Rheumatology Advice Lines: How to Manage Rising Demand and Limited Capacity?

Background/Aims Advice lines services (ALS) are a key aspect of providing coordinated patient care in rheumatology. Demand for rapid access to specialist advice increased during the pandemic due to the disruption of routine outpatient services but it is not clear whether this demand is sustained. We aimed to investigate the changes in demand for ALS, how this varied pre/during COVID-19 and audit the effect upon response times. We also aimed to assess the impact of introducing an email advice service on demand. Methods We audited the number of advice line contacts of a single rheumatology department, serving a population of 500,000 people. The telephone adviceline is provided as an answer machine with an email advice service set up in April 2020. The outcome of each contact is recorded as a) advice only b) action required (e.g., prescription, blood test, GP letter) or c) required appointment (monitor/nurse/ medical). We audited response times using the RCN guidelines of a two-day response1 as the gold standard. Results Demand for advice had been increasing pre-COVID with an average of 368 calls/month (1/1/19-1/7/19) to 420/month (1/7/19-31/12/19). Sixty percent were advice only calls but 27% required additional action. Response times met the audit standard in 97% of cases pre-COVID. During the first two months of COVID demand for advice services doubled, however demand continued to rise although outcomes were similar (Table 1). As the number of contacts increased the proportion of telephone contacts responded to within the audit standard fell. Numbers of email contacts were variable, but response times exceeded the audit standard. Conclusion This audit demonstrates the demand of adviceline services has continued to increase throughout the pandemic and beyond, impacting the ability of services to respond within a timely manner. Ongoing QI work is assessing mechanisms to manage increased demand (using healthcare support workers to triage calls) and investigating reasons for accessing ALS to ensure appropriate advice is available. (Table Presented).

JAE, 2022: Report of the Editor‐in‐Chief

Submissions to the Journal have stabilised since the Covid‐related surge in 2020, and continue their strong international pattern. Our response times continue to meet or exceed our targets, with a few regrettable exceptions, for which our sincere apologies. The JAE's citation impact factor increased again in 2021 to 4.16, a modest increase from the 2020 score. Our total 2‐year citations, however, show a worrying decline since last year. Our sincere thanks are due to our authors and our many reviewers for their contributions. Wiley continue to provide a strong publishing platform with our full archive, generating continuing growth in downloads.

Analysis of Prolonged Caesarean Section Response Time in True Emergency Obstetric Care during Covid-19 Pandemic Era: Study at Kariadi Tertiary Hospital Indonesia

Intro: COVID-19 pandemic era makes quality of obstetric triage care including caesarean section in obstetric true emergency cases delayed. Maternal fetal triage index (MFTI) score is an instrument used to define true emergency in obstetric cases. Decision to delivery interval (DDI) is time interval from caesarean section decision to delivery within <30 minutes standard in emergency cases.This study was designed to evaluate the decision to delivery time interval and its effect on perinatal outcomes and the associated factors during category-1 emergency caesarean section deliveries. Method(s): A prospective observational descriptive study was conducted from 2020-2022 at Kariadi tertiary Hospital. A total of 40 clients who were undergone category-1 emergency caesarean section were included in this study. This is a indepht analysis pregnant women confirmed with COVID-19 infection and had true emergency cases based on MFTI score (stat-priority 1). Finding(s): Among 346 pregnant women with COVID-19, total 160 C-section cases with 40 eligible data were included in this study. Gestational age mostly in their second and third trimester. Maternal comorbidities were diabetes in pregnancy, HIV, pre eclampsia, SLE and thyroid disease. This study showed that DDI <30 minutes were found in 34 cases (85%), DDI 30-60 minutes as many as 6 (15%), and no (0%) DDI >60 minutes. Emergency cases with the shortest DDI were umbilical cord prolapse 3 (100%), fetal distress 14 (93%), placental abruption 5 (83%), impending uterine rupture 5 (83%), and antepartum hemorrhage 7 (70%). Perinatal outcome were Apgar score lower than 7 at 1 minutes (25%) and stillbirth (5%). Conclusion(s): Most of DDI in this study met the recommendation of <30 minutes, but some cases did not meet the standard. This can be caused by multifactorial factors such as advice from the doctor in charge, patient transfer distance, operating room preparation, and anesthetic preparation due to COVID-19.Copyright © 2023

Recovery of Platinum and Palladium from Spent Automotive Catalysts: Study of a New Leaching System Using a Complete Factorial Design

The recovery of materials and energy from end-of-life products is increasingly a fundamental factor in the sustainable development of various countries. Recovering metals from different types of waste is not only a practice in support of the environment, but is also a profitable economic activity. For this reason, exhausted automotive catalysts can become renewable sources of critical raw materials such as Pt, Pd, and Rh. However, recovering Pt and Pd from spent catalysts through an efficient, economical, and green method remains a challenge. This article presents a new leaching process for the hydrometallurgical recovery of Pt and Pd from exhausted automotive catalysts. The leaching solution consists of an aqueous mixture of hydrochloric acid, two organic acids (citric acid and acetic acid) and hydrogen peroxide. A complete factorial plan on two levels (2k) was performed in order to evaluate the main effects of the analyzed factors and their interactions. The factors that were presumed to be the most influential on the leaching of Pt and Pd were the concentrations of the different reagents and the reaction time. The optimal circumstances for achieving the largest recovery (over 80% Pt and 100% Pd) were achieved using the following conditions: a concentration of HCl of 5 M, a concentration of H2O2 of 10% wt./vol., a concentration of C2H4O2 of 10%vol./vol., and a reaction time of 3 h.

Comparison of code blue application and results in a training and research hospital before and during the COVID-19 pandemic

Background & Objective: Code blue is an emergency management system that allows for a rapid professional response to the patients of cardiopulmonary arrest (CPA) in hospitals. The time to initiate the call and the response of the 'Code Blue Team' may vary in different hospitals, and it me be linked with the survival of the victim. We examined and compared the code blue application utilized in our hospital before and during the COVID-19 pandemic. Methodology: Code Blue Call (CBC) logs from March 01, 2018 to March 31, 2022 were retrospectively analyzed. The study period was divided into two parts: March 01, 2018-February 28, 2020 (Group I, pre-pandemic period) and March 01, 2020-March 31, 2022 (Group II, pandemic period). Result(s): During the study period, a total of 1542 CBC's were received, of which 837 (54.3%) were 'true' CBC's. Of the 837 true CBC's included in the study, 477 (56.7%) were for male patients and 360 (43.3%) were for the females. We evaluated the month-wise distribution of the CBC's;the month with the highest number of calls in Group I was January 2019 (n = 29, 17.3%), while in Group II it was December 2020 (n = 59, 23.1%). The arrival time of the code blue team was significantly different between the groups, e.g., 3.15 +/- 0.52 vs. 3.81 +/- 0.58 min in Group I vs. Group II respectively. Conclusion(s): The intervention times of the code blue team and the success of cardiopulmonary resuscitation were observed to be comparable during the pre-pandemic and pandemic periods. The duration of commencement of intervention is important for the efficacy of cardiopulmonary resuscitation during a pandemic.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Advocacy and Adoption of Technology and Disparities in India

The number of people with diabetes globally, is rising at an alarming rate. South Asia is one of the hot spots of the diabetes epidemic. In India alone, there are over 74 million people with diabetes today. Unfortunately, 70% of the doctors in India practice in urban areas while 70% of India's population lives in rural areas. This mismatch between the availability of health care professionals and the rapid spread of diabetes in rural areas, provides an opportunity to use technology to deliver the diabetes care to remote rural areas. The first part of this presentation will talk about a model of successful delivery of diabetes health care in rural India. The Chunampet Rural Diabetes Program was carried out in a group of 42 villages in Kancheepuram District in Tamilnadu. Using a Mobile van, a population of 27,014 individuals (86.5% of the adult population) were screened for diabetes. All those detected with diabetes were offered a follow up care at a rural diabetes centre which was set up during the project. The results were very impressive and led to good improvement in A1c levels using low cost generic drugs. The second use of technology was during the COVID - 19 pandemic and the lock down which was enforced in India and many other countries. Thankfully, Telemedicine was also legalized in India at that time. Using technology, a system was created whereby the doctor and the patient stayed at home but blood tests were arranged at home for the patient.With the results, teleconsultation was done by doctors using the Electronic Medical Records which were made available on their mobile phones. Thus, despite the lockdown, patients managed to get their tests and diabetes consultations done remotely. The third use of technology is through our network of diabetes clinics across India. Even at centres where there was no ophthalmologist, retinal photographs were obtained using a lowcost retinal camera and were uploaded for centralized diabetic retinopathy grading unit where the images were read by trained retina specialists. The eye reports were sent back to the peripheral clinics in real time. Over one year period, 25,316 individuals with diabetes could have their eyes screened for diabetic retinopathy. Only 11.4 % needed referral to an ophthalmologist for further management. Finally, the use of mobile Apps has revolutionized diabetes treatment. Recently, we have developed three diabetes related tools. 'DIA' - an AI powered chatbot to assist people through automated digital conversations, 'DIALA' - a patientfriendly mobile app and 'DIANA' - a healthcare application for precision diabetes care. The details of these three tools are briefly described below : DIA : The Conversational AI Virtual Assistant 'DIA' can interact in English with its unique conversational AI technology and intuitive interface, it has proved to be a useful solution for patients, providing complex dialogues, with quick response time and offers comprehensive solutions for patients with diabetes. DIA's uses range from scheduling appointments and reminders for visits, lab tests and teleconsultation, to addressing enquiries on available medicines, treatments, and facilities.During an emergency, health crisis or in pandemic situations, it connects with caregivers and patients to take proper action as per the seriousness of their conditions. Further, it shares notifications, updates patient engagement and special offers. In addition to this, DIA can assist patients through reminders on their medicine refill via WhatsApp or SMS notifications and even facilitate purchase and tracking of medicine orders. DIALA : 'DIALA' is a DIAbetes Lifestyle Assistant Mobile Application. This app helps deliver superior and positive patient outcomes with weight tracking, step counts, diet plan adjustment, prescription refilling, availing reports of tests done, glucose monitoring data, scheduling appointments and sends reminders. It can help to monitor one's health and manage diabetes effectively. It is currently available in Android. DIANA : An advanced machine learning tool DIANA (DIAbetes Novel subgroup Assessment) is used to classify individuals with newly detected type 2 diabetes into specific subgroups such as insulin deficient or insulin resistance forms. This tool also gives the estimates of the risk for developing diabetes complications like eye or kidney disease. This machine learning approach has been developed based on published real world clinical data and will help the clinician offer individualized care for people with diabetes. In conclusion, judicious use of technology can help to bridge the socioeconomic and geographical challenges in delivering diabetes health care in developing countries.

Diagnostic test property of transcription-reverse transcription concerted reaction reagent TRCReady® SARS-CoV-2 i using nasopharyngeal swab samples

TRCReady® SARS-CoV-2 i is a reagent for transcription-reverse transcription concerted reaction (TRC) to detect SARS-CoV-2 N2 gene, used with the automated rapid isothermal nucleic acid amplification test (NAAT) analyzer TRCReady®-80. Sensitivity and specificity of TRCReady® SARS-CoV-2 i was assessed by comparison with the results of real-time reverse transcription-polymerase chain reaction (RT-PCR) using nasopharyngeal swab samples. From November 2020 to March 2021, a total of 441 nasopharyngeal swabs were obtained and analyzed both with TRCReady® SARS-CoV-2 i and RT-PCR. Sensitivity and specificity of TRCReady® SARS-CoV-2 i were 94.6% (53/56) and 99.2% (382/385), respectively. Reaction time to positivity of TRCReady® SARS-CoV-2 i ranged from 1.166 to 9.805 (median: 2.887) min, and minimum detection sensitivity of TRCReady® SARS-CoV-2 i was 9 copies per test, with reaction time as 5.014 min. Detection of SARS-CoV-2 gene from nasopharyngeal swab sample using TRCReady® SARS-CoV-2 i shows comparative diagnostic test accuracy with RT-PCR, and can be used as a useful test to diagnose SARS-CoV-2 infection. © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases

Towards assisting visually impaired individuals: A review on current status and future prospects

Visually impaired people require support with regular tasks including navigating, detecting obstacles, and maintaining safety, especially in both indoor and outdoor environments. As a result of the advancement of assistive technology, their lives have become substantially more convenient. Here, cutting-edge assistive devices and technologies for the visually impaired are reviewed, along with a chronology of their evolution. These methodologies are classified according to their intended applications. The taxonomy is combined with a description of the tests and experiments that can be used to examine the characteristics and assessments of assistive technology. In addition, the algorithms used in assistive devices are examined. This paper looks at solar industry innovations and promotes using renewable energy sources to create assistive devices, as well as, addresses the sudden advent of COVID-19 and the shift in the development of assistive devices. This review can serve as a stepping stone for further research on the topic. Copyright © 2022 The Author(s)

Can Qigong Be a Tool to Assist Students in Handling COVID-19's Resulting Academic Stress?

The recent COVID-19 pandemic has increased students' stress as they may feel under increased pressure to have a good performance and compensate for the disruption to their education. Improving attention levels and learning capacity may assist in ameliorating academic performance. Qigong is a traditional Chinese medicine technique that appears to have positive effects on the management of mental health and may provide tools for coping with stressful situations. This paper explores data obtained while conducting a previous study and includes an excess of data from a total of 44 participants who were previously divided into an experimental Qigong group and a sham Qigong control group. The improvements in specific auditory processing and reaction times may indicate benefits in attention and learning capacity. These improvements were more pronounced in the experimental Qigong group compared to the sham Qigong group. Qigong may be able to assist in improving students' academic performance and can be easily integrated into physical education classes. It could also assist students to cope with the increased academic pressure resulting from the COVID-19 pandemic context.

Can the choice reaction time be modified after COVID-19 diagnosis? A prospective cohort study.

Assessment of cognitive processing speed through choice reaction time (CRT) can be an objective tool to assess cognitive functions after COVID-19 infection. Objective: This study aimed to assess CRT in individuals after acute COVID-19 infection over 1 year. Methods: We prospectively analyzed 30 individuals (male: 9, female: 21) with mild-moderate functional status after COVID-19 and 30 individuals (male: 8, female: 22) without COVID-19. Cognitive and neuropsychiatric symptoms were evaluated using the Montreal Cognitive Assessment (MoCA) and Hospital Anxiety and Depression Scale (HADS), respectively. CRT (milliseconds) was evaluated by finding the difference between the photodiode signal and the electromyographic (EMG) onset latency of anterior deltoid, brachial biceps, and triceps during the task of reaching a luminous target. CRT was evaluated three times over 1 year after COVID-19: baseline assessment (>4 weeks of COVID-19 diagnosis), between 3 and 6 months, and between 6 and 12 months. Results: The multiple comparison analysis shows CRT reduction of the anterior deltoid in the COVID-19 group at 3-6 (p=0.001) and 6-12 months (p<0.001) compared to the control group. We also observed CRT reduction of the triceps at 6-12 months (p=0.002) and brachial biceps at 0-3 (p<0.001), 3-6 (p<0.001), and 6-12 months (p<0.001) in the COVID-19 compared to the control group. Moderate correlations were observed between MoCA and CRT of the anterior deltoid (r=-0.63; p=0.002) and brachial biceps (r=-0.67; p=0.001) at 6-12 months in the COVID-19 group. Conclusions: There was a reduction in CRT after acute COVID-19 over 1 year. A negative correlation was also observed between MoCA and CRT only from 6 to 12 months after COVID-19 infection.

A avaliação da velocidade de processamento cognitivo por meio do tempo de reação de escolha (TRE) pode ser uma ferramenta objetiva para acompanhar as alterações cognitivas após a COVID-19. Objetivo: Avaliar o TRE em pacientes após infecção aguda por COVID-19 ao longo de um ano. Métodos: Foram avaliados 30 indivíduos (sexo masculino: nove; feminino: 21) com estado funcional leve-moderado após infecção por COVID-19 e 30 (sexo masculino: oito; feminino: 22) sem COVID-19. A avaliação foi feita pelo Montreal Cognitive Assessment (MoCA) e pela Escala Hospitalar de Ansiedade e Depressão. O TRE (milissegundos) foi avaliado pela diferença entre o sinal luminoso e a latência de início da atividade muscular (EMG) do deltoide anterior (DA), do bíceps braquial (BB) e do tríceps durante uma tarefa de alcance. O TRE foi avaliado ao longo de um ano: avaliação inicial (>4 semanas após diagnóstico de COVID-19), em 3­6 meses e em 6­12 meses. Resultados: Houve redução do TRE do DA no grupo COVID-19 em 3­6 meses (p=0,001) e 6­12 meses (p<0,001) em comparação com o grupo de controle. Também foi observada redução na TRE do tríceps em 6­12 meses (p=0,002) e do BB em 0­3 meses (p<0,001), 3­6 meses (p<0,001) e 6­12 meses (p<0,001) no grupo COVID-19 em comparação com o grupo de controle. Correlações moderadas foram observadas entre MoCA e TRE do DA (r=-0,63; p=0,002) e BB (r=-0,67; p=0,001) aos 6­12 meses no grupo COVID-19. Conclusões: Houve redução do TRE após COVID-19 ao longo de um ano, além de correlação negativa entre MoCA e TRE no período de seis a 12 meses após COVID-19.

Procedural Motor Learning in Long COVID

Background: Early in the Covid pandemic, reports started to emerge of patients with lingering symptoms following recovery from acute infection, so called Long Covid (Miners, 2020;Nath, 2020;Troyer, 2020). Despite the high prevalence of neurological symptoms like brain fog and memory dysfunction (Davis, 2020), most research has relied on surveys or clinical tools typically used to assess declarative memory (Alemanno, 2021;Mendez 2021;Taquet, 2021). To our knowledge, no studies have examined Long Covid patients' ability to learn and consolidate a procedural motor skill. Method(s): We addressed this question in a group of 108 patients with Long Covid and 108 age-and sex-matched controls. Participants performed a well-characterized motor sequence typing task alternating 10-second practice with 10-second rest for 36 trials over 12 minutes (Bonstrup, 2020;Bonstrup, 2019;Buch, 2021). The following day, performance was tested to evaluate overnight consolidation. The behavioral endpoint measure was correct sequence typing speed (Buch, 2021) . Data were fitted to a 3-parameter model (initial performance, maximum performance, learning rate). Simple reaction times (RT) were measured twice: at the beginning and the end of the experimental session. Result(s): On average, patients had experienced 50 weeks of symptoms at time of testing. Long Covid patients' typing speed was slower than healthy controls at the beginning of the session (p=0.00075). While learning rates were comparable across groups (p=0.142), at the end of training Long Covid patients had not reached the same performance level as controls (p=0.046). Overnight consolidation was not statistically different between groups (p=0.58). Fourteen patients were hospitalized during their acute infection;they did not perform differently to patients who were not hospitalized. There were no sex differences when comparing healthy, long covid or combined groups. Pre-task RT was slower in Long Covid patients than in healthy controls (Covid 373+/-131ms, controls 317+/-43ms) but did not predict initial or final typing speed, nor learning rate in either group. Post-task RT was also faster in both groups, marginally more so in patients (Covid 353+/-117ms, controls 314+/-51ms). Conclusion(s): Long Covid patients exhibited slower starting performance. While they learned the skill at about the same pace, they failed to reach the same typing speed as healthy controls by the end of the task. Reaction times, here used as a measure of attention, did not exhibit a direct link with learning metrics.

COVID-19 Long-Term Effects: Is There an Impact on the Simple Reaction Time and Alternative-Forced Choice on Recovered Patients?

A comparative single-evaluation cross-sectional study was performed to evaluate cognitive damage in post-COVID-19 patients. The psychophysics tests of Two-Alternative Forced Choice (2AFC) and Simple Reaction Time (SRT), under a designed virtual environment, were used to evaluate the cognitive processes of decision-making, visual attention, and information processing speed. The population under study consisted of 147 individuals, 38 controls, and 109 post-COVID patients. During the 2AFC test, an Emotiv EPOC+® headset was used to obtain EEG signals to evaluate their Focus, Interest, and Engagement metrics. Results indicate that compared to healthy patients or recovered patients from mild-moderate COVID-19 infection, patients who recovered from a severe-critical COVID infection showed a poor performance in different cognitive tests: decision-making tasks required higher visual sensitivity (p = 0.002), Focus (p = 0.01) and information processing speed (p < 0.001). These results signal that the damage caused by the coronavirus on the central nervous and visual systems significantly reduces the cognitive processes capabilities, resulting in a prevalent deficit of 42.42% in information processing speed for mild-moderate cases, 46.15% for decision-making based on visual sensitivity, and 62.16% in information processing speed for severe-critical cases. A psychological follow-up for patients recovering from COVID-19 is recommended based on our findings.

Impact of Fatigue on Cognitive Function in Post-COVID19 Survivors

Background: Coronavirus 2 is the cause of COVID-19, a hazardous respiratory disease (SARS-CoV-2). More than 80% of hospitalized patients and 30% of COVID-19 survivors may have long-term effects. The most prevalent and incapacitating symptoms of the post-COVID-19 syndrome are thought to be fatigue and cognitive impairment. Objective: The major objective of the current study is to trace fatigue affected post-COVID survivors’ cognitive function. Subjects and Methods: In this study, 84 cases were enlisted, and they were subdivided into two groups. The study group consisted of 42 post-COVID survivors, and the control group consisted of 42 healthy individuals who were age-and sex-matched. Addenbrooke's cognitive examination revised scale, the fatigue rating scale, and the computer-based Cognitive Assessment therapy (Rehacom system) were adopted in the current study to evaluate each case. Results: A clear negative correlation was found between the FSS scores and the ACE-R (r =-0.98, p = 0.001), as well as between the FSS scores and the degree of logical thinking difficulty (r =-0.74, p = 0.001) and the FSS scores and the level of figural memory difficulty (r =-0.93, p = 0.001). Clear positive correlation were detected between the FSS scores and the first quartile response time (r = 0.94, p = 0.001), the third quartile reaction time (r = 0.96, p = 0.001), the acquisition time (r = 0.97, p = 0.001), and the solution time (r = 0.98, p = 0.001). Conclusion: In post-COVID survivors, fatigue has a major impact on cognitive abilities.

USEFULNESS of AN ELECTRONIC CONSULTATION SYSTEM between PRIMARY CARE HEALTH CENTERS and RHEUMATOLOGY DEPARTMENT of A TERTIARY HOSPITAL

Background: The EPISER study is the frst Spanish epidemiological study that has confrmed the great burden of rheumatic diseases in the general population: they consume a large quantity of health resources (doctor visits, medical products) and imply a high social impact in terms of work absenteeism. Rheumatic diseases represent almost 30% of Primary Care medical consultations in Spain1,2. Electronic consultation could be an alternative response to the increase of this demand, both to make an early diagnosis and derivation and to improve communication with Primary Care physicians3,4. Objectives: To analyze the demand of Primary Care and its resolution through the electronic consultation system of the Rheumatology Department of a tertiary hospital. Methods: Retrospective descriptive study of the data collected in the request and information system (Sistema de Peticiones Electrónicas, SIPE) that supports electronic consultation between primary care physicians of the health area and the Rheumatology Department of a tertiary hospital, between July 2020 and May 2021.The following variables were collected: age, sex, reason for consultation, response time in days and destination (primary care/outpatient follow-up). Descriptive statistics were used to present the results. Results: The last 500 consecutive electronic consultations registered in the system, referring to 496 patients, were collected. Mean age was 59.5±17.7 years;74.2% women. Mean response time was 2 days, median response time 1 day and range 0-45. The reasons for consultation (see Graph 1) were: osteoporosis assessment 55 (11%), treatment adjustment 50 (10%), appointment request 49 (9.8%), loss to follow-up 43 (8.6%), local-regional pathology assessment 39 (7.8%), infltration request 28 (5, 6%), suspected rheumatoid arthritis 19 (3.8%), fare 18 (3.6%), suspected polymyalgia rheumatica or giant cell arteri-tis 16 (3.2%), COVID vaccine consultation 14 (2.8%), Raynaud's phenomenon 13 (2.6%), monoarthritis assessment 12 (2.4%), assessment of polyarthritis 11 (2.2%), adverse effects of treatment 11 (2.2%), suspected spondyloarthritis 11 (2.2%), suspected psoriatic arthritis 8 (1, 6%), generalized pain 7 (1.4%), suspected Sjögren's syndrome 5 (1%), suspected systemic lupus erythematosus 1 (0.2%), suspected other systemic autoimmune diseases 9 (1.8%), others 81 (16.2%). Fifty-seven and four % (287) of the patients required an appointment at the Rheumatology outpatient clinic and in 42.6% of the patients (213) the electronic consultation was successful, so it was not necessary to refer the patient to the hospital. Conclusion: Forty-two and six percent of the queries were resolved thanks to the electronic consultation system in an average of two days, otherwise that patients would have been referred to specialized care. The main reasons for consultation were osteoporosis assessment and clarifcation of doubts about the treatment of patients who were already being followed up by the Rheumatology Department.

ASSESSING THE UTILIZATION OF INPATIENT ECONSULTS DURING COVID-19

BACKGROUND: Electronic consultations (eConsults) are formal, asynchronous clinical consultations between primary care providers and specialists. With increasing implementation of inpatient eConsult programs, studies have classified the most frequently consulted departments and reported hospitalist satisfaction, with logistic discussion of inpatient eConsults. However, there are no studies analyzing the time to inpatient eConsult response and the prevalence of COVID-19 in eConsult patients. METHODS: A retrospective chart review of inpatient eConsults at a single U.S. tertiary care medical center from 3/26/20 to 10/8/20. We reviewed patient demographics, COVID-19 status, type of consult question, time to response, conversion rate to a face-to-face visit, and recommendation for outpatient specialty follow-up. RESULTS: There were 538 documented eConsults for 417 patients, with an average age of 52.8 years, 59.0% male, 72.9% white. The most frequently eConsulted departments were Physical Medicine and Rehabilitation (25.7%), Hematology Oncology (13.2%), and Cardiology (7.80%). Inpatient eConsults were predominately regarding patient management questions (87.9%), compared to questions about diagnosis (14.3%) and interpretation of labs or imaging (14.9%). eConsults with multiple question types (15.8%) were more frequent than previously observed in studies of outpatient eConsults. The majority of eConsults were answered and resolved by specialists after one note (61.7%);however, 34.9% of eConsults were followed virtually with multiple notes, and 3.35% were converted to face-to-face consults. Outpatient specialty follow-up was recommended in 12.6% of eConsults. Only 92 (17%) eConsults were linked to orders, enabling measurement of the time the note was signed by the consultant attending physician. The median time from eConsult order until the attending note signature was 14.1 hours. 65.2% of these eConsults had a response within 1 day. 68 study patients (16.3%) were hospitalized with COVID-19, comprising 123 (22.9%) inpatient eConsults. 1.63% of COVID-19 eConsults were converted to face-to-face consultations versus 3.86% of non-COVID-19 eConsults. 72 patients (17.3%) had multiple eConsults, with 39 (9.35%) of these patients having eConsults to multiple different specialties. Of these 39 patients, 21 had COVID-19 during their hospitalization, a higher proportion than the nonCOVID-19 cohort, χ2 (1, N = 417) = 28.083, p < 0.001. CONCLUSIONS: Evaluation of our inpatient eConsult program demonstrates that the majority of eConsults were regarding patient management, with few consults requiring conversion to face-to-face encounters. The findings also reveal an association of multiple specialty eConsults for COVID19 patients. Additionally, inpatient eConsults provide an avenue for reducing consultant exposure to COVID-19. Further efforts can focus on improving the workflow in an effort to optimize consultant response times and assessing the conclusion of outpatient specialty follow-up recommendations.

Development of a digital tool for home-based monitoring of skin disease for older adults

The COVID-19 pandemic has accelerated the adoption of telemedicine. However, current tools pose substantial barriers for older adults and those with low digital literacy. By implementing user-centered design, we developed a digital tool, Dermatology for Older Adults (DORA), for home-based monitoring of skin disease, specifically designed for older adults. DORA is a virtual assistant based on REDCap and Twilio APIs that automates image and symptom collection and allows communication between patients and the research team. We evaluated the feasibility, usability, patient compliance, retention, and clinical utility of DORA. Eligibility criteria included patients >70 years with any skin disease, access to a smartphone, and no cognitive impairment. We recruited 62 patients aged 70-94 (mean age 77), 39% female, 81% white from Stanford’s Dermatology Clinic from August-December 2021. We asked patients to send weekly photos and answer a questionnaire of a single skin lesion for 4 weeks, then monthly for 4 months. We measured response time, photo quality, and participant satisfaction using mHealth app usability questionnaire (MAUQ). The median response time was 1.4 days (IQR 0.6-3.4). Four participants dropped out. 83% completed photo submission requests (48% at initial request, 19% after 1st reminder and 16% after 2nd reminder). 80% of all questionnaires requested (131 of 163) were completed. Four dermatology clinicians evaluated the quality of the first 88 images and reported good confidence in triaging skin diseases. MAUQ scores were high for ease of use (5.6 SD1.3), interface satisfaction (5.5 SD1.3), and usefulness (5.2 SD1.3). Patients were consistently able to use DORA to submit photos and symptoms and reported high usability and satisfaction. Patient retention was high, and clinicians felt confident making triage recommendations based on DORA images. This approach can be used in other settings where digital literacy barriers and unequal access to dermatologists contribute to healthcare disparities.

Change in BMI and Fitness among Primary School Children in Austria: A 24-Month Follow-Up Study of 303 Children Measured before and during the Ongoing COVID-19 Pandemic.

The ongoing COVID-19 pandemic not only impacted the health of school children directly through SARS-CoV-2 infections, but the associated closures of schools and sports facilities also resulted in long-term negative side effects. The aim of this study was to investigate the effects of COVID-19-related mitigation measures on the health and fitness status of primary school children in Austria. A total of 303 primary school children participated in the longitudinal study. Data on height, weight, and fitness were collected before the COVID-19 pandemic (September 2019) and at one-year intervals (September 2020 and September 2021) during the course of the pandemic. In the first year, from September 2019 to September 2020, there were alarming increases in body mass index (BMI) standard deviation scores (SDSs) (from 0.32 to 0.49) and dramatic decreases in both cardiorespiratory endurance (CRE) (from 0.49 to -0.43) and action speed (from -0.31 to -0.64). In the second year (September 2020 to September 2021), the BMI scores stabilized, and improvements in CRE were observed, especially in the subgroup of children who were members of sports clubs. In the future, more initiatives and projects, in addition to sports club activities, should be started and expanded, particularly in schools, to specifically counteract the observed health damage and, thus, have a positive effect on the development of all children, especially those without sports club membership.

CARTITUDE-2 UPDATE: CILTACABTAGENE AUTOLEUCEL, A B-CELL MATURATION ANTIGEN-DIRECTED CHIMERIC ANTIGEN RECEPTOR T-CELL THERAPY, IN LENALIDOMIDEREFRACTORY PATIENTS WITH PROGRESSIVE MULTIPLE MYELOMA AFTER 1-3 PRIOR LINES OF THERAPY

Introduction: Ciltacabtagene autoleucel (cilta-cel) is a chimeric antigen receptor T-cell (CAR-T) therapy expressing two B-cell maturation antigen (BCMA)-targeting, single-domain antibodies. The multicohort, open-label, phase 2 CARTITUDE-2 study (NCT04133636) is assessing cilta-cel in patients (pts) with multiple myeloma (MM) under various clinical settings and evaluating the suitability of outpatient administration. Updated results of CARTITUDE-2 cohort A are presented here. Methods: Cohort A pts had progressive MM after 1-3 prior lines of therapy (LOT;included proteasome inhibitor [PI] and immunomodulatory drug [IMiD]), were lenalidomide-refractory, and had no previous exposure to BCMA-targeting agents. A single cilta-cel infusion at a target dose of 0.75×106 CAR+ viable T cells/kg was given 5-7 d after start of lymphodepletion (cyclophosphamide [300 mg/m2] and fludarabine [30 mg/m2] for 3 d). The primary endpoint was minimal residual disease (MRD) negativity at 10-5 at any time point. Secondary endpoints were overall response rate (ORR), duration of response (DOR), time and duration of MRD negativity, and incidence and severity of adverse events (AEs). Response was assessed per International Myeloma Working Group criteria and AEs were graded by Common Terminology Criteria for Adverse Events version 5.0 (cytokine release syndrome [CRS] and immune effector cell-associated neurotoxicity syndrome [ICANS] by American Society for Transplantation and Cellular Therapy). Results: As of April 15, 2021 (median follow-up of 9.7 mo), 20 pts (65% men;median age 60 y [range 38-75]) received cilta-cel, with 1 pt treated in an outpatient setting. Pts had a median of 2 prior LOT (range 1-3);60% had 1-2 prior LOT and 40% had 3 prior LOT. All pts were exposed to a PI, IMiD, and dexamethasone;95% were exposed to alkylating agents and 65% to daratumumab. 95% of pts were refractory to last LOT;40% were triple-class refractory. ORR was 95% (95% CI 75.1-99.9);85% (95% CI 62.1-96.8) had ≥complete response (CR), and 95% (95% CI 75.1-99.9) had ≥very good partial response (Figure). Median time to first response was 1.0 mo (range 0.7-3.3) and median time to ≥CR was 2.6 mo (range 0.9-7.9). Median DOR was not reached;progression-free survival (PFS) at 6 mo was 90% (95% CI 65.6-97.4). Of 13 MRD-evaluable pts, 92.3% (95% CI 64.0-99.8) were MRD-negative at 10-5. Hematologic AEs (≥20% of pts) were neutropenia (95%;grade [gr] 3/4: 95%), thrombocytopenia (80%;gr 3/4: 35%), anemia (75%;gr 3/4: 45%), lymphopenia (65%;gr 3/4: 60%) and leukopenia (55%;gr 3/4: 55%). 95% of pts had CRS (gr 3/4: 10%);median time to onset was 7 d (range 5-9) and median duration was 4 d (range 2-11). Four pts (20%) had CAR-T neurotoxicity (all gr 1/2). Three pts (15%) had ICANS (all gr 1/2);median time to onset was 8 d (range 7-10) and median duration was 3 d (range 1-3). One pt had facial paralysis (gr 2) with time to onset of 29 d and duration of 51 d. No movement and neurocognitive treatment-emergent adverse events (TEAEs) were reported. One death due to COVID-19 was assessed as treatment-related. Safety was manageable in the pt treated in an outpatient setting. Conclusions: A single cilta-cel infusion led to early and deep responses in pts with MM who had 1-3 prior LOT and were lenalidomide-refractory. No movement and neurocognitive TEAEs occurred, suggesting successful implementation of monitoring and pt management strategies across phase 2/3 studies in the CARTITUDE program.

Comparison of New Viscoelastic Coagulation Monitor with Standard of Care Thromboelastography for Anticoagulation Monitoring during 72-Hour Extracorporeal Life Support

Introduction: Management of coagulation remains the foremost challenge during extracorporeal life support (ECLS). Thromboelastography (TEG) and other viscoelastic clotting tests have shown utility for assessing coagulation status in trauma and ECLS patients and have also been utilized in COVID 19 patients. However, with few exceptions, these methods are performed in a laboratory setting, not at the bedside, and rely on cumbersome, non-portable equipment. The Viscoelastic Coagulation Monitor (VCM;Entegrion;Durham, NC) is a portable device/test developed for use at the bedside and outside hospitals to assess clot formation and lysis using a small sample of whole blood. Blood coagulation is activated by contact with the glass surface on the cartridge, and measurements are derived pertaining to clot formation, stability, and lysis - similar to metrics obtained by the TEG 5000 (Haemonetics;Boston, MA). In a recent study, the relationship of VCM results and heparin dose administered in 36 COVID-19 patients was investigated;however, use of VCM for ECLS with application of heparinase has not been reported. We investigated efficacy of the VCM for coagulation monitoring during 72 hours of continuous ECLS in swine and hypothesized that the VCM with heparinase correlates with TEG heparinase. Methods: Female Yorkshire swine (n=3, 53.4±1.6kg) were anesthetized, mechanically ventilated, and systemically heparinized. Blood samples were collected at baseline, post ECLS, 6, 24, 48, and 72-hours post ECLS initiation. For the VCM, 350μL of whole blood was added to a 0.05 IU heparinase vial, mixed, and then added to a VCM cartridge. For TEG, 340μL of citrated whole blood was added to 20μL 0.2 M CaCl2, and samples were activated with a kaolin reagent. Heparinase cups (Haemonetics;Boston, MA) were used for testing. Spearman correlation was performed to compare standard VCM metrics (clotting time [CT], clot formation time [CFT], alpha, maximum clot firmness [MCF], clot retraction/fibrinolysis [LI30]) to the respective TEG metrics (reaction time [R], clot formation time [K], alpha, maximum amplitude [MA], clot retraction/fibrinolysis [LY30]), and also to other conventional coagulation measurements such as prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen (FIB), and platelet count (PLT) for each timepoint. A p-value of 0.05 was used for significance. Results: All VCM metrics significantly correlated with the respective TEG measurements (see Table 1). Both VCM and TEG show the same positive and negative correlation relationships for clot formation time, clot kinetics, and clot retraction with conventional coagulation tests (see Table 2). Additionally, clotting time and maximum clot firmness did not show moderate or significant correlation with conventional tests. Prothrombin time did not correlate with any values. Conclusion: The VCM is comparable to TEG in assessing coagulation status in heparinized swine and can be used during austere care with ECLS application. In the next round of experiments, we will validate the VCM in clinically-relevant trauma with and without ECLS.

Ciltacabtagene Autoleucel, a BCell Maturation Antigen-Directed Chimeric Antigen Receptor T-Cell Therapy, in Lenalidomide-Refractory Patients With Progressive Multiple Myeloma After 1-3 Prior Lines of Therapy: Updated Results From CARTITUDE-2 Cohort A

Ciltacabtagene autoleucel (cilta-cel) is a chimeric antigen receptor T-cell (CAR-T) therapy expressing two B-cell maturation antigen (BCMA)-targeting, singledomain antibodies. The multicohort, open-label, phase 2 CARTITUDE-2 study (NCT04133636) is evaluating ciltacel in patients (pts) with multiple myeloma (MM) in various clinical settings and assessing the suitability of outpatient administration. Updated results from CARTITUDE-2 cohort A are presented here. Cohort A pts had progressive MM after 1-3 prior lines of therapy (LOT;included proteasome inhibitor [PI] and immunomodulatory drug [IMiD]), were lenalidomide-refractory, and had no previous exposure to agents targeting BCMA. A single cilta-cel infusion at a target dose of 0.75 × 106 CAR+ viable T cells/kg was given 5-7 days after start of lymphodepletion (cyclophosphamide [300 mg/m2 ] and fludarabine [30 mg/m2 ] for 3 days). The primary endpoint was minimal residual disease (MRD) negativity at 10 -5 at any time point. Secondary endpoints were overall response rate (ORR), duration of response (DOR), time and duration of MRD negativity and adverse events (AEs). Response was assessed by International Myeloma Working Group criteria and AEs were graded by Common Terminology Criteria for Adverse Events version 5.0 (cytokine release syndrome [CRS] and immune effector cell-associated neurotoxicity syndrome [ICANS] by American Society for Transplantation and Cellular Therapy). As of April 15, 2021 (median follow-up 9.7 months), 20 pts (65% men;median age 60 years [range 38-75]) received ciltacel, with 1 pt treated in an outpatient setting. Pts had a median of two prior LOT (range 1-3);60% with 1-2 prior LOT and 40% with three prior LOT. All pts were exposed to a PI, IMiD and dexamethasone;95% were exposed to alkylating agents and 65% to daratumumab. 95% of pts were refractory to last LOT;40% were triple-class refractory. ORR was 95% (95% CI 75.1-99.9);85% (95% CI 62.1-96.8) had ≥complete response (CR), and 95% (95% CI 75.1-99.9) had ≥very good partial response. The median time to first response was 1.0 months (range 0.7-3.3) and the median time to ≥CR was 2.6 months (range 0.9-7.9). The median DOR was not reached;progression-free survival (PFS) at 6 months was 90% (95% CI 65.6-97.4). Of MRD-evaluable pts ( n = 13), 92.3% (95% CI 64.0-99.8) were MRD-negative at 10 -5 . Haematological AEs (≥20% of pts) were neutropenia (95%;grade [gr] 3/4: 95%), thrombocytopenia (80%;gr 3/4: 35%), anaemia (75%;gr 3/4: 45%), lymphopenia (65%;gr 3/4: 60%) and leukopenia (55%;gr 3/4: 55%). Ninety-five percent of pts had CRS (gr 3/4: 10%);median time to onset was 7 days (range 5-9) and median duration was 4 days (range 2-11). Four pts (20%) had CAR-T neurotoxicity (all gr 1/2). Three pts (15%) had ICANS (all gr 1/2);median time to onset was 8 days (range 7-10) and median duration was 3 days (range 1-3). One pt had facial paralysis (gr 2) with time to onset of 29 days and duration of 51 days. No movement and neurocognitive treatment-emergent adverse events (TEAEs) occurred. One death occurred due to COVID-19 (assessed as treatment-related). Safety was manageable in the pt treated in an outpatient setting. Lenalidomide-refractory pts with MM and 1-3 prior LOT showed early and deep responses with a single cilta-cel infusion. No movement and neurocognitive TEAEs were reported, suggesting utilisation of successful monitoring and pt management strategies across phase 2/3 studies in the CARTITUDE program.