Integrating a nationally scaled workforce of community health workers in primary care: a modelling study.

Objective To model cost and benefit of a national community health worker workforce. Design Modelling exercise based on all general practices in England. Setting United Kingdom National Health Service Primary Care. Participants Not applicable. Data sources Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. Main outcome measures We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. Results Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. Conclusion A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure < 100 mmHg (n = 1127), estimated glomerular filtration rate < 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

Quadricuspid aortic valve with sinus of Valsalva rupture.

A 22-year-old female with no medical history presented to the emergency room with 2 weeks of rapidly worsening dyspnea on exertion, orthopnea, and cough. On cardiac auscultation, she was noted to have to-and-fro murmurs and a continuous murmur with signs of right heart failure. Echocardiographic images obtained showed moderate to severe aortic regurgitation, severe tricuspid regurgitation, and a "windsock" originating in the right coronary sinus of Valsalva and terminating in the right atrium. The aortic valve had four leaflets, with the right leaflet function compromised by the ruptured sinus, causing aortic regurgitation. The patient underwent resection of the sinus aneurysm and aortic valve replacement with a bioprosthetic valve. Quadricuspid aortic valves are uncommon and are rarely associated with sinus of Valsalva aneurysm. The prevalence in the general population, clinical progression, and prognosis of this unique congenital abnormality are reviewed

Pulmonary embolus caused by Suttonella indologenes prosthetic endocarditis in a pulmonary homograft.

A 28-year-old Cambodian man with a history of congenital heart disease presented with a 6-month history of increasing fatigue, night sweats, and weight loss. His surgical history included two Blalock-Taussig shunts, ventricular septal defect closure, and placement of a pulmonary valve conduit via a Rastelli procedure. Echocardiographic and cardiac computed tomographic studies revealed a vegetation in the pulmonary homograft. Blood cultures grew gram-negative rods that were eventually identified as Suttonella indologenes. The patient underwent a prolonged course of intravenous antibiotics, which was complicated by septic pulmonary embolism that clinically resolved. Bacterial endocarditis caused by aerobic gram-negative organisms is uncommon. The authors report the first case of S. indologenes endocarditis in a patient with complex congenital heart disease

Pulmonary embolus caused by Suttonella indologenes prosthetic endocarditis in a pulmonary homograft.

A 28-year-old Cambodian man with a history of congenital heart disease presented with a 6-month history of increasing fatigue, night sweats, and weight loss. His surgical history included two Blalock-Taussig shunts, ventricular septal defect closure, and placement of a pulmonary valve conduit via a Rastelli procedure. Echocardiographic and cardiac computed tomographic studies revealed a vegetation in the pulmonary homograft. Blood cultures grew gram-negative rods that were eventually identified as Suttonella indologenes. The patient underwent a prolonged course of intravenous antibiotics, which was complicated by septic pulmonary embolism that clinically resolved. Bacterial endocarditis caused by aerobic gram-negative organisms is uncommon. The authors report the first case of S. indologenes endocarditis in a patient with complex congenital heart disease