Trauma Prehospital Hypothermia Prevention and Treatment: An Observational Study.

BACKGROUND: Hypothermia in trauma patients causes increased morbidity and mortality. Swift recognition and treatment are important to prevent any further heat loss. In addition, patient discomfort from cold decreases satisfaction with care. The administration of active and passive rewarming measures is important in the prevention and treatment of hypothermia, but their use in prehospital trauma patients in Portugal has not been previously reported. OBJECTIVE: To assess the prevalence of hypothermia, the impact of rewarming measures, and the management of the discomfort caused by cold. METHODS: This is a prospective cohort study conducted in Immediate Life Support Ambulances in Portugal between March 1, 2019, and April 30, 2020. RESULTS: This study included records of 586 trauma patients; of whom, 66.2% were men. Cranioencephalic trauma was the most common trauma observed, followed by lower limb and thoracic traumas. Mean body temperature increased 0.12 °C between the first and last assessments (p < .05). Most patients experiencing a level of discomfort of 5 or more on a 0-10 scale reported improvement (from 17.2% to 2.4% after nurses' intervention). Warmed intravenous fluids proved to be effective (p < .05) in increasing body temperature, and passive rewarming measures were effective in preventing hypothermia. CONCLUSIONS: Hypothermia management has to consider the initial temperature, the season, the available rewarming measures, and the objectives to be achieved. The optimization of resources for the monitoring and treatment of hypothermia should be a priority in prehospital assistance. The implementation of rewarming measures improves patients' outcomes and decreases the discomfort caused by cold in prehospital care.

The impact of fatigue in rheumatoid arthritis and the challenges of its assessment.

Fatigue is one of the most important symptoms for patients with RA, and imposes a great burden on patients' lives, being associated with significantly reduced health-related quality of life. Although being recognized by the rheumatology community as a major gap in the current management of the disease, fatigue has not been easy to measure and conceptualize. Part of the problem seems to reside in the multidimensional causality of this phenomenon, which may warrant dedicated measures and interventions. Although there are several instruments available to measure it, no consensus has yet been reached to recommend a 'gold-standard'. This review aims at synthesizing the role of fatigue in the global impact of RA; describing validated instruments and their psychometric properties as measures of fatigue among patients with RA; and finally proposing a clinically meaningful, valid and feasible process to measure fatigue in clinical practice.

Treating-to-target in rheumatology: Theory and practice.

Despite its inclusion in current treatment recommendations, adherence to the treat-to-target strategy (T2T) is still poor. Among the issues are the definition(s) of target, especially the caveats of the patient global assessment (PGA), included in all recommended definitions of remission. The PGA is poorly related to inflammation, especially at low levels of disease activity, rather being a measure of the disease impact. Up to 60% of all patients otherwise in remission still score PGA at >1 and as high as 10. These patients (PGA-near-remission) are exposed to overtreatment if current recommendations are strictly followed and will continue to endure significant impact, unless adjuvant measures are implemented. A proposed method to overcome both these risks is to systematically pursue two targets: one focused on the disease process (the biological target) and another focused on the symptoms and impact (the impact target), the dual-target strategy. Candidate instruments to define each of these targets are discussed.

Portuguese multidisciplinary recommendations for non-pharmacological and non-surgical interventions in patients with rheumatoid arthritis.

BACKGROUND: Patients with rheumatoid arthritis (RA) report significant levels of disease impact, which are improved, but not fully abrogated by immunosuppressive therapy, even when remission is achieved. This imposes the need for adjuvant interventions targeting the uncontrolled domains of disease impact. Non-pharmacological interventions are widely used for this purpose, but they have not been the object of professional recommendations or guidelines. OBJECTIVE: To propose multidisciplinary recommendations to inform clinical care providers regarding the employment of non-pharmacological and non-surgical interventions in the management of patients with RA. METHODS: The EULAR standardized operating procedures for the development of recommendations were followed. First, a systematic literature review was performed. Then, a multidisciplinary Technical Expert Panel (TEP) met to develop and discuss the recommendations and research agenda. For each developed recommendation i) the level of evidence and grade of recommendation were determined, and ii) the level of agreement among TEP members was set. A recommendation was adopted if approved by ≥75% of the TEP members, and the level of agreement was considered high when ≥8. All relevant national societies were included in this construction process to attain their endorsement. RESULTS: Based on evidence and expert opinion, the TEP developed and agreed on five overarching principles and 12 recommendations for non-pharmacological and non-surgical interventions in patients with RA. The mean level of agreement between the TEP members ranged between 8.5 and 9.9. The recommendations include a broad spectrum of intervention areas, such as exercise, hydrokinesiotherapy, psychological interventions, orthoses, education, general management of comorbidities, among others; and they set the requirements for their application. CONCLUSIONS: These recommendations are based on the consensus judgment of clinical experts from a wide range of disciplines and patients' representatives from Portugal. Given the evidence for effectiveness, feasibility and safety, non-pharmacological and non-surgical interventions should be an integral part of standard care for people with RA. It is hoped that these recommendations should be widely implemented in clinical practice. The target audience for these recommendations includes all health professionals involved in the care of patients with RA. The target patient population includes adult Portuguese people with RA.

Health Care Workers not in the frontline are more frequently carriers of Coronavirus Disease 2019: The Experience of a Tertiary Portuguese Hospital.

BACKGROUND: Health care workers (HCWs) have a high risk of infection with coronavirus disease 2019 (COVID-19), especially those treating patients with confirmed or suspected diagnosis (front-line). AIM: To evaluate the incidence and prevalence of the COVID-19 infection among HCWs and to analyse the risk factors and the clinical characteristics among infected ones. METHODS: Observational, retrospective, single-center study (Centro Hospitalar e Universitário de Coimbra, Portugal). Data were collected from March 1 to June 30, 2020. FINDINGS: Overall, 211 (2.63%) out of 8037 HCWs were diagnosed with COVID-19. Most of the infections occurred during the early stage of disease outbreak. Among the infected HCWs, only 20.9% (n=44) were from the front-line. Both front-line and non-front-line HCWs were exposed primarily to patients (48.6% in both groups), but the non-front-line were (presumably) more infected by colleagues (10.8% vs 24.8%, P=0.04). Front-line HCWs performed more family isolation than non-front-line (88.9% vs 82.5%, P>0.05) and presumably less family members were infected in the former group (19.4% vs 26.3%, P>0.05). The proportion of HCWs with asymptomatic infection was statistically significantly lower in the front-line group (2.4% vs 19.9%, P=0.05). CONCLUSION: The prevention and control actions implemented were effective in mitigating the COVID-19 outbreak; HCW infections occurred mainly in the early stages. Non-front -line HCWs were at a higher risk, warranting specific attention and interventions targeting this group.

Effectiveness of non-pharmacological and non-surgical interventions for rheumatoid arthritis: an umbrella review.

OBJECTIVE: This umbrella review aimed to determine the effectiveness of non-pharmacological and non-surgical interventions on the impact of rheumatoid arthritis. INTRODUCTION: Patients with rheumatoid arthritis have identified seven major domains of the impact of disease: pain, functional disability, fatigue, sleep, coping, emotional well-being and physical well-being. This impact persists in many patients even after inflammatory remission is achieved, requiring the need for adjunctive interventions targeting the uncontrolled domains of disease impact. Several systematic reviews have addressed non-pharmacologic interventions, but there is still uncertainty about their effectiveness due to scarce or conflicting results or significant methodological flaws. INCLUSION CRITERIA: This review included studies of adult patients with rheumatoid arthritis in any context. Quantitative systematic reviews, with or without meta-analysis, that examined the effectiveness of non-pharmacological and non-surgical interventions of any form, duration, frequency and intensity, alone or in combination with other interventions designed to reduce the impact of disease, were considered. The outcomes were pain, functional disability, fatigue, emotional well-being, sleep, coping, physical well-being and global impact of disease. METHODS: A comprehensive search strategy for 13 bibliometric databases and gray literature was developed. Critical appraisal of eight systematic reviews was conducted independently by two reviewers, using the Joanna Briggs Institute critical appraisal checklist for systematic reviews and research syntheses. Data extraction was performed independently by two reviewers using a standard Joanna Briggs Institute data extraction tool, and data were summarized using a tabular format with supporting text. RESULTS: Eight systematic reviews were included in this umbrella review, with a total of 91 randomized controlled trials and nine observational studies (6740 participants). Four systematic reviews examined the effects of multicomponent or single exercise/physical activity interventions, two examined the effects of hydrotherapy/balneotherapy, two examined the effects of psychosocial interventions, and one examined the effects of custom orthoses for the foot and ankle. Multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses appeared to be effective in improving pain and functional disability. Fatigue also improved with the implementation of multicomponent or single exercise/physical activity interventions and psychosocial interventions. Only exercise/physical activity interventions appeared to be effective in reducing the global impact of disease and quality of life. None of the included systematic reviews reported on emotional well-being, sleep, coping or physical well-being as an outcome measure. Other types of interventions were not sufficiently studied, and their effectiveness is not yet established. CONCLUSIONS: Of the included interventions, only multicomponent or single exercise/physical activity interventions, psychosocial interventions and custom orthoses seem to reduce the impact of rheumatoid arthritis. Future evidence should be sought and synthesized in the domains identified as knowledge gaps, namely, emotional well-being, sleep, coping and physical well-being. Further examination of the effects of interventions that have not been assessed sufficiently is suggested in order to establish their effectiveness so decisions and recommendations can be made.