Heart valve service provision in the United Kingdom and the effect of the COVID 19 pandemic; improved but must do better. A British Heart Valve Society national survey

BACKGROUND

Outpatient care for patients with heart valve disease (HVD) is best provided by valve clinics delivered by specialists. Modern day practice in the United Kingdom (UK) is currently poorly understood and has not been evaluated for nearly a decade. Furthermore, the COVID 19 pandemic changed the management of many chronic diseases, and how this has impacted patients with heart valve disease is unclear.

METHODS

A British Heart Valve Society survey was sent to 161 hospitals throughout the UK.

RESULTS

There was a general valve clinic in 46 of the 68 hospitals (68%), in 19 of 23 Heart Centres (83%) and 29 of 45 DGHs (64%). Across all settings, 3824 new patients and 17,980 follow up patients were seen in valve clinics per annum. The mean number of patients per hospital were 197 (median 150, range 48-550) for new patients and 532 (median 400, range 150-2000) for follow up. On the day echocardiography was available in 55% of valve clinics. In patients with severe HVD, serum brain natriuretic peptide (BNP) was measured routinely in 39% of clinics and exercise testing routinely performed in 49% of clinics. A patient helpline was available in 27% of clinics. 78% of centres with a valve clinic had a valve multidisciplinary team meeting (MDT). 45% centres had an MDT co-ordinator and MDT outcomes were recorded on a database in 64%. COVID-19 had a major impact on valve services in 54 (95%) hospitals.

CONCLUSIONS

There has been an increase in the number of valve clinics since 2015 from 21 to 68% but the penetration is still well short of the expected 100%, meaning that valve clinics only serve a small proportion of patients requiring surveillance for HVD. COVID-19 had a major impact on the care of patients with HVD in the majority of UK centres surveyed.

Impact of a peer-support programme to improve loneliness and social isolation due to COVID-19: does adding a secure, user friendly video-conference solution work better than telephone support alone? Protocol for a three-arm randomised clinical trial

INTRODUCTION

The COVID-19 pandemic has forced the implementation of physical distancing and self-isolation strategies worldwide. However, these measures have significant potential to increase social isolation and loneliness. Among older people, loneliness has increased from 40% to 70% during COVID-19. Previous research indicates loneliness is strongly associated with increased mortality. Thus, strategies to mitigate the unintended consequences of social isolation and loneliness are urgently needed. Following the Obesity-Related Behavioural Intervention Trials model for complex behavioural interventions, we describe a protocol for a three-arm randomised clinical trial to reduce social isolation and loneliness.

METHODS AND ANALYSIS

A multicentre, outcome assessor blinded, three-arm randomised controlled trial comparing 12 weeks of: (1) the HOspitals WoRking in Unity ('HOW R U?') weekly volunteer-peer support telephone intervention; (2) 'HOW R U?' deliver using a video-conferencing solution and (3) a standard care group. The study will follow Consolidated Standard of Reporting Trials guidelines.We will recruit 24-26 volunteers who will receive a previously tested half day lay-training session that emphasises a strength-based approach and safety procedures. We will recruit 141 participants ≥70 years of age discharged from two participating emergency departments or referred from hospital family medicine, geriatric or geriatric psychiatry clinics. Eligible participants will have probable baseline loneliness (score ≥2 on the de Jong six-item loneliness scale). We will measure change in loneliness, social isolation (Lubben social network scale), mood (Geriatric Depression Score) and quality of life (EQ-5D-5L) at 12-14 weeks postintervention initiation and again at 24-26 weeks.

ETHICS AND DISSEMINATION

Approval has been granted by the participating research ethics boards. Participants randomised to standard care will be offered their choice of telephone or video-conferencing interventions after 12 weeks. Results will be disseminated through journal publications, conference presentations, social media and through the International Federation of Emergency Medicine.

TRIAL REGISTRATION NUMBER

NCT05228782.

Going home positive: a qualitative study of the experiences of care for patients with COVID-19 who are not hospitalized

BACKGROUND

Most Canadians diagnosed with COVID-19 have had mild symptoms not requiring hospitalization. We sought to understand the patient experience of care while being isolated at home after testing positive for SARS-CoV-2 infection.

METHODS

We conducted a phenomenologically informed qualitative descriptive study using in-depth semistructured interviews to identify common themes of experience for patients sent home from hospital with a positive COVID-19 diagnosis. Between July and December 2020, we conducted interviews with patients who were followed by the North York General Hospital COVID Follow-Up Clinic. Patients with mild to moderate symptoms were interviewed 4 weeks after their COVID-19 diagnosis. We conducted the interviews and performed a thematic analysis of the data concurrently, in keeping with the iterative process of qualitative methodology.

RESULTS

We conducted interviews with 26 patients. From our analysis, 3 themes were developed regarding participants' overall experience: lack of adequate communication, inconsistency of information from various sources, and the social implications of a COVID-19 diagnosis. The implications of a positive test for SARS-CoV-2 infection are substantial, even when symptoms are mild and patients self-isolate as recommended. Participants noted communication challenges and inconsistent information, leading to exacerbated stress.

INTERPRETATION

Participants shared their experiences of the stigma of testing positive and the frustration of poor communication structures and inconsistent information. Experiencing care during self-isolation at home is an area of increasing importance, and these findings can inform improved support, ensuring access to equitable and safe COVID-19 care for these patients.

Carboxymethyl cellulose-alginate interpenetrating hydroxy ethyl methacrylate crosslinked polyvinyl alcohol reinforced hybrid hydrogel templates with improved biological performance for cardiac tissue engineering

Cardiac tissue engineering is an emerging approach for cardiac regeneration utilizing the inherent healing responses elicited by the surviving heart using biomaterial templates. In this study, we aimed to develop hydrogel scaffolds for cardiac tissue regeneration following myocardial infarction (MI). Two superabsorbent hydrogels, CAHA2A and CAHA2AP, were developed employing interpenetration chemistry. CAHA2A was constituted with alginate, carboxymethyl cellulose, (hydroxyethyl) methacrylate, and acrylic acid, where CAHA2AP was prepared by interpenetrated CAHA2A with polyvinyl alcohol. Both hydrogels displayed superior physiochemical characteristics, as determined by attenuated total reflection infrared spectroscopy spectral analysis, differential scanning calorimetry measurements, tensile testing, contact angle, water profiling, dye release, and conductivity. In vitro degradation of the hydrogels displayed acceptable weight composure and pH changes. Both hydrogels were hemocompatible, and biocompatible as evidenced by direct contact and MTT assays. The hydrogels promoted anterograde and retrograde migration as determined by the z-stack analysis using H9c2 cells grown with both gels. Additionally, the coculture of the hydrogels with swine epicardial adipose tissue cells and cardiac fibroblasts resulted in synchronous growth without any toxicity. Also, both hydrogels facilitated the production of extracellular matrix by the H9c2 cells. Overall, the findings support an appreciable in vitro performance of both hydrogels for cardiac tissue engineering applications.

The ability of machine learning algorithms to predict defibrillation success during cardiac arrest: A systematic review

OBJECTIVE

To evaluate the existing knowledge on the effectiveness of machine learning (ML) algorithms inpredicting defibrillation success during in- and out-of-hospital cardiac arrest.

METHODS

MEDLINE, Embase, CINAHL and Scopus were searched from inception to August 30, 2022. Studies were included that utilized ML algorithms for prediction of successful defibrillation, observed as return of spontaneous circulation (ROSC), survival to hospital or discharge, or neurological status at discharge.Studies were excluded if involving a trauma, an unknown underlying rhythm, an implanted cardiac defibrillator or if focused on the prediction or onset of cardiac arrest. Risk of bias was assessed using the PROBAST tool.

RESULTS

There were 2399 studies identified, of which 107 full text articles were reviewed and 15 observational studies (n = 5680) were included for final analysis. 29 ECG waveform features were fed into 15 different ML combinations. The best performing ML model had an accuracy of 98.6 (98.5 - 98.7)%, with 4 second ECG intervals. An algorithm incorporating end-tidal CO2 reported an accuracy of 83.3% (no CI reported). Meta-analysis was not performed due to heterogeneity in study design, ROSC definitions, and characteristics.

CONCLUSION

Machine learning algorithms, specifically Neural Networks, have been shown to have potential to predict defibrillation success for cardiac arrest with high sensitivity and specificity.Due to heterogeneity, inconsistent reporting, and high risk of bias, it is difficult to conclude which, if any, algorithm is optimal. Further clinical studies with standardized reporting of patient characteristics, outcomes, and appropriate algorithm validation are still required to elucidate this. PROSPERO 2020 CRD42020148912.

Bioactive extracellular matrix fragments in tendon repair

Tendinopathy is a common tendon disorder that causes pain, loss of strength and function, and local inflammation mainly characterized by hypoxia, collagen degradation, and extracellular matrix (ECM) disorganization. Generally, ECM degradation and remodeling is tightly regulated; however, hyperactivation of matrix metalloproteases (MMPs) contributes to excessive collagenolysis under pathologic conditions resulting in tendon ECM degradation. This review article focuses on the production, function, and signaling of matrikines for tendon regeneration following injury with insights into the expression, tissue compliance, and cell proliferation exhibited by various matrikines. Furthermore, the regenerative properties suggest translational significance of matrikines to improve the outcomes post-injury by assisting with tendon healing.

Establishing a multicenter, preclinical consortium in resuscitation: A pilot experimental trial evaluating epinephrine in cardiac arrest

BACKGROUND

Large animal studies are an important step in the translation pathway, but single laboratory experiments do not replicate the variability in patient populations. Our objective was to demonstrate the feasibility of performing a multicenter, preclinical, randomized, double-blinded, placebo-controlled cardiac arrest trial. We evaluated the effect of epinephrine on coronary perfusion pressure (CPP) as previous single laboratory studies have reported mixed results.

METHODS

Forty-five swine from 5 different laboratories (Ann Arbor, MI; Baltimore, MD; Los Angeles, CA; Pittsburgh, PA; Toronto, ON) using a standard treatment protocol. Ventricular fibrillation was induced and left untreated for 6 min before starting continuous cardiopulmonary resuscitation (CPR). After 2 min of CPR, 9 animals from each lab were randomized to 1 of 3 interventions given over 12 minutes: (1) Continuous IV epinephrine infusion (0.00375 mg/kg/min) with placebo IV normal saline (NS) boluses every 4 min, (2) Continuous placebo IV NS infusion with IV epinephrine boluses (0.015 mg/kg) every 4 min or (3) Placebo IV NS for both infusion and boluses. The primary outcome was mean CPP during the 12 mins of drug therapy.

RESULTS

There were no significant differences in mean CPP between the three groups: 14.4 ± 6.8 mmHg (epinephrine Infusion), 16.9 ± 5.9 mmHg (epinephrine bolus), and 14.4 ± 5.5 mmHg (placebo) (p = NS). Sensitivity analysis demonstrated inter-laboratory variability in the magnitude of the treatment effect (p = 0.004).

CONCLUSION

This study demonstrated the feasibility of performing a multicenter, preclinical, randomized, double-blinded cardiac arrest trials. Standard dose epinephrine by bolus or continuous infusion did not increase coronary perfusion pressure during CPR when compared to placebo.

Towards quality assurance: implementation of a POCUS image archiving system in a high-volume community emergency department

BACKGROUND

Quality assurance review is an integral part of point-of-care ultrasound (POCUS) programs but may not be routine practice in community hospitals. Lack of image acquisition and documentation can result in suboptimal patient care. In cases with an adverse outcome and no record of images, there is no mechanism for quality improvement.

OBJECTIVES

Our goal was to implement a system of POCUS image archiving in a community hospital. Our SMART (Specific, Measurable, Actionable, Realistic, Timely) aim was to have > 50% of emergency department (ED) POCUS users archiving scans, and > 80% of all billed POCUS scans archived, measuring improvements bi-weekly over a period of 9 months.

METHODS

The study was conducted at a single-community ED between August 2020 and April 2021. The POCUS archiving workflow was developed and refined through multiple plan-do-study-act (PDSA) cycles. Surveys, stakeholder meetings, audits, and feedback were used to generate and re-evaluate the interventions. These included introduction of QPathE© software, streamlining of the workflow process, strategic machine placement, POCUS rounds, use of a website for POCUS workflow instructions, and dissemination of audit results. Scans were tracked biweekly, and indexed by the number of scans billed. The primary outcome measure was the number of POCUS scans archived per 100 scans billed.

RESULTS

Over a 9-month period, spanning 72,986 ED visits, 550 scans were archived. The percentage of POCUS users who changed practice to consistently archiving scans was 51%. The rate of POCUS scans archived per 100 scans billed was > 80%, compared to no archiving at baseline.

CONCLUSION

We were able to transition from a system with entirely unarchived POCUS scanning, to one with > 80% of scans archived over a period of 9 months. This is the first published paper documenting implementation of a POCUS image archiving system in a Canadian Community ED.

First-line Medications for the Outpatient Treatment of Alcohol Use Disorder: A Systematic Review of Perceived Barriers

OBJECTIVES

Alcohol use disorder (AUD) is a common illness with significant health and economic consequences. Although three pharmacotherapeutic agents have been shown to decrease heavy drinking days among individuals with AUD, they are vastly underutilized in clinical practice. The objective of this review was to elucidate barriers that may prevent patients from obtaining medication for addiction treatment (MAT) for AUD in an outpatient or residential setting.

METHODS

Electronic searches of Medline and EMBASE were conducted, and reference lists were hand-searched. All study designs which discussed the use of MAT for AUD in an outpatient or residential setting were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible articles, the full texts of which were retrieved and assessed for inclusion.

RESULTS

After eliminating duplicate citations and articles that did not meet eligibility criteria, 23 articles were included in the review. Perceived barriers to obtaining pharmacotherapy for the treatment of AUD in an outpatient or residential setting were grouped into 3 themes: lack of knowledge and concerns about efficacy and complexity of prescribing; treatment philosophy and stigma; medication accessibility including formulary restrictions, geographical and socioeconomic barriers.

CONCLUSIONS

Although evidence-based pharmacotherapeutics have been approved for the treatment of AUD, our findings suggest patients continue to experience barriers to the use of these medications. Efforts should be made to increase rates of prescribing by providers and the use of medications by patients. More research is needed to further elucidate perceived barriers to MAT use, along with strategies to overcome them.

SARS-CoV-2 Detection in Gingival Crevicular Fluid

Understanding the pathophysiology of the coronavirus disease 2019 (COVID-19) infection remains a significant challenge of our times. The gingival crevicular fluid being representative of systemic status and having a proven track record of detecting viruses and biomarkers forms a logical basis for evaluating the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The study aimed to assess gingival crevicular fluid (GCF) for evidence of SARS-CoV-2 in 33 patients who were deemed to be COVID-19 positive upon nasopharyngeal sampling. An attempt was also made to comparatively evaluate it with saliva in terms of its sensitivity, as a diagnostic fluid for SARS-CoV-2. GCF and saliva samples were collected from 33 COVID-19-confirmed patients. Total RNA was extracted using NucliSENS easyMAG (bioMérieux) and eluted in the elution buffer. Envelope gene (E gene) of SARS-CoV-2 and human RNase P gene as internal control were detected in GCF samples by using the TRUPCR SARS-CoV-2 RT qPCR kit V-2.0 (I) in an Applied Biosystems 7500 real-time machine. A significant majority of both asymptomatic and mildly symptomatic patients exhibited the presence of the novel coronavirus in their GCF samples. Considering the presence of SARS-CoV-2 RNA in the nasopharyngeal swab sampling as gold standard, the sensitivity of GCF and saliva, respectively, was 63.64% (confidence interval [CI], 45.1% to 79.60%) and 64.52% (CI, 45.37% to 80.77%). GCF was found to be comparable to saliva in terms of its sensitivity to detect SARS-CoV-2. Saliva samples tested positive in 3 of the 12 patients whose GCF tested negative, and likewise GCF tested positive for 2 of the 11 patients whose saliva tested negative on real-time reverse transcription polymerase chain reaction. The results establish GCF as a possible mode of transmission of SARS-CoV-2, which is the first such report in the literature, and also provide the first quantifiable evidence pointing toward a link between the COVID-19 infection and oral health.

Development of the Canadian COVID-19 Emergency Department Rapid Response Network population-based registry: a methodology study

BACKGROUND

Emergency physicians lack high-quality evidence for many diagnostic and treatment decisions made for patients with suspected or confirmed coronavirus disease 2019 (COVID-19). Our objective is to describe the methods used to collect and ensure the data quality of a multicentre registry of patients presenting to the emergency department with suspected or confirmed COVID-19.

METHODS

This methodology study describes a population-based registry that has been enrolling consecutive patients presenting to the emergency department with suspected or confirmed COVID-19 since Mar. 1, 2020. Most data are collected from retrospective chart review. Phone follow-up with patients at 30 days captures the World Health Organization clinical improvement scale and contextual, social and cultural variables. Phone follow-up also captures patient-reported quality of life using the Veterans Rand 12-Item Health Survey at 30 days, 60 days, 6 months and 12 months. Fifty participating emergency departments from 8 provinces in Canada currently enrol patients into the registry.

INTERPRETATION

Data from the registry of the Canadian COVID-19 Emergency Department Rapid Response Network will be used to derive and validate clinical decision rules to inform clinical decision-making, describe the natural history of the disease, evaluate COVID-19 diagnostic tests and establish the real-world effectiveness of treatments and vaccines, including in populations that are excluded or underrepresented in clinical trials. This registry has the potential to generate scientific evidence to inform our pandemic response, and to serve as a model for the rapid implementation of population-based data collection protocols for future public health emergencies.

TRIAL REGISTRATION

Clinicaltrials.gov, no. NCT04702945.

Coinfection of H1N1 Influenza and Scrub Typhus-A Review

The H1N1 influenza infection usually coincides with the typical scrub typhus season in North India. This leads to diagnostic difficulties due to their similar and non-specific symptoms. We describe three patients with confirmed co-infection of pandemic (H1N1) influenza and scrub typhus who had presented with acute respiratory distress syndrome. A systematic review of database yielded one case of scrub typhus and H1N1 influenza co-infection reported from South Korea. Co-infection of influenza with tropical infections may not be uncommon in endemic countries and hence a high index of suspicion on the part of physicians coupled with appropriate investigations are needed. The true burden of co-infections needs to be evaluated during outbreaks of influenza in a systematic manner.

Study of the Effects of Epinephrine on Cerebral Oxygenation and Metabolism During Cardiac Arrest and Resuscitation by Hyperspectral Near-Infrared Spectroscopy

OBJECTIVES

Epinephrine is routinely administered to sudden cardiac arrest patients during resuscitation, but the neurologic effects on patients treated with epinephrine are not well understood. This study aims to assess the cerebral oxygenation and metabolism during ventricular fibrillation cardiac arrest, cardiopulmonary resuscitation, and epinephrine administration.

DESIGN

To investigate the effects of equal dosages of IV epinephrine administrated following sudden cardiac arrest as a continuous infusion or successive boluses during cardiopulmonary resuscitation, we monitored cerebral oxygenation and metabolism using hyperspectral near-infrared spectroscopy.

SETTINGS

A randomized laboratory animal study.

SUBJECTS

Nine healthy pigs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Our study showed that although continuous epinephrine administration had no significant impact on overall cerebral hemodynamics, epinephrine boluses transiently improved cerebral oxygenation (oxygenated hemoglobin) and metabolism (cytochrome c oxidase) by 15% ± 6.7% and 49% ± 18%, respectively (p < 0.05) compared with the baseline (untreated) ventricular fibrillation. Our results suggest that the effects of epinephrine diminish with successive boluses as the impact of the third bolus on brain oxygen metabolism was 24.6% ± 3.8% less than that of the first two boluses.

CONCLUSIONS

Epinephrine administration by bolus resulted in transient improvements in cerebral oxygenation and metabolism, whereas continuous epinephrine infusion did not, compared with placebo. Future studies are needed to evaluate and optimize the use of epinephrine in cardiac arrest resuscitation, particularly the dose, timing, and mode of administration.

Positing a difference between acts and omissions: the principle of justice, Rachels' cases and moral weakness

The difficulty in discovering a difference between killing and letting die has led many philosophers to deny the distinction. This paper seeks to develop an argument defending the distinction between killing and letting die. In relation to Rachels' cases, the argument is that (a) even accepting that Smith and Jones may select equally heinous options from the choices they have available to them, (b) the fact that the choices available to them are different is morally relevant, and (c) this difference in available choices can be used to distinguish between the agents in certain circumstances. It is the principle of justice, as espoused by Aristotle, which requires that equal things are treated equally and that unequal things are treated unequally that creates a presumption that Smith and Jones should be treated differently. The magnitude of this difference can be amplified by other premises, making the distinction morally relevant in practical reality.

Selective inflammatory effect of systemic fluorouracil in actinic keratosis

A selective inflammatory reaction involving actinic keratosis may occur in patients receiving systemic 5-fluorouracil as part of a chemotherapeutic protocol. This may be effectively treated with topical 5-fluorouracil.