Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

COVID-19: using chest CT of major trauma patients to monitor and evaluate the second wave in London and the development of routine monitoring in practice

AIM

To follow-up previous work evaluating incidental findings of COVID-19 signs on computed tomography (CT) images of major trauma patients to include the second wave prior to any major effects from vaccines.

MATERIALS AND METHODS

The study population included all patients admitted following major trauma between 1 January 2020 and 28 February 2021 with CT including the lungs (n=1776). Major trauma patients admitted pre-COVID-19 from alternate months from January 2019 to November 2019 comprised a control group (n=837). The assessing radiologists were blinded to the time period and used double reading in consensus to determine if the patient had signs of COVID-19. Lung appearances were classified as no evidence of COVID-19, minor signs, or major signs.

RESULTS

The method successfully tracked the second wave of the COVID-19 pandemic in London. The estimated population affected by the disease based on those with major signs was similar to estimates of the proportion of the population in London with antibodies (around 30% by end February 2021) and the total of major and minor signs produced a much higher figure of 68%, which may include all those with both antibody and just T-cell responses.

CONCLUSIONS

Incidental findings on CT from major trauma patients may provide a novel and sensitive way of tracking the virus. It is recommended that all major trauma units include a simple question on signs of COVID-19 to provide an early warning system for further waves.

Oral health education and prevention strategies among remote Aboriginal communities: a qualitative study

BACKGROUND

The delivery of effective oral health promotion strategies is essential to improving oral health outcomes among remote Aboriginal communities. This study aimed to explore the perceptions and attitudes of Aboriginal Australians living in remote Kimberley communities towards oral health education and disease prevention.

METHODS

Semi-structured interviews and yarning circles were carried out following purposive sampling of Aboriginal adults living in the East Kimberley region of Western Australia.

RESULTS

A total of 80 community members participated in the yarning process. School-based oral health promotion and community-driven restrictions on the sale of sugary food and drink were seen as positive strategies in improving oral health. Lifestyle changes brought about by modernity, internet availability and fixed community stores were perceived to create new challenges and shift the priorities for those living in remote communities.

CONCLUSIONS

Community-based yarning may better inform future oral health strategies in the Kimberley. A neoliberal approach of shifting responsibility onto the individual ignores the complex social inequities faced by Aboriginal people living in remote communities where macro-level determinants such as remoteness, food security and education significantly influence decisions around diet and oral health.

Rapid upper airway obstruction after arteriovenous malformation rupture in a patient with neurofibromatosis

Neurofibromatosis type 1 is rarely associated with arteriovenous malformation rupture. We present a case of a rapidly compromised upper airway due to extrinsic compression as a consequence of the rupture of an arteriovenous malformation fed by the inferior thyroid artery which required emergency cricothyroidotomy following failed attempts at orotracheal intubation. While the patient had a good overall outcome, our reflection on the management of this case highlights several important learning points. These include the importance of clear communication between different medical specialties to promote shared situation awareness, the importance of training anaesthetists in the limitations of standard difficult airway management algorithms, and the implications of the skillset mix of doctors responding to airway emergencies in district general hospitals.

Racial disparities in the use of mechanical circulatory support devices in cardiogenic shock

Background

Racial bias has always been a concern for healthcare. Lack of guideline directed utilization of mechanical circulatory support (MCS) devices in cardiogenic shock (CS) may lead to implicit and racial bias.

Purpose

To identify the racial differences in the use of mechanical circulatory support in cardiogenic shock and its association with outcomes.

Methods

National Inpatient Database from 2015–2018 using ICD 10 codes was used. Patients >18 years of age admitted for cariogenic shock were included.

Results

Among 1,021,274 patients hospitalized for cardiogenic shock, overall MCS was utilized in 11.4% (N=116,539). Use of MCS for patients stratified by race was 12.2% white (N=85543), 8% Blacks (N=14688), 11.3% Hispanics (N=11067), 13.8% Asian (N=4417), 12.3% Native American (N=825). IABP was the most commonly used MCS device, followed by Impella, ECMO and LVAD. Overall odds of MCS insertion was significantly higher in white population [1.18 (1.13–1.23) <0.001] and significantly lower in Blacks [0.65 (0.61–0.69) <0.001] and Hispanics [0.89 (0.83–0.97) 0.004]. Among black patients with CS requiring MCS, odds of LVAD insertion were similar compared to other races [1.03 (0.89–1.19) 0.714], while odds of all other types of MCS devices including ECMO [0.83 (0.72–0.95) 0.009], IABP [0.63 (0.59–0.68) <0.001] and Impella [0.61 (0.54–0.70) <0.001] were significantly lower compared to other races. This trend also holds true for patients with CS associated with acute myocardial infarction. Among all patients with CS, the odds of mortality were significantly lower among white patients [0.92 (0.90–0.95) <0.001], on the contrary, odds of mortality were significantly higher in Blacks [1.06 (1.02–1.10) 0.001] and Asians [1.11 (1.02–1.20) 0.012]. Interestingly, when only comparing patients who underwent MCS utilization for CS, odds of mortality were similar in black population compared to other races. [1.03 (0.91–1.17) 0.636].

Conclusion(s)

There still exist significant racial differences in the use of mechanical circulatory devices for cardiogenic shock potentially leading to significantly higher mortality in black population compared to whites. This difference in mortality is mitigated with equal use of MCS devices in cardiogenic shock among all races.

Funding Acknowledgement

Type of funding sources: None.

589 Role of Liver Support Systems in The Management of Post Hepatectomy Liver Failure: A Meta-Analysis and Systematic Review of Literature

Aim

Post hepatectomy liver failure (PHLF) is a rare but serious complication following liver resection. PHLF is associated with high mortality of up to 50% in severe cases. With limited treatment options available, there is a need to evaluate the role of systems that support the function of the liver as treatment modalities following PHLF development.

Method

The aim of this study was to review the literature and summarise the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications were extracted, pooled where possible, and analysed.

Results

Systematic review identified ten studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF development. The sample sizes of included studies were small, ranging from N = 2 to N = 13. Across all studies, the pooled 90-day mortality rate was 40% (95% CI: 15% - 68%). However, there was substantial heterogeneity (I2=64%), likely since the studies used a variety of definitions for PHLF and had different selection criteria for patient eligibility for LSS treatment.

Conclusions

Despite potential benefits, the current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicentre, prospective studies evaluating the conventional and newer modalities of support systems with a view to improve the outcomes in this group of patients.

Effects of Supervised Exercise-Based Telerehabilitation on Walk Test Performance and Quality of Life in Patients in India With Chronic Disease: Combatting Covid-19

Background:

The world is currently undergoing a pandemic, caused by the SARS-CoV-2 virus (COVID-19). According to the World Health Organization, patients with chronic illnesses appear to be at the highest risk for COVID-19 associated sequelae. Inability to participate in outpatient-based rehabilitation programs and being home-bound can increase the risk for and potential worsening of chronic health conditions. This study evaluated the short-term effects of telerehabilitation on patients' walk test performance and health related quality of life (HRQoL).

Methods:

47 patients (23 cardiovascular, 15 pulmonary, 9 oncology) participated in the telerehabilitation program. At baseline and following a 1-month intervention, patients had their 6-minute walk test distance (6MWTD) and HRQoL assessed. Average daily step counts were measured by the PACER App.

Conclusions:

Our results indicate that a short-term, supervised virtual telerehabilitation program had significant positive effects on 6MWTD and HRQoL in cardiac, pulmonary and oncology patients during COVID-19.

AB0648 REACTIVE ARTHRITIS IN SYPHILIS MIMICKING RHEUMATOID ARTHRITIS: A CASE REPORT

Background:

Reactive arthritis is a form of spondyloarthritis with aseptic joint involvement occurring after a gastrointestinal or urogenital infection. Most commonly associated with Chlamydia trachomatis, Salmonella, Shigella, Campylobacter, and Yersinia. Syphilis is an infection caused by the spirochete Treponema pallidum and is not usually associated with reactive arthritis. Syphilis is a great imitator of other diseases due to its broad presentation including painless chancre, constitutional symptoms, adenopathy, rash, synovitis, neurological and ocular findings.

Objectives:

To discuss a patient who presented with symptoms of rheumatoid arthritis (RA) but was later diagnosed with syphilis.

Methods:

31 year old male, former tobacco smoker, referred to Rheumatology for sudden onset joint pains, elevated anti-cyclic citrullinated peptide (anti-CCP), and elevated inflammatory markers. He reported pain in bilateral wrists, fingers, and right elbow for 6 weeks. Associated with 45 minutes of morning stiffness and new onset lower back pain without stiffness. He denied trauma, fever, chills, skin rash, dysuria, or diarrhea. Initiated trial naproxen 500mg twice a day only to have minimal relief. Patient is sexually active with men and was recently diagnosed with oropharyngeal gonorrhea treated with azithromycin 4 months prior. All other STI screening including syphilis, gonorrhea, HIV were negative at that time. Patient is on emtricitabine and tenofovir disoproxil fumarate for HIV pre-exposure prophylaxis. He denied family history of immune mediated conditions. Exam was significant for mild synovitis of both wrists and bilateral 2nd metacarpophalangeal joints. Initial labs revealed weakly positive anti-CCP 21 (normal <20), sedimentation rate 64 (normal ESR 0-15 mm/hr), C-reactive protein 24 (normal CRP 0-10 mg/L), and negative RF, ANA, HLA B27. During a short trial of prednisone taper, there was temporary improvement in symptoms, however synovitis recurred upon completion. Hydroxychloroquine (HCQ) 200mg twice a day was started for possible RA and he was referred to Ophthalmology for baseline retinopathy screening. Incidentally, he developed right sided blurry vision 2 weeks after initiation of HCQ. He was diagnosed with panuveitis of the right eye with inflammation of the optic nerve head and prednisone 40mg daily was initiated for presumed ocular manifestation of RA. However, further workup of panuveitis revealed reactive Treponema pallidum antibody and RPR quantity 1:32. Prednisone was immediately discontinued and he was referred to the emergency department for possible neurosyphilis.

Results:

Lumbar puncture showed cerebral spinal fluid with 260 red blood cells, 1 white blood cell, 27mg/dL protein, 60mg/dL glucose, non reactive VDRL, reactive pallidum IgG antibody, and negative cultures. Meningitis and encephalitis panels were negative. Patient completed a 14 day course of IV penicillin G with complete remission of joint pain, visual symptoms, and normalization of anti-CCP, ESR, and CRP.

Conclusion:

This case highlights how syphilis may mimic signs and symptoms of RA including symmetrical small joint pain, morning stiffness, elevated inflammatory markers, and positive anti-CCP. Anti-CCP is >96% specific for RA but was a false positive in this patient. There have only been few reported cases noting positive anti-CCP with reactive arthritis. This is a rare case of reactive arthritis secondary to syphilis with resolution of symptoms upon treating the syphilis.

References:

[1]Carter JD. Treating reactive arthritis: insights for the clinician. Ther Adv Musculoskelet Dis. 2010 Feb;2(1):45-54.

[2]Cohen SE, Klausner JD, Engelman J, Philip S. Syphilis in the modern era: an update for physicians. Infect Dis Clin North Am. 2013 Dec;27(4):705-22.

[3]Singh Sangha M, Wright ML, Ciurtin C. Strongly positive anti-CCP antibodies in patients with sacroiliitis or reactive arthritis post-E. coli infection: A mini case-series based review. Int J Rheum Dis. 2018 Jan;21(1):315-321.

Disclosure of Interests:

None declared.

Optimal Use of Physical Centric Relation Records for Digital Workflows

Correctly articulated dental casts are essential for certain dental treatment. Articulation can be traditional: using a physical articulator; digital: using a physical articulator followed by 3D scanning, or virtual: using 3D scanning and software to articulate scans without initial physical articulation. This study compared the precision of traditional articulation, using physical centric relation records and an articulator and virtually, by digitally aligning scans of the casts and record. Articulated casts and centric relation records were obtained. 12 record pairs were recorded from the articulated casts. Virtual method: all records were scanned, unclamped, in a custom laboratory scanner. The casts were aligned to each scanned record to create virtual articulations. Traditional method: each record was used to physically articulate the casts. Each articulation was recorded using an intraoral scanner. The mean inter-arch separation between three key-points on each cast-pair were used to determine differences in occlusal separation in three anatomical directions, and precision of methods. Traditional articulations: standard deviations in key-point distance never exceeded 0.102mm. The virtual equivalent was 0.059mm. Statistically significant differences (p⟨0.05) between all anteroposterior separation distances were found between the methods, and in three of six lateral/vertical separations. Virtual articulation was significantly more precise than traditional articulation.

Association between chronic airflow obstruction and socio-economic position in Morocco: BOLD results

BACKGROUND: Chronic obstructive lung disease (COPD) is the third most common cause of death in the world. Factors other than smoking, such as socio-economic status, could be involved in the development of COPD.OBJECTIVE: To investigate the association between chronic airflow obstruction and socio-economic status in Morocco.DESIGN: Questionnaires were administered and spirometry tests performed as part of the BOLD (Burden of Obstructive Lung Disease) Study carried out in Fez, Morocco. Socio-economic status was evaluated using a wealth score (0-10) based on household assets. The ratio of forced expiratory volume in 1 s (FEV₁) to forced vital capacity (FVC) was used to measure airflow obstruction.RESULTS: A total of 760 subjects were included in the analysis. The mean age was 55.3 years (standard deviation [SD] 10.2); the average wealth score was 7.54 (SD 1.63). After controlling for other factors and potential confounders, FEV₁/FVC increased by 0.4% (95%CI 0.01-0.78; P < 0.04) per unit increase in wealth score. Ageing, tobacco smoking, underweight, history of tuberculosis and asthma were also independently associated with a higher risk of airflow obstruction.CONCLUSION: Our findings suggest that airflow obstruction is associated with poverty in Morocco. Further investigations are needed to better understand the mechanisms of this association.

Decline of Psychological Health Following the Designation of COVID-19 as a Pandemic: Descriptive Study

BACKGROUND

COVID-19 was declared a pandemic by the World Health Organization on March 11, 2020, and as of this writing, Texas, United States, has reported >675,000 cases with over 14,000 deaths. Many of the preventive measures implemented during the pandemic can increase sedentary lifestyles, which can lead to the development of chronic diseases, including obesity, among the general population and cause serious threats to people's physical health and overall quality of life. Individuals with pre-existing comorbidities are at an increased risk of COVID-19 and may hence have higher levels of stress.

OBJECTIVE

This study aimed to investigate the relationship between physical activity levels and mental health status on an individual level and to compare them between those with and those without comorbidities in a cohort of Texas residents, before and after COVID-19 was declared a pandemic.

METHODS

An electronic survey was disseminated throughout various regions of Texas. In total, 160 individuals were asked questions about their demographic characteristics, time spent on daily physical activities, and daily mental health status before and after COVID-19 was declared a pandemic. Frequency distributions and descriptive statistics were analyzed.

RESULTS

Overall, 94 (58%) participants reported having ≥1 medical condition, and 31 (13.1%) had >3 medical conditions. Physical activity levels among participants with ≥1 pre-existing comorbidity drastically-but not significantly-decreased, as evident from a 10% increase in sedentary lifestyles after COVID-19 was declared a pandemic. On the contrary, we observed a 9% increase in the number of individuals without a pre-existing comorbidity who reported 30-60 min of physical activity per week. There was a 2-fold increase in the number of participants reporting more frequent feelings of nervousness, too much worry, trouble relaxing, and the fear of something awful happening after the pandemic. More specifically, individuals with pre-existing medical conditions reported, on average, a 10% higher incidence of feelings of stress, anxiety, and sadness compared to their healthy counterparts after COVID-19 was declared a pandemic.

CONCLUSIONS

Stressful life conditions and chronic comorbidities are risk factors that can affect mental health and reduce the ability to perform activities of daily life. Therefore, when implementing pandemic protocols, municipalities should consider providing mental health support to their citizens to protect them from this rather inconspicuous adverse effect.

Lung Transplantation in COVID 19 ARDS - Short Term Outcomes

Introduction

COVID-19 associated severe acute respiratory syndrome rapidly progress to irreversible lung injury, multiple organ failure and death. Lung transplantation is considered as the rescue therapy for these patients. Herein, we reported a case series of two successful life-saving bilateral lung transplantations for COVID-19-associated respiratory failure.

Case Report

Case 1: A 69-year-old male was admitted for hypoxia and altered mental status. He was diagnosed with COVID-19 pneumonia by abnormal CT findings and positive PCR result. After receiving a course of dexamethasone, convalescent plasma, remdesivir and broad-spectrum antibiotics, he remained to be profoundly hypoxic, requiring non-invasive ventilation. Following two negative PCR results, he underwent bilateral lung transplantation on day 57. He was discharged to rehab unit on postoperative day 26. No desaturation was observed with the 6-min walk test on 30-day follow-up.

Case 2: A 63-year-old male was presented with cough, and dyspnea. He was hemodynamically stable, SpO2 was 94%, chest x-ray was normal and tested positive for COVID-19. He was discharged home with dexamethasone and bronchodilators. However, he presented back on day 6 with worsening dyspnea. He was admitted and received a course of dexamethasone, remdesivir, convalescent plasma and broad-spectrum antibiotics. Due to persistent hypoxic respiratory failure, the patient underwent bilateral orthotopic lung transplantation on day 68. His postoperative course was complicated by primary graft dysfunction stage 3 and required open tracheostomy. His condition gradually improved and decannulated. He is currently on room air and able to walk 30 ft using a roller walker.

Summary

SARS-CoV-2 recovery is characterized by post inflammatory fibrosis and multi organ dysfunction. Lung transplantation can be successfully performed in patients with final stage respiratory failure of COVID-19 related pulmonary fibrosis.