Transvenous phrenic nerve stimulation to treat central sleep apnoea in patients with heart failure may improve sleep, quality of life, and symptoms.

AIMS: Sleep disorder breathing is an important non-cardiovascular comorbidity in patients with heart failure (HF). However, central sleep apnoea (CSA) remains poorly diagnosed and treated. This post hoc analysis examined symptoms and quality of life in patients with CSA and HF following 12 months of transvenous phrenic nerve stimulation (TPNS) therapy. METHODS AND RESULTS: Patients enrolled in the remede System Pivotal trial were invited to complete self-reported questionnaires. Symptoms and responses to three validated questionnaires were examined. Percentage of patients noting an impairment was calculated at baseline. At 12 months, % of patients experiencing improvement, no change, or worsening was calculated. Shifts from symptom presence at baseline to absence at 12 months were assessed for those symptoms experienced by ≥50% of patients at baseline. Seventy-five patients were included. Most frequently reported symptoms were fatigue and daytime sleepiness. Following 12 months of TPNS, a variety of subjective improvements were observed; 45% of patients indicating cessation of daytime sleepiness, 44% cessation of fatigue/weakness, and 52% no longer having difficulty falling/staying asleep. Specific questions related to tiredness/fatigue, motivation, and chance of dozing provided an insight into potential areas of improvement. Furthermore, at least 60% of patients reported resolution of insomnia/fragmented sleep and snoring on therapy. CONCLUSION: Adult patients with CSA and HF experience distressing symptoms and limitations. Transvenous phrenic nerve stimulation was found to improve many of these. Awareness of key symptoms or limitations patients experience can be used to inform the development of a CSA-specific patient questionnaire to identify CSA sooner and aid treatment decisions.

The Muslim football player and Ramadan: current challenges.

Islam is a monotheistic Abrahamic faith characterised by devotional orthopraxy. The actions expected of followers of Islam are closely prescribed in the Qur'an. Muslims understand Ramadan as a mandatory requirement, excused only in the event of illness, infirmity or extremes of age. Due to the increasing popularity of football among Muslims, more and more Muslim football players of all levels make the decision to follow the Ramadan fast while they need to practise and compete. Sports medicine clinicians and scientists have the responsibility to provide them with the knowledge and evidence on how exactly Ramadan fasting impacts on their performance and how to optimise their eating, drinking and sleeping in order to minimise negative effects of their religious practice, should any have been demonstrated. The first International Federation of Football Associations (FIFA) Medical Assessment and Research Centre (F-MARC) study concluded that biochemical, nutritional, subjective well-being and performance variables were not adversely affected in young male national level players who followed Ramadan fasting in a controlled environment. Match performance was however not measured and the study did not include elite level players, leading to the Ramadan consensus meeting in order to answer the remaining questions. The conclusions and recommendations published in this supplement suggest that the best coping strategies will remain individual - as is the choice to fast.

The cancellation of mass gatherings (MGs)? Decision making in the time of COVID-19.

Our recommendation, as experts who have monitored health hazards at the Hajj for over 15 years, especially if the situation with COVID-19 continues to escalate globally is that Hajj 2020 will be at risk of being suspended and a means for Muslims to fulfill their rights in the future either personally or even by proxy need to be announced. The same holds true for the Summer 2020 Olympics in Japan and for many other MGs and large gatherings. Decisions in the time of COVID-19 will be closely followed and will be a blueprint for other mass gatherings.

All Hands on Deck: A synchronized whole-of-world approach for COVID-19 mitigation.

The COVID-19 pandemic can no longer be mitigated by a nationwide approach of individual nations alone. Given its scale and accelerating expansion, COVID-19 requires a coordinated and simultaneous Whole- of-World approach that galvanizes clear global leadership and solidarity from all governments of the world. Considering an 'all hands-on deck' concept, we present a comprehensive list of tools and entities responsible for enabling them, as well a conceptual framework to achieve the maximum impact. The list is drawn from pandemic mitigation tools developed in response to past outbreaks including influenza, coronaviruses, and Ebola, and includes tools to minimize transmission in various settings including person-to-person, crowd, funerals, travel, workplace, and events and gatherings including business, social and religious venues. Included are the roles of individuals, communities, government and other sectors such as school systems, health, institutions, and business. While individuals and communities have significant responsibilities to prevent person-to-person transmission, other entities can play a significant role to enable individuals and communities to make use of the tools. Historic and current data indicate the role of political will, whole-of-government approach, and the role of early introduction of mitigation measures. There is also an urgent need to further elucidate the immunologic mechanisms underlying the epidemiological characteristics such as the low disease burden among women, and the role of COVID-19 in inducing Kawasaki-like syndromes in children. Understanding the role of and development of anti-inflammatory strategies based on our understanding of pro-inflammatory cytokines (IL1, IL-6) is also critical. Similarly, the role of oxygen therapy as an anti-inflammatory strategy is evident and access to oxygen therapy should be prioritized to avoid the aggravation of COVID-19 infection. We highlight the need for global solidarity to share both mitigation commodities and infrastructure between countries. Given the global reach of COVID-19 and potential for repeat waves of outbreaks, we call on all countries and communities to act synergistically and emphasize the need for synchronized pan-global mitigation efforts to minimize everyone's risk, to maximize collaboration, and to commit to shared progress.

From the "Madding Crowd" to mass gatherings-religion, sport, culture and public health.

Human behavior has long engaged in collective behavior assembling in crowds. The Christian pilgrimage to the Holy Land has been recorded since the 4th century, while the Hajj, Islam's great pilgrimage, has existed for fourteen centuries, of which a body of literature devoted to the travelogues of the Hajj has been recorded for over ten centuries. Football is a sport played worldwide by more than 1.5 million teams and in 300,000 clubs. Most however play outside of the officially organized sphere: more than 4 percent of the global population plays football, including 270 million amateur players. Assembling for specific events is a uniquely human behavior, though the formal study of crowds did not begin until the mid-Twentieth Century. Today Mass Gathering Medicine focuses on the public health challenges to hosting events attended by a large enough number of people, at a specific site, for a defined period of time, likely to strain both the planning and response to the mass gathering of a community, state, or nation. All of us can recall attending a mass gathering, whether it be watching one's favorite rock group in performance or assembling for religious pilgrimage. Certainly, the event itself is transporting and transforming and the unison of behaviors and activities can be enormously enriching, uplifting and overwhelming, just as much as they may be at times dangerous and high risk. This review seeks to draw contrasts and comparisons between sporting gatherings and religious gatherings with a chief focus on Hajj, among the largest of all mass gatherings today. We will find there are some powerful similarities as well as stark differences. Each bequeaths a legacy which can inform the other and, as we make our observations, we join with you and the legions of other investigators who continue to remain fascinated and enthralled by mass gatherings which are among the most beloved and beholden events of modern humanity.

Hajj abattoirs in Makkah: risk of zoonotic infections among occupational workers.

At completion of Hajj, the Islamic pilgrimage to Makkah, pilgrims give thanks for the blessing, and acceptance, of Hajj, marking the end of the pilgrimage by sacrificing an animal and distributing the sacrificial meat to the poor. With over two million Muslims making Hajj, each Hajj, more than 1.2 million heads of cattle: sheep, goats and camels are slaughtered. Over 16 000 abattoir workers work around the clock to sacrifice and process the cattle in keeping with Islamic law and public health guidelines. Because of their proximity to high densities of cattle and cattle meat, Makkah's abattoir workers are at risk of zoonosis. This was a longitudinal study aimed at determining the risk of some zoonotic diseases among male permanent abattoir workers during Hajj. Specifically, seroprevalence of antigens for Brucella, Crimean-Congo haemorrhagic fever (CCHF), Alkhurma haemorrhagic fever (AHF) and Rift Valley Fever (RVF) were determined, among the study participants. An enrolment questionnaire, and a follow-up questionnaire, with provision of 10 mL blood for testing 2 days before intense Hajj animal exposure, up to 20 days after intense animal exposure and between 30 and 42 days after Hajj butchering exposures. While working with livestock, study participants were interrogated on hand hygiene and personal protection. Eighty male permanent abattoir workers participated in the study. Majority, 96.25% (n = 77) declared washing their hands with soap and water, most 98.75% (n = 79) never used eye protection, few occupational workers dressed in personal protective clothing or footwear. All workers tested negative for CCHF and RVF, one was positive for AHF and six for Brucella. The risk of some zoonotic infections like Brucella and AHF is low among permanent occupational workers in the slaughtering house in Makkah during Hajj 2013. No serological evidence for CCHF and RVF viruses, even though workers showed low compliance with use of personnel protective equipment.

Ventilator-associated pneumonia as a quality indicator for patient safety?

The economic and clinical burden of ventilator-associated pneumonia (VAP) is uncontested. In many hospitals, VAP surveillance is conducted to identify outbreaks and to monitor infection rates. Here, we discuss the concept of benchmarking in health care as modeled on industry, and we contribute personal arguments against considering the VAP rate as a potential candidate for benchmarking or for monitoring the quality of patient care. Accurate benchmarking of VAP rates currently seems to be unfeasible, because the patient case mix is often too diverse and complicated to be adjusted for, and diagnostic criteria and surveillance protocols vary. Thus, the risk of drawing inaccurate comparisons is high. In contrast, some risk factors for VAP are modifiable and can be monitored and used as quality indicators. Process-oriented surveillance permits bypass of case-mix and diagnostic constraints. A well-defined interhospital surveillance system is necessary to prove that interventions on procedures do really lead to a reduction of VAP rates.

Effects of common medications used for sleep disorders.

Sleep disorders are common and their diagnosis is becoming more widespread with improved awareness among clinicians and patients. The armamentarium for the pharmacologic treatment of sleep disorders is rapidly growing, demanding that clinicians be aware of their indications, adverse effects, and interactions. As disorders, such as narcolepsy, shift-work sleep disorder, and RLS are more readily identified, pharmacologic treatments for these conditions will also become more common.

Metabolic complications of obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome is a widely prevalent disorder, hallmarked by partial or total upper airway obstruction during sleep. These events fracture sleep integrity resulting in chronic partial sleep deprivation with destructive metabolic sequelae, the focus of this review.

Health risks at the Hajj.

Annually, millions of Muslims embark on a religious pilgrimage called the "Hajj" to Mecca in Saudi Arabia. The mass migration during the Hajj is unparalleled in scale, and pilgrims face numerous health hazards. The extreme congestion of people and vehicles during this time amplifies health risks, such as those from infectious diseases, that vary each year. Since the Hajj is dictated by the lunar calendar, which is shorter than the Gregorian calendar, it presents public-health policy planners with a moving target, demanding constant preparedness. We review the communicable and non-communicable hazards that pilgrims face. With the rise in global travel, preventing disease transmission has become paramount to avoid the spread of infectious diseases, including SARS (severe acute respiratory syndrome), avian influenza, and haemorrhagic fever. We examine the response of clinicians, the Saudi Ministry of Health, and Hajj authorities to these unique problems, and list health recommendations for prospective pilgrims.

The public health planners' perfect storm: Hurricane Matthew and Zika virus.

Hurricane Matthew threatened to be one of the most powerful Hurricanes to hit the United States in a century. Fortunately, it avoided making landfall on Florida, the eye of the Hurricane remaining centered 40 miles off the Florida coast. Even so it has resulted in over $7 Billion USD in damage according to initial estimates with much of the damage ongoing in severe flooding. Response to and recovery from Hurricane Matthew challenged Florida's public health services and resources just as emergency Zika-specific congressional funding to combat Zika outbreaks in Florida had become available. Hurricanes can disrupt the urban environment in a way that increases the likelihood of vector-borne illnesses and their aftermath can severely strain the very infectious disease and infection control academe needed to combat vector-borne outbreaks. This commentary attempts to examine the challenges posed by Hurricane Matthew in Florida's efforts to contain Zika.

Yellow fever from Angola and Congo: a storm gathers.

In common with Zika, Chikungunya and Dengue, Yellow Fever (YF) is an arthropod-borne flavivirus. It is transmitted between humans and from monkeys by mosquitoes of the Aedes aegypti (its principal vector), haemogogus and albopictus varieties. Three cycles of transmission may occur: urban; sylvatic; and intermediate. Recently, sub-Saharan Africa has seen the resurgence of this neglected disease. The current YF outbreak in Angola began in December 2015 in the capital Luanda and by October 2016 there had been > 4300 suspected cases, with 376 deaths (case fatality rate = 8.8%). A total of 884 were laboratory confirmed but it is likely that case numbers may be seriously underestimated. YF has subsequently quickly spread to neighbouring Congo and further afield to Kenya and also China, this being of grave concern as this was a first introduction of YF to Asia. YF has recently hit Brazil, with 555 suspected cases and 107 deaths reported by the end of January 2017. Extremely rapid unplanned urban migration in Africa by non-immune rural populations to already densely populated cities, where high densities of mosquitoes co-exist with city dwellers in makeshift flimsy accommodation, poses a ready recipe for an epidemic of massive proportion. In such conditions, with enormously strained public services existing among the most needy and vulnerable populations, mosquito control programmes are nearly impossible. YF in Congo is a tempest barely restrained. However, it is one that can be controlled by focused and committed international collaboration, by intense and united political will and by the marriage of old and trusted techniques: a vaccine almost a century old and some of the most modern technologies available to man.

Yellow fever and Hajj: with all eyes on Zika, a familiar flavivirus remains a threat.

Hajj is among the world's largest mass gatherings, drawing between 2 and 3.5 million Muslims from 183 nations annually to perform pilgrimage in Mecca, Saudi Arabia. Infectious disease outbreaks can be imported both into the Hajj population and exported internationally by returning pilgrims. The domestic Saudi population can also be at risk of outbreaks traveling amid this mass migration. With yellow fever reported for the first time in China following the infection of expatriate Chinese workers in Angola and a full blown outbreak underway in wider West Africa, the prospect of yellow fever outbreaks in Asia threatens to impact Saudi Arabia, both during and beyond the Hajj season. With global focus trained on Zika, the rising threat of yellow fever cannot be overlooked. Strategies to mitigate risk to Saudi Arabia and the global population are thereby suggested.

Travel epidemiology: the Saudi perspective.

The Kingdom of Saudi Arabia occupies four-fifths of the Arabian Peninsula, with a land area of 2 million square kilometres. Saudi Arabia holds a unique position in the Islamic world, as the custodian of the two holiest places of Islam, in Mecca and Medina. Annually, some 2 million Muslims from over 140 countries embark on Hajj. This extraordinary en masse migration is a unique forum for the study of travel epidemiology since the Hajj carries various health risks, both communicable and non-communicable, often on a colossal scale. Non-communicable hazards of the Hajj include stampede and motor vehicle trauma, fire-related burn injuries and accidental hand injury during animal slaughter. Communicable hazards in the form of outbreaks of multiple infectious diseases have been reported repeatedly, during and following the Hajj. Meningococcal meningitis, gastroenteritis, hepatitis A, B and C, and various zoonotic diseases comprise some of the possible infectious hazards at the Hajj. Many of these infectious and non-infectious hazards can be avoided or averted by adopting appropriate prophylactic measures. Physicians and health personnel must be aware of these risks to appropriately educate, immunize and prepare these travellers facing the unique epidemiological challenges of Hajj in an effort to minimize untoward effects. Travel epidemiology related to the Hajj is a new and exciting area, which offers valuable insights to the travel specialist. The sheer scale of numbers affords a rare view of migration medicine in action. As data is continually gathered and both national and international policy making is tailored to vital insights gained through travel epidemiology, the Hajj will be continually safeguarded. Practitioners will gain from findings of travel related epidemiological changes in evolution at the Hajj: the impact of vaccinating policies, infection control policies and public health are afforded a real-world laboratory setting at each annual Hajj, allowing us to learn from this unique phenomenon of migration medicine.

Guidelines for the management of community-acquired pneumonia in Saudi Arabia: a model for the Middle East region.

Worldwide, community-acquired pneumonia (CAP) is a common respiratory tract infection and is now a growing public health concern in Saudi Arabia. In an effort to simplify treatment regimens to aid the practitioner, empirical treatment guidelines for CAP have evolved across the international medical community, reducing the number of antibiotics used and improving outcomes. Saudi Arabia and the surrounding region have no such consensus guidelines and this document aims to redress this lack. The potential impacts of developing and implementing CAP treatment guidelines in Saudi Arabia, which are new to the Kingdom, will be examined. Widespread adoption of these SACAP guidelines could lead to nationwide reductions of antibiotic resistance and improvement of clinical outcomes. Ultimately, Kingdomwide uniformity of treatment algorithms provides a foundation for both database generation and valuable outcomes of research in the future.