Sickness absence has been identified as needing to be addressed through multilevel interventions, but knowledge regarding optimal design and implementation of such interventions is scarce. The aim of this study was to evaluate the implementation and effects of a large-scale multilevel intervention in the public sector in Sweden.The overall effect of the intervention was assessed using mixed-effect models. Sickness absence data  for 90 intervention groups and 378 reference groups was retrieved from administrative personnel systems from the two participating regional councils. The implementation processes were evaluated using qualitative content analysis of qualitative interviews conducted at two timepoints.The results show that the vast majority of implemented measures were on an individual level and the integration of the intervention differed between the two regions. The reception and perception of the intervention activities seem to have been influenced by the implementation process, and how well the interventions were communicated and integrated, both regarding the integration of the different interventions and their integration into the discrete context and existing routines. No short-term overall effects on sickness absence were found.The results point to the many challenges in implementing complex interventions, especially where organizational measures are involved—including adequate participation by, and communication between, the involved actors, as well as sufficient resources. The results indicate potential learning effects regarding the awareness of organizational factors in sick leave, after implementing and integrating multilevel strategies. Sickness absence, especially in the public sector, is a major challenge for employers, both in Sweden and in other countries. Even though the relationship between specific working conditions and ill health has been studied for various diagnoses, there is still limited knowledge about how to improve these adverse working conditions and thus decrease the sickness absence among employees , an umbrella organization for Swedish regions, initiated a project to develop a risk group-oriented approach for decreasing sickness absence among public health care and service employees. The project began with screening in five regions and eight municipalities with the aim to identify needs and specific groups at risk for long-term sickness absence (> 60 days). On an individual level, risk groups identified in this process were employees with repeated short-term sickness absence (≤ 14 days), and employees returning to work after longer sickness absences. On a workplace level, the screening identified workplaces with a high level of short-term sickness absence, and workplaces with high or increasing sickness absence, as being at risk.Based on these screenings, a multilevel intervention approach was developed by SALAR and a consulting company, targeting the employee, group/workplace, and management level. The implemented measures within this intervention were designed by local rehabilitation coordinators (RCs) and intervention leaders (see below) in cooperation with the participating individuals and workplaces to ensure a good fit between the interventional measures and the local context , and health care providers. The first part of the intervention then focused on providing support to employees at risk for sickness absence, employees who were currently part-time absent, and employees recently returning to work from a longer sickness absence (> 15 days). The method used primarily consisted of motivational support for the employee, coordinating the sickness absence and RTW process, and reporting of work environment issues at the workplace level if considered relevant. The RCs had a background in HR or health care and all RCs received 2 days of training.The second part of the intervention was targeted towards the workplace and included an initial screening to identify workplaces with high or increasing rates of sickness absence. The workplaces were contacted by an intervention leader to initiate a dialogue and to map risk factors, to develop specific measures to be carried out and followed up. The interventions were led by one person in each region who received a 2-day training.The third part of the intervention consisted of a series of workshops aiming to improve cooperation between health care organizations and managers in health care. The purpose was to increase an exchange of knowledge and experiences and develop new ideas and solutions based on problems identified by the participants. The third part of the intervention included six meetings with participation from employers, health care, the Social Insurance Agency, occupational health care, and union representatives. A process leader in each region was responsible for the series regionally.The intervention was piloted in two regions in the south and north of Sweden (hereafter named Regions 1 and 2) in 2018 and 2019. In Region 1, about half of the healthcare workers in the intervention groups worked within the primary care, 25% within the dental healthcare and the remaining 25% within hospital care. In Region 2, about 75% worked within hospital care and about 25% within the primary care. The pilot implementation was evaluated both by the consulting company which participated in developing the interventions, and by the team of researchers who have authored this article.The study applied a mixed-methods approach to capture the effects and processes of the interventions. The effects were measured based on statistics from administrative personnel systems, and the processes were evaluated using qualitative interviews at two timepoints.The process evaluation was conducted using qualitative interviews at two timepoints. The first wave of interviews was carried out at the beginning of the interventions autumn 2018), and the second was conducted 1 year later. Participants included managers and staff engaged in the implementation of the interventions. The first wave included 20 interviews , while the second wave included 14 interviews , i.e., a total of 34 interviews . The second wave of interviews was a follow-up on the first wave and included questions about the extent to which interventions were used as well as their perceived usefulness; and whether they had led to any changes in practices related to sickness absence and work environment management.Interviews were carried out face to face, audio-recorded, and transcribed verbatim. Qualitative content analyses , monthly data from the two regions’ administrative personnel systems were obtained for each intervention group and for the remaining workplaces at the respective departments . In Region 1, data was obtained for the period January 2015 to August 2019 and sickness absence was expressed as the number of absence days per employee on a workplace level . In Region 2, data obtained covered the period January 2012 to March 2019. Sickness absence was calculated as the percentage absence on a workplace level based on the number of hours of absence due to sickness, divided by the total number of hours the group was expected to work each month . The sickness absence was stratified by short-term (1–14 days) and long-term sickness absence (> 60 days). The intervention was planned to start in September and October 2018 for Region 1 and Region 2, respectively.In total, 503 workplaces  from ten departments  were originally included in the study (151 workplaces from six departments in Region 1 and 352 workplaces from four departments in Region 2). In total, 125 of these workplaces received the intervention, while the remaining 378 workplaces served as reference groups. However, eight intervention groups underwent organizational changes right before or immediately after the intervention start and could not be included in the effect evaluation. In addition, 27 intervention groups with very few employees (fewer than ten employees) were also excluded from the evaluation, resulting in 90 intervention groups remaining in the effect evaluation. Descriptive information on these groups and the intervention they received is presented in Table The measures of sickness absence , and long-term (> 60 days) sickness absence) were tested for normality using the Shapiro–Wilks test and visual inspection of the generated histograms. The normality assumption was deemed to be plausible. In the subsequent analyses, parametric methods were used on untransformed data. The intervention effect was evaluated separately for the two regions due to differences in calculating sickness absence , using a mixed-effect model , with workplace, department, and time (nested within workplaces and departments) as random effects  acted as advisors in the process but were not involved in either developing or implementing the interventions. None of the authors have any conflicts of interest, and none of the involved organizations has had any influence over the design, analysis, or conclusion of the study.Participants in the interview study were invited via email. Participants were given information about the purpose of the study and were assured that participation was voluntary and that they could withdraw their participation at any time. Register data was collected from the regions by the consulting company; personal data, such as names and social security numbers, were replaced with a unique identification number before being distributed to the authors of the present study, to ensure the anonymity of the employees of the participating workplaces.The project was reviewed and approved by the Regional Ethics Review Boards in Gothenburg  and Linköping .In total, 52 employees received support from RCs in Region 1, and 37 employees in Region 2. Of those who were offered support, 74% accepted it. The most common diagnostic groups were musculoskeletal and mental disorders. The majority of those who received support had had several prior short-term sickness absence spells but were not commonly absent at the time of the intervention. Workplace support was carried out at four workplaces in Region 1 and at five workplaces in Region 2, reaching 255 and 264 employees, respectively. Six workshops were carried out in each region.The results from the process evaluation are reported following Nielsen & Randall’s model  of the study is described in the Introduction. The discrete context in which the implementation was planned to take place consists of the workplaces and their existing practices regarding how they manage the work environment. Both regions described their work on managing the work environment as being based on a yearly routine, including safety rounds, regular workplace meetings, and yearly manager–employee conversations. Some managers highlighted the continuous character of this work, which occurred daily through dialogue with employees, and emphasized that they, as managers, ought to be available for their employees and act on everyday obstacles.At the time of reporting (and of the interviews), the guidelines for how to manage sickness absence were similar in the two regions, where sickness absence was reported to first-line managers or the managerial administrative support. The guidelines also stated that managers were to contact employees on sickness absence within 3 days. Employees with repeated short-term sickness absence (more than three occasions in 6 months) were invited to a meeting with their first-line manager. The guidelines further contain policies for prevention, rehabilitation, and RTW; some managers mentioned these policies, while others did not. Managers could also use HR departments and external occupational health services to support them in working with these processes. As for work adaptations, a common statement from managers was that these were difficult to arrange due to “slim” organizations, especially regarding changing and adapting work tasks. Usually, only temporary adaptations, mostly in the form of reduced work hours, were possible. Hence, regular practice in relation to sickness absence was an individual-oriented process with limited leeway to adjust the work context. The role of RCs, as detailed in the description of the intervention, includes the possibility of raising workplace issues when they were identified, which increases the possibility of identifying organizational risk factors. However, it is not certain that identified measures are acted upon, since this may be influenced by the context, including the capacity and resources of the organization.The context can both facilitate and hinder implementation of interventions. The existing routines can be considered a facilitating aspect, since they provide a structure within which interventions can be introduced to supplement current measures. They could, however, also be hindering if such structures are incompatible with the interventions, e.g., if responsibilities outlined in the interventions do not correspond to the responsibilities in the organization. One example concerns how RCs were meant to interact with managers and what mandate RCs should have, since the RC role was not included in the ordinary structures of the organization. Another contextual issue was problems with recruiting people with relevant competencies to work as RCs; more generally, logistic problems as well as lack of time and resources when introducing new routines were considered hindering factors for implementing the interventions.initiation of the interventions, the activities, and the implementation strategy.The intervention part of Nielsen and Randall’s model . As for activities, since the project was mainly top-down initiated, several representatives from both regions reported problems in anchoring the project in their organizations, with uncertainties both regarding its purpose and the various roles in it. These uncertainties were also experienced by the managers responsible for carrying out the interventions, which prevented them from communicating the interventions to the employees in an adequate way. Consequently, some employees expressed resistance towards participating, including receiving support from the RCs. Region 1 had a large turnover among managers, which further complicated communication. Both regions largely followed the handbook without significant adaptations to the local context. Among the adaptations made, Region 1 customized communication with the RCs based on managers’ wishes. In Region 2, some adaptations were made to the second part of the intervention , where the handbook suggested that one group should perform the work environment screening, and another group should lead the actual work with implementing changes; in Region 2, it was decided that both the screening and the changes were to be carried out by the same group.The project was In Region 1, the RCs and the workplace support were separately organized, and therefore, these parties did not interact. In Region 2, there was a collaboration between the RCs and the local workplace support. As RCs generally worked faster with implementation, RCs entered the workplace first, after which local workplace support was added. There were also differences in the two regions regarding the required competencies of RCs, where Region 2 chose people with an HR background, while Region 1 employed health care professionals. In Region 2, RCs and occupational health care staff experienced some problems in finding employees who wanted to participate in the intervention, and the RCs felt insecure in their role. Recruitment was identified as an important issue and something that should have been given more attention before implementation began.implementation of the first part of the intervention (RCs) was based on different perspectives on the purpose of the RC role and whom the RCs were serving. This intervention was seen as a support primarily for individuals on sickness absence, and secondarily for managers. The task of the RCs was seen as identifying people who are at risk for sickness absence and initiating early interventions, shortening existing sickness absence spells, and helping employees in the RTW process. However, representatives from both regions were slightly unclear about the role, especially regarding the RC’s responsibilities. The selection of individuals to be offered the intervention was made in dialogue with the manager based on sickness absence statistics and the manager’s knowledge of the employees. After initiating contact, the RC carried out an exploratory conversation and formed an individual plan with the employee. In cases where the employee was considered to have the situation under control, no specific measures were taken.The The handbook was generally followed although the templates for conversations were perceived to be cumbersome. The RCs instead chose to develop their own conversations and plans, based on the handbook, which can be considered a local adaptation of the intervention. The types of activities carried out included supportive conversations, help in navigating through measures from the health care or occupational health care systems, contacts with the Social Insurance Agency, and work adjustments.Overall, the RCs were well received by most managers and employees in both regions. Managers perceived them as helping with the workload and considered it positive that employees could feel seen and listened to. They believed that employees appreciate the contact, especially having an outside professional who may be easier to talk to than their managers. Some managers, however, thought the contact with and feedback from RCs was poor. In Region 1, some discontent was expressed that was generally not reported in Region 2, including managers feeling that their responsibilities had been taken away and they were, therefore, becoming more distanced from their employees. Some managers also did not think that they received sufficient feedback from the RCs due to confidentiality. The first of these points (responsibility) is an example of a situation where existing routines (context) can hinder implementation. The second point  was handled differently in the regions, where Region 2 was very clear that the RCs were representing the employer. This could also explain why fewer employees in this region agreed to participate in the intervention. Managers in both regions reported that some employees felt they were “being questioned” when contacted by the RC, especially those with short-term sickness absence.In both regions, the RCs had to spend much time explaining the intervention to both managers and employees, since it was not perceived as clear. This could partly explain the skepticism several employees expressed towards the intervention, some even declining it, especially in Region 2. The managers expressed that while the support from the RCs was appreciated by employees, the intervention did not seem to lead to any changes in the workplace. Several managers did, however, think that it could have a long-term effect on sickness absence.implementation of the second part of the intervention  differed between the two regions: it seems to have been well integrated in Region 2, and largely ignored in Region 1. In Region 1, the position of intervention leader was vacant for a long time, and the intervention was consequently not widely used. Some workplaces started work environment screenings and also suggested some measures, but few of them were conducted. From the interviews, we can conclude that those who carried out measures resisted attributing the work done to the intervention, because they did not receive any special support for this work.The In Region 2, the first intervention leader quit, and a new person was recruited at the end of 2018. This person had a background as an occupational health nurse and as an RC in primary health care, which was described as a strength. Consequently, the work was perceived to be more effective and to progress. At this point, several changes were introduced regarding the work procedures, where the intervention leader carried out the initial work environment screenings on her own, and thereafter added the necessary competencies from occupational health care. Workplaces that received this support described having received help with structuring their work and prioritizing what to focus on. This support was also oriented towards how to continue after the intervention ended. Overall, those involved considered the intervention as very positive.Some of the measures taken in Region 2 were to revise routines and structures in work environment management, and develop these together with occupational health care. Measures also included risk assessments, workflow revisions, specific measures targeting certain professions, medical controls, ergonomic surveys, and schedule changes. Training focusing on psychosocial health, and on discrimination, threats, and violence in the workplace also took place. Hence, the measures varied quite significantly depending on the identified needs in the specific workplace. Finding the root cause of problems was described as the crucial aspect of the intervention and it was vital to have consensus on both problems and measures to address them. The representatives described changes in the work environment management in the workplaces and reported that awareness of the issues had increased. In Region 2, the implementation strategy worked well, with adequate participation from employees and managers. Moreover, communication about measures, and their implementation, seems to have been well adapted to local conditions.implementation of the third part of the intervention (workshops) was affected by the fairly vague purpose of the intervention. This intervention served as an arena for discussion, but the outcomes were highly dependent on whether the participants used it and also on organizational prerequisites for moving from discussion to concrete action.The In Region 1, the experiences of the workshops were mixed. Workshops were considered as a meeting place for the central actors in rehabilitation processes and as creating extended networks. However, criticism was raised about the limited time available for the intervention so that discussions remained superficial and, hence, did not lead to any concrete measures. In Region 2, participants in the workshop series were relatively positive and described the contents of the workshops as concrete and the workshops as useful for identifying areas that needed improvement. The workshops resulted in guidelines for creating health-promoting workplaces, and working with sickness absence and rehabilitation processes. The participants described the workshops as an important piece of the larger project whose interventions all interact.integration of the interventions, Region 1 treated the RCs and the local workplace support (to the extent that this was carried out) as parallel interventions and there was no collaboration between them. The RCs in the region described that they identified problems in the workplaces, but that they did not have anyone to report to. Such issues were raised on several occasions to the management, but nothing changed. Representatives also raised the lack of integration between the different interventions as a problem.As for the In Region 2, the interventions seem to have worked in concert, as the implementation strategy focused on integration. The quicker intervention  entered the workplaces first, followed by the slower local workplace support intervention (the second part of the intervention). The RCs had dialogue with the local workplace support, reporting what they had learned. They participated in meetings to add their perspectives, which added information that could be used in work environment management. Representatives from Region 2 perceived the integration of the interventions as successful as it made it possible to work on individual and organizational levels simultaneously. The workshop series was considered an arena for integrating the different parts. The representatives in Region 2 also described a well-integrated team working closely together, which led to a constant flow of information and work procedures. Occupational health care was also involved to a large extent.“Mental models” refer to how people think about certain phenomena, where interventions that can be proven to have an effect on such models can be said to have a learning component. In Region 1, no specific changes in awareness of the different issues influencing sickness absence were reported. This is possibly related to the lack of focus on workplace aspects, as this region primarily implemented the first part of the intervention (RCs) which focused on individual support. The integration between individual support and the more organizationally focused interventions was poor, which reasonably limits the impact on organizational learning, and on recognizing non-individual causes for sickness absence.In Region 2, the representatives reported that working with the interventions led to increased awareness about work environment issues, both among employees and among managers, indicating a change in mental models. They also reported having seen concrete changes in the workplaces regarding work environment management and increased focus on such issues, which also indicates how these mental models increased the readiness for change, as the management and employees had already started translating their new awareness into action. Furthermore, Region 2 chose to continue using the interventions, albeit with slight modification, after the end of the project, which is an indication of changed mental models, where the staff could see the value of continuing with changing the workplace.Hence, the effect on mental models seems to have been influenced by how well the interventions were communicated and integrated, regarding both the integration of the different interventions and how well they were integrated into the discrete context and existing routines.The distribution of individual workplace average levels of sickness absence, pre- and post-intervention, among intervention groups participating in the first two interventions and reference groups is presented in Fig. n = 52) participating in the first and/or second intervention  had somewhat higher total and short-term sickness absence compared to the reference groups (n = 99)  0.21–1.4, p = 0.007, and β = 0.20, 95% CI 0.13–0.27, p < 0.001, respectively), but no difference was seen between the intervention groups and reference groups in Region 2  , or long-term (> 60 days) sickness absence could be seen for the intervention groups participating in the first and/or second intervention in Region 1 or 2 Table .Furthermore, stratifying the results for intervention groups receiving only individual rehabilitation coordination and for workplaces receiving individual rehabilitation coordination in combination with organizational workplace measures did not change the overall result.This study illustrates the complexities of conducting preventive interventions which focus on multiple levels, in this case the individual and organizational levels. It also illustrates how differently the same intervention can be implemented in different contexts, and how this relates to interactions and communications between the various actors involved.The interventions were developed through an interactive process between a national organization, consultants, and representatives from different regions, but the design and preparation did not involve the employees who would implement them and be most affected by them; likewise, unions’ involvement was limited to the workshop series. When implementation commenced, consequently, the interventions were considered top-down initiatives. The implementation included participants from the different workplaces to varying degrees, where such involvement facilitated a more purposeful adaptation to fit the local context. Insufficient stakeholder involvement and contextual restraints, such as production pressures, has been identified in the literature as potentially hampering interventions (Cole et al. In Region 1, the implementation primarily focused on the individually oriented RC part of the intervention, while Region 2 to a larger extent adapted and integrated the multilevel approach of the three parts of the intervention, and, therefore, also included the workplace level. This latter approach seems to have had a stronger impact on the mental models of people involved and resulted in a more developed perspective on the types of factors that can influence sickness absence, including work environment issues. A key for this development was the integration of the individual and the organizational interventions. Only implementing individual support, as in Region 1, does not seem to have effected changes in routines or work environment management, while combining such support with a workplace component facilitated a broader approach towards working with prevention, which has also been reported by others Hasson . The RCsThe qualitative results from Region 2 indicate that the intervention may have been the start of a development process in the workplaces, where sickness absence was treated as both an individual and an organizational issue, and as an issue that calls for measures on both these levels. The results are interesting, because they illustrate how a multilevel intervention, implemented through participative methods, is more likely to be integrated in the daily operations; this is an example of an adaptive and developmental learning process Ellström . TherefoThe effect evaluation did not show any significant effects on sickness absence for either of the regions. Varying results for organizational-level workplace interventions have also been reported by others (Gray et al. Other possible reasons for the relative lack of an intervention effect could be due to the use of sickness absence as the single effect measure. Other outcome measures, such as employee turnover or different work environment measures, may be more appropriate for capturing intervention effects compared to measuring sick leave only. In addition, the somewhat limited follow-up time in this study should be noted: the interventions began in 2018, and follow-up ended in August 2019 for Region 1 and in March 2019 for Region 2. This may potentially have affected the possibility to evaluate the total effect of the intervention as it is reasonable to assume that especially organizational effects take longer to develop.This study was based on a mixed-methods approach, where we combined a register study with document studies and with interviews conducted at two timepoints. This approach makes it possible to study both effects and processes, which can be considered a strength. For the quantitative material, the short follow-up time for measuring intervention effects is a weakness as the outcomes can be expected to develop over a longer period than that covered by the available data. In Region 1, the trend for an overall decrease in total and long-term sickness absence for all workplaces could, to some extend been explained by regression to the mean in both the intervention and reference group. In addition, the effect evaluation was limited to evaluating effects on sickness absence on an organizational level in accordance with multilevel strategy. Hence, positive effects may still have been achieved for individual employees receiving the RCs’ support.For the qualitative material, we chose to compare results from the two regions rather than on a workplace level, since the interventions were planned and implemented on the regional level. While variation can be expected also between workplaces, this was not our unit of analysis. Interventions focusing on identifying risk groups may have a potential stigmatizing effect by singling out people with health problems, which the fact that some workers refused the intervention could indicate. It is possible that including data from those who refused the intervention could have added important insights, although this was not possible in the current study.The interventions evaluated in this study was initiated and performed by a third party in a collaboration with the workplaces, and the research group had no part in carrying out the intervention nor deciding on which data variables that were available for analysis. Several aspects regarding contextual information related to work conditions and more in-depth information about the individuals receiving the intervention was not available for the research group. Thus, research questions related to how different contextual and individual factors plausibly could affect sick leave could not be answered in this study.Combining and integrating preventive strategies on an individual and an organizational level can result in stronger awareness of the multifaceted causes of sickness absence and contribute to organizational development and learning, which may lead to long-term changes in workplaces’ approaches to workplace sickness prevention. Although we did not see any short-term effects on sickness absence in this study, the results related to learning within the organizations regarding the awareness of integrating interventions are promising. The results also point to the many challenges in implementing complex interventions, especially where organizational measures are involved—including adequate participation by, and communication between, the involved actors, as well as sufficient resources.


The objective of the study is to present a case of hemodialysis in which the covered stent that had migrated into the right ventricle was retrieved by exploratory thoracotomy, and to review the literature on the diagnosis and treatment of stent migration in thoracic central vein obstruction (TCVO) procedures for hemodialysis patients.A systematic search of the PubMed database was performed to identify clinical presentations, imaging strategies, stent types, and treatment modalities for stent migration in hemodialysis patients.A total of 14 case reports on stent migration in TCVO procedures for hemodialysis patients were included and analyzed. Ten cases included migration to the cardiac chambers and the remainder migration to the pulmonary artery. The common symptoms of stent migration in TCVO procedures are reported to be chest pain and dyspnea, while three of the cases studied involved no symptoms. Echocardiography, chest X-ray, and computed tomography are the commonly used methods for the diagnosis of stent migration and identification of the precise positioning of the stent. Stent migration to the right subclavian or innominate veins was the most prevalent case (seven cases). All were bare stents. Seven cases involved retrieval by interventional surgery, while four cases involved retrieval by open heart surgery. However, there were three cases in which the “wait-and-see” approach was adopted since the patients were asymptomatic.Stent migration in TCVO procedures is a rare but extremely serious complication. The causes are not fully understood. The current treatment strategies include interventional surgery, open heart surgery, and the “wait-and-see” approach. Thoracic central vein obstruction (TCVO) is a common complication that occurs with prolongation of the survival time of hemodialysis patients, and it seriously affects the function of vascular access or the quality of hemodialysis –3. PercuStent migration is a rare complication, with the incidence reported to be as low as 2%−3% –10. HoweA 65-year-old male had been undergoing hemodialysis with an arteriovenous fistula placed on his right wrist for 11 years. He was transferred to our hospital with a main complaint of swelling of the right hand, and he had experienced high venous pressure with no clear cause around 4 months earlier. The patient had a history of right internal jugular vein catheterization. The digital subtraction angiography (DSA) examination revealed stenosis at the confluence of the right subclavian vein and the innominate vein . A 13.5 On physical examination, the heart rate recorded was 115 times/min, respiratory rate was 26 times/min, and blood pressure was 81/55 mmHg. Cyanosis of the lip and low heart sounds were detected. Following an echocardiography examination, pericardial effusion and a stent in the right atrium and ventricle were identified . It was Pericardiocentesis was then immediately conducted under the guidance of ultrasound, with 270 ml of pericardial effusion extracted, and the patient's symptoms were relieved. The thoracotomy and transesophageal echocardiography procedures indicated that the stent had migrated to the right ventricle  with itsA PubMed search of literature published from 1975 to February 2022 was conducted along with a bibliographic search of published articles to identify clearly documented cases of stent migration in TCVO procedures for hemodialysis patients. All available data were reviewed including in terms of clinical presentation, imaging strategy, stenttype, and treatment.A total of 14 case reports on stent migration in TCVO procedures for hemodialysis patients were included and analyzed. Ten of the cases –21 involIn terms of imaging strategies, echocardiogram, chest X-ray, and computed tomography examinations were the commonly used methods for the diagnosis of stent migration and identification of the precise positioning of the stent. There were seven cases of stent migrating to the right subclavian or innominate veins, four cases of migration to the superior vena cava (SCV), and three cases of migration to the left innominate vein. All were bare stents, and no covered stent migration was reported.In terms of treatment strategy, seven cases involved retrieval by interventional surgery with the help of a snare, and the stent ultimately had to be surgically retrieved from the groin by opening the femoral vein or expanding the stent with the help of a balloon to immobilize it in the wall of the femoral vein. Four cases involved retrieval by open heart surgery, including two cases in which retrieval by interventional surgery had failed , 18. HowNowadays, the use of stent placement to enhance the patency rate of vascular access in hemodialysis patients has been increasing, especially in terms of TCVO . As suchTo the best of our knowledge, this is the first study to review the literature related to stent migration in TCVO procedures for hemodialysis patients. Only one previous study involved a review of 29 case reports and two short case series of venous stent migration; it detailed 54 events of venous stent migration . Here, tHemodialysis patients have certain particularities in terms of different hemodynamics for the establishment of vascular access. In addition, previous researchers have not discussed the advantages and disadvantages of various treatments in-depth or have subsequently provided recommendations.Stent migration can be caused by multiple factors including positional distinctiveness of the venous stent, hemodynamics, properties of the stent, and improper selection of stent . In addiFirst, most of the stents in the reported cases were located in the right subclavian vein or the right innominate vein , 22–24. Second, it can be difficult to select the correctly sized stent, since the expansion of the vein occurs far more easily than that of the artery. This is particularly true in the case of hemodialysis patients, with the central vein more likely to expand and distort in the process of arterialization of the central vein due to the vascular access, while its shape is subjected to respiratory motion and external compression from surrounding structures since this vein is more pliable . This phThird, the length of the stent should cover the lesion with at least 10 mm free at both the proximal and the distal directions to the lesion, with 60% of the stent ideally located at the distal end of the lesion and 40% at the proximal end to avoid the migration of the stent toward the latter end due to extrusion , 32. HowThe treatment strategies for the stent migration in TCVO procedures include retrieval by interventional surgery, surgical removal, and “leave it alone” and “wait-and-see” approaches. Interventional surgery includes extracting the stent to the femoral vein using a “gooseneck” device, opening the femoral vein, and retrieving the stent or the implanted stent in the vein with optimally sized balloon inflation. However, in the case of stent migration to the pulmonary artery, the better option may be to withdraw the stent by balloon-assisted reposition. There was also one case in which the stent was immobilized with another stent from the SVC to the IVC through the migrated right atrial stent using the bridging stent technique .The literature review revealed that the success rate of interventional surgery for retrieving a migrated stent is high, and that this is the first option for most cases. However, in two cases, the attempt to retrieve the migrated stent using a gooseneck device failed, but the retrieval was ultimately achieved by surgical thoracotomy , 18. In The current study involved several limitations. First, the risk of publication bias was strong given the paucity of reported data. In addition, since many migration events are potentially asymptomatic, the possibility that stent migration may not have been reported was high, meaning the sample size was comparatively small. Second, while by literature review and through our own clinical experience the causes of stent migration were discussed, it proved difficult to identify an appropriate method with which to verify them. Third, while various treatment options were discussed and analyzed, there exists no definitive evidence of their safety and effectiveness.More accurate assessment of the thoracic central vein and further guidance for selection of an appropriately sized stent are key points for future research. The recent years have witnessed an increase in the use of intravascular ultrasound in venous applications as endovascular therapy for central venous diseases since it is more sensitive in terms of detecting and characterizing stenotic diseases and assessing the intraluminal parameters of the central vein . A numbeIn TCVO procedures, stent migration is a rare but extremely serious complication. The causes are not yet fully understood, and the current treatment strategies include interventional surgery, open heart surgery, and the “wait-and-see” approach.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.SF was responsible for polishing the language of manuscript. All authors contributed to the article and approved the submitted version.This work was supported by Science-Health Joint Medical Research Project of Chongqing (Number: 2020FYYX064).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Health issues are associated with artisanal mining in the DR Congo. The scenario is worst when artisanal mining is done informally or with limited material and technical resources.This paper argues that the adoption of healthy practices by artisanal miners might be limited given that it involves unrealistic socio-economic, and administrative aspects and access to health risk prevention means.Making a conceptual framework on the feasibility of revolutionizing artisanal mining practices linked to health risks in the DR Congo requires trans-disciplinary interventions and researches. This case study aims at co-analyzing with actors in the Luhihi artisanal gold mine, the epidemiology of health issues. It also aims at describing the dynamics of resources that mining actors mobilize or think they can mobilize in order to prevent health risks.A “socio-anthropological” qualitative study with “transdisciplinary methods” was carried out the Luhihi artisanal mining. Data collection tools and methods included an exploratory survey, semi-structured interviews. Focus groups (FG) mixed with proportional piling were used to support the open-ended interview discussions. The actors interviewed were selected by “convenience sampling” and the saturation principle indicated the size of the sampling. In total, 67 persons were interviewed and 5 FG each consisting of 5 to 10 mining actors were organized. Data were triangulated among respondents to ensure their veracity and an “inductive thematic data analysis” was applied.Key findings are the role of actors involved the organization system at the Luhihi artisanal mining site; a description of a participative epidemiology and determinants of health issues; presentation of the importance of health risks as perceived by mining actors; the constraints in the common illenesses treatment; and opportunities of collective actions for gathering resources required for the organization of healthcare services.The results are translated into a grid of powers and interests in relation to the mobilization of resources for the prevention and treatment of health issues. The dialogue for change regarding the ignorance of the actors to exposure to chemical risks such as to exposure mercury, silica, carbon monoxide, and cyanide also entailed the translation of the results. In addition, an analysis of the ability of artisanal mining actors to implement health risk prevention services was made. Artisanal mining is a crucial source of income for rural communities especially in developing countries. Besides agriculture, artisanal mining is the most important activity for rural economy in sub-Saharan Africa . ResearcAlthough practices in ASM vary around the world, it is recognized that artisanal mining frequently creates environmental, social and health problems. This is due to the informal nature of the artisanal mining sector, where national standards for health and safety are often not applicable , 6. FormThe DR Congo harbors approximately two million ASM workers and occupies the third place worldwide in terms of the absolute number of people working in ASM. The eastern part of the country hosts at least 382,000 artisanal miners across 2700 sites, and the subsistence of millions of people depends on artisanal mining , 14. DesIn the DR Congo, many work-related and health risks are associated with ASM, especially when it is practiced informally or with limited material and technical resources . Health Health risks and hazards from artisanal mining are categorized as chemical, biological, biomechanical, physical and psychosocial. (i) Chemical risks include exposure to mercury, silica, arsenic, lead, methane, sulfur dioxide, nitrous oxide, carbon monoxide and cyanide among others . Evidenc(ii) Biological risks include exposure to sexually transmitted infections as well as exposure to pathogenic microorganisms such as cholera, malaria, dengue causative agents among others . A study(iii) Biomechanical risks include overworking and exposure to factors causing musculoskeletal disorders, trauma, etc.  (iv) In In eastern DR Congo, several research projects have been conducted to characterize and assess the risks of using chemical agents in artisanal mining on health, ecology and agriculture. These include a study on the effects of heavy metals on health and the environment; a study on environmental risks and respiratory health; a study on the mining sector and heavy metal pollution; a study on environmental change related to artisanal mining, etc. Besides, in partnership with government agencies, research findings on chemical agents in artisanal mining have been translated into a National Action Policy in the DR Congo , 23, 25.The adoption of health risks prevention practices in the artisanal mining sector faces several socio-economic and administrative issues that may limit their adherence and access by artisanal miners. Therefore, in order to optimize the translation of existing research insights into societal change, it is necessary to mobilize “trans-disciplinary investigation on the subject”. “ Transdisciplinary research Fig.  brings tWithout addressing the various socio-anthropological components of mine actors, this report presents observations from a study conducted in November 2021 on participatory epidemiology. Besides, it addresses the dynamics of preventive health resources at the Luhihi artisanal gold mining, in the South Kivu, DR Congo.This socio-anthropological study was conducted with the aim of generating together with the actors of the Luhihi gold mine, their perceptions and the importance they give to health risks. This study also aimed at describing the dynamics of the resources of health risk prevention which the actors mobilize or may be able to mobilize.The Luhihi mining site is located at the locality of Luhihi, in the Kabare territory, in South Kivu Province, in the DR Congo, at about 50 km north of Bukavu town. Soon after the discovery of Luhihi mining site by the local population in 2019, many diggers settled in Luhihi. The cholera outbreak that occurred at the mine site in September 2020 illustrates one of the environmental health issues.The division of mining of the South Kivu Province declared that the miners through the COMILU cooperative illegally carry out their artisanal gold mining activities in a mining square which has no national approval, In addition, they operate in a site that is not qualified in accordance with article 114 of the mining code. The current mining code in the DR Congo, recommend mining cooperatives to operate in Artisanal Exploitation Zone (AEZ). AEZs are areas exclusively designated for artisanal mining activities. The formation of an AEZ is restricted to areas where ‘the technological and economic factors are not suited for industrial exploitation’ . To estaA qualitative study through a “ socio-anthropological “ survey  was condThe interviewed actors were selected by “convenience sampling” . FirstlyDuring the exploratory investigation we used “the consultation approaches”  to make A total of 67 people was interviewed at the Luhihi gold mining using an open-ended interview guide lasting a maximum of 1 h Table .Table 2PWe organized 5 Focus Groups Fig.  with 5 tDuring the semi-structured interview and focus groups guides we used open questions on the subject of participatory epidemiology, availability and access to health care, initiative of collective actions for care as well as the power dynamics and actors’ interests in mobilizing health care resources Table .Table 4TDuring field data collection; local traditions, folk customs, norms and values have been respected. In addition, the ethical principles of respect for persons, respect for the interests of justice of respondents, and respect for communities have been observed. Respondents consciously gave their consent before the interviews begun. During the data collection process, we faced ethical considerations related to the conditions and the expectations of the respondents. Some of the respondents requested for some money and sometimes for some beer in order to participate the interviews. We managed these in an amicable way taking into consideration the opinion of the respondents. Furthermore, some of the informants expected us to introduce NGOs as an output of this research. The respondents were ensured that the unique objective of this research is to collect information and to disseminate the results and recommendations.The Luhihi artisanal mine covers several mountains located in Luhihi Health Subarea, Katana Health Zone and Kabare territory in South Kivu. The state health system organizes a reference Hospital for the Katana Health Zone which gather 18 Health Areas each with a Health Center, including Luhihi. With the discovery of the mining in 2019, around 1000 households of diggers have settled on the Luhihi site. The habitations are of poor quality and the surrounding environment has unfavorable hygiene and sanitary conditions. The conditions spontaneously resulted from the installation of the mine. The habitations are made up of straw and plastic sheeting while the toilets are made up of different types of materials and are not adequately supplied with water. The main source of water is the river that overhangs the hill and is also used for the gold panning. On the mining site there are around 10 small shops from which drugs are acquired on the basis of self-medication. The shops are owned by shopkeepers without health training. In addition, medical treatments and hospitalization are provided in around three buildings each made up of plastic falls without basic equipment Fig. . A shopkHealth risks related to artisanal mining is a societal challenge involving many actors with different roles, interests, and power. Understanding this is important as specify the people who should be involved in the research and project actions. The actors  acting at the Luhihi gold mining site were identified and a clear image of their role related to the mining activities was established Table .Table 5AThe importance of health risks and diseases was assesseded in terms of perception of level of danger that the risk agent bears, the frequency of occurrence of consequences related to the risk, morbidity and mortality of the disease, and accessibility of treatment of the disease Table .Table 6PFrom the above, the mining actors give more attention to biological and biomechanical health risks than other risk agents . In addition, epidemiological data from health centers in the Luhihi health area indicate that the diseases with the highest incidences are malaria, acute renal failure, thyphoid fever, bloody diarrhea, cholea, measles .In Luhihi, the major determinants of the recrudescence of biological risks and pathologies  are mainly the precarious hygiene, sanitation conditions and the scarcity of potable drinking water and to adequate health care services such as an antibiotic treatment. The tropical climate and the stagnant water around the junk houses are conducive for malaria development. The Cholera outbreaks that occured in September 2020 at the Luhihi mine site were favored by the lack of toilets, the defecation in the nature, the inaccessibility to potable drinking water, etc. The prevalence of sexually transmitted diseases is maintained by unprotected sex and lack of information. Furthermore, the mining site is always a vestive environment where on one hand, diggers want to enjoy the money they earn after risking their own lives by entering the underground in search for gold. On the other hand the availability of sex partners  who are harbored and kept by the owners of the beer auction houses as they attract beer consumers. In addition, the high level of biological pathologies at the mining site is maintained by inadequate treatments using drugs (mainly antibiotic therapy) consisting of self-medication (wrong medication and wrong dosage).Biomechanical health risks  may result from the fact that diggers work with inappropriate equipment for long periods of time in uncomfortable postures in the mines. Furthermore, diggers are pushed to make extra hours of work searching for survival means due to poverty and the local perception of ‘virility’ according to which “men don’t get tired”. Enduring prolonged hours of work is a leading criterion for being selected as a digger irrespective of the associated biomechanical risks.Proportional piling is a tool that is effective in prioritizing local community participation activities . It enabThe proportional piling illustrates that according to community perceptions, the most common diseases are STIs, including WASHA and gonorrhea Fig.  followedSome treatment constraints are associated with the unavailability and accessibility of drugs as well as disease recurrence. The pathologies that are mostly associated with treatment constraints are “washa” and typhoid fever Fig. . It has “...gonorrhea is nothing compared to WASHA, just a bottle of “Simba“  is enough to cure gonorrhea.” Extract from a digger/miner during a focus group. November, 2021 at Luhihi Mining Camp.Also, a store owner of a drugstore told us the following:“To treat gonorrhea, we give a mixture of half a bottle of the strong alcoholic liquor “SIMBA“, 10 capsules of chloramphenicol and one capsule of ampicillin. If it doesn’t work, we give the cefixime”. Extract from the semi-structured interview with a drug seller. November, 2021 at the Luhihi Mining Site.A dispensary of the Luhihi mining site named “Mungu ni jibu” meaning “God is the answer” Fig. . It’s inMine diggers are the main actors in the gold mining activities Table . Ideally“As in the old mining carrier where I worked, we were able to make weekly contributions of 2,000 Congolese francs  or more depending on our agreement to help each other with health care...” Extract from a digger/miner during a focus group. November, 2021 at Luhihi Mining Camp.Mine actors have reported that diggers Fig.  are in a“When a colleague is seriously ill, the miners contribute 1500 Congolese francs  to pay for the transportation of the patient to join his family in the city for medical care”. Extract from a Sex professional during a focus group. November, 2021 at Luhihi Mining Camp.In addition, a sex professional said the following:The actors in the Luhihi Mining site are on one hand the « PDG », the « Supporters », the Diggers called « demushimba », the Transportors, the person in charge of crushing and « washing », the economic dealers and sex professionals of called “Diggers without spade”. On the other hand, there are actors involved in the mining site administration such us mining agents, the camp Committee, the mining cooperative, the mine police. In the DR Congo, the artisanal mining sector faces considerable challenges including socio-economic problems, underutilization of production capacity, lack of state monitoring, and above all the activism of armed groups, some of whom control certain mining sites outright . FormaliAt the Luhihi artisanal mining site, biological health issues  are perceived as having a high level of risk by the actors in the mining work place. In artisanal mining, the most common biological hazards affecting them are waterborne and vector-borne diseases, STIs, HIV/AIDs, and tuberculosis. Water and sanitation infrastructure are often limiting factors in artisanal and small-scale mining camps given that many sites are in remote locations that are hard to reach and the mining is often a transient activity .Psychosocial and biomechanical hazards such as exposition to stress and fatigue are ranked second by mining players considering the levels of risk. In artisanal mining, biomechanical hazards such as heavy workloads, repetitive tasks, prolonged working hours and unsafe equipment can lead to the development of musculoskeletal disorders. Mostly recorded musculoskeletal disorders include shoulder disorders, fatigue and lower back pain among others . SeveralThe mine actors do not consider high risks from exposure to physical agents  or chemical agents , even though these agents are associated with mining practices. Some mine actors have stated that “they use mercury and coal in the processing of gold” . A study on artisanal mining in the DR Congo reported that miners barely access health care as the result of limiting factors incluging the instability of their incomes, the scarcity of health care facilities and shortage of qualified personnel in addition to the hardness of reaching most hospitals with are located far from most mines . Using aConstraints for treatment were related to the unavailability and inaccessibility of drugs in addition to disease recurrence. The main mining actors consider their individual resources as their primary means of treatment, followed by assistances from their respective families. In addition, they have confirmed their willingness for the prevention of health risks through participation in cost-sharing initiatives. These constitute an enormous progress for the development of sustainable risk prevention services based on the resources of mining actors. These individual, contextual and relational resources mobilized by mining actors constitute assets for the development of services. Examining the resurgence role, Village Development Associations in Cameroon, Fonchingong and Fonjong found that community members are increasingly shouldering the adverse consequences of the economic downturn and the growing inability of the state to provide economic and social development by initiating, mobilizing and galvanizing their own resources with the aim of improving their standards of living .We used the “power/interest grid” Table  to transArtisanal miners living in the Eastern DR Congo are encouraged by the government to gather into mining cooperatives, in line with formalization policies . AccordiThe challenge of implementing management options for biological pathologies  and health outcomes of biomechanical hazards  is primarily organizational. To prevent these risks, the various actors of the mine have different levels of responsibilities. However, the miner code and the pontential ressourses attribute more acting power to state agencies such as the SAEMAPE, the mining cooperatives and the owners of the mining shafts (“PDG” and “Suporteurs”). These are able to set up sanitary facilities, to take care of the hygiene and sanitation, to guarantee the supply of potable water through alternative sources as reservoirs, wells, boreholes, river water treatment, etc. In addition, these actors can guarantee access to basic health care services in the mines by providing adequate equipment to mobile clinics. It is mandatory to provide for mechanized drilling and heavy transport equipment and protection against rockfall and explosions. The above mentioned actors, have the pontential to oraganize prevention services of biological and biomechanical health risks through mobilization of financial means and regulation of services in mining sites. The others actors of the mining site  can adopt these health care initiatives given that they have declared in this study, that they are highly interested in preventing these risks. They can also have access to sanitary services as they are constatly financing their sanitary care themselves.In addition to the organizational challenges outlined above and the responsibilities of actors, there is a need of awakening awareness among artisanal miners about the harmful effects of the chemicals and physical hazards to which they are exposed. This study highlights the exposure of miners to mercury, carbon monoxide, heat, humidity, low levels of oxygen, loud noise, electricity, etc. Evidence from studies on long-term health effects of these hazards should support the organization of outreach and engagement activities with mining actors. Furthermore, personal experiences of mine workers on health risk effects such as chronic pulmonary diseases, tuberculosis, insomnia, gastrointestinal disorders, headaches, etc. should be used to raise awareness and promote the adoption of the most accessible protective measures. These include wearing masks, reducing humidity and ensuring the level of oxygen in the underground pipes, etc. Nevertheless, the application of these measures would be threatened by the weariness of the actors to support its financial cost in the medium and long term. Thus, to ensure that they are applied continuously, the state agencies in the mining will have to set incentives.In order to intervene on the health effects of psychological hazards , actions to respond to socio-economic constraints of the mine workers must be taken in addition to the organizational and awareness-raising measures mentioned above. Due to the lifestyle factors of the workers  they need to benefit from pyschological follow-up based on their socio-anthropological context. They should also be trained on how to save money in order to make efficient use of it. These activities should be integrated into the training tasks that the mining cooperatives are required to perform by the legal framwork for ASM activities in DR Congo.Although we recorded the use of mercury in gold panning at the Luhihi mine, the miners seemed not to be aware of the health risks that it poses. After the Minamata Convention (MC) on mercury (Hg) control came into force, the demand for Hg in the ASGM sector may not have decreased, thus driving the increase in the Hg trade through illegal routes such as mislabeling, smuggling, or black markets .Participatory behavioral change research, awareness, and regulatory incentives are needed as key actions for addressing artisanal mine actors’ ignorance of the danger of exposure to chemical hazards such as mercury. Firstly, these actions will aim at delivering appropriate messages to drive change. This requires identifying target audiences, formulating key messages, adapting messages to the roles that different stakeholders may play. It also entails informing through accessible communication channels, incorporating ethical considerations, and integrating interactive communication by considering feedback from target audiences. Secondly, to ensure the message of the communications remain in the memories of the target audiences and raise their conscience, the awareness activities should be based on the “dialogue for change” pedagogy . This prIn the artisanal mining site, where monetary flows are certain, stakeholders must take in charge the health care cost in order to prevent health risks such as the cholera epidemic that occurred in the Luhihi mining site in 2020. A model for the provision of health care services and responsibilities have to be established between mine actors. Within the model the state agencies should set on regulations for the control of the implementation of health care services. From the observations on the Luhihi mine case study, it is clear that there is a need to strengthen the provision of health care factors, including materials, infrastructure, personnel, services, drugs, water supply, hygiene and sanitation. There is a need of organizing a financing scheme, which can be public financing or actors gathered in mutual or private insurance companies. The health care demand and the financing scheme have to integrate socio-economic, financial and cultural accessibility determinants.This article argues that the adoption of positive practices involves many socio-economic and administrative aspects that may limit artisanal miners’ adherence and access to the means of health risk prevention practices. This transdisciplinary essay brought together scientists and people concerned with the health risk issue in the Luhihi gold mine, in South Kivu. It recorded that biological risks and psychosocial risks are perceived as having a high level of risk by the actors in the mining work place. The most constraints for treatment of the common illnesses were associated with the unavailability and inaccessibility of health services, drugs as well as the disease recurrence. As to prevent these, the actors of the mine system have to set up sanitary facilities, to take care of the hygiene and sanitation as well to ensure the use of mechanized drilling and heavy transport and protection equipments. Although, mine actors do not perceive a high risk from exposure to physical agents  and chemical agents , these are closely related to their mining practices. For addressing these ignorance, participatory behavioral change research, awareness, and regulatory incentives are needed as key actions. The main source for medical treatment is the individual resources of mine diggers. However, we have recorded that more acting power for organising health services is attributed to the state agencies, the mining cooperatives and the owners of the mining shafts.The originality of this paper is to complete the exiting literature on health risks in artisanal mining by translating its finding into perceptives. These included the grid of powers and interests in relation to the mobilization of resources for the prevention and treatment of health risks. The contribution to the dialogue for change regarding the ignorance of exposure to chemical risks by the actors of the mine was also taken into consideration. In addition, an analysis of the ability of artisanal mining actors in the DR Congo to organize health risk prevention services in the mining sector was performed.


A 31-year-old man hospitalized during the first wave of the pandemic in 2020 suffering from severe psychological distress, requested psychological assistance as his condition progressively worsened, eventually requiring intubation. After being referred to the clinical psychology service by a ward physician, the patient was assisted remotely for two months for a total of 22 sessions during hospitalization and after discharge. A psychometric evaluation was carried out when the patient was close to discharge and longitudinally, for a total of four times, for depression ), anxiety ), post-traumatic stress disorder ) and insomnia (Insomnia Severity Index (ISI)). Support was provided remotely, mainly through audio and video calls, and text chats were also utilized when possible and as required. The initial psychometric evaluation indicated moderate depression, severe anxiety, the presence of post-traumatic stress disorder and sleep problems. Psychological distress decreased until reaching a situation of no distress in the final evaluation. Psychological interventions from which the patient benefitted were stress reduction and breathing techniques, empathic support, elaboration of the possibility of grief and cognitive restructuring regarding fears relative to his condition. Psychological support provided remotely and the monitoring of psychological status after discharge are highly advisable in pandemic emergency situations. The CARE checklist of information to include when writing a case report was utilized in the writeup of this case report.  A 31-year-old man was admitted to the hospital’s emergency room during the peak of the pandemic in early March 2020 in Milan following an episode of loss of consciousness resulting in a head injury. In the three days prior to accessing the emergency room, the patient reported fever, even though during hospitalization, his temperature was normal, and his breathing was regular, with an absence of coughing or wheezing. The next day, the positive diagnosis of COVID-19 was confirmed through a nasopharyngeal swab.In the following days, the patient’s condition worsened following the onset of SARS-CoV2-induced pneumonia, which resulted in excessive overregulation of cytokine production (cytokine storm). Initially, a respiratory assistance procedure was implemented through continuous positive airway pressure (CPAP) with subsequent induction of a coma state preparatory to intubation.The patient explicitly requested the possibility of psychological support to a physician in the ward. He was experiencing high levels of anxiety and panic due to breathing difficulties, insomnia and fear of death experienced during CPAP care. He had previously sought psychotherapeutic care, mainly to improve his intimate relationships, and he reported having obtained benefit from it, concluding treatment in December 2019. No major psychological and/or psychiatric disturbances were reported prior to his hospitalization.The experience of hospitalization following COVID-19 infection is frequently associated with the appearance of significant levels of anxiety , depressThe case described herein therefore represents an example of treatment with the aim of assisting an emotionally and physically fragile patient, whose expectations related to hope of survival and recovery were negatively affected by the severity of his health condition.Initially, relaxation and guided breathing techniques  were utiIn an extensive search of the relevant databases, no similar description of a similar case study was found in the literature. Such reports could be of help for clinical psychologists who find themselves having to assist patients remotely in similar critical situations.The first contact with the patient occurred 3 days after his hospitalization. All sessions were organized remotely through the use of phone calls or video calls through WhatsApp, as well as through WhatsApp chats when the patient did not have the necessary strength to speak, following all guidelines and recommendations, indicating that clinical psychology services should be organized online and/or via telephone  because An Excel database was utilized to report the days and times of each session, and notes were taken in a Word document after each session. These documents, together with the record of the text messages on WhatsApp (which were removed from the author’s mobile device for privacy reasons ) are stoPsychometric testing was utilized to assess and monitor the patient’s psychological functioning and as an indicator of the effectiveness of the psychological intervention as soon his physical and psychological condition permitted him complete the questionnaire. The questionnaires were administered by sending the patient a link which led to online forms which could be filled in directly from his device. The only face-to face session was the last one, and it occurred 66 days after the patient’s discharge from hospital.a) The Generalized Anxiety Disorder Scale-7 (GAD-7) , a screeb) The Patient Health Questionnaire-9 (PHQ-9) , a shortc) The Impact of Event Scale - Revised (IES-R) , a self-d) The Insomnia Severity Index (ISI) , a self-In accordance with the literature cited in the Introduction, the following tests were selected for psychometric assessment of both hospitalized and discharged COVID-19 patients: The patient was assisted remotely for two months for a total of 22 sessions during hospitalization and after discharge for a total 12 h and 29 min (excluding the last face-to-face session). The first psychometric assessment was carried out approximately 1 month and 5 days after the patient’s hospitalization, just before he was discharged from the hospital.During the critical phase, the focus was on the management of the very high anxiety, which was amplified by difficulties in breathing. In the first session, the patient was already using CPAP, and this caused anxiety and panic due to the discomfort created by the strong jet of the air blowing and the noise of the machine. The patient also requested the support of psychotropic drugs to manage anxiety levels, which were, unfortunately, refused due to his clinical condition. The only alternative that remained was psychoeducation through breathing and relaxation exercises. Considering the critical situation and the physical condition of the patient, which did not enable concentration for long stretches of time, as well as high anxiety levels, it was agreed to establish contact 3 times per day. The sessions were brief and focused on symptom management and provision of support. The patient showed considerable improvement in terms of anxiety symptom management after the initial sessions. As his medical condition worsened, physicians anticipated the necessity of intubation to manage the situation. In this phase, the interventions helped the patient to articulate fears and questions regarding his condition and to facilitate communication with the healthcare staff, who were considerably burdened due to the sudden pandemic onset. When the necessity of intubation became more probable, the focus of the interventions was to support the patient on how to handle communication with his partner and his family. High emotional distress, physical fragility, and physical isolation from the people he cared for acted as very important barriers and created a sense of disorientation regarding what to say and to whom in this extremely critical moment. It was therefore suggested to work on a written document that I could deliver to his loved ones in the case of the worst outcomes. At the same time, the sessions were focalized on increasing emotional awareness and supporting the patient in his decisions on what to communicate and to whom during this critical time. The patient was subsequently intubated for 12 days. During the post-intubation phase, the patient reported disorientation and difficulty in reconstructing what had happened to him. In this phase, we agreed on one session daily. The patient reported feeling emotionally overwhelmed and having a lot of fear about the possibility of long-term outcomes resulting from being infected. The first psychometric assessment was carried out at this point. During this period, the focus of the sessions was on the management of post-hospitalization complications, in particular the management of anxiety levels and catastrophic thoughts. In some specialized medical visits, there was a contemplation of the utilization of psychotropic drugs (a physician suggested this during a follow-up visit), mainly for the management of anxiety; however, the patient decided to proceed only with psychological support. After two weeks and 4 days, the second assessment was carried out, and there was an indication that the psychological situation was improving. It was therefore decided to reduce the sessions to once every 2 days. The main theme of the next sessions was the patient’s return to work and his previous commitments. There was a gradual shift from the management of post-traumatic aspects to handling issues concerning everyday life, in particular, to establish healthy boundaries and the capacity to say no to some requests. The sessions were gradually reduced to twice a week, then once a week. In this phase, after about three weeks, the third assessment took place, which confirmed the absence of post-traumatic stress disorder (PTSD) symptoms and improvement in psychological functioning. The sessions were concluded with a face-to-face session (the only one), in which it was established that the support could be concluded, as also confirmed by the final evaluation carried out about two weeks after the previous one, which indicated that no symptoms of distress were present.As indicated in the table below , during The experience of hospitalization resulting from COVID-19 infection is frequently associated with the appearance of significant levels of psychological distress in response to the dynamics of isolation within the hospital environment and the methods of treatment of associated respiratory problems ,4. The pWhen caring for such critical patients, integrating psychological and personal variables in medical databases, for example, with patient-reported outcomes, can potentially improve the power of eventual decision support systems. The patients might also feel better cared-for if their perspective is included, possibly having a positive influence on their emotional wellbeing and improving communication between the physician and the patient .Anxiety, depressive symptoms and impaired sleep behavior are the main expressions of psychological distress generally reported by patients ,2, as coIt is not surprising that patients who face these kinds of situations experience high emotional distress . In thisAnother important aspect to consider is that in these very critical periods, healthcare staff is extremely burdened and lack time; therefore, referral of patients to psychological support is probably not optimal, especially in cases in which education is required. For this reason, during the progression of the pandemic and the further waves, we organized to contact all patients who were hospitalized due to COVID-19, presenting ourselves  and explaining what kind of support we could provide.One important difference in the handling of this case compared to other hospitalized patients was the change in the setting, in terms of both the temporal and spatial dimensions and the modalities with which the psychological support was provided. Fortunately, the patient did not have any pre-existent psychiatric conditions, which could have complicated the handling of the absence of stronger temporal and physical boundaries. The critical situation demanded an important flexibility in this sense, and after the critical phase, the patient was gradually supported to reach a psychological equilibrium, at which point the support was no longer needed.Apart from the adequate referral, it is important to ensure that the necessary human resources to provide psychological support are present in medical departments when these situations occur and that they are implemented under conditions of safety and with the possibility of technically providing the required services. In this particular case, the entire clinical psychology service team was heavily exposed to the virus; therefore, I found myself in a situation in which I was supporting a patient who was suffering tremendously from a virus to which I was exposed to. This could have potentially interfered with the efficacy of the psychological support that was provided. Daily team supervisions and support between colleagues were paramount to create the necessary protective factors to enable the staff to function well.The patient was highly motivated to receive psychological support and reported benefit from the intervention, both through the patient-reported outcomes and by expressing his gratitude during the sessions. In the follow-up phase, the patient reported greater awareness about his emotions and a better management of anxiety stress levels by progressively learning to apply breathing and relaxation exercises independently.It is highly advisable to provide remote structured and systematic psychological support provided for patients who are hospitalized during a pandemic. The psychological distress that often accompanies the experience of dealing with acute health situations is compounded by isolation and difficulties in breathing, which potentially amplify levels of anxiety and panic. Psychological support is even more essential, as psychotropic drugs are often not advisable in patients with such low saturation levels. When providing care in critical conditions, the patients’ psychological wellbeing should be carefully monitored with the inclusion of patient-reported outcomes administered longitudinally when the patients’ conditions allow for this. Support should be offered to all patients during the hospitalization phase and during follow-up after discharge, with quantitative and qualitative monitoring of eventual psychological distress levels.Finally, mental health professionals taking care of patients in acute settings also need to take care of their own mental health with frequent checks with colleagues and/or supervisors.


Apert's syndrome is an autosomal dominant inherited disease characterized mainly by achrocephalia due to synostosis of the coronary suture and by usually symmetrical syndactyly involving the four extremities.2In most cases the disorder results from a mutation in the father; its prevalence at birth is 1:65,0003 and the incidence in Asians is high.4 Mental retardation is common. The literature shows that this syndrome is caused by one of two mutations in the receptor 2 of the growth factor gene (FGFR2) involving two adjacent aminoacids.Treatment of these patients is done by multidisciplinary teams. Planning of surgery should be done in stages: craniotomy aims to decompress the brain and is done in infancy; advancement of the middle third improves airway-nasal flow, and may be done in puberty; and finally, orthognathic surgery improves occlusion and dental esthetics, and may be done in adolescence.DOS, a male black patient aged 19 years, a student who was the first child of three. The other two siblings were normal. His mother brought him to the Buccomaxillofacial Trauma Surgery Unit of the Santa Casa de Misericordia, Sao Felix, state of Bahia, with the following complaint: “I would like to have the appearance of my son improved.” The family history contained no report of similar cases. The mother said that the pregnancy for this patient was normal and had no type of physical, pharmacological or psychological trauma. He was the first child of a couple in their third decade of life.The physical examination showed the features of acrocephalosyndactyly . The facThe fingers and toes were fused, at times forming a mass with a single nail.The maxilla was atresic, the palatal ceiling was arched and there was gingival fibromatosis, which is typical of a pseudo-grooved palate. The teeth were generally ill positioned, with ectopic eruption, crowding and gyroversions. Toot eruption was delayed. Some teeth had been destroyed by caries, partially explained by lack of motor coordination. There was an anterior open bite and a posterior crossed bite.A posteroanterior and lateral face X-ray and X-rays of the hands and feet were taken.The lateral face X-ray shows clearly hypoplasia of the middle third and mandibular pseudoprognathism, demonstrating the bone discrepancy and decreased anteroposterior size of the cranium, as well as increased vertical length, yielding a turricephalic aspect. Hand and feet radiographs showed the pathognomonic syndactyly of Apert's syndrome.The patient underwent nine surgical procedures to separate the hand fingers so that he could learn to write and carry out basic care such as holding objects and food and personal hygiene. Surgery was successful and the patient is currently independent in some tasks.He was eventually referred to the Facial Deformity Unit of the Santo Antonio Hospital, Salvador, Bahia, where he is undergoing preoperative testing. He continues to be monitored at the unit in which the diagnosis was made.In these heterogeneous dysplasias, each case has to be classified individually. The aim is to alert clinicians and surgeons about the prognosis and possible correction - including esthetic ones - for increased acceptance by the patient. The importance of social adjustment and the need for occupational therapy and physical activities should not be underestimated. The benefits are both emotional and physical, and postpone major malformations caused by synostosis.