Donald Trump and Boris Johnson: The unfulfilled relationship

At the 2020 Republican National Convention, accepting his party's nomination for President in 'the most important election in the history of our country', Donald Trump historicised his controversial use of the White House as the mise-en-scène for so party-political an event. 'Two weeks after Pearl Harbor, Franklin Delano Roosevelt welcomed Winston Churchill, and just inside, they set our people on a course to victory in the Second World War.' The President, a 'big fan' of the movie Darkest Hour, was known to have screened it, just inside, to members of Congress. Two years earlier, at 'historic Chequers', a place 'I've heard so much about and read so much about growing up', Trump had reclined in Churchill's chair, a photograph of which the White House Press Secretary tweeted. 'It was from right here at Chequers that Prime Minister Churchill phoned President Roosevelt after Pearl Harbor', Trump informed the media, just outside. 'In that horrific war, American and British service members bravely shed their blood alongside one another in defense of home and in defense of freedom. And together, we achieved a really special, magnificent victory.' As his opponents mobilised for the 2020 election, the President dismissed each Democrat standing to unseat him as being 'not Winston Churchill'. In the year of the election, with the Churchill statue in Parliament Square in London having to be defended against incivility triggered by racial violence in the US, the President drew to the attention of his 85m Twitter followers the publication of Trump and Churchill, Defenders of Western Civilization;it was, he confessed, 'a great honor to be compared, in any way, to Winston Churchill'. Five days later Trump walked amidst smouldering scenes just outside his residence. 'Like Churchill, we saw him inspecting the bombing damage;it sent a powerful message of leadership', the White House Press Secretary explained. The summer of protest constituted the second national crisis of 2020. The first had been the reason for the unconventional convention: a crisis which dwarfed those faced by any President and Prime Minister since that foundational pairing. When accused wilfully of understating the seriousness of Coronavirus Covid-19, Trump channelled Churchill, citing his 'calmness'. At the same time, and for the same reasons, Boris Johnson, who had spent his life channelling Churchill, invoked Roosevelt. Trump had appropriated Churchill's character;Johnson, Roosevelt's policies. Recall of heterodox politicians yoked by circumstance, and at great personal cost, to set their people on a course to victory was a reminder that, in a year when 'unprecedented' became the commentators' word of choice, not everything actually was. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022. All rights reserved.

SYSTEM OPTIMISATION IN TIMES OF CRISIS

Introduction: The benefits of reorganisation (System optimisation) of stroke services to create sustainable, high-quality larger units are well known. This frequently takes many years of planning and public consultation. We report the benefits of co locating two smaller acute stroke units (600 confirmed strokes each per year) onto one non-acute site, planned and delivered to support the wider COVID 19 response in England. Methods: Planned and delivered over 10 days in May 2020: Innovations introduced: 1) Prehospital: telemedicine assessment between stroke specialist and ambulance crew;improving sensitivity and specificity of triage to support time critical access to Thrombolysis and Thrombectomy. 2) Adherence to a National Optimal Stroke Imaging Pathway (NOSIP): 24/7 access to CTA, CTP with AI support and 12hrs access to MRI. 3) Autonomy of stroke bed base 4) Inpatient stroke care redesign: to deliver initial acute care (72 hours) and early rehabilitation (post 72 hours) with medical and therapy care delivered routinely 7 days per week. Monthly evaluation of quality indicators (SSNAP) enabled evaluation, benchmarked against local (pre-pandemic) and national performance. Mortality and length of stay outcomes analysed. Results: Significant and sustained improvement across all 10 domains of care with increased thrombolysis rates >20%, thrombectomy rates >5%, statistically significant relative mortality risk of 59.6% (65 lives saved) and 38% reduction in length of stay (17 to 11 days). Conclusions: Sustainable improvements to stroke services may be delivered rapidly, incorporating innovative solutions to deliver sustainable high-quality stroke care, whilst supporting the wider health care response to the COVID pandemic. (Figure Presented).

Stigma syndemics and ESKD in disenfranchised urban communities fighting COVID-19

Background: Although COVID-19 is impacting all communities, the distribution of its harms is not equal. Poor, urban people of color with compromised health are particularly hard-hit. This study explores how patients with end-stage kidney disease (ESKD), living in underprivileged urban communities, manage their illness and treatment experiences and disease-associated stigmas in the face of COVID-19. Methods: We used purposive sampling to enroll patients with ESKD at a safety net hospital in Boston, MA. 12 remote ethnographic interviews were conducted from December 2020 to June 2021. Interviews were recorded and transcribed, and data were analyzed using grounded theory and dimensional narrative analysis. We identified dominant themes reflecting the biosocial harms caused by ESKD as well as patients' sense of isolation and stigmatization before and during the COVID-19 pandemic. Results: The mean age of patients was 56±14 years, 50% were female, and 90% selfidentified as Black. Almost all patients reported adverse effects from dialysis treatment which leaves them depleted and precludes them from working. Facing the biosocial implications of dialysis, patients also experienced severe economic hardship which has been intensified by the COVID-19 pandemic. While many patients framed COVID-19 as just one more thing and denied increased stigmatization by others due to their potentially increased susceptibility to infection, male patients more frequently reported experiencing racial stigmatization and narrated it as contributing to and exacerbating their chronic illness and suffering. Conclusions: Biosocial and environmental factors as well as institutional racism and stigmatization play significant roles in amplifying the burden of ESKD in patients of color who are now syndemically impacted by COVID-19 (Figure 1). A better understanding of how these factors interplay will help to inform policy makers in alleviating tensions and structural conditions that impinge on patients' well-being and health outcomes.

COVID-19 and Co-production in Health and Social Care Research, Policy, and Practice

EPDF and EPUB available Open Access under CC-BY-NC-ND licence. Groups most severely affected by COVID-19 have tended to be those marginalised before the pandemic and are now largely being ignored in developing responses to it. This two-volume set of Rapid Responses explores the urgent need to put co-production and participatory approaches at the heart of responses to the pandemic and demonstrates how policymakers, health and social care practitioners, patients, service users, carers and public contributors can make this happen. The first volume investigates how, at the outset of the pandemic, the limits of existing structures severely undermined the potential of co-production. It also gives voice to a diversity of marginalised communities to illustrate how they have been affected and to demonstrate why co-produced responses are so important both now during this pandemic and in the future. © their respective authors, 2021. All rights reserved.

COVID-19 and Co-production in Health and Social Care Vol 2: Volume 2: Co-production Methods and Working Together at a Distance

EPDF and EPUB available Open Access under CC-BY-NC-ND licence. Groups most severely affected by COVID-19 have tended to be those marginalised before the pandemic and are now being largely ignored in developing responses to it. This two-volume set of Rapid Responses explores the urgent need to put co-production and participatory approaches at the heart of responses to the pandemic and demonstrates how policymakers, health and social care practitioners, patients, service users, carers and public contributors can make this happen. The second volume focuses on methods and means of co-producing during a pandemic. It explores a variety of case studies from across the global North and South and addresses the practical considerations of co-producing knowledge both now - at a distance - and in the future when the pandemic is over. © the editors. Individual chapters. their respective authors 2021. All rights reserved.

Remote Monitoring of Heart Transplant Recipients during the COVID-19 Pandemic

Purpose The COVID-19 pandemic created significant challenges in monitoring heart transplant (HT) recipients for rejection due to efforts to minimize contact with the hospital setting. The aim of this study was to evaluate the safety and efficacy of transitioning HT patients to home phlebotomy and a monitoring protocol based on gene expression profiling (GEP) and donor derived cell free DNA (ddcfDNA). Methods A single-center cohort study that prospectively enrolled consecutive HT patients who were transitioned to a remote monitoring protocol employing home phlebotomy and non-invasive surveillance for rejection. Patients were enrolled starting at 2 months post-HT. Positive GEP values were defined as ≥32 (up to 6 months post-HT) and ≥34 (> 6 months post-HT). A positive ddcfDNA score was defined as >0.12%. A positive biopsy was defined as grade ≥1B/1R Results 246 HT patients were enrolled and followed for a minimum of 3 months. Mean age was 56±14, 71.5% were male, and median time from transplant was 2.7 years. The average distance of patients from the hospital was 25.6 miles. 359 blood tests were drawn for detection of GEP and ddcfDNA and 102 biopsies performed (Figure). Among 32 patients who had negative results on both tests and had a biopsy, 0 had a positive biopsy. Of 25 patients who had positive results on both tests and had a biopsy, 3 (12%) had a positive biopsy. The biopsy positivity rate in patients who were GEP+/ddcfDNA- was 6% and in patients who were GEP-/ddcfDNA+ was 8%. None of the positive biopsies were associated with hemodynamic compromise. 15 (6%) of patients were admitted due to allograft rejection during the study period. There were no deaths. Conclusion Using a remote monitoring protocol with home phlebotomy and noninvasive rejection surveillance was feasible and safe in HT recipients. In this cohort, the combination of negative GEP and ddcfDNA scores was accurate at predicting a lack of allograft rejection.

The Utility of Televisits in Heart Transplant Recipients

Purpose In the current era, televisits have become requisite to assess patients and monitor their conditions. Heart transplant (HT) recipients represent a complex population with multiple co-morbidities that require frequent evaluation. This study aimed to assess the effectiveness of televist encounters in a post-heart transplant cohort during the COVID-19 pandemic. Methods This was a prospective cohort study of all HT recipients evaluated via a televist between 3/1/20-5/30/20, at a large academic medical center. Patient demographics, baseline medications and details of televisit encounters were collected from electronic medical records. Patients were followed for 3-months from their first televisit for medication changes, in-person visits, hospital admissions, treated rejection or infection episodes and mortality. Results 301 patients were enrolled, mean age was 56.0±15.1 years and 213 were males (71%). Mean time between transplant and first televisit was 49 months. The number of televisits per patient is seen in Figure 1a. Following-televisits 152 patients (50.5%) had medication changes, mostly immunosuppression (43.5%) followed by diuretics (6.0%). 141 patients (46.8%) were seen in person for either a clinic visit or RHC following a televisit. There were 61 ED visits resulting in 42 admissions in 36 patients (12.0%) (Figure 1b). Of those, 17 occurred within 2 weeks of a televisit (40.5%). There were 8 cardiac related admissions (19.0%, 5 due to treated rejection), 14 (33.3%) due to infection, and 6 due to COVID-19. One patient died due to complications of COVID-19 during the study period. Conclusion In this post HT cohort, there was a high rate of admissions, with most readmissions due to non-cardiac or infectious causes. This study calls into question the role of televisits in this complex patient population and merits further study of how they can best supplement usual care to enhance outcomes in patients post-HT.

Six-Month Outcomes of Heart Transplant Recipients Infected by COVID-19

Purpose COVID-19 infection might be associated with higher mortality risk for transplanted patients, as a result of their multiple co-morbidities and their immunosuppressed status. We sought to describe the six-month outcomes of heart transplant (HT) recipients infected by COVID-19. Methods We retrospectively analyzed clinical and echocardiographic data from all HT recipients infected with COVID-19 between March and April 2020. All patients were followed for a minimum of 6 months or until death. Results Twenty-eight HT patients were studied, median age was 64 (range 59-69) and 22 were male. Co-morbidities included obesity (25%), diabetes (61%), HTN (71%), CKD (68 %) and chronic lung disease (36%). Eight patients died (29%) (non-survivors) and 20 survived (survivors) COVID-19 infection. All patients who survived the initial hospitalization period remained alive at 6 months (figure 1). There was no difference in the prevalence of co-morbidities between survivors and non-survivors. Survivors had lower peak ferritin (2185 ± 793 vs 18023 ± 16724, p= 0.04) and procalcitonin (0.8 ± 0.3 vs 104 ± 31, p<0.005). Baseline allograft function was similar between survivors and non-survivors and it remained unchanged at 6 months for the survivors’ group (LVEF baseline: 58 ± 1% vs LVEF 6 m 61 ± 3%). Renal function returned to baseline in 85% of survivors at 6 months after hospitalization. Mycophenolate mofetil was held during the acute infection and was resumed after discharge. At 6 months follow-up, all patients returned to their baseline immunosuppression regimen, have no further symptoms of COVID-19 and there have been no subsequent rejection events. Conclusion COVID-19 infection is associated with a high fatality rate (29%) among HT recipients, however, HT recipients that survive the acute COVID-19 infection have preserved allograft function and end-organ function has returned to baseline at 6 months follow-up.