Incidence of barotrauma in an intensive care unit: new data from COVID-19?

Introduction: During COVID-19 pandemic, the massive use of ventilatory support made its complications even more common. This study aimed to analyse the incidence of barotrauma in COVID-19 patients as well as its consequences. Method(s): Retrospective cohort study. All patients undergoing mechanical ventilation in an intensive care unit (ICU) during 2020- 2021 were included. The time of both noninvasive and invasive ventilation was considered together. Statistical analysis was performed using IBM SPSS Statistics 28.0. Result(s): A total of 967 patients were included, with 42 cases of barotrauma being reported (28 men and 14 women, median age 69 years [interval 22-94] and median APACHE 13). Out of those, 40 had severe COVID-19. Regarding patients with and without COVID-19, the incidence of barotrauma (episodes/1000 days of ventilation) was 0.64 and 9.22 (RR 14.86, p < 0.001) and the barotrauma rate (episodes/number of patients) was 0.4% and 8.5% (RR 21.25, p < 0.001), respectively. The most common type of barotrauma was subcutaneous emphysema (52.4%, CI 95% 37.3-67.5%), followed by pneumomediastinum (47.6%, CI 95% 32.5-62.7%) and pneumothorax (35.7%, IC 95% 21.2-50.2%). The median time to diagnosis was 11.5 days after initiation of ventilatory support [interval 1-67]. In the COVID-19 group, barotrauma was associated with longer ventilation (14.06 vs 7.91 days, p < 0.001), longer ICU stay (16.74 vs 8.17 days, p < 0.001) e higher mortality rates (45.0% vs 26.2%, RR 1.72, p 0.011). Conclusion(s): We found a higher susceptibility to developing barotrauma as a potential complication of COVID-19 patients undergoing mechanical ventilation. From those, subcutaneous emphysema and pneumomediastinum seem to be more prevalent than pneumothorax. Barotrauma seems to be associated with longer periods undergoing mechanical ventilation, longer ICU stays and higher hospital mortality rates.

Social and Environmental Triggers of Multiple Sclerosis onset: A Retrospective Study from Iran

Introduction: Multiple sclerosis (MS) is an often-disabling disease of the central nervous system (CNS). The possible triggers of its first presentation such as stressful events, viral infections, vaccinations, and labor are still a matter of debate among scientists. Considering the possible role of infections in MS onset and the reported cases of CNS demyelination following COVID-19 infection and variety of COVID-19 vaccines, this study was conducted to investigate and compare the possible social, environmental, and physical triggers of MS onset before and during the COVID-19 pandemic. Material(s) and Method(s): A cross-sectional study was conducted from 28 February 2022 to 9 June 2022. A researcher-made questionnaire was designed in MS research center of Iran and distributed as an online google form on social media among 1340 Iranian MS patients. Demographic information, MS disease-related data, possible MS triggers (stressful life events, COVID-19 and other infections, COVID-19 and other vaccines, pregnancy or labor, head trauma, surgery, weight loss) were recorded. Patients were divided into two groups regarding the time of MS diagnosis (before and during the COVID-19 pandemic). Binary logistic regression method was used to determine the possible association between patient-reported triggers and diagnosis time (before and during the pandemic) adjusting for possible confounders. Result(s): Of 920 participants, 670 (72.8 %) were female, and the mean age (SD) was 35.63 (+/-8.1). The majority of participants 637 (69.2%) had non-progressive forms of MS, and only 70 (7.6 %) needed assistance for ambulation. The time of MS diagnosis was before the start of the COVID-19 pandemic in 635 (69 %) participants. The differences between the most common first symptoms which led to MS diagnosis, visual type (n: 317 (49.9 %)) before the pandemic and sensory type (n: 170 (59.6 %)) after the pandemic were significant (p-values: 0.008 and <0.01 respectively). A stressful life event was the most common patient-reported MS trigger in both groups, (n: 356 (56.1%)) in patients who were diagnosed before the COVID-19 pandemic, and (n: 156 (54.7%)) in the latter group. Comparing two groups (MS diagnosed before and during the pandemic), economic problems (AOR: 1.81;95%ACI: 1.23-2.65) and job loss (AOR: 2.89;95%ACI: 1.37-6.08) were significantly more frequent stressful life event which trigger MS onset in the latter group while, the stress of occupational or educational exams (AOR: 0.52;95%ACI: 0.34-0.79) was more prevalent in the first group. Conclusion(s): Social triggers such as stressful life events are closely associated with MS onset that had been increased in some categories after the COVID-19 pandemic. If truly recognized, they could be used to prevent the development and exacerbation of the disease.Copyright © 2022

Impact of the COVID-19 Pandemic on Breast Cancer Patient Care: A Retrospective Study in a Tertiary Care Center in Lebanon

INTRODUCTION: The COVID-19 pandemic poses challenges to the healthcare systems including cancer treatment. We aim to evaluate the impact of lockdown during COVID-19 on breast cancer (BC) care in terms of BC stage at presentation, treatment compliance and delays, and follow-up in a tertiary care center in Lebanon. METHOD(S): This is a retrospective observational study comparing patients with BC who presented to a tertiary care center in Lebanon in the pre-COVID period (Sep 2019-Dec 2019) and during COVID (Sep 2020-Dec 2020). After receiving the IRB approval, we retrieved the charts of BC patients who had their initial presentation, were under treatment or were on follow-up during our period of interest. We extracted data from electronic medical records of patients related to demographic parameters, cause of visit, tumor description, and type of treatment received. Descriptive analysis, as well as multivariate analysis, were done using SPSS. RESULT(S): Out of the 497 patients included, 274 visited the hospital in the pre-COVID period (median age 52.5 years) and 223 patients during COVID (median age 54.7 years). More than half of patients presented for BC screening in the pre-COVID (52%), while 52% came symptomatic during COVID. Almost 54% had advanced BC at presentation in the COVID period compared to 48% pre-COVID but with no statistical significance (p=0.36). During the COVID period, almost 39% of patients had surgery, 79.7% received chemotherapy, and 21.2% received radiotherapy, but with no significant difference between the two periods. Also, no difference was found in the type of surgery done between the two periods. The mean time between the onset of symptoms and biopsy was significantly longer in the COVID period (4.8 +/- 3.5 months) than that in the pre-COVID (3.2 +/- 5.1 months). The mean time between the biopsy and first treatment was not significantly different between the two periods (1.5 +/- 2.2 months versus 2.1+/-3.8 months). For patients who received neoadjuvant chemotherapy, the mean time between the last chemotherapy and surgery was longer in the COVID period (1.9 +/- 1.4 months) than in the pre-COVID period (1.2 +/- 1.1 months). Multivariate analysis showed that age at diagnosis (p=0.014) and time to diagnosis (p=0.01) were significantly associated with the advanced stage of BC. CONCLUSION(S): This study showed that COVID pandemic has resulted in a delay in the initial presentation of patients resulting in more advanced stages at presentation. However, the management of breast cancer was not substantially impacted by the COVID-19 lockdown.

Mucormycosis: Modern diagnostics and treatment, existing problems and new trends in antifungal therapy.

Over the last decade, the introduction of new antifungal drugs and diagnostic procedures has improved the prognosis of hematological patients with invasive fungal disease (IFD), primarily invasive aspergillosis. Despite effective antifungal prophylaxis against the most common IFD caused by Aspergillus spp., rates of IFD due to rare pathogens being resistant to most antifungal drugs, including mucormycosis have been increased. The main group of patients having a high risk of mucormycosis is deeply immunocompromised patients who received chemotherapy for acute leukemia, patients undergoing allogeneic bone marrow transplantation, or treated with corticosteroids for graft-versushost disease. Currently, the urgency of this complication is significantly higher due to COVID-19 pandemic and extensive use of corticosteroids for the treatment of COVID-19. Despite the fact that the criteria for the diagnosis of IFD EORTC/MSG 2008 and 2020 have been developed and implemented into practice in most countries, mucormycosis still remains a difficult-to-diagnose IFD, where the factor of rapid diagnosis is a main factor of treatment success. Medications available for the treatment of IFD include polyenes, triazoles, and echinocandins. For a long time, the drug of choice for the treatment of mucormycosis was liposomal amphotericin B. However, a new effective drug has been approved for the treatment of both mucormycosis and IFD, caused by multiple pathogens - isavuconazole. This review presents new data on the epidemiology of mucormycosis, diagnosis approaches and current international treatment guidelines.Copyright © 2021, Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy. All rights reserved.

New onset chronic spontaneous urticaria post COVID-19 vaccination in South Africa

Background: Chronic spontaneous urticaria (CSU) is a common chronic inflammatory disease. There have been small case series of new onset CSU post COVID-19 infection as well as reports of new onset CSU or worsening of existing CSU post COVID-19 vaccination. Dermatological side effects post COVID-19 vaccine are typically delayed, self-limiting urticaria. We have described the characteristics of patients who have developed new onset CSU post COVID-19 vaccination. Method(s): All patients referred to the UCT Lung Institute Allergy clinic from the initiation of the COVID-19 vaccine roll out (February 2021) were reviewed to identify patients that developed new onset CSU within 12 weeks of receiving a COVID-19 vaccine. Medical history, response to therapy, and available laboratory investigations were reviewed by clinic physicians. Result(s): We identified seven patients that developed CSU post COVID-19 vaccine. The median age of the cohort is 39 (IQR 32-45) and the majority are female (n = 5). The most common vaccine was the Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine (n = 6, 85.7%), and one patient received the Jansen Ad26.COV2.S vaccine. No patients had COVID-19 infection prior to vaccination and only one patient contracted COVID-19 post vaccination. The median time to the development of symptoms post vaccination was 14 days (IQR 2;44) and the median time to diagnosis was 90 days (IQR 45;120). Most patients (n = 4) reported angioedema and urticaria, one patient reported isolated angioedema, and two isolated urticaria. The median initial UAS7 score was 37.5 (IQR 24.5;46) and the initial CU-Q2oL score was 72 (IQR 56;76) indicating severe disease activity. All but one patient had a history of atopy with the most common diagnoses being allergic rhinitis (n = 5) and atopic dermatitis (n = 3). All patients had normal eosinophil counts and over half of the patients (n = 4) had an elevated total IgE level (median 26.4 [IQR 9.8;194]). All patients were HIV negative and one patient had positive Helicobacter pylori serology. All had normal serum protein electrophoresis, thyroid function (with negative thyroid autoantibodies), and negative antinuclear antibodies. All patients started on high dose antihistamine therapy with 71.1% having partial or no response to therapy. Conclusion(s): New onset CSU is a rare side effect of COVID-19 vaccination with poor response to high dose antihistamine therapy. It is important that allergists and physicians are aware of the possibility of new onset CSU post COVID-19 vaccine and further research is needed to identify risk factors.

The impact of COVID-19 on Tuberculosis diagnosis

Introduction: The impact of COVID-19 on the transmission of M. tuberculosis has not yet been accurately ascertained. In addition to the exposure of contacts in household settings, it will be worth considering the impact of respiratory contacts in the community and health care settings, due to the widespread use of masks. Aims and Objectives: We aimed to know if there is an increase in a local hospital TB diagnosis in the postpandemic period and which causes are associated with that increase. Method(s): We collected data from April 2018 to December 2021 and divided it into two 20 months groups - prepandemic (Apr18'-Jan20') and post-pandemic (Mar20'-Dec21'). We analyzed sociodemographic variables, time to diagnosis and type of tuberculosis. Results and Discussion We notified a total of 41 cases after the pandemic started, a 78% increase from the pre-pandemic period (N=23). This increase happened mainly in patients who worked in the primary sector of the economy (agriculture), showing a 4.6x increase in the number of cases (p<0.05) and is probably related to household transmission in low socioeconomic backgrounds. The mean age was 51 years, and most of the patients (78.5%) were male. Time until diagnosis was 102 days (compared to 82 days before). Increased time until diagnosis was independent of any of the variables studied (p>0.05) and happened across all groups. People with>6 months of symptoms were more frequent after Mar20' (8 vs 2). Conclusion(s): The number of cases and the time to diagnosis increased after the onset of the pandemic. The increase was cross-sectional for all groups of patients. The increase in cases occurred mainly in farmworkers, with 40% of post-pandemic cases (and statistical significance) compared to the pre-pandemic period.

Adnexal masses surgery in prepubertal and adolescent girls during COVID-19 pandemic

Study Objective: Global burden on healthcare system by COVID-19 patients had a significant impact on non-COVID diseases treatment.1-3 This study compares the characteristics of adnexal masses surgery in girls and adolescents during the 2020 and 2021 COVID-19 pandemic with the homologous non-COVID-19 period in 2018 and 2019. Design(s): A retrospective observational study using medical records of girls under 19 years of age with surgery of adnexal masses. Patients with neonatal cysts and patients with differences of sex development were excluded from the study. Setting(s): Mother and Child Health Care Institute of Serbia 'Dr Vukan Cupic' (Belgrade, Serbia). The study was approved by the Clinical Research Committee of the Institution. Participant(s): Patients (N=130) who had surgery for adnexal masses, of whom 49 with ovarian torsion. Interventions and Main Outcome Measure(s): Patients were diagnosed in the Institute, but also in other health institutions that referred them for final treatment to the Institute. Surgery was usually performed by gynecologists, and sometimes by pediatric surgeons as urgent abdominal operations. Open or minimally invasive approaches were used, depending on the medical indications, surgeon's experience, and the circumstances related to the organization of work in the COVID-19 period. Results and Discussion: All data of the main outcome measures are shown in Table 1. In the COVID-19 period, the time from the onset of symptoms to diagnosis is statistically significantly longer than in the non-COVID-19 period (t=2,151;p=0,034). In the COVID-19 period, there were statistically significantly fewer adnexal masses surgery than in non-COVID-19 period (chi2=8,892;p=0,003). There was also decrease in number of surgically treated patients with twisted adnexal masses, but without statistical significance. Ovarian preservations in benign adnexal processes were statistically more frequent in the non-COVID-19 period (chi2=6,575;p=0,01). There was increase in percentage of adnexectomies in the COVID-19 period. During the COVID-19 period, the number of laparoscopic procedures decreased significantly, which could be associated with the technical issues and deficit in medical staff during that period (chi2=50,915;p < 0,001). Conclusion(s): Advice on reducing non-necessary visits to the doctor given to patients during the COVID-19 pandemic led to a decrease in number of surgical procedures for adnexal masses in girls and adolescents. This also caused prolonged time to diagnosis, but did not affect the interval from the symptoms onset to operation. Reduction of number of laparoscopic procedures and ovarian preservation in benign adnexal diseases indicates a decline in the quality of health care during COVID-19 pandemic. [Formula presented]Copyright © 2023

New-Onset Chronic Spontaneous Urticaria Post Covid-19 Vaccination in South Africa

INTRODUCTION Chronic spontaneous urticaria (CSU) is a common chronic inflammatory disease. There have been small case series of new onset CSU post-COVID-19 infection and reports of new onset or worsening of existing CSU post COVID-19 vaccination. A dermatological side-effect post COVID-19 vaccine is typically delayed, self-limiting urticaria. We have described the characteristics of patients who have developed new-onset CSU post COVID-19 vaccination. METHOD All patients referred to the Allergy Clinic since the initiation of the COVID-19 vaccine roll-out in South Africa were reviewed to identify patients who had developed new-onset CSU within 12 weeks of receiving a COVID-19 vaccine. Medical history, response to therapy and available laboratory investigations were reviewed by clinic physicians. RESULTS We identified seven patients who developed CSU post COVID-19 vaccination. The median age of the cohort is 39 (IQR 32-45) and the majority are female (n = 5). The most common vaccine was the Pfizer-BioNTech BNT162b2 mRNA COVID-19 vaccine (n = 6;85). The median time to the development of symptoms post-vaccination was 14 days (IQR 2;44) and the median time to diagnosis was 90 days (IQR 45;120). The median initial UAS7 score was 37.5 (IQR 24.5;46) and the initial CU-Q2oL score was 72 (IQR 56;76), which indicated severe disease activity. All but one patient had a history of atopy, with the most common diagnoses being allergic rhinitis (AR) (n = 5) and atopic dermatitis (AD) (n = 3). All the patients had normal eosinophil counts and more than half of the patients (n = 4) had an elevated total IgE level (median 26.4 [IQR 9.8;194]). All of the patients were HIV-negative. All of them had normal serum protein electrophoresis, thyroid function (with negative thyroid autoantibodies) and negative antinuclear antibodies. All of them started on high-dose antihistamine therapy, with 71.1% having partial or no response to the therapy. CONCLUSION New-onset CSU is a rare side-effect of COVID-19 vaccination, with poor response to high-dose antihistamine therapy. It is important that allergists and physicians are aware of the possibility of new-onset CSU post COVID-19 vaccination and further research is needed to identify any risk factors.

Impact of Covid-19 pandemic on care pathways of lungcancer in Longjumeau hospital

Background: Beyond its direct consequences on the morbimortality, COVID-19 pandemic significantly influences themanagement of other chronic diseases, such as lung cancer. Objective(s): To assess the impact of Covid-19 pandemic on hospital care pathways of lung cancer in term of medianwaiting time. Method(s): This is a retrospective, single-center and cross-sectional study, conducted in Longjumeau Hospital. Wecompared the main median waiting times during patients hospital care pathways between the last 22 months beforethe start of the pandemic (from june 1st, 2018 to february 29, 2020) and the first 22 months of COVID-19 pandemic(from march 1st, 2020 to december 31, 2021) in France. Result(s): 152 patients were included in this study. Their mean age was 68.4+/-12.4 years. The male gender was morerepresented (63.8%) with a sex ratio M/F of 1.8. The median diagnosis time was 16 days [IQR,7-26] before versus 15days [IQR,9-28] during the pandemic, p=0.63. The median waiting time to therapeutic decision was 5 days [IQR,2-10.25] before versus 6 days [IQR, 2-14] during the pandemic, p=0.57. Median global time was 35 days [IQR, 25.75- 56] before versus 35.5 days [IQR, 22.75-56.5] during the pandemic, p=0.96. The median first treatment time was 7 days [IQR, 4-7] before versus 5 days [IQR,1-12] during the pandemic, p=0.30. The median care time was 39 days [IQR,26.5-59] before versus 37 days [IQR,23-59.25] during the pandemic, p=0.88. Conclusion(s): This study does not show any significant difference in terms of care pathways of lung cancer between the periods before and the period during the COVID-19 pandemic in LONGJUMEAU hospital. All median waiting times were consistent with international recommendation.

Change in Incidence of Central Precocious Puberty Treated with GnRHa During COVID- 19 Pandemic: Single-center Retrospective Review

Objectives To study the incidence of new central precocious puberty (CPP) patients treated with GnRH agonist (GnRHa) in our Endocrinology clinic during Covid. Findings add to literature pertaining Covid pandemic effects on pediatric endocrine conditions, including CPP. Methods We performed a retrospective comparison of the incidence of newly diagnosed CPP with GnRHa treatment during the Covid pandemic (5/2020-4/2021) and pre-covid (5/2018-4/2019). CPP diagnosis was defined by a random LH >0.3 IU/L, a GnRH stimulated LH >5 IU/L, or a GnRH stimulated estradiol >40 pg/mL. Girls had onset of breast development at < 8 years-old, and boys had testicular size >4 ml at <9 years-old. We compared the number of new Endocrinology visits during the time periods. We evaluated time from diagnosis to GnRHa order, and time from GnRHa order to first day of treatment. We compared bone age (BA) and chronological age (CA), BA/CA and BA-CA between treatment windows. Results During pre-Covid year, 28 children (1 boy, 27 girls) were treated with GnRHa for CPP out of 2340 new Endocrinology visits (1.2% of patients seen). During Covid year, 64 children (7 boys, 57 girls) were treated out of 2261 new visits (2.8%). The incidence of new CPP cases on GnRHa during Covid has more than doubled compared to pre-Covid (p<0.01, Chi Square). There were no significant differences between the groups in age at diagnosis, time between diagnosis and treatment order, time between order and treatment, degree of BA advancement, or BMI (Tables 1-2). CPP incidence was consistent between 26-37 cases/year over the past 4 years prior to Covid. The number of cases per month did not correlate with the peaks of Covid cases (Figure). Conclusions CPP cases requiring GnRHa treatment significantly increased during the first year of Covid compared to pre-covid. There was no delay in presentation or treatment initiation during Covid based on bone age advancement. Preliminary data did not show a significant difference in rate of BA progression, time from diagnosis to onset of treatment, or changes in BMI during covid. Factors influencing a higher incidence of CPP during the pandemic are unclear, and likely multifactorial, including lifestyle changes and direct effects of the virus, potentially contributing to disruption of hormonal pathways. Controlled studies in larger cohorts are required to understand the pathogenic factors contributing to higher incidence of CPP during the pandemic.

Analysis of Diagnostic and Medical Delay Data Among Lung Cancer Patients in 2019 and 2020

Objectives: This study aims to investigate the diagnosis and medical delay among lung cancer patients, furthermore, the involvement of the SARS-CoV-2 pandemic in diagnostic delay. Method(s): The retrospective study was performed in Pulmonology Department at Fejer County University Teaching Hospital in Hungary, between January 1, 2019 and December 31, 2020. We analysed the data of patients with primary lung cancer and changes in the diagnostic and medical delay time (n=102). Descriptive statistical analyses were applied (mean, standard deviation, absolute and relative frequency). Result(s): The average age is 68 years. 44.1% of patients were admitted to the institution from lung care, 12.7% from the emergency department and 43.1% from other providers. The mean diagnostic delay was 89.8+/-47.9 days in the two years. The time from first appointment to the chest CT was 21.42+/-28.08 days. On average, 21.93+/-25.1 days elapsed from CT to bronchoscopy. On average 35.79+/-29.2 days elapsed between oncoteam consultation and initiation of treatment. For those requiring PET/CT, the total diagnostic time increased from 69.7 days to 119.6 days (p<0.001). The total diagnostic time of patients receiving chemotherapy (22.9 days) was significantly lower compared to both patients receiving surgery (50.9 days) and those receiving radiotherapy (101.3 days) (p<0.001). In 2020, the number of primary lung care appointments decreased significantly, from 58% to 31% of all primary care visits, while the proportion of primary appointments in other care settings increased significantly from 2019 to 2020, from 28% to 58% (p=0.008). No significant difference was observed in the mean of the total diagnostic delay times (p=0.273), it was 83.8+/-47.9 days in 2019 and then 94.7+/- 47.8 days. Conclusion(s): Reducing the therapeutic delay - which constitutes a substantial part of the total diagnostic period, is a realistic goal and should be targeted. Copyright © 2022

Systemic Amyloid Light Chain (AL) Amyloidosis Patient Experience Research

Background: There is limited empirical evidence exploring the patient experience and treatment needs in AL-amyloidosis. Many patients experience delays in receiving a diagnosis and research suggests they suffer from a lack of support and information about the condition, worsening the impact of the disease on their quality-of-life. In June 2021 the EMA granted marketing authorisation for daratumumab in combination with bortezomib, cyclophosphamide and dexamethasone (DBCd) to treat adults with newly diagnosed AL-amyloidosis. Previously, patients have been treated with off-label therapies for multiple myeloma. Objective(s): To develop greater understanding of the diagnosis, management of the disease, and impact on patients and carers, in the UK. Method(s): A literature review and focus groups with adults living with AL-amyloidosis and a carer. Group 1 consisted of 3 adults, group 2 of 3 adults plus 1 carer. Groups were semi-structured;discussion topics included the patient journey, impact of disease, and COVID-19. Result(s): Despite delays to diagnosis, ongoing relationships with consultants fostered good communication with patients. In the treatment pathway, patients prioritised extension of life and quality-of-life, even if side-effects from treatment impaired quality-of-life. Participants spoke highly of their healthcare teams and experiences with the National Amyloidosis Centre. Impacts on daily life and emotional well-being tended to be more prominent among patients with a more complex disease pathway. For patients, time to diagnosis, ongoing communication with a trustworthy consultant, treatment outcomes and support was important. Although generally satisfied, suggestions for change across the diagnostic and treatment pathway were recommended. Striving for consistency of care and communication was paramount, and treatment impacts on day-to-day life (e.g., through minimising side-effects and convenient administration) should be prioritised. Conclusion(s): Results have the power to better inform healthcare decisions and the development of specific treatments, prioritising interventions that align with the unmet needs and preferences of people living with AL-amyloidosis. Copyright © 2022

Impact of a Cadaver Lab and Video Content-Based Curriculum on Emergency Physician and Advanced Practice Provider Performance Confidence and Clinical Utilization of Ultrasound-Guided Knee and Ankle Arthrocentesis

Study Objectives: The diagnosis of septic arthritis cannot be ruled out without performing an arthrocentesis. Delay in diagnosis leads to potentially irreversible joint damage and patient mortality. It is essential for emergency physicians (EPs) and advanced practice providers (APPs) to perform this procedure. Ultrasound guidance during arthrocentesis has been shown to reduce procedural pain scores and improve first-pass success rates compared to a landmark-guided approach. However, many providers trained when ultrasound was not readily available and feel uncomfortable recognizing a joint effusion on ultrasound. The study objective was to assess the impact of a hands-on cadaver lab arthrocentesis training on emergency medicine provider confidence in performing knee and ankle ultrasound-guided arthrocentesis and subsequent utilization in clinical practice. Method(s): EPs and APPs from a large academic, quaternary-care hospital prospectively enrolled in a 2-hour cadaver lab ultrasound-guided arthrocentesis training intervention. Didactic video content was created and distributed prior to cadaver lab training. The cadaver knee and ankle joint capsules were pre-injected with saline to create realistic effusions. Participant confidence performing and interpreting US-guided arthrocentesis was assessed pre- and post-cadaver lab via electronic survey based on a 0-10 scale (0=not confident at all, 10=extremely confident). Ultrasound-guided knee and ankle arthrocentesis utilization in clinical practice was compared before and after the cadaver lab which was held on October 4, 2021. The pre- intervention comparison time frame was January 1, 2019-December 31, 2019 to avoid changes in ED visits and practice associated with the COVID-19 pandemic. The post-intervention comparison time frame was October 5, 2021 through April 4, 2022. Median confidence scores with interquartile ranges (IQR) and monthly rates of ultrasound-guided arthrocentesis were calculated and presented with 95% confidence intervals. Result(s): A total of 28 emergency providers participated in the ultrasound-guided arthrocentesis cadaver lab (17 EPs, 10 APPs, 1 unknown) and 28 (100%) completed both pre- and post-intervention surveys. Sixty-one percent (17/28) of participants had greater than 5 years of post-training clinical practice. The median (IQR) confidence rating was 7.5 (IQR 5.0-9.0) pre-intervention and 8.0 (IQR 6.0-9.8) post-intervention (p=.153) for performance of ultrasound-guided knee arthrocentesis and was 2.5 (IQR 1.0-4.3) pre-intervention and 7.0 (IQR 6.0-8.8) post-intervention (p<.001) for performance of ultrasound-guided ankle arthrocentesis. Ultrasound-guided knee arthrocentesis utilization increased from a monthly average of 2.3 (95% CI 1.5-3.3) pre-intervention to 6.3 (95% CI 4.5-8.6) post-intervention, rate ratio 2.74 (95% CI 1.64 - 4.63), p<.001. Ultrasound-guided ankle arthrocentesis utilization increased from a monthly average of 0.8 (95% CI 0.4-1.5) pre-intervention to 2.5 (95% CI 1.4-4.1) post-intervention, rate ratio 3.02 (95% CI 1.27 - 7.53), p=.009. Conclusion(s): Our data demonstrate that a cadaver-based educational intervention increased EP and APP confidence in performing ultrasound-guided ankle arthrocentesis and increased ultrasound-guided ankle and knee arthrocentesis utilization in clinical practice. Further studies are needed to determine if this resulted in a meaningful reduction in time to diagnosis and ED length of stay. No, authors do not have interests to disclose Copyright © 2022

Assessment of interhospital transfers of acute surgical patients within an NHS trust

Acute surgical services at our trust were moved from two sites to a single site, due to CoVID-19. This project was inspired by cases of transfer whereby significant time delays resulted in poorer patient clinical outcome. Aim(s): To assess The times and delays in The transfer of an acute surgical patient at Site A to Site B for either continuing or definitive surgical intervention To assess The risks to patient safety and patient outcomes resulting from transfer To assess whether NCEpoD guidance for urgent surgery were adhered to Methods: * Total transfers were audited over a three month period. The following parameters were recorded: Patient demographics Time patient referred to On call surgical team at Site A Time patient seen by On call surgical team at Site A Times to diagnosis and subsequent decision to transfer Time patient reached Site B Any procedure or operation or higher lever treatment The patient received Length of stay Any complications noted during inpatient stay Results: Total cases of transfer 188 No. cases that went for CEpoD 78 No. of cases for procedures of any sort 99 Complications post/during procedure 37 Deaths 7 Average time from decision to transfer until arrival time at 11:11 Site B Average decision to transfer until procedure time 46:54 Conclusion(s): Interhospital transfer must focus On maintaining optimal Health and outcomes for The patient. A guideline and framework for safe transfers must be implemented and adhered to strictly.

More Than Meets the Eye: A Closer Look at Demyelinating Diseases in Zambia

Background: The number of people with multiple sclerosis (MS) globally has increased from 2.3 million in 2013 to 2.8 million in 2020. However, MS and other demyelinating diseases are reported to be very rare in sub-Saharan Africa. Objective(s): We aimed to describe demographic and clinical characteristics of the first cohort of patients with MS and neuromyelitis optica (NMO) from Zambia and one of the first such cohorts from the sub-Saharan African region. Method(s): Adults diagnosed with either MS, NMO, NMO spectrum disorder (NMOSD), or clinically isolated syndrome (CIS) at the neurology outpatient clinic at the University Teaching Hospital in Lusaka, Zambia, the only neurology clinic in the country, were eligible to participate. Participants were enrolled from October 2019 through February 2022 with significant interruptions due to Covid- 19. An MS-trained nurse administered structured questionnaires regarding sociodemographic characteristics, and each participant also underwent a comprehensive neurological history and examination by a neurologist. Finally, plasma 25-hydroxyvitamin D levels were obtained. For analysis, the cohort was dichotimized into a MS/CIS disease group and NMO/NMOSD disease group. Descriptive statistics of the cohort are presented and compared between both groups. Result(s): Amongst the 34 participants, mean age was 36 + 9 years, 65% (n=22) were female, 90% were Black-African, 10% were of Southeast Asian decent, 50% had MS/CIS, and 50% had NMO/NMOSD. The average age was 34 + 11 years in the MS/CIS group and 37 + 7 years in the NMO/NMOSD group (p=0.28). Females constituted 65% (n=11) of both disease groups. Median time to diagnosis was 242 days (interquartile range IQR: 91-974) and did not differ significantly between the groups. The majority (82%) of the NMO/NMOSD group presented with bilateral optic neuritis. Among the MS/CIS group, median EDSS was 4 (IQR: 2.25-4.25), median Disease Steps were 2 (IQR: 1-2), and 59% (n=10) had an abnormal gait at enrollment. Median 25-hydroxyvitamin D level was 29 (IQR: 24-46) ng/mL in the overall cohort but did not differ by disease group or supplementation status. Conclusion(s): In this sub-Saharan African cohort of adults with demyelinating diseases, MS and NMO were equally prevalent. Furthermore, delays in diagnosis resulted in high levels of disability in both groups. This demonstrates the need for more research and funding towards demyelinating diseases in sub-Saharan Africa.

Impact of the Covid-19 Pandemic in the Diagnosis and Therapy of Single Hepatocellular Carcinoma Less Than 3 Cm in a Western Country

Introduction: The aim of a cancer screening program is to reduce cancerrelated mortality. For that reason patients with liver cirrhosis are enrolled into surveillance through biannual ultrasonography plus AFP to detect single hepatocellular carcinomas (HCC) less than 3 cm, best candidates to apply therapies with curative intent. This study evaluates the impact of the COVID-19 pandemic in the time between detection, diagnosis, and treatment in patients with uninodular HCC < = 3 cm. The secondary objective is to assess the number and sequence of tests needed to achieve the final diagnosis. Aims & Methods: Retrospective inclusion of consecutive patients with final diagnosis of single HCC <= 3 cmat ourcentre. Baseline clinical and analytical variables, date of detection, diagnosis, treatment / entry on the transplant waiting list and the sequence of tests performed (CT, MRI, biopsy) were recorded. Time to diagnosis (period from detection to diagnosis), time to treatment (from diagnosis to date of treatment/entry on the waiting list) and overall time (the sum of the above) were defined. The results were analyzed globally and divided into two periods: pre-COVID (Jan-15 to Feb-2020) and COVID (Mar-20 to the present). Result(s): From Jan 27th2015 to Dec 27th2021, 128 patients of 685 had a final diagnosis of single HCC <= 3 cm, 18% in the pre-COVID era and 22% in the COVID era. Baseline characteristics: median age 64 years old, 84% males, aetiology: alcohol 46%, hepatitis C 39%, fatty liver disease 5%. Child-Pugh class A 86%, BCLC-0 29%, BCLC-A 71%. Median size 20.5 mm, median AFP 5 ng/mL. Only 74% were diagnosed within the screening program. Thermal ablation was applied in 58 patients, liver transplantation in 29, surgical resection in 21 and intraarterial therapy in 16. Twelve patients were left in natural history. Diagnosis was reached by non-invasive criteria (imaging) in 112 patients and by biopsy in 16.The tests performed are shown in the TABLE 1. No statistically significant differences were found in the diagnostic capacity between multiphasic CT (67.6%) and dynamic MRI (73.3%), p-value 0.113. There were no differences in the diagnostic method (imaging versus biopsy) according to the size of the nodule (21.43 mm vs. 21.13 mm), p-value 0.199;nor in the number of studies performed according to the sequence (CT-MR-Biopsy vs MR-CT-Biopsy vs others), p-value 0.746. There were no significant differences neither in the proportion of tumors diagnosed between 10-20 mm and 21-30 mm on the pre-COVID vs COVID era, p-value 0.80, nor in the therapy applied (surgical versus loco-regional, p-value 0.639). Time to diagnosis, time to treatment, and overall time are shown in TABLE 2. Significant differences were found in the time to treatment between the pre-COVID and COVID eras:8 weeks vs 11 weeks, p-value 0.038. Conclusion(s): The COVID pandemic did not affected the proportion of single HCC <=3 cm diagnosed, but it increased the median time from diagnosis to treatment.

COVID-era influence on follow-up trends and the impact on retinovascular disease progression

Purpose : COVID changed follow-up logistics starting 3/2020 in South Texas (STX). The incidence of proliferative retinovascular (RV) events in the emergent setting increased after shut down in STX. We investigate patterns of follow-up behavior in patients with and without proliferative complications of RV diseases. Methods : We used CPT and ICD-10 codes in date range 1/2018 to 4/2021 to include patients diagnosed with diabetic retinopathy (DR) and retinal vein/artery occlusions (RVO/RAO) and analyzed them as two groups: anti-VEGF ± panretinal photocoagulation (PRP) (nonvitrectomy group) vs vitrectomies. We compared before and after COVID-era: appointment intervals and lapses, rate of progression in EDTRS staging for patients with DR. Results : At initial encounter, 2/133/125 patients of 1503 had mild/moderate/severe DR. 40/5 patients had RVO/RAO. There were 429/1074 patients in the vitrectomy/nonvitrectomy group. Vitrectomy group had 123 non-clearing vitreous hemorrhages, 72 tractional retinal detachments, and 189 unclassified proliferative retinovascular complications. Prior to COVID, visit interval was 28.4 ± 43.2 vs 30.8 ± 47.8 days in the vitrectomy vs nonvitrectomy group (p=0.61). After COVID, the interval duration for the vitrectomy group increased to 39.8 ± 76.5 days with no increase in the nonvitrectomy group (p<0.001). Time to diagnosis of EDTRS-staged progression after COVID increased by an average of 21.5 days in the vitrectomy group and by 26.7 days in the nonvitrectomy group. After COVID restrictions, missed appointments in the vitrectomy vs nonvitrectomy group changed from 24.5% to 30.8% vs 28.1% to 33.4%. Across all encounters, the vitrectomy versus nonvitrectomy group had 19.1% vs 21.9% cancellation rate (6.08 vs 5.85 appointments/patient) and 7.81% vs 8.39% no show rate (3.09 vs 2.97 appointments/patient). Overall, patients with DR who experienced EDTRS-staged progression missed 21.2% of appointments (6.8 per patient for those with missed appointments). Conclusions : Patients who required vitrectomy versus those able to be managed in clinic missed appointments in the same proportion and quantity before COVID and increased appointment lapses similarly after COVID restrictions, but interval duration and variability was significantly higher in patients that eventually suffer a complication severe enough to necessitate vitrectomy.

Impact COVID-19 pandemic on lung cancer care from screening to postoperative follow-up

Background: The COVID-19 pandemic has presented various challenges for the healthcare system. This study aims to estimate the impact of the COVID-19 pandemic on Lung Cancer Screening (LCS), Lung Resections (LR), and Outpatient Visits (OPV). Methods: This is a longitudinal quasi-experimental time-series analysis using data from the institutional electronic medical records (EMR) from January 2018 to December 2021, considering the first and second waves of COVID-19 cases in Massachusetts;March, and November 2020, respectively. The main outcomes were (A) Monthly LCS exams, (B) Monthly LR surgeries, (C) Monthly Overall-cancer-OPV. Results: 9,057 LSC exams, 333 LR surgeries, and 5,918 outpatient visits were analyzed. The average patient age that underwent LCS was 64;48.9% were female and 91.4% White. LR was performed in patients 67 years old on average, 67.7% female and 93.6% White. The Overall-cancer-OPV was 58.1% for female patients, 89.4% for White patients, and the overall average patient age was 68 years. The monthly number of LCS (A) presented a statistically significant reduction in the first wave (p = 0.001) with a significant recovery in the following months with a monthly increase rate of 26 exams per month (p = 0.002). The second wave did not represent a sharp reduction in the LCS. Nevertheless, a significant monthly reduction of 44 exams was found. There was no statistical decline for the monthly LR surgeries (B). However, an increase in time from the first visit to the surgery was observed. The COVID-19 surges did not significantly impact the (C) Monthly Overall-cancer-OPV, and it was due to the implementation of telehealth services. The use of telehealth prevented a decline in OPV of 59% (p = 0.001) overall and 40% (p = 0.0190) for cancer. Telehealth visits accounted for 27.7% of cancer-related visits. Female patients were more likely to have a telehealth appointment. White, Black, and Asian patients presented with a similar percentage of telehealth use (26.3%, 25.0%, and 26.8%), while Latinos were less likely to have a telehealth appointment when compared with non-Latinos (18%, p < 0.02). Age was not significantly different between telehealth and non-telehealth appointments. However, for those who preferred a phone appointment, the average age was 67 years old, while for those who used video appointments, the age was 63 (p-value < 0.05). Conclusions: The COVID-19 pandemic affected significantly LCS while lung resections were stable over time;nonetheless, the time from the first visit to surgery increased. The use of telehealth technology allowed patients with cancer to safely receive care throughout the COVID-19 Pandemic. The adoption of telehealth can expand access to care in the pandemic context in low-resource areas. Still, future studies should assess the impact of the COVID-19 pandemic on staging at diagnosis, time to treatment initiation, and survival, especially for the underserved population.

DRIVING IMPROVEMENT in AXIAL SPONDYLOARTHRITIS SERVICES: The USE of QUALITY IMPROVEMENT APPROACHES and TOOLS

Background: Quality Improvement (QI) methods have been used in healthcare since the late 1980s across a wide range of healthcare settings. However, in the UK they have not been applied widely within rheumatology including axial Spon-dyloarthritis (axial SpA). In 2017, the UK healthcare regulator, NICE, produced a national clinical guideline for axial SpA, but there was no mechanism to encourage uptake of its recommendations. The National Axial Spondyloarthritis Society created a programme to use QI approaches to help encourage uptake of the Guidelines and act as a catalyst for wider improvement in axial SpA care. Objectives: To encourage service improvement in axial Spondyloarthritis care through the use of quality improvement theory and methods. Methods: In late 2019 six rheumatology departments were selected to participate in the frst cohort. The programme design was underpinned by: A framework for management grounded in systems theory1 A learning system that brings healthcare organisations together2 A set of tools to develop, test and implement changes: the Model for Improvement3. The teams met four times for training in QI methods, plus team-based online coaching. They had time to develop their projects and networking opportunities to share their data and experiences of implementation. We conducted a qualitative review of the programme in year one. We interviewed 31 programme participants and reviewed programme documentation. Results: The review found that: A proven QI framework provides a strong basis to build improvement A competitive programme helps foster motivation and accountability The programme provides the time to use tools to understand the problem and construct improvement aims Measurement is key to understand improvement and to create a story of change Collaboration and engagement is key within the team and with other stakeholders. The teams have: • Trained community-based physiotherapists, leading to improved rheumatology referrals Implemented an infammatory back pain pathway from primary care Introduced an MRI spine IBP protocol to reduce variation in imaging Established a tertiary referral service which has improved time to diagnosis Implemented mental health interventions for patients and reduced the percentage of patients with abnormal scores Established a pathway for physiotherapy self-referral and reduced Did Not Attend rates Used audit to make the business case for an extended scope practitioner Conclusion: Despite the challenges of posed by the Covid-19 pandemic, a structured QI programme has enabled clinicians to stay engaged and implement projects to reduce diagnostic delay and improve care.

MALAYSIA SPONDYLARTHRITIS ACCELERATED MANAGEMENT (SAM) MODEL: EXPEDITING AXSPA PATIENT JOURNEY from EARLY REFERRAL, DIAGNOSIS and ACCESS to OPTIMAL CARE

Background: Axial spondyloarthritis (axSpA) is an important cause of infam-matory back pain (IBP). It is under-recognized, leading to signifcant delays in diagnosis. Early recognition and diagnosis are crucial to achieve the best outcomes for patients and in Malaysia, signifcant gaps in the clinical management of axSpA remain. Therefore, we sought to implement a strategy to improve the time to diagnosis and management of axSpA in Malaysia by collaborating and adopting guidance from an international axSpA expert. Objectives: The objectives were to improve disease recognition among healthcare practitioners (HCPs), reducing time to specialist referral and diagnosis whilst improving disease management by developing and implementing a new patient care model called the Spondyloarthritis Accelerated Management (SAM) and measure its effectiveness in 3 Rheumatology centers in Malaysia. Methods: The SAM initiative was developed by the Malaysian SpA Consortium Working Group involving 8 Malaysian rheumatologists from 3 local centers and 1 international axSpA expert from the UK as part of the steering committee. Selections were based on clinical expertise. The frst local alignment meeting on model structure was held in July 2020 with subsequent meetings held to address key barriers to early axSpA diagnosis and timely access to quality care. A care model with feasible key performance indicators (KPIs) was established, adapted and tracked monthly in the 3 rheumatology centers (Figure 1). Referral tools were developed to facilitate early referrals to rheumatologists. These included a QR-coded '3-R' referral guide1 and a patient self-screening tool with a patient self-referral letter all hosted on the Malaysian Society of Rheumatology (MSR) website, educational talks to HCPs and public awareness forums on IBP and axSpA. Data were collected on referral source, duration of referrals, knowledge on IBP in HCPs by surveys and imaging accessibility at baseline and at 1 year after the initiative was launched. Baseline data collected were from August to October 2020 and 1 year data were from November 2020 to November 2021. Results: At 1 year, the SAM initiative showed a 44.4% (Median: 1.33 [IQR 1-1.7] vs 1.92 [IQR 1.6-2.1]) increase in IBP referrals, a reducing trend from 9.5 (IQR 8-11.1) to 5.9 (IQR 5.1-6.8) weeks of waiting time to a frst Rheumatology visit and an increase of 37.2% (34% vs 71%) in IBP patients who were seen at the rheumatology clinic within 6 weeks. All patients with IBP had X-rays (sacroiliac joints or pelvis). MRI requests in X-ray negative patients suspected of axSpA was increased by 13.9% (77.8% vs 91.7%) and waiting time for MRI was reduced by 3.1 weeks (12 vs 8.9 weeks). The IBP knowledge among 224 HCPs improved by 40.6% (45.7% vs 86.3%). The number of patients newly diagnosed with axSpA increased by 40% (Median: 5 [IQR 4-9.5] vs 7 [IQR 6.5-7]) despite the COVID-19 pandemic. Conclusion: The SAM initiative has shown promising initial results in improving referrals of patients with IBP, promoting earlier diagnosis and establishing the importance of having timely access to optimal care. A nationwide implementation is being planned to improve the recognition of the axSpA in Malaysia.