The impact of COVID-19 on recovery after heart surgery: preliminary findings from the CardiacCovid Study

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

The COVID-19 pandemic has had far-reaching effects on everyday life leading to stress and anxiety, which may be heightened in those undergoing cardiac surgery. Health impacts following a traumatic event may be apparent at one month but can also present after many months.

Purpose

The aim of the CardiacCovid study was to explore the effect of the pandemic on recovery from cardiac surgery. We report the preliminary results from a single centre study in the UK during the early phase of the COVID-19 pandemic.

Methods

Patients >18 years old undergoing any form of cardiac surgery between 23rd March 2020 (UK lockdown) to 4th July 2020 (lifting of most restrictions) were recruited to this prospective observational study. Those too unwell or unable to give consent/complete study questionnaires were excluded. Participants completed a Quality of Life (QoL) (EQ-5D), impact of event (IES-R), depression (CES-D) and health service use questionnaire at baseline, 1 week after hospital discharge, and 6 weeks after surgery. Questionnaires were completed electronically on the Amplitude platform or via post. Ethics approval (20/YH/0132) was obtained and the study was registered (Clinicaltrials.gov:NCT04366167).

Results

A total of 395 patients had surgery of which 298 (91.7%) were screened and 203 (68.1%) were enrolled to the study.  Participants were mostly male (74.6%), with a mean age of 63 years, undergoing urgent/emergency (57.9%) CABG +/-valve (70.1%). Mean inpatient stay was 8.6 days and in-hospital mortality was 0.5%. No patients had Covid-19. The initial findings suggest a deterioration of QoL at 1 week post discharge with near restoration to baseline level at 6 weeks post-surgery. Mean scores for CES-D and IES-R remained within subclinical levels at all available time points. However, at 6 weeks, a proportion of patients reached levels for depression on the CES-D and had high IES-R scores indicating possible post-traumatic stress.

Conclusion

We believe that this is the largest/only study exploring the impact of the pandemic on cardiac surgery recovery, including QoL, spanning the immediate recovery phase but will continue until 1 year. The findings so far show that recovery from cardiac surgery during the Covid-19 pandemic is similar to that reported prior to the pandemic (Cromhout et al 2018) and reinforces the need for psychosocial assessments to identify patients who may require additional support during the immediate recovery phase.

[Maternal deaths due to sudden death. Results from the French confidential enquiry into maternal deaths, 2010-2012]

Sudden death is defined as unexpected cardiac arrest occurring less than one hour after the onset of the first symptoms. Between 2010 and 2012, 23 maternal deaths were considered as unexplained sudden deaths and three of them were not evaluated due to a lack of clinical data. In addition, 13 maternal deaths with an identified cause occurred in a clinical context of sudden death (7 cases of pulmonary embolism, 2 cases of epilepsy, and 2 cases of cardiomyopathy). The first maneuvers of resuscitation in the presence of bystanders were attempted in 8 of 22 cases (36%). This emphasizes the importance of teaching the non-medical resuscitation modalities of cardiac arrest in pregnant women. Pregnant women must receive accurate resuscitation as the whole population. An autopsy was performed in 10 of 33 cases (30%) and was considered incomplete in 3 patients. This result emphasizes the necessity to perform a systematic and specialized autopsy in the context of sudden maternal death, which is mostly unexplained.

A pilot study exploring the relationship between self-compassion, self-judgement, self-kindness, compassion, professional quality of life and wellbeing among UK community nurses

BACKGROUND

Compassion fatigue and burnout can impact on performance of nurses. This paper explores the relationship between self-compassion, self-judgement, self-kindness, compassion, professional quality of life, and wellbeing among community nurses.

AIM

To measure associations between self-compassion, compassion fatigue, wellbeing, and burnout in community nurses.

METHOD

Quantitative data were collected using standardised psychometric questionnaires: (1) Professional Quality of Life Scale; (2) Self-Compassion Scale; (3) short Warwick Edinburgh Mental Wellbeing Scale; (4) Compassion For Others Scale, used to measure relationships between self-compassion, compassion fatigue, wellbeing, and burnout.

PARTICIPANTS

A cross sectional sample of registered community nurses (n=37) studying for a postgraduate diploma at a University in the North of England took part in this study.

RESULTS

Results show that community nurses who score high on measures of self-compassion and wellbeing, also report less burnout. Greater compassion satisfaction was also positively associated with compassion for others, and wellbeing, whilst also being negatively correlated with burnout.

CONCLUSION

High levels of self-compassion were linked with lower levels of burnout. Furthermore when community nurses have greater compassion satisfaction they also report more compassion for others, increased wellbeing, and less burnout. The implications of this are discussed alongside suggestions for the promotion of greater compassion.

Does Compassion-Focused Therapy Training for Health Care Educators and Providers Increase Self-Compassion and Reduce Self-Persecution and Self-Criticism?

INTRODUCTION

There is a growing body of evidence within the health care community suggesting that developing feelings of compassion can profoundly affect physical and psychological health. This is an important area of work, and initial research with nonprofessional groups has found that practicing compassion through a variety of experiential practices and meditations can lead to higher levels of compassion for others, sensitivity to suffering, motivation to help, and altruism. This study examines outcome measures after a 3-day introductory workshop on compassion-focused therapy provided to health care providers and educators. The aim of the research is to explore whether the training would increase self-compassion and reduce self-criticism and self-persecution.

METHODS

A total of 28 participants who were classified into three groups "nurses and midwives," "counselors/psychotherapists," and "other health care providers" completed the Self-Compassion Scale and Functions of Self-Criticizing and Self-Attacking Scale before and after training.

RESULTS

Results reveal an overall statistically significant increase in self-compassion and statistically significant reduction in self-critical judgment after training. There was no statistically significant reduction in self-persecution or self-correction scores after training.

DISCUSSION

Developing self-compassion and compassionately responding to our own "self-critic" may lead the way forward in the development of more compassionate care among health care professionals. Training people in compassion-based exercises may bring changes in levels of self-compassion and self-critical judgment. The findings are exciting in that they suggest the potential benefits of training health care providers and educators in compassion-focused practices.

Compassion for others, self-compassion, quality of life and mental well-being measures and their association with compassion fatigue and burnout in student midwives: A quantitative survey

BACKGROUND

compassion fatigue and burnout can impact on the performance of midwives, with this quantitative paper exploring the relationship between self-compassion, burnout, compassion fatigue, self-judgement, self-kindness, compassion for others, professional quality of life and well-being of student midwives.

METHOD

a quantitative survey measured relationships using questionnaires: (1) Professional Quality of Life Scale; (2) Self-Compassion Scale; (3) Short Warwick and Edinburgh Mental Well-being Scale; (4) Compassion For Others Scale.

PARTICIPANTS

a purposive and convenience sample of student midwives (n=103) studying at university participated in the study.

RESULTS

just over half of the sample reported above average scores for burnout. The results indicate that student midwives who report higher scores on the self-judgement sub-scale are less compassionate towards both themselves and others, have reduced well-being, and report greater burnout and compassion fatigue. Student midwives who report high on measures of self-compassion and well-being report less compassion fatigue and burnout.

CONCLUSION

student midwives may find benefit from 'being kinder to self' in times of suffering, which could potentially help them to prepare for the emotional demands of practice and study.

IMPLICATIONS

developing, creating and cultivating environments that foster compassionate care for self and others may play a significant role in helping midwives face the rigours of education and clinical practice during their degree programme.

Using Compassionate Mind Training as a Resource in EMDR: A Case Study

This case study examines the contribution of compassionate mind training (CMT) when used as a resource in the eye movement desensitization and reprocessing (EMDR) treatment of a 58-year-old man, who presented after a recent trauma with psychological distress and somatic symptoms—an inability to sign his name. Self-report questionnaires (Hospital Anxiety and Depression Scale [HADS], Impact of Events Scale-R [IES-R], and Self-Compassion Scale [SCS]) were administered at pretherapy, midtherapy, posttherapy, and 9-month follow-up. EMDR with CMT facilitated recall of forgotten memories about his sister’s traumatic death decades previously, with related emotions of shame and grief, creating insight into how these past events linked to his current signature-signing phobia. Eight sessions of therapy resulted in an elimination of the client’s signature-signing phobia and a reduction in trauma-related symptoms, elevation in mood, and increase in self-compassion. Effects were maintained at 9-month follow-up. The “Discussion” section highlights the value of working collaboratively with clients to best meet their individual needs.

Neurovascular deconvolution of optical signals as a proxy for the true neuronal inputs

Since the Kalman filter and Monte Carlo techniques, much theoretical work has been put into the development of signal deconvolution tools. Among recent developments taking place in neuroscience are Dynamic Expectation Maximization, Generalized Filtering and the Cubature Kalman Filter. While there are exciting prospects to use these tools for Dynamic Causal Modeling and other analyses of networks, there has been comparatively little work to validate the algorithms on controlled experimental data. In this work, the latest evolution of these tools, the square-root cubature Kalman smoother (SCKS), is tested for its effectiveness on multimodal neurovascular data. Multispectral intrinsic optical imaging and electrophysiological measurements of Wistar rats are used in combination with somatosensory stimulation. The Buxton-Friston (B-F) balloon model is then deconvolved with the SCKS algorithm to obtain the estimated neuronal inputs u(t) from the hemodynamic measurements (flow, oxy- and deoxygenated hemoglobin).

RESULTS

The estimated neuronal inputs are compared to the stimulation protocol and a sensitivity and specificity analysis is carried out. SCKS succeeds in recovering most of the stimulations. Next, the estimated inputs are compared to actual measures of neuronal activity: local field potentials (LFPs) and multiunit activity (MUA). Good sensitivity of the technique is obtained with both LFPs and MUA over the whole recordings, with the area of the ROC curves favoring LFPs. A weak correlation between SCKS estimated inputs and LFPs is found outside stimulation periods, significant at one standard deviation. Finally, the accuracy of state reconstructions is studied and SCKS reconstructed states are highly concordant with measured states.

Plasticity of rat motoneuron rhythmic firing properties with varying levels of afferent and descending inputs

Hindlimb motoneuron excitability was compared among exercise-trained (E), sedentary (S), and spinal cord transected (T) Sprague-Dawley rats by examining the slope of the frequency-current (F/I) relationship with standard intracellular recording techniques in rats anesthetized with ketamine-xylazine. The T group included spinal transected and spinal isolated rats; the E animals were either spontaneously active (exercise wheel) or treadmill trained; and rats in the S group were housed in pairs. An analysis of motoneuron initial [1st interspike interval (ISI)], early (mean of 1st three ISIs), and steady-state (mean of last 3 ISIs) discharge rate slopes resulting from increasing and decreasing 500-ms injected square-wave depolarizing current pulses was used to describe rhythmic motoneuron properties. The steepest slope occurred in the S group (55.3 ± 22.2 Hz/nA), followed by the T group (35.5 ± 15.3 Hz/nA), while the flattest slope was found in the E group (25.4 ± 10.9 Hz/nA). The steepest steady-state slope occurred in the S group but was found to be similar between the T and E groups. Furthermore, a spike-frequency adaptation (SFA) index revealed a slower adaptation in motoneurons of the E animals only (∼40% lower). Finally, evidence for a secondary range of firing existed more frequently in the T group (41%) compared with the S (12%) and E (31%) groups. The lower F/I slope and lower SFA index of motoneurons for E rats may be a result of an increase in Na(+) conductance at the initial segment. The results show that motoneuronal rhythmic firing behavior is plastic, depending on the volume of daily activation and on intact descending pathways.

Biophysical model estimation of neurovascular parameters in a rat model of healthy aging

Neuronal, vascular and metabolic factors result in a deterioration of the cerebral hemodynamic response with age. The interpretation of neuroimaging studies in the context of aging is rendered difficult due to the challenge in untangling the composite effect of these modifications. In this work we integrate multimodal optical imaging in biophysical models to investigate vascular and metabolic changes occurring in aging. Multispectral intrinsic optical imaging of an animal model of healthy aging, the LOU/c rat, is used in combination with somatosensory stimulation to study the modifications of the hemodynamic response with increasing age. Results are fitted with three macroscopic biophysical models to extract parameters, providing a phenomenological description of vascular and metabolic changes. Our results show that 1) biophysical parameters are estimable from multimodal data and 2) parameter estimates in this population change with aging.

Cerebrovascular hemodynamic correlates of aging in the Lou/c rat: a model of healthy aging

The LOU/c rat is an inbred strain considered a model of healthy aging. It exhibits a longer free disease lifespan and a low adiposity throughout life. While this animal model has been shown to maintain eating behavior and neuroendocrine, metabolic and cognitive functions with age, no study has yet investigated vascular correlates in this model of healthy aging. In the present work, multispectral optical imaging was used to investigate the hemodynamic response in the somatosensory cortex of LOU/c rats following forepaw stimulation in three age groups, 4, 24 and 40months. Results indicate reduced hemodynamic responses in the contralateral somatosensory cortex between young (4months) and older groups following stimulation. This decrease was associated with an increase in the spatial extent of activation. The ipsilateral response did not change with aging leading to decreased laterality. Estimations of the relative change in the local cerebral metabolic rate of oxygen during stimulation based on multimodal data showed no significant change with age. The exponent describing the relation between blood volume and blood flow changes, Grubb's parameter, did display a significant change with age which may suggest vessel compliance modifications. This work finds its relevance in recent findings underlying the importance of vascular changes with aging and its impact on neurodegenerative disease.

Effects of rolipram on adult rat oligodendrocytes and functional recovery after contusive cervical spinal cord injury

Traumatic human spinal cord injury (SCI) causes devastating and long-term hardships. These are due to the irreparable primary mechanical injury and secondary injury cascade. In particular, oligodendrocyte cell death, white matter axon damage, spared axon demyelination, and the ensuing dysfunction in action potential conduction lead to the initial deficits and impair functional recovery. For these reasons, and that oligodendrocyte and axon survival may be related, various neuroprotective strategies after spinal cord injury are being investigated. We previously demonstrated that oligodendrocytes in the adult rat epicenter ventrolateral funiculus (VLF) express 3'-5'-cyclic adenosine monophosphate-dependent phosphodiesterase 4 (PDE4) subtypes and that their death was attenuated up to 3 days after contusive cervical SCI when rolipram, a specific inhibitor of PDE4, was administered. Here, we report that (1) there are more oligodendrocyte somata in the adult rat epicenter VLF, (2) descending and ascending axonal conductivity in the VLF improves, and that (3) there are fewer hindlimb footfall errors during grid-walking at 5 weeks after contusive cervical SCI when rolipram is delivered for 2 weeks. This is the first demonstration of improved descending and ascending long-tract axonal conductivity across a SCI with this pharmacological approach. Since descending long-tract axonal conductivity did not return to normal, further evaluations of the pharmacokinetics and therapeutic window of rolipram as well as optimal combinations are necessary before consideration for neuroprotection in humans with SCI.

Evaluation of the quality of care for severe obstetrical haemorrhage in three French regions

OBJECTIVE

To determine what factors related to health services in France might explain substandard care of severe morbidity due to obstetric haemorrhage.

DESIGN

Retrospective questionnaire survey.

SETTING

Three administrative regions of France.

POPULATION

All women who were pregnant or had recently given birth during the year before the survey.

METHODS

A European survey (MOMS-B) defined severe haemorrhages as blood loss > or = 1500mL. A specific questionnaire was added in France to analyse the quality of care of these haemorrhages. The survey was carried out in three different administrative regions: Champagne-Ardenne, the Centre and Lorraine. An expert committee was appointed and began by establishing a framework for qualitative assessment. One hundred and sixty-five cases of severe haemorrhage were reviewed and classified into one of three levels of care: appropriate, inadequate or mixed. Inadequate care and 'mixed' care were both considered substandard. The 165 cases were coded and then studied with uni- and multivariate analysis (logistic regression with SAS and SPSS software).

RESULTS

Of the 165 cases identified, 51% (85/165) were vaginal, 19% (31/165) operative vaginal, and 30% (49/165) caesarean. The leading cause of haemorrhage was uterine atony. Overall, 62% of the cases received appropriate care, 24% received totally inadequate care and 14% mixed care. After adjustment for sociodemographic factors, antenatal care and organisational aspects, the lack of a 24-hour on-site anaesthetist at the hospital and a low volume of deliveries (<500 births per year) were the factors associated with substandard care.

CONCLUSION

Organisational features are so important that application of good clinical practices for safer motherhood reinforce the need for new organisation of obstetric services. For the first time, the presence of an anaesthetist is shown to have a measurable effect on the quality of care for women giving birth. These results need to be confirmed by others.

Teaching colleagues and the general public about automatic external defibrillators

Every year 250,000 or more people with cardiovascular disease die within an hour of symptom onset and before they arrive at a hospital. With appropriate early defibrillation and follow-up treatment many people who might have died can now live. Nurses are key health care professionals for using automatic external defibrillators in hospitals and for teaching other first responders--inside and outside hospitals--how to use automatic external defibrillators. Features of automatic and semiautomatic external defibrillators are reviewed as well as ethical considerations for the use of automatic external defibrillators.

FAD insertion is essential for attaining the assembly competence of the dihydrolipoamide dehydrogenase (E3) monomer from Escherichia coli

Dihydrolipoamide dehydrogenase (E3) from Escherichia coli, an FAD-linked homodimer, can be fully reconstituted in vitro following denaturation in 6 m guanidinium chloride. Complete restoration of activity occurs within 1-2 h in the presence of FAD, dithiothreitol, and bovine serum albumin. In the absence of FAD, the dihydrolipoamide dehydrogenase monomer forms a stable folding intermediate, which is incapable of dimerization. This intermediate displays a similar tryptic resistance to the native enzyme but is less heat-stable, because its ability to form native E3 is lost after incubation at 65 degrees C for 15 min. The presence of FAD promotes slow, additional conformational rearrangements of the E3 subunit as observed by cofactor-dependent decreases in intrinsic tryptophan fluorescence. However, after 2 h, the tryptophan fluorescence spectrum and far UV CD spectrum of E3, refolded in the absence of FAD, are similar to that of the native enzyme, and full activity can still be recovered on addition of FAD. Cross-linking studies show that FAD insertion is necessary for the monomeric folding intermediate to attain an assembly competent state leading to dimerization. Thus cofactor insertion represents a key step in the assembly of this enzyme, although its initial presence appears not to be required to promote the correct folding pathway.

Health and neurodevelopmental outcome at 1-year adjusted age in 508 infants weighing 700 to 1100 grams who received prophylaxis with one versus three doses of synthetic surfactant. American Exosurf Neonatal Study Groups I and II

A three-dose prophylactic regimen of synthetic surfactant replacement has been shown to improve neonatal and 1-year survival rates in infants of 700 to 1100 gm birth weight when compared with a single prophylactic dose. The purpose of this study was to evaluate the growth, development, and late morbidity at 1 year adjusted age among the survivors of the 826 patients enrolled in the protocol. Complete follow-up data were obtained for 75% of the survivors in both groups. Chronic lung disease, need for respiratory support, neurologic disease requiring medication, visual or auditory impairments, and the incidence and severity of retinopathy of prematurity were equivalent in the two groups. The frequency of neurodevelopmental impairment was also comparable in the groups that received one dose versus three doses: moderate to severe cerebral palsy was found in 9% versus 6%, mental retardation assessed by Bayley Scales of Infant Development scores less than 69 was found in 16% vs 14%, and moderate to severe impairments of any kind were found in 33% vs 24%, respectively. Furthermore, the absolute number of impaired survivors was 92 in the three-dose group versus 106 in the one-dose group, despite a higher survival rate in the three-dose group. This study demonstrates that developmental outcomes of infants weighing 700 to 1100 gm who received three prophylactic doses of synthetic surfactant are at least as good as those of infants receiving a single dose, and that improving survival rates of very premature infants with synthetic surfactant does not result in increased numbers of infants with impairments.

Differential binding of erythroid and myeloid progenitors to fibroblasts and fibronectin

Using a novel coverslip-transfer culture technique, we recently demonstrated that primitive erythroid burst-forming units (BFU-E) can migrate, proliferate, and differentiate in intimate association with stromal fibroblastoid cells in the presence of serum proteins and erythropoietin. No other exogenous hemopoietic growth factors are required. Most of the colonies that develop in this system are very large erythroid bursts, and very few granulocyte-macrophage (GM) colonies are observed. In this report, we present data indicating that the predominance of erythroid burst colonies in this culture system is due to preferential binding of primitive erythroid progenitors to the stromal fibroblastoid cells and not to differential stimulation of these erythroid progenitors by these cells. We next show that the binding of BFU-E to stromal cells is blocked by anti-fibronectin antibodies. Finally, we demonstrate the preferential binding of BFU-E to fibronectin by using glass coverslips or Petri dishes coated with purified human plasma fibronectin. The binding is blocked by a monoclonal antibody specific for the cell-binding domain of fibronectin. We conclude that: primitive erythroid progenitors bind strongly whereas G and/or M progenitors (CFU-G/M) bind only weakly to fibronectin; primitive erythroid progenitors bind to the cell-binding domain on the fibronectin molecule; and erythroid progenitors and precursors remain bound to fibronectin throughout differentiation.