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BACKGROUND: Assessing transmission of SARS-CoV-2 by children in schools is of crucial importance to inform public health action. We assessed frequency of acquisition of SARS-CoV-2 by contacts of pupils with COVID-19 in schools and households, and quantified SARS-CoV-2 shedding into air and onto fomites in both settings. METHODS: We did a prospective cohort and environmental sampling study in London, UK in eight schools. Schools reporting new cases of SARS-CoV-2 infection to local health protection teams were invited to take part if a child index case had been attending school in the 48 h before a positive SARS-CoV-2 PCR test. At the time of the study, PCR testing was available to symptomatic individuals only. Children aged 2-14 years (extended to

Introduction The use of implantable cardiac electronic devices (ICEDs) is rising in part due to expanding indications and an aging population [1]. ICED infection occurs in 0.5-2.2% of all implants [1] and implicated in around 10% of cases of infective endocarditis (IE) [2]. ICED infection is associated with prolonged antibiotic therapy and hospital stays, with a mortality rate as high as 35% [1,3,4]. Echocardiography has an established role in the diagnosis of ICED infection and is advocated by guidelines [1], however whether imaging can guide duration of antimicrobial therapy is unclear. Methods We aimed to determine whether echocardiography following ICED extraction was associated with length of antibiotic therapy. Consecutive patients undergoing ICED extraction at Leeds Teaching Hospitals between 01/01/2006 and 31/12/2017 were identified from a prospectively maintained IE database. Patient demographics, microbiology and echocardiographic data were recorded. Results During the study period 64 patients underwent ICED extraction, had suspicion of IE and had available imaging data; of whom median age was 67.5(17) years and 52(81.3%) were male. IE was caused by Staphylococcus species in 44(68.8%), 51(79.7%) episodes were definite according to the Duke criteria and 13 Duke possible. Device removal was usually performed percutaneously in 48(75%), with surgical extraction in 16. Reported complications included lead fracture (1) and superior vena cava dissection (1). Median episode duration (diagnosis to completion of antibiotics) was 40.5(23.75) days, diagnosis to extraction was 17(23) days and extraction to completion of antibiotic therapy was 14(17.75) days. All included patients had an echocardiogram prior to extraction, 41(64.1%) had evidence of vegetation and of these, 32 were confined to the ICED lead whilst nine had endocardial involvement. Following extraction 43(67.2%) underwent echocardiography after a median of 8(7) days, demonstrating residual vegetation on native structures in 11 (figure 1). Compared to those without evidence of persistent vegetation, the duration of antibiotic therapy following extraction (20(10) vs 7.5(15.3) days) and imaging (28(19) vs 14(13.8) days) was longer. Patients without evidence of vegetations on post extraction echocardiogram had similar episode duration to those who did not have further imaging (38.5(23) vs 36(29) days). Twenty (31.3%) were pacing dependent and either received temporary pacing or immediate re-implantation, and a further 37(57.8%) were re-implanted during the index presentation (table 1). Conclusions In this series, in the absence of persistent vegetations on echocardiogram, after removal of an infected ICED, duration of antibiotic therapy was shorter. This suggests imaging can help guide course length, potentially reduce the length of hospital stays, antibiotic risks and selection for resistant bacteria. Conflict of Interest No

Background Observational studies investigating risk factors in coronavirus disease 2019 (COVID-19) have not considered the confounding effects of advanced care planning, such that a valid picture of risk for elderly, frail and multi-morbid patients is unknown. We aimed to report ceiling of care and cardiopulmonary resuscitation (CPR) decisions and their association with demographic and clinical characteristics as well as outcomes during the COVID-19 pandemic. Methods Retrospective, observational study conducted between 5th March and 7th May 2020 of all hospitalised patients with COVID-19. Ceiling of care and CPR decisions were documented using the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) process. Unadjusted and multivariable regression analyses were used to determine factors associated with ceiling of care decisions and death during hospitalisation. Results A total of 485 patients were included, of whom 409 (84·3%) had a documented ceiling of care; level one for 208 (50·9%), level two for 75 (18·3%) and level three for 126 (30·8%). CPR decisions were documented for 451 (93·0%) of whom 336 (74·5%) were ‘not for resuscitation’. Advanced age, frailty, White-European ethnicity, a diagnosis of any co-morbidity and receipt of cardiovascular medications were associated with ceiling of care decisions. In a multivariable model only advanced age (odds 0·89, 0·86–0·93 p p p = 0·048) were independently associated. Death during hospitalisation was independently associated with age, frailty and requirement for level two or three care. Conclusion Ceiling of care decisions were made for the majority of patients during the COVID-19 pandemic, broadly in line with known predictors of poor outcomes in COVID-19, but with a focus on co-morbidities suggesting ICU admission might not be a reliable end-point for observational studies where advanced care planning is routine.

Introduction Severe chronic heart failure (CHF) has a high symptom burden due to breathlessness, fatigue and fluid retention, comparable to many types of cancer but despite this, patients are often not referred to palliative care services. The ’Surprise Question’ - ‘would you be surprised if this patient were to die within the next year?’ has been proposed as a screening tool to prompt earlier recognition that patients are nearing the end of life. It forms part of the Gold Standards Framework and is included in the National Institute of Health and Clinical Excellence (NICE) guidance for end-of-life care. We have previously demonstrated the ability of this simple and intuitive question to predict mortality in hospitalised CHF patients and that it can be used by cardiologists and heart failure nurse (HFN) specialists with similar levels of accuracy. Aims We aimed to determine whether the Surprise Question could influence advanced care planning and referrals to palliative care in hospitalised CHF patients. Methods Retrospective analysis of 89 hospitalised CHF patients who received either a ‘surprised’ or ‘not surprised’ response from their HFN. We analysed the rate of referral to palliative care, completion of not-for-resuscitation status, readmission with decompensation and mortality after 2-years. Results Sixty patients (67%) received a ‘not surprised’ and 29 (33%) a ‘surprised’ response. In patients who received a ‘not surprised’ response, 25 (28%) were referred to palliative care within the study period, compared to 0 (0%) in the ‘surprised’ group. The median time from study enrolment to referral was 55 days, which was on average 19 days before death, but occurred within 30-days of enrolment for only 8 patients. Not-for-resuscitation status was completed for 11% and 3% of patients, respectively. The Surprise Question also predicted readmission with decompensation, occurring in 25 (42%) and 4 (14%), and continued to predict mortality beyond 1-year with 35 (58%) and 4 (14%) patients having died respectively. Discussion Our analysis highlights the potential of the Surprise Question to act as a prompt for earlier referral to palliative care services and advanced care planning. Decompensation of heart failure is a poor prognostic sign, but despite this there was a low rate of not-for-resuscitation decisions during the index admission, and referrals to palliative care were usually made shortly before death. In the future we aim to assess in a randomised controlled trial whether the introduction of the Surprise Question into routine clinical care can achieve these aims. HFNs are able to use the Surprise Question with similar levels of accuracy to cardiologists and are the point of contact for patients with whom they have regular interaction. HFN are therefore ideally placed to develop relationships conducive to palliative care planning and can lead in this area. Conflict of Interest None

Isolated myocardial involvement in tuberculosis is exceedingly rare but there are reports it can present with sudden cardiac death, atrioventricular block, ventricular arrhythmias or congestive cardiac failure. We report the case of a 33-year-old male, of South Asian descent, who presented with chest pain, shortness of breath and an abnormal ECG. The patient had no significant past medical history and coronary angiogram showed no evidence of coronary artery disease. Of note, the patient had recently been discharged from a local district hospital with an episode of myocarditis. The patient was found to be severely hypoxic with evidence of severe biventricular failure on echocardiography. Computed tomography of the chest demonstrated hilar lymphadenopathy, and the differential diagnosis was thought to be tuberculosis or sarcoidosis. A TB Quantiferon gold test performed at the district hospital was positive; however, fine needle aspiration was negative for acid-fast bacilli. Despite aggressive diuresis, the patient became increasingly hypoxic and suffered a cardiac arrest. Post-mortem confirmed a diagnosis of myocardial tuberculosis – a rare case of acute decompensated heart failure. Learning points: Tuberculosis myocarditis is a rare diagnosis but should be considered in at risk individuals presenting with acute fulminant myocarditis. Cardiac failure can occur even in the absence of disseminated tubercular disease. TB myocarditis is not just a disease of the immunocompromised. Definitive diagnosis of cardiac tuberculosis during life requires a myocardial biopsy. Echocardiography is a vital tool for the assessment of cardiac function, filling pressures and fluid status in the critically unwell patient.

The SARS-CoV-2 pandemic is accompanied by an ever-rising death toll attributed to coronavirus disease 2019 (COVID-19), but questions have persisted regarding deaths formally attributed to COVID-19. We aimed to provide an independent review of clinical features of patients who died during hospitalisation with a positive PCR test for SARS-CoV-2 and relate these to the reported cause of death. Between 23 March and 28 April 2020, a total of 162 patients with a positive SARS-CoV-2 PCR died in our NHS trust. COVID-19 infection was documented as the direct cause of death in 150 (93%). Review of the records revealed 138 (92%) patients had pulmonary infiltrates on chest radiography, and 146 (97%) required oxygen therapy. This retrospective review of cause of death has demonstrated that the overwhelming majority of hospitalised patients with positive SARS-CoV-2 PCR died as a direct consequence of COVID-19 infection.

Background Following the development of resistance to anti-malarial mono-therapies, malaria endemic countries in Africa now use artemisinin-based combination therapy (ACT) as recommended first-line treatment for uncomplicated malaria. Patients' adherence to ACT is an important factor to ensure treatment efficacy, as well as to reduce the likelihood of parasite resistance to these drugs. This study reports adherence to a specific ACT, artemether-lumefantrine (AL), under conditions of routine clinical practice in Kenya. Method The study was undertaken in Garissa and Bunyala districts among outpatients of five government health facilities. Patients treated with AL were visited at home four days after having been prescribed the drug. Respondents (patients ≥ 15 years and caregivers of patients < 15 years) were interviewed using a standardized questionnaire, AL blister packs were physically inspected and the adherence status of patients was then recorded. Multivariate logistic regression modelling was used to determine predictors of adherence. Results Of the 918 patients included in the study, 588 (64.1%) were 'probably adherent', 291 (31.7%) were 'definitely non-adherent' and 39 (4.2%) were 'probably non-adherent'. Six factors were found to be significant predictors of adherence: patient knowledge of the ACT dosing regimen (odds ratio (OR) = 1.76; 95% CI = 1.32-2.35), patient age (OR = 1.65; 95% CI = 1.02-1.85), respondent age (OR = 1.37; 95% CI = 1.10-2.48), whether a respondent had seen AL before (OR = 1.46; 95% CI = 1.08-1.98), whether a patient had reported dislikes to AL (OR = 0.62 95% CI = 0.47-0.82) and whether a respondent had waited more than 24 hours to seek treatment (OR = 0.73; 95% CI = 0.54-0.99). Conclusion Overall, adherence to AL was found to be low in both Garissa and Bunyala districts, with patient knowledge of the AL dosing regimen found to be the strongest predictor of adherence. Interventions aimed at increasing community awareness of the AL dosing regimen, use of child friendly formulations and improving health workers' prescribing practices are likely to ensure higher adherence to AL and eventual treatment success.