Throwing cardiac rehabilitation into the 21st Century: a focus group study exploring the impact of COVID-19 on cardiac rehabilitation delivery in Victoria, Australia

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR) education and exercise are predominantly delivered in group face-to-face settings. This delivery model was challenged during the COVID-19 pandemic due to government enforced lockdowns which restricted the delivery of these models of care. The Australian state of Victoria experienced the longest and most severe local restrictions and was in lockdown for approximately 26 weeks of 2020. 

Purpose

We aimed to explore the experience, barriers and enablers of delivering CR during a pandemic, and identify strategies for future COVID-safe programs among cardiac rehabilitation clinicians.

Methods

Victorian members of the Australian Cardiovascular Health and Rehabilitation Association (ACRA) were invited to attend an exploratory qualitative online focus group in November 2020. An inductive thematic analysis was undertaken before deductively applying the Non-adoption, Abandonment, Scale-up, Spread and Sustainability (NASSS) framework to identify barriers and enablers for technology adoption in CR.

Results

30 members participated in a 106 minute focus group. 17 members who provided demographics represented multiple disciplines (nursing n = 13, exercise physiology n = 3, physiotherapy n = 1) and geographical settings (metropolitan n = 10, regional n = 4, rural n = 3). Four main themes were identified: Consequences of sudden service delivery change; Technology use – challenges and benefits; Capacity (program and staff); and The way forward. The deductive NASSS analysis demonstrated the main challenges of continuing remotely delivered CR lie with all adopters (staff, patients, carers) and with organisations. Future CR strategies included the importance of resuming face-to-face programs but important barriers including finding capacity, particularly staffing, to run concurrent telehealth programs remain to be addressed. 

Conclusion

The COVID-19 pandemic forced and expedited significant changes to CR delivery models. While clinicians agreed that delivery of CR via telehealth will continue, it is now timely to review remote models of care and plan how they will integrate alongside traditional face-to-face programs.

Early-cannulation arteriovenous grafts are safe and effective in avoiding recurrent tunneled central catheter infection

Objective

Tunneled central venous catheter infection (TCVCi) is a common complication that often necessitates removal of the TCVC and a further TCVC. Theoeretically, insertion of an early-cannualtion graft (ecAVG) early after TCVC infection is possible but not widely practiced with concerns over safety and infection in the ecAVG. With 8 years of ecAVG experience, the aim of this study was to compare the outcomes following TCVC infection, comparing replacement with TCVC (TCVCr) versus immediate ecAVG (ecAVGr).

Methods

Retrospective comparison of two cohorts, who underwent replacement of an infected TCVC either by an early cannulation graft (n = 18) or by a further central catheter (n = 39).

Data were abstracted from a prospectively completed electronic patient record and collected on patient demographics, TCVC insertion, duration and infection, including culture proven bacteriaemia and subsequent access interventions.

Results

18/299 patients identified from 2012-2020 had an ecAVG implanted as treatment for a TCVCi. In a one-year time-period (1/1/2015 -31/12/2015) out of 222 TCVC inserted, 39 were as a replacement following a TCVCi. No patient with an ecAVGr developed an immediate infection, nor complication from the procedure. The rate of subsequent vascular access infection was significantly more frequent for those with TCVCr than with an ecAVGr (0.6 vs. 0.1/patient/ 1000 HD days, p < 0.000). The number of further TCVC required was significantly higher in the TCVCr group (7.1 vs. 0.4/patient/ 1000 HD days, p = 0.000).

Conclusion

An ecAVG early following a TCVC infection is safe, reduces the incidence of subsequent infectious complications and reduces the number of TCVC required, with a better functional patency.

A Phase II Study of Biodegradable Stents Plus Palliative Radiotherapy in Oesophageal Cancer

AIMS

Self-expanding metal stents provide rapid improvement of dysphagia in oesophageal cancer but are associated with complications. The aim of the present study was to test the effectiveness of an alternative treatment of combining biodegradable stents with radiotherapy.

MATERIALS AND METHODS

A Simon two-stage single-arm prospective phase II trial design was used to determine the efficacy of biodegradable stents plus radiotherapy in patients with dysphagia caused by oesophagus cancer who were unsuitable for radical treatment. Fourteen patients were recruited and data from 12 were included in the final analyses.

RESULTS

Five of 12 patients met the primary end point: one stent-related patient death; four further interventions for dysphagia within 16 weeks of stenting (41.7%, 95% confidence interval 15.2-72.3%). The median time to a 10-point deterioration of quality of life was 2.7 weeks. Nine patients died within 52 weeks of registration. The median time to death from any cause was 15.0 weeks (95% confidence interval 9.6-not reached).

CONCLUSION

The high re-intervention observed, which met the pre-defined early stopping criteria, meant that the suggested alternative treatment was not sufficiently effective to be considered for a larger scale trial design. Further work is needed to define the place of biodegradable stents in the management of malignant oesophageal strictures.

Early-Cannulation Arteriovenous Grafts Are Safe and Effective in Avoiding Recurrent Tunneled Central Catheter Infection

OBJECTIVES

Tunneled central venous catheter infection (TCVCi) is a common complication that often necessitates removal of the TCVC and replacement by a further TCVC. Theoretically, insertion of an early - cannulation graft (ecAVG) early after TCVC infection is possible but not widely practiced with concerns over safety and infection in the ecAVG. With 8 years of ecAVG experience, the aim of this study was to compare the outcomes following TCVC infection, comparing replacement with TCVC (TCVCr) versus immediate ecAVG (ecAVGr).

DESIGN

Retrospective comparison of 2 cohorts, who underwent replacement of an infected TCVC either by an early cannulation graft (n = 18) or by a further central catheter (n = 39).

METHODS

Data were abstracted from a prospectively completed electronic patient record and collected on patient demographics, TCVC insertion, duration and infection, including culture proven bacteriaemia and subsequent access interventions.

RESULTS

Eighteen of 299 patients identified from 2012 to 2020 had an ecAVG implanted as treatment for a TCVCi. In a 1-year time-period (January 1, 2015-December 31, 2015) out of 222 TCVC inserted, 39 were as a replacement following a TCVCi. No patient with an ecAVGr developed an immediate infection, nor complication from the procedure. The rate of subsequent vascular access infection was significantly more frequent for those with a TCVCr than with an ecAVGr (0.6 vs. 0.1/patient/1000 HD days, P< 0.000). The number of further TCVC required was significantly higher in the TCVCr group (7.1 vs. 0.4/patient/1000 HD days, P= 0.000).

CONCLUSIONS

An ecAVG early following a TCVC infection is safe, reduces the incidence of subsequent infectious complications and reduces the number of TCVC required, with a better functional patency.

Communication from the cerebellum to the neocortex during sleep spindles

Surprisingly little is known about neural activity in the sleeping cerebellum. Using long-term wireless recording, we characterised dynamic cerebro-thalamo-cerebellar interactions during natural sleep in monkeys. Similar sleep cycles were evident in both M1 and cerebellum as cyclical fluctuations in firing rates as well as a reciprocal pattern of slow waves and sleep spindles. Directed connectivity from motor cortex to the cerebellum suggested a neocortical origin of slow waves. Surprisingly however, spindles were associated with a directional influence from the cerebellum to motor cortex, conducted via the thalamus. Furthermore, the relative phase of spindle-band oscillations in the neocortex and cerebellum varied systematically with their changing amplitudes. We used linear dynamical systems analysis to show that this behaviour could only be explained by a system of two coupled oscillators. These observations appear inconsistent with a single spindle generator within the thalamo-cortical system, and suggest instead a cerebellar contribution to neocortical sleep spindles. Since spindles are implicated in the off-line consolidation of procedural learning, we speculate that this may involve communication via cerebello-thalamo-neocortical pathways in sleep.

Clinical characteristics and outcome of critically ill COVID-19 patients with acute kidney injury: a single centre cohort study

BACKGROUND

Acute kidney injury (AKI) is a common manifestation among patients critically ill with SARS-CoV-2 infection (Coronavirus 2019) and is associated with significant morbidity and mortality. The pathophysiology of renal failure in this context is not fully understood, but likely to be multifactorial. The intensive care unit outcomes of patients following COVID-19 acute critical illness with associated AKI have not been fully explored. We conducted a cohort study to investigate the risk factors for acute kidney injury in patients admitted to and intensive care unit with COVID-19, its incidence and associated outcomes.

METHODS

We reviewed the medical records of all patients admitted to our adult intensive care unit suffering from SARS-CoV-2 infection from 14th March 2020 until 12th May 2020. Acute kidney injury was defined using the Kidney Disease Improving Global Outcome (KDIGO) criteria. The outcome analysis was assessed up to date as 3rd of September 2020.

RESULTS

A total of 81 patients admitted during this period. All patients had acute hypoxic respiratory failure and needed either noninvasive or invasive mechanical ventilatory support. Thirty-six patients (44%) had evidence of AKI (Stage I-33%, Stage II-22%, Renal Replacement Therapy (RRT)-44%). All patients with AKI stage III had RRT. Age, diabetes mellitus, immunosuppression, lymphopenia, high D-Dimer levels, increased APACHE II and SOFA scores, invasive mechanical ventilation and use of inotropic or vasopressor support were significantly associated with AKI. The peak AKI was at day 4 and mean duration of RRT was 12.5 days. The mortality was 25% for the AKI group compared to 6.7% in those without AKI. Among those received RRT and survived their illness, the renal function recovery is complete and back to baseline in all patients.

CONCLUSION

Acute kidney injury and renal replacement therapy is common in critically ill patients presenting with COVID-19. It is associated with increased severity of illness on admission to ICU, increased mortality and prolonged ICU and hospital length of stay. Recovery of renal function was complete in all survived patients.

Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method

BACKGROUND

Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI).

AIM

To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort.

METHODS

Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases.

FINDINGS

Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S. aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population.

CONCLUSION

Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.

National Guidelines on the Provision of Outpatient Parenteral Antimicrobial Therapy (OPAT)

Aim Outpatient parenteral antimicrobial therapy (OPAT) is an option in patients who require parenteral antimicrobial administration and are clinically well enough for hospital discharge. This is an update of the Irish National OPAT guidelines which were last reviewed in 2011. Methods The guideline was devised through a collaborative process with the national OPAT Working Group and a review of the literature. It is intended for clinicians who prescribe any intravenous (IV) antimicrobials outside of the inpatient setting in the Republic of Ireland. Results Patient care while on OPAT should be provided by a designated OPAT service, with clear managerial and clinical governance lines of responsibility. It should be conducted using a team approach with a clinical lead on each site either as an infection specialist, or a general medical physician with infection specialist input and an OPAT nurse. An antimicrobial pharmacist is also desirable. Several factors must be considered when assessing patient's suitability for OPAT including exclusion criteria, infection-specific factors, and patient specific factors such as physical, social and logistic criteria. Conclusion This updated guideline advocates a more individualised OPAT approach, with the recognition that specific antimicrobials and/or specific delivery models may be more appropriate for certain patient groups. Full guidelines are available through www.opat.ie.

Patient Safety Event Reporting and Opportunities for Emergency Medicine Resident Education

Introduction

Healthcare systems often expose patients to significant, preventable harm causing an estimated 44,000 to 98,000 deaths or more annually. This has propelled patient safety to the forefront, with reporting systems allowing for the review of local events to determine their root causes. As residents engage in a substantial amount of patient care in academic emergency departments, it is critical to use these safety event reports for resident-focused interventions and educational initiatives. This study analyzes reports from the Virginia Commonwealth University Health System to understand how the reports are categorized and how it relates to opportunities for resident education.

Methods

Identifying categories from the literature, three subject matter experts (attending physician, nursing director, registered nurse) categorized an initial 20 reports to resolve category gaps and then 100 reports to determine inter-rater reliability. Given sufficient agreement, the remaining 400 reports were coded individually for type of event and education among other categories.

Results

After reviewing 513 events, we found that the most common event types were issues related to staff and resident training (25%) and communication (18%), with 31% requiring no education, 46% requiring directed educational feedback to an individual or group, 20% requiring education through monthly safety updates or meetings, 3% requiring urgent communication by email or in-person, and <1% requiring simulation.

Conclusion

Twenty years after the publication of To Err is Human, gains have been made integrating quality assurance and patient safety within medical education and hospital systems, but there remains extensive work to be done. Through a review and analysis of our patient safety event reporting system, we were able to gain a better understanding of the events that are submitted, including the types of events and their severity, and how these relate to the types of educational interventions provided (eg, feedback, simulation). We also determined that these events can help inform resident education and learning using various types of education. Additionally, incorporating residents in the review process, such as through root cause analyses, can provide residents with high-quality, engaging learning opportunities and useful, lifelong skills, which is invaluable to our learners and future physicians.

AB0402 DISEASE ACTIVITY AND OBSESSIVE-COMPULSIVE DISORDER IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Obsessive-compulsive disorder (OCD) is more prevalent in systemic autoimmune diseases when compared to healthy controls. This is in part due to inflammatory mechanisms, common across both conditions. Neuroinflammation and specifically problems within the basal ganglia are associated with OCD.

Objectives:

The primary objective of this analysis was to investigate the effects of disease activity in systemic lupus erythematosus (SLE) on OCD. Other variables investigated included psychiatric aspects, inflammatory biomarkers and structural brain abnormalities.

Methods:

SLE patients who met ACR or SLICC criteria were recruited. Demographic and clinical data were collected and data measuring disease activity (BILAG and SLEDAI-2K), disease damage (SLICC-DI), depression (MADRS, BDI-II, HADS), anxiety (HADS, STAI), fatigue (FSMC), quality of life (LupusQoL and EQ5D), inflammatory and endothelial activation (EA) biomarkers (IL-6, ESR, TNF-α, MCP-1, hsCRP, BLyS, VCAM-1, VEGF, EMVs) and OCD (OCI-R). MRI FLAIR structural scans were also used to examine signal hyperintensities in the brain. Participants with active disease (SLE-F) also had a 2ndvisit approx. 4 months later. Non-parametric correlations with the OCI-R were undertaken for all SLE participants and for the change over time scores for the SLE-F participants (n=11).

Results:

39 participants were included in the analysis and were typical for a SLE population. 6 (23%) patients had scores above the threshold for OCD. OCI-R significantly correlated with disease activity, quality of life, fatigue, depression and anxiety measures for all the SLE participants. Change in monocyte chemoattractant protein-1 (MCP-1) correlated with the OCI-R for the within SLE-F group analysis (Table 1). No significant correlations were found with the full SLE group for inflammatory or EA biomarkers or with either group for the structural brain analysis.

Table 1.

Significant correlations with the OCI-R for: a) all SLE participants; b) the SLE-F group only (visit 1 minus visit 2).

Variablersp-valuea)All SLE participants, n=39Disease activity: BILAG global score0.4080.01Quality of life: LupusQoL – Physical-0.4950.001  – Pain-0.535<0.001  – Planning-0.586<0.001  – Intimate-0.3420.03  – Burden-0.5040.001  – Emotion-0.3970.01  – Fatigue-0.4710.002 EQ5D: VAS-0.4180.01  total-0.3590.03Fatigue measures (FSMC): Cognitive0.5210.001 Motor0.4480.004Depression measures: MADRS0.4670.003 HADS – D0.545<0.001Anxiety measure: HADS-A0.3750.02b)SLE-F group (v1-v2), n=11Inflammatory marker: MCP-10.7710.006

BILAG The British Isles Lupus Assessment Group index, LupusQoL Lupus quality of life, EQ5D European quality of life, VAS visual analogue scale, FSMC Fatigue scale for motor and cognitive function, MADRS Montgomery Asberg depression rating scale, HADS Hospital anxiety and depression scale, D-depression, A-anxiety score, MCP-1 monocyte chemoattractant protein-1

Conclusion:

OCD in lupus is strongly related to other psychological co-morbidities, fatigue and quality of life. Our results also support a role for inflammatory pathways in mediating some of these changes and so obsessive-compulsive features should be assessed in SLE patients who flare. A larger study is underway to better understand the mechanisms underlying these associations.

Acknowledgments:

This study was partially funded by an unrestricted grant from Sanofi Genzyme and supported by the NIHR Manchester Biomedical Research Centre.

Disclosure of Interests: :

Michelle Barraclough Grant/research support from: This study was partially funded by an unrestricted grant from Sanofi Genzyme., Ben Parker Grant/research support from: GSK and Sanofi Genzyme, Consultant of: GSK, AstraZenaca, UCV, Abbvie, Pfizer, BMS, Celltrion, Shane McKie: None declared, Philip Pemberton: None declared, Alan Jackson: None declared, Rebecca Elliott: None declared, Ian N. Bruce Grant/research support from: Genzyme Sanofi, GSK, and UCB, Consultant of: Eli Lilly, AstraZeneca, UCB, Iltoo, and Merck Serono, Speakers bureau: UCB

Safety of hospital discharge before return of bowel function after elective colorectal surgery

BACKGROUND

Ileus is common after colorectal surgery and is associated with an increased risk of postoperative complications. Identifying features of normal bowel recovery and the appropriateness for hospital discharge is challenging. This study explored the safety of hospital discharge before the return of bowel function.

METHODS

A prospective, multicentre cohort study was undertaken across an international collaborative network. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The main outcome of interest was readmission to hospital within 30 days of surgery. The impact of discharge timing according to the return of bowel function was explored using multivariable regression analysis. Other outcomes were postoperative complications within 30 days of surgery, measured using the Clavien-Dindo classification system.

RESULTS

A total of 3288 patients were included in the analysis, of whom 301 (9·2 per cent) were discharged before the return of bowel function. The median duration of hospital stay for patients discharged before and after return of bowel function was 5 (i.q.r. 4-7) and 7 (6-8) days respectively (P < 0·001). There were no significant differences in rates of readmission between these groups (6·6 versus 8·0 per cent; P = 0·499), and this remained the case after multivariable adjustment for baseline differences (odds ratio 0·90, 95 per cent c.i. 0·55 to 1·46; P = 0·659). Rates of postoperative complications were also similar in those discharged before versus after return of bowel function (minor: 34·7 versus 39·5 per cent; major 3·3 versus 3·4 per cent; P = 0·110).

CONCLUSION

Discharge before return of bowel function after elective colorectal surgery appears to be safe in appropriately selected patients.

Safety and efficacy of non-steroidal anti-inflammatory drugs to reduce ileus after colorectal surgery

BACKGROUND

Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery.

METHODS

A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury.

RESULTS

A total of 4164 patients were included, with a median age of 68 (i.q.r. 57-75) years (54·9 per cent men). Some 1153 (27·7 per cent) received NSAIDs on postoperative days 1-3, of whom 1061 (92·0 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4·6 versus 4·8 days; hazard ratio 1·04, 95 per cent c.i. 0·96 to 1·12; P = 0·360). There were no significant differences in anastomotic leak rate (5·4 versus 4·6 per cent; P = 0·349) or acute kidney injury (14·3 versus 13·8 per cent; P = 0·666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35·3 versus 56·7 per cent; P < 0·001).

CONCLUSION

NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement.

A trio of simple optimized axisymmetric kinematic dynamos in a sphere

Planetary magnetic fields are generated by the motion of conductive fluid in the planet's interior. Complex flows are not required for dynamo action; simple flows have been shown to act as efficient kinematic dynamos, whose physical characteristics are more straightforward to study. Recently, Chen et al. (2018, J. Fluid Mech. 839, 1-32. (doi:10.1017/jfm.2017.924)) found the optimal, unconstrained kinematic dynamo in a sphere, which, despite being of theoretical importance, is of limited practical use. We extend their work by restricting the optimization to three simple two-mode axisymmetric flows based on the kinematic dynamos of Dudley & James (1989, Proc. R. Soc. Lond. A 425, 407-429. (doi:10.1098/rspa.1989.0112)). Using a Lagrangian optimization, we find the smallest critical magnetic Reynolds number for each flow type, measured using an enstrophy-based norm. A Galerkin method is used, in which the spectral coefficients of the fluid flow and magnetic field are updated in order to maximize the final magnetic energy. We consider the t ⁰ ₁ s ⁰ ₁, t ⁰ ₁ s ⁰ ₂ and t ⁰ ₂ s ⁰ ₂ flows and find enstrophy-based critical magnetic Reynolds numbers of 107.7, 142.4 and 125.5 (13.7, 19.6 and 16.4, respectively, with the energy-based definition). These are up to four times smaller than the original flows. These simple and efficient flows may be used as benchmarks in future studies.