Deep recurrent reinforced learning model to compare the efficacy of targeted local versus national measures on the spread of COVID-19 in the UK

OBJECTIVES: To prevent the emergence of new waves of COVID-19 caseload and associated mortalities, it is imperative to understand better the efficacy of various control measures on the national and local development of this pandemic in space–time, characterise hotspot regions of high risk, quantify the impact of under-reported measures such as international travel and project the likely effect of control measures in the coming weeks. METHODS: We applied a deep recurrent reinforced learning based model to evaluate and predict the spatiotemporal effect of a combination of control measures on COVID-19 cases and mortality at the local authority (LA) and national scale in England, using data from week 5 to 46 of 2020, including an expert curated control measure matrix, official statistics/government data and a secure web dashboard to vary magnitude of control measures. RESULTS: Model predictions of the number of cases and mortality of COVID-19 in the upcoming 5 weeks closely matched the actual values (cases: root mean squared error (RMSE): 700.88, mean absolute error (MAE): 453.05, mean absolute percentage error (MAPE): 0.46, correlation coefficient 0.42; mortality: RMSE 14.91, MAE 10.05, MAPE 0.39, correlation coefficient 0.68). Local lockdown with social distancing (LD_SD) (overall rank 3) was found to be ineffective in preventing outbreak rebound following lockdown easing compared with national lockdown (overall rank 2), based on prediction using simulated control measures. The ranking of the effectiveness of adjunctive measures for LD_SD were found to be consistent across hotspot and non-hotspot regions. Adjunctive measures found to be most effective were international travel and quarantine restrictions. CONCLUSIONS: This study highlights the importance of using adjunctive measures in addition to LD_SD following lockdown easing and suggests the potential importance of controlling international travel and applying travel quarantines. Further work is required to assess the effect of variant strains and vaccination measures

Effect of on-pump vs. off-pump coronary artery bypass grafting in patients with non-dialysis-dependent severe renal impairment: propensity-matched analysis from the UK registry dataset

IntroductionOn-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis-dependent pre-operative severe renal impairment undergoing OPCABG vs. ONCABG, captured in a large national registry dataset.MethodsAll data for patients with a pre-operative creatinine clearance of less than 50 mL/min who underwent elective or urgent isolated OPCABG or ONCABG from 1996 to 2019 were extracted from the UK National Adult Cardiac Surgery Audit (NACSA) database. Propensity score matching was performed using 1:1 nearest neighbor matching without replacement using several baseline characteristics. We investigated the effect of ONCABG vs. OPCABG in the matched cohort using cluster-robust standard error regression.ResultsWe identified 8,628 patients with severe renal impairment undergoing isolated CABG, of whom 1,142 (13.23%) underwent OPCABG during the study period. We compared 1,141 propensity-matched pairs of patients undergoing OPCABG vs. ONCABG. The median age of the matched population was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCABG and ONCABG in in-hospital mortality rates, post-operative dialysis, and stroke rates. However, the return to theatre for bleeding or tamponade was higher in ONCABG vs. OPCABG (P > 0.02); however, OPCABG reduced the total length of stay in the hospital by 1 day (P = 0.008). After double adjustment in the matched population using cluster-robust standard regression, ONCABG did not increase mortality compared to OPCABG (OR, 1.05, P = 0.78), postoperative stroke (OR, 1.7, P = 0.12), and dialysis (OR, 0.7, P = 0.09); however, ONCABG was associated with an increased risk of bleeding (OR, 1.53, P = 0.03).DiscussionIn this propensity analysis of a large national registry dataset, we found no difference in early mortality and stroke in patients with pre-operative severe renal impairment undergoing OPCABG or ONCABG surgery; however, ONCABG was associated with an increased risk of return to theatre for bleeding and an increased length of hospital stay

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom

ObjectiveSurgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.MethodsAll patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50–59, 60–69, 70–79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.ResultsThe number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60–69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.ConclusionSurgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups

Patterns of cytokine release and association with new onset of post-cardiac surgery atrial fibrillation

IntroductionPostoperative Atrial Fibrillation (POAF) is a common complication of cardiac surgery, associated with increased mortality, stroke risk, cardiac failure and prolonged hospital stay. Our study aimed to assess the patterns of release of systemic cytokines in patients with and without POAF.MethodsA post-hoc analysis of the Remote Ischemic Preconditioning (RIPC) trial, including 121 patients (93 males and 28 females, mean age of 68 years old) who underwent isolated coronary artery bypass grafting (CABG) and aortic valve replacement (AVR). Mixed-effect models were used to analyze patterns of release of cytokines in POAF and non-AF patients. A logistic regression model was used to assess the effect of peak cytokine concentration (6 h after the aortic cross-clamp release) alongside other clinical predictors on the development of POAF.ResultsWe found no significant difference in the patterns of release of IL-6 (p = 0.52), IL-10 (p = 0.39), IL-8 (p = 0.20) and TNF-α (p = 0.55) between POAF and non-AF patients. Also, we found no significant predictive value in peak concentrations of IL-6 (p = 0.2), IL-8 (p = >0.9), IL-10 (p = >0.9) and Tumour Necrosis Factor Alpha (TNF-α)(p = 0.6), however age and aortic cross-clamp time were significant predictors of POAF development across all models.ConclusionsOur study suggests no significant association exists between cytokine release patterns and the development of POAF. Age and Aortic Cross-clamp time were found to be significant predictors of POAF

National survey of variations in practice in the prevention of surgical site infections in adult cardiac surgery, United Kingdom and Republic of Ireland

Background: Currently no national standards exist for the prevention of surgical site infection (SSI) in cardiac surgery. SSI rates range from 1% to 8% between centres. Aim: The aim of this study was to explore and characterize variation in approaches to SSI prevention in the UK and the Republic of Ireland (ROI). Methods: Cardiac surgery centres were surveyed using electronic web-based questionnaires to identify variation in SSI prevention at the level of both institution and consultant teams. Surveys were developed and undertaken through collaboration between the Cardiothoracic Interdisciplinary Research Network (CIRN), Public Health England (PHE) and the National Cardiac Benchmarking Collaborative (NCBC) to encompass routine pre-, intra- and postoperative practice. Findings: Nineteen of 38 centres who were approached provided data and included responses from 139 consultant teams. There was no missing data from those centres that responded. The results demonstrated substantial variation in over 40 aspects of SSI prevention. These included variation in SSI surveillance, reporting of SSI infection rates to external bodies, utilization of SSI risk prediction tools, and the use of interventions such as sternal support devices and gentamicin impregnated sponges. Conclusion: Measured variation in SSI prevention in cardiac centres across the UK and ROI is evidence of clinical uncertainty as to best practice, and has identified areas for quality improvement as well as knowledge gaps to be addressed by future research

Impact of Bacillus Calmette-Guérin (BCG) vaccination on postoperative mortality in patients with perioperative SARS-CoV-2 infection

There is little evidence around the potentially protective role of previous Bacillus Calmette-Guerin (BCG) vaccination on postoperative mortality in patients with perioperative SARS-CoV-2 vaccination. Prior BCG vaccination did not protect SARS-CoV-2 infected patients against postoperative pulmonary complications and 30-day mortality

Transition, Integration and Convergence. The Case of Romania

This volume comprises several studies and papers published in the last decades. They have been selected and ranged so that to provide a minimum of coherence concerning the phases which Romania has crossed in her way to the advanced socio-economic system of European type: transition to the market economy, accession to the EU, the economic convergence in the three fundamental domains: institutions, real economy, and nominal economy. The readers may find in this volume a description of debates, difficulties and solutions adopted for building-up the market economy by a state being in a profound transformation from weak transition institutions towards hard democratic institutions. Because the transition to the market economy and the association of Romania with the EU and then the integration presenting strategic political decisions, I have included in this work two studies devoted to the political forces state and political parties that elaborated and applied these strategic decisions underlining their structure, role and function and their transformation. Integration into the EU of a country like Romania, which emerged from a different system comparing with the West-European one, has proved to be difficult and lasting many years because of the structural transformations. In five chapters I am referring to the essential characteristics of the integration process, such as: market liberalization, competitiveness of the local (national) firms on the national and EU markets, institutional reforms so that the institutions of candidate countries have to become compatible with those of the EU and finally the perspective assessment to find out the real and nominal convergence. Putting into practice the EU competitivity and cohesion principles, Romania has good prospects to close, in a reasonable time, the economic gap and to be admitted into the Euro Zone. Although the real convergence of Romania with the EU requires higher growth rates for the former, a new approach is compulsory to take into consideration the environment quality, the natural resources and the equity between the present and the future generations as natural resource consumers. Just these problems have determined me to include in this volume the last two chapters which, on the one hand, try to prove the necessity of the economy growth harmonization with the environment evolution as well as the saving of the energy resources, and, on the other hand, to point out the main ways to be followed and instruments to be used