Insights from a single centre implementation of a digitally-enabled atrial fibrillation virtual ward

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia and poses a significant public health burden. Virtual wards are a novel approach utilising digital solutions to provide hospital-level care remotely; their rollout has become a key priority for the UK National Health Service to expand acute care capacity. We devised and implemented a digitally-enabled AF virtual ward to monitor patients being established onto medical therapy following an AF diagnosis or an AF-related hospitalisation. Patients were onboarded either as outpatients to avoid admission or on discharge after an acute AF hospitalisation. Remote monitoring was undertaken using a clinically validated photoplethysmography-based smartphone app. Over a 1-2 week period, patients performed twice daily measurements of heart rate and rhythm and provided corresponding symptoms. A traffic light system guided frequency of telephone assessments by specialist practitioners. Red flag symptoms or abnormal heart rate parameters prompted an urgent care escalation. We report our experience of the first 73 patients onboarded to the AF virtual ward from October 2022 to June 2023 (mean age 65 years, median 68 years, IQR range 27-101 years; 33 females). Thirty-nine (53%) patients had red flag features requiring care escalation, of whom 9 (23%) were advised to attend ED (emergency department) for urgent assessment, 10 (26%) attended for expedited review and 14 (36%) required medication changes. By 3 months post-monitoring, only 3 patients (4%) had re-attended ED with an arrhythmia-related presentation. Virtual ward patients had an average 3-day shorter inpatient stay (mean duration 4 days) compared with AF patients hospitalised prior to virtual ward implementation (mean duration 7 days). Overall, 22 arrhythmia-related readmissions were prevented via the virtual ward model. In this study, we present a novel implementation of a digitally-enabled virtual ward for the acute management of patients with newly diagnosed or poorly controlled AF. Our pilot data indicate that this model is feasible and is potentially cost-effective. Further longitudinal study is needed to definitively evaluate long-term clinical utility and safety.

Impact of maternal bariatric surgery on offspring perinatal cardiac function: A prospective study

OBJECTIVE

To assess perinatal cardiac function in offspring of women with previous bariatric surgery and examine its association with maternal glucose control.

DESIGN

Prospective study.

SETTING

Maternity unit, UK.

POPULATION

Fifty-four fetuses/neonates; 29 of post-bariatric surgery women and 25 of women without surgery.

METHODS

Prospective, longitudinal observational study of pregnant women with and without previous bariatric surgery, matched for early pregnancy body mass index. Cardiac function of all offspring was assessed by two-dimensional conventional, spectral tissue Doppler and speckle-tracking echocardiography at 35-37 weeks of gestation and at 5-7 weeks of age. Maternal glycated haemoglobin (HbA1c) was measured at 27-30 weeks of gestation. Maternal demographics and fetal/infant cardiac function indices were compared between the groups. Correlation coefficient (r) is reported.

MAIN OUTCOME MEASURES

Fetal/infant cardiac function indices.

RESULTS

Compared with no-bariatric neonates, offspring of post-bariatric women were smaller at birth (birthweight centiles: 64.96 ± 36.41 versus 40.17 ± 27.99; p = 0.007). There were no significant differences in fetal/infant cardiac function indices and perinatal cardiac changes, between groups. There was a positive correlation between maternal HbA1c and fetal left ventricular (LV) longitudinal strain (r = 0.33) and LV longitudinal strain rate (r = 0.29), suggesting an inverse relation between HbA1c and fetal LV systolic function, but this was mainly seen in offspring of women with no previous bariatric surgery (r = 0.56 and r = 0.50, respectively).

CONCLUSIONS

Maternal bariatric surgery does not appear to inadvertently affect the offspring cardiac performance. We found an inverse correlation between maternal HbA1c levels and fetal LV systolic function but this was mainly seen in the no-bariatric pregnancies.

Evaluating the implementation and impact of a new model of care for integrating children and young people's acute mental healthcare in a paediatric setting: a protocol for a realist, mixed-methods approach

INTRODUCTION

The mental health of children and young people in the UK has been declining and has continued to worsen throughout the pandemic, leading to an increase in mental health-related emergencies. In response, the Best for You programme was developed as a new service designed to integrate mental healthcare for children and young people between acute hospital and community services. The programme is comprised of four new services: a rapid assessment young people's centre with dual-trained staff, a co-located day service offering family-based care,a digital hub, designed to integrate with the fourth element of the model, namely community support and mental health services. This evaluation protocol aims to assess the development, implementation and outcomes of the Best for You programme and develops a scalable model that could be implemented in other parts of the National Health Service (NHS).

METHODS AND ANALYSIS

This mixed-methods realist evaluation aims to delineate the components of the system to assess their interdependent relationships within a wider context. Data collection will include interviews, participant observations, focus groups and the collection of local quantitative healthcare data. The research will be conducted across four phases. Phase 1-captures the development of the underlying programme theory. Phase 2-a process evaluation testing the programme theory. Phase 3- an outcome and economic evaluation. Phase 4-consolidation of learning from phases 1-3 to identify barriers, facilitators and wider contextual factors that have shaped implementation drawing on the Consolidated Framework for Implementation Research.

ETHICS AND DISSEMINATION

Ethical approval for the evaluation was received from the NHS local ethics committee. Embedded within the evaluation is a formative review to feedback and share learning with stakeholders to scale-up the programme. Findings from this study will be disseminated in peer-reviewed journals as well as presentations to be useful to service user organisations and networks.

Evaluating the performance characteristics of five lateral flow assays for the detection of the SARS-CoV-2 nucleocapsid antigen

In response to the COVID-19 pandemic, lateral flow assays (LFAs) for the detection of SARS-CoV-2 antigen have been proposed as a complementary option to the more costly and time consuming reverse-transcriptase polymerase chain reaction (RT-PCR). We assessed five commercially available SARS-CoV-2 antigen detecting LFAs (ASSUT EUROPE (Rome, Italy), Besthree (Taizhou, China), Encode (Zhuhai, China), Fortress (Antrim UK), and Hughes Medical (Buckinghamshire, UK), using samples collected from hospitalised individuals with COVID-19 and compared these results against established RT-PCR assays with the aim of estimating test performance characteristics. We performed a diagnostic accuracy study of the five LFAs on 110 inpatients with confirmed COVID-19 and 75 COVID-19 negative control participants. Assay evaluation was performed using a modified version of each manufacturer's protocol allowing for parallel testing of a single sample on multiple assays. Additional variables were studied including infection acquisition, oxygenation requirements at time of swabbing, and patient outcomes. The 110 patients were 48% (53) female, with mean age 67 years (range 26-100 years), and 77% (85) cases were community onset SARS-CoV-2. Across the five assays, sensitivity ranged from 64 (95% CI 53-73) to 76% (95% CI 65-85); Fortress performed best with sensitivity of 76% (95% CI 65-85). Specificity was high across all assays with 4/5 LFAs achieving 100%. LFA sensitivity was not dependant on RT-PCR cycle thresholds. SARS-CoV-2 antigen detecting LFAs may complement RT-PCR testing to facilitate early diagnosis and provide community testing strategies for identification of patients with COVID-19, however we find suboptimal test performance characteristics across a range of commercially available manufacturers, below WHO and MHRA pre-set sensitivity performance thresholds. With such variation in sensitivity between LFAs and PCR testing and between assay brands, we advise caution in the deployment of LFAs outside of environments with clinical oversight.