Using Novel Remote Electronic Monitoring to Measure and Manage the Rheumatology Clinic Backlog Generated by Covid-19

Background/Aims During the COVID-19 pandemic we were unable to provide regular outpatient services for patients with chronic rheumatic diseases. A ''backlog'' of 6812 patients without an allocated follow-up appointment accrued by September 2021. We quantified this cohort and analysed attempts to deliver care remotely (using video, telephone, and electronic remote management forms (RMFs)). Methods We selected a 12-month ''window'' (May 2020-May 2021) and analysed the number of patients awaiting follow-up during this period. This was initially 3259 patients out of the total backlog 6812. We revisited the number of patients remaining in that cohort on four occasions between September 2021 and September 2022: at baseline, then at 1-, 2-, 6- and 12-month intervals. Each audit cycle was conducted using the same methodology. Alongside usual follow up pathways, (face to face, video or telephone), we implemented remote management forms (RMFs) for different disease groups which were designed by the department;they contained a triage questionnaire, including calculation of disease severity scores, and questions about medications. These were sent out by clinicians to some patients in lieu of a telephone, video or face to face appointments. Data from RMFs was stored in a secure database for clinician review. Data analysis performed in Microsoft Excel and R (version 4.2.1). Results The number of patients without allocated follow-up appointments reduced from 3259 to 326 between Sep-21 and Sep-22. This is a 90% reduction in the backlog over a 12-month period, with a 71% reduction achieved by 6 months. There was a significant, progressive reduction in the number of patients over time (p<0.001 - Chi-square test for trend). Of the 1956 RMFs completed between Sep-21 - Mar-22, only 261 patients recorded a previous appointment date. 154/261 (59%) were completed by patients waiting in the ''window'' of May-20 - May- 21. This indicates a preferential use of RMFs targeting backlog patients. Between 2-8% of the total backlog patients were managed using RMFs based on available data. Conclusion We have significantly reduced the size of our backlog of outpatient follow-up due to COVID-19 over a 12-month period. In-addition these results likely underestimate the effect of RMFs due to this dataset being incomplete. Remote management made a sizeable contribution to this reduction, meaning some of this reduction was achieved without face-to-face encounters. The use of 1956 forms over a 6- month period shows robust integration of our RMFs into outpatient services disrupted by COVID-19 and provides evidence for remote management as a useful tool in outpatient management, with relevance to areas such as Patient Initiated Follow Up pathways. Further work is needed to clarify where remote management is best deployed and which patient groups benefit most from this.

Lipid coating technology: A potential solution to address the problem of sticky containers and vanishing drugs

Pharmaceutical drugs and vaccines require the use of material containers for protection, storage, and transportation. Glass and plastic materials are widely used for packaging, and a longstanding challenge in the field is the nonspecific adsorption of pharmaceutical drugs to container walls – the so-called "sticky containers, vanishing drugs” problem – that effectively reduces the active drug concentration and can cause drug denaturation. This challenge has been frequently discussed in the case of the anticancer drug, paclitaxel, and the ongoing coronavirus disease 2019 (COVID-19) pandemic has brought renewed attention to this material science challenge in light of the need to scale up COVID-19 vaccine production and to secure sufficient quantities of packaging containers. To reduce nonspecific adsorption on inner container walls, various strategies based on siliconization and thin polymer films have been explored, while it would be advantageous to develop mass-manufacturable, natural material solutions, especially ones involving pharmaceutical grade excipients. Inspired by how lipid nanoparticles have revolutionized the vaccine field, in this perspective, we discuss the prospects for developing lipid bilayer coatings to prevent nonspecific adsorption of pharmaceutical drugs and vaccines and how recent advances in lipid bilayer coating fabrication technologies are poised to accelerate progress in the field. We critically discuss recent examples of how lipid bilayer coatings can prevent nonspecific sticking of proteins and vaccines to relevant material surfaces and examine future translational prospects. © 2021 The Authors. VIEW published by Shanghai Fuji Technology Consulting Co., Ltd, authorized by Professional Community of Experimental Medicine, National Association of Health Industry and Enterprise Management (PCEM) and John Wiley & Sons Australia, Ltd.

IS THE USE OF A NON INVASIVE MOBILE APPLICATION AN EFFECTIVE WAY TO SCREEN WOMEN FOR ENDOMETRIOSIS DURING THE COVID-19 PANDEMIC?

OBJECTIVE: The purpose of this study is to determine the positive predictive value (PPV) of diagnosis for endometriosis by the Nezhat Endometriosis Advisor (NEA) mobile application to serve as a screening tool MATERIALS AND METHODS: A retrospective cohort study was conducted at a university-affiliated private practice. Inclusion criteria were women with no previous surgical diagnosis of endometriosis who also completed an endometriosis assessment using the application. Patients with symptoms desiring definitive diagnosis and treatment of endometriosis then underwent laparoscopic surgery once surgeries were once again allowed. The diagnosis of endometriosis was confirmed visually by a surgeon specialized in treating endometriosis and also through biopsy sent to pathology. The primary outcome measured was the PPVof NEA mobile application questionnaire to the surgical diagnoses of endometriosis. RESULTS: A total of 100 patients met the inclusion criteria for this study. 95% of the patients whose score on the app was 90% or above, had a surgical pathology confirmed diagnosis of endometriosis (PPV 95%). CONCLUSIONS: NEA mobile application questionnaire has a high PPVof 95% for diagnosing endometriosis and can help identify a patient population that may require surgical treatment for pelvic pain or unexplained infertility. This will be helpful as it may lead to earlier diagnosis and management of endometriosis. Patients can reduce risk exposure of COVID-19 by avoiding multiple medical office visits. The COVID-19 pandemic has also decreased the availability of healthcare for many, and they may suffer for a long time with pain or infertility before a diagnosis is made. The mobile application is a possible alternative method to assess risk of endometriosis while avoiding risk of COVID-19 exposure. Patients can be medically treated based on symptoms and application results until surgery can be performed. With further research, the application has the potential to be the diagnostic measure of endometriosis. More research is needed to determine the continued accuracy of the application in different patient population and demographics IMPACT STATEMENT: Endometriosis is ectopic uterine lining growing outside the uterus which causes pain and infertility. Currently, definitive diagnosis is with pelvic laparoscopic surgery, as no screening test is widely available or accepted. The Coronavirus Disease 2019 (COVID-19) pandemic due to the infectious pathogen Severe Acute Respiratory Syndrome Coronavirus 2 has altered ambulatory and inpatient health care. For several months commencing March 2020, non-emergent surgeries came to an abrupt hault due to the COVID- 19 pandemic. Many patients who were scheduled to have diagnostic laparoscopies for suspected endometriosis were not able to have their surgeries performed. As an alternative NEA was utilized to determine the likelihood of endometriosis based on self-answered questionnaires about experienced symptoms. The mobile app is free and available for patients worldwide. Patients with a high probability of endometriosis can be treated medically until surgery resume.

Surface engineering of plasmonic gold nanoisland platforms for high-sensitivity refractometric biosensing applications

Plasmonic chips comprising gold nanoisland structures that are fabricated by solution-phase seeding, have demonstrated excellent promise as high-sensitivity substrates for molecular detection and medical diagnostic applications. Even so, there still remains an outstanding need to examine the potential utility of these plasmonic chips for label-free refractometric biosensing and to understand how nanostructure design principles affect measurement sensitivity. Herein, we developed a thiol-based surface functionalization strategy to fabricate gold nanoislands on a functionalized glass surface with improved fractional surface coverages and inter-island gap distances of 80–85% and 5–10 nm, respectively, as compared to values of 50–65% and 15–20 nm for gold nanoislands on bare glass substrates. By tuning the gap distance, it was possible to adjust the bulk refractive index sensitivity of the measurement signal from ∼99 nm per refractive index unit (nm/RIU) for gold nanoislands on a non-functionalized glass surface to ∼180 nm/RIU for gold nanoislands on a functionalized glass surface. The nanoplasmonic biosensing capabilities of the latter plasmonic chip were further investigated and demonstrated larger measurement responses for detecting bovine serum albumin (BSA) protein adsorption compared to other types of plasmonic gold nanostructures. It was also possible to detect antigen-antibody interactions related to coronavirus disease-2019 (COVID-19), especially binding events that occurred near the sensor surface. These findings demonstrate the broad application possibilities of gold nanoisland platforms for refractometric biosensing and emphasize the importance of finetuning nanostructure dimensions to optimize sensing performance. © 2021

Remote clinical management: Incorporating electronic assessment of patients with rheumatic diseases into standard clinical pathways during the COVID-19 pandemic: A pilot study

Background: Many patients with rheumatic disease require immunosuppressive medication putting them at high risk of COVID-19 infection. Reduced staffing in rheumatology due to redeployment to COVID-19 work, limited out patient capacity and patient vulnerability have had a major impact on our ability to review our patients to assess their condition and treatment (by face-to-face, video or telephone consultations). Novel strategies are essential to safely and effectively treat patients with rheumatic disease whilst minimising their risk of exposure to COVID-19 infection. Objectives: The objective was to develop a digital solution to help deliver safe, efficient and effective care for patients with rheumatic diseases. The aim was to produce a system that allowed us to integrate data recorded directly by patients with information held in our electronic health records to provide a virtual review of care. Methods: An online questionnaire was used to collect clinical information, including validated disease activity measures, to conduct a remote assessment in 175 patients awaiting follow-up appointments. This assessment was integrated within our electronic health records (EHR). The questionnaire contained measures of disease activity (DAS28 or BASDAI);patient reported outcomes;patient preferences regarding the urgency and type of appointment;any recent problems or changes in medication. This information was imported into a database for clinician review, together with previous clinical records and results of relevant investigations, to inform clinical decisions and to decide on the safest and most appropriate timing for follow-up. Report letters were sent to the patient and their primary care providers. Results: Of the 175 patients (149 with RA and 26 with AS), 108 patients (89/149 [60%] with RA [mean age=64;female=65%] and 19/26 [73%] with AS [mean age=45;female=54%]) submitted responses over a 6-week period based on which clinical decisions were made. The mean questionnaire completion time was 19 minutes for RA responders and 16 minutes for AS responders. Non responders (67/175 [mean age=61;female=63%]) remained on our list of patients awaiting follow-up arrangements to be made. Sixty-nine responders (64%) had stable disease therefore did not require any changes to their treatment and were offered an appointment within the next 6 months, of whom 12 (11%) requested face-to-face follow-up. Of the remaining 39 -with less stable disease -requiring more rapid follow-up assessment, 22 patients (56%) required a face-to-face consultation to consider treatment change. So far 9 of these patients have had follow-up, of whom 6 necessitated treatment escalation (Methotrexate increase n=2;anti-inflammatory increase n=2;intramuscular steroid n=1;anti-TNF escalation n=1). Thirty-nine patients (36%) provided feedback on the process of completing the questionnaire, 85% of whom used a mobile phone and the remainder used a computer or tablet. The majority (70%) found it “extremely easy” or 'somewhat“extremely difficult” 0%. Conclusion: We have created and tested a system of remote clinical management for patients with RA and AS. Amongst the 108 responders, just 31% required a face-to-face appointment, with treatment changes made accordingly. With a backlog of 3,800 awaiting allocation to follow-up appointments, remote clinical management will allow us to safely and efficiently prioritise patients requiring urgent follow-up for treatment optimisation. We will integrate this system into our standard care pathway beyond the COVID-19 pandemic to streamline our service, deliver effective care and provide evidence to support the use of costly biologic drugs.1 We plan to investigate the barriers for non-responders.