A 32-year-old woman suffering from systemic lupus erythematosus presented with a 6-week history of progressive dyspnoea and pleuritic chest pain. Examination was normal apart from reduced air entry at the lung bases.Arterial blood gases showed hypoxaemia and chest X-ray revealed raised hemidiaphragms without any pleural effusions. Lung function showed a restrictive pathology while high-resolution chest CT and CT pulmonary angiogram were negative. Echocardiography showed normal ventricular diameters and no pericardial effusion. Reduced lung volumes and a positive fluoroscopic sniff test lead to a diagnosis of shrinking lung syndrome. Symptoms improved following treatment with glucocorticoids and non-invasive ventilation, but there was no change in lung function.A year later, our patient presented again with worsening dyspnoea. This time echocardiography revealed severe mitral stenosis with pulmonary hypertension. Mitral valve replacement was performed and dyspnoea resolved. Histology showed Libman-Sachs endocarditis.

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Funding Acknowledgements Type of funding sources: None. Introduction The global COVID19 pandemic has led to significant morbidity and mortality to millions of cardiac patients across the globe. Inferior clinical standards, modified clinical pathways and limited hospital resources has unfortunately translated to significant premature cardiac deaths. Cardiac rehabilitation has also been hit significantly. Study Objectives The aim of this study was to assess the impact of cardiac rehabilitation during COVID-19, comparing the referral, adherence and outcomes with patients admitted a year previously. Methodology Patients were divided in two groups. Group 1 were those admitted between March-August 2019 (Pre-COVID). Group 2 included those admitted between March-August 2020 (during COVID). Program completion was defined as adherence to ≥6 sessions (Group 1) or ≥ 4 sessions (Group 2). Data was collected from electronic case summaries and cardiac rehabilitation unit medical records. Data was tabulated in SPSS v23. Categorical variables were presented as percentages. Statistical analysis was computed with SPSS v23. A p value of <0.05 was deemed statistically significant. Results 710 patients were admitted with a cardiac diagnosis (Group 1 n=360, Group 2 n=350), mean age 66.71 ± 13.21 years, dominant male population (n=548, 77.2%). Both groups had comparable proportions of smoking, hypertension, diabetes and hyperlipidaemia. The referral rate to cardiac rehabilitation was rather poor in both groups, though better in Group 1 (Group 1 38.3% vs 26.6%, p=0.001), partly because of temporary discontinuation of the rehabilitation program at the start of the pandemic. The completion rate was also unfortunately quite low. It was better in Group 2, possibly because of the shorter program duration (Group 1 23.5% vs Group 2 38.7%, p=0.018). The 1 year readmission rate was significantly higher in Group 1 (22.8% vs 15.1%, p=0.022)), possibly because patients were more open to seek medical advice before the pandemic. The 30 day death rate was comparable in both groups (5.0% vs 5.7%, p=0.672). The 1 year mortality was also comparable (Group 1 12.5% vs Group 2 10.6%, p=0.481) Cardiac rehabilitation did not impact the 1 year readmission rate, 30 day and 1 year mortality. Conclusion The 30 day and 1 year mortality in patients admitted during the first 6 months of the pandemic was comparable to the same timeframe the year before. The 1 year readmission rate was higher in patients admitted before COVID, possibly explained by patients being more inclined to seek medical advice. Referral to cardiac rehabilitation was generally low. Adherence to the program did not impact readmission and mortality.

BackgroundFibromyalgia (FM) is a chronic non inflammatory condition characterized by pain and fatigue as well as physical and psychological symptoms. Management can be particularly challenging and a combination of pharmacological and non pharmacological treatments are recommended.ObjectivesThe aim was to study the level of anxiety and depression in fibromyalgia patients and whether these were associated with symptom severity, functional status, social or demographic factors.MethodsA cross sectional survey of 155 consecutive patients attending the nurse-led fibromyalgia clinic was carried out. Patients were diagnosed using the 2010 ACR diagnostic criteria. Demographic data, Widespread Pain Index (WPI), Symptom Severity Score (SSS), VAS pain and VAS fatigue were recorded. Patients filled in the self-administered questionnaires including the Revised fibromyalgia impact questionnaire (FIQR), Hospital Anxiety and Depression Scale (HADS). Patients were classified as suffering from high anxiety or depression if HADS was ≥11, moderate if 8–10 and low ≤7 for each scale respectively.Cross tabs and chi squared were used to study associations between anxiety and depression and social and demographic factors. Logistic regression analysis was performed to identify whether WPI, SSS, FIQR, VAS pain and VAS fatigue were predictors of severe anxiety and depression.ResultsOne hundred fifty five patients (92% female) participated in the survey. The average age was 50.3 years (SD 11.5) and mean duration of symptoms 13.4 years (SD 11.3). The mean HADS-A (anxiety) was 11.8 (SD 4.13), HADS-D (depression) 9.1 (SD 3.8) and FIQR 60.3 (SD 17.6).High levels of depression were reported by 31.5%, moderate 32.1% and low 30.3%. High levels of anxiety were reported by 60%, moderate 21.2% and low 13.3%. Both high levels of anxiety and depression were found in 25.2% of patients.SSS was the single best predictor for anxiety (p=0.001) while disease duration (p=0.01), SSS (p=0.02) and FIQR (0.04) predicted depression. VAS pain and VAS fatigue were not good predictors of severe anxiety and depression. When patients with high levels of anxiety and depression were compared with those with moderate and lower levels no association was found with age or social factors including occupation, marital status, level of education and family support.ConclusionsBoth severe anxiety and depression were highly prevalent in our FM cohort, particularly anxiety. All FM patients need to be screened for anxiety and depression particularly those with high SSS and FIQR scores and longer disease duration.A psychiatrist and psychotherapist with a special interest in FM are essential members of the multidisciplinary team to ensure that anxiety and depression are addressed early prior to starting further interventions for FM.References Jensen KB, Fransson P, Marcus HM, Williams SCR, Choy E, Mainguy Y, Gracely R, Ingvar M, Kosek E (2010) anxiety and depression in fibromyalgia are related to poor perception of health but not to pain sensitivity or cerebral processing of pain. Arthr...

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