Determinants of domestic violence against women: Evidence from Khulna District of Bangladesh

Domestic violence against women is a major social problem in Bangladesh. This paper examines the determinants of domestic violence in Bangladesh during the COVID-19 pandemic. The project was carried out in selected areas of Khulna district of the country and followed survey research design. A total of 312 ever married female respondents who experienced domestic violence at any stage of their life were surveyed. The respondents were selected through simple random sampling as a semi-structured questionnaire/ interview schedules was used as the primary tool for data collection. The data were collected in two stages between the months of May-October, 2021 through face-to-face interviews. Results from the chi-square analysis show that, respondents' residence, educational status, age at first marriage, duration of marriage life, husband's income, husband's occupation, and a demand for dowry were all associated with domestic violence against women (p <.01). The study concludes that creation of awareness and empowerment of women through income generating activities particularly in the rural areas of Bangladesh is necessary to reduce the prevalence of domestic violence.Copyright © Nova Science Publishers, Inc.

Thyroid Eye Disease Following COVID-19 Infection in a Patient with a History of Graves' Disease

Introduction: Autoimmune and inflammatory thyroid diseases have been reported following SARS-CoV-2 infection or vaccination, but thyroid eye disease (TED) post-COVID-19 infection is less common. We describe a case of TED following SAR-CoV-2 infection in a patient with a history of Graves' disease. Case Description: A 59-year-old female with history of Graves' disease status post radioiodine ablation therapy in 2002. She developed post-ablative hypothyroidism which has been stable on levothyroxine 88 mcg daily. In January 2021, the patient's husband and daughter were diagnosed with COVID-19 infection. A few days later, the patient developed an upper respiratory tract infection associated with loss of sense of smell and taste consistent with COVID-19 infection. Three days later, she developed bilateral watery eyes which progressed to eye redness, eyelid fullness, retraction, and pain with eye movement over 1-month duration. Her eye examination was significant for severe periocular soft tissue swelling, lagophthalmos and bilateral exophthalmos. The laboratory workup was consistent with normal TSH 0.388 mIU/L (0.358-3.740 mIU/L) and positive TSI 1.01 (0.0-0.55). The patient was referred to an Ophthalmologist for evaluation of TED. He noted bilateral exophthalmos, no restrictive ocular dysmotility or compressive optic neuropathy (clinical activity score 4/7 points). CT scan of orbit showed findings compatible with thyroid orbitopathy. Based on clinical activity score of 4, treatment with Teprotumumab was recommended pending insurance approval. Discussion(s): Many cases of new-onset Graves' hyperthyroidism have been reported after COVID-19, with only a few associated with TED. Our patient has been in remission for 20 years before she developed COVID-19 infection with occurence of TED.This suggests that COVID-19 infection may have played a role. SARS-CoV-2 may act through several mechanisms, including breakdown of central and peripheral tolerance, molecular mimicry between viral and self-antigens, stimulation of inflammasome with release of type I interferon. In our patient, treatment with Teprotumumab was indicated due to Graves' orbitopathy clinical activity score greater than or equal to 3. In conclusion, it is very uncommon for TED to present after COVID-19 infection. Our case reinforces the speculative hypothesis that SARS-CoV-2 virus could have triggered an autoimmune response against eye antigens. There is a need for increased awareness about the link between COVID-19 and autoimmunity to help better define the management of patients.Copyright © 2023

Born or not: A moderated mediation model of the relationship between work-family conflict and female employees' wellbeing based on fertility intention during the COVID-19 pandemic.

The previous academic research on work-family conflict mainly focused on the relevant elements in the work field. This study concludes that elements of the family domain have a significant impact on the relationship between work-family conflict and employee wellbeing. Female employees' perceptions of wellbeing largely depend on their willingness to have children when they take on family roles. During COVID-19, employees had more time to fulfill both work and family roles in the family sphere due to the epidemic blockade, the contribution of the female employee's significant other (husband) in family matters had a significant impact on Fertility intention. This study using SPSS 24.0 AMOS 20.0 and M plus 7.4 statistical analysis tools to test the proposed hypotheses. In the paired data of 412 working female employees and husbands of Chinese dual-earner families with different occupational backgrounds, hypothesis testing results support that female employees' work → family conflict is negatively related to female employees' fertility intentions, and female employees' fertility intentions are positively related to wellbeing; female employees' family → work conflict is negatively related to female employees' wellbeing; husband's flexible work stress is negatively related to husband's share of housework; husband's share of housework moderated the front, rear and overall mediating effects by the fertility intention. When formulating policies, the managers should consider not only the direct effects of policies, but also the indirect effects that policies may have on other family members of employees. Managers should develop management policies during an epidemic that are more responsive to the actual needs of employees during an epidemic. The management of female employees should give due consideration to the family status of female employees and the enterprises should recognize the importance of childcare for female employees.

Factors associated with the willingness to receive COVID-19 vaccination among pregnant women

Pregnant women are a vulnerable group to be infected by COVID-19, and have a higher risk of serious illness, morbidity, and mortality than the general population. Willingness to receive COVID-19 vaccination has a decisive role in successfully controlling the COVID-19 pandemic. The objective of this study was to determine the factors related to the willingness to get COVID-19 vaccination in pregnant women at the Teluknaga Public Health Center. A total of 102 pregnant women with gestational ages of 13 to 33 weeks were selected by convenience sampling. Data were collected by filling out a questionnaire during November to December 2021. All respondents had a health status that meets the requirements for COVID-19 vaccination. Overall, 63% of pregnant women wanted to receive COVID-19 vaccination. There were significant relationships between education (p=0.029), frequency of antenatal care (p=0.019), husband's support (p<0.001) and willingness to receive vaccination. Religion, occupation, knowledge about COVID-19, parity, frequency of antenatal care visits, and sources of information did not show significant relationships with the willingness to receive COVID-19 vaccination among them. Education and awareness campaigns about the safety of the COVID-19 vaccine for pregnant women and the role of health workers are needed to raise awareness. © 2023, Intelektual Pustaka Media Utama. All rights reserved.

The importance of husband support for breastfeeding during pandemic COVID-19

Introduction: Unachieved exclusive breastfeeding is still a problem in Indonesia. During pandemic covid-19 situation, the condition required to keep the distance from other people resulting the limited access between breastfeeding mothers and midwives. The role of the closest person that is husband is needed to constantly provide support. The objective of this research is to determine the relationship between husband's support during the covid-19 pandemic with exclusive breastfeeding.Methods: The type of research used is an analytic survey with a cross sectional method. The total population are 51 people and the sample of 45 people is taken using purposive sampling technique. Collecting data using questionnaire sheets given to respondents. Data analysis using Chi Square test (X2).Results: Based on analysis, we found that husband's support has a significant association with the quality of exclusive breastfeeding with p=0.000.Conclusion: The result of the research informed husbands who want to provide support in the form of effective communication between husband and wife during the breastfeeding process, able to help breastfeeding mothers to keep the spirit of breastfeeding, and will help provide breast milk as the best food for their babies. There is a significant relationship between husband's support in the success of exclusive breastfeeding during the covid-19 pandemic.

BLUE FINGERS, EOSINOPHILIC LUNGS: ACUTE EOSINOPHILIC PNEUMONIA FOLLOWING COVID-19 INFECTION

SESSION TITLE: Unique Inflammatory and Autoimmune Complications of COVID-19 Infections SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Acute eosinophilic pneumonia is a rare illness characterized by eosinophilic infiltration of the lung parenchyma. Cases often present with fever, severe dyspnea, bilateral infiltrates, and eosinophilia on BAL exams. The cause of eosinophilic pneumonia is unknown, but is thought to be related to inhalational exposure of an irritant or toxin. Most cases are responsive to steroid treatment. This case demonstrates acute eosinophilic pneumonia in a patient who recently recovered from COVID-19 pneumonia. CASE PRESENTATION: A 50 year old female with a history of multiple sclerosis, seizure disorder secondary to MS, Irritable Bowel Syndrome, and a distant history of tobacco smoking and opiate dependence on chronic suboxone therapy, presented with dyspnea secondary to respiratory failure. The patient was urged to present by her husband after findings of hypoxia to 79% on room air with cyanosis of the lips and fingers. She recently recovered from COVID-19 1 month prior, at which time she had symptoms of cough productive of red mucus, fever, and exhaustion;but states she never returned to her baseline. With ongoing hypoxia, the patient was intubated for mechanical ventilation. Subsequent bronchoscopy with BAL resulted in a elevated eosinophil count to 76%, with fungal elements and PCR positive for HSV-1. The patient was initiated on high dose glucocorticoid therapy in addition to Acyclovir and Voriconazole. A CT with IV contrast revealed extensive bilateral pulmonary emboli involving the segmental and subsegmental branches throughout both lungs and extension into the right pulmonary artery;the patient was started on anticoagulation. Shortly after beginning glucocorticoid therapy, the patient had significant improvement and was able to be weaned off ventilation to simple nasal cannula. She was able to be safely discharged home with two liters of supplemental oxygen and steroid taper. DISCUSSION: Acute Eosinophilic pneumonia is a rare condition with an unknown acute disease process. The diagnostic criteria for acute eosinophilic pneumonia includes: a duration of febrile illness less than one month, hypoxia with an SpO2 <90%, diffuse pulmonary opacities, and otherwise absence of inciting causes of pulmonary eosinophilia (including asthma, atopic disease, or infection). Diagnosis of eosinophilic pneumonia is attained after meeting clinical criteria with a BAL sample demonstrating an eosinophilia differential of >25%. The mainstay of treatment for this condition is glucocorticoid therapy with most cases resolving rapidly after treatment. CONCLUSIONS: Fewer than 200 cases of acute eosinophilic pneumonia have been reported in medical literature. It is imperative to keep a wide differential as critical illness may be rapidly improved with appropriate therapy. The cause of acute eosinophilic pneumonia is largely unknown, it is unclear what role COVID-19 may have played in the development of this pneumonia. Reference #1: Allen J. Acute eosinophilic pneumonia. Semin Respir Crit Care Med. 2006 Apr;27(2):142-7. doi: 10.1055/s-2006-939517. PMID: 16612765. Reference #2: Nakagome K, Nagata M. Possible Mechanisms of Eosinophil Accumulation in Eosinophilic Pneumonia. Biomolecules. 2020 Apr 21;10(4):638. doi: 10.3390/biom10040638. PMID: 32326200;PMCID: PMC7226607. Reference #3: Yuzo Suzuki, Takafumi Suda, Eosinophilic pneumonia: A review of the previous literature, causes, diagnosis, and management, Allergology International, Volume 68, Issue 4, 2019, Pages 413-419, ISSN 1323-8930 DISCLOSURES: No relevant relationships by Tayler Acton No relevant relationships by Calli Bertschy No relevant relationships by Stewart Caskey No relevant relationships by Shekhar Ghamande No relevant relationships by Tyler Houston No relevant relationships by Zenia Sattar No relevant relationships by Heather Villarreal

I never leave the house and keep both phones in my pockets all day so that whichever phone you ring, I never miss your call

Introduction: I will never forget the tightness in my throat and the pressure rising in my chest when I heard those words spoken by the husband of an ICU survivor. How ashamed I felt that despite all we do to alleviate the suffering of our patients, sometimes we create new suffering for those left at home. Main Body: Restricted visiting during the pandemic has created unprecedented challenges for patients, staff, and families. Not able to rely on family visits to communicate news and to help families appreciate any change in the condition of their loved ones, we have had to develop new ways of working. The consultants enthusiastically rallying juniors into daily telephone updates, emailed messages read to patients by nursing staff, pictures on the walls of a hospital room, and wrestling with technology to bring families together in one room via video call. Despite all the energy and innovation, I am sure I'm not the only person who has found themselves thinking that perhaps the call to update the wife/father/daughter of our patient can wait. They had an update yesterday;maybe someone else can speak to them later. This phone call, one of several to ICU survivors and their families, was the first time I had fully understood the reality for the loved ones of so many of our patients. They are barred from the hospital due to covid restrictions, struggling to build a picture of their loved one from the snatches of information given down a phone, desperate for news. Since this conversation, I am incredibly mindful of the responsibility to care for families as well as our patients. Even if they aren't with their loved ones in person, we have an opportunity to include them in the journey. Maybe we remember to share the big things, but sometimes the small things are the ones that matter most: a shave, the music on the radio, ice cream with their lunch. Each member of the ICU team has a different story to share, and it's these human connections this patient's husband was waiting for by the phone. Conclusion: As we slowly arrive at “the new normal” we might be relieved to see the end of some of our pandemic practices. However, I will never forget the lesson this man taught me. I will use my privileged position to make painful times perhaps a little more bearable for the families and friends of those we treat.

A CLASSIC CASE OF CREUTZFELDT-JAKOB DISEASE (CJD)

CASE: A 64-year-old woman was brought in by husband for inability to care for patient. Previously active, she developed gait instability, slurred speech, and memory lapse to the point of selective mutism and being bed-bound within three months. Her medical history was notable for hypertension and Covid four months prior. She had had mild upper respiratory symptoms and recovered in ten days. Examination revealed general encephalopathy, dysarthria, limited ability to follow commands. She had decreased strength but increased tone and rigidity in all extremities. She had rhythmic jaw movement and bradykinesia with scatter myoclonic movements. Cerebellar exam was notable for ataxia, but she had normal cranial nerve and sensory exams and normal reflexes. MRI of the brain revealed restricted diffusion and T2/Flair signal abnormality involving bilateral basal ganglia, ventral medial thalami, hippocampi, and cerebral cortices. Toxic metabolic workup was unrevealing. CSF was positive for 14-3-3 protein and elevated total tau protein, confirming Creutzfeldt-Jakob disease. IMPACT/DISCUSSION: Creutzfeldt-Jakob Disease (CJD) is a prion disease with one in a million prevalence. Patients present with rapidly progressing dementia, myoclonus, and signs of cerebellar, corticospinal and extrapyramidal involvement including nystagmus, ataxia, hyperreflexia, spasticity, hypokinesia, bradykinesia, dystonia, and rigidity. CJD is fatal within months to two years. Patients with end stage disease may have akinetic mutism. Magnetic resonance imaging (MRI), electroencephalogram (EEG), and cerebrospinal fluid (CSF) analysis are important for evaluation of CJD. Most sensitive in early stages, MRI Brain commonly shows hyperintense signal involving the cerebral cortex, corpus striatum, caudate, and putamen. EEG may capture pattern of periodic bi-or triphasic period sharp wave complexes. CSF might detect 14-3-3 protein with elevation of tau protein but real-time quaking-induced conversion (RT-QuIC) has the highest specificity for diagnosis for CJD. Though brain biopsy is the sole method of definitive diagnosis, results of MRI, EEG, and CSF analysis along with presenting signs and symptoms are sufficient for clinical diagnosis of CJD. Our patient's dementia, myoclonus, ataxia, hypokinesia, bradykinesia, dystonia, and rigidity all progressing to akinetic mutism within three months are classic presentation of CJD. EEG was normal, but MRI with hyperintensity of basal ganglia and cerebral cortices and CSF analysis with positive 14-3-3 and elevated tau proteins are all lead to diagnosis of CJD. CONCLUSION: This case illustrates a classic case of a Creutzfeldt-Jakob Disease, a rare prion disease marked by rapidly progressive dementia with neuropsychiatric features.

OCULOMOTOR NERVE PALSY FOLLOWING COVID-19 INFECTION

CASE: Patient is a 60-year-old woman who works at a local hospital in billing department. She has a history of rheumatic fever, non ST elevation MI, osteoarthritis, Crohn's disease. Her husband was diagnosed with COVID-19 infection in November 2020. A Week later, patient developed myalgias, diarrhea and subsequent testing confirmed COVID-19 infection. Overall, her symptoms were mild and required no treatment or hospitalization. Six weeks following the infection she woke up one morning with diplopia and a large left pupil. She tried to manage this by covering one eye initially, but later visited with a neurologist, ophthalmologist, neuro-ophthalmologist. She was found to have fixed, dilated left pupil and horizontal diplopia with some diagonal component. There were no other neurological signs or meningismus. Laboratory tests showed hemoglobin of 12.5, White cell count 5.7, platelets 405. Electrolytes, kidney function, liver function tests were normal. ACH receptor antibodies were negative. Imaging studies included a negative CTA head, negative brain MRI, face, orbits and optic nerves. She was diagnosed with left third cranial nerve palsy possibly as a complication of COVID-19 infection. She was prescribed oral prednisone 60 mg with a slow taper. Her pupil size and vision gradually improved over the ensuing weeks and the recovery of the third cranial nerve was nearly complete. IMPACT/DISCUSSION: The third cranial nerve supplies the levator muscle of the eyelid, medial rectus, superior rectus, inferior rectus, and inferior oblique;constricts the pupil through its parasympathetic fibers. Patients with oculomotor cranial nerve palsy develop diplopia and droopy eyelid. Etiology for third cranial nerve palsy include many pathologies such as a structural lesion, infectious or inflammatory conditions, cerebrovascular disease and trauma. Our patient developed acute 3rd cranial nerve palsy 6 weeks following the COVID-19 infection. The workup was negative for any structural lesions, CVA or other known causes. This raised the possibility that her symptoms are possibly complications of COVID-19 infection. Neurological complications of COVID-19 infection have been well documented. These include encephalopathy, stroke, dysgeusia and anosmia. There were two case reports of oculomotor nerve palsy that occurred during the acute phase of COVID-19 infection. These were thought to be from direct invasion of the virus. Our patient however, had developed symptoms 6 weeks following the infection raising the possibility of immune mediated complication. She made near complete recovery with oral glucocorticoid treatment. However, it is not known whether the improvement is the result of the treatment. CONCLUSION: 1. Oculomotor cranial nerve palsy is potentially associated with COVID-19 infection. 2. Oculomotor cranial nerve palsy could present several weeks after the acute COVID-19 infection. 3. In patients presenting with 3rd cranial nerve palsy, it is important to obtain the history of past COVID-19 infection.

COMPLICATED COMMUNICATIONS DURING THE PANDEMIC

CASE: The Pandemic has been one of the greatest challenges in health care. Communication is the most vital part of the patient visit. The pandemic hindered the doctor-patient communiciation in unimaginable ways. Besides using Televisits with its new set of challenges, I present these clinic visits with complicated communication. Case 1-Deaf mute patient 45 year male deaf mute with chronic kidney disease stage 3a with hypertension and med "non compliance." The interpreter used Americal sign language along with lip reading. Lip reading is hindered by the standard mask. This interpreter used a special type of lip tranparent mask. We discovered that the patient was confused regarding the BP medications attributing to his non compliance. Repeat BP check at 1 and 3 months was at goal after he understood the instructions. Other patients also found the lip transparent mask to be useful when they had hearing deficit or English accent problem and relied on lip reading for communication. Case 2-Grieving 42 year old Spanish only speaking lady just lost her husband to COVID. She herself was recovering from COVID and was grieving. Computer based interpreter was used along with social distancing and shield and mask. This made comforting the patient challenging. Case 3-Computer based interpreters A 28 year female patient speaking only Amharric had breast pain. I used computer based interpreter with audio only option and kept the video off, especially during the physical examination. 89 year Vietnamese only speaking male had multi organ failure. I had to use the computer based interpreter to explain the situation to him and family and offer them hospice. Hospice concept was totally new to them. They were committed to caring for him at home and felt that hospice was an intrusion that God did not want and was not culturally acceptable. Today they are happy with home hospice care. Case 4-Intellectually challenged patients-Cerebral palsy 40 year aphasic male with cerebral palsy came with his host caregiver. Patient had open sores on his neck that he had been scratching. He was cooperative but was pulling at his mask and was unable to understand my simple instructions through my mask and shield. IMPACT/DISCUSSION: Clear communication is a key to a good clinic visit and patient and provider satisfaction. Low English proficiency (LEP) is a road block that we try to overcome by using interpreters. This vignette is an excellent demonstration of challenges to communication that we encountered during the pandemic. Publication here will give an opportunity to identify with our struggles, exchange ideas and help our trainees. CONCLUSION: Wearing mask and social distancing saved countless lives during the COVID pandemic.It presented unprecendented challenges to doctor-patient communication. It is important to anticipate, understand and educate our learners about these challenges and continue to provide culturally competant care.

Self-Management of Fear due to the Covid-19 Pandemic and the Changes it has brought to the Every Day Life

Introduction: The recent pandemic of the new coronavirus, COVID-19, has had financial and social repercussions apart from its consequences to the physical and mental health of humans. Aim: The aim of this work was to study the way of the self-management of stress and fear which has been caused by the pandemic crisis, as well as the impact of the pandemic on daily living. More specifically, the factors which influenced the management of the symptoms of fear, either in a positive or in a negative way, were studied, and also the ways individuals and their families use to manage fear. Method: The method which was used was the case study of an adult female who lives and works in a Greek town, during the third curfew, in March 2021. The tool which was used for data collection was the semistructured interview, by utilizing a questionnaire consisting of 10 open-ended questions. Before the start of the interview, a signed informed consent form was obtained. The questions were divided into three topic areas, with the first concerning the demonstration of stress before the pandemic broke out, the second concerning the fear during the pandemic, and the third dealing with the ways of managing fear, the availability of persons capable of helping, as well as the kind of help she could have sought to cope with this situation. Results: The results of this study showed the impact of the curfew restrictions for the management of the pandemic on the daily lives of the people who experience them. Before the start of the pandemic, stress was primarily related to work and to the need of maintaining a routine. Public fear intensified during the pandemic and the lockdown, both in relation to work and in relation to the pandemic itself, and also in relation to its effects on work and social life, and certainly on physical and mental health. Her stress affected the rest of her family members;however, her social network proved to be a significant support. Conclusions: Stress and fear increased during the pandemic and the lockdown which was imposed in Greece in order to prevent the spread of COVID-19. This stress, which prior to the pandemic was focused mainly on work-related issues, spread to other areas of daily life, a fact that affected all the family members. Discussions and support from the husband, and also from the wider circle of family and friends, helped deal with and manage the situation which was caused by the pandemic, due to the special living conditions which were in force.

Emergency Peripartum Hysterectomy in a Tertiary Care Centre of North India during COVID-19 Pandemic: A Retrospective Study

Introduction: The pandemic of Coronavirus Disease 2019 (COVID-19) had a significant impact on obstetric surgeries. Obstetric surgical procedures during the COVID-19 pandemic affect individuals who are suspected or proven to be high-risk endeavors. Aim: To evaluate the demographic characteristics, indications, intraoperative and postoperative complications, and foetomaternal outcomes in the women who had an Emergency Peripartum Hysterectomy (EPH) during the first and second waves of the COVID-19 at a tertiary care centre in North India. Materials and Methods: This was a retrospective cohort study, conducted in the Department of Obstetrics and Gynaecology at a tertiary care centre in Uttar Pradesh, India, including women who underwent EPH operated from March 2020 to May 2021 in terms of demographic characteristics, indications, intraoperative and postoperative complications, and foetomaternal outcomes. Information about their self-reported health issues due to traumatic birth (when they came for a follow-up visit at five weeks) were also obtained. Simple frequency, percentage, and proportion were calculated using descriptive statistics. Results: A total number of 1827 deliveries were conducted and out them 11 cases underwent emergency peripartum hysterectomy at our institute during the time frame of the COVID-19 pandemic. All of the patients were in their 20s or 30s, with ages ranging from 21 to 34. All of these were unplanned pregnancies and arrived at various gestational ages. Eight cases had the previous scarring on the uterus, with six women having morbidly adhered placenta. All of the women in the study cohort were unbooked, and 72.73 % (eight out of 11) of them were referred to our centre because they had high-risk factors. Due to substantial blood loss, five females required Critical Care Unit (CCU) support. The study sample had a poor newborn outcome, with three early neonatal deaths out of 11 deliveries. As a part of their 5th-week follow-up, after the women had been stabilized and discharged from the ICU, they were asked to share their major issues related to health, psychological status and social interaction. The main worries revolved around the newborn child's and COVID-19 positive husband's health. Pregnant women who delivered during the COVID-19 pandemic had a significant rate of postpartum depression and Post-traumatic Stress Disorder (PTSD). Conclusion: The predominant cause of EPH in the study population was a morbidly adherent placenta. It is critical to protect women's physical and psychological health during traumatic childbirth in order to mitigate the pandemic's already-existing harmful impacts.

Mezile’s Model (Back Massage and Self-Hypnosis) Based on Information and Technology to Lose the Anxiety of Postpartum Mothers in COVID-19 Pandemic Era

BACKGROUND: The roles of husbands to keep the psychological condition of pregnant and postpartum mothers are low. Many husbands could not perform full attention and support during the pregnancy, delivery, and postpartum period. Heretofore, the researchers do not find studies that include the roles of the husband from antenatal until postnatal care during the COVID-19 pandemic. AIM: This research aims to create Mezile’s model in the form of back massage and self-hypnosis based on information and technology with adequate design and effective implementation to lose the anxiety of postpartum mothers. This model also involved husbands taking the role from the antenatal until postnatal care. METHODS: This research and development used a true experimental design with pre-and post-test control group design. The researchers used simple random sampling. The subjects consisted of 50 participants in the experimental group and 50 participants in the control group. The experimental group received the intervention with self-hypnosis training, while the husbands of the experimental group received back massage training. The husbands in the control group received only back massage training. The intervention lasted from the 2nd until the 15th day after normal delivery. Then, mothers with post-section cesarean received the training on the 8th until the 21st day. The researchers used Wilcoxon and Mann–Whitney tests. RESULTS: Mezile’s model refers to back massage and self-hypnosis based on information and technology. It was reliable as the holistic-based education media to apply effective management to lose anxiety (p = 0.03), higher than the control group. CONCLUSION: Mezile’s model, back massage, and self-hypnosis, based on information and technology, are reliable for obstetric care education based on holistic nature during pregnancy and postpartum. The implementation was effective in managing the anxiety of postpartum mothers in the control group.

The Relationship Between Husband Support and Behavior of Pregnant Teenagers to Face Pregnancy During the Covid-19 Pandemic in Gombong, Kebumen, Indonesia

Background: Age influences pregnancy and childbirth. Pregnant women aged less than 20 years old or pregnant adolescents are not physically and mentally ready to cope with pregnancy or childbirth. The husband's support highly determines the health status of the mother. This research aimed to determine the relationship between husband support and the behavior of pregnant adolescents to face pregnancy during the COVID-19 pandemic in the Gombong District, Kebumen Regency. Methods: This study used a cross-sectional approach. The population was all pregnant women aged less than 20 years in the Gombong District, Kebumen Regency. It used a saturated sampling technique involving 256 people. Data were analyzed using univariate and bivariate analysis to answer the percentage and the Chi-Square test to answer the research hypothesis. Results: The study showed that 130 (50.8%) husbands did not support the mothers, and 126 (49.2%) husbands supported the mothers. The result also showed that 116 (45.3%) of the pregnant women showed positive behavior, while140 (54.7%) pregnant women showed negative behavior. The chi-square test found a p-value of 0.005, which proved a significant relationship between the husband's support and the behavior of pregnant adolescents to overcome pregnancy during the covid-19 pandemic. Conclusion: Pregnant teenagers with husband support will prepare for pregnancy and childbirth programs more maturely to ensure the safety of both mother and fetus.

The Relationship between Demographic Factors and Levels of Self-Care Against Coronavirus in Pregnant Women Referred to Maternity Wards

Introduction: The adverse effects of coronavirus infection on pregnant women and their infants are not apparent. The best strategies to deal with this disease is avoiding the infection and preventing its transmission. Objectives: the present study aimed to investigate the relationship between demographic factors and levels of self-care against coronavirus in pregnant women referred to maternity wards of Kerman, Iran. Methods: The present descriptive study was conducted on 200 pregnant women who referred to maternity wards in Kerman, Iran in 2020 and met the inclusion criteria. The required information was collected using demographic questionnaires and a self-care checklist. Results: The mean age of the participants was 28.89 ± 7.07. Iranian and Afghan citizens comprised 82% and 18% of the participants, respectively. The highest level of self-care measures against coronavirus in pregnant women was attributed to the use of face masks (74%), and the lowest was warning the personnel to wear masks (28%). There was a statistically significant relationship between the nationality of the participants and warning the personnel to wear face masks (P = 0.02), the pregnant mothers' attention to wearing a scarf or cap during labor with the mothers' occupation (P = 0.006), having a sick spouse (P = 0.039), and having a sick child (P = 0.043), and between the patients' husbands' job and the patients' demand for a private room (P = 0.013). Conclusion: The results indicated that most pregnant women in the present study were active in self-care against coronavirus. Using face masks was more widely followed than other self-care measures;moreover, there was a relationship between personal characteristics and self-care levels.

Terminal transplant failure due to Covid-19 associated nephrotic glomerulonephritis

Background: Covid 19 infection associated glomerulopathy has most often been described as collapsing FSGS and occurs almost exclusively in black patients carrying APOL1 risk genotypes. Methods: We report an acute, COVID19-associated nephrotic glome-rulonephritis in a caucasian transplant recipient which led to terminal graft failure. Results: This 67 y old white female had received a living donor kidney 31 years ago for medullary cystic disease. Her clinical course on cyclos-porin/MMF had been stable with an eGFR around 20 ml/min/1.73 m in the last years. On her 31st annual checkup, she presented with an unusually high blood pressure (171/108), but afebrile (36.9°C), with an eGFR or 21 ml/min/1.73 m, a protein/creatinine ratio (PCR) of 503 mg/mmol and normal serum albumin. Physical examination was unremarkable except for some pain from thoracic herpes zoster 2 months previously. Her husband had tested positive for Covid19 on the same morning. She developed fever (38.9 °C) and cough on the same evening and tested positive for Covid19 the next day. MMF was paused and low dose steroids were instituted. In the following weeks, full nephrotic syndrome developed (edema, PCR of 1350 mg/mmol, serum albumin ↓ to 28 g/l). eGFR decreased to 8-10 ml/min/1.73 m. Renal biopsy on day 42 showed several instances of focal segmental sclerosis with collapsing morphology (Figure 1, consistent with "collapsing glomerulopathy"). In addition there were signs of capsular proliferation and electron dense deposits in the GBM, consistent with glome-rulonephritis. Sequencing of Exon 6 of the APOL1 gene was negative for G1 and G2 risk alleles in the patient and her kidney donor. Nephrotic syndrome never remitted, and renal function did not recover. Peritoneal dialysis was initiated 9 months after the Covid 19 infection. Figure 2: Self-rated health status over time Conclusions: Higher mortality in older recipients complies with data from the general population. The non-linear relationship between age and graft loss and the higher scored self-rated health status at all follow-up time-points compared to the pre-transplant status-regardless of age-highlight that age alone might not be an accurate measure for risk prediction and clinical decision making in kidney transplantation. Exploring other independent predictors, such as frailty as an indicator for biological age should be considered. Conclusions: This case documents an unusal Covid19-associated glo-merulonephritis with "collapsing features" which led to the loss of a 31 years functioning living donor kidney.

Phase I Study of Novel SYK Inhibitor TAK-659 in Combination with R-CHOP for Front-Line Treatment of High Risk Diffuse Large B-Cell Lymphoma

Background: DLBCL is highly heterogeneous in underlying biology and clinical behavior. Several high-risk disease features and poor prognostic factors are associated with a higher propensity for refractory disease or relapse after standard R-CHOP therapy;these subset patients require novel strategies to improve upon outcomes. Single-agent TAK-659, a novel oral SYK inhibitor, has demonstrated efficacy in heavily pre-treated DLBCL (Gordon et al., Clin Cancer Res, 2020). We report results of a phase I single institution, single arm dose escalation study that assessed safety of 1 st line treatment with R-CHOP and adjunctive TAK-659 for treatment naïve high-risk DLBCL. Methods: Patients aged ≥18 years, ECOG 0-2 with untreated stage I-IV DLBCL with high-risk features defined as, ABC/non-GCB subtype, high-intermediate or high-risk NCCN-IPI (score ≥4), MYC gene rearranged by FISH including double hit lymphoma (DHL), double expressing DLBCL (DEL;overexpression of MYC ≥40% AND BCL2 ≥50% by IHC respectively), or previously treated transformed low-grade lymphoma without prior exposure to anthracycline, were eligible. Patients were treated with R-CHOP for 1 cycle on or off study followed by combined treatment with R-CHOP and TAK-659 for an additional 5 cycles on study. TAK-659 was dosed daily with dosing escalated from 60mg (dose level 1), to 80mg (dose level 2) to 100mg (dose level 3) based on a 3+3 design. The primary objective was to determine the safety and establish the maximum tolerated dose of TAK-659 when combined with R-CHOP in the front-line treatment of high-risk DLBCL. Secondary objectives were to assess preliminary efficacy of this combination as determined by overall response rate (ORR) by PET-CT (Lugano 2014 criteria), progression free survival (PFS), overall survival (OS) and establish the pharmacokinetics of TAK-659 according to dose. Results: 12 pts were enrolled from Dec 2019 to Nov 2021. The median age was 64 yrs (range 25-75);8 (67%) had stage III/IV disease, 4 (33%) with high risk NCCN-IPI ≥ 4. Histology included 7 (58%) with de novo DLBCL (4 GCB, 3 non-GCB subtype DLBCL) including 7 (58%) with DEL, 3 (25%) with transformed FL, 1 (8%) with Richter's and 1 (8%) with DHL. Dose level 3 (100 mg) was established as the MTD. PKs were measured pre- and post-dose D1 and D15 of cycle 2;Cuzick's test signaled an increase in AUC by dose level on D1 (p = 0.01) but not on D15 (Fig 1). ORR was 100% (CR 92%;Fig 2). With a median follow-up of 14.2 months, 1 pt had primary refractory disease (ABC and DEL), 2 pts with CR subsequently progressed (1 non-GC DLBCL, 1 Richter's) and 1 died of cardiogenic shock unrelated to study drug. The 12-month PFS and OS rates were 82% and 90% respectively with estimated 18-month PFS and OS rates of 68% and 90% respectively. The most common treatment related adverse events (TRAEs) attributed to TAK-659 were lymphopenia (n=12, 100%), infection (6=, 50%), AST elevation (n = 12, 100%) and ALT elevation (n = 10, 83%) (Table). Incidence and severity of transaminitis was consistent with prior reports for this agent. Most common grade 3/4 toxicities were hematologic. Median number of cycles of TAK-659 delivered was 5 (range 3-5). TRAEs led to TAK-659 dose modifications in 8 (67%) pts, though none at dose level 1: 2 (17%) required permanent dose reductions (both for lung infections), while 5 (42%) required discontinuation (4 for infection, and 1 for febrile neutropenia). R-CHOP administration was delayed in 2 pts because of TAK-659 related TRAEs. Aside from dose modifications of vincristine for peripheral neuropathy, no additional dose modifications for R-CHOP were needed. Infections encountered included bacterial and opportunistic infections (1 each for PJP, CMV and aspergillosis) and 1 case of COVID. Growth factor prophylaxis and anti-fungal therapy were not mandated;PJP prophylaxis was advised for CD4 counts < 200 at initial diagnosis. Conclusion: TAK-659, a novel SYK inhibitor combined with R-CHOP in pts with newly diagnosed high-risk DLBCL including DLBCL transformed from follic lar lymphoma and DEL produces high CR rates;survival at 12 months appears promising. A dose of 60 mg was well tolerated, did not require dose modifications and maintained a similar AUC to the MTD of 100 mg with ongoing treatment. Opportunistic infections were noted with this treatment combination suggesting that patients should receive aggressive anti-microbial prophylaxis with future evaluation of this combination. [Formula presented] Disclosures: Karmali: BeiGene: Consultancy, Speakers Bureau;Morphosys: Consultancy, Speakers Bureau;Kite, a Gilead Company: Consultancy, Research Funding, Speakers Bureau;Takeda: Research Funding;Karyopharm: Consultancy;EUSA: Consultancy;Janssen/Pharmacyclics: Consultancy;AstraZeneca: Speakers Bureau;BMS/Celgene/Juno: Consultancy, Research Funding;Genentech: Consultancy;Epizyme: Consultancy;Roche: Consultancy. Ma: Beigene: Research Funding, Speakers Bureau;Juno: Research Funding;AstraZeneca: Honoraria, Research Funding, Speakers Bureau;Loxo: Research Funding;Janssen: Research Funding, Speakers Bureau;Abbvie: Honoraria, Research Funding;TG Therapeutics: Research Funding;Pharmacyclics: Research Funding, Speakers Bureau. Winter: BMS: Other: Husband: Data and Safety Monitoring Board;Agios: Other: Husband: Consultancy;Actinium Pharma: Consultancy;Janssen: Other: Husband: Consultancy;Epizyme: Other: Husband: Data and Safety Monitoring Board;Gilead: Other: Husband: Consultancy;Ariad/Takeda: Other: Husband: Data and Safety Monitoring Board;Karyopharm (Curio Science): Honoraria;Merck: Consultancy, Honoraria, Research Funding;Novartis: Other: Husband: Consultancy, Data and Safety Monitoring Board. Gordon: Zylem Biosciences: Patents & Royalties: Patents, No royalties;Bristol Myers Squibb: Honoraria, Research Funding. OffLabel Disclosure: TAK-659 will be discussed for the treatment of DLBCL (not FDA approved for this indication)

Pre-hospital care for a patient with moderate severity of COVID-19

Patient 60 years old, a teacher working from home, got infected from her husband. The husband was an asymptomatic. Symptoms were loss of taste and smell, fever, weakness, nausea, vomiting, diarrhea, blurred vision. Hemodynamic parameters-BP 90/60 mm Hg, HR-99 bpm. Her regular HR was 55-60 bpm. Due to the overloading of hospitals, there was a queue for hospitalization at home. She was receiving the treatment of a family doctor. On the 9th day, her condition became worst. CT-scan picture showed 20% of lung lesions. Hemodynamic parameters were-BP 80/50 mm Hg, HR-115 beats. Due to of progressive dehydration, the high temperature lasted for 12 days. In anamnesis she has a drug allergy, chronic hypertension with left anterior bundle branch block because of suffering with rheumatic heart disease from the childhood. Any kind of liquid per oral caused immediate nausea and vomiting. Saturation was 74. We had to start i/v therapy at home in order to stop severe dehydration and high fever. Mobile oxygen delivery devices were used to monitor saturation. With that treatment during the day, the saturation indicator was 92. But at night, when the saturation went down below 86, the device, by means of an audible alert, gave a signal to connect oxygen. BP dropped to 70/50 mm Hg, HR-120 bpm. The patient also received factor XA inhibitor, antibiotic therapy, antiviral therapy, vitamins C and D. After these measures, she felt better, but could not take liquid on her own, as it still caused nausea. On the 14th day, a place was vacated in one of the hospitals and she was hospitalized. In the hospital, she spent another 10 days, the hemodynamics returned to normal and the second CT-scan showed 5% of the lungs damage. She was discharged of her own free will. For 1.5 months after that, she still felt severe weakness and was unable to work.

A case of granulomatosis with polyangiitis complicated by COVID-19: Challenges in diagnosis and management

Case report-IntroductionGranulomatosis with Polyangiitis (GPA) is a rare small-to medium-vessel vasculitis associated with anti-neutrophil cytoplasmic autoantibody (ANCA). Its multi-systemic features include pulmonary, ear, nose, and throat (ENT), renal, and neurological manifestations. Its incidence is estimated to be 10.2 cases per million population. It is challenging to diagnose when its symptoms are treated in isolation from one another. This case highlights the difficulty in diagnosing GPA in a patient with respiratory symptoms during the Coronavirus Disease 2019 (COVID-19) pandemic and describes the challenges of managing it in the context of a subsequent COVID-19 infection as the mainstay of treatment remains immunosuppression.Case report-Case descriptionA 78-year-old female non-smoker with a history of leg ulcers developed a 3-month history of cough and haemoptysis and was treated in primary care for suspected sinus and chest infections. She then presented to Accident and Emergency twice for the same symptoms and was discharged after having her antibiotics changed.2 weeks later, she presented for the third time with cough, ongoing haemoptysis, conjunctivitis in the right eye, pain over the right side of her head, and discharge from her right ear. She was admitted as she was pyrexical, tachycardic and her CRP was 60. COVID-19 swabs were negative. ENT team recommended IV ceftriaxone and metronidazole for suspected orbital cellulitis. Blood cultures remained negative. CT sinuses with contrast showed right sided thrombosis of transverse sinus and bilateral mastoid effusion of the middle ear. Following neurology review, she was anticoagulated with dalteparin. A day later, she was transferred to the Respiratory ward and dropped her Haemoglobin level to 70. Her chest radiograph showed diffuse alveolar haemorrhage and CT images showed widespread bilateral peri-hilar consolidation.A rheumatology opinion was sought and vasculitic screen showed ANCA 268, and PR3 >177. Her urinary protein/creatinine ratio was elevated at 90. Rheumatology team confirmed multi-systemic GPA and recommended starting oral Prednisolone 60 mg daily. After the renal team was consulted, she was moved to a side-room and started on IV Methylprednisolone (pulsed with three doses), along with cyclophosphamide and rituximab. Dalteparin was discontinued.2 days later, she desaturated, and became pyrexical. Repeat COVID-19 swabs were positive.Three Consultants agreed that Plasma Exchange and Non-Invasive Ventilation (NIV) would be inappropriate. A Do Not Attempt Resuscitation form was signed, and prognosis was discussed with the patient and her 78-year-old husband who requested to visit. Patient deteriorated and unfortunately died 6 days later.Case report-DiscussionThis case is interesting because it highlights the diagnostic challenge of GPA. Retrospectively, it may be noted that doctors persisted in treating suspected infection although the patient continued to deteriorate. However, a diagnosis should be re-considered if the patient does not respond to treatment and it is important to consider vasculitis as a cause of haemoptysis.Anticoagulation was started since the benefits were considered to outweigh the risks as her haemoptysis was of small volume. The patient soon developed pulmonary haemorrhage, so the risks of anticoagulation should not be underestimated in vasculitis.The Rheumatology team's cautious approach to immunosuppression was in stark contrast to the renal team's aggressive approach. The Renal team believed that concerns about protecting the patient from COVID-19 when she was negative from this infection should not take precedence over appropriate immunosuppression from a potentially fatal vasculitis.The patient was admitted at the start of the COVID-19 pandemic and was negative for COVID-19 on admission. She was nursed in a bay on the Respiratory ward where she later became COVID-19 positive. This raises questions about whether the earlier test was a false negative result or whether her infection was hospital-acquired. Infection cont ol guidelines were changing rapidly at the start of the COVID-19 pandemic.The decision to avoid plasma exchange was based on the findings of the PEXIVAS trial. NIV was avoided as it required a full-face mask to minimize particle dispersion but would pose an asphyxiation risk as patient was coughing up blood.Finally, the team learnt to be flexible in these extraordinary circumstances when dealing with the end-of-life decisions of the COVID-19 positive patient. Although her husband was a vulnerable person because of his age, he was given the opportunity to visit while wearing Personal Protective Equipment and agreed to self-isolate for two weeks.Case report-Key learning pointsThis case helped me appreciate the complexity of deciding to immunosuppress an already severely ill patient in the context of the COVID-19 pandemic. I recognised that the patient had a poor prognosis with or without immunosuppression and our role as healthcare professionals was to give her the best chance of recovery. The conference will allow me to interact with other colleagues and discuss what they would do in this situation as our Rheumatology and Renal teams had different approaches.After further reading on false negative results, we found that Johns Hopkins researchers found that testing people for SARS-CoV2 too early in the course of infection is likely to result in a false negative test even though they may eventually test positive for the virus.I have also learnt about the PEXIVAS trial which found that the addition of plasma exchange to standard therapy does not reduce the risk for all-cause mortality among patients with severe ANCA-associated vasculitis. Moreover, a reduced-dose regimen of glucocorticoids is non-inferior to a standard-dose protocol, while reducing the risk for serious infections.Diffuse alveolar haemorrhage (DAH) is not treatable with arterial embolization or bronchoscopic methods due to the diffuse nature of the bleeding. Extracorporeal membrane oxygenation (ECMO) has been used to support patients with DAH but the use of ECMO is controversial due to the need for anticoagulation.The conference will help me deepen my understanding of epidemic rheumatology which will be useful for my clinical practice going forward, especially if there is a second wave of the COVID-19 pandemic. I am keen to use this event to engage with other clinicians on immunosuppression in the context of infection so that I may confidently manage similarly complex cases in the future.