Observations during the COVID-19 pandemic in chronic heart failure patients with complex devices in a tertiary care cardiac centre using the HeartLogic software

Funding Acknowledgements

Type of funding sources: None.

Introduction

Decompensation of heart failure leading (HF) to hospitalisation is the single most important drain on healthcare resources when managing patients with left ventricular systolic dysfunction. Cardiac resynchronisation therapy with/without defibrillators (CRT-P/D) decreases hospitalisation due to HF and improves survival while implantable cardiac defibrillators (ICD"s) have a favourable effect on the former. Proprietary software algorithms embedded in these complex devices give an early warning to clinicians when decompensation of HF is imminent allowing preventative action to be undertaken.

HeartLogic (HL) is one such new algorithm in Boston Scientific CRT-D/ICD devices using multiple sensors to track 5 physiological parameters, combining them into one composite Index, with an Alert being triggered if the Index is >16. The COVID-19 pandemic, due to multiple reasons, resulted in a significant decrease in availability of routine HF services in the United Kingdom, especially during the initial lockdown period from 23rd March to 1st July 2020.

Aim

To assess the impact of the COVID-19 pandemic, using HL, in patients with HF and complex devices. 

Materials and Methods

Retrospective analysis of patients in a tertiary care cardiac centre in whom the HL software had been activated in March/April 2019 (n = 49) and comparison of those with (Group A n = 21) and without (Group B n = 28) an Alert (HLA) during the COVID-19 pandemic. 

Results (Table): Whole cohort n = 49. Age:  72 ± 12 years, Median: 75, Range: 36-95. 36/49 (73.5%) males. Type of device implanted: Resonate X4 CRT-D: 28/49 (57.1%); Momentum CRT-D: 8/49 (16.3%); Resonate ICD: 13/49 (26.5%). Ischaemic aetiology of HF: 35/49 (71.4%), Total duration of HL monitoring: 632 ± 7 days (median: 632; range: 626-672).  There was no difference in the age, gender, and type of device implanted between Group A and Group B. Over nearly ∼1 year of monitoring in each of the groups, Group A had more unstable HF with 10/21 (47.6%) having their first HLA during the pandemic. Multiple HLA"s, longer period in HLA and those with ischaemic aetiology of HF were higher in Group A. 17/40 (42.5%) HLA"s in Group A were within the first lockdown period (March - July). 24/28 (85.7%) patients in Group B had no HLA"s either before or during the pandemic. There was no difference in the HLA score between Groups A and B.

Conclusion

In this limited group of patients with a medium term follow-up, using the HeartLogic software, patients with ischaemic aetiology of HF and those with more HLA"s prior to the pandemic did worse than those who no HLA"s. First HLA"s, multiple alerts and longer duration of alerts in this group of patients suggests a lack of access to adequate HF services during the pandemic. It has implications with regard to how HF services are configured in future whenever resources are constrained.

Evaluation of a program to improve intermediate diabetes outcomes in rural communities in the Dominican Republic

AIMS

To describe implementation of diabetes and hypertension program in rural Dominican Republic (DR), and report six years of quality improvement process and health outcomes.

METHODS

Dominican teams at two clinics are supported by Chronic Care International with: supervision and continuing education, electronic database, diabetes and hypertension protocols, medications, self-management education materials, behavior change techniques, and equipment and testing supplies (e.g., HbA1c, lipids, blood pressure, BMI). A monthly dashboard for care processes and health outcomes guides problem solving and goal setting. Results were analyzed for quality improvement reports and by fitting the clinical data to random-effects linear models.

RESULTS

1191 adults were enrolled in the program at two clinics (44% men, baseline means: 56.4 years, BMI 27.4 kg/m², HbA1c 8.8% (73 mmol/mol), BP 133/81 mmHg). Data show steady growth in clinic populations reaching capacity. Protocols for comprehensive foot examinations, BP and HbA1c assessments, and proportions reaching quality measures improved over time, especially after clinic goal setting. Modeling of BP, BMI and HbA1c values revealed important differences in outcomes by clinic over time.

CONCLUSIONS

Improvements in process and health outcomes are attainable in rural DR when medical teams have support and access to data. Scalability and sustainability are continuing goals.

Sport and Personality: Effects of Type of Sport and Level of Competition

Personal information and personality profiles, using the Cattell 16 PF, were collected from 93 sportsmen and sportswomen. Players involved in team (volleyball) and in individual (squash) sports were represented. Athletes were at a high level of competition (those selected for training at State level) and an average level. Discriminant analysis indicated significant differences in personality characteristics between squash and volleyball players and between high- and average-level competitors. Differences on a larger number of personality dimensions as a function of type of sport were also noted when analyses were carried out on the State (high) level competitors only.

Observation of picometer vertical emittance with a vertical undulator

Using a vertical undulator, picometer vertical electron beam emittances have been observed at the Australian Synchrotron storage ring. An APPLE-II type undulator was phased to produce a horizontal magnetic field, which creates a synchrotron radiation field that is very sensitive to the vertical electron beam emittance. The measured ratios of undulator spectral peak heights are evaluated by fitting to simulations of the apparatus. With this apparatus immediately available at most existing electron and positron storage rings, we find this to be an appropriate and novel vertical emittance diagnostic.

Evidence for direct CP violation in B0-->K+pi- decays

We report evidence for direct CP violation in the decay B0-->K+pi(-) with 253 fb(-1) of data collected with the Belle detector at the KEKB e(+)e(-) collider. Using 275x10(6) BB pairs we observe a B-->K+/-pi(-/+) signal with 2140+/-53 events. The measured CP violating asymmetry is A(CP)(K+pi(-))=-0.101+/-0.025(stat)+/-0.005(syst), corresponding to a significance of 3.9sigma including systematics. We also search for CP violation in the decays B+-->K+pi(0) and B+-->pi(+)pi(0). The measured CP violating asymmetries are A(CP)(K+pi(0))=0.04+/-0.05(stat)+/-0.02(syst) and A(CP)(pi(+)pi(0))=-0.02+/-0.10(stat)+/-0.01(syst), corresponding to the intervals -0.05<A(CP)(K+pi(0))<0.13 and -0.18<A(CP)(pi(+)pi(0))<0.14 at 90% confidence level.

Evidence for B0-->rho0pi0

We present the first evidence of the decay B0-->rho(0)pi(0), using 140 fb(-1) of data collected at the Upsilon(4S) resonance with the Belle detector at the KEKB asymmetric e(+)e(-) collider. We detect 15.1+/-4.8 signal events with a significance of 3.5 standard deviations and measure the branching fraction to be B(B0-->rho(0)pi(0))=(5.1+/-1.6(stat)+/-0.9(syst))x10(-6).

Role of calcium, vitamin D, and other essential nutrients in the prevention and treatment of osteoporosis

Calcium is an essential nutrient for the prevention and treatment of osteoporosis. Despite universal recognition of its importance, most people still do not obtain recommended amounts. Recent additions to the treatment of osteoporosis with potent bone active drugs produce an even greater need for calcium and total nutrition for restoration of lost bone. Practitioners and patients need to emphasize and appreciate the role that calcium, vitamin D, and other nutrients play in the promotion of health and in the prevention and treatment of disease.

Association of estrogen receptor-alpha genotypes with body mass index in normal healthy postmenopausal Caucasian women

Several lines of evidence suggest the importance of the estrogen receptor (ER) in determining body mass index (BMI). Our purpose was to investigate whether genetic polymorphisms at the restriction enzyme PvuII site of the ER-alpha gene locus are associated with BMI variation. Data on BMI, age, and ER-alpha genotypes were obtained from 108 healthy midwestern U.S. postmenopausal Caucasian women. The study subjects were unrelated and aged 65 yr and over (mean age +/- SD, 73.4 +/- 5.1 yr), with an average BMI of 25.25 (SD, 4.04). The ER-alpha genotypes were obtained by PCR followed by restriction enzyme PvuII digestion. We found that in our study subjects the ER-alpha genotypes are significantly associated with BMI (by ANOVA, P = 0.04), explaining about 6.2% of the BMI variation in our study sample. The allelic effects of this locus on BMI are approximately additive. In our sample, individuals of the PP and Pp genotypes have, respectively, 11.4% and 4.8% higher BMI than individuals of the pp genotype. There is a significant ER-alpha genotype by age interaction, so that in our sample PP individuals tend to gain weight with age, whereas Pp and pp individuals tend to lose weight with age. Therefore, the ER-alpha polymorphisms are associated with BMI variation in healthy postmenopausal Caucasian women aged 65 yr and over. Our result is consistent with some recent findings suggesting the potential effects of the ER on BMI. The importance of the ER-alpha genotypes in other populations and other age groups needs to be demonstrated. Although the results of the ER-alpha genotype by age interaction are obtained here from cross-sectional data, direct confirmation may come from longitudinal studies in which individuals are measured multiple times over several years. The importance of the ER-alpha genotypes on BMI should be confirmed by further studies using methods robust to the potential problem of population substructuring that may confound the conclusions of population association studies.

Study subjects and ordinary patients

Clinical trials of treatment agents impose strict and often necessary inclusion and exclusion criteria, while patients presenting to physicians for treatment frequently exhibit complicating features that would have excluded them from entry into study. To quantify the degree of discordance between ordinary patients and study subjects, a retrospective chart review was carried out of all new patients with osteoporosis seen in an academic medical center within a consecutive 40-month period, meeting clinical treatment criteria. Each patient chart was reviewed for the inclusion and exclusion criteria of four large, multicenter study protocols. There were 120 consecutive female patients seeking health care, with bone density T-scores below -2.0 and/or with one or more low-trauma fractures. The four trials would have accepted 4, 5, 25 and 8 of our 120 patients. The trial with the most liberal inclusion criteria would have taken only 21% of the total. Principal reasons for ineligibility were comorbidity, prior treatment with bone-active agents, and current therapy with glucocorticoids, anticoagulants and anticonvulsants. Some of these exclusions inevitably reflect the patient mix of a referral center; nevertheless, comorbidity and its therapy are common in the age range in which osteoporosis is prevalent and would, therefore, be expected to be present in patients in general medical practice as well. Thus a large fraction, perhaps the majority, of patients with diagnoses of osteoporosis who are candidates for treatment by their physicians, are not eligible for entry into typical treatment trials. The results of such trials may, therefore, have uncertain applicability to types of patients excluded, both for safety and for efficacy.

Patient care of osteoporosis

Osteoporosis is a condition of excessive skeletal fragility that afflicts more than 25 million Americans and results in over one half million fractures per year in the United States. Evaluation of patients presenting with symptoms of osteoporosis includes measurement of serum 25 hydroxy, vitamin D, thyroxine, thyroid-stimulating hormone, serum protein electrophoresis, in addition to blood count, urinalysis, and multichannel screen. Spine and other films are indicated as necessary, and although bone density measurements are useful, they are somewhat restricted in availability. There are lifestyle measures that influence the cause as well as the treatment of osteoporosis. Symptomatic patients benefit most by interventions that include nutrition, physical fitness, calcium, and vitamin D.

Hemisphere asymmetry and the processing of emotional words in anxiety

High- and low-trait anxious subjects participated in a divided visual field emotional Stroop task. Subjects identified the colour of unilaterally presented threat-related, positive and neutral words. The high- and low-trait groups differed in terms of their accuracy scores but not in their reaction times. Analysis of the accuracy data revealed that the high-trait group exhibited right hemisphere interference for emotional relative to neutral trials whereas the low-trait showed right hemisphere interference for threat-related trials only. The idea that the right hemisphere is differentially specialised for the processing of emotional information was supported.

An unusual variant of blood group A

A blood specimen from a forensic science case appeared to violate Landsteiner's Rule. The red cells failed to react with anti-A, anti-B, or O serum while reacting strongly with Ulex europaeus lectin but not other anti-A lectins. The saliva from the person involved was found to contain both A and H blood group substances in a ratio of 4:1. The blood group was determined to be type Am.

Erythrocyte diaphorases DIA1 and DIA2 in bloodstains

The ability to determine the phenotypes of erythrocyte NADH diaphorase (DIA1) was demonstrated in bloodstains, the utility of the system extending about two weeks. Electrophoretic variants representing three uncommon phenotypes (DIA1 2-1, DIA1 4-1 and DIA1 7-1) were found in five of 785 individuals tested. The NADPH diaphorase DIA2 isozymes could not be resolved sufficiently for practical use.