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1.
Investigative Ophthalmology and Visual Science ; 63(7):1738-F0198, 2022.
Article in English | EMBASE | ID: covidwho-2058702

ABSTRACT

Purpose : The American Academy of Ophthalmology (AAO) and the National Heart, Lung, and Blood Institute (NHLBI) suggest sickle cell patients undergo dilated funduscopic exams (DFE) every 1-2 years to screen for sickle cell retinopathy, but there is a paucity of research reporting whether such guidelines are followed in the sickle cell disease (SCD) population. A retrospective study was performed to assess whether adults with SCD at our institution are adhering to the recommendations. Methods : This study is a chart review of 842 adult patients with sickle cell diagnosis, seen from 3/17-3/21 by internists in the Montefiore healthcare system. Data was collected through the Electronic Medical Record (EMR) of patients with a DFE categorized as normal (Retinopathy -, n = 216) or with retinopathy (Retinopathy +, n = 199). A regular DFE was defined as at least one DFE every 2 years. Screening rates were calculated by removing patients with retinopathic disease noted in EMR from total SCD patients. Yearly DFE rates were calculated from March to March, since COVID-19 was declared a global pandemic in March 2020. Two-tailed Student's t-test was used for statistical analysis of continuous data, Fisher's exact test for categorical data, and two-sample proportion test for comparison of yearly exam rates. Results : The Retinopathy-group was younger (p<0.001) and contained less SC genotype (p<0.001) compared to Retinopathy +. 40.3% of the Retinopathy-patients were screened regularly (n = 87), whereas 59.7% had irregular screening (n = 129). There was a significant decrease in the total rate of all patients with DFEs, comparing the average rate of 29.8% pre-COVID (3/17-3/20) to 13.6% during COVID (3/20-3/21) (p<0.001). Similarly, the screening rate for non-retinopathic patients decreased from an average rate of 18.6% pre-COVID to 6.7% during COVID (p<0.001). Conclusions : The results demonstrate that our rate of routine dilated fundoscopic examination for SCD patients is very low. These low rates were even more adversely affected by the onset of the COVID-19 pandemic, as clinics closed and access to physicians decreased. Screening rates need to be increased by patient involvement and education, easier access to ophthalmologists and novel ways of screening for retinopathy (e.g. annual screening fluorescein angiograms) to reduce risk of blindness in these patients.

2.
HemaSphere ; 6:2865-2866, 2022.
Article in English | EMBASE | ID: covidwho-2032101

ABSTRACT

Background: Initially, the marketing authorization (MA) of EPAG and ROMI was to adult patients (p.) with ITP ≥12 months (m.) and refractory to other treatments (t.), splenectomized or contraindicated to splenectomy. The MA was extended for EPAG in 2019 to p. aged ≥1 year with ITP ≥6 m., refractory to other t. (corticoids (CS), IgIV). In 2017, French national guidelines suggested the use of TPO-RA as an option of t. in 2nd line (L). Aims: The PEPITE study, still ongoing, aims to assess the modalities of use, effectiveness and safety of TPO-RAs in reallife. Methods: Prospective, observational, multicenter study including adult p. who initiated TPO-RA with persistent (pITP) or chronic (cITP) ITP. Inclusions occurred between 12/21/2018 and 07/17/2020. Here's the interim analysis, cut-off date: 03/22/2021. Characteristics at baseline were presented in 114 p. (analyzed pop). Efficacy analysis of TPO-RA was assessed in p. with a platelet count (PLAT) <100 G/L at TPO-RA initiation (efficacy pop 113 p.). Responses were defined as: response (R) = PLAT ≥30 G/L, complete response (CR) = PLAT ≥100 G/L and non-response (NR) = PLAT <30 G/L. Results: 123 p. included through 40 centers by 25 hematologists and 15 internists, and 77 p. were still on TPO-RA at 6 m. At baseline, mean age 62.7 ± 20.1 years, 55% men, 29% with at least 1 cardiovascular risk factor. At diagnosis: median PLAT = 26 G/L [0 to 134 G/L], 31% of p. with bleedings. 97% of p. received at least one L of t. before TPO-RA: CS 96%, IVIG 56%, rituximab 47%, dapsone 18%, hydroxychloroquine 11%, danazol 6% and 7% of p. were splenectomized. Median number L of t. = 2 and 8% of p. had more than 4 L. Median time between diagnosis and TPO-RA initiation was 2.6 years [0.3 to 49.3 years], 33% of p. with pITP (n=21 with ITP 3 -<6 months, n=16 with ITP 6 - <12 months) and 67% with cITP. At TPO-RA initiation: 9% of p. were on CS and 48% p. had PLAT <30 G/L (median PLAT = 30 G/L), 95 p. (83%) received EPAG and 19 p. (17%) ROMI. For the 77 p. still on TPO-RA at 6 m., R rate = 97% and CR = 60%. Within 6 m., 10 p. had permanently (perm.) discontinued TPO-RA, main causes were therapeutic effect deemed sufficient (TEDS) for 6 p. and NR for 2 p. For the 27 p. still treated with TPO-RA at 18 m., R rate = 93% and CR = 48%. Within 18 m., 12 p. had perm. stopped TPO-RA, including 7 p. for TEDS and 1 p. NR. P. initiated TPO-RA with ITP 3 -<6 months (N = 21), 9 (43%) p. were still on TPO-RA at 6 months, 5 (56%) in CR. Over the entire follow-up, 24p. (21%) perm. discontinued TPO-RA, main causes were TEDS for 9 p., adverse event (AE) for 5 p. and absence of R for 4 p. Of the 105 p. treated with EPAG at least once, 62 (59%) experienced at least one AE, and 26 SAE occurred in 17 p. The most common AEs were respectively 6% for headache and 3% for SARS-CoV-2 infections, diarrhea, asthenia, insomnia, arthralgia and alopecia. Of the 40 p. treated with ROMI at least once, 19 (48%) experienced at least one AE and 17 SAEs occurred in 10 p. The most common AEs: SARS-CoV-2 infections (5%) and arthralgias (5%). No deaths related to TPO-RA was reported. Summary/Conclusion: Preliminary data from the PEPITE study show that TPO-RA are prescribed in early ITP, including 33% with pITP (18% with ITP 3-<6 m.) and are used in 7% of cases after splenectomy. At 6 m. R on t. was 97% and CR on t. was 60%. Within 6 m., 6 p. had perm. stopped TPO-RA due to TEDS. The real-life effectiveness and safety data for EPAG and ROMI are consistent with data reported in extension studies, with the specificity of occurrence of SARS-CoV-2. The final analysis is scheduled after 24 m.

3.
Journal of General Internal Medicine ; 37:S491, 2022.
Article in English | EMBASE | ID: covidwho-1995765

ABSTRACT

CASE: A 40-year-old white female with medical history significant for COVID-19 infection three months prior to presentation and previous spontaneous miscarriage presented with bilateral lower extremity lesions present for several weeks and described as “sunburn-like” with blistering. The lesions were initially located on her anterior thighs and spread to the lateral thighs and lower back. On presentation, she was found to have several distinct lower extremity lesions, with evidence of necrosis and eschar formation, along with blackened mottled skin. The lesions were extremely painful to the patient. Laboratory evaluation demonstrated hyponatremia, elevated ESR and CRP, with normal serum creatine and calcium. Calciphylaxis was confirmed with biopsy. The patient was treated with strict wound care to prevent infection and received sodium thiosulfate three times weekly and anticoagulation with apixaban due to concern for underlying hypercoagulability. An extensive work-up for underlying autoimmunity and hypercoagulability demonstrated presence of antiphospholipid antibodies with positive Cardiolipin IgM, lupus anticoagulant, and a homogenous ANA patern that showed a titer of 1:160. Her clinical status improved on extensive pain regimen and on follow-up one week later, the lesions were unchanged. IMPACT/DISCUSSION: Calciphylaxis is a known dermatologic finding that is typically diagnosed in the setting of End-stage Renal disease (ESRD). It presents with non-healing, painful skin ulcers that are at a high risk for infection and have poor healing. In the absence of ESRD, calciphylaxis is rare but has been reported in certain settings including hypercoagulable states and/ or autoimmune conditions. We present a case that has an absence of known etiologies for calciphylaxis and hypothesize that this is due to a hypercoagulable state caused by recent COVID-19 infection, or COVID-19 aggravating an underlying hypercoagulable state. This case offers an uncommon diagnosis with an even rarer presentation. Calciphylaxis must be confirmed with biopsy and is extremely debilitating and painful. In the setting of non-uremic calciphylaxis, prevention of infection and management of pain should be prioritized. Additionally, this case offers a platform to identifying COVID-19 as a risk factor for development of calciphylaxis in previously healthy individuals. CONCLUSION: The general internist should be aware of non-uremic calciphylaxis and also be concerned for hypercoagulable state induced from COVID-19. It is important to have accurate history-taking and consider delayed reactions, as in this case.

4.
Journal of General Internal Medicine ; 37:S392, 2022.
Article in English | EMBASE | ID: covidwho-1995749

ABSTRACT

CASE: We report a 50-year-old Caucasian female with a history of systemic lupus erythematosus (SLE) in remission and chronic kidney disease (CKD) stage 5. The patient presented with dyspnea on exertion and orthopnea for two weeks. Six weeks ago, she was diagnosed with COVID-19 after presenting to the ED for substernal chest pain, myalgias, and fatigue. During this admission, she denied any current joint pain, chest pain, or rashes. She denies a history of alcohol or illicit drug use. EKG in the ED showed T-wave inversions in lead I and aVL, stable from prior EKG. The brain natriuretic peptide level was elevated at 3,500 pg/ml. There was no transaminitis, and kidney function was at baseline. Chest x-ray showed pulmonary vascular congestion and cardiomegaly. A transthoracic echocardiogram showed a left ventricular ejection fraction of 15-20% with severe global hypokinesis. The patient had a full cardiomyopathy workup. We ruled out ischemic cardiomyopathy with a negative coronary angiogram. Non-ischemic cardiomyopathy (NICMO) workup was initiated, with a focus on viral or autoimmune myocarditis. While a cardiac MRI would have been the gold standard to assess for myocardial scarring, the patient's CKD status prohibited this possibility. Similarly, an endomyocardial biopsy was not performed due to its low sensitivity for diagnosing viral or autoimmune myocarditis. Without evidence of infiltrative disease, or other exposures, it was deemed that the patient's recent history of COVID-19 infection, in conjunction with underlying SLE, were the causes of her new-onset NICMO. The patient's dyspnea responded to intravenous bumetanide. We initiated guideline-directed medical therapy with carvedilol and isosorbide-dinitrate. She continues regular follow-up in the outpatient heart failure clinic. IMPACT/DISCUSSION: Classification and evaluation of NICMO can be broad, and thus the clinical picture plays an essential role in the workup. Acquired cardiomyopathy from prior myocarditis was the most likely etiology of our patient's new-onset NICMO. Our patient had no clinical symptoms of myocarditis prior to her exposure to COVID-19, making it unlikely that SLE was the sole driving factor. There is a known association between COVID-19 and myocarditis. A few proposed mechanisms for COVID-19 induced myocarditis include upregulation of cytokines, particularly interleukin-6, and downregulation of ACE2, leading to microvascular and cardiac pericyte dysfunction. Cytokine release from COVID-19 coupled with subclinical SLE could have acted synergistically to cause this patient's condition. Given the increasing incidence of COVID-19 infections, internists must consider COVID-19 exposures during the workup of new-onset heart failure. CONCLUSION: The workup for NICMO in the COVID-19 era must include detailed history taking for sick contacts and prior history of COVID-19 diagnosis. More research is needed to determine if COVID-19 infection can increase the risk of NICMO in patients with a known history of SLE.

5.
Journal of General Internal Medicine ; 37:S365, 2022.
Article in English | EMBASE | ID: covidwho-1995660

ABSTRACT

CASE: Mr. S is a 60 yo man with DM, HTN and HLD who presents to the urgent care (UC) clinic complaining of sore throat and phlegm in the throat. He is noted to have normal vital signs except for a BP of 75/47. Exam showed slight erythema of the oropharynx, normal cardiac and pulmonary exams. Initial treatment of fluid resuscitation is started for his presumed sepsis, thought secondary to presumed COVID-19 as this occurred during the Omicron surge. An EKG was performed showing anteriolateral ST elevations. The patient was transported emergently to the hospital. An immediate cardiac catheterization was performed which showed mild coronary artery disease, but no obstruction. At this time, COVID-19 PCR test returns negative. The patient is transfered to the MICU for further evaluation and treatment for hypotension/septic shock. At this time, a chest x-ray demonstrated subcutaneous gas in the soft tissues of the neck. CT imaging showed subcutaneous gas extending from the neck to the mediastinum. Patient was taken to the operating room and found to have significant pus in the neck and mediastinum. He was diagnosed with necrotizing mediastinitis requiring multiple surgical wash-outs and prolonged SICU stay. The source was a suspected dental extraction. His ST elevations were presumed to be secondary to a pericarditis effect from the mediasinitis. IMPACT/DISCUSSION: Overall, this case presents necrotizing mediastinitis which is a very unusual and rare presentation, however, it is a surgical emergency so internists need to be aware of this disease and its presentation. Additionally, this case identifies four important points. The first is to make a broad differential, specifically for hypotension. In the setting of a sore throat during the Omicron surge, it was easy to assume this was COVID-19 but thinking of other etiologies led to the EKG being performed. The second is the importance of the physical exam. After the CXR was seen, the patient was examined and noted to have subcutaneous gas which could have been noted at the initial UC visit but that piece of the exam was not performed as the focus was on the hypotension. Third, there is a differential for etiologies of ST elevation on EKG which include STEMI, pericarditis, early repolarization, etc. that should be considered while preparing for treatment of STEMI. Lastly, taking a extensive history, to include dental work, is important as there may be systemic effects of these experiences/treatments. CONCLUSION: -Make a broad differential for atypical patient presentations and physical exam findings -Review EKGs carefully and make a differential for those findings -Necrotizing mediastinitis is a rare presentation but life threatening and needs immediate surgical attention.

6.
Journal of General Internal Medicine ; 37:S624, 2022.
Article in English | EMBASE | ID: covidwho-1995600

ABSTRACT

SETTING AND PARTICIPANTS: Since 2020, allopathic and osteopathic residency programs have been required to meet uniform standards under the Accreditation Council for Graduate Medical Education (ACGME). These standards require programs to advance teaching skills and education scholarship among faculty. Resources to address these requirements are commonly available in large, urban GME programs. However, meeting the standards can be challenging for smaller, community-based programs, particularly those that were previously accredited by the American Osteopathic Association (AOA). “Enhancing Teaching Skills for Medical Educators” was created to promote core teaching and education scholarship competencies, and advance collaboration among medical educators in the University of Pittsburgh Medical Center (UPMC) Graduate Medical Education (GME) system, which is the third largest GME system in the US and includes sites within 200-miles of Pittsburgh. This virtual faculty development program was designed to be convenient, digestible, feasible, and relevant to GME educators in diverse settings. Faculty from UPMC residency programs are invited to participate. Since inception in 2019, participation has increased from 10-15 to more than 50 participants per session, representing multiple sites and specialties. DESCRIPTION: “Enhancing Teaching Skills” is a virtual webinar offered over the lunch hour every other month during the academic year. We choose core topics in education that are practically applied to real-life teaching scenarios, so they are relevant for the broad faculty audience. Facilitators include at least one allopathic physician, most of whom are faculty in the Department of Medicine, and one osteopathic physician, most of whom are community-based internists or family medicine physicians. The latter are encouraged to include osteopathic principles to appeal to programs with an osteopathic focus, including those seeking Osteopathic Recognition. Participants are offered AMA or AOA CME credit. Sessions are recorded and archived online. The series has completed a total of 15 sessions over 4 academic years to date. EVALUATION: Formal assessment is being planned. Informal, qualitative feedback indicates participants find the sessions are relevant and convenient. As participation is voluntary, the sustained increase in attendance is a testament to the value educators find in participation. DISCUSSION / REFLECTION / LESSONS LEARNED: The success of our series has stemmed from the high degree of collaboration between academically- based faculty and those who work in community settings, the convenience of a virtual session, and the practical teaching strategies that can be employed in diverse teaching settings. Although our series has been held in virtual format since inception, the COVID-19 pandemic has increased the comfort of facilitators and participants with virtual teaching. The archived content creates a curriculum that supports ongoing education for faculty and chief residents throughout the GME network.

7.
European Journal of Clinical Pharmacology ; 78:S130, 2022.
Article in English | EMBASE | ID: covidwho-1955961

ABSTRACT

Introduction: Zolpidem and zopiclone are widely used for sleep disorders, yet their abuse and dependence potential has been underestimated. The electronic prescription of zolpidem/zopiclone became mandatory on 17.07.2019 in Greece. Objectives: To investigate descriptive characteristics of zolpidem/ zopiclone prescriptions and the impact of the mandatory electronic prescription mandate. Methods: Anonymized prescriptions of zopiclone (ATC: N05CF01) and/or zolpidem (ATC: NC05CF02) that were executed in pharmacies between 01.10.2018 and 01.10.2021 were obtained from the Greek nationwide prescription database. The database covers almost the entire Greek population and it is administrated by IDIKA of the Greek Ministry of Health. We investigated descriptive characteristics of prescriptions, and calculated themonthly number of prescriptions taking into consideration dates with potential impact, i.e., the date of the mandatory electronic prescription mandate (on 17.07.2019) and the date of the first case of COVID-19 in Greece (on 26.02.2020). Results and Conclusion: During the investigated period of three years, there were 1229842 executed prescriptions of zolpidem (89.4%), zopiclone (10.4%) or both (0.3%), considering 156554 unique patients. The patients weremainly elderly (73.1%were ≥ 65 years old) andwomen (64.5%). The majority of the prescription physicians (69.9%) were general practitioners or internists, followed by 17% psychiatrists or neurologists, 5.3% cardiologists, 4.5% physicians in specialty training, 1% nephrologists and 2.4% of physicians with another specialty. After the mandatory electronic prescription mandate and before COVID- 19 in Greece, i.e., between 08.2019 to 03.2020, there was a notable increase of prescriptions in comparison to the previous period from 10.2018 to 07.2019 (median 37267 vs median 34106;Mann-Whitney U=9, p-value=0.009). After COVID-19, the median monthly number of prescriptions was 36363, yet there were variations ranging from 16963 to 39956. In conclusion, the mandatory electronic prescription system could increase the surveillance of drugs with abuse potential such as zolpidem and zopiclone. Nevertheless, the large number of prescriptions in elderly patients and prescribed by primary care physicians is worrisome and warrants further investigation.

8.
European Journal of Clinical Investigation ; 52:162, 2022.
Article in English | EMBASE | ID: covidwho-1937926

ABSTRACT

Familial Mediterranean fever (FMF) is a hereditary autoinflammatory disorder characterized by recurrent attacks of fever and serosal inflammation. The clinical features consist of especially abdominal pain, chest pain and arthralgias, plus erysipelas-like manifestations. According to the available literature, most patients with FMF experience their first attack in early childhood, before the ages of 10 and 20 years in 65 and 90% of cases, respectively. Rarely, the initial attack can occur in individuals older than 50 years of age. We report our experience with FMF during the last 14 yrs [1], following case #1 aged 36 yrs. [2]. In the regions of Apulia and Basilicata, we could identify several family clusters due to historical and geographical roots. In the initial series of 60 cases, the five most frequent MEFV variants were E148Q/R761H (41.9%, compound heterozygosity), K695R (10.2%, heterozygosity), E148Q (8.2%, heterozygosity), E148Q/R761H/A744S (6.1% compound heterozygosity), and P369S (6.1%, heterozygosity). Notably, the mean disease onset was 22 yrs and the diagnostic delay was 15 yrs. The severity of symptoms was generally mild/intermediate but about 30% of this initial series had undergone unnecessary abdominal surgery. Females were significantly older than males (median 40 vs. 30 yrs., respectively, P = 0.03). Symptoms including fever were largely responsive to the average dose of colchicine 1 mg/day ad libitum. Only one case required canakinumab for resistance/intolerance to colchicine. We did not observe severe cases of secondary amyloidosis and kidney damage. Later, we extended our observations and concluded that the combination of available expert information with sensitive predictor tools could result in a more accurate interpretation of clinical consequences of MEFV gene variants, and a better genetic counselling and patient management, with respect to symptom severity as well [3, 4]. We recently reported the rare case of a very late onset of FMF symptoms in a patient aged 86 [5]. Further studies in FMF have focused the attention on environmental factors including intestinal microbiota [6], COVID-19 pandemic [7], blood-based test for diagnosis and functional subtyping of FMF by the ex vivo colchicine assay [8], and histopathological characteristics of synovitis in FMF [9]. Following these seminal observations, we conclude that the Apulia region represents a new endemic area for FMF, a puzzling inherited autoinflammatory disorder. Clinical presentation of FMF can be misleading and requires a complete and early workup to recognize the disease and avoid unjustified surgery. Colchicine remains the gold standard therapy to prevent FMF attacks and fatal long-term complications [10, 11].

9.
European Journal of Clinical Investigation ; 52:160-161, 2022.
Article in English | EMBASE | ID: covidwho-1937924

ABSTRACT

Background: Familial Mediterranean fever (FMF) is an autosomal recessive autoinflammatory disease characterized by recurrent fever and serositis attacks. We aimed to explore clinical aspects of FMF including knowledge, diagnosis, symptoms, and medication in a Lebanese cohort enrolled by ad-hoc questionnaire. Methods: During November 2021-March 2022 we conducted an online survey by a google form questionnaire (33 items) advertised across Lebanese communities, hospitals, internists, and specialists. Patients and children's parents voluntarily provided information about FMF knowledge, diagnosis, presence, and severity of symptoms before and after medication. Since COVID-19 and FMF may share some common symptoms due to activation of the inflammasome pathway, we further investigated this aspect in the FMF cohort with symptomatic COVID-19. Results: A total of 123 FMF patients participated in this survey (75 females, age range 1-67 years;10 subjects from Armenia, Persia, and Turkey). The most frequent MEFV variants were M694V, M694I, E148Q, V726A, R202Q, and A744S. Before the diagnosis 70% of the subjects had no knowledge about FMF. The diagnosis was late in 40% of subjects (at age ≥20 years). A misdiagnosis occurred in 21% of subjects and was associated with unnecessary procedures such as heavy antibiotic prescription, appendectomy, and abdominal surgery. Prior to the diagnosis and targeted FMF therapy, subjects described typical febrile periodical attacks of systemic serositis with a frequency of more than attack once per month (48%) with intensity ranging from moderate to severe (95%). Following therapy with colchicine, 65% of the subjects reported mild symptoms. In addition, 60% of subjects had COVID-19 infection which was symptomatic in 80% of the cases. Concerning COVID-19, 63% of symptomatic COVID-19 subjects reported that FMF symptoms were higher compared to COVID-19, 23% reported that COVID-19 symptoms were higher than FMF symptoms, and 14% reported no difference between the two diseases. Additionally, 12% reported consequences of FMF-COVID- 19 combined symptoms, mainly joint pain due to persisting arthralgias. Conclusion: In Lebanon, an endemic region for FMF with a mixture of the ethnic communities from the Mediterranean area, FMF diagnosis can be missed, delayed, or initially erroneously classified. Nevertheless, the diagnostic ability is improving over time. This is the first study in Lebanon to clarify aspects of FMF knowledge, diagnosis, and symptoms as well as evaluation of COVID-19 and FMF interplay. The complex interaction and consequences between COVID-19 infection and the genetic autoinflammatory FMF is being further investigated.

10.
European Journal of Hospital Pharmacy ; 29(SUPPL 1):A115, 2022.
Article in English | EMBASE | ID: covidwho-1916415

ABSTRACT

Background and importance In the context of the COVID-19 pandemic, one of the strategies implemented to minimise patient visits to health centres was switching the administration of tocilizumab (TCZ) from intravenous (IV) to subcutaneous (SC). Aim and objectives To evaluate the effectiveness and safety of switching from IV to SC TCZ. Material and methods Retrospective observational study conducted in a tertiary hospital including patients receiving active treatment of IV TCZ during the period March-April 2020. Data were collected on the following variables: age, sex, pathology, switching to SC TCZ, switching back to IV administration, physician assessment or patient self-assessment, as well as adverse reactions. The follow-up period was 1 year. Results A total of 45 patients were included, with a median age of 54 (40-62) years. Women represented 85%. Patients included were diagnosed with rheumatoid arthritis (49%), juvenile idiopathic arthritis (18%), Graves disease (13%), lupus (2%), spondylarthritis (2%) and other diagnoses (16%). The prescribing physicians were rheumatologists (62%), internists (24%) and paediatricians (13%). Of 45 patients, 71% (n=32) switched to SC TCZ during the study period. 86% of rheumatology, 83% of paediatrics and 27% of internal medicine patients changed to SC TCZ. Aggravation after switching to SC TCZ was reported in 7/ 32 (22%) cases (5 with rheumatoid arthritis and 2 with juvenile idiopathic arthritis). All of these switched back to IV administration, plus 4 additional patients for undetermined reasons. Of those who switched back to IV administration due to clinical worsening, 4 reported improvement afterwards. Regarding safety, only 2 patients suffered adverse reactions after switching to SC (injection site reaction, palpitations, tremor and oedema). Neither of them switched back to IV administration. Conclusion and relevance One-fifth of the patients reported loss of effectiveness when changing from IV to SC form, and one-third switched back to IV administration. Regarding safety, the toxicity profile of both forms was similar to other studies. The effectiveness results observed are in contrast with the MUSASHI study, which did not report loss of efficacy after switching from IV to SC. However, effectiveness was not measured using the internationally validated ordinary objective scales (DAS28, CDAI), but physician subjective assessments or patient self-assessments, which represents a significative limitation for our study.

11.
Italian Journal of Medicine ; 16(SUPPL 1):6-7, 2022.
Article in English | EMBASE | ID: covidwho-1912921

ABSTRACT

Background: Arterial catheterization is frequently used in the management of critically ill patients, but their use in internal medicine is limited by the lack of monitoring systems and fewer nursing staff. The aim of our study is to demonstrate the safety of arterial catheters in the internal medicine ward. Materials and Methods: We conducted a retrospective cohort study between January 2018 and December 2021 at the Department of Internal Medicine 1 of the AOU Careggi. All patients with arterial catheters were enrolled. Patients with SARS-CoV2 infection were excluded. We conducted a univariate analysis on the association between self-removal of the device and complications. Results: We enrolled 488 patients. Mean age was 74.26±14.85 years. The main site of arterial access was radial artery (84.83%), followed by femoral artery (10.45%). The average length of stay of the device was 6.39±5.01 days, and in 3.48% there was an accidental self-removal of the device. The most frequent complication was mild bleeding (1.6%), followed by infection of the insertion site (0.8%) and distal embolization (0.3%). Delirium occurred in 20.3% of patients, and an association was found between delirium and self-removal of the arterial catheter (p <0.001, OR 5.35, CI 2.05-13-94). However, there was no association between delirium and any complications (p=1.000). Conclusions: arterial catheterization is a low-complication procedure;the internist should acquire this competence to deal with the presence of critically ill patients and the development of subintensive therapy units.

12.
Italian Journal of Medicine ; 16(SUPPL 1):83-84, 2022.
Article in English | EMBASE | ID: covidwho-1912916

ABSTRACT

Introduction: Rarely, lactic acidosis can be a life-threatening medication side effect. Hence, determining the etiology of lactic acidosis early in patients is necessary to choose the correct therapeutic intervention. Although lactic acidosis as an adverse drug reaction of linezolid is a well-recognized and documented clinical entity. Case Report: A 90-years-old woman was hospitalized for Sars- CoV-2 related pneumonia, due to an increase of CRP, WBC count and appearance of new opacities on chest CT, it has been decided to start an atimicrobial therapy with Linezolid, suspecting an MRSA superinfection. After six doses she presented an episode of consciusness alteration, lethargy and allucinations.The head CT any bleeding or mass effect has been demonstrate, but blood gas analysis showed a significant lactic acid increase and an important HOC3- reduction. After the suspencion of Linezolid lactate rapidly decrease. Conclusions: Several publications demonstrate that linezolid induces lactic acidosis by disrupting crucial mitochondrial functions, rarely with a rapid onset.It is important that internist are aware that linezolid can cause lactic acidosis not only after a long threatment period but also after few somministration, and that often it may mimic a common disease like cerebrovascular accident. In conclusion, linezolid should be suspected in the differential diagnosis if lactic acidosis exists with an uncommon clinical picture.

13.
Italian Journal of Medicine ; 15(3):44, 2021.
Article in English | EMBASE | ID: covidwho-1567571

ABSTRACT

Introduction: Antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitides (AAV) are a group of systemic vasculitides that predominantly affect small vessels. Clinical phenotype is heterogeneous: kidney and/or pulmonary involvement is described in up to 75-90% of cases. Among these, rapidly progressive glomerulonephritis and diffuse alveolar haemorrhage are the most serious manifestations. Description of the case: A 73-year-old man presented with 15 days history of fever, productive cough and fatigue (SARS-CoV- 2 nasopharyngeal swab negative);antibiotic therapy prescribed was ineffective. Afterwards he developed necrosis of right hand distal phalanx, oedema of lower extremities, dyspnoea for mild exertion and acute renal failure, that needed dialysis. A lung HRCT showed ground glass opacities, blood tests underlined high inflammatory indices and high title PR3-ANCA positivity. Diagnosis of PR3-ANCA associated vasculitis was made and glucocorticoid therapy with methylprednisolone (1mg/Kg/day) was started. For the occurrence of emoptysis, respiratory failure and anemization, suspecting diffuse alveolar haemorrhage, methylprednisolone pulse therapy (500 mg/day for 5 days), plasmapheresis and rituximab (375 mg/m2/week for 4 infusions) were administered. There was a progressive clinical-laboratory improvement. However the patient developed intestinal perforation and died. Conclusions: AAV represent rare diseases, burdened by a poor prognosis. They need a careful internist and a multidisciplinary approach to ensure an early therapeutic intervention.

14.
Intern Med J ; 51(11): 1940-1945, 2021 11.
Article in English | MEDLINE | ID: covidwho-1526372

ABSTRACT

The COVID-19 pandemic has increased anxiety in society and particularly in healthcare workers, as shown with a questionnaire in our centre at the beginning of the pandemic. In this collaborative study, we aimed to evaluate the effects of the pandemic on anxiety 1 year later by applying the same questionnaire to the physicians working in the same department. A total of 77 participants consented to the study. The median age was 28 (interquartile range = 4) years and 55.8% were male. As in the first survey, female gender, having family members over 65 years of age, and having family members with chronic diseases were significantly associated with high anxiety scores and levels. There were no statistically significant differences between the first and second survey participants in any of the anxiety scales, which means anxiety persists.


Subject(s)
COVID-19 , Physicians , Anxiety/diagnosis , Anxiety/epidemiology , Child, Preschool , Cross-Sectional Studies , Depression , Female , Humans , Internal Medicine , Male , Pandemics , SARS-CoV-2
15.
Intern Med J ; 50(11): 1350-1358, 2020 11.
Article in English | MEDLINE | ID: covidwho-810874

ABSTRACT

BACKGROUND: Internists who have an important role in the global response to the COVID-19 pandemic are under both physical and psychological pressures. AIMS: To assess the anxiety among physicians working in the internal medicine department of a tertiary care hospital who are on the frontline of the COVID-19 pandemic. METHODS: This single-centre, non-intervention, cross-sectional descriptive study was conducted using an online survey questionnaire from 1 April to 14 April 2020. Physicians of the Department of Internal Medicine were invited to participate with a self-administered questionnaire. The degree of symptoms of anxiety was assessed by the Turkish versions of the 7-item Generalised Anxiety Disorder scale and Beck Anxiety Inventory, respectively. RESULTS: A total of 113 participants consented for the study and completed the questionnaire. The median age was 29 (IQR = 5) years and 53.1% were male. A total of 72 internists (63.7%) worked as 'frontline' healthcare workers directly engaged in diagnosing, treating or caring for patients with or suspected to have COVID-19. Female gender was significantly associated with high scores and levels in all scales compared to the male gender (P < 0.005). Having family members over 65 years old and with chronic diseases were significantly associated with high anxiety scores and levels (P < 0.005). CONCLUSIONS: In this survey of internists in a university hospital equipped with clinics, wards and intensive care unit for patients with COVID-19, female gender and having family members over 65 years old and with chronic diseases were associated with increased anxiety levels.


Subject(s)
Anxiety/etiology , COVID-19/psychology , Mental Health , Physicians/psychology , Adult , Anxiety Disorders , Cross-Sectional Studies , Family , Female , Humans , Internal Medicine , Male , Sex Factors , Stress, Psychological , Surveys and Questionnaires , Tertiary Care Centers , Turkey
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