Corynebacterium amycolatum infective endocarditis in a patient with severe COVID-19: a case report.

Objective. To present a case of successful treatment of a secondary bacterial infection caused by non-diphtheritic corynebacterium in a patient with severe COVID-19 and known beta-lactam intolerance. Materials and methods. A clinical case of infective endocarditis (IE) caused by Corynebacterium amycolatum in a 74-year-old patient hospitalized with severe COVID-19 is presented. Comorbidity (secondary immune deficiency due to active malignancy, chemotherapy courses;previous heart disease) and the need for immunosuppressive therapy were triggers for infection caused by a rare Gram-positive bacterium which is usually considered as clinically non-significant. The choice of empiric antimicrobial treatment was limited by the patient's history of beta-lactam intolerance. Results. A multidisciplinary approach to medical care of the patient and alertness to secondary infections helped to diagnose IE in a timely manner and to choose effective antimicrobial therapy. Combination therapy with vancomycin and amikacin helped to make blood flow free from infection. The further switch to oral doxycycline in outpatient settings resulted in the patient recovery from the infection. Conclusions. Under conditions of limited choice of drug therapy, it is critical to have access to modern microbiological diagnostics which make it possible to diagnose rare pathogens. A dialogue between treating physician and clinical pharmacologist helps to choose an empirical and targeted antimicrobial therapy with the best efficacy-safety ratio. There is a need to be alert to secondary infections, including those of atypical locations and courses and caused by rare or opportunistic pathogens.Copyright © 2022, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

Anxiety and depression among patients attending a multidisciplinary foot clinic

Aim: Diabetic foot ulcers (DFUs) are linked to morbidity, decreased mobility, and feelings of isolation, powerlessness and sadness. The aim of our study was to explore the prevalence of anxiety and depression symptoms in adult patients with DFU. Method(s): We analysed questionnaires completed by patients with DFU attending our University Hospital Multidisciplinary Foot Clinic service over a one-month period in March 2022. The patients had completed three questionnaires, comprising of questions relating to socio-demographic status and care perceptions, the Patient Health Questionnaire-9 (PHQ-9) scale to assess depression, and the Generalized Anxiety Disorder scale (GAD-7) to assess anxiety. Result(s): Of the 60 patients who completed the questionnaires, 35% (n=21) reported anxiety symptoms and 40% (n=24), depressive symptoms. Individuals with comorbidities were three times more likely to report depression relative to those without any comorbidities (OR 3.3;95% CI 1.13-12.56). Younger individuals (less than 50 years), were almost nine times more likely to report anxiety in comparison to those aged 60 years or more (adjusted OR 8.9;95% CI 1.01-86.41), despite adjustment for confounding variables. Conclusion(s): The prevalence of depression and anxiety in this cohort of patients with DFU was low, but those who were affected reported moderate to severe symptoms. Younger individuals and those with comorbid conditions with DFU are more likely to experience an adverse impact on their mental health. This is a crucial factor to consider in the management of people undergoing DFU care. Strategies to reduce anxiety and/or depressive symptoms could impact both quality of life and wound healing. Copyright © 2023 John Wiley & Sons.Copyright © 2023 John Wiley & Sons, Ltd.

Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review

Integrating mental health care in primary healthcare settings is a compelling strategy to address the mental health treatment gap in low- and middle-income countries (LMICs). Collaborative Care is the integrated care model with the most evidence supporting its effectiveness, but most research has been conducted in high-income countries. Efforts to implement this complex multi-component model at scale in LMICs will be enhanced by understanding the model components that have been effective in LMIC settings. Following Cochrane Rapid Reviews Methods Group recommendations, we conducted a rapid review to identify studies of the effectiveness of Collaborative Care for priority adult mental disorders of mhGAP (mood and anxiety disorders, psychosis, substance use disorders and epilepsy) in outpatient medical settings in LMICs. Article screening and data extraction were performed using Covidence software. Data extraction by two authors utilized a checklist of key components of effective interventions. Information was aggregated to examine how frequently the components were applied. Our search yielded 25 articles describing 20 Collaborative Care models that treated depression, anxiety, schizophrenia, alcohol use disorder or epilepsy in nine different LMICs. Fourteen of these models demonstrated statistically significantly improved clinical outcomes compared to comparison groups. Successful models shared key structural and process-of-care elements: a multi-disciplinary care team with structured communication;standardized protocols for evidence-based treatments;systematic identification of mental disorders, and a stepped-care approach to treatment intensification. There was substantial heterogeneity across studies with respect to the specifics of model components, and clear evidence of the importance of tailoring the model to the local context. This review provides evidence that Collaborative Care is effective across a range of mental disorders in LMICs. More work is needed to demonstrate population-level and longer-term outcomes, and to identify strategies that will support successful and sustained implementation in routine clinical settings. Copyright © The Author(s), 2023. Published by Cambridge University Press.

Tocilizumab as a promising treatment for MIS-C in JIA: Implications for countries with inaccessible anti-IL1 agents

Background: Multisystem inflammatory syndrome in children (MIS-C), causing high morbidity and mortality, is the hyperinflammatory response following COVID-19 infection (CI). According to the MISC management guideline, Anakinra (anti-IL1) is the preferable agent among other biologic agents: Infliximab, Tocilizumab (TCZ), and baricitinib if the patient is refractory to intravenous immunoglobulin (IVIG) and systemic corticosteroid (CS). However, these are not available in a number of countries, including Thailand. Our case represents refractory MIS-C in a systemic juvenile idiopathic arthritis (SJIA) patient responding well to TCZ. Method(s): Diagnostic investigations, including basic and immunological blood tests, and echocardiography assessment, were conducted. Result(s): A 12-year- old boy has been diagnosed with SJIA since he was 2 years old, according to the presentation of prolonged fever, hepatomegaly, and evanescent rash. CS, cyclosporin-a, and TCZ have been prescribed, and he has been in clinical remission off medication for two years. He experienced acute fever, rash, shortness of breath, nausea and vomiting for few days. Physical examination revealed a febrile boy with respiratory failure, compensated shock, and a generalized persistent maculopapular rash. The other was unremarkable. MIS-C was one of the possible diagnoses according to fever accompanied by more than two systems involved and his previous CI four weeks prior. Laboratory investigation revealed an elevated inflammatory response (Figure 1). The echocardiography was done by an experienced cardiologist with concern for myocardial dysfunction in MIS-C and showed a significant poor ejection fraction of the left ventricle of 42% under dobutamine, milrinone, and norepinephrine. Broad spectrum antibiotics and IVIG (1 g/kg/dose for two days) were initiated. After hemoculture did not report bacteria growth, pulse intravenous methylprednisolone (IVMP) 1000 mg for 3 days was given for the MIS-C treatment. After initial aggressive treatment with IVIG and pulse IVMP, the patient still has a high grade fever with laboratory revealed ongoing elevated inflammatory markers. The other possible causes of fever, such as infection and active SJIA were suspected. Immunological profiles returned with positive SAR-COV2 IgG, negative SAR-COV2 IgM, which confirmed the diagnosis of MIS-C with refractory to IVIG and CS. After multidisciplinary team discussion, TCZ was given. He had neither fever, dyspnea, nor heart failure. His clinical condition gradually improves together with laboratory parameters (Figure 1). Conclusion(s): In conclusion, our case demonstrated TCZ as a potential therapeutic agent in refractory MIS-C patients living in countries with limited access to anti-IL1 agents. The multidisciplinary care team together with prompt management is advisable to the best benefit of the patient. (Figure Presented).

Pharmacist care in Federally Qualified Health Centers: A narrative review

Federally Qualified Health Centers (FQHCs) are critical to providing care to underserved populations in the United States. Their focus on interprofessional care has also made FQHCs ideal locations to integrate pharmacists into care teams and advance pharmacy practice. However, despite long-standing involvement by pharmacists, there have been limited attempts to synthesize this literature. We conducted a comprehensive search for published literature on the roles of pharmacists in FQHCs and narrowed our search to 54 manuscripts and s for inclusion in this narrative review. We found that pharmacists in FQHCs are providing care that is interprofessional, multifaceted, and evolving rapidly in response to environmental changes. Pharmacists are routinely involved in the traditional management of chronic disease, such as diabetes, hypertension, behavioral health, and respiratory conditions. In addition, pharmacists have forged roles in preventive care, infectious disease, and pain management. Models include appointment-based approaches;however, there was also heterogeneity in approaches consistent with the dynamic nature of the healthcare system in the United States with engagement in population health, transitions of care, and telehealth, as a few examples. Collaborative practice agreements were used to deliver care in some cases, although this was not commonplace, and reimbursement by third party payers was rarely addressed. Relationships with community pharmacies, often driven by the 340B Drug Pricing Program, were also noted. Recommendations for future research in this area include increasing the rigor of future research by standardizing pharmacy interventions and including comparator groups, a greater focus on financial sustainability, and further exploration of how state laws surrounding pharmacist provider status and scope of practice impact pharmacy service development. Copyright © 2022 The Authors. JACCP: Journal of the American College of Clinical Pharmacy published by Wiley Periodicals LLC on behalf of Pharmacotherapy Publications, Inc.

ONCE AT THE EPICENTER OF THE PANDEMIC, ELMHURST HOSPITAL LEADING EQUITY FOR DIABETES CARE

STATEMENT OF PROBLEM/QUESTION: Improve diabetes quality and equity during the pandemic. DESCRIPTION OF PROGRAM/INTERVENTION: Elmhurst hospital center is one of 11 acute care hospitals in the NYC H+H network, the largest public health care system in the United States. Elmhurst hospital was at the epicenter of the COVID 19 pandemic in March 2020;providing care for immigrant, uninsured and underinsured patients, including more than 5000 patients with diabetes. As NYC emerged from the first surge, the primary care clinic assessed and addressed care gaps. Difficulties in accessing in-person visits, lab, and the social and economic impact on patients added to the challenges of managing diabetes during the pandemic. Disproportionately burdened were ethnic and racial minorities. An assessment of the diabetes outcome revealed that the control rate of diabetes defined as Hemoglobin A1c (A1c) less than 8% dropped by 8% compared to the pre-pandemic rate. There was a 4% difference in diabetes outcomes between the insured and uninsured patient populations.The clinic leadership implemented a collaborative care model. The collaborative care model consists of clinical pharmacists, registered nurses, a diabetes education-certified dietitian, and the population health team that provides outreach and data analytics support. Patients referred to the collaborative team by the primary care provider who assists in setting the treatment plan and goals. The collaborative care team screens every patient for barriers and social needs, provides diet education and a self-management plan. Each patient receives medication management in either the RN led treat-totarget clinic or by the clinical pharmacist. The referral criteria follow an algorithm based on the A1c level of control, number of medications, and the use of injectables. Cases are discussed weekly in collaboration with the primary care provider. The level of care is adjusted to address patient needs. The team determines the number of visits and time between visits based on the clinical progress. Visits are conducted in person and virtually;tailored to the patient's ability to use telehealth. MEASURES OF SUCCESS: Diabetes control improved by 10% in 8 months. The gap between insured and uninsured was reduced from 4% to 1% at the end of the study project period. FINDINGS TO DATE: A team-based approach using risk stratification that incorporates clinical outcomes and patient social barriers led to significant improvement in diabetes outcomes and closed the inequity gap. KEY LESSONS FOR DISSEMINATION: - High-quality diabetes care requires a multi-disciplinary team approach. - Treat-to-target RN visits improved access and equity in diabetes care. - Clinical Risk algorithms must incorporate social barriers. - Team-based approaches require continuous training and evaluation, with team members empowered for decision making.

A qualitative study of the impact of COVID 19, on health care providers for cancer patients: An original research

Introduction: In the challenging times of the COVID-19, the care of individuals with the debilitating diseases such as cancers has been an additional burden to the medical team. We aim to find out about the obstacles for the clinical care of the patients in the COVID, the questions frequently asked by cancer patients, and the medical care and support teams' general experience in taking care of cancer patients during the times of the pandemic. Materials and Methods: We conducted a Qualtrics survey that was developed by Cancer and Aging Research Group among 275 health care providers to cancer patients during. There were twenty questions in the survey. Of these 20, three open-ended questions were included that inquired about the barriers to the clinical care of cancer patients during COVID-19;the questions asked to the health care team by cancer patients or the attendants;health care teams general experience in the situations of the COVID-19. Two different reviewers performed the quality analysis for the open-ended questions after they were assigned a code. SPSS ver-23 was used for the descriptive statistics. Results: Medical services organizational difficulties and addressing necessities and support were generally reported. Hindrances to the medical health teams included the included administrative difficulties, access of the patient to the support and basic resources, uncertainties for patients' psychological and physical well-being, and teleconsultation challenges. The most common concern of the patients was the safety and the need for the treatment. Medical health care teams were seen to worry for the mental and the physical health of cancer patient. There was also reported concern for the medical team's own safety, obstruction in multi-level establishments;also the health team was seen feeling positive leadership and communications. Conclusion: The medical health provider teams felt a need for thorough support at the organizational level for cancer patients. Medical teams were expected to comprehend the short-Term and long-Term impact of the COVID-19 on cancer patients. It was accepted that there has been an increased workload and mental stress among the providers. Appreciating the experiences of the medical teams during the pandemic may help in the future guidance in the care of cancer patients.