In-utero vascular accidents in neonates from COVID-19 infected mothers

PURPOSE

Infection with COVID-19 during pregnancy has been associated with a hypercoagulable state. It is unknown if maternal COVID-19 infection results in congenital anomalies secondary to intrauterine vascular accidents. This study sought to determine if the rate of in-utero vascular complications (intestinal atresia and limb abnormalities) that may be attributable to the hypercoagulable states associated with COVID-19 and pregnancy increased after the onset of the pandemic.

METHODS

Pregnancy, neonatal, and congenital defect data from a single academic medical center and the partner's children's hospital were collected and compared to the period prior to onset of the pandemic. A subanalysis including pregnant woman 18 years or greater with documented COVID-19 infection during gestation between March 2020-2021 was performed.

RESULTS

Rates of intestinal atresia did not differ prior to or after the onset of the pandemic (3.78% vs 7.23%, p = 0.21) nor did rates of limb deficiency disorders (4.41% vs 9.65%, p = 0.09). On subanalysis, there were 194 women with COVID-19 infection included in analysis: 135 (69.6%) were positive during delivery admission and 59 (30.4%) were positive earlier in their pregnancy. There was one infant born with intestinal atresia.

CONCLUSION

We report a low incidence of congenital anomalies in infants born to mothers with COVID-19 infection. It remains unclear if the impact of COVID-19 on the coagulative state augments the normal pro-thrombotic state of pregnancy; ongoing surveillance is warranted.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Prescribing differences among older adults with differing health cover and socioeconomic status: a cohort study

Introduction

Ireland currently has a mixed public-private health system, where about 40% of individuals are entitled to free or low-cost public care based on their income and age (1). As health reforms move Ireland toward universal healthcare, it is important to understand divergent prescribing practice to patients with differing health cover and socioeconomic status.

Aim

To determine how prescribing patterns for patients aged ≥65 years in primary care in Ireland differ between public and private patients.

Methods

Data were collected during a larger study from 44 general practices in Ireland (2). Data were extracted from the patient management system relating to demographics and prescribing. Patients were included in the present analysis if they had prescriptions issued on at least two dates during the study period (2011-2018), and had demographics (age and sex) and prescription dates recorded. The cohort was divided between those with public health cover (via the GMS scheme, which over-represents socioeconomically deprived people) and those without. We calculated the standardised rate of prescribing for drug classes separately for GMS and non-GMS (private) patients. We pre-specified 12 drug classes of specific interest, due to their prevalence, inclusion in Ireland’s Preferred Drugs Initiative, or potential for sub-optimal prescribing. We also analysed the number of medications, polypharmacy, and trends over time between groups, using multilevel linear regression adjusting for age and sex.

Results

The study included 42,456 individuals, 62% with GMS cover. The rate of prescribing for all pre-specified drug classes was higher for GMS patients compared to non-GMS patients. In all cases, the rate of prescribing was at least 1.6 times higher in the public group, with this being the minimum difference between groups in the rate of antibacterials for systemic use. We saw the greatest disparity in inhaled adrenergics combined with corticosteroids and/or anticholinergics where the rate of public prescribing was 2.25 times higher. The mean number of unique medications prescribed to GMS patients was 10.9 (SD 5.9), and 8.1 (SD 5.8) for non-GMS patients. Among GMS patients, 85% had polypharmacy (being on ≥5 medications) compared to 77% among the non-GMS patients, while 51% and 43% respectively had major polypharmacy (≥10 medications). The mean number of medications prescribed per person increased in both groups over time. The increase was steeper and more sustained in the public health cover group where the mean number of medications prescribed increased by 0.67 medications/year for GMS patients. The rate of increase was 0.13 (95%CI 0.13, 0.14) medications/year lower for non-GMS patients, a statistically significant difference.

Conclusion

Our study found a significantly larger number of unique medicines were prescribed to patients with public health cover, compared to those without. This disparity increased over time and was consistent within all drug classes analysed. This may be driven by socioeconomic deprivation rather than health cover, although a limitation is that we were unable to examine or adjust for these potential contributors separately. Our study provides new evidence that the growth in medication burden and polypharmacy among older adults is accelerated for those of lower socioeconomic status.

References

(1) Thomson S, Jowett M, Mladovsky P. The editors Observatory Studies Series No. 33 33 Observatory Studies Series Health system responses to financial pressures in Ireland.

(2) Pérez T, Moriarty F, Wallace E, McDowell R, Redmond P, Fahey T. Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: Longitudinal study. BMJ. 2018;363.

182 QUALITY IMPROVEMENT OF THE REFERRAL SYSTEM TO EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

Our department has been providing an Emergency Department in the Home (EDITH) service since early 2020. The goal is to bring the emergency services to older people and prevent unnecessary attendances to the ED. With over 3,000 patients seen in its first 14 months, this heavily used service needs a proficient and safe referral system.

The previous referral system predominately involved handwritten referrals and phone calls. Our aim was to streamline this via the introduction of the Siilo Application as a solitary referral source. A referral proforma was also drawn up to ensure all relevant details were included.

Methods

A baseline survey was conducted to establish staff’s opinion on the initial referral system. The questions were.

1. Are you happy with the current system of referring patients to EDITH?

2. Do you think that some referrals are being missed or delayed secondary to the current system?

3. Rank your current satisfaction with the referral system out of ten?

There was also an area for feedback in the survey. The new system was then introduced using the Siilo Application. Staff were trained in its use and a referral proforma was put in place. After three months of use a second survey was conducted with the same questions.

Results

60% were happy with the new referral system, up from 11% on the first survey. Those who believed referrals were being missed had fallen from 88.9% to 70%. The average score out of ten for the current system was 6.9, improved from 5.7.

Conclusion

Having a safe, user friendly and efficient referral system for complex patients is a fundamental part on the service we provide. Staff satisfaction with the referral system, especially in an emergency setting, is paramount to ensure adequate and safe referrals. Satisfaction rates did improve with the introduction of the Siilo Application, but there is room for further improvement.

Diffusion tensor cardiovascular magnetic resonance detects altered myocardial microstructure in patients with acute st-elevation myocardial infarction

Background

Diffusion Tensor Cardiovascular Magnetic Resonance (DT-CMR) can quantify metrics of tissue integrity (mean diffusivity [MD] and fractional anisotropy [FA]) and changes in laminar microstructures (sheetlets), which reorientate from more wall-parallel in diastole (DIA) towards wall-perpendicular in systole (SYS) as the myocardium thickens, quantified by E2 angle [E2A]. Microstructural changes after STEMI may provide new insights into adverse LV remodelling and risk stratification.

Methods

In vivo DT-CMR was performed 3–5 days after PPCI for first presentation STEMI (N=19, mean age 57±9, 79% male). DT-CMR was acquired in 2 short-axes (SYS & DIA) using a STEAM-EPI sequence. 12 segment analysis of MD, FA, E2A and E2A mobility (ΔE2A = E2ASYS − E2ADIA) was performed. Infarct (INF) segments were defined as >25% LGE, adjacent (ADJ, located contiguous to INF) and remote (REM, all other segments). Wilcoxon signed rank tests were used with threshold P<0.017 (Bonferroni corrected).

Results

See Table.

MD in both SYS and DIA was significantly higher in INF and ADJ regions compared to REM. FA in both SYS and DIA was lower in the INF and ADJ compared to REM. E2ADIA was higher in INF, indicating a more wall-perpendicular orientation of sheetlets, compared to ADJ and REM zones. E2ASYS in INF was significantly reduced, indicating a more wall-parallel orientation of sheetlets, compared to ADJ and REM regions, resulting in significantly reduced sheetlet mobility (ΔE2A).

Conclusions

Microstructural changes can be detected after acute STEMI by in vivo DT-CMR. Zonal changes in MD and FA may suggest loss of barriers to water diffusion and altered cardiomyocyte organisation, respectively. We provide the first report of reduced sheetlet mobility after acute STEMI in INF. Ongoing work is evaluating the mechanisms and prognostic importance of altered sheetlet mobility after STEMI.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Burnout in the Plastic Surgeon: Implications and Interventions

A career as a plastic surgeon is both rewarding and challenging. The road to becoming a surgeon is a long arduous endeavor and can bring significant challenges not only to the surgeon but their family. A study by the American College of Surgeons (ACS) suggested that over 40% of surgeons experience burnout and a recent survey of American Society of Plastic Surgeons (ASPS) showed that more than one-fourth of plastic surgeons have signs of professional burnout. Burnout is a state of physical and mental exhaustion. The three main components of burnout are emotional exhaustion, depersonalization, and reduced personal accomplishment. Exhaustion occurs as a result of emotional demands. Depersonalization refers to a cynical, negative or a detached response to patient care. The reduced accomplishment refers to a belief that one can no longer work effectively. There has been a recent explosion in the literature characterizing burnout within the surgical profession. Reports of burnout, burnout victims, and burnout syndrome are filling the medical literature, books, blogs, and social media across all different specialties. Burnout in a plastic surgeon has negative and potentially fatal repercussions to the surgeon, their family, their patients, their staff, colleagues, coworkers, and their organization. To date, there are a limited number of publications addressing burnout in the plastic surgery community. The goals of this paper are to review the symptoms of burnout, its effect on plastic surgeons, and discuss potential solutions for burnout prevention and physician wellness.

An unusual case of pneumocephalus

The authors present an unusual cause of pneumocephalus in a previously fit and well female octogenarian who presented with acute onset altered level of consciousness and generalised weakness. Radiological imaging demonstrated widespread cerebritis with pneumocephalus and gas within the superior sagittal sinus. Blood culture grew Clostridium septicum, a virulent but rare organism that can infect normal tissues. The close association between C septicum and both haematological and bowel malignancies must be considered if this organism is cultured.

Race and ethnicity correlate with survival in patients with gastric adenocarcinoma

BACKGROUND

Asian centers have consistently reported superior gastric cancer outcomes. Our study examines gastric cancer survival among different races and ethnicities in a large, heterogeneous USA population.

PATIENTS AND METHODS

Patients with gastric adenocarcinoma treated in Los Angeles County from 1988 to 2006 were identified from the Los Angeles County Cancer Surveillance Program. Patients were categorized by race and ethnicity as White, Asian, Hispanic and Black.

RESULTS

Of 13 084 patients, 39% were White, 22% Asian, 28% Hispanic, 11% Black and 2% other. Asian patients demonstrated higher survival than Whites, Hispanics and Blacks [median survival (MS) 16.3 versus 8.4, 8.7 and 7.9 months, respectively; log-rank P values < 0.001]. Multivariate Cox regression analysis showed that Asians had improved probability of survival [hazard ratio (HR) 0.76, 95% confidence interval (CI) 0.72-0.82; P < 0.001]. In patients who underwent curative-intent surgery, Asian patients demonstrated higher survival than Whites, Hispanics and Blacks (MS 32.7 versus 18.8, 19.9 and 18.9 months, respectively; log-rank P values < 0.001). Multivariate Cox regression analysis showed that Asians had improved probability of survival after surgery (HR 0.79, 95% CI 0.71-0.88; P < 0.001).

CONCLUSIONS

Asians with gastric adenocarcinoma have superior outcomes in Los Angeles County. These outcomes verify disparities in gastric cancer survival among different races and ethnicities independent of established clinical and pathologic factors.

The anatomic location of pancreatic cancer is a prognostic factor for survival

BACKGROUND

Pancreatic cancers of the body and tail (BT) appear to have poorer survival compared with head (HD) lesions. We hypothesized that potential disparities in outcome may be related to tumor location. Our objective was to examine the relationship between tumor location and survival.

METHODS

The Surveillance, Epidemiology, and End Results registry identified 33,752 patients with pancreatic adenocarcinoma and 6443 patients who underwent cancer-directed surgery between 1988 and 2004. Differences in survival and relationships between tumor location and clinical factors were assessed. Multivariate analysis was performed to determine the prognostic significance of tumor location.

RESULTS

Median survival for the entire cohort was five months and was significantly lower for BT compared to HD lesions (four vs. six months, p<0.001). Distant metastases (67% vs. 36%, p<0.001) were greater and cancer-directed surgery (16% vs. 30%, p<0.001) was lower for BT tumors. Of 6443 resected patients, HD patients (n=5118) were younger, had a greater number of harvested lymph nodes, were more likely to be lymph node-positive, and had a higher proportion of T3/T4 lesions. Significant univariate predictors of survival included age, T-stage, number of positive and harvested lymph nodes. On multivariate analysis, BT location was a significant prognostic factor for decreased survival (OR 1.11, 95% CI 1.00-1.23, p=0.05).

DISCUSSION

Pancreatic BT cancers have a lower rate of resectability and poorer overall survival compared to HD lesions. Prospective large-cohort studies may definitively prove that tumor location is a prognostic factor for survival in patients with pancreatic cancer.

Raised troponin T and echocardiographic abnormalities after prolonged strenuous exercise--the Australian Ironman Triathlon

BACKGROUND

There is concern about whether cardiac damage occurs as a result of prolonged strenuous exercise.

OBJECTIVE

To investigate whether competing in a triathlon is associated with cardiac damage based on a sustained increase in cardiac troponin T (cTnT), and whether such an increase correlates with echocardiographic changes

METHODS

cTnT and echocardiographic measurements were made in 38 participants in the 2001 Australian ironman triathlon. cTnT was measured the day before, immediately after, and the day following the race. Echocardiography was done the day before, immediately after, and two to six weeks later for measurement of ejection fraction, stroke volume, cardiac output, wall motion analysis, and global left ventricular function (LVF).

RESULTS

No subject had detectable cTnT in the pre-race sample. Following the race, 32 subjects (86.5%) had detectable levels of cTnT (>0.01 ng/ml), with six (16.2%) having >0.10 ng/ml. The day after the race, nine subjects (23.7%) still had detectable cTnT, with two recording a level >0.10 ng/ml. Previously described echocardiographic changes of "cardiac fatigue" were observed in the whole cohort. There was a modest but significant correlation between change in ejection fraction and peak cTnT level (p = 0.02, r = 0.39). Athletes with a post-race cTnT >0.10 ng/ml had a greater decrease in global LVF (p = 0.02) and a trend toward a greater fall in ejection fraction and stroke volume than athletes with cTnT levels <0.10 ng/ml. Cardiac output fell in the group with cTnT >0.10 ng/ml (p>0.05).

CONCLUSIONS

Participation in ironman triathlon often resulted in persistently raised cTnT levels, and the troponin rise was associated with echocardiographic evidence of abnormal left ventricular function. The clinical significance and long term sequelae of such damage remains to be determined.

The relationship of blood glucose and haemoglobin A1 levels in diabetic subjects

Recommendations exist that fasting plasma glucose (FPG) levels can be substituted for glycosylated haemoglobin A1 (HbA1) in Type II diabetic subjects (DM II), which have potential important financial implications. The present study was designed to expand this examination and to include Type I DM (DMI) patients and random blood glucose (RBG) values. Data were obtained from 234 DM II and 104 DM I patients, over 3 years. Correlation of HbA1 with FPG levels in DM II yielded an r value of 0.61. Correlation of HbA1 with RBG and 2 h post prandial glucose measurements yielded r values of 0.59 and 0.51 respectively, p < 0.001. In DM I, similar correlations gave r values ranging between 0.27 and 0.38, p < 0.01-0.001. Thus while significant correlations exist between HbA1 and FPG and RBG measurements in both DM I and DM II, clinically applicable information on long-term diabetic control can only be achieved from glucose measurements in DM II but the correlation is not sufficiently tight to recommend substitution of plasma glucose for HbA1 determinations, despite the cost advantages.