COVID-19 pandemic and physical health screening in an assertive community treatment service

Introduction

Patients with severe mental illness experience physical health inequities. They are less likely to receive preventative care and adequate treatment for physical illnesses. Physical health screening of patients receiving antipsychotics is usually carried out every six months. This comprises screening bloodwork and ECGs, and the sharing of results with family physicians.

Objectives

We sought to investigate whether the pandemic affected the receipt of routine physical health screening in patients managed by an Assertive Community Treatment (ACT) Service.

Methods

A comprehensive chart review was performed on 62 ACT patients. We compared the receipt of screening bloodwork and ECGs from March—December 2020 to the same period in 2019. Results were analyzed using McNemar’s Chi square test with Yates’ correction.

Results

Patients were less likely to have received an ECG during the pandemic period. 69% received an ECG from March—December 2019 versus 42% from March—December 2020 (χ²= 7.76, p<0.01). Similarly, patients were less likely to have received screening bloodwork during the pandemic period (69% vs. 50%, Χ²= 4.32, p<0.05). Qualitative discussion with ACT staff regarding the 39 patients who had not received an ECG and/or bloodwork during the pandemic period revealed system-related (8%), patient-related (23%), and Covid-related (69%) barriers to screening. Covid-related barriers included transport concerns and lab closures.

Conclusions

ACT patients were less likely to have received routine health screening during the Covid-19 pandemic. Thus, the pandemic may have exacerbated physical health inequities for patients with severe mental illness. Covid-related barriers to screening represent an important target for intervention.

Disclosure

No significant relationships.

Impact of an Innovative Patient Navigation Project in Nigeria: Preliminary Results

Background: Cancer patients in Nigeria are known to present late and have poor awareness of their disease. Among the factors which limit early presentation are aversion for orthodox medicine due to perceived complexity of health institutions, and belief in superiority of traditional medicine. Patient navigation has been shown to improve patient treatment adherence. There is limited evidence on the impact of PN in Nigeria, and other resource-limited settings. Aim: Study sought to introduce a hospital-based patient navigation program (PNP) and evaluate its impact. Methods: PNP was initiated at the University of Uyo Teaching Hospital in June 2016 with focus on breast cancer patients. A young, male public health officer, who spoke the local language was recruited and trained to guide cancer breast patients through the hospital. Training focused on hospital services, sensitive communications, patient management process, confidentiality and resource identification. The service was announced to the hospital community, and his contact information was advertised. Patients and hospital community could contact the navigator via phone calls and text messaging. Impact data collection included services provided, patient characteristics and feedback on services. Data analysis included descriptive statistics and thematic analysis. Results: In the first year of the PNP (June 2016-17), 202 breast cancer cases were seen, and 137 connected with the navigator; service utilization rate was 67.8% (137/202). More patients in the PNP received diagnosis within 90 days of their first visit, 58.4% (80/137) presented with stage 4 disease, and 20 had mastectomy. Most patients had low income and low education. Two patients died after completing three courses of chemotherapy. Finance, transportation and poor social support were the most common barriers to access. Health care providers positively reviewed the PNP, often saying that “it made their work” and “added value to hospital care and cancer management”. Physicians who did not speak the local language often used the navigator as a translator. Most patients echoed “God bless you” in prayers offered to appreciate the navigator. They agreed that the PNP reduced some barriers to hospital service utilization, although 32 patients (23%) expressed frustration over unmet expectations financial support from the navigator. Physicians who manage other cancers have started referring patients to the PNP since its initiation. Conclusion: This evaluation showed that PNP program was well used and led to improvements in breast cancer patient management. It proves that patient navigation is feasible in a resource-limited setting. Funding to sustain and expand the program is a limitation. More patient satisfaction and outcome studies are needed to evaluate PNP impact.

The ASOS Surgical Risk Calculator: development and validation of a tool for identifying African surgical patients at risk of severe postoperative complications

BACKGROUND

The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications.

METHODS

ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery.

RESULTS

The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784.

CONCLUSIONS

This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance.

CLINICAL TRIAL REGISTRATION

NCT03044899.

The challenge of Vitamin D deficiency in an inpatient ward

Aims and hypothesis

We set out to determine standards that would enable the identification of persons at risk of Vitamin D (VitD) deficiency in our ward; the prevalence of deficiency in at risk patient group on a 25-bedded ward (Brunswick). Deficiencies were identified, managed according to local guidelines and care plans were updated to reflect this change.

Background

Low VitD levels have been associated with depression, psychosis, schizophrenia, suicidality, treatment resistance and poor coping. However, serum VitD levels is not a routine investigation on inpatient psychiatric admissions. Factors associated with VitD deficiency include prolonged stay in inpatient units with limited exposure to sun; Inpatients’ diet; Self-neglect and social isolation.

Methods

Criteria for identifying patents who may be at increased risk was agreed.

These patients were approached, and consented to screening. Results of the investigation were discussed with patients and actioned according to need. Study period May 2015–July 2015.

Results

We were unable to identify any criteria in use for identifying persons at risk in psychiatric services. The following criteria were agreed: Hospital stay for > 2 months and limited opportunities of leaving the ward (Detention); Transfer from another unit with a total of hospital stay > 2 months; Admission from the community with severe depression or history of social isolation.

7 patients (28%) were identified to be at increased risk. Of this, 6 patients (85.7%) were deficient and another 1 (14.3%) had insufficient level. Management was instituted.

Conclusions

If indicated, psychiatrists ought to consider monitoring VitD levels during inpatient stays and managing as appropriate.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Cytokine inducible matrix metalloproteinase expression in immortalized rat chondrocytes is independent of nitric oxide stimulation

The objective of this study was to determine if an immortalized mammalian chondrocyte cell line had a profile of matrix metalloproteinase (MMP) expression that was consistent with what has been reported for primary chondrocytes in vitro and in vivo. A combination of zymography, Western, and Northern analysis was used to examine the expression of MMPs that are relevant to cartilage degradation. Both interleukin-1beta and tumor necrosis factor alpha induced a 4- to 9-fold increase in the level of MMP-9 expression in conditioned media, and a 17- to 24-fold increase in MMP-3 mRNA. Other compounds such as basic fibroblast growth factor and staurosporine each increased MMP-9 expression individually and potentiated the effects of the two cytokines. Transforming growth factor beta had no positive or inhibitory effects. N-methyl arginine blocked the increase in nitric oxide observed following treatment with the cytokines but did not prevent the increased expression of MMPs. The pattern of metalloproteinase expression observed in IRC cells and the response to cytokines is very similar to what has been reported during the pathogenesis of osteoarthritis. The IRC cells should be useful as a model system to study basic mechanisms controlling chondrocyte MMP expression and to identify pharmacological modulators of this process.