Health workforce needs and health policy responses to COVID-19: a European comparative assessment

Background

The COVID-19 pandemic revealed the importance of the health workforce for health system resilience. This study aims to explore whether and how healthcare system in Europe have responded to new emergent needs and transformed their health workforce policies.

Methods

A qualitative comparative approach is applied, based on multi-level governance theory and a rapid assessment of three areas of health workforce policy: mental health, gender equality, and public health competencies. We consider two years of the pandemic with a focus on recent waves, October 2021-January 2022. Denmark, Germany, Portugal, Romania and Switzerland are selected for comparison, representing different health systems, health workforce conditions and COVID-19 indicators in the European Union and European Economic Area.

Results

Across countries the pandemic has highlighted mental health needs, persisting gender inequalities and demand for public health competencies. Our comparison reveals similar weaknesses and governance gaps. (1) Mental health needs of healthcare workers are increasingly recognised (more strongly in Denmark and less in Romania with the other countries clustering in-between); however, health workers’ perceptions are not used as guidance and effective programmes are lacking. (2) The situation is worst in relation to gender equality goals that are largely ignored in pandemic policy and recovery plans. (3) Public health competences are more advanced and integrated in the NHS systems in Denmark and Portugal, but no country has taken action to innovate health workforce education and strengthen public health.

Conclusions

The comparative assessment highlights that health systems failed to adequately respond to health workforce needs and the COVID-19 challenges. Action has to be taken to implement participatory governance and step up efforts towards more responsive and resilient health workforce policy.

Health workforce protection and preparedness during COVID-19: a rapid assessment of EU countries

Background

Healthcare workers face high pressures and new threats during the COVID-19 pandemic, and health systems and governance are key to improve preparedness and protection. This study aims to introduce a tool for rapid assessment based on an integrated multi-level governance approach and to empirically explore preparedness and protection.

Methods

The study is explorative in nature and applies a comparative approach. The assessment tool comprises four major dimensions of governance: system, sector, occupational and sociocultural issues (focus on gender issues and migrant healthcare workers) of protection and preparedness. Secondary sources and expert information serve the empirical exercise, using material from Denmark, Germany, Portugal and Romania.

Results

We revealed similar developments across countries: action has been taken to improve physical protection, vaccination of healthcare workers and digitalisation, while social and mental health support programmes were poor or lacking. Developments were more diverse in relation to occupational/ organisational preparedness: some ad-hoc transformations of work routines and tasks were observed in all countries, yet skill-mix innovation and collaboration were strong in Demark and weak in Portugal and Romania. We are able to identify major governance gaps in relation to integration of education and health systems, social and mental health support programmes, gendered issues of health workforce capacity, integration of migrant healthcare workers, and comprehensive surveillance and monitoring.

Conclusions

There is a need to step up efforts and make health systems more accountable to the needs of healthcare workers during global public health emergencies.

Semi-industrial development of nutritious and healthy seafood dishes from sustainable species

This study aimed to devise innovative, tailor-made, appealing, tasty and semi-industrialized dishes, using sustainable and under-utilized seafood species (bib, common dab, common carp, blue mussel and blue whiting), that can meet the specific nutritional and functional needs of children (8-10-years), pregnant women (20-40-years) and seniors (≥60-years). Hence, contests were organised among cooking schools from 6 European countries and the best recipes/dishes were reformulated, semi-industrially produced and chemically and microbiologically evaluated. The dishes intended for: (i) children and pregnant women had EPA + DHA and I levels that reached the target quantities, supporting the claim as "high in I"; and (ii) seniors were "high in protein" (24.8%-Soup_S and 34.0%-Balls_S of the energy was provided by proteins), "high in vitamin B12", and had Na contents (≤0.4%) below the defined limit. All dishes reached the vitamin D target value. Sausages_C, Roulade_P, Fillet_P and Balls_S had a well-balanced protein/fat ratio. Roulade_P presented the highest n-3 PUFA/n-6 PUFA ratio (3.3), while Sausages_C the lowest SFA/UNS ratio (0.2). Dishes were considered safe based on different parameters (e.g. Hg-T, PBDEs, Escherichia coli). All represent dietary sources contributing to meet the reference intakes of target nutrients (33->100%), providing valuable options to overcome nutritional and functional imbalances of the three groups.

Strategies to reduce sodium levels in European seabass sausages

Considering the increasing demand towards "ready-to-cook" processed seafood products, recognised as being potential contributors to high sodium (Na) intake by consumers, this study aimed to assess the effect of sodium chloride (NaCl) reduction on physicochemical, microbiological and sensory properties of European seabass (Dicentrarchus labrax) sausages stored in chilling conditions during 5 weeks. Three formulations were tested in comparison with a control (100% NaCl, CTR): (i) 50% NaCl+50% ME (oleoresins microcapsules) (F1); (ii) 50% NaCl+50% KCl (F2); and (iii) only 50% NaCl (F3). The NaCl reduction mainly affected the texture and the salty taste, resulting in softer and perceived as less salty sausages after processing. However, hardness differences disappeared after 5 weeks. It seems that an antioxidant protection was obtained in sausages formulated with oleoresins microcapsules. No or low growth of psychrotrophic and mesophilic bacteria was observed (≤2.40 log CFU/g). Decreasing NaCl content and/or partially replacing it (50%) by KCl or oleoresins microcapsules seem to be suitable solutions to reduce Na (30.9-36.3%) levels, while maintaining the chilled sausages quality for 5 weeks. The partial replacement of NaCl by KCl also allows obtaining a product richer in K (997.2 mg/100 g), which ingestion may contribute for a cardiovascular protective effect.

High-resolution CINE MRI allows estimation of 3D regional atrial strains

Introduction

It is increasingly evident that atrial function is an important marker of cardiovascular health. Impaired global left atrial strain has been associated with risk of thromboembolic events, atrial fibrillation and heart failure. When performed at high spatial resolution, CINE MRI allows the estimation of regional atrial strains, which may facilitate earlier identification of atrial disease and improved (non-contrast) characterisation of atrial fibrosis. Nevertheless, to date, high resolution regional atrial strains has not been assessed using CINE MRI.

Purpose

We introduce a novel rapid 2.2-mm isotropic atrial CINE MRI protocol used to image healthy subjects and patients with cardiovascular disease (CVD). We additionally present a dedicated image analysis pipeline to estimate regional 3D atrial strains from these images.

Methods

We imaged 10 healthy subjects (5 female, 24–36 years old) and 6 patients referred for cardiac MRI due to known or suspected CVD (2 female, 25–80 years old). All subjects were scanned in a 1.5T Philips Ingenia MRI scanner in a single breath-hold (<25 s), using a short-axis 3D bSSFP protocol (flip angle: 60°, TE/TR: 1.6/3.3 ms) with retrospective cardiac gating, SENSE = 2.3 (along both phase encode directions), typical FOV: 400 x 270 x 70 mm3, isotropic acquisition resolution of 2.2 mm3. Images were reconstructed to 20 cardiac phases with 55% view sharing.

The left atrium (LA) was manually segmented in atrial diastole. We tracked the position of evenly spaced points along the LA contour across all phases of the cardiac cycle using the Medical Image Tracking Toolbox. This was used to create a series of deforming smooth triangular meshes, from which Lagrange strain tensors were estimated.

Results

Figs a-c show 3 orthogonal views of the proposed high-resolution atrial CINE MRI scans for a representative CVD patient, with the LA segmentation overlaid in red. Representative LA principal strain directions (as arrows) with the colour indicating the amount of strain observed along this direction are shown in Fig d for active atrial contraction (posterior view). The calculated strain directions varied smoothly in space and time, as expected, and were largest in amplitude in the regions closest to the mitral valve.

Overall, principal strains were larger in healthy subjects (AC strains: 0.12±0.06) than in the CVD cohort (AC strains: 0.04±0.01). This difference was statistically significant during AC (p-value: 0.02), but not during atrial diastole (p-value: 0.06).

Conclusions

We present a novel high-resolution CINE-MRI protocol for estimating regional atrial strains in 3D, with pilot data from 10 healthy subjects and 6 cardiovascular patients. Future studies will compare regions of abnormal atrial strain with fibrosis identified in late gadolinium enhanced MRI to assess whether regional strains can provide a better characterisation of atrial tissue and improved stratification of patients at risk.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, EPSRC/Wellcome Trust Centre for Medical Engineering

Automatic estimation of left atrial function from short axis CINE-MRI using machine learning

Introduction

The importance of atrial mechanical dysfunction in atrial and ventricular pathologies is becoming increasingly recognised. Although machine learning (ML) tools have the ability to automatically estimate atrial function, to date ML techniques have not been used to automatically estimate atrial volumes and functional parameters directly from short axis CINE MRI.

Purpose

We introduce a convolutional neural network (CNN) to automatically segment the left atria (LA) in CINE-MRI. As a demonstration of the clinical utility of this technique, we calculated LA and left ventricular (LV) ejection fractions automatically from CINE images.

Methods

Short axis CINE MRI stacks, covering both ventricles and atria, were obtained in a 1.5T Philips Ingenia scanner. A 2D bSSFP ECG-gated protocol was used (FA=60°, TE/TR=1.5/2.9 ms), typical FOV =385 x 310 x 150 mm3, acquisition matrix = 172 x 140, slice thickness = 10 mm, reconstructed with resolution 1.25 x 1.25 x 10 mm3, 30–50 cardiac phases. Images were collected from 37 AF patients in sinus rythm at the time of scan (31–72 years old, 75% male, 18 with paroxysmal AF (PAF), 19 with persistent AF (persAF)).

To automatically segment the LA, we used a dedicated CNN that follows a U-Net architecture and was trained in 715 images of the LA, manually segmented by an expert. Data augmentation techniques that included noise addition and linear and non-linear image transforms were also used to increase the training dataset. Ventricular structures, including the LV blood pool, were automatically segmented in these images using a CNN previously trained for this task.

Volumetric time plots of LA and LV volume were produced and used to automatically compute maximal and minimal volumes, from which LA and LV ejection fractions (EFs) were assessed. A Bland-Altman analysis compared these automatically computed LA volumes and LA EFs with clinical manual estimates from the same scanning session.

Results

The CNN achieved very good quality LA segmentations when compared to manual ones (Fig a,b): Dice coefficients (0.90±0.07), median contour distances (0.50±1.12mm) and Hausdorff distances (6.70±6.16mm). Bland-Altman analyses show very good agreement between automatic and manual LA volumes and EFs (Fig e). A moderate linear correlation between LA and LV EFs in AF patients was found (Fig d). The measured LA EF was higher for PAF (29±8%) than PersAF patients (21±11%), although non-significantly (t-test p-value: 0.10).

Conclusions

We present a reliable automatic method to perform LA segmentations from CINE MRI across the entire cardiac cycle. This approachs opens up the possibility of automatically calculating more sophisticated biomarkers of LA function which take into account information about LA volumes across the entire cardiac cycle, including biomarkers of LA booster pump function.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation; EPSRC/Wellcome Centre for Medical Engineering

Hyperbaric oxygen for radiation-induced cystitis: A long-term follow-up

INTRODUCTION AND OBJECTIVES

Bladder complications may be seen in up to 12% of patients treated with pelvic irradiation. Hyperbaric oxygen therapy (HBOT) is an option for the management of radiation-induced hemorrhagic cystitis (RIHC). The aim of this study was to evaluate the efficacy of HBOT in radiation cystitis and to identify the predictive factors for a successful outcome.

MATERIAL AND METHODS

We retrospectively reviewed 105 patients diagnosed with RIHC which were treated with HBOT between 2007 and 2016 in our institution. Patients received 100% oxygen in a multiplace hyperbaric chamber at 2.4atm for 80minutes. All patients fulfilled a questionnaire documenting symptom severity pre-HBOT and at the end of the follow-up period.

RESULTS

After a median of 40 HBOT sessions, there was success rate of 92,4% in the control of hematuria. During our follow-up period (median of 63 months) 24,7% patients presented with recurrence of hematuria. The mean score of the questionnaire-assessed variables: dysuria, urinary frequency and hematuria, was significantly lower after the follow-up period (P<.05). Our data shows that the sooner HBOT is delivered after the first episode of hematuria, better response rates are achieved and lower recurrences concerning hematuria were registered (P<.05). No serious complications were observed.

CONCLUSIONS

Our results support the safety and long-term benefits of HBOT on RIHC and other distressful bladder symptoms, which represents an expected improvement of quality of life in our patients.

Listening to doctors on patients' use of healthcare during the crisis: uncovering a different picture and drawing lessons from Portugal

Background

The consequences of financial crises on patients' use of healthcare have been widely discussed. This paper seeks to ascertain whether the position of key players, i.e. doctors, may reveal realities other than those officially reported about the 2008 financial crisis.

Methods

In 2013-14, a national survey of doctors was conducted in Portugal, which received international assistance in the wake of the financial crisis. An exploratory model comprising descriptive statistics, regression and independence analyses focused on doctors' experience of patients' use of medications, consultations, exams and treatment services, and whether they stopped treatments.

Results

According to doctors, an unspecified number of patients experienced difficulties using healthcare as more patients requested prescriptions for cheaper medications or simply stopped treatments. Significant variations were found according to speciality, years of practice and sector of activity.

Conclusions

Cost-containment mechanisms are regarded as necessary. However, the evidence indicated a side effect, i.e. a decrease in patients' ability to use healthcare, including in the National Health Service (NHS). It also highlighted the need to listen to health professionals as key informants on patient's behaviour and the daily functioning of health services.

Obsessive-Compulsive Disorder in Childhood and Adolescence

Obsessive-compulsive disorder (OCD) is a severe mental illness that causes significant stress in children and adolescents. It is possible to infer three distinct etiologies – neurobiology, environment and dysfunctional interpretative patterns. Certain characteristics are attributable to OCD with onset in childhood or adolescence as higher prevalence in males, increased frequency of isolated compulsions (more cleaning, repeating and checking), higher rate of aggressive obsessions and more common accumulation behaviors. There are several psychiatric comorbidities associated with OCD like anxiety disorder and major depression. The first-line treatment in OCD is the association of a selective serotonin reuptake inhibitor (SSRI) and individual psychotherapy.

The authors reviewed the clinical records of patients diagnosed with OCD observed in a child and adolescence psychiatry liaison consultation between April and September 2015, inclusive, aiming to characterize the sample, to describe the typical clinical picture and to evaluate the existence of physical and/or psychiatric comorbidities, comparing the results with those expected in literature.

The typical patient profile found was a 12-year-old male, living with relatives, with no neonatal complications, with stable home environment, without family psychiatric history, with associated medical comorbidities, with age of onset symptoms at 10.5 years-old, with only an obsession (contamination), with only a compulsion (cleaning or checking), with psychiatric comorbidities, treated with SSRI and without psychologyaccompaniment.

There are some limitations that must be taken into account because the sample was taken from a liaison psychiatry consultation, but in general terms, the results were similar to those described in the literature.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Effect of blood in the cerebrospinal fluid on the accuracy of cerebral oxygenation measured by near infrared spectroscopy

Near infrared spectroscopy (NIRS) is an optical technique used to examine the oxygenation state of tissues such as the brain in patients, including those with brain injury. We have examined the effect of a cerebrospinal fluid (CSF) contaminant, specifically haemoglobin, on the sensitivity of cerebral NIRS signals through computer simulation. Previous models of light transport in the head have shown that the clear CSF layer has a profound effect on the sensitivity profile of the NIRS signal due to its low absorbing, low scattering qualities. In subarachnoid haemorrhage, which may accompany brain injury, the principal near infrared chromophore, haemoglobin, is released into the CSF. Sensitivity was measured through forward modeling and the presence of haemoglobin within the CSF was modeled by increasing the absorption coefficient of the layer, with sensitivity quantified in terms of the partial pathlength of light within the brain. The model demonstrated that increases in the CSF absorption led to a marked decrease in the sensitivity to changes in the brain layer. This suggests that blood or other contaminants in the CSF may have a significant effect on the utility of NIRS for measurement of cerebral oxygenation, and merits further investigation.

Effects of temperature on tuning of the auditory pathway in the cicada Tettigetta josei (Hemiptera, Tibicinidae)

The effects of temperature on hearing in the cicada Tettigetta josei were studied. The activity of the auditory nerve and the responses of auditory interneurons to stimuli of different frequencies and intensities were recorded at different temperatures ranging from 16 degrees C to 29 degrees C. Firstly, in order to investigate the temperature dependence of hearing processes, we analyzed its effects on auditory tuning, sensitivity, latency and Q(10dB). Increasing temperature led to an upward shift of the characteristic hearing frequency, to an increase in sensitivity and to a decrease in the latency of the auditory response both in the auditory nerve recordings (periphery) and in some interneurons at the metathoracic-abdominal ganglionic complex (MAC). Characteristic frequency shifts were only observed at low frequency (3-8 kHz). No changes were seen in Q(10dB). Different tuning mechanisms underlying frequency selectivity may explain the results observed. Secondly, we investigated the role of the mechanical sensory structures that participate in the transduction process. Laser vibrometry measurements revealed that the vibrations of the tympanum and tympanal apodeme are temperature independent in the biologically relevant range (18-35 degrees C). Since the above mentioned effects of temperature are present in the auditory nerve recordings, the observed shifts in frequency tuning must be performed by mechanisms intrinsic to the receptor cells. Finally, the role of potassium channels in the response of the auditory system was investigated using a specific inhibitor of these channels, tetraethylammonium (TEA). TEA caused shifts on tuning and sensitivity of the summed response of the receptors similar to the effects of temperature. Thus, potassium channels are implicated in the tuning of the receptor cells.

[Kikuchi-Fujimoto disease]

Kikuchi and Fujimoto's disease, also known as histiocytic necrotizing lymphadenopathy, is a rare and benign disorder of the lymph nodes of young adults. The etiology of this disease is unknown, an autoimmune mechanism has been suggested, although some cases of association with several viruses has been described. We report a pediatric case of Kikuchi and Fujimoto's disease in a 14 years old girl with persistent fever, enlarged cervical lymph node and weight loss. A diagnosis of Kikuchi and Fujimoto's disease was made by cervical lymph node histology. We present a case of Kikuchi and Fujimoto disease that benefited significantly from steroids.

Cd8(+)/V beta 5.1(+) large granular lymphocyte leukemia associated with autoimmune cytopenias, rheumatoid arthritis and vascular mammary skin lesions: successful response to 2-deoxycoformycin

We report a case of CD8(+)/V beta 5.1(+) T-cell large granular lymphocyte leukemia (T-LGL leukemia) presenting with mild lymphocytosis, severe autoimmune neutropenia, thrombocytopenia, polyarthritis and recurrent infections with a chronic disease course. Immunophenotyping showed an expansion of CD3(+)/TCR alpha beta(+)/CD8(+bright)/CD11c(+)/CD57(-)/CD56(-) large granular lymphocytes with expression of the TCR-V beta 5.1 family. Southern blot analysis revealed a clonal rearrangement of the TCR beta-chain gene. Hematopoietic growth factors, high dose intravenous immunoglobulin and corticosteroids were of limited therapeutic benefit to correct the cytopenias. During the disease course, the patient developed a severe cutaneous leg ulcer and bilateral vascular mammary skin lesions. Treatment with 2-deoxycoformycin resulted in both clinical and hematological complete responses, including the resolution of vascular skin lesions. Combined immuno-staining with relevant T-cell associated and anti-TCR-V beta monoclonal antibodies proved to be a sensitive method to assess the therapeutic effect of 2-deoxycoformicin and to evaluate the residual disease.

Biotechnology and genetics of ergot alkaloids

Ergot alkaloids, i.e. ergoline-derived toxic metabolites, are produced by a wide range of fungi, predominantly by members of the grass-parasitizing family of the Clavicipitaceae. Naturally occurring alkaloids like the D-lysergic acid amides, produced by the "ergot fungus" Claviceps purpurea, have been used as medicinal agents for a long time. The pharmacological effects of the various ergot alkaloids and their derivatives are due to the structural similarity of the tetracyclic ring system to neurotransmitters such as noradrenaline, dopamine or serotonin. In addition to "classical" indications, e.g. migraine or blood pressure regulation, there is a wide spectrum of potential new applications of this interesting group of compounds. The biotechnology of ergot alkaloids has a long tradition, and efficient parasitic and submerse production processes have been developed; the biochemistry of the pathway and the physiology of production have been worked out in detail. The recent identification of a cluster of genes involved in ergot alkaloid biosynthesis in C. purpurea and the availability of molecular genetic techniques allow the development of strategies for rational drug design of ergoline-related drugs by enzyme engineering and by biocombinatorial approaches.

Fringe-dependent separation of dorsal and ventral cells in the Drosophila wing

The separation of cells into populations that do not intermix, termed compartments, is a fundamental organizing principle during development. Dorsal-ventral compartmentalization of the Drosophila wing is regulated downstream of the apterous (ap) gene, which encodes a transcription factor that specifies dorsal wing fate. fringe (fng) is normally expressed by dorsal cells downstream of ap; here we show that fng plays a key role in dorsal-ventral compartmentalization. Loss of fng function causes dorsal cells to violate the compartment boundary, and ectopic expression of the Fng protein causes ventral cells to violate thecompartment boundary. Fng modulates signalling through the Notch receptor. Notch and its ligands are essential for formation of the dorsal-ventral compartment border, and repositioning the stripe of Notch activation that is normally established there appears to reposition the compartment border. However, activation of Notch does not itself confer either dorsal or ventral cell location, and fng can influence compartmentalization even within regions of ubiquitous Notch activation. Our results indicate that the primary mechanism by which fng establishes a compartment border is by positioning a stripe of Notch activation, but also that fng may exert additional influences on compartmentalization.

Evidence for an ergot alkaloid gene cluster in Claviceps purpurea

A gene (cpd1) coding for the dimethylallyltryptophan synthase (DMATS) that catalyzes the first specific step in the biosynthesis of ergot alkaloids, was cloned from a strain of Claviceps purpurea that produces alkaloids in axenic culture. The derived gene product (CPD1) shows only 70% similarity to the corresponding gene previously isolated from Claviceps strain ATCC 26245, which is likely to be an isolate of C. fusiformis. Therefore, the related cpd1 most probably represents the first C. purpurea gene coding for an enzymatic step of the alkaloid biosynthetic pathway to be cloned. Analysis of the 3'-flanking region of cpd1 revealed a second, closely linked ergot alkaloid biosynthetic gene named cpps1, which codes for a 356-kDa polypeptide showing significant similarity to fungal modular peptide synthetases. The protein contains three amino acid-activating modules, and in the second module a sequence is found which matches that of an internal peptide (17 amino acids in length) obtained from a tryptic digest of lysergyl peptide synthetase 1 (LPS1) of C. purpurea, thus confirming that cpps1 encodes LPS1. LPS1 activates the three amino acids of the peptide portion of ergot peptide alkaloids during D-lysergyl peptide assembly. Chromosome walking revealed the presence of additional genes upstream of cpd1 which are probably also involved in ergot alkaloid biosynthesis: cpox1 probably codes for an FAD-dependent oxidoreductase (which could represent the chanoclavine cyclase), and a second putative oxidoreductase gene, cpox2, is closely linked to it in inverse orientation. RT-PCR experiments confirm that all four genes are expressed under conditions of peptide alkaloid biosynthesis. These results strongly suggest that at least some genes of ergot alkaloid biosynthesis in C. purpurea are clustered, opening the way for a detailed molecular genetic analysis of the pathway.

Contact allergy to gold sodium thiosulfate. A comparative study

During 1995, we added gold sodium thiosulfate and potassium dicyanoaurate to the patch test standard series. Our purpose was to compare the reactivity of the gold salts, to determine the frequency of contact allergy to gold in our country, to compare our results with those of the Malmö group and, finally to try to clarify the clinical relevance 2853 patients were routinely tested and 168 patients answered a questionnaire similar to that used by the Malmö group. Contact allergy to gold was found in 23 patients, all women: 22 to gold sodium thiosulfate (0.78%), only 1 to potassium dicyanoaurate and 2 to both salts. All reactors had their ears pierced and were exposed to gold jewelery (mainly earrings). Simultaneous allergies to nickel and cobalt were statistically significant in patients with positive patch tests to gold sodium thiosulfate. Atopy was no more common among these patients.