SAFETY ANALYSIS OF JAKINIBS IN REAL CLINICAL PRACTICE IN A COHORT OF 116 PATIENTS

BackgroundJanus kinase inhibitors (JAKinibs) have demonstrated efficacy in the treatment of rheumatoid arthritis (RA) and spondyloarthritis (SpA), although their safety profile continues to be analysed due to the possible increase in adverse events (AEs) in relation to anti-TNFs (mild and severe infections, haematological alterations, thromboembolism, increase in neoplasms).ObjectivesTo evaluate in real clinical practice the AEs of JAKinibs in a cohort of patients with RA and SpA. In addition, adherence and reasons for discontinuation (1st or 2nd failure, AE) are analysed.MethodsObservational study of 116 patients diagnosed with RA or SpA who received treatment with JAKinibis (tofacitinib, baricitinib, upadacitinib) after failure of treatment with different classical synthetic (FAMEsc) or biological (FAMEb) disease-modifying drugs. The following data were analysed: demographic characteristics of the patients, years of disease progression, 1st or 2nd failures and AE.ResultsMean age was 52 years, with Baricitinib being older (60 years -SD 13.6), higher prevalence of females in all groups, and a disease progression time of about 10 years. Mean number of FAMEsc was 1.6 and mean number of FAMEb was 2,3 to Tofacitinib(Tofa), 2,76 to Baricitinib(Bari) and 4,4 to Upadacitinib(Upa). 71 (63%) patients had active corticosteroid therapy. The median treatment time with Tofa was 8.8 months, Bari 9.5 and Upa 2.4 months.Most frequent AEs with Tofa were urinary tract infections(UTI) (11.9%, 7 cases) and headaches (8.47%, 5 cases). There were 3 cases of herpes zoster (5.1%), one of which was recurrent, and 2 cases respectively of tachycardia and gastrointestinal intolerance (3.4%). With Baricitnib, 2(5%) cases of UTI and 2(5%) of influenza A were reported. Most frequent AEs related to Upadacitinb are gastrointestinal intolerance, labialis and facial herpes, anterior uveitis and recurrent UTI, with 1 case for each adverse event. There were 4 success with Baricitinib treatment: 2 due to severe COVID, 1 influenza A and 1 due to stroke. 17 patients had 1st failure to Tofa(28.81%), 8 to Bari20.0%) and 3 to Upa(18.75%);7(11.86%) and 2(5%) patients had 2nd failure to Tofa and Bari respectively, no with Upa.Mean CRP to Tofa-SD 18.9-was 17.19, 20-SD 22.7- to Bari and 24.2-SD 27.40- to Upa. Mean ESR-SD 15.3- was 25.4, -SD 26.4 and 44.3 -SD 32-, respectively. At 6 months, 36(62%) were continuing on Tofa, 22(56%) on Bari and 4(27%) on Upa. At 12 months, 27(46.6%) were still on Tofa and 12 on Bari(30.8%) and no patients were on upa.Table 1.TofaBariUpaMean age496047Male19%18%20%Female81%82%80%Time course of disease(years)81111Permanence 6 months62%56%27%Permanence 12 months46,6%31%0%Patients with corticotherapy62%64%60%Previous biological drugs2,3 SD 22,8 SD 2,34,4 SD 2,9Patients who discontinued the drug62%59%33%Mean CRP at the end of treatment172024Mean end-of-treatment ESR252644Repeated AEsUTI(7) Headache(5) Shingles(3) Nephritic colic(2) Gastrointestinal intolerance(2) Tachycardia(2)UTI(4) Headache(2)Serious AEsShingles (3)Varicella encephalopathy(1) Stroke(1) Shingles (1)1st failure28,8%20%18,7%2nd failure11,9%5%0%SuccessSARS-Cov2(2) Influenza(1) Stroke(1)Figure 1. Months stay pharmacoConclusionMost frequent adverse events with JAKinibs are mild infections, except gastrointestinal complaints with upadacitinib. Serious adverse events, including 3 deaths from viral infections, were observed, mostly in patients over 65 years. Most frequent cause of discontinuation was treatment failure. We believe that further observational studies are needed to stratify and profile the risk of infection with JAKinibs.References[1]Atzeni F, Popa CD, et al. Safety of JAK inhibitors: focus on cardiovascular and thromboembolic events. Expert Rev Clin Immunol. 2022 Mar;18(3):233-244. Doi: 10.1080/1744666X.2022.2039630 Epub 2022 Feb 17.PMID: 35129033[2]Alves C, Penedones A,et al. The Risk of Infections Associated With JAK Inhibitors in Rheumatoid Arthritis: A Systematic Review and Network Meta-analysis. J Clin Rheumatol. 2022 Mar 1;28(2):e407-e414 PMID:33902098Ackn wledgements:NIL.Disclosure of InterestsNone Declared.

PERICARDITIS AFTER COVID-19 VACCINATION: A CASE SERIES

BackgroundCOVID-19 vaccination campaigns successfully impacted on viral spreading and in particular on clinical course of the disease. However, secondary to a highly extended vaccination program, several local and systemic adverse events associated with mRNA COVID-19 vaccines have been reported. Pericarditis and myocarditis are examples of cardiac complications related to these vaccines. In particular, cases of pericarditis have occurred after mRNA COVID-19 vaccination (mostly secondary to vaccination with Moderna than Pfizer-BioNTech), especially in male adolescents and young adults, more often after the second dose. The incidence is approximately of 1-2 cases/100.000.ObjectivesAim of our study was to study the clinical profile of pericarditis occurred within 30 days after COVID-19 vaccines in our clinic.MethodsWe present a case series of patients who developed pericarditis after COVID-19 vaccination in the Department of Internal Medicine at Fatebenefratelli Hospital in Milan, followed from December 1, 2021 to April 15, 2022.ResultsTwenty-five individuals, of which 18 (72%) were women and 7 (28%) were males, had vaccine related pericarditis. Two patients were vaccinated with AstraZeneca, 2 with Moderna, the remaining with Pfizer-BioNTech. Median age was of 42 years. Of all patients, one subject was affected by constrictive effusive pericarditis, while another required treatment of pericarditis with Anakinra, switched to Canakinumab after severe skin reactions, because of failure of therapeutic response to first-line treatments.Two patients required hospital admission, in one case for a transient constrictive pericarditis. In the remaining cases clinical symptoms associated with post-vaccines pericarditis were mild and didn't require hospitalization.Chest pain was reported in 100% of cases, whereas pericardial effusion (in one case larger than 10 mm) was evidenced in 30% of subjects. Eighty percent of patients experienced tachycardia, whereas 90% reported asthenia.An increase in indices of inflammation (CRP) was documented in 50% of patients, usually mild.With regard to therapy, 90% of patients were treated with NSAIDs, 95% with colchicine, while 50% of cases required treatment with low-dose steroids.ConclusionCOVID-19 vaccination induces a particular form of pericarditis, often insidious and very troublesome, but with good prognosis. The clinical phenotype showed less typical chest pain, often normal indices of inflammation and little or no instrumental changes, but patients often experimented tachycardia and functional limitation. With regard to therapy, we used NSAIDs at adequate dosages to control the clinical condition, or low-dose colchicine. Low doses of cortisone (e.g., prednisone 5-10 mg a day) were useful in the presence of marked asthenia or systemic symptoms. Beta-blockers or ivabradine were used in the presence of tachycardia.References[1]Barda N, Children 2021, 8(7), 607;Safety of the BNT162b2 mRNA Covid-19 in a Nationwide setting. N Engl J med 2021;385:1078-1090.[2]Diaz GA, Myocarditis and Pericarditis After Vaccination for COVID-19. JAMA 2021;326 (12): 1210-1212.[3]Bibhuti D, Myocarditis and Pericarditis Following mRNA COVID-19 Vaccination: What Do We Know So Far?. Children 2021, 8(7), 607.[4]Giacomo Maria Viani, Patrizia Pedrotti, Romano Seregni, and Brucato Antonio;Effusive–constrictive pericarditis after the second dose of BNT162b2 vaccine (Comirnaty): a case report;European Heart Journal - Case Reports (2022) 6(2), 1–6.[5]Francesco Perna, Elena Verecchia, Gaetano Pinnacchio, Laura Gerardino, Antonio Brucato, and Raffaele Manna;Rapid resolution of severe pericardial effusion using anakinra in a patient with COVID-19 vaccine-related acute pericarditis relapse:a case report;European Heart Journal - Case Reports (2022) 6, 1–6.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Assessment and treatment of eating disorders in adolescents

Pediatric health care providers understand that eating disorders are not lifestyle choices but lifethreatening mental health conditions Among patients of all ages, anorexia nervosa (AN) has the second-highest mortality rate of all mental health conditions, after substance abuse.1 Both suicide and the physical effects of nutritional deficit are implicated. Prevalence Analyses of prevalence vary widely in their findings.2 One meta-analysis found lifetime prevalence of AN from 1.7% to 3.6% for female patients and 0.1% for male patients;lifetime prevalence of BN for female patients was about 2.1%.3 BED, with reported prevalence rates of approximately 2% to 4%, is almost as common among male as female patients.2 4 Among adolescents aged 13 to 18 years, one study found prevalence rates of 0.3% for AN, 0.9% for BN, and 1.6% for BED.5 Long characterized as affecting primarily affluent White adolescent girls, eating disorders now affect people from lower socioeconomic groups, members of non-White ethnic groups, preteen children, and boys.2 LGBTQIA+ young people may be at particular risk.6 During the early months of the COVID-19 pandemic, hospitalizations for eating disorders doubled,7 and patients reported significant increases in unhealthy behaviors.8 Screening Caregiver reports about a child's weight or eating habits or clinical observation of unexpected weight changes are likely to alert the pediatrician to the possibility of an eating disorder. Presence of any one of the following symptoms indicates the need for immediate medical hospitalization for refeeding2'14: O Heart rate less than 50 beats per minute (bpm) while awake;less than 45 bpm while asleep O Systolic pressure less than 90/45 mm Hg O Orthostatic changes: decrease in blood pressure of more than 20 mm Hg systolic or 10 mm Hg diastolic;heart rate increase of more than 20 bpm O ECG abnormalities: Prolonged corrected QT interval or other arrhythmia O Syncope O Temperature less than 96 °F (35.6 °C) O Electrolyte abnormalities O Uncontrollable binge eating and purging Dehydration Suicide risk O Less than 75% of expected body weight O Failed outpatient management O Acute weight loss and food refusal Communication Today's young people typically know what anorexia and bulimia are.

Myocardial Infarction in Patients with and without COVID-19: Comparisons of Characteristics, Clinical Courses, and Outcomes.

Background: COVID-19 has rapidly become a global health emergency. This infection can cause damage to various organs. Injury to myocardial cells is one of the salient manifestations of COVID-19. The clinical course and outcome of acute coronary syndrome (ACS) are influenced by various factors, including comorbidities and concomitant diseases. One of these acute concomitant diseases is COVID-19, which can affect the clinical course and outcome of acute myocardial infarction (MI). Methods: The present cross-sectional study compared the clinical course and outcome of MI and some of its practical factors between patients with and without COVID-19. The study population consisted of 180 patients (129 males and 51 females) diagnosed with acute MI. Eighty patients had COVID-19 infection concurrently. Results: The mean age of the patients was 65.62 years. The frequencies of non-ST-elevation MI (vs ST-elevation MI), lower ejection fractions (<30), and arrhythmias were significantly higher in the COVID-19 group than in the non-COVID-19 group (P=0.006, 0.003, and P<0.001, respectively). The single-vessel disease was the most frequent angiographic result in the COVID-19 group, while the double-vessel disease was the most frequent angiographic result in the non-COVID-19 group (P<0.001). Conclusion: It appears that patients with ACS who are co-infected with COVID-19 infection need essential care.

Prediction and Analysis of Heart Diseases Using Heterogeneous Computing Platform

The work in this paper helps study cardiac rhythms and the electrical activity of the heart for two of the most critical cardiac arrhythmias. Various consumer devices exist, but implementation of an appropriate device at a certain position on the body at a certain pressure point containing an enormous number of blood vessels and developing filtering techniques for the most accurate signal extraction from the heart is a challenging task. In this paper, we provide evidence of prediction and analysis of Atrial Fibrillation (AF) and Ventricular Fibrillation (VF). Long-term monitoring of diseases such as AF and VF occurrences is very important, as these will lead to occurrence of ischemic stroke, cardiac arrest and complete heart failure. The AF and VF signal classification accuracy are much higher when processed on a Graphics Processor Unit (GPU) than Central Processing Unit (CPU) or traditional Holter machines. The classifier COMMA-Z filter is applied to the highly-sensitive industry certified Bio PPG sensor placed at the earlobe and computed on GPU.

COVID-19 and Cardiac Arrhythmias: a Contemporary Review.

Purpose of Review: A significant proportion of patients infected by the severe acute respiratory syndrome-coronavirus (SARS-CoV2) (COVID-19) also have disorders affecting the cardiac rhythm. In this review, we provide an in-depth review of the pathophysiological mechanisms underlying the associated arrhythmic complications of COVID-19 infection and provide pragmatic, evidence-based recommendations for the clinical management of these conditions. Recent Findings: Arrhythmic manifestations of COVID-19 include atrial arrhythmias such as atrial fibrillation or atrial flutter, sinus node dysfunction, atrioventricular conduction abnormalities, ventricular tachyarrhythmias, sudden cardiac arrest, and cardiovascular dysautonomias including the so-called long COVID syndrome. Various pathophysiological mechanisms have been implicated, such as direct viral invasion, hypoxemia, local and systemic inflammation, changes in ion channel physiology, immune activation, and autonomic dysregulation. The development of atrial or ventricular arrhythmias in hospitalized COVID-19 patients has been shown to portend a higher risk of in-hospital death. Summary: Arrhythmic complications from acute COVID-19 infection are commonly encountered in clinical practice, and COVID-19 patients with cardiac complications tend to have worse clinical outcomes than those without. Management of these arrhythmias should be based on published evidence-based guidelines, with special consideration of the acuity of COVID-19 infection, concomitant use of antimicrobial and anti-inflammatory drugs, and the transient nature of some rhythm disorders. Some manifestations, such as the long COVID syndrome, may lead to residual symptoms several months after acute infection. As the pandemic evolves with the discovery of new SARS-CoV2 variants, development and use of newer anti-viral and immuno-modulator drugs, and the increasing adoption of vaccination, clinicians must remain vigilant for other arrhythmic manifestations that may occur in association with this novel but potentially deadly disease.

Passive Suicidal Ideations in Older Adults: A Case Report

This case study presents the diagnosis and treatment of an older adult with depression and passive suicide ideation (SI). While treating depressed patients at risk for suicide, family nurse practitioners must stay grounded in patient data related to medications, ideally using the patient's psychiatric condition (ie, depression with suicidal risk) as the separate and appropriate target of clinical intervention, and discuss the risks and benefits of medications targeting both conditions with the patient. The response and ongoing management of individuals with passive SI depend on determining their risk level.

Oral anticoagulants, dementia . . . and other stories

Anticoagulants conferred a small increase in life expectancy—but at the price of an increase in bleeding complications. Since the primary goal of treatment for patients with advanced dementia should surely be comfort, this may not be optimal care (J Am Ger Soc doi:10.1111/jgs.18108). Intravenous antihypertensives Rapid treatment may do more harm than good, according to a retrospective study of 20 000 adults who developed a systolic blood pressure of greater than 180 mm Hg or a diastolic pressure greater than 110 mm Hg while in hospital for a reason other than hypertension. Vitamin D supplementation and dementia A recent meta-analysis concluded that vitamin D supplementation had no useful protective effect on cognitive function.

Comment on: "Risk of Erectile Dysfunction in Male Patients with Gout Treated with Febuxostat or Allopurinol: A Propensity Score-Matched Cohort Study"/Authors' Reply to Huang and Zhang: Comment on "Risk of Erectile Dysfunction in Male Patients with Gout Treated with Febuxostat or Allopurinol: A Propensity Score-Matched Cohort Study"

[...]a time frame could be set before the Covid-19 epidemic attack in January 2020, owing to the association between Covid-19 infection (ICD-10-CM B34.2, U07.1, U07.2, J12.81, J12.82, B97.29) and new-onset ED, which was recently detected in the same database [6]. According to the National Institute for Health and Care Excellence (NICE) guideline [15], treat-to-target (T2T) approach should be adhered to with serum urate level of at least < 360

Whole blood drug levels do not correlate with QTc intervals in hydroxychloroquine treated systemic lupus erythematosus patients.

OBJECTIVES: Hydroxychloroquine is recommended for all patients with systemic lupus erythematous, but reports of cardiac toxicity in SARS CoV-2 patients raised concerns. We aimed to study the relationship between hydroxychloroquine blood levels and QTc intervals. METHODS: Cohort 1 is a retrospective review of 90 SLE patients with data collected regarding demographics, QTc interval and chronic kidney disease (CKD). Cohort 2 is a prospective study of 84 SLE patients with data collected regarding demographics, dose of HCQ, duration of HCQ treatment, presence of echocardiographic abnormalities, and CKD simultaneous with whole blood HCQ levels measured by high performance liquid chromatography. Statistical analysis utilized one way ANOVA, Pearson's correlation coefficient and t test. RESULTS: In the retrospective cohort there was no significant difference in mean QTc based on 75 HCQ-treated (437.91 +/- 20.02) as compared with 15 untreated (434.6 +/- 27.49) patients. In patients with CKD mean QTc in HCQ users (448 +/- 23.37) as compared with non-users (444.5 +/- 24.61) was also with no significant difference. In the prospective cohort HCQ levels did not correlate with QTc interval (r = 0.017) and this applied regardless of dose prescribed (r = 0.113 for 400 mg and r = 0.06 for 200 mg), duration of exposure (p= 0.36 for 0-5, 5-10, or > 10 years), CKD (r = 0.482) or underlying cardiac abnormalities (r = 0.430). CONCLUSION: This is the first study relying on measured blood levels demonstrating the absence of clinically consequential increase in QTc levels in HCQ treated SLE patients.

Clinical Rounds

Dogs can detect human stress... Children with COVID-19 at higher risk of T1D... ED-ICU not associated with substantially increased costs... Strategies to reduce pediatric deaths by guns... Electronic gaming and pediatric dysrhythmias

Experience with tumour necrosis factor-alpha inhibitors for the treatment of cardiac sarcoidosis in a UK medical centre

P217 Table 1Case series outcomes table Case no. IFX dose& regime Follow-up duration (months) Change in prednisolone dose Change in FDG-PET uptake Change in LV systolic function Change in arrythmia burden Adverse events Composite Endpoint Dose pre-IFX(mg) Dose post-IFX(mg) Pre-IFX Post-IFX LVEF pre-IFX (%) LVEF post-IFX(%) Pre-IFX Post-IFX Infections Heart failure VT/VF (requiring device) All-cause mortality Aborted SCD (device) Cardiac Transplant Case 1 IFX 3 mg/kg every 8 weeks (break after 10th dose due to covid pandemic;restarted 3 months later) 29 20 15 Active CS(SUVmax 11.1) Improvement(SUVmax3.5) 58 59 N/A N/A 0 0 0 0 0 0 Case 2 IFX 3 mg/kg every 8 weeks. Stopped after 15.6 months due to resolution 15.6 10 10 Active CS(SUVmax 10.2) Improvement(SUVmax 2.65) 55 62 VA 0 1 (chest infection) 0 0 0 0 0 Case 2Relapse (7 months after stopping IFX) due to VT and FDG uptake IFX 3 mg/kg every 8 weeks 12 10 10 Active CS(SUVmax 3.3) Improvement(no uptake) N/A 50 VA 0 0 Mild LVSD 0 0 0 0 Case 3 IFX 3 mg/kg0 weeks and 4 weeks;missed 8 weeks’ appointment due to COVID-19 10 20 20 Active CS(SUVmax 11.3) N/A 55 N/A 0 N/A 1 (Covid-19) 0 0 0 0 0 Case 4 IFX 3 mg/kg at 0, 2 and 8 weeks afterwards 16 20 10 Active CS(SUVmax 13) Improved(SUVmax 3.4) 45 66 VA N/A 0 0 0 1 (PFO and shunt/complications) 0 0 Case 5 IFX 3 mg/kg 0, 2, 6 and every 8 weeks 8.5 30 15 Active CS(SUVmax 11.3) Improved(no uptake) 46 51 VA 0 0 0 0 0 0 0 Totals 6 IFX 3 mg/kg Mean=15.2 Mean=18.3 Mean=13.3 All had active CS 5 improved;1 data not available Mean=51.8 Mean=57.6 4 had VAs;1 data not available None had VA;3 had data not available 2 1 0 1 0 0 CS = cardiac sarcoidosis;FDG-PET =fluorodeoxyglucose positron emission tomography;IFX = Infliximab;LV = left ventricular;LVEF = left ventricular ejection fraction;LVSD = left ventricular systolic dysfunction;N/A = data not available;PFO= patent foramen ovale;

Polymorphic VT following anaphylaxis to COVID-19 vaccination

63 Figure 1ECG[Figure omitted. See PDF] 63 Figure 2ECG[Figure omitted. See PDF]DiscussionPolymorphic ventricular tachycardia, has a multitude of causative factors including QT prolonging drugs, cardiac ischaemia, underlying genetic arrhythmias such as and catecholaminergic polymorphic ventricular tachycardia (CPVT) and inherited sodium and potassium channel mutations, most notably, long QT syndromes and Brugada syndrome. It can also be as a result of early repolarisation syndromes such as J wave syndrome. Myocarditis has now been linked to the covid vaccine, with a generally benign course of illness observed. It is unclear in our case, whether an underlying genetic predisposition, in combination with the covid vaccine and medications which can cause prolonged QT intervals, provoked this episode of polymorphic ventricular tachycardia. This patient, had never observed cardiac symptoms including chest pain or palpitations, leading a very active lifestyle prior to this event. We suspect an underlying early repolarisation syndrome, as a potential precipitant of this cardiac arrest. There has been an estimated rate of 11.1 cases of anaphylaxis, per 1 million Pfizer-BioNTech Covid-19 vaccines. Cardiovascular compromise, due to anaphylaxis, is well described in the acute setting. This patient had symptoms of a prolonged allergic reaction to the vaccine, as noted by her continued allergic symptoms days after her initial anaphylaxis. This may have contributed to the development of cardiovascular collapse in this case.

Introduction of a physical activity assessment and exercise prescription to the cardiac risk in the young clinic

49 Table 1Exercise Prescription template using the FITT-VP (frequency, intensity, type, time, volume and progress) principle of exercise prescription.Exercise type Frequency (per week) Intensity Time (mins/session) Volume (weekly mins) Progression As always if you develop any concerning symptoms during exercise please stop and seek medical advice 49 Table 2‘How do I estimate exercise intensity?’ patient guide as part of the exercise prescription template and patient information leafletIntensity RPE (Rating of perceived exertion) % of HR max** Talk test 0 Resting 1 2 Very light No noticeable change in breathing or sweating Low 3 Somewhat light <55% Can talk and sing 4 Light Moderate 5 Somewhat moderate 55–74% Can talk, can’t sing Increased breathing and sweating 6 Moderate 7 Somewhat hard Feeling ‘out of breath’ and increased sweating High 8 Very hard 75–90% Can’t talk or sing 9 Extremely hard 10 Maximal exertion **%HR max will not be an accurate measure of exercise intensity if your heart rate is effected by certain medications or conditions 49 Figure 1Levels of self reported physical activity based on the NAPQ-short questionnaire and WHO 2020 physical activity guidelines[Figure omitted. See PDF] 49 Figure 2Variety of patients with a diagnosis of a cardiac condition or a family history of a cardiac condition receiving an exercise prescription. HCM;hypertrophic cardiomyopathy, DCM;dilated cardiomyopathy, ARVC;arrhythmogenic right ventricular cardiomyopathy, LQTS;long QT syndrome, Brugada;brugada Syndrome, CPVT;catecholaminergic polymorphic ventricular tachycardia, SADS;sudden adult death syndrome, Other;Friedreich’s ataxia, ischemic heart disease, supraventricular tachycardia)[Figure omitted. See PDF]ConclusionsCompared to the general adult Irish population, self reported adherence to the WHO PA Guidelines was 6% lower among the CRY Clinic patient cohort (33% vs. 27%). Additionally, reported resistance exercise levels was lower (30%) than aerobic exercise (72%). This is despite resistance exercise being additionally beneficial for many cardiac conditions. During the period of data collection, access to gyms and group exercise was limited due to pandemic government restrictions that likely effected resistance exercise more than aerobic exercise. In fact, a significant increase in recreational walking during covid restrictions was previously reported. Exercise is often discussed during medical consultation but rarely prescribed. In our cohort only 0.5% of patients received an Ex Rx. The reported barriers to Ex Rx are lack of time, perceived lack of patient engagement, complex co-morbidities and clinician education. Attempts were made in the form of education and resource provision to clinicians to challenge perceived barriers. Ex Rx are important in the CRY Clinic not only for the known benefits of PA but as inappropriate exercise can be harmful for some cardiac conditions. The Ex Rx enabled the benefit of PA to be gained by the safe promotion of appropriate exercise to such patients (figure 2). The introduction of this PA assessment and Ex Rx was a successful call to action to incorporate exercise as medicine to the CRY Clinic. ‘Walking is a (wo)mans best medicine’ (Hippocrates 460BC).

A young girl with fever and atypical rash

Kawasaki disease Scarlet fever Multisystem inflammatory syndrome in children (MIS-C) Hand, foot and mouth disease (coxsackievirus) For answer see page 02 For question see page 01 Answer: C Multisystem inflammatory syndrome in children (MIS-C) was highly suspected because of the biological inflammatory syndrome and the Kawasaki-like dermatological presentation. Majority of published cases have positive serologic testing for SARS-CoV-2 (67%) and less commonly positive RT-PCR testing from nasopharyngeal testing (33%),2 suggesting that the pathogenesis of this syndrome involves post infection immune dysregulation rather than related to acute early infection.2 3 This affliction is life-threatening as it is usually associated with severe physiological impairment (hypotension, tachycardia) requiring admission in an intensive care unit in more than 50% of cases. Multi-System inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection: review of clinical presentation, hypothetical pathogenesis, and proposed management.

Tom Nolan’s research reviews—1 September 2022

Unfortunately, the data used did not include patients on direct oral anticoagulants, which have largely replaced warfarin in the treatment of atrial fibrillation, meaning the conclusion that LAAO may be of most benefit to those with a high bleeding risk and low stroke risk is very much up for debate (Ann Intern Med doi:10.7326/M21-4653). What is the sensitivity and clinical value of a low home oxygen saturation reading when over 20% of participants in all study arms reported hypoxaemia, yet so few required hospital admission? (N Engl J Med doi:10.1056/NEJMoa2201662). [...]a linked editorial calls for more caution: no evidence has been seen of hepatocellular adenoviral infection on histological examinations in these cases: might the virus activity be an immunological response leading to acute hepatitis, or could adenovirus even be an “innocent bystander?” Better epidemiological data and registries of clinical studies are needed, it argues (NEJM doi:10.1056/NEJMoa2206704;10.1056/NEJMoa2206294).

Abstracts from international Emergency Medicine journals

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an from each publication.

Automatic Atrial Fibrillation Arrhythmia Detection Using Univariate and Multivariate Data

Atrial fibrillation (AF) is still a major cause of disease morbidity and mortality, making its early diagnosis desirable and urging researchers to develop efficient methods devoted to automatic AF detection. Till now, the analysis of Holter-ECG recordings remains the gold-standard technique to screen AF. This is usually achieved by studying either RR interval time series analysis, P-wave detection or combinations of both morphological characteristics. After extraction and selection of meaningful features, each of the AF detection methods might be conducted through univariate and multivariate data analysis. Many of these automatic techniques have been proposed over the last years. This work presents an overview of research studies of AF detection based on RR interval time series. The aim of this paper is to provide the scientific community and newcomers to the field of AF screening with a resource that presents introductory concepts, clinical features, and a literature review that describes the techniques that are mostly followed when RR interval time series are used for accurate detection of AF.

Differences in Treating Patients with Palpitations at the Primary Healthcare Level Using Telemedical Device Savvy before and during the COVID-19 Pandemic.

Background: Palpitations are one of most common reasons why a patient visits a general practitioner (GP) and is referred to a cardiologist. Coronavirus disease 2019 (COVID-19) has been associated with new-onset arrhythmias, which are difficult to diagnose at the primary healthcare level during pandemic-related lockdown periods. Methods: A total of 151 patients with a complaint of heart rhythm disorder were included from before and during the COVID-19 pandemic, as well as after the start of vaccination, in this cohort retrospective study. We used a telemedical device-namely, a personal electrocardiographic (ECG) sensor called Savvy-to investigate heart rhythm in patients. The primary outcome of the study was to evaluate the number of actual heart rhythm disorder patients and any differences that infection with or vaccination for COVID-19 had on patients handled in a primary healthcare setting. Results: We found a heart rhythm disorder in 8.6% of patients before the COVID-19 pandemic and in 15.2-17.9% of patients during the COVID-19 pandemic, where the difference was statistically significant (p = 0.002). During the COVID-19 pandemic, we found a heart rhythm disorder in almost 50% of patients that had tested positive for the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) more than one month ago. After the vaccinations started, we also found a heart rhythm disorder in almost 50% of non-vaccinated patients. Conclusions: Using a telemedical approach or remote consultation is a useful method, at the primary healthcare level, for diagnosing and treating patients with palpitations during times of lockdown.

A prospective and observational study to evaluate short-term adverse event following immunization of COVID-19 vaccination

COVID-19;Covishield;Covaxin;Immunization;Adverse Events Following Immunization INTRODUCTION COVID-19 also known as novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) was declared Pandemic by the World Health Organization (WHO) and a Public Health Emergency of International Concern on January 30, 2020. Data Collection Pertinent medical history of the vaccinated population was collected, including name, age, sex, complete address, phone number, batch number, and date of vaccination, as well as the site of simultaneous vaccination. Description of various reported combined covishield first and second dose AEFI after vaccination is separated with the number of patients suffered with a particular adverse events- fever (75%), pain at injection site (32%), headache (23%), weakness (3%), body pain (29%), vomiting (4.5%), myalgia (2%), nausea (1%), cough (2.6%), red patches (2%), cramps (2%), chills (25%), diarrhea (3%), dizziness (7%), loss of appetite (6%), hypertension (0.52%), tachycardia (3%), flushing (1.2%), drowsiness (6%), restlessness (0.65%), stomach pain (2%), and fatigue (17%). [...]description of various reported combined covaxin first and second dose AEFI after vaccination is separated with the number of patients suffered with a particular adverse events - fever (63%), pain at injection site (30%), headache (22%), weakness (5%), body pain (50%), vomiting (2%), myalgia (2%), nausea (2.5%), cough (8%), red patches (2%), cramps (3.5%), chills (27%), diarrhea (2%), dizziness (5%), loss of appetite (4%), hypertension (2%), tachycardia (1.75%), flushing (1%), drowsiness (7%), restlessness (3%), stomach pain (4%), and fatigue (11%) illustrated in Figure 1.