England must aim for “zero tolerance” to avoid 27 000 predicted deaths, experts say #covid19rftlks

The UK government should take a “zero tolerance” approach to covid-19 to prevent thousands more deaths, a group of experts from across England, Scotland, Wales and Ireland have warned | via BMJ | 2020; 370: m2749 

The panel, which included members from the Independent Scientific Advisory Group for Emergencies (iSAGE), the former health secretary for England, Jeremy Hunt, and advisers from across the nations, met to discuss a covid-19 elimination strategy. They raised concerns over the number of covid-19 deaths occurring in England and the government’s lack of a policy to reduce deaths.

Given that currently more than 100 people are dying each day, iSAGE estimated that this would mean around 27 000 deaths in England by March 2021, even without a second wave. “It is the view of Independent SAGE that a death toll from covid-19 of this magnitude is not only preventable but is absolutely unacceptable,” the group said. “The UK government must fundamentally change its approach.”

Full detail: England must aim for “zero tolerance” to avoid 27 000 predicted deaths, experts say

See also: Zero COVID-UK: Why is England not pursuing an elimination strategy? | The Independent SAGE Report 7

Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK #covid19rftlks

The Lancet Child & adolescent Health | 9th July 2020

In April, 2020, clinicians in the UK observed a cluster of children with unexplained inflammation requiring admission to paediatric intensive care units (PICUs).

This paper aims to describe the clinical characteristics, course, management, and outcomes of patients admitted to PICUs with this condition, which is now known as paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS).

Full document: Intensive care admissions of children with paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the UK: a multicentre observational study.

COVID-19: Digestive symptoms in COVID-19 patients with mild disease #covid19rftlks

Han C, Duan C, Zhang S, et al. (2020)| Digestive symptoms in COVID-19 patients with mild disease severity: clinical presentation, stool viral RNA testing, and outcomes| Am J Gastroenterol. 2020;115(6):916-923. 2020

Bottom Line

Among a group of hospitalised patients with low severity COVID-19, digestive symptoms were present in 57%. Patients with digestive symptoms were more likely to be fecal virus-positive than those with respiratory symptoms.

Evidence Summary

206 hospitalised patients diagnosed with low severity COVID-19 were identified, 117 of these presented with digestive symptoms.

Within the 117 experiencing digestive symptoms,

  • 48 presented with a digestive symptom alone,
  • 69 with both digestive and respiratory symptoms,
  • 67 presented with diarrhoea, of whom 19.4% experienced diarrhoea as the first symptom in their illness course.

Diarrhoea lasted from 1 to 14 days, with an average duration of 5.4 days and a frequency of 4.3 bowel movements per day.

Concurrent fever was found in 62% of the patients with a digestive symptom. Patients with digestive symptoms presented for care later than those with respiratory symptoms (16.0 ± 7.7 vs 11.6 ± 5.1 days, P < 0.001).

Patients with digestive symptoms had a longer duration between symptom onset and viral clearance (P < 0.001) and were more likely to be fecal virus-positive (73.3% vs 14.3%, P = 0.033) than those with respiratory symptoms.

What did they do?

The researchers identified COVID-19 patients with mild disease and one or more digestive symptoms (diarrhoea, nausea, and vomiting), with or without respiratory symptoms,

These COVID-19 cases were compared with a group presenting solely with respiratory symptoms.  Patients were clinically followed up until they tested negative for COVID-19 on at least two sequential respiratory tract specimens collected ≥24 hours apart.

Clinical features between those with digestive symptoms and those with respiratory symptoms were compared.

Full review from CEBM

Major study into long-term health effects of COVID-19 launched in the UK #covid19rftlks

The Health and Social Care Secretary has announced the launch of a major £8.4 million research study into the long-term health effects of COVID-19 on hospitalised patients, which has been funded by the NIHR and UK Research and Innovation | National Institute for Health Research

The researchers hope their findings will support the search for treatments for COVID-19 and the development of care pathways that will help patients recover as fully as possible after having experienced the disease.

Symptoms of COVID-19 have varied among those who have tested positive: some have displayed no symptoms, while others have developed severe pneumonia and, tragically, have even lost their lives.

For those who were hospitalised and have since been discharged, it is not yet clear what their medical, psychological and rehabilitation needs will be to enable them to make as full a recovery as possible.

The Post-Hospitalisation COVID-19 Study (PHOSP-COVID), led by the NIHR Leicester Biomedical Research Centre, will draw on expertise from a consortium of leading researchers and doctors from across the UK to assess the impact of COVID-19 on patient health and recovery.

This includes looking at possible ways to help improve the mental health of patients hospitalised with coronavirus, and how individual characteristics influence recovery, such as gender or ethnicity.

Full detail: Major study into long-term health effects of COVID-19 launched in the UK

The divergence of mental health experiences during the pandemic #covid19rftlks

via Mental Health Foundation 

This briefing reports findings from the Coronavirus: Mental Health in the Pandemic study as of the fifth wave of data collection carried out between 18th and 22nd June. The study is led by the Mental Health Foundation, in collaboration with the University of Cambridge, Swansea University, the University of Strathclyde and Queen’s University Belfast.

While most people will exit the pandemic with good mental health, the findings of the study clearly suggest that the benefits of exiting the lockdown measures will not be enjoyed equally by all.

Divergence of experience presents a big policy challenge as there are many different groups, areas, impacts and experiences to consider. This huge variety of individual and group identities is difficult to capture in research and it is challenging to produce nuanced policy recommendations that recognise all these different experiences and their effects.  A recovery response needs to take a holistic approach that addresses social, systemic and structural inequalities rather than placing the onus on the individual.

Full detail: Coronavirus: The divergence of mental health experiences during the pandemic

BMJ: Complete protection from covid-19 is possible for health workers #covid19rftlks

Complete protection from covid-19 is possible for health workers

An editorial published in the BMJ:

All they need is the right protective equipment

At the start of the new coronavirus epidemic in Wuhan, healthcare workers were insufficiently protected because of lack of awareness of the emergence of a novel infectious disease. As recognition increased of the contagiousness of what was to be named covid-19, the strains on the medical system quickly became overwhelming, and initial shortages of personal protective equipment (PPE) continued to contribute to a substantially increased risk of infection among healthcare workers. Multifaceted efforts, which included increased production and reallocation of PPE, rigorous contact tracing and quarantine measures, as well as moving healthcare workers from other parts of China to the epicentre, may all have contributed to reducing the risk for healthcare workers and curbing the epidemic in Hubei province.

In a recent BMJ study Liu and colleagues found that none of 420 doctors and nurses reallocated to frontline work at Wuhan hospitals from 24 January to 7 April 2020 contracted covid-19. The staff received training in proper use of PPE before their assignment and were provided with “appropriate PPE,” which included protective suits, isolation gowns, gloves, face shields or goggles, hair covers, boots, and shoe covers as well as N95 respirators or surgical masks (both being used at the same time during aerosol generating procedures). Their main role was to care for critically ill patients with covid-19 in intensive care units, and they all participated in aerosol generating procedures. Lack of transmission of SARS-CoV-2 to healthcare workers was determined by the absence of covid-19 symptoms, repeated negative SARS-CoV-2 polymerase chain reaction test results on return from Wuhan, and serological testing.

The authors’ findings are encouraging, and in line with a recent preprint study from Hefei and Wuhan that also reported that none of 426 frontline healthcare workers provided with appropriate access to PPE contracted covid-19. These studies underscore that adequate training and uninterrupted availability of sufficient, adequate PPE protects healthcare workers from harm, and such provision remains critical to their safety during a pandemic likely to continue for the foreseeable future.

Evidence based requirements

But what is appropriate PPE? Although it is paramount that PPE recommendations are not influenced by availability, recommending “everything always” may not improve the outcomes—infection control guidelines must be based on evidence and proper risk assessments. Transmission of SARS-CoV-2 was initially thought to be mainly airborne. Fear evoked by the death of whistle blower ophthalmologist Li Wenliang, and reports of high mortality among healthcare workers, combined with experiences from the SARS-CoV-1 epidemic, contributed to initial recommendations for maximum protection.

We now have reasonable evidence that, in accordance with WHO guidelines, droplet and contact precautions provided by a surgical face mask, eye protection, a gown, and gloves offer adequate protection in most circumstances when caring for patients with covid-19.Airborne transmission is considered rare, though some official guidelines have kept a cautious approach.

The recommendation to use airborne precautions during aerosol generating procedures is universal, however, even though defining the procedures likely to create infectious aerosols is based mostly on observations from the SARS-CoV-1 epidemic.10 Importantly, differences in transmission dynamics between SARS-CoV-2 and SARS-CoV-1 make direct extrapolation between the two unwise. While SARS-CoV-1 transmission peaked at the time of hospital admission, viral shedding of SARS-CoV-2 may peak around the time of symptom onset and even before.1112 As hospital admissions for covid-19 often occur a week or more after symptom onset (when recovery of viable virus is becoming more difficult), hospital patients, and specifically those with prolonged disease in intensive care units, may not be the most infectious individuals. Where adequate PPE is available, the risk of transmission from patients to healthcare workers is therefore low, despite variations in the definition of what is appropriate.

Unprotected close contact with presymptomatic or mildly symptomatic patients or colleagues with unrecognised covid-19 may confer greater risk. Social distancing, a generic message in guidelines for the public, is not always achievable in a hospital. Apart from providing training in proper use of, and robust access to, appropriate PPE, implementing control measures to prevent spread of infection between healthcare workers may increase safety even further.

Current infection control guidelines seem to provide a “better safe than sorry” approach to PPE, although details may be adjusted as new evidence emerges. National authorities must make sure that durable supplies of PPE are available so that healthcare workers can abide by the guidelines. The international community must focus its efforts on supporting faltering healthcare systems, to make sure that adequate PPE is available for health workers in low and middle income countries who otherwise face a particularly high risk (Source: BMJ)

Sheffield Teaching Hospitals & Sheffield University research suggests IVF ‘scratch’ offers no benefit to women undergoing IVF for the first time

NIHR | July 2020 | New Sheffield Teaching Hospitals & Sheffield University research suggests IVF ‘scratch’ offers no benefit to women undergoing IVF for the first time

New NIHR-funded research has shown that women undergoing IVF for the first time did not benefit from having an endometrial scratch prior to IVF treatment.

An endometrial scratch is a simple procedure undertaken before IVF or ICSI treatment. It involves a clinician placing a small tube about the size of a small straw through the neck of the womb and gently scratching the lining in the hope of making the womb more receptive to embryo fertilisation.

The findings of the £1.2m UK Multicentre Endometrial Scratch Randomised Trial, found no statistical difference in live birth and pregnancy rates in a large number of women who were offered the procedure prior to having their main IVF treatment.

The large randomised study was led by Sheffield Teaching Hospitals NHS Foundation Trust and the University of Sheffield and was run across 16 UK fertility centres. During 2016 to 2019, 1048 women under the age of 38 and having their first cycle of IVF or ICSI took part in the study. Women taking part were randomly allocated to receive either the endometrial scratch (523 women) or no scratch prior to the start of their main treatment (525 women).

Results showed that live birth rates were similar in women who received the scratch (38.6%) and in those who did not (37.1%), Similarly, there was no statistical difference in pregnancy rates with 42.6% of women who had the scratch achieving a pregnancy and 40.6% in those who did not have the scratch.

Mr Mostafa Metwally, a Consultant Gynaecologist and Sub-Specialist in Reproductive Medicine and Surgery at Sheffield Teaching Hospitals NHS Foundation Trust who led the trial, said: “Our ‘gold standard’ study set out to determine whether the endometrial scratch should be routinely offered to women as an additional treatment prior to IVF. By comparing the effectiveness of the treatment in a large group of women in similar circumstances, we aimed to provide robust evidence for women undergoing IVF or ICSI for the first time about the benefits of having the endometrial scratch before their treatment.

“These findings are definitive and can help women to make more informed decisions about their treatment. A review of the practice of offering women and endometrial scratch prior to first time IVF or ICSI should now be made.”

Professor Andy Shennan, Professor of Obstetrics, and Clinical Director NIHR Clinical Research Network South London, said: “This important study, funded by the NIHR HTA Programme, provides high quality evidence that a commonly used procedure in assisting infertility treatment is not necessary. Many procedures are routinely adopted in this area, with little evidence, and it is essential to prove efficacy before this happens. The results are welcomed and this paves the way for more research in infertility treatments.”  (Source: NIHR)

New research suggests IVF ‘scratch’ offers no benefit to women undergoing IVF for the first time

Sheffield Teaching Hospitals’ news release New research findings show no benefit of IVF ‘scratch’ in women undergoing IVF for the first time

Leeds Teaching Hospital: COVID-19 patient rehabilitation booklet @rotherham_ahps

Leeds Teaching Hospital| July 2020| COVID-19 patient rehabilitation booklet

A group of Allied Health Professionals from Leeds Teaching Hospital came together to develop some original work done by the Liverpool Heart and Chest Hospital into a “COVID-19 patient rehabilitation booklet”. (NHS Networks)

Image source:

The booklet provides patients and their families information on all aspects of the COVID rehabilitation process, including breathing, exercise, diet, swallowing and speech, fatigue and post-traumatic stress.

COVID-19 patient rehabilitation booklet

NIHR: Combined drug and psychological therapies may be most effective for depression

NIHR | July 2020 | Combined drug and psychological therapies may be most effective for depression

The most effective treatment for adults with moderate depression is likely to be a combination of antidepressant drugs and psychological interventions. A new summary provides the strongest evidence to date that the combination of treatments work better than either alone.

The most recent advice from National Institute for Health and Care Excellence (NICE) comes in a clinical knowledge summary (March 2020). It suggests low-intensity psychosocial interventions such as self-help, computerised cognitive behavioural therapy (CBT), or group exercise programmes for mild to moderate depression. Routine use of antidepressants is not suggested for this group. The combination of drug and high intensity psychological therapy is reserved for those with severe depression.

Routine use of combination treatment will require increased access to psychological therapies, including computerised and group CBT as well as individual treatment.

What’s the issue?

There is clear evidence that drug-based and psychological therapies are effective treatments for depression. How these therapies compare with each other, alone or in combination, is less clear. Previous studies suggested the combination might be more effective than either alone but were not conclusive.

Combination treatment is likely to be more expensive to deliver than a single treatment. Psychological therapies are more expensive than drug treatments. Commissioners need good evidence if they are to fund psychological therapies and combination treatment. This study was designed to give more precise estimates of how effective each treatment is, to allow treatments to be ranked.

What’s new?

This meta-analysis included 101 trials, with 11,910 participants. The most commonly used psychotherapy was CBT, and the most commonly used group of drugs were the selective serotonin reuptake inhibitors (SSRIs).

The researchers considered that patients had responded to therapy if their symptoms of depression were reduced by half. They found that patients receiving combination psychological and drug therapy were most likely to respond. They were:

  • 27% more likely to respond than those receiving psychotherapy alone
  • 25% more likely to respond than those receiving drug treatment alone

There were no significant differences in response rates between psychotherapy alone and drug treatment.

Treatment acceptability was based on the number of patients who dropped out of studies. The study found that:

  • combined treatment was 23% more acceptable than drug treatment alone
  • psychological therapy alone was 17% more acceptable than drug treatment alone
  • combined treatment and psychological therapy alone were equally as acceptable

Combination treatment was superior overall for both moderate and severe depression. There were too few studies to calculate the effectiveness of these treatments on mild depression.

Why is this important?

This research suggests that, for people with moderate depression, combination treatment should be offered before antidepressants alone. Where a single treatment is chosen, the results suggest that psychological treatment is more acceptable to patients than drug treatment.

The added benefit of combined treatment is greatest for those with the highest chance of responding to either therapy alone. When considering treatment options, patient preferences, individual circumstances, and treatment history also need to be taken into account.

What’s next?

New NICE guidelines on depression in adults are planned. The existing NICE guidelines, published in 2009, recommend a stepped-care model for those with mild to moderate depression. Either psychological therapy or antidepressant drugs were offered only after earlier steps have been exhausted.

The recent NICE clinical knowledge summary (March 2020) recommends low-intensity psychosocial therapies in newly-diagnosed mild-to-moderate depression. Routine use of antidepressants is not recommended for mild-to-moderate depression unless people have a history of the condition, persistent symptoms, or another ongoing physical health problem. Combination therapy with an antidepressant and a high-intensity psychological intervention is reserved for those with severe depression.

Further research needs to focus on long-term results. Most studies included in this meta-analysis lasted eight to 16 weeks, which is not long enough to consider relapse rates. Further analysis could identify the specific groups likely to benefit from one or another treatment approach.

Source: NIHR

British Geriatrics Society: Capturing beneficial change from the Covid-19 pandemic: response from the British Geriatrics Society #covid19rftlks

British Geriatrics Society| July 2020| Capturing beneficial change from the Covid-19 pandemic: response from the British Geriatrics Society

The COVID-19 pandemic has disproportionately affected older people – around half of diagnoses have been in people aged over 65 and nearly 90% of deaths have been in that age group. As such, our members have been at the forefront of this pandemic, working in acute, primary and community care with older people who have COVID-19 and continuing to help people without COVID-19 to manage their long-term conditions and
remain healthy. They have implemented changes to practice to enable them to continue to provide high quality care to their patients while ensuring that they and their patients are protected from the risk of contracting COVID-19. Many of these changes have shown better ways of working and our members believe they should be retained and shared more widely as we move out of the pandemic.

Through our Special Interest Groups and communications with our members, we asked for examples of beneficial changes to practice that members have implemented during the pandemic. Members were asked to complete a form stating what the innovation was, the difference it made to staff, patients and carers and what they would do differently if doing it again. The responses received were analysed by BGS staff and members and
organised into the themes provided in this report. The responses we received are from across the country and across a range of settings.
We have organised the responses we received into ten themes. For each theme we have provided a short description of the innovation, one or two examples of this innovation being implemented and a brief outline of the benefits to patients and staff. Where possible we have also added links to BGS publications and groups that support the innovation. We conclude with details of the key enablers that are present throughout the themes and detail on how these innovations can be sustained nationally to ensure that the lessons learned in the pandemic are not lost (Source: British Geriatrics Society)

Further details from the British Geriatrics Society