Hand Surgical Simulation in the Pandemic Era: A Systematic Review

Introduction: The COVID-19 pandemic and duty hour restrictions have illuminated a role for surgical simulation in trainees that permits meaningful technical experience outside the operating room. There is a need for the implementation of surgical simulation infrastructure adjacent to clinical training with practical considerations for complexity and cost. This systematic review analyzes surgical simulations that train hand surgical techniques and procedures with subjective or objective competency assessment. Method(s): A systematic review was conducted according to PRISMA- P guidelines using the PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane databases. Selected search terms included procedures relevant to the field of hand surgery and various types of simulation training. Data, including skills and techniques taught and assessed, model type, equipment, cost, and emphasis placed in training for each article, were extracted. Result(s): Of 2,519 articles, 40 met inclusion criteria. Models were described as: synthetic benchtop/3D-printed (40.0%), animal (22.5%), cadaveric (20.0%), augmented and virtual reality (AR/ VR;12.5%), and other computer simulation (12.5%). Three models incorporated both a physical benchtop component and an AR/ VR component. The procedures most represented included tendon repair (30.0%), fracture fixation (27.5%), wrist arthroscopy (15.0%), and carpal tunnel release (15.0%). Sixty-five percent of articles emphasized the importance of surgical simulation in a surgeon's training. Conclusion(s): A diversity of surgical simulation models exist for the practice of various aspects of hand surgery. The existing literature demonstrates their utility for increasing expertise with surgical techniques and procedures in a low-risk setting.

Isometric thumb extension exercise as part of a multimodal intervention for de Quervain's syndrome: A randomised feasibility trial

Introduction: de Quervain's syndrome is a painful condition commonly presented to hand therapists. Exercise is utilised as an intervention, but isometric exercise has not been investigated. We aimed to assess the feasibility and safety of isometric thumb extension exercise for de Quervain's syndrome and to explore differences between high-load and low-load isometric exercise. Method(s): This parallel-group randomised clinical feasibility trial included individuals with de Quervain's syndrome. All participants underwent a 2 week washout period where they received an orthosis, education, and range of motion exercises. Eligible participants were then randomised to receive high or low-load isometric thumb extension exercises, performed daily for 4 weeks. Feasibility and safety were assessed by recruitment and drop-out rates, adherence, adverse events, and participant feedback via semi-structured interviews. Secondary outcomes included patient-reported outcomes for pain and function, and blinded assessment of range of motion and strength. Result(s): Twenty-eight participants were randomised. There were no drop-outs after randomisation, and no serious adverse events. Adherence to exercise was 86.7%, with 84% of participants stating they would choose to participate again. There were clinically and statistically significant improvements in pain and function over time (p < 0.001) but not in range of motion or strength. There were no statistically significant between-group differences. Conclusion(s): Isometric thumb extension exercise within a multimodal approach appears a safe and feasible intervention for people with de Quervain's syndrome. A large multi-centre trial would be required to compare high- and low-load isometric exercises. Further research investigating exercise and multimodal interventions in this population is warranted.Copyright © The Author(s) 2023.

Just Keep Swimming...Just Keep Swimming

History: We present a 15-year-old right hand dominant high school swimmer with no significant past medical history, who complains of right elbow pain along the distal biceps' tendon for a 2 months. Pain was insidious in onset, sharp, intermittent, and described as a 0 to 6 out of 10. The patient has been swimming more frequently over the last few months to prepare for competition and noticed progressive pain with swimming. He went on vacation and then was diagnosed with a COVID-19 infection and took an additional 2 weeks off due to fatigue. He returned to sport without re-integration and increased his swimming intensity to 1 to 2 hours daily, which worsened his pain. Performing the butterfly and breaststroke provoke symptoms and cessation of activity reduces the pain. Denies pain at rest. He took Advil which did not reduce his pain. Denies acute trauma, prior injuries, or paresthesias. Physical Exam: Inspection of right elbow: no swelling or signs of discoloration. Palpation: Tenderness at the distal biceps tendon but can hook the tendon without pain. No shoulder or wrist tenderness. Active Range of Motion: Elbow extension 0 degrees, elbow flexion 130 degrees, supination and pronation normal. Normal shoulder and wrist ROM. Muscle strength: 5/5 grip, wrist extension, and wrist flexion. Pain elicited with resisted elbow flexion at the distal humerus. Maneuvers: pain with distal humerus squeeze. Negative Maudsley and negative Cozen test. Differential Diagnosis: 36. Distal Biceps Tendonitis/Tear 37. Stress Reaction of the Distal Humerus 38. Medial Epicondyle Apophysitis 39. Capitellar Osteochondritis Dissecans 40. Radiocapitellar Plica Syndrome Test Results: x-ray right elbow: AP and Lateral views indicate no abnormalities to the bones, alignment, or soft tissue structures. MRI right elbow No IVCON: Biceps tendon intact. There is periosteal edema and endosteal aspect marrow edema along the medial aspect of the distal diaphysis and metaphysis of the humerus. Several small foci of increased cortical signal. No fractures, joint effusion, or chondral defects. Findings comparable to Fredrickson grade 4a distal humerus diametaphysis stress injury. Final Diagnosis: Right Elbow Supracondylar Grade 4a Stress Reaction. Discussion(s): Actives that involve repetitive motion are susceptible to overuse injuries. Cases of upper extremity stress reactions in swimmers have been documented along the inferior angle of the scapula, upper ribs, and olecranon. Stress reactions along the distal humerus in swimmers is not well documented. This pathology has been seen in baseball players, cricket bowlers, and tennis players. In swimming, the butterfly technique requires significant endurance and athletic strength. During a sprint, fast synchronized upper extremity revolutions occurring up to 60 cycles perminute counterforcewater surface area friction leading to excessive loading forces even at 50 meter distances. Outcome(s): The patient was withheld from upper body work outs and swimming for 6 weeks. VitaminDand Calcium levels were drawn revealing a normal calcium level (10.2), but a vitamin D level of 28.1. Patient was started on 600 IU of Vitamin D and 1300 mg of Calcium daily. The patient started a return to swim program and returned to full competition at 7 months post presentation. Follow-Up: At 6 weeks, started an upper extremity low impact non-aquatic physical therapy program. Then a slow progressive return to swimming was initiated at 50% effort for 4 weeks. At 10 weeks, a return to sport plan including 200 m all strokes except butterfly, progressed to 250 m at week 2, 300 m at week 3, and 350 m at week 4. Finally, initiated speed work in =0 to 100 m increments and elbow loading workouts.

Covid-19 Vaccine-Induced Myositis

Background/Aims Through the COVID pandemic there have emerged reports of autoimmunity or new rheumatic diseases presenting in patients after they had COVID-19. This is thought to be caused by cross-reactivity of the COVID-19 spike protein to human antigens. Given the use of mRNA COVID-19 vaccinations which express the spike protein we might expect to see presentation of new rheumatic diseases following their use. We discuss a case where this appears to have occurred. Methods Our patient is a 24-year-old male with mixed phenotype acute leukaemia who had been treated with allogenic stem cell transplant and was currently in remission. He presented with fevers, palpitations, myalgia and bilateral arm and leg swelling. Symptoms began the day after receiving the first dose of an mRNA COVID-19 vaccination (Pfizer/BioNTech.) There were no other symptoms or recent change in medications. Physical examination revealed tender oedema in his forearms, biceps and thighs bilaterally with sparring of the hands. He had reduced power with shoulder (MRC 3/5), elbow (4), wrist (4+) and hip (4) movements. Observations revealed tachycardia and fevers up to 40C. Results Laboratory studies showed markedly elevated C-reactive protein (202), creatinine kinase (6697) and troponin (593) whilst investigations for infection were negative. An autoimmune panel was positive for anti- PM-SCL-75-Ab. An electrocardiogram showed sinus tachycardia. Echocardiogram was normal. Bilateral upper limb dopplers revealed no deep vein thrombus. An MRI of his thighs showed diffuse symmetrical oedema within the muscles, in keeping with an inflammatory myositis. A quadricep muscle biopsy showed evidence of MHC class 1 up-regulation, suggesting an inflammatory process. In addition, there were numerous macrophages evident in the endomysium. While this can be seen in graft-versus-host disease (GVHD), they would usually be found in the perimysium. After discussion between haematology, rheumatology and neurology, this was felt to be a case of vaccine induced myositis and myocarditis. Autoimmune myositis was thought to be less likely due to the relative sparing of the hands and the absence of Raynaud's phenomenon. 1 gram of intravenous methylprednisolone was then given for 3 days. The patient had a marked response with defervescence, improving laboratory markers, improved myalgia and decreased limb swelling. The patient was stepped down to a reducing regime of prednisolone and discharged. Due to relapse whilst weaning he has started on mycophenalate mofetil and rituximab and now continues to improve. Conclusion There are case reports of myositis following COVID-19 vaccination but our patient's case is complicated by the differential diagnosis of GVHD and concurrent myocarditis. Ongoing work is needed to clarify the exact link between vaccination and the presentation of a new inflammatory myositis, but it is important to recognise and start treatment early in order to preserve muscle bulk and ensure recovery.

Enhancing Notification Awareness for Online Presenters via a Wrist-Worn Device

The practice of giving presentations online has exploded during the Covid pandemic. However, in these settings, presenters often find themselves overlooking questions and feedback, e.g. via chat, from the audience, because the presenter's screen is dominated by their slides, with other channels becoming less noticeable. This causes frustration among presenters and their audience alike. We investigate the impact of additional visual, auditory, and haptic cues for presenters in online scenarios, using a wrist-worn prototype. For this, we conducted a study where participants gave presentations via the videoconferencing tool Zoom on specific topics while trying to notice and correctly identify incoming notifications. Our findings indicate that supplementary notifications can be helpful in online presentations without inappropriately disturbing the presenter. © 2023 Owner/Author.

A Template for Video Telehealth Hand and Wrist Consultations during the Covid-19 Pandemic: A Preliminary Analysis of Patient and Provider Reported Outcomes

Purpose of Study: COVID-19 introduced a rapid shift to video telehealth patient visits. At our institution in Loma Linda, California, less than 13% of hand surgery patients were seen in person at the height of the pandemic, with the majority of patients being triaged to video telehealth appointments. This was challenging for the hand surgeon due to the complexity of a hand patient's physical examination. During this time, it was critical to rapidly develop, test, and implement a tool to assist the surgeon in evaluating and triaging patients effectively over video. The purpose of this project was to develop and implement a tool that would improve the effectiveness and efficiency of video telehealth visits for hand and wrist patients. Methods Used: We developed an informational packet that was sent to patients prior to their video telehealth visit containing a letter of explanation, a new patient questionnaire, and a step-by-step guide with photos for a virtual hand examination. The letter explained the guide's purpose and provided additional instructions to ensure visit effectiveness- remove jewelry and watches, find a space with optimal lighting, wear a short sleeve shirt, etc. In the virtual hand examination guide, we explained common physical examination maneuvers and The Ten Test to assist with virtual sensation assessment. A short "how-to" description in lay terms was given for each of the physical examination maneuvers and included corresponding photographs to maximize patient comprehension. Patients were instructed to read the guide prior to their video visit and to have it available during the visit. Summary of Results: We began to implement this tool in our hand practice for new and established patients in March 2020, and we have since found that our virtual hand examination has become more thorough and efficient. Surgeon satisfaction with this tool has been high, and patients have reported satisfaction and comfort. Patients have felt that it increased their understanding of the virtual physical examination process, decreased frustration, and have stated that they would recommend this guide to other patients scheduled to undergo a video telehealth visit. Conclusion(s): The COVID-19 pandemic necessitated a rapid shift from in-person visits to video telehealth consultations. This subsequently changed the way in which hand surgeons could evaluate their patients. The procedural changes that were adopted during the pandemic can be viewed as a sign of things to come, and we anticipate that video telehealth visits will continue to be commonplace in the future. In the wake of this change, we feel confident that this tool equips the hand surgeon well for an effective and efficient virtual examination and ultimately contributes to patient satisfaction.

Covid-19 Booster Vaccine Related Dermatitis: A Case Study

Case Report: A 28 year old male with a past medical history of hypothyroidism and positive ANA presented to an outpatient dermatology clinic with a diffuse pruritic rash two weeks after the administration of his first Moderna COVID booster vaccine. He denied any other accompanying symptoms such as fever or chills as well as any similar rashes to prior doses of the Moderna COVID vaccine. The rash consisted of pink erythematous minimally scaly papules, thin plaques and patches involving the left and right dorsal hands, forearms, wrists, face, neck and left shoulder. The remainder of the patient's skin including the bilateral lower extremities, the eyelids, conjunctiva and oral mucosa was clear. The patient denied any similar rashes in the past. The patient denied any allergies to medications, or food or environmental allergies. He denied any notable contact allergen exposures, including to soaps, lotions, and cosmetic products. The patient also denied any significant family history or past surgical history. The patient was on Armour Thyroid for hypothyroidism and testosterone for low levels since age eighteen. The patient was started on cetirizine 10 mg once daily for the rash with minimal improvement. Autoimmune workup for the rash was notable for an elevated anti-RNP and as the patient's past medical history included Raynaud's phenomenon and ANA positivity for ten years, the patient was diagnosed with mixed connective tissue disease (MCTD). Autoimmune conditions can often have an indolent course, where symptoms progressively develop and worsen. MCTD is an autoimmune overlap syndrome that can consist of the following three connective tissue diseases: systemic lupus erythematosus, scleroderma, and polymyositis. Millions of individuals across the world are receiving COVID vaccines to protect themselves and members of their community, and it is of utmost importance that we continue to investigate adverse events. Although of low incidence, these rare effects have the ability to impact large numbers of people within both healthy and immunocompromised populations. It is critical that we examine and document them in a rigorous manner, to ensure safe vaccine delivery and reassure the public about vaccine safety overall.

Effects of Critical Components of Home Office on Ergonomics of Workers during COVID-19 Pandemic

Background: The COVID-19 has impacted our education system in various ways and to compensate the losses, teachers had to make quick transition from face to face teaching to online mode of teaching. This unexpected transition has entailed challenges and constraints for the health all of us. Objective: To find the effect of critical components of home-office on the ergonomics of workers. Study type, settings and duration: This cross sectional survey was conducted at Riphah International University (all departments), Lahore Grammar School, Lahore and Minhaj University, Lahore from March to June 2020. Methodology: This was a cross sectional survey on computer workers and faculty from educational setups such as university centers in an attempt to determine the effects of critical components of home-office on the ergonomics of the workers. The sample size was calculated to N=80. As per inclusion criteria, workers and members of faculty working on computers from Lahore, had worked from home-office during the lock down for consistent 4 months and the working should be synchronous, were included in this study. REBA questionnaire was used to collect data from the workers in person. Frequencies and percentages were calculated to find the impact of home-office components on the ergonomics of the workers. Results: The study found that 57% of computer workers between 26-30 years had a high risk index for poor ergonomics, with moderate changes in 71.3% of the population. The REBA score represents MSD risk for the job task and the design goal is 4. Conclusion: From this study it was concluded that nearly 70% of the population was having an ergonomically poor posture while working. In addition to that, in nearly half of the population the risk was significant.

Cystic fibrosis fitness during inpatient treatment

Background: Physical activity has been shown to have a positive impact on cystic fibrosis (CF) symptoms and slows decline in lung function. Additionally, moderate-intensity activities have been shown to improve sputum expectoration and oxygen saturation in children with CF, improving symptoms [1]. This study assessed whether using fitness trackers and providing a daily step goal would increase physical activity in hospitalized children with CF. Method(s): This pre-post pilot study included participants aged 6 to 21 who were admitted to the hospital for a pulmonary exacerbation of CF between October 2020 and November 2021. Garmin vivosmart 4 wrist-based activity trackers were issued, and baseline datawere tracked and analyzed for the first 2 study days. Pre-goal number of steps was defined as average number of steps taken on those 2 days. On study day 3, a step goal and menu of activities designed to increase physical activity were shared with the participants. Steps after goal settingwere defined as average number of steps taken on study day 3 and beyond while hospitalized, excluding day of discharge. Data collected from the medical record and the activity tracker web-based profile included daily oxygen requirement, daily step count, sleep duration, overnight pulse oximetry levels, resting heart rate, calories expended, and intensity minutes. The primary outcome of change in daily steps and attainment of step goals was analyzed using descriptive statistical testing, means, and standard deviations. Outpatient data were collected for 3 months to observe adherence to goals after discharge. Result(s): Eight participants aged 6 to 18 completed the study. Hospital length of stay ranged from 4 to 14 days. Participants took an average of 1508 +/- 1078 steps before goal setting, which increased to an average of 3704 +/- 1555 steps after the intervention. Step goals were met 56% of the time, although these data were highly variable. During the first week after hospital discharge, participants took an average of 6303 +/- 1786 steps per day (Figure 1).(Figure Presented) Figure 1. During the intervention, patients met their step goal 56% of the time, although this was highly variable. Two patients met their goal 100% of the time (9- year-old boy, 7-year-old girl), two met it 0% of the time (18-year-old boy, 17-year-old girl), one met it 44% of the time (6-year-old boy), and the remaining three met it 67% of the time (10-year-old girl, 17-year-old girl, 14-year-old boy). Conclusion(s): This intervention shows promise, with daily number of steps doubling from baseline during the intervention period. There was great variability among participants, suggesting that the approach helps some more than others. Enrollment was initially planned for 20 patients, but the SARS-CoV-2 pandemic and changes to CF therapy reduced hospitalizations during the study period. Outpatient data were analyzed for only the first week after discharge because of poor adherence to wearing the device. Although our results showa positive impact, further research is needed to determine the effect such an intervention would have on a larger scale. Future directions of research include determining potential clinical benefit from increased activity during hospitalization and prolonged follow-up to assess long-term benefits of intervention.Copyright © 2022, European Cystic Fibrosis Society. All rights reserved

Development of Elbow-Wrist Telerehabilitation System - An Affordable, Available, Accessible, and Acceptable (4As) System

The application of telerehabilitation system has gained popularity and acceptance recently due to the restrictions in controlling the COVID-19 pandemic. This paper described the development of an elbow-wrist telerehabilitation system that complement the disrupted routine rehabilitation session. The developed system consists of a wearable exoskeleton system that assist in rehabilitation of the elbow and wrist joints for individuals with neurological conditions such as Parkinson's and Spinal Cord Injuries that affects movements of the upper extremities. The two modes of operation available enables the adoption of the 5G technology in the near future. This system also potentially fulfills the requirement of Accessibility, Availability, Affordability, and Acceptability (4As) of Telerehabilitation System in Malaysia. Overall development cost of the system is approximately MYR 500. The system enable rehabilitation to be performed at home-setting with a cloud-based monitoring system that will provide long-term monitoring for clinician's assessment. The project provides a proof-of-concept of such system in the Malaysian context.Clinical Relevance - This work demonstrated the proof-of concept of a 4A system is applicable in the Malaysian context. © 2022 IEEE.

A Cost-effective, Patient-facing Electronic Stethoscope For Telemedical Cardiac Auscultation

Introduction: The COVID19 pandemic spurred an unprecedented growth in telehealth utilization across medical specialties which challenged providers to adapt their standard history and physical protocols for the virtual realm. Heart failure clinicians could readily translate some aspects of physical examination such as jugular venous distention and lower extremity edema assessment over video incorporating bendopnea to gain additional information. However, objective data for clinicians to rely on and guide therapy was often missing. A myriad of technology is available to bridge this gap ranging from simple wearables to invasive hemodynamic monitors though come with varying price tags and avenues of accessibility. Objective(s): We sought to develop an affordable, patient-facing electronic stethoscope of comparable quality to those existing that could seamlessly integrate with any telemedicine platform for real-time or asynchronous clinician review. Method(s): A rigorous design process guided by clinician and patient input generated nearly 100 concepts stratified through a pugh decision matrix in reference to an existing product, the Eko Core, to decide on the most suitable design - the AusculBand. With the form factor of a wrist-band, the AusculBand encases a custom bell with a high fidelity microphone and unique circuitry to sit comfortably in the palm of a user's hand to facilitate self-auscultation over the chest wall for real-time clinician review via telemedicine. Recognizing cardiac sounds to fall between 20 Hz and 2000 Hz, frequency response testing was conducted to determine the cut-off frequency of the AusculBand. With knowledge of an industry standard signal-to-noise ratio of 10.31 dB, a simple comparative study was devised between our novel AusculBand and the commercial Eko Core. With each device, a single-user in replicative fashion collected cardiac signals from the chest wall and background noise from the bicep to generate signal-to-noise ratio readouts and compare overall sound quality. Result(s): In response to frequency testing, the AusculBand was found to attenuate frequencies higher than 1997 Hz when testing a signal that swept through a range of 0 to 3,000 Hz at a constant amplitude. This result was within 0.2% of the 2000 Hz upper-limit of cardiac sounds and surpassing our design input goal of <= 1%. Signal-to-noise ratio analysis revealed 27.29 dB for the AusculBand and 24.02 dB for the Eko Core each exceeding the industry standard of 10.31 dB. Head-to-head comparison revealed the AusculBand achieved nearly double the loudness of the Eko Core. The projected price of the AusculBand is $80. The Eko Core is currently marketed at $350. Conclusion(s): The AusculBand is a cost-effective, patient-facing electronic stethoscope that surpasses industry standards in signal-to-noise ratio and is readily adaptable to popular telemedicine platforms. Additional modification is underway to add a single-lead electrocardiogram to bolster the device as an all-in-one, affordable and accessible telemedicine tool for cardiac analysis.Copyright © 2022

A rare case of CSU+CIndU resistant to systemic treatment with GCS and methotrexate initiated to Takayasu's disease

Case report Background: It is well known that chronic spontaneous urticaria (CSU) has an autoimmune etiology in 40% of cases. It is often comorbid with other autoimmune diseases and a wide spectrum of autoantibodies involved in the pathogenesis of CSU is discussed. Objective(s): We share a clinical case of a rare underline autoimmune disease with later onset of CSU and chronic induced urticaria (CIU). Case: A 38-year- old woman was admitted to the hospital with SARS-CoV- 2 infection. At the age of 22, she was diagnosed with Takayasu's disease involving the aorta, the common and external carotid artery, and the left subclavian artery. Surgical interventions were performed twice -angioplasty of the involved vessels, but in both cases restenosis of the affected arteries was observed. Regarding the underlying disease, the patient received 10 mg of methotrexate once a week and 20 mg of prednisone daily. Due to detailed history collection, the patient noted that for the last 4 months she has rashes, bright red in color, rising above the surface of the skin and accompanied by a strong burning and itching dominantly on the upper and lower extremities, trunk. Appearing every day spontaneously, they have a rounded shape (diameter of up to 40-50 mm). While liner scratching the rash has similar contour. Rash elements disappear within a few hours, do not leave traces. During the current hospitalization, a wheal element up to 40 mm in diameter was observed at the wrist area, stayed for a few hours. UAS-7 -42. According to examination: eosinophils 1000 cells/mcl (patient noticed that eosinophilia of the blood has happened before, an examination was conducted, helminthiasis and parasitosis were excluded), total IgE -more than 2000 IU/ml, antibodies to b2-glycoprotein were revealed. Freak test -negative, but the linear wheals were confirmed by retrospective photos. Result(s): In this clinical case, CSU occurs in combination with induced dermographic urticaria. This patient has extremely aggressive urticaria according to its frequency of occurrence despite therapy with systemic GCS and methotrexate. After recovery from coronavirus infection, further examination and consideration of the appointment of biologicals(anti-IgE) is planned.

Immunological examination of patients with rheumatological involvement after Covid-19 infection

Background: The emergence of autoinflammatory/autoimmune disorders in COVID-19 patients has necessitated the development of new strategies for the management of these phenomena. Several viruses have been shown to cause autoimmunity by boosting the production of autoreactive lymphocytes, resulting in a lack of tolerance in the host's immune response. The SARS-CoV- 2 virus and/or its proteins can cause autoimmunity by molecular mimicry, superantigen activity, and disruption of type I IFN production. Method(s): The data of three patients who applied to the outpatient clinics of pediatric immunology and rheumatology at Uludag University Hospital between March 2020 and December 2021 and were followed up with autoimmune/autoinflammatory disease following CCovid-19- 19 infection were analyzed retrospectively. Result(s): All patients were female and aged between 2-17 years. They had SARS-COV- 2 infection which was mild a few months ago. Before the Covid-19 infection, all of the patients were in good health. The patients had no history of frequent infections or familial predisposition to rheumatic diseases. Following the Covid-19- infection, all of our patients showed fever, rash, joint discomfort, and muscle soreness. Despite the fact that myalgia affects the whole body, arthralgia was present on the wrists and knees of patients. CRP, sedimentation rate, and acute phase reactants increased in all of them. According to the American College of Rheumatology's diagnostic criteria, our first patient was diagnosed with systemic lupus erythematosus (SLE) and was treated with hydroxychloroquine, intravenous immunoglobulin treatment and anakinra. Two of three were diagnosed with systemic juvenile idiopathic arthritis (sJIA) according to the League of Associations for Rheumatology (ILAR) criteria. Only one patient had low IgG and IgA levels (Table 1). Two patients showed a decrease in CD19+ naive cells percent and numbers. Conclusion(s): Following SARS-CoV- 2 infection, autoimmune and autoinflammatory disorders such as rheumatoid arthritis, psoriatic arthritis, type 1 diabetes and Still disease have been documented in adult cases. There are limited pediatric cases on this issue. It has been suggested that the persistence of the latent immune response after COVID-19 infection happens by sensitizing the immune system to viral particles long after they have been eliminated from organisms. Is the autoimmune process the effect of a viral infection or mis-targeted immune system? These questions need deep research and discussion.

An 81-Year-old Woman With Proximal Weakness

An 81-year-old woman developed progressive proximal weakness and myalgias several months following a COVID-19 infection. She was admitted to her local hospital for progressive weakness, peripheral edema, and exertional dyspnea. Neurology evaluation noted proximal arm and leg weakness. She had creatine kinase 740 U/L, white blood cells 21,000/mL (with abnormal differential), and abnormal antibody serologies. Additional diagnostic testing obtained included a thigh MRI and muscle biopsy. During her COVID-19 admission, a mediastinal mass had been detected, which was increased in size on this current admission. Notably, she had a remote history of an incidentally discovered mediastinal mass, which had been incompletely resected 18 years prior. At neuromuscular follow-up one month later, she reported improvement in peripheral edema and dyspnea but ongoing weakness. Strength exam noted symmetric Medical Research Council grade 4 weakness in neck flexion/extension, shoulder abduction, elbow flexion/extension, wrist extension, hip flexion/abduction/extension, and knee flexion. She had no fatiguability and no facial or bulbar weakness. Remainder of her neuromuscular examination was unremarkable. Her white blood cell count differential remained abnormal but had improved from her initial presentation. Her recent muscle biopsy slides were reviewed again. Bone marrow biopsy and mediastinal mass biopsy were obtained. A unifying diagnosis was made, and she was started on therapy with resolution of her weakness, myalgias, and abnormal cell counts.

Case report of an antimelanoma differentiationassociated protein 5 antibody-associated amyopathic dermatomyositis

Autoantibodies against melanoma differentiation-associated protein 5 (MDA5) associated with dermatomyositis have recently been described in Asians with rapidly progressive respiratory disease. Here we report the case of a middle-aged white woman with anti-MDA5 antibody-associated amyopathic dermatomyositis with interstitial lung disease (ILD), which is stable with minimal immune suppression. A 55-year-old woman was referred to a virtual dermatology clinic during the COVID-19 pandemic suspected of having widespread eczema involving the chest, face, arm and hands on the background of atopy. On direct questioning, she admitted to having constitutional symptoms, exertional dyspnoea, joint pain and symptoms of proximal muscle weakness. On clinical suspicion of possible connective tissue disorder, she was urgently reviewed in the hospital, where she was found to have a photodistributed rash involving cutaneous ulceration and violaceous plaques. Hand examination showed mechanic's hand mimicking hand eczema, ragged nail cuticles and acute tenosynovitis in the left index finger. Her upper and lower limb muscle power was normal and respiratory examination revealed bi-basal fine end-expiratory crepitation. Her repeated biochemical, haematological and muscle enzymes remained normal. Skin biopsy taken from photosensitive rash over the wrist showed hypergranulosis, Civatte body formation, colloid bodies and dyskeratotic keratinocytes, in keeping with severe lichenoid eruption. Superficial dermis showed patchy red-cell extravasation, perivascular chronic infiltration, dermal oedema and serum on the surface, in keeping with ulceration secondary to severe inflammatory processes. There were no eosinophils and eccrine coils were free of inflammation, raising the suspicion of a drug eruption. Her antinuclear antibody and double-stranded DNA were repeatedly negative. Myositisspecific antibody panel was performed owing to a high clinical suspicion of photosensitive dermatoses, both clinically and histologically. Histology revealed positive anti-MDA5 antibodies;repeated positive testing confirmed this. Although lung function was normal, computed tomography revealed evidence of ILD. We made a diagnosis of anti-MDA5 antibodyassociated amyopathic dermatomyositis with ILD. Her malignancy screening was negative. The patient was started on lowdose prednisolone and hydroxychloroquine 200 mg twice daily, with topical steroid applications, which resulted in remarkable clinical improvement. Anti-MDA5 associated dermatomyositis has characteristic cutaneous lesions consisting of skin ulceration and tender palmar papules, mechanic's hands, inflammatory arthritis and rapidly progressive ILD, which is frequently fatal. Although our patient had ILD, she was relatively stable on minimal immunosuppression. It is important for clinicians to have an increased awareness of this disease as it could have a highly variable clinical presentation in the white population.

Usefulness of Intravenous Regional Anesthesia for Upper Extremity Arterial Injury Emergencies in Patients with COVID-19: A Case Series and Literature Review

The medical field has undergone many changes since the start of the coronavirus disease 19 (COVID-19) pandemic. In small-and medium-sized hospitals that lack negative pressure facilities for operating rooms, it is impossible to operate on patients infected with COVID-19. As a result, many patients requiring emergency surgery experience serious complications or die. The authors performed intravenous regional anesthesia (IVRA) and emergency surgery in an isolation room on three patients who needed prompt surgical management for upper extremity arterial injuries but could not enter the operating room due to COVID-19 infection. Anesthesia was successful in all cases. A minor anesthetic complication occurred in one patient, who recovered spontaneously. IVRA is a relatively safe and easy method for anesthesia. More-over, since the tourniquet is inflated before anesthesia, it is well-suited for patients with arterial injury. The method is simple and therefore easy to perform in an isolation room where space and manpower are limited. IVRA can be a good option in emergency surgery for upper extremity artery injury. © 2023 Korean Wound Management Society.

Prevalence of Musculoskeletal Disorders among Nursing Personnel

Background: Health sectors can be listed under the high-risk work areas. As we all know, in this COVID 19 pandemic, doctors, nurses, health workers are the front line warriors. If we consider only the nursing personnel here, their tasks alone are prone to occupational hazards. Musculoskeletal disorders (MSDs) are most common among the self-reported occupational diseases. In previous studies, a significantly large number of participants reported musculoskeletal symptoms faced at least once. Insufficiency of ergonomic expertise is one of the most important recognizable risk factors as well as the shortage of staff in hospitals. MSDs are caused due to stressful physical work, static work postures, frequent bending, and twisting, lifting, pushing, and pulling of heavy objects, vibrations, localized mechanical pressure, etc. Various studies have shown that the daily chores of nursing personnel put them at high risk of MSDs. Methods : The study areas were different hospitals and nursing homes in West Bengal. Only the female, registered nurses working in different wards are chosen for this study. The study's inclusion criteria were only the female, registered nurses and the absence of any chronic disease in them. The exclusion criteria were the nursing students, nurses having histories of recent or previous major accidents/injuries or chronic diseases. The study population was interviewed on a one-to-one basis by means of a questionnaire based on Modified Nordic Musculoskeletal Questionnaire. Result(s): Among the total study population, 67.5% of subjects reported low back pain (LBP). 22.5% reported upper back, knee, and ankle discomfort. 27.5%, 15%, and 12.5% reported neck, shoulder, and wrist/hand discomfort, respectively. Conclusion(s): The results of this study have revealed that MSDs are a common phenomenon among nursing personnel. LBP is the most familiar among them, 67.5% of subjects have reported the presence of discomfort. Not only LBP, subjects reported neck, shoulder, knee, and upper back discomfort along with ankle and wrist symptoms. In this COVID-19 scenario, their jobs have become more strenuous than usual. It is found that tasks requiring continuous long hours to perform are causing symptoms to appear. Shift rotations, splitting of shifts, using more ergonomically designed tools, knowledge of ergonomic skills are required in this situation to avoid the aggravation of symptoms.

Remote Upper Limb group intervention post stroke increases intensity and improves wellbeing

Introduction: Increasing the intensity for upper limb rehabilitation post stroke has been emphasized in research and evidence. COVID-19 limitations with face-to-face therapy, have increased the opportunities to consider remote rehabilitation to provide the intensity needed. The aim of the group is to provide a goal based, structured exercise programme for upper limb among stroke survivors. Method(s): The Remote Upper Limb group has started to be part of the service that CST provides since 2020. The group consists of a warm-up, exercises using activity station, and functional exercises where we use items available at patients' home. The exercises are designed to address these areas: shoulder, elbow, forearm, wrist fingers, activities, and functional activities. The group also provides education session for the upper limb including pain, sensory deficits, specificity, subluxation, oedema and, learned non-use. Standardised outcome measures are taken at the beginning and the end of the group and used to measure progression and improvement. Result(s): The remote upper limb group intervention has emerged as a promising intervention to increase intensity and achieve patients' outcomes. The outcome measures have shown clinically significant improvement in patients' physical outcomes and their wellbeing. The patients report opportunities for peer support as their main benefit. Conclusion(s): The remote upper limb group is an intervention that increases patients' intensity and improves well-being in a costly effective way for both therapists and stroke survivors.

Free-living core body temperature monitoring using a wrist-worn sensor after COVID-19 booster vaccination: a pilot study.

Core body temperature (CBT) is a key vital sign and fever is an important indicator of disease. In the past decade, there has been growing interest for vital sign monitoring technology that may be embedded in wearable devices, and the COVID-19 pandemic has highlighted the need for remote patient monitoring systems. While wrist-worn sensors allow continuous assessment of heart rate and oxygen saturation, reliable measurement of CBT at the wrist remains challenging. In this study, CBT was measured continuously in a free-living setting using a novel technology worn at the wrist and compared to reference core body temperature measurements, i.e., CBT values acquired with an ingestible temperature-sensing pill. Fifty individuals who received the COVID-19 booster vaccination were included. The datasets of 33 individuals were used to develop the CBT prediction algorithm, and the algorithm was then validated on the datasets of 17 participants. Mean observation time was 26.4 h and CBT > 38.0 °C occurred in 66% of the participants. CBT predicted by the wrist-worn sensor showed good correlation to the reference CBT (r = 0.72). Bland-Altman statistics showed an average bias of 0.11 °C of CBT predicted by the wrist-worn device compared to reference CBT, and limits of agreement were - 0.67 to + 0.93 °C, which is comparable to the bias and limits of agreement of commonly used tympanic membrane thermometers. The small size of the components needed for this technology would allow its integration into a variety of wearable monitoring systems assessing other vital signs and at the same time allowing maximal freedom of movement to the user.