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Aims/background The number of cardiac devices implanted increases year on year, as does the complexity of the patients being managed. A large proportion of this patient group have an indication for anticoagulation, and this raises challenges around the perioperative management of these agents. Method A quality improvement project was conducted to review current practice, understand local experience and improve patient care. Results Following the initial review, local guidelines were updated, the postoperative anticoagulation decision escalated to the responsible clinician and a clearer pathway for communicating the decision created. Conclusions The implemented changes have shown an overall improvement in junior doctor feedback and also clinical documentation in the electronic patient records.

To discuss the benefits of centralization of gynaecological cancer care on patients and the healthcare system and how to overcome its barriers.Evidence demonstrates that adherence to clinical practice management guidelines is more likely; the risk of adverse events is lower; survival is improved; in young women fertility preservation is higher; and cost effectiveness is higher; in systems that employ centralized care for women with gynaecological cancer. Barriers to the uptake of centralized models include knowledge, attitude as well as deficient systems and processes, including a lack of governance and leadership. Collaborative centralization refers to a model that sees both elements (centralization and treatment closer to home) utilized at the patient level that addresses some of the barriers of centralized gynaecological cancer care.Evidence supports centralized gynaecological cancer care, as it results in reduced risks of adverse events, improved survival and higher fertility rates at lower cost to funders. Collaborative centralization is a process that considers both the value of centralization and collaboration amongst healthcare professionals at primary, secondary and tertiary levels of healthcare to benefit patient outcomes.

Background Ebstein’s anomaly is a rare condition due to incomplete delamination of the tricuspid valve (TV) leaflets with downward displacement of the proximal leaflet attachments. It is associated with a smaller functional right ventricle (RV) and tricuspid regurgitation (TR) that is typically treated with TV replacement or repair. However, future re-intervention poses challenges. We describe a multidisciplinary team approach to re-intervention in a pacing-dependant Ebstein patient with severe bioprosthetic TV regurgitation. Case summary A 49-year-old female patient underwent bioprosthetic TV replacement for severe TR in Ebstein’s. Post-operatively, she developed complete atrioventricular (AV) block necessitating the implantation of a permanent pacemaker which included a coronary sinus (CS) lead as the ventricular lead. Five years later, she presented with syncope due to a failing ventricular pacing lead, and a new RV lead was positioned across the TV bioprosthesis due to the lack of CS options. Two years later, she presented with breathlessness and lethargy with severe TR identified on transthoracic echocardiography. She successfully underwent a percutaneous leadless pacemaker implant, extraction of existing pacing system, and implantation of valve-in-valve TV. Discussion Patients with Ebstein’s anomaly typically undergo TV repair or replacement. Following surgical intervention, owing to the anatomical location, patients can develop AV block requiring a pacemaker. Pacemaker implantation may involve a CS lead to avoid placing a lead across the new TV in efforts to avoid lead induced TR. Over time, these patients not uncommonly require re-intervention that can be challenging especially in pacing-dependant patients with leads across the TV.

Cardiac implantable electronic device (CIED) implants are rising in an older, more co-morbid population. The prevalence of CIED infection ranges from 1–4%. Whilst complete extraction of all transvenous hardware is recommended for infected, eroded, or pre-eroding CIEDs, this approach is not without risk and may be unacceptable to some patients. Long-term data on a more conservative strategy is lacking. We report on our experience of conservative management with pocket revision as a primary strategy in carefully selected patients. Method: A retrospective review of all CIED revision procedures was undertaken at a large tertiary center, over a 7-year period, with a mean follow-up timeframe of 39 months. Results: A total of 86 patients underwent 96 revision procedures; 7 patients required further revisions and 13 went on to undergo CIED extraction by the end of the follow-up period. The overall rate of mortality at 12 months was 8.1%, increasing to 24.4% at the end of the follow-up period. Conclusion: Our data provide important outcome information on an alternative strategy to lead extraction in carefully selected patients where the risk of extraction is perceived to be unacceptable. The absence of systemic infection appears to predict better outcomes than previously reported, and over two-thirds of patients remained complication-free at 12 months.

A current limitation of single chamber implantable cardioverter defibrillators (ICDs) is the lack of an atrial lead to reliably detect atrial fibrillation (AF) episodes. A novel ventricular based atrial fibrillation (VBAF) detection algorithm was created for single chamber ICDs to assess R-R variability for detection of AF.Patients implanted with Visia AF™ ICDs were prospectively enrolled in the Medtronic Product Surveillance Registry from December 15, 2015 to January 23, 2019 and followed with at least 30 days of monitoring with the algorithm. Time to device-detected daily burden of AF ≥ 6 min, ≥6 h, and ≥23 h were reported. Clinical actions after device-detected AF were recorded.A total of 291 patients were enrolled with a mean follow-up of 22.5 ± 7.9 months. Of these, 212 (73%) had no prior history of AF at device implant. However, 38% of these individuals had AF detected with the VBAF algorithm with daily burden of ≥6 min within two years of implant. In these 80 patients with newly detected AF by their ICD, 23 (29%) had a confirmed clinical diagnosis of AF by their provider. Of patients with a clinical diagnosis of AF, nine (39%) were newly placed on anticoagulation, including five of five (100%) patients having a burden23 h.Continuous AF monitoring with the new VBAF algorithm permits early identification and actionable treatment for patients with undiagnosed AF that may improve patient outcomes.

Introduction: Catheter-associated urinary tract infections (CAUTI), remains the commonest hospital-acquired infection (HAI). This emphasizes the need to implement and monitor effective infection control programs to reduce the risk of CAUTI. Objectives: Aim of the present study was to determine the etiology with antibiotic susceptibility and also to calculate CAUTI rate. Materials and Methods: The Patients admitted in intensive care unit (ICU), Rajarajeshwari Medical College and Hospital who were on urinary catheter insertion for >48 hours from 1 August, 2019 to 30 September, 2019 were included in the study. Under aseptic conditions urine samples were collected from clinically suspected cases of CAUTI, the samples were processed in the department of Microbiology, as per standard protocols. Uropathogens were isolated, identified and subjected to antibiotic sensitivity test. CAUTI rate was calculated and results were noted. Results: Among 460 patients on catheter in ICU, 28(6%) patients developed clinical signs or symptoms of UTI. Of 28 urine samples cultured, 4(14%) yielded growth of single organis [Escherichia coli (3), Klebsiella (1)] and 24(86%) showed no evidence of growth. 2300 catheter days were obtained of 460 patients on indwelling catheter in ICU. Thus CAUTI rate was 1.74 per 1000 catheter days over a 2 month period. Discussion and Conclusion: CAUTI remained a great burden to patient safety and a challenge to the infection control team. Implementation of proper care bundles and continuous education to health care workers plays a key role in reducing the CAUTI rates, thereby decreasing the morbidity and hospital stay to the patients. Keywords: CAUTI, Devise associated, Hospital acquired, UTI, CAUTI rate.

Background: HIV/AIDS poses a significant and one of the most genuine general well-being challenges. For HIV anticipation in the Indian scenario, the main plausible and financially savvy approach that can be adapted is proper training about HIV/AIDS and its various aspects. The present study was embraced to survey the degree of information and awareness about HIV/AIDS among clients attending ICTC facility in our hospital. Materials and Methods: A total of 200 clients, of age >18yrs, attending the ICTC for HIV testing were studied over a period of 3 months. A questionnaire was prepared in regards to the methods of transmission, preventive techniques, mentality towards patient living with HIV/ AIDS and the source of HIV/ AIDS. The response of clients to the questionnaire was recorded. Results: Among 200 participants, 97% were aware that unprotected sex is a mode of HIV transmission and 64% were aware that infected blood transfusion, use of unsterile needles and syringes contribute to other modes of HIV transmission. It was also noted that uneducated clients had a false perception that HIV can be transmitted by drinking water from same glass and by mosquito bite and this was statistically significant compared to educated individuals. The main source of acquiring positive information among the clients regarding HIV was observed to be television (32.5%). Conclusion: Stigma among the general public was mostly due to fear of contracting the illness. There is a requirement for more noteworthy endeavours toward making data with respect to HIV/AIDS accessible to all. The level of awareness regarding HIV/AIDS needs to be elevated among the public. Keywords : HIV, AIDS, Awareness, Education.

The transition to consultant practice represents an important transition from the role of trainee to trainer. We used the theoretical framework of Threshold Concepts to better understand this transition by analysing data from a broader qualitative study examining the experience of early career Certified Gynaecological Oncologists (CGOs) in Australia and New Zealand.Semi-structured interviews were conducted with CGOs of5 years consultant experience. Transcripts were analysed using reflexive thematic analysis, sensitised by the theoretical framework of Threshold Concepts.Seven early career CGOs were interviewed. Analysis resulted in the construction of five main themes related to the trainer role, each demonstrating characteristics of Threshold Concepts: 'Part of becoming and being a consultant'; 'Managing complex work environments and training responsibilities'; 'Optimising near peer relationships'; 'Recency informing evolution of training'; and "'Being responsible and letting go…' - the next transition."The themes offer insights into the areas of the transition to trainer that are troublesome, the impact of negotiating these challenges on professional identity formation, and the strategies used by CGOs to negotiate them. Using the lens of Threshold Concepts, these experiences can be normalised, and supported through efforts to facilitate the development of skills in reflection, feedback, coaching and mentorship.

Effects of the COVID-19 pandemic on cardiac rhythm management (CRM) services remain poorly quantified.To describe the impact of COVID-19 on specialist CRM centers in the United Kingdom (UK).Two-center study involving the Liverpool Heart and Chest Hospital NHS Foundation Trust and Royal Papworth Hospital NHS Foundation Trust. The first nationwide lockdown lasted from April to July 2020 and the second from December 2020 to March 2021.Compared to the pre-pandemic period,During the COVID-19 pandemic, specialist centers in the UK were affected such that the number of procedures performed was greatly reduced in the initial period with latter improvements as better coping strategies were developed.

Pacemakers are a key technology in the treatment of bradyarrhythmias. Leadless pacemakers (LP) were introduced to address limitations of transvenous devices. However, guidelines and other restrictions have led to LPs becoming niche products. The aim of this consensus statement was to determine the strength of opinion of UK implantation experts as to how LPs can be more optimally used. Using a modified Delphi approach, a panel of LP experts developed 36 statements that were used to form a survey that was distributed to LP implanters in the UK. Stopping criteria included a 3-month window for response, a minimum 25% response rate and at least 75% of statements achieving the threshold for consensus (agreed at 66%). In all, 31 of 36 statements reached consensus, and 23 of these achieved ≥90% agreement. Five statements did not achieve consensus. On the basis of these results, seven recommendations were proposed. The implementation of these recommendations may increase the use of LPs, with the aim of improving patient outcomes.

Introduction: Infections due to Gram-positive bacteria are on a rise, of which those due to Enterococcus spp. form a major part. The shifting pattern of infections caused by Enterococci from novel urinary tract infections to soft tissue and wound infections are increasingly reported. Objective: The aim of the present study is to isolate, speciate Enterococci, determine the antibiotic resistance pattern and to detect vancomycin resistance by E- test. Materials and Methods: All wound swabs, pus samples sent for bacterial culture, irrespective of the diagnosis of the patients which were received to the department of microbiology for a period of one year were included in the study. The samples were processed for isolation, identification and speciation of Enterococci. Antimicrobial susceptibility testing was done by Kirby-Bauer disk diffusion method. Vancomycin resistance was determined by E-test. Results: A total of 3000 pus samples were received over a period of one year. Out of which 43 isolates were detected as Enterococcus species. Among 43 isolates, 26 were E.faecalis, 17 were E.faecium. In present study, ampicillin resistance was seen in 88% followed by resistance to erythromycin (86%) and clindamycin (72%). High level gentamycin resistance was seen in 28% cases. Vancomycin resistance was not detected in any of the samples. Conclusion: The shifting spectrum of infections due to Enterococcus is gaining inquisitiveness among health care workers especially in the trauma care units. Thus there is a prerequisite to isolate speciate and determine the resistance that helps in holistic health care. Keywords: Enterococci, Soft tissue infection, Antibiotic resistance, Vancomycin resistance, E test.

Background/Aims Implantable cardiac defibrillators reduce the risk of sudden cardiac death in selected patients. The value of an implantable cardiac defibrillator declines as the patient's disease progresses. Guidelines suggest that the appropriateness of maintaining implantable cardiac defibrillator therapy be regularly reviewed as part of monitoring of the patient's disease trajectory. It is recommended that implantable cardiac defibrillators are deactivated as patients approach the end of life. Patients with a better understanding of their current state of health and the role that the implantable cardiac defibrillator plays within it are more likely to make informed decisions about the timing of deactivation. Methods: A quality improvement project was undertaken on appropriate deactivation of implantable cardiac defibrillators within a large tertiary cardiac centre. This was driven by audit data showing inadequate patient communication and documentation around deactivation. Drivers for change included the introduction of electronic data records, clinical review of comorbid patients approaching elective battery change and an ongoing forum for patient and carer education. Measured outcomes included the number of deactivations performed, evidence of patient discussion and consent, and timing of deactivation of the implantable cardiac defibrillator. Results There were increased numbers of timely device deactivations undertaken following the interventions with improved documented evidence of patient discussion and consent. The educational forum was received favourably. Conclusions Focused multidisciplinary interventions can impact favourably on appropriate implantable cardiac defibrillator deactivation and improve patient engagement.

Introduction: Carriage of Staphylococcus aureus in the web spaces and anterior nares among the health care workers is a substantial source of human infections. Screening, detection and treatment of such carriers is an important modality in prevention of infections. Colonized health workers especially in teaching hospitals may subsequently develop clinical infections and act as reservoirs for infection among vulnerable individuals. Objectives: Screening of the nursing staff from various departments including critical and non critical areas, identification and speciation of staphylococcus and determining its resistance to cefoxitin and Mupirocin. Materials and Methods: The study was done in the department of Microbiology, Rajarajeswari medical college and hospital, Bangalore, Karnataka. Two swabs were collected from each health care personnel, one swab from anterior nares and other from the web spaces. Swabs were streaked on to blood agar and MacConkey agar plate and incubated at 37?C for 48hours. Identification done by standard protocols. Susceptibility to cefoxitin and mupirocin was done by Kirby- baeur disc diffusion method. MIC of mupirocin was done E-test method. Results: A total of 200 nursing staff was screened during the study period. Majority of the cultures yielded Coagulase negative staphylococcus followed by no growth from the anterior nares. From the web spaces majority yielded no growth. Out of 78 CONS that were isolated 72 were sensitive to cefoxitin and 8 were resistant. Out of 24 isolated Staphylococcus aureus isolates 20 isolates were sensitive and 4 were resistant to cefoxitin. The MIC values of the four methicillin resistant Staphylococc us aureus were 0.38, 0.25, 0.25, 0.19 which were reported as sensitive strains. Keywords: MRSA, Staphylococcus aureus, Mupirocin, Nasal carriers, Webspaces, Screening nursing staff.

ObjectiveTo determine the role of vaginal vault cytology as a surveillance tool for the detection of recurrence in patients with early stage cervical cancer treated with hysterectomy without adjuvant therapy.MethodsA retrospective cohort study was conducted of all women with cervical cancer treated with a hysterectomy from January 2000 to July 2016 at the Royal Brisbane & Women’s Hospital, Australia. Women included were diagnosed with the equivalent of International Federation of Gynecology and Obstetrics (FIGO) 2018 stage 1A1 to 1B3 squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma, received either simple or radical hysterectomy with or without pelvic lymph node dissection, and did not receive adjuvant therapy. Age, stage, histology, surgical procedure, and details of individual surveillance regimens including examination findings and indications and results for all vault cytology tests performed in the first 5 years following surgical management were collected.ResultsA total of 155 women met the inclusion criteria. Most cases were FIGO 2018 stage 1B1 (61.9%) and squamous cell carcinoma (64.5%). Included women underwent a median of 80 months of surveillance (range 25–200, IQR 64–108). In the first 5 years of surveillance, there were a total of 1001 vault cytology smears performed, with a median of 6 smears (IQR 5–9) per woman. A total of 19 smears were abnormal (1.9%). Of the cohort of 155 women, 19 (12.3%) had an abnormality detected; 1 (0.65%) had a high-grade intraepithelial abnormality and 2 (1.3%) had recurrences detected on cytology; however, a lesion was also seen and biopsied in all three women. A total of 16 of 1001 smears (1.6%) had low-grade abnormalities detected, all of which resolved with clinical observation only. All were alive and well at last review. There were in total 6 (3.9%) recurrences, 2 (33%) of which had abnormal cytology as above, and all of which had a lesion to biopsy and/or abnormal medical imaging.ConclusionsThe routine use of vaginal vault cytology in surveillance following hysterectomy for early stage cervical cancer did not appear to alter the detection of recurrent malignancy.

AimsHeart failure (HF) is associated with multiple co-morbidities which independently influence response to treatment as well as outcomes. This retrospective observational study (January 2020-June 2021) analysed the impact of monthly virtual HF multi-specialty multi-disciplinary team (MDT) meetings to address the management of associated comorbidities and thereby upon provision, cost of care and HF outcomes.MethodsPatients acted as their own controls, with outcomes compared for equal periods (for each patient) pre versus post-MDT meeting. The MDT comprised of HF cardiologists (primary, secondary, tertiary care), HF specialist nurses (hospital, community), nephrologist, endocrinologist, palliative care specialist, chest physician, pharmacist, clinical pharmacologist and geriatrician. Outcome measures were 1) all-cause hospitalisations, 2) outpatient clinic attendances, and 3) cost.Results334 patients (mean age 72.5±11 years) were discussed virtually through MDT meetings and follow-up duration was 13.9 ± 4 months. The mean age-adjusted Charlson Co-morbidity Index was 7.6 ± 2.1 and Rockwood Frailty Score was 5.5 ± 1.6. The mean number of clinic attendances prevented was 1.6 ± 0.4. The total cost of funding monthly meetings for the duration of the study was £32400 and the 64 clinic appointments generated cost £9600. The MDT meetings prevented 534 clinic appointments (cost saving £80,100) and reduced all-cause hospitalisations (pre-MDT meeting 1.1±0.4 vs. 0.6±0.1 post-MDT meeting; pConclusionThe HF multispecialty virtual MDT model provides integration of care across all tiers of healthcare for HF management and a holistic approach addressing associated co-morbidities. This approach can reduce the need for out-patient attendances and all-cause hospitalisations, leading to significant cost-savings.Key questionsWhat is already known about this subject?Heart failure is associated with several co-morbid health conditions (multi-morbidity) which independently influence outcomes as well as response to treatment.What does this study add?This study assesses the impact of multispecialty multi-morbidity input into the management of co-morbidities and thereby the effect upon all-cause outcomes.How might this impact on clinical practice?Results of this study illustrate that multi-speciality management of comorbidities associated with heart failure, may not only improve all-cause outcomes but could also prove to be cost-beneficial.

Aim: To evaluate use of CIED-generated Heart Failure Risk Score (HFRS) alerts in an integrated, multi-disciplinary approach to HF management. Methods: We undertook a prospective, single centre outcome study of patients implanted with an HFRS-enabled Medtronic CIED, generating a “high risk” alert between November 2018 and November 2020. All patients generating a “high risk” HFRS alert were managed within an integrated HF pathway. Alerts were shared with local HF teams, prompting patient contact and appropriate intervention. Outcome data on health care utilisation (HCU) and mortality were collected. A validated questionnaire was completed by the HF teams to obtain feedback. Results: 367 “High risk” alerts were noted in 188 patients. The mean patient age was 70 and 49% had a Charlson Comorbidity Score of >6. Mean number of alerts per patients was 1.95 and 44 (23%) of patients had >3 “high risk” alerts in the follow up period. Overall, 75 (39%) patients were hospitalised in the 4–6-week period of the alert; 53 (28%) were unplanned of which 24 (13%) were for decompensated HF. A total of 33 (18%) patients died in the study period. Having three or more alerts significantly increased the risk of hospitalisation for heart failure (HR 2.5, CI 1.1–5.6 p = 0.03). The feedback on the pathway was positive. Conclusions: Patients with “high risk” alerts are co-morbid and have significant HCU. An integrated approach can facilitate timely risk stratification and intervention. Intervention in these patients is not limited to HF alone and provides the opportunity for holistic management of this complex cohort.

To determine the feasibility of a double-blinded randomized, placebo-controlled study in determining the efficacy of antibiotic prophylaxis in preventing postoperative infections (POIs) in elective nonhysterectomy laparoscopic procedures for benign gynecologic conditions.Double-blinded, randomized, placebo-controlled trial.University-affiliated tertiary referral hospital in Sydney, Australia.Women older than 18 years undergoing elective nonhysterectomy laparoscopic procedures for benign gynecologic conditions were eligible for the study and approached.Before surgery, participants were randomized to receive either 2-g cephazolin or placebo (10-mL normal saline) administered by the anesthetist. Participants and other research staff were blinded to group allocation.The primary outcome was study feasibility measured by recruitment rates, compliance rates of drug administration, compliance rates of delivery, maintenance of double blinding, and follow-up rates. Secondary outcomes included rate of POIs, length of hospitalization, readmission to hospital, unscheduled presentations to healthcare facilities, and antibiotic-related reactions. Between February 2019 and March 2021, 170 patients were approached with 117 participants (68.8%) recruited and randomized. The study had a high compliance rate of trial drug delivery (95.7%) and a high follow-up rate (99.1%).This pilot study has demonstrated feasibility of a large-scale study with a recruitment rate of 68% of patients approached and excellent trial drug delivery and follow-up rates. As anticipated, it is underpowered for identifying clinically significant findings for POI rates. A large-scale study is appropriate and essential to determine the health-related risks of antibiotic prophylaxis with an emphasis on antimicrobial stewardship. The sample size for a large-scale study is 1678 participants based on infection rates in this pilot study.

Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. A total of 189 patients were discussed from January-December 2020. This was uninterrupted during the COVID-19 pandemic. The mean age was 70.3±18.1 years and median follow-up 6 months (range 1–13 months). The mean Charlson Co-morbidity score was 5.3±1.2 and Rockwood Frailty Score was 4.9±1. The mean number of outpatient clinic attendances avoided was 1.7±0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p The HF multispecialty virtual MDT approach provides seamless integration of primary care community services with secondary and tertiary care. Consensus decision from MDT meetings provides holistic approach for HF patients with comorbidities and frailty, and reduces inconvenience to patients by preventing the need to attend multiple specialty clinics. This approach can also lead to significant cost-savings to the healthcare system. Funding Acknowledgement Type of funding sources: None.

Introduction: Ventilator-associated pneumonia (VAP) is a serious health care-associated infection. It prolongs hospital stay and drives up hospital costs reporting high morbidity and mortality. VAP is defined as pneumonia that occurs 48h or more after endotracheal intubation or tracheostomy, caused by infectious agents not present or incubating at the time mechanical ventilation.VAP requires rapid diagnosis and initiation of the appropriate antibiotics. Materials and Methods: The present study was done in the department of Microbiology, Rajarajeswari Medical college, Bangalore. All the clinically suspected cases of VAP from intensive care units over a period of one year were included in the study. Endotracheal aspirate (ETA) and bronchoalveolar lavage (BAL) samples were collected from all patients and processed . Identification was carried out according to standard biochemical tests. Sensitivity pattern was determined using Kirby-bauer disc diffusion according to CLSI guidelines. Results: Out of 160 patients, who were on mechanical ventilation, 7 patients fulfilled the clinical and microbiological criteria. Incidence of VAP in our study is 4.4 and incidence density is 10.5 for 1000 ventilator days.57% of bacterial isolates were found to be Acinetobacter spp. followed by Pseudomonas aeruginosa 29% and Klebsiella pneumoniae 14%. Among 7 cases, 3(43%) were Early onset, 4(57%) were late onset VAP. Discussion and Conclusion: Even in the era of advanced medical care VAP remains a major challenge. The risk of developing VAP can be reduced by VAP prevention care bundles. Timely diagnosis is a major step to initiate appropriate antibiotics for better outcomes. Both patients and units are at risk of developing multidrug–resistant organisms and therefore appropriate antibiotic stewardship is essential. Better knowledge of local patterns of pathogens causing VAP can help facilitate treatment choice, in turn reducing the ventilator days and hospital stay.

Aims/Background Heart failure affects approximately 1 million people in the UK, adversely affecting quality of life, functional capacity and cognitive health. Iron deficiency complicates heart failure in approximately 50% of patients. Giving intravenous ferric carboxymaltose has been shown to improve quality of life in patients with heart failure (New York Heart Association class and Kansas City Cardiomyopathy Questionnaire). Methods A quality improvement project was designed to assess the feasibility, safety and cost implications of establishing an intravenous iron service in the authors' centre. Results Between July and December 2019 61 patients who were screened met the inclusion criteria and were administered intravenous ferric carboxymaltose. There were statistically significant improvements in ferritin levels (83.3 ug/litre to 433 ug/litre; PConclusions Intravenous iron replacement with ferric carboxymaltose is safe and cost effective, and should be considered in eligible iron-deficient patients with symptomatic heart failure. Integration with another day case intravenous service represented the most logistically simple and economically viable method of service delivery.

Background/Introduction Heart Failure is frequently associated with several comorbidities such as ischaemic heard disease, diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease and frailty. This level of complexity is best dealt with by a multispecialty multidisciplinary team (MDT) model. Methods This was a single centre observational study (January 2020-December 2020) that was undertaken in a British university hospital looking at effect of HF multispecialty virtual MDT meetings on HF outcomes. Patients acted as their own controls outcomes compared for equal period pre versus post MDT meeting. The multi-specialty meeting was conducted once monthly via video-conferencing. It consisted of heart failure cardiologists (from primary secondary and tertiary care), heart failure specialist nurses (hospital and community), nephrologist, endocrinologist, palliative care specialists, chest physician, pharmacist, pharmacologist and geriatrician. Recommendations were made as consensus from the multispecialty meeting. The main outcome measures were 1) number of hospitalisations and 2) outpatient clinic attendances 3) cost savings. Results A total of 189 patients were discussed from January- December 2020. This was uninterrupted during the COVID- 19 pandemic. The mean age was 70.3 ± 18.1 years and median follow-up 6 months (range 1-13 months). The mean Charlson Co-morbidity score was 5.3 ± 1.2 and Rockwood Frailty Score was 4.9 ± 1. The mean number of outpatient clinic attendances avoided was 1.7 ± 0.4. This reduced inconvenience to patients, saved patients money (transport and parking costs) and led to carbon footprint reduction. The MDT meeting total costs were £15,400 and the 31 clinic appointments they generated cost an estimated £3720. However, the MDT meetings prevented 277 clinic appointments (cost saving £33,352). Finally, the mean number of hospitalisations pre-MDT was 0.7 Vs 0.2 post MDT (p

Funding Acknowledgements Type of funding sources: None. Background The Heart Rhythm Society (HRS) and European Heart Rhythm Association (EHRA) consensus states complete extraction is recommended for all patients with definite cardiac implantable electronic device (CIED) infection. Although complete removal of hardware is the best way to manage infections, lead extraction is a complex procedure with significant risk. As age and complexity of patients increase so too does extraction risk. In very high risk cases conservative management is cited, though little is known on outcomes. Purpose We are a high volume tertiary centre which serves a population of 2 million. 2 experienced operators perform 65 extraction procedures per year for the past 10 years. We report our experience of device reburial as initial management of CIED pre-erosion and erosion in cases deemed too high risk for extraction. Method We retrospectively reviewed all reburial procedures undertaken over 9 years. Patient and lead factors influencing decisions were assessed. Information on number of leads, dwell time, prior procedure, infective status and comorbidity was collated. The outcomes included morbidity, defined by repeat procedure (revision and/or extraction) and mortality. Results 86 patients underwent 96 procedures from March 2013 until August 2020. All patients undergoing device reburial were included. 55.8% of patients were male, mean age was 73. 21 patients died, 7 of these deaths occurred within 12 months of the index reburial procedure. The mean follow up period was 39 months (range 5–90). 65.1% of patients had a procedure (de novo implant, upgrade or replacement) within 12 months prior to revision. We reviewed patients in 2 subgroups based on revision indication – erosion and pre-erosion. Erosion was defined as externalised lead/device. Pre-erosion was defined as superficial device with skin tethering but no exposure. The former is a definite indication for lead extraction, the latter a relative indication. All in the pre-erosion group were systemically well with no infection evident. One patient with erosion had a positive blood culture. The mean age in the erosion group was 85 years with a Clinical Frailty Score (CFS) 4.98 and lead dwell time 17.87 years compared to age 68 years, CFS 3.98 and dwell time 8.14 years in the pre-erosion group. Patients in this cohort with an eroded device were deemed too high risk to undergo transvenous lead extraction. A higher proportion of patients presenting with erosion died within 12 months of the index reburial procedure (16.67% vs 4.84%). 21% with an eroded device and 11% with a pre-eroding device undergoing reburial as first line management required future extraction. Conclusion Our 9 year data suggests less invasive intervention is a valid option in high risk groups such as older age, frailty, long lead dwell time, with an acceptable incidence of reintervention and/or extraction. This data can help guide informed consent in the future.

The essence of appropriate nutritional intake on a regular basis has a great impact in maintaining fundamental physiological functions and the body metabolism. Considering how pivotal maintaining a nourishing fat diet is to human health, Omega-3 fatty acids have gained a lot of attention in recent times. Omega-3 fatty acids (n-3 FAs) such as eicosapentaenoic acid (EPA) and DHA are considered as essential fatty acids (EFAs) offering enormous nutritional benefits: from playing a major role in the prevention and treatment of a number of human diseases, such as cardiovascular disorders and neurological disorders, to having anti-inflammatory properties, to providing joint support, etc. Hence, their incorporation into our daily diet is of great importance. Also, both EPA and DHA have been shown to be therapeutically significant in treating several infectious diseases. EFAs were initially thought to be marine in origin, produced by fishes. Consequentially, this led to the increase in the industrial extraction of fish oils for meeting the commercial need for of n-3-rich dietary supplements. Although fish oil supplementation met almost all of the dietary demand for EFAs, they did come with a fair share of drawbacks such as undesirable odour and flavour, heavy metal contamination, extinction of fish species, etc. Oleaginous micro-organisms are a promising alternative for the production of a more sustainable, consistent and quality production of n-3 FAs. Thus, the entire review focuses on understanding the eco-friendlier production of n-3 FAs by micro-organisms.

Exopolysaccharide is long-chain high molecular weight polymeric carbohydrates composed of monosaccharide units bound together by glycosidic linkage, which are secreted extracellularly by the secreting microscopic cell or organism. These exopolysaccharides can be either homopolysaccharide or heteropolysaccharide in nature. Exopolysaccharide comprises repeated units of sugar moieties attached to the carrier lipid and can be associated with proteins, lipids, organic and inorganic compounds, and metal ions. Bacteria, archaea, yeast, filamentous fungi, and single cell of eukaryotes produce microbial exopolysaccharides. Microbial synthesis of polysaccharides is greatly influenced by environmental factors such as temperature, pH, pressure, salinity, toxicity, and radiation levels across their ecological niche. Due to the very less production time of exopolysaccharides and its simple purification process, these have found various successful applications in various industrial sectors such as pharmacology, diagnostics, nutraceuticals, functional foods, cosmetics, herbicides and insecticides, bioremediation, biotechnology, petrochemicals, dairy industry, and paint industry. Some of the most important exopolysaccharides and its industrial applications are Acetan (as preservative), Alternan (as commercial gum Arabic), Biodispersion (as remediation of oil spills), Cellulose (as non-indigestible fiber), Curdlan (as a food additive and gelling agent), Dextran (as moisturizers), Emulsan (as crude oil recoveree), Gellan (as stabilizer and microencapsulation matrix), Hyaluronan (as for the removal of dead cells in skincare products), Kefiran (as anti-cancer agents), Levan (as viscosifier), Mutan (as adhesives), Succinoglucan (as emulsion stabilizers), Welan (as thickening agents in high-temperature industries), Xanthan (as an emulsifier and suspending agent), and Pullulan (as orally consumable films). These exopolysaccharides are produced by bacterial species such as Acetobacter, Pseudomonas, Leuconostoc, Alteromonas, Alcaligenes, Lactobacillus, Zymomonas, Xanthomonas, Aureobasidium (fungus). These compounds are purified by techniques such as membrane filtration, dialysis, precipitation, various types of column chromatography, lyophilization, distillation, and rotatory vaporization. This chapter describes different isolation and purification techniques for microbial exopolysaccharides.

The dairy industry is regarded as an important food industry that provides everyone with different nutrients containing dairy products. In addition to these nutritional qualities, the dairy industry is seen as a strong source of other industries’ raw materials. Most notably, the dairy industry utilizes environmentally friendly innovations that conserve energy. Membrane separation technology is one of those that also focuses on a cost-effective and environmentally sustainable way that can be widely implemented for many useful purposes in the dairy industry. Technological developments related to the production of new membranes, process engineering improvements and a greater understanding of the functionality of milk components have expanded the range of processes of membrane separation to cover the entire milk composition spectrum. Advanced membrane processes make it possible to recover and purify milk components. It also improves the shelf life of milk without heat treatment exposure, standardizes the milk components for the tailoring of milk products and increases the yield.

Pharmaceuticals and personal care products (PPCPs) do not have standard regulations for discharge in the environment and are categorized as contaminants of emerging concern as they pose potential threats to ecology as well as humans even at low concentrations. Conventional treatment processes generally employed in the wastewater treatment plants are not adequately engineered for effective removal of PPCPs. Identifying cost-effective tertiary treatment is therefore, important for complete removal of PPCPs from wastewater prior to discharge or reuse. Present study demonstrates adsorption using granular-activated carbon (GAC) as a possible tertiary treatment for simultaneous removal of five PPCPs from aqueous media. Adsorbent was characterized in terms of morphology, surface area, surface charge distribution, and presence of functional groups. Performance of GAC was investigated for sorption of three hydrophilic (ciprofloxacin, acetaminophen, and caffeine) and two hydrophobic (benzophenone and irgasan) PPCPs from aqueous solution varying the process parameters (initial concentration, adsorbent dose, pH, agitation time). Langmuir isotherm model (correlation coefficients (R2): 0.993 to 0.998) appeared to fit the isotherm data better than Temkin isotherm model for these adsorbates. Adsorption efficiencies of these compounds (8.26 to 20.40 mg g-1) were in accordance with their log Kow values. While the adsorption kinetics was best explained in terms of a pseudo-second-order kinetic model, the data suggested that adsorption mechanism was mainly governed by the intraparticle diffusion. The role of physical factors like molecular volume, molecular size, and area of targeted PPCPs were investigated through computational studies which in turn can help predicting their uptake onto GAC.

Introduction Heart failure (HF) affects approximately 1 million people in the UK, adversely affecting quality of life, functional capacity and cognitive health. This results in frequent hospitalisation and significant healthcare costs1, 2. Iron deficiency complicates heart failure in approximately 50% of patients3, and is increasingly recognised as a significant contributor to morbidity in this group. Intravenous ferric carboxymaltose (FCM) has been shown to improve quality of life (New York Heart Association [NYHA] class and Kansas City Cardiomyopathy Questionnaire [KCCQ]), performance in 6-minute walk test (6MWT), reduce hospitalisations, and is reflected in international guidelines4-7. We aimed to assess the feasibility, safety and cost implications of establishing an IV iron service for patients with HF in a large tertiary cardiology centre. Method Over a 6-month period (July-December 2019), outpatients with symptomatic heart failure (NYHA class ≥2) and severe left ventricular systolic dysfunction (LVEF ≤40%) were screened, and serum iron studies performed. Patients with iron deficiency (ferritin Results Fifty-two patients underwent IV iron replacement (69% male, mean age 66 years) with no significant adverse events or hospital admissions. The financial impact to the trust was a net income of £55 per patient (FCM treatment £290, remuneration £345). Ferritin increased significantly 83.3ug/L to 433ug/L (p Conclusion Utilisation of the existing iron infusion service facilitated the delivery of IV iron replacement for patients with heart failure with little need for additional training and resources. Delivery of the service did not incur additional cost to the trust and in fact there was a small net gain. In-keeping with published data we demonstrated comparable improvements in serum iron parameters and a trend towards improvement in NYHA class. IV iron replacement with FCM is safe and affordable and should be considered in all iron deficient patients with symptomatic heart failure. Conflict of Interest Yes - recieved honorarium from Vifor

The aim of our study is to determine if there is a natural progression of QRSd in ICD-only patients. Retrospective study over a 7-year period of 86 consecutive patients who underwent ICD-only implantation in 2008 at the Liverpool Heart and Chest Hospital, UK. The mean age at ICD implantation was 62.3 (± 11.5) years, range 24–82 years. Mean length of follow-up ECGs available was 5.0 (± 1.6) years, total of 431 patient-years. We observed a progressive prolongation of QRSd over the 7-year study period. The linear mixed model found a statistically significant (p

Aims Pacing and Cardiac Resynchronization Therapy (CRT) procedural training for novice operators usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee ability to perform required tasks at predetermined performance levels prior to in-vivo practice. We sought to characterize and validate with experts a reference approach to pacing/CRT implants based on objective and explicit performance quality metrics, for the development of a reproducible, simulation-based, training curriculum aiming to operator proficiency. Methods Three experienced CRT implanters, a behavioural scientist and two engineers performed a detailed task deconstruction of the pacing/CRT procedure and identified the performance metrics (phases, steps, errors, critical errors) that constitute an optimal CRT implant for training purposes. The metrics were stress tested to determine reliability and score-ability and then subjected to detailed systematic review by an international panel of 15 expert implanters in a modified Delphi process. Results Thirteen procedure phases were identified, consisting of 196 steps, 122 errors, 50 critical errors. The expert panel deliberation added 16 metrics, deleted 12, and modified 43. Unanimous panel consensus on the resulting CRT procedure metrics was obtained, which verified face and content validity. Conclusion A reference pacing/CRT procedure and metrics created by a core group of experts accurately characterize the essential components of performance and were endorsed by an international panel of experienced peers. The metrics will underpin quality-assured novice implanter training.

Background: Hope is important to patients with cancer. Identifying factors that influence hope is important. Anxiety, depression, fatigue, and pain are reported to impair hope. The objective of this study was to determine whether age, gender, marital status, duration of cancer, symptoms, or symptom burden measured by the sum of severity scores on the Edmonton Symptom Assessment Scale (ESAS) correlated with hope measured by the Herth Hope Index (HHI). Methods: Patients with advanced cancer in a palliative care unit participated. Demographics including age, gender, marital status, cancer site, and duration of cancer were collected. Individuals completed the ESAS and HHI. Spearman correlation and linear regression were used to assess associations adjusting for gender (male vs female), age (< 65 vs ≥ 65 years), marital status (married or living with a partner vs other), and duration of cancer (≤ 12 vs > 12 months). Results: One hundred and ninety-seven were participated in the study, of which 55% were female with a mean age of 61 years (standard deviation 11). Hope was not associated with gender, age, marital status, or duration of cancer. In univariable analysis, hope inversely correlated with ESAS score (−0.28), lack of appetite (−0.22), shortness of breath (−0.17), depression (−0.39), anxiety (−0.32), and lack of well-being (−0.33); only depression was clinically relevant. In multivariable analysis, total symptom burden weakly correlated with hope; only depression remained clinically significant. Discussion: This study found correlation between symptom burden and hope was not clinically relevant but was so for depression. Conclusion: Among 9 ESAS symptoms, only depression had a clinically relevant correlation with hope.

Aims Transvenous lead extraction is challenging, often requiring specialist equipment and prolonged hospital admission. A single tariff or itemized costs may be available for reimbursement. Due to limited data relating to the costs of transvenous extraction, it is unclear whether either form of reimbursement is adequate. We aim to describe accurately the total real-world costs of managing patients undergoing transvenous extraction at a single, large centre. We further aim to consider the additional costs of device reimplantation. Methods and results At a single UK extraction centre, a retrospective, patient level service line analysis was undertaken, during a complete financial year. Seventy-four patients required transvenous extraction (47 infected and 27 non-infected; 156 leads). Sixty-nine procedures (93%) were performed under general anaesthesia, with a median time in theatre of 95 min [interquartile range (IQR) 71-120]. Specialist extraction tools were required for 130 leads (83%). The median hospitalization duration was 3 days (IQR 1-8). The mean cost of extraction was £9228 (±4099); infected £10 727 (±4178) and non-infected £6619 (±2269). With the additional costs of device reimplantation, the overall mean cost rose to £17 574 (±12 882); infected £22 615 (±13 343) and non-infected £8801 (±5007). At the time of this study, the UK NHS tariff was £2530 for elective and £4764 for non-elective extraction, covering barely half of the real costs. Conclusion We demonstrated a substantial difference between the real-world cost of extraction and the UK NHS tariff. Extracting centres should scrutinize their practice, including the timing of reimplantation.

Background Implantable cardiac defibrillators (ICD) improve survival from life-threatening arrhythmias, and have rapidly become a standard therapy for those at risk of arrhythmic cardiac death. However, shock therapy can be associated with anxiety and a reduction in quality of life. We sought to ascertain anxiety levels in our patient cohort with ICDs who had received shock therapy. Methods All patients at the Liverpool Heart and Chest Hospital who received shock therapy and were reviewed in the ICD clinic between May and August 2017 were screened retrospectively. Anxiety was evaluated using the Generalised Anxiety Disorder (GAD-7) and graded as none (0–4), mild (5–9), moderate (10–14) and severe (15–21). The questionnaire was undertaken via a telephone survey. To account for post-shock distress, the GAD-7 was administered a minimum of six weeks post shock. Results During the study period, 38 patients who experienced 45 shock therapy episodes were identified. Four (11%) patients died and two (5%) patients did not complete the GAD-7 questionnaire (one had recently experienced a VT storm and the other patient was diagnosed with palliative malignancy). They were excluded from further analysis. Thirty two patients (who experienced 38 shock episodes) completed a GAD-7 questionnaire. Table 1 outlines the baseline characteristics of these patients. Twenty seven out of 32 (84%) patients received shock therapy on one occasion, four (13%) on two occasions and one (3%) on three occasions during the study period. The mean GAD-7 score was 9±7. The degree of anxiety levels due to shock therapy are depicted in figure 1. Of the 24 patients reporting at least mild anxiety levels, 16 (67%) reported their symptoms had a negative impact on their daily life. During six (16%) out of 38 episodes of shock therapy, multiple shocks (>2) were delivered per episode. Thirty five (92%) of these shocks were appropriate. There was no significant correlation between whether patients received single or multiple shocks during the study period and the GAD-7 score (R=0.166, p>0.05). Conclusions Shock therapy from an ICD is associated with significant anxiety. However, psychological support including cognitive behavioural therapy may also be of value in these patients and requires further evaluation.

Solar Energy converts heat from the sun into electricity, either directly making use of Photovoltaic (PV) or Compressed Solar Panel (CSP). It is a clean green electricity which is the Earth's most available source of energy. Solar energy is the future of power generation due to its renewability nature. It has gained a wide acceptance across the world. Many research works are going on to harness the maximum power from sunlight, but few of the main hindrances in harnessing maximum power are dust accumulation on solar panels and air pollution, which cuts solar cell energy output by over 25% – 40% in some portions of globe in which one among tropical countries like India. Since our Indian government has set an ambitious target of installation of grid connected rooftop solar photovoltaic project with the capacity of 40GW out of the total target of 175GW of renewable energy capacity over the next five years by 2022, it's also our responsibility to be as a part in achieving nation's target. This proposed paper describes the implementation of a Smart Solar panel cleaning system with primary focus on making use of Internet of things (IoT) technology. This enables dust monitoring capability, advanced analysis and system control which prompts to increase the total efficiency of the solar PV panel.

Online social media is an important platform over the globe to share once opinion. People go for online social media as it is easy to convey their opinions, to have an up-to-date knowledge about the ongoing trends on a daily basis. Twitter is one of the biggest and renowned online social media gets a large number of tweets each day on various topics. This huge volume of raw information can be used for Social, Industrial, Economic, or Government approaches by arranging as per our need and processing. Hadoop is the best tool for analyzing the twitter data as it processes the huge sets of data in parallel. Since twitter contains a variety of opinions on various topics it is necessary to analyze these opinions to know the customer behavior. Analysis is done using Hadoop and its ecosystem to know the polarity of every tweet. In this paper, we have discussed how effectively sentiment analysis is performed on the tweets gathered from twitter using Big data approach. We have used Apache Flume to stream ongoing twitter data into the Hadoop Distributed File System (HDFS). The pig scripts are written to extract tweet from the raw nested twitter data. The dictionary based method is used for sentiment analysis and tweets are classified into three groups such as positive, negative and neutral.

We describe the case of a 75-year-old woman with permanent atrial fibrillation and advanced chronic kidney disease who was referred with worsening dyspnoea. She previously underwent surgical mitral and aortic mechanical valve replacements in 1989 for severe mitral and aortic stenoses secondary to

BACKGROUND: Extra pulmonary tuberculosis (EPTB) is a major health problem due to its destructive nature. The term EPTB, which encompasses all forms of TB other than pulmonary TB (PTB), has a broad spectrum of clinical manifestations, hence a real diagnostic challenge. AIM: The primary objective of this study was to describe the basic demographic, clinical characteristics, trends of various types of tuberculosis and to detect the incidence of EPTB in Mysore over a period of two years. MATERIALS AND METHODS: This is an observational study of patients of all types of Extrapulmonary tuberculosis from January 2011 to December 2013 in all age groups, evaluated at Mysore Medical College and Research institute, Mysore, Karnataka, India. RESULTS: Among 4500 cases registered for treatment of all forms of tuberculosis, 710(15.77%) had EPTB. More than half of the cases of EPTB (n = 472, 66%) were among adult age groups. Pleural TB was the commonest type of EPTB (n = 268, 37.03%), followed by lymph node TB (n = 210, 29.81%). Involvement of lymph nodes was the commonest manifestation in less than 14 years of age group, while involvement of pleura was more common among > 65 years. CONCLUSION: The burden of EPTB is more among the productive age group. Increase in the trend of EPTB cases, and other rare forms of EPTB are a point of concern highlighting the importance of strengthening the services towards this group.

Background: The use of pacemakers in the treatment of cardioinhibitory vasovagal syncope is controversial with a mixed message from the limited evidence base. Single chamber leadless pacemakers have been shown to be an effective alternative option to conventional pacemakers. Objective: This study examines the use of leadless pacemakers in a cardioinhibitory vasovagal population in the United Kingdom. Methods: Observational data on 32 patients implanted with the Micra Transcatheter Pacemaker System for vasovagal syncope are presented. Data was collected on implant indications, implant procedure and follow up data from 12 centres across the United Kingdom that had elected to use a Micra leadless pacemaker in this patient population. Results: 32 patients aged 37 ± 14 years (range 18 to 64 years) with 62% of the patients being female were recruited to the study. Vasovagal syncope was diagnosed clinically and with the support of Holter monitoring, tilt table testing and implantable loop recorders. The duration of symptoms was 8 ± 8 yrs. with an average frequency of syncope being 4 ± 6 times/year. The Micra pacemaker was successfully implanted in all patients with a major complication rate of 3.1%. Patients were followed up for 404 ± 237 days (range 63–928 days). At follow up 28 (87%) patients were free from symptoms. Conclusions: This observational study suggests that the use of a single chamber leadless pacemaker in the treatment of cardioinhibitory vasovagal syncope might be a reasonable clinical option. Keywords: Vasovagal, Cardioinhibitory, Syncope, Pacemaker, Leadless pacemaker, Micra