New cardiogenic shock service to help save lives

 

Clinicians at Royal Brompton and Harefield hospitals (RB&HH) have developed a programme to improve the survival of patients with cardiogenic (heart) shock. This is the first comprehensive cardiogenic shock service in the UK.

Cardiogenic shock is a life-threatening condition, where the heart is unable to pump a sufficient amount of blood around the body, leading to progressive and rapid failure of all the organs, and is associated with a high risk of death. The condition is most often caused by a severe heart attack and is currently the most common reason people die after suffering a heart attack, but a number of other conditions can also cause cardiogenic shock. If it is recognized early enough, appropriate specialist intervention significantly increases the chances of survival. If not, patients can deteriorate very rapidly and may not survive.

Cardiogenic shock affects an estimated 10,000¹ people of all ages each year in the UK. Currently, there is no dedicated national pathway in the UK for cardiogenic shock patients. However, this new programme developed by the teams at RB&HH means that specialist expertise and technology is immediately available to patients no matter where they are, across the UK.

The RB&HH Shock Programme consists of two main components. First, if cardiogenic shock is suspected, clinicians around the country can access expert advice on treatment from RB&HH’s Shock Team, including advice on the need for highly specialist treatments that are only available at a few hospitals. This input comes through an emergency virtual multidisciplinary team meeting, linking experts from RB&HH to the treating clinicians at remote centers, enabling review of diagnostic tests and facilitating optimal decision-making at the earliest possible stage.

Second, in circumstances where highly specialist treatment is required, the RB&HH Shock Team deploy their rapid response vehicle to wherever their specialist expertise is needed in order to institute highly specialist life-saving support to stabilize the patient and bring them safely to a specialist hospital for ongoing treatment.

Professor Susanna Price, consultant cardiologist and intensivist and lead for the service, said: “Cardiogenic shock represents one of the most critical cardiac conditions, and demands some of the most complex interventions within cardiology and cardiac intensive care. As specialist heart hospitals, we recognized the role we could play together in improving immediate access to specialist knowledge in this area, and so provide a service that would benefit the diagnosis and management of patients with cardiogenic shock.

“Royal Brompton and Harefield hospitals are uniquely placed to be able to offer this service as we have all the required expertise to provide assessment and management for the full range of complex cardiac conditions up to and including congenital heart disease, inherited cardiac conditions, heart disease in pregnancy, and cardiac transplantation. This, together with our long history in provision of extracorporeal mechanical circulatory support means we can provide the full range of acute and advanced cardiac interventions that a cardiogenic shock patient may need to survive. All of this expertise in one place is rare, so we saw an opportunity to build on existing pathways, rapidly convening experts from multiple teams to work with referring clinicians in order to help as many patients as possible across the country.”

David Randall’s wife, Christina, suffered from cardiogenic shock in February this year. Moments after a planned caesarian section at Watford General Hospital, Christina’s heart failed due to an amniotic fluid embolism, a rare but serious condition where the amniotic fluid that surrounds a baby in the womb during pregnancy enters the mother's bloodstream. Royal Brompton’s Shock Team retrieved her from Watford and took her back to Royal Brompton Hospital where she was placed on extracorporeal membrane oxygenation (ECMO), a life-support machine that takes over the function of the heart and lungs by pumping oxygenated blood around the body while a patient recovers.

David said: “I was still holding Christina’s hand after the baby was delivered, when she turned to me and said she couldn’t breathe. Watford said they would need to move her to Royal Brompton, but that she might not survive the journey. When I heard that, my world crumbled. People always tell me it’s a miracle Christina survived, but it’s definitely not. It’s thanks to the experts at Royal Brompton, and for Watford for knowing who to call when it happened, that she survived. I was so grateful when she was home with me and the kids after just two weeks.”

Dr Vasileios Panoulas, Harefield consultant cardiologist and interventional lead for the programme, said: “Cardiogenic shock patients are some of the sickest patients in the country, so it is fantastic that we are able to offer this vital service by collaborating with colleagues around the UK. This is just one of the great examples of how Royal Brompton and Harefield combine their specialist expertise to improve the outcomes of these truly sick patients.”

New review highlights impact on cardiovascular system

 

The wide-ranging effects of Long COVID and the associated issues for healthcare providers have been revealed in a new review of the major studies into the condition, co-authored by a consultant cardiologist at Royal Brompton and Harefield hospitals.

Published in the European Heart Journal, the review specifically highlights the impact of Long COVID on the cardiovascular system. 

According to one of its co-authors, Professor Thomas Lüscher, Director of Research, Education and Development at Royal Brompton and Harefield Clinical Group, this is “the first review to summarize the diverse evidence on Long COVID and provide a balanced picture of this important issue.”

Professor Lüscher said: “The pandemic brought not only acute illness and death, it became a chronic disease of many organs, not just the lungs, but the heart, brain and kidney, among others.”

“Long COVID is, besides its huge impact for the affected individual, of great societal and economic importance as it leads to leave of absence from work, reduced work performance and hence unforeseen costs.”

The review was conducted by researchers from the University of Oxford, the University of Wisconsin School of Medicine and Public Health, Royal Brompton Hospital and Imperial College, London, and the University of Zurich, Switzerland.

The review spans each step from a patient’s original coronavirus infection and the direct impacts, such as myocardial infarction or inflammatory myocarditis, to the long-term impacts on aspects of wellbeing such as mental health and fatigue.

The researchers also concluded that current evidence for the treatment of Long COVID is lacking and that our current understanding of pathophysiological mechanisms and treatment options remains limited. They also found that the vast inequalities in healthcare provision exposed by COVID-19 continue to be magnified by Long COVID, a problem that calls for global humanitarian efforts to promote and fund equitable access to healthcare, social and welfare support and vaccines across the world.

Dr Betty Raman, of Oxford’s Radcliffe Department of Medicine, said: “Long COVID is emerging as a major public health issue, which makes it important that we better understand the long-term effects of COVID-19 to improve our treatment of it.

“This review highlights the wide range of short and long-term health impacts and the mechanisms behind them, which is key to providing treatment and ongoing care.”

Professor Stefan Neubauer, Head of the Division of Cardiovascular Medicine, Radcliffe Department of Medicine, said: “Long COVID is a huge medical challenge. This review gives a comprehensive update on its effect on the cardiovascular system and will also be important in guiding future research into the condition and for finding new treatments.”

Dr Betty Raman is leading one of the first randomized, double-blind, placebo-controlled studies in the UK. The team’s work is supported by the NIHR Oxford Biomedical Research Centre, a partnership between Oxford University Hospitals NHS Foundation Trust and the University of Oxford. Other trials to date have been open-label or non-random assignment of therapy. 

Screen Time in First Year May Raise Autism Risk at Age 3

 

Boys exposed to at least 2 hours a day of screen time by 1 year of age were significantly more likely to have an autism spectrum disorder (ASD) diagnosis at 3 years, based on data from more than 80,000 children.

The World Health Organization and the American Academy of Pediatrics recommend against any screen time for infants up to 1 year of age and 18 months of age, respectively, wrote Megumi Kushima, MA, of the University of Yamanashi (Japan), and colleagues on behalf of the Japan Environment and Children's Study Group.

The extent to which screen time duration in infancy is associated with subsequent ASD diagnosis remains unclear, the researchers said. The ongoing COVID-19 pandemic has increased screen time among children worldwide, which makes an examination of the impact of screen time on children's health an important public health issue.

In a study published in JAMA Pediatrics, the researchers recruited pregnant women between 2011 and 2014; data were analyzed in December 2020. The final study population included 84,030 mother-child pairs. The primary exposure of screen time at 1 year of age was assessed by questionnaire, in which mothers were asked to report their number of hours they let their child watch TV or DVDs daily. Responses were none (no screen time), less than 1 hour, 1 hour or more but less than 2 hours, 2 hours or more but less than 4 hours, and 4 hours or more.

The primary outcome was ASD diagnosis at 3 years of age, and mothers were asked via questionnaire whether their 3-year-old had been diagnosed with ASD from age 2.

The study was conducted by the Japan Environment and Children's Study Group at 15 regional centers across Japan.

Overall, 330 children had received an ASD diagnosis at age 3 years, a prevalence of 0.4%. Of these, 251 (76%) were boys, and 79 (24%) were girls. Independent of ASD, the most common response for screen time was less than 1 hour, which was reported by 27,707 mothers. The proportion of children with ASD at age 3 increased as screen time at age 1 increased, the percentages were 5.8%, 22.3%, 30.2%, and 31.7% for children with no screen time, less than 1 hour, 1 to less than 2 hours, and 2 to less than 4 hours, respectively. The percentage of children with ASD diagnoses who had 4 hours or more of daily screen time was 10%.

Logistic regression analysis showed that longer screen time at age 1 year was significantly associated with higher odds of ASD at 3 years in boys, but not in girls. The researchers controlled for variables including maternal maltreatment and children's predisposition to ASD. Among boys, the adjusted odds ratios for screen times of less than 1 hour, 1 hour to less than 2 hours, 2 hours to less than 4 hours, and more than 4 hours.

 

Screen time at age 3 years was not associated with ASD diagnosis at age 3 years, potentially "because the association with environmental factors on brain development varies with age," the researchers noted.

The study findings were limited by several factors including the reliance on parental reports of screen time and potential for reporting bias, the researchers noted. Other limitations included the possible missed diagnoses of mild ASD cases at 3 years, and the inability to consider variables such as childcare environment, living conditions, diseases, genetics, and disabilities.

 

However, the results were strengthened by the large study population and examination of screen time in early childhood, they said. More research is needed to examine other factors that contribute to the association between ASD and screen time but given the rapid increase in device use in children, "it is necessary to review its health effects on infants and control excessive screen time."