The adverse impact of COVID-19 pandemic on cardiovascular disease prevention and management in England, Scotland and Wales: A population-scale descriptive analysis of trends in medication data

ObjectivesTo estimate the impact of the COVID-19 pandemic on cardiovascular disease (CVD) and CVD management using routinely collected medication data as a proxy. DesignDescriptive and interrupted time series analysis using anonymised individual-level population-scale data for 1.32 billion records of dispensed CVD medications across 15.8 million individuals in England, Scotland and Wales. SettingCommunity dispensed CVD medications with 100% coverage from England, Scotland and Wales, plus primary care prescribed CVD medications from England (including 98% English general practices). Participants15.8 million individuals aged 18+ years alive on 1st April 2018 dispensed at least one CVD medicine in a year from England, Scotland and Wales. Main outcome measuresMonthly counts, percent annual change (1st April 2018 to 31st July 2021) and annual rates (1st March 2018 to 28th February 2021) of medicines dispensed by CVD/ CVD risk factor; prevalent and incident use. ResultsYear-on-year change in dispensed CVD medicines by month were observed, with notable uplifts ahead of the first (11.8% higher in March 2020) but not subsequent national lockdowns. Using hypertension as one example of the indirect impact of the pandemic, we observed 491,203 fewer individuals initiated antihypertensive treatment across England, Scotland and Wales during the period March 2020 to end May 2021 than would have been expected compared to 2019. We estimated that this missed antihypertension treatment could result in 13,659 additional CVD events should individuals remain untreated, including 2,281 additional myocardial infarctions (MIs) and 3,474 additional strokes. Incident use of lipid-lowering medicines decreased by an average 14,793 per month in early 2021 compared with the equivalent months prior to the pandemic in 2019. In contrast, the use of incident medicines to treat type-2 diabetes (T2DM) increased by approximately 1,642 patients per month. ConclusionsManagement of key CVD risk factors as proxied by incident use of CVD medicines has not returned to pre-pandemic levels in the UK. Novel methods to identify and treat individuals who have missed treatment are urgently required to avoid large numbers of additional future CVD events, further adding indirect cost of the COVID-19 pandemic.

An external validation of the QCovid risk prediction algorithm for risk of mortality from COVID-19 in adults: national validation cohort study in England

BackgroundTo externally validate a risk prediction algorithm (QCovid) to estimate mortality outcomes from COVID-19 in adults in England. MethodsPopulation-based cohort study using the ONS Public Health Linked Data Asset, a cohort based on the 2011 Census linked to Hospital Episode Statistics, the General Practice Extraction Service Data for pandemic planning and research, radiotherapy and systemic chemotherapy records. The primary outcome was time to COVID-19 death, defined as confirmed or suspected COVID-19 death as per death certification. Two time periods were used: (a) 24th January to 30th April 2020; and (b) 1st May to 28th July 2020. We evaluated the performance of the QCovid algorithms using measures of discrimination and calibration for each validation time period. FindingsThe study comprises 34,897,648 adults aged 19-100 years resident in England. There were 26,985 COVID-19 deaths during the first time-period and 13,177 during the second. The algorithms had good calibration in the validation cohort in both time periods with close correspondence of observed and predicted risks. They explained 77.1% (95% CI: 76.9% to 77.4%) of the variation in time to death in men in the first time-period (R2); the D statistic was 3.76 (95% CI: 3.73 to 3.79); Harrells C was 0.935 (0.933 to 0.937). Similar results were obtained for women, and in the second time-period. In the top 5% of patients with the highest predicted risks of death, the sensitivity for identifying deaths in the first time period was 65.9% for men and 71.7% for women. People in the top 20% of predicted risks of death accounted for 90.8% of all COVID-19 deaths for men and 93.0% for women. InterpretationThe QCovid population-based risk algorithm performed well, showing very high levels of discrimination for COVID-19 deaths in men and women for both time periods. It has the potential to be dynamically updated as the pandemic evolves and therefore, has potential use in guiding national policy. FundingNational Institute of Health Research RESEARCH IN CONTEXTO_ST_ABSEvidence before this studyC_ST_ABSPublic policy measures and clinical risk assessment relevant to COVID-19 need to be aided by rigorously developed and validated risk prediction models. A recent living systematic review of published risk prediction models for COVID-19 found most models are subject to a high risk of bias with optimistic reported performance, raising concern that these models may be unreliable when applied in practice. A population-based risk prediction model, QCovid risk prediction algorithm, has recently been developed to identify adults at high risk of serious COVID-19 outcomes, which overcome many of the limitations of previous tools. Added value of this studyCommissioned by the Chief Medical Officer for England, we validated the novel clinical risk prediction model (QCovid) to identify risks of short-term severe outcomes due to COVID-19. We used national linked datasets from general practice, death registry and hospital episode data for a population-representative sample of over 34 million adults. The risk models have excellent discrimination in men and women (Harrells C statistic>0.9) and are well calibrated. QCovid represents a new, evidence-based opportunity for population risk-stratification. Implications of all the available evidenceQCovid has the potential to support public health policy, from enabling shared decision making between clinicians and patients in relation to health and work risks, to targeted recruitment for clinical trials, and prioritisation of vaccination, for example.

Non-pharmacologic management of sickle cell pain.

Patients with sickle cell disease (SCD) suffer from both acute and chronic pain. The latter includes avascular necrosis of the hip joints mostly in the adult population. It has a negative impact on the quality of life of affected individuals and is often associated with depression, disability, unemployment and dependence on opioid analgesics. In this study, we show that a non-pharmacologic approach to management with deep tissue/deep pressure massage therapy technique, including neuromuscular trigger point treatment with acupressure, in patients with SCD has a salutary effect on pain relief and quality of life.

Current Policies and New Directions for Speech-Language Pathology Assistants.

This article provides an overview of current American Speech-Language-Hearing Association (ASHA) policies for the appropriate use and supervision of speech-language pathology assistants with an emphasis on the need to preserve the role of fully qualified speech-language pathologists in the service delivery system. Seven challenging issues surrounding the appropriate use of speech-language pathology assistants are considered. These include registering assistants and approving training programs; membership in ASHA; discrepancies between state requirements and ASHA policies; preparation for serving diverse multicultural, bilingual, and international populations; supervision considerations; funding and reimbursement for assistants; and perspectives on career-ladder/bachelor-level personnel. The formation of a National Leadership Council is proposed to develop a coordinated strategic plan for addressing these controversial and potentially divisive issues related to speech-language pathology assistants. This council would implement strategies for future development in the areas of professional education pertaining to assistant-level supervision, instruction of assistants, communication networks, policy development, research, and the dissemination/promotion of information regarding assistants.

Peer-related communicative competence of preschool children: developmental and adaptive characteristics.

The peer-related communicative interactions of nonhandicapped 3- and 4-year-old children as well as a group of 4-year-old mildly developmentally delayed children were investigated in a cross-sectional descriptive study. Adjustments of speakers to companions varying in terms of chronological age and developmental status were of interest, as were comparisons among the three groups. All three groups made adjustments in communicative functions (directives and information statements), interactive style (strong and joint directives), and communications involving affect (disagreements), but only to mildly delayed children. Adjustments to mildly delayed children were more closely related to interpersonal and social status factors than to children's developmental levels. The communicative interactions of mildly delayed children were highly similar to the developmentally matched nonhandicapped group on all measures except for a lower level of speech complexity. Significant differences between 3- and 4-year-old nonhandicapped children were obtained only for measures of speech complexity.

Temporal changes in word revisions by children and adults.

A study was conducted to investigate the temporal changes that occur when a speaker attempts to revise words for a listener. Specifically, the study was designed to examine whether adults and children modify the timing of vowel and consonant production in response to listener miscomprehension. Four adults and sixteen 5-year-old boys and girls served as subjects. They were asked to repeat words that differed in voicing of initial and final stop consonants (back, pack, cab, cap), and to respond to either specific revision requests focused on initial or final sound segments, or to a general revision request. The speech waveform was used to measure the following: Voice Onset Time, vowel duration, final closure duration, and total word duration. Results revealed that children and adults made segmental changes in duration while preserving total word length in revised speech. The effect was a decrease in vowel duration and an increase in final closure duration for revised responses, regardless of the source of miscomprehension. These durational changes result in an apparent enhancement of the final consonantal portion of the misperceived word. All linguistic distinctions in voicing were maintained in the revised words. There were no major differences between adults and children in the type of revision responses produced.

A classroom-based model of language intervention for preschool language-impaired children: Principles and procedures.

It is now generally recognized that a language impairment in preschool children may be predictive of later linguistic, reading, and academic difficulties. Language intervention procedures, derived from theoretically-based principles of language development and implemented in a child's regular classroom environment, may benefit children at risk for persistent language and learning problems. This paper describes the development and application of individualized intervention procedures in a classroom for preschool language-impaired children. The discussion focuses on selected language development principles which helped determine the setting, timing, interactive participants, purpose, and content of the language intervention program. Resulting changes in language comprehension and production are reported based on individual classroom performance as well as a comparison of pre-and posttest scores for a range of comprehension skills.

Communicative interactions of mildly delayed and normally developing preschool children: effects of listener's developmental level.

The communicative interactions of mildly delayed and normally developing preschool children were recorded during free play as they interacted with children at different developmental levels in a mainstreamed program. Analyses of syntactic complexity, semantic diversity, functional aspects of speech, and the use of selected discourse devices indicated that mildly delayed children adjusted important characteristics of their speech in accordance with the cognitive and linguistic levels of their companions. Specifically, speech addressed to less developmentally advanced children was less complex, more diverse, and consisted of a greater proportion of behavior requests but contained proportionally fewer information requests or information statements. These adjustments appeared to be well suited for improving communicative effectiveness and were similar in magnitude and direction to those of normally developing children. In addition, both mildly delayed and normally developing groups were generally successful in obtaining responses to their behavior and information requests. The implications of these findings were discussed in relation to the communicative competence of young children and to early childhood mainstreaming.

Functional and discourse analyses of nonhandicapped preschool children's speech to handicapped children.

Functional and discourse analyses of the communicative interactions of nonhandicapped preschool children when addressing children at different developmental levels were carried out in an instructional setting. Listeners were classified as manifesting either mild, moderate, severe, or no developmental delays. The results indicated that the nonhandicapped children appropriately adapted their interactions in a manner that would suggest an increased likelihood that messages would be understood and responded to. In addition, the modified interactions appeared to be consistent with the communicative goals of the speaker and the social roles of the participants. These findings were discussed in terms of their relevance to the issue of mainstreaming and early intervention.

The nature of verbal interactions among handicapped and nonhandicapped preschool children.

The nature of verbal interactions among handicapped and nonhandicapped preschool children was examined in instructional and free-play settings. A wide variety of linguistic parameters designed to reflect verbal productivity and grammatical complexity was selected for analysis. The speech of designated nonhandicapped children wddressed. Listeners were classified as manifesting mild, moderate, severe, or no developmental delays. The results indicated that the speech of the designated children tended to be more complex, more frequent, and more diverse when addressed to developmentally more advanced children in both settings. These results were discussed in terms of their significance for facilitating the development of the language-delayed child.