Hydroxyurea and pyridostigmine repurposed for treating Covid-19 multi-systems dysfunctions

Early in the COVID-19 pandemic, medical care providers at an acute illness hospital received increasing numbers of post-acute advanced COVID-19 patients from referring hospitals where they were showing no signs of improvement after receiving treatments from standard Emergency Use Authorization (EUA)-type protocols. The care providers turned to repurposing medications to treat these patients and added hydroxyurea, a medication commonly used for treating sickle cell anemia, to the hospital's COVID-19 treatment protocol and began to see notable clinical improvements. As the pandemic continued and new concerns arose concerning COVID-19 complications, those same care providers again turned to repurposing drugs. Focusing on the neuromuscular effects seen in COVID-19 patients, care providers turned to medications used to treat chronic neuromuscular conditions. Post-acute advanced Covid-19 patients initially received an abbreviated course of hydroxyurea followed by titrated doses of pyridostigmine. Positive responses were noted with cognition, diminished oxygen demands, progressive decrease in ventilator support, improved swallowing, and mobility. The authors suggest repurposed drugs could have great utility for treating COVID-19. It is recommended larger, COVID-19 clinical trials be completed to include hydroxyurea and pyridostigmine for validating the outcomes and clinical observations seen in these presented cases.

EVOLVING CHARACTERISTICS OF COVID-19 INPATIENTS AT AN AUSTRALIAN CENTRE

Since the declaration of the global pandemic in March 2020, the novel coronavirus disease (COVID-19) has caused dynamic pressures on healthcare systems worldwide. This study aims to compare the demographic and clinical characteristics, management, and outcomes of patients with COVID-19 at a single centre in Sydney, Australia. Using the clinical coding data, we identified all patients aged > 16 years admitted to our centre between February 1st, 2020, and March 31st, 2022. We categorised the time periods 'pre-delta' (February 1st, 2020 – June 15th, 2021), 'delta' (June 16th, 2021 – November 25th, 2021), and 'omicron' (November 26th, 2021 – March 31st, 2022). We retrospectively extracted the demographic, administrative, and clinical data from the electronic medical records and performed a descriptive analysis of the data. A total of 1842 patients were identified (pre-delta N=18;delta N=788;omicron N=1036). The percentage of male patients was 83%, 54%, and 56% and the median ages at admission were 55, 49, and 70 years during the pre-delta, delta, and omicron periods, respectively. The median length of hospital stay was the longest during the pre-delta period (8.5 days vs. 7 vs. 6). ICU admission rate was 39%, 21%, and 10% for each period and of the ICU-admitted patients 43%, 40%, and 36% respectively required mechanical ventilation. Inhospital mortality was the highest during the omicron period (pre-delta inhospital mortality 5.6%;delta 4.1%;omicron 7.3%). A total of 219 (28%) patients of delta and 185 (18%) of omicron periods received at least one dose of dexamethasone and 175 (22%) and 44 (4.2%) respectively received at least one dose of remdesivir. The demographic and clinical characteristics of admitted COVID-19 patients varied across the 'pre-delta', 'delta', and 'omicron' time periods. The median age at admission and in-hospital mortality was the highest during the omicron period. [ FROM AUTHOR] Copyright of International Journal of Infectious Diseases is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

TALKING ABOUT LONELINESS: QUALITATIVE INSIGHTS FROM OLDER ADULTS: IMPLICATIONS FOR RESEARCH, POLICY, AND SERVICES

The very personal and complex nature of loneliness is too rarely articulated in research papers. Each presenter in this interdisciplinary and international symposium presents insights into loneliness and /or social isolation that can help bridge this gap. Victor (Social Gerontology) using open ended responses from the 2018 BBC Loneliness Experiment, presents how 1480 older people describe loneliness and highlights the need to give more attention to existential loneliness. O'Sullivan (Public Health) presents the results of 18 life story interviews with older adults attending a mental health service. The analysis identified three different typologies of loneliness with specific recommendations for training and services. Phone-based support programs are increasingly being used as a solution for those experiencing loneliness. However, less is known about what aspects are most helpful. Perissinotto (Geriatrics and Palliative care) presents results from 38 qualitative interviews with a focus on barriers and facilitators to implementing a phone-based support intervention, particularly for older adults experiencing loneliness. Cudjoe (Medicine) presents qualitative data from older adults (English, Spanish and Mandarin speaking), living in non-profit affordable housing in 22 different states. Drawing on experiences of their social connections during the COVID-19 pandemic, the paper gives voice to the implications of the loss of common facilities, and opportunities to socialize with other residents, and the increased role technology plays in staying connected. Our discussant, Prof Leavey, a leader in the field of mental health, will reflect on the major themes emerging from these multidisciplinary perspectives, especially what they mean for public health and services.

Role strain and COVID-era burden among South Asian caregivers of individuals with brain health conditions and disabilities

Background: The COVID-19 pandemic has renewed attention to the conflicting demands placed on caregivers worldwide. Nowhere is this more evident than in South Asia, where cultural norms and a scarcity of long-term care facilities have made the home the locus of caregiving for individuals with brain health conditions and disabilities. A hidden cost of this informal arrangement is the burden experienced by the primary caregiver. This may be exacerbated when traditional caregiving expectations clash with personal aspirations outside the family. Method(s): The COVID-19 pandemic has renewed attention to the conflicting demands placed on caregivers worldwide. Nowhere is this more evident than in South Asia, where cultural norms and a scarcity of long-term care facilities have made the home the locus of caregiving for individuals with brain health conditions and disabilities. A hidden cost of this informal arrangement is the burden experienced by the primary caregiver. This may be exacerbated when traditional caregiving expectations clash with personal aspirations outside the family. Result(s): The COVID-19 pandemic has renewed attention to the conflicting demands placed on caregivers worldwide. Nowhere is this more evident than in South Asia, where cultural norms and a scarcity of long-term care facilities have made the home the locus of caregiving for individuals with brain health conditions and disabilities. A hidden cost of this informal arrangement is the burden experienced by the primary caregiver. This may be exacerbated when traditional caregiving expectations clash with personal aspirations outside the family. Conclusion(s): Role strain may be a significant driver of burden when the caretaker's educational and professional potential collide with traditional South Asian family obligations. The burden reported by our respondents suggests that role strain may elevate stress among young, educated caregivers. Our results, therefore, provide indirect evidence concerning the changing economic and socio-cultural context of caregiving in South Asian households. Copyright © 2022 the Alzheimer's Association.

COVID-19-related loneliness, social isolation and burden in informal caregivers worldwide

Background: Informal caregivers may experience high levels burden. Prior to COVID-19, loneliness and social isolation, and especially the discordance between them, were recognized for rapid aging-related cognitive decline. The COVID-19 has significantly increased social isolation and loneliness in caregivers. Thus, we aimed to explore the variables that were associated with higher care burden among all caregivers and only among caregivers for people living with dementia, and whether the increased burden could be associated with a discrepancy between loneliness and social isolation. Method(s): 'Comparing Loneliness and Isolation in COVID-19' was an online global survey of over 20,000 respondents, including 5243 caregivers across 50 countries with enduring brain or/and physical health conditions. We first used a multilevel modelling to identify risk factors associated with higher burden. Then, we defined profiles of discrepancy between loneliness and social isolation, based on the differences between standardized score on a scale of loneliness and of social connectedness and estimated the association between the discrepancy and higher burden. Result(s): In our sample, 74% of caregivers were female, 44% were caring for people with dementia, and 22% for people with multiple conditions, including dementia. The most prevalent age group was 60-69 years old. Factors significantly associated with higher care burden were being female, having poorer financial situation, worse mental health during the pandemic, caring for people with dementia or intellectual disabilities, caring in the same home, being diagnosed with COVID, and changes of care abilities. 40% of caregivers consistently reported high level of loneliness and social isolation, 38% reported consistent lower levels of both, and two groups reported discordance (low levels of loneliness and high social isolation in 13%;high levels of loneliness and mild social isolation in 12%). The latter group was at the highest risk of self-reported increased and intense care burden. Conclusion(s): This represents the largest, most widespread survey on the impact of the COVID-19 pandemic on caregivers of people with long-term conditions to date and reflects the importance of capturing the nuances in the relationship between loneliness and social isolation in caregivers. It will be an important resource for support agencies and to inform policy. Copyright © 2022 the Alzheimer's Association.

Risk factors for loneliness in family caregivers of people with dementia and enduring mental health conditions during the COVID-19 pandemic in Latin America

Background: During the COVID-19 pandemic, loneliness has increased in the general population due to government measures to contain the spread of the disease. In Latin America (LA), caregiving is most often delivered informally by family members Family caregivers often face mental health challenges linked to their caregiving role and their social context. Pandemic-related social restrictions have been especially detrimental for older people with dementia or other brain health challenges, as well as their family caregivers. We aimed to investigate the associations of loneliness, social isolation and care burden in these family caregivers. Method(s): We undertook a cross-sectional survey of over 300 informal caregivers of people with dementia or enduring mental health problems living in 4 Latin American countries, Mexico, Brazil, Chile, and Peru. We categorized loneliness into 3 groups 'low', 'moderate' and 'severe loneliness'. Here, we analyzed factors related to changes in the prevalence of moderate and severe loneliness before and during the pandemic using a longitudinal multinomial logistic regression model. Result(s): During the pandemic, there was a significant increase in loneliness prevalence (p<.001) among caregivers in Latin America, with more people having moderate (6.25% pre-pandemic;17.67% mid-pandemic) and severe loneliness (2.78% pre-pandemic;15.19% mid-pandemic). Gender differences in the prevalence of loneliness or higher levels of loneliness among dementia caregivers compared to caregivers of other conditions were not seen. The regression model revealed that the increment in risk for moderate loneliness during the pandemic was related to caregivers' age, level of education, and social contact/isolation. Increased risk for severe loneliness was related to caregivers' social contact during the pandemic and perceived mental health. Conclusion(s): Public health interventions regarding COVID-19 pandemic should consider increased loneliness in Latin-American caregivers. This population will need both, short and long-term mental health and practical support. Next steps include gathering more evidence on specific risk factors for loneliness and its impact on caregivers' physical and mental health. Copyright © 2022 the Alzheimer's Association.

COVID-19 outcomes in fingolimod- or siponimod - treated patients: clinical trial and post marketing cases

Introduction: Understanding how immunomodulatory therapies influence COVID-19 outcomes in people living with multiple sclerosis (PlwMS) is vital to patients and physicians alike. Aims and Objective: Evaluate COVID-19 outcomes in PlwMS receiving either fingolimod or siponimod. Method(s): The Novartis clinical trial (CT) and safety databases were reviewed to identify confirmed (CT: confirmed if patient is SARS COV-2 positive;post-marketing [PM]: considered as reported) or suspected cases of COVID-19 in PlwMS receiving either fingolimod or siponimod (CT cut-off: fingolimod 04-Aug- 2021, siponimod 29-Oct-2021;PM cut-off: fingolimod 28-Feb- 2022, siponimod 25-Mar-2022). Result(s): For fingolimod, there were 1054 cases comprising of 45 suspected (PM=45) and 1009 confirmed cases (CT=9;PM=1,000) of COVID-19 (mean age in years: 17 [CT], 43 [PM];female: 71% [715/1009;CT=4, PM=711];male: 25% [254/1009;CT=5, PM=249] and not reported: 4% [40/1009;PM=40]). Of these, 35% (358/1009;CT=8, PM=349) were from Europe, 30% (305/1009;PM=305) from the US and 34% (347/1009;CT=1, PM=346) from the rest of the world (ROW). Hospitalisation was required for 13% of patients (130/1009;PM=130);1% (13/1009;PM=13) had a fatal outcome;and 43% (437/1009;CT=9, PM=428) recovered or were recovering at the most recent follow-up. For siponimod there were 321 cases comprising of 6 suspected (CT=1;PM=5) and 315 confirmed cases (CT=53;PM=262) of COVID-19 (mean age in years: 49 [CT], 53 [PM];female: 68% [214/315;CT=34, PM=180];male: 28% [88/315;CT=19, PM=69] and not reported: 4% [13/315;PM=13]). Of these, 53% (168/315;CT=6, PM=162) were from the US;30% (96/315;CT=46, PM=50) from Europe;and 16% (51/315;CT=1, PM=50) from the ROW. Hospitalisation was required for 19% of patients (60/315;CT=15, PM=45);2% (7/315;CT=3, PM=4) had a fatal outcome;and where information was provided 42% (131/315 CT=50, PM=81) recovered or were recovering at the most recent follow-up. Conclusion(s): Available data indicates that most COVID-19 cases among PlwMS treated with fingolimod or siponimod were nonserious. Among PlwMS exposed to disease-modifying therapies (DMTs), the reported hospitalisation and mortality rates are 12.8%-21.5% and 1.62%-3.5%, respectively (Reder et al 2021;Sormani et al 2022). Thus, hospitalisation and fatality rates with siponimod and fingolimod in these series of Novartis reported cases were similar to those observed in PlwMS on other DMTs.

Developing an Online Practicum in Professional Education: A Case Study from UK Teacher Education

A ‘practicum’, ‘clinical experience’ or ‘internship’ is an established component of professional preparation in education, health, social work, law, accountancy and engineering. Across diverse occupational fields, employability and work readiness are gaining prominence in college marketing strategies. The disruption to work placements during the Covid-19 pandemic in programmes linked to licensure rapidly increased the pace and scale of virtualisation and the need for systematic evaluation of curriculum re-design. This chapter presents a case study of the transition to a fully online practicum for UK university students training to be teachers during 2020/21. Drawing on interviews with students, university tutors and school partners, the chapter outlines key learning about partnership formation and innovation. The evaluation suggests that online supervision requires participants to work harder to establish a positive working alliance and sense of belonging across time–space-digital media. The study highlights the importance of iterative review to promote reciprocity, transparency and voice. © 2022, The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd.

AN EXPLORATION OF RHEUMATOLOGY PATIENTS' PERCEPTIONS AND KNOWLEDGE ABOUT SICK DAY RULES WHILE USING STEROIDS FOR IMMUNOSUPPRESSION

Background/Aims Steroids are commonly used for immunosuppression in the majority of rheumatology conditions. Patients on long-term steroids are vulnerable to adrenal insufficiency during acute illness or if steroids are stopped or weaned down abruptly. During the COVID-19 pandemic, this risk has further multiplied due to change in practice with inclusion of telephone consultations and less frequent hospital visits. Although our patients were routinely provided with steroid alert cards by pharmacy, we aim to ascertain the knowledge and understanding of sick day rules in patient who are on steroids for immunosuppression. Methods We designed a novel questionnaire consisting of 10 questions, designed to determine patients' knowledge about steroid sick day rules. All questions were close-ended, either single best answer or yes/ no except question about primary rheumatological condition and type of steroids. A total of 100 patients (including new and follow-ups) attending rheumatology clinics between January and June 2020 were screened and selected randomly. Questionnaires and consent forms were sent by post as agreed with clinical effectiveness team with return envelopes. Results 29 completely filled questionnaires were received back. The majority of patients (96.5%;n=28) were on prednisolone and only 3.44% (n=1) were on hydrocortisone. The majority of the patients (95.6.6%;n=29) were on steroids for duration between 1-6 months. Answering the question on steroid dose during an acute illness,10.3% (n=3) patients had knowledge to take double dose of steroids, 55.1% (n=16) responded to take regular dose, 3.44 (n=1) answered by lowering dose to half, and strikingly 10.3% (n=3) answered to stop steroids. For further question on when to seek medical advice during an acute illness while on steroids, 31.0% (n=9) responded by answering correctly, 37.9% (n=11) were unsure when to take medical attention, and 3.44% (n=1) responded to wrong option. Despite providing steroids alert cards to everyone, only 65.5% (n=19) answered yes on asking about carrying alert card with them. Conclusion Despite providing steroid alert card and verbal information, these data highlight a significant dearth of knowledge and understanding about sick day rules among rheumatology patients on steroids for immunosuppression. This knowledge gap increases the risk of potentially lifethreatening emergency of adrenal crisis among this patient group. To bridge this knowledge gap, we started to provide steroid sick day rules written information leaflet to all new and old rheumatology patients on steroids to reduce risk of future adrenal crisis. We are aiming to re audit this after 1 year to check improvement in patient knowledge and understanding of sick day rules with this change in practice.

Clinical and demographic characteristics associated with shorter time to COVID-19 death

Introduction: Cancer patients have been considered a high-risk population in the COVID-19 pandemic. We previously investigated risk of COVID-19 death in COVID-19 positive cancer patients during a median follow-up of 134 days, and identified the following risk factors: male sex, age >60 years, Asian ethnicity, hematological cancer type, cancer diagnosis for >2.5 years, patients presenting with fever or dyspnea, and high levels of ferritin and C-reactive protein (CRP). Here, we further investigate which factors are associated with a COVID-19 related death within 7 days of diagnosis. Methods: Using data from Guy's Cancer Centre and one of its partner trusts (King's College Hospital), we included 306 cancer patients with a confirmed COVID-19 diagnosis (February 29th-July 31st 2020). 72 patients had a COVID-19 related death (24%) of whom 35 died within 7 days (50%). Cox proportional hazards regression was used to identify which factors were associated with a COVID-19 related death <7 days of diagnosis. Results: Of the 72 cancer patients who had a COVID-19 related death, the mean age was 72 years (Standard Deviation (SD) 14). A total of 53 (74%) patients were men. 37 (52%) had a hematological cancer type, 47 (65%) had stage IV cancer, and 42 (58%) had been diagnosed with cancer more than 24 months before COVID-19 related death. In the group of patients who died within 7 days of diagnosis (n= 35), mean age was 73 years (SD 13.96), 24 (68%) were men, 20 (57%) had a hematological cancer type, 26 (74%) had stage IV cancer, and 24 (68%) had been diagnosed with cancer >24 months before COVID-19 diagnosis. Factors associated with COVID-19 related death <7 days of diagnosis were: hematological cancer (Hazard Ratio (HR): 2.74 (95% Confidence Interval (CI): 1.21-6.22)), 2-5 yrs since cancer diagnosis (HR: 4.81 (95%CI: 1.47-15.69)), and >5 yrs since cancer diagnosis (HR: 4.41 (95%CI: 1.38-14.06)). Additionally, patients who presented with dyspnea had increased risk of COVID-19 related death <7 days compared to asymptomatic patients (HR: 5.25 (95%CI 2.14-12.89)). CRP levels in the third tercile (146-528 mg/L) as compared to the first were also associated with increased risk of an early death due to COVID-19. Conclusion: From all the factors identified in our previous COVID-19 related death analysis, only hematological cancer type, a longer-established cancer diagnosis (2-5 years and more than 5 years), dyspnea at time of diagnosis and high levels of CRP were indicative of an early COVID-19 related death (within 7 days of diagnosis) in cancer patients.

A global snapshot of the impact of the COVID-19 pandemic on cancer research: Report from a Global Cancer and COVID-19 Task Force

Introduction: The COVID-19 pandemic has had profound effects on healthcare systems worldwide. It has also had global economic impacts that will continue to be felt for years. The effects have implications for how cancer research is conducted and funded. The REPRISE project aims to learn from the COVID-19 pandemic to provide opportunities to redefine cancer research priorities in low- to middle-income countries (LMICs). We aim to characterize the nature of these practical and economic impacts and use this information to redefine research priorities in a changed world moving forward. Methods: As a first step, we conducted a snapshot survey of members of the 'Cancer and COVID-19 Global Task Force', which consists of experienced cancer researchers across the world. We asked about the extent to which the COVID-19 outbreak and resulting public health measures had affected cancer research in their centers. Results: We received 57 responses to our questionnaire. The respondents worked in 22 countries, representing all Word Health Organization (WHO) regions. 67% of respondents worked in either an academic/university setting, or in a public teaching hospital. The specialities of medical oncology, radiation oncology, surgery, and epidemiology were each represented by >25% of all respondents, which also included those with backgrounds in nursing, palliative care, survivorship, psychology, pathology, and prevention. Respondents in 17/22 countries reported that some (n=10) or all (n=7) cancer research studies were suspended at their center following the outbreak of COVID-19. Respondents in 5 countries reported that suspension of these studies had lasted >6 months. Respondents in 8/22 countries reported that staff redeployment, furlough, or restriction from clinical areas had had a 'large impact' on the conduct of research they were involved with. Respondents in 4 further countries reported that these factors had had a 'moderate impact'. Respondents also reported local impacts on cancer research from in-center outbreaks of COVID-19 (14 countries);government-imposed 'lockdowns' (20 countries);compliance with COVID-19 safety (18 countries);decreases in participant accrual (11 countries);and decreased patient access to diagnostics or treatment (19 countries). Nine countries yielded reports of funding cuts in their center. Twenty countries yielded reports of concerns about future funding cuts. Fifteen countries yielded reports of issues from delays to postgraduate education. Additionally, respondents were concerned about future impacts on cancer research from COVID-19 safety measures, funding cuts, and decreased patient access to diagnostics or treatments. Conclusion: The COVID-19 pandemic has profoundly impacted on the conduct of cancer research in many different countries and in several different ways. The process of redefining cancer research priorities throughout the REPRISE project will ensure that the impacts we have documented here are mitigated as far as possible and that moving forward, we can begin to address global disparities in cancer research.

Factors affecting COVID-19 outcomes in cancer patients from Guy's Cancer Center and King's College Hospital

Background: The Coronavirus disease 2019 (COVID-19) pandemic continues to have a significant impact on the treatment of cancer patients. Understanding the clinical course, potential risk factors for severe infection and excess mortality, is essential to improve patient outcomes. We previously presented preliminary results from 156 SARS-CoV-2 positive cancer patients from Guy's Cancer Center, which suggested that increased COVID-19 mortality was associated with a diagnosis of cancer for over 2 years, Asian ethnicity and being on palliative treatment. Herein, we present an updated analysis using data from Guy's Cancer Centre and a partner Hospital Trust (King's College Hospital), with an increased number of patients and an extended follow up. Methods: We performed an analysis of all cancer patients who had a positive RT-PCR nasal/throat swab for SARS-CoV-2 infection at our Centers between 29th February and 31st July 2020. Associations between patients' demographics, clinical characteristics, and laboratory investigations with COVID-19 severity and mortality, were assessed using Logistic regression and Cox proportional hazards models. Results: 306 SARS-CoV-2 positive cancer patients were included in the analysis with a median follow up of 134 days (IQR 32-156). 184 (60%) were male and 217 (71%) were aged over 60 (mean age: 66). The most common malignancies were haematological (38%) and urological-gynaecological (20%). 218 (71%) had mild/moderate COVID-19 and 88 (29%) had severe disease. The overall COVID-related mortality rate was 24%;19% in solid and 32% in haematological cancers. Male sex [OR: 1.84 (95%CI:1.08-3.13)], Asian ethnicity [3.86 (1.20-12.36)], haematological cancer type [2.16 (1.18-3.95)], being diagnosed with cancer for 2-5 years [3.74 (1.80-7.78)] or ≥5 years [3.06 (1.50-6.26)] and a ferritin > 1964 mcg/l [54.92 (5.90-511.33)] were all associated with a risk of developing severe COVID-19 disease. Similarly, male sex [HR:1.97 (95%CI:1.15-3.38)], Asian ethnicity [3.42 (1. 59-7.35)], haematological cancer type [2.03 (1.16-3.56)] as well as a cancer diagnosis for >2-5 years [2.81 (1.41-5.59)] or ≥5 years [2.13 (1.06-4.27)] and a ferritin > 1964 mcg/l [16.11 (3.81-68.17)] were associated with an increased risk of death from COVID-19. Age >60 [2.14 (1.15-3.98)] and a raised CRP [4.10 (1.66-10.10)] were also associated with COVID-19 death. An inverse relationship was observed between a raised albumin and COVID-19 related death [0.12 (0.03- 0.51)]. Performance status and treatment paradigm were not associated with COVID-19 severity or mortality. Conclusions: This study further substantiates the evidence for an increased risk of severe COVID-19 infection and mortality for male and Asian patients with cancer, and those with haematological malignancies or with a diagnosis of cancer for over 2 years. These risk factors should be taken into account when making clinical decisions for cancer patients during the pandemic.

COVID-19 infection and mortality in patients with skin malignancies receiving systemic anti-cancer therapy (SACT): The Guy's Cancer Centre experience

Background: The COVID-19 pandemic has influenced treatment decisions in cancer patients. There is increasing evidence that not all oncology patients are at increased risk of COVID-19 infection or death. This study aimed to look at rate of SARS-CoV-2 infection and mortality in patients with skin malignancies receiving systemic anti-cancer therapy (SACT) during the pandemic in Guy's Cancer Centre. Methods: All patients with skin cancer receiving SACT at Guy's Cancer Centre between March 1st and May 31st 2020 were included. Demographic data: sex, age, socio-economic status (SES), ethnicity, comorbidities, medications and smoking history were collected along with cancer characteristics: cancer type, stage, treatment paradigm, modality and line. COVID-19 infection was confirmed by PCR and severity defined by the World Health Organisation classification. Patients with radiological or clinical diagnoses alone were excluded. Results: Of 116 skin cancer patients on SACT over the 3-month period, 89% had Melanoma, 5% Kaposi's Sarcoma (KS), 3% Squamous Cell, 2% Merkel Cell, 1% Basal Cell Carcinoma and 1% Angiosarcoma. 53% were male and 78% were of low SES. 62% were being treated with palliative intent and 70% of these were on first line palliative treatment. The median age was 57.6 years in COVID-19 positive patients (n=3) compared to 60.3 years in the negative group (n=113). 58.6% received immunotherapy, 28.4% targeted therapy, 7.8% chemotherapy and 4.3% combined treatment. Of the 3 patients (2.6%) with confirmed COVID-19 infection, the two patients with KS were receiving liposomal doxorubicin hydrochloride and the other paclitaxel chemotherapy and the patient with Melanoma was receiving encorafenib and binimetinib. All COVID-19 positive patients were of low SES, 2 females and 1 male. There was a low rate of co-morbidities with hypertension in 1 COVID-19 positive patient and none in the negative group. All 3 confirmed COVID-19 patients developed severe pneumonia and were diagnosed within 7 days of the onset of symptoms. There were no COVID related deaths and one disease-related death in the negative cohort. Conclusion: There was a low rate of COVID-19 infection in the 116 skin cancer patients on SACT (2.6%) with 60% of patients on immunotherapy. All 3 confirmed cases had severe pneumonia with no COVID-19 related deaths (0%);2 were receiving chemotherapy and 1 on targeted therapy. Patients on treatment were encouraged to shield between hospital attendances during this period which may account for the reduced rate of SARS-CoV-2 infection. This data supports the emerging observations that immunotherapy does not confer an increased risk of severe COVID-19 infection in cancer patients. This observation is confounded by the relatively young age and low co-morbidity rates in the cohort which may have contributed to the low infection and mortality rate.

Diagnosis and Management of Acute Joint Pain in the Emergency Department

Acute monoarticular and polyarticular joint pain that results from infection, trauma, and autoimmune and inflammatory processes are a major cause of disability that is often preventable with early diagnosis and management. Septic arthritis presents a particular danger, with a high potential for morbidity and mortality. This issue presents an overview of the various types of acute joint pain that present to the emergency department, and outlines systematic, evidence-based strategies for diagnosis and treatment. Emerging infectious and reactive causes of arthritis, including Zika, chikungunya, and COVID-19 are reviewed. Best-practice recommendations for treatment and disposition based on diagnosis are highlighted.

Outcomes of COVID-19 in patients with relapsing multiple sclerosis receiving ofatumumab: Data from the ALITHIOS study and post marketing surveillance

Introduction: Per WHO, >190 million people worldwide have been affected by COVID-19 as of 20-Jul-2021. Although people with MS are not at a higher risk of SARS-CoV-2 infection, factors such as age, comorbidity, MS severity and treatment with DMTs may affect COVID-19 severity and outcomes. Understanding the risks, severity and outcomes of COVID-19 in people with MS receiving DMTs, including anti-CD20 DMTs, is important to healthcare practitioners (HCPs) managing MS. Objectives: To report the characteristics and outcomes of COVID- 19 adverse events (AEs) in relapsing MS (RMS) patients taking ofatumumab enrolled in the ongoing, open-label, long-term extension Phase 3b ALITHIOS study and from post-marketing surveillance of people receiving ofatumumab 20 mg subcutaneously. Methods: Patient demographics, baseline characteristics, incidence of COVID-19 AEs, seriousness category (including hospitalization), severity, outcomes, ofatumumab exposure before the start of infection, and action taken with ofatumumab were assessed. Results: As of 29-Jan-2021, 139/1703 (8.2%) patients enrolled in ALITHIOS (mean±SD age at baseline: 37.7±8.7 years;female, 64%) treated with ofatumumab reported COVID-19 AEs (confirmed: 115 [82.7%];suspected: 24 [17.3%]). Of these, 10 (7.2%) experienced COVID-19 serious AEs and all 10 (7.2%) were hospitalized. Most AEs reported were mild (Grade [G] 1;69 [49.6%]) or moderate (G2;62 [44.6%]) in severity. Severe (G3) and life threatening (G4) AEs were reported in 6 (4.3%) and 2 (1.4%) patients, respectively. One (0.7%) patient (48-year-old at COVID- 19 onset;BMI 28.3 kg/m2;recent MS relapse) with confirmed COVID-19 and pneumonia had a fatal outcome. At data cut-off, most patients (128 [92.1%]) had recovered from COVID-19 AEs;2 (1.4%) were recovering, 4 (2.9%) had recovered with sequelae and 4 (2.9%) had not recovered. COVID-19 AEs led to temporary interruption of ofatumumab in 22 (15.8%) patients. As of 31-Jan- 2021, an additional 28 RMS patients with COVID-19 AEs were identified in the Novartis safety database. Further details to be presented. Conclusions: In ALITHIOS, 139 RMS patients on ofatumumab reported COVID-19 AEs (as of 31-Jan-2021). Most (94%) COVID-19 cases were mild or moderate in severity. There were few hospitalizations but one fatal outcome. At data cut-off, most (92%) patients had recovered/resolved from COVID-19. ALITHIOS data extends the understanding of the long-term safety profile of ofatumumab in people living with MS.

Bringing our heeadsss together-prioritising the voices of children and young people Collaborators

Background Children and young people (CYP) are increasingly attending acute paediatric services due to mental health difficulties. 50% of all mental health problems are established by 14 years of age and 75% by 24 years. Underinvestment in mental health has been a longstanding concern, amplified by the COVID-19 pandemic through extra stress caused by prolonged school closures, social isolation and a lack of access to usual support services. In 2020, the Royal College of Paediatrics and Child Health highlighted that suicide is now the leading cause of death in England and Wales for children aged 5-19 years, emphasising the need to prioritise and improve mental health. Paediatricians must develop the knowledge and skills to identify, support and make appropriate referrals for common mental health problems. HEEADSSS is a well-known psychosocial screening tool with eight domains, used to identify potential or actual harm. Objectives Establish whether CYP within the West Midlands, UK are receiving adequate psychosocial assessments on hospital admission and whether healthcare professionals are signposting to relevant services. The primary outcome was the percentage of CYP with documented evidence of being offered a HEEADSSS assessment. Methods A regional prospective audit across nine hospitals was performed for three days per week from 4st -31st January 2021. A standardised proforma was used to gather information from medical records of all CYP aged >12 years admitted to paediatric wards. Pooled data were analysed using Microsoft Excel. Results 231 patients were included. The median age was 14 years old (range 12-17 years). 163(71%) were female. 202 (87%) had no known communication difficulties. 53(23%) were known to CAMHS and 43(19%) to social care. 78/231 (34%) were admitted with mental health as the presenting complaint. 35/231(15%) were documented to be given the opportunity to be spoken to alone;29(82%) accepted. No department had a psychosocial screening tool embedded in the admission document. 158/231(69%) had less than half of the eight domains completed. The median was 1.5 (range 0-8). Home and education/ employment were most frequently asked (37-42%). Eating/exercise, drugs, safety, sexual activity and other activities were the least frequently asked (14-27%). The proportion of those with a concern identified when asked ranged from 18%-39%. However, in self-harm, depression and suicide, only 85/231 (37%) were asked, with concern identified in 87%. 78 patients were admitted for mental health;28(39%) had less than half the domains completed (median 5, range 0-8). Drug use 46/78(59%), safety and sexual activity (both 38/78 (49%)) were inconsistently documented in this group, with concerns identified in 20-26% of those asked. 90/231(39%) were referred to CAMHS, social care, counselling, online or other support services. 16/77(21%) patients with a concern documented in at least one domain were not referred onwards. Conclusions This study demonstrates poor implementation of the HEEADSSS tool on admission, across a wide geographical area. Increased utilisation of a psychosocial screening tool would provide more opportunities to CYP to discuss their psychosocial health and receive appropriate support, in line with national guidance standards. Further work is underway addressing barriers to using HEEADSSS, considering electronic or embedded tools and signposting to relevant services.