Evaluation of Time From Pre-Hospital Symptom Onset to Angiography on Coronary Artery Occlusion Status and Outcomes in Patients Presenting With NSTE-ACS

Introduction: Current guidelines for invasive coronary angiography (ICA) in patients presenting with NSTE-ACS outline two treatment pathways: early (within 24 hours [hrs]);or late (>24 hrs). Time of hospital admission is used as the start time, however, we hypothesize that pre-hospital time of symptom onset may be a more optimal starting time. This study was designed to test optimal symptom onset-to-angiography time (OAT) and its association with the presence of coronary occlusion and adverse outcomes. Method(s): Secondary data analysis in NSTE-ACS patients (pre-COVID-19) who underwent ICA. We tested the optimal cutoff point of OAT in classifying coronary occlusion using Youden-index analysis. We tested the association of OAT and in-hospital complication (i.e., myocardial infarction [MI] after admission, unplanned transfer to the cardiac intensive care unit, pulmonary edema, cardiogenic shock, dysrhythmia with intervention) and hospital length of stay [LOS]) using regression models. Result(s): In 163 patients: 124 (76%) had an occluded artery;37 (23%) had an in-hospital complication. Overall, the mean OAT was 26+/-22 hrs (24+/-22 vs. 31+/-21, with and without occluded artery, respectively), and the median LOS was 55 hrs. The Youden-index optimum OAT cutoff point was 13.4 hrs. In the two logistic models, the adjusted OAT was associated with the presence of coronary occlusion (Figure A). OAT, as a continuous variable, was associated with LOS (beta=0.64, 95% CI 0.08-1.21, p=0.025), no other in-hospital complications were significant (Figure B) Conclusion(s): In patients presenting with NSTE-ACS, OAT at both 13.4 and <24 hrs is a significant predictor of the presence of coronary artery occlusion. Every hour of delayed OAT was associated with a prolonged hospital LOS 0.64 hrs (38 min). Symptom onset appears to be an important starting point in determining optimal timing of ICA in patients with NSTE-ACS, but requires further study with a large sample of patients.

Radiopacity of sodium zirconium cryosilicate on plain radiography

Introduction: Sodium zirconium cyclosilicate is a novel potassium binder developed by AstraZeneca and is sold under the brand name Lokelma (TM). It has been approved for use in England in 2020 for the treatment of non-lifethreatening hyperkalaemia, and stable hyperkalaemia in patients with chronic kidney disease.1 It is available as powder sachets (5 grams and 10 grams) and is designed to be mixed with water and administered enterally. The starting dose is recommended as 10 grams three times per day, and resolution of hyperkalaemia is usually seen within two days, after which a lower maintenence dose may be administered. The radiopaque properties of sodium zirconium cyclosilicate have previously been noted on computed tomography before in 2021,2 but, to our knowledge, this has not yet been described on plain radiography. Case presentation: We present the case of a critically unwell lady in her 50s with COVID-19 pneumonitis. As a feature of her critical illness syndrome, she developed acute renal failure, and required renal replacement therapy. Persistent problems with hyperkalaemia were noted, and sodium zirconium cyclosilicate was administered enterally via a nasogastric tube as directed in the product literature. For unrelated reasons, she also required a chest radiograph within the following hour. On reviewing the radiograph, a radiopaque material was noted in the stomach, and was seen to very clearly outline the major anatomical features of the organ, including the greater and lesser curve, and gastric rugae. After discussion with our local radiology colleagues and finding the material is opaque on computed tomography, we concluded this material must be the recently administered sodium zirconium cyclosilicate. Investigation: Image of radiograph showing radiopaque material in the stomach of a critically unwell patient. Discussion: To our knowledge, the radiopaque properties of sodium zirconium cyclosilicate have not been described before in the medical literature as relating to plain radiography. When interpreting plain radiographs, it is important to understand and exclude sources of artefact. As sodium zirconium cyclosilicate becomes widespread in critical care areas, we believe the above-described scenario will be commonly encountered. Moreover, we believe that sodium zirconium cyclosilicate may have additional utility as a well tolerated enteral contrast agent with the added benefit of lowering serum potassium concentration.

Change in incidence of cardiovascular diseases during the covid-19 pandemic and vaccination campaign: data from the nationwide French hospital discharge database (preprint)

Importance The covid-19 pandemic induced a severe disruption in hospital activity. Cardiovascular illnesses represent a major health burden in industrialised countries and are second in terms of hospital bed occupancy in France. Considering the resources mobilized and the public health issue involved, it is necessary to study the impact of the pandemic on their incidences. Objective To monitor changes in the incidence of cardiovascular diseases during years 2020 and 2021 compared to 2019. Design Nationwide population-based cohort study. Setting French hospital discharge database between January 1 and October 30 in 2019, 2020 and 2021. Participants New patients hospitalized for vascular disease in Metropolitan France. A patient was considered as incident for a morbidity if not present in the database in the previous two years with the morbidity as the primary reason for admission. Main outcome measures Standardized hospitalization incidence difference and relative risk of hospitalization for a series of targeted vascular diseases from January 1 to October 31 for 2021 versus 2019. Demographic data from 2019 were used for the standardization of patient counts by 10-year age strata for each morbidity and year. Results While the relative risk of hospitalization in 2021 versus 2019 decreased for almost all diseases, an increase in relative risk was observed for myocarditis (28.0%) and pulmonary embolisms (10.0%). In 2020, the relative risk of hospitalization versus 2019 also decreased for almost all diseases but remained stable for myocarditis and increased by 4.0% for pulmonary embolisms. In 2021, the difference in myocarditis coincided with the vaccination campaign in young individuals. The increase in pulmonary embolism occurred predominantly in older women, with a weak but still noticeable coincidence with the vaccination campaign. Conclusions The deficit in care for patients with acute atherothrombotic manifestations in 2021 and 2020 shows a failure by the French healthcare system to rectify the deficiencies of 2020. The risk excess for pulmonary embolism cannot be entirely explained by covid-19 or by vaccine-induced immune thrombotic thrombocytopenia. This warrants investigating the risk/efficacy ratio of a temporary thromboprophylaxis in individuals at risk before vaccine.

Did COVID-19 impact Positive Airway Pressure adherence in 2020? A cross-sectional study of 8477 patients with sleep apnea.

BACKGROUND: Whether the COVID-19 pandemic impacts Positive Airway Pressure (PAP) adherence over the long-term is unknown and only preliminary short-term data have been reported. METHODS: With the aim of describing the impact of the first and second waves of COVID-19 on PAP adherence during 2020 in France, we designed a cross-sectional study of Sleep-Apnea (SA)-patients under PAP telemonitoring. To examine PAP adherence in adult SA patients, we assessed de-identified data from a non-profit healthcare provider database during the period January 1, 2019 to December 31, 2020. Included patients met the following criteria: (i) PAP-treated for at least 4 months before January 1, 2019 and with continuous PAP during both 2019 and 2020; (ii) ≥ 360 daily PAP telemonitored data per year. For PAP adherence, data were collected using the PAP-software. RESULTS: 8477/10482 patients were finally included in the analysis [72.4% male, median age 70 years (IQ25-75: 61-77], 25.6% < 62 years old, initial Apnea-Hypopnea Index (AHI) of 41 (31-59)/h. Median PAP adherence was 7.21 (6.12-8.10) h/day in 2020 versus 7.12 (6.05-8.02) h/day in 2019, p < 0.001. The median difference in PAP adherence between the first 2020 lockdown and the corresponding 2019 weeks was 9.75 (CI95% 8.75-10.75) min/day, p < 0.001. The median difference in PAP adherence between the second 2020 lockdown and the corresponding 2019 weeks was 5.00 (CI95% 4.00-6.00) min/day, p < 0.001. If we consider the minimal clinically important difference of 30 min for PAP adherence, 30.4% and 26% of the patients increased their PAP adherence by at least 30 min during the first and second lockdowns respectively; 17.6% and 19.3% of the patients lowered their PAP adherence by at least 30 min in the first and second lockdowns, respectively. CONCLUSION: During the first and second lockdowns, the COVID-19 pandemic had a clinically irrelevant effect on PAP adherence for the study population. Future studies are needed to describe COVID-19 pandemic impact on PAP adherence not only for long-term PAP-treated SA patients but also for incident cases. Trial registration The COVADENE study was registered on March 1st, 2021 on ClinicalTrials.gov (Identifier: NCT04775966).

Pharmacological strategies used to manage symptoms of patients dying of COVID-19: A rapid systematic review

Background: COVID-19 has tragically resulted in over 2 million deaths globally. Despite this, there is a lack of research on how to care for patients dying of COVID-19, specifically pharmacological management of symptoms. Aims: The aim was to determine the dose ranges of pharmacological interventions commonly used to manage symptoms in patients dying of COVID-19, establish how effectiveness of these interventions was measured, and whether the pharmacological interventions were effective. Methods: This was a rapid systematic review with narrative synthesis of evidence, prospectively registered on PROSPERO (ID: CRD42020210892). We searched MEDLINE, EMBASE, CINAHL via the NICE Evidence Health Databases Advanced Search interface;medRxiv;the Cochrane COVID-19 Study Register;and Google Scholar with no date limits. We included primary studies which documented care of patients dying of COVID-19 under the care of a specialist palliative care team. Results: Seven studies, documenting the care of 493 patients met the inclusion criteria. Approximately two thirds of patients required a continuous subcutaneous infusion with median doses of 15mg morphine and 10mg midazolam in the last 24 hours of life. Four studies described effectiveness by retrospective review of documentation. One study detailed the effectiveness of individual medications. Conclusions: A higher proportion of patients required continuous subcutaneous infusion than is typically encountered in palliative care. Doses of medications required to manage symptoms were generally modest. There was no evidence of a standardised yet holistic approach to measure effectiveness of these medications and this needs to be urgently addressed.

Negotiating Desire and Uncertainty on Tinder During the COVID-19 Pandemic: Implications for the Transformation of Sexual Health Communication.

Research on the impact of the COVID-19 pandemic on communication on Tinder is presented in this article. This research examines reported changes in communication about sex and health during COVID-19 and the potential implications of those changes on hookup culture and sexual health communication beyond the pandemic. Data from 29 in-depth qualitative interviews with 20 female and 9 male college students are reported. Results include discussion of how college students are managing uncertainty, particularly uncertainty about health status, changes in communication and information-seeking strategies, different COVID-19 safety measures they have employed, and the future impact on communication about sexual health post-COVID-19. Participants in this study use uncertainty reduction communication strategies to gauge whether the risks of remaining on Tinder or meeting in person are worth the benefit. Results show that the quality and quantity of communication around first time in-person meetings have been modified, as the traditional public spaces for meeting have been reduced or eliminated and replaced by private spaces. Participants stated that they communicate more frequently and more directly about health, sexual health, and infection transmission. Finally, results indicate that participants have a strong desire to be more cautious and cognizant of health and safety in the future by using some of the communication strategies they developed during COVID-19.

Clinical Characteristics and Outcomes in Patients with COVID-19 and Cancer: a Systematic Review and Meta-analysis.

Much of routine cancer care has been disrupted due to the perceived susceptibility to SARS-CoV-2 infection in cancer patients. Here, we systematically review the current evidence base pertaining to the prevalence, presentation and outcome of COVID-19 in cancer patients, in order to inform policy and practice going forwards. A keyword-structured systematic search was conducted on Pubmed, Cochrane, Embase and MedRxiv databases for studies reporting primary data on COVID-19 in cancer patients. Studies were critically appraised using the NIH National Heart, Lung and Blood Institute's quality assessment tool set. The pooled prevalence of cancer as a co-morbidity in patients with COVID-19 and pooled in-hospital mortality risk of COVID-19 in cancer patients were derived by random-effects meta-analyses. In total, 110 studies from 10 countries were included. The pooled prevalence of cancer as a co-morbidity in hospitalised patients with COVID-19 was 2.6% (95% confidence interval 1.8%, 3.5%, I2: 92.0%). Specifically, 1.7% (95% confidence interval 1.3%, 2.3%, I2: 57.6.%) in China and 5.6% (95% confidence interval 4.5%, 6.7%, I2: 82.3%) in Western countries. Patients most commonly presented with non-specific symptoms of fever, dyspnoea and chest tightness in addition to decreased arterial oxygen saturation, ground glass opacities on computer tomography and non-specific changes in inflammatory markers. The pooled in-hospital mortality risk among patients with COVID-19 and cancer was 14.1% (95% confidence interval 9.1%, 19.8%, I2: 52.3%). We identified impeding questions that need to be answered to provide the foundation for an iterative review of the developing evidence base, and inform policy and practice going forwards. Analyses of the available data corroborate an unfavourable outcome of hospitalised patients with COVID-19 and cancer. Our findings encourage future studies to report detailed social, demographic and clinical characteristics of cancer patients, including performance status, primary cancer type and stage, as well as a history of anti-cancer therapeutic interventions.