The effect of the different waves of COVID-19 pandemic on the outcome of diabetic foot ulcers

AIMS

COVID-19 pandemic has massively impacted human health. We studied the effect of COVID-19 on outcome of Diabetic foot ulcers (DFUs).

OBJECTIVES AND METHODS

We recruited 483 people with DFUs from June 2020 to April 2022 (pandemic) together with a matched group of 226 people with DFU from March 2019 to March 2020 (pre-pandemic). Primary endpoint was outcome of ulcers-healed or amputation (major/minor). It was sub-analysed into 3 waves of COVID-19. Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data included site and type of ulcer (ischemic or neuropathic), duration, presence or absence of infection and Wagner's grading of DFUs was collected for all patients. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ankle brachial index (ABI). Standardized treatment protocol was provided. All patients were monitored for 6 months.

RESULTS

In the pandemic group 323 (66.9%) patients in whom ulcers healed, 70 (14.5%) underwent minor amputation, 11 (2.2%) major amputation, 29 (6%) were lost to follow up, 22 (4.6%) were not healed. Rate of healing of DFU was higher (66.9% vs 53.5%) and rate of amputation was lower (16.7% vs 23.4%) in the pandemic group than in the pre-pandemic group (P = 0.001 and 0.037 respectively). Rate of healing in first, second and third wave was 65.4%, 75.2%, 58.3% respectively (P = 0.001). Neuropathic ulcers though less prevalent (49.8% vs 57.8%) in the first two waves than in the third wave, healing was better (79.3% vs 75.6%) in the first two waves than in the third wave (P = 0.085 and 0.488 respectively). Similarly, amputation rates in ischemic and neuro-ischemic ulcers were greater in the third wave than first two waves (46.7% vs 15.7%, P = 0.049).

CONCLUSION

During the COVID-19 pandemic, healing of neuropathic ulcers was better, especially in the first and second waves and travel restriction may have accounted for this. However, worsening of ischemic and neuro-ischemic ulcers was observed with more amputation in these two groups. Conversely, in the third wave withdrawal of lockdown led to worsening of DFUs resulting in less healing and more amputation.

Tumor microenvironment-induced tumor cell plasticity: relationship with hypoxic stress and impact on tumor resistance

The role of tumor interaction with stromal components during carcinogenesis is crucial for the design of efficient cancer treatment approaches. It is widely admitted that tumor hypoxic stress is associated with tumor aggressiveness and thus impacts susceptibility and resistance to different types of treatments. Notable biological processes that hypoxia functions in include its regulation of tumor heterogeneity and plasticity. While hypoxia has been reported as a major player in tumor survival and dissemination regulation, the significance of hypoxia inducible factors in cancer stem cell development remains poorly understood. Several reports indicate that the emergence of cancer stem cells in addition to their phenotype and function within a hypoxic tumor microenvironment impacts cancer progression. In this respect, evidence showed that cancer stem cells are key elements of intratumoral heterogeneity and more importantly are responsible for tumor relapse and escape to treatments. This paper briefly reviews our current knowledge of the interaction between tumor hypoxic stress and its role in stemness acquisition and maintenance. Our review extensively covers the influence of hypoxia on the formation and maintenance of cancer stem cells and discusses the potential of targeting hypoxia-induced alterations in the expression and function of the so far known stem cell markers in cancer therapy approaches. We believe that a better and integrated understanding of the effect of hypoxia on stemness during carcinogenesis might lead to new strategies for exploiting hypoxia-associated pathways and their targeting in the clinical setting in order to overcome resistance mechanisms. More importantly, at the present time, efforts are oriented towards the design of innovative therapeutical approaches that specifically target cancer stem cells.

The collective impact of childhood abuse, psychache, and interpersonal needs on suicidal ideation among individuals with bipolar disorder: A discriminant analysis

BACKGROUND

Suicide is one of the ten leading causes of death in the United States. Childhood abuse, psychache (intense emotional pain), and interpersonal needs are widely known to be associated with suicidal thoughts and behaviors. However, only a limited number of studies investigate whether these variables, when analyzed collectively, are able to distinguish between a group of individuals who report suicidal ideation and those who deny such thoughts.

PARTICIPANTS AND SETTING

Data were collected from individuals (N =177) with a diagnosis of bipolar disorder participating in an intensive outpatient program that provides mental health care to indigent, mostly minority patients in Southeast United States.

METHODS

The dependent variable was item number 9 on the Beck Depression Inventory that asks about any suicidal thoughts in the past two weeks. We utilized discriminant analysis to test whether childhood abuse, interpersonal needs, and psychache were collectively able to accurately identify group membership of the study participants.

RESULTS

The discriminant model included six independent variables: three different types of childhood abuse (emotional, physical, and sexual), interpersonal needs (perceived burdensomeness and thwarted belongingness), and psychache. Results revealed that the model was able to correctly classify group membership in 75% of the individuals in the study.

CONCLUSION

In context of bipolar disorder, history of childhood abuse (particularly sexual and emotional abuse), intense psychache, and greater perceived thwarted belongingness and burdensomeness put an individual at a higher risk of suicidal ideation. Gaining insight into the interactions among these variables may lead to formulating early interventions to prevent suicide in patients reporting this constellation of symptoms.

‘Natural’ Label Halo Effect on Consumer Buying Behavior, Purchase Intention and Willingness to Pay for Skincare Products

Healthy skin will never go out of style, and the advancements and improvements in the cosmetics industry guarantee to provide improved products with a healthy and personal touch. However, for consumers, it is difficult to assess the quality and effectiveness of a product. Extrinsic cues like the “Natural” or “Organic” labels are used to help the consumer distinguish between alternatives. This paper analyses how the organic label biases the consumers’ buying behavior, perceived value, and finally, the consumer’s purchase decision and the price he willingly pays for the product (willingness to pay). This phenomenon is known as the natural label halo effect. It further means to reveal the connections between the effect of the ‘Natural’ label on the factors affecting buying behavior and it’s out-turn as emulated in the consumer’s perceived value. It intends to identify if those outcomes at last lead to positive buying decisions and greater willingness to pay. A quantitative study in an experimental online shopping scenario was conducted to understand the relations. Structural equation modeling (SEM) was done to test the hypothesized statements. The results show that the halo effect of the ‘Natural’ label positively influences the factors affecting consumer buying behavior and eventually improves the probability of the product being bought by the consumer and also the price the consumer is willing to pay for it through inferential beliefs on quality attributes and functional value evoked by the label. The study also reveals that natural skincare products are perceived to be more compliant with a consumer’s beliefs/attitudes relating to environmental protection and animal protection, which positively influences the propensity of a consumer towards buying the product and paying a high price for it by increasing the perceived functional and hedonic values associated with the natural cosmetic product.

The effect of sulforaphane on perinatal hypoxic-ischemic brain injury in rats

Perinatal hypoxic-ischemic insult (HII) is one of the main devastating causes of morbidity and mortality in newborns. HII induces brain injury which evolves to neurological sequelae later in life. Hypothermia is the only therapeutic approach available capable of diminishing brain impairment after HII. Finding a novel therapeutic method to reduce the severity of brain injury and its consequences is critical in neonatology. The present paper aimed to evaluate the effect of sulforaphane (SFN) pre-treatment on glucose metabolism, neurodegeneration, and functional outcome at the acute, sub-acute, and sub-chronic time intervals in the experimental model of perinatal hypoxic-ischemic insult in rats. To estimate the effect of SFN on brain glucose uptake we have performed 18F-deoxyglucose (FDG) microCT/PET. The activity of FDG was determined in the hippocampus and sensorimotor cortex. Neurodegeneration was assessed by histological analysis of Nissl-stained brain sections. To investigate functional outcomes a battery of behavioral tests was employed. We have shown that although SFN possesses a protective effect on glucose uptake in the ischemic hippocampus 24 h and 1 week after HII, no effect has been observed in the motor cortex. We have further shown that the ischemic hippocampal formation tends to be thinner in HIE and SFN treatment tends to reverse this pattern. We have observed subtle chronic movement deficit after HII detected by ladder rung walking test with no protective effect of SFN. SFN should be thus considered as a potent neuroprotective drug with the capability to interfere with pathophysiological processes triggered by perinatal hypoxic-ischemic insult.

Effectiveness of two tobacco cessation methods among TB patients

BACKGROUND: Tobacco and TB are the world´s two greatest public health problems. Exposure to tobacco has been shown to be associated with higher risk of acquiring TB and adverse outcomes such as relapse and TB mortality.OBJECTIVE: To assess and compare self-reported tobacco quit status and biochemically verified cotinine levels among TB patients at different time intervals among two study groups.METHODS: A cluster, randomised controlled trial was conducted on TB patients attending DOTS centres in Delhi, India, who reported using tobacco in any form. Participants were assigned into one of two treatment groups. Centres were randomly assigned to two intervention groups: 1) integrated intervention using behavioural counselling with nicotine replacement therapy (NRT) gum, and 2) intervention using behavioural counselling alone (50 each in intervention and control group). The subjects were followed at Week 1, Month 1, Month 3 and Month 6 for tobacco cessation.RESULTS: At the end of 6 months, patients who received the integrated intervention had significantly higher rate of success in quitting tobacco than those who received the conventional TB treatment alone (78.7% vs. 57.8%; P < 0.03).CONCLUSION: DOTS with tobacco use dependence treatment was successful in our study in helping TB patients to quit tobacco dependence and should therefore be offered to every tobacco user.

741 Manipulation and Reduction of Paediatric Forearm Fractures in The Emergency Department Using Intranasal Diamorphine and Entonox

Background

Paediatric forearm fractures are commonly encountered in Trauma and Orthopaedics. Currently most forearm fractures are manipulated in theatre the following day, increasing resource burden and delays in management. The aim of this project was to introduce guidelines to reduce fractures in the Emergency Department (ED) using intranasal Diamorphine and Entonox.

Method

197 cases were identified over a 6-month period in 2018 and 2019. 74 distal radial fractures and 123 mid shaft forearm fractures were analysed. Fractures with an intact periosteal hinge or a Salter Harris type 2 were reduced in ED. The pre manipulation and post manipulation radiographs were compared with particular attention to the post reduction angles.

Results

67% of fractures were reduced in the correct setting. A number of fractures reduced in ED required re-manipulation or internal fixation. Overall, there was a 56% reduction in patients undergoing general anaesthetic. There was a reduction in the mean length of stay from 36 hours to 3.5 hours.

Conclusions

Intranasal Diamorphine and Entonox offer a safe method for managing paediatric forearm fractures in ED. Implementation of this method facilitates early access to treatment and early patient discharge. Manipulation in ED offers significant financial savings and reduces demands on the Trauma Theatres.

870 Early Weight Bearing In &gt; 60 Years - Is It All A Dream?

Background: Early weight bearing (EWB) is increasingly considered acceptable in surgically managed fractures. However, there are two different outlooks for rehabilitation. EWB in a biologically weak bone may lead to implant failure compared to EWB being beneficial for quicker recovery. We aim to review outcomes for EWB in surgically managed fragility fractures.

Method: This was a retrospective analysis; data was collected from departmental records of operative fixation of lower limb injuries in patients above 60 years. We excluded patients who had procedures for proximal femoral fractures and polytrauma. We compared SF-12 scores, complications, and reoperation rates in those that were EWB to those that were at the conventional 6-week mark.

Results: During a 6-month period from November 2019 to April 2020 we performed 60 operations. N = 30 surgeries were performed in EWB group versus 30 surgeries in late weight bearing group (LWB). The average physical and mental SF-12 score in EWB group was 44.82 and 56.36 compared to a SF-12 score of 44.51and 52.18 in LWB.

Conclusions

We found that the SF-12 scores were different despite EWB. There was no evidence of early complications in the EWB group. Therefore, we advocate EWB for group &gt;60 who were known to have osteoporosis.

SAT0645-HPR MYTHS AND MISCONCEPTION ABOUT THE ILLNESS AND CONVENTIONAL SYNTHETIC DMARDS (CSDMARDS) IN PATIENTS WITH SYSTEMIC IMMUNO-INFLAMMATORY RHEUMATIC DISEASES (SIRDS): A STUDY BY RHEUMATOLOGY NURSE COUNSELOR

Background:

Myths and misconceptions about illness and conventional disease modifying anti-rheumatic drugs directly influence adherence to the prescribed treatment. It is estimated that 30–50% of patients do not adhere to their prescribed treatment due to various reasons where the beliefs of the patients play a crucial role. At our centre we the specialist rheumatology nurse counsel the patients at every visit and try to remove their myths and negative beliefs about the disease as well as the medications.

Objectives:

•To explore the common myths and misconceptions of regarding their disease and regarding the csDMARDs.

•To assess the efficacy of counseling in allaying their unfounded fear.

Methods:

A total of 450 patients with SIRDs at least 3 times attended the rheumatology out-patient clinic on csDMARDs were enrolled to complete a questionnaire that, besides demographic information, socio-economic status, and co- morbidities, had the following questions:

1.Self reported adherence to medication

2.Misbelieves regarding food items

3.What kind of health-provider was consulted at the onset of the symptoms

4.Their belief/knowledge regarding:

A. The need for physiotherapy.

B. Life style modification requirement

C. About osteoarthritis

D. Medication requirement during remission

E. Pregnancy and DMARDs

F. The need of vaccination

G. Health hazards of smoking and alcohol use

H. Harms of discontinuing treatment when they felt well

Results:

A total of 450 patients included spondyloarthropathy 150(34%), rheumatoid arthritis 200(45.7%), psoriatic arthritis 45(10%), and others 25(5.5%).The following observations was made:

1.Self-reported adherence to medication was in 250 (55%) patients; 200(45%) patient were non-adherent to treatment

2.382/450 (85%) patients had misbelieves regarding different food items.

3.225/450(50)% of the patients were not doing regular physiotherapy they were totally dependent on medications for symptoms relief.

4.387/450 (86%) patients confused the symptoms of osteoarthritis with that of RA.

5.315/450 (70 %) patients did not feel the requirement of continuing drugs during remission.

6.135/450 (30%) patients believed that while on DMARDs they cannot contemplate pregnancy.

7.351/450(78%) patients accept the need for vaccination when staring DMARDs

8.360/450 (80%) patients aware about side effect of smoking in disease but only 40 % were able to quit.

9.273/450 (60%) patients felt that more expensive medicines e.g.bDMARDs have more effects.

10.360/450 (80%) patients believed that DMARDs were ‘steroids’ and they increased weight. On analysis one patient have more than two myths simultaneously.

Conclusion:

Increased awareness of the patient’s beliefs about medicines is needed among health care providers. We should encourage patients to express their views about medicines as well as disease in order to optimize and personalize the information process. This can stimulate concordance and adherence to medication and follow up.These myths are deeply rooted in our society, single sitting counseling is not enough, and reinforcement is needed.

References:

[1]Tom Greenhalgh. Facts about rheumatoid arthritis: 7 myths you may encounter. Rheumatology Advisor. March 28, 2019.

Acknowledgments:

no

Disclosure of Interests:

None declared

SAT0644-HPR COMPLIANCE OF BIOLOGIC DISEASES MODIFYING ANTI-RHEUMATIC DRUGS (BDMARDS) WITH SYSTEMIC IMMUNO-INFLAMMATORY RHEUMATIC DISEASES (SIRDS). AN ASSESSMENT OF PATIENTS’ ADHERENCE AND NON- ADHERENCE CONCERNS

Background:

Patients with systemic immunoinflammatory rheumatic diseases (SIRDs) are often treated with bDMARDs when the response to conventional disease-modifying antirheumatic drugs (csDMARDs) is inadequate.There are, however, concerns about non-adherence to bDMARDs among patient. The non-adherence to bDMARDs may be caused by the various factors.

Objectives:

1.The main objective of present study was to find out the cause of discontinuation of bDMARDs

2.To find out the adherence and non-adherence rate for bDMARDs.

3.To identify the factors that are modifiable.

Methods:

800patients with SIRDs prescribed bDMARDs were interviewed to find out the demographic information, their socioeconomic status,and the disease duration.Additional information gathered included the comorbidities, the time for starting bDMARDs, the route of administration of bDMARDs, beliefs and perceptions about treatment efficacy and side effects if any.This was followed by looking at the adherence of bDMARDs; if they had discontinued then efforts was made to find out the reasons for the same.

Based on these findings the patients were classified into adherent and non-adherent categories. The data were analyzed further for

1.Factors that associated with persistence of bDMARDs.

2.Factors that were associated with discontinuation of bDMARDs.

Results:

A total of 800 patients were interviewed that included patients with ankylosing spondylitis 430(52.4%), rheumatoid arthritis 300(37.7%), psoriatic arthritis 45(5.2%), and others 25 (0.7%).On analysis 610(76%) patient were compliant but 190(24%) patient had discontinued the bDMARDs on their own. On comparison of both groups

Factors that were significantly related to self-discontinuation were:

•Negative beliefs about biologics (37%)

•Cost (33%)

•Reading side-effect profile on Google search (25%)

•Other co-morbidities (6%)

Factors that were significantly related to persistence of biologic treatment were:

•Good counseling by rheumatologist and rheumatology nurse (60%)

•Faith in the treating rheumatologist (25%)

•Fear of deformities and pain(15%)

On analysis it was found that a good counseling and clarifying the doubts of the patients regarding bDMARDs before starting the treatment encourages the patient to continue the biologic treatment, especially it allays their doubts about the drug adverse effects.

Conclusion:

Despite negative beliefs and misconceptions about bDMARDs, patient non-adherence at our center is not alarming.A positive reinforcement counseling appears to be the most significant factor to overcome the negative belief of patients.The affordability of the biologic treatment however remains a limiting factor in our centre as in other parts of India.

References:

[1]Tamas Koncz,MD,Marta,Pentek,Valentin,Brodszky,Katalin Ersek,MSc,Ewaorlewska&Laszlo Gulasi Volume10,2010 –Issue9 Adherence to biologic DMARD therapies in rheumatoid arthritis

Acknowledgments:

no

Disclosure of Interests:

None declared

FRI0601-HPR IMPACT OF LIFE STYLE MODIFICATION TECHNIQUE IN SYSTEMIC SCLEROSIS (SSC) PATIENTS: A STUDY BY RHEUMATOLOGY NURSES COUNSELOR

Background:

Systemic sclerosis (SSc) is an autoimmune the disease of the connective tissue that is clinically characterized by the involvement of skin (fibrosis, contractures of the finger joints), microvascular abnormalities (Raynaud’s phenomenon and complications), gastrointestinal involvement (gastroesophageal reflux disease - GERD, the lower GI tract involvement), musculoskeletal involvement (polyarthralgia, muscle disease), and involvement of internal organs (especially lungs, heart, and kidneys). Lifestyle modification techniques could have significant impact on various aspects of the disease including early disease control, increased drug adherence, positive attitude towards life, decreased financial burden of treatment, maintaining mobility and joints range of motion, minimizing or delaying joint contractures and decreased dependency with regular physical therapy. Counselling explaining the benefits of lifestyle modification related to these aspects of daily living may make a major difference in the quality of life of the patients with SSc.

Objectives:

To assess the benefits of lifestyle modification technique in improving the quality of life in patients with SSc.

Methods:

Patients with SSc attending the Rheumatology clinic of this institution, willing to participate in the survey, were enrolled in this study. All the information including the follow-up details were recorded in a pre-designed form. Their demographic information (age, gender) and disease characteristics (diagnosis, duration, treatment) were recorded, All the patients were explained the lifestyle modifications and their benefits, reinforced at each follow-up visit using posters (visual), written lifestyle modification techniques (using printed material) to raise their awareness of how to improve several of the above manifestations of SSc.

Results:

One hundred fifty (n=150) consecutive SSc patients were included in the study. It was observed that with repeated counselling 125 (83.3 %) patients adopted the lifestyle modification technique according to the advice imparted and felt a positive benefit in their daily life. However, 25 (16.6%) could not or did not follow the imparted lifestyle change advice on a regular basis. Those who were able to modify the life-style as counselled showed the following results:

Conclusion:

The lifestyle modification techniques are important to control disease and its complications. Thus, after intense and regular counselling by the specialist rheumatology nurses on the lifestyle modification technique (83.3%) adapted the advised lifestyle modifications. The study showed the important role specialist rheumatology nurses can play in educating patients and helping them improving their quality of life.

References:

[1] Hudson M, Thombs BD, Steele R. at ell. Canadian Scleroderma Research G. QOL in patients with systemic sclerosis compared to the general population and patients with other chronic conditions. J Rheumatol. 2009;36(4):768–72.

Disclosure of Interests:

None declared

Indian childhood cirrhosis - down but not out: Report of a rare case with a practical clinicopathological diagnostic approach

Indian childhood cirrhosis is an entity believed to be on the verge of extinction. We present the case of a 13-month-old girl presenting acutely with jaundice, fever, and persistently increasing bilirubin. Investigations revealed direct hyperbilirubinemia, elevated transaminases, anemia, a blood with few schistocytes, positive direct coombs test, and deranged prothrombin time. Viral, autoimmune, and metabolic workup was unremarkable. Ultrasonography showed chronic liver disease, portal hypertension, and ascites. Due to numerous confounding factors and a low index of suspicion, the diagnosis of Indian childhood cirrhosis remained elusive and was clinched only on liver biopsy, albeit more than three weeks later, shortly after which the child expired. The timing and technique of the liver biopsy may have profound impact on the ultimate clinical outcome. Close coordination between the clinical and pathological teams is essential for deciphering acute presentations where the etiology is uncertain. We highlight the clinical considerations, varied morphological pointers, and offer a diagnostic algorithm facilitating the consideration of this disease.

Impact of red blood cell transfusions on intestinal barrier function in preterm infants

OBJECTIVE

To determine the relationships of red blood cell (RBC) transfusion and enteral feeding to changes in intestinal permeability (IP) measured by the relative intestinal uptake of lactulose (La) and rhamnose (Rh) in preterm infants <33 wk gestation.

DESIGN/METHODS

Infants 240-326wk gestation received La/Rh solution enterally on study days 1, 8 and 15.Urinary La/Rh ratio was measured by HPLC. Hematocrit preceding transfusion, total RBC transfusion volume, volume/kg, and feeding status during each study interval (birth-d1; d1-d8, and d8-d15) were determined.

RESULTS

Of the seventeen (40.5%) subjects who received≥1 transfusion during the study period, 12 (70.6%) infants were <28 wk gestation and 5 (29.4%) infants were≥28 wk gestation, p < 0.0001. Lower pre-transfusion hematocrit was observed in intervals preceding high IP (La/Rh > 0.05) than in intervals preceding low IP (La/Rh≤0.05) measurements (33 vs 35.8, p = 0.1051). RBC transfusions occurred more frequently in intervals preceding high IP than in intervals preceding low IP (26.8%; vs 8.3%, p = 0.0275) with 5-fold higher total RBC volume and volume/kg in intervals preceding any time point with high IP. RBC transfusion during an interval was associated with a three-fold increased risk of high IP (aOR 2.7; 95% C.I 0.564-12.814; p = 0.2143). Exclusive breast milk exposure and post-menstrual age reduced the risk for high IP following RBC transfusion.

CONCLUSIONS

Both RBC transfusion number and volume was associated with subsequent high IP measurements in preterm infants <33 weeks gestation and potentially may contribute to impairment of the preterm intestinal barrier.

An innovative way of managing coeliac artery stenosis during pancreaticoduodenectomy

Coeliac artery stenosis (CAS) is rarely of consequence owing to rich collateral supply from the superior mesenteric artery via the pancreatic head. Pancreaticoduodenectomy (PD) in CAS disrupts these collaterals, and places the liver, stomach and spleen at risk of ischaemia. A 56-year-old man presented with a 3-week history of obstructive jaundice. Computed tomography revealed an operable periampullary tumour with CAS due to compression by the median arcuate ligament with multiple collaterals in the pancreatic head and a prominent gastroduodenal artery (GDA). Following unsuccessful coeliac axis endovascular stenting, a PD was performed. Intraoperative median arcuate ligament release failed to restore good flow in the common hepatic artery (CHA) and splenic artery (SpA) A decision was made to use the left gastric artery (LGA) for arterial reconstruction, disconnect it from the stomach with its origin intact and anastomose it to the supracoeliac aorta. Doppler ultrasonography with a GDA clamp confirmed good filling of the CHA and SpA via the LGA. The GDA was ligated and the PD completed. The patient had an uneventful recovery except for a biochemical pancreatic leak and was discharged on day 10. CAS during PD (confirmed by a decrease in CHA flow with a GDA clamp) requires an additional procedure to restore blood flow to the liver, stomach and spleen. Anastomosing the LGA to the supracoeliac aorta is a simple reconstruction technique for achieving this.