Improving New Patient Appointment Utilisation in Rheumatology Advanced Practice Physiotherapy

Background/Aims Long Rheumatology waiting lists in the UK were further affected by the COVID-19 pandemic;resulting in negative impacts upon the timeliness and efficiency of patient care. The use of Advanced Practitioners within Rheumatology care pathways has been shown to be safe and effective;they can support the Rheumatology workforce and expedite care where patients are appropriately triaged to them. As part of a service provision change in a NHS Trust, an Advanced Practice Physiotherapist (APP) post was funded with the intent to harness these benefits. Initial utilisation of the APP appointments within the Rheumatology provision was found to be low and could be improved. A Quality Improvement (QI) Project was initiated, with the aim to increase APP appointment utilisation to at least 85% over a period of four months, and for at least 75% of these appointments to contain patients who had been appropriately triaged. Methods The 'Model for Improvement' was chosen as the QI approach. The project was led by an APP. Firstly, a stakeholder analysis was performed to identify staff with influence and interest in the project. A root cause analysis found lack of awareness of triaging clinicians and challenges with booking processes as potential reasons for lowerthan- expected appointment utilisation. Change interventions were devised and tested over three Plan, Do, Study, Act (PDSA) cycles. PDSA one developed communication with booking and triage staff to clarify these processes with them. PDSA two educated clinical staff about the APP role, triage criteria and the booking procedures confirmed in PDSA one. PDSA three focused upon sustaining change by reinforcement of the topics established in PDSA two among staff. Outcome measures used were the percentage of available APP appointments utilised per week, and the percentage of these which contained patients who were appropriately triaged. Results APP appointment utilisation increased from a mean of 22% pre-project to 61% during the change intervention period. Sixty-three patients were seen over the 17-week change intervention period;of which 86% had been appropriately triaged. Data showed that 70% of the patients directed to the APP were managed by them (24% discharged and 46% reviewed). Of the remaining patients, 13% were followed up by a Rheumatologist, 12% did not attend and 5% had an alternative outcome such as awaiting advice. Conclusion This QI project led to an improvement in Rheumatology care provision locally. Engagement with support staff, education of clinical staff and implementation of clear standard operating procedures improved the utilisation of the Rheumatology APP resource. Results suggest that the APP role was effective locally in managing appropriately triaged patients, without a negative effect on patient care or other services. Continuing to improve utilisation will support management of the Rheumatology waiting list and improve patient care.

Long-Term Hydroxychloroquine and Its Association with Covid-19 Infection, a Cohort Study from a South American Hospital

Objectives: We aimed at examining whether patients with rheumatological conditions receiving chronic hydroxychloroquine therapy are at a lower risk of developing SARS-CoV-2 infection than those not receiving hydroxychloroquine. Method(s): This historical cohort study included information of all patients aged 18 years or older with rheumatoid arthritis, systemic lupus erythematosus, or associated rheumatological conditions (based on International Classification of Diseases, 10th edition, diagnostic codes). A propensity score was calculated for each patient, and each patientwho was receiving hydroxychloroquine was matched to two patients who were not receiving hydroxychloroquine (controls). The primary endpoint was the proportion of patients with PCR-confirmed SARS-CoV-2 infection among those receiving chronic hydroxychloroquine versus the propensity-matched patients not receiving chronic hydroxychloroquine in 2021. Result(s): 322 patients receiving hydroxychloroquine and 645 patients not receiving hydroxychloroquine were included in the primary analysis. The incidence of active SARS-CoV-2 infections during the study period did not differ between patients receiving hydroxychloroquine and patients not receiving hydroxychloroquine ( [0 3%] vs 78 [0 4%] of 21406;odds ratio 0 79, 95% CI 0 52-1 20, p = 0 27). There were no significant differences in secondary outcomes between the two groups of patients who developed active SARS-CoV-2 infection. For all patients in the study, overall mortality was lower in the hydroxychloroquine group than in the group of patients who did not receive hydroxychloroquine (odds ratio hydroxychloroquine was not associated with the development of active SARS-CoV-2 infection (odds ratio 0 79, 95% CI 0 51-1 42) Conclusion(s): Hydroxychloroquine was not associated with a protective effect against SARS-CoV-2 infection in a large group of patients with rheumatological conditions.

The sense of loneliness in couples and the impact of the health crisis: A review of literature

Objective: The purpose of this review is to define the feeling of loneliness within a couple while taking into consideration the factors that lead a person to feel lonely in a couple or in a romantic relationship. Our goal is to understand the effects of the feeling of loneliness on these individuals during the global health crisis brought on by COVID-19 and to take these factors into account in designing effective therapeutic care. The different manifestations of loneliness in a couple should also be highlighted. Method(s): We used the PRISMA methodology to select the relevant studies. The keywords ("Solitude" or "Loneliness") and ("Couple" or "Married" or "Partnership") allowed us to select 19 references dealing with the theme. We conducted searches of the following databases: "Cairn", "PsychInfo and Psycarticle", "PubMed and Medline", "ScienceDirect" and finally, "Web of Science" in order to find articles covering a ten-year period. Result(s): There are different definitions for the subjective experience of loneliness. The review of the literature highlights the fact that loneliness can lead to positive or negative psychological consequences (it can lead to the development of creative capacity or, on the contrary, result in depression in some cases). Attachment patterns have been shown to be the basis for the tolerance of feelings of loneliness. Indeed, an anxious attachment would encourage the couple to avoid the feeling of loneliness. According to the literature, this defensive mechanism of seeking presence in the couple would make it possible to limit the impact of loneliness. This solitude depends on the level of relational quality within the couple. A poor relational quality would lead to greater loneliness and would impact intimate relationships. Loneliness is supposedly not experienced in the same way by men and women: Men seem to be more protected by marriage while women's level of loneliness may be higher because of the household chores they have to do. Men and women would nevertheless remain subject to the phenomena of contamination, i.e., when one of the partners feels lonely, the other will also be lonely. However, it seems that marriage protects against feelings of loneliness and its negative consequences. Loneliness does not have only negative effects. It can be beneficial for developing creativity and finding oneself. The periods of confinement during the COVID-19 crisis provided people with an increase in the amount of time they didn't normally have on a daily basis. This may have been beneficial for some people and can be associated with positive emotions. Individuals who spent the lockdowns with others felt less alone and experienced less psychological distress. However, confinements did produce some negative effects on couples. The increased stress of the pandemic and the constant proximity led to an increase in spousal abuse. The consequences of confinement for couples whose relationships were already troubled resulted in frequent separation and/or divorce. The potential for conflict was related to limited financial resources, not working, and the significant risk of contracting SARS COV-2. Conclusion(s): The articles dealing with the feeling of loneliness that we reviewed presented quantitative methods to the detriment of qualitative aspects and focused largely on the negative aspects of the feeling of loneliness. Other academic disciplines, such as sociology, demonstrate a lack of understanding concerning what is at stake with the feeling of loneliness. The articles intersect and tend to highlight the attachment relationships that are formed in childhood as a determining factor in the feeling of solitude later in life. The quality of the relationship, gender, and marital status are also factors to be considered. Loneliness has a clear influence on the well-being of the relationship but it is not an individual characteristic of the relationship itself. It finally appears as an individual characteristic with an impact on the assessment of the quality of the relationship and on the appreciatio of the spouse.Copyright © 2023 Elsevier Masson SAS

Clinical significance of serum interleukin 6 in elderly patients infected with severe acute respiratory syndrome coronavirus 2 omicron variant and its correlation with underlying diseases

Objective To investigate the clinical significance of serum interleukin 6 (IL-6) in elderly patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) omicron variant and its correlation with underlying diseases. Methods A total of 22 elderly patients (>80 years old) infected with omicron variant, who were admitted to Department of Infectious Diseases, The First Affiliated Hospital of Naval Medical University (Second Military Medical University) from Apr. to Jun. 2022 and tested positive for SARS-CoV-2 RNA, were included. The level of serum IL-6 was measured by flow cytometry, and the level of serum C reactive protein (CRP) was measured by immunonephelometry. Patients were divided into pneumonia group (16 cases) and non-pneumonia group (6 cases) according to the imaging examination results, and were divided into severe group (severe and critical type, 5 cases) and non-severe group (mild and normal type, 17 cases) according to the condition. Binary logistic regression model and receiver operating characteristic (ROC) curve were used to analyze the correlation between serum IL-6 and CRP levels and the severity of the disease and whether it would progress to pneumonia. Meanwhile, the relationships between underlying diseases and serum IL-6 level were explored. Results Among the 22 patients, 6 were mild, 11 were normal, 3 were severe, and 2 were critical. The baseline serum IL-6 level in the pneumonia group was significantly higher than that in the non-pneumonia group ([20.16+/-12.36]pg/mL vs [5.42+/-1.57] pg/mL, P=0.009), and there was no significant difference in baseline serum CRP level between the 2 groups (P>0.05). There were no significant differences in baseline serum IL-6 or CRP levels between the severe group and the non-severe group (both P>0.05). Logistic regression analysis showed that the baseline serum IL-6 and CRP might be related to pneumonia after infection with omicron variant (odds ratio [OR]=2.407, 95% confidence interval [CI]0.915-6.328;OR=1.030, 95% CI 0.952-1.114). ROC curve analysis showed that the area under curve values of serum IL-6 and CRP in predicting the progression to pneumonia were 0.969 (95% CI 0.900-1.000) and 0.656 (95% CI 0.380-0.932), respectively, with statistical significance (Z=2.154, P=0.030). There were no significant differences in the baseline serum IL-6 level or proportions of severe patients or pneumonia patients among patients with or without hypertension, diabetes mellitus, coronary heart disease, chronic kidney disease or chronic obstructive pulmonary disease (all P>0.05). The baseline serum IL-6 levels of the omicron variant infected elderly patients with 1, 2, and 3 or more underlying diseases were 12.50 (9.15, 21.75), 23.55 (9.63, 50.10), and 10.90 (5.20, 18.88) pg/mL, respectively, with no statistical significance (P>0.05). Conclusion For omicron variant infected patients, serum IL-6 level is significantly increased in patients with pneumonia manifestations and is correlated with disease progression. Serum IL-6 level is of great guiding significance to judge disease progression and evaluate efficacy and prognosis of elderly coronavirus disease 2019 patients.Copyright © 2022, Second Military Medical University Press. All rights reserved.

Effect of Aboand Rh Blood Type on Sars-Cov-2 Infection Severity in Patients with Rheumatic Diseases: Data from the National Sar-Covid Registry

Objectives: To evaluate the association between the ABO and Rh antigens and the clinical characteristics and evolution of the SARS-CoV-2 infection in patients with rheumatic diseases. Method(s): SAR-COVID is a national, longitudinal, and observational registry. Patients >=18 years of age with a diagnosis of inflammatory or degenerative rheumatic disease, and confirmed SARS-CoV-2 infection (RT-PCR or serology) were included. Data were collected from August 2020 to June 2022. Sociodemographic, clinical data, comorbidities, underlying rheumatic disease, disease activity, and its treatment at the time of infection were recorded, aswell as symptoms, complications and treatments received for COVID-19. The WHO ordinal scale (WHO-OS) was used, and severe COVID-19was defined as WHO-OS>=5. Patients were categorized as follows: blood group A or non-A, and Rh factor positive or negative. Result(s): A total of 1356 patients were included, 547 (40,3%) had blood group A and 809 non-A (59,7%). Regarding the Rh factor, 1230 (90,7%)were positive and 126 (9,3%) negative. Age, sex, ethnicity and comorbidities were comparable between both groups. In both cases, the most frequent rheumatic diseases were rheumatoid arthritis (38,9%;p = 0,052), systemic lupus erythematosus (17,4%;p = 0,530) and osteoarthritis (10,1%;p = 0,888). Patients with non-A blood type presented a higher frequency of psoriatic arthritis (group A 5,1% vs non-A 8,7%;p = 0,015). During SARS-CoV-2 infection, more than 90% of patients in both groups were symptomatic (group A 96.0% vs non-A 94,8%;p = 0,384). Non-A blood group patients had a significantly higher frequency of arthralgia and dysgeusia. In A blood group 18.5% of the patients required hospitalization, 41,0% of them were admitted in the intensive care unit and 5.9% presented complications, while in the non-A blood group, were 16,7%, 31,1% and 5,5%, respectively (p > 0,05 in all the cases). The most frequent complications in both groups were respiratory distress syndrome and sepsis (p > 0,05). The outcome of the COVID-19 infection is detailed in Figure 1. In the multivariate analysis, adjusted for poor prognostic factors, patients with A blood type and those with negative Rh factor presented more likely severe COVID-19. (OR 1,75, 95%CI 1,20-2,56, p = 0,003 and OR 2,63, 95%CI 1,45-4,55, p = 0,001, respectively). Conclusion(s): Blood type A and negative Rh factor were associated with worse COVID-19 outcomes in this national cohort of patients with rheumatic diseases.

Evaluation of Disease Activity in Patients with Systemic Lupus Erythematosus in Follow-Upata University Hospital in Manaus Aftervaccination against Covid-19

Objectives: Patients with Systemic Lupus Erythematosus (SLE) are predisposed to serious infections due to immunocompromise, comorbidities, immunomodulatory and/or immunosuppressive therapy, as well as the lack of these medications faced by patients dependent on the Sistema Unico de Saude (SUS) during the COVID-19 pandemic. Studies revealed a low risk of worsening disease activity after vaccination against SARS-CoV-2 and safety in the continuity of immunomodulatory therapy during the vaccination stages. Thus, immunization against COVID-19 is an important pillar in reducingmorbidity and mortality related to infectious conditions and SLE. This study had the objective to understand the disease activity in SLE patients after vaccination against COVID-19. Method(s): This is an observational, longitudinal, ambidirectional study with follow-up of subgroups of patients with immune-mediated rheumatic diseases immunized with vaccines made available by the Programa Nacional de Imunizacao (Butantan Institute, Pfizer/BioNTech, BioManguinhos/Fiocruz and Janssen). Data from the SLE disease activity index 2000 (SLEDAI-2 K) and sociodemographic data were collected and stored via an online platform, with a comparison of the index before and after each dose. This study was approved by the local Research Ethics Committee, and it is associated to the SAFER Project from Brazilian Society of Rheumatology. Result(s): A total of 223 patients were included, of which 83% were female and 39% had SLE, 36.7 +/- 11.76 years old. Regarding the disease activity, at inclusion the mean PGA score(SD) was 2,61 +/- 2,77. After the 1st dose it was 1.38 +/- 2.17, after the 2nd dose it was 2,35 +/- 2,99, after the 3rd dose it was 2,19 +/- 2,58 and after the 4th dose 1.18 +/- 1.88. The mean SLEDAI-2 K score at inclusion was 7,27 +/- 9,70, after the 1st dose it was 2,75 +/- 5,29, after the 2nd dose it was 4,73 +/- 6,40, after the 3rd dose 3,33 +/- 5,51 and after the 4th dose 2.12 +/- 4.27. 6% of the patients referred worsening disease activity after the 1st dose, 14,3%after the 2nd dose, and no patient reportedworsening of disease activity after the 3rd and 4th doses. Conclusion(s): Vaccination did not contribute toworsening disease activity of the SLE patientss studied, according to the indices used to assess disease activity.

Cases of Covid-19 in Patients Withi Mmune-Mediated Rheumatic Diseases after Vaccination against Sars-Cov-2 in Manaus-Amazon

Objectives: Immunization against SARS-CoV-2 is an effective strategy to reduce morbidity and mortality in the face of the COVID-19 pandemic. People with Immune-mediated Rheumatic Diseases (IMRD) also benefited from this campaign. However, there is a limited amount of data on the outcome of vaccination in these patients, in terms of those who were infected by the virus. This study had the objective to evaluate the rate of COVID-19 cases in patients with IMRD after vaccination against SARS-CoV-2. Method(s): Observational, longitudinal and ambidirectional study with follow-up of subgroups of patients with IMRD immunized with vaccines made available by the National Immunization Plan (inactivated adsorbed vaccine registered by the Instituto Butantan (IB), recombinant vaccines registered by Bio Manguinhos/ Fiocruz and by Janssen, and Pfizer/BioNTech). Sociodemographic data and questionnaires on flu syndrome, laboratory confirmation of infection and need for hospitalization and outcomes were collected and stored via an online platform. This study is associated to the SAFER Project from the Brazilian Society of Rheumatology and it was approved by the local Research Ethics Committee. Result(s): A total of 223 patients aged over 18 years, mean age 42.79 +/- 15.18 years, were included. All were within the inclusion/exclusion criteria, with 83% being female. The main IMRD included were systemic lupus erythematosus (39%) and rheumatoid arthritis (33.6%). After the 1st dose, 1.45% of patients had COVID-19, 50% sought health services (emergency care), without the need for hospitalization and after the 2nd dose, 1.5% had the disease, of which none sought health services, required hospitalization or had a negative outcome. After the 3rd dose,: 2.9%were infected with SARS-CoV-2 one month later, 15.6% two to three months later and 5.5% four to six months later, all with laboratory confirmation;only 4% presenting any serious complication;there were no deaths. After the 4th dose, 9.1%of patients had COVID-19, of which 40%were hospitalized, without the need for assisted ventilation;half of these patients had a serious complication, but there no deaths. Conclusion(s): In this study, we observed the effectiveness of the vaccine in preventing severe cases of COVID-19 and complications of SARS-CoV-2 infection.

Assessment of Disease Activity in Adolescent Patients with Chronic Inflammatory Diseases after Vaccination against Covid-19ata University Hospital in Manaus

Objectives: Chronic Inflammatory Immune-mediated Diseases (CIMD) can cause pain and severe discomfort to the patient, leading to significant reductions in his/her quality of life. Vaccination against COVID-19 has proven to be an efficient method in preventing cases and serious repercussions. However, there is insufficient evidence on the safety of these vaccines in the CIMD population. Objective(s): To assess disease activity in adolescent patients with CIMD after vaccination against SARS-CoV-2. Method(s): Observational, longitudinal, ambidirectional study with follow-up of groups of adolescent patients with CIMDwho received the vaccine provided by the National Immunization Program -Pfizer/BioNTech. Sociodemographic and clinical disease activity data were collected before and after each vaccine dose. Data were stored through an online platform (REDCap). This study is associated to the SAFER Project from the Brazilian Society of Rheumatology and was approved by the local Research Ethics Committee. Result(s): Nineteen adolescents aged between 12 and 17 years were included, all of whom met the inclusion/exclusion criteria. Of the total, 31.6% have Juvenile Idiopathic Arthritis (JIA)-14.33 +/- 2.25 years of age, whose subtypes included persistent oligoarticular JIA (16.7%), Polyarticular Rheumatoid Factor (RF) negative (33.3%), Polyarticular RF positive (16.7%) and Systemic (33.3%);68.4% have Systemic Lupus Erythematosus (SLE) -14.77 +/- 1.96 years of age. Regarding JIA patients, at inclusion, the mean disease activity assessed by the physician was 3 +/- 3.83 and 3.25 +/- 3.77 as assessed by the patient. After the 1st dose, the mean activity assessed by the physician was 2.8 +/- 3.9 and after the 2nd dose it was 3 +/- 4.24. Themean activity after the first dose as assessed by the patient was 3.2 +/- 3.96, and after the 2nd dose it was 2.8 +/- 3.11. In the SLE patients, at inclusion, the mean degree of disease activity was 1.92 +/- 1.83 and of the SLEDAI-2 K was 4.67 +/- 5.14. After the 1st dose, the mean disease activity was 1.11 +/- 1.96, and after the 2nd dose, it was 2.25 +/- 2.76. After the 1st dose, the SLEDAI-2 K was 1.11 +/- 1.76, and after the 2nd dose it was 4.25 +/- 5.28. No reports of worsening of disease activity after the vaccine were found. Conclusion(s): The vaccination proved not to contribute to worsening of clinical activity of rheumatic diseases in adolescents, without significant changes in SLE assessment indices and in the personal and medical assessment of JIA patients.

Adverse Effects of Vaccines against Covid-19 in Adolescent Patients with Chronic Inflammatory Immune Diseases in Manaus-Amazon

Objectives: In the Chronic Inflammatory Immune-mediated Diseases (CIMD), infections mainly occur in the respiratory tract and their occurrence is related to drug-induced immunosuppression, underlying diseases and comorbidities. To reduce this morbidity and mortality, vaccination is an effective means of prevention. However, the available studies on SARS-CoV-2 vaccines have not addressed this group of patients with CIMD, and there are still many doubts regarding the indications, adverse effects, safety and efficacy of these vaccines. Objective(s): to evaluate the adverse effects of vaccines against SARS-CoV-2 in adolescent patients with CIMD. Method(s): Research associated to the SAFER Project from Brazilian Society of Rheumatology. It is an observational, longitudinal, ambidirectional study, with follow-up of groups of vaccinated adolescent patients with CIMD, vaccine by Pfizer/BioNTech. Sociodemographic data were collected, stored on an online platform, and adverse events were presented by filling in diaries issued for each patient. This study was approved by the local Research Ethics Committee. Result(s): We included 19 adolescents, aged between 12 to 17 years, who met the inclusion and exclusion criteria. The mean age was 14.63 +/- 2.01 years. Of these, 68.4% were female. In relation to CIMD, 31.6% have Juvenile Idiopathic Arthritis and 68.4% have Systemic Lupus Erythematosus. All were vaccinated with the Pfizer vaccine. In the 1st dose, the main adverse effects presented were Pain at the injection site (85.7%), Headache (42.9%), Tiredness (33.3%) and Edema and skin induration at the injection site (26, 7%). After the 2nd dose, the only adverse effect reported was Pain at the injection site (57.1%), with no other complaints. Conclusion(s): The adverse effects reported are of mild tomoderate reactogenicity;no serious adverse events were reported.

Covid-19 Vaccination Impact on Atrial Arrhythmias - Real-World Evidence from the Certitude Registry

Background: The COVID-19 vaccines were developed unprecedentedly and have proven safe and efficacious in reducing transmissibility and severe infection. The impact of mRNA-based COVID-19 vaccines on atrial arrhythmias (AA) incidence is unknown. Objective(s): To analyze the incidence of AA after COVID-19 vaccination in patients with a cardiac implantable electronic device (CIED). Method(s): BIOTRONIK Home Monitoring data and Medicare claims data from CERTITUDE patients implanted with a CIED between 2010-20 were utilized to identify recipients of one or more doses of the COVID-19 vaccine in 2021. Those who had influenza vaccination in 2020 were also identified in the same cohort as a control. From remote monitoring data, the number of atrial high rate events (AHR) and % burden of AA in the three months post-vaccination was compared to the preceding three months using Wilcoxon signed rank test. Kruskal-Wallis test was used for group difference comparisons. New AF diagnosis was determined from ICD-10 diagnosis codes in Medicare claims. Result(s): First and 2nd doses of COVID vaccine (50% Pfizer, 47% Moderna, and 3% J&J) were administered to 7757 and 6579 individuals with a CIED (age 76.2 (+/-9.0) y, 49% males), respectively. In the same cohort, 4723 (61%) individuals received the influenza vaccine. A statistically significant increase in the number of AHR episodes and % burden of AA was noted in the three months post-vaccination compared to the preceding three months after the 1st and 2nd doses of the COVID-19 vaccine (Figure). No such association was noted following influenza vaccination. In subgroup analysis, AHR episodes increased significantly in age groups >70 and men. Post-vaccination increase in AHR episodes was more significant in those without a pre-vaccination history of AHR episodes (mean increase of AHR 6.9+/-88.4, p<0.001) and was non-significant in those with a preceding history of AHR (p=0.8). Among the 764 patients with no AF diagnosis in claims preceding the first COVID-19 vaccine, 87 (11.4%) developed a new AF diagnosis or AHR event in the first three months post-vaccination. Conclusion(s): We report a small but significant increase in the number of CIED-detected atrial arrhythmias following vaccination for COVID-19 but not influenza, specifically in men and age >70 years. Acknowledging the immense public health benefit of COVID-19 vaccines, our results should prompt increased awareness of evaluating for AF in this high-risk group following vaccination. [Formula presented]Copyright © 2023

The Use of Acute-Phase Proteins Apache Ii and Sofa to Predict the Mortality of Covid-19 Patients

Objective: Acute-phase proteins are a family of proteins synthesized by the liver. With this study, we aimed to investigate the effects of COVID-19 infection on acute phase reactants (AFR) and determine the usability of AFRs as prognostic factors in COVID-19 disease. Material(s) and Method(s): Serum samples taken for routine analysis of the patients admitted to the Emergency Department and diagnosed with COVID-19, were used. AFR levels of 30 patients who resulted in mortality and 30 recovered patients were evaluated. C-reactive protein (CRP), ferritin (FER), ceruloplasmin (Cp), albumin (Alb), prealbumin (Prealb), transferrin (Trf), lactate, Acute Physiology and Chronic Health Evaluation (APACHE), and Sequential Organ Failure Assessment (SOFA) assessment was performed. Result(s): The hazard ratio and 95% confidence interval for FER, CRP, lactate, Alb, Cp, Prealb, Trf, Age, SOFA, and APACHE were 1.001 (1.000-1.001), 1.005 (1.001- 1.008), 1.141 (1.016-1.243), 1.016 (0.740-1.399), 1.016 (0.740-1.399), 1.056 (1.017-1.100), 0.978 (0.917-1.035), 1.000 (0.995-1.006), 1.032 (1.004- 1.064), 1.104 (0.971-1.247), and 1.012 (0.974-1.051), respectively, in univariable model. Only CRP, lactate, and FER found significant in multivariable model. In addition, patients in the nonsurvivors group had significantly higher FER, CRP, lactate, APACHE, age, and SOFA. Nonsurvivors also had lower Alb, Prealb, and serum Trf level compared to survivors. Conclusion(s): CRP, lactate, and FER, which we have shown to be significantly higher in severe COVID-19 patients, will be valuable parameters that will contribute to clinical improvement if they are used in the follow-up of patients due to their easy measurement and predictive values.Copyright © 2023, Nobelmedicus. All rights reserved.

Novel Ga-68-FAPI PET/CT offers oncologic staging without COVID-19 vaccine-related pitfalls

Ziel/Aim The global SARS-CoV-2 vaccination campaign brought attention to a recent pitfall in tumor staging by PET/CT. Several publications reported a non-specific F-18-FDG tracer uptake in axillary lymph nodes after COVID-19 vaccination. Ga-68-FAPI PET/CT is a new oncologic imaging tool that may overcome this limitation. Methodik/Methods For this purpose, we compared the tracer uptake in a head-to-head and same-day F-18-FDG and Ga-68-FAPI PET/CT study. 11 patients from our prospective database (NCT04571086) were included showing vaccine-related tracer uptake in axillary lymph nodes up to 6 weeks after COVID- 19 vaccination. Ergebnisse/Results Among the total of 11 patients, all (n = 11) showed visual positive uptake in the lymph nodes ipsilateral to the injection side on F-18-FDG PET. None (n = 0) of the included patients showed significant tracer uptake on Ga-68-FAPI PET. Follow-up imaging confirmed reactive nodal uptake in all patients. The tumor detection efficacy for these patients was 73 % for F-18-FDG and 94 % for Ga-68-FAPI. Schlussfolgerungen/Conclusions In our case series, Ga-68-FAPI demonstrated resistance to vaccine-related pitfalls while presenting superior tumor detection.

Patient Safety Culture in the Emergency Center at the University Clinical Center of Kosovo and the COVID-19 Pandemic

BACKGROUND: Despite the developments in Kosovo's healthcare, there are still many challenges that hamper the delivery of proper health-care service. This was especially highlighted during the coronavirus disease 2019 (COVID-19) pandemic. AIM: This study aims to elucidate the factors that impede proper health service as well as reduce preventable medical errors by focusing on safety as a fundamental principle in patient care and a key component health services quality management. The main goal is to improve the overall approach to the patient by improving the workers performance and redesigning systems, with the goal of reducing patient risk not only in normal working environment but also in new and unusual situations such as COVID-19 pandemic. METHOD(S): In this cross-sectional study, data were collected and analyzed. Two questionnaires were compiled for this research: one was compiled to address patients who sought health services at the Emergency Center;the second questionnaire was designed for the Emergency Center personnel to identify the relationships between the workers, managerial staff, the problems of reporting errors, and similar. Moreover, relevant publications on the impact of the pandemic on the provision of health services were compared. Statistical analysis was done by IBM SPSS version 25. CONCLUSION(S): There is a need for improving Patient Safety Culture in The Emergency Center at the University Clinical Center of Kosovo. By reorganizing working hours for the workers of the Emergency Center, preventable medical errors would be reduced. Raising the capacities of the primary care level would reduce the load of the Emergency Center from interventions, which can be handled without a problem at the lower levels. Continuous professional trainings, as well as trainings focused on stress management, working under time pressure, and relationships between health service providers would significantly improve the level of patient safety in the Emergency Center.Copyright © 2023, Scientific Foundation SPIROSKI. All rights reserved.

Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

Perception of training and job perspectives among final-year residents in the specialty of Endocrinology and Nutrition

Introduction: The medical specialisation model in Spain is carried out in the context of specialised health training, through the residency programme. The aim of the study is to analyse, by an anonymous survey, the opinion on three aspects among final-year residents in Endocrinology and Nutrition (E&N): self-assessment of the knowledge acquired, working prospects, care and training consequences arising from the pandemic COVID-19. Material(s) and Method(s): Cross-sectional observational study using a voluntary and anonymous online survey, shared among final-year national interns in the last year of the E&N programme, carried out between June-July 2021. Result(s): 51 responses were obtained, 66% of the fourth-year residents. Overall perception of their knowledge was 7.8 out of 10. Most external rotations were in thyroid and nutrition areas. A total of 96.1% residents, carried out some activity associated with COVID-19, with a training deterioration of 6.9 out of 10. 88.2% cancelled their rotations and 74.5% extended their working schedule. The average negative emotional impact was 7.3 out of 10. 80.4% would like to continue in their training hospital, remaining 45.1%. 56.7% have an employment contract of less than 6 months, most of them practising Endocrinology. Conclusion(s): The perception of the knowledge acquired during the training period is a "B". Residents consider that the pandemic has led to a worsening of their training, generating a negative emotional impact. Employment outlook after completing the residency can be summarised as: temporality, practice of Endocrinology and interhospital mobility.Copyright © 2022 SEEN y SED

Covid 19 in Patients with Rheumatic Diseases

Objectives: BIOBADAGUAY is the Paraguayan/Uruguayan registry of adverse events in patients with inflammatory rheumatic conditions under biologic therapy (BT). Three years have elapsed from the first case of coronavirus and data about South American patients with COVID are still scarce. In this study we analyzed the frequency and clinical outcomes of COVID-19 in a cohort of patients with rheumatic diseases from Paraguay. Method(s): A cross sectional study of Paraguayan patients with rheumatic diseases from BIOBADAGUAY and controls without BT. Clinical, epidemiological, and COVID-19 data were analyzed. Only cases confirmed by SARSCoV-2 positive PCR test were included. Descriptive analysis were performed for this study. Result(s): 832 patients were included (696 under BT and 136 controls). 116 (13.9%) had COVID-19. 22 had a second infection and 9 a third reinfection. Table 1 shows characteristic of COVID-19 patients. The most frequent diagnosis was rheumatoid arthritis (n = 93, 80.2%) followed by ankylosing spondylitis (n = 6, 5.2%), undifferentiated spondylarthritis (n = 5, 4.3%), psoriatic arthritis (n = 4, 3.4%), juvenile onset arthritis (n = 2, 1.7%), vasculitis (n = 2, 1.7%). Only 1 case (0.8%) were registered for Still's disease, enteropathic spondylarthritis, systemic sclerosis and seronegative polyarthritis, respectively. When comorbidities were analyzed, 46 (39.6%) patients had at least one (Table 1). Of the total treatments received: 65 (56.0%) had methotrexate, 53 (45.7%) leflunomide, 3 (2.5%) sulfasalazine, 15 (12.9%) hydroxychloroquine, 25 (21.5%) glucocorticoid, 52 (44.8%) anti-TNF and 20 (17.2%) non-anti-TNF. COVID-19 severity outcomes were: 101(87%) non severe, 31 (26.7%) severe and 1 fatal(0.8%). 189 (90.9%) patients received vaccination and the mean number of doses were 2.5 doses. 55 (26.4%) had COVID prior to vaccination Conclusion(s): In this study we examined the frequency of COVID-19 in Paraguayan patients with rheumatic diseases. In this cohort of rheumatologic patients, COVID 19 severity was similar to the one in the general population.

‘The one thing guaranteed in life and yet they won't teach you about it': The case for mandatory grief education in UK schools

Nearly all British children are bereaved of someone close to them by the time they turn 16 and, with the Covid-19 pandemic and world humanitarian crises across the news and social media, they are being exposed to more anxiety about death than ever before. Learners need to be taught about grief and death to prepare them to manage bereavement and support others. As it stands, although teaching resources exist and some curriculum guidance documents mention loss or death, there is no statutory requirement for schools anywhere in the UK to cover grief or bereavement and many pupils have no classes about these difficult topics. This article consolidates the case for grief education in schools. We discuss six key questions to examine evidence that children benefit from talking about grief, death and loss;the current provision for grief education in UK schools;the obstacles to teaching these topics and ways to overcome them;and the potential further implications of a policy change. Following the lead of child bereavement charities, research and new national reports on UK bereavement support, we demonstrate the need for mandatory grief education in all four countries of the UK and offer evidence-based recommendations for its implementation. © 2023, Cruse Bereavement Care. All rights reserved.

Ahead of the Curve - Experience from the Uk's First Dedicated Specialist Crm Clinic for Achd Patients

Background: The population of Adults with Congenital Heart Disease (ACHD) is expanding. A significant number will require Cardiac Rhythm Management (CRM) devices. In current UK practice, these patients are routinely seen in non-specialist CRM clinics and little is published regarding best-practice CRM programming and management in the ACHD population. Objective(s): Our objective was to establish a new model of patient-centred/-specific care delivered by specialist CRM physiologists, supported by an EP consultant (with a special interest in ACHD) in a dedicated clinic. We hoped to set new standards of care and patient experience, and improve efficiency and outcomes. Method(s): Data was collected from the electronic record system and CRM device database. A control group of non-ACHD patients was selected at random at our institution over the same period (2018-2022). Result(s): The clinic population n = 468 had a sex ratio of 0.92 (M:F) and mean age of 44 years (range 16 - 86). Mean time since primary implant was 9 years. All device types were represented: loop recorder (52), pacemaker (262), cardioverter defibrillator (116) and cardiac resynchronisation therapy devices (38). The underlying ACHD condition was: simple 46%, moderate 28% and complex 26%. Outcomes of appointments (n = 1,234) are shown vs controls (n = 126) (figure 1). Appointment and patient numbers rose year-on-year (100 to 226 patients, 281 to 367 appointments). There was a lower incidence of 'no review / reprogramming ' in ACHD CRM clinic appointments compared to the non-ACHD population, as well as a higher incidence of programming changes, however the trend over time within the ACHD group showed an increase in 'no review / reprogramming' and a decrease in reviews / reprogramming events. In contrast, non-ACHD patients had an increase in medical reviews and reprogramming required between 2018/19 and 2021/22. This is likely due to the COVID pandemic and deferred time to appointments and review. Conclusion(s): Our data demonstrate that the ACHD CRM population require additional input from the medical and scientist teams when compared to non-ACHD patients, however over time there has been a reduction in major programming/review and a commensurate increase in minor programming/discussion and no review. A reverse trend was observed in the non-ACHD patients pre- and post- COVID. These data support the proposal that specialised clinics provide the optimal management ACHD CRM clinics and should be delivered by dedicated practitioners. [Formula presented]Copyright © 2023

Addressing loneliness and dietary needs during the COVID-19 pandemic: experiences of people living with HIV receiving support from a small HIV support organisation

Background: The Voluntary and Community Sector (VCS) is a vital partner in delivering care and support needs: enabling vulnerable people to live fulfilling, independent lives;helping them maintain good health and wellbeing. People living with HIV are disproportionately impacted by poverty, financial instability, stigma and discrimination, all of which were exacerbated during the COVID-19 pandemic. Pre-pandemic, this small HIV support organisation (part of the VCS) provided community, food, friendship and peer-support for people living with or affected by HIV, primarily via a weekly lunch club and monthly supper. This qualitative impact study explored clients' experiences of the change in service provision (eg food collection, doorstep food delivery, and companionship telephone calls) as the organisation adapted to members' needs during lockdowns and as restrictions altered. Method(s): Nineteen clients gave informed consent and participated in a facilitated in-person focus group. Two groups (n=10 and n=9) were held concurrently in June 2021 (after the second lockdown, but before all COVID restrictions were lifted). Focus groups lasted 60-90 minutes, with semi-structured interview question guides to structure discussions;they were recorded and transcribed verbatim. Deductive thematic analysis was conducted using a coding procedure to identify patterns between the groups and emerging themes. Result(s): The following themes relating to clients' experiences of the pandemic and their engagement with the organisation emerged from the focus groups: * Pre-lockdown services * Loneliness * Regular food parcels * Telephone companionship calls * Value of non-judgemental space Pre-lockdown, participants valued peer support and sharing meals together. During the pandemic, some clients experienced food insecurities;some felt disconnected and socially isolated;some lost their jobs or retired. Clients trusted the organisation to keep them safe (eg social distancing), and the volunteers delivering food made them feel valued and connected to their peers. Telephone check-ins helped tackle loneliness and reassured those who were anxious or afraid. Conclusion(s): During the pandemic this organisation helped address stigma, food insecurities and social isolation experienced by people living with HIV. Participants appreciated the organisation's mission and commitment to people living with HIV, and how welcoming and supportive the service is.

Clostridium Difficillae Infection in Post-Covid Patients

Intro: The ongoing pandemic caused by the SARS-CoV-2 virus has brought many new insights into medicine. During the first months of the pandemic, when there were no comprehensive guidelines for precise antimicrobial therapy, empirical overuse of broad-spectrum antibiotics was observed. Which resulted in the development of clostidium infection in certain cases. In our report, we address 83 cases of clostridial colitis in post-covid patients from 3/2020 to 3/2021 and their specific therapy. Method(s): Retrospective analysis of risk factors for clostridial infection and therapy of clostridial colitis. Finding(s): In the period 3/2020-3/2021, 9617 patients were diagnosed with SARS-CoV-2 virus infection in our hospital, of which 1247 were hospitalized. In 83 cases, clostridial colitis occurred during or after the covid infection had resolved. Mortality in this group was 17%, which corresponds to 14 patients. Previous empirical administered antiobiotics in COVID-19 infection contributed to the development of clostridial colitis in case of 22 patients (27%) by clarithromycin, in 14 pacients (17%) by penicillins and by 3rd generation cephalosporins in 9 patients (11%). The average duration of therapy with broad-spectrum antibiotics was 15.63 days (+-8.99). Other risk factors we observed are: PPI use (25%), active malignant disease (10%), previous glucocorticoid therapy (22%). Vancomycin was used in clostridial infection therapy in 47% (39), metronidazole in 31% (25) and fidaxonicin in 7% (6). In the group, we observed recurrence of clostridium difficile infection in 14% of patients and FMT was performed in 6 patients. Conclusion(s): This study shows a higher percentage of clostridial infection in cases of long-term therapy with broad-spectrum antibiotics. It also points to the effect of specific antimicrobial therapy for infection caused by the bacterium Clostridium difficile and the possibility of using fecal bacteriotherapy.Copyright © 2023