Digital health, cardiometabolic disease and ethnicity: an analysis of United Kingdom government policies from 2010 to 2022.

Recent health policies in the United Kingdom (UK) and internationally have focussed on digitisation of healthcare. We examined UK policies for evidence of government action addressing health inequalities and digital health, using cardiometabolic disease as an exemplar. Using a systematic search methodology, we identified 87 relevant policy documents published between 2010 and 2022. We found increasing emphasis on digital health, including for prevention, diagnosis and management of cardiometabolic disease. Several policies also focused on tackling health inequalities and improving digital access. The COVID-19 pandemic amplified inequalities. No policies addressed ethnic inequalities in digital health for cardiometabolic disease, despite high prevalence in minority ethnic communities. Our findings suggest that creating opportunities for digital inclusion and reduce longer-term health inequalities, will require future policies to focus on: the heterogeneity of ethnic groups; cross-sectoral disadvantages which contribute to disease burden and digital accessibility; and disease-specific interventions which lend themselves to culturally tailored solutions.

Ethnic health inequalities in the NHS

Improvement is urgently required "from board to ward”

Speaker Gender Representation at the North American Neuromodulation Society Annual Meeting (2017-2021): Have We Made Progress in Closing the Gender Gap?

Background: Speaker gender representation at medical conferences is a significant site of gender disparity. Our primary objective was to quantify the proportion of female speakers and compare plenary session opportunities by gender at the North American Neuromodulation Society (NANS) Annual Conference. Methods: Data from the 2017-2021 NANS Annual Conference presentations were abstracted. Primary outcomes included gender composition of speaker slots, gender composition of individual speakers, and comparison of plenary speaker slots by gender. Secondary outcomes included comparisons of session size, age, professional degree, and number of presentations per speaker based on gender. Results: Gender composition of annual speaker slots was (% slots presented by women): 2017:14.6%; 2018:20.5%; 2019:23.5%; 2020:21.0%; 2021:41.4%. Annual gender composition of individual speakers was (% women): 2017:18.7%; 2018:20.6%; 2019:24.6%; 2020:24.9%; 2021:33.8%. Of all speaker slots, the percentage of plenary slots did not differ based on gender, with 11.4% presented by female speakers versus 11.2% presented by male speakers (OR 1.0, 95% CI 0.7-1.5, P=0.893). Compared to male speaker slots, there was an association of lower age (43.9±5.6 vs 50.8±8.9, P<0.001), lower odds of holding a single doctorate degree (OR 0.3, 95% CI 0.2-0.5, P<0.001), and lower odds of holding a dual MD/PhD or DO/PhD degree (OR 0.3, 95% CI 0.1-0.5, P<0.001) in female speaker slots. Compared to male speakers, there was an association of higher number of presentations per female speaker at the 2021 NANS Annual Meeting (2.48±1.60 vs 1.79±1.30, P=0.008). Conclusion: Although the volume of female speaker slots and individual speakers trailed behind their male counterparts, female speaker representation steadily increased at each subsequent annual NANS meeting. We identified no difference in plenary session slots based on gender.

Frameworks for Implementation, Uptake, and Use of Cardiometabolic Disease-Related Digital Health Interventions in Ethnic Minority Populations: Scoping Review.

BACKGROUND: Digital health interventions have become increasingly common across health care, both before and during the COVID-19 pandemic. Health inequalities, particularly with respect to ethnicity, may not be considered in frameworks that address the implementation of digital health interventions. We considered frameworks to include any models, theories, or taxonomies that describe or predict implementation, uptake, and use of digital health interventions. OBJECTIVE: We aimed to assess how health inequalities are addressed in frameworks relevant to the implementation, uptake, and use of digital health interventions; health and ethnic inequalities; and interventions for cardiometabolic disease. METHODS: SCOPUS, PubMed, EMBASE, Google Scholar, and gray literature were searched to identify papers on frameworks relevant to the implementation, uptake, and use of digital health interventions; ethnically or culturally diverse populations and health inequalities; and interventions for cardiometabolic disease. We assessed the extent to which frameworks address health inequalities, specifically ethnic inequalities; explored how they were addressed; and developed recommendations for good practice. RESULTS: Of 58 relevant papers, 22 (38%) included frameworks that referred to health inequalities. Inequalities were conceptualized as society-level, system-level, intervention-level, and individual. Only 5 frameworks considered all levels. Three frameworks considered how digital health interventions might interact with or exacerbate existing health inequalities, and 3 considered the process of health technology implementation, uptake, and use and suggested opportunities to improve equity in digital health. When ethnicity was considered, it was often within the broader concepts of social determinants of health. Only 3 frameworks explicitly addressed ethnicity: one focused on culturally tailoring digital health interventions, and 2 were applied to management of cardiometabolic disease. CONCLUSIONS: Existing frameworks evaluate implementation, uptake, and use of digital health interventions, but to consider factors related to ethnicity, it is necessary to look across frameworks. We have developed a visual guide of the key constructs across the 4 potential levels of action for digital health inequalities, which can be used to support future research and inform digital health policies.

Hyperbaric oxygen therapy for the treatment of long COVID: early evaluation of a highly promising intervention.

BACKGROUND: Long COVID is a common occurrence following COVID-19 infection. The most common symptom reported is fatigue. Limited interventional treatment options exist. We report the first evaluation of hyperbaric oxygen therapy (HBOT) for long COVID treatment. METHODS: A total of 10 consecutive patients received 10 sessions of HBOT to 2.4 atmospheres over 12 days. Each treatment session lasted 105 minutes, consisting of three 30-minute exposures to 100% oxygen, interspersed with 5-minute air breaks. Validated fatigue and cognitive scoring assessments were performed at day 1 and 10. Statistical analysis was with Wilcoxon signed-rank testing reported alongside effect sizes. RESULTS: HBOT yielded a statistically significant improvement in the Chalder fatigue scale (p=0.0059; d=1.75 (very large)), global cognition (p=0.0137; d=-1.07 (large)), executive function (p=0.0039; d=-1.06 (large)), attention (p=0.0020; d=-1.2 (very large)), information processing (p=0.0059; d=-1.25 (very large)) and verbal function (p=0.0098; d=-0.92 (large)). CONCLUSION: Long COVID-related fatigue can be debilitating, and may affect young people who were previously in economic employment. The results presented here suggest potential benefits of HBOT, with statistically significant results following 10 sessions.

Reflective practice in nursing: A concept analysis.

PURPOSE: This paper aims to clarify the concept of reflective practice in nursing by using Rodgers' evolutionary method of concept analysis. DATA SOURCES: Literature and references on the concept of reflective practice were obtained from two databases: Scopus and Nursing and Allied health database. Peer-reviewed articles published in English language between 2011-2021 that included the terms 'reflection' and/or 'reflective practice' in the title were selected. Seminal pieces of work were also considered in this analysis. A total of 23 works were included. Most of the selected works addressed the concept of reflective practice in nursing education or nursing practice. DATA SYNTHESIS: The data analysis integrated the stages identified in Rodgers' method of concept analysis to analyze the concept of reflective practice. Analysis of selected works provided an understanding of common surrogates, antecedents, attributes, and consequences of the concept of reflective practice. CONCLUSIONS: Reflective practice is a cognitive skill that demands conscious effort to look at a situation with an awareness of own beliefs, values, and practice enabling nurses to learn from experiences, incorporate that learning in improving patient care outcomes. It also leads to knowledge development in nursing. Considering the current circumstances of the COVID-19 pandemic, this paper identifies the need for nurses to go beyond reflection-on-action and also include reflection-in-action and reflection-for-action as part of their practice. IMPLICATIONS FOR NURSING PRACTICE: This analysis identifies the need for future nursing researchers to develop reflective models or strategies that promote reflection among nurses and nursing students before, during, and after the clinical experiences.

Safety and feasibility of trans-venous cardiac device extraction using conscious sedation alone-Implications for the post-COVID-19 era.

BACKGROUND: Transvenous lead extraction (TLE) for implantable cardiac-devices is traditionally performed under general anesthesia (GA). This can lead to greater risk of exposure to COVID-19, longer recovery-times and increased procedural-costs. We report the feasibility/safety of TLE using conscious-sedation alone with immediate GA/cardiac-surgery back-up if needed. METHODS: Retrospective case-series of consecutive TLEs performed using conscious-sedation alone between March 2016 and December 2019. All were performed in the electrophysiology-laboratory using intravenous Fentanyl, Midazolam/Diazepam with a stepwise approach using locking-stylets/cutting-sheaths, including mechanical-sheaths. Baseline patient-characteristics, procedural-details and TLE outcomes (including procedure-related complications/death) were recorded. RESULTS: A total of 130 leads were targeted in 54 patients, mean age ± SD 74.6 ± 11.8years, 47(87%) males; dual-chamber pacemakers (n = 26; 48%), cardiac resynchronization therapy-defibrillators (n = 17; 31%) and defibrillators (n = 8; 15%) were commonest extracted devices. Mean ± SD/median (range) lead-dwell times were 11.0 ± 8.8/8.3 (0.3-37) years, respectively. Extraction indications included systemic infection (n = 23; 43%) and lead/pulse-generator erosion (n = 27; 50%); mean 2.1 ± 2.0 leads were removed per procedure/mean procedure-time was 100 ± 54 min. Local anesthetic (LA) was used for all (mean-dose: 33 ± 8 ml 1% lidocaine), IV drug-doses used (mean ± SD) were: midazolam: 3.95 ± 2.44 mg, diazepam: 4.69 ± 0.89 mg and fentanyl: 57 ± 40 µg. Complete lead-extraction was achieved in 110 (85%) leads, partial lead-extraction (<4 cm-fragment remaining) in 5 (4%) leads. Sedation-related hypotension requiring IV fluids occurred in 2 (managed without adverse-consequences) and hypoxia requiring additional airway-management in none. No procedural deaths occurred, one patient required emergency cardiac surgery for localized ventricular perforation, nine had minor complications (transient hypotension/bradycardia/pericardial effusion not requiring intervention). CONCLUSION: TLE undertaken using LA/conscious-sedation was safe/feasible in our series and associated with good clinical outcome/low procedural complications. Reduced risk of aerosolization of COVID-19 and quicker patient recovery/reduced anesthetic risk are potential benefits that warrant further study.

Healthcare Staff Perceptions Following Inoculation with the BNT162b2 mRNA COVID-19 Vaccine at University Hospitals Coventry & Warwickshire NHS Trust.

Background: COVID-19 vaccination programmes offer hope for a potential end to the acute phase of the COVID-19 pandemic. We present perceptions following from a cohort of healthcare staff at the UK NHS hospital, which first initiated the BNT162b2 mRNA COVID-19 ("Pfizer") vaccination program. Methods: A paper-based survey regarding perceptions on the BNT162b2 mRNA COVID-19 vaccine was distributed to all healthcare workers at the University Hospitals Coventry & Warwickshire NHS Trust following receipt of the first vaccine dose. Results: 535 healthcare workers completed the survey, with a 40.9% response rate. Staff felt privileged to receive a COVID-19 vaccine. Staff reported that they had minimised contact with patients with confirmed or suspected COVID-19. Reported changes to activity following vaccination both at work and outside work were guarded. Statistically significant differences were noted between information sources used by staff groups and between groups of different ethnic backgrounds to inform decisions to receive vaccination. Conclusions: NHS staff felt privileged to receive the COVID-19 vaccine, and felt that their actions would promote uptake in the wider population. Concerns regarding risks and side effects existed, but were minimal. This research can be used to help inform strategies driving wider vaccine uptake amongst healthcare staff and the public.

Introduction of a novel COVID-19 biomarker panel by coventry and warwickshire pathology services (CWPS)

COVID-19 is heterogeneous in presentation, with cough, fever, dyspnoea and in some cases, acute respiratory distress syndrome documented. Confidence in the interpretation of clinical symptoms and management of patients can be enhanced with the use of biomarkers and could provide clinicians with a tool to predict prognosis and mortality, allowing for earlier interventions and optimal resource allocation.In March 2020, clinicians approached CWPS requesting the provision of biomarkers, as highlighted in early publications. The aim of this change was to improve the clinical management of patients, remove the need for referral laboratory testing and ensure swift translation of recent evidence into clinical practice. Cost, method availability, IT requirements, assay verification, sample needs and appropriate testing were all considered when extending the scope of service. Continued dialogue with those leading the local COVID clinical pathway ensured the change was clinically supported and that testing was incorporated into the trust ward management strategies.Royal College of Pathology guidelines later published in April 2020 supported the service change and literature reviews continue to highlight the role of inflammatory markers for patient stratification;with a recent systematic review finding some of the included biomarkers increased in more severe infections. The Association of Clinical Biochemistry have also made a statement encouraging this type of innovation, utilising both scientific and medical staff in the improvement of patient care.In collaboration with statisticians from local universities, biomarker data is being interrogated so that any findings may be translated into practice. Currently, multiple regression analysis has allowed the creation of models to explain association of analytes with outcomes and it is hoped continued work will allow the creation of decisions trees and clinical reference values.

Understanding the lived experience of redeployed consultant physicians in the COVID-19 pandemic: essential information for leaders of future pandemics and emergencies

A key challenge early in the COVID-19 pandemic was to identify staff able to meet the demand for senior medical assessment of an influx of acutely unwell respiratory patients. At UHCW we proposed that specialist physicians without recent general medicine experience could be safely and effectively redeployed to support the acute medical take.A rota of consultant physicians from 8 medical specialties, who did not participate in the acute medical take, was developed at pace to work alongside the medical registrar, in the segregated respiratory area of ED, following limited training. Two shifts were implemented within 6 days of inception, fitted around doctors’ ongoing specialty roles.We gained feedback iteratively during the early phases. We then used a survey of all those asked to redeploy to explore their lived experiences and perceptions, with a 71% response rate.Median time since consultants had participated in an unselected medical take was 12 years. 66% were not GIM accredited. 84% found the online training useful. Many had concerns regarding availability of PPE and the risk of passing infection on to others, including their own vulnerable patients. 81% described concerns around personal competence.63% of respondents felt this redeployment had made a positive difference to the COVID-19 response. However, 57% felt other groups should have been redeployed before them, and 45% reported they would not agree to be redeployed in a repeat scenario. Transparency regarding who was redeployed and equity amongst all physicians were the most important factors influencing decisions on future redeployment.We rapidly implemented a consultant redeployment programme during the pandemic, and redeployed doctors felt they made a positive difference. However, the same staff group may not willingly be redeployed during any future emergency. We hope this open and honest approach to collecting feedback will help to shape local and national planning for future major incidents

Increasing adiposity and the presence of cardiometabolic morbidity is associated with increased Covid-19-related mortality: results from the UK Biobank.

BACKGROUND: Although obesity, defined by body mass index (BMI), has been associated with a higher risk of hospitalisation and more severe course of illness in Covid-19 positive patients amongst the British population, it is unclear if this translates into increased mortality. Furthermore, given that BMI is an insensitive indicator of adiposity, the effect of adipose volume on Covid-19 outcomes is also unknown. METHODS: We used the UK Biobank repository, which contains clinical and anthropometric data and is linked to Public Health England Covid-19 healthcare records, to address our research question. We performed age- and sex- adjusted logistic regression and Chi-squared test to compute the odds for Covid-19-related mortality as a consequence of increasing BMI, and other more sensitive indices of adiposity such as waist:hip ratio (WHR) and percent body fat, as well as concomitant cardiometabolic illness. RESULTS: 13,502 participants were tested for Covid-19 (mean age 70 ± 8 years, 48.9% male). 1582 tested positive (mean age 68 ± 9 years, 52.8% male), of which 305 died (mean age 75 ± 6 years, 65.5% male). Increasing adiposity was associated with higher odds for Covid-19-related mortality. For every unit increase in BMI, WHR and body fat, the odds of death amongst Covid19-positive participants increased by 1.04 (95% CI 1.01-1.07), 10.71 (95% CI 1.57-73.06) and 1.03 (95% CI 1.01-1.05), respectively (all p < 0.05). Referenced to Covid-19 positive participants with a normal weight (BMI 18.5-25 kg/m2), Covid-19 positive participants with BMI > 35 kg/m2 had significantly higher odds of Covid-19-related death (OR 1.70, 95% CI 1.06-2.74, p < 0.05). Covid-19-positive participants with metabolic (diabetes, hypertension, dyslipidaemia) or cardiovascular morbidity (atrial fibrillation, angina) also had higher odds of death. CONCLUSIONS: Anthropometric indices that are more sensitive to adipose volume and its distribution than BMI, as well as concurrent cardiometabolic illness, are associated with higher odds of Covid-19-related mortality amongst the UK Biobank cohort that tested positive for the infection. These results suggest adipose volume may contribute to adverse Covid-19-related outcomes associated with obesity.

Differential perceptions regarding personal protective equipment use during the COVID-19 pandemic by NHS healthcare professionals based on ethnicity, sex and professional experience.

OBJECTIVES: To capture perceptions regarding personal protective equipment (PPE) among healthcare professionals during the COVID-19 pandemic, including staff subgroups at high risk for severe COVID-19, such as black and minority ethnic (BAME) groups. DESIGN: Electronically distributed survey with semi-quantitative analysis. Survey distributed at a major academic NHS tertiary referral centre in the West Midlands with a diverse medical workforce to medically qualified staff who completed COVID-19 redeployment training. (N=121; 47% female; 49% of BAME background; 26% international medical graduates). RESULTS: All demographic groups reported overall good awareness of when and how to use PPE during COVID-19 pandemic. Statistically significant differences in the perceptions regarding PPE use during COVID-19 were noted between BAME vs non-BAME staff, international vs UK medical graduates, and male vs female participants, as well as between professionals at different stages of their career. The differences related to perceptions around availability, degree of protection provided, perceived inconvenience, ability to raise concerns about availability, confidence in sharing underlying health conditions with managers and the impact of full PPE in emergency situations causing delay patient care. CONCLUSIONS: Amongst medically qualified staff, significant differences exist in the perceptions relating to the, availability and effectiveness of PPE during the COVID-19 pandemic depending on country of training, ethnic background and sex. GAFREC STUDY APPROVAL: Study ID GF0392.

Rising to the challenge: Qualitative assessment of medical student perceptions responding to the COVID-19 pandemic.

BACKGROUND: Medical students internationally have volunteered and stepped up to support frontline clinical teams during the COVID-19 pandemic. We know very little about the motivation of those volunteering, or their concerns in deploying to a new role. We aim to establish the reasons that medical students volunteered in one Trust and understand to their concerns. METHODS: Structured survey, thematic analysis and categorisation of volunteer student perceptions. RESULTS: Medical students volunteered for broadly four reasons: to make a contribution, to learn, to benefit from remuneration and for an activity during the national lockdown. There were disparate concerns; however, the most common involved availability of personal protective equipment, uncertainty as to expectations and becoming infected. CONCLUSIONS: We must recognise and applaud the motivations of our future workforce who have stepped up to support the NHS at a time of unprecedented demand. The experiences and learning gained during this period will undoubtedly shape their future medical training and careers.