Successful Drilling of the Deepest and Hottest HPHT Carbonate Well in Central Luconia, Off the Coast of Sarawak, Offshore Malaysia

HPHT wells are typically associated with high complexity, technically challenging, long duration, high risk and high NPT as many things could go wrong especially when any of the critical nitty- gritty details are overlooked. The complexity is amplified with high risk of losses in carbonate reservoir with high level of contaminants compounded by the requirement of high mud weight above 17 ppg during monsoon season in an offshore environment. The above sums up the challenges an operator had to manage in a groundbreaking HPHT carbonate appraisal well which had successfully pushed the historical envelope of such well category in Central Luconia area, off the coast of Sarawak where one of the new records of the deepest and hottest carbonate HPHT well had been created. This well took almost 4 months to drill with production testing carried out in a safe and efficient manner whereby more than 4000m of vertical interval was covered by 6 hole sections. With the seamless support from host authority, JV partners and all contractors, the well was successfully delivered within the planned duration and cost, despite the extreme challenges brought about by the COVID-19 pandemic. This paper will share the experience of the entire cycle from pre job engineering/planning, execution and key lesson learnt for future exploitations. Copyright © 2022, Offshore Technology Conference.

COVID-19 HYPERINFLAMMATION CAN BE PREDICTED USING ROUTINE CLINICAL LABORATORY MARKERS

Background/Aims Since early in the COVID-19 pandemic, there has been interest in the concept that some morbidity and mortality may be due to excessive inflammation. Several definitions of COVID-19 hyperinflammation COV-HI) have been proposed, including Manson criteria (C-reactive protein, CRP ≥150mg/L or doubling above 50mg/L in 24 hours and/or ferritin 1500ug/L);and Webb criteria (includes CRP ≥150mg/L or ferritin ≥750ug/L). A consistent finding has been worse outcomes. Little is known regarding the underlying pathologies separating these patients from others. Aim To investigate whether machine learning using standard laboratory features can identify a distinguishing 'COV-HI signature'. Methods A database of daily clinical and laboratory features was collected from 611 patients admitted to hospital with confirmed COVID-19 during the first wave of community-acquired infection at University College London Hospitals, Sheffield Teaching Hospitals, Newcastle upon Tyne Hospitals and Royal Wolverhampton. All data prior to mechanical ventilation were interrogated. Patients were categorised as COV-HI based on Webb thresholds (CRP >150 mg/L or ferritin ≥750ug/L). Laboratory features (peak or nadir depending on recognised predictors of illness severity) included: minimum lymphocyte count 10

The rheumatological history

Rheumatology encompasses conditions affecting multiple body systems and requires a wide-lens approach to history-taking. The diagnostic challenge of rheumatological disease is best considered through a thorough multisystem history to elicit past and present symptomatology. The pattern of affected body systems, combined with more specific questioning to illustrate associated features, can then be used to formulate a diagnosis and exclude other differentials. This article provides a systematic approach to the rheumatological history and guidance on seeking out relevant clues to help make the diagnosis.

Enhancing first contact practitioners’ continuous professional development within an integrated care system using project ECHO (Extension for Community Health Outcomes)

Keywords: Project ECHO;Telementoring;First contact physiotherapists Purpose: The Chartered Society of Physiotherapy and Health Education England advise that first contact practitioners (FCPs) undertake regular continuous professional development (CPD) to meet the pillars of advanced practice. FCPs in primary care may be at risk of isolation and reduced learning opportunities. Project ECHO has international success using technology for remote learning to increase clinician knowledge and confidence, reduce isolation, and improve patient outcomes. The aim of this project was to ascertain the accessibility and acceptability of Project ECHO methodology in delivering CPD to FCPs remotely within an Integrated Care System (ICS). Methods: Between February 2020 and June 2020 an initial knowledge event and five 90-min ECHO sessions took place via Zoom©. Participants joined sessions from their place of work or residence. Evaluation used mixed methods consisting of attendance monitoring, pre- and post- evaluation of competence and confidence in curriculum topics, a satisfaction survey via Survey Monkey, session evaluations using the polling function on Zoom©, and a 2-person interview via Zoom© following the conclusion of the programme. As the project was a service evaluation, no ethics approval was needed however regulation was governed by the institution's evaluation department. Results: There was a total of 41 individual attendances across the five sessions. Average attendance was 72%. Self-rated knowledge and confidence increased in all areas, 78% of participants felt that they learnt something new and 51% felt they would change their practice due to something they had learnt. The potential miles saved over 6 sessions (knowledge event plus 5 ECHO sessions) from remote learning was 1010.6 miles which equates to £565.94 if paid at the NHS rate of 56p per mile. The average time saved in return travel was 32.8 h (equates to £652.39–£746.53 at bottom–top AfC Band 7). This equates to 336 patient consultations, based on 20 min appointments. Qualitative evaluation from both the post-session evaluation and interviews revealed that participants found the sessions supportive and accessible at a time when all face-to-face training had been halted due to the COVID pandemic. They enjoyed networking with a broader peer group, however recognised that this might also be intimidating to less experienced FCPs. Recommendations made for future programmes included case studies related to the session's topic allowing for consolidation of learning and to split cohorts into entry-level FCPs where topics can be broader and more experienced FCPs where topics and cases can be more specific. Conclusion(s): Project ECHO is an accessible and acceptable median of using technology to provide CPD to FCPs. Participants found the content relevant, enjoyed the peer-support, and most reported taking away new learning. Impact: Utilising Project ECHO for FCP CPD has the potential to reduce the isolation of clinicians working in Primary Care by creating a virtual community of practice, promoting knowledge exchange and improving clinician job satisfaction and patient care. HEE in collaboration with the ICS and the ECHO hub are looking at further ways that Project ECHO can be used to develop FCPs including developing wider regional communities of practice. Funding acknowledgements: This project was funded by Health Education England in partnership with St Luke's Hospice, Sheffield.

Adult onset PIMS-TS with secondary haemophagocytic lymphistiocytosis: Into the eye of the cytokine storm

Case report-IntroductionA small sub-group of COVID-19 patients develop secondary haemophagocytic lymphohistiocytosis (sHLH), a multisystem progressive hyperinflammatory syndrome characterised by fever, hepatosplenomegaly, hyperferritinaemia, cytopenia, and multiple-organ failure, which if not identified and promptly treated may be fatal. There have been isolated reports of adults developing PIMS-TS, a rare inflammatory multisystem syndrome seen in children with COVID-19 which shares common features with Kawasaki disease, toxic shock syndrome and macrophage activation syndrome/sHLH. Here we present a case of COVID-19-associated PIMS-TS in an adult complicated by frank sHLH (COV-HLH) which, after a protracted course, responded to combination immunotherapy including the IL-1 antagonist anakinra.Case report-Case descriptionA 22-year-old female of Nigerian-descent with sickle cell trait presented with fever, headache, sore throat, arthralgia, abdominal pain, diarrhoea/vomiting, swollen feet/legs, and macular rash on hands/forearms. A 3-day flu-like illness occurred 8 weeks earlier. Persistent pyrexia, tachycardia and hypotension required ICU admission for inotropic support. Although she briefly required oxygen, hypoxaemia was not a prominent feature. Bloods revealed CRP>200mg/L, ferritin<14,000ng/mL, raised D-Dimer, procalcitonin, Troponin-T and ALT, anaemia, lymphopenia, and neutrophilia. Computed-tomography showed mild bibasilar subpleural ground-glass changes, pelvic free fluid, and peritoneal enhancement. As treatment for suspected COV-HLH, or connective tissue disorder, intra-venous hydrocortisone 100mg QDS was given;fever resolved and blood parameters transiently improved. Second nasopharyngeal SARS-CoV-2 RT-PCR was positive and screen for other infection and autoimmune disease negative. Echocardiography and CTA excluded coronary aneurysms although Troponin-T peak was 330ng/L.Rapidly rising ferritin and triglycerides, falling cell counts and fibrinogen, led to a diagnosis of COV-HLH. Intra-venous anakinra 70mg (1mg/kg) BD was initiated. When pyrexia remained >40 °C, inotrope requirement persisted, cell counts fell and ferritin rose to 45,861ng/ml, anakinra was increased over 48h to 200mg BD with intra-venous methylprednisolone 1g OD x2. After 7 days anakinra was weaned to 100mg subcutaneous BD enabling discharge. Outpatient bone marrow aspirate/trephine showed reactive hyperplasia, no leukaemia or haemophagocytosis. Genomic testing showed no primary genetic cause. A week later she was readmitted with fatigue, arthralgia, pyrexia, tachycardia, haematuria, and ferritin of 23,000ng/mL (nadir 4,000ng/mL). FDG-PET showed hepatosplenomegaly with no lymphoma. Anakinra was increased to 200mg IV BD with IVIG 1mg/kg OD x2 and methylprednisolone 1g IV OD x3, then cyclosporine 1mg/kg IV BD. Fevers and haemoproteinuria resolved within 1 week and inflammatory markers fell allowing discharge on a reducing regime of subcutaneous anakinra, oral prednisolone and cyclosporine. She remained well;ferritin and FBC finally normalised >2 months after presentation.Case report-DiscussionThrough the UK HLH across speciality collaboration (HASC) we are aware of only a handful of UK cases of adult presentation PIMS-TS and even fewer with frank sHLH. Our patient's ethnic background and presentation were typical for paediatric PIMS-TS. Hence, we actively excluded coronary artery aneurysms, a key feature of the Kawasaki-type variant of PIMS-TS.Initial COVID-19 swabs were negative as was extensive investigation for other sepsis triggers. A high clinical suspicion of COVID-19 led to the second positive swab and early recognition of sHLH. Diagnosis of HLH can be challenging due to its non-specific features and was even more difficult in critically ill patients during the peak of the pandemic, where bone marrow biopsy and cross-sectional imaging (key components of diagnostic scoring systems such as the HScore) were difficult to obtain. Persistent pyrexia, hyperferritinaemia and recognition of worsening trends in all relevant domains raised suspic on of sHLH. On initiation of anakinra, her HScore was only 118, although her illness peak was 162, well above the HASC agreed threshold of 132 for HLH diagnosis during the pandemic. She subsequently had a negative bone marrow biopsy in line with >50% of critical care patients with sHLH;a demonstration that biopsy proven haemophagocytosis is not necessary for a clinical diagnosis of sHLH. No other sHLH trigger was found.Early recognition and intensive treatment may have contributed to the positive outcome;sHLH mortality in ICU patients can reach nearly 70%. These decisions were facilitated by early discussion with MDT members of HASC. The initial dose of 70mg IV BD and speed of wean after an effective dose was achieved were insufficient. A longer period on 400mg anakinra daily, a slower wean, plus addition of methylprednisolone, IVIG and cyclosporin appeared to aid the resolution of her relapse. Case report-Key learning points COVID-19 infection is complicated by hyperinflammatory syndromes (cytokine storm, PIMS-TS, sHLH) in a significant minority of patients. In the absence of a treatment for COVID-19, early recognition of treatable complications should be a clinical priority.Adult clinicians should be aware of PIMS-TS which may rarely occur in young adults, especially those of African descent. The CDC definition extends to those aged up to 21. Cardiac aneurysms should be actively excluded in this group.The challenges associated with sHLH diagnosis became more apparent during the peak of the COVID-19 pandemic where key tests were difficult to obtain. Current scoring systems are insensitive for evolving sHLH. A high index of clinical suspicion and a multidisciplinary team approach, in which rheumatologists are key, is important for early recognition and treatment. Although no other sHLH trigger was found in this case, we have seen COV-HLH patients with underlying connective tissue disorder, haematological malignancy or a primary genetic defect, which should be considered if COV-HLH patients do not respond to treatment.Optimal treatment for sHLH and the hyperinflammatory syndromes associated with COVID-19 is not supported by randomised controlled trials but there is accumulating evidence for anakinra. Whilst its use in sHLH remains off-license, UK guidelines have been developed, with an emphasis on early and high dose treatment. Careful anakinra weaning regimens should be considered and patient progress regularly reviewed to avoid relapse of sHLH and subsequent readmission. Our patient also appeared to have a favourable response to corticosteroid and other combined immunosuppressive treatments including IVIG and cyclosporine. It remains to be seen if the incidence of adult-onset PIMS-TS and COV-HLH will reduce now that Dexamethasone is standard of care in adult patients with COVID-19.

How do our patients feel about face-to-facereview in rheumatology clinics since COVID-19? Asingle tertiary care centre experience

Background/AimsThe COVID-19 pandemic has had a significant impact on themanagement of outpatients. During the first wave of the pandemic, and in common with other departments, almost all our patientconsultations happened over the phone. As the rate of infection fell, we felt it was crucial that the patient voice was heard as we reorganised clinical areas and re-opened services. In view of this, weconducted an online survey to better understand patient concernsaround visiting our hospital for appointments and how we can adaptthe way we work to ensure patient safety and satisfaction.MethodsUsing our electronic patient record, we identified patients from the cliniclists of 2 adult rheumatology consultants over a 6-week period betweenJune and August 2020. This timeframe was selected as it was towardsthe end of the UK nationwide shielding period and our department wasreturning to deliver an increasing proportion of outpatient care face-toface. Included patients had to have been treated with an immunosuppressive drug and only those on monotherapy hydroxychloroquine, sulfasalazine or prednisolone under 5mg were excluded. We consentedeach patient via telephone before sending them an email link to an onlineanonymised survey. This included a combination of 9 multiple choiceand white space questions.Results65 patients were identified of which 16 were excluded as we wereunable to contact them or they declined consent. 49 patients weresent the survey of which 31 responses were received. 21/31 (67%) ofpatients had been shielding. The survey revealed six themes ofconcern. These include: lack of social distancing in common hospitalareas, lack of personal protective equipment compliance amongststaff, prolonged time spent in waiting rooms, lack of knowledge onnew hospital policies, logistics of using public transport to come to thehospital, and the importance of retaining virtual consultations goingforward. 55% of patients stated they would feel safe in returning to thehospital for face-to-face appointments over the next few months.ConclusionImportant themes have emerged from this project that we havepresented to our rheumatology multi-disciplinary team, Director ofInnovation and Head of Patient Experience. This has reinforcedadaptations in our hospital environment such as installing safedistance seating in waiting rooms and scheduled phlebotomy slots.Further, where possible we call patients before face-to-face appointments to inform them of our safety measures and try to schedule thesepatients for outside peak travel hours. We acknowledge that using anonline survey may limit responses from older individuals or those withEnglish as a second language. Despite this, our project has shown theimportance of recognising the unique concerns of rheumatologypatients and the value in using their opinions to create a ''new normal''for our outpatient environment.

Laboratory biomarkers associated with COVID-19 severity and management.

The heterogeneous disease course of COVID-19 is unpredictable, ranging from mild self-limiting symptoms to cytokine storms, acute respiratory distress syndrome (ARDS), multi-organ failure and death. Identification of high-risk cases will enable appropriate intervention and escalation. This study investigates the routine laboratory tests and cytokines implicated in COVID-19 for their potential application as biomarkers of disease severity, respiratory failure and need of higher-level care. From analysis of 203 samples, CRP, IL-6, IL-10 and LDH were most strongly correlated with the WHO ordinal scale of illness severity, the fraction of inspired oxygen delivery, radiological evidence of ARDS and level of respiratory support (p ≤ 0.001). IL-6 levels of ≥3.27 pg/ml provide a sensitivity of 0.87 and specificity of 0.64 for a requirement of ventilation, and a CRP of ≥37 mg/l of 0.91 and 0.66. Reliable stratification of high-risk cases has significant implications on patient triage, resource management and potentially the initiation of novel therapies in severe patients.