ABSTRACT
Background: Stratified care aims at matching the intensity and setting of mental health interventions to the needs of help-seeking Young People. In Australia, a 5-tiered system of mental health services is in operation. To aid patient triage to the most appropriate tier, a Decision Support Tool (DST) has been developed and is being rolled out nationally Methods: We analysed outcome data pre-and post-enrolment of about 1500 Young People (aged 16-25) referred to a Youth Mental Health Service delivering medium- and high intensity psychological treatment programs (tiers 3 and 4). We compared outcomes in both tiers during three 12-month periods: (a) in the inaugural phase of tier 4, prior to service saturation and stringent triaging, and prior to the COVID-19 pandemic (2019);(b) during the COVID-19 pandemic when all services were delivered remotely over phone- and video facilities, and when DST triaging was introduced (2020);(c) following return of face-to-face consultations, in a situation of service saturation and stringent DST triaging (2021) Findings: About 22% of Young People in the tier 3 program experienced reliable improvement according to their Kessler-10 (K-10) scale ratings, regardless of changing circumstances. In contrast, 40% of people in the tier 4 program reliably improved during the inaugural phase When circumstances and service delivery changed (COVID-19 restrictions service saturation, DST triaging), the rate of reliable improvement halved to about 20% Conclusion(s): Access to higher intensity psychological programs improves treatment outcomes for help-seeking Young People. However high-intensity services are more sensitive to external and service factors than less intense treatment models.
ABSTRACT
Objectives: Reviewing current literature and case reports of patients placed on Venous-Venous ECMO support for HIV and AIDS, with confection with Pneumocystis pneumonia and covid-19 pneumonia. The use of extracorporeal membrane oxygenation (ECMO) in patients who have acute respiratory distress syndrome has been shown to have very good outcomes. However, there is limited data to support the initiation of ECMO in patients who have human immunodeficiency virus infection with or without acquired immune deficiency syndrome. Method(s): We present a unique and challenging case of a 30 year old male, with no known past medical history, unvaccinated against covid-19, who presented with one week of progressive shortness of breath. On admission he was found with moderate bilateral infiltrates and was diagnosed with covid-19 pneumonia. Despite appropriate medical therapy, patient developed worsening hypoxic respiratory failure. Found to have elevated (1- 3)-7beta;-d-glucan and tested positive for HIV. CD4 count 11, HIV viral load 70,000. The patient remained severely hypoxemic despite mechanical ventilation, sedation, paralytics and proning. Venous venous extracorporeal membrane oxygenation was initiated. Considering his non improvement with variety of antivirals and antibiotics and with elevated (1-3)-7beta;-d-glucan in the setting of AIDS he was treated for presumed Pneumocystis pneumonia. The patient tolerated proning while on VV ECMO and his course was complicated with bilateral pneumothorax necessitating chest tube placement. Result(s): The patient successfully completed 64 days on VV ECMO, where he was treated for PCP pneumonia, covid pneumonia, CMV viremia and tolerated initiation of anti-retroviral therapy. Patient was successfully decannulated, and ultimately discharged from the hospital. Conclusion(s): VV-ECMO can be a beneficial intervention with successful outcomes in severely immunocomprimised patients with AIDS. This case highlights the importance of minimizing sedation and early mobilization on ECMO support. (Figure Presented).
ABSTRACT
Background: COVID-19 vaccines are safe & effective, though patients with rheumatic diseases like idiopathic inflammatory myositis (IIMs), and those with multiple comorbidities continue to be hesitant. Adverse events after vaccination are not extensively studied in those with multiple coexisting autoimmune diseases. Patients with IIM often have multiple autoimmune rheumatic and autoimmune non-rheumatic comorbidities (IIM-AIDs), with potentially increased risk of AEs. The COVAD study aimed to assess COVID-19 vaccination-related AEs till 7 days post-vaccination in IIM-AIDs compared to IIMs and healthy controls (HCs) group. Method(s): T he C OVAD s tudy g roup c omprised > 110 c ollaborators across 94 countries. The study was conducted from March-December 2021. A survey monkey platform-based self-reported online survey captured data related to COVID-19 vaccination-related AEs in IIMs, AIDs, and HCs. We compared COVID-19 vaccination-related AEs among IIM-AID patients and IIM alone and HCs, adjusting for age, gender, ethnicity, vaccine type, immunosuppression, and numbers of AIDs, using binary logistic regression. Statistically significant results following multivariate regression are reported. Result(s): Among 6099 participants, 1387 (22.7%) IIM, 4712 (77.2%) HC, 66.3% females, were included from 18 882 respondents: 573 (41.0%) people with IIM-AIDs;814 (59.0%) with IIM without other AIDs;and 4712 HCs. People with IIM were older [median 54 (45-66) IIM-AIDs, 64 (50-73) IIM, 34 (26-47) HC years, P < 0.001]. BNT162b2 (Pfizer) (37.5%) and ChAdOx1nCoV-19 (Oxford) (11.1%) were the most common vaccines. When compared to IIM alone, IIM-AID patients reported higher overall AEs [OR 1.5 (1.1-2.1)], minor AE [OR 1.5 (1.1-2.1)] &major AE [OR 3 (1.5-5.8)]. IIM-AIDs patients also reported higher body ache, nausea, headache, & fatigue (OR ranging 1.3-2.3). After adjusting for the number of AIDs, the major AEs equalized but overall AEs, & minor AEs, such as fatigue remained higher. When compared to HCs, IIM-AIDs patients reported similar overall AEs, minor AEs but higher major AEs [OR 2 (1.2-3.3)] nausea/ vomiting [OR 1.4 (1.01-2)], headache [OR 1.2 (1.01-1.6)], and fatigue [OR 1.3 (1.03-1.6)]. Dermatomyositis with AIDs (n = 183) reported higher major AEs [OR 4.3 (1.5-12)] compared to DM alone (n = 293). Active IIM with AIDs (n = 482) reported higher overall AEs [OR 1.5 (1.1-2.2)], minor AEs [OR 1.5 (1.1-2.2)] and major AEs [OR 2.6 (1.2-5.2)] compared to active IIM alone (n = 643). Conclusion(s): COVID-19 vaccination is safe with minimal to no risks of short-term AEs in patients with IIM without other concomitant autoimmune diseases. The presence of autoimmune multimorbidity conferred higher self-reported short-term risks of overall, major, and minor COVID-19 vaccination-related AEs 7 days post-vaccination, particularly in those with active IIM.
ABSTRACT
The Coronavirus (COVID-19) pandemic, typified as such in March 2020 by the World Health Organization (WHO), has exceeded the capacity of health systems to aid victims, and triggered a radical change in medical research, and in the monitoring of the enrollment for clinical trials in urologic fields around the world. Last year, almost 90% of clinical sites closed patient enrollment, while at the same time, researchers around the world initiated almost 1000 COVID-19 clinical trials. This catastrophic pandemic has allowed us to expand our medical knowledge exponentially. The global urological community has created and published an infinity of scientific articles: establishing guideline reactions for diagnosis, treatment, and follow-up of the different urologic conditions across all areas of the field, reporting the experiences at urology services, and putting forward new strategies. The Confederacion Americana de Urologia (CAU) has promoted international collaborative projects that have led to gaining insight into how the Latin American Urology Services faced the pandemic, including the challenges, strengths, and the areas of opportunity for urologic care. It also allowed us to increase the number and quality of publications. Also, we have created new virtual platforms and international networks to exchange our knowledge. We have as well transformed this social, economic and health crisis brought upon us by COVID-19, into a source of opportunities for the growth and promotion of research in Latin America. Urologic patients, require researchers to work on favoring their goals. A collaborative network, the established and coordinated protocols, the safety of patients and researchers, assertive and constant communication, and effective technology use, are the essential tools to resume institutional investigation under these critical conditions. Copyright © 2022 Sociedad Mexicana de Urologia. Colegio de Profesionistas A.C.. All rights reserved.
ABSTRACT
Introduction: In 2016, WHO announced a plan to eliminate viral hepatitis C as a public health threat by 2030. However, for achieving this goal, not only access to highly effective drugs, but also the ability to detect hidden infections by launching national screening programs is important. Lithuanian health authorities decided as a first step of the program, to pay general practitioners (GPs) a special fee for a service of promoting and performing serological tests for hepatitis C virus (HCV) antibodies (14.3 per screened person): 1. For the population born in 1945-1994 (once per life), and;2. For persons who inject drugs and AIDS patients (annual HCV testing). The program will start in July 1st, 2022. Here we present the results of pilot study in the primary health care centre of seaport Klaipeda conducted before starting of hepatitis C screening program in Lithuania. Aims & Methods: Patients were invited to participate in the HCV screening by GPs during the visits. Additionally, regional media, social networking sites, and leaflets were used to inform about the possibility of being tested free of charge. Screening involved a blood test for the presence of antibodies to HCV (TOYO rapid test, Turklab Tibbi Malzemeler A.S., Turkey). Patients who tested positive were referred to a gastroenterologist for further examination. A case-control study was performed to identify risk factors for hepatitis C infection. All seropositive patients (case group) were invited to participate in a telephone interview, and 65 out of 81 (80.2%) responded. The control group (n=130) matched by gender and age with the cases was randomly selected from seronegative patients and interviewed by telephone using the same questionnaire as the case group. The associations of possible risk factors with HCV infection were analysed using univariable and multivariable logistic regression analysis. Result(s): From November 2020 to February 2022, 4867 patients were screened in the primary health care centre in Klaipeda. Positive test results were found in 81 (1.7%) patients. Of all screened patients, 4167 (85.6%) were born in 1945-1994, and 79 (1.9%) of them were seropositive. Seroprevalence of HCV antibodies was higher among men than women, 49 out of 2363 (2.1%) and 32 out of 2504 (1.3%) respectively (p=0.03). In men, the highest HCV seroprevalence was found in age groups of 30-39 years (3.6%) and 40-49 years (3.5%), in women - in 50-59 years (1.9%). In case-control study, injection of illegal drugs was reported by 23.8% of HCV positive patients;27.0% of seropositive patients were in prison for more than 3 months. The odds ratio (OR) of HCV infection in patients who reported blood transfusions before 1993 was 6.8 (95% CI 2.0-23.2) compared to those who did not have a blood transfusion or had it later. HCV infection was diagnosed more often among patients who were blood donors before 1993 compared to those who were not donors or were later (OR 4.6;95% CI 2.1-10.2). Having a tattoo increased the odds of HCV infection by 6.5 times (95% CI 2.8-14.8). Conclusion(s): Despite the COVID 19 pandemic, the pilot study revealed active participation of individuals in HCV screening organised by the primary health care centre. Although adults > = 18 years of age were invited to the pilot study, all serologically positive cases of hepatitis C fell into the following categories: 1) born in 1945-1994;and 2) persons who inject drugs.
ABSTRACT
Purpose: Telemedicine is an essential part of healthcare delivery and has grown exponentially during the COVID-19 pandemic. Data on optimal utilization and implementation of telemedicine in SOT care remain limited. We aimed to evaluate patient, provider and clinic staff perspectives on telemedicine use and potential barriers in SOT clinics. Method(s): We prospectively enrolled adults seen via telemedicine (video or telephone) in SOT clinics at a single academic transplant center between 9-10/2021. Patients completed a survey administered either online or phone following their visit. Providers and clinic staff involved in telemedicine completed online surveys. Surveys were tailored to patient, provider and clinic staff to assess specific concerns, barriers and satisfaction with telemedicine. Result(s): Survey response rate was 21% (175/853) for patients, 57% (70/122) for providers and 31% (20/64) for clinic staff. 95% of visits were video and seen in liver (39%), kidney (40%), lung (16%) and heart transplant (5%) clinics. Patients were male (51%) with a median age of 62, English-speaking (95%) and had some college experience (84%). Patient and provider descriptions of telemedicine use are shown in Figure 1. Patients were not concerned with privacy (86%), lack of physical exam (76%), audio/video difficulties (89% and 93%) or help with setup (82%). Most were satisfied with the ease of video visit (85%) and quality of care (80%). Compared to in-person visits, patients felt their telemedicine visit was similar (66%) if not better (16%). Among providers, most were satisfied with ease of video visits (74%) and quality of care (60%), but 48% were dissatisfied with telephone visits. Providers spent time assisting patients (72%) or required help from staff to aid patients (7%) with visits;90% noted functioning of software/hardware before visits as crucial to improving telemedicine use. Among clinic staff, 50% reported additional time spent aiding patients with initial visit setup due to needing to instruct how to use telemedicine software (60%) and providing additional instructions to caregiver(s) (20%). Conclusion(s): Telemedicine via video is an effective and convenient method of healthcare delivery across the continuum of SOT care according to patients, providers and clinic staff. However, concerns about time assisting with setup were noted by providers and staff. Additional resources and support are needed to improve navigation of telemedicine for patients and to improve efficiency with telemedicine for providers and staff. (Figure Presented).
ABSTRACT
Purpose: SARS-CoV-2 infection in kidney transplant recipients is associated with an increased risk of severe disease and mortality relative to other patient populations, with mortality reported to be as high as 30% early in the pandemic. It has been demonstrated that vaccination against SARS-CoV-2 after transplantation is less effective as when administered prior to immunosuppression administration. To reduce the risk of poorer outcomes associated with immunosuppression, it is advisable that transplant candidates complete a SARS-CoV-2 vaccine series prior to transplantation. SARS-CoV-2 vaccine hesitancy contributes to under-vaccination in the transplant candidate population. We describe candidate perspectives associated with vaccine hesitancy in kidney transplant candidates. Method(s): Vaccination status of actively listed kidney transplant candidates at our center was reviewed in January 2022. The infectious disease nurse practitioner performed counseling telephone visits with all available candidates not vaccinated against SARS-CoV-2 to uncover their perspectives around vaccination and determine reasons for vaccine refusal/hesitancy. Result(s): Of the 233 candidates actively listed for kidney transplant, 23 (9.8%) were found to be unvaccinated against SARS-CoV-2. Of the 23 patients, 20 (87%) were successfully contacted for telephone interview. Thirteen (65%) candidates described safety concerns as their primary reason for vaccine hesitancy. The most common concerns shared by unvaccinated candidates were a lack of trust in the development of SARS-CoV-2 vaccines, speed of development and general lack of safety data. Five (38%) of the 13 candidates expressed additional concern about the effect of vaccines could have on their native kidney function. One candidate expressed fear that vaccine will increase HLA sensitization, making it more difficult for organ matching. Three candidates stated they did not need the vaccine, citing isolation, healthy diet and prior infection as protective factors. Three candidates cited medical reasons. These included recent monoclonal antibody treatment for SARS-CoV-2 infection (2) and lymphadenopathy (1). Conclusion(s): For patients awaiting kidney transplant, the primary reason contributing to vaccine hesitancy is concern regarding vaccine safety. For some, concerns are specific to diagnosis and status as a transplant candidate. Transplant centers should continue to address vaccine hesitancy in order to provide accurate information and targeted patient education around vaccine safety and benefit to aid patients in making decisions based on available scientific data.
ABSTRACT
SESSION TITLE: Procedures in Chest Infections Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Pneumonia is a common condition that is seen in hospitals. Pneumocystis Jirovecii is an opportunist fungal pathogen. Bordetella bronchiseptica is a gram negative bacteria that causes infectious bronchitis in dogs and other animals, but rarely infects humans. CASE PRESENTATION: Patient is a 34 year old African American female with history of sickle cell trait, reported Lupus (not on treatment), asthma, COVID pneumonia who was admitted for worsening shortness of breath & productive cough with yellow sputum. She was previously hospitalized and discharged after being treated for Community-Acquired Pneumonia. In the ER, she was febrile, tachycardic, tachypneic, & hypoxic requiring BiPAP. CXR obtained showed findings concerning for multifocal pneumonia. Chest CT Angiogram was negative for PE. Patient was started on Vancomycin & Meropenem for treatment of her pneumonia. Blood cultures, Legionella, Strep pneumoniae, Aspergillus, Beta-D-glucan, Sputum culture, & MRSA screen were ordered for further evaluation of her infection. ANA screen reflex panel, lupus anticoagulant, anticardiolipin antibodies, beta-2 glycoprotein antibodies were also ordered given patient's reported history of SLE and the concern for SLE pneumonitis: ANA & Sjogren's Anti-SSA were positive;otherwise, autoimmune workup was unremarkable. During hospitalization, patient was eventually weaned down to nasal cannula and antibiotic was de-escalated to levaquin. However, sputum culture eventually grew Bordetella Bronchiseptica that was resistant to Levaquin so antibiotic regimen was switched to Doxycycline. In addition, Beta-D-glucan was noted to be elevated. Bronchoscopy was done for further evaluation;multiple transbronchial biopsies were positive Pneumocystis Jirovecii. Patient was then initiated on Bactrim for treatment of PJP Pneumonia along with a steroid taper. Patient was tested for HIV and it was negative. DISCUSSION: In this case, patient was found to have two rare pathogens, that are more common in immunocompromised patients such as those with HIV/AIDS, on high-dose corticosteroids or malignancy. This patient had a unconfirmed diagnosis of SLE and past COVID Pneumonia. Patient had Bordetella bronchiseptica pneumonia that is frequently isolated in the respiratory tract of animals but can cause severe respiratory infection in humans. This microorganism can cause upper respiratory tract infections, pneumonitis, endocarditis, peritonitis, meningitis, sepsis and recurrent bacteremia. Upon further discussion with the patient, she was found to have a recent pet dog. CONCLUSIONS: High level of clinical suspicious is needed in patient presenting with recurrent pneumonia with chest imaging findings suggestive of multifocal pneumonia. The mainstay of treatment for PJP is TMP-SMX and steroid. We recommend Fluoroquinolones or tetracycline for Bordetella bronchiseptica pneumonia. Reference #1: Benfield T, Atzori C, Miller RF, Helweg-Larsen J. Second-line salvage treatment of AIDS-associated Pneumocystis jirovecii pneumonia: a case series and systematic review. J Acquir Immune Defic Syndr. 2008 May 1;48(1):63-7. Reference #2: de la Fuente J, Albo C, Rodríguez A, Sopeña B, Martínez C. Bordetella bronchiseptica pneumonia in a patient with AIDS. Thorax. 1994 Jul;49(7):719-20. doi: 10.1136/thx.49.7.719. PMID: 8066571;PMCID: PMC475067. DISCLOSURES: No relevant relationships by Priya George No relevant relationships by ELINA MOMIN No relevant relationships by Mohammedumer Nagori
ABSTRACT
SESSION TITLE: Critical Care in Chest Infections Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: During the COVID-19 pandemic, acute respiratory distress syndrome (ARDS) was a very common presentation. Many clinicians sought to rule out COVID-19 in those presenting with hypoxia and shortness of breath due to the importance of triage and quarantining infected individuals and those under investigation. As a result, delay in diagnosis of other viral and bacterial pathogens occurred. There is a known but rare overlapping of disease processes and sometimes even co-infections with COVID-19 and Pneumocystis jirovecii pneumonia (PJP) which made narrowing the differential challenging [1,2]. We present a case of a patient with known HIV who presented with typical features of COVID-19 and clinically worsened. Further investigation revealed PJP and AIDS. CASE PRESENTATION: A 55-year-old female with a past medical history of human immunodeficiency virus (HIV), previously controlled on highly active antiretroviral therapy (HAART), presented with shortness of breath, cough, and syncope. She required sedation and mechanical ventilation following significant hypoxia on admission. Chest radiograph and computed tomography (CT) were concerning for acute respiratory distress syndrome (ARDS) with diffuse bilateral ground glass opacities (Figure 1 and Figure 2) and she was found to be in septic shock requiring vasopressors. She presented during the COVID-19 pandemic and it was initially thought to be the cause of her condition, however she repeatedly tested negative via polymerase chain reaction (PCR). Through further investigation, it was found that her total cluster of differentiation 4 (CD4) cell count was 184/??L, posing a risk for opportunistic infections. Prior records indicated her last CD4 count was greater than 250/??L. Bronchoscopy showed progressively darker-tinged aliquots significant for diffuse alveolar hemorrhage that stained positive for Pneumocystis jirovecii pneumonia (PJP). She was treated with appropriate antimicrobial therapy, eventually weaned from ventilation, and transferred to the floor despite her high risk of morbidity and mortality [3]. DISCUSSION: This clinical case demonstrates PJP infection in an individual with features on imaging nearly identical to those of COVID-19 during the pandemic. There is a strong role in verifying CD4 count and HIV viral level in those affected with HIV with reported medication adherence who present with critical illness. There should be a low threshold to perform bronchoscopy in patients with ARDS and negative COVID-19 if no known source is identified. CONCLUSIONS: It is important to consider all causes of ARDS in patients who are immunocompromised with a low threshold to test for and treat uncommon causes, such as opportunistic infections, because the treatment should be directed at the underlying cause. Reference #1: Coleman, H., Snell, L., Simons, R., Douthwaite, S. and Lee, M., 2020. Coronavirus disease 2019 and Pneumocystis jirovecii pneumonia: a diagnostic dilemma in HIV. AIDS, 34(8), pp.1258-1260. Reference #2: Menon, A., Berg, D., Brea, E., Deutsch, A., Kidia, K., Thurber, E., Polsky, S., Yeh, T., Duskin, J., Holliday, A., Gay, E. and Fredenburgh, L., 2020. A Case of COVID-19 and Pneumocystis jirovecii Coinfection. American Journal of Respiratory and Critical Care Medicine, 202(1), pp.136-138. Reference #3: Dworkin, M., Hanson, D. and Navin, T., 2001. Survival of Patients with AIDS, after Diagnosis of Pneumocystis carinii Pneumonia, in the United States. The Journal of Infectious Diseases, 183(9), pp.1409-1412. DISCLOSURES: No relevant relationships by salah alandary No relevant relationships by Joella Lambert No relevant relationships by Joshua Lung
ABSTRACT
Introduction/ Background: Nigeria, like the rest of the world, introduced public health measures to control SARS-CoV-2 infection. These measures especially movement restrictions impacted all aspects of citizens' life including health services. This study was conducted to determine the impact of COVID-19 movement restriction on treatment outcomes among individuals living with HIV/AIDS. Methods: This was a retrospective review of the electronic database at the HIV clinic of the Nigerian Institute of Medical Research over a 5-month period (three months before, during, and after the COVID-19 movement restriction). The study population were people living with HIV attending the HIV clinic. Information on sociodemographic, and clinical (type of ARTs, duration on ART, laboratory evaluation) were extracted from database and analyzed using the SPSS version 22.0. Results: The data of 4145 individuals in the database were extracted and reviewed. The median age of PLWH was 45 years, with the majority within the age group being 25-49years (65.4%), married (59.5%), had at least secondary education (82.8%), and employed (81.5%). The median duration on ARTs was 102 months (IQR: 67-138) with the most on non-Protease Inhibitor based regimen (77.7%). The drug pickup declined by 40% from the pre-movement restriction period levels. Three months post movements restriction, laboratory monitoring for treatment outcomes were mostly affected as none of the patients had their routine test performed during the locked down period. Impact: The COVID -19 movement restriction had a significant impact on the treatment access among people living with HIV. This could portend untowards public health effect on the gains of HIV care. Conclusion: The COVID -19 movement restriction resulted in the decline of antiretroviral drug pick by 40% and almost no performance of laboratory monitoring HIV diseases. It is recommended that in future restriction of movement government and institutions should put in palace contingency plan to ensure that HIV services are not compromised.
ABSTRACT
Background: The National Cancer Institute (NCI) estimates that approximately one-quarter of adults with cancer are parents to children less than 18 years. Further, it is estimated that 2.85 million minor children in the United States have a parent undergoing cancer treatment. Previous studies have demonstrated that parents with cancer experience significant stress and disruptions to familial life following a cancer diagnosis. In a study of women with breast, gynecologic cancer and other cancers undergoing cancer therapy, 48.7% of women endorsed needing help with childcare and 64.1% needing help with household management. Despite this evidence supporting both a need for childcare among patients with cancer, data regarding the availability of on-site childcare programs and resources at NCI-designated cancer centers is limited. The objective of this cross-sectional study was to assess the availability of childcare resources for parents who are undergoing cancer treatment at NCI-Designated Cancer Centers. Methods: The availability of childcare resources for parents undergoing cancer treatment at all 51 NCI-designated comprehensive cancer centers and 13 NCI-designated cancer was assessed in January 2021 and February 2021. Childcare resources were assessed via online search and telephone calls. Specifically, centers were queried regarding availability of daycare programs for children of patients undergoing treatment and whether resources were available to assist patients in need of childcare. Descriptive statistics were performed. Results: In total, only 1/64 (1.6%) of NCI-designated cancer centers currently offer childcare resources for patients undergoing cancer treatment. This center offers childcare for children ages 2-8, free of charge with multiple outpatient locations. One additional institution previously provided patients with access to daycare, but has closed due to the COVID-19 pandemic. Further, only 1/64 (1.6%) NCI-designated cancer center offers financial assistance grants to aid patients to subsidizing childcare costs during cancer treatment. Conclusions: Institution sponsored options for childcare for patients undergoing cancer treatments are highly limited, even in the best resourced cancer care settings. The COVID-19 pandemic has limited options further, and many hospitals now restrict visitors under the age of 18. Patient grants or institutionally sponsored childcare provider networks may represent an avenue for supporting parents who are facing a cancer diagnosis. Supporting families of patients with cancer has great potential to impact quality of life, economic and psychological stress.
ABSTRACT
CASE: A 25-year-old homeless male with nonadherent HIV presented with dyspnea on exertion for 4 days, productive cough for 1 week, fevers, chills and night sweats. He arrived hypoxic to 74% requiring 2L O2 and was cachectic on exam. WBC, lactate and procalcitonin were normal. C-reactive protein was 26.7 mg/L, LDH was 686 units/L and COVID-19 was positive. An arterial blood gas showed a primary respiratory alkalosis with a secondary metabolic alkalosis. Computed tomography of the chest, abdomen and pelvis with contrast showed multifocal large thin-walled cavitary lesions throughout the bilateral lungs with subpleural large cystic disease. Dexamethasone, remdesivir and empiric antibiotics were initiated. Absolute CD4 count was 7 cells/uL with HIV-1 RNA load of 139,000 copies/mL. Sputum was positive for Pneumocystis jirovecii (PCP) by DFA and PCR, but no evidence of mycobacterium. Trimethoprim-sulfamethoxazole (TMP-SMX) was added. On hospital day 13, he developed severe right-sided chest pain, dyspnea and required up to 15L O2. A chest x-ray revealed a large right-sided pneumothorax (PTX) and a chest tube was placed. Cardiothoracic Surgery was consulted for consideration of bullectomy with pleurodesis;this was not recommended as the cystic lesions were extensive with some intraparenchymal. His oxygen requirements improved and his chest tube was removed in 6 days. He was discharged on hospital day 21 to begin prophylactic dosing of TMP-SMX until his CD4 count was over 200 cells/uL and to attend his first appointment at an outpatient HIV clinic the following day. IMPACT/DISCUSSION: Secondary spontaneous pneumothorax (SSP) can be a complication of necrotizing pneumonia due to PCP. In one study, in a cohort of 599 patients with HIV infection, only 1.2% developed a PTX. Bilateral PTX is more common with PCP, unlike in our patient. In HIV, the degree of immunosuppression can influence the cause of PTX. Our patient had a PTX with a CD4 count under 200, which is more common with PCP. In addition, SSP as a complication of SARS-CoV-2 is more rare. There are case series that describe COVID-19 patients who develop PTX in the absence of barotrauma secondary to mechanical ventilation. However, this is uncommon as one retrospective study reports PTX occurring in 1% of patients with COVID-19 requiring hospital admission. In this case, it is unclear to what extent the patient's concomitant COVID-19 contributed to the development of a PTX. Our patient was ineligible for definitive intervention to prevent recurrence, thus underwent tube thoracostomy placement which is consistent with the majority of treated patients. While the prognosis of PTX secondary to COVID-19 is generally good, prognosis of cominant co-infection with PCP is an area of further research as the overall mortality of PCP-induced PTX alone can be 23%. CONCLUSION: This case represents a rare occurrence of spontaneous pneumothorax secondary to both PCP and COVID-19. We suggest the incidence to increase as the pandemic continues.
ABSTRACT
BACKGROUND: One strategy to aid patients in managing their diabetes is group visits (GVs) that include group education and individual medical visits with a provider. Though in-person GVs have been shown to benefit patients, few studies have evaluated virtual diabetes GVs. METHODS: In this single-arm trial, adult patients with A1c ≥ 8% from six community health centers were recruited to participate in monthly virtual GVs for 6 months. Patients completed surveys about diabetes self-care, support, distress, and the group visit concept before and after they participated in GVs. Health center staff trained to lead the GVs completed surveys pre and post virtual GVs. Linear mixed effects models were used to adjust cohort-based association and model the survey data over time for the time trend effect. RESULTS: Forty-five patients enrolled in the study and thirty-eight patients completed the baseline survey. The average age was 55 (range of 36-83) and 65% of enrollees were female. 63% were black/African American, 32% were white/Caucasian, and 8% were Hispanic/Latino. Thirty-four patients attended one or more GVs and twenty-one patients completed the post GV survey. Overall satisfaction with the virtual GVs was high with 18/20 (90%) of participants being very satisfied and 20/21 (95%) saying they would attend GVs in the future. Most participants agreed that GVs helped improve diabetes self-management skills (78%), motivated them to achieve health goals (89%), and introduced them to others living with diabetes (78%). Barriers to participation were the timing of the GVs and access to a computer, tablet, phone, and internet. Patients had an increase in their diabetes knowledge (mean (SD): 3.2/ 5 (0.9) to 3.6/5 (0.7), p= 0.02) and diabetes support (3.5/5 (0.64) to 4.1/5 (0.7), p <0.001) as well as decreased diabetes distress (2.9/6 (1.5) to 1.2/6 (0.5), p=0.03) from baseline to 6 months. Thirty-five staff enrolled in the study and seventeen completed a post GV survey. Most staff agreed that GVs provided patients with social support and more frequent contact with medical providers. Staff largely agreed that virtual GVs increased opportunity for teamwork and collaboration (94%), care coordination (82%), and understanding of patients (94%). However, only 5/17 (29%) and 3/17 (18%) staff members agreed that virtual GVs increased provider productivity or led to higher reimbursement, respectively. Staff cited other priorities at the health center, difficulty recruiting patients, and concerns about access to technology as the biggest barriers to implementing virtual GVs. CONCLUSIONS: Virtual GVs show promise as evidenced by high patient satisfaction and improvements in support, distress, and diabetes knowledge in patients. Staff also perceived virtual GV benefits to patients, staff, and health centers despite concerns about logistics such as productivity, reimbursement, and the health center's ability to continue visits virtually.
ABSTRACT
Background: In past 2 years, COVID-19 pandemic has affected the health care system adversely. World statistics showed a huge rise in the incidence of this highly infectious disease. Abnormal and unregulated immune response was found to be the key deciding factor for the outcome of this disease. A lot of studies showed a promising role of corticosteroids as immunosuppressant agents. They reduce morbidity and mortality in patients with moderate-to-severe COVID-19 disease. However, steroid therapy comes with a huge concern in form of their adverse effects, especially on prolonged use. Optimum duration of steroid therapy is not standardized. Aim and Objectives: The present study was carried out to determine days of oxygen requirement and duration of hospital stay in patients receiving short course steroid vis-à-vis long course steroid therapy. Materials and Methods: A retrospective observational study was conducted in tertiary care teaching hospital after prior permission of the Institutional Ethics Committee. All patients diagnosed as having moderate COVID-19 illness with age group of 18–80 years with minimum 03 days of 6 mg dexamethasone or other equivalent steroid administration were included in the study. Patients who were living with HIV/AIDS, cancer, hepatic and renal illness, ischemic and other valvular diseases, and chronic pulmonary diseases affecting oxygenation status were excluded from the study. A total of 203 study participants were enrolled during study period (68 in short course while 135 in long course steroid group). Data were enrolled in predesigned structured and validated case record form. Results: Short course steroid therapy was found more frequent in <60 years of age. Mean and SD of days of oxygen administration were (4.36 vs. 8.88) and (2.15 vs. 3.43) in short course and long course steroid therapy, respectively. Oxygen requirement for ≥7 days was in (10, 7.41%) patients and (45, 66.18%) patients in short course steroid group and long course steroid group, respectively. Mean and standard deviation of duration of hospital stay were (6.64, 2.87) and (11.9, 4.03) in short course and long course steroid group, respectively. Hospital stay for more than 9 days was (20, 14.81%) and (47, 69.12%) in short course and long course steroid group, respectively. Conclusion: A positive association was found between duration of hospital stay and long course steroid therapy and was statistically significant. Similarly, a positive association between days of oxygen requirement and long course steroid therapy was found and again it was statistically significant. The study findings indicated that short course steroid therapy was found to be more effective in treatment outcome of COVID-19 illness as far as the duration of hospital stay and oxygen administration parameters are concerned.
ABSTRACT
BACKGROUND: Telemedicine is an essential part of healthcare delivery and has grown exponentially as a result of the COVID-19 pandemic. However, data on optimal utilization and implementation of telemedicine in solid organ transplant care remains limited. We aimed to evaluate patient, provider, and clinic staff perspectives on telemedicine use and potential barriers in solid organ transplant clinics. METHODS: We prospectively enrolled adults seen via telemedicine (video or telephone) in solid organ transplant clinics at a single academic transplant center between 9-10/2021. Patients completed a survey administered either online or via phone following their visit. Providers and clinic staff involved in telemedicine completed online surveys. Surveys were customized to patient, provider, and clinic staff to assess specific concerns, barriers, and satisfaction with telemedicine. RESULTS: Survey response rate was 21% for patients (175 of 853), 57% for providers (70 of 122) and 31% for clinic staff (20 of 64). 95% of telemedicine visits were video and were from liver (39%), kidney (40%), lung (16%) and heart transplant (5%) clinics. The majority of patients were male (51%) with a median age of 62, English-speaking (95%), and had some college experience (84%). Descriptions of telemedicine use among patients and providers are shown in Figure 1. Most patients were not concerned about privacy (86%), lack of physical exam (76%), audio/video difficulties (89% and 93%), or assistance with setup (82%). The majority were satisfied with the ease of video visit (85%) and quality of care (80%). Compared to traditional in-person visits, most patients felt their telemedicine visit was similar (66%) if not better (16%). Among providers, the majority were satisfied with ease of video visits (74%), quality of care (60%), and overall use of video visits (64%), but 48% were dissatisfied with telephone visits. Most providers reported spending time assisting patients (72%) with 7% requiring assistance from clinic staff to aid patients with video visits. 90% of providers identified appropriate software/hardware functioning prior to visits as a key feature to improve telemedicine use. Among clinic staff, 50% reported spending additional time assisting patients with setting up their initial visit due to needing to instruct how to use telemedicine software (60%) and providing additional instructions to caregiver(s) (20%). CONCLUSION: Telemedicine via video is an effective and convenient method of healthcare delivery across the continuum of solid organ transplant care according to patients, providers and clinic staff. However, concerns about time assisting with setup were highlighted by providers and clinic staff. Additional resources and support are needed to improve navigation of telemedicine for patients and to improve efficiency with telemedicine for providers and clinic staff. (Figure Presented)
ABSTRACT
HIV (Human Immunodeficiency Virus) is the virus that causes AIDS (Acquired Immune Deficiency Syndrome), while PCP (Pneumocystis jiroveci pneumonia), tuberculosis, CMV (Cytomegalovirus) and candidiasis are the OIs (opportunistic infections) occurring due to immune deficiency. OIs, and bacterial pneumonias in particular, are the most common causes of mortality, which makes the screening and prophylactic therapy for OIs necessary. The synergy between tuberculosis and HIV has long been known, and worsens the prognosis. PCP is an OI that is caused by a fungus named P. jiroveci. COVID-19 has emerged as a new cause of death among AIDS patients. Screening and prophylactic therapy for Ols is vital for patients with AIDS, however, mortality may be high due to delays in screening and prophylaxis in those whose HIV positivity is detected coincidentally. We report here on a patient who applied to our hospital with suspected COVID-19 pneumonia who was found during followup to be HIV positive with PCP and pulmonary tuberculosis.
ABSTRACT
Aim To define COVID toes and fingers in paediatrics, and to explain the aetiology, the assessment and investigation management, the diagnosis, the clinical presentation and the care management including the use of oral nifedipine in this newly found disease during the COVID-19 pandemic. In addition, we will illustrate the process using the multi-disciplinary approach to prepare the Paediatric COVID toes guideline in our Trust, and to cite some examples of the related patient cases seen in our hospital as well as to summarise the total number of patient cases seen to date. Method To carry out a literature search to find out the latest related articles and clinical studies, and to summarise the findings to prepare for the drafting of the clinical guideline. This guideline was initially prepared by the medical team and was then reviewed using multi-disciplinary team (MDT) approach including the paediatric pharmacists and the consultation from the tertiary paediatric centre. We also summarised the number of paediatric patient cases that were seen in our Trust and categorised them into different age groups, ethics background, and referral systems. Results A number of related articles were found after the literature search. The first draft of the Paediatric COVID-toes guideline was prepared in March 2021 and it was then reviewed by the MDT in the Paediatric Clinical Guideline Group of our Trust. The paediatric pharmacist expressed her comments including the drug of choice such as oral nifedipine, the dosages below and above 2 years of age, the evidence to support the dosage recommendations, the different formulations available in the market for oral nifedipine such as oral suspension, capsule, tablet and modified-released (MR) tablet, recommended effective method for oral administration, side effects profile, monitoring such as blood pressure, patient counselling and education, and provision of patient leaflet and video-link to aid patient compliance. Conclusion The final version of the Paediatric COVID toes guideline was prepared by the multi-disciplinary team in July, 2021, and it was uploaded in the Trust intranet in August 2021. In view of the literature search, there is limited evidence to support the use of oral nifedipine under 2 years of age for this indication. In our guideline, we recommend the dose of nifedipine to be 2.5-10 mg 2-4 times a day for children age 2 to 17 years old, starting with low doses at night and increase gradually by closely monitoring blood pressure and other side effects. The use of oral nifedipine is unlicensed for this indication in children. In our guideline, we recommend the use of oral MR nifedipine tablet after the consultation with the tertiary centre. Oral suspension is not routinely used. During counselling session, the pharmacist will advise the parent/carer to crush and dissolve the MR tablet in water and give appropriate dose accordingly. To date, 15 patients diagnosed with this disease were seen in our clinic. They are mainly referred to the clinic via the Accident and Emergency Department. The patient ages are all above 8 years old and they are mainly of Asian ethical background.
ABSTRACT
In the light of the recent events in the world concerning COVID-19 virus, it is important to review the challenges faced by the world by another pandemic, AIDS. The painstaking research by the scientists, the pharmaceutical companies, the medical professionals have led to this day when AIDS patients are living their whole life span. Though we do not have any vaccine for AIDS but by intelligent use of medication, we have been able to combat the disease to a large extent. HIV is a RNA virus, whose treatment is mainly done by finding the structure and function of the proteins that are vital to its life cycle. Designing a drug/inhibitor to make those proteins ineffective constitutes the next step. WHO has recognized AIDS as a pandemic almost 40 years back but the world is yet to find a cure or a vaccine. The current treatment method is called HAART, Highly Active Anti Retroviral Therapy, where different types of inhibitors,eg. Reverse Transcriptase inhibitors, Protease inhibitors;each arresting a different important protein are given in combination. The virus replicates very fast and forms mutations which render it ineffective to the inhibitors thus resistance to the inhibitors develop. Hence development of new types of inhibitors is crucial to the problem. There are certain similarities between AIDS and COVID-19, both in terms of the attacking virus and effective medication, which make it more important than ever that the research on HIV is revisited and knowledge we gain from it is used to battle the new pandemic.
ABSTRACT
The Global COVID-19 Neuro Research Coalition was formed in May 2020 by 24 expert neurologists and researchers from around the world. Together, they published a call to the global neurology community in The Lancet Neurology to establish a network where members exchange ideas, share research into the intersection of COVID-19 and neurology, and foster communication between international colleagues and institutions, particularly in low- and middle-income countries (LMICs). Now comprising over 100 members from 34 countries, the Coalition works closely with the WHO Neurology and COVID-19 Global Forum to address pressing questions facing neurologists and their patients. In addition to its LMIC focus, the Coalition works to harmonize research networks and strategies, not only for COVID-19, but also for other neurological challenges and future global research. The Coalition has published five papers on diverse topics related to COVID-19 and neurology. These include methodological approaches to understanding neurological associations of COVID-19, support of the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders, and COVID- 19-associated headache. The Coalition is involved in ongoing reviews into neurological complications of COVID-19 and COVID-19 vaccinations, and as well as studies about accurate diagnoses of these complications and the overall impact of this pandemic on neurological services. It also engages with the WHO-supported Brain Health Clinical Exchange, which invites neurologists around the world to present on relevant neurology topics and engage in interactive discussion. The success of the Global COVID-19 Neuro Research Coalition underlines the need for a platform that brings together the international neurology community in addressing the large burden of neurological disease and shares strategies to face them. With its continent-spanning network of experts, the Coalition will continue to initiate high-quality research that will bring global neurology to the forefront of public health efforts and guide policies that will aid patients everywhere.
ABSTRACT
Aims/Objectives/Background Patients admitted to hospital via the emergency department (ED) need to be separated by SARS-CoV-2 infection status to prevent transmission. Using clinical criteria alone is not feasible due to the range of symptoms and asymptomatic spread. Turnaround time of laboratory PCR assays (~6-24 hrs) hinders patient movement through the hospital with pressure on side-rooms pending results and exposure risk if unsuspected cases are moved into bays. Lateral flow devices (LFD) can provide a rapid diagnosis and aid patient movement. This implementation study aimed to assess the accuracy and safety of LFDs within an ED during a highprevalence period. Methods/Design Two rapid point-of-care tests (POCT) were introduced during December 2020: Cobas®-Liat® system (Roche Diagnostics) is a 20-minute assay comparable to laboratory PCR (in-house validation), and LFDs. Symptomatic patients with a positive LFD were cohorted on a 'red' ward. Asymptomatic patients with a negative result were allocated an 'amber' ward, pending lab PCR. Where there were discrepancies between results and symptoms;a Liat® was performed. The LFDs were validated by PCR swabs to determine true positive and false negative (FN) rates and to minimise fallout via contact tracing. The PCR cycle threshold (CT) values were recorded to evaluate the LFD sensitivity and specificity. Results were collected between December 2020-March 2021. Results/Conclusions Comparing LFD with PCR results, the sensitivity and specificity were 70.7% and 99.1%. LFD FNs had higher CT values (25), indicating the beginning or end of infection - unlikely infectious. One period of false positives during lower prevalence revealed a faulty batch. During the study period 90% of patients left the ED with a virological diagnosis. We conclude that POCT can aid the diagnosis of COVID- 19 in the ED when combined with existing laboratory-based PCR algorithms. We demonstrate a safe and effective use of POCT in the ED which could be replicated across other centres.