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BackgroundHuman SARS-CoV-2 infection is responsible for a large variety of clinical manifestations related to Coronavirus disease-19 (COVID-19) [1]. SARS-CoV-2 can induce microvascular damage, that can be safely detected by nailfold videocapillaroscopy (NVC), as recently demonstrated [2-4]. Virus-induced endothelial dysfunction has been implicated in the pathogenesis of both active infection and long-COVID clinical manifestations (the last as persistence of disease symptoms after at least three months from onset) [5]. The study group on capillaroscopy and microcirculation in rheumatic diseases of the Italian Society of Rheumatology (CAPSIR) carried out an internal survey on the interest of the Italian Centers that perform NVC in participating in a detailed capillaroscopic and clinical data collection in long-COVID patients.ObjectivesTo carry out an Italian multicenter cognitive survey on the interest in collecting NVC and clinical data of patients affected by long-COVID with or without previous rheumatological diseases.MethodsThe steering committee of the CAPSIR study group formulated a cognitive questionnaire, entitled "Study on the role of capillaroscopy in patients with long-COVID” (CAPSIR_2 Study), consisting of 27 open or multiple-choice questions. A Google Form of the questionnaire was emailed to all the member of the study group between September and October 2022. Data are reported with a descriptive analysis.ResultsThe online questionnaire was completed by 41 CAPSIR members, belonging to 33 different Italian centers. Of note, 63% of participants had already experienced NVC in patients with long-COVID. The primary indication to perform the NVC was the onset of a new Raynaud's phenomenon (46% of cases) and the requests come mainly from General Practitioners (33% of cases). In 2/3 of the cases, patients with long-COVID and previous rheumatic diseases, who underwent NVC examination, represented less than 20% of the total. It should be noted that always in 2/3 of the cases there was no preferential channel for the study of the microcirculation in patients affected by long-COVID nor a NVC investigation prior to the SARS-CoV-2 infection. According to the previous experience of the participants in the interview, the most important NVC parameters considered to be evaluated in long-COVID patients were number of capillaries per linear millimeter (24% of cases), presence of hemorrhages (34% of cases) and giant capillaries (22% of capillaries). All participants (100%) therefore agreed to participate in a further collection of NVC and clinical data in this cohort of patients.ConclusionThis survey highlighted the interest of Italian Rheumatologists in assessing by NVC the COVID-related microvascular involvement. A consensus has emerged that future research is needed. After this pilot survey, the second part of the CAPSIR_2 Study will concern the collection/analysis before and after the SARS-CoV-2 infection of NVC and clinical data in patients with primary and secondary (to rheumatic diseases) Raynaud's phenomenon and affected by long-COVID versus adequate controls. The aim is to investigate if the presence/severity of the microvascular damage might be involved in the pathogenesis of the clinical manifestations observed in COVID-19 patients after the active infection. CAPSIR_2 Study will be open to all Italian rheumatological centers that participated in the previous national CAPSIR_1 Project [6].References[1]Fernandes Q et al. Ann Med. 2022;54:524-540.[2]Cutolo M et al. Nat Rev Rheumatol. 2021;17:665-677.[3]Sulli A et al. Microvasc Res 2022;142:104361.[4]Natalello G et al. Microvasc Res. 2021;133:104071.[5]Charfeddine S et al. Front Cardiovasc Med. 2021;8:745758.[6]Ingegnoli F et al. Reumatismo. 2022;74.AcknowledgementsAuthors wrote the on behalf of the study group on capillaroscopy and microcirculation in rheumatic diseases of the Italian Society of Rheumatology (SIR) - CAPSIR.CAPSIR Study Group thanks the EULAR Study Group of Microcirculation in Rheumatic Diseases for the continuous cultural support.Dis losure of InterestsNone Declared.
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PurposeThis study aims to explore how the COVID-19 pandemic has impacted parents of autistic children and their families in Ireland. Design/methodology/approachA qualitative thematic analysis methodology was applied using semi-structured interviews. A total of 12 parents (ten mothers, one father and one grandfather speaking on behalf of a mother) of autistic children were asked how the COVID-19 pandemic impacted them and their autistic child with a particular focus on how it has impacted their access to respite care. Interviews were completed remotely from July 2021 to October 2021. FindingsData analysis identified four themes that reflect an adverse pandemic impact. These were: world gone;alone and isolated;constantly fighting for help;and negative and positive impact of COVID-19 on child and family. Two parents reported positive outcomes of the pandemic such as social distance requirements. Five parents (42%) reported an increase in the amount of respite received. Three parents (25%) reported a decrease and four (33%) parents reported no change in their access to respite. Research limitations/implicationsCOVID-19 has turned a spotlight on mental health for politicians, policymakers and the public and provides an opportunity to make mental health a higher public health priority for autistic children and their families. Originality/valueThis study highlights the need for access to respite for autistic children and for respite services to be responsive to the ongoing needs, in particular, the mental health needs of autistic children and their family, particularly in a crisis situation.
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Background The cancellation of placements due to the pandemic had a huge impact on the provision of clinical placements for Allied Health Professional (AHP) students. Educators developed new and innovative ways of delivering placements due to social distancing restrictions. Alternative models have included remote placements clinical simulation, research project-based education and leadership. Health Education England launched a Fair Share model asking all AHPs to commit to a minimum of 7 weeks of student placement per year. Methods In June 2021 the AHP education team at Great Ormond Street Hospital developed and delivered a split leadership placement for two physiotherapy students. The students spent four days a week on a remote leadership placement and one day with the physiotherapy team. The placement included supervision coaching formal teaching a leadership course, project work (development of leadership resources) and shadowing of senior leaders. Results We debriefed the students to discuss the placement and gather information about how the placement could be improved. The students enjoyed the opportunity and felt they had learnt a lot about leadership. Feedback included a preference for five days of leadership or an even split between leadership and clinical the same clinical days (to support peer learning) and the need for better IT systems. The students enjoyed meeting senior leaders peer work and facilitating the student forum. The average placement and supervising team scores were both 4.5 out of 5 (above target score). Conclusion This novel placement evaluated well and was enjoyed by educators and students alike. We plan to run another leadership placement and will be using feedback to further enhance and improve the learning opportunity. We are dedicated to providing AHP placements to ensure we can help met the shortfall and that all students can achieve their 1000 hours of practice-based education.
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Background The Clinical Placement Expansion Programme (CPEP) aims to increase clinical placements in the National Health Service (NHS) and to support growth across all Allied Health Professionals (AHPs). At Great Ormond Street Hospital (GOSH), this programme was implemented in 2020, and extended to 2022, with the aim to steadily increase placement capacity across all AHP services. Additionally, the Fair Share model was introduced in London to help benchmark the provision of practice learning relative to workforce capacity, focusing specifically on Speech and Language Therapy, Physiotherapy and Occupational Therapy. The aim is to provide seven weeks of student placement per whole time equivalent. Methods Retrospective data were collected from seven AHP services throughout two academic years: September 2020 to September 2022. This included achieved number of students and placement weeks. Student placement feedback was collected and reported as an average out of five for both academic years. Results From September 2020 to September 2021, a total number of 400 student placements (1153 weeks) were supported at GOSH. From September 2020 to September 2021, 145 students were placed (433 weeks) and from September 2021 to September 2022, a total of 255 students were placed (720 weeks). This shows an increase of 110 students and 283 weeks from 2020/2021 to 2021/2022. The average student feedback for academic years 2020-2022 was 4.75 out of 5. Conclusion Student numbers and weeks increased per academic year from 2020-2022. Barriers to increasing student capacity included clinical capacity and staff pressures, lack of space, changes in service delivery during the COVID-19 pandemic, and staff attitude towards student placements. Placement innovation, such as leadership placements and hybrid working models, positively influenced student numbers at GOSH. There is a continued drive to achieve the Fair Share model, and the sustainability of placement expansion should be reviewed in future.
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The SARS-CoV-2 infection causing the Coronavirus disease-19 (COVID-19) is characterized by a broad range of clinical manifestations, implicating microvascular damage with endothelial dysfunction and different organ involvement.
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COVID-19 , Nails , Humans , Nails/blood supply , Capillaries , SARS-CoV-2 , SurvivorsABSTRACT
This dialogue is a structured account of an experiment that we, as researchers in the Vā Moana–Pacific Spaces cluster at Auckland University of Technology, carried out during and between lockdowns in Tāmaki Makaurau Auckland during the COVID-19 pandemic in 2020–2021. The previous year, Vā Moana had begun to investigate how—without shared physical presence—virtual participation in events can uphold central Māori and Moana (Pacific) traditional values of tikanga (te reo Māori: correct procedure, custom) and teu le vā (gagana Sāmoa: nurturing relational space). Aspects of our research concern practices that continue to emphasize vā—as the attachment and feeling for place and relatedness—outside the Pacific homelands. These nascent practices contribute to an emerging understanding of place as an imaginary space of belonging, in which online environments (the digital vā) play a role. The outbreak of COVID-19 gave this general interest unexpected but sharp focus. In this essay, we present, contextualize, and analyze excerpts from three conversations between Vā Moana team members in Aotearoa. Held during, between, and after lockdown periods between March and November 2020, these conversations were conducted either fully online or in a blended format. In the latter case, some members met face-to-face in a "hub,” and others used online platforms to participate in reviewing and reorganizing our research relationships under the new conditions, using the challenge thrown before us as an opportunity for experimentation and change. © 2022, University of Hawaii Press. All rights reserved.
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Most studies of the effect of COVID-19 restrictions on home advantage have been conducted on men’s soccer, with the women’s game lacking scientific attention. The present study fills this gap by investigating games in Swedish Damallsvenskan women’s soccer league. Comparing games in the 2019 and 2020 seasons, we find a slight, but not statistically significant reduction in home advantage in games without crowds in terms of goals scored and points achieved. However, unlike in most studies on men’s soccer, we find that away teams received significantly more yellow cards in games without crowds compared to games with crowds. We discuss our results in the context of the findings in men’s soccer. JEL Classification: D00, J71, L00, Z13, Z20. © 2022 SAGE Publications.
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Background: Human SARS-CoV-2 infection can induce a wide spectrum of organ dysfunctions, including microvascular impairment [1]. S1 subunit of viral receptor-binding domain binds to the angiotensin-converting enzyme 2 receptor on endothelium and S2 subunit allows the virus to enter endothelial cells. The resulting breakdown of barrier integrity drives a cascade of infammatory and thrombotic events, that aggravate the course of COVID-19 together with other risk factors [2-4]. Up to date, a lower capillary density has been reported in several distinct body districts, using sublingual video microscopy, ocular optical coherence tomography angiography, skin functional laser Doppler perfusion imaging and nailfold videocapillaroscopy (NVC) [5-8]. NVC examination has been performed in adult COVID-19 patients, however, without a control group [8]. Objectives: To confrm the statistical signifcance of the reduction in capillary density per linear millimeter evaluated by NVC in comparison with primary Ray-naud's phenomenon (PRP) patients and control subjects (CNT) and to evaluate the impact of an aggressive therapy against COVID-19 on the sparing in the number of capillaries. Methods: Sixty-one COVID-19 survivors, thirty-one PRP patients and thirty CNT age and sex-matched underwent NVC analysis. Demographic and clinical data of COVID-19 survivors were collected with special regard to concomitant therapies, that included antivirals, antibiotics, anticoagulants and anti-infamma-tory/immunomodulant drugs (glucocorticoids, hydroxychloroquine, IL-6 receptor antagonist). COVID-19 survivors were divided in two subgroups according to the severity of the active infection: thirty-four survivors with past mild-moderate disease (either unneedy for oxygen supplementation or need for Venturi mask) and twenty-seven survivors with past severe disease (need for Continuous Positive Airways Pressure and/or mechanical ventilation). The same Rheumatologist performed NVC evaluations in all patients and controls, using an optical probe, equipped with a 200x magnifcation lens and connected to a picture analysis software (Videocap, DS Medica, Milan, Italy). Absolute capillary number per linear millimeter was counted. Results: COVID-19 survivors underwent NVC examination after a mean period of 126±53 days from the disease onset. Multivariate analysis showed differences in absolute capillary number per linear millimeter (p<0.001) after adjusting for age, sex, body mass index, comorbidities and concomitant drugs. The mean (± standard deviation) absolute nailfold capillary number per linear millimeter was signifcantly lower in severe (8.2±1.15) and mild-moderate (8.4±0.75) COVID-19 survivors than in both PRP (8.7±0.68) and CNT subjects (9.3±0.53) (p<0.001). The analysis of the impact of treatments on capillary density in the severe COVID-19 patients showed a positive trend (preservation of the capillary number) with antivirals (no: 7.8±1.53;yes: 8.5±0.64;p=0.35) and anti-IL-6 receptor antagonist administration (no: 7.8±1.36;yes: 8.6±0.74;p=0.16), while none of the other drugs was shown to be effective (glucocorticoids p = 0.46;antibiotics = 0.52;anticoagulants not evaluable as they were used in all COVID-19 patients). Conclusion: SARS-CoV-2 infection seems associated to a signifcant capillary loss as distinctive NVC feature and data concerning the comparison of capillary density pre COVID-19 and post COVID-19 are desirable to reinforce this observation. The positive trend in saving the number of capillaries induced by aggressive anti-infammatory therapies in COVID-19 survivors needs larger cohorts of patients.
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Background: Since the COVID-19 vaccination campaign was launched all over Europe, there has been general agreement on how benefts of SARS-CoV2 vaccines outweigh the risks in patients with rare connective tissue diseases (rCTDs). Yet, there is still limited evidence regarding safety and efficacy of such vaccines in these patients, especially in the long-term. For this reason, in the framework of ERN-ReCONNET, an observational long-term study (VACCINATE) was designed in order to explore the long-term outcome of COVID-19 vaccination in rCTDs patients. The consent form was developed thanks to the involvement of the ERN ReCONNET ePAG Advocates (European Patients Advocacy Group). Objectives: To evaluate the safety profile of COVID-19 vaccination in rCTDs patients and the potential impact on disease activity. Primary endpoints were the prevalence of adverse events (AEs) and of disease exacerbations post-vaccination. Secondary endpoints were the proportion of serious adverse events (SAEs) and adverse events of special interest for COVID-19 (adapted from https://bright-oncollaboration.us/wp-content/uploads/2021/01/SO2-D2.1.2-V1.2-COVID-19- AESI-update-23Dec2020-review-fnal.pdf) Methods: The frst ad-interim analysis of the VACCINATE study involved 9 ERN-ReCONNET Network centres. Patients over 18 years of age with a known rCTD and who received vaccine against COVID-19 were eligible for recruitment. Demographic data and diagnoses were collected at the time of enrolment, while the appearance of AEs and potential disease exacerbations were monitored after one week from each vaccination dose, and then after 4, 12 and 24 weeks from the second dose. A disease exacerbation was defned as at least one of the following: new manifestations attributable to disease activity, hospital-ization, increase in PGA from previous evaluation, addition of corticosteroids or immunosuppressants. Results: A cohort of 300 patients (261 females, mean age 52, range 18-85) was recruited. Systemic lupus erythematosus (44%) and systemic sclerosis (16%) were the most frequent diagnoses, followed by Sjogren's syndrome (SS,12%), idiopathic infammatory myositis (IMM,10%), undifferentiated connective tissue disease (UCTD,8%), mixed connective tissue disease (MCTD,4%), Ehlers-Dan-los's syndrome (EDS,4%), antiphospholipid syndrome (APS,2%). AEs appearing 7 days after the frst and second doses were reported in 93 (31%) and 96 (32%) patients respectively, mainly represented by fatigue, injection site reaction, headache, fever and myalgia. Otitis, urticaria, Herpes Simplex-related rash, stomatitis, migraine with aura, vertigo, tinnitus and sleepiness were reported with very low frequency. Less than 2% of patients experienced AEs within 24 weeks from the second dose. No SAEs or AEs of special interest were observed in the study period. There were 25 disease exacerbations (8%), 7 of which severe. The highest number of exacerbations was observed after 4 weeks from the second dose (12 within week 4, 6 within week 12 and 7 within week 24). Disease exacerbation was most frequent in patients with EDS (33%) and MCTD (25%). Conclusion: This preliminary analysis shows that COVID-19 vaccination is safe in rCTDs patients. AEs appear most often early after vaccination and are usually mild. Disease exacerbations are not frequent, but can be potentially severe and tend to occur most frequently within the frst month after vaccination. Exacerbations can also occur 3-6 months after vaccination, although a causal relationship with the vaccination remains to be established. Our present data underline the importance of long-term observational studies.
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In order to address the main challenges related to the rare diseases (RDs) the European Commission launched the European Reference Networks (ERNs), virtual networks involving healthcare providers (HCPs) across Europe. The mission of the ERNs is to tackle low prevalence and RDs that require highly specialised treatment and a concentration of knowledge and resources. In fact, ERNs offer the potential to give patients and healthcare professionals across the EU access to the best expertise and timely exchange of lifesaving knowledge, trying to make the knowledge travelling more than patients. For this reason, ERNs were established as concrete European infrastructures, and this is particularly crucial in the framework of rare and complex diseases in which no country alone has the whole knowledge and capacity to treat all types of patients. It has been five years since their kick-off launch in Vilnius in 2017. The 24 ERNs have been intensively working on different transversal areas, including patient management, education, clinical practice guidelines, patients' care pathways and many other fundamental topics. The present work is therefore aimed not only at reporting a summary of the main activities and milestones reached so far, but also at celebrating the first 5 years of the ERN on Rare and Complex Connective Tissue and Musculo-skeletal Diseases (ReCONNET), in which the members of the network built together one of the 24 infrastructures that are hopefully going to change the scenario of rare diseases across the EU.
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The BCL2-specific inhibitor, venetoclax, has demonstrated remarkable clinical activity in the treatment of chronic lymphocytic leukemia (CLL), either alone or in combination with CD20 antibodies. Nevertheless, patients who fail to attain a complete remission relapse, and require further therapy. Data on retreatment with venetoclax at disease progression are currently limited. Here, we report patterns of clonal evolution in an R/R CLL patient that has demonstrated successful retreatment. A 57 year-old lady with chemotherapy- refractory (FCR, RCHOP, high dose methyl prednisolone) TP53 mutant CLL was treated for 21 months with single-agent venetoclax in 2014 (NCT01889186). She attained an MRD positive CR with the resolution of massive lymphadenopathy and with only low-level (0.01%) disease in the bone marrow. However, she subsequently progressed rapidly with a lymphocyte doubling time of only 4 weeks and was treated with tirabrutinib and idelalisib in combination (NCT02968563) from December 2015 for 37 months before progressing December 2019. She was retreated with venetoclax and rituximab but died of COVID-19-induced respiratory failure in March 2020. To study the clonal evolution underlying these events, in vitro drug sensitivity assays and whole exome sequencing (WES) were used to study peripheral blood mononuclear (PBMC) and bone marrow samples. WES of sample 1 showed multiple mutations in CLL driver genes: SF3B1 R625C, KMT2C R4434Q, and TP53 R110L at VAFs of 37, 17, 35%, respectively. Mutations in other genes associated with CLL included FANCA L217F (47%) and SPEN P3402S (46%). At disease progression (sample 2), following venetoclax, there was the loss of detectable (WES at 100× coverage) TP53 R110L (with loss of 17p deletion on interphase FISH and analysis of copy number) but maintenance of SF3B1 R625C (44%), KMT2C R4434Q 30%), FANCA L217F (47%), and SPEN P3402S (55%). These data, therefore, suggest the TP53 mutant subclone was largely lost during therapy. No other mutations were identified as possible resistance mediators. There were no detectable BCL2 mutations. In vitro drug sensitivity testing to venetoclax showed an EC50 of 228nM (CLL EC50 usually 3-5 nM). The patient was then treated with the BTK inhibitor tirabrutinib in combination with idelalisib, with an excellent clinical response. After 10 months (sample 3, during the lymphocytosis induced by BTKi/PI3Kdi) SF3B1, KMT2C, FANCA, and SPEN mutations were detected at VAFs of 26, 30, 54, and 56%, respectively. At this point the TP53 R110L mutation was detected again at a VAF of 4%, indicating that stopping venetoclax allowed the clone to re-emerge. At this time, there were no detectable BTK or PLCG2 mutations. The patient then responded for a further 37 months before disease progression. At progression (sample 4), SF3B1, KMT2C, FANCA, and SPEN mutations were still detected in the peripheral blood at VAFs of 43, 31, 48, and 50%, respectively. The VAF of the TP53 R110L mutation had increased to 33%. Additionally, a BTK mutation (T474I) was identified with a VAF of 16%. Identical results were obtained using a bone marrow sample. Now, however, in vitro analysis demonstrated a high degree of sensitivity to venetoclax (EC50 0.72 nM). The patient was, therefore, retreated with venetoclax and rituximab. At the point of re-treatment, VAFs were maintained, with the emergence of a new subclonal NOTCH1 G1001D mutation at a VAF of 3%. The patient, unfortunately, died 4 months after commencing therapy due to COVID-19 associated pneumonitis. A full disease reassessment was not made but the patient's blood count had normalized, with rapid clearance of CLL cells from the peripheral blood, recovery of normal hematological indices, resolution of splenomegaly, and partial resolution of lymphadenopathy on CT scan. These data, therefore, suggest that re-treatment with venetoclax in CLL can be successful. Regaining sensitivity to venetoclax may largely depend on shifting clonal dynamics. The molecular basis of venetoclax resistance in this case is currently being investigated. A so in this particular case, it appears that the TP53 mutant subclone was more sensitive to BCL2 inhibition than TP53 wild-type subclone(s), and was largely eliminated by initial venetoclax treatment, contrasting with recently published data suggesting resistance of TP53 mutant hematological malignancies to BCL2 inhibition due to increased thresholds for BAX/BAK activation (Thijssen et al., 2021).
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In 2019, the Vā Moana-Pacific Spaces research group at Auckland University of Technology (AUT) began to investigate how core Moana and Māori values can be translated from onsite, embodied engagements into digital environments. This was prompted by our wish to provide access to all those who could not travel to attend a conference in late 2021 for our Marsden-funded research project, ‘Vā Moana: Space and relationality in Pacific thought and identity' (2019-22). The onset of the COVID-19 pandemic fundamentally reframed this premise, as providing offsite access was no longer simply a ‘nice option'. The crisis challenged us to find out how virtual participation in events can uphold values of tikanga (correct procedure, custom) and teu le vā (nurturing relational space). In particular, our research examines practices foregrounding vā as the attachment to and feeling for place, as well as relatedness between people and other entities. We have observed an emerging conceptual deployment of vā as relational space and a mode of belonging, especially in diasporic constellations oriented by a cosmopolitan understanding of vā. Due to this focus, we noticed early on that simply moving meetings online is unlikely to create a supportive environment for Indigenous researchers in diaspora, who share principal values and a commitment to a kaupapa (agenda, initiative). This realization led us to interrogate how research collaboration and circulation are influenced by the distinct features of physical and online contexts, protocols and connectivity. To develop the alternative kind of vā we envisaged -together with strategies to sustain it through our online practices - thus became a much larger project in the times of rapid change under COVID-19. This is a very brief, initial report on our experiences. © 2021 Intellect Ltd Research Report. English language. All Rights Reserved.
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Introduction and ObjectivesThe Covid-19 pandemic has driven forward a number of remote monitoring schemes (virtual wards) across the country to support the early discharge of patients with covid-19. Technology can assist clinical teams to deliver comprehensive care in the community. In this study we aim to evaluate the safety and effectiveness of an innovative, telehealth-led virtual ward for Covid-19.MethodsPatients discharged from hospital respiratory wards with a diagnosis of Covid-19 and deemed at risk of readmission (or requiring home oxygen weaning) were eligible for referral. Monitoring equipment (thermometers and digital pulse oximeters) was provided and patients were on-boarded into a telehealth platform prior to discharge. Smartphones and tablets were supplied by the service if required. A Covid-19 digital clinical question set and triaging algorithm was developed locally. Patients were instructed to complete it daily remotely during follow-up and to enter their observations three times daily. Clinical data fed into a dashboard reviewed daily by the community respiratory specialist team who would contact and assess patients submitting symptoms of concern. Monitoring lasted for up to 14 days, and escalation processes to the acute Trust were in place for those patients showing evidence of deterioration.Results218 patients were monitored between December 2020 and May 2021, 29 for oxygen weaning. 41% were female, mean age 57 years old (minimum 21, maximum 89). Average oxygen weaning time was 11 days, with 319 days of hospital bed days saved by the oxygen weaning service and an estimated £127,600 cost saving to the system. Only 10 patients (4.9%) were readmitted after 14 days (versus 9% in usual care from hospital Covid-19 wards). Four patients (1.8%) died in hospital after a readmission. 83% of patients felt ‘very supported’ by the service and 73% expressed that it had ‘fully’ improved their confidence. Average score of satisfaction with the service, measured by a self-reported questionnaire, was 9.9/10.ConclusionsA telehealth-assisted remote monitoring service for Covid-19 is a safe way to provide specialist care at home and can reduce hospital readmissions whilst improving patient experience.
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Through qualitative feedback from professionals in healthcare, mental health, and child welfare, this study explored the impact of the COVID-19 pandemic on the health and well-being of children in the child welfare system. Positive outcomes and challenges related to the care of children in foster or kinship care in Texas during the COVID-19 pandemic are described. Themes identified included disparities in the child welfare system;utilization of telehealth;cross-sector communication and collaboration;safety considerations;and placement stability and support. The article concludes with recommendations in each of these areas for ensuring the health and well-being of children in foster and kinship care during a pandemic. © 2021 Taylor & Francis Group, LLC.
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Background: Vitamin D regulates the innate and adaptive immune system responses and low vitamin D levels have been associated with the increased risk of respiratory tract infections (1). Vitamin D deficiency has been recently reported to interfere with the prognosis of COVID-19 (2,3). Objectives: The aim of this study was to correlate the 25OH-vitamin D serum levels with lung involvement and disease severity, in a cohort of elderly patients hospitalized for SARS-CoV-2 infection. Methods: Sixty-five COVID-19 patients (mean age 76±13 years) and sixty-five sex-and age-matched control subjects (CNT) were included in the study. Respiratory parameters (PaO2, SO2, PaCO2, PaO2/FiO2), clinical and laboratory parameters (including 25OH-vitamin D, D-dimer, C-reactive protein) and type of radiological pulmonary involvement were collected at hospital admission. Statistical analysis was performed by non-parametric tests. Results: Vitamin D sufficiency (≥30 ng/ml), insufficiency (between 20 and 30 ng/ ml), deficiency (between 10 and 20 ng/ml) and severe deficiency (<10 ng/ml) were observed respectively in 11, 11, 21 and 57 % of COVID-19 patients. Vitamin D serum levels were found significantly lower in COVID-19 patients than in CNT (median 8 vs 16 ng/ml, p=0.001). A statistically significant positive correlation was observed between vitamin D serum levels and SO2 (p=0.05), PaO2 (p=0.03), PaO2/FiO2 (p=0.02). A statistically significant negative correlation was found between vitamin D serum levels and severity of radiologic pulmonary involvement: vitamin D was significantly lower in COVID-19 patients with either diffuse/ severe interstitial lung involvement (p=0.05) or multiple lung consolidations (p=0.0001) than in those with mild radiological lung involvement. Significantly lower vitamin D serum levels were found in COVID-19 patients who died during hospitalization, compared to those who survived (median 3 vs 8 ng/ml, p=0.05). Finally, a statistically significant negative correlation was found between vitamin D serum levels and D-dimer (p=0.04), C-reactive protein (p=0.04) and disease duration (p=0.05). Conclusion: This study confirms that severe vitamin D deficiency is associated with more severe lung involvement, longer disease duration and risk of death in elderly COVID-19 patients.
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Background: COVID-19 is a multifaceted condition with a wide range of clinical manifestations, including microvascular/endothelial dysfunction, that starts in the early phase of the disease and may become dramatically harmful in the late stage, causing a massive pro-thrombotic state. Nailfold videocapillaroscopy (NVC) is the most used tool to identify microvascular status in a large spectrum in a cohort of COVID-19 patients (no controls used) [2]. Objectives: To assess microvascular damage in recovered COVID-19 patients (range of 40-270 days from recovery) by considering the previous severity of the disease, and, as mandatory, the comparison with matched individuals suffering from primary Raynaud's phenomenon (PRP) and healthy volunteers (HV). Methods: NVC investigations were performed during standard clinical assessments in forty-four recovered COVID-19 patients (mean age 58±14 years, mean days from disease onset 129±54, mean days from disease recovery 106±52), twenty-two patients with PRP (mean age 60±15 years, mean years from disease onset 11±10) and twenty-two HV (mean age 60±14 years). COVID-19 patients were divided into two subgroups, according to the need of oxygen supplementation: twenty-two patients with severe lung involvement (need of Continuous Positive Airways Pressure and/or mechanical ventilation, mean age 57±12 years) vs twenty-two patients with mild-moderate lung involvement (need of Venturi mask or no need of oxygen supplementation, mean age 59±15 years). Clinical and demographic data of all the enrolled subjects were collected, during NVC examination. The following capillaroscopic parameters were evaluated: capillary number, dilated capillaries, giant capillaries, microhemorrhages, angiogenesis, disorganization of the microvascular array. A validated semiquantitative scoring (0-3) was adopted for NVC abnormalities [3-5]. Statistical analysis was carried out by non-parametric tests. Results: After COVID-19 recovery, no statistically significant difference was observed between COVID-19 patients and control groups of subjects concerning the score for the following NVC parameters: dilated capillaries, giant capillaries, disorganization of the microvascular array, angiogenesis. However, the capillary number per linear millimeter was significantly lower in COVID-19 patients (8.3±0.9) than in PRP (8.8±0.7, p=0.05) and HV (9.3±0.6, p<0.0001). Surprisingly, recovered COVID-19 patients showed significantly less microhemorrhages (score 0.4±0.3) than subjects of the other groups (PRP 0.6±0.5, p=0.01;HV 0.6±0.6, p=0.05). In particular, recovered patients who had more severe COVID-19 showed less microhemorrhages than patients with mild/moderate disease (score 0.18±0.4 vs 0.36±0.5), but this didn't reach the statistical significance (p=0.18). On the other hand, patients recovered from severe SARS-CoV-2 infection also showed higher rate of angiogenesis (0.18±0.4) than patients with mild/ moderate disease (no case, p=0.04). Conclusion: COVID-19 doesn't seem to significantly induce, in short-term, specific alterations in peripheral microvascular array as evaluated by NVC, despite the severity of the disease, except for a significant reduction of the absolute number of nailfold capillaries. The topic needs longer time of evaluation and larger number of COVID-19 recovered cases to also assess the role of concomitant therapies.
ABSTRACT
Background: With the rapid spread of SARS-CoV-2 across the globe, numerous authors have noted different patient characteristics that may relate to an increased admission rate to an intensive care unit (ICU). However, little data has been presented comparing these characteristics among those who receive care at either a rural or urban emergency department (ED). Study Objective: To compare the clinical characteristics and outcomes of patients with COVID-19 admitted to the ICU from rural and urban EDs. Methods: A retrospective, multi-center cohort study of adult patients who required hospitalization between March 01, 2020 and July 01, 2020 due to confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection from two rural and one urban ED in Arizona were included in analysis. Research assistants who were blinded to the study hypothesis were trained on proper data abstraction prior to the collection of data by the study team. With adherence to a quality-controlled protocol and structured abstraction tool, research assistants manually collected patient demographics, ED laboratory values, initial vital signs, total hospitalizations, ICU admissions, and mortality in a with a one-to-one allocation ratio non-White and White patients. Comparisons of the comorbidities among patients transferred to the ICU in urban and rural hospitals were conducted with the chi-squared analysis. Factors that may predict transfer to the ICU were determined via a stepwise multivariable binomial logistic regression. Results: A total of 304 patients (175 urban and 129 rural) with confirmed SARS-CoV-2 infection were admitted to the hospital during the study period with 63 patients (24 urban vs 39 rural;OR=2.1, p=0.01) being admitted to the ICU. Of those admitted to the ICU, a total of 21 (33.3%) were female (11 urban and 10 rural). The median age of patients admitted to the ICU from the urban cohort was 66.0 years old (IQR=35.0) and from the rural cohort was 62.6 years (IQR=28).The most common comorbidity seen in both urban and rural patients admitted to the ICU was hypertension (12 [50%] urban;21 [53.8%] rural). In the overall cohort, multivariable logistic regression showed an increase in the odds of ICU admission among patients presenting with concurrent bacterial infection (p=0.043), elevated temperature (p=0.002), respiratory rate (p=0.003), white blood cells (p=0.034), and reduced hemoglobin levels (p=0.014). Across the total cohort, these factors predicted transfer to the ICU with a sensitivity of 39.5% and specificity of 95.2%. Conclusion: Patients with confirmed SARS-CoV-2 are more likely to require critical care intervention if presenting to the emergency department with concurrent bacterial infection, elevated temperature, respiratory rate, white blood cells, and reduced hemoglobin. The degree to which these factors generalize between urban and rural hospitals remains to be elucidated.
ABSTRACT
Background: Although over half of all counties in the United States are classified as rural, less than 20% of the population live in rural areas. Those who live in rural areas have been shown to have a higher mortality rate from heart disease, cancer and cerebral vascular accidents as compared to their urban counterparts. However, no data is currently available for those with COVID-19. Study Objective: To describe and compare the clinical characteristics and outcomes of patients with COVID-19 who presented to rural and urban emergency departments (ED). Methods: A retrospective, multi-center cohort study of adult patients who required hospitalization between March 01, 2020 and July 01, 2020 due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was conducted. All data was abstracted from two rural and one urban ED in Arizona. Research assistants who were blinded to the study hypothesis were trained on proper data abstraction prior to collection. With adherence to a quality-controlled protocol and structured abstraction tool, research assistants manually collected patient demographics, intake laboratory values, initial vital signs, ICU admissions, and mortality. Data was collected using a one-to-one allocation ratio based upon ethnicity for each site. Comparisons between rural and urban populations were completed using chi-square, Mann-Whitney U, and independent samples T-tests. Results: A total of 304 patients (175 urban and 129 rural) with confirmed SARS-CoV-2 infection were admitted to the hospital during the study period. Patients presenting to a rural ED were more likely to be admitted to the ICU (24 urban vs 39 rural;OR = 2.1;p=0.01). Of those hospitalized, a total of 137 (43.9%) were female (87 [47.5%] urban and 50 [38.8%] rural). The median age of patients hospitalized from the urban cohort was 67 years old (IQR=25) and from the rural cohort was 63 years (IQR=28).Of those studied, 43 (14.1%) patients expired from COVID-19 with 24 (13.1%) patients in the urban cohort and 19 (14.7%) in the rural cohort (p=0.06). Those in the rural population presented to the ED 7.0 (IQR 7) days from initial symptoms onset and those in the urban population 5 (IQR 4) (p=0.005). Patients treated at urban EDs had a higher systolic blood pressure (138.6 mmHg vs 130.3 mmHg;p=0.01) but lower oxygen saturation (91.7% vs 93.1%;p=0.04) than those treated at a rural ED. When intake laboratory values were considered, patients treated in an urban ED had a statistically significant lower white blood cell count and ferritin level as compared to those at a rural ED but a higher hemoglobin, hematocrit, and calcium level (Table). Conclusion: Rural patients with COVID-19 exhibit a delay in presentation to their local ED, producing atypical prognostic laboratory measures when compared to urban centers. This delay may contribute to symptom exacerbation and a higher rate of critical care admissions among rural patients. [Formula presented]
ABSTRACT
BACKGROUND: The complexity of fetal medicine (FM) referrals that can be managed within obstetric units is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service linking a specialist fetal medicine (FM) centre and a remote obstetric unit. METHODS: Over a four-year period from October 2015, all women referred for FM consultation from the obstetric unit were seen via telemedicine, excluding cases where invasive testing, intrauterine therapy or cardiac anomalies were anticipated. The outcomes measured included the indication for FM referral; scan duration and image and sound quality during the consultation. Women's perceptions of the telemedicine consultation and estimated costs to attend the FM centre were measured by a structured questionnaire completed following the first telemedicine appointment during the Phase 1 of the project. RESULTS: Overall, 297 women had a telemedicine consultation during Phase 1 (pilot and evaluation) and Phase 2 (embedding and adoption) of the project, which covered a 4 year period 34 women completed questionnaires during the Phase 1 of the study. Travel to the telemedicine consultation took a median (range) time of 20 min (4150), in comparison to an estimated journey of 230 min (120,450) to the FM centre. On average, women would have spent approximately £28 to travel to the FM centre per visit. The overall costs for the woman and her partner/ friend to attend the FM centre was estimated to be £439. Women were generally satisfied with the service and valued the opportunity to have a FM consultation locally. CONCLUSIONS: We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced to provide FM ultrasound of sufficient quality to allow fetal diagnosis and specialist consultation with parents. Furthermore, the service is acceptable to parents, has shown a reduction in family costs and journey times.