Real-life prospective study on tocilizumab in severe COVID-19 infection

The outcomes of tocilizumab (recombinant monoclonal antibody inhibiting IL-6) in SARS-CoV-2 infection have been variable, with REMAP-CAP and RECOVERY being the largest trials to show benefits. In this prospective, observational study we compared tocilizumab plus standard care (dexamethasone) vs standard care alone in patients with severe COVID-19 infection. Eligibility criteria included patients (age >18 years) with radiological evidence of COVID-19 Pneumonia, PO2/FiO2 (PF) ratio of <300 mmHg and an inflammatory phenotype defined by raised CRP, IL-6 and Ferritin. The primary outcome was a composite of mechanical ventilation and death. A total of 36 patients were included in this study, 27 in the treatment group and 9 in the standard care group. The treatment arm received tocilizumab 8mg/kg (maximum 800mg) as a single infusion within the first 24 hours of respiratory deterioration (identified as worsening RR and PF ratio). Results showed significantly lower mortality rate in the tocilizumab group compared to standard care group (3% vs 33% respectively, p=0.013). Patients who received tocilizumab were also less likely to progress to mechanical ventilation, with only 3.7% of the treatment group requiring mechanical ventilation vs 44% in the control group (p=0.002). Our findings support the use of tocilizumab in severe COVID-19 infection when given early in respiratory deterioration. The predominant variant at the time of this study was the Alpha variant, and so further investigation is required into its effectiveness in newer variants. Limitations include small sample size.

Correlation between vitamin D and anosmia in post acute Covid syndrome clinic

Introduction: Anosmia has emerged as a clinical feature of Covid-19. It is estimated over half of patients with Covid19 report anosmia. It is primarily transient, but can persist over a month in around 20% of cases. There is a hypothetical interaction between hypovitaminosis D and diminished smell. A deficiency may lead to neurologic decline in cranial nerves, including the olfactory nerve. Few studies investigating this are available. Loss of smell is a common occurrence through adulthood, with many physiologic and anatomic contributing factors. Limited data is available addressing anosmia post Covid-19. Aim(s): To assess the correlation between vitamin D (VD) and anosmia, in patients referred to post acute COVID syndrome (PACS) clinic, and to assess the variation of data across age groups. Method(s): A "Sniffin' Sticks" test was undertaken for all patients referred to the PACS clinic. This was correlated with a recent serum VD level. Result(s): 143 patients presented to the PACS clinic over a 10 month period. 84% were under 65 years. 60% of these patients who developed anosmia were found to have VD insufficiency. A similar proportion of patients with hyposmia, and patients with normal smell were found to be VD insufficient (36% vs 34.7%). Within the older cohort, none of the patients with anosmia were deficient in VD, and 7.7% of patients with smell dysfunction had insufficiency. Conclusion(s): There is an association between anosmia and VD deficiency in patients under 65 years of age seen at PACS clinic. This did not reflect in the cohort with hyposmia. In the older age group, the majority of patients had normal VD levels, which may indicate other contributing factors towards the decrease in smell.

Bank supervision between risk reduction and economic renewal

This paper investigates specific challenges of Covid for balancing economic growth and financial stability as they apply to paradigms, programmes and policies of bank regulation and supervision at the European Commission and European Central Bank. It finds that dominant paradigms of risk reduction and control remained intact, despite a temporary programme of regulatory relaxation to spur credit growth. The ECB and the Commission were united on state aid, regulatory loosening and promoting credit creation. However, while the Commission sought credit for businesses, much of the credit went into the European housing sector, with ECB support. © 2023 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

Monitoring bone mineral density in patients with chronic intestinal failure on home parenteral nutrition – a national centre experience

Type 3 intestinal failure (IF) is known to negatively impact bone metabolism contributing to increased prevalence of osteoporosis and associated increases in morbidity and mortality. It has been challenging to appropriately monitor for these pathologies under the restrictions imposed by the ongoing COVID-19 pandemic. We performed a retrospective audit assessing compliance with current guidelines1. All type 3 IF patients receiving home parenteral nutrition (HPN) prescribed at a national centre prior to 1st May 2021 were included. Data was collected from hospital electronic recorded, de-identified and collated on an excel spreadsheet that was securely stored on a departmental computer. 270 patients fulfilled inclusion criteria (35.5% male, mean age 54.0 ± 17.5 years). The mean age at HPN initiation was 45.8 ± 18.5 years and the mean number of years on HPN was 8.2 ± 7.2 years. The maximum duration of HPN administration in this cohort was 37 years. DEXA scan results performed within the preceding 5 years were available for 23.0% of patients. Of these scans 96.8% of patients had evidence of reduced bone density (45.2% osteopenic, 51.6% osteoporotic). Comparing DEXA results at diagnosis and in the last 5 years, a majority (54.2%) of patients progressed or remained osteoporotic, with 8.3% showing improvement in bone density and 4.2% of patients having a return to normal bone density. 59.6% of patients had blood tests performed within the preceding 12 months. 54.4% of patients had undergone plasma vitamin D levels measurement. Vitamin D levels were found to be low (<50nmol/L) in 32.7%. 44.4% of patients were receiving vitamin D supplementation of which 86.7% were prescribed oral supplements and 13.3% intramuscular supplements. 31.3% of patients with osteoporosis were on bisphosphonate therapy. These results demonstrate high prevalence of metabolic bone disease amongst type 3 IF patients on HPN. This highlights a potentially modifiable risk of low-trauma fracture which has a very high morbidity and mortality index. Our findings regarding the prevalence and longitudinal changes in bone density are in agreement with the published ESPEN surveys2,3. The results also demonstrate poor compliance with current guidelines. We believe this reflects the challenges of obtaining non-emergent scans and blood test due to COVID-related restrictions as well as our patients’ very understandable fear of exposure should they attend hospital for a face-to-face review. It is also possible that some of these tests were performed locally, due to many patients living far away from our national referral centre, and thus not visible to the audit team. These findings have highlighted the need for greater education and prompted our group to increase our focus on metabolic bone disease during clinic interactions and to create a subsection of our database for tracking DEXA intervals for this patient cohort. References 1. Pironi L, Arends J, Bozzetti F, et al. ESPEN guidelines on chronic intestinal failure in adults. Clin Nutr 2016;35: 247-307. 2. Pironi L, Labate AM, Pertkiewicz M, et al. Prevalence of bone disease in patients on home parenteral nutrition. Clin Nutr 2002;4: 289-296 3. Pironi L, Tjellesen L, De Francesco A, et al. Bone mineral density in patients on home parenteral nutrition: a follow-up study. Clin Nutr. 2004 Dec;23(6):1288-302

Long COVID syndrome and the lung: how long will it last?

The prevalence and duration of the long-term respiratory complications of COVID-19 infection remains to be elucidated. This short commentary reports on recently published studies in patients post-acute COVID-19 infection in terms of symptom prevalence, physiological and radiological sequela and where only symptoms are present despite investigation. Pulmonary function testing, 6-min walk tests, computed tomography chest and more advanced imaging modalities have been incorporated to reveal the underlying pathophysiology that cause such disabling symptoms in patient with post-acute COVID-9 syndrome (PACS). PACS has a serious impact on people's ability to return to work, affecting the physical, mental, social sphere and with significant healthcare and general economic consequences for them, their families and society.

Evaluating the patient experience of the BartsHealth MySpA app for axial spondyloarthritis andpsoriatic arthritis

Background/AimsIn 2018, MySpA App was developed and launched by theRheumatology team at Whipps Cross Hospital to empower patientswith axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) in selfmanagement of their condition. MySpA is an internationally available, free educational App providing instant access to evidence basedmedical information about axSpA and PsA. It includes a library ofexercise videos created by specialist physiotherapists in axSpA, enabling patients and clinicians to build exercise programmes tailoredto individual patient needs. Validated outcome measures can becompleted by patients throughout the year, with the option of sharingthose results with their rheumatology clinicians. Our objective was toevaluate patient opinion and usefulness of MySpA among our patients.MethodsTwo years since MySpA was launched at BSR, an online questionnairewas sent to 198 patients with axSpA and PsA from Whipps CrossRheumatology Service. The questions enquired about awareness ofMySpA for download and use amongst patients with managing theircondition.ResultsOverall response was 36% (n = 72). 61% (n = 44) of the patientsresponded had downloaded MySpA with 64%(n = 28) of thosepatients using the app throughout the year. The majority that hadnot downloaded, were not aware the app existed (70%). All featureswithin the app were used, with the axSpA and PsA Information sectionand exercise library most popular with comments ''I use my exerciseplan daily'' and ''great app.'' 53% of patients used the app as aneducational resource and 46% used the exercise library tailored totheir own needs. The most common reason for not using the app wasforgetting (29%). The majority (91%) would recommend MySpA toother patients with axSpA and PsA, with 63% reported MySpAsupported them managing their condition.ConclusionMySpA is well received by patients with axSpA and PsA at WhippsCross Hospital as a resource where they find specialist support, information and exercise guidance to empower management. Itprovides a useful virtual tool to assist patients take control of theirarthritis and track and monitor their condition and has been particularlyuseful in this regard during the Covid pandemic. Patients used thefacility to complete and share their assessment results and journal logsvirtually with their healthcare team. However, continual awareness ofMySpA amongst patients and clinicians is required to enable theopportunity to utilise instant specialist support and direction that mayhelp patients manage their condition. The usefulness of the virtualmonitoring feature of the app amongst clinicians should be explored infuture research.

COVID-19 infection in patients with intestinal failure: UK experience.

BACKGROUND: The direct effect of the coronavirus disease 2019 (COVID-19) pandemic on patients with intestinal failure (IF) has not been described. METHODS: We conducted a nationwide study of UK IF centers to evaluate the infection rates, presentations, and outcomes in patients with types 2 and 3 IF. RESULTS: A total of 45 patients with IF contracted COVID-19 between March and August 2020; this included 26 of 2191 (1.2%) home parenteral nutrition (HPN)-dependent adults and 19 of 298 (6.4%) adults hospitalized with type 2 IF. The proportion of patients receiving nursing care for HPN administration was higher in those with community-acquired COVID-19 (66.7%) than the proportion in the entire HPN cohort (26.1%; P < .01). Two HPN-dependent and 1 hospitalized patient with type 2 IF died as a direct consequence of the virus (6.7% of 45 patients with types 2 or 3 infected). CONCLUSION: This is the first study to describe the outcomes of COVID-19 in a large cohort of patients requiring long-term PN. Methods to reduce hospital and community nosocomial spread would likely be beneficial.