IMPROVING ANNUAL DIABETIC RETINAL SCAN SCREENING RATES IN A PRIMARY CARE CLINIC DURING THE COVID-19 PANDEMIC

STATEMENT OF PROBLEM/QUESTION: How can systems-based changes increase the rate of diabetic retinal scan (DRS) completion in a primary care clinic during the COVID pandemic with decreased in-person visits? DESCRIPTION OF PROGRAM/INTERVENTION: The intervention was based in a primary care clinic associated with a public county-based health system. During the COVID-19 pandemic, in-person clinic visits were drastically reduced to prevent transmission, leading to a significant decrease in DRS completion rates. Additional barriers to completion of DRS screening included the following: (1) patients needed a separate, scheduled visit in our electronic medical record system (EPIC) for the DRS exam, (2) DRS clinic had limited hours during the primary care visit day, (3) many of our underserved patients could not afford consecutive clinic visits within a short period of time, and (4) providers signed the orders for DRS at the end of the visit;thus, nursing staff could not start scheduling patients an appointment until the end of the primary care visit. The intervention included two Plan-Do-Study-Act (PDSA) cycles. The first PDSA cycle involved a physician manually screening all patients due for DRS on a weekly basis if they were scheduled for a clinic visit in the upcoming week. For those identified, our nursing staff scheduled and completed a separate DRS appointment for the same day as the patient's clinic visit to minimize multiple visits. The second PDSA cycle involved using an EPIC tool, SlicerDicer, to automatically identify patient charts with overdue DRS screenings and upcoming clinic visits. The list of identified patients were then sent over to our nursing staff in order to schedule patients for their DRS on the same day as their clinic visit. MEASURES OF SUCCESS: We recorded diabetic retinal scan completion rate each month for one year from September 2020 to August 2021 to assess if rates would improve after our interventions. Monthly completion rates were measured on a rolling basis and based on the completion of the annual DRS for all clinic patients within the last 12 months. FINDINGS TO DATE: The percent of completed annual diabetic retinal exams for all clinic patients increased from 32.4% in September 2020 to 70.9% in August 2021 after implementation of our interventions. KEY LESSONS FOR DISSEMINATION: We identified system-based barriers that were negatively impacting our patients' ability to complete an important health maintenance screening such as the DRS exam. After identifying these barriers, we utilized existing tools and technology within our electronic medical record system to help patients complete their annual DRS exams and drastically increased overall clinic DRS completion rates.

Potential Dermatological Conditions Resulting from a Prolonged Stay at Home during the COVID-19 Pandemic: A Review

A new coronavirus emerged in 2019 in Wuhan, China named Severe Acute Respiratory Syndrome type 2 coronavirus (SARS-CoV-2). Later, this virus spread worldwide, causing a disease called coronavirus disease (COVID-19). To control the outbreak, many countries announced mandatory quarantine;thus, people changed their lifestyles and started engaging in most activities from home. This review explains how some dermatological pathologies may be precipitated by prolonged stays at home, considering that quarantine was a widely used public health measure during 2020. Most of these dermatoses had to be seen, diagnosed, and treated through tele-dermatology, a remote health care system that took force during the COVID-19 pandemic because of its ease and efficiency in connecting health care professionals and their patients;therefore, reducing the risk of contagion and costs associated to medical care. This review of the principal dermatologic conditions during confinement could allow for a better preparation of health professionals.

A RAPIDLY PROGRESSIVE AND RARE ILLNESS: AUTOANTIBODIES AGAINST MELANOMA DIFFERENTIATION-ASSOCIATED PROTEIN 5 (ANTI-MDA5): AMYOPATHIC DERMATOMYOSITIS WITH PROGRESSIVE INTERSTITIAL LUNG DISEASE THAT DEVELOPED AFTER COVID-19 VACCINE

TOPIC: Critical Care TYPE: Global Case Reports INTRODUCTION: Anti-MDA5 dermatomyositis is a subtype of dermatomyositis characterized by a high risk of rapidly progressive interstitial lung disease. It is characterized by fever, progressive shortness of breath, joint swelling and skin ulcerations. (1) There is invariable hyper-ferritinemia and radiographically there is a pattern of diffuse bilateral ground glass opacities. Complications with spontaneous pneumothorax and pneumomediastinum are not uncommon. Diagnosis is confirmed by biopsy as well as serum antibodies against MDA5. A known trigger is viral infection. (2) CASE PRESENTATION: We present the case of a 58-year-old man who was admitted to the Intensive Care Unit on account of respiratory failure and shock. He had a progressive Illness that started 4 days after receiving a novel mRNA COVID-19 Vaccine. He developed bilateral extremities edema, oral sores, worsening fatigue and dyspnea on exertion. He failed outpatient treatment for empiric pneumonia as well as prednisone for vaccine reaction. He presented to the hospital with fever, progressive dyspnea and fatigue. On physical exam he had oral blisters, digital tip ischemia and ulceration. His vital signs were pertinent for a SpO2 of 90% on ventilator support. A chest CT revealed diffuse and sub-pleural ground-glass opacities.There was an extensive negative infectious work up from serum, urine and BAL samples. These included negative SARS COV2 Antigen and SARS-Cov2 IgG. His inflammatory markers were pertinent for a positive ANA with titer of 1:320, Ferritin of 2,143 mcg/L, LDH of 1,105 U/L and CRP of 2.7mg/dL. Based on this information the differential for amyopathic dermatomyositis with progressive interstitial lung disease was considered. A skin biopsy of his index finger confirmed the diagnosis. His therapeutic interventions through his hospitalization included a trial of stress dose steroids, cyclophosphamide, IVIG, colchicine and tacrolimus. His ICU course was complicated by pneumomediastinum, pneumothorax and pericardial effusion. These were managed by placing a chest tube thoracotomy and pericardial drain respectively. His plan of care was changed to comfort measures after he had a drastic and prolonged desaturation episode without recovery. DISCUSSION: For conditions that lead to cytokine storm with subsequent development of ARDS or multi-organ dysfunction;there is a progressive clinical deterioration and high risk of death. We had insufficient evidence to definitively demonstrate a direct correlation between the vaccination and the patient's illness. CONCLUSIONS: In conditions that lead to Cytokine storm with multi-organ dysfunction targeting timely control of this inflammatory cascade via immunomodulation, cytokine antagonist and reduction of inflammatory cell infiltration in particular early in the process could lead to a reduction in mortality. REFERENCE #1: Fiorentino D, Chung L, Zwerner J, Rosen A, Casciola-Rosen L. The mucocutaneous and systemic phenotype of dermatomyositis patients with antibodies to MDA5 (CADM-140): a retrospective study. J Am Acad Dermatol. 2011;65(1):25-34. doi:10.1016/j.jaad.2010.09.016 REFERENCE #2: Sakamoto N., Ishimoto H., Nakashima S. Clinical features of anti-MDA5 antibody-positive rapidly progressive interstitial lung disease without signs of dermatomyositis. Intern Med. 2019;58(6):837–841. doi: 10.2169/internalmedicine. 1516-18. REFERENCE #3: Margherita Giannini,1 Mickael Ohana,2 Benoit Nespola,3 Giovanni Zanframundo,4,5 Bernard Geny,1,6 and Alain Meyer1,6,7 Similarities between COVID-19 and anti-MDA5 syndrome: what can we learn for better care? Eur Respir J. 2020 Sep;56(3): 2001618. Published online 2020 Sep DISCLOSURES: No relevant relationships by Ashlie Arthur, source=Web Response No relevant relationships by Leonel Carrasco, source=Web Response no disclosure on file for Chad Case;No relevant relationships by Juan Gaitan Rueda, source=Web Response

Acute pericarditis associated with COVID-19 infection

Infection by coronavirus type 2 that causes severe acute respiratory syndrome (SARS-CoV-2) has been associated with multiple cardiovascular manifestations. The mechanism by which the virus affects the heart is under discussion;however, it has been proposed that the angiotensin-converting enzyme 2 (ACE2) serves as a direct entry point for the virus;likewise, the state of inflammation mediated by cytokine storm can ge-nerate multiorgan failure, explaining some cardiac manifestations. The main associations to the cardiovascular system reported in COVID-19 infection are acute coronary syndrome, acute heart failure, cardiogenic shock and arrhythmias. Acute pericarditis is an inflammatory syndrome of mainly viral etiology, and its relationship to SARS-CoV-2 infection seems infrequent, with few reports in the literature. We present the case of a patient who developed pericarditis, concomitant with SARS-CoV-2 infection. © 2022, Universidad de Antioquia. All rights reserved.