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This study investigates the decision-making process for outdoor leisure activities of the Chinese people in the context of COVID-19. An online survey of residents of Heilongjiang Province was conducted in September and October 2020. In total, 441 questionnaires were returned for empirical analysis. The results reveal that fears of contamination and compulsory checking/reassurance-seeking have had a significant impact on the respondents' goal-directed behavior for nature-based outdoor leisure activities during the pandemic. The theoretical contribution is that extended goal-directed behavior expands with the inclusion of emotional variables and can be used to predict individual outdoor activity intention and decision-making process in the COVID-19 situation relating to leisure. This study provides useful insights for public health ministries and local governments in any country to encourage nature-based outdoor leisure activities as a public health policy for the mental health of the people.
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Introduction: The COVID-19 pandemic necessitated multiple changes to the format of myeloma clinics to minimise the risk of infection among patients and staff. These included changing in-person clinic appointments to telephone appointments when there was no medical need for face-to- face review and instituting a courier service for delivery of oral or self-administered medications. As COVID-19 restrictions relaxed, we sought to investigate the acceptability of these changes to our patients and to determine which, if any, of the new arrangements should continue. Method(s): Patients who attended the Myeloma Clinic at The Royal Marsden Hospital, both in-person and by telephone, on four separate dates in August and September 2022 were asked to complete a questionnaire to provide their opinions using a combination of multiple-choice, Likert scale and free-text questions. These covered the main domains of change outlined above along with questions about blood test location and attendance with family and friends. Result(s): Questionnaires were returned by 59 patients, 11 relating to in-person appointments and 48 to telephone appointments. 86.0% of patients were in favour of continuing the option of telephone appointments, with many highlighting their convenience and the avoidance of long travel and waiting times, with some also mentioning their COVID-19 security. However, a number of patients expressed concerns including communication difficulties, the inability to effectively assess physical health with an examination and a lack of reassurance. Furthermore, those who attended in-person appointments felt they were very COVID-secure, assigning them a mean of score of 4.5, where 1 was very insecure and 5 very secure. Several suggested that the optimum schedule would include regular telephone appointments with occasional in-person meetings. Interestingly, only 25.5% of patients wanted a video calling option. Patients were also very positive about receiving medications by courier, with 94.1% of patients receiving their medications within two working days of their clinic appointment. 81.8% of patients expressed a wish for this option to continue, highlighting the increased convenience and reduction in waiting times. Conclusion(s): These results suggest that changes made to the Myeloma Clinic in response to the COVID-19 pandemic have improved the patient experience. A mixture of telephone and in-person appointments may be preferable for this cohort of patients, many of whom require regular appointments for chemotherapy approval but are medically stable, and whose frailty makes long travel and waiting times challenging. These findings have implications for the planning of myeloma clinics across the UK.
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Introduction: It is well documented that survivors of ICU admissions struggle to return to pre-admission level of function because of both physical and psychological burden. Current guidance therefore recommends a follow-up service to review patients 2-3 months post discharge [NICE 2009]. Prior to 2020 University Hospitals Bristol and Weston had no such service. With the increase in patient numbers seen during the COVID-19 pandemic, funding was received to provide a follow-up clinic to COVID-19 survivors. Objective(s): To provide a service that supports and empowers patients with their recovery from critical illness. Improving quality of life, speed of recovery and reducing longer term health care needs. Method(s): Referral criteria for the clinic included COVID-19 patients who received advanced respiratory support within intensive care and the high dependence unit. 8 weeks post discharge patients had a telephone appointment where ongoing symptoms could be identified. Advice around recovery, signposting to resources and onward referrals to appropriate specialities were provided. At 10 weeks post discharge patients had lung function tests and a chest X-ray which were reviewed by respiratory consultants. Based on the combination of these assessments, patients would be discharged or referred into the multidisciplinary team (MDT) follow-up clinic. The face to face clinic consisted of appointments with an intensivist, clinical psychologist, physiotherapist, and occupational therapist. Where needed patients would also be seen by a speech and language therapist or dietitian. Patients were seen only once in follow up clinic but again would be referred onto appropriate services within trust or the community, including but not exclusively community therapy services, secondary care services, SALT, dietetic or psychology clinics. Result(s): One of the key outcomes was the need for 147 onward referrals (an average of 1.13 referrals per patient). This included, 31 referrals to musculoskeletal physiotherapy outpatients for problems originating or made worse by their admission. 20 referrals to secondary care, including cardiology and ENT. 16 referrals to community occupational therapy, for provision of equipment, home adaptations and support in accessing the community. Subjectively, patient feedback was excellent. When asked what they felt was the most valuable thing they had taken from the clinic they reported: "Reassurance";"To know I'm not alone, others feel like this";"They listened to me and gave advice";"The ability to ask anything I wanted and the obvious kindness and support from all the clinicians I saw". Conclusion(s): Onward referral rates made by the follow-up clinic highlight the many issues faced by patients following discharge from ICU and hospital. With timely recognition and management, we can prevent a majority of these symptoms manifesting into chronic problems. This has the potential to lower the long-term burden on health care and improve quality of life for patients in both the short and long term. Without the follow-up clinic, these issues may have been missed or delayed. This reinforces the importance of the follow-up clinic and the need for ongoing investment.
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Background/Aims The immune response to SARS-CoV-2 is known to be reduced in the immunocompromised. However, extent to which immunity is affected by immunosuppression in specific disease cohorts remains poorly characterised. Furthermore, implications of the ongoing vaccination booster programme require further study. Individuals with lupus nephritis (LN) require prolonged high-dose immunosuppression in order to maintain disease control, rendering them important to study in this context. We evaluated SARS-CoV-2 nucleocapsid and spike antibody response in this cohort during the Spring/Summer 2022 booster vaccine campaign. Nucleocapsid antibody indicates previous infection whilst spike antibody indicates previous infection and/or vaccination response. Titre of spike antibody to prevent infection is not known, but presence of antibodies is likely to protect against severe disease. Methods SARS-CoV-2 spike and nucleocapsid antibody were measured in adult patients with LN attending a tertiary centre rheumatology clinic. Data was collected retrospectively on disease, immunosuppression, vaccine status and history of natural exposure. Results 35 cases of LN were investigated, of which LN III, IV and V were predominant biopsy diagnoses. Regarding immunosuppressants, the Eurolupus Cyclophosphamide protocol had been used in the majority of patients to achieve initial control, with 3/35 patients still receiving pulsed courses at data collection. 18/35 were on Mycophenolate Mofetil;a further 13/35 had previously received this. 31/35 took at least 5mg Prednisolone daily;25/35 took Hydroxychloroquine;7/35 took Azathioprine;7/35 had previously been on Methotrexate, 3/35 took Tacrolimus;1/35 took Ciclosporin. Regarding B-cell depleting monoclonal antibody therapy, 13/35 had received Rituximab and 8/35 were receiving Belimumab. Antibody levels were measured between 4 weeks and 13 months after last dose of vaccination;mean duration was 6 months. 11/35 had confirmed COVID-19 infection;a further 8/35 reported a possible history. Of the 35, 32 (91%) had mounted detectable SARS-CoV-2 spike antibody above the bottom 10% of assay detection, indicating some immunity to vaccination or natural exposure. 20 (57%) had detectable nucleocapsid antibody, suggesting natural infection with antibody response. Only 2 (6%) had not mounted any antibody response. Of note, neither were fully vaccinated: one had 1 vaccination with blood test 8 months subsequent;one had 2 vaccinations with blood test 7 months subsequent. The latter was also notably on haemodialysis. All who received 3+ vaccinations had detectable spike antibody responses, as well as 75% of those who had received 2 vaccinations. Conclusion Our study is the first analysis, to our knowledge, of SARS-CoV-2 antibody response in a LN cohort. Whilst neutralising capacity and level of antibody providing protection remains under research, these findings provide at least some reassurance that individuals with LN on immunosuppression are capable of mounting an immune response against SARS-CoV-2. Further work is required to establish extent and duration of protection with serial vaccinations in this cohort.
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Purpose of Study: During the COVID-19 pandemic, the number of home births increased due to a rising perception of danger at hospitals. Social media is a way to share stories and experiences on topics including birth, and it has become a main means by which people gather information, regardless of whether it is accurate or not. While reasons for choosing home birth have been studied before, gathering this information from social media, especially considering the recent pandemic, has not yet been done. Reddit is a social media platform that includes 52 million daily users that post publicly and anonymously, thus sharing unfiltered information for anyone to see. Through a review of public posts and comments on Reddit from January 2017 through July 2022, using guidelines from previous studies, major themes on perceptions, attitudes, and advice people have about home birth were gathered. Methods Used: Search words on Reddit included home birth?, home vs. hospital birth?, home birth and covid?, home birth and birth trauma?, and home birth and trans men?. There were up to five themes per post or comment. These themes were categorized as positive (in support of home birth), negative (against home birth), or neutral. Posts had to be from the US, in English, with at least 10 comments and 10 upvotes, and from the last five years. Posts were excluded if they did not meet minimum comments and/or upvotes requirement, were explicitly from another country, were not directly related to home birth, it was not a planned home birth, it was a free birth, or they were from more than five years ago. Summary of Results: A total of 425 posts and 13,013 comments were reviewed for all search words. Out of 142 posts included, 68% were in support, 21% were against, and 11% were neutral. There were 1,384 comments included. Specific communities (subreddits?) were also searched and 36% of posts came from r/homebirth?. Supportive themes included concerns about safety in hospital delivery and reassurance about home birth safety, patient control with home deliveries, and advice about preparing for home birth. Negative themes included concerns about the risk of home birth, charges of negligence for those attempting it, reassurance that hospital birth offers women more control, and that medical interventions can be lifesaving. Conclusion(s): The results of this study will be used to help physicians recognize what women worry about hospital birth and what (mis)information they may have about home birth to better advise patients about their delivery options. This gives a voice to patients and their concerns regarding birth, which can help bridge gaps in physician-patient communication.
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Background: The long-lasting impact of the COVID-19 pandemic cannot be overstated. To combat its dire consequences, some screening measures have been hastily developed and require robust verification to explore their adequacy across different groups. The present research study aimed to analyze measurement invariance by sociodemographic characteristics of the Coronavirus Reassurance Seeking Behavior Scale (CRSB) in Peruvian adults. Methods: A total of 661 participants completed The Coronavirus Reassurance Seeking Behavior Scale (CRSB), the Coronavirus Anxiety Scale (CAS), and sociodemographic information a subgroup filled in the Patient Health Questionnaire (PHQ-9). Reliability and measurement invariance across sociodemographic characteristics were analyzed. Likewise, associations with depression and dysfunctional coronavirus anxiety were examined. Results: Results showed that the single factor structure of the CRSB with correlated errors fitted the data adequately and the instrument was invariant across gender, age, and loss of a significant relative to COVID-19. In addition, significant associations with depressive symptoms and dysfunctional anxiety were found. Conclusion: The findings of the present study suggest that the Coronavirus Reassurance Seeking Behaviors Scale is invariant across different sociodemographic characteristics.
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Background: Adults with congenital heart disease (ACHD) are considered at increased risk for complications due to COVID-19, especially in those with cyanosis or heart failure. However, data regarding the rate of infection as well as regarding a myocardial involvement of a COVID-19 infection in ACHD patients are currently lacking. Purpose(s): To study the rate of COVID-19 infections in ACHD patients from a tertiary centre as well as the rate of myocardial involvement of a COVID- 19 infection. Method(s): All consecutive ACHD patients (over the age of 18 years) who attended the outpatient clinic of a tertiary centre from January 2021 to June 2021 were eligible to participate. Demographic data, as well as medical/ surgical data including a history of a COVID-19 infection were collected. All patients had an antibody test for COVID-19. Patients with a positive antibody test were offered cardiovascular magnetic resonance imaging (CMR). Result(s): Altogether, 420 patients (44.8% female, mean age 36.4+/-11.6 years) were included in the study. Congenital heart defect (CHD) complexity according to the Bethesda classification was simple in 96 (22.9%), moderate in 186 (44.3%), complex in 117 (27.9%), and miscellaneous in 21 (5.0%) patients. A positive antibody test for COVID-19 was present in 28 (6.7%) patients (CHD complexity: Simple n=5, moderate n=14, severe n=7, miscellaneous n=2). Out of these 28 patients, 14 had no symptoms at all. Those with symptoms had mainly mild symptoms and were all managed in the outpatient setting. While 11 patients (39.3%) were not at all aware of their infection, 17 already knew that they had COVID-19. There was no significant difference between ACHD patients with a positive test vs those with a negative test regarding age, gender, New York Heart Association class, or complexity of CHD. Out of the 28 patients with a positive antibody test, 14 agreed to a CMR. A myocardial involvement, i.e. signs of active or healed myocarditis, was not present in any of these. Conclusion(s): In this single-centre study, 6.7% of ACHD patients attending the outpatient clinic had positive antibodies for COVID-19. Out of these, 50% were asymptomatic and 39.3% were not aware of their infection. A myocardial involvement was not found in any of the patients that underwent a CMR. These results indicate a large number of undetected cases of COVID-19 in the ACHD population and offer reassurance that in the vast majority of cases the infection has a mild course.
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In this session, we will present and discuss successful strategies and methods employed during the COVID pandemic from 2020 to 2021 by the Glycemia Reduction Approaches in the Diabetes Comparative Effectiveness (GRADE) Study to navigate the challenges of trial implementation and study closeout, and to maintain integrity of the study conduct, data collection, and analysis. During the period between July 2013 and August 2017, this National Institutes of Health (NIH)-funded, multicenter clinical trial enrolled and followed 5047 participants at 36 clinical centers and 9 clinical sites nationwide. Participants were followed quarterly and the study closeout (final patient visits) was planned to occur during the period from November 2020 to April 2021, the peak of the pandemic. The Research Group was able to complete study follow-up and closeout with almost 95% of final participant study visits completed and less than 1% of participants lost to follow-up. Most notably, there was continuity of participant management, treatment, and follow-up during the pandemic. Participants with type 2 diabetes (T2D) were recruited with an emphasis on including a cohort that broadly represented the T2D US population by race and ethnicity. We enrolled a diverse participant cohort with 20% of participants self-identified as Black/African American, and 19% Hispanic/Latino. Clinical sites enrolling Hispanic/ Latino participants had study-funded bilingual research staff. Each clinical center enrolled and followed approximately 150-200 participants for quarterly visits to collect study assessments. We will describe effective study communications with the study research group and participants, operational and clinic-level changes made to optimize the continuity of study treatment and management of participants, completion of visit assessments, and measures taken to ensure staff and participant safety during visits completed through the height of the pandemic. We will discuss problem-solving strategies, adjustments to visits and data collection, strategies employed to optimize data collection under varying constraints, pivoting to a hybrid of remote/in-clinic work for research staff and study visits, collection of laboratory specimens for study outcomes and participant safety, and the implementation of study closeout. We will present the mass utilization of a remote HbA1c collection kit by participants, essential for the primary outcome assessment. Early in the pandemic (March 2020), enhanced communication from the Executive Committee and Coordinating Center to the Study Group was key to keeping research sites up to date on continuity of operations, providing direction to prioritize study assessments, and addressing questions. Site communications with participants were essential for reassurance of continued care and treatment. We will describe the challenges imposed by the pandemic and solutions from several different research perspectives. Research staffing and study coverage were complicated by institution restrictions, working remotely without comparable communications/equipment, risk of COVID exposure, and temporary reassignment of research personnel at the site-level. Site clinical research managers will present experiences and innovative approaches implemented to communicate effectively with study participants, conduct visits, complete study assessments and data collection, and manage treatment changes to include initiation of insulin. We will present successful strategies implemented to handle study logistics, minimize participant and research staff risk, and navigate visit and institutional restrictions. About 96% of sites were closed for inperson clinical activities and conducted completely remote visits for some period of time during the early waves of the COVID pandemic. Sites pivoted to working under new conditions to maintain Health Insurance Portability and Accountability Act (HIPAA) protections while ensuring the integrity of data and sample collection. Two percent of sites did not resume in clinic visits by the end of the study in April 2021. We will also share innovative strategies used to remotely instruct participants on how to use new medications required per protocol. Protocol managers from the Coordinating Center will discuss key leadership decisions and communications implemented to facilitate follow-up that include methods for prioritizing of visit assessments, enhancing remote A1c collection, tracking of study visits and assessments, and monitoring of cold-chain drug shipments to clinical sites. The Coordinating Center implemented weekly WebEx meetings with clinical sites during the first 7 months of the COVID pandemic to facilitate site sharing of information, identify problems and problem solve, collect site information from dynamic surveys, and confirm priorities for study visits and maintaining participant and research staff safety. Site research staff frequently presented strategies or scenarios for discussion. In addition, the Coordinating Center rapidly implemented a COVID website with hot links to important documents. We will highlight modifications in research implementation made to optimize the conduct of clinical care, remote laboratory sample collections, development of a capillary collection kit for mass distribution and collection of key study data, and reports provided by the Coordinating Center to keep sites on track for visit completion. The Coordinating Center biostatistician will summarize the impact of COVID on data collection and discuss completeness of assessments, serious adverse event reporting during the pandemic, and sensitivity analyses to examine the integrity of results. The trial continued without changes to the protocol with about 95,000 total visits completed and 18% of visits completed during COVID. Talk titles: The Role of Leadership, Communications, Infrastructure, and Access to Tools and Resources in Implementing Wide-Scale Operational Changes During COVID-19. Institutional Restrictions and Site-Level Strategies for Communications and Protocol Implementation While Pivoting to Hybrid Work Arrangements and Remote/In-Clinic Visits. Executing a Large Multi-Center Trial During a Pandemic: Challenges and Lessons Learned from the GRADE Coordinating Center. Implementation of Successful Strategies for Study Closeout Visits, Final Data Collection, and Transition of Participant Clinical Care at Trial End. The Impact of COVID on Data Collection, Completeness of Visit Assessments, Serious Adverse Event Reporting, and Approaches to Analysis of Study Results and Reporting.
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While teledermatology has been a feature of some dermatology services for some time, the COVID-19 pandemic has led to both a deterioration in waiting lists for routine patients, and the use of distance consultation as a means of providing and improving access for such patients. The majority of teledermatology platforms rely on general practitioner (GP)-submitted information and images, and most data suggest that these systems result in around 50% of patients avoiding hospital attendance through the implementation of management plans suggested by hospital-based consultants (Mehrtens SH, Shall L, Halpern SM. A 14 year review of a UK teledermatology service: experience of over 40,000 teleconsultations. Clin Exp Dermatol 2019;44: 874-81). We now report the use of an online platform (Virtual LucyTM) using patient-provided information via a structured questionnaire, and patient images uploaded following clear online guidance, reinforced by call centre interaction. The data are derived from funded National Health Service (NHS) work: there was no specific funding for its generation. In total, 3500 patients from two hospital trusts with routine waiting list pressures were invited to use the system as an alternative to eventual hospital attendance. After secure registration, they completed dermatology and general health questionnaires based on conventional medical history taking, as well as a Dermatology Life Quality Index and then uploaded one or more images as appropriate. The patient data were reviewed by a consultant and a self-populated report provided to the patient, GP and trust within 72 h. Forty-eight per cent of patients were discharged to their GP with reassurance or a management plan. Patients requiring hospital attendance were signposted to appropriate clinics (e.g. isotretinoin, phototherapy, patch testing) or to surgical clinics for biopsy or excision. Hospital trust-based consultants were able to access the platform to view images prior to any surgery. Of patients directed to hospital clinics, 32% were reclassified as being urgent - waiting list duration was the main determinant of the need for reclassification. Of all images, 0.5% were unsatisfactory, and those patients were contacted through the platform to ask for a replacement image with specific advice. One per cent of patients were contacted by clinical staff by telephone or video to clarify or expand on the information given, and approximately 1% of patients used the platform to ask for additional treatment details. There were no patient complaints, and GP and hospital staff issues related to logistics were increasingly uncommon as iterative development of the system and support processes occurred. Teledermatology using patient-derived information and images gives similar outcomes to those seen in published conventional teledermatology, puts fewer demands on clinical staff, is popular with patients and has a significant benefit to the NHS.
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Introduction: The Age-related DeVelopments ANd Comorbidities in haemophilia (ADVANCE) Working Group is a European collaboration of over 20 Haemophilia Treatment Centres (HTCs) that focuses on the management of PWH aged >=40 years. As it soon became apparent that the risk of severe outcomes from COVID-19 infection was increased in older adults, we aimed to identify the incidence, severity and outcomes of COVID-19 inPWHaged >=40 years treated at ADVANCE centres. Method(s): The number of hospital admissions, ICU admissions and deaths due to COVID-19 was recorded retrospectively via survey for all patients aged >=40 years with haemophilia A or B at ADVANCE HTCs throughout the pandemic over a 24-month period (until 30 April 2022). Patient numbers were recorded for the most serious outcome at month/year of first occurrence. Aggregated data was provided as requested by Ethical Committees. For reported cases, information on age, comorbidities and risk factors for severeCOVID-19 infection were collected where available. Result(s): Of the overall haemophilia A and B population, 36/4166 suffered a serious outcome due to COVID-19 infection;27 required hospital admission, 5 were admitted to the ICU and 4 died (3 with haemophilia A and 1 with haemophilia B). Nearly all patients with haemophilia A who were admitted to the ICU or died had >=1 comorbidity associated with worse outcomes. Most reported cases occurred early in the pandemic with no clear distinction according to haemophilia severity or age. Discussion/Conclusion: This is the first study to evaluate the impact of the pandemic on PWH >=40 years in terms of severe adverse clinical outcomes. Although only limited data were collected, the study provides reassurance that the haemophilia population was not at risk of more serious outcomes due to their haemophilia alone.
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The Caring Callers Program was developed as a telephone-based intervention utilizing Senior Companion volunteers to reach older adults at greater risk for loneliness during the COVID-19 pandemic. This pilot program consisted of trained volunteers who provided supportive, weekly calls as well as community resources with their Caring Callers clients. The purpose of this study was to qualitatively explore the experiences of Senior Companion volunteers in the Caring Callers Program through the lens of productive aging. We completed semi-structured interviews with 18 Caring Callers volunteers. We used Rapid and Rigorous Qualitative Date Analysis (RADaR) which yielded four themes: (1) reciprocity; (2) purposeful use of time; (3) learning new skills; and (4) gaining perspective. Our findings provide insight for gerontological researchers examining volunteering as a productive aging activity and offer strategies for designing peer-led, telephone-based interventions to promote social connectedness in an unprecedented time.
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Introduction/Background: Antiphospholipid syndrome (APS) is a rare autoimmune multisystem disease characterised by thrombosis and pregnancy morbidity in the presence of persistently elevated titres of: lupus anticoagulant, anticardiolipin and/or anti-glycoprotein 1. It may be primary (occurring alone) or secondary (in combination with another disease, most commonly systemic lupus erythematosus (SLE)). Recent publications highlighted clinical criteria limitations for children and raised awareness of the burden and prevalence of non-criteria manifestations in this population. This case report adds further weight to the need to raise multi-specialty awareness of non-criteria manifestations to aid recognition and treatment of this rare condition with potentially severe sequelae. Description/Method: 13-year-old female with SLE diagnosed aged 8 in India with bilateral optic neuritis occurring two months later. ANA positive at diagnosis with low complement and thrombocytopenia. Treated with prednisolone and hydroxychloroquine. Patient moved to the UK aged 9;initial abnormal bloods: mildly positive ANA (ENA negative), thrombocytopenia, strong lupus anticoagulant. As serology not strongly suggestive and optic neuritis rare in lupus diagnosis questioned. Ophthalmology review confirmed bilateral optic atrophy without evidence of previous vasculitis. There was debate whether the postretinal demyelination was due to antiphospholipid syndrome or a primary demyelinating condition. Hydroxychloroquine stopped and azathioprine started. Following normal neurology investigations (brain, spine MRI/MRV/MRA) concluded if patient developed new APSrelated symptoms or worsening visual evoked potentials anticoagulation would be discussed. Patient remained stable over four years with chronic thrombocytopenia and ESR persistently elevated. Azathioprine changed to Mycophenolate mofetil (MMF) due to side effects. Routine medication monitoring bloods in 2022 showed ESR 97, CRP 78, Platelets 61. Review identified vasculitic rash on soles of both feet with palpable nodules and normal pulses. Further investigation confirmed antiphospholipid antibody triple positivity. Aspirin commenced, hydroxychloroquine restarted, MMF dose increased and rituximab administered. Left foot rash settled but right progressed with toe discolouration and numbness. Skin biopsy considered but not performed due to skin integrity concerns. Foot pulses remained present and normal. Bilateral lower limb doppler reported as normal;increased symptoms resulted in CT angiogram which revealed bilateral non-occlusive popliteal thrombus and left pulmonary embolus. Subsequent echocardiogram was normal. Patient was anticoagulated with low molecular weight heparin followed by warfarin. Vascular surgical team advocated medical management and patient received seven infusions of Iloprost followed by Sildenafil. She achieved near total resolution of skin changes to toes with only minimal loss of skin over tip of right great toe. Patient will now require long-termanticoagulation. Discussion/Results: APS was considered in initial differential diagnosis but patient did not meet current clinical criteria as no past evidence of thrombosis. Lupus anticoagulant was consistently strongly positive and anticardiolipin repeatedly negative. As anti-B2 glycoprotein 1 antibody is not routinely tested and must be verbally requested, it was only checked once (negative) prior to discovery of triple positivity. ANA reported as strongly positive at time of SLE diagnosis but reviewing original notes from India titre was 1:100 and therefore not highly convincing. ENA negative and complement and white cell count normal on repeat testing since. Therefore, it is probable that this patient has primary APS as opposed to secondary APS in association with SLE. However, it is possible that this patient may develop more symptoms of SLE over time. When this patient presented with foot rash there were high numbers of children presenting with varying severity of painful, itchy toes coined 'covid toes' due to suspected lin to SARS-CoV-2 infection. Patient had exposure history, and COVID antibody serology was difficult to interpret due to recent vaccination. Dermatology found appearance to be consistent with 'covid toes' and advised supportive treatment. The triple APS antibody positivity result provided probable aetiology. Providing evidence of thrombus was problematic with false reassurance from apparently normal lower limb arterial doppler when actually popliteal arteries were not checked in view of the presence of normal flow proximally at the groin and distally in the feet. This case highlights the need to continue to search for thrombus in presence of high titres antiphospholipid antibodies and particularly in the case of triple positivity as although patient presented with colour change to toes, she was entirely asymptomatic from her PE and her left foot improved spontaneously despite a left popliteal thrombus also being present. Key learning points/Conclusion: Non-criteria manifestation of thrombocytopenia (occurs in 25% paediatric APS patients) was present throughout and patient had past history of haematuria (a recognised renal non-criteria manifestation). A paediatric specific APS criteria including these may have resulted in earlier detection of triple antiphospholipid antibody positivity and thus earlier treatment escalation and possible avoidance of thrombus. It has been reported that a high proportion of children with positive antiphospholipid antibodies don't develop a thrombus. However, it is interesting that our patient was entirely asymptomatic from her pulmonary embolus which was an incidental finding on her CT angiogram. This prompts a discussion about how much imaging should be performed in those with high levels of persistent positive antiphospholipid antibodies. Rituximab resulted in normalisation of platelet count and ESR for the first time since initial presentation. Anticardiolipin antibodies normalised, lupus anticoagulant decreased from strong to moderate and anti- B2 glycoprotein levels decreased but remained positive. Rituximab is a recognised treatment for catastrophic antiphospholipid syndrome (CAPS) but not routinely used in APS. The consistently raised ESR in an apparently clinically well patient is a reminder to continue to search for causes of inflammation. As the CRP was largely in normal range, this demonstrates the unique value of the ESR. In view of anti-B2 glycoprotein 1 antibody requiring to be verbally requested, discussions are ongoing with the laboratory department regarding the possibility of electronic request and a comment with recommendation to check other two antiphospholipid antibodies following one positive antibody result. As a result of this case, a plan will be put in place to ensure annual screening of antiphospholipid antibodies in all juvenile SLE patients in our care. It is hoped that this case report promotes discussion amongst the paediatric rheumatology community regarding further research required for development of paediatric specific APS criteria and management.
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Introduction/Background: Chronic pain is persistent pain lasting more than three months, impacting many aspects of a person's life. 20- 30% of UK adolescents experience chronic pain (although studies vary greatly). The previous pathway through our service was unclear, which meant young people were not accessing all available resources or being seen promptly. We aimed to create a model that optimised available resources, including local networks and ensured equitable access to our service across the region. We wanted to target critical barriers such as mental health, school attendance and sleep, and delivering asset-based care. Description/Method: We followed the plan, do, study, act PDSA cycle for this quality improvement project (QIP). The initial evaluation involved multidisciplinary team (MDT) meetings, site visits, and the MDT experience using other models of care. Patient cases were reviewed for weaknesses in existing models. Discussions highlighted the need to match resources to needs instead of a onesize- fits-all approach. Changes include creating our own model for Chronic Pain, introducing a specialist physiotherapy Triage Clinic to the pathway, converting our Pain Education Workshop (PEW) to virtual and utilising local resources by expanding our network. PEW seeks to empower patients and families to understand their pain. It is also offered to local healthcare professionals to increase confidence in supporting patients. We adapted the Thrive Mental Health Model to create a Triaged Model for Chronic Pain. We needed to streamline the service, as some patients became lost within the original pathway, not attending PEW and being on long waiting lists. We needed to manage difficulties faced with an increased patient cohort and case complexity, including mental health. Feedback demonstrated some patients found it difficult coming to MDT appointments without knowing who would be present. Triage Clinic helped to mitigate this. Young people with a lower level of need can be assessed virtually, have symptoms validated, receive advice and be discharged to appropriate care. Those with pain not managed by this reassurance are assessed within our service including, One-Stop-Shop, Adolescent Clinic for Rheumatology patients and Biomechanical clinic. Those requiring more support are referred to the MDT for intervention and education for serial day-case rehabilitation or more intensive intervention (PRIME). Ongoing challenges, such as severe mental health difficulties, mean some may not be ready to access support. We liaise with local services such as CAMHS, and patients may be reintroduced to the team later if appropriate. Discussion/Results: Our model showed improved outcomes compared to our previous service. We looked at data from 2018-2019 and 2021, removing the years involving the initial waves of the pandemic as the service adapted to the changes this brought. The physiotherapy Triage Clinic utilised our new Triage Model for the service. Following this we can discharge a portion of our patients to other services, some remain under the physiotherapy team, and the majority are seen in the Chronic Pain MDT clinic. It has been an opportunity, on initial consultation, to engage YP and their families and validate their pain. 22% of our patients had full school attendance on their initial review by our team. The average was a 59% attendance. There was an increase in 83% of those with initially reduced attendance following intervention with the chronic pain team. On average, attendance went from 44% to 71%. We saw a rise in the number of local services involved with young people under our care. Other services involved safeguarding teams, allied healthcare professionals and CAMHS teams. In 2018 on average, 1.4 services were involved;this increased to 1.8 in 2019 and 2.4 in 2021. This may be due to increased complexity of the cases we see or due to more local support requirements. Our plans following the MDT clinic increasingly show more specific goals and activities of daily living targets year on year, from 53% in 2018 to 0% having this as part of their plan in 2021. There have been regional development over the past three years of the service. We now have over 100 staff, including 43 local physiotherapists working collaboratively with our team in supporting the young people and their parents in our care. The Evelina team aims to lead regional meetings and communities of practice. Key learning points/Conclusion: With the limited available resources, our team is continuing to work towards managing a complex cohort of patients successfully. We were shortlisted for a British Society of Rheumatology Award for Best Practice following the changes made within our department. This QIP and our new model can be adapted to many other specialities and teams. Changes we have made are especially relevant following the impacts of the Covid-19 pandemic and continued pressure with reduced resources and increased demand. The virtual PEW allows for increased access for young people that previously struggled to attend face-to-face workshops in a timely fashion. The young people and their families benefit from improving their understanding of their pain and learning new strategies to manage it. Some patients find the virtual setting more practical as they miss less school and do not have to pay for costly transport to attend. Others miss the face-to-face interaction with peers who have similar difficulties. Both individual peer support and expert patients are areas we would like to explore as a service allowing the ripple effect of our model to continue. While improving the efficiency of some aspects of our service, we know that a further challenge is managing other 'bottle necks' created. From this conference, we hope our new model will be critically appraised and answer questions from our peers in other services. We look forward to learning from the experience of our colleagues who also work with this often complex cohort of patients.
ABSTRACT
Upper respiratory tract infection (URI) is one of the most frequent diseases observed at centers for pediatric care and results in significant morbidity worldwide. URI is the most common cause in children treated against acute respiratory infection. The difficulty found by clinicians in establishing the differential and etiologic diagnosis of URIs and the occasionally indiscriminate use of antimicrobial drugs. URIs range from the common, cold-typically a mild, self-limited, catarrhal syndrome of the nasopharynx to life-threatening illnesses such as epiglottitis. Viruses account for most URIs. Appropriate management in these cases may consist of reassurance, education, and instructions for symptomatic home treatment. Diagnostic tests for specific agents are helpful when targeted URI therapy depends on the results. Bacterial primary infection or superinfection may require targeted therapy. The upper respiratory tract includes the sinuses, nasal passages, pharynx, and larynx, gateways to the trachea, bronchi, and pulmonary alveolar spaces. Rhinitis, pharyngitis, sinusitis, epiglottitis, laryngitis, and tracheitis are specific manifestations of URIs. Most URIs are viral in origin. Typical viral agents that cause URIs include the Rhinoviruses, Coronaviruses, Adenoviruses, and Coxsackieviruses. In the emergency department, attention should be paid to the patient's vital signs, including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation (if obtained). Neonates are obligate nose breathers and may be at greater risk for respiratory distress;hence practitioners should auscultate the lungs for adequate aeration and assess breathing quality. The cardiovascular examination should assess adequate distal perfusion and an appropriate-for-age heart rate. Finally, dehydration can be a complication of any viral illness, and therefore, an assessment of hydration should be a part of the initial evaluation. Tests of nasopharyngeal specimens for specific pathogens are helpful when targeted therapy depends on the results (e.g., group A streptococcal infection, gonococcus, pertussis). Specific bacterial or viral testing is also warranted in other selected situations, such as when patients are immunocompromised, during inevitable outbreaks, or provide specific therapy to contacts. Symptombased therapy represents the mainstay of URI treatment in immunocompetent adults. Antimicrobial or antiviral therapy is appropriate in selected patients.
ABSTRACT
Purpose : To determine whether there is an increased risk of herpes zoster ophthalmicus (HZO) following COVID-19 vaccination. Methods : Retrospective observational study utilizing OptumLabs® Data Warehouse, a longitudinal, real-world data asset with de- identified administrative claims and electronic health record data. A cohort study design and a self-controlled design were both utilized to investigate HZO following vaccination, defined by an ICD-10 diagnosis code within 30 days after vaccine administration (or up to the second dose if a second dose was administered), plus a new prescription or dose escalation of antivirals within 5 days of HZO diagnosis. Using a cohort design, COVID-19 vaccinated individuals from 12/11/2020- 6/30/2021 were compared to two influenza-vaccinated cohorts: a pre-pandemic group (1/1/2018-12/13/2019) and an early pandemic group (3/1/2020-11/1/2020). Cox proportional hazard models were used to identify unadjusted and adjusted hazard ratios for HZO. Using a self-controlled design, the incidence rate ratio comparing the risk of HZO in the risk intervals following COVID-19 vaccination to a control interval 60 to 90 days prior to the first dose was estimated using conditional Poisson regression. Results : Among 3,567,715 patients in the COVID-19 vaccinated cohort, there were 60 post-vaccine HZO cases. Patients vaccinated against COVID-19 were not at increased risk of HZO compared to pre-pandemic influenza vaccinated patients (N= 5,101,709;HR= 0.84;95% CI: 0.61-1.16;p= 0.29) and early pandemic influenza vaccinated patients (N= 4,060,412;HR= 0.93;95% CI: 0.64-1.34;p= 0.69) after adjustment for demographics, comorbidities, zoster vaccine, and medication use. Additionally, HZO cases post-COVID-19 vaccination were less likely to be prescribed ophthalmic steroids compared to cases following pre-pandemic and early pandemic influenza vaccination (18.3% vs 29.6% vs 41.4%, respectively). In the self-controlled design, patients were not at increased risk of HZO after COVID-19 vaccination compared to their control interval (IRR= 0.74;95% CI: 0.49-1.12;p= 0.15). Conclusions : There is not an increased risk of HZO following COVID-19 vaccination. These results provide reassurance for the safety of the COVID-19 vaccine from an ophthalmic standpoint.
ABSTRACT
Introduction: Retrieve is the South West's dedicated Adult Critical Care Transfer Service (ACCTS), commissioned to meet the needs of the COVID-19 pandemic and build a permanent legacy for the region's critical care patients. The South West Critical Care Network (SWCCN) has long had an interest in critical care transfer and in 2020, published a retrospective analysis of its transfer activity.1 Whilst there were limitations of the data, it identified a clear need for a transfer service in terms of activity and the need to improve the consistency and quality of transfer care. Retrieve launched on 2 November 2020 and undertakes all types of critical care transfer, from time-critical and urgent escalations of care to repatriations and capacity transfers. It operates two consultant-led clinical teams 12 hours a day. As a fully digital service, it has collected data about every referral and transfer since then. This dataset is essential in informing the ongoing development of Retrieve as well as other ACCTS across England. Objectives: To describe the first 500 transfers undertaken by the Retrieve ACCTS and compare this to existing regional data. Methods: Using the Retrieve electronic patient record and database system, the first 500 transfers that the service undertook were identified and an anonymised dataset downloaded. This data was categorised by type of transfer, time of day, referring and receiving hospitals, patient demographics, referring clinician and specialty. Results: The first 500 transfers by Retrieve were completed in 258 days, with 161 (32%) being undertaken by the Peninsula team and 339 (68%) by the Severn team. Sixty one percent of transfers (303)were escalations of care to specialist centres, of which 1 in 3 were classified as 'time critical'. The service undertook 87 repatriations (17% of work). Capacity transfers (previously called 'non-clinical transfers') comprised 22% of transfers (110), including interregional mutual aid work undertaken as part of the COVID-19 wave 2 in January and February 2021. Comparing the data to SWCCN published work, a smaller proportion of transfers were for escalation of care (61% vs 83.2%) and a higher proportion of repatriations (17% vs 10.5%). Conclusion: The Retrieve data provides valuable insight into the work of a new dedicated ACCTS and is helpful in informing future development regionally and nationally. The reasons for transfer are similar to published data1 but are skewed by the capacity transfer work generated by the COVID-19 pandemic as well as a strict adherence to database definitions and data integrity. This data should provide reassurance to those involved in ACCTS development across England that the workload and approximately breakdown of types of transfer matches that which has been anticipated.
ABSTRACT
Background: In the canton De Vaud, 604'633 individuals received at least one dose of COVID-19 vaccine. An online evaluation form was built to identify patients at increased risk of anaphylaxis and facilitate the in-center triage. Aim: To evaluate the outcomes of the vaccination, allergic reactions and satisfaction level of this online screening method. Methods: Individuals with documented allergy to any vaccine components and/or who suffer from severe allergic reactions to infused or injectable drugs were asked to fill an online form to define their eligibility for mRNA vaccines by an allergist. Several months after this assessment, a survey was sent back to get feedback on the outcomes of the vaccination status. Results: 3519 (0.58%) individuals underwent online risk assessment for mRNA vaccines. Of those, 1658 (47%) completed the survey. 80.4% had received two doses. Frequent adverse events included fever (24%), headache (27%), fatigue (39%) and muscular/articular pain (28%). Of the 420 (27%) who reported to be asthmatic, 12.8% complained worsening of asthma control after vaccination. Severe allergic reactions were reported in 24 (1.5%) cases and, after online review, considered as possible in 10 cases (0.6%). The median satisfaction and reassurance of the online form were 91/100 and 98/100, respectively. Satisfaction was significantly influenced by age and the number of vaccines received (0-vs-1-vs-2). Conclusions: Providing an online assessment for vaccine eligibility from an allergist reassured the allergic population and may represent a valuable tool to increase vaccine adherence.
ABSTRACT
Background: With the growing acceptance of the role for the expansion of suitable indications for liver transplantation, such as selected cases of hilar cholangiocarcinoma and unresectable colorectal liver metastases, the imbalance between clinical need for liver transplantation and supply of suitable donor organs is likely to widen in Europe for the foreseeable future. Novel organ perfusion technologies are likely to play a fundamental role in maximising utilisation of all donor organs and facilitating the safe transplantation of marginal grafts. Herein we describe the initial experience of implementing Normothermic Machine Perfusion (NMP) in a liver transplant centre just before the onset of the COVID-19 pandemic. Methods: Retrospective analysis of a prospectively-maintained comprehensive database encompassing donor characteristics, perfusion parameters and post-transplantation outcomes. Results: Between February 2020 and October 2021 (20 months), 37 liver grafts were perfused with NMP and 23 proceeded to transplantation. The indications for NMP included logistics - 16 grafts (69%), further assessment of marginal grafts - 5 (22%) livers and facilitation of a predicted difficult hepatectomy (e.g. redo transplant) - 2 livers (9%). Overall, a total of an additional 15 livers, 3 kidneys and one pancreas were transplanted that absolutely could not have been transplanted without NMP (e.g. logistics, unacceptable cold ischaemic time with static cold storage) and a further 7 livers were successfully transplanted that may have been declined without the additional reassurance of dynamic functional assessment and safe prolongation of preservation time. No grafts were lost as a result of perfusion with NMP. Conclusions: NMP is a safe and effective technique for improving graft utilisation in liver transplantation and has become an integral component of routine clinical practice since its introduction in Edinburgh. As collective experience with NMP increases, the prognostic predictive ability of serum (and potentially bile) analysis on the machine is likely to improve graft utilisation further.
ABSTRACT
Purpose: To date, we know little about the impact of responsive shifts from conventional to remote learning during the Covid-19 pandemic on student outcomes. If learning suffered, this may potentially have significant negative effects on students’ knowledge and skills acquisition hence eventually impacting the overall quality of our doctors and the care they provide. To address this gap in knowledge, we investigated the impact of switching from classroom team-based learning (cTBL) to online TBL (oTBL) on medical student performance in class tests and end-of-year examinations. Methods: Our participants were 137 second-year medical students who had cTBL experience prior to the shift to oTBL. We held the structure, activities and organisation of TBL constant. The only difference was that oTBL students engaged virtually while cTBL students met in person. We examined if there were differences between cTBL and oTBL in terms of individual (iRA) and team performance (tRA) in class and end-of-year exam scores. Our educational focus was the female reproductive system. We also examined the mean iRA and tRA scores for all modules. Analysis was via repeatedmeasures ANOVA. Results: There was a statistically significant difference between cTBL and oTBL groups’ iRA, tRA and specific exam items for female reproductive knowledge. Similarly, when we looked at year 2 teaching more generally, students scored significantly higher on the iRAs and exam items that were taught by means of oTBL compared to cTBL. Discussion: During a time of educational disruption, shifting a highly structured instructional design from the classroom to online, while keeping all other factors constant, maintained learning outcomes. This reassurance of the effectiveness in respect of student learning opens the door for further research to explore the educational, social and interactional processes of both face-to-face and online TBL © 2022 Association of Medical Education in the Eastern Mediterranean Region (AMEEMR). This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/). Sponsored by King Saud bin Abdulaziz University for Health Sciences
ABSTRACT
Background and aims: Cyberchondria is characterized by repeated and compulsive online searches for health information, resulting in increased health anxiety and distress. This behaviour has been considered an emerging public health issue, which may have been exacerbated by the COVID-19 pandemic. The present study aimed to investigate changes in the severity of cyberchondria during the pandemic and identify predictors of cyberchondria at this time. Method: Self-reported data on cyberchondria severity (before and during the pandemic), attachment style, impulsivity traits, somatic symptoms, COVID-19 related fears, health anxiety, and intolerance of uncertainty were collected from 725 participants using an online survey distributed in French-speaking European countries during the first wave of the COVID-19 pandemic. Results: COVID-19 pandemic affected various facets of cyberchondria: cyberchondria-related distress and interference with functioning increased, whereas the reassurance facet of cyberchondria decreased. Using supervised machine learning regression analyses, the specific COVID-19-related fears and health anxiety emerged as the strongest predictors of cyberchondria-related distress and interference with functioning during the pandemic. Conclusions: These findings provide evidence about the impact of the COVID-19 pandemic on cyberchondria and identify factors that should be considered in efforts to prevent and manage cyberchondria at times of public health crises. In addition, the findings have implications for the conceptualization and future assessment of cyberchondria.