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209 Figure 1Kaplan-Meier curves displaying cumulative all-cause mortality[Figure omitted. See PDF]Conflict of InterestNo conflicts of interest
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Humans can be said to be social creatures who always cannot be separated from communicating with other humans. This study aims to determine the influence that can attract tourists to continue to visit and feel satisfied with the facilities provided. This research method is quantitative research, the type of data needed in this research is primary data and secondary data, the source of the data used in this study is by distributing questionnaires (questionnaires), the data collection technique used in this study is through the Likert scale. The results of the study show that this Jaddih Hill tour has utilized good electronic media, so that tourists are interested in visiting again besides tourists who visit have a sense of security and calm.
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[...]the journal Nutrition and Food Science has published this special issue exploring the intersection of nutrition and COVID-19 [1], [2], [3], [4], [5], [6], [7], [8]. [...]a study explored the factors related to sedentary lifestyle in a Brazilian sample during the COVID-19 initial quarantine [8]. [...]the papers published in the special issue "The relationship between nutrition and COVID-19” underlined the importance of nutrition in mitigating the mental and health-related impacts of the COVID-19 pandemic.
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[...]the mortality reduction has previously been reported in the prospective meta-analysis [2] conducted by The WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group. Nonetheless, owing to relatively scarce evidence, it is still unclear whether monoclonal IL-6 antibodies reduce mortality in patients with COVID-19, similar to the IL-6 receptor inhibitors. [...]large-scale randomised trials should also be conducted to establish the role of monoclonal IL-6 antibodies in the treatment of COVID-19. [...]among hypothetical long-term complications, peripheral neuropathy would also be noticeable [10] and may contribute to the broad long COVID pattern. [...]there is a theoretical risk of altering the efficacy of immune checkpoint inhibitors during tumour disease management [11].
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Background and ImportanceIn recent years not just the novel therapeutic approaches, but the Coronavirus pandemic has also affected the therapy management of patients with rheumatoid arthritis. Beside these changes, the immunisation against COVID-19 has also been an issue and raised several questions from clinicians to patients.Aim and ObjectivesTherefore, our aim was to find out the possible changes that patients were experiencing and the potential factors influencing their therapy.Material and MethodsData was collected through structured personal interviews with a 33-item questionnaire licensed by the Regional Research Ethics Committee of the University of Pécs and review of the medical records from January until September in 2022. We used the data available in the ambulatory medical records and the itemised reporting interface of the National Health Insurance Fund. Drug interactions were analysed using UpToDate Lexicomp database.Results35 female patients (average age: 63.53 years ± 13.82) and 23 male patients (average age: 53.54 ± 12.96) received biological or targeted therapy for an average of 7.17 years ( ± 4.12), while the average patient activity index DAS28 was 3.15 ( ± 1.17) and BASDAI was 5.29 ( ± 5.52). 87.93% (51/58) of the patients have used non-medication health products, mainly vitamin C or D. 34.48% of the patients were confirmed with coronavirus infection during the pandemic, while the vaccination rate was 87.89%. 83.45% of the patients received at least one mRNA vaccine. In our patient group, the influenza vaccination rate was 36.21%, while only 5.21% of the patients had been vaccinated against Pneumococcus in six months previous to our survey. The total number of serious (category X and D) interactions were 216, in 135 cases a vaccine and in 58 cases a monoclonal antibody or targeted therapy was included as interacting pair.Conclusion and RelevanceDespite the growing number of new therapeutic approaches and vaccines, the screening methods for analysing potential drug interaction are lacking behind and the Summary of Product Characteristics are not suitable for comprehensive evaluations. The inclusion of these therapies and the optimisation in vaccination status in the medication review process and the understanding of immunological mechanism potentially influencing the therapy of patients is warranted.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportancePaxlovid® is indicated for the treatment of COVID-19 in adults who do not require supplemental oxygen and who are at increased risk for progressing to severe COVID-19. The Spanish Drug Agency published prioritisation criteria for it access. Paxlovid® has significant drug interactions, mainly due to ritonavir. Hospital pharmacists must validate the prescription, carrying out a thorough review of the patient‘s medical history to check its suitability, as well as the concomitant medication to avoid interactions.Aim and ObjectivesAnalyse the use of Paxlovid® in Huesca and Sector-1 of Zaragoza (Aragon, Spain) in early months post-authorisation.Material and MethodsAll Paxlovid's prescriptions from April to September 2022 were reviewed. The following variables were collected: gender, age, vaccination schedule, prioritised high-risk criteria and renal function. All concomitant medication was reviewed for drug interactions using a protocol created by Coordination Unit for the Rational Drug Use of Aragon. The observations made to the prescribing physician by the hospital pharmacist were recorded.Results40 requests were received. 5 were prescription errors. 29 (82.9%) were accepted and 6 (17.1%) rejected. Median age (years, interquartile-range q1-q3) was 52.2 (45.6–65.3), 57.1% were male. Vaccination status was complete primary vaccination with booster-dose (62.8%) followed by complete vaccination (25.7%) and incomplete vaccination (11.5%). As high-risk criteria prioritised, 91.4% belonged to group composed by immunocompromised persons. 91.4% had renal function >60ml/min. Only in 3 cases (8.6%) the prescribing physician indicated the patient had potential drug interactions.All patients had concomitant medication, median of 8 drugs (4–10). 60% had any potential interaction, with serious drug interactions in 42.9% of them. Drugs with potential serious interactions were statins (5/11);benzodiazepines (2/11) and antithrombotic agents (2/11).44.8% prescriptions were accepted with recommendations to modify or temporary stop some of the patient‘s usual treatment. 80% of the rejected cases were due to serious drug interactions.Conclusion and RelevanceIn the use of Paxlovid®, the role of hospital pharmacists was crucial, as drug interactions were detected in 60% of patients and were serious in 42.9% of them, leading to recommendations for adjustments in patients‘ drug therapy in almost half of the cases, with potentially serious drug interactions being the main reason to not dispense Paxlovid®.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportanceIn the context of pre-exposure prophylaxis of COVID-19 in adults and adolescents aged 12 years and older (> 40 kg), tixagevimab-cilgavimab is currently included in clinical guidelines. The recommended dose is administered as two separate sequential intramuscular injections (150 mg of tixagevimab and 150 mg of cilgavimab), preferably in the gluteal muscles. Due to their recent authorisation, effectiveness and security of this treatment is not well known.Aim and ObjectivesThe aim of this study was to analyse the effectiveness and security of tixagevimab-cilgavimab in patients with COVID-19 risk after a complete vaccination regimen, collated with the data from PROVENT clinical trial.Material and MethodsRetrospective observational study in a cohort of COVID-19 risk patients. Electronic medical record and prescription application were used to collect the following data: sex, age, comorbidities, anticoagulation, and titles of anti-Spike antibodies, and COVID-19 infections after administration.ResultsThe study includes 41 patients (52.5% women, median age 64.5 years (SD 13.5)), who were candidates to prophylaxis because of their comorbidities: anti-CD20 active treatment (21), solid organ transplantation (renal (10) and pulmonary (14)), chronic kidney disease (2), immunosuppression (1), cytotoxic chemotherapy (1) or haematopoietic Stem Cell transplant (1). After the last vaccination, 97.5% of the patients had low antibodies (< 260 BAU/mL), which demonstrates an inadequate response to active immunisation. These comorbidities and clinical conditions were similar in PROVENT.In PROVENT, the duration of protection is estimated to be at least 6 months (0.2% COVID-19 positive cases after administration prior to day 183). In our study population, 3 patients were COVID-19 positive (7.5%) prior to day 90 after administration without severe or critical symptomatic illness.As with any other intramuscular injections, should be given with caution to patients with thrombocytopenia or coagulation disorders;5 patients were on anticoagulation therapy and no bleeding events were recorded. Therefore, non-hypersensitivity reactions have been observed.Conclusion and RelevanceEffectiveness and security of the pre-exposure prophylaxis with tixagevimab-cilgavimab was adequate in most of the patients treated, and similar to the data of the clinical trials. Even so, pre-exposure prophylaxis is not a substitute for vaccination. Nevertheless, further studies were necessary to establish the effective and security profile.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportanceIn Europe, the VITAE study estimates an annual incidence of venous thromboembolic disease (VTD) of 243/100,000 inhabitants.About 25% of VTD cases are related to hospital admissions and 50–75% of VTD cases occur in non-surgical hospitalised patients. PRETEMED is a validated thrombotic risk (TR) scale for clinical prediction that have been designed to be used in daily clinical practice. As well, it is recommended to assess the bleeding risk (BR) with another validated scale called IMPROVE scale before starting thromboprophylaxis (TP).Aim and ObjectivesDetermine the (TR/BR) and analyse whether the prescription of thromboprophylaxis in patients from the Emergency Department who are going to be admitted to the hospital ward is adequate.Material and MethodsProspective observational cohort study, carried out in a 2nd level hospital during a period of 10 days. Adult patients in the ED awaiting admission to the hospital ward were included.Patients with therapeutic effort limitation, COVID-19 patients, those who had been transfused in the last 48 hours, bleeding patients or those with underlying pathology that require anticoagulation were excluded. Using the PRETEMED/IMPROVE scales, the TR/BR was determined, as well as the indication of thromboprophylaxis.Results62 patients. 31 women (50%). The median age [range] was 71 [18–93] years. 31 patients with TP regimen, no interventions had to be performed, they had an adequate indication with PRETEMED> 4 and IMPROVE <7. 31 patients without TP regimen;7 (23%) of them had indication for TP and they went into the operating room with PRETEMED> 4 and IMPROVE <7. 7 (11.3%) of the patients required pharmaceutical intervention to adequate their TP, all of them by default.Conclusion and RelevanceThe prescription of TP in adults who visit the ED could be considered adequate in a high percentage, however it can be optimised according to the PRETEMED and IMPROVE guidelines. It is essential to recommend on the use of scales that assess TR/BR for the correct decision-making in the prescription of TP. The limitation of the study was the small sample size.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportanceNew drugs have been investigated with the aim of preventing serious pathology in high-risk patients with COVID. As a result, nirmatrelvir-ritonavir emerged, approved by the European Medicines Agency in December 2021 thanks to the pivotal EPIC-HR clinical trial.Aim and ObjectivesTo analyse the effectiveness and pharmacological interaction profile of nirmatrelvir-ritonavir in patients diagnosed with SARS-Cov2.Material and MethodsRetrospective study in which patients diagnosed with mild-moderate SARS-Cov2 for whom treatment with nirmatrelvir-ritonavir was requested from the approval of the drug until 08/31/2022 were preselected. Patients who received treatment were included. The primary effectiveness endpoint was hospital admission or death from any cause through day 28. As a secondary variable, the profile of pharmacological interactions between nirmatrelvir-ritonavir and the patients‘ medication and its management. Selection of patients, demographic and clinical data were obtained from the electronic medical record. Descriptive statistical analysis was performed using Excel®16.48.ResultsWe preselected 86 patients, 37 (43.02%) did not receive treatment. The reasons for non-indication were: patients not considered high risk 30/37 (81.08%), receiving oxygen therapy 4/37 (10.82%), >6 days of symptoms, unmanageable interactions and received remdesivir, 1/37 (2.70%) each one. Obtaining a final sample of 49 patients. Mean age was 67.5 years(SD=16) and 25(51.02%) of them were men. Indication's reasons were: high-risk immunocompromised patients 32/49 (65.31%), vaccinated >6 months ago over 80 years with risk factor 14/49 (28.57%), unvaccinated over 80 years 2/49 (4.08%), unvaccinated over 65 years with a risk factor 1/49 (2.04%). Of these, 10/49 (20.41%) required adjustment to renal function. An event (hospital-admission or death) during the 28 days after the start of treatment was registered in 16/49 (32.65%) patients. Of these 14 (28.57%) events were hospital-admission and 2 (4.08%) deaths. We detected 77 interactions in 39/49 (79.59%) patients [2.14 interactions/patient;SD=1.42], that required: to monitor 55/77 (71.43%), suspend treatment and reintroduce it 3 days after 20/77 (25.98%) and reduce dose 2/77 (2.59%). Main therapeutic groups with interactions: statins 14/77 (18.17%), metamizole 9/77 (11.68%), calcium channel blockers 8/77 (10.38%), antidepressants 5/77 (6.49%),opioids 4/77 (5.19%), direct oral anticoagulants 4/77 (5.19%), and tamsulosin 4/77 (5.19%).Conclusion and RelevanceIt seems that real-life results of nirmatrelvir-ritonavir are inferior to those obtained in the pivotal RCT, due to higher number of hospital admissions. Most patients presented interactions, which could be managed in a simple way through temporary suspension and monitoring.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportanceThe opening of a pharmaceutical care service for onco-haematology patients (OHP) in the midst of the health care crisis caused by the COVID19 pandemic, made it possible to maintain the healthcare activity, avoid the collapse and provide the opportunity to implement Comprehensive Medication Management (CMM).Aim and ObjectivesTo investigate the pharmacotherapeutic experience of OHP in outpatient therapy with CMM services;to know important aspects perceived for the identification of barriers/facilitators that determine the quality of the service and proposals for improvement.Material and MethodsDescriptive observational design with a qualitative approach, using informal and semi-structured in-depth interviews (participant observation and peer review) during January-June 2021. ATLAS.ti software was used for content analysis. Oncohaematology patients in outpatient therapy with any medication-related problem and who received CMM services were interviewed. Those who, due to cognitive limitation, could not be interviewed or who did not have a caregiver/family member available were excluded.Results19 interviews were conducted: 57.89% patients and 42.10% caregivers;57.89% were women. All patients were very satisfied with the care received, the vast majority preferred to be attended by a pharmacist, and valued telepharmacy as an alternative or complementary option. The vision of the pharmacy professional as an expert in medicines improves. They suggest improvement related to location, waiting times and greater accessibility of the pharmacist. After the researchers' reflective process, were identified as barriers: care pressure, limited time/resources, lack of interlevel coordination, and facilitators: prioritisation of interventions, integration of pharmacist in the multidisciplinary team, trust in the pharmacist and the new model of care. Improvement strategies: provision of human/material resources with release of pharmacist's time to provide the CMM, extension of hours, information management with the development of personal learning environment and use of programs for recording/integration of information and interventions.Conclusion and RelevanceDelving into patients‘ experiences can be key to improving the quality of care. In our case, the implementation of the CMM service in OHP has been a challenge and an opportunity in the current context of the COVID-19 pandemic. The pharmacy adapted to the needs and implemented a new model of care with excellent acceptance by users.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportanceInterstitial lung diseases (ILD) is a group of rare diseases with bad prognosis, being Idiopathic pulmonary fibrosis (IPF) the most frequent of them. They can be treated with antifibrotic drugs: nintedanib or pirfenidone. However, these drugs have a high rate of adverse effects, which has a significant impact on treatment persistence.Aim and ObjectivesTo analyse the safety of pirfenidone and nintedanib in patients with ILD as well as treatment's persistence, in a third-level hospital.Material and MethodsRetrospective observational study of patients with ILD treated with antifibrotic drugs from January 2016 to August 2022. Variables: sex, age, drug, duration of antifibrotic treatment, associated drug, switch to another antifibrotic drug, side effects, discontinuations, deaths. Information was collected from the hospital's information systems.Results66 patients, 67% men, mean age 67 (47–86).44 patients with nintedanib: 23 IPF, 14 progressive pulmonary fibrosis (PPF), 2 ILD associated with systemic sclerosis, 4 fibroemphysema and 1 ILD not classified. 5 of them were treated with an associated immunosuppressive drug: mycophenolate mofetil. 12 patients needed a dose reduction due to gastrointestinal effects: 100% diarrhea, 80% nausea. 1 patient needed temporary discontinuation due to increased transaminases, which were finally stabilised, being able to return to a higher dose. 2 patients needed discontinuation of treatment due to bleeding: 1 patient was on antiplatelet therapy and the other had a background of epistaxis. These two patients switched to pirfenidone.22 patients with pirfenidone: all of them IPF. 2 patients needed dose reduction due to diarrhoea and 2 needed treatment discontinuation due to severe sunburns. These patients switched to nintedanib.Persistence until progression18 months with nintedanib and 24 months with pirfenidone. 8 patients died during treatment, 4 of them because of COVID-19 infection.Conclusion and RelevanceThanks to a close follow-up in patients with ILD, it is possible to modify the dose and to achieve greater tolerance to treatments. The pandemic affected negatively during the year 2020, not only because of the impossibility of receiving medical appointments, but also due to the acceleration of their death. The rapid establishment of anti-fibrotic treatment and the adequate control of adverse effects are the key for this type of patients.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Background and ImportanceBacillus cereus is a spore-forming, gram-positive bacterium that is ubiquitous in the environment. It is frequently dismissed as contaminants, however, in the proper setting these organisms have the potential to be virulent. Clinical infections caused by B. cereus fall into six broad groups: local infections of wounds, burns, bacteraemia, CNS infections, respiratory infections, endocarditis and food poisoning. Despite aggressive treatment with broad-spectrum antibiotics and using them appropriately, the mortality is high.Aim and ObjectivesTo describe a case of Bacillus cereus central nervous system infection associated with post-surgical meningitis and a patient successfully treated with antibiotics.Material and MethodsDescriptive and retrospective clinical case. Data were obtained by review of electronic medical records.ResultsA 72-year-old woman underwent a decompressive laminectomy due to lumbar spinal stenosis. Past medical history included hypertension and dyslipidaemia. She was discharged without complications. One week later, the patient was brought to the emergency room for altered consciousness, dysarthria, hemiplegia and fever. Her vital signs included a blood pressure of 109/82 mmHg, heart rate 125 beats/min, SpO2 92%, and Glasgow Coma Scale score of 7/15. C-reactive protein (CRP) level was 95 mg/l (reference <5 mg/l). Polymerase chain reaction (PCR) testing for SARS-CoV-2 was negative. Blood culture was negative. After a lumbar puncture, Bacillus cereus was isolated. The isolate was found resistant to β-lactam antibiotics (including penicillin, ampicillin and cephalosporin) and trimethoprim/sulfamethoxazole, and showed susceptibility to macrolides, vancomycin, clindamycin, carbapenems and quinolones. Triple antibiotherapy with meropenem, vancomycin and linezolid was initiated. After a few days of clinical stability, absence of fever and negative microbiological cultures, the triple antibiotic therapy was withdrawn and vancomycin and meropenem were continued. With adequate control of the source of infection and after a good evolution of the surgical wound, antibiotic therapy was switched to the oral route with linezolid. The patient was discharged with no evidence of sequelae from the meningeal infection, normal neurologic examination and CRP levels within the normal range.Conclusion and RelevanceThis case highlights the clinical challenge to diagnose B. cereus and the importance of the delay between the detection of B. cereus and the establishment of an effective, targeted antibiotic therapy, especially in immunocompromised patients.References and/or AcknowledgementsConflict of InterestNo conflict of interest
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Unlike the 2007–2009 economic meltdown, the COVID-19 pandemic was not caused by problematic market situation or reckless financial policy;it was, in fact, completely unpredicted (Hsu and Tang 2022). [...]it contrasted from other earlier dramatic events caused by economic and financial circumstances, including the Asian financial crisis in 1997–1998 or the European debt crisis in 2010–2013 (Dong et al. 2022). [...]the similarity of these downturns is that they commenced in one nation or area and spread rapidly to other markets, prompting considerable disruption in the worldwide financial system (Zhang et al. 2022). [...]COVID-19 has been regarded as an "exogenous shock” or potentially a "black swan”, as it was such a rare occurrence that has major repercussions for stock markets without any reasonable anticipation (Costola et al. 2023). According to Yu and Xiao (2023), the pessimistic news from COVID-19 government restriction policies generated more instability in stock markets than the optimistic news. [...]Conlon and McGee (2020) raised suspicions on Bitcoin's potential to provide protection from volatility in conventional markets. [...]the publications featured in this Special Issue expanded our comprehension surrounding the effect of the COVID-19 pandemic on financial markets and the real economy, and they proposed appealing future research avenues.
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Although mRNA vaccine responses following previous coronavirus disease 2019 (COVID-19) infection have not been assessed in trials, it has been shown that serological evidence of previous COVID-19 generates strong humoral and cellular responses to one dose of mRNA vaccine. We describe a patient with prior COVID-19 infection who developed acute transient encephalopathy with elevated inflammatory markers within 24 h of her first injection of Moderna COVID-19 vaccine. A 69-year-old cognitively normal woman presented with intermittent inattention, disorientation, left/right confusion, weakness, gait instability, and decreased speech. Head CT, brain MRI and MRA, complete blood count, liver enzymes, hepatitis B serology, ammonia, thyroid function, vitamin B12, and pulse oximetry were normal. Electroencephalography performed 48 h after symptom onset showed diffuse triphasic waves, diffuse theta and delta slowing, and no posterior dominant rhythm. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) IgG was positive and inflammatory markers were elevated. On day 5 post-vaccine, she returned to her baseline, without neurological sequelae. The reported patient likely developed a transient inflammatory encephalopathy associated with an abnormal immunologic reaction to one dose of COVID-19 vaccine, in the setting of remote COVID-19 infection (1 year prior), SARS-CoV-2 IgG-positivity, and multiple comorbidities. Physicians should be alert to possible postvaccination reactogenicity in individuals with SARS-CoV-2 IgG-positivity, including risk of neuro-inflammation.
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Pool toes, a sport-related dermatosis, are caused by mechanical friction and water exposure, resulting in a special variant of irritant contact dermatitis. It is common in children, often misdiagnosed, and rarely reported. Here we report a case of a 7-year-old girl who developed this unusual type of frictional dermatitis;a pool toes diagnosis has been made. With topical corticosteroids, favorable results have been achieved. The recovery and healing process will be facilitated if one is aware of the underlying causes of such dermatitis and ceases the triggering factors.
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This report describes a case of a newly diagnosed 49-year-old HIV patient, who presented with decreased visual acuity and retinal lesions characterized by ischemia at the level of the deep retinal capillary plexus, documented with optical coherence tomography (OCT), OCT angiography, fluorescein angiography, and visual fields testing. These lesions closely resembled the morphologic and clinical characteristics of late paracentral acute middle maculopathy. The presence of these lesions suggests that HIV microangiopathy can potentially affect both superficial and deep retinal capillary plexuses.