Everybody hurts - What can physical health professionals learn about how mental health professionals support their own emotional resilience and mental health?

The physical aspects of ultrasonography, difficult posture with prolonged pressure exertion, have been extensively researched and addressed with advances in machine ergonomics, operator awareness of posture and positioning and workplace tools to identify musculoskeletal problems. The mental stresses are less well recognized and have only recently started getting investigated. Ultrasonography is a mentally challenging activity requiring long periods of intense concentration, empathy and communication of complex and often difficult information to patients and clinicians, all of which carries an emotional toll. Practitioners are also under increasing time and caseload pressures exacerbated by COVID recovery and chronic fatigue from two years of pandemic. A survey of UK obstetric sonographers showed 92.1% and 91.0% met the burnout thresholds for exhaustion and disengagement, respectively).1 While many Trusts provide training to support physical health, few radiology departments educate their staff on emotional resilience or offer regular support to either promote or maintain mental wellbeing. Training, when available, is often focused on the receiver and not on the impact of vicarious traumas experienced as a result of repeatedly discovering/delivering difficult outcomes to patients on a regular and prolonged basis. Few health professionals are face-to-face with their patient at point of significant discovery whether that information is imparted to the patient or not. Mental health professionals have adopted a traumainformed stance into their working practices. This has not only informed the direct clinical work with patients but is also evident in the way the workforce is supported by the trust. Regular supervision, reflective practice and debriefs are required and monitored by the trust, based on research in clinical psychology to inform best practice. Some of these practices could be applied to physical health professionals to address some of the emotional burdens experienced as part of day-to-day delivery of care.

Autonomic Dysfunction after Covid-19 Immunization - Case Report

Background: The infection caused by the SARS-CoV-2 continues affecting millions of people worldwide and vaccines to prevent the coronavirus disease (COVID-19) are considered the most promising approach for curbing the pandemic. Otherwise, cardiovascular and neurological complications associated with the vaccines were speculated and some few case reports were published. Objective(s): We describe a case of postural orthostatic tachycardia syndrome (POTS) after viral vector COVID-19 vaccination and the possible autoimmune process of the syndrome. Method(s): A 35-year-old female, without previous symptoms or comorbidities, developed intermittent palpitation, intense fatigue and dyspnea, compromising her daily activities, triggered by upright position, seven days following the second dose of the Oxford vaccine. Physical examination was normal, except for a heart rate (HR) increase of 33 beats/min from supine to standing position, with no significant change in blood pressure and reproduction of symptoms. Result(s): A 24-hour Holter monitoring revealed episodes of spontaneous sinus tachycardia correlated with palpitation and fatigue. Extensive diagnostic investigations excluded primary cardiac, endocrine, infectious and rheumatologic etiologies. The patient underwent an autonomic function test which demonstrated normal baroreflex sensitivity, as well as normal cardiovagal and adrenergic scores. Head-up tilt test showed persistent orthostatic tachycardia (HR increase from a medium of 84 beats/min in supine position to 126 beats/min during upright tilt), without hypotension, consistent with the diagnostic criteria for POTS. According to the current guidelines, general behavior recommendations, pharmacotherapy with low dose of propranolol associated with the autonomic rehabilitation were oriented. Along three months of follow-up, the patient reported a gradually improvement in her symptoms. Conclusion(s): POTS is a heterogeneous disorder of the autonomic nervous system characterized by orthostatic tachycardia associated with symptoms of orthostatic intolerance. Although the physiopathology of COVID-19 vaccine and autonomic disorders remains speculative, autoimmune response is one of the possible mechanisms. Based on clinic presentation, the time frame of symptom onset is consistent with other well-known post-vaccination syndromes, which may be an indicator of an autoimmune process induced by immunization. Further studies are needed to assess causal relationship between immunization and autonomic dysfunction.Copyright © 2023

Pneumomediastinum and pneumothorax as extrapulmonary complications of pneumonia due to SARS-CoV-2.

BACKGROUND: Barotrauma is a lesion generated for changes in the pressure and/or volume within a specific anatomic way;pneumo-mediastinum and pneumothorax are clear samples of this effect, frequently related to infectious symptoms. CLINICAL CASES: Two clinical cases are presented, 34 and 44 years old, that had pneumonia due to COVID-19, with subsequent exacerbation of the symptoms caused by barotrauma. Patients were evaluated at emergency unit of the Hospital Angeles Pedregal, Mexico City;their clinical presentation was similar and was unleashed by repeated cough in the context of pneumonia due to SARS-CoV-2. CONCLUSION(S): Now there is more experience on the complications associated during COVID-19, although more cases must be study to know their prognostic meaning and, in case it becomes a progression marker of the illness, to establish specific measures and therapeutic recommendations. The presentation of pneumonia stands out despite the vaccination, having to get the general population make consciousness of continuing with measures of respiratory isolation.Copyright © 2022 Comunicaciones Cientificas Mexicanas S.A. de C.V.. All rights reserved.

Feasibility of a pain informed movement program for people with symptomatic knee osteoarthritis

Purpose: Disability in knee osteoarthritis (KOA) is known to be largely due to pain, the mechanism of which is complex and multidimensional with alterations in nociceptive processing in the peripheral and central nervous system (CNS) leading to persistent pain. Current clinical practice guidelines for KOA provide strong recommendations for education and exercise including land-based or mind-body approaches. However, individually these strategies are only moderately effective. One potential reason for this is a lack of understanding of their underlying mechanisms and how their combination might impact nervous system modulation. Neuromuscular exercise is known to improve lower extremity strength. Mind-body approaches as well as pain neuroscience education (PNE) are uniquely positioned to potentially reverse CNS adaptations by inducing positive neuroplastic changes and improving descending modulation of pain resulting in decreased pain. To our knowledge, neuromuscular exercise, mind-body techniques, and PNE have not been studied in combination. We therefore aimed to establish the feasibility of an intervention consisting of these three elements referred to as Pain Informed Movement (PIM). The results of this study will inform necessary modifications for a two-arm pilot randomized controlled trial (RCT). Method(s): This study was a single-arm feasibility trial with a nested qualitative component and the primary feasibility outcome of complete follow up. Inclusion criteria: age >= 40 years, KOA clinical diagnosis or people fulfilling the NICE diagnostic criteria, and average pain intensity >=3/10 on the numeric pain rating scale. PIM consisted of twice weekly in-person exercise sessions and a third home exercise session for 8 weeks. In addition, PNE, provided as online videos, covered the following topics: purpose of pain, neurophysiological changes associated with pain, movement guidelines when pain persists, mind-body techniques to impact neurophysiology and support moving with ease that included breath awareness and regulation, muscle tension regulation, awareness of pain related thoughts and emotions, and relaxation. The mind-body techniques and the PNE topics were implemented during the group exercise sessions that included evidence-based neuromuscular exercises aimed at improving sensorimotor control and functionality of the knee joint. Participants completed questionnaires and in-person assessments at baseline and at program completion. Assessments included weight and height, chair stands as a measure of functional leg strength, and conditioned pain modulation to assess efficiency of the descending modulatory pathways. Participants also had their blood drawn to monitor changes in brain derived neurotrophic factor (BDNF), a marker of neuroplasticity. Questionnaires included the Pain Catastrophizing Scale, Hospital Anxiety and Depression Scale, the Knee Injury and Osteoarthritis Outcome Score - function and pain subscales, Chronic Pain Self Efficacy scale, pain intensity rated in the past 24 hours, the past week, and worst pain in the past 24 hours. Secondary feasibility outcomes included acceptability of the intervention, burden of assessments, recruitment rate, compliance rate, adherence rate, and self-reported adverse events. Feasibility findings were evaluated against a-priori success criteria. In the qualitative component, participants were invited to an online focus group and were asked about their experience and perceptions of the program. Interview recordings were analyzed using thematic content analysis to identify suggestions for program modification. Result(s): In total, 19 participants (mean age 63.3 years (SD 10.5), 73% female) were enrolled, with a complete follow up rate of 74% (n=14) for our primary objective, indicating that modifications would be needed to proceed. Of the 5 dropouts, only one was study related. We will be adding additional inclusion criteria of: ability to get up and down from the floor independently, and no use of mobility aids. Adherence to in-person treatment sessions was 91%, hich indicates proceeding with the protocol for the next phase (i.e., pilot RCT). Some absences were due to unmodifiable factors (e.g., COVID-19). We will make protocol amendments for the purpose of improving the adherence rate to include 'no planned absences'. All other success criteria were met: recruitment rate, compliance to exercise sessions, program acceptability, duration, frequency, and delivery, likelihood of recommending the program to others and taking the program again, burden, and adverse events (Table 1). Analysis of the focus groups revealed that the video content pertaining to the mind-body techniques would benefit from on screen demonstrations by the instructor to assist with participants' execution of breath and muscle tension regulation. The majority of participants improved in most of the physical assessment outcomes and questionnaires (Table 2). Conclusion(s): The PIM program is feasible, acceptable, not burdensome, does not cause adverse events, and had an excellent compliance rate. Minor modifications are needed to optimize enrolment and adherence rates. Although improvements in pain, function, and psychological measures were observed, the feasibility nature of this study precludes any conclusions regarding efficacy. A pilot two-arm RCT will be conducted to establish the feasibility and explore potential effects of PIM when compared to conventional neuromuscular exercise and standard OA education. [Formula presented] [Formula presented]Copyright © 2023

Superior Cerebellar Artery Dissection in a Patient Diagnosed with Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Arterial dissection is an uncommon complication of reversible cerebral vasocon-striction syndrome (RCVS). We describe the case of a 35-year-old woman with a migraine history who presented with recurrent thunderclap headache and focal neurological signs, including right hemiataxia. She had been diagnosed with COVID-19 disease two weeks earlier. Neuroimaging revealed multifocal stenosis of the posterior circulation arteries and dissection of the right superior cerebellar artery. She improved significantly throughout her one-week hospitalization and maintained only mild ataxia. The interplay between COVID-19 disease, RCVS, and arterial dissection requires further investigation.Copyright © Author(s) (or their employer(s)) and Sinapse 2022.

Qualitative research for the analysis and evaluation of obstetrical assistance to immigrant women in labor and delivery: the woman's point of view

Objective. To analyse, through the experience of the women interviewed, the impact that the migratory experience has had on them in the context of pregnancy and childbirth, and the quality of the obstetric care received during labor and childbirth. Materials and Methods. For this study, a qualitative methodology was adopted known as Cohen's phenomenology. The study was conducted in the period between January 2022 - March 2022 recruiting a sample of 11 immigrant women at the Policlinico of Bari and the Societa Cooperativa Sociale OASI 2 San Francesco Onlus. Results. From the analysis of the interviews, five main themes emerged: Migration, Memory, Assistance to immigrant women, The language barrier, Loneliness. The stories uncovered the basic needs that bring every woman together during pregnancy and childbirth and the cultural aspects, bringing out the impact of migratory trauma. The women reported that they had received good obstetric care, defining the image of a midwife as the one who stands beside. However, several difficulties emerged, from the language barrier to loneliness, burdened by the restrictions imposed by the COVID-19 pandemic. Conclusions. It emerged from the interviews that the preparation of the midwife in the transcultural field is essential in order to be able to provide appropriate and personalized assistance. The goal of health workers is to create a mental attitude of openness towards confrontation and knowledge, and suspension from judgment. It is important to approach the life of immigrant women and tear down barriers, embracing the possibility of other narratives of body, health and disease.

Accommodating ''History Effects'' in Long Duration, Multisite Clinical Trials to Ensure Relevant and Compelling Evidence

Over the course of a clinical trial, changes in the practice environment have the potential to reduce internal and external validity and impact change in patient outcomes. Such ''history effects''1 can take the form of changes in standard of care, clinical guidelines and recommendations, new drug/device availability in the marketplace, testing and screening procedures, and, as recently experienced, a global pandemic. Clinical trials conducted over many years are particularly susceptible to history effects. Such effects can impact foundational ability to continue a trial, including clinician equipoise and ability to implement trial interventions, necessitating awareness and action planning. For example, Curtis et al.2 acknowledged challenges with clinical guideline history effects and issued recommendations for addressing them such as consideration of participant wellbeing, stakeholder engagement, safety monitoring, review of guideline and policy changes, and development of rules for protocol changes. This session will explore how four multisite clinical trials conducted with VA Cooperative Studies Program sponsorship and coordination have weathered history effects during prolonged periods of enrollment. Topics to be covered include the implementation of pragmatic designs, monitoring of clinical guidelines, assessing control group treatment conditions, modifying protocols, adjusting quality assurance procedures, refining recruitment pathways, and training site investigators. The speakers, Study Chairs, will describe best practices and provide recommendations for navigating history effects in prolonged multisite clinical trials that can ensure outcomes remain relevant and compelling to inform public health at trial commencement. The CSP 2008/PTXRx study is a pragmatic, randomized, double-blind, placebo-controlled, multicenter clinical trial of Veteran patients with diabetic kidney disease (DKD) examining whether pentoxifylline (PTX), when added to usual care, can delay time to end-stage renal disease or death. Enrollment for the study began in 2019, and it is anticipated that 9 years of follow-up will be required to observe the required number of primary events. Given the long duration of the study, changes in clinical guidelines were anticipated and have occurred, including the approval of new DKD therapies and introduction of a new formula for estimated glomerular filtration rate (eGFR) calculation. In anticipation of these changes, the study design allows for whatever standard of care is extant at any time during the course of the study. PTXR's pragmatic trial design and protocol leverage the VA's research infrastructure and remote platforms allowing the study to be responsive to external changes and to safely continue during a global pandemic. The CSP 596/OPTION study is a randomized, double- blind, multicenter trial of Veteran patients with a first or second recurrent Clostridium difficile infection (CDI) comparing (1) fidaxomicin and (2) vancomycin, followed by a taper and pulse to (3) a standard vancomycin regimen. Since enrollment began in 2016, significant changes in CDI epidemiology and clinical management have impacted the study. The COVID-19 pandemic also resulted in an administrative hold on all trial activity followed by staggered reopening of sites due to variable COVID-19 activity and clinical priorities. Many clinical laboratories switched to algorithms that included free toxin assays in addition to polymerase chain reaction (PCR) tests out of concern for overdiagnosis based on PCR testing alone, reducing the number of potentially enrollable cases. There has been increased empirical vancomycin treatment for recurrent CDI without confirmation by stool testing, a requirement for enrollment, and a recruitment strategy for identifying potential cases. Finally, conflicting clinical guidelines for recurrent CDI has created potential equipoise when considering enrollment. Ongoing educational efforts have been made to clarify the protocol and emphasize the validity of the research question as well as protoco changes to allow safe enrollment and follow-up of participants in the face of the ongoing COVID-19 pandemic. The CSP 2005/VALOR is a phase III randomized, open label, multicenter clinical trial of Veteran patients with operable stage I non-small cell lung cancer that compares stereotactic radiotherapy and anatomic pulmonary resection with a primary outcome measure of overall survival. The study was activated in 2017 and recruitment to the trial has been affected by ongoing changes in public and clinician perceptions about stereotactic radiotherapy and surgery that have interfered with equipoise and willingness of participants to enroll. The study team perpetually addresses this challenge through group conversations with local site investigators, study coordinators, and other research personnel to preserve group equipoise across the study. Since the study's activation, new safety information about stereotactic radiotherapy has emerged necessitating protocol modifications while aiming to preserve internal and external validity. The includes modifying standard operating procedures for the study's centralized quality assurance program that has had to adapt its process to remain contemporary. STARPORT, funded by VA CSRD with CSP collaboration, is a randomized, open label, multicenter clinical trial of Veteran patients with oligorecurrent prostate cancer comparing the effects of standard systemic therapy (SST) alone or with PET-directed local therapy using surgery or radiation. Although enrollment was initiated in 2021, changes are already evident in clinical practice guidelines regarding the use of imaging in workup in this patient population. Shortly before the start of accrual, 18F-DCFPyL PSMA PET/CT received FDA-approval. Consequently, it is being rapidly adopted at the STARPORT VA medical centers and the use of conventional imaging using CT or bone scan prior to PET/CT imaging-part of the original eligibility criteria-quickly is falling out of favor. Furthermore, shortly after the start of enrollment, NCCN guidelines adopted the stance that conventional imaging was no longer required in the setting of PSMA PET/CT imaging, solidifying the transition away from conventional imaging. Thus, the protocol is being amended to remove the requirement for conventional imaging as part of workup for oligorecurrence. In addition, to be generalizable, the study is designed to integrate future PSMA radiotracers that are incorporated into practice as well as changes in SST regimens over the time of the study.

Integrating Mindfulness and Acceptance Into Traditional Cognitive Behavioral Therapy During the COVID-19 Pandemic: A Case Study of an Adult Man With Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be chronic and impairing, highlighting the need for effective treatments. Although Cognitive Behavior Therapy (CBT) is an effective treatment for GAD, a number of patients continue to report GAD symptoms treatment. Integrating evidenced-based treatment components into CBT treatments, such as mindfulness- and acceptance-based treatment components found in Acceptance and Commitment Therapy (ACT), may help improve the efficacy of treatment. Emerging interventions and research suggest that the cognitive restructuring aspect of CBT and acceptance stance of ACT (e.g., cognitive defusion) can be implemented into treatment concurrently from a stance of increasing a patient's coping skills repertoire and psychological flexibility. This systemic case analysis examined the efficacy and clinical utility of integrating ACT into a manualized CBT treatment for GAD. Furthermore, this study examined treatment efficacy and therapeutic alliance as the treatment rapidly and unexpectedly transitioned from in-person to telehealth due to the COVID-19 pandemic. Pre- to post-treatment and time-series analyses showed significant decreases in anxiety symptoms, worry, depressive symptoms, and emotion dysregulation. Although there was an initial increase in depressive and anxiety symptoms, worry, and emotion dysregulation following the switch from in-person to telehealth services, these quickly subsided and resumed a downward trend. The therapeutic relationship did not deteriorate during the transition to telehealth. This case study provides evidence of feasibility and efficacy of an integrated CBT/ACT approach in treating GAD. It also suggests that despite some temporary increase in symptoms, therapeutic alliance and treatment efficacy were not impacted by the switch to telehealth.Copyright © The Author(s) 2022.

Platypnea-Orthodeoxia Syndrome Due to Patent Foramen Ovale Shunt Caused by Aortic Root Dilation

Background Orthodeoxia syndrome (OS) is a rare clinical condition characterized by oxygen desaturation noted in the upright position (orthodeoxia). OS can originate in the heart, lungs, abdomen, or elsewhere due to either an intracardiac (cardiac OS) or intrapulmonary shunt, or a ventilation-perfusion mismatch. Anecdotal reports suggest that the enlargement of the aortic root could interfere with atrial septal mobility (ASM) and cause patent foramen ovale (PFO) shunt. Case A 77-year-old male patient was admitted to the ICU with pneumonia due to COVID-19. During the evaluation, the patient presented orthodeoxia detected by pulse oximetry, with oxygen saturation (SpO2) of 96% in supine and 70% in upright positions. COVID-19 was treated with remdesivir and corticosteroids without orthodeoxia improvement. Decision-making Pulmonary embolism was ruled out with CT Angiography. Transthoracic Echocardiogram was also normal. A microbubble contrast-enhanced Transesophageal echocardiography was done and confirmed an aortic root dilatation with atrial septal mobility leading to a significant patent foramen ovale (PFO) shunt. The patient was submitted to interventional closure of the patent foramen ovale with the resolution of orthodeoxia. Conclusion Increased Mobility of the Atrial Septum in Aortic Root Dilation can be a cause of PFO shunt and orthodeoxia [Formula presented]Copyright © 2023 American College of Cardiology Foundation

The Drive into the Wilderness

This study offers an example of ‘standing theology', as distinguished from sitting theology and kneeling theology. It was prepared as an online sermon during the Covid 19 ‘lockdown' for the congregation of St Margaret of Antioch, Durham, for Lent 1, 2021. The Gospel reading was Mark 1: 9–15. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

An Otorhinolaryngology Perspective Into a Hospital COVID-19 Cluster

In this commentary, we share our experience of a COVID-19 cluster which developed within a frontline healthcare facility designated for treating COVID-19 patients. We provide an Otorhinolaryngology perspective into the key challenges, analyses and responses. We discuss how we identified and isolated infected patients and staff, uncovered the responsible COVID-19 variant strain B1.617.2 and instituted various measures to overcome this cluster. The measures include ceasing non-essential services, limiting transfers of patients, a heightened stance of personal protective equipment, ring-fencing of staff and enhanced COVID-19 testing. With rapid hospital wide efforts, there were no new non-isolated cases from our hospital cluster 3 days after the wards were locked down. The cluster which developed on 28-April-2021 was closed on 6-Jun-2021, with 48 cases, ten of whom were healthcare workers. Some of these lessons may be useful for consideration should another healthcare institution face a similar crisis in the future.Copyright © The Author(s) 2022.

A Note on Estimating the Case Fatality Ratio for Novel Corona Virus Disease (COVID-19)

Background: In this paper, an attempt has been made to estimate the Case Fatality Ratio (CFR) for coronavirus disease of India and a few selected countries. And also, it highlighted the pros and cons of obtaining crude and adjusted CFR of COVID-19 pandemic. Material(s) and Method(s): Data extracted from the WHO situation report and the University of Oxford website have been used for this analysis. The CFR and its 95% confidence interval were computed, trend and bar plot was used for graphical representation. Result(s): The worldwide crude CFR stands 6.73% (95% CI 6.69 to 6.76) based on 21, 83, 877 confirmed and 1,46,872 death cases(as on 17th April, 2020). Belgium was the highest CFR at 13.95% as compared to others. However, India's CFR was found to be around 3.26% (as on 17th April, 2020). Conclusion(s): In conclusion, the estimation and interpretation of CFR are critical in response to ongoing COVID-19. The initial CFR estimates are subject to change, still, it is useful for healthcare planning over the coming months. Moreover, the precise and robust estimates of CFR will be available only at the end of the epidemic.Copyright © 2021 Bentham Science Publishers.

Influence of Discontinuation of Cardiac Rehabilitation in Elderly Outpatients Due to the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has restricted people's activities and necessitated the discontinuation of cardiac rehabilitation (CR) programs for outpatients. In our hospital, CR for outpatients had to be discontinued for 3 months. We investigated the influence of this discontinuation of CR on physical activity, body composition, and dietary intake in cardiovascular outpatients. METHOD: Seventy-eight outpatients who restarted CR were investigated. We measured body composition, balance test, stage of locomotive syndrome, and food frequency questionnaire (FFQ) results at restart and 3 months later. We also investigated the results of examination that were obtained before discontinuation. RESULTS: With regard to baseline characteristics, the percentage of male was 62.7% (n = 49), and average age and body mass index were 74.1 ± 8.5 years and 24.9 ± 7.0 kg/m2, respectively. Stage of locomotive syndrome and the results of FFQ did not change significantly. The one-leg standing time with eyes open test significantly worsened at restart (p < 0.001) and significantly improved 3 months later (p = 0.007). With regard to body composition, all limb muscle masses were decreased at restart and decreased even further 3 months later. CONCLUSIONS: Discontinuation of CR influenced standing balance and limb muscle mass. While the restart of CR may improve a patient's balance, more time is required for additional daily physical activities. The recent pandemic-related interruption of CR should inspire the development of alternatives that could ensure the continuity of CR in a future crisis.

PEG allergy - A COVID-19 pandemic-made problem? A German perspective.

Background: Polyethylene glycol (PEG) has been used for decades, but only caused allergic reactions exceptionally. Introduction of PEG-containing COVID-19 vaccines might have fostered public interest beyond medical reasoning. Objectives: To investigate the impact of the SARS-CoV-2 pandemic on the public interest in PEG allergy in Germany and the published PEG allergy cases worldwide. Methods: A retrospective longitudinal study was conducted to measure public interest in PEG allergy analyzing Google search volume in Germany from February 2018 to January 2022. Medically confirmed "PEG allergy" cases were analyzed by looking at the numbers of PubMed case reports and case series from 1977 until January 2022. Results: Web results in Germany before COVID-19 show search volumes related to "PEG allergy/testing" was negligible, with 10 search queries per month. The pandemic led to a >200-fold increase from 250 queries 2 years before to 55 720 queries 2 years thereafter, reflecting tremendous public interest. Additionally, the maximum monthly search volume from before to during the pandemic increased immensely for "vaccination" (57-fold), "vaccination and adverse effects" (85-fold), "vaccination and allergy" (71-fold). In contrast, the increase of publication numbers for the search term "PEG allergy" was small from 2019 to 2021 (2.5-fold). Only a very low number of 211 cases with "PEG allergy" worldwide since 1977 could be identified. Conclusion: PEG allergy became a topic of major public interest because of COVID-19 vaccination. Scientific publications have increased to a lesser extent, probably promoted by public awareness. Conversely, the overall number of cases published with PEG allergy remain very low. The current high demand for COVID-19 vaccination allergy testing is triggered by public interest instead of medical reasoning.

Autoimmune reactions associated with various types of sars-cov- 2 vaccines among rheumatic disease patients: a case series

Background: Vaccinations are of paramount importance in eradicating various diseases. Currently, there have been numerous reports on the development of new-onset autoimmune phenomena and disease flares following COVID-19 vaccination. The etiology and vaccine trigger mechanism of autoimmune disease still remains unclear. Molecular mimicry, by-stander activation and role of vaccine adjuvants are the main pathogenic mechanisms linked to an autoimmune phenomenon. However, vaccines as inducers of an autoimmunity is still an arguable subject. Case: We report a case series of six patients who developed new onset autoimmune reaction and disease flares following SARS-COV 2 vaccine. The patients received viral vector vaccine, inactivated vaccine and mRNA vaccine who developed symptoms in an average of 7-28 days following inoculation. A 27 year old male, previously healthy developed new onset of clinical amyopathic dermatomyositis after a week of 1st and 2nd dose of a viral vector vaccine. Two patients with systemic lupus erythematous developed severe cutaneous, hematologic and renal flare 14 and 28 days following vaccination. Two rheumatoid arthritis patients in long remission, developed atypical arthritis and disease flares after 10 and 14 days of inactivated and mRNA vaccine inoculation. One patient with spondylarthritis in remission experienced disease flare 7 days following inactivated SARS-COV- 2 vaccination. The patient age ranges from 19-72 years old of whom two are males and four are females. The management was individualized which includes oral corticosteroid and disease modifying anti-rheumatic drugs which showed improvement of symptoms. Conclusion: Development of an autoimmune reaction following SARS-COV 2 vaccination is of scientific and public importance. Vaccination might potentially trigger an autoimmune disease, however further investigations need to be established. The causative link between vaccination and autoimmunity needs to be studied. Susceptibility to a vaccine-induced autoimmunity might be triggered by the individual's genetic predisposition and several pathomechanisms.

Diagnosis of Skin Cancer by Using Fuzzy-Ann Expert System with Unification of Improved Gini Index Random Forest-Based Feature

In addition to being one of the most widespread and lethal diseases in the world, skin cancer is also one of the most common types of cancer. However, due to its complexity and fuzzy nature, the clinical diagnosis process of any disease, including skin cancer, prostate cancer, coronary artery disorders, diabetes, and COVID-19, is frequently accompanied by doubt. In order to address the uncertainty and ambiguity surrounding the diagnosis of skin cancer as well as the heavier burden on the overlay of the network nodes of the fuzzy neural network system that frequently occurs due to insignificant features that are used to predict or diagnose the disease, a fuzzy neural network expert system with an improved Gini index random forest-based feature importance measure algorithm was proposed in this work. A Greater Gini Index Out of the 30 features in the dataset, the five most fitting features of the diagnostic Wisconsin breast cancer database were chosen using a random forest-based feature importance measure algorithm. Two sets of classification models were created using the logistic regression, support vector machine, k-nearest neighbour, random forest, and Gaussian naive Bayes learning algorithms. As a result, models for classification that included all features (30) and models that only used the top five features were used. The efficacy of the two sets of categorization models was assessed, and the results of the assessment were compared. The comparison's results show that the models with the fittest features outperformed those with the most complete features in terms of accuracy, sensitivity, and sensitivity. A fuzzy neural network-based expert system was therefore developed, utilising the five best features, and it achieved 99.83 percent accuracy, 99.86 percent sensitivity, and 99.64 percent specificity. The system built in this study also stands to be the best in terms of accuracy, sensitivity, and specificity when compared to prior research that used fuzzy neural networks or other applicable artificial intelligence techniques on the same dataset for the diagnosis of skin cancer. The z-test was also performed, and the test result demonstrates that the system has significantly improved accuracy for early skin cancer diagnosis. Copyright © 2023 Wolters Kluwer Medknow Publications. All rights reserved.

Standing waves in a patient with systemic scleroderma

Standing waves are a very rare angiographic image with an unclear etiology. Many theories have been developed to explain this phenomenon, but none have been confirmed. We present an interesting case of a 57-year-old woman, whose angiography showed standing waves along the entire length of the superficial femoral artery. On admission, the patient's general condition was fairly good. No significant abnormalities were observed in the P-A chest feet and hands X-ray, as well as in the ultrasound of the abdominal cavity and pelvis. On March 8, the patient underwent angiography documenting the presence of regular "goose trachea-like" 'notched walls' over the entire length of the right superficial femoral artery. Angiography was then followed by an ultrasound exam of femoral arteries, however, no femoral artery wall changes were seen. The diagnosis was standing waves. Moreover, extensive diagnostics for systemic disease, as well as the overall clinical picture allowed for the diagnosis of systemic scleroderma. Standing waves are a rare phenomenon, harmless to the patient's life and health. Researchers have put forward many theories to explain its unclear etiology. The presence of standing waves has also been reported with the coexistence of diseases such as Buerger's, Tolos-Hunt's, or rheumatic heart disease. Moreover, it is worth mentioning the possibility of misdiagnosing standing waves as FMD. To summarize, standing waves are a harmless phenomenon. Despite its rare occurrence, it is worth remembering not to misdiagnose it and consequently, implement unnecessary diagnostics and treatment and cause superfluous anxiety in the patient. Copyright © 2022 Via Medica.

Automated Puff Tonometry in Comprehensive Community Based Screening for Vision Threatening Diseases during SARS-CoV-2

Purpose : Over 50% of individuals with vision-threatening disease (VTD) (e.g., diabetic retinopathy, glaucoma, macular degeneration) are unaware of their condition, and once diagnosed, 80% will not follow up for clinical care, especially since the onset of SARS-CoV-2 in 2020. Remote teleophthalmology with real-time robotic teleconsultation was implemented to include automated puff-tonometry (APT) as pre-triage to identify patients who require more detailed clinical assessment and treatment. Methods : 224 subjects (58% male) of average age 55 years were screened over 8 events. Following COVID-19 protocols screenings took place in New Jersey churches and health fairs featuring a high prevalence of African American and Hispanic subjects. Masked and self-reported vaccinated subjects underwent medical history, blood pressure, visual acuity (with pinhole), automated puff-tonometry (APT) for intraocular pressures (IOP), automated refraction, non-mydriatic retinal imaging, optical coherence tomography (OCT), and wearable visual field device (WVFD) testing. Face masks were fitted with surgical tape on the nose bridge to limit instrument fogging. To minimize equipment contact, all subjects were screened in the standing position, including APT and retinal imaging (Fig.1). Chi-square and t-tests were performed to assess factors associated with glaucoma referral. Subjects without IOP readings were excluded;significance was set at p<0.05. Results : 10.29% of measured eyes had an IOP>18 and underwent additional testing including OCT-B of the optic nerve head, nerve fiber layer, and ganglion cell complex. 31.43% of eyes with IOP>18 underwent teleconsultation with a glaucoma specialist, vs. 8.85% of eyes with IOP≤18 ((p<0.001), Table 1). The difference in mean age in subjects with glaucoma referral vs. without (57.42 vs. 51.61 years) was significant (p=0.008). Conclusions : APT was useful in supporting on-site OCT-B imaging and WVFD referral (37.67%, 8.52% of total subjects) that yielded 17.94% referral to on-site teleconsultation through a real-time telerobot. Future investigation will include larger and more diverse community-based populations.