STIMULATE-ICP: A pragmatic, multi-centre, cluster randomised trial of an integrated care pathway with a nested, Phase III, open label, adaptive platform randomised drug trial in individuals with Long COVID: A structured protocol

INTRODUCTION

Long COVID (LC), the persistent symptoms ≥12 weeks following acute COVID-19, presents major threats to individual and public health across countries, affecting over 1.5 million people in the UK alone. Evidence-based interventions are urgently required and an integrated care pathway approach in pragmatic trials, which include investigations, treatments and rehabilitation for LC, could provide scalable and generalisable solutions at pace.

METHODS AND ANALYSIS

This is a pragmatic, multi-centre, cluster-randomised clinical trial of two components of an integrated care pathway (Coverscan™, a multi-organ MRI, and Living with COVID Recovery™, a digitally enabled rehabilitation platform) with a nested, Phase III, open label, platform randomised drug trial in individuals with LC. Cluster randomisation is at level of primary care networks so that integrated care pathway interventions are delivered as "standard of care" in that area. The drug trial randomisation is at individual level and initial arms are rivaroxaban, colchicine, famotidine/loratadine, compared with no drugs, with potential to add in further drug arms. The trial is being carried out in 6-10 LC clinics in the UK and is evaluating the effectiveness of a pathway of care for adults with LC in reducing fatigue and other physical, psychological and functional outcomes at 3 months. The trial also includes an economic evaluation which will be described separately.

ETHICS AND DISSEMINATION

The protocol was reviewed by South Central-Berkshire Research Ethics Committee (reference: 21/SC/0416). All participating sites obtained local approvals prior to recruitment. Coverscan™ has UK certification (UKCA 752965). All participants will provide written consent to take part in the trial. The first participant was recruited in July 2022 and interim/final results will be disseminated in 2023, in a plan co-developed with public and patient representatives. The results will be presented at national and international conferences, published in peer reviewed medical journals, and shared via media (mainstream and social) and patient support organisations.

TRIAL REGISTRATION NUMBER

ISRCTN10665760.

Primary prevention of acute cardiovascular events by influenza vaccination: an observational study

AIMS

Previous studies show a reduced incidence of first myocardial infarction and stroke 1-3 months after influenza vaccination, but it is unclear how underlying cardiovascular risk impacts the association.

METHODS AND RESULTS

The study used linked Clinical Practice Research Datalink, Hospital Episode Statistics Admitted Patient Care and Office for National Statistics mortality data from England between 1 September 2008 and 31 August 2019. From the data, individuals aged 40-84 years with a first acute cardiovascular event and influenza vaccination occurring within 12 months of each September were selected. Using a self-controlled case series analysis, season-adjusted cardiovascular risk stratified incidence ratios (IRs) for cardiovascular events after vaccination compared with baseline time before and >120 days after vaccination were generated. 193 900 individuals with a first acute cardiovascular event and influenza vaccine were included. 105 539 had hypertension and 172 050 had a QRISK2 score ≥10%. In main analysis, acute cardiovascular event risk was reduced in the 15-28 days after vaccination [IR 0.72 (95% CI 0.70-0.74)] and, while the effect size tapered, remained reduced to 91-120 days after vaccination [0.83 (0.81-0.88)]. Reduced cardiovascular events were seen after vaccination among individuals of all age groups and with raised and low cardiovascular risk.

CONCLUSIONS

Influenza vaccine may offer cardiovascular benefit among individuals at varying cardiovascular risk. Further studies are needed to characterize the populations who could derive the most cardiovascular benefits from vaccination.

Minimum intervention oral care management of early childhood caries: a 17-year follow-up case report

BACKGROUND

Early childhood caries (ECC) has a profound impact on a child's quality of life, and its management remains a challenge for the paediatric dentist, mainly because it depends on radical changes in the child/carers' daily behaviour and any dental treatment must be provided to very young child.

CASE REPORT

This case report describes the on-going care of a 2-year-old child presenting with ECC and management until permanent dentition is complete. All patient-focused, teamdelivered care was delivered using the minimum intervention oral care framework, implementing non-invasive and minimally invasive preventive procedures. Throughout the care provided, oral and dental health education was reinforced in all visits. The child's mother was trained to perform effective biofilm control and dietary habits were adjusted, especially baby-bottle removal during sleep. The child was initially anxious and resistant towards any dental examination and clinical procedures. However, with effort from the oral healthcare team members, the patient became compliant, allowing the mother to perform suitable oral hygiene measures, as well as accepting the clinical procedures carried out by the paediatric dentist. The clinical procedures consisted of atraumatic restorations and fluoride varnish applications. During the subsequent years after the baseline treatment, follow-up visits included continued dietary and oral hygiene instruction with positive behavior reinforcement, fluoride topical applications and tooth-restoration complex maintenance with glass-ionomer cement where needed. Currently, the patient is 19 years old and has a stable, healthy permanent dentition.

CONCLUSION

Understanding of the causes of oral diseases by the patients' caregivers, alongside with pragmatic practical guidance to maintain good oral health, can reduce the risk for acquiring future disease, since caries activity control is the basis for successful caries management.

Early Release Science of the exoplanet WASP-39b with JWST NIRSpec PRISM

Transmission spectroscopy1-3 of exoplanets has revealed signatures of water vapour, aerosols and alkali metals in a few dozen exoplanet atmospheres4,5. However, these previous inferences with the Hubble and Spitzer Space Telescopes were hindered by the observations' relatively narrow wavelength range and spectral resolving power, which precluded the unambiguous identification of other chemical species-in particular the primary carbon-bearing molecules6,7. Here we report a broad-wavelength 0.5-5.5 µm atmospheric transmission spectrum of WASP-39b8, a 1,200 K, roughly Saturn-mass, Jupiter-radius exoplanet, measured with the JWST NIRSpec's PRISM mode9 as part of the JWST Transiting Exoplanet Community Early Release Science Team Program10-12. We robustly detect several chemical species at high significance, including Na (19σ), H2O (33σ), CO2 (28σ) and CO (7σ). The non-detection of CH4, combined with a strong CO2 feature, favours atmospheric models with a super-solar atmospheric metallicity. An unanticipated absorption feature at 4 µm is best explained by SO2 (2.7σ), which could be a tracer of atmospheric photochemistry. These observations demonstrate JWST's sensitivity to a rich diversity of exoplanet compositions and chemical processes.

Cardiac abnormalities in Long COVID 1-year post-SARS-CoV-2 infection

BACKGROUND

Long COVID is associated with multiple symptoms and impairment in multiple organs. Cross-sectional studies have reported cardiac impairment to varying degrees by varying methodologies. Using cardiac MR (CMR), we investigated a 12-month trajectory of abnormalities in Long COVID.

OBJECTIVES

To investigate cardiac abnormalities 1-year post-SARS-CoV-2 infection.

METHODS

534 individuals with Long COVID underwent CMR (T1/T2 mapping, cardiac mass, volumes, function and strain) and multiorgan MRI at 6 months (IQR 4.3-7.3) since first post-COVID-19 symptoms. 330 were rescanned at 12.6 (IQR 11.4-14.2) months if abnormal baseline findings were reported. Symptoms, questionnaires and blood samples were collected at both time points. CMR abnormalities were defined as ≥1 of low left or right ventricular ejection fraction (LVEF), high left or right ventricular end diastolic volume, low 3D left ventricular global longitudinal strain (GLS), or elevated native T1 in ≥3 cardiac segments. Significant change over time was reported by comparison with 92 healthy controls.

RESULTS

Technical success of multiorgan and CMR assessment in non-acute settings was 99.1% and 99.6% at baseline, and 98.3% and 98.8% at follow-up. Of individuals with Long COVID, 102/534 (19%) had CMR abnormalities at baseline; 71/102 had complete paired data at 12 months. Of those, 58% presented with ongoing CMR abnormalities at 12 months. High sensitivity cardiac troponin I and B-type natriuretic peptide were not predictive of CMR findings, symptoms or clinical outcomes. At baseline, low LVEF was associated with persistent CMR abnormality, abnormal GLS associated with low quality of life and abnormal T1 in at least three segments was associated with better clinical outcomes at 12 months.

CONCLUSION

CMR abnormalities (left entricular or right ventricular dysfunction/dilatation and/or abnormal T1mapping), occurred in one in five individuals with Long COVID at 6 months, persisting in over half of those at 12 months. Cardiac-related blood biomarkers could not identify CMR abnormalities in Long COVID.

TRIAL REGISTRATION NUMBER

NCT04369807.

Differential expression of TLR4 in patients of coronary artery disease with and without traditional cardiovascular risk factors

Funding Acknowledgements

Type of funding sources: None.

Background

Atherosclerosis is inherently an inflammatory process, with a complex interplay of inflammatory markers. It is established that these inflammatory markers play an important role in patients of Coronary Artery Disease(CAD) with traditional cardiovascular risk factors. However, the role of inflammation in the atherosclerotic process in patients of CAD without traditional risk factors is still not clearly known.

Purpose

Our purpose was to determine whether in patients of CAD without traditional risk factors, TLR4(Toll like receptor 4) expression as a marker of inflammation is similar to that in patients of CAD with traditional risk factors.

Materials and Methods

This observational cross sectional study was done between July’20 to Dec’21. Equal number of patients of CAD with and without traditional cardiovascular risk factors undergoing Coronary Artery Bypass Grafting (CABG) were enrolled. The risk factors considered were Hypertension, Diabetes, Dyslipidemia, Obesity and Addiction to Tobacco and/or Alcohol. A minimum of two punch biopsy samples of aortic tissue was taken from each subject undergoing CABG. Immunohistochemistry for TLR4, was done in Ventana BenchMark GX System. The primary TLR4 antibody was procured from reputed source.

Results

The presence or absence of TLR4 expression was associated significantly with the Syntax scores (37.40±4.74 vs 29.5±8.71; p value=0.036), total Cholesterol (187±35.06mg/dL vs 130±35.69 mg/dL ;p value 0.010) and LDL cholesterol (118.86±28.12mg/dL vs 64.21±25.61 mg/dL; p value 0.003). TLR4 expression, however, was not significantly associated with the number of coronary vessels involved (p=0.298). TLR4 expression was also not significantly associated with any other individual risk factors. However, when the traditional risk factors were considered in combination, TLR4 expression was associated significantly with the number of risk factors present(p=0.029) the strongest being in those having 4 traditional risk factors. The level of TLR4 expression gradually declined with the decrease in the number of risk factors, having mostly weak or negative expression in patients without any traditional risk factors.

Conclusion

Patients with CAD without any traditional risk factors, had a less severe coronary artery disease as manifested by lower Syntax scores, and had lower degree of TLR4 expression. Patients with CAD with traditional risk factors had more severe coronary artery disease as evidenced by higher Syntax scores, and had higher degree of TLR4 expression proportional to the number of traditional risk factors present. Thus, differential TLR4 expression in CAD patients with and without traditional risk factors indicated a difference in inflammatory state between the two groups and warrants further investigation.

Model-based estimation of burden of COVID-19 with disability-adjusted life years and value of statistical life in West Bengal, India

OBJECTIVES

The COVID-19 pandemic has posed unprecedented challenges to health systems and populations, particularly in India. Comprehensive, population-level studies of the burden of disease could inform planning, preparedness and policy, but are lacking in India. In West Bengal, India, we conducted a detailed analysis of the burden caused by COVID-19 from its onset to 7 January 2022.

SETTING

Open-access, population-level and administrative data sets for West Bengal were used.

PRIMARY AND SECONDARY OUTCOME MEASURES

Disability-adjusted life years (DALYs), years of potential productive life lost (YPPLL), cost of productivity lost (CPL: premature mortality and absenteeism), years of potential life lost (YPLL), premature years of potential life lost, working years of potential life lost (WYPLL) and value of statistical life (VSL) were estimated across scenarios (21 for DALY and 3 each for YPLL and VSL) to evaluate the effects of different factors.

RESULTS

COVID-19 had a higher impact on the elderly population with 90.2% of deaths arising from people aged above 45. In males and females, respectively, DALYs were 190 568.1 and 117 310.0 years, YPPLL of the productive population was 28 714.7 and 16 355.4 years, CPL due to premature mortality was INR3 198 259 615.6 and INR583 397 335.1 and CPL due to morbidity was INR2 505 568 048.4 and INR763 720 886.1. For males and females, YPLL ranged from 189 103.2 to 272 787.5 years and 117 925.5 to 169 712.0 years for lower to higher age limits, and WYPLL was 54 333.9 and 30 942.2 years. VSL (INR million) for the lower, midpoint and upper life expectancies was 883 330.8; 882 936.4; and 880 631.3, respectively. Vaccination was associated with reduced mortality.

CONCLUSIONS

The losses incurred due to COVID-19 in terms of the computed estimates in West Bengal revealed a disproportionately higher impact on the elderly and males. Analysis of various age-gender subgroups enhances localised and targeted policymaking to minimise the losses for future pandemics.

The Use of Digital Health Interventions for Cardiometabolic Diseases Among South Asian and Black Minority Ethnic Groups: Realist Review

BACKGROUND

Digital health interventions (DHIs) for the prevention and management of cardiometabolic diseases have become increasingly common. However, there is limited evidence for the suitability of these approaches in minority ethnic populations, who are at an increased risk of these diseases.

OBJECTIVE

This study aimed to investigate the use of DHIs for cardiovascular disease and type 2 diabetes among minority ethnic populations in countries with a majority of White, English-speaking populations, focusing on people who identified as South Asian, Black, or African American.

METHODS

A realist methodology framework was followed. A literature search was conducted to develop context-mechanism-outcome configurations, including the contexts in which DHIs work for the target minority ethnic groups, mechanisms that these contexts trigger, and resulting health outcomes. After systematic searches, a qualitative analysis of the included studies was conducted using deductive and inductive coding.

RESULTS

A total of 15 studies on the uptake of DHIs for cardiovascular disease or diabetes were identified, of which 13 (87%) focused on people with an African-American background. The review found evidence supporting the use of DHIs in minority ethnic populations when specific factors are considered in implementation and design, including patients' beliefs, health needs, education and literacy levels, material circumstances, culture, social networks, and wider community and the supporting health care systems.

CONCLUSIONS

Our context-mechanism-outcome configurations provide a useful guide for the future development of DHIs targeted at South Asian and Black minority ethnic populations, with specific recommendations for improving cultural competency and promoting accessibility and inclusivity of design.

The prevalence and long-term health effects of Long Covid among hospitalised and non-hospitalised populations: A systematic review and meta-analysis

BACKGROUND

The aim of this study was to systematically synthesise the global evidence on the prevalence of persistent symptoms in a general post COVID-19 population.

METHODS

A systematic literature search was conducted using multiple electronic databases (MEDLINE and The Cochrane Library, Scopus, CINAHL, and medRxiv) until January 2022. Studies with at least 100 people with confirmed or self-reported COVID-19 symptoms at ≥28 days following infection onset were included. Patient-reported outcome measures and clinical investigations were both assessed. Results were analysed descriptively, and meta-analyses were conducted to derive prevalence estimates. This study was pre-registered (PROSPERO-ID: CRD42021238247).

FINDINGS

194 studies totalling 735,006 participants were included, with five studies conducted in those <18 years of age. Most studies were conducted in Europe (n = 106) or Asia (n = 49), and the time to follow-up ranged from ≥28 days to 387 days. 122 studies reported data on hospitalised patients, 18 on non-hospitalised, and 54 on hospitalised and non-hospitalised combined (mixed). On average, at least 45% of COVID-19 survivors, regardless of hospitalisation status, went on to experience at least one unresolved symptom (mean follow-up 126 days). Fatigue was frequently reported across hospitalised (28.4%; 95% CI 24.7%-32.5%), non-hospitalised (34.8%; 95% CI 17.6%-57.2%), and mixed (25.2%; 95% CI 17.7%-34.6%) cohorts. Amongst the hospitalised cohort, abnormal CT patterns/x-rays were frequently reported (45.3%; 95% CI 35.3%-55.7%), alongside ground glass opacification (41.1%; 95% CI 25.7%-58.5%), and impaired diffusion capacity for carbon monoxide (31.7%; 95% CI 25.8%-3.2%).

INTERPRETATION

Our work shows that 45% of COVID-19 survivors, regardless of hospitalisation status, were experiencing a range of unresolved symptoms at ∼ 4 months. Current understanding is limited by heterogeneous study design, follow-up durations, and measurement methods. Definition of subtypes of Long Covid is unclear, subsequently hampering effective treatment/management strategies.

FUNDING

No funding.

The impact of the COVID-19 pandemic on cardiovascular disease prevention and management

How the Coronavirus Disease 2019 (COVID-19) pandemic has affected prevention and management of cardiovascular disease (CVD) is not fully understood. In this study, we used medication data as a proxy for CVD management using routinely collected, de-identified, individual-level data comprising 1.32 billion records of community-dispensed CVD medications from England, Scotland and Wales between April 2018 and July 2021. Here we describe monthly counts of prevalent and incident medications dispensed, as well as percentage changes compared to the previous year, for several CVD-related indications, focusing on hypertension, hypercholesterolemia and diabetes. We observed a decline in the dispensing of antihypertensive medications between March 2020 and July 2021, with 491,306 fewer individuals initiating treatment than expected. This decline was predicted to result in 13,662 additional CVD events, including 2,281 cases of myocardial infarction and 3,474 cases of stroke, should individuals remain untreated over their lifecourse. Incident use of lipid-lowering medications decreased by 16,744 patients per month during the first half of 2021 as compared to 2019. By contrast, incident use of medications to treat type 2 diabetes mellitus, other than insulin, increased by approximately 623 patients per month for the same time period. In light of these results, methods to identify and treat individuals who have missed treatment for CVD risk factors and remain undiagnosed are urgently required to avoid large numbers of excess future CVD events, an indirect impact of the COVID-19 pandemic.

Long COVID: mechanisms, risk factors and recovery

NEW FINDINGS

What is the topic of this review? The emerging condition of long COVID, its epidemiology, pathophysiological impacts on patients of different backgrounds, physiological mechanisms emerging as explanations of the condition, and treatment strategies being trialled. The review leads from a Physiological Society online conference on this topic. What advances does it highlight? Progress in understanding the pathophysiology and cellular mechanisms underlying Long COVID and potential therapeutic and management strategies.

ABSTRACT

Long COVID, the prolonged illness and fatigue suffered by a small proportion of those infected with SARS-CoV-2, is placing an increasing burden on individuals and society. A Physiological Society virtual meeting in February 2022 brought clinicians and researchers together to discuss the current understanding of long COVID mechanisms, risk factors and recovery. This review highlights the themes arising from that meeting. It considers the nature of long COVID, exploring its links with other post-viral illnesses such as myalgic encephalomyelitis/chronic fatigue syndrome, and highlights how long COVID research can help us better support those suffering from all post-viral syndromes. Long COVID research started particularly swiftly in populations routinely monitoring their physical performance - namely the military and elite athletes. The review highlights how the high degree of diagnosis, intervention and monitoring of success in these active populations can suggest management strategies for the wider population. We then consider how a key component of performance monitoring in active populations, cardiopulmonary exercise training, has revealed long COVID-related changes in physiology - including alterations in peripheral muscle function, ventilatory inefficiency and autonomic dysfunction. The nature and impact of dysautonomia are further discussed in relation to postural orthostatic tachycardia syndrome, fatigue and treatment strategies that aim to combat sympathetic overactivation by stimulating the vagus nerve. We then interrogate the mechanisms that underlie long COVID symptoms, with a focus on impaired oxygen delivery due to micro-clotting and disruption of cellular energy metabolism, before considering treatment strategies that indirectly or directly tackle these mechanisms. These include remote inspiratory muscle training and integrated care pathways that combine rehabilitation and drug interventions with research into long COVID healthcare access across different populations. Overall, this review showcases how physiological research reveals the changes that occur in long COVID and how different therapeutic strategies are being developed and tested to combat this condition.

Using national electronic health records for pandemic preparedness: validation of a parsimonious model for predicting excess deaths among those with COVID-19-a data-driven retrospective cohort study

OBJECTIVES

To use national, pre- and post-pandemic electronic health records (EHR) to develop and validate a scenario-based model incorporating baseline mortality risk, infection rate (IR) and relative risk (RR) of death for prediction of excess deaths.

DESIGN

An EHR-based, retrospective cohort study.

SETTING

Linked EHR in Clinical Practice Research Datalink (CPRD); and linked EHR and COVID-19 data in England provided in NHS Digital Trusted Research Environment (TRE).

PARTICIPANTS

In the development (CPRD) and validation (TRE) cohorts, we included 3.8 million and 35.1 million individuals aged ≥30 years, respectively.

MAIN OUTCOME MEASURES

One-year all-cause excess deaths related to COVID-19 from March 2020 to March 2021.

RESULTS

From 1 March 2020 to 1 March 2021, there were 127,020 observed excess deaths. Observed RR was 4.34% (95% CI, 4.31-4.38) and IR was 6.27% (95% CI, 6.26-6.28). In the validation cohort, predicted one-year excess deaths were 100,338 compared with the observed 127,020 deaths with a ratio of predicted to observed excess deaths of 0.79.

CONCLUSIONS

We show that a simple, parsimonious model incorporating baseline mortality risk, one-year IR and RR of the pandemic can be used for scenario-based prediction of excess deaths in the early stages of a pandemic. Our analyses show that EHR could inform pandemic planning and surveillance, despite limited use in emergency preparedness to date. Although infection dynamics are important in the prediction of mortality, future models should take greater account of underlying conditions.

Predictors of self-management in patients with chronic low back pain: a longitudinal study

BACKGROUND

Self-management (SM) is a key recommended strategy for managing chronic low back pain (CLBP). However, SM programmes generate small to moderate benefits for reducing pain and disability in patients with CLBP. The benefits of the SM programme can potentially be optimised by identifying specific subgroups of patients who are the best responders. To date, no longitudinal study has examined the predictive relationships between SM and biopsychosocial factors in patients with CLBP. The aim was to determine whether biopsychosocial factors predict SM and its change over time in patients with CLBP.

METHODS

In this multi-centre longitudinal cohort study, we recruited 270 working-age patients with CLBP (mean age 43.74, 61% female) who consulted outpatient physiotherapy for their CLBP. Participants completed self-reported validated measures of pain intensity, disability, physical activity, kinesiophobia, catastrophising, depression and SM at baseline and six months. SM constructs were measured using eight subscales of the Health Education Impact Questionnaire (heiQ), including Health Directed Activity (HDA), Positive and Active Engagement in Life (PAEL), Emotional Distress (ED), Self-Monitoring and Insight (SMI), Constructive Attitudes and Approaches (CAA), Skill and Technique Acquisition (STA), Social Integration and Support (SIS) and Health Service Navigation (HSN). Data were analysed using General Linear Model (GLM) regression.

RESULTS

Physical activity and healthcare use (positively) and disability, depression, kinesiophobia, catastrophising (negatively) predicted (p < 0.05, R² 0.07-0.55) SM constructs at baseline in patients with CLBP. Baseline depression (constructs: PAEL, ED, SMI, CAA and STA), kinesiophobia (constructs: CAA and HSN), catastrophising (construct: ED), and physical disability (constructs: PAEL, CAA and SIS) negatively predicted a range of SM constructs. Changes over six months in SM constructs were predicted by changes in depression, kinesiophobia, catastrophising, and physical activity (p < 0.05, R² 0.13-0.32).

CONCLUSIONS

Self-reported disability, physical activity, depression, catastrophising and kinesiophobia predicted multiple constructs of SM measured using the heiQ subscales in working-age patients with CLBP. Knowledge of biopsychosocial predictors of SM may help triage patients with CLBP into targeted pain management programmes.

TRIAL REGISTRATION

The study protocol was registered at ClinicalTrials.gov on 22 December 2015 (ID: NCT02636777).

Evaluating a novel, integrative dashboard for health professionals' performance in managing deteriorating patients: a quality improvement project

BACKGROUND

The quality of recording and documentation of deteriorating patient management by health professionals has been challenged during the COVID-19 pandemic. Non-adherence to escalation and documentation guidelines increases risk of serious adverse events. Electronic health record (EHR)-integrated dashboards are auditing tools of patients' status and clinicians' performance, but neither the views nor the performance of health professionals have been assessed, relating to management of deteriorating patients.

OBJECTIVE

To develop and evaluate a real-time dashboard of deteriorating patients' assessment, referral and therapy.

SETTINGS

Five academic hospitals in the largest National Health Service (NHS) trust in the UK (Barts Health NHS Trust).

INTERVENTION

The dashboard was developed from EHR data to investigate patients with National Early Warning Score (NEWS2)>5, assessment, and escalation of deteriorating patients. We adopted the Plan, Do, Study, Act model and Standards for Quality Improvement Reporting Excellence framework to evaluate the dashboard.

DESIGN

Mixed methods: (1) virtual, face-to-face, interviews and (2) retrospective descriptive EHR data analysis.

RESULTS

We interviewed three nurses (two quality and safety and one informatics specialists). Participants perceived the dashboard as a facilitator for auditing NEWS2 recording and escalation of care to improve practice; (2) there is a need for guiding clinicians and adjusting data sources and metrics to enhance the functionality and usability. Data analysis (2019-2022) showed: (1) NEWS2 recording has gradually improved (May 2021-April 2022) from 64% to 83%;(2) referral and assessment completion increased (n: 170-6800 and 23-540, respectively).

CONCLUSION

The dashboard is an effective real-time data-driven method for improving the quality of managing deteriorating patients. Integrating health systems, a wider analysis NEWS2 and escalation of care metrics, and clinicians' learning digital solutions will enhance functionality and experience to boost its value. There is a need to examine the generalisability of the dashboard through further validation and quality improvement studies.

STIMULATE-ICP-Delphi (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways Delphi): Study protocol

INTRODUCTION

As mortality rates from COVID-19 disease fall, the high prevalence of long-term sequelae (Long COVID) is becoming increasingly widespread, challenging healthcare systems globally. Traditional pathways of care for Long Term Conditions (LTCs) have tended to be managed by disease-specific specialties, an approach that has been ineffective in delivering care for patients with multi-morbidity. The multi-system nature of Long COVID and its impact on physical and psychological health demands a more effective model of holistic, integrated care. The evolution of integrated care systems (ICSs) in the UK presents an important opportunity to explore areas of mutual benefit to LTC, multi-morbidity and Long COVID care. There may be benefits in comparing and contrasting ICPs for Long COVID with ICPs for other LTCs.

METHODS AND ANALYSIS

This study aims to evaluate health services requirements for ICPs for Long COVID and their applicability to other LTCs including multi-morbidity and the overlap with medically not yet explained symptoms (MNYES). The study will follow a Delphi design and involve an expert panel of stakeholders including people with lived experience, as well as clinicians with expertise in Long COVID and other LTCs. Study processes will include expert panel and moderator panel meetings, surveys, and interviews. The Delphi process is part of the overall STIMULATE-ICP programme, aimed at improving integrated care for people with Long COVID.

ETHICS AND DISSEMINATION

Ethical approval for this Delphi study has been obtained (Research Governance Board of the University of York) as have approvals for the other STIMULATE-ICP studies. Study outcomes are likely to inform policy for ICPs across LTCs. Results will be disseminated through scientific publication, conference presentation and communications with patients and stakeholders involved in care of other LTCs and Long COVID.

REGISTRATION

Researchregistry: https://www.researchregistry.com/browse-the-registry#home/registrationdetails/6246bfeeeaaed6001f08dadc/.

Effects of the COVID-19 pandemic on secondary care for cardiovascular disease in the UK: an electronic health record analysis across three countries

BACKGROUND

Although morbidity and mortality from COVID-19 have been widely reported, the indirect effects of the pandemic beyond 2020 on other major diseases and health service activity have not been well described.

METHODS

Analyses used national administrative electronic hospital records in England, Scotland and Wales for 2016-2021. Admissions and procedures during the pandemic (2020-2021) related to six major cardiovascular conditions (acute coronary syndrome, heart failure, stroke/transient ischaemic attack, peripheral arterial disease, aortic aneurysm, and venous thromboembolism) were compared to the annual average in the pre-pandemic period (2016-2019). Differences were assessed by time period and urgency of care.

RESULTS

In 2020, there were 31 064 (-6%) fewer hospital admissions (14 506 [-4%] fewer emergencies, 16 560 [-23%] fewer elective admissions) compared to 2016-2019 for the six major cardiovascular diseases combined. The proportional reduction in admissions was similar in all three countries. Overall, hospital admissions returned to pre-pandemic levels in 2021. Elective admissions remained substantially below expected levels for almost all conditions in all three countries (-10 996 [-15%] fewer admissions). However, these reductions were offset by higher than expected total emergency admissions (+25 878 [+6%] higher admissions), notably for heart failure and stroke in England, and for venous thromboembolism in all three countries. Analyses for procedures showed similar temporal variations to admissions.

CONCLUSION

This study highlights increasing emergency cardiovascular admissions during the pandemic, in the context of a substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years.

Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study

OBJECTIVE

To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment.

DESIGN

Retrospective cohort study.

SETTING

Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD).

PARTICIPANTS

Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg.

MAIN OUTCOME MEASURE

First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%.

RESULTS

Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies.

CONCLUSIONS

This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model's clinical utility and cost effectiveness.

Significant reduction in chronic kidney disease progression with sodium-glucose cotransporter-2 inhibitors compared to dipeptidyl peptidase-4 inhibitors in adults with type 2 diabetes in a UK clinical setting: An observational outcomes study based on international guidelines for kidney disease

AIMS

To confirm the reno-protective effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors compared with dipeptidyl peptidase-4 (DPP-4) inhibitors on the onset and progression of chronic kidney disease (CKD) in routine clinical practice.

MATERIALS AND METHODS

We conducted a retrospective cohort study using the Clinical Practice Research Datalink Aurum database linked to Hospital Episode Statistics. The primary outcome was risk of the composite CKD endpoint based on the recent consensus guidelines for kidney disease: >40% decline in estimated glomerular filtration rate (eGFR), kidney death or end-stage kidney disease (ESKD; a composite of kidney transplantation, maintenance of dialysis, sustained low eGFR <15 ml/min/1.73m² or diagnosis of ESKD). Secondary outcomes were components of the composite CKD endpoint, analysed separately. Patients were propensity-score-matched 1:1 for SGLT2 inhibitor versus DPP-4 inhibitor use.

RESULTS

A total of 131 824 people with type 2 diabetes (T2D) were identified; 79.0% had no known history of CKD. During a median follow-up of 2.1 years, SGLT2 inhibitor initiation was associated with lower risk of progression to composite kidney endpoints than DPP-4 inhibitor initiation (7.48 vs. 11.77 events per 1000 patient-years, respectively). Compared with DPP-4 inhibitor initiation, SGLT2 inhibitor initiation was associated with reductions in the primary composite CKD endpoint (hazard ratio [HR] 0.64, 95% confidence interval [CI] 0.56-0.74), all-cause mortality (HR 0.74, 95% CI 0.64-0.86) and ESKD (HR 0.37, 95% CI 0.25-0.55), reduced the rate of sustained low eGFR (HR 0.33, 95% CI 0.19-0.57), and reduced diagnoses of ESKD in primary care (HR 0.04, 95% CI 0.01-0.18). Results were consistent across subgroup and sensitivity analyses.

CONCLUSIONS

In adults with T2D, initiation of an SGLT2 inhibitor was associated with a significantly reduced risk of CKD progression and death compared with initiation of a DPP-4 inhibitor.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

CODE-EHR best practice framework for the use of structured electronic healthcare records in clinical research

Big data is central to new developments in global clinical science aiming to improve the lives of patients. Technological advances have led to the routine use of structured electronic healthcare records with the potential to address key gaps in clinical evidence. The covid-19 pandemic has demonstrated the potential of big data and related analytics, but also important pitfalls. Verification, validation, and data privacy, as well as the social mandate to undertake research are key challenges. The European Society of Cardiology and the BigData@Heart consortium have brought together a range of international stakeholders, including patient representatives, clinicians, scientists, regulators, journal editors and industry. We propose the CODE-EHR Minimum Standards Framework as a means to improve the design of studies, enhance transparency and develop a roadmap towards more robust and effective utilisation of healthcare data for research purposes.

Impact of COVID-19 on cardiac procedure activity in England and associated 30-day mortality

Background

The COVID-19 pandemic had a significant impact on the quality of healthcare provision across all specialities and disciplines. However, there are limited data on the scale of its disruption to cardiac procedure activity from a national perspective and whether procedural outcomes different before and during the COVID-19 pandemic.

Methods

Major cardiac procedures (n=374,899) performed between 1st January and 31st May for the years 2018, 2019 and 2020 were analysed, stratified by procedure type and time-period (pre-COVID: January-May 2018 and 2019 and January-February 2020 and COVID: March-May 2020). Multivariable logistic regression modelling was undertaken to examine the odds ratio (OR) of 30-day mortality for procedures performed in the COVID period (vs. pre-COVID).

Results

There was a deficit of 45,501 procedures during the COVID period compared to the monthly averages (March-May) in 2018–2019. Cardiac catheterisation and cardiac electronic device implantations were the most affected in terms of numbers (n=19,637 and n=10,453) while surgical procedures including mitral valve replacement, other valve replacement/repair, atrial and ventricular septal defect repair, and CABG were the most affected as a relative percentage difference (D) to previous years' averages. TAVR was the least affected (D-10.6%). No difference in 30-day mortality was observed between pre-COVID and COVID time-periods for all cardiac procedures except cardiac catheterisation (OR 1.25 95% confidence interval (CI) 1.07–1.47, p=0.006) and cardiac device implantation (OR 1.35 95% CI 1.15–1.58, p&lt;0.001).

Conclusion

There was a significant decline in national cardiac procedural activity in England during the COVID-19 pandemic, with a deficit in excess of 45000 procedures over the study period. However, there was no increase in risk of mortality for most cardiac procedures performed during the pandemic. While health service pressures are gradually easing given the increased roll out of vaccination and decline in infection rates, there is a need for major restructuring of cardiac services deal with this significant backlog of procedures, which would inevitably impact longer-term morbidity and mortality.

Funding Acknowledgement

Type of funding sources: None.

Point-of-care NT-proBNP for the screening of PREGnancy-related Heart Failure – the PREG-HF study

Introduction

Cardiovascular disease is an important cause of maternal mortality worldwide. However, diagnosing heart failure (HF) during pregnancy remains challenging. Patients with HF present with symptoms that are often attributed to the physiological changes of pregnancy. Although the measurement of natriuretic peptides (such as NT-proBNP) has been recommended as a cost-effective screening test for HF, its value in predicting underlying structural heart disease on echocardiography during pregnancy is unclear.

Purpose

To evaluate the accuracy of point-of-care (POC) NT-proBNP to predict echocardiographic evidence of structural heart disease in pregnant women.

Methods

All consecutive consenting pregnant women with symptoms of HF (New York Heart Association functional class [NYHA FC] II–IV), who underwent echocardiography at Groote Schuur Hospital (a tertiary hospital in South Africa) between 1 March 2021 and 15 March 2022 were recruited and compared with asymptomatic pregnant women (NYHA FC I). Demographic and obstetric data were collected, as well as clinical and echocardiographic parameters. POC NT-proBNP was measured; a receiver operating characteristic (ROC) curve was used to determine the level of NT-proBNP that would have the best predictive value for detecting structural heart disease on echocardiography.

Results

We included 121 women with a median age of 31.3 years (IQR 24.9–36.4) and a median gravidity of 3 (2–4), mostly in their third trimester of pregnancy (75.2%). Symptomatic women (66.1%) presented mainly with dyspnoea (92.5%) and fatigue (73.8%). Most common signs of HF were peripheral oedema (46.8%), jugular venous distension (17.7%) and pulmonary crackles (17.7%). Overall, the median POC NT-proBNP was 98pg/ml (60–506) but was not statistically different between symptomatic and asymptomatic participants. However, NT-proBNP levels were significantly elevated in those with left ventricular (LV) dilatation (376 [86–744] vs 65 [60–191], p=0.001), left atrial enlargement (395 [65–744] vs 60 [59–108], p&lt;0.001), LV systolic dysfunction (510 [113–1668] vs 65 [60–210], p&lt;0.001), diastolic dysfunction (300 [77–1450] vs 78 [60–257], p=0.031), mitral regurgitation (167 [60–672] vs 78 [60–243], p=0.038) and pericardial effusion (440 [81–1031] vs 71 [60–243], p=0.011) (Figure 1). An NT-proBNP of &lt;200pg/ml had the highest negative predictive value (83%) to rule out structural heart disease (AUC 0.68 [0.59–0.77]). Patients with NT-proBNP of ≥200pg/ml were at increased risk of having echocardiographic evidence of structural heart disease (diagnostic odds ratio 4.9 [95% confidence interval 2.0–11.7]).

Conclusion

In this cohort of pregnant women with symptoms suggestive of HF, POC NT-proBNP identified those with structural heart disease with acceptable discrimination. POC NT-proBNP testing might be particularly useful as a screening test in settings where pregnant women do not readily have access to echocardiography.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): World Heart Federation Salim Yusuf Emerging Leaders Programme