An Unwelcome House Guest: Coronary Aneurysms and Evolving Stemi

Case Description: 54-year-old man presented to the Emergency Department (ED) three weeks after Covid-19 infection for progressively worsening dyspnea and hypoxemia. Dexamethasone and prophylactic apixaban (2.5mg twice a day) were initiated and he was discharged 48 hours later. A week after discharge he re-presented to the ED requiring 6L of oxygen (O ) despite uninterrupted dexamethasone and apixaban therapy. His past medical history was significant for quiescent IgG4 disease on Rituximab and Type 1 Diabetes. He was afebrile, tachycardic and tachypneic with decreased right lower lobe breath sounds. He had an elevated erythrocyte sedimentation rate and C-reactive protein, no leukocytosis and no pulmonary embolism of CT. He was admitted and vancomycin and cefepime antibiotic therapy for a superimposed bacterial pneumonia was begun. On day 12 of the hospital stay, he experienced new onset chest pain. Evaluation showed an elevated troponin and submillimeter ST segment elevation concerning for an evolving STEMI. Coronary angiography demonstrated an 90% diffuse mid LAD stenosis and two large coronary aneurysms of the left circumflex artery (LCx). The mid-LAD was stented using a 3.0 x 38 mm and 2.75 x 26 mm Onyx drug eluting stents with resolution of his chest pain. IgG4 serum level was normal and imaging did not demonstrate active IgG4 disease. He was discharged on aspirin and clopidogrel. Due to concern for a hypercoagulable state in the setting of Covid 19 infection, IgG4 disease and the large coronary aneurysms for thrombus formation, warfarin anticoagulation was also initiated. On review of his coronary imaging, the largest LCx aneurysm was 9mm on admission and 12mm three weeks later with evidence of diffuse coronary inflammation. CT Fractional Flow Reserve (abnormal <= 0.80) demonstrated decreased flow at the distal aneurysm with no focal stenosis to account for flow reduction. Conclusion(s): 54-year-old man with IgG4 disease presenting with prolonged Covid-19 infection and acute NSTEMI. He was found to have large, flow limiting coronary aneurysms and inflamed coronary arteries all consistent with his IgG4 disease. Management of these aneurysms will be discussed.

THE SOCIAL CONSTRUCTION OF AIRBORNE INFECTIONS

Airborne pathogens are capable of hovering within enclosed spaces for minutes or hours. They travel as tiny particles emitted when a person who has an active infection coughs, sneezes, speaks, sings, or laughs. When a susceptible host is exposed to this air space, they risk inhaling the particles into their lungs and catching the infection. Globally, rapid population growth in urban areas and a widespread lack of adequate housing are creating more opportunities for airborne pathogens to hover and spread through crowded interiors. The populations with fewer services and heavier burdens of disease are more susceptible to airborne infections. This chapter explores the environmental determinants of health that enable these pathogens, as well as approaches to facilitate their prevention and control. It also examines the most enduring airborne pathogen, tuberculosis, and how policies that favored higher living standards in urban areas, and treatments that revolved around clean air, helped reduce its prevalence in the past. In the 21st century, policy interventions that promote health through better ventilation standards in buildings, easier access to adequate housing, and observance of international human rights standards are recommended to help curb ongoing global pandemics like tuberculosis, and newer ones like COVID-19. Along with source control and vaccinations, addressing the underlying social forces that influence the air we breathe indoors has the potential to prevent mortality and morbidity on a large scale. © 2023 selection and editorial matter, AnnaMarie Bliss and Dak Kopec;individual chapters, the contributors.

Quality Improvement Project to Reduce Turnaround Times to Improve Vascular Theatre Efficiency

Aims: Delays in turnaround time (TAT) have significant financial implications for the National Health Service, estimated to be as much as £347 327 per year. Considering this, we aimed to reduce the TAT by 25% in a vascular surgical theatre, via a Quality Improvement Project (QIP), as part of an MBBS component. We hypothesised that improvements in TAT would also lead to beneficial secondary effects, such as improved theatre utilisation, reduced on the day cancellations, and fewer minutes overrun. Methods: TAT was defined as the time between the last patient going to recovery (“wheels out”) to the next one entering the theatre (“wheels in”). Using the electronic theatre record system “Galaxy”, we established a baseline average TAT using data from October 2019 to January 2020. To identify the common issues underlying TAT delays, a group of three medical students undertook a four week research period, involving ad hoc staff interviews and review of postoperative debrief forms. From this, we constructed our interventions and implemented them over a six week period. Results: Our research period suggested ward-based preparation was a common reason for delay. To address this, we created interventions that focused on giving the ward staff more time, to promote “patient readiness”. An advanced warning system when sending for the patient (30 minutes prior to the end of surgery;previously, the ward was only notified when the patient was being closed) and a newly designed ward based checklist (shown in Fig. 1;the checklist allowing systematic review of tasks needed to be completed) were utilised. Baseline average TAT was 51.7 minutes and the pre-intervention theatre utilisation percentage was 86%. After a PDSA cycle using the interventions described above, we reduced the average TAT to 42.1 minutes, an 18.4% decrease. Figure 2 shows a run chart visualising these results. While the reduction did not meet our 25% target, it remains a significant one. Unfortunately, reduced TAT did not translate into significant improvement in theatre utilisation, on the day cancellations, or minutes overrun, all of which remained at the median of the pre-intervention period. However, improvements in these metrics were impeded by factors out of our control (e.g., surgical complications causing delays). These “unpreventable” delays had particularly significant impacts on our results when they occurred due to the intervention period being conducted over only one PDSA cycle (owing to the COVID-19 pandemic halting elective procedures). Conclusion: Our ward based interventions have shown they can reduce turnaround times in vascular surgery. Less idle theatre time and improved theatre utilisation will be imperative in reducing the backlog of surgeries the COVID pandemic has created. While this QIP was unable to translate reduced TAT to beneficial secondary effects, such as improved theatre utilisation, we hypothesise that with a larger sample size, reduced turnaround times will improve these long term, as there will be more opportunity for the interventions to have their effect without being obstructed by unpreventable delays. Therefore, we believe these interventions should be considered for further exploration on a larger scale to ascertain their true value. This will begin with the resumption of our second PDSA cycle, once surgeries resume [Formula presented] [Formula presented]

The Assistive Technology Services Experience of the 2020-2021 School Year

Assistive Technology Services (ATS) is the central group of itinerants and resource staff directly working with students and schools to provide assistive technology accommodations within the Fairfax County Public School (FCPS) system in Virginia. When schools closed in March 2020 because of the COVID-19 pandemic, the group was required to make immediate, yet impactful adjustments to its daily operation. ATS worked within the purview of the evolving technology climate that was gradually occurring with the district’s FCPSOn technology initiative. This initiative went from a yearly rollout to placing computer devices in all students’ hands in the scope of a few months. Assistive Technology Services was able to collaborate with diverse groups in the school system, assist in safely providing access to technology devices, assess specific student assistive technology needs, and develop effective training practices within a new virtual learning environment. As concurrent learning emerged and students returned to school in January 2021, Assistive Technology Services adapted its standard operating procedures to that of the “new normal” that will continue to evolve not only as the pandemic subsides, but as emerging technologies continue to change the face of education. © ATIA 2022.

A behavioral insights approach to recruiting entrepreneurs for an academic study during the COVID-19 pandemic

What should researchers say when recruiting entrepreneurs to participate in their study? Using a sample of entrepreneurs (N = 1,450) who were being asked to participate in an academic research project, we conducted an experiment to determine recruitment message efficacy. Drawing on best practices from the behavioral insights literature, we developed different email message recruitment statements that were randomly assigned across four phases of our experiment. Results indicate that a message grounded in the “descriptive norms” (i.e., social norms) approach resulted in the highest percentage of participants who clicked on the link to participate in our online survey. We discuss the theoretical as well as practical implications of our work. © 2021

Quality improvement project to reduce turn-around times to improve vascular theatre efficiency

Aim: One of the factors influencing theatre efficiency is turn-around time (TAT). The aim of this QIP was to reduce turnaround times by 25% thereby reducing financial implications of theatre idle time. Methods: Baseline data was obtained from electronic theatre record system 'Galaxy' for the period October 2019 to February 2020. TAT (Time from the last patient going to recovery and the next one coming into the theatre) was measured and a period average was established. This QIP mapped processes and conducted interviews, to identify issues contributing to longer turnaround times. Interventions were then constructed and implemented over 6 weeks. Results: One of preventable causes of delay identified from staff interviews and personal observations was inadequate patient preparation by the ward. Preintervention percentage theatre utilisation was 86% and turnaround times was 51.7 minutes. A PDSA cycle was initiated focusing on advanced warning (30 minutes prior to the end of the previous surgery) from theatres to wards and advanced preparation from wards, using a newly designed ward-based checklist. After the first PDSA cycle there has been an improvement in TAT to 42.8 minutes, a decrease of 18.2%. Whilst this did not meet our goal of a 25% reduction, this remains significant. Unfortunately due to COVID -19 the second cycle has been delayed. Conclusions: Affordable and sustainable improvements will be needed in post COVID-19 recovery phase to tackle the backlog of surgeries. This project has demonstrated that advanced warning system can decrease turnaround times.

Covi d-19 and cri me effects of stay-at-home orders on domestic violence

COVID-19 has led to an abrupt change in time spent at home, with many cities and states implementing official stay-at-home (SAH), or “lockdown,” policies. Using cell phone block-level activity data and administrative 911 and crime data from the City of Chicago, we estimate the effects of the Illinois governor’s SAH order on calls for police service, crimes recorded by police, and arrests made relating to domestic violence. We find that the SAH order announcement increased time spent at home, leading to a decrease in total calls for police service, but a subsequent increase in domestic violence–related calls for police service. However, we find that official reports by police officers and arrests for domestic violence crimes fell by 6.8 percent and 26.4 percent, respectively. Declines in reported domestic violence crimes mirror drops in total reported crimes;however, the reduction for domestic violence crimes is around 5 times smaller than the decline in overall crime rates. © 2021 American Society of Health Economists.