Significant reduction in the incidence of non-coronavirus infections in patients with chronic lymphocytic leukemia on ibrutinib and venetoclax treatment during the COVID-19 pandemic: An additional benefit of lockdown.

Effective treatment and prevention of infections challenge management of patients with chronic lymphicytic leukemia (CLL). The COVID-19 pandemic resulted in the reduction of outpatient hospital visits as a part of non-pharmaceutical interventions that could affect the incidence of infectious complications. Study enrolled patients with CLL receiving ibrutinib or/and venetoclax who were observed at the Moscow City Centre of Hematology from 01 April 2017 to 31 March 2021. We found a reduction in the incidence of infectious episodes after the implementation of the lockdown in Moscow in 01 April 2020, when compared to data on the year prior to the lockdown (p < 0.0001), as well as when compared to the predictive model (p = 0.02), and based on individual infection profiles using cumulative sums (p < 0.0001). Bacterial infections had 4.44-fold decrease, bacterial in combination with undefined infections had 4.89-fold decrease, viral infections had unsignificant changes. The decrease in the number of outpatient visits coincides with the time of the lockdown could be a likely factor, explaining a decline in the incidence of infection. Patients were clustered according incidence and severity of infectious episodes for subgroup mortality assessment. No differences in overall survival due to COVID-19 were observed. Typical respiratory infections, bacterial and undefined, the transmission of which may be affected by patient-to-patient contact in the settings of out-patient health care visits were decreased, possibly due to SARS-CoV-2 restrictive measures. A positive correlation between outpatient visits and the incidence of bronchial and upper respiratory tract infection points at the role of hospital-acquired infection and attests to the necessity of reorganizing care for all patients with CLL.

Pulmonary rehabilitation outcome in patients recovering from COVID-19 disease

In patients who have recovered from COVID-19, the functional impairment and prolonged symptoms of dyspnea, cough, weakness and fatigue can persist for a long period. The aim of this study was to evaluate functional capacity, respiratory muscle and hangrip strenght, pulmonary function tests and pulmonary rehabilitation outcome in patients recovering from COVID-19 disease. Study included patients recovering from COVID-19 diasese who attended standard in-person pulmonary rehabilitation program (PRP) five days a week, for three weeks. Patients were recruited during six months period, mainly treated on an outpatient basis for acute COVID-19 disease without previously recorded lung disease, and the reason for referral to PRP was dyspnea and exercise intolerance. Pulmonary function testing (spirometry, diffusing lung capacity for carbon monoxide, body pletysmography), maximum static inspiratory pressure (Pi max), maximum static expiratory pressure (Pe max), 6-minute walking test (6MWT) and handgrip musle strength were performed. There where 87 patients (40 male and 47 female), with mean age of 52,3 years. Average results of pulmonary function tests and Pe max prior to PRP showed no limitations, with reduced Pi max (73 cmH2O, 68%) and 6MWT distance (435m, 77%). There were statistically significant difference in 6MWT distance, Pi max and Pe max, hand grip muscle strength prior and after PRP (p<0.05). Patients in our study had exercise intolerance and decreased inspiratory muscle strength prior PRP with significant improvement after PRP. Our study shows that pulmonary rehabilitation is effective and important in patients recovering from COVID-19 disease.

Teledermatology triage models: redesigning the concept of outpatient referral

A total triage model for dermatology outpatient referrals has become increasingly important following the COVID-19 pandemic, both to ensure prioritization of outpatient appointments and to provide digital advice based on teledermatology images to support patients on long outpatient waiting lists. Digital specialist advice can support general practitioners (GPs) to commence appropriate treatment before or instead of a face-to-face review for selected patients. In England, the National Health Service (NHS) e-referral service (e-RS) offers two distinct triage channels: the referral assessment service (RAS) channel, and the advice and guidance (A&G) channel. In this study we compared the quantitative and qualitative impact of the RAS and A&G channels on non-2-week wait patient referrals in a large teaching hospital dermatology department between October and December 2021. Teledermatology images were encouraged with all referrals and all GPs had access to the Consultant Connect © secure clinical image app to allow use of personal mobile phones for image capture. In total, 984 patient 'referrals' were sent to the dermatology department through the RAS channel and 642 patient 'advice +/- referral' requests were sent through the A&G channel. Ninety-four per cent of patients referred through the RAS channel were added to an elective care waiting list with a waiting time of several months and no interim advice as RAS does not allow consultants to provide interim advice in e-RS. Only 6% of patient RAS referrals were returned with advice. In contrast 73% of patients sent through the A&G channel were managed with digital advice within 2 working days, and 27% of A&G requests were converted to referral with interim advice for the GP to help manage the patient while on the waiting list. The A&G channel of the NHS e-RS was converted into an advice, guidance and referral channel in February 2021 to support elective care recovery. By allowing two-way dialogue, A&G supports shared decision-making between GP and consultant, regardless of whether the patient is added to a waiting list or not. This new A&G functionality is helping to redesign the concept of 'outpatient referral', moving away from a refer/accept/reject model towards a model of 'specialist input and dialogue' and educational exchange. The A&G model is supported by the 'Getting It Right First Time' (GIRFT) Dermatology programme, and the Dermatology National Outpatient Transformation Programme, promoting equitable patient access to digital specialist advice using teledermatology.

Teledermatology reduces waiting times for skin cancer diagnosis

Teledermatology triages large volumes of general practitioner (GP) referrals for suspicious lesions to outpatient services. A commercial, National Health Service (NHS) compliant teledermatology service was supported and evaluated in 12 GP practices during the COVID-19 pandemic. Images from a GP were transferred for review by a dermatology consultant via a mobile phone, a customized dermatoscope, mobile application and web platform. This platform, untested in the UK, showed benefits to both patients and GP services in reducing waiting times for dermatology diagnosis. Between January 2020 and May 2021, a mixed-method evaluation assessed whether this teledermatology platform was fit for purpose, provided benefits to patients and primary care, and reduced unnecessary referrals to secondary care. Data sources were surveys, patient questionnaires, informant interviews and NHS activity. Activity outcomes during teledermatology implementation were compared to those expected in the original pathway (no teledermatology). Avoided face-to-face activity was used as a surrogate assessment to estimate economic impact. Successful implementation across GP practices diverted patients away from the urgent 2-week wait outpatient appointment straight to biopsy, if necessary. This reduced waiting times from between 10 and 47 days to < 1 day between GP referral and lesion review. Eighty-eight per cent of referrals using teledermatology were associated with avoided face-to-face appointments. Most patients (92%) welcomed the ease, simplicity, speed of diagnosis and follow-up information, finding the new pathway 'excellent' and 'quick'. Some previously treated patients were less happy with photographing their lesion vs. those not previously treated (85% vs. 92%). Some patients still prefer to see a consultant dermatologist. Professionals reported patients were receptive, but not all understood the remote management of their skin lesion. Staff across GP practices found teledermatology worked well, but greater familiarity would normalize use. Technical issues were resolved promptly by the supplier;however, local NHS provider teledermatology configuration requires careful consideration. Pathway adaptions included use of eConsult to triage patient images to an advanced nurse practitioner-led skin clinic, creating additional efficiencies. Images were used at secondary care multidisciplinary team meetings to agree treatment plans. Inexperienced GPs had an opportunity to improve their diagnostic skills. However, teledermatology does not offer the opportunity for a full body scan. An estimated 63% reduction in future outpatient appointments was predicted from the results of this teledermatology. Future economic assessment of teledermatology vs. the benefits achieved, especially avoidance of unnecessary dermatologist consultations, would validate these estimated avoided appointment numbers. Teledermatology had a positive impact on patients and NHS services.

The effectiveness of telepsychiatry: thematic review.

AIMS AND METHOD: This review aims to clarify the evidence on the effectiveness of telepsychiatry following the COVID-19 pandemic. We conducted a literature review of three databases (Cochrane Library, PubMed and PsycINFO), using the terms virtual consultation/telepsychiatry/video consultation AND psychiatry/mental illness. RESULTS: We identified 325 eligible papers and conducted a thematic analysis resulting in five themes: patient and clinical satisfaction, diagnostic reliability, outcomes, technology and professional guidance. The most significant factors linked to effectiveness of telepsychiatry were patient and clinician satisfaction and adequate technology to facilitate examination of the patient. CLINICAL IMPLICATIONS: The consistent diagnostic reliability, satisfactory clinical outcomes and patient satisfaction linked to telepsychiatry favour its continued use once the pandemic ends. The main barrier is reluctance among clinicians and lack of professional guidance. We recommend education on the uses of telepsychiatry among clinicians, and the provision of professional guidance for its use from medical bodies and organisations.

Coronary calcium score in COVID-19 survivors: Association with cardiac injury and cardiac function after 6 weeks.

Aims: Cardiac manifestations are common in COVID-19, often elevated serum troponin levels or myocardial dysfunction on trans-thoracic echocardiography (TTE) is observed. Both parameters are associated with increased in-hospital mortality. Possibly, subclinical coronary atherosclerosis plays a role, of which severity can be assessed by calculating the coronary artery calcium (CAC) score. This study aims to determine the relation between coronary atherosclerosis and cardiac manifestations in COVID-19 survivors. Methods: This study was conducted at the Leiden University Medical Center. All patients admitted for COVID-19 were included and scheduled for a 6-week follow-up visit with trans-thoracic echocardiography (TTE). CAC was assessed according to an ordinal score on non-gated, non-contrast enhanced computed tomography of the chest. Patients with and without CAC were compared on cardiac injury as reflected by elevated serum troponin levels and impaired cardiac function assessed through TTE. Results: In total, 146 patients were included. Mean age was 62 years and 62 % of the patients were male. During admission, patients with CAC showed significantly higher levels of troponin (19 ng/L vs 10 ng/L; p < 0.01). Overall, mild echocardiographic abnormalities were seen; 12 % showed reduced left ventricular function (left ventricular ejection fraction of <50 %) and 14 % reduced right ventricular function (tricuspid annular planar systolic excursion ≤17 mm). Following multivariable adjustments, there was no significant relation between CAC and myocardial function at 6 weeks. Conclusion: The present study shows that coronary atherosclerosis is associated with cardiac injury in COVID-19 survivors. However, no significant relation with impaired cardiac function was demonstrated.

Methodology for designing intrahospital transportation of patients with suspected infectious disease that limits infection spread risk in China.

Aims: The transport of patients suspected of having COVID-19 requires careful consideration. Using paths selected at random and not accounting for person flow along the path are risk factors for infection spread. Intrahospital transportation (IHT) protocols and guidelines should be used to help reduce the risk of secondary virus transmission during transport. This study aimed to propose optimal IHT for patients with an infectious disease presenting in an out-patient area. Design: The map of a West China Hospital was used. We also used field investigation findings and simulated person flow to establish pathway length and transportation time. We identified three optimum pathways and estimated safety boundary marks, including a patient transportation border (PTB) and safety transportation border (STB). Finally, IHT, PTB, and STP formed a virtual transport pipeline (VTP) and a traceable IHT management system, which can generate a virtual isolation space. Results: The three pathways met efficiency, accessibility, and by-stander flow criteria. No facility characteristic modification was required. Conclusions: Using virtual models to identify pathways through out-patient hospital areas may help reduce the risk of infection spread.

Remote Delivery of Service: A Survey of Occupational Therapists' Perceptions.

Background: Telehealth has been declared an accepted method of occupational therapy (OT) service delivery and has been shown to be effective. However, studies done before the outbreak of coronavirus disease (COVID-19) show that most occupational therapists didn't use it. Aim: The aim of this exploratory study was to examine the perceptions of occupational therapists regarding remote delivery of service following the COVID-19 outbreak. Material and methods: An online survey, including 11-item five-point Likert scale, and 2 open-ended questions were distributed to occupational therapists. Results: Responses were received from 245 Israeli occupational therapists. The majority of the participants (60%) strongly agreed that remote delivery allows an ecological and effective intervention, while 76% strongly agreed that an ideal treatment is one that would combine telehealth with in-person intervention. Qualitative findings indicated that the most significant advantage was providing care in the natural environment and improving accessibility to the service. The most salient barriers were limitations of the therapeutic relationship and threats on clinical reasoning. Conclusion: The study results highlight the complexity of telehealth. Findings indicate that overall occupational therapists perceive remote care as an effective and legitimate service delivery method that cannot be used as an alternative to in-person treatment. These findings can help in developing intervention programs for remote treatment, and their implementation.

[The analysis of opinions of pediatricians about organization and perspectives of development of primary medical sanitary care of children].

The analysis of opinions of district pediatricians about state and perspectives of development of primary medical sanitary care for children in the Kabardino-Balkarian Republic permitted to obtain competent assessment of quality of polyclinic medical care. The positive tendencies in activities of children polyclinics were established. However, the problem of achieving higher quality of medical care of children continues to be actual. According to survey results, character and direction of organizational managerial decision making concerning improvement of material and technical equipment of children polyclinics in accordance with modern requirements (37.6%), elimination of defects in organization of free medication support (63.6%), improvement of organization of free nutrition supply of children (50%), etc. Among the priority tasks of pediatric service is the solution of the medical personnel issue and full staffing of pediatric districts with physicians (66.7%), paramedical personnel (29.6%) and medical specialists (61.7%), as well as the need to include in staff of the polyclinic positions of child psychologist (54.0%) and social worker (31.5%). One of the main problems of primary medical sanitary care of modern pediatric service remains high work overload of district pediatricians that which undoubtedly impacts quality of medical and preventive activities. The low readiness of district pediatricians to active acceptance of innovative transformations in functioning of children polyclinic, requiring psychological readjustment of medical personnel is established. This was most strikingly manifested by process of implementing information technologies and the National project "Lean Polyclinic". All issues identified by sociological survey significantly strained during coronavirus pandemic in 2020. The pandemic inputted its own adjustments in medical care support of children in the region. Despite the fact that disease did not affect children to large extent, due to prolonged absence of physicians suffering from coronavirus, quality of dynamic monitoring and treatment of children suffered. Factually, no dispensarization activities were implemented and prevention measures as well. The results of survey contributes to the formation of monitoring of quality of out-patient care of children at the regional level and makes the research data highly relevant.

Transitions from intensive eating disorder treatment settings: qualitative investigation of the experiences and needs of adults with anorexia nervosa and their carers.

BACKGROUND: Relapse rates for individuals with anorexia nervosa after intensive hospital treatment (in-patient or full-time day care) are high. Better knowledge about the difficulties and opportunities that arise during this transition is needed to identify factors that support or hinder continued recovery upon discharge. AIMS: The aim of this study was to explore the experiences of adult patients and their chosen carers on the process of transitioning from intensive eating disorder treatment settings to the community. METHOD: Semi-structured interviews were conducted with patients with anorexia nervosa (n = 11) discharged from day or in-patient care from specialised eating disorder units across the UK, and their chosen carers (n = 20). Data were analysed with inductive thematic analysis. RESULTS: Four interrelated themes were identified for both groups. For patients, themes were continuity of care, ambivalence about continued recovery, the value of social support and a call for enhanced transition support. For carers, themes were the impact of the eating disorder on themselves and the family, perceptions of recovery and support post-discharge, the impact of previous treatment and care experiences, and desire to create a supportive transition process. CONCLUSIONS: The study provides an insight into the unique challenges that individuals with anorexia nervosa face upon leaving intensive treatment. A lack of post-discharge planning, support system and identity formation outside of anorexia nervosa were perceived as barriers to continued recovery. Patients and carers advocated for transition support that incorporates a phased, inclusive approach with accessible professional and social support in the community.

Suicide among users of mental health and addiction services in the first 10 months of the COVID-19 pandemic: observational study using national registry data.

Although many studies have reported no rise in suicides in the general population following the COVID-19 pandemic, little is known regarding mental health and substance misuse service patients, groups who have reportedly faced substantial reductions in their access to care during phases of lockdown. However, in this observational study using national registry data, during the first 10 months of the pandemic we found no evidence of an increased risk among people in recent (within 12 months) contact with secondary care. Both long-term and differential effects on subgroups remain to be studied.

Changes in the identification and management of mental health and domestic abuse among pregnant women during the COVID-19 lockdown: regression discontinuity study.

BACKGROUND: Domestic violence and abuse (DVA) and mental illness during pregnancy have long-lasting and potentially serious consequences, which may have been exacerbated during the COVID-19 pandemic. AIMS: To investigate how the UK COVID-19 lockdown policy influenced the identification of DVA and depressive symptoms during pregnancy in health services in South-East London in Spring 2020, using eLIXIR (Early-Life Data Cross-Linkage in Research) maternity and mental routine healthcare data. METHOD: We used a regression discontinuity approach, with a quasi-experimental study design, to analyse the effect of the transition into and out of the COVID-19 lockdown on the rates of positive depression screens, DVA recorded in maternity and secondary mental health services, and contact with secondary mental health services during pregnancy. RESULTS: We analysed 26 447 pregnancies from 1 October 2018 to 29 August 2020. The rate of DVA recorded in maternity services was low throughout the period (<0.5%). Within secondary mental health services, rates of DVA dropped by 78% (adjusted odds ratio 0.219, P = 0.012) during lockdown, remaining low after lockdown. The rate of women screening positive for depression increased by 40% (adjusted odds ratio 1.40, P = 0.023), but returned to baseline after lockdown lifted. CONCLUSIONS: Rates of DVA identification in secondary mental health services dropped during and after lockdown, whereas overall rates of DVA identified in maternity services were concerningly low. Healthcare services must adopt guidance to facilitate safe enquiry, particularly in remote consultations. Further research is vital to address the longer-term impact on women's mental health caused by the increase in depression during the lockdown.

Experiences of care for self-harm in the emergency department: the perspectives of patients, carers and practitioners.

Emergency departments are often the point of entry to the healthcare system for people who self-harm, and these individuals are at high risk of further self-harm and suicide in the post-discharge period. These settings therefore provide a critical opportunity for intervention. However, many studies have identified that the experiences of patients, carers and the emergency department staff themselves is often suboptimal. In this editorial we summarise one such study, by O'Keeffe and colleagues, and consider strategies for improving the experiences of patients and their carers when presenting to the emergency department. We also reiterate the need for wider systemic change in attitudes and approaches towards people who self-harm that are pervasive across the healthcare system and beyond.

Service evaluation of the impact of implementing a novel physiotherapy band 5 mixed research and clinical rotation

Keywords: Clinical Academic;Impact;Workforce Purpose: Research active healthcare organisations have improved patient outcomes compared to their non-research active counterparts (Hanney et al., 2013). To increase this activity there are growing opportunities for physiotherapists to be involved in clinical research. However, there are few roles that include time for that research (Westwood et al., 2018). Further, there are fewer opportunities for band 5 clinicians to gain research experience to foster research awareness. To impact the research awareness and clinical practice of our Band 5 rotational physiotherapists, a mixed research and clinical musculoskeletal rotation was implemented at a London Healthcare Trust. The objective of this service evaluation was to evaluate whether the rotation impacted the activity of these clinicians. Methods: The full time rotation was structured with 2 days research activity alongside 3 days clinical activity within musculoskeletal outpatients. Two band 5 physiotherapists were invited to undertake this 4 month rotation. Any prior research experience related to their physiotherapy qualification. They were trained and mentored by the Lead Clinical Academic for Therapies, and each research activity was supervised by pre-doctoral to post-doctoral Therapy clinical academic fellows. The rotation included completion of research relevant training, fortnightly mentorship, and research activity relating to on-going projects. These projects included two systematic reviews and a scoping review at different stages of completion, analysis of a national survey and conducting a COVID-19 related service evaluation. The physiotherapists were asked to provide feedback of their experience. Results: The therapists reported perceived improvement and new skills in: adapting to change, time management, understanding of research governance, use of reference management and data software, and management of data. The therapists also reported improvement in the ability to read, search, and appraise the literature, and applied these new skills to research projects. Importantly, they reported that all the skills were applied to their clinical workload, in particular to implementation of evidence base care. They reported that this confidence and skill led to evidence based discussions with their musculoskeletal out-patient colleagues. Further impacts have been that to date, the therapists have 1 paper in review and will co-author 2 additional papers. Finally, they have submitted two s for conference. Conclusion(s): The rotation provided an opportunity to develop research skills – both in theory and in practice. The structure of the rotation and time given for learning allowed for consolidation of new knowledge. The skills gained during the rotation had positive impact on approaches to patient care, as well as research activity. Limitations include the timing of research days within the working week, leading to challenges of adapting between clinical and non-clinical settings. This could be addressed by placing research days at the beginning or end of the week. Impact: Early adoption, training and practice of research activity impacts evidence based patient care, and the research awareness of the clinicians and their colleagues. This rotation has been established within the wider Therapies Department. The benefits reported could inspire creation of similar opportunities, and so serve as an important step in the paradigm shift towards research active clinical practice. Funding acknowledgements: No funding was received to conduct this service evaluation.

Can a virtual PBL experience for MSc (pre-registration) physiotherapy achieve placement learning outcomes?

Keywords: Practice-based learning;Digital;Transformative Purpose: The 2020 pandemic majorly impacted upon clinical placement provision for Healthcare students, with a dramatic reduction in the number of student placements offered across NHS, Private, Independent and Voluntary sectors. This led to the need to investigate alternative models of practice-based learning (PBL) delivery. The purpose of this study was to describe the format and evaluation of an observational virtual PBL experience for Oxford Brookes University Pre-registration MSc Physiotherapy Students. Methods: The virtual PBL experience was provided by Physiotherapy Practice Educators from Oxford Health NHS FT, Healthshare Oxfordshire, Great Western NHS FT, Warwick Physio & Rehab, the Bosworth Clinic, Oxford University and Oxford University Hospitals NHS FT. It was facilitated by Academic faculty staff from Oxford Brookes University. The placement was a three week experience covering three core speciality areas – Cardiorespiratory, Musculoskeletal and Neurology. Blended virtual learning activities included live streamed in/outpatient face-to-face patient assessment/treatment, community virtual follow-up appointments, pre-recorded assessment/treatment interventions and community-based virtual rehabilitation classes. The sessions were supported with question and answer sessions, de-briefing, clinical reasoning discussions, documentation skills and critical reflection. A placement notepad was generated daily to develop skills of documentation. Student, Educator and Academic faculty quantitative and qualitative feedback was generated based on a SLOT framework pre- and post-placement. Results: Eight pre-registration MSc physiotherapy students commenced the virtual PBL experience in January 2021, increasing to 15 students over the three week period, including three final year BSc students (92% year 1 MSc, 8% BSc), due to the various impacts of Covid-19. 13 students and three educators completed pre- and post-placement questionnaires. Key findings: When asked to rate their placement experience, eight out of 13 students (62%) gave a response of 8/10 (10 = excellent).Three students responded with 9 or above. When asked how confident they would feel about going on to their next placement in a face-to-face setting, the majority (84%) felt ‘very’ or ‘a little confident’. All students were assessed in a standardised way, identical to face-to-face settings, and judged to have met all learning outcomes. Students consistently reported developing communication, assessment, clinical reasoning,reporting and professionalism skills. Educators reported a positive experience and perceived value in the diversity and efficiency of the format. Conclusion(s): It is feasible to achieve the desired learning outcomes of a PBL experience through a virtual observational placement. Student and educator evaluation was very positive, showing themes of developing important core skills to provide best patient care. Reflective practice was enhanced beyond the expected levels through facilitation led by the academic faculty staff. Future work will aim to explore further the preparedness for placements within the ever evolving physiotherapy landscape. Impact: This study offers a viable and effective alternative model for delivering a three week observational PBL experience to first year pre-registration MSc physiotherapy students and could be widely implemented. Funding acknowledgements: This project had no external funding.

Seizure, abdominal pain, and urine pink in an adolescent female-what's the link?

Case Report A 17 year-old female with history of depression was transferred to the pediatric intensive care unit (PICU) from an emergency department (ED) for first time seizure and subsequent encephalopathy after five days of severe, diffuse abdominal pain and vomiting. The night prior to admission, she complained of lightheadedness and then had a witnessed generalized tonic-clonic seizure lasting 45 seconds. She initially returned to her baseline but then had three additional seizures requiring ED evaluation. She received intravenous doses of lorazepam and levetiracetam that aborted the clinical seizures. She remained encephalopathic and was orotracheally intubated for airway protection. Family denied known ingestions but reported she did vape nicotine. Urine drug screen was positive for benzodiazepines, consistent with seizure management. Cerebrospinal fluid analysis was unrevealing. Urinalysis showed moderate ketones and trace blood. Urine pregnancy test and nasopharyngeal SARS-CoV-2 polymerase chain reaction were negative. Head computerized tomography scan showed no intracranial pathology. On arrival to the PICU, the patient was afebrile, tachycardic, and hypertensive to 171/118 mmHg. She was somnolent on arrival but aroused to sternal rub without focal neurologic deficit. She presented with a Foley catheter that drained pinkorange urine. A nicardipine infusion was started given concern for the development of posterior reversible encephalopathy syndrome (PRES). Thyroid function tests were consistent with euthyroid sick syndrome. BioFire meningitis panel, plasma SARS-CoV-2 IgG, and toxicologic evaluation were all negative. Electrocardiogram showed sinus tachycardia. Magnetic resonance imaging of the brain revealed cortical and subcortical areas of diffusion restriction consistent with PRES. Ultimately, a random urine porphobilinogen and a 24-hour measurement of urine porphyrins collected on hospital day 1 were both markedly elevated. A diagnosis of Acute Intermittent Porphyria (AIP) was made. A gastrointestinal porphyria specialist was consulted and recommended monthly outpatient injections of givosiran upon hospital discharge. Discussion This case illustrates the importance of considering AIP in the differential diagnosis of new onset seizure or encephalopathy associated with hypertension, tachycardia, and abdominal pain in an adolescent. This case also adds to a small number of cases associating AIP with PRES. AIP is often viewed as an adult disease because it typically presents in the third or fourth decade of life. Timely recognition of AIP in the pediatric setting is critical to preventing delays in diagnosis, treatment, and patient education on triggers of acute attacks. AIP attacks are treated with dextrose and hemin infusions to reduce production of porphyrin precursors. Prophylactic treatment of AIP now includes givosiran, an interfering mRNA that reduces levels of intermediates in heme synthesis that are neurotoxic when elevated.

A double-blind placebo-controlled study of brexpiprazole for the treatment of borderline personality disorder.

BACKGROUND: Borderline personality disorder is associated with impaired quality of life and has a number of untoward public health associations. There is no established first-line pharmacological treatment for borderline personality disorder, and available options are not suitable for all individuals. AIMS: To evaluate brexpiprazole, which has effects on the dopaminergic and serotonergic systems, for the reduction of borderline personality disorder symptoms. METHOD: Eighty adults with borderline personality disorder were recruited for a randomised, double-blind placebo-controlled study. Participants received 12-week treatment with brexpiprazole (1 mg/day for 1 week, then increasing to 2 mg/day) or placebo in a parallel design. The primary efficacy outcome measure was the clinician-rated Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD). Safety data were collected. Effects of active versus placebo treatment were characterised with linear repeated measures models. RESULTS: There was a significant interaction between treatment and time on the ZAN-BPD scale (P = 0.0031), solely because of differentiation specifically at week 12. Brexpiprazole was generally well tolerated. Secondary measures did not result in statistically significant differences from placebo. CONCLUSIONS: Brexpiprazole appears to have some possible effect on borderline personality disorder symptoms, but further studies are needed because of the significant effects evident, specifically at the final time point. These findings also need to be viewed cautiously, given the small sample size, large drop-out rate and robust placebo response.

Impact of the first COVID-19 outbreak on mental health service utilisation at a Dutch mental health centre: retrospective observational study.

BACKGROUND: Previous studies into mental health service utilisation during the COVID-19 pandemic are limited to a few countries or specific type of service. In addition, data on changes in telepsychiatry are currently lacking. AIMS: We aimed to investigate whether the COVID-19 pandemic is associated with changes in mental health service utilisation, including telepsychiatry, and how these changes were distributed among patients with mental illness during the first COVID-19 outbreak. METHOD: This retrospective study obtained routinely assessed healthcare data from a large Dutch mental healthcare institute. Data from the second quarter of 2020 (the first COVID-19 outbreak period) were compared with the pre-pandemic period between January 2018 and March 2020. Time-series analyses were performed with the quasi-Poisson generalised linear model, to examine the effect of the COVID-19 lockdown and the overall trend of mental health service utilisation per communication modality and diagnostic category. RESULTS: We analysed 204 808 care contacts of 28 038 patients. The overall number of care contacts in the second quarter of 2020 remained the same as in the previous 2 years, because the number of video consultations significantly increased (B = 2.17, P = 0.488 × 10-3) as the number of face-to-face out-patient contacts significantly decreased (B = -0.98, P = 0.011). This was true for all different diagnostic categories, although this change was less pronounced in patients with psychotic disorders. CONCLUSIONS: Diminished face-to-face out-patient contacts were well-compensated by the substantial increase of video consultations during the first COVID-19 outbreak in The Netherlands. This increase was less pronounced for psychotic disorders. Further research should elucidate the need for disorder-specific digital mental healthcare delivery.

Efficacy of Incentive Spirometer in Increasing Maximum Inspiratory Volume in an Out-Patient Setting.

Background Incentive spirometry (IS) is the mainstay of care in postoperative patients that has been heavily studied in the inpatient setting. Studies have shown that the utilization of IS improves lung volumes and reduces the rate of pneumonia in post-surgical patients. However, the literature is ambiguous on its benefit as many studies also demonstrate no significant benefit, especially in comparison to early ambulation. Our study sought to determine whether a consistent IS regimen can improve lung function in an outpatient setting. Methods This prospective cohort study included patients in a physical medicine and rehabilitation clinic setting during the COVID pandemic. Patients with severe respiratory disease, baseline cough, those unable to perform deep breathing, fever greater than 100.4 F due to non-pulmonary on initial evaluation, or inability to fill out the forms and complete the study were excluded. Each participant was given the IS along with hands-on instruction on how to use the device and accurately record measurements. Patients were asked to lie down and inhale and exhale through the tube ten times. They were asked to mark the highest volume during their 10 breaths. Patients were instructed to complete this exercise three times a day for 30 days. Patients were also asked to perform light exercises or walking for 20 minutes per day three times a week and postural drainage. Patients were instructed to call their primary care physician if a 20% or more decrease from their baseline was noted or if they experienced any new coughs, fever, or shortness of breath during the 30 days of exercise. Results A total of 48 patients enrolled in the study with a (median) age of 58.0 years (SD 10.2 years), 21 females and 27 males. Baseline maximal inspiration for study participants was 1885.4 mL prior to exercise, with a subsequent increase in lung capacity observed for all participants enrolled in the study. At the end of the study period, week four, the average maximal inspiratory volume was 2235.4 mL. Paired t-test showed a significant difference between baseline (1885.4) and maximum (2235.4) volumes (t=-4.59, p<0.0001). Analysis of variance (ANOVA) showed no significant difference among Week 1-4 averages (F=1.08, p=0.36). None of the participants reported any symptoms (fever, coughing, shortness of breath) or COVID-19 infection during the 30-days period. None of the participants reported contacting primary care physicians.  Conclusion When prescribed daily breathing exercises with an incentive spirometer, study participants experienced a 16% increase in maximal inspiratory volume over a span of 30 days and did not need to contact their primary care physician during the study period.

COVID-19 among children seeking primary paediatric care with signs of an acute infection.

AIM: It can be challenging to distinguish COVID-19 in children from other common infections. We set out to determine the rate at which children consulting a primary care paediatrician with an acute infection are infected with SARS-CoV-2 and to compare distinct findings. METHOD: In seven out-patient clinics, children aged 0-13 years with any new respiratory or gastrointestinal symptoms and presumed infection were invited to be tested for SARS-CoV-2. Factors that were correlated with testing positive were determined. Samples were collected from 25 January 2021 to 01 April 2021. RESULTS: Seven hundred and eighty-three children participated in the study (median age 3 years and 0 months, range 1 month to 12 years and 11 months). Three hundred and fifty-eight were female (45.7%). SARS-CoV-2 RNA was detected in 19 (2.4%). The most common symptoms in children with as well as without detectable SARS-CoV-2 RNA were rhinitis, fever and cough. Known recent exposure to a case of COVID-19 was significantly correlated with testing positive, but symptoms or clinical findings were not. CONCLUSION: COVID-19 among the children with symptoms of an acute infection was uncommon, and the clinical presentation did not differ significantly between children with and without evidence of an infection with SARS-CoV-2.