A service evaluation of Zio XT: the Liverpool experience

Introduction

The Zio XT is an adhesive, ambulatory heart rhythm monitoring device that can be worn for up to 14 days. It can be fitted by patients and utilises an Artificial Intelligence-based algorithm for rhythm analysis, offering potential convenience, accuracy and efficiency compared to Holter monitors. However, there is a lack of data regarding its efficacy and long-term impact. Thus, until further evidence ensues, NICE guidelines recommend Zio XT as a potential option for those requiring prolonged rhythm monitoring.

Purpose

We evaluated the efficacy of Zio XT for heart rhythm monitoring compared to Holter monitors.

Methods

200 sequential patients that had Holter monitors and 204 that had Zio XT were included. Zio cases were randomly selected over 6 months to avoid the learning curve effect. Primary outcomes included time to results and the arrhythmia detection rate. Secondary outcomes included the proportion of patients that had heart rhythm monitoring in the 12 months preceding their investigation, those who required further tests as well as rates of outpatient appointments (OPAs) for device fitting and follow-up, and procedures such as device implantation and ablations.

Results

Data from 22 (10.8%) Zio patches was unavailable due to these being lost/not returned/unwearable, thus post-investigation outcomes were analysed for 182 Zio and 200 Holter cases. Zio XT was associated with a significantly shorter time to results compared to Holter monitors (median time: 21 days (interquartile range (IQR) 18–25) vs. 46 days (IQR 37.3–87.8), p<0.001), and a higher significant arrhythmia detection rate (55.4% vs. 17.5%, p<0.001). 26.5% of Zio patients had heart-rhythm monitoring in the preceding 12 months, compared to the 14.5% in the Holter group, p=0.003, with 55.8% having Holters and 28.8% having Zios previously, in the Zio group. A higher proportion of Zio recipients also required repeat tests (19.4 vs. 8.5%, p=0.002). Reasons for this included post-intervention monitoring (44.1%), lack of results due to devices being lost/faulty/not returned (41.2%) and a lack of diagnosis (14.7%). Zio monitoring was associated with a significant reduction in the need for OPAs for fitting (0.5% vs. 96%, p<0.001) and follow-up (70.1% vs. 87.0, p<0.001), and resulted in a significant increase in ablations (5.9% vs. 1.0%, p=0.005) but not device implantations (5.9% vs. 3.9, p=0.209).

Conclusion

Our findings indicate that Zio XT is associated with a statistically significant reduction in time to results, higher arrhythmia detection rate and a reduced need for OPAs. We demonstrated a higher rate of both Holter and Zio testing before and Zio testing after these investigations. We postulate that this has partly been due to a learning curve effect with the introduction of a new technology compared to the Holter which has been in use for many decades. Further large-scale evaluation is recommended to yield vital information on management pathways and cost efficacy.

Funding Acknowledgement

Type of funding sources: None.

Promoting resilience in healthcare workers during the COVID-19 pandemic with a brief online intervention

INTRODUCTION

The psychological wellbeing of healthcare workers has been impacted by the high levels of stress many have experienced during the Coronavirus Disease 2019 (COVID-19) pandemic. This study aimed to examine the feasibility and acceptability of a brief online course focused on introducing evidence-based skills that could increase resilience and decreases emotional distress in healthcare workers during the pandemic.

MATERIALS AND METHODS

Employees of a large healthcare system completed a mental health survey at baseline, and then one month and two months after some employees participated in an online resilience-enhancement course consisting of three 12-19 min videos focused on mindfulness, mentalization, and self-compassion.

RESULTS

A total of 554 participants completed the baseline survey, endorsing moderate to high levels of emotional distress. Of those who completed all three assessments and participated in the course (n = 38), significant improvements in resilience and reductions in emotional distress were found one and two months later, in comparison to those who did not participate in the course (n = 110).

DISCUSSION

These findings suggest that a brief, online intervention can improve the mental health of healthcare workers during a crisis such as the COVID-19 pandemic.

Favipiravir strikes the SARS-CoV-2 at its Achilles heel, the RNA polymerase

The ongoing Corona Virus Disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has emphasized the urgent need for antiviral therapeutics. The viral RNA-dependent-RNA-polymerase (RdRp) is a promising target with polymerase inhibitors successfully used for the treatment of several viral diseases. Here we show that Favipiravir exerts an antiviral effect as a nucleotide analogue through a combination of chain termination, slowed RNA synthesis and lethal mutagenesis. The SARS-CoV RdRp complex is at least 10-fold more active than any other viral RdRp known. It possesses both unusually high nucleotide incorporation rates and high-error rates allowing facile insertion of Favipiravir into viral RNA, provoking C-to-U and G-to-A transitions in the already low cytosine content SARS-CoV-2 genome. The coronavirus RdRp complex represents an Achilles heel for SARS-CoV, supporting nucleoside analogues as promising candidates for the treatment of COVID-19.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

A Phase II Toxicity End Point Trial (ICORG 99-09) of Accelerated Dose-escalated Hypofractionated Radiation in Non-small Cell Lung Cancer

AIMS

The objective of this phase II clinical trial was to prospectively evaluate the safety and efficacy of accelerated hypofractionated three-dimensional conformal radiation therapy (3DCRT) in localised non-resectable/non-operable non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Sixty patients with stage I-III NSCLC were enrolled in a prospective single-arm All Ireland Co-operative Oncology Research Group (ICORG 99-09) toxicity end point phase II trial. The protocol allocated patients between three radiation schedule dose levels (60, 66 or 72 Gy, in 20, 22 and 24 fractions, respectively, 3 Gy daily, five fractions per week) according to combined lung V_25Gy (V_25Gy ≤ 30%) with built-in early stopping toxicity rules. The primary end point was toxicity with evaluation of dose-limiting toxicity. The secondary objectives included radiological tumour response rate at 3 months after the completion of radiation therapy and the thoracic progression-free survival time.

RESULTS

Sixty patients were recruited from August 1999 to June 2009. Forty-nine patients were included in the primary per-protocol analysis. Eleven patients were not evaluable. In the first 30 evaluable patient cohort, severe oesophageal toxicity was reported in two patients (2/49; 4% experiencing grade 5 oesophageal late toxicity, related to the 97% oesophageal length). The trial was temporarily closed and was then reopened to validate an oesophageal dose volume constraint (DVC) of limiting the length of oesophagus fully encompassed by the 97% isodose to less than 1 cm (applied to 21 patients). The trial prospectively showed the safety of the oesophageal DVC, with no oesophageal toxicity above grade 3 thereafter. Thirty-nine per cent of patients had disease progression at 3-4 months after radiotherapy, 22% had stable disease, 20% had a complete response and 14% had a partial response. The median overall survival was 13.6 months (95% confidence interval 10.5-16.7) and overall survival at 1 and 3 years was 57% and 29%, respectively.

CONCLUSION

A strategy using accelerated hypofractionated 3DCRT is feasible and reasonably safe for patients with inoperable NSCLC. It is safe to deliver for centrally located tumours if DVCs are applied to the oesophagus, which is the primary dose-limiting toxicity. Further studies are required to assess the efficacy of hypofractionated regimens for centrally located tumours using an oesophageal DVC and monitoring for oesophageal toxicity.

Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Hip Fracture Anaesthesia Network

The aim of this audit was to investigate process, personnel and anaesthetic factors in relation to mortality among patients with proximal femoral fractures. A questionnaire was used to record standardised data about 1195 patients with proximal femoral fracture admitted to 22 hospitals contributing to the Hip Fracture Anaesthesia Network over a 2-month winter period. Patients were demographically similar between hospitals (mean age 81 years, 73% female, median ASA grade 3). However, there was wide variation in time from admission to operation (24-108 h) and 30-day postoperative mortality (2-25%). Fifty percent of hospitals had a mean admission to operation time < 48 h. Forty-two percent of operations were delayed: 51% for organisational; 44% for medical; and 4% for 'anaesthetic' reasons. Regional anaesthesia was administered to 49% of patients (by hospital, range = 0-82%), 51% received general anaesthesia and 19% of patients received peripheral nerve blockade. Consultants administered 61% of anaesthetics (17-100%). Wide national variations in current management of patients sustaining proximal femoral fracture reflect a lack of research evidence on which to base best practice guidance. Collaborative audits such as this provide a robust method of collecting such evidence.

A stable cell line with a proportion of cells persistently infected with bovine viral diarrhoea virus

Bovine turbinate (BTu) and lamb testis (LT) cell lines persistently infected with bovine viral diarrhoea virus (BVDV) arose as a result of a single change of medium containing commercial foetal calf serum. Infected cells comprise 30% and 50% respectively, of the total cell population, determined by immunohistochemical staining. The ratio of positive cells has remained unchanged during successive passages. Characterization of the persistently-infected BTu cells (BTuI) showed that only full length viral RNA was detected by northern blot hybridisation, indicating that DI particles were not involved. Secreted and intracellular virus from these cells was fully infectious for fresh BTu and LT cells. The BTuI cell line was fully permissive for a cytopathic BVDV isolate and a bovine herpesvirus, but non-permissive for two non-cytopathic BVDV isolates. Attempts to induce the permissive state in the BVDV-negative cells of the BTuI culture by treatment with actinomycin D and 5'-aza-cytidine failed. These cells provide a convenient model to study aspects of BVDV pathogenesis and replication.

Indirect posterior restorations: steps to clinical success

Continued advances in adhesive dentistry allow predictable bonding of tooth-supporting restorations using conservative preparation. As tooth-colored restorative materials continually yield improved durability and esthetic properties, treatment options expand. There has been slow acceptance of both direct and indirect posterior esthetics. The focus of this article is to review clinically proven techniques that when followed will consistently result in long-term functional indirect restorations.

Smile enhancement using indirect veneers

The anterior 8 veneers provided the patient with a much improved appearance. She was more self confident and happy with her smile. It was great to see the immediate gratification cosmetic procedures can have on a people. It was also great to receive a sincere thanks for really making a difference.

The replicative intermediate molecule of bovine viral diarrhoea virus contains multiple nascent strands

The replication of bovine viral diarrhoea virus (BVDV) RNA is considered to involve replicative intermediates (RI) and replicative forms (RF) of virus RNA. These RNA species were radiolabelled metabolically by 3H-uridine in BVDV-infected cells and separated by sucrose gradient centrifugation. RNA in the fractions was then digested with RNase A in high salt (2 x SSC) and the RNase-resistance was determined. Using the Baltimore formula, this led to the calculation that the RI of BVDV contained 6-7 nascent strands on the template. This suggests that the structure of the BVDV RI is similar to that of poliovirus and dengue 2 virus.

Clinical guidelines for indirect resin restorations

Ongoing advances in adhesive dentistry have made it possible to successfully and predictably bond tooth-supporting restorations using conservative preparation techniques. Improvements in the durability and esthetic properties of tooth-colored restorative materials have also increased the range of available treatment options. However, dentists have been slow to accept both direct and indirect posterior esthetics. This article provides a step-by-step technique for practitioners who choose to treat their patients with indirect resin esthetic restorations. It will not discuss other posterior restorative treatment techniques or materials (i.e. gold, porcelain, amalgam, bonded amalgam, or direct resin).

Growth of coagulase negative staphylococci in peritoneal dialysate fluid. Effect of calcium concentration

The growth of coagulase negative staphylococci (CNS) in spent and unspent peritoneal dialysate of physiologic (1.25 mmol/l) and standard (1.62 mmol/l) [Ca2++] was studied. Dialysate was prepared by filter sterilization and pH and iCa were measured. Three isolates of CNS grown in unsupplemented Mueller Hinton broth for 18 to 20 hr at 37 degrees C were adjusted to a density of 1.5 x 10(8) CFU/ml. The dialysate (5.4 ml) was inoculated with 0.6 ml of a 10(-4) dilution and then incubated aerobically at 35 degrees C. Plates were made at 0, 6, and 24 hr, and CFU/100 microliters were counted after 24 hr. In a larger study, 10 isolates of CNS were examined. Coagulase negative staphylococcal growth was inhibited by unspent dialysate (P = 0.000; unpaired t-test). Growth was greater in spent physiologic [Ca++] dialysate (iCa -0.76 mmol/l) at 6 hr (P = 0.007) and at 24 hr (P = 0.000) than in standard dialysate (iCa = 0.86 mmol/l) for two of three strains in the pilot study. Similar findings were noted for 4 of 8 strains in the larger study. There was an overall trend for greater growth in physiologic [Ca++] dialysate (P = 0.09). Some strains of CNS grow better in lower [Ca++] dialysate, perhaps representing clinically relevant trophism.

Isoniazid resistant tuberculosis in a school outbreak: the protective effect of BCG

An outbreak of isoniazid resistant tuberculosis occurred in a large second level school. A total of 1,160 teenage pupils were at risk. Nineteen cases of tuberculosis were diagnosed, 15 were students, 9 of whom were among 251 non-vaccinated students and 6 among 909 vaccinated students. Two cases of miliary tuberculosis, one of whom also had tuberculous (TB) meningitis, occurred in the non-vaccinated group. The number of children with Heaf grade +3 or +4 was significantly greater among children who had been given Bacille Calmette-Guérin (BCG) vaccination (8 vs 4.4%). This suggests a boosting effect on the response in vaccinated children. The protective effect of neonatal BCG vaccination in this school outbreak suggests that it provides significant protection against tuberculosis lasting into adolescence.

Isoniazid resistant tuberculosis in a school outbreak: the protective effect of BCG

An outbreak of isoniazid resistant tuberculosis occurred in a large second level school. A total of 1,160 teenage pupils were at risk. Nineteen cases of tuberculosis were diagnosed, 15 were students, 9 of whom were among 251 non-vaccinated students and 6 among 909 vaccinated students. Two cases of miliary tuberculosis, one of whom also had tuberculous (TB) meningitis, occurred in the non-vaccinated group. The number of children with Heaf grade +3 or +4 was significantly greater among children who had been given Bacille Calmette-Guerin (BCG) vaccination (8 vs 4.4%). This suggests a boosting effect on the response in vaccinated children. The protective effect of neonatal BCG vaccination in this school outbreak suggests that it provides significant protection against tuberculosis lasting into adolescence.

Effect of sex and gonadal hormones on rat plasma lipids during the development of an essential fatty acid deficiency

1. Male, female and castrated rats treated with oestradiol (30mug./week) or testosterone (2mg./week) were given an essential fatty acid-deficient diet containing 10% of hydrogenated coconut oil for 9 weeks. The concentrations and fatty acid composition of plasma phospholipids, cholesteryl esters and triglycerides were determined. 2. Between the second and third weeks of the deficiency, concentrations of plasma cholesteryl esters, phospholipids and triglycerides decreased, then remained relatively constant. There were no significant differences between males and females, but oestradiol caused a significant rise in plasma phospholipids and triglycerides as compared with testosterone-treated animals. 3. During the first 2 weeks of the deficiency, linoleic acid in the plasma lipids of all groups decreased to low concentrations and changed very little thereafter. 4. Female rats maintained higher percentages and concentrations of arachidonic acid and stearic acid in plasma phospholipids and arachidonic acid in cholesteryl esters than did males. Males had higher proportions of eicosatrienoic acid and oleic acid. There was no sex difference in the fatty acid composition of plasma triglycerides. 5. Oestradiol-treated rats had concentrations of cholesteryl and phospholipid arachidonate comparable with those of female rats and higher than the testosterone-treated group. Eicosatrienoic acid in the oestradiol-treated rats was high and resembled that of the male rats, apparently because of the higher concentration of plasma phospho lipids in this group. 6. Supplementation of the essential fatty acid-deficient rats with linoleate restored plasma cholesteryl and phospholipid linoleate and arachidonate nearly to normal concentrations in a single day. The increase in arachidonic acid in these fractions was accompanied by a similar quantitative decrease in eicosatrienoic acid. 7. These sex differences appear to be related to the smaller size of the female rat and to a more direct influence of oestradiol on the formation or maintenance of phospholipids rich in arachidonic acid.