ABSTRACT
The aim of the study is to find out any association between time of death in coronavirus disease (COVID-19) patients and variables like age, sex, and existence of comorbidities including type II diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease, etc. An attempt was also made to elucidate the reasons for relationship between time of death and other aforementioned variables. Mortality data of 1,553 COVID-19 cases from a tertiary care hospital between March 2020 to September 2021 were analyzed. Maximum deaths occurred between 18:01 hours to 06:00 hours of the 24-hour cycle. There is a significant statistical association between time of death and age, time of death and sex, time of death and having a comorbidity of diabetes mellitus in the study sample. The study confirms that the chronofatality of COVID-19 deaths has a nocturnal predilection. The circadian rhythms of glucocorticoids, respiratory physiology of sleep, and circadian hemodynamic variations may have a role in prognosis and fatality of COVID-19. © This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/bync/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright © 2021 Korean Academy of Sleep Medicine
ABSTRACT
Introduction: The COVID-19 pandemic disrupted the traditional inperson healthcare delivery model, prompting a shift to telemedicine to ensure continuity of care for pediatric rheumatology patients. The change to virtual practice affected healthcare provider's assessments of disease activity in patients with juvenile idiopathic arthritis (JIA) as they were unable to perform hands-on physical assessments. Understanding the impact of this shift is critical to help address any care gaps that are faced during virtual visits for patients with JIA. Objectives: The objectives of the survey were four-fold: a) understand the impact of the switch from in-person to telemedicine visits from the healthcare provider perspective;b) identify the barriers and facilitators to collecting critical data elements that are important in monitoring JIA disease activity and outcomes;c) identify tools that providers are using during their telemedicine visits to perform disease activity assessments;and d) examine the impact of the telemedicine healthcare delivery on clinical research. Methods: A cross-sectional survey sent to members from all Pediatric Rheumatology Care and Outcomes Improvement Network (PR-COIN) centers (n=21) with total number of targeted respondents of 121. The survey was sent out for completion between 08/17/2020 - 09/ 02/2020. Quantitative responses were analyzed using descriptive statistics. Qualitative responses were analyzed by content and theme. Results: Survey ersponse rate was 98% (n=119) 90% fully completed. Most respondents (99%) indicated that they documented six critical data elements [CDE] (physician global assessment, patient global assessment, active joint count, morning stiffness, arthritis-related pain, and completion of uveitis screen) in 75% of telemedicine visits. Most respondents (74%) indicated that they documented active joint count over 70% of the time, while 30% of respondents reported barriers to documenting active joint count such as inability to palpate joints and the inability to visualize all joints on virtual examination. Identified barriers to assessment and visit documentation included challenges with assessing joint disease activity and platform technical issues. Ten percent of the respondents reported they often forgot to document CDE during telemedicine visits, indicating that setting up automated reminders in their electronic medical records may help with increasing their likelihood of documentation. A few centers reported having processes to assist with the collection of patient data in advance of the visit, such as pre-visitquestionnaires and planning. The ability to perform research activities was significantly impacted with only 37% of centers reported participating in research activities via telemedicine, and 29% reported their ability to consent patients via telemedicine visits. Conclusion: There are multiple barriers and facilitators to conducting successful clinical visits as well as performing clinical research over telemedicine. Our data suggests variation in telemedicine practice and process across centers, as well as within each center, reflecting the need to standardize the process of telemedicine visits. Given that a portion of patients with JIA will likely continue to be serviced over telemedicine post-pandemic, teams need to adapt their existing practices to continue providing quality care and integrating clinical research over this platform where appropriate.
ABSTRACT
Content: Management of patients with sickle cell disease (SCD) in the UK relies largely on transfusion therapy and hydroxycarbamide alongside supportive care. New therapies to improve morbidity and mortality are needed. Two new therapies undergoing NICE technology appraisal are crizanlizumab and voxelotor. Crizanlizumab, a p-selectin inhibitor, has been shown to reduce the frequency of vaso-occlusive crisis in patients aged 16 or over in a randomised, placebo-controlled phase 2 trial (SUSTAIN)1. Voxelotor is an HbS polymerisation inhibitor and showed increased haemoglobin levels with reduced markers of haemolysis in a phase 3 trial (HOPE)2. Both were approved by the FDA in November 2019. The eligibility criteria used in the SUSTAIN and HOPE trials have been compared against the Bristol Haematology and Oncology Centre and Oxford University Hospitals SCD cohorts to identify those patients who would be eligible for these emerging therapies. The patient databases were cross-referenced with electronic notes to identify eligibility data. Vaso-occlusive crises (VOC) were determined by calls to the haemoglobinopathy team or helpline, attendance at the Acute Haematology Unit or admission. Electronic blood results were checked to ensure haemoglobin fell within the specified ranges. Results of analysis of SCD patient database according to eligibility criteria for crizanlizumab and voxelotor as described in the SUSTAIN and HOPE trials1,2 are shown in Table 1. Results show that, out of 158 patients with eligible sickle cell disorders, only 7 (4.4%) were eligible for both therapies. 8 (5.1%) were eligible for voxelotor only, and 2 (1.3%) were only eligible for crizanlizumab. Patients with no VOC in 12 months were ineligible for either therapy (n = 75, 47.5%) and just under half of these patients had a baseline haemoglobin over the range of eligibility for voxelotor (n = 37, 23.4%). 5 patients with a single VOC in 12 months had an Hb out of range for voxelotor (3.2%). Regular transfusion therapy was the second most common exclusion (n = 29, 18.3%). Age over 65 excluded 8 (5.1%) of our patients, and 6 (3.8%) had significant comorbidity that rendered them ineligible. 15 (9.5%) of our patients had moved out of area so estimates of VOC per year are likely to be inaccurate. Other reasons for exclusion included titration of hydroxycarbamide and family planning. Though new therapies are being developed for prevention of VOC in SCD, few patients in our cohort are eligible for these. Incidence of severe VOC may be underestimated as patients self-manage at home, particularly in the current COVID-19 pandemic. This should be kept under review and closer liaison with patients about their VOC may help identify eligible patients. Strict adherence to eligibility based on that of clinical trials is likely to result in very few patients benefitting from these new therapies.