Short-Term Outcomes in Elderly Patients with SARS-CoV-2 Infections Discharged from Community Hospitals

open access journalIntroduction: Clinical outcomes from very elderly hospitalised patients with SARS-COV-2 (Covid-19), are poor, with a reported in-patient mortality as high as 20%. Age, sex, comorbidities, ethnicity and deprivation have all been shown to correlate with worse outcomes in patients with Covid-19, however the outcomes of elderly hospitalised patients once discharged remains unknown. We looked at our cohort of very elderly patients treated within community hospital settings. Methods & Results: A retrospective case note analysis was undertaken within our 222 bedded community hospital structure during the first wave of the pandemic from April to August 2020. A total of 129 patients were treated during this period. The average age of the patients was 78.8 ± 2.7 years. In patient mortality was 11% (14 patients). 83% of patients were discharged from the hospitals. 27% were discharged to care home facilities. At 90 days, 83% of patients were still alive but a third of these patients were re-admitted into hospital with various different diagnoses. Conclusion: Elderly patients who survived Covid-19 infection and left hospital have a relatively high mortality rate in the short-term. Also connected with this is a high morbidity rate and therefore care must be directed within primary care to ensure that this group stay out of hospital

Vitamin B12 Deficiency and Hyperhomocysteinemia in Outpatients with Stroke or Transient Ischemic Attack: a cohort study at an academic medical centre

Objective We sought to assess the current magnitude of the opportunity for secondary stroke prevention with B vitamins. Design A cohort study. Setting The Urgent TIA (Transient Ischaemic Attack) Clinic at an academic medical centre. Main outcome measures We assessed the prevalence of biochemical vitamin B 12 deficiency (B 12 Def, serum B 12 \u3c156 pmol/L), hyperhomocysteinaemia (HHcy; plasma total homocysteine [tHcy] \u3e14 μmol/L) and metabolic B 12 deficiency (MetB 12 Def, serum B 12 \u3c258 pmol/L and HHcy) between 2002 and 2017, by age group and by stroke subtype. Results Data were available in 4055 patients. B 12 Def was present in 8.2% of patients overall; it declined from 10.9% of patients referred before 2009 to 5.4% thereafter (p=0.0001). MetB 12 Def was present in 10.6% of patients, and HHcy was present in 19.1% of patients. Among the patients aged ≥80 years, MetB 12 Def was present in 18.1% and HHcy in 35%. Among the 3410 patients whose stroke subtype was determined, HHcy was present in 18.4% of patients: 23.3% of large artery atherosclerosis, 18.1% of cardioembolic, 16.3% of small vessel disease, 10.8% of other unusual aetiologies and 13.6% of undetermined subtypes (p=0.0001). Conclusions Despite a decline in our referral area since 2009, B 12 Def, MetB 12 Def and HHcy remain common in patients with stroke/TIA. Because these conditions are easily treated and have serious consequences, all patients with stroke/TIA should have their serum B 12 and tHcy measured

Distinct Effects of Blood Flow and Temperature on Cutaneous Microvascular Adaptation

Aims: We performed two experiments to determine whether cutaneous microvascular adaptations in response to repeated core temperature elevation are mediated by increases in skin temperature, and/or, skin blood flow. Methods: Healthy subjects participated for 8-weeks in thrice-weekly bouts of 30mins lower limb heating (40°C). In Study 1, both forearms were “clamped” at basal skin temperature throughout each heating bout (n=9). Study 2 involved identical lower limb heating, with the forearms under ambient conditions (unclamped, n=10). In both studies, a cuff was inflated around one forearm during the heating bouts to assess the contribution of skin blood flow and temperature responses. We assessed forearm skin blood flow responses to both lower limb (systemic reflex) heating, and to local heating of the forearm skin, pre and post intervention. Results: Acutely, lower limb heating increased core temperature (Study 1: +0.63±0.15°C, Study 2: +0.69±0.19°C, P<0.001) and forearm skin blood flow (Study 1: 10±3 vs 125±44, Study 2: 16±9 vs 136±41 PU, P<0.001), with skin responses significantly attenuated in the cuffed forearm (P<0.01). Skin blood flow responses to local heating decreased in Study 1 (clamped forearms, week 0vs8: 1.46±0.52 vs 0.99±0.44 CVC, P<0.05), whereas increases occurred in Study 2 (unclamped; week 0vs8: 1.89±0.57 vs 2.27±0.52 CVC, P<0.05). Cuff placement abolished local adaptations in both studies. Conclusion: Our results indicate that repeated increases in skin blood flow and skin temperature result in increased skin flux responses to local heating, whereas repeated increases in skin blood flow in the absence of change in skin temperature induced the opposite response. Repeated increases in core temperature induce intrinsic microvascular changes, the nature of which are dependent upon both skin blood flow and skin temperature

Left ventricular morphology and function in adolescents: Relations to fitness and fatness.

BACKGROUND: Obesity in childhood predisposes individuals to cardiovascular disease and increased risk of premature all-cause mortality. The aim of this study was to determine differences in LV morphology and function in obese and normal-weight adolescents. Furthermore, relationships between LV outcomes, cardiorespiratory fitness (CRF) and adiposity were explored. METHODS: LV morphology was assessed using magnetic resonance imaging (MRI) in 20 adolescents (11 normal-weight [BMI equivalent to 18kg/m(2)-25kg/m(2)] and 9 obese [BMI equivalent to ≥30kg/m(2)]); 13.3±1.1years, 45% female, Tanner puberty stage 3 [2-4]) using magnetic resonance imaging (MRI). Global longitudinal strain (GLS), strain rate (SR) and traditional echocardiographic indices were used to assess LV function. CRF (peak oxygen consumption), percent body fat (dual-energy x-ray absorptiometry), abdominal adipose tissue (MRI), and blood biochemistry markers were also evaluated. RESULTS: Adolescents with obesity showed significantly poorer LV function compared to normal-weight adolescents (P0.05). Moderate to strong associations between myocardial contractility and relaxation, adiposity, arterial blood pressure and cardiorespiratory fitness were noted (r=0.49-0.71, P<0.05). CONCLUSION: Obesity in adolescence is associated with altered LV systolic and diastolic function. The notable relationship between LV function, CRF and adiposity highlights the potential utility of multidisciplinary lifestyle interventions to treat diminished LV function in this population. CLINICAL TRIAL REGISTRATION: NCT01991106

Repeat controlled human malaria infection of healthy UK adults with blood-stage plasmodium falciparum:Safety and parasite growth dynamics

In endemic settings it is known that natural malaria immunity is gradually acquired following repeated exposures. Here we sought to assess whether similar acquisition of blood-stage malaria immunity would occur following repeated parasite exposure by controlled human malaria infection (CHMI). We report the findings of repeat homologous blood-stage Plasmodium falciparum (3D7 clone) CHMI studies VAC063C (ClinicalTrials.gov NCT03906474) and VAC063 (ClinicalTrials.gov NCT02927145). In total, 24 healthy, unvaccinated, malaria-naïve UK adult participants underwent primary CHMI followed by drug treatment. Ten of these then underwent secondary CHMI in the same manner, and then six of these underwent a final tertiary CHMI. As with primary CHMI, malaria symptoms were common following secondary and tertiary infection, however, most resolved within a few days of treatment and there were no long term sequelae or serious adverse events related to CHMI. Despite detectable induction and boosting of anti-merozoite serum IgG antibody responses following each round of CHMI, there was no clear evidence of anti-parasite immunity (manifest as reduced parasite growth in vivo) conferred by repeated challenge with the homologous parasite in the majority of volunteers. However, three volunteers showed some variation in parasite growth dynamics in vivo following repeat CHMI that were either modest or short-lived. We also observed no major differences in clinical symptoms or laboratory markers of infection across the primary, secondary and tertiary challenges. However, there was a trend to more severe pyrexia after primary CHMI and the absence of a detectable transaminitis post-treatment following secondary and tertiary infection. We hypothesize that this could represent the initial induction of clinical immunity. Repeat homologous blood-stage CHMI is thus safe and provides a model with the potential to further the understanding of naturally acquired immunity to blood-stage infection in a highly controlled setting. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, identifier NCT03906474, NCT02927145

Ethical Considerations for the Clinical Oncologist in an Era of Oncology Drug Shortages

Shortages of injectable drugs affect many cancer patients and providers in the U.S. today. Scholars and policymakers have recently begun to devote increased attention to these issues, but only a few tangible resources exist to guide clinical oncologists in developing strategies for dealing with drug shortages on a recurring basis. This article discusses existing information from the scholarly literature, policy analyses, and other relevant sources and seeks to provide practical ethical guidance to the broad audience of oncology professionals who are increasingly confronted with such cases in their practice. We begin by providing a brief overview of the history, causes, and regulatory context of oncology drug shortages in the U.S., followed by a discussion of ethical frameworks that have been proposed in this setting. We conclude with practical recommendations for ethical professional behavior in these increasingly common and challenging situations