What is current care for people with Long COVID in England? A qualitative interview study

OBJECTIVE

To investigate current care for people with Long COVID in England.

DESIGN

In-depth, semistructured interviews with people living with Long COVID and Long COVID healthcare professionals; data analysed using thematic analysis.

SETTING

National Health Service England post-COVID-19 services in six clinics from November 2022 to July 2023.

PARTICIPANTS

15 healthcare professionals and 21 people living with Long COVID currently attending or discharged (18 female; 3 male).

RESULTS

Health professionals and people with lived experience highlighted the multifaceted nature of Long COVID, including its varied symptoms, its impact on people's lives and the complexity involved in managing this condition. These impacts encompass physical, social, mental and environmental dimensions. People with Long COVID reported barriers in accessing primary care, as well as negative general practitioner consultations where they felt unheard or invalidated, though some positive interactions were also noted. Peer support or support systems proved highly valuable and beneficial for individuals, aiding their recovery and well-being. Post-COVID-19 services were viewed as spaces where overlooked voices found validation, offering more than medical expertise. Despite initial challenges, healthcare providers' increasing expertise in diagnosing and treating Long COVID has helped refine care approaches for this condition.

CONCLUSION

Long COVID care in England is not uniform across all locations. Effective communication, specialised expertise and comprehensive support systems are crucial. A patient-centred approach considering the unique complexities of Long COVID, including physical, mental health, social and environmental aspects is needed. Sustained access to post-COVID-19 services is imperative, with success dependent on offering continuous rehabilitation beyond rapid recovery, acknowledging the condition's enduring impacts and complexities.

Impact of Society Guidelines on Trends in Use of Newer P2Y12 Inhibitors for Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

BACKGROUND

Over the past decade, major society guidelines have recommended the use of newer P2Y12 inhibitors over clopidogrel for those undergoing percutaneous coronary intervention for acute coronary syndrome. It is unclear what impact these recommendations had on clinical practice.

METHODS AND RESULTS

All percutaneous coronary intervention procedures (n=534 210) for acute coronary syndrome in England and Wales (April 1, 2010, to March 31, 2022) were retrospectively analyzed, stratified by choice of preprocedural P2Y12 inhibitor (clopidogrel, ticagrelor, and prasugrel). Multivariable logistic regression models were used to examine odds ratios of receipt of ticagrelor and prasugrel (versus clopidogrel) over time, and predictors of their receipt. Overall, there was a significant increase in receipt of newer P2Y12 inhibitors from 2010 to 2020 (2022 versus 2010: ticagrelor odds ratio, 8.12 [95% CI, 7.67-8.60]; prasugrel odds ratio, 6.14 [95% CI, 5.53-6.81]), more so in ST-segment-elevation myocardial infarction than non-ST-segment-elevation acute coronary syndrome indication. The most significant increase in odds of receipt of prasugrel was observed between 2020 and 2022 (P<0.001), following a decline/plateau in its use in earlier years (2011-2019). In contrast, the odds of receipt of ticagrelor significantly increased in earlier years (2012-2017, Ptrend<0.001), after which the trend was stable (Ptrend=0.093).

CONCLUSIONS

Over a 13-year-period, there has been a significant increase in use of newer P2Y12 inhibitors, although uptake of prasugrel use remained significantly lower than ticagrelor. Earlier society guidelines (pre-2017) were associated with the highest rates of ticagrelor use for non-ST-segment-elevation acute coronary syndrome and ST-segment-elevation myocardial infarction cases while the ISAR-REACT 5 (Prospective, Randomized Trial of Ticagrelor Versus Prasugrel in Patients With Acute Coronary Syndrome) trial and later society guidelines were associated with higher prasugrel use, mainly for ST-segment-elevation myocardial infarction indication.

Cardiac resynchronization therapy in inotrope-dependent heart failure: a meta-analysis

AIMS

The viability of cardiac resynchronization therapy (CRT) in inotrope-dependent heart failure (HF) has been a matter of debate.

METHODS AND RESULTS

We searched Medline, EMBASE, Scopus, and the Cochrane Library until 31 December 2022. Studies were included if (i) HF patients required inotropic support at CRT implantation; (ii) patients were ≥18 years old; and (iii) they provided a clear definition of 'inotrope dependence' or 'inability to wean'. A meta-analysis was performed in R (Version 3.5.1). Nineteen studies comprising 386 inotrope-dependent HF patients who received CRT (mean age 64.4 years, 76.9% male) were included. A large majority survived until discharge at 91.1% [95% confidence interval (CI): 81.2% to 97.6%], 89.3% were weaned off inotropes (95% CI: 77.6% to 97.0%), and mean discharge time post-CRT was 7.8 days (95% CI: 3.9 to 11.7). After 1 year of follow-up, 69.7% survived (95% CI: 58.4% to 79.8%). During follow-up, the mean number of HF hospitalizations was reduced by 1.87 (95% CI: 1.04 to 2.70, P < 0.00001). Post-CRT mean QRS duration was reduced by 29.0 ms (95% CI: -41.3 to 16.7, P < 0.00001), and mean left ventricular ejection fraction increased by 4.8% (95% CI: 3.1% to 6.6%, P < 0.00001). The mean New York Heart Association (NYHA) class post-CRT was 2.7 (95% CI: 2.5 to 3.0), with a pronounced reduction of individuals in NYHA IV (risk ratio = 0.27, 95% CI: 0.18 to 0.41, P < 0.00001). On univariate analysis, there was a higher prevalence of males (85.7% vs. 40%), a history of left bundle branch block (71.4% vs. 30%), and more pronounced left ventricular end-diastolic dilation (274.3 ± 7.2 vs. 225.9 ± 6.1 mL).

CONCLUSIONS

CRT appears to be a viable option for inotrope-dependent HF, with some of these patients seeming more likely to respond.

Prevalence of mental health conditions and brain fog in people with long COVID: A systematic review and meta-analysis

OBJECTIVE

Long COVID can include impaired cognition ('brain fog'; a term encompassing multiple symptoms) and mental health conditions. We performed a systematic review and meta-analysis to estimate their prevalence and to explore relevant factors associated with the incidence of impaired cognition and mental health conditions.

METHODS

Searches were conducted in Medline and PsycINFO to cover the start of the pandemic until August 2023. Included studies reported prevalence of mental health conditions and brain fog in adults with long COVID after clinically-diagnosed or PCR-confirmed SARS-CoV-2 infection.

FINDINGS

17 studies were included, reporting 41,249 long COVID patients. Across all timepoints (3-24 months), the combined prevalence of mental health conditions and brain fog was 20·4% (95% CI 11·1%-34·4%), being lower among those previously hospitalised than in community-managed patients(19·5 vs 29·7% respectively; p = 0·047). The odds of mental health conditions and brain fog increased over time and when validated instruments were used. Odds of brain fog significantly decreased with increasing vaccination rates (p = ·000).

CONCLUSIONS

Given the increasing prevalence of mental health conditions and brain fog over time, preventive interventions and treatments are needed. Research is needed to explore underlying mechanisms that could inform further research in development of effective treatments. The reduced risk of brain fog associated with vaccination emphasizes the need for ongoing vaccination programs.

Indirect impact of the war in Ukraine on primary percutaneous coronary interventions for ST-elevation myocardial infarction in Poland

INTRODUCTION

The Russian invasion of Ukraine in February 2022 resulted in the displacement of approximately 12.5 million refugees to adjacent countries including Poland, that may have strained healthcare service delivery.

OBJECTIVES

Using the ST-elevation myocardial infarction (STEMI) data, we aimed to evaluate whether the Russian invasion of Ukraine has indirectly impacted the delivery of acute cardiovascular care in Poland.

PATIENTS AND METHODS

We analyzed all adult patients undergoing percutaneous coronary interventions (PCI) for STEMI across Poland between 25th February 2017 to 24th May 2022. Centers were allocated to regions of <100km and >100km of the Polish-Ukraine border. Mixed effect generalized linear regression models with random effects per hospital were used to explore the associations between the war in Ukraine starting with several outcomes of interest, and whether these associations differed across regions of 100km from the Polish-Ukraine border.

RESULTS

A total of 90,115 procedures were included in the analysis. The average number of procedures per-month was similar to predicted volume for centers in the >100km region, while the average number of PCI was higher than expected (by an estimated 15 (11-19)) for the <100km region. There was no difference in adjusted fatality rate or quality of care outcomes pre- vs. during-war in both <100 and >100 km regions, with no evidence of a difference-in-difference across regions.

CONCLUSIONS

Following the Russian invasion of Ukraine, there was only a modest and temporary increase in primary PCI predominantly in centers situated within 100km of the border, although no significant impact on in-hospital fatality rate.

Design, implementation and evaluation of a spiral module combining data science, digital health and evidence-based medicine in the undergraduate medical curriculum: a mixed methods study

BACKGROUND

Digital health, data science and health informatics are increasingly important in health and healthcare, but largely ignored in undergraduate medical training.

METHODS

In a large UK medical school, with staff and students, we co-designed a new, "spiral" module (with iterative revisiting of content), covering data science, digital health and evidence-based medicine, implementing in September 2019 in all year groups with continuous evaluation and improvement until 2022.

RESULTS

In 2018/19, a new module, "Doctor as Data Scientist", was co-designed by academic staff(n=14), students(n=23), and doctors(n=7). The module involves 22 staff, 120 hours(43 sessions: 22 lectures, 15 group and 6 other) over a 5-year curriculum. Since September 2019, 5200 students have been taught with good attendance. Module student satisfaction ratings were 92%, 84%, 84% and 81% in 2019, 2020, 2021 and 2022 respectively, compared to the overall course(81%).

CONCLUSIONS

We designed, implemented and evaluated a new undergraduate medical curriculum that combined data science and digital health with high student satisfaction ratings.

Barriers to healthcare access and experiences of stigma: Findings from a coproduced Long Covid case-finding study

BACKGROUND AND AIM

Long Covid is often stigmatised, particularly in people who are disadvantaged within society. This may prevent them from seeking help and could lead to widening health inequalities. This coproduced study with a Community Advisory Board (CAB) of people with Long Covid aimed to understand healthcare and wider barriers and stigma experienced by people with probable Long Covid.

METHODS

An active case finding approach was employed to find adults with probable, but not yet clinically diagnosed, Long Covid in two localities in London (Camden and Merton) and Derbyshire, England. Interviews explored the barriers to care and the stigma faced by participants and were analysed thematically. This study forms part of the STIMULATE-ICP Collaboration.

FINDINGS

Twenty-three interviews were completed. Participants reported limited awareness of what Long Covid is and the available pathways to management. There was considerable self-doubt among participants, sometimes reinforced by interactions with healthcare professionals (HCPs). Participants questioned their deservedness in seeking healthcare support for their symptoms. Hesitancy to engage with healthcare services was motivated by fear of needing more investigation and concerns regarding judgement about the ability to carry out caregiving responsibilities. It was also motivated by the complexity of the clinical presentation and fear of all symptoms being attributed to poor mental health. Participants also reported trying to avoid overburdening the health system. These difficulties were compounded by experiences of stigma and discrimination. The emerging themes reaffirmed a framework of epistemic injustice in relation to Long Covid, where creating, interpreting and conveying knowledge has varied credibility based on the teller's identity characteristics and/or the level of their interpretive resources.

CONCLUSION

We have codeveloped recommendations based on the findings. These include early signposting to services, dedicating protected time to listening to people with Long Covid, providing a holistic approach in care pathways, and working to mitigate stigma. Regardless of the diagnosis, people experiencing new symptoms must be encouraged to seek timely medical help. Clear public health messaging is needed among communities already disadvantaged by epistemic injustice to raise awareness of Long Covid, and to share stories that encourage seeking care and to illustrate the adverse effects of stigma.

PATIENT OR PUBLIC CONTRIBUTION

This study was coproduced with a CAB made up of 23 members including HCPs, people with lived experience of Long Covid and other stakeholders.

Bands renormalization and superconductivity in the strongly correlated Hubbard model using composite operators method

We use the composite operator method (COM) to analyze the strongly correlated repulsive Hubbard model, investigating the effect of nearest-neighbor hoppings up to fourth order on a square lattice. We consider two sets of self-consistent equations, one enforcing the Pauli principle and the other imposing charge-charge, spin-spin, and pair-pair correlations using a decoupling scheme developed by Roth (1969Phys. Rev.184451-9). We extract three distinct solutions from these equations: COM1 and COM2 by imposing the Pauli principle and one from Roth decoupling. An overview of the method studying the validity of particle-hole symmetry and the Luttinger theorem for each solution is presented. Additionally, we extend the initial basis to study superconductivity, concluding that it is induced by the Van Hove singularity. Finally, we include higher-order hoppings using realistic estimates for tight binding parameters and compare our results with ARPES measurements on cuprates.

Socioeconomic and Ethnic Disparities in the Process of Care and Outcomes Among Cancer Patients With Acute Coronary Syndrome

Cancer and acute coronary syndrome (ACS) are the leading causes of morbidity and mortality globally, with many shared risk factors. There are several challenges to the management of patients with cancer presenting with ACS, owing to their higher baseline risk profile, the complexities of their cancer-related therapies and prognosis, and their higher risk of adverse outcomes after ACS. Although previous studies have demonstrated disparities in the care of both cancer and ACS among patients from ethnic minorities and socioeconomic deprivation, there is limited evidence around the magnitude of such disparities specifically in cancer patients presenting with ACS. This review summarises the current literature on differences in prevalence and management of ACS among patients with cancer from ethnic minorities and socioeconomically deprived backgrounds, as well as the gaps in evidence around the care of this high-risk population and potential solutions.

Sex-Based Disparities in Acute Myocardial Infarction Treatment Patterns and Outcomes in Older Adults Hospitalized Across 6 High-Income Countries: An Analysis From the International Health Systems Research Collaborative

BACKGROUND

Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries.

METHODS

We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality.

RESULTS

Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI.

CONCLUSIONS

We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.

Disparities by Social Determinants of Health: Links Between Long COVID and Cardiovascular Disease

Long COVID has been defined by the World Health Organisation as "continuation or development of new symptoms 3 months after the initial SARS-CoV-2 infection, with these symptoms lasting for at least 2 months with no other explanation." Cardiovascular disease is implicated as a risk factor, concomitant condition, and consequence of long COVID. As well as heterogeneity in definition, presentation, and likely underlying pathophysiology of long COVID, disparities by social determinants of health, extensively studied and described in cardiovascular disease, have been observed in 3 ways. First, underlying long-term conditions, such as cardiovascular disease and its risk factors, are associated with incidence and severity of long COVID, and previously described socioeconomic disparities in these factors are important in exacerbating disparities in long COVID. Second, socioeconomic disparities in management of COVID-19 may themselves lead to distal disparities in long COVID. Third, there are socioeconomic disparities in the way that long COVID is diagnosed, managed, and prevented. Together, factors such as age, sex, deprivation, and ethnicity have far-reaching implications in this new postviral syndrome across its management spectrum. There are similarities and differences compared with disparities for cardiovascular disease. Some of these disparities are in fact, inequalities, that is, rather than simply observed variations, they represent injustices with costs to individuals, communities, and economies. This review of current literature considers opportunities to prevent or at least attenuate these socioeconomic disparities in long COVID and cardiovascular disease, with special challenges for research, clinical practice, public health, and policy in a new disease which is evolving.

Low temperature Raman spectroscopic study of anharmonic and spin-phonon coupled quasi-two dimensional rare earth based francisites

Mineral francisites Cu3Bi(SeO3)2O2Cl are unique compounds with interesting quasi two-dimensional structure along with fascinating magnetic properties. The magnetic properties can be fine-tuned when non-magnetic Bi is replaced by a suitable rare earth (RE) metal. It is because of the inclusion of additional magnetic sub-centre RE apart from Cu. Temperature dependent Raman spectroscopy measurements in RE based francisites [Cu3RE(SeO3)2O2Cl, shortly RECufr] were performed in the range of 11 K-295 K. Among the three studied RECufr (LaCufr, NdCufr, and DyCufr) compounds, the properties of phonon vibration vary from moderate (in DyCufr) to weak (in LaCufr) spin phonon coupled and the absence of spin phonon coupling (SPC) (i.e. strictly anharmonic in nature) was observed in NdCufr and the reason for this observation has been provided. More specifically, two Raman-active phonons soften below the antiferromagnetic ordering temperature ofTN≈ 39 K in DyCufr compound, indicating the existence of moderate SPC. This trend of phonon vibration is correlated with magnetic properties, particularly field induced metamagnetic transition (MMT). Strong MMT enabled DyCufr develops SPC, while weak MMT enabled NdCufr is unable to develop SPC.

Ethnicity data resource in population-wide health records: completeness, coverage and granularity of diversity

Intersectional social determinants including ethnicity are vital in health research. We curated a population-wide data resource of self-identified ethnicity data from over 60 million individuals in England primary care, linking it to hospital records. We assessed ethnicity data in terms of completeness, consistency, and granularity and found one in ten individuals do not have ethnicity information recorded in primary care. By linking to hospital records, ethnicity data were completed for 94% of individuals. By reconciling SNOMED-CT concepts and census-level categories into a consistent hierarchy, we organised more than 250 ethnicity sub-groups including and beyond "White", "Black", "Asian", "Mixed" and "Other, and found them to be distributed in proportions similar to the general population. This large observational dataset presents an algorithmic hierarchy to represent self-identified ethnicity data collected across heterogeneous healthcare settings. Accurate and easily accessible ethnicity data can lead to a better understanding of population diversity, which is important to address disparities and influence policy recommendations that can translate into better, fairer health for all.

BATMAN: Improved T cell receptor cross-reactivity prediction benchmarked on a comprehensive mutational scan database

Predicting T cell receptor (TCR) activation is challenging due to the lack of both unbiased benchmarking datasets and computational methods that are sensitive to small mutations to a peptide. To address these challenges, we curated a comprehensive database encompassing complete single amino acid mutational assays of 10,750 TCR-peptide pairs, centered around 14 immunogenic peptides against 66 TCRs. We then present an interpretable Bayesian model, called BATMAN, that can predict the set of peptides that activates a TCR. When validated on our database, BATMAN outperforms existing methods by 20% and reveals important biochemical predictors of TCR-peptide interactions.

Study of wave motion on the emergence of veering, locking, and coupling in periodic composite panels

This research proposes the effect of micropolar-Cosserat (MC) parameters (length-scale parameters and Cosserat shear modulus) on the dispersion characteristics of propagating wave modes in periodic composite panels (PCPs). These inbuilt parameters are due to the assumption of the length-scale boundary conditions that allow for capturing the micro-rotational (MR) wave mode along with the flexural ones. A significant contribution of this study is the transformation of the two-dimensional (2-D) periodic composite problem into a series of one-dimensional (1-D) ones using the MC continuum theory. The analysis employs the transfer matrix method in the framework of the state-space approach to investigate periodic systems in the eigenvalue domain. Additionally, Bloch-Floquet's periodic boundary conditions (PBCs) are applied to the unit cell to ensure the periodicity of the system. The main innovation lies in observing veering, locking, and coupling phenomena, which occur due to alterations in lamina orientation and MC parameters. Moreover, the presence of inbuilt parameters renders the dispersion characteristics highly sensitive to even minor coefficient variations, with a mere 1% change significantly impacting eigenmode fluctuations. The sudden bandgap (BG) disappearing nature could be used to identify the accurate value of the coefficient for designing and analyzing PCPs.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

Two-component nematic superconductivity in 4Hb-TaS2

Most superconductors have an isotropic, single component order parameter and are well described by the standard (BCS) theory for superconductivity. Unconventional, multiple-component superconductors are exceptionally rare and are much less understood. Here, we combine scanning tunneling microscopy and angle-resolved macroscopic transport for studying the candidate chiral superconductor, 4Hb-TaS2. We reveal quasi-periodic one-dimensional modulations in the tunneling conductance accompanied by two-fold symmetric superconducting critical field. The strong modulation of the in-plane critical field, Hc2, points to a nematic, unconventional order parameter. However, the imaged vortex core is isotropic at low temperatures. We suggest a model that reconciles this apparent discrepancy and takes into account previously observed spontaneous time-reversal symmetry breaking at low temperatures. The model describes a competition between a dominating chiral superconducting order parameter and a nematic one. The latter emerges close to the normal phase. Our results strongly support the existence of two-component superconductivity in 4Hb-TaS2 and can provide valuable insights into other systems with coexistent charge order and superconductivity.

Challenges in Clinical Research in Low and Middle Income Countries: Early Career Cardiologists' Perspective

Despite a growing burden of cardiovascular diseases (CVDs) in Low and Middle Income Countries (LMICs), there remain significant barriers to researchers living in these countries regarding the initiation, progression and completion of research. These obstacles are multifactorial, ranging from a lack of general incentives, national and institutional initiatives and capacity, limited opportunities for funding, and lack of mentorship and support for the presentation and publication of research. In this perspective piece, we highlight some of the challenges we have observed from our experience as early career cardiologists in LMICs and present some potential solutions to address these issues.

Corrigendum: Concurrent use of oral anticoagulants and sulfonylureas in individuals with type 2 diabetes and risk of hypoglycemia: a UK population-based cohort study

[This corrects the article DOI: 10.3389/fmed.2022.893080.].

On the estimation of the effect of weight change on a health outcome using observational data, by utilising the target trial emulation framework

BACKGROUND/OBJECTIVES

When studying the effect of weight change between two time points on a health outcome using observational data, two main problems arise initially (i) 'when is time zero?' and (ii) 'which confounders should we account for?' From the baseline date or the 1st follow-up (when the weight change can be measured)? Different methods have been previously used in the literature that carry different sources of bias and hence produce different results.

METHODS

We utilised the target trial emulation framework and considered weight change as a hypothetical intervention. First, we used a simplified example from a hypothetical randomised trial where no modelling is required. Then we simulated data from an observational study where modelling is needed. We demonstrate the problems of each of these methods and suggest a strategy.

INTERVENTIONS

weight loss/gain vs maintenance.

RESULTS

The recommended method defines time-zero at enrolment, but adjustment for confounders (or exclusion of individuals based on levels of confounders) should be performed both at enrolment and the 1st follow-up.

CONCLUSIONS

The implementation of our suggested method [adjusting for (or excluding based on) confounders measured both at baseline and the 1st follow-up] can help researchers attenuate bias by avoiding some common pitfalls. Other methods that have been widely used in the past to estimate the effect of weight change on a health outcome are more biased. However, two issues remain (i) the exposure is not well-defined as there are different ways of changing weight (however we tried to reduce this problem by excluding individuals who develop a chronic disease); and (ii) immortal time bias, which may be small if the time to first follow up is short.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study

BACKGROUND

Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries.

METHODS

We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery.

RESULTS

The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada).

CONCLUSIONS

We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

Impact of Social Vulnerability on Diabetes-Related Cardiovascular Mortality in the United States

Background Social vulnerability impacts the natural history of diabetes as well as cardiovascular disease (CVD). However, there are little data regarding the social vulnerability association with diabetes-related CVD mortality. Methods and Results County-level mortality data (where CVD was the underlying cause of death with diabetes among the multiple causes) extracted from the Centers for Disease Control multiple cause of death (2015-2019) and the 2018 Social Vulnerability Index databases were aggregated into quartiles based on their Social Vulnerability Index ranking from the least (first quartile) to the most vulnerable (fourth quartile). Stratified by demographic groups, the data were analyzed for overall CVD, as well as for ischemic heart disease, hypertensive disease, heart failure, and cerebrovascular disease. In the 5-year study period, 387 139 crude diabetes-related cardiovascular mortality records were identified. The age-adjusted mortality rate for CVD was higher in the fourth quartile compared with the first quartile (relative risk [RR], 1.66 [95% CI, 1.64-1.67]) with an estimated 39 328 excess deaths. Among the youngest age group (<55 years), those with the highest social vulnerability had 2 to 4 times the rate of cardiovascular mortality compared with the first quartile: ischemic heart disease (RR, 2.07 [95% CI, 1.97-2.17]; heart failure (RR, 3.03 [95% CI, 2.62-3.52]); hypertensive disease (RR, 3.79 [95% CI, 3.45-4.17]; and cerebrovascular disease (RR, 4.39 [95% CI, 3.75-5.13]). Conclusions Counties with greater social vulnerability had higher diabetes-related CVD mortality, especially among younger adults. Targeted health policies that are designed to reduce these disparities are warranted.

Liver disease is a significant risk factor for cardiovascular outcomes - A UK Biobank study

BACKGROUND & AIMS

Chronic liver disease (CLD) is associated with increased cardiovascular disease (CVD) risk. We investigated whether early signs of liver disease (measured by iron-corrected T1-mapping [cT1]) were associated with an increased risk of major CVD events.

METHODS

Liver disease activity (cT1) and fat (proton density fat fraction [PDFF]) were measured using LiverMultiScan® between January 2016 and February 2020 in the UK Biobank imaging sub-study. Using multivariable Cox regression, we explored associations between liver cT1 (MRI) and primary CVD (coronary artery disease, atrial fibrillation [AF], embolism/vascular events, heart failure [HF] and stroke), and CVD hospitalisation and all-cause mortality. Liver blood biomarkers, general metabolism biomarkers, and demographics were also included. Subgroup analysis was conducted in those without metabolic syndrome (defined as at least three of: a large waist, high triglycerides, low high-density lipoprotein cholesterol, increased systolic blood pressure, or elevated haemoglobin A1c).

RESULTS

A total of 33,616 participants (mean age 65 years, mean BMI 26 kg/m2, mean haemoglobin A1c 35 mmol/mol) had complete MRI liver data with linked clinical outcomes (median time to major CVD event onset: 1.4 years [range: 0.002-5.1]; follow-up: 2.5 years [range: 1.1-5.2]). Liver disease activity (cT1), but not liver fat (PDFF), was associated with higher risk of any major CVD event (hazard ratio 1.14; 95% CI 1.03-1.26; p = 0.008), AF (1.30; 1.12-1.51; p <0.001); HF (1.30; 1.09-1.56; p= 0.004); CVD hospitalisation (1.27; 1.18-1.37; p <0.001) and all-cause mortality (1.19; 1.02-1.38; p = 0.026). FIB-4 index was associated with HF (1.06; 1.01-1.10; p = 0.007). Risk of CVD hospitalisation was independently associated with cT1 in individuals without metabolic syndrome (1.26; 1.13-1.4; p <0.001).

CONCLUSION

Liver disease activity, by cT1, was independently associated with a higher risk of incident CVD and all-cause mortality, independent of pre-existing metabolic syndrome, liver fibrosis or fat.

IMPACT AND IMPLICATIONS

Chronic liver disease (CLD) is associated with a twofold greater incidence of cardiovascular disease. Our work shows that early liver disease on iron-corrected T1 mapping was associated with a higher risk of major cardiovascular disease (14%), cardiovascular disease hospitalisation (27%) and all-cause mortality (19%). These findings highlight the prognostic relevance of a comprehensive evaluation of liver health in populations at risk of CVD and/or CLD, even in the absence of clinical manifestations or metabolic syndrome, when there is an opportunity to modify/address risk factors and prevent disease progression. As such, they are relevant to patients, carers, clinicians, and policymakers.

Impact of Frailty on Emergency Department Encounters for Cardiovascular Disease: A Retrospective Cohort Study

Data are limited on whether the causes of emergency department (ED) encounters for cardiovascular diseases (CVDs) and associated clinical outcomes vary by frailty status. Using the United States Nationwide ED Sample, selected CVD encounters (acute myocardial infarction [AMI], ischemic stroke, atrial fibrillation [AF], heart failure [HF], pulmonary embolism, cardiac arrest, and hemorrhagic stroke) were stratified by hospital frailty risk score (HFRS). Logistic regression was used to determine the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) of ED mortality among the different frailty groups. A total of 8,577,028 selected CVD ED encounters were included. A total of 5,120,843 (59.7%) had a low HFRS (<5), 3,041,699 (35.5%) had an intermediate HFRS (5 to 15), and 414,485 (4.8%) had a high HFRS (>15). Ischemic stroke was the most common reason for the encounter in the high HFRS group (66.9%), followed by hemorrhagic stroke (11.7%) and AMI (7.2%). For the low HFRS group, AF was the most common reason for the encounter (30.2%), followed by AMI (23.6%) and HF (16.8%). Compared with the low-risk group, high-risk patients had a decreased ED mortality and an increased overall mortality across most CVD encounters (p <0.001). The strongest association with overall mortality was observed among patients with a high HFRS admitted for AF (aOR 27.14, 95% CI 25.03 to 29.43) and HF (aOR 13.71, 95% CI 12.95 to 14.51) compared with their low-risk counterparts. In conclusion, patients presenting to the ED with acute CVD have a significant frailty burden, with different patterns of CVD according to frailty status. Frailty is associated with an increased all-cause mortality in patients for most CVD encounters.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Understanding ethnic inequalities in the design and implementation of digital health interventions for cardiometabolic disease: a qualitative study

BACKGROUND

The use of digital health interventions (DHIs), such as apps and wearable devices, for prevention and management of cardiometabolic disease, has been accelerated by the impact of COVID-19 on health-care services. Digital inequalities disproportionately affect those most at risk of wider health inequalities (e.g., older age, minority ethnicity, and lower household income) and might intersect with populations with higher cardiometabolic disease risk such as South Asians in the UK. We wanted to understand how those involved in DHI implementation perceive and address these inequalities, to help develop recommendations to reduce the risk of DHI implementation exacerbating existing health inequalities.

METHODS

For this qualitative study we used a purposive sampling strategy, whereby focus groups and semi-structured interviews were done online between April 7 and Dec 8, 2022, with stakeholders, including health-care professionals (n=15); technology developers and digital experts (n=10); those in strategy, evaluation, or policy roles (n=15); and charities (n=4). Discussions covered barriers and facilitators to inclusive design and implementation of DHIs, with focus dependent on expertise. Findings from a qualitative study with South Asian patients have been reported separately. Audio recordings were transcribed and coded using reflexive thematic analysis. Participants provided written consent and the study received NHS Health Research Authority approval from London - Brent Research Ethics Committee (IRAS 261047).

FINDINGS

Participants had a good understanding of barriers to DHI use for cardiometabolic disease faced by South Asians, highlighting the need to design for language, culture, and diet. Many emphasised the link between digital exclusion and socioeconomic deprivation, across all ethnic groups in the UK. The potential for DHIs in improving patient outcomes was recognised; however, equity concerns included unequal patient access, lack of data and resources to target support, and need for quality evidence to recommend and commission digital tools. A range of solutions for improving equity were suggested such as resourcing support for digital upskilling, community engagement, and the role of regulation in embedding improved design and evaluation of DHIs available through health-care services.

INTERPRETATION

This study reflects the experiences of professionals interested in (digital) health inequalities. However, challenges to equitable digital health implementation and use are well described. Our findings present multi-sectoral responsibilities and opportunities for action.

FUNDING

National Institute for Health and Care Research (NIHR).

Intracoronary imaging guided percutaneous coronary intervention outcomes among individuals with cardiogenic shock

BACKGROUND

Limited data exist around the utility of intracoronary imaging (ICI) during percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) and cardiogenic shock (CS), who are inherently at a high risk of stent thrombosis (ST).

METHODS

All PCI procedures for ACS patients with CS in England and Wales between 2014 and 2020 were retrospectively analysed, stratified into two groups: ICI and angiography-guided groups. Multivariable logistic regression analyses were performed to examine odds ratios (OR) of in-hospital outcomes, including major adverse cardiovascular and cerebrovascular events (MACCE; composite of all-cause mortality, acute stroke/transient ischaemic attack (TIA), and reinfarction) and major bleeding, in the ICI-guided group compared with angiography-guided PCI.

RESULTS

Of 15,738 PCI procedures, 1240(7.9%) were ICI-guided. The rate of ICI use amongst those with CS more than doubled from 2014 (5.7%) to 2020 (13.3%). The ICI-guided group were predominantly younger, males, with a higher proportion of non-ST-elevation ACS and ST. MACCE was significantly lower in the ICI-guided group compared with the angiography-guided group (crude: 29.8% vs. 38.2%, adjusted odds ratio (OR) 0.65 95% confidence interval [CI] 0.56-0.76), driven by lower all-cause mortality (28.6% vs. 37.0%, OR 0.65 95% CI 0.55-0.75). There were no differences in other secondary outcomes between groups.

CONCLUSION

ICI use among CS patients has more than doubled over 6 years but remains significantly under-utilized, with less than 1-in-6 patients in receipt of ICI-guided PCI by 2020. ICI-guided PCI is associated with prognostic benefits in CS patients and should be more frequently utilized to increase their long-term survival.

Sociodemographic and health-related differences in undiagnosed hypertension in the health survey for England 2015-2019: a cross-sectional cohort study

Background

Hypertension is a leading cause of morbidity and mortality worldwide, yet a substantial proportion of cases are undiagnosed. Understanding the scale of undiagnosed hypertension and identifying groups most at risk is important to inform approaches to detection.

Methods

In this cross-sectional cohort study, we used data from the 2015 to 2019 Health Survey for England, an annual, cross-sectional, nationally representative survey. The survey follows a multi-stage stratified probability sampling design, involving a random sample of primary sampling units based on postcode sectors, followed by a random sample of postal addresses within these units. Within each selected household, all adults (aged ≥16 years) and up to four children, were eligible for participation. For the current study, individuals aged 16 years and over who were not pregnant and had valid blood pressure data were included in the analysis. The primary outcome was undiagnosed hypertension, defined by a measured blood pressure of 140/90 mmHg or above but no history of diagnosis. Age-adjusted prevalence of undiagnosed hypertension was estimated across sociodemographic and health-related characteristics, including ethnicity, region, rural-urban classification, relationship status, highest educational qualification, National Statistics Socio-Economic Classification (NS-SEC), Body Mass Index (BMI), self-reported general health, and smoking status. To assess the independent association between undiagnosed hypertension and each characteristic, we fitted a logistic regression model adjusted for sociodemographic factors.

Findings

The sample included 21,476 individuals, of whom 55.8% were female and 89.3% reported a White ethnic background. An estimated 30.7% (95% confidence interval 29.0-32.4) of men with hypertension and 27.6% (26.1-29.1) of women with hypertension were undiagnosed. Younger age, lower BMI, and better self-reported general health were associated with an increased likelihood of hypertension being undiagnosed for men and women. Living in rural areas and in regions outside of London and the East of England were also associated with an increased likelihood of hypertension being undiagnosed for men, as were being married or in a civil partnership and having higher educational qualifications for women.

Interpretation

Hypertension is commonly undiagnosed, and some of the groups that are at the lowest risk of hypertension are the most likely to be undiagnosed. Given the high lifetime risk of hypertension and its strong links with morbidity and mortality, our findings suggest a need for greater awareness of the potential for undiagnosed hypertension, including among those typically considered 'low risk'. Further research is needed to assess the impact of extending hypertension screening to lower-risk groups.

Funding

None.

Estimation of non-health gross domestic product (NHGDP) loss due to COVID-19 deaths in West Bengal, India

OBJECTIVES

The state of West Bengal witnessed a significant surge of COVID-19 in all three waves. However, there is a gap in understanding the economic loss associated with COVID-19. This study estimates future non-health gross domestic product (NHGDP) losses associated with COVID-19 deaths in West Bengal, India.

SETTING

Various open domains were used to gather data on COVID-19 deaths in West Bengal and the aforementioned estimates.

PRIMARY AND SECONDARY OUTCOME MEASURES

The NHGDP losses were evaluated using the cost-of-illness approach. Future NHGDP losses were discounted at 3%. Excess death estimates by the WHO and Global Burden of Disease (GBD) were used. Sensitivity analysis was carried out by varying discount rates and average age of death (AAD).

RESULTS

21 532 deaths in West Bengal from 17 March 2020 to 31 December 2022 decreased the future NHGDP by $0.92 billion. Nearly 90% of loss was due to deaths occurring in the age group of 30 years and above. Majority of the NHGDP loss was borne by the 46-60 years age group. NHGDP loss/death was $55,171; however, the average loss/death declined with rise in age. Based on the GBD and WHO excess death estimates, the NHGDP loss increased to $9.38 billion and $9.42 billion, respectively. When the lower age interval is considered as AAD, the NHGDP loss increased to $1.3 billion. At 5% and 10% discount rates, the losses reduced to $0.767 billion and $0.549 billion, respectively.

CONCLUSIONS

Results from the study suggest that COVID-19 contributed to a major economic loss in West Bengal. The mortality and morbidity caused by COVID-19, the substantial economic costs at individual and population levels in West Bengal, and probably across India and other countries, is another economic argument for better infection control strategies across the globe to minimise the impact of COVID-19.

Discovering Distinct Phenotypical Clusters in Heart Failure Across the Ejection Fraction Spectrum: a Systematic Review

REVIEW PURPOSE

This systematic review aims to summarise clustering studies in heart failure (HF) and guide future clinical trial design and implementation in routine clinical practice.

FINDINGS

34 studies were identified (n = 19 in HF with preserved ejection fraction (HFpEF)). There was significant heterogeneity invariables and techniques used. However, 149/165 described clusters could be assigned to one of nine phenotypes: 1) young, low comorbidity burden; 2) metabolic; 3) cardio-renal; 4) atrial fibrillation (AF); 5) elderly female AF; 6) hypertensive-comorbidity; 7) ischaemic-male; 8) valvular disease; and 9) devices. There was room for improvement on important methodological topics for all clustering studies such as external validation and transparency of the modelling process. The large overlap between the phenotypes of the clustering studies shows that clustering is a robust approach for discovering clinically distinct phenotypes. However, future studies should invest in a phenotype model that can be implemented in routine clinical practice and future clinical trial design. HF = heart failure, EF = ejection fraction, HFpEF = heart failure with preserved ejection fraction, HFrEF = heart failure with reduced ejection fraction, CKD = chronic kidney disease, AF = atrial fibrillation, IHD = ischaemic heart disease, CAD = coronary artery disease, ICD = implantable cardioverter-defibrillator, CRT = cardiac resynchronization therapy, NT-proBNP = N-terminal pro b-type natriuretic peptide, BMI = Body Mass Index, COPD = Chronic obstructive pulmonary disease.

Human pelvis injury risk curves from underbody blast impact

INTRODUCTION

Underbody blast loading can result in injuries to the pelvis and the lumbosacral spine. The purpose of this study was to determine human tolerance in this region based on survival analysis.

METHODS

Twenty-six unembalmed postmortem human surrogate lumbopelvic complexes were procured and pretest medical images were obtained. They were fixed in polymethylmethacrylate at the cranial end and a six-axis load cell was attached. The specimens were aligned in a seated soldier posture. Impacts were applied to the pelvis using a custom vertical accelerator. The experimental design consisted of non-injury and injury tests. Pretest and post-test X-rays and palpation were done following non-injury test, and after injury test medical imaging and gross dissections were done. Injuries were scored using the Abbreviated Injury Scale (AIS). Axial and resultant forces were used to develop human injury probability curves (HIPCs) at AIS 3+ and AIS 4 severities using survival analysis. Then ±95% CI was computed using the delta method, normalised CI size was obtained, and the quality of the injury risk curves was assigned adjectival ratings.

RESULTS

At the 50% probability level, the resultant and axial forces at the AIS 3+ level were 6.6 kN and 5.9 kN, and at the AIS 4 level these were 8.4 kN and 7.5 kN, respectively. Individual injury risk curves along with ±95% CIs are presented in the paper. Increased injury severity increased the HIPC metrics. Curve qualities were in the good and fair ranges for axial and shear forces at all probability levels and for both injury severities.

CONCLUSIONS

This is the first study to develop axial and resultant force-based HIPCs defining human tolerance to injuries to the pelvis from vertical impacts using parametric survival analysis. Data can be used to advance military safety under vertical loading to the seated pelvis.

Contouring - How Do We Manage This Pivotal but Time-Consuming Workload?

PURPOSE/OBJECTIVE(S)

Advanced radiation treatment planning is a complex, multi-step process beginning with image acquisition and using these images to contour radiation targets and organs at risk prior to radiation treatment planning. Contouring is a time-consuming process. Unfortunately, few radiation oncologists have dedicated contouring time allocated in their daily schedule. Also, across radiation practices there is variability amongst dosimetrists, physicists, and physicians in the assignment of contouring responsibilities. The goal of this survey was to explore how the multi-disciplinary task of contouring for treatment planning is managed across radiation oncology practices and its impact on quality of life (QOL) amongst dosimetrists, physicists, and physicians.

MATERIALS/METHODS

A comprehensive 19-question Qualtrics survey was created evaluating all aspects of contouring and radiation treatment planning and its impact on QOL. The survey was distributed through Twitter, AAMD, a Medical Physics Journal, as well as directly to radiation oncology practices. Survey responses were summarized as proportions and associations tested using Fisher's exact test.

RESULTS

Physicians spent more time completing job responsibilities after work than dosimetrists and physicists, with an average of 6.22 hours (range 0-20) in comparison to 4.16 (0-30) for dosimetrists and 1.55 (0-12) for physicists (p-value 0.001). Physicians on average spent more time contouring on weekends with 1.81 hours (0-10) in comparison to 0.54 (0-10+) for dosimetrists and 0.31 (0-10) for physicists (p-value <0.001). When considering QOL and time spent after work, more respondents agreed there was a negative impact on QOL with increased responsibilities outside work hours (p-value <0.001). On average, respondents performed anywhere from 0 to 85 weekly radiotherapy simulations. The average time delay between simulation and when the imaging datasets are ready for contours was 1.31 days (1-4). 84 respondents signified there is no repercussion for delayed contour plans as planning is fast-tracked to meet the deadline, while 52 respondents signified postponement of radiotherapy start date. Time spent contouring after work hours (p-value 0.148) and on the weekend (p-value 0.403) were similar for both academic and private centers. Similarly, there was no difference in time of days of completion of 3D Conformal Radiation Therapy (p-value 0.551), Intensity Modulated Radiation Therapy (p-value 0.222), or Stereotactic Body Radiation Therapy (p-value 0.551) from academic versus private centers.

CONCLUSION

We present new insight into the amount of time spent in radiation oncology practices by dosimetrists, physicists, and physicians, performing the critical task of contouring for radiation treatment planning and its impact on QOL. These results can be used to guide decisions in the clinic for allocation of radiation treatment planning time and manpower.

Cardiovascular mortality in Brazil during the COVID-19 pandemic: a comparison between underlying and multiple causes of death

OBJECTIVES

The COVID-19 pandemic has differentially impacted cardiovascular disease (CVD) mortality worldwide. Causes of death misclassification may be one of the reasons. We evaluated the impact of the pandemic on CVD mortality in Brazil, comparing underlying causes (UCs) and multiple causes (MCs) of death.

STUDY DESIGN

Ecological time-series study.

METHODS

An ecological, time-series study was conducted analysing age-standardised death rates for CVD, from epidemiological week (EW) 10/2020 to 39/2021, using data from the Mortality Information System, Brazil. CVD was defined using the International Classification of Diseases (ICD-10) coding, if reported as UC or MC of death. Observed and expected data (mean for the same EW, 2017-2019) were compared. Risk ratios (RiRs) were analysed, and 95% confidence intervals (CIs) were calculated.

RESULTS

Age-standardised mortality rate for CVD as UC of death was 165.8 (95%CI: 165.4-166.3) per 100,000 inhabitants, similar to what was expected (165.6/100,000, 95%CI: 165.2-166.1, RiR = 1.00). There was increased out-of-hospital mortality (RiR = 1.18; 95%CI: 1.17-1.19) and deaths of ill-defined causes (RiR = 1.43; 95%CI: 1.42-1.44). The increase in out-of-hospital deaths was more pronounced in the North (RiR = 1.33; 95%CI 1.30-1.36) region, with a less resilient health system. Conversely, as MCs of death, there was a 10% increase in CVD mortality (observed: 243.2 [95%CI: 242.7-243.7], expected: 221.6 [95%CI: 221.1-222.1] per 100,000). An increase also occurred in the North and Central West regions (RiR = 1.16; 95%CI: 1.15-1.18), among men (RiR = 1.11; 95%CI: 1.11-1.12) and individuals aged ≥60 years (RiR = 1.11; 95%CI: 1.10-1.11).

CONCLUSIONS

During the pandemic, mortality rates for CVD as MCs of death increased in Brazil, whereas as UC mortality rates did not change. Higher out-of-hospital mortality, misclassification, and competing causes of death may explain this pattern.

Highly correlated structural, local structural, Raman spectroscopic and magnetic properties of Mn-substituted Cu2V2O7

Low-dimensional quantum spin ½ system Cu2V2O7has been investigated in the framework of Mn-substitution at the Cu site, which is really un-investigated. The studied compounds Cu2 -xMnxV2O7(x= 0, 0.05, 0.1 and 0.15) have been synthesized and characterized structurally, spectroscopically, local structurally and magnetically via x-ray diffraction, Raman, x-ray absorption and temperature, field dependent magnetization measurements respectively. Although Cu2V2O7can be found inα, βandγ-phase, however all of the studied compounds are found in single orthorhombicα-phase which has crucial magneto-electric application potential. Temperature dependent Raman spectra indicated anharmonic phonon-phonon scattering but there is no spin-phonon coupling for VO4vibrational modes. The local structure probed via x-ray absorption near edge structure and extended x-ray absorption fine structure spectroscopy at 15 K, 300 K indicates Cu2+, V5+and mixed valent Mn2+and Mn3+ionic states and justified local structure for the probed ions. Magnetic measurements indicate long-range antiferromagnetic ordering with doping independent Neel temperature (32.5 K). Further observations are strong magnetic hysteresis at 5 K (due to canted spin structure), zero field exchange-bias and their noteworthy enhancement upon Mn-substitution. Interesting correlation between structural parameters and magnetic exchanges has been developed.

Risk factors, outcomes and healthcare utilisation in individuals with multimorbidity including heart failure, chronic kidney disease and type 2 diabetes mellitus: a national electronic health record study

BACKGROUND

Heart failure (HF), type 2 diabetes (T2D) and chronic kidney disease (CKD) commonly coexist. We studied characteristics, prognosis and healthcare utilisation of individuals with two of these conditions.

METHODS

We performed a retrospective, population-based linked electronic health records study from 1998 to 2020 in England to identify individuals diagnosed with two of: HF, T2D or CKD. We described cohort characteristics at time of second diagnosis and estimated risk of developing the third condition and mortality using Kaplan-Meier and Cox regression models. We also estimated rates of healthcare utilisation in primary care and hospital settings in follow-up.

FINDINGS

We identified cohorts of 64 226 with CKD and HF, 82 431 with CKD and T2D, and 13 872 with HF and T2D. Compared with CKD and T2D, those with CKD and HF and HF and T2D had more severe risk factor profile. At 5 years, incidence of the third condition and all-cause mortality occurred in 37% (95% CI: 35.9%, 38.1%%) and 31.3% (30.4%, 32.3%) in HF+T2D, 8.7% (8.4%, 9.0%) and 51.6% (51.1%, 52.1%) in HF+CKD, and 6.8% (6.6%, 7.0%) and 17.9% (17.6%, 18.2%) in CKD+T2D, respectively. In each of the three multimorbid groups, the order of the first two diagnoses was also associated with prognosis. In multivariable analyses, we identified risk factors for developing the third condition and mortality, such as age, sex, medical history and the order of disease diagnosis. Inpatient and outpatient healthcare utilisation rates were highest in CKD and HF, and lowest in CKD and T2D.

INTERPRETATION

HF, CKD and T2D carry significant mortality and healthcare burden in combination. Compared with other disease pairs, individuals with CKD and HF had the most severe risk factor profile, prognosis and healthcare utilisation. Service planning, policy and prevention must take into account and monitor data across conditions.

Prognosis, characteristics, and provision of care for patients with the unspecified heart failure electronic health record phenotype: a population-based linked cohort study of 95262 individuals

Background

Whether the accuracy of the phenotype ascribed to patients in electronic health records (EHRs) is associated with variation in prognosis and care provision is unknown. We investigated this for heart failure (HF, characterised as HF with preserved ejection fraction [HFpEF], HF with reduced ejection fraction [HFrEF] and unspecified HF).

Methods

We included individuals aged 16 years and older with a new diagnosis of HF between January 2, 1998 and February 28, 2022 from linked primary and secondary care records in the Clinical Practice Research Datalink in England. We investigated the provision of guideline-recommended diagnostic investigations and pharmacological treatments. The primary outcome was a composite of HF hospitalisation or all-cause death, and secondary outcomes were time to HF hospitalisation, all-cause death and death from cardiovascular causes. We used Kaplan-Meier curves and log rank tests to compare survival across HF phenotypes and adjusted for potential confounders in Cox proportional hazards regression analyses.

Findings

Of a cohort of 95,262 individuals, 1271 (1.3%) were recorded as having HFpEF, 10,793 (11.3%) as HFrEF and 83,198 (87.3%) as unspecified HF. Individuals recorded as unspecified HF were older with a higher prevalence of dementia. Unspecified HF, compared to patients with a recorded HF phenotype, were less likely to receive specialist assessment, echocardiography or natriuretic peptide testing in the peri-diagnostic period, or receive angiotensin-converting enzyme inhibitors, beta blockers or mineralocorticoid receptor antagonists up to 12 months after diagnosis (risk ratios compared to HFrEF, 0.64, 95% CI 0.63-0.64; 0.59, 0.58-0.60; 0.57, 0.55-0.59; respectively) and had significantly worse outcomes (adjusted hazard ratios compared to HFrEF, HF hospitalisation and death 1.66, 95% CI 1.59-1.74; all-cause mortality 2.00, 1.90-2.10; cardiovascular death 1.77, 1.65-1.90).

Interpretation

Our findings suggested that absence of specification of HF phenotype in routine EHRs is inversely associated with clinical investigations, treatments and survival, representing an actionable target to mitigate prognostic and health resource burden.

Funding

Japan Research Foundation for Healthy Aging and British Heart Foundation.

Acute Cardiovascular Events After COVID-19 in England in 2020: A Self-Controlled Case Series Study

Purpose

To assess the risk of incident cardiovascular outcomes after COVID-19 by level of cardiovascular risk in waves one and two of the pandemic in England in 2020.

Patients and methods

We conducted a self-controlled case-series study among adults aged 40-84 years with no pre-existing cardiovascular disease using linked data from the Clinical Practice Research Datalink. We generated season-adjusted incidence ratios (IRs) for first acute cardiovascular event after SARS-CoV-2 infection compared with baseline time before and >91 days after infection. We used composite and individual acute cardiovascular event outcomes including myocardial infarction, major ventricular arrhythmia, left ventricular heart failure, and ischemic stroke. We stratified by cardiovascular risk, using diagnosed hypertension and QRISK3 predicted risk, and by wave one and two of the pandemic.

Results

We included 1762 individuals, 76.6% had a QRISK3 score ≥10% and 59.4% had hypertension. The risk of any cardiovascular event was elevated in the 1-7 days after infection (IR 7.14 [95% CI 6.06-8.41]) and, while the effect size tapered, the risk remained for 15-28 days after infection (1.74 [1.33-2.26]). Risks were similar for individual event type, differing by level of cardiovascular risk, and in wave one and two of the pandemic.  .

Conclusion

SARS-CoV-2 infection is associated with early elevations in the risk of first acute cardiovascular event, across cardiovascular risk levels and in both wave one and two of the pandemic. Prevention of COVID-19 is important to avert cardiovascular complications.

Socioeconomic inequalities of Long COVID: a retrospective population-based cohort study in the United Kingdom

OBJECTIVES

To estimate the risk of Long COVID by socioeconomic deprivation and to further examine the inequality by sex and occupation.

DESIGN

We conducted a retrospective population-based cohort study using data from the ONS COVID-19 Infection Survey between 26 April 2020 and 31 January 2022. This is the largest nationally representative survey of COVID-19 in the UK with longitudinal data on occupation, COVID-19 exposure and Long COVID.

SETTING

Community-based survey in the UK.

PARTICIPANTS

A total of 201,799 participants aged 16 to 64 years and with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

MAIN OUTCOME MEASURES

The risk of Long COVID at least 4 weeks after SARS-CoV-2 infection by index of multiple deprivation (IMD) and the modifying effects of socioeconomic deprivation by sex and occupation.

RESULTS

Nearly 10% (n = 19,315) of participants reported having Long COVID. Multivariable logistic regression models, adjusted for a range of variables (demographic, co-morbidity and time), showed that participants in the most deprived decile had a higher risk of Long COVID (11.4% vs. 8.2%; adjusted odds ratio (aOR): 1.46; 95% confidence interval (CI): 1.34, 1.59) compared to the least deprived decile. Significantly higher inequalities (most vs. least deprived decile) in Long COVID existed in healthcare and patient-facing roles (aOR: 1.76; 95% CI: 1.27, 2.44), in the education sector (aOR: 1.68; 95% CI: 1.31, 2.16) and in women (aOR: 1.56; 95% CI: 1.40, 1.73) than men (aOR: 1.32; 95% CI: 1.15, 1.51).

CONCLUSIONS

This study provides insights into the heterogeneous degree of inequality in Long COVID by deprivation, sex and occupation. These findings will help inform public health policies and interventions in incorporating a social justice and health inequality lens.

Long Covid active case finding study protocol: A co-produced community-based pilot within the STIMULATE-ICP study (Symptoms, Trajectory, Inequalities and Management: Understanding Long-COVID to Address and Transform Existing Integrated Care Pathways)

BACKGROUND AND AIM

Long Covid is a significant public health concern with potentially negative implications for health inequalities. We know that those who are already socially disadvantaged in society are more exposed to COVID-19, experience the worst health outcomes and are more likely to suffer economically. We also know that these groups are more likely to experience stigma and have negative healthcare experiences even before the pandemic. However, little is known about disadvantaged groups' experiences of Long Covid, and preliminary evidence suggests they may be under-represented in those who access formal care. We will conduct a pilot study in a defined geographical area in London, United Kingdom to test the feasibility of a community-based approach of identifying Long Covid cases that have not been clinically diagnosed and have not been referred to Long Covid specialist services. We will explore the barriers to accessing recognition, care, and support, as well as experiences of stigma and perceived discrimination.

METHODS

This protocol and study materials were co-produced with a Community Advisory Board (CAB) made up primarily of people living with Long Covid. Working with voluntary organisations, a study leaflet will be distributed in the local community to highlight Long Covid symptoms and invite those experiencing them to participate in the study if they are not formally diagnosed. Potential participants will be assessed according to the study's inclusion criteria and offered the opportunity to participate if they fit them. Awareness of Long Covid and associated symptoms, experiences of trying to access care, as well as stigma and discrimination will be explored through qualitative interviews with participants. Upon completion of the interviews, participants will be offered a referral to the local social prescribing team to receive support that is personalised to them potentially including, but not restricted to, liaising with their primary care provider and the regional Long Covid clinic.

Evidence of population expansion and insecticide resistance mechanism in invasive fall armyworm (Spodoptera frugiperda)

BACKGROUND

The invasive and calamitous polyphagous pest Spodoptera frugiperda or commonly known as fall armyworm (FAW) poses serious menace to the global agricultural production. Owing to the revamped invasion of FAW in 2018 in India, present study was undertaken for precise assessment of its genetic identity and pesticide resistance to aid in pest-management strategies.

RESULTS

To evaluate the diversity in FAW population across Eastern India, mitochondrial COI sequences were used which revealed a low nucleotide diversity. Analysis of molecular variance indicated significant genetic variation between four global geographical FAW populations with lowest differentiation between India and Africa suggesting a present-day and shared origin of FAW. The study demonstrated existence of two different strains ('R' strain and 'C' strain) based on COI gene marker. However, discrepancies between COI marker and host plant association of FAW was observed. Characterization of Tpi gene revealed abundance of TpiCa1a followed by TpiCa2b and TpiR1a strains respectively. The FAW population showed higher susceptibility towards chlorantraniliprole and spinetoram than cypermethrin. Insecticide resistance genes depicted marked upregulation although with lot of variance. Chlorantraniliprole resistance ratio (RR) exhibited significant correlation with 1950 (Glutathione S-transferase, GST), 9131 (Cytochrome P450, CYP) and 9360 (CYP) genes, while spinetoram and cypermethrin RR was found to correlate with 1950 (GST) and 9360 (CYP) genes.

CONCLUSION

This study manifests Indian subcontinent as the potential new hotspot for the growth and distribution of FAW population that can be effectively controlled using chlorantraniliprole and spinetoram. This study also adds novel significant information on FAW population across Eastern India for developing a comprehensive pest management approach for S. frugiperda.

Identifying subtypes of heart failure from three electronic health record sources with machine learning: an external, prognostic, and genetic validation study

BACKGROUND

Machine learning has been used to analyse heart failure subtypes, but not across large, distinct, population-based datasets, across the whole spectrum of causes and presentations, or with clinical and non-clinical validation by different machine learning methods. Using our published framework, we aimed to discover heart failure subtypes and validate them upon population representative data.

METHODS

In this external, prognostic, and genetic validation study we analysed individuals aged 30 years or older with incident heart failure from two population-based databases in the UK (Clinical Practice Research Datalink [CPRD] and The Health Improvement Network [THIN]) from 1998 to 2018. Pre-heart failure and post-heart failure factors (n=645) included demographic information, history, examination, blood laboratory values, and medications. We identified subtypes using four unsupervised machine learning methods (K-means, hierarchical, K-Medoids, and mixture model clustering) with 87 of 645 factors in each dataset. We evaluated subtypes for (1) external validity (across datasets); (2) prognostic validity (predictive accuracy for 1-year mortality); and (3) genetic validity (UK Biobank), association with polygenic risk score (PRS) for heart failure-related traits (n=11), and single nucleotide polymorphisms (n=12).

FINDINGS

We included 188 800, 124 262, and 9573 individuals with incident heart failure from CPRD, THIN, and UK Biobank, respectively, between Jan 1, 1998, and Jan 1, 2018. After identifying five clusters, we labelled heart failure subtypes as (1) early onset, (2) late onset, (3) atrial fibrillation related, (4) metabolic, and (5) cardiometabolic. In the external validity analysis, subtypes were similar across datasets (c-statistics: THIN model in CPRD ranged from 0·79 [subtype 3] to 0·94 [subtype 1], and CPRD model in THIN ranged from 0·79 [subtype 1] to 0·92 [subtypes 2 and 5]). In the prognostic validity analysis, 1-year all-cause mortality after heart failure diagnosis (subtype 1 0·20 [95% CI 0·14-0·25], subtype 2 0·46 [0·43-0·49], subtype 3 0·61 [0·57-0·64], subtype 4 0·11 [0·07-0·16], and subtype 5 0·37 [0·32-0·41]) differed across subtypes in CPRD and THIN data, as did risk of non-fatal cardiovascular diseases and all-cause hospitalisation. In the genetic validity analysis the atrial fibrillation-related subtype showed associations with the related PRS. Late onset and cardiometabolic subtypes were the most similar and strongly associated with PRS for hypertension, myocardial infarction, and obesity (p<0·0009). We developed a prototype app for routine clinical use, which could enable evaluation of effectiveness and cost-effectiveness.

INTERPRETATION

Across four methods and three datasets, including genetic data, in the largest study of incident heart failure to date, we identified five machine learning-informed subtypes, which might inform aetiological research, clinical risk prediction, and the design of heart failure trials.

FUNDING

European Union Innovative Medicines Initiative-2.

Corrigendum to "The prevalence and long-term health effects of long Covid among hospitalised and non-hospitalised populations: a systematic review and meta-analysis"

[This corrects the article DOI: 10.1016/j.eclinm.2022.101762.].

Digital health, cardiometabolic disease and ethnicity: an analysis of United Kingdom government policies from 2010 to 2022

Recent health policies in the United Kingdom (UK) and internationally have focussed on digitisation of healthcare. We examined UK policies for evidence of government action addressing health inequalities and digital health, using cardiometabolic disease as an exemplar. Using a systematic search methodology, we identified 87 relevant policy documents published between 2010 and 2022. We found increasing emphasis on digital health, including for prevention, diagnosis and management of cardiometabolic disease. Several policies also focused on tackling health inequalities and improving digital access. The COVID-19 pandemic amplified inequalities. No policies addressed ethnic inequalities in digital health for cardiometabolic disease, despite high prevalence in minority ethnic communities. Our findings suggest that creating opportunities for digital inclusion and reduce longer-term health inequalities, will require future policies to focus on: the heterogeneity of ethnic groups; cross-sectoral disadvantages which contribute to disease burden and digital accessibility; and disease-specific interventions which lend themselves to culturally tailored solutions.