763 QUALITY IMPROVEMENT PROJECT (QIP) ON IMPROVING THE USE OF THE CLINICAL FRAILTY SCALE (CFS) DURING THE COVID-19 PANDEMIC

Introduction

Older people were disproportionally affected by the COVID-19 pandemic resulting in a surge in the demand for healthcare resources. The aim of this QIP was to assess and improve the compliance of using the CFS in patients over the age of 65 with COVID-19 to aid in establishing appropriate Treatment Escalation Plans (TEPs) during admission.

Method

Prospectively, clinical notes of 80 patients were reviewed to calculate the compliance of documenting the CFS on admission. Multiple Plan-Do-Study-Act (PDSA) cycles were implemented. As the first intervention, a trust-wide email message was sent to all medical doctors highlighting the importance of assessing CFS in all patients during admission. Also, reminder emails and text messages were sent to all medical doctors’ WhatsApp groups. As the second intervention, we designed an e-poster and displayed it as a screensaver on all trust computers for 2 weeks. Data was collected and analysed after each intervention.

Results

The baseline audit showed that only 42% of patients had a CFS documented during admission. The majority (55%) had a CFS above 5 and 93% of the patients had a ‘Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order in place. Compliance in assessing CFS after the two interventions was 65% and 68% respectively. In both cycles, all patients who had a CFS of 5 and above had DNACPR decisions in place. Moreover, significant variability in escalation plans was noted when the CFS was 4.

Conclusion

The compliance in assessing CFS progressively improved with each intervention. Although the CFS is a valuable tool in assisting TEPs, it should be treated as a spectrum that is independent of age, rather than a binary phenomenon. We hope to further improve compliance by arranging teaching sessions for doctors in our hospital and thereby ensure appropriate TEPs are in place.

Intrusive Thoughts Elicited by Direct Electrical Stimulation during Stereo-Electroencephalography

Cortical direct electrical stimulation (DES) is a method of brain mapping used during invasive presurgical evaluation of patients with intractable epilepsy. Intellectual auras like intrusive thoughts, also known as forced thinking (FT), have been reported during frontal seizures. However, there are few reports on FT obtained during DES in frontal cortex. We report three cases in which we obtained intrusive thoughts while stimulating the dorsolateral prefrontal cortex and the white matter in the prefrontal region. In order to highlight the effective connectivity that might explain this clinical response, we have analyzed cortico-cortical potentials evoked by single pulse electrical stimulation.

IL-17 patterns in synovium, serum and synovial fluid from treatment-naïve, early rheumatoid arthritis patients

BACKGROUND

There are actually becoming controversial data regarding the profiles of interleukin-17 (IL-17) in different pathogenical stages of rheumatoid arthritis (RA).

OBJECTIVES

To assessing the IL-17 patterns in synovium, serum and synovial fluid from treatment-naïve early RA patients and to identifying potential correlations with disease activity markers and with synovial histopathological profile.

MATERIALS AND METHODS

Serum samples from 30 treatment-naïve early RA patients were evaluated for C-reactive protein (CRP), erythrocytes sedimentation rate (ESR), rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP). IL-17A levels were also assessed in serum and synovial fluid (SF). Disease activity score (DAS28) calculation was done for all patients. Control serum and SF samples were obtained from 29 patients with osteoarthritis (OA); control synovium specimens were obtained from eight patients with OA and during surgery for knee tear ligaments. Histopathological (Hp) score, immunohistochemical reactivity for IL-17 were also assessed in synovium of early RA patients and controls. Dependencies between serum and synovial profile of IL-17A and the other parameters were statistically tested.

RESULTS

In early RA patients, strong correlations of serum and SF IL-17A levels were found with ESR, CRP, RF, anti-CCP, Hp score and IL-17 synovial immunoreactivity; a good correlation was noted with DAS28 score. Also, strong correlation was noted between serum and SF IL-17A levels.

CONCLUSIONS

In early stages of untreated RA, simultaneous IL-17 assessment of serum, SF and synovium might be valuable in defining activity and predictive patterns, given that synovium is highly suggestive for an disease aggressivity and might express specific therapeutically targets.

Immunohistochemical study of stellate cells in patients with chronic viral hepatitis C genotype 1

INTRODUCTION

Hepatic stellate cells (HSC) are key-players in the pathogenesis of liver fibrosis, inducing collagen deposition and abnormal extracellular matrix remodeling.

AIM

The purpose of this study was to identify the stellate cells using immunohistochemical techniques and to establish if there is a correlation between the expression of stellate cells and the clinical and histological parameters in patients with chronic viral hepatitis C.

MATERIALS AND METHODS

The studied group included 30 patients with chronic viral hepatitis C genotype 1, in whom a liver biopsy was performed previous to the antiviral treatment. After the histological analyze, the biopsy was stained with an anti-SMA antibody (Dako, Carpinteria, CA). The amount of positive stained area was determined using an arbitrary semiquantitative score from 1 to 4.

RESULTS

Our observations suggest that there is a strong correlation between the stellate cells activity, evaluated using a semiquantitative score, and the stage of liver fibrosis (rs=0.76, p<0.001). Also, our study revealed a direct correlation, but less intense, with the necro-inflammatory activity (rs=0.39, p=0.03), the steatosis degree (rs=0.428, p=0.01) and the value of alanine aminotransferase (rs=0.4, p=0.03). The age and the viremia level were not correlated with the activity of the stellate cells.

CONCLUSIONS

This study suggests that the transition of stellate cells from inactivated state to the state of highly fibrogenic cell is influenced mainly by the histological liver modifications (necroinflammatory activity and steatosis) and less by clinical parameters (age, sex) or the viremia level.

[Relations between the principal classes of serum immunoglobulins and serodiagnostic tests in viroses. I. Influenza infection]

The relationship between the main serum immunoglobulin classes (IgM, IgG) and the positive diagnostic serologic tests (hemagglutination-inhibition and complement fixation) followed up in 30 paired serum samples from patients in the course of a primary influenza infection with B virus strain, before and after treatment with 2-ME, showed actual participation of the IgM molecules sensitive to 2-ME in the CF test. HI with the serum fractions of patients and convalescents of influenza B, in the presence of virus strains A and B, that had circulated earlier in the area, showed anamnestic responses by the presence of IgG and IgA antibodies in the patients' sera; HI and CF with the same serum fractions in the presence of virus B/Iaşi/74 of the epidemic, showed the presence of IgM, IgG and IgA in the convalescent sera, as also demonstrated by immunoprecipitation in agar gel with specific IgM, and IgA antisera and by treatment with 2-ME. Separation of these sera on a Sephadex G-200 column revealed filtration of IgM antibodies at the same peak as the IgG and IgA antibodies, possessing a closely resembling molecular weight (7S) and probably being IgM subunits with an immunologic behaviour similar to that of the intact molecule sensitive to 2-ME.