Echocardiographic assessment of left ventricular structure and function in hypertensive disorders of pregnancy at six months and two years postpartum

Purpose: Hypertensive disorders of pregnancy (HDP) are associated with longer term postpartum cardiovascular sequelae, including double the risk of ischaemic heart disease and cardiovascular mortality (1). Transthoracic echocardiograms (TTE) were performed in women with pregnancies complicated by gestational hypertension and pre-eclampsia, or uncomplicated pregnancy, at six months and two years postpartum. The aim was to longitudinally assess cardiac structure and function in women with HDP and compare this to women who had a normotensive pregnancy. The six-month results have been previously reported, we now present the two-year data. Method(s): A prospective cohort study was conducted in a pre-specified subgroup of 126 patients within a single, tertiary referral centre as part of the P4 (Post Partum, Physiology, Psychology, and Paediatric Follow Up) study (2). 74 (59%) women had a normotensive pregnancy, and 52 (41%) had a pregnancy complicated by HDP. Women with pre-existing hypertension were excluded from the study. The mean patient age at time of six-month postpartum TTE was 32 years (range 22-47 years). TTEs were performed by blinded experienced sonographers and reported by a single blinded imaging cardiologist. Result(s): Six months postpartum. 126 women underwent TTE at six months postpartum. Although all results fell within normal ranges, compared to women with a normotensive pregnancy, those with HDP had increased left ventricle (LV) wall thickness, higher relative wall thickness, and increased LV mass. E/A ratio was lower, and E/E' ratios higher in the group with pregnancy complicated by HDP, indicating a trend towards poorer diastolic function (2,3). Two years postpartum. 35 women completed a two year postpartum TTE (18 normotensive, 17 HDP). Measurements fell within normal ranges in both groups of women. At two years postpartum, women with HDP had larger BSA (1.9 vs 1.71 2 p=0.003), larger LV internal diastolic diameter (48.4 vs 45.5mm p=0.017) and increased inter-ventricular septum thickness (8.5 vs 7.7mm p=0.007) compared to those with normotensive pregnancy. LV mass was greater in women with HDP (98.1 vs 81.5g), as was LA volume indexed (25.4 vs 23.4 cm3/m3), however these differences did not reach significance (p=0.053 and 0.196 respectively). Compared to normotensive women, those with HDP had higher septal (8.7 vs 7.3 p=0.014) and lateral (6.6 vs 5.4 p=0.017) E/E' ratios, indicating a trend towards diastolic dysfunction. Conclusion(s): Despite measurements falling within normal ranges, our results indicate that women with HDP have changes in cardiac structure and function that persist out to two years postpartum. Limitations exist due to incomplete follow up, leading to small sample size;this was partially due to restrictions on service provision in the context of the COVID-19 pandemic. (Table Presented).

Reintroducing rest: evaluation of a patient-guided sleep workbook in a community mental health team setting

Purpose: Sleep disturbance is a common difficulty in the general population. It has become particularly prevalent in the context of disruption to routine brought about by the COVID-19 pandemic. The purpose of this study was to trial a patient-guided “sleep workbook” intervention, which was developed by multidisciplinary team members, combining principles of sleep hygiene education and cognitive behavioural therapy for insomnia behavioural strategies, and to evaluate its efficacy in a mixed-methods study. Design/methodology/approach: Service users of the community mental health service were invited to participate. A total of 30 service users agreed to participate. A total of 15 participants completed both the intervention and the mixed-methods survey. Four participated in the focus group. Descriptive and inferential statistics were performed on the collected quantitative data. A thematic analysis was carried out of qualitative survey responses and focus group discourse. Findings: There was a statistically and clinically significant improvement in quantity and quality of sleep following intervention. Mean hours of sleep prior to the intervention was 4.4 hours [standard deviation (SD) = 2.2], compared to 6.1 hours (SD = 2.2) afterwards (p = 0.003). Quality of sleep improved from a mean of 2.5 (SD = 2.1) to 6.1 (SD = 2.3) following the intervention (p = <0.001). Four themes were developed using the qualitative data: “under-recognition of sleep difficulties”, “ruminations”, “practical utility” and “therapeutic autonomy”. Originality/value: There is a growing need for occupational therapists and clinicians to provide interventions for patients with sleep difficulties and to develop sleep management practice. This patient-guided sleep workbook may be an effective intervention for these patients. © 2022, Rebecca Conlan-Trant, Paula Connolly, Alison O’Sullivan, Anurag Nasa, Mary Sammon and Lauren Alexander.

ASSESSMENT OF AEROSOL DRUG DELIVERY DURING THE ESCALATION OF TREATMENT FOR A SIMULATED COVID-19 ADULT PATIENT

The effect of the various COVID-19 clinical interventions on aerosol delivery is not well known. This study investigated the use of a vibrating mesh nebuliser to deliver aerosolised drugs during mouthpiece-mediated aerosol drug delivery, high flow nasal therapy and invasive mechanical ventilation employing a low tidal volume ventilation strategy. Simulated adult healthy and mild adult COVID-19 breathing patterns were used for spontaneous breathing assessments. A mechanical ventilator delivered standard and low tidal volume ventilation parameters. The results presented represent the percentage drug delivered to a simulated healthy adult and mild adult COVID-19 patient during concurrent aerosol therapy during these interventions. The highest delivered drug dose was measured during mouthpiece-mediated aerosol therapy with a result of 57.93 %- 1.05 % for mild COVID-19, 56.64 %- 2.94 % for healthy, as a comparator. Use of HFNT resulted in the lowest percentage drug delivered (2.33 %- 0.99 % for 30 LPM;1.80 %- 0.61 % for 60 LPM), with no significant difference between the flow rates (p=0.6220). For mechanical ventilation, there was a significant difference in adopting a LTV ventilation strategy (13.66 %- 0.75 %) in comparison to a standard ventilation (30.34 %- 0.27 %) (p < 0.0001). It can be concluded that the choice of clinical intervention in the oxygenation and ventilatory support of the COVID-19 patient influences aerosol delivery to the lung. This variability may be significant and therefore should be noted in the design of dosing strategies, and de-risking of clinical trial programs. Key Message: The choice of clinical intervention in the oxygenation and ventilatory support of the COVID-19 patient influences aerosol delivery to the lung. This variability may be significant and therefore should be noted in the design of dosing strategies, and derisking of clinical trial programs.

Clinical Management of Patients with Schizophrenia Treated with Long-Acting Injectable Antipsychotics and Telepsychiatry Use During COVID-19 Pandemic

BACKGROUND: The COVID-19 pandemic substantially impacted care of patients with schizophrenia treated with long-acting injectable antipsychotics (LAIs). This study examined how clinics adapted operations to maintain a standard of care for these patients after pandemic onset. METHODS: Online surveys were completed in October-November 2020 by one principal investigator (PI) or PI-appointed designee at 35 clinics participating in OASIS (NCT03919994). Items concerned pandemic impacts on clinic operations, particularly telepsychiatry, and on the care of patients with schizophrenia treated with LAIs. RESULTS: All 35 clinics reported using telepsychiatry;20 (57%) implemented telepsychiatry after pandemic onset. Telepsychiatry visits increased from 12%-15% to 45%-69% across outpatient visit types after pandemic onset;frequency of no-show and/or canceled telepsychiatry visits decreased by approximately one-third. Nearly half of clinics increased the frequency of telepsychiatry visits for patients with schizophrenia treated with LAIs. Approximately one-third of participants each reported switching patients treated with LAIs to longer injection interval LAIs or to oral antipsychotics. The most common system/clinic- and patient-related barrier for telepsychiatry visits was lower reimbursement rate and access to technology/reliable internet, respectively. Almost all participants (94%) were satisfied with telepsychiatry for maintaining care of patients with schizophrenia treated with LAIs;most predicted a hybrid of telepsychiatry and office visits post-pandemic. CONCLUSIONS: Changes made by clinics after pandemic onset were viewed by almost all participants as satisfactory for maintaining a standard of care for patients with schizophrenia treated with LAIs. Most participants predicted continuing telepsychiatry to support patient care post-pandemic;equitable access to telepsychiatry will be important in this regard. FUNDING: Alkermes, Inc.

Evaluation of ventilation parameters on Aerosol delivery during mechanical Ventilation of covid-19 patients

Introduction and Objectives COVID-19 can cause serious respiratory complications. One form of treatment utilises aerosolised therapeutics concurrently with mechanical ventilation (MV). Clinicians have adopted low tidal volume ventilation (LTV) strategies (4-6 mL/kg body weight)1 in these patients. Nebuliser performance is typically characterised in accordance with international ventilatory standard ISO274272 (ISO ventilation). The objective of this study was to compare the aerosol dose delivered to a simulated adult model with either LTV ventilation or ISO ventilation settings. Methods A 2.5 ml dose of 1 mg/ml of salbutamol (GlaxoSmithKline Ltd., Ireland) was aerosolised with a vibrating mesh nebuliser (VMN) (Aerogen Ltd., Ireland) positioned on the dry side of the humidifier within a dual limb circuit (Fisher & Paykel, New Zealand) during simulated MV (Servo-I, Maquet, Sweden). Two adult breath patterns were generated: 1) ISO ventilation, Tidal Volume VT: 500 mL, Breathing Rate BR = 15 BPM, Inhalation Exhalation ratio I:E: 1:1, and 2) LTV, VT: 400 mL, BR = 20 BPM, I:E: 1:2. A capture filter (Respirgard, Baxter, Ireland) was placed between the ETT (8.0 mm, Flexicare Medical Inc., UK) and the test lung. The mass of drug was determined using UV spectrophotometry (276 nm). Results are expressed as the percentage of the nominal dose placed in the nebuliser's medication cup. All testing was performed in triplicate. Results The results of this study, presented in figure 1, highlight the difference in the aerosol dose delivered to the simulated patient at the two different ventilatory settings. Conclusions Study results confirm that a simulated adult patient undergoing MV utilising LTV ventilation strategy would receive approximately half of the aerosol dose delivered in comparison with the ISO ventilation parameters typically used in reporting nebuliser performance. These findings should provide clinicians with an approximation of the administered dose that is delivered. This may be useful when optimising aerosol dosing strategies during LTV ventilation in COVID-19 patients.

An in vitro investigation into the release of fugitive medical aerosols into the environment during manual ventilation.

BACKGROUND: During manual resuscitation, nebulizer therapy may be used to deliver therapeutics to patients in respiratory distress. However, the devices used to generate and deliver these medical aerosols have the potential to release these therapeutics into the local environment and expose caregivers to unwanted medical aerosols. AIM: To quantify the levels of fugitive medical aerosol released into the environment during aerosol drug delivery using a manual resuscitation bag with and without filtration. METHODS: Time-varying fugitive aerosol concentrations were measured using an aerodynamic particle sizer placed at a position designed to mimic a caregiver. Two nebulizer types were assessed, a vibrating mesh nebulizer and a jet nebulizer. The aerosol dose delivered to the simulated patient lung was also quantified. FINDINGS: Filtration of the exhalation port of the manual resuscitation bag was seen to reduce fugitive medical aerosols to ambient levels for both nebulizer types. The vibrating mesh nebulizer delivered the greatest quantity of aerosol to the simulated adult patient (18.44 ± 1.03% versus 3.64 ± 0.26% with a jet nebulizer). CONCLUSIONS: The results highlight the potential for exposure to fugitive medical aerosols released during the delivery of aerosol therapy with a manual resuscitation bag and also the potential for significant variation in patient lung dose depending on nebulizer type.