dairy products may be related to the recommendation of a potassiumrestricted nutrition care plan in the K+KP population. Conclusion: Conclusion: We report no association between vitamin D intake and episodes of infection, rejection, or LOS(H) likely due to the fact that the majority of our population's dietary intake did not meet vitamin D intake recommendations. Our future research will focus on improving patient vitamin D intake, supplementation and investigating 25(OH)D3 levels in association with episodes of infection, rejection, and LOS(H).
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Background: Although disease activity is a significant outcome in rheumatology, few studies have investigated the relationship between routine care of rheumatic conditions and disease activity control. Objectives: To determine the association between delay in routine care of chronic inflammatory arthritides (CIAs) and disease activity during the first wave of coronavirus disease 19 pandemic in Verona, Italy. Methods: This study enrolled patients with an established diagnosis of rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA). Between 01/04/2020 and 30/06/2020, participants were emailed an online questionnaire. Items comprised multiple or single-choice questions evaluating routine rheumatology care disruptions/delays and disease characteristics, treatments, comorbidities, and demographics. Compliance to anti-rheumatic medications was evaluated with I-CQR5. Disease activity was assessed with RAPID3, and active disease was defined as a RAPID3 score≥1. Study period referred to the time between the last rheumatology assessment and the date of enrolment. Results: Of 1210 patients contacted, 450 participated, of whom 219 CIAs patients were included (RA 55.3%, PsA 35.2%, AS 15.1%, UA 3.7%). One hundred twenty-five patients (57.1%) had their routine clinical assessment delayed (median days 68.4;IQR 66.8, 85.9). Patients in this group had significantly higher MDHAQ (p=0.001) and RAPID3 (p=0.031) scores, while they did not differ for disease severity, medications or compliance. Most (87.7%) reported good compliance to therapy;only 5.9% had difficulties in supplying anti-rheumatic medications, and 13.2% discontinued medications for at least four weeks for any reason. However, several patients (37.9%) reported moderate-to-high worse disease activity perception due to routine care delay, and 31.1% self-reported a disease flare (median RAPID3 score 3.8;IQR 2.0, 5.4). One hundred one patients (46.1%) had high disease activity, while only 15.1% were in remission. In logistic regression, active disease was significantly associated with delay of scheduled routine care visit, independent of disease duration, time from last rheumatology assessment, therapy with b/tsDMARDs, and compliance (Table 1, Figure 1 below). Conclusion: In patients with established CIAs, a relatively short delay in routine assessment by a rheumatologist resulted in higher disease activity. Frequent rheumatology referrals appear to be a critical factor for disease activity control in CIAs.
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The role of 25-OH-vitamin D in the assessment of coronavirus disease 19 (COVID-19) has not been investigated. We sought to investigate the prevalence of 25-OH-vitamin D deficiency among COVID-19 patients, and to determine the associations between 25-OH-vitamin D status and the severity of the disease. We have conducted a retrospective observational study of COVID-19 patients admitted to the University of Verona Hospital Trust. Demographic, clinical and biochemical parameters were collected at hospital admission, and serum 25-OH-vitamin D levels were measured. The following outcomes were assessed: arterial partial oxygen pressure (PaO2); C-reactive protein (CRP); length of hospitalization; requirement of oxygen therapy; non-invasive ventilation (NIV); mechanical ventilation; and death. Among 61 patients enrolled, 72.1% was 25-OH-vitamin D deficient (<20 ng/mL) and 57.4% had 25-OHvitamin D <15 ng/mL. Patients with arterial PaO2 <60 mmHg had significantly lower mean 25-OH-vitamin D levels compared to patients with PaO2 ≥60 mmHg (13.3 ng/mL vs 20.4 ng/mL respectively, p=0.03). Vitamin D deficiency was associated with 3-fold higher risk of having arterial pO2 <60 mmHg. 25-OH-vitamin D deficiency was associated with increased CRP and dyspnea. 25-OH-vitamin D deficiency was associated with more severe systemic inflammatory response and respiratory failure in COVID-19 patients.