Systematic review of influenza vaccine effectiveness against laboratory-confirmed influenza among older adults living in aged care facilities

We estimated the effectiveness of influenza vaccines in preventing laboratory-confirmed influenza among older adults in aged care. Electronic database searches were conducted using search terms, and studies were selected as per the selection criteria. Fourteen studies were included for final review. The studies exhibited considerable variation in reported vaccine effectiveness (VE) across different seasons. Among the observational studies, VE ranged from 7.2% to 89.8% against laboratory-confirmed influenza across different vaccines. Randomized clinical trials demonstrated a 17% reduction in infection rates with the adjuvanted trivalent vaccine. The limitations include the small number of included studies conducted in different countries or regions, varied seasons, variations in diagnostic testing methods, a focus on the A/H3N2 strain, and few studies available on the effectiveness of enhanced influenza vaccines in aged care settings. Despite challenges associated with achieving optimal protection, the studies showed the benefits of influenza vaccination in the elderly residents.

Association of recent respiratory illness and influenza with acute myocardial infarction among the Bangladeshi population: A case-control study

Current evidence suggests that recent acute respiratory infections and seasonal influenza may precipitate acute myocardial infarction (AMI). This study examined the potential link between recent clinical respiratory illness (CRI) and influenza, and AMI in Bangladesh. Conducted during the 2018 influenza season at a Dhaka tertiary-level cardiovascular (CV) hospital, it included 150 AMI cases and two control groups: 44 hospitalized cardiac patients without AMI and 90 healthy individuals. Participants were matched by gender and age groups. The study focused on self-reported CRI and laboratory-confirmed influenza ascertained via quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) within the preceding week, analyzed using multivariable logistic regression. Results showed that cases reported CRI, significantly more frequently than healthy controls (27.3% vs. 13.3%, adjusted odds ratio (aOR): 2.21; 95% confidence interval (CI): 1.05-4.06), although this was not significantly different from all controls (27.3% vs. 22.4%; aOR: 1.19; 95% CI: 0.65-2.18). Influenza rates were insignificantly higher among cases than controls. The study suggests that recent respiratory illnesses may precede AMI onset among Bangladeshi patients. Infection prevention and control practices, as well as the uptake of the influenza vaccine, may be advocated for patients at high risk of acute CV events.

Optimal timing of influenza vaccination among patients with acute myocardial infarction - Findings from the IAMI trial

Influenza vaccination reduces the risk of adverse cardiovascular events.The IAMI trial randomly assigned 2571 patients with acute myocardial infarction (AMI) to receive influenza vaccine or saline placebo during their index hospital admission. It was conducted at 30 centers in 8 countries from October 1, 2016 to March 1, 2020. In this post-hoc exploratory sub-study, we compare the trial outcomes in patients receiving early season vaccination (n = 1188) and late season vaccination (n = 1344).The primary endpoint wasthe composite of all-cause death, myocardial infarction (MI), or stent thrombosis at 12 months. Thecumulative incidence of the primary and key secondary endpoints by randomized treatment and early or late vaccination was estimated using the Kaplan-Meier method. In the early vaccinated group, the primary composite endpoint occurred in 36 participants (6.0%) assigned to influenza vaccine and 49 (8.4%) assigned to placebo (HR 0.69; 95% CI 0.45 to 1.07), compared to 31 participants (4.7%) assigned to influenza vaccine and 42 (6.2%) assigned to placebo (HR 0.74; 95% CI 0.47 to 1.18) in the late vaccinated group (P = 0.848 for interaction on HR scale at 1 year). We observed similar estimates for the key secondary endpoints of all-cause death and CV death. There was no statistically significant difference in vaccine effectiveness against adverse cardiovascular events by timing of vaccination. The effect of vaccination on all-cause death at one year was more pronounced in the group receiving early vaccination (HR 0.50; 95% CI, 0.29 to 0.86) compared late vaccination group (HR 0.75; 35% CI, 0.40 to 1.40) but there was no statistically significant difference between these groups (Interaction P = 0.335). In conclusion,there is insufficient evidence from the trial to establish whether there is a difference in efficacy between early and late vaccinationbut regardless of vaccination timing we strongly recommend influenza vaccination in all patients with cardiovascular diseases.

Lessons learned from identifying clusters of severe acute respiratory infections with influenza sentinel surveillance, Bangladesh, 2009-2020

Background

We explored whether hospital-based surveillance is useful in detecting severe acute respiratory infection (SARI) clusters and how often these events result in outbreak investigation and community mitigation.

Methods

During May 2009-December 2020, physicians at 14 sentinel hospitals prospectively identified SARI clusters (i.e., ≥2 SARI cases who developed symptoms ≤10 days of each other and lived <30 min walk or <3 km from each other). Oropharyngeal and nasopharyngeal swabs were tested for influenza and other respiratory viruses by real-time reverse transcriptase-polymerase chain reaction (rRT-PCR). We describe the demographic of persons within clusters, laboratory results, and outbreak investigations.

Results

Field staff identified 464 clusters comprising 1427 SARI cases (range 0-13 clusters per month). Sixty percent of clusters had three, 23% had two, and 17% had ≥4 cases. Their median age was 2 years (inter-quartile range [IQR] 0.4-25) and 63% were male. Laboratory results were available for the 464 clusters with a median of 9 days (IQR = 6-13 days) after cluster identification. Less than one in five clusters had cases that tested positive for the same virus: respiratory syncytial virus (RSV) in 58 (13%), influenza viruses in 24 (5%), human metapneumovirus (HMPV) in five (1%), human parainfluenza virus (HPIV) in three (0.6%), adenovirus in two (0.4%). While 102/464 (22%) had poultry exposure, none tested positive for influenza A (H5N1) or A (H7N9). None of the 464 clusters led to field deployments for outbreak response.

Conclusions

For 11 years, none of the hundreds of identified clusters led to an emergency response. The value of this event-based surveillance might be improved by seeking larger clusters, with stronger epidemiologic ties or decedents.

Influenza-associated respiratory illness among five cohorts of pregnant women and their young infants (0-6 months), Bangladesh, 2013-2017

Background

Pregnant women with their infants are considered at higher risk for influenza-associated complications, and the World Health Organization (WHO) recommends influenza vaccination during pregnancy to protect them, including their infants (0-6 months). There are limited data on the influenza burden among pregnant women and their infants (0-6 months), and there are no routine influenza vaccinations in Bangladesh.

Methods

Five annual cohorts (2013-2017) of pregnant women were enrolled from the eight sub-districts of Bangladesh before the influenza season (May-September); they were contacted weekly to identify new onset of influenza-like illness (ILI) (subjective or measured fever and cough) and acute respiratory illness (ARI) (at least two of these symptoms: cough, rhinorrhea, or difficulty in breathing) among their infants from birth to 6 months of age. We collected nasopharyngeal swabs from ILI and ARI cases, tested by real-time reverse transcription polymerase chain reaction (rRT-PCR) for influenza virus (including types and subtypes) and estimated influenza incidence (95% CI)/10000 pregnant women-months or infant-months, respectively.

Results

We enrolled 9020 pregnant women, followed for 26,709 pregnancy-months, and detected 1241 ILI episodes. We also followed 8963 infants for 51,518 infant-months and identified 5116 ARI episodes. Influenza positivity was 23% for ILI and 3% for ARI cases. The overall incidence (2013-2017) of influenza among pregnant women was 158.5/10000 pregnant women-months (95% CI: 141.4-177.6) and that among infants was 21.9/10000 infant-months (95% CI: 18.2-26.5).

Conclusions

Although the data was collected more than 5 years ago, as the only baseline data, our findings illustrate evidence of influenza burden among pregnant women and infants (0-6 months), which may support preventive policy decisions in Bangladesh.

The impact of COVID-19 and COVID vaccination on cardiovascular outcomes

COVID-19 is an independent risk factor for cardiovascular disease. COVID-19 vaccination may prevent this, but in some cases, COVID-19 vaccination may cause myocarditis or pericarditis. Patients with COVID-19 may present with non-specific symptoms that have a cardiac origin. This review examines the cardiovascular complications of COVID-19 infection and the impact of COVID-19 vaccination. COVID-19 cardiovascular complications include myocardial injury, pericarditis, coagulopathy, myocardial infarction, heart failure, arrhythmias, and persistent post-acute risk of adverse cardiovascular outcomes. Diagnostic and referral pathways for non-specific symptoms, such as dyspnoea and fatigue, remain unclear. COVID-19 vaccination is cardioprotective overall but is associated with myopericarditis in young males, though at a lower rate than following SARS-CoV-2 infection. Increased awareness among primary care physicians of potential cardiovascular causes of non-specific post-COVID-19 symptoms, including in younger adults, such as fatigue, dyspnoea, and chest pain, is essential. We recommend full vaccination with scheduled booster doses, optimal management of cardiovascular risk factors, rapid treatment of COVID-19, and clear diagnostic, referral, and management pathways for patients presenting with non-specific symptoms to rule out cardiac complications.

Clinical impact of influenza vaccination after ST- and non-ST-segment elevation myocardial infarction - insights from the IAMI trial

BACKGROUND

Influenza vaccination early after myocardial infarction (MI) improves prognosis but vaccine effectiveness may differ dependent on type of MI.

METHODS

A total of 2,571 participants were prospectively enrolled in the Influenza vaccination after myocardial infarction (IAMI) trial and randomly assigned to receive in-hospital inactivated influenza vaccine or saline placebo. The trial was conducted at 30 centers in eight countries from October 1, 2016 to March 1, 2020. Here we report vaccine effectiveness in the 2,467 participants with ST-segment elevation MI (STEMI, n = 1,348) or non-ST-segment elevation MI (NSTEMI, n = 1,119). The primary endpoint was the composite of all-cause death, MI, or stent thrombosis at 12 months. Cumulative incidence of the primary and key secondary endpoints by randomized treatment and NSTEMI/STEMI was estimated using the Kaplan-Meier method. Treatment effects were evaluated with formal interaction testing to assess for effect modification.

RESULTS

Baseline risk was higher in participants with NSTEMI. In the NSTEMI group the primary endpoint occurred in 6.5% of participants assigned to influenza vaccine and 10.5% assigned to placebo (hazard ratio [HR], 0.60; 95% CI, 0.39-0.91), compared to 4.1% assigned to influenza vaccine and 4.5% assigned to placebo in the STEMI group (HR, 0.90; 95% CI, 0.54-1.50, P = .237 for interaction). Similar findings were seen for the key secondary endpoints of all-cause death and cardiovascular death. The Kaplan-Meier risk difference in all-cause death at one year was more pronounced in participants with NSTEMI (NSTEMI: HR, 0.47; 95% CI 0.28-0.80, STEMI: HR, 0.86; 95% CI, 0.43-1.70, interaction P = .028).

CONCLUSIONS

The beneficial effect of influenza vaccination on adverse cardiovascular events may be enhanced in patients with NSTEMI compared to those with STEMI.

Acute febrile illness among outpatients seeking health care in Bangladeshi hospitals prior to the COVID-19 pandemic

Understanding the distribution of pathogens causing acute febrile illness (AFI) is important for clinical management of patients in resource-poor settings. We evaluated the proportion of AFI caused by specific pathogens among outpatients in Bangladesh. During May 2019-March 2020, physicians screened patients aged ≥2 years in outpatient departments of four tertiary level public hospitals. We randomly enrolled patients having measured fever (≥100.4°F) during assessment with onset within the past 14 days. Blood and urine samples were tested at icddr,b through rapid diagnostic tests, bacterial culture, and polymerase chain reaction (PCR). Acute and convalescent samples were sent to the Centers for Disease Control and Prevention (USA) for Rickettsia and Orientia (R/O) and Leptospira tests. Among 690 patients, 69 (10%) had enteric fever (Salmonella enterica serotype Typhi orSalmonella enterica serotype Paratyphi), 51 (7.4%) Escherichia coli, and 28 (4.1%) dengue detected. Of the 441 patients tested for R/O, 39 (8.8%) had rickettsioses. We found 7 (2%) Leptospira cases among the 403 AFI patients tested. Nine patients (1%) were hospitalized, and none died. The highest proportion of enteric fever (15%, 36/231) and rickettsioses (14%, 25/182) was in Rajshahi. Dhaka had the most dengue cases (68%, 19/28). R/O affected older children and young adults (IQR 8-23 years) and was detected more frequently in the 21-25 years age-group (17%, 12/70). R/O was more likely to be found in patients in Rajshahi region than in Sylhet (aOR 2.49, 95% CI 0.85-7.32) between July and December (aOR 2.01, 1.01-5.23), and who had a history of recent animal entry inside their house than not (aOR 2.0, 0.93-4.3). Gram-negative Enterobacteriaceae were the most common bacterial infections, and dengue was the most common viral infection among AFI patients in Bangladeshi hospitals, though there was geographic variability. These results can help guide empiric outpatient AFI management.

Anatomical variations in coronary venous drainage: challenges and solutions in delivering cardiac resynchronisation therapy

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac resynchronisation therapy (CRT) is the cornerstone of heart failure management. Delivery of a left ventricular lead can occur in a small proportion of patients undermining the benefits of this treatment. Abnormal coronary venous anatomy is a contributing factor to this failure. Although epicardial lead placement is available, this patient cohort requiring CRT is subject to higher peri-operative morbidity and mortality than the general population; a transvenous approach is preferable.

Purpose

To investigate the abnormalities of the coronary venous system in candidates for cardiac resynchronization therapy (CRT) and describe methods for circumventing the resulting difficulties.

Methods

From 4 implanting institutes, data of all CRT implants between October 2008-October 2020 were screened for abnormal cardiac venous anatomy, defined as an anatomical variation not conforming to the accepted ‘normal’ anatomy. Patient demographics, procedural detail and subsequent left ventricle (LV) lead pacing indices were collected.

Results

From a total of 3548 CRT implants, 15 (0.42%) patients (80% male) of 72.2±10.6 years in age with a LV ejection fraction of 34±10.3% were identified to have had an abnormal cardiac venous anatomy over the study period. There were 13 cases of persistent left side superior vena cava (pLSVC), 5 of which had coronary sinus ostium atresia (CSOA) including 2 with an ‘unroofed’ coronary sinus (CS); 1 patient had a unique anomalous origin of the CS and 1 patient had an isolated CSOA. In total 14 patients (60% repeat attempt) had successful percutaneous implant under general anaesthesia (46.7%) via the cephalic vein (59.1%), using the femoral approach (53.3%) for levophase venography and/or pull-through, including 1 case of endocardial LV implant. Pacing follow-up over 37.64±37.6 months demonstrated LV lead threshold between 0.62-2.9 volts (pulsewidth 0.4-1.5 milliseconds) in all cases; 5 patients died within 2.92±1.6 years of successful implant.

Conclusion

CRT devices can be implanted percutaneously even in the presence of substantial abnormalities of coronary venous anatomy. Alternative routes of venous access may be required.

Transvenous lead extraction: the Tandem approach

Funding Acknowledgements

Type of funding sources: None.

Background

Transvenous lead extraction (TLE) has become an important strategy in the management of patients with cardiac implantable electronic devices (CIEDs). A rising population of patients with CIEDs coupled with an expanding indication for TLE, has fuelled demand. There are notable procedural risks however development of techniques and tools have contributed to an improvement in the safety and efficacy of TLE. The mechanical rotational dissecting sheath is safe and efficacious whilst the Needle’s Eye Snare (NES) is an additional ‘bail-out’ strategy contributing to procedural success.

Purpose

We sought to evaluate the outcomes of TLE performed from the superior access in conjunction with counter-traction provided by snaring of the targeted lead via the femoral access.

Method

The ‘Tandem’ procedure consisted of the rotational powered sheath performing dissection of the adhesions encapsulating the leads (at the superior access), in ‘Tandem’ with the Needle’s Eye Snare providing countertraction via the femoral vein. In brief: after deployment of the locking stylet in the lead lumen, the NES was used to grasp the lead in the right atrium and hold it tort while a rotational sheath was used to dissect through the veins. Once the sheath reached the right atrium, the lead was released from the snare and the sheath was used to continue dissection toward the lead tip. Data for all consecutive ‘Tandem’ procedures performed between 1/1/2021 – 1/1/2022 in our high-volume TLE institute were collected and evaluated for safety and efficacy.

Results

Forty patients aged 69.2±16.3 (70% male), underwent TLE of 75 leads (45 right ventricle, 25, right atrium, 5 left ventricle) with dwell time of 150.1±80.3 months for a non-infectious indication (65%). Of the 40 cases, 27 were hypertensives, 14 had ischaemic heart disease whilst 5 suffered diabetes with a left ventricle ejection fraction of 46.8±10.2%; 12 (30%) were pacing dependent. Procedures were performed by cardiologists in the cardiac catheterisation suite under general anaesthesia (95%) using a locking stylet (100%) with an Evolution RL (11-french 58.7%); a NES 13 millimetres curve (88%) was used to successfully snare 91% of the targeted leads. Complete procedural success was achieved in 92% of leads with 98.7% clinical success. Minor complications occurred in 2 cases (pneumothorax, pocket haematoma requiring intervention), in the absence of any major complications or peri-procedural mortality; there was no 30-day mortality.

Conclusion

The ‘Tandem’ procedure provides an additional strategy to improve the safety and efficacy of TLE, especially in leads of a long dwell time.

Oesophageal protection during AF ablation: real world registry data and mechanisms behind the therapeutic effect of tissue cooling

Funding Acknowledgements

Type of funding sources: None.

Background

Oesophageal protection using a dedicated device to provide controlled active thermal protection of the oesophagus during atrial fibrillation ablation has been shown to be effective at reducing endoscopically detected oesophageal lesions. Real world registry data of this device and established evidence on the effect of cooling on localized tissue after thermal injury have been under review.

Purpose

To determine the safety of an oesophageal temperature control device by a review of real-world registry data on its clinical use during catheter ablation procedures and to clarify basic mechanisms of its therapeutic action by a literature review of scientific studies on cooling in the context of thermal injury.

Methods

The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA) databases were reviewed for any device-related adverse events. A systematic literature review was conducted to clarify the findings from studies investigating the physiological processes behind the therapeutic effect of cooling after tissue thermal injury.

Results

Of over 20,000 oesophageal temperature control devices clinically used, 7976 were recorded as having been used for the purpose of oesophageal protection during left atrial catheter ablations. No adverse events occurred related to its use during left atrial catheter ablations. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device. 208 research articles retrieved from PubMed and MEDLINE that met the search criteria were reviewed. The common finding in all the studies was that cooling had an anti-inflammatory and restorative effect via modulation of several immune-mediated pathways, local cellular function and genetic expression.

Conclusions

There have been no adverse events reported to date in real world clinical use of an oesophageal temperature control device during left atrial catheter ablations, for the purpose of active thermal protection. Literature review data suggests that there are complex biophysical and cellular effects from cooling that leads to its therapeutic effect but further work is required to define the mechanisms of action of thermal protection in this specific context.

Randomised comparison of achieve and traditional circular mapping catheters in cryoballoon ablation: results at up to a decade

Funding Acknowledgements

Type of funding sources: None.

Background

A single-centre trial randomised patients to the use of the Achieve mapping catheter or a traditional circular mapping catheter during cryoballoon procedures for paroxysmal atrial fibrillation (AF) in 2011-2014. Long-term outcomes from the cohort were determined in 2021.

Purpose

To evaluate the determinants of long-term outcome of ablation for paroxysmal AF.

Methods

Patient and study procedure characteristics and clinical outcomes were determined, including mapping catheter assignment, model of cryoballoon used, AF recurrence, repeat ablations required, findings at repeat ablation long term survival of the patient.

Results

Of 102 patients in the original study, 98 had long-term (4.11+/-2.82 years) follow up data available. 35 patients (35.7%) had AF recurrence, giving a long-term success rate at 64.3% after 1 ablation, increasing to 81.6% after repeat ablation. Of the study cohort n=8 (8.16%) died at a median of 4.9 years after ablation (IQR:1.7-5.7). 25/98 (25.5%) patients had a second ablation and 7 (7.1%) had a third or more ablations. Those who had AF recurrence were older, with a higher prevalence of prior ischaemic heart disease and cardiac device implantation (p=0.02-0.03). After multi-variate analysis, a prior implanted cardiac device was the only significant predictor of recurrence (p=0.03).

Conclusion

Long-term outcomes after a 1st time PAF cryoablation were similar regardless of the type of mapping catheter used, the generation of cryoballoon, and traditional procedure endpoints. AF recurrences were more often detected in older patients with a history of ischaemic heart disease and implanted cardiac devices.

Tunnelled dialysis catheter extraction: a cardiology experience

Funding Acknowledgements

Type of funding sources: None.

Background

Tunnelled dialysis catheters are integral to the management of patients with chronic kidney disease (CKD), providing a means to dialysis. They are prone to blockages necessitating removal. Most catheters are removed with manual traction without any sequalae by renal physicians whilst a small proportion require further intervention which may include interventional radiology or an ‘open’ surgical removal which carries additional risk. Cardiologists versed in transvenous lead extraction (TLE) provide an additional strategy.

Purpose

To evaluate the outcomes of tunnelled dialysis catheter ‘extractions’ performed by cardiologists at a high-volume TLE institute.

Method

All consecutive patients referred to cardiologists (1/10/2016 – 1/10/21) for extraction of tunnelled dialysis catheters following an unsuccessful attempt by the renal physicians and interventional radiology, were included in this series. Data of procedural outcomes was evaluated for safety and efficacy.

Results

Twelve patients (7 male) aged 64.15±15.04 years with a body mass index of 28.3 kg/m2 were referred for tunnelled catheter extraction for non-functioning lines (75%). Of these 12 CKD patients, the aetiology included focal segmental glomerulosclerosis (n=2), hypertension (n=2), diabetes (n=1) and sickle cell disease (n=1). In total, 12 tunnelled catheters (75%; n=9 right side) were completely removed (100%) using local anaesthesia (83.3%) in a procedure lasting 54.7±29.8 minutes and requiring 0.79±1.32 minutes of fluoroscopy. Eleven patients (91.7%) had their catheters successfully extracted with manual traction alone; 3 necessitated the use of a 0.035 stiff J-tip wire whilst one required the use of a rotational dissecting sheath Evolution (Cook Medical, USA). Of the 12 cases, 11 had a failed previous attempt including 1 patient who suffered a ventricular fibrillation cardiac arrest during the procedure and 1 was referred directly without an attempt as there was a concurrent pacemaker situated from the contralateral side; 4 patients had new lines placed and no significant complications occurred. There were no complications or procedural mortality.

Conclusion

Extraction of tunnelled dialysis catheter lines performed by cardiologists is safe and efficacious; experience in TLE is vital. This may provide an additional strategy for removal of these catheters when other percutaneous attempts fail.

Pattern of Antibiotic Dispensing at Pharmacies According to the WHO Access, Watch, Reserve (AWaRe) Classification in Bangladesh

The WHO Essential Medicines List Access, Watch, and Reserve (AWaRe) classification could facilitate antibiotic stewardship and optimal use. In Bangladesh, data on antibiotic dispensing in pharmacies according to the AWaRe classification are scarce. We aimed to explore antibiotic dispensing pattern in pharmacies according to the WHO AWaRe classification to aid pharmacy-targeted national antibiotic stewardship program (ASP). From January to July 2021, we interviewed drug-sellers from randomly selected pharmacies and randomly selected customers attending the pharmacies. We collected data on demographics and medicines purchased. We classified the purchased antibiotics into the Access, Watch, and Reserve groups among 128 pharmacies surveyed, 98 (76.6%) were licensed; 61 (47.7%) drug-sellers had pharmacy training. Of 2686 customers interviewed; 580 (21.6%) purchased antibiotics. Among the 580 customers, 523 purchased one, 52 purchased two, and 5 purchased three courses of antibiotics (total 642 courses). Of the antibiotic courses, the Watch group accounted for the majority (344, 53.6%), followed by the Access (234, 36.4%) and Reserve (64, 10.0%) groups. Approximately half of the antibiotics (327/642, 50.9%) were purchased without a registered physician's prescription. Dispensing of non-prescribed antibiotics was higher in the Access group (139/234, 59.4%), followed by Watch (160/344, 46.5%) and Reserve (28/64, 43.8%) groups. These findings highlight the need to implement strict policies and enforce existing laws, and pharmacy-targeted ASP focusing on proper dispensing practices to mitigate antimicrobial resistance in Bangladesh.

Characteristics of severely malnourished under-five children immunized with Bacillus Calmette-Guérin following Expanded Programme on Immunization schedule and their outcomes during hospitalization at an urban diarrheal treatment centre, Bangladesh

Background

Bacillus Calmette-Guérin (BCG) vaccination has recently been found to have beneficial effects among children infected other than Mycobacterium tuberculosis. Due to the paucity of data on the outcomes of children who had successful BCG vaccination following Expanded Programme on Immunization (EPI) schedule, we aimed to investigate the characteristics of such children and their outcomes who were hospitalized for severe malnutrition.

Methods

A prospective observational study was conducted to determine the viral etiology of pneumonia in severely malnourished children those were admitted to the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) between April 2015 and December 2017, constituted the study population. Using a case-control design for the analysis, children having BCG vaccination prior hospital admission were treated as cases (n = 611) and those without vaccination, constituted as controls (n = 83). Bi-variate analysis was conducted using socio-demographic, clinical, laboratory, and treatment characteristics on admission and outcomes during hospitalization. Finally, log-linear binomial regression analysis was done to identify independent impact of BCG vaccination.

Results

The cases more often presented with older age, have had lower proportion of maternal illiteracy, higher rate of breastfeeding, severe wasting and lower rate of hypoglycemia, compared to the controls. The cases were also found to have lower risk of severe sepsis and deaths, compared to the controls (for all, p<0.05). However, in log-linear binomial regression analysis, after adjusting for potential confounders, BCG vaccination following EPI schedule (RR:0.54; 95%CI = 0.33–0.89; p = 0.015) and breastfeeding (RR:0.53; 95%CI = 0.35–0.81; p = 0.003) were found to be protective for the development of severe sepsis.

Conclusion

BCG vaccination and breastfeeding were found to be protective for the development of severe sepsis in hospitalized severely malnourished under-five children which underscores the importance of continuation of BCG vaccination at birth and breastfeeding up to two years of age.

Identifying the research, advocacy, policy and implementation needs for the prevention and management of respiratory syncytial virus lower respiratory tract infection in low- and middle-income countries

INTRODUCTION

The high burden of respiratory syncytial virus (RSV) infection in young children disproportionately occurs in low- and middle-income countries (LMICs). The PROUD (Preventing RespiratOry syncytial virUs in unDerdeveloped countries) Taskforce of 24 RSV worldwide experts assessed key needs for RSV prevention in LMICs, including vaccine and newer preventive measures.

METHODS

A global, survey-based study was undertaken in 2021. An online questionnaire was developed following three meetings of the Taskforce panellists wherein factors related to RSV infection, its prevention and management were identified using iterative questioning. Each factor was scored, by non-panellists interested in RSV, on a scale of zero (very-low-relevance) to 100 (very-high-relevance) within two scenarios: (1) Current and (2) Future expectations for RSV management.

RESULTS

Ninety questionnaires were completed: 70 by respondents (71.4% physicians; 27.1% researchers/scientists) from 16 LMICs and 20 from nine high-income (HI) countries (90.0% physicians; 5.0% researchers/scientists), as a reference group. Within LMICs, RSV awareness was perceived to be low, and management was not prioritised. Of the 100 factors scored, those related to improved diagnosis particularly access to affordable point-of-care diagnostics, disease burden data generation, clinical and general education, prompt access to new interventions, and engagement with policymakers/payers were identified of paramount importance. There was a strong need for clinical education and local data generation in the lowest economies, whereas upper-middle income countries were more closely aligned with HI countries in terms of current RSV service provision.

CONCLUSION

Seven key actions for improving RSV prevention and management in LMICs are proposed.

COVID-19 opens the door for right iliac fossa pain treatment pathway

INTRODUCTION

The COVID-19 pandemic has increased the risks of surgery and management of common surgical conditions has changed, with greater reliance on imaging and conservative management. The negative appendectomy rate (NAR) in the UK has previously remained high. The aim of this study was to quantify pandemic-related changes in the management of patients with suspected appendicitis, including the NAR.

METHODS

A retrospective study was performed at a single high volume centre of consecutive patients aged over five years presenting to general surgery with right iliac fossa pain in two study periods: for two months before lockdown and for four months after lockdown. Pregnant patients and those with previous appendectomy, including right colonic resection, were excluded. Demographic, clinical, imaging and histological data were captured, and risk scores were calculated, stratifying patients into higher and lower risk groups. Data were analysed by age, sex and risk subgroups.

RESULTS

The mean number of daily referrals with right iliac fossa pain or suspected appendicitis reduced significantly between the study periods, from 2.92 before lockdown to 2.07 after lockdown (p<0.001). Preoperative computed tomography (CT) rates increased significantly from 22.9% to 37.2% (p=0.002). The NAR did not change significantly between study periods (25.5% prior to lockdown, 11.1% following lockdown, p=0.159). Twelve (75%) out of sixteen negative appendectomies were observed in higher risk patients aged 16-45 years who did not undergo preoperative CT. The NAR in patients undergoing CT was 0%.

CONCLUSIONS

Greater use of preoperative CT should be considered in risk stratified patients in order to reduce the NAR.

152. Use of Antimicrobials among Suspected COVID-19 Patients at Selected 12 Hospitals in Bangladesh: Findings from the First Wave of COVID-19 Pandemic

Background

Antimicrobials are empirically used in COVID-19 patients resulting in inappropriate stewardship and increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients while waiting for the COVID-19 test report.

Methods

From March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; and tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis.

Results

Among 1188 suspected COVID-19 patients, the median age was 34 years (IQR:2–56), 69% were male, 40% had comorbidities, 53% required oxygen, and 1% required ICU or ventilation support after admission. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral, mostly favipiravir (1%) and antiparasitic drugs particularly ivermectin (3%). Third-generation cephalosporin use was the highest (708;60%), followed by macrolide (481;40%), and the majority (853;78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Before admission, 3% patients had two antibiotics, and on admission, 27% received two to four classes of antibiotics at the same time. According to WHO AWaRe classification, the Watch group antibiotics were mostly used before (43%) as well as on admission (80%). Reserve group antibiotic particularly linezolid was used in 1% patients includes mild cases on admission. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7;95%CI:4.5–30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6;95%CI:1.0–2.5).

Antimicrobials used among suspected COVID-19 patients and SARS-CoV-2 positive and negative patients 24 h before and on hospital admission at 12 selected hospitals in Bangladesh, March–August 2020

Antimicrobials used on admission among suspected COVID-19 patients according to disease severity at 12 selected hospitals in Bangladesh, March–August 2020

Conclusion

Antimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with Watch group antibiotics like third-generation cephalosporin and azithromycin among mild to moderately ill patients were common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.

Disclosures

All Authors: No reported disclosures

Establishing a sentinel surveillance system for the novel COVID-19 in a resource-limited country: methods, system attributes and early findings

OBJECTIVES

To establish a hospital-based platform to explore the epidemiological and clinical characteristics of patients screened for COVID-19.

DESIGN

Hospital-based surveillance.

SETTING

This study was conducted in four selected hospitals in Bangladesh during 10 June-31 August 2020.

PARTICIPANTS

In total, 2345 patients of all age (68% male) attending the outpatient and inpatient departments of surveillance hospitals with any one or more of the following symptoms within last 7 days: fever, cough, sore throat and respiratory distress.

OUTCOME MEASURES

The outcome measures were COVID-19 positivity and mortality rate among enrolled patients. Pearson's χ² test was used to compare the categorical variables (sign/symptoms, comorbidities, admission status and COVID-19 test results). Regression analysis was performed to determine the association between potential risk factors and death.

RESULTS

COVID-19 was detected among 922 (39%) enrolled patients. It was more common in outpatients with a peak positivity in second week of July (112, 54%). The median age of the confirmed COVID-19 cases was 38 years (IQR: 30-50), 654 (71%) were male and 83 (9%) were healthcare workers. Cough (615, 67%) was the most common symptom, followed by fever (493, 53%). Patients with diabetes were more likely to get COVID-19 than patients without diabetes (48% vs 38%; OR: 1.5; 95% CI: 1.2 to 1.9). The death rate among COVID-19 positive was 2.3%, n=21. Death was associated with age ≥60 years (adjusted OR (AOR): 13.9; 95% CI: 5.5 to 34), shortness of breath (AOR: 9.7; 95% CI: 3.0 to 30), comorbidity (AOR: 4.8; 95% CI: 1.1 to 21.7), smoking history (AOR: 2.2, 95% CI: 0.7 to 7.1), attending the hospital in <2 days of symptom onset due to critical illness (AOR: 4.7; 95% CI: 1.2 to 17.8) and hospital admission (AOR: 3.4; 95% CI: 1.2 to 9.8).

CONCLUSIONS

COVID-19 positivity was observed in more than one-third of patients with suspected COVID-19 attending selected hospitals. While managing such patients, the risk factors identified for higher death rates should be considered.

SARS-CoV-2 and influenza virus coinfection among patients with severe acute respiratory infection during the first wave of COVID-19 pandemic in Bangladesh: a hospital-based descriptive study

OBJECTIVE

To estimate the proportion of SARS-CoV-2 and influenza virus coinfection among severe acute respiratory infection (SARI) cases-patients during the first wave of COVID-19 pandemic in Bangladesh.

DESIGN

Descriptive study.

SETTING

Nine tertiary level hospitals across Bangladesh.

PARTICIPANTS

Patients admitted as SARI (defined as cases with subjective or measured fever of ≥38 C° and cough with onset within the last 10 days and requiring hospital admission) case-patients.

PRIMARY AND SECONDARY OUTCOMES

Proportion of SARS-CoV-2 and influenza virus coinfection and proportion of mortality among SARI case-patients.

RESULTS

We enrolled 1986 SARI case-patients with a median age: 28 years (IQR: 1.2-53 years), and 67.6% were male. Among them, 285 (14.3%) were infected with SARS-CoV-2; 175 (8.8%) were infected with the influenza virus, and five (0.3%) were coinfected with both viruses. There was a non-appearance of influenza during the usual peak season (May to July) in Bangladesh. SARS-CoV-2 infection was significantly more associated with diabetes (14.0% vs 5.9%, p<0.001) and hypertension (26.7% vs 11.5%, p<0.001). But influenza among SARI case-patients was significantly less associated with diabetes (4.0% vs 7.4%, p=0.047) and hypertension (5.7% vs 14.4%, p=0.001). The proportion of in-hospital deaths among SARS-CoV-2 infected SARI case-patients were higher (10.9% (n=31) vs 4.4% (n=75), p<0.001) than those without SARS-CoV-2 infection; the proportion of postdischarge deaths within 30 days was also higher (9.1% (n=25) vs 4.6% (n=74), p=0.001) among SARS-CoV-2 infected SARI case-patients than those without infection. No in-hospital mortality or postdischarge mortality was registered among the five coinfected SARI case-patients.

CONCLUSIONS

Our findings suggest that coinfection with SARS-CoV-2 and influenza virus was not very common and had less disease severity considering mortality in Bangladesh. There was no circulating influenza virus during the influenza peak season during the COVID-19 pandemic in 2020. Future studies are warranted for further exploration.

Influenza Vaccination After Myocardial Infarction: A Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

BACKGROUND

Observational and small, randomized studies suggest that influenza vaccine may reduce future cardiovascular events in patients with cardiovascular disease.

METHODS

We conducted an investigator-initiated, randomized, double-blind trial to compare inactivated influenza vaccine with saline placebo administered shortly after myocardial infarction (MI; 99.7% of patients) or high-risk stable coronary heart disease (0.3%). The primary end point was the composite of all-cause death, MI, or stent thrombosis at 12 months. A hierarchical testing strategy was used for the key secondary end points: all-cause death, cardiovascular death, MI, and stent thrombosis.

RESULTS

Because of the COVID-19 pandemic, the data safety and monitoring board recommended to halt the trial before attaining the prespecified sample size. Between October 1, 2016, and March 1, 2020, 2571 participants were randomized at 30 centers across 8 countries. Participants assigned to influenza vaccine totaled 1290 and individuals assigned to placebo equaled 1281; of these, 2532 received the study treatment (1272 influenza vaccine and 1260 placebo) and were included in the modified intention to treat analysis. Over the 12-month follow-up, the primary outcome occurred in 67 participants (5.3%) assigned influenza vaccine and 91 participants (7.2%) assigned placebo (hazard ratio, 0.72 [95% CI, 0.52-0.99]; P=0.040). Rates of all-cause death were 2.9% and 4.9% (hazard ratio, 0.59 [95% CI, 0.39-0.89]; P=0.010), rates of cardiovascular death were 2.7% and 4.5%, (hazard ratio, 0.59 [95% CI, 0.39-0.90]; P=0.014), and rates of MI were 2.0% and 2.4% (hazard ratio, 0.86 [95% CI, 0.50-1.46]; P=0.57) in the influenza vaccine and placebo groups, respectively.

CONCLUSIONS

Influenza vaccination early after an MI or in high-risk coronary heart disease resulted in a lower risk of a composite of all-cause death, MI, or stent thrombosis, and a lower risk of all-cause death and cardiovascular death, as well, at 12 months compared with placebo. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02831608.

Antibiotic Use for Febrile Illness among Under-5 Children in Bangladesh: A Nationally Representative Sample Survey

Fever in children under five years of age is a common and predominantly self-limiting sign of illness. However, in low- and middle-income countries, antibiotics are frequently used in febrile children, although these children may not benefit from antibiotics. In this study, we explored the prevalence of, and factors associated with, antibiotic use in children under five years old with febrile illness in Bangladesh. We analysed data from the 2017–2018 Bangladesh Demographic and Health Survey to determine the prevalence of antibiotic use in children under five years of age with a febrile illness. We used a causal graph and performed a multivariable logistical regression to identify the factors associated with antibiotic use in children under five years old with febrile illness in Bangladesh. Of the 2784 children aged less than five years with fever included in our analysis, 478 (17%, 95% CI 15% to 19%) received antibiotics. Unqualified sources, including unqualified providers and pharmacies, contributed to 60% of antibiotic prescriptions in children with fever, followed by the private medical sector (29%) and the public sector (23%). The highest use of antibiotics was found in children under six months of age (25%). Children with parents who completed secondary or higher education were more likely to receive antibiotics (adjusted OR (aOR): 2.61 (95% CI 1.63 to 4.16)) than children whose parents did not complete primary education. Educational interventions promoting rational use of antibiotics and improved regulations governing over the counter purchase of antibiotics in Bangladesh may improve antibiotic dispensing practices.

Antibiotics Use and Its Knowledge in the Community: A Mobile Phone Survey during the COVID-19 Pandemic in Bangladesh

The general population has been excessively using antibiotics during the COVID-19 pandemic. Therefore, the use of antibiotics for any reported illnesses in the preceding four weeks and knowledge of antibiotics among the general population in the community were assessed for possible interventions. A mobile phone survey among a general population across eight administrative divisions of Bangladesh was conducted during January-March 2021. Reported illness episodes irrespective of COVID-19 in the preceding four weeks of the interview, use of antibiotics for the illnesses, and knowledge on antibiotics among the general population were recorded. Descriptive analyses were performed. We randomly interviewed 1854 participants, with a mean age of 28.5 years (range: 18-75 years); 60.6% were male. Among all participants, 86.3% (95% CI: 84.7-87.8) heard names of antibiotics, but only 12.1% reported unspecified harmful effects, and 3.5% reported antimicrobial resistance when antibiotics were taken without a physician's prescription. Among 257 (13.9%) participants, who consumed medicines for their recent illness episode, 32.7% (95% CI: 27.2-38.6) reported using antibiotics. Of those who could recall the names of antibiotics prescribed (n = 36), the most frequently used was azithromycin (22.2%) followed by cefixime (11.1%) and ciprofloxacin (5.6%). Our findings show an increased antibiotic use for illnesses reported in the preceding four weeks and an elevated knowledge at the community level during the COVID-19 pandemic compared with the pre-pandemic period.

Antibiotic Usage and Resistance in Food Animal Production: What Have We Learned from Bangladesh?

Irrational and inappropriate use of antibiotics in commercial chicken and aquaculture industries can accelerate the antibiotic resistance process in humans and animals. In Bangladesh, the growing commercial chicken and aquaculture industries are playing significantly important roles in the food value chain. It is necessary to know the antibiotic usage practices and antibiotic resistance in food animal production to design rational policies, guidelines, and interventions. We conducted a narrative review to understand the level of antibiotic usage and resistance in food animal production in Bangladesh. Information about antibiotic usage in different food animal production systems, including commercial chickens and aquaculture in Bangladesh is inadequate. Only a few small-scale studies reported that the majority (up to 100%) of the broiler and layer chicken farms used antibiotics for treating and preventing diseases. However, numerous studies reported antibiotic-resistant bacteria of public health importance in commercial chicken, fish, livestock, and animal origin food. The isolates from different pathogenic bacteria were found resistant against multiple antibiotics, including quinolones, the third or fourth generation of cephalosporins, and polymyxins. Veterinary practitioners empirically treat animals with antibiotics based on presumptive diagnosis due to inadequate microbial diagnostic facilities in Bangladesh. Intensive training is helpful to raise awareness among farmers, feed dealers, and drug sellers on good farming practices, standard biosecurity practices, personal hygiene, and the prudent use of antibiotics. Urgently, the Government of Bangladesh should develop and implement necessary guidelines to mitigate irrational use of antibiotics in food animals using a multi-sectoral One Health approach.

Seasonal influenza during the COVID-19 pandemic in Bangladesh

INTRODUCTION

During the 2019 novel coronavirus infectious disease (COVID-19) pandemic in 2020, limited data from several countries suggested reduced seasonal influenza viruses' circulation. This was due to community mitigation measures implemented to control the pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We used sentinel surveillance data to identify changes in the 2020 influenza season compared with previous seasons in Bangladesh.

METHODS

We used hospital-based influenza surveillance (HBIS) data of Bangladesh that are generated year-round and are population-representative severe acute respiratory infection (SARI) data for all age groups from seven public and two private tertiary care level hospitals data from 2016 to 2019. We applied the moving epidemic method (MEM) by using R language (v4.0.3), and MEM web applications (v2.14) on influenza-positive rates of SARI cases collected weekly to estimate an average seasonal influenza curve and establish epidemic thresholds.

RESULTS

The 2016-2019 average season started on epi week 18 (95% CI: 15-25) and lasted 12.5 weeks (95% CI: 12-14 weeks) until week 30.5. The 2020 influenza season started on epi week 36 and ended at epi week 41, lasting for only five weeks. Therefore, influenza epidemic started 18 weeks later, was 7.5 weeks shorter, and was less intense than the average epidemic of the four previous years. The 2020 influenza season started on the same week when COVID-19 control measures were halted, and 13 weeks after the measures were relaxed.

CONCLUSION

Our findings suggest that seasonal influenza circulation in Bangladesh was delayed and less intense in 2020 than in previous years. Community mitigation measures may have contributed to this reduction of seasonal influenza transmission. These findings contribute to a limited but growing body of evidence that influenza seasons were altered globally in 2020.

Use of Antimicrobials among Suspected COVID-19 Patients at Selected Hospitals, Bangladesh: Findings from the First Wave of COVID-19 Pandemic

Antimicrobials are empirically used in COVID-19 patients resulting in increased antimicrobial resistance. Our objective was to assess antimicrobial use among suspected COVID-19 in-patients. From March to August 2020, we collected data from in-patients of 12 tertiary-level hospitals across Bangladesh. We identified suspected COVID-19 patients; collected information on antimicrobial received within 24 h before and on hospitalization; tested nasopharyngeal swab for SARS-CoV-2 using rRT-PCR. We used descriptive statistics and a regression model for data analysis. Among 1188 suspected COVID-19 patients, 69% were male, 40% had comorbidities, and 53% required oxygen. Antibiotics were used in 92% of patients, 47% within 24 h before, and 89% on admission. Patients also received antiviral (1%) and antiparasitic drugs (3%). Third-generation cephalosporin use was the highest (708; 60%), followed by macrolide (481; 40%), and the majority (853; 78%) who took antibiotics were SARS-CoV-2 negative. On admission, 77% mild and 94% moderately ill patients received antibiotics. Antibiotic use on admission was higher among severely ill patients (AOR = 11.7; 95% CI: 4.5-30.1) and those who received antibiotics within 24 h before hospital admission (AOR = 1.6; 95% CI: 1.0-2.5). Antimicrobial use was highly prevalent among suspected COVID-19 in-patients in Bangladesh. Initiating treatment with third-generation cephalosporin among mild to moderately ill patients was common. Promoting antimicrobial stewardship with monitoring is essential to prevent blanket antibiotic use, thereby mitigating antimicrobial resistance.

Maternal Characteristics Mediating the Impact of Household Poverty on the Nutritional Status of Children Under 5 Years of Age in Bangladesh

OBJECTIVES

We explored the maternal characteristics that mediate the effect of household poverty on childhood undernutrition.

METHODS

We used the population-based Bangladesh Demographic Health Survey data from 2014 for demographic characteristics, child and maternal factors.

RESULTS

Of the 7173 under-5 children, 3456 (48.2%) had undernutrition. The prevalence of undernutrition was less common in wealthy households (poorest vs richest: adjusted prevalence ratio [aPR] = 1.37), mothers having history of antenatal care (ANC) visits (no visit vs ≥ 4 visits: aPR = 1.22), maternal higher education (no education vs higher education: aPR = 1.54), and mothers with good nutritional status (underweight vs healthy: aPR = 1.13). The risk of undernutrition (37.1%) was attributed to household wealth, mediated 55% by maternal factors; of which 20% by maternal education, 21% by ANC visits, and 14% by maternal nutritional status.

CONCLUSIONS

Our study findings outlined higher maternal education, ≥ 4 ANC visits and good maternal nutritional status in mediating the impact of household wealth on childhood nutrition.

PROMET: The effect of operator profession on non-laser transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

PROMET group

Background

As implantation of cardiac implantable devices (CIED) rises globally, there is a paralleled need for extraction of these devices. Indications for transvenous lead extraction (TLE) is expanding, fuelling demand. This lifesaving procedure is performed by cardiologists and cardiac surgeons (CS). Cardiologists are familiar with transvenous methods whilst cardiac surgeons possess the skillset to address the significant complications associated with this procedure.

We compared non-laser TLE outcomes performed by cardiologists and cardiac surgeons from six high-volume extraction centres across Europe.

Methods

Data was collected retrospectively from six major European TLE centres of 2205 patients and 3849 leads (PROMET). Propensity 1:1 score matching (PSM) was performed to account for confounding variables. PSM model with variables: lead dwell time, infection indication, biventricular system and defibrillator device, was best matched. This dataset was analysed to compare outcomes of TLE performed by the cardiologists and CS. Predictors of 30-day mortality and complications were identified using a multivariate regression analysis.

Results

Patients treated by CS and cardiologists were similar in age (64.7 vs 66.7 years, p = NS) and equally male (70.3% vs 72.3%, p = 0.39) with a parallel infectious indication (51.7% vs 47.6%, p = 0.1). Surgeons achieved a significantly higher proportion of clinical success than cardiologists (98.9% vs 96.4%, p = 0.001) and complete lead extraction (98% vs 95.9%, p &lt; 0.01) with a higher rate of minor complications (4.1% vs 2.2%, p = 0.024); major complications were similar (0.9% vs 1.2%, respectively, p = 0.46) as was 30-day mortality (3.2% vs 2%, respectively, p = 0.28). Multivariate regression analysis revealed systemic infection (p &lt; 0.001, OR 7.2 [CI 2.3-20.1]) and defibrillator system extraction (p = 0.025, OR 3.4 [CI 1.2-10.2]) increased the odds of 30-day mortality, whilst Evolution™ sheath use reduced the odds (p = 0.025, OR 0.34 [CI 0.13-0.88]); lead dwell time (p = 0.02, OR 1.005 [1-1.009] and Evolution™ sheath use (p = 0.023, OR 2.15[1.1-4.15]) increased the odds of complications.

Conclusion

Cardiac surgeons and cardiologists achieved a high rate of TLE procedural success and with a similar safety profile, replicating standards seen across Europe.

PROMET: the effect of age on patient outcomes in non-laser transvenous lead extraction

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

PROMET group

Background

Cardiac implantable electronic devices (CIEDs) improve morbidity and mortality. This has fuelled an upsurge in implantation of these devices across all patient cohorts, simultaneously increasing the need for transvenous lead extractions (TLE). As the global population expands and life-expectancy extends, TLE will play a significant role in CIED management. Advancing patient age is a recognised risk factor for poor outcomes however the association between patient age and TLE outcomes remains unclear. 

We sought to evaluate the relationship between patient age and non-laser TLE outcomes.

Method

Data of 2205 patients (3849 leads) was collected retrospectively from six high-volume TLE institutes across Europe (PROMET) between January 2005-December 2018. Propensity 1:1 score matching was performed to limit the effects of confounding variables, pairing 353 patients in the &gt;80 years of age category with 353 patients in &lt;80 years of age group. Procedural outcomes were compared between the two age groups and multivariate regression analysis was used for predictors of 30-day mortality.

Results

In the &lt;80 and &gt;80 years-of-age cohorts, there was a similar proportion of male patients (65.3% vs 67.9%, p = 0.47) treated under general anaesthesia (96.5% vs 93.4%, p = 0.078) for a pre-dominant infectious indication (56.7% vs 60.3%, p = 0.52) but with a higher requirement of the EvolutionTM sheath in the octogenarians (39.4% vs 48.4%, p = 0.015). A similar clinical success per lead was achieved between the two age groups (96.6% vs 98%, &lt;80 vs &gt;80 years, p = 0.245) as was complete lead extraction (95.5% vs 96.6%, &lt;80 vs &gt;80 years, p = 0.44) with a comparable minor complication rate (2.3% vs 3.1%, &lt;80 vs &gt;80 years, p = 0.29) and major complications (1.1% vs 1.4%, &lt;80 vs &gt;80 years, p = 0.74). Thirty-day mortality was higher in the octogenarian cohort than the &lt;80-year-olds without reaching statistical significance (5.4% vs 2.6%, p = 0.08); peri-procedural mortality was similar in both age groups (0.3% vs 0.6%, respectively, p = 0.56). Multivariate regression analysis revealed age (p = 0.013, OR 1.06 [1.01-1.12]), systemic infection (p = 0.026, OR 3.4 [1.16-10.35]) and lead dwell time (p = 0.007, OR 1.01 [1.003-1.017]) increased the odds of 30-day mortality.

Conclusion

Transvenous lead extraction is similar in efficacy and safety across all age groups. Thirty-day mortality is higher in the advanced age group, signifying the importance of post-procedural management in this cohort.

Transvenous lead revision for cardiac perforation: a single centre experience

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac perforation is an uncommon but life-threatening complication of cardiac implantable electronic device (CIED) implantation. Management strategy commonly relies on diagnostic Computed Tomography (CT) imaging and cardiac surgery. Emerging evidence has indicated a diversion from this approach. Transvenous culprit lead revision has been shown to be safe and efficacious in limited series.

We sought to evaluate the outcomes of transvenous lead revision in patients with cardiac perforation.

Method

Data was collected retrospectively of patients admitted to a single tertiary centre with CIED-related cardiac perforation between December 2013 – October 2019. Transvenous lead revision was performed as standard with cardiac surgery on standby. Patient demographics, use of CT imaging, method of removal and 30-day outcomes were recorded.

Results

Of the 46 recorded CIED-related cardiac perforations, the majority occurred in female patients (63%) and hypertensives (61%), whilst a proportion had cancer (20%) and ischaemic heart disease (30%). The culprit in most cases was a standard pacing lead (92%) of an active fixation (98%) in the right ventricle (80%) positioned at the ventricular apex (65%). The median time to presentation from implant was 14 days [IQR 4-50 days] with chest pain (44%); abnormal pacing indices was highly prevalent (95%) whilst a pericardial effusion was noted in the majority of cases (57%). CT scanning was performed in 19 cases (41%) for various indications but deemed essential in only 4, all of which had non-diagnostic pacing indices and imaging. Chest X-ray (CXR) found clear perforation, lead displacement or pleural effusion in 74% of cases, whilst an echocardiogram found these in 64% of cases. The culprit lead was replaced in the majority of cases (87%) under local anaesthesia (76%) with surgical backup. The median hospital stay was 7 days [IQR 3-10 days] with zero procedural and 30-day mortality.

Conclusion

Transvenous lead revision for CIED-related cardiac perforation is safe and efficacious. CT modality for diagnostic purposes is useful in providing incremental value in a minority of cases; patients with non-diagnostic pacing parameters and non-CT imaging benefit most from this.

A registry review of 2532 catheter ablations for atrial fibrillation using active thermal protection

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Dr Leung has received research support from Attune Medical (Chicago, IL). Dr Gallagher has received research funding from Attune Medical (Chicago, IL).

Background

  Thermal injury to the oesophagus causes a spectrum of adverse effects after ablation for atrial fibrillation (AF); at the most severe end, atrio-oesophageal fistula carries a high mortality rate. Controlled active thermal protection in the oesophagus during ablation is the most promising method of oesophageal protection. Randomized evidence from the IMPACT trial (NCT03819946) showed an 83.4% reduction in endoscopically detected oesophageal lesions compared to standard care when an oesophageal temperature control device was used to control the local temperature. The IMPACT patients who were randomized to the use of the device had no adverse event related to its use.  Real world registry data on applications of this device have not previously been available. 

Purpose

To determine the safety of an oesophageal temperature control device by review of real-world registry data on its clinical use and any reported device-related adverse events.

Methods

  We reviewed the following databases for any reported oesophageal temperature control device-related complications: The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA). An internal registry (post-marketing follow up) database maintained by the manufacturer of the device was used to quantify the number used for each indication.  Reported events were reviewed and catalogued for description and identification of any events related to its use in the cardiac electrophysiology lab. The IMPACT study patients were reviewed for any device-related events.

Results

  Of the 13, 284 oesophageal temperature control devices used, 2532 were recorded as having been used for the purpose of oesophageal protection during catheter ablation for AF.  A total of 5 events associated with the device were identified, all from the MAUDE database.  Three were from 2017, one from 2018, and one from 2019.  All involved its use in critical care or trauma patients and were related to user error or contraindicated patient selection; none resulted in serious harm to the patient. No adverse events occurred related to its use in the cardiac electrophysiology lab. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device.

Conclusions

Real world registry data has shown no adverse events reported to date in over 2500 uses of an oesophageal temperature control device in the cardiac electrophysiology lab, for the purpose of active thermal protection. This data supports the randomized trial evidence of its clinical effectiveness. Abstract Figure. Oesophageal active thermal protection

Undiagnosed SARS-CoV-2 infection and outcome in patients with acute MI and no COVID-19 symptoms

OBJECTIVE

We aimed to determine the prevalence and outcome of occult infection with SARS-CoV-2 and influenza in patients presenting with myocardial infarction (MI) without COVID-19 symptoms.

METHODS

We conducted an observational study from 28 June to 11 August 2020, enrolling patients admitted to the National Institute of Cardiovascular Disease Hospital, Dhaka, Bangladesh, with ST-segment elevation MI (STEMI) or non-ST-segment elevation MI who did not meet WHO criteria for suspected COVID-19. Samples were collected by nasopharyngeal swab to test for SARS-CoV-2 and influenza virus by real-time reverse transcriptase PCR. We followed up patients at 3 months (13 weeks) postadmission to record adverse cardiovascular outcomes: all-cause death, new MI, heart failure and new percutaneous coronary intervention or stent thrombosis. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

We enrolled 280 patients with MI, 79% male, mean age 54.5±11.8 years, 140 of whom were diagnosed with STEMI. We found 36 (13%) to be infected with SARS-CoV-2 and 1 with influenza. There was no significant difference between mortality rate observed among SARS-CoV-2 infected patients compared with non-infected (5 (14%) vs 26 (11%); p=0.564). A numerically shorter median time to a recurrent cardiovascular event was recorded among SARS-CoV-2 infected compared with non-infected patients (21 days, IQR: 8-46 vs 27 days, IQR: 7-44; p=0.378).

CONCLUSION

We found a substantial rate of occult SARS-CoV-2 infection in the studied cohort, suggesting SARS-CoV-2 may precipitate MI. Asymptomatic patients with COVID-19 admitted with MI may contribute to disease transmission and warrants widespread testing of hospital admissions.

Vitamin D supplementation among Bangladeshi children under-five years of age hospitalised for severe pneumonia: A randomised placebo controlled trial

INTRODUCTION

Vitamin D is important for its immunomodulatory role and there is an independent association between vitamin D deficiency and pneumonia. We assessed the effect of vitamin D supplementation on the outcome in children hospitalized for severe pneumonia.

METHODS

This was a randomised, double blinded, placebo-controlled clinical trial in children aged >2-59 months with severe pneumonia attending Dhaka Hospital, icddr,b. Children received age-specific megadose of vitamin D3 (20,000IU: <6 months, 50,000 IU: 6-12 months, 100,000 IU:13-59 months) or placebo on first day and 10,000 IU as maintenance dose for next 4 days or until discharge (if discharged earlier) along with standard therapy. This trial is registered at ClinicalTrials.gov, number NCT02185196.

FINDINGS

We enrolled 100 children in placebo group and 97 in vitamin D group. On admission, 50 (52%) and 49 (49%) of children in vitamin D and placebo groups, respectively were vitamin D deficient. Among children with a sufficient serum vitamin D level on admission, a lower trend for duration of resolution of severe pneumonia in hours [72(IQR:44-96)vs. 88(IQR:48-132);p = 0.07] and duration of hospital stay in days [4(IQR:3-5)vs.5(IQR:4-7);P = 0.09] was observed in vitamin D group compared to placebo. No beneficial effect was observed in vitamin D deficient group or irrespective of vitamin D status.

CONCLUSION

Age-specific mega dose of vitamin D followed by a maintenance dose shown to have no statistical difference between the two intervention groups, however there was a trend of reduction of time to recovery from pneumonia and overall duration of hospital stay in under-five children with a sufficient serum vitamin D level on hospital admission.

In-hospital and 30-day major adverse cardiac events in patients referred for ST-segment elevation myocardial infarction in Dhaka, Bangladesh

BACKGROUND

There is a paucity of data regarding acute phase (in-hospital and 30-day) major adverse cardiac events (MACE) following ST-segment elevation myocardial infarction (STEMI) in Bangladesh. This study aimed to document MACE during the acute phase post-STEMI to provide information.

METHODS

We enrolled STEMI patients of the National Institute of Cardiovascular Disease, Dhaka, Bangladesh, from August 2017 to October 2018 and followed up through 30 days post-discharge for MACE, defined as the composite of all-cause death, myocardial infarction, and coronary revascularization. Demographic information, cardiovascular risk factors, and clinical data were registered in a case report form. The Cox proportional hazard model was used for univariate and multivariate analysis to identify potential risk factors for MACE.

RESULTS

A total of 601 patients, mean age 51.6 ± 10.3 years, 93% male, were enrolled. The mean duration of hospital stay was 3.8 ± 2.4 days. We found 37 patients (6.2%) to experience an in-hospital event, and 45 (7.5%) events occurred within the 30 days post-discharge. In univariate analysis, a significantly increased risk of developing 30-day MACE was observed in patients with more than 12 years of formal education, diabetes mellitus, or a previous diagnosis of heart failure. In a multivariate analysis, the risk of developing 30-day MACE was increased in patients with heart failure (hazard ratio = 4.65; 95% CI 1.64-13.23).

CONCLUSIONS

A high risk of in-hospital and 30-day MACE in patients with STEMI exists in Bangladesh. Additional resources should be allocated providing guideline-recommended treatment for patients with myocardial infarction in Bangladesh.

Combination anti-coronavirus therapies based on nonlinear mathematical models

Using nonlinear mathematical models and experimental data from laboratory and clinical studies, we have designed new combination therapies against COVID-19.

Patient outcomes after AF ablation using Ablation Index technology with oesophageal protection: insight from the IMPACT study

Background

Atrio-oesophageal fistula formation accounts for the majority of AF ablation-related morbidity and mortality. Thermal injury to the oesophagus can be significantly reduced by application of oesophageal cooling for protection during AF ablation. The effect of this method of oesophageal protection in patients receiving radiofrequency (RF) ablation guided by Ablation Index technology is currently unknown.

Objective

To investigate the ability of a temperature control device to protect the oesophagus from ablation-related thermal injury in patients receiving AF ablation guided by Ablation Index technology.

Methods

The IMPACT study is a single-centre, prospective, double-blind randomized controlled trial, which investigated the ability of a controlled method of oesophageal cooling to protect the oesophagus from ablation-related thermal injury. The EnsoETM device was used to deliver oesophageal cooling. This method was compared in a 1:1 randomization to a control group of standard practice utilizing a single-sensor temperature probe. In the study group, the device was used to keep the luminal temperature at 4°C during RF ablation. All participants received AF ablation using Ablation Index technology at posterior and anterior settings (30W at 350–400 and 40W at 450–500, respectively). Endoscopic examination was performed within 7 days post-ablation and oesophageal injury was graded. The patient and the endoscopist were blinded to the randomization. Structured clinical follow up occurred after 3 months post-ablation; both patient and follow up clinician were blinded.

Results

We recruited 188 patients, of whom 120 underwent endoscopic evaluation. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 versus 2/60; P=0.008). There was no difference between groups in RF time, lesion duration, force, power and combined ablation index (P value range= 0.2–0.9). Procedure and fluoroscopy duration were similar (P=0.97, P=0.91 respectively). The majority of those who passed through the 1st follow up evaluation (n=136) did not have gastrointestinal or chest pain symptoms post ablation and there was no difference between the randomized groups. Only 4.4% overall had severe symptoms and they were poorly correlated against those who sustained mucosal lesions. AF recurrence was similar in both groups (8% vs 8.8%). There were 2 cases of vascular trauma needing intervention in the control group and 1 case of conservatively managed pericardial effusion in the protected group only. Clinical and endoscopy findings did not report any EnsoETM device-related trauma.

Conclusion

Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared to standard care when ablation is performed using radiofrequency with Ablation Index technology. This method of oesophageal protection is safe and does not compromise the efficacy of the ablation procedure.

Endoscopy findings and patient symptoms.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): 1. Public hospital: St. George's NHS Foundation Trust; 2. Private company: Attune Medical (Chicago, IL)

Viral etiology of pneumonia among severely malnourished under-five children in an urban hospital, Bangladesh

BACKGROUND

In Bangladesh, pneumonia has a higher mortality among malnourished children aged <5 years. Evaluating pneumonia etiology among malnourished children may help improve empiric treatment guidelines.

METHODS

During April 2015-December 2017, we conducted a case-control study among severe acute malnourished (SAM) children aged <5 years admitted to the Dhaka hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). We enrolled hospital admitted SAM children with clinical or radiological pneumonia as cases (during April 2015 to March 2017) and hospital admitted SAM children without any respiratory symptom in the past 10 days before admission as controls (during February 2016 to December 2017). We tested nasopharyngeal wash from both case and control for respiratory syncytial virus (RSV), human metapneumovirus (HMPV), influenza viruses, human parainfluenza viruses (HPIV), rhinovirus and adenovirus by singleplex real-time reverse transcriptase polymerase chain reaction. To identify the independent association of pneumonia with viral pathogens during February 2016 to March 2017, we used multivariable logistic regression for calculating adjusted odds ratios.

RESULTS

We enrolled 360 cases and 334 controls. For case and control the median age was 8 months (IQR: 5-13) and 11 months (IQR: 6-18) (p = 0.001) respectively. Weight/age Z-score was -4.3 (SD ±0.7) for cases and -4.1 (SD ±1.1) for controls (p = 0.01). Among cases 68% had both clinical and radiological pneumonia, 1% had clinical pneumonia and 31% had only radiological pneumonia. Respiratory virus detection was high in cases compared to controls [69.9% (251) vs. 44.8% (148), p = 0.0001]. The most frequently detected viruses among cases were rhinoviruses (79, 22.0%) followed by RSV (32, 8.9%), adenovirus (23, 6.4%), HPIV (22, 6.1%), influenza virus (16, 4.5%), and HMPV (16, 4.5%). Among the controls, rhinoviruses (82, 24.8%) were most commonly detected one followed by adenovirus (26,7.9%), HMPV (5, 1.5%), HPIV (4, 1.2%), RSV (3, 0.9%), and influenza virus (2, 0.6%). RSV (OR 13.1; 95% CI: 1.6, 106.1), influenza virus (OR 8.7; 95% CI: 1.0, 78.9), HPIV (3.8; 95% CI: 1.0, 14.8), and HMPV (2.7; 95% CI: 1.3, 5.5) were independently associated with pneumonia while compared between 178 cases and 174 controls.

CONCLUSION

Viral etiology of pneumonia in SAM children were mainly attributable to RSV, influenza, HPIV and HMPV. Our study findings may help in planning further studies targeting vaccines or drugs against common respiratory viruses responsible for pneumonia among SAM children.

Potential of exocellular carbohydrate antigens of Staphylococcus epidermidis in the serodiagnosis of orthopaedic prosthetic infection

The potential of exocellular carbohydrate antigens of Staphylococcus epidermidis as markers of infection in bone was investigated by immunoblotting and enzyme-linked immunosorbent assay (ELISA). Exocellular antigens were prepared by gel filtration chromatography of concentrated brain heart infusion culture supernates. The antigenic material appeared as diffuse bands between 24 and 32 kDa on the immunoblots and was not susceptible to digestion with trypsin, indicating that the response in the patients was to non-protein (polysaccharide or teichoic acid, or both) exocellular material. Significant differences were detected between the immunoblot antigen profiles for serum IgG from patients with S. epidermidis bone infection and those with an uninfected prosthetic joint. Thirteen of 16 patients with S. epidermidis prosthetic joint infection showed an elevated serum IgG level by ELISA compared with controls with uninfected joints. However, the antigen was not specific for S. epidermidis bone infection; high levels of IgG were also detected in patients with other serious staphylococcal and streptococcal infections. The ELISA test may be valuable in distinguishing between staphylococcal infection of joints and aseptic loosening by excluding cases of infection.