Disconnected during disruption: Energy insecurity of Indigenous Australian prepay customers during the COVID-19 pandemic

Energy policy measures aimed at mitigating the impacts of energy insecurity during the first years of the COVID-19 pandemic, such as moratoriums on disconnection from electricity, were widespread. In Australia, early pandemic safeguards against electricity disconnection were successful in temporarily protecting most people. However, their application was uneven. For remote-living Indigenous community residents, who are required by policy or elect to use prepay metering and are known to experience frequent ‘self-disconnection', energy insecurity continued as the impacts of the pandemic accrued. The risks associated with the regular de-energization of prepay households have long been overlooked by government reporting and this contributed to a lack of visibility of energy insecurity and available protections for this group during the pandemic response. In contrast to the rest of Australia, energy insecurity in the form of disconnections remained unrelentingly high or worsened for prepay households during this time. COVID-19 magnifies pre-existing health and socio-economic inequities. There is a need to pay closer attention to the rationales and impacts of energy policy exceptionalism if we are to mitigate the potential for compounding impacts of energy insecurity among specific groups, such as Indigenous Australian prepay customers, including during times of crisis. © 2023 The Authors

Extracorporeal support of the respiratory system

Extracorporeal membrane oxygenation (ECMO) support of the respiratory system has undergone significant evolution over the past decade. Historically used as rescue therapy, the treatment is now being utilized earlier in the disease course, and its indications for use expanded. The coronavirus disease (COVID-19) pandemic has further increased the experience of ECMO centres and expanded the body of evidence. This article will review the physiology of veno-venous (V-V) ECMO, con-trol of oxygenation and carbon dioxide, principal equipment, patient se-lection and timing, complications and weaning from V-V ECMO.

Multidisciplinary Care of Pediatric Disroders of Gut-Brain Interaction in the Era of Telemedicine: Equal Patient Satisfaction and Outcomems of in-Person Vs Telemedicine Encounters

Background: Patients with Disorders of Gut-Brain Interaction (DGBI) respond best to multidisciplinary treatment. With the emergence of the Coronavirus disease 2019 (COVID-19) pandemic in 2020 and the implemented lockdown in large areas of the United States, the multidisciplinary functional abdominal pain program (FAPP) at Boston Children's Hospital for the first time switched to providing care via telemedicine. We aimed to evaluate patient satisfaction and outcomes of patients seen in a multidisciplinary telemedicine visit compared to in-person care at the time of initial evaluation and follow-up. Method(s): Prospective study in which families were given a questionnaire to evaluate the visit and treatment (satisfaction, improvement overall, of abdominal pain (Abdominal Pain Index, API) and of daily functioning (Functional Disability Index, FDI) since initial visit in the FAPP. Patients <= 18 years seen for an initial visit in the FAPP between 4/1/20 and 6/20/21 were recruited. Multidisciplinary evaluation was performed in-person or via zoom (Gastroenterology, Pain medicine, Psychology, Social services, Dietician). Initially all visits were done via telemedicine (4/1/20-7/1/2020) due to the temporary closure of outpatient clinics. Thereafter, in-person visits restarted but telemedicine visits were continued to be offered. Result(s): Patient population: 41 patients completed the study. Two groups were defined based on initial visit type: Group A (Gr-A = Telemedicine, n=26) and group B (Gr-B = in-person, n=15). For Gr-A, follow-up visits were via telemedicine (n=17), in-person (n=2) and 7 patients had no follow-up. For Gr-B, the follow-up visits were via telemedicine (n=9), in-person (n=4) and 2 patients had no follow up visit. Mean age of participants was 14.5+/-2.8 years with female predominance (73.2%). No significant difference was found in age, gender, race, DGBI diagnosis, presence of extra-intestinal symptoms, number of follow-up visits, baseline API or FDI between groups. Patient satisfaction with multidisciplinary care at initial visit (Figure 1): No significant differences were detected between Gr-A and Gr-B (p>0.05). Patient visit type preference: Families preferred in-person visits (73%) for the first visit, but telemedicine (46%) or no preference (47%) for follow-up visits. When asked if patients were equally satisfied with telemedicine and in-person visits, 81.9% agreed, 9.1% were undecided and 9.1% disagreed. 81.9% were not worried about somethinig being missed during the telemedicine visit, while18.2% were undecided about this. When asked if patients felt telemedicine was more efficient than in-person visits, 54.6% agreed, 27.3% were undecided and 45.5% disagreed. 90.9% of patients agreed that telemedicine visits were more convenient, where 9.1% were undecided. Patient outcomes: There was no clinically significant improvement of the API score in either group (Gr-A: 2.7+/-0.8 to 2.4+/-1.1, p=0.04;Gr-B: 2.6+/-0.9 to 2.4+/-1.0, p=0.5) or FDI (Gr-A: 13.4+/-11.2 to 13.9+/-10.5,p=0.8, Gr-B: 15.4+/-10.7 to 14.3+/-8.0, p=0.8) between the initial and follow-up visit. When asked how patients felt subjectively at the time of study, there was improvement but no difference between groups: Much better (Gr-A: 52.6% vs Gr-B: 84.6%), Better (Gr-A: 47.4% vs Gr-B: 15.4% ), no patients in either group reported feeling worse (p=0.07). Subjective improvement of functioning was reported in Gr-A: 58.5% fair to excellent, 29.4% poor and 11.8% none, whereas in Gr-B 58.3% felt fair to excellent improvement of functioning and 41.7% continued to function poorly (p=0.4). Conclusion(s): Patients are equally satisfied with delivery of multidisciplinary care for pediatric DGBI via telemedicine and in-person, suggesting this may be a promising route for expanding delivery of care even in the post-pandemic era. Limitations of this study are the small sample size. Further the lock-down promoted lack of functioning and measures of disability such as the FDI may not be representative.

MANAGEMENT OF REFRACTORY SYMPTOMATIC PREMATURE VENTRICULAR CONTRACTIONS IN A PATIENT WITH LOUIS-DIETZ SYNDROME TYPE 3, EHLERS-DANLOS SYNDROME, AND SYSTEMIC LUPUS ERYTHEMATOSUS

Background: Louis-Dietz syndrome (LDS) Type 3 is a rare disorder caused by an autosomal-dominant mutation in SMAD-3, altering the TGF-β pathway. LDS Type 3 typically manifests as aortic aneurysms and early-onset osteoarthritis, however other dermatologic, cardiovascular, and skeletal abnormalities have been reported. Case: A 51-year-old woman was referred to the cardiology clinic for episodes of palpitations, syncope, chest pain, and shortness of breath during the COVID-19 pandemic. She had a history of congestive heart failure, cardiomyopathy, patent foramen ovale, atrial septal aneurysm, pre-COVID myocarditis, mitral valve prolapse, mitral regurgitation, and pericarditis. She also has a pertinent medical history of hypermobile Ehlers-Danlos syndrome (hEDS) and systemic lupus erythematosus (SLE). Her family and social history were remarkable for a daughter with SLE. Cardiopulmonary and general physical exams were remarkable for hypermobility. Evaluation with an ECG and Holter monitor showed normal sinus rhythm with unifocal premature ventricular contractions (PVCs) that correlated with her symptoms. Decision-making: The patient was initially managed un-successfully with beta and calcium channel blockers. Cardiac ablation was subsequently performed on a left ventricular septal focus with remote magnetic navigation using the Niobe system from Stereotaxis inc. (due to its low risk for cardiac perforation). At 6 months follow up, the patient exhibited an increase in left ventricular ejection fraction from 40-50% to 55-60%, fewer symptoms, and fewer PVCs. She was later diagnosed with a right internal carotid artery aneurysm that prompted genetic testing that was positive for LDS Type 3. Conclusion: This patient’s unique combination of illnesses required a multidisciplinary team for management. The Stereotaxis robotic system safely and successfully treated the patient’s PVCs and resulted in improvement of left ventricular function. Due to previous reports of arrhythmias associated with these connective tissue disorders, additional studies are necessary to understand the role of the SMAD-3 mutation, EDS, and SLE in contributing to arrhythmogenicity.

THE MANAGEMENT AND SCREENING OF FAMILIAL ARRHYTHMOGENIC CARDIOMYOPATHY

Background: Arrhythmogenic cardiomyopathy (ACM) is a hereditary condition associated with VT and sudden cardiac death (SCD). Currently, only 50% of individuals diagnosed with ACM have identifiable gene variants. Case: A 55-year-old woman presented with rapid palpitations, and recurrent syncope and presyncope. Her past medical history included Ehlers-Danlos syndrome and spontaneous carotid artery dissection. Her family history included MI in her father and cardiac disorders - including SCD - in many non-first-degree relatives. Her ECG revealed sinus rhythm with RBBB and LAFB. Decision-making: Our team performed an EP study in which atrial fibrillation and two beats of AVNRT were induced, and an ILR was implanted. A 28 beat run of symptomatic VT at 166 bpm was detected during the COVID-19 pandemic when elective procedures were suspended. This prompted the use of a wearable defibrillator to prevent SCD. When elective procedures resumed, the patient underwent CTA (negative) and cardiac MRI revealing localized RV apical free wall akinesia and mild RV enlargement. The Mount Sinai Morningside EP team concluded the patient met the task force criteria for ACM (class IIa per HRS consensus) and recommended the use of an ICD which was implanted two days later. Additionally, genetic testing was performed and was negative for identifiable gene variants (Invitae Arrhythmogenic Cardiomyopathy Panel). Her three daughters also underwent EP studies and ILR implantations as a result of rSR’ patterns seen on their ECGs. The eldest daughter had 6 beats of VT and a cardiac MRI found diffuse cardiomyopathy (but not ACM), the youngest had SVT but no ACM, and the middle daughter had no arrhythmia/ACM. Workup and management are in progress and involve the same approach received by the incident patient. Conclusion: This case demonstrates that during a pandemic lockdown wearable defibrillators can be used as an effective bridge to definitive treatment of VT. It also illustrates that additional ACM gene mutations have yet to be discovered since a genetic component is likely involved in this pedigree. Close follow-up with the cardiac team will ensure safe and effective management of this potentially lethal, but treatable condition.

Acute, non-COVID related medical admissions during the first wave of COVID-19: A retrospective comparison of changing patterns of disease.

COVID-19 may have altered the case-mix of non-COVID acute medical admissions. Retrospective analysis of acute medical admissions to University Hospitals Birmingham NHS Foundation Trust, showed that medical admissions decreased in April 2020 compared to April 2019. The proportion of young adults, non-cardiac chest pain, musculoskeletal conditions and self-discharges decreased. The proportion of admissions due to alcohol misuse, psychiatric conditions, overdoses and falls increased. There were a higher number of patients admitted to ICU and greater inpatient mortality but not once COVID diagnoses were excluded. There was a significant change in hospitalised case-mix with conditions potentially reflecting social isolation increasing and diagnoses which rarely require hospital treatment, reducing. This analysis will help inform service planning.