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Background: Unexpectedly, COVID-19 was less prevalent in Chronic Respiratory Disease(CRD) than in the general population (Gupta N et al. Lung India. 2021;38(5):454-9). The vaccine and infection-related immune status of CRD patients is unknown. Aims and Objectives: Our primary objective was to study the cross sectional seroprevalence among chronic respiratory disease patients attending the Pulmonary medicine outpatients service and comparing it with the national seroprevalence data. Method(s): Consecutive subjects with CRD were recruited. History of past COVID 19 infection and other relevant information was obtained. Blood sample was taken for Roche Elecsys SARS-CoV-2 assay to detect anti-N and anti-S antibodies. Result(s): We recruited 364 patients(Asthma & COPD-100 each, Bronchiectasis, ILD & PTB-sequelae- 50 each and other restrictive diseases-14). The overall seroprevalence in CRD(Anti-S) was 85.16%, which was significantly higher than the 4th national serosurvey seroprevalence of 67.60%(p=0.001) (ICMR, Ministry of Health and Family Welfare;2021). Asthma had the highest seroprevalence, which was higher than COPD [93% vs 78%, p=0.027] and bronchiectasis [93% vs 80%, p=0.018]. Seroprevalence dropped with increasing age: <40 yrs: 93%, 41-60 yrs: 87% and >= 61 yrs: 77% (p=0.004). Patients on inhaled-steroids had higher seroprevalence than those without (89% vs 80%;p=0.026) and those on inhaled-anticholinergics (89% VS 79%;p=0.013). Conclusion(s): COVID-19 seroprevalence is higher in CRD than in the general population. Asthmatics had the highest prevalence and the seroprevalence dropped with increasing age.
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Introduction: While an estimated 50% of adult women experience urinary incontinence (UI), the majority will never receive treatment. Most studies of incontinence care delivery have been limited to administrative (billing) data following treatment. Much less is known about earlier steps in evaluation, including primary care intentions to refer to specialty care. Objective: To better understand the gaps and barriers to receiving care, we examined referral patterns from primary care providers for patients with new diagnoses of urinary incontinence between 2018-2020 and the extent to which such referrals changed during the COVID-19 pandemic. Methods: Electronic health records (EHR) from 24 primary care practices within a single academic medical system were queried to identify a cohort of adult (18 - 90-year-old) female patients first diagnosed with urinary incontinence during primary care (family or general internal medicine) outpatient visits between January 2018 and December 2020. Demographics were determined from appropriate EHR fields, and diagnoses pulled from problem lists, past medical histories, and office visit diagnosis fields. EHR referral fields were utilized to ascertain referral dates, types, and associated diagnoses. Electronic prescription fields were used to record treatment information including medication class, name, and prescription dates. Subjects were excluded if there was EHR evidence of urinary tract infection at diagnosis, UI in the prior year based on diagnosis or medication usage (anticholinergic, B3 agonists), or presence of conditions for which incontinence management might differ substantially in the prior year (pregnancy, spinal cord injury). Referrals to specialty physicians (urology/urogynecology) and pelvic floor physical therapy (PFPT) were examined for the year after UI diagnosis. Logistic regression was then used to assess for associations between referrals and patient demographics, comorbidity, and diagnosis dates (pre-vs during-COVID-19). Results: The study identified 514 women with a newly diagnosed urinary incontinence diagnosis (Table 1). In the year following UI diagnosis, 31.91% were referred to specialty care for management -29.0% to urology/urogynecology and 3.5% to pelvic floor physical therapists. Women diagnosed with UI during the COVID-19 pandemic, starting January 2020, were less likely to be referred with an odds ratio of 0.29 (95% CI 0.19, 0.45) compared to those diagnosed before (Table 2). There was no association of referrals with patient age, race, or number of comorbidities (Elixhauser Comorbidity Index), but confidence intervals were wide. Patterns were similar for models that examined specialty physician or PFPT referral separately. Conclusions: Less than 1 in 3 women were referred to specialty care for UI by their primary care provider with less than 1 in 25 referred to PFPT. There was a significant decrease in likelihood of referrals during 2020 suggesting that the COVID-19 pandemic interfered with UI patients receiving quality care. Future studies aiming to improve incontinence care should examine other aspects of nonsurgical UI care delivery, including barriers to behavioral self-management, medication use, and completion of specialty referrals.
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Introduction: Reports of vestibular syndrome have been associated with COVID vaccination in the recent literature. In this study, we aimed to evaluate the association between COVID-19 vaccines and vestibular disorders using Vigibase®, the WHO pharmacovigilance database. Material and methods: On January 5th, 2022, we extracted in a deduplicated dataset of VigiBase® reports of vestibular disorders for tozinameran (Pfizer®), elasomeran (Moderna®), Ad26.COV2.S (Janssen®) and ChadOx1nCov-19 (Astra-Zeneca®), using MedDRA preferred terms neuronitis vestibular, acute vestibular syndrome, vestibular disorder and the low level term vestibular vertigo. Seriousness was analyzed and reported odds ratio (ROR) were calculated. We also reviewed the management of COVID-vaccine associated vestibular disorders reported in Caen Regional Pharmacovigilance Center. Results: In Vigibase®, 226 reports of vestibular disorders were found for ChadOx1nCov-19, 40 for Ad26.COV2.S, 254 for elasomeran and 1,050 for tozinameran. The ROR were respectively 2.5 (2.2-2.8), 2.5 (1.8-3.2), 3.6 (3.2-4.0) and 7.0 (6.6-7.4). Reports were considered serious in 74.3% for ChadOx1nCov-19, 70.0% for Ad26.COV2.S, 60.6% for elasomeran and 56.01% for tozinameran. Finally, we collected 13 reports of COVID-19 vaccines associated vestibular disorders in our pharmacovigilance center. Concerning the management of those vestibular disorders, 4 patients received antiemetics, 1 received betahistine, 7 received acetylleucine, 2 received corticoids and 6 had vestibular physiotherapy sessions. After 1 month of follow-up, only one patient had recovered. Discussion/Conclusion: The Vigibase® analysis showed a statistically significant association between the 4 COVID-19 vaccines under study and vestibular disorders. Short-term anticholinergics, antiemetics, antihistamines or benzodiazepines, and a corticosteroid burst with rapid taper as well as vestibular rehabilitation are usually recommended treatments. In our case series we noticed the long duration of the symptoms despite the treatments received and the heterogeneity of the adopted therapeutic strategy. Physicians should be aware and careful of the potential association of COVID-19 vaccines and vestibular disorders. Management guidelines are needed given the wide exposure to COVID-19 vaccines.
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Background: Delirium, a syndrome characterized by impairment in attention and consciousness, commonly occurs in hospital setting and is associated with higher mortality and poor long-term outcomes. With precise etiology of delirium yet to be elucidated, our current understanding describes delirium as a state of multifactorial global brain dysfunction occurring in susceptible elderly and critically ill patients. (Maldonado, 2008) To treat such a multimodal disorder, we propose investigating two novel multimodal pharmacological approaches: Granulocyte-macrophage colony stimulating factor (GM-CSF) inhibitors and pro-cholinergic muscarinic-receptor agonists. Discussion: Neuroinflammation is a focus of inquiry in a number of neuropsychiatric diseases. Unlike individual cytokine (TNF, IL-6) inhibitors, GM-CSF inhibitors combat the entire inflammatory cascade implicated in delirium: blunting the cytokine response (IL-1, IL-6, TNF) to reduce inflammation, limiting chemotaxis (IL-8 inhibition), reducing cell degradation (H2O2, MMPs), and dulling the T- and B-cell response. (Patel, 2021) GC-CSF inhibitors (otilimab and TMJ2) have already been shown to be effective in and approved for the treatment of inflammatory conditions, such as Rheumatoid Arthritis, and have been effective in treatment of inflammatory processes of COVID-19. (Patel, 2021) Given the role of the neuroinflammatory cascade in delirium, we propose investigating the GM-CSF inhibitors to treat delirium. Acetylcholine dysregulation (‘anticholinergic surge’), on the other hand, has long been implicated in delirium and studies suggest some efficacy of acetylcholinesterase inhibitors in treatment of delirium. Novel schizophrenia treatment studies combine xanomeline, a M-receptor agonist, with trospium, a peripheral anticholinergic, to create a net-positive pro-cholinergic state in the brain while minimizing systemic side-effects. (Brannan, 2020) In addition to treating schizophrenia and cognitive impairment, this combination (KarXT), may be useful in reversing the anti-cholinergic state of the delirious brain. Currently in Phase III clinical trials, KarXT should be considered a viable candidate for delirium treatment, once FDA-approved. Conclusions: Pharmacological approaches to delirium have been limited to managing behavioral dysregulation and sleep-wake cycle disturbances. Presently, we are looking at two potential additional approaches to delirium treatment. One is limited to cholinergic circuitry and aims to restore AcH balance via direct M-receptor agonism. The other, based on Systems Integration Failure Hypothesis, addresses the entire inflammatory cascade via GM-CSF inhibition. As agents from both classes are either approved or are close to FDA-approval, we should consider them as candidates for delirium management. References: 1. Maldonado, J, Kapinos, G. (2008). Pathoetiological Model of Delirium, Critical care clinics. 24. 789-856, ix. 10.1016/j.ccc.2008.06.004. 2. Brannan, S, Sawchak, S, et al.(2020). Efficacy and Safety of Xanomeline, a M1/M4 Receptor Preferencing Agonist, Plus Trospium, a Peripheral Muscarinic Antagonist, in Schizophrenia. Biological Psychiatry, 87(9), S169. doi: 10.1016/j.biopsych.2020.02.446 3. Patel, S, Saxena, B., Mehta, P. (2021). Recent updates in the clinical trials of therapeutic monoclonal antibodies targeting cytokine storm for the management of COVID-19. Heliyon, 7(2), e06158. doi: 10.1016/j.heliyon.2021.e06158
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Objective: In some countries the Thursday before Easter is called Green Thursday according to the Christian calendar, and in this tradition, a green meal should be eaten on this day to ensure good health throughout the coming year. A few days before Easter the National Toxicological Information Centre (NTIC) registered an increased number of toxicological consultations following consumption of deep-frozen spinach puree which was sold in retail chains throughout Slovakia. Symptoms were characteristic of tropane alkaloid intoxication and experts suspected the spinach was contaminated with Jimson weed (Datura stramonium). Methods: A retrospective analysis of all telephone calls concerning frozen spinach products from the database of the NTIC from 1 March 2021 to 30 April 2021 was conducted. Results: The NTIC received 93 telephone calls from people who had consumed frozen spinach, of which 64 people (7 children) had mild symptoms of intoxication (PSS1) and 5 moderate poisoning (PSS2). The most commonly reported symptoms were malaise, dizziness, dry mouth, mydriasis and blurred vision that appeared within 1 to 2 hours after ingestion. Patients with moderate symptoms of intoxication were confused, disoriented and had hallucinations. The symptoms disappeared spontaneously within 48 hours. The country was in a state of emergency that had been declared before Easter due to COVID-19 and people were afraid to attend hospitals. Therefore, only 7 out of 69 people with symptoms arrived in hospital. Only 3 patients were hospitalised. Treatment was symptomatic, without the administration of an antidote physostigmine. The other patients were treated at home. Unfortunately, an increased number of consultations was recorded on Good Friday afternoon, when it was very difficult to initiate a wide scale alert informing the public through the media. Over the Easter weekend, the NTIC alerted the public to avoid the contaminated spinach via social media and the NTIC website. The State Veterinary and Food Administration of the Slovak Republic arranged analyses of contaminated frozen spinach samples in an accredited laboratory and this confirmed the presence of atropine and scopolamine. Conclusion: Datura stramonium grew with spinach in the field as a weed and contaminated the spinach due to insufficient entry and exit controls. As a result of promptly spreading information and informing the public about the contaminated spinach product in the media, further cases of poisoning over the Easter holidays were successfully averted.
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Background: Unexpectedly, COVID-19 is less prevalent in Chronic Respiratory Disease(CRD) than in the general population.[1-4] The vaccine and infection-related immune status of CRD patients are unknown. We performed a cross-sectional COVID-19 seroprevalence study among our CRD patients. Methods: Patients with Asthma, COPD, ILD, PTBsequelae and restrictive lung diseases attending the pulmonology OPD were recruited. Relevant clinical and laboratory information were captured. The Roche Elecsys SARS-CoV-2 assay was used to detect anti-N and anti-S antibodies. Results: We recruited 364 patients (Asthma & COPD -100 each, Bronchiectasis, ILD & PTB-sequelae - 50 each and restrictive diseases-14 ). The overall seroprevalence in CRD (Anti-S) was 85.16%, significantly higher than the 4th national serosurvey data of 67.60% (p = 0.001).[5] Asthma had a higher seroprevalence than COPD [93% vs 78%, p=0.027] and bronchiectasis [93% vs 80%, p=0.018]. Prevalence of antibody through natural infection as assessed by Anti-N was nearly 5 folds higher (67.62%) than those with PCR confirmed COVID-19 (13.74%). PTB-sequelae patients had higher natural infections than COPD. [48 (75%) vs 57 (59.37%), p=0.065]. Seroprevalence dropped with age: <40 years: 93%, 41-60 years: 87% and 61+ years: 77% (p=0.004). Those on inhaled-steroids had higher seroprevalence than those without (89% vs 80%, p = 0.026). Patients on inhaled-anticholinergics had lower seroprevalence (79%vs 89%;p=0.013) and lower confirmed COVID (6% vs 19%, p<0.001) than no-anticholinergics. Conclusion: The COVID-19 overall seroprevalence is higher in CRD than in the general population.
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The proceedings contain 66 papers. The topics discussed include: exploring elderly patients? perspectives on deprescribing: a qualitative study interim analysis;supporting safe and gradual reduction of long-term benzodiazepine receptor agonist use: development of the safeguarding-BZRAs toolkit using a co-design approach;a feasibility study of a pharmacist led proton pump inhibitor deprescribing intervention in older patients in an Irish hospital;using risk prediction to case-find frail older people at risk of anticholinergic burden for structured medication reviews: a qualitative study exploring the views and perspectives of primary care professionals;routinely implementing safe deprescribing in primary care: a scoping review;and antimicrobial consumption in hospitalized COVID-19 patients: a systematic review and meta-analysis.
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INTRODUCTION: Post-Intensive care syndrome (PICS) is the culmination of cognitive, psychological and physical issues critical illness survivors encounter. More than half of critically ill patients may experience cognitive impairment after hospital discharge. There is limited information on cognitive impairment surrounding PICS in COVID-19 survivors. This study aims to evaluate the impact anticholinergic cognitive burden has on cognitive function in the COVID-19 survivor patient population. METHODS: This retrospective, observational cohort study included patients from the post-intensive care survivor clinic at Indiana University Health that were discharged from April 2020 to March 2021. Patients were excluded if they did not have an admitting diagnosis of respiratory failure secondary to COVID-19 or did not have discharge documentation. Cognitive impairment was evaluated using the Montreal Cognitive Assessment (MoCA). Demographics and anticholinergic cognitive burden (ACB) scores were compared between patients with cognitive impairment (MoCA < 26) versus those without cognitive impairment (MoCA > 26). RESULTS: Twenty-six patients were included in this evaluation. Twelve patients had cognitive impairment and fourteen patients did not have cognitive impairment. ACB score at discharge for those with and without cognitive impairment had a median (IQR) score of 2.5 (0.75-4.25) and 1 (0.25-2), respectively (p=0.208). The patients with cognitive impairment had a median (IQR) ACB score at the start and end of the initial appointment of 1.5 (0.75-2.5) and 1.5 (0.75-2.25), respectively. The median (IQR) ACB score at the start and end of the initial appointment for patients without cognitive impairment was 1 (0-1.75). Delirium was reported 7 patients (58%) with cognitive impairment compared to 5 patients (36%) without cognitive impairment (p=0.431). The Charlston comorbidity score was higher in those with cognitive impairment, with a median (IQR) score of 3.5 (2.75-5) compared to 0 (0-2) for those without cognitive impairment (p=0.002). CONCLUSIONS: The difference in ACB scores at discharge was not statistically different between patients with and without cognitive impairment. Patients with cognitive impairment post ICU discharge tended to have a higher Charlston comorbidity score.
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The proceedings contain 148 papers. The topics discussed include: developing and validating a prediction model for in-hospital mortality associated with anticholinergic drug burden among older hospitalized patients with dementia;undergraduate students and educators' views on interprofessional behavior change support education in chronic disease;are pharmacists competent enough to provide patient education about drugs used to treat autism spectrum disorder?;antimicrobial stewardship program implementation during the global pandemic of coronavirus disease (COVID-19);a systematic review of interventions to enhance adherence and persistence with ADHD pharmacotherapy;portrayal of autism spectrum disorder and related treatments in Qatar's printed media;drug-disease interactions in mental illness: clinically relevant alerts for depression and psychotic disorders;and exploring non-prescribing hospital pharmacists' views of pharmacist prescribing in hospital settings.