Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices.

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries.

The 2011 UN high-level meeting on non-communicable diseases (NCDs) called for multisectoral action including with the private sector and industry. However, through the sale and promotion of tobacco, alcohol, and ultra-processed food and drink (unhealthy commodities), transnational corporations are major drivers of global epidemics of NCDs. What role then should these industries have in NCD prevention and control? We emphasise the rise in sales of these unhealthy commodities in low-income and middle-income countries, and consider the common strategies that the transnational corporations use to undermine NCD prevention and control. We assess the effectiveness of self-regulation, public-private partnerships, and public regulation models of interaction with these industries and conclude that unhealthy commodity industries should have no role in the formation of national or international NCD policy. Despite the common reliance on industry self-regulation and public-private partnerships, there is no evidence of their effectiveness or safety. Public regulation and market intervention are the only evidence-based mechanisms to prevent harm caused by the unhealthy commodity industries.

Diagnostic quality electrocardiogram from a HeartMate 3 supported patient using a smartphone-based recording device.

Patients with implantable left ventricular assist devices (LVAD) are at risk of ventricular arrhythmias but these may be hemodynamically tolerated. An electrocardiogram (ECG) is essential to determine whether an LVAD-supported patient is experiencing a ventricular arrhythmia. Access to 12 lead ECG is predominantly in healthcare facilities. Implantable LVAD also cause significant electromagnetic interference leading to artefacts on ECG. We report a patient on Heartmate 3 LVAD with a diagnostic quality 6 lead ECG obtained with an AliveCor device during an episode of sustained palpitations. The AliveCor device may be used for remote identification of ventricular arrhythmias in LVAD patients.

UN High-Level Meeting on Non-Communicable Diseases: addressing four questions.

Non-communicable diseases (NCDs), principally heart disease, stroke, cancer, diabetes, and chronic respiratory diseases, are a global crisis and require a global response. Despite the threat to human development, and the availability of affordable, cost-effective, and feasible interventions, most countries, development agencies, and foundations neglect the crisis. The UN High-Level Meeting (UN HLM) on NCDs in September, 2011, is an opportunity to stimulate a coordinated global response to NCDs that is commensurate with their health and economic burdens. To achieve the promise of the UN HLM, several questions must be addressed. In this report, we present the realities of the situation by answering four questions: is there really a global crisis of NCDs; how is NCD a development issue; are affordable and cost-effective interventions available; and do we really need high-level leadership and accountability? Action against NCDs will support other global health and development priorities. A successful outcome of the UN HLM depends on the heads of states and governments attending the meeting, and endorsing and implementing the commitments to action. Long-term success requires inspired and committed national and international leadership.

Priority actions for the non-communicable disease crisis.

The UN High-Level Meeting on Non-Communicable Diseases (NCDs) in September, 2011, is an unprecedented opportunity to create a sustained global movement against premature death and preventable morbidity and disability from NCDs, mainly heart disease, stroke, cancer, diabetes, and chronic respiratory disease. The increasing global crisis in NCDs is a barrier to development goals including poverty reduction, health equity, economic stability, and human security. The Lancet NCD Action Group and the NCD Alliance propose five overarching priority actions for the response to the crisis--leadership, prevention, treatment, international cooperation, and monitoring and accountability--and the delivery of five priority interventions--tobacco control, salt reduction, improved diets and physical activity, reduction in hazardous alcohol intake, and essential drugs and technologies. The priority interventions were chosen for their health effects, cost-effectiveness, low costs of implementation, and political and financial feasibility. The most urgent and immediate priority is tobacco control. We propose as a goal for 2040, a world essentially free from tobacco where less than 5% of people use tobacco. Implementation of the priority interventions, at an estimated global commitment of about US$9 billion per year, will bring enormous benefits to social and economic development and to the health sector. If widely adopted, these interventions will achieve the global goal of reducing NCD death rates by 2% per year, averting tens of millions of premature deaths in this decade.

Reducing health inequalities in priority public health conditions: using rapid review to develop proposals for evidence-based policy.

BACKGROUND: In November 2008, the Secretary of State for Health (England) commissioned an independent review to propose effective strategies for reducing health inequalities. Review task groups were given just 3 months to make preliminary evidence-based recommendations. In this paper, we describe the methodology used, and the recommendations made, by the group tasked with inequalities in priority public health conditions. METHODS: A series of rapid literature reviews of the policy-relevant international evidence base was undertaken. Quantitative studies of any design, which looked at the effects on health inequalities, the social gradient or overall population health effects, of interventions designed to address the social determinants of selected public health priority conditions were examined. Recommendations were distilled using a Delphi approach. RESULTS: Five key policy proposals were made: reduce smoking in the most deprived groups; improve availability of and access to healthier food choices amongst low income groups; improve the early detection and treatment of diseases; introduce a minimum price per unit for alcohol and improve the links between physical and mental health care. CONCLUSION: The combination of rapid review and Delphi distillation produced a shortlist of evidence-based recommendations within the allocated time frame. There was a dearth of robust evidence on the effectiveness and cost-effectiveness of the interventions we examined: our proposals had to be based on extrapolation from general population health effects. Extensive, specific and robust evidence is urgently needed to guide policy and programmes. In the meantime, our methodology provides a reasonably sound and pragmatic basis for evidence-based policy-making.

Improving anticoagulation of patients with an implantable left ventricular assist device.

Patients supported with implantable left ventricular assist devices (LVAD) have a significant risk of bleeding and thromboembolic complications. All patients require anticoagulation with warfarin, aiming for a target international normalised ratio (INR) of 2.5 and most patients also receive antiplatelet therapy. We found marked variation in the frequency of INR measurements and proportion of time outside the therapeutic INR range in our LVAD-supported patients. As part of a quality improvement initiative, home INR monitoring and a networked electronic database for recording INR results and treatment decisions were introduced. These changes were associated with increased frequency of INR measurement. We anticipate that changes introduced in this quality improvement project will reduce the likelihood of adverse events during long-term LVAD support.

Local action on outdoor air pollution to improve public health.

OBJECTIVES: The National Institute for Health and Care Excellence, jointly with Public Health England, have developed a guideline on outdoor air pollution and its links to health. The guideline makes recommendations on local interventions that can help improve air quality and prevent a range of adverse health outcomes associated with road-traffic-related air pollution. METHODS: The guideline was based on a rigorous assessment of the scientific evidence by an independent advisory committee, with input from public health professionals and other professional groups. The process included systematics reviews of the literature, expert testimonies and stakeholder consultation. RESULTS: The guideline includes recommendations for local planning, clean air zones, measures to reduce emissions from public sector transport services, smooth driving and speed reduction, active travel, and awareness raising. CONCLUSIONS: The guideline recommends taking a number of actions in combination, because multiple interventions, each producing a small benefit, are likely to act cumulatively to produce significant change. These actions are likely to bring multiple public health benefits, in addition to air quality improvements.

The resilience of postglacial hunter-gatherers to abrupt climate change.

Understanding the resilience of early societies to climate change is an essential part of exploring the environmental sensitivity of human populations. There is significant interest in the role of abrupt climate events as a driver of early Holocene human activity, but there are very few well-dated records directly compared with local climate archives. Here, we present evidence from the internationally important Mesolithic site of Star Carr showing occupation during the early Holocene, which is directly compared with a high-resolution palaeoclimate record from neighbouring lake beds. We show that-once established-there was intensive human activity at the site for several hundred years when the community was subject to multiple, severe, abrupt climate events that impacted air temperatures, the landscape and the ecosystem of the region. However, these results show that occupation and activity at the site persisted regardless of the environmental stresses experienced by this society. The Star Carr population displayed a high level of resilience to climate change, suggesting that postglacial populations were not necessarily held hostage to the flickering switch of climate change. Instead, we show that local, intrinsic changes in the wetland environment were more significant in determining human activity than the large-scale abrupt early Holocene climate events.

Thoratec implantable ventricular assist device: the Papworth experience.

OBJECTIVE: The Thoratec (Thoratec Corp, Pleasanton, Calif) implantable ventricular assist device (IVAD) can be used for univentricular or biventricular support. The objective of this study is to review the 5-year experience of bridging patients to heart transplantation with this device in a single center. Surgical aspects, including hybrid pump pocket, double tunneling of driveline, and optimal cannulae placement, are discussed. METHODS: This is a retrospective review of 24 patients treated between January 2002 and December 2007. Nineteen patients (79.1%) received a single implantable ventricular assist device as left ventricular assist devices, and 5 patients (21.9%) received 2 implantable ventricular assist devices as biventricular assist devices. The devices were implanted in pre-peritoneal/posterior rectus hybrid pump pockets. The driveline was passed through a 2-stage double-tunnel to exit onto the lateral chest wall. Patients were anticoagulated with Warfarin aiming for an international normalized ratio of 2.0 to 3.0. RESULTS: Twenty male and 4 female patients with a mean age of 39.8 years (17-57 years) and a body surface area of 1.87 m(2) (1.63-2.2 m(2)) were supported for a total of 2308 patient-days. Mean duration of support was 96 days (10-301 days). The cause of heart failure was dilated cardiomyopathy in 18 patients and ischemic cardiomyopathy in 6 patients. Preoperatively, 23 patients were receiving inotropes, 12 patients required intra-aortic balloon pump support, 5 patients were intubated and mechanically ventilated, and 3 patients required continuous venovenous hemofiltration for renal support. Eleven patients (45.8%) were discharged with ventricular assist device support (1015 home patient-days). Complications observed were a) neurologic: stroke in 3 patients, transient ischemic attacks in 4 patients; and b) infection: driveline infection in 3 patients and pump pocket infection in 1 patient. There was no mechanical device failure. Support to transplantation was achieved in 17 patients (70.8%): 3 of 5 biventricular assist devices (60%) and 14 of 19 left ventricular assist devices (73.7%). CONCLUSION: The Thoratec IVAD is a versatile and reliable ventricular assist device. It can provide univentricular or biventricular support for bridging patients to heart transplantation with acceptable complication rates. The portable Thoratec TLC-II console facilitated discharge while patients waited for a suitable donor heart.