Outpatient Care Aspects of Rheumatic Patients in Latvia : Real Life Data in the Context of the First Month of the COVID-19 Pandemic

Publisher Copyright: © 2023 Julija Zepa et al., published by Sciendo.The aim of this study was to analyse the rheumatic disease profile and treatment aspects of the patients consulted in the outpatient department of Pauls Stradiņš Clinical University Hospital during the first month of the COVID-19 pandemic from 2020 March 13 till April 14. A total of 457 (76.04%) remote and 144 (23.96%) face-to-face consultations were analysed, totalling 601 patients: 434 (72.21%) females and 167 (27.79%) males with mean age 51.40 ± 14.73 years. Rheumatoid arthritis (223 (37.10%)), psoriatic arthritis (93 (15.47%)) and ankylosing spondylitis (80 (13.31%)) were the most frequently consulted conditions. Disease modifying antirheumatic drugs (DMARDs) or immunosuppressants (IS) were taken by 515 (85.69%) patients. These included synthetic DMARD (242 (46.99%)), mainly methotrexate; and biologic DMARD (156 (30.29%)), mainly tumour necrosis factor inhibitor. More than one-half of the cohort (427 (71.05%)) was not taking a glucocorticoid (GC). NSAIDs were used in 391 (65.08%) patients, mainly on demand (354 (90.54%)). Most patients (401 (66.72%)) had no comorbidities (hypertension, diabetes, malignancy and/or chronic respiratory disease). The profile of patients consulted in the outpatient department consisted mainly of middle-age females with autoimmune inflammatory arthritis treated by DMARD. Most of the patients did not use GCs, they did not regularly use NSAIDs and did not have comorbidities. Telemedicine is an acceptable way of care delivery for chronic rheumatic patients with previously known disease and treatment, especially during a pandemic.publishersversionPeer reviewe

Novel insights into the management of rheumatoid arthritis: one year in review 2022

New evidence for the treatment of rheumatoid arthritis (RA) has emerged during the last year. Specifically, updated guidelines on pharmacological and non-pharmacological management of RA have emphasised the necessity of global patient's care, and have shifted the role of some older drugs, such as glucocorticoids and methotrexate. In addition, the long-term safety of Janus kinase inhibitors was investigated and reinforced. With respect to the coronavirus-19 pandemic, reassuring data on the efficacy and safety of vaccinations in the RA population were acquired, as well as on the potential role of telemedicine in RA management. Machine learning prediction models and biomarkers development have emerged as promising innovations in the area of precision/personalised medicine, appearing to encourage future expansion.In this narrative review, the authors aim to give their specific point of view on the most relevant and potentially impacting novelties published during 2021 and early 2022 in the context of RA management

Influence of COVID-19 pandemic on decisions for the management of people with inflammatory rheumatic and musculoskeletal diseases: a survey among EULAR countries

Objectives: To investigate how the first wave of COVID-19 pandemic influenced decisions of rheumatologists and health professionals in rheumatology regarding the management of patients with inflammatory rheumatic and musculoskeletal diseases (RMDs). Methods: An English-language questionnaire was developed by a EULAR working group and distributed via national rheumatology societies of EULAR countries, EMEUNET and individual working group members. Responses were collected using an online survey tool. Descriptive statistics were calculated. Results: We analysed 1286 responses from 35/45 EULAR countries. Due to containment measures, 82% of respondents indicated cancellation/postponement of face-to-face visits of new patients (84% of them offering remote consultation) and 91% of follow-up visits (96% with remote consultation). The majority of respondents (58%) perceived that the interval between symptom onset and first rheumatological consultations was longer during containment restrictions than before. Treatment decisions were frequently postponed (34%), and the majority (74%) of respondents stated that it was less likely to start a biological disease modifying anti-rheumatic drug (DMARD)/targeted synthetic DMARD during the pandemic, mainly because of patients’ fear, limited availability of screening procedures and decreased availability of rheumatological services. Use of (hydroxy)chloroquine (HCQ) and tocilizumab (TCZ) for the COVID-19 indication was reported by 47% and 42% of respondents, respectively, leading to a shortage of these drugs for RMDs indications according to 49% and 14% of respondents, respectively. Conclusion: Measures related to containment of COVID-19 pandemic led to a perceived delay between symptom onset and a first rheumatological visit, postponement of treatment decisions, and shortage of HCQ and TCZ, thereby negatively impacting early treatment and treat-to-target strategies

Adding value to outpatient heart failure services and the patient journey through digital transformation of services

Introduction Heart failure (HF) is a chronic condition affecting over 900,000 people in the UK. The management of patients with HF frequently involves regular face-to-face appointments. Digital transformation of care with telemedicine, remote monitoring and mobile applications (Apps) may help improve patient experience and relieve demand on services. The Covid-19 pandemic resulted in an acceleration in telemedicine. This thesis evaluates pre-pandemic HF services at the Royal Brompton Hospital (RBH), identifying potential areas for improving patient journeys. Methods Retrospective cohort studies including over 200 patients were used to analyse the activities and actions resulting from HF clinic appointments over 3 years. Time-and-motion studies were conducted for each of the 4 consultant-led HF clinics at RBH, where flow through hospital was analysed for 58 patients. Eight clinicians and 8 patients who had undergone telemedicine consultations were interviewed about their experiences and perceptions, with narrative data thematically analysed. Focus groups and existing educational material were used to design an educational App for HF. Results Most HF patients under long-term follow-up were followed up twice yearly. At clinic visit, worsening HF symptoms and therapy change by clinicians were uncommon (21% and 36% of appointments respectively). Patients spent a median of 103 minutes in hospital on the day of an appointment for a median 20-minute consultation. The majority of consultations ran late. Clinicians and patients found telemedicine consultations generally acceptable, but both groups identified changes in time utilisation, clinical assessment, communication, and technology. Telemedicine appointments were shorter and involved less time waiting and travelling for patients. Patients and clinicians agreed that when patients are “stable”, telemedicine is preferred. A prototype HF educational “Avatar”-based App was produced. Conclusion Digital transformation of outpatient services, including telemedicine can improve patient and clinician experience, efficiency and rationalise limited resources, thus adding value to outpatient HF care.Open Acces

Therapists’ experiences of remotely delivering cognitive-behavioural or graded-exercise interventions for fatigue: a qualitative evaluation

Objectives: Fatigue is a challenging feature of all inflammatory rheumatic diseases. LIFT (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomised Trial) included remotely delivered personalised exercise programme (PEP) or cognitive-behavioural approach (CBA) interventions. The aim of this nested qualitative evaluation was to understand rheumatology health professionals (therapists’) perspectives of delivering the interventions in the LIFT trial. Methods: A subgroup of therapists who had delivered the PEP and CBA interventions took part in semi-structured telephone interviews. Results: Seventeen therapists (13 women, 4 men) who delivered PEP (n = 8) or CBA (n = 9) interventions participated. Five themes were identified: In ‘The benefits of informative, structured training’, therapists described how they were able to practice their skills, and the convenience of having the LIFT manual to refer to. When ‘Getting into the swing of it’, supporting patients gave therapists the confidence to tailor the content of the manual to each patient. Clinical supervision supported therapists to gain feedback and request assistance when required. In ‘Delivering the intervention’ therapists reported that patients valued the opportunity to address their fatigue and challenge their own beliefs. ‘Challenges in delivering the LIFT intervention’ therapists struggled to work collaboratively with patients who lacked motivation or stopped engaging. Finally, ‘Lift developing clinical skills’ therapists gained confidence and professional satisfaction seeing patients’ fatigue improve. Conclusion: Findings support the value of skills training for rheumatology health professionals to deliver a remote fatigue management intervention tested in the LIFT trial. These insights can inform service provision and clinical practice Lay summary What does this mean for patients ? Fatigue can be a challenge in inflammatory rheumatic diseases (IRDs). The LIFT study (Lessening the Impact of Fatigue in inflammatory rheumatic diseases: a randomized Trial) explored interventions to support people with fatigue. These were: a cognitive-behavioural approach (CBA), a personalized exercise programme (PEP), or usual care. People with IRDs were chosen randomly to take part in seven sessions of CBA, seven sessions of PEP or usual care. All sessions (aside from the first PEP session) were delivered over the phone. The aim of this study was to explore therapists' experiences of delivering the intervention. Seventeen therapists (13 women and 4 men) took part; eight had delivered the PEP intervention, and 9 delivered the CBA intervention. Therapists who delivered LIFT told us they enjoyed the chance to practice their skills, and that the LIFT manual gave them the confidence to tailor the intervention to each patient. Clinical supervision was valued. Therapists also shared that LIFT improved their skills and they were happy to see patients' fatigue improve over time. These new results can inform clinical practice, and how services are provided

The impact of SARS-CoV-2 infection and vaccination on inflammatory arthritis: a cohort study

Objectives. To investigate the effects of SARS-CoV-2 infection, as well as short- (within 48 hours) and long-term (within 30 days) adverse events (AEs) of SARS-CoV-2 vaccines, including arthritis flares in a large cohort of patients with inflammatory arthritis (IA). Methods. A retrospective cohort study comprising 362 patients: 94 (26%) rheumatoid arthritis, 158 (43.6%) psoriatic arthritis and 110 (30.4%) ankylosing spondylitis; and 165 healthy controls (HC) to ascertain the prevalence and severity of SARS-CoV-2 infection in patients with IA, the rate of AEs associated with SARS-CoV-2 vaccines and disease flares within a month of the vaccination. All patients provided informed consent and data about SARS-CoV-2 infection and/or vaccination status. Results. One-hundred-seventeen (32.3%) patients and 39 (23.6%) HC were affected by SARS-CoV-2 infection. Forty (34.2%) patients experienced an IA flare within one month of infection, of whom 3 (7.5%) needed to switch therapy. The prevalence of SARS-CoV-2 infection, disease severity, and hospitalization rate were not significantly different. At least one shot of SARS-CoV-2 vaccine was administered in 331 (91.4%) patients and 147 (89.1%) HC. Within 48 hours, 102 (30.8%) patients developed vaccine-related AEs; 52 (15.7%) patients with >1 vaccine dose experienced an IA flare-up, of whom 12 (23.1%) needed to switch therapy. Conclusions. A significantly higher rate of IA flare was observed among patients who contracted SARS-CoV-2 infection vs. those without infection. Patients with IA experienced flares after SARS-CoV-2 vaccination, though it was not statistically significant.Objectives. To investigate the effects of SARS-CoV-2 infection, as well as short- (within 48 hours) and long-term (within 30 days) adverse events (AEs) of SARS-CoV-2 vaccines, including arthritis flares in a large cohort of patients with inflammatory arthritis (IA). Methods. A retrospective cohort study comprising 362 patients: 94 (26%) rheumatoid arthritis, 158 (43.6%) psoriatic arthritis and 110 (30.4%) ankylosing spondylitis; and 165 healthy controls (HC) to ascertain the prevalence and severity of SARS-CoV-2 infection in patients with IA, the rate of AEs associated with SARS-CoV-2 vaccines and disease flares within a month of the vaccination. All patients provided informed consent and data about SARS-CoV-2 infection and/or vaccination status. Results. One-hundred-seventeen (32.3%) patients and 39 (23.6%) HC were affected by SARS-CoV-2 infection. Forty (34.2%) patients experienced an IA flare within one month of infection, of whom 3 (7.5%) needed to switch therapy. The prevalence of SARS-CoV-2 infection, disease severity, and hospitalization rate were not significantly different. At least one shot of SARS-CoV-2 vaccine was administered in 331 (91.4%) patients and 147 (89.1%) HC. Within 48 hours, 102 (30.8%) patients developed vaccine-related AEs; 52 (15.7%) patients with >1 vaccine dose experienced an IA flare-up, of whom 12 (23.1%) needed to switch therapy. Conclusions. A significantly higher rate of IA flare was observed among patients who contracted SARS-CoV-2 infection vs. those without infection. Patients with IA experienced flares after SARS-CoV-2 vaccination, though it was not statistically significant

Cardiovascular Risk Stratification in Diabetic Retinopathy via Atherosclerotic Pathway in COVID-19/non-COVID-19 Frameworks using Artificial Intelligence Paradigm: A Narrative Review

Diabetes is one of the main causes of the rising cases of blindness in adults. This microvascular complication of diabetes is termed diabetic retinopathy (DR) and is associated with an expanding risk of cardiovascular events in diabetes patients. DR, in its various forms, is seen to be a powerful indicator of atherosclerosis. Further, the macrovascular complication of diabetes leads to coronary artery disease (CAD). Thus, the timely identification of cardiovascular disease (CVD) complications in DR patients is of utmost importance. Since CAD risk assessment is expensive for lowincome countries, it is important to look for surrogate biomarkers for risk stratification of CVD in DR patients. Due to the common genetic makeup between the coronary and carotid arteries, lowcost, high-resolution imaging such as carotid B-mode ultrasound (US) can be used for arterial tissue characterization and risk stratification in DR patients. The advent of artificial intelligence (AI) techniques has facilitated the handling of large cohorts in a big data framework to identify atherosclerotic plaque features in arterial ultrasound. This enables timely CVD risk assessment and risk stratification of patients with DR. Thus, this review focuses on understanding the pathophysiology of DR, retinal and CAD imaging, the role of surrogate markers for CVD, and finally, the CVD risk stratification of DR patients. The review shows a step-by-step cyclic activity of how diabetes and atherosclerotic disease cause DR, leading to the worsening of CVD. We propose a solution to how AI can help in the identification of CVD risk. Lastly, we analyze the role of DR/CVD in the COVID-19 framework

eHealth in Chronic Diseases

This book provides a review of the management of chronic diseases (evaluation and treatment) through eHealth. Studies that examine how eHealth can help to prevent, evaluate, or treat chronic diseases and their outcomes are included

Defining and refining nurse-led care for people with early rheumatoid arthritis

Nurse-led care in rheumatoid arthritis (RA) has been shown to be effective. However, the role of the nurse in early RA is not well-defined, and it is not known how well care needs are met in early RA nurse-led care. This PhD research aims to provide new knowledge in understanding nurse-led care in early RA and to propose a model of early RA care.Three studies were conducted using a sequential exploratory mixed method approach: a systematic review of qualitative studies, an interview study with rheumatology nurse specialists, and a cross-sectional survey with patients in early RA. Evidence from the three studies was compared with EULAR recommendations for the role of the nurse, EULAR recommendations for management of early RA, and with an earlier model of rheumatology nursing care.The systematic review found that patients valued nurse-led care. It was characterised by professionalism, person-centeredness, and a capacity to address holistic care needs. However, only few studies specifically included the perspective of patients with early RA. The interview study with rheumatology nurse specialists found that nurse-led care in early RA is a specialist service that is delivered with compassion and addresses complex and holistic care needs using person-centred approaches. Innovation and service improvement are part of the role. The study provided a provisional model of nurse-led care in early RA. In the patient survey, questionnaire items representing the provisional model of care were assessed as highly important. Analysis of participant comments generated themes of patient needs such as being listened to, involved, and informed.The synthesis of evidence generated a novel model of nurse-led care in early RA with the potential to meet patients’ complex and holistic care needs. The research contributes to knowledge about rheumatology nursing and can inform practice, training, and further research