OBJECTIVE:To investigate whether a multifaceted intervention for building resilience to external provocations to health reduced the number of all-cause hospital re-admissions and deaths of people hospitalised with multimorbid heart disease, compared with standard post-discharge management. STUDY DESIGN:Single centre, prospective, open, randomised trial with blinded endpoint acquisition and adjudication (REsilience to Seasonal ILlness and Increased Emergency admissioNs CarE, RESILIENCE). SETTING, PARTICIPANTS:Adults (aged 18 years or older) admitted as emergency medical patients with multimorbid heart disease to Austin Hospital, a tertiary hospital in Melbourne, 19 November 2020 - 28 July 2022, with planned discharge to home. INTERVENTION:Standard post-discharge management, as well as the 12-month active management program: home visits by a nurse, specialist clinical review, and tailored recommendations for optimising clinical management and promoting resilience to external provocations; the nurse coordinated the additional care, provided individualised support, and arranged RESILIENCE physician reviews as required. The comparator group received standard post-discharge management only. MAJOR OUTCOME MEASURE:Proportion of days alive and out of hospital during follow-up (minimum, twelve months) with respect to the maximum number possible. RESULTS:Of 203 participants (mean age, 75.7 years; standard deviation [SD], 10.2 years; 104 women), 103 were randomly allocated to the intervention group, 100 to the standard management group; median follow-up time was 600 days (interquartile range, 416-681 days). A total of 470 hospital admissions and 3874 days of hospital stay during follow-up were recorded for 138 of the 203 trial participants (68%); 38 people (19%) died during follow-up. The days alive and out of hospital proportion was 86.5% (SD, 25.3 percentage points) for the intervention group and 88.3% (SD, 23.5 percentage points) for the standard management group (adjusted difference, 2.04 percentage points; 95% CI, -4.97 to 8.56 percentage points). CONCLUSION:A multifaceted intervention for reducing bio-behavioural vulnerability to external events was ineffective in increasing the proportion of days alive and out of hospital after hospital discharge for people admitted with multimorbid heart disease. However, the program could be modified to improve health outcomes for such people. TRIAL REGISTRATION:ClinicalTrials.gov, NCT04614428 (prospective).

Objective: Australia is experiencing ever more frequent/provocative weather and environmental challenges, including more extreme heatwaves and catastrophic bushfires. Concurrently, the annual challenge of wintry conditions to a population adapted to warmer conditions persists. Remarkably, however, there are no proven interventions to reduce seasonal challenges to the cardiovascular health of vulnerable individuals. In a world-first, the REsilience to Seasonal ILlness and Increased Emergency admissioNs CarE (RESILIENCE) Trial will test the hypothesis that an individually tailored, intervention program will reduce the risk of re-hospitalisation and mortality in vulnerable individuals. Design and method: 300 adult patients admitted to the Austin Hospital in Melbourne, Australia with heart disease and multimorbidity will be recruited and randomised (1:1) to standard care (SC) or the RESILIENCE program (RP) over 12-months. Applying a COVID-19 adapted protocol, the RP group will have their bio-behavioural profile and home environment assessed post-discharge, to determine their vulnerability to seasonal events. An individualised case-management program, including a virtual clinic review with a dedicated RP cardiac nurse and physician, will be applied to promote seasonal resilience. The primary end-point is all-cause days alive out of hospital (DAOH) during 12-month follow-up. Results: With study recruitment delayed due to COVID-19 restrictions, virtual screening of medical in-patients has confirmed the need and potential for the RP. Of 630 potential participants identified over a 6 week period, 196 patients (31%) met eligibility criteria – 85 women and 79 men, mean (±SD) age 79 ± 11 years. Non-eligibility was largely due to non-chronic form of heart disease (34%), no comorbidity (23 %), and inability to give informed consent (15%). Conclusions: Preliminary data suggest that once commenced, we will rapidly recruit the requisite number of trial participants and depending on the results, we will be able to determine the cost-effectiveness of the RP to reduce seasonally-induced admissions and mortality.

We thought we got away lightly, the first time round. Early on I made myself available to return to clinical work from a long-awaited research role I had only just begun. I was on the ward the day we received our first COVID-positive patients and can remember all of those we admitted by name. They were not many, but we had no idea what to expect. We ended up with a small but significant number of cases, with every death poignant and tragic. It was nothing compared with the tidal wave hitting our colleagues in Europe and North America. Every day, even us non-believers had the words “there but for the Grace of God go we” hanging in our thoughts. By June, we felt victorious as our numbers were dwindling and business as usual became the mantra. I felt confident enough to ask my research supervisor for a return date and handed in my notice to the clinical team, who accepted it with grace. In any case, things were fine now, and the surge staffing we planned for was not necessary. I had worked hard in the 3 months until then, so the last weekend in June I escaped to the mountains with my partner and friends for some fresh air and exercise. I will never forget the car journey back to the city. Tuning into the radio it felt like we were listening into a foreign broadcast. Case numbers were increasing. Lockdown was returning. A curfew was imposed. State borders were closing. Residents of commission housing apartments—some of the city's most vulnerable people for many reasons—were forcibly locked in their buildings with little notice, under police guard. Their anguish was unimaginable. I closed my eyes and planned the call I knew I would have to make to my research supervisor. My absence from clinical work was short-lived—barely a week. Never once did I doubt my responsibilities, but the hero worship in the media made me uncomfortable. I often used to message my colleagues in Europe and ask them what to expect, but I found them oddly silent, as though they could not find the words to speak of what they had been through. Lockdown and an enforced curfew hit me hard as did the realisation that I would not see my family this year. I knew the measures made sense and agreed in principle, but I could not shake a feeling of entrapment. Every morning I woke with a heaviness over me as I checked my phone and email for messages from home. Every day I was in fear of an encounter with the police or military even though I was never guilty of leaving my house without valid reason. Returning to the clinical team was seamless. One afternoon I was on duty with a colleague I had never met who has since become a great friend. We forged a plan to split the afternoon's workload, one of us heading to the emergency department (ED) and the other supporting the ward and manning the referral phone. I scanned the ED admissions board—a process familiar to internal medicine doctors the world over trying to pre-empt referrals. One caught my eye with the descriptor: “covid +ve: shortness of breath”. I quickly admitted the patient and called the boss. “It is starting”, he noted. He was right. After that day, every day we admitted patient after patient with COVID-19. Outbreaks in nursing homes were devastating, especially to relatives who were unable to visit. Every patient was breathless. Some quietly so, resting in bed but with abnormal vital signs. Some violently so, their oxygen requirements escalating dramatically in a short space of time. The ward filled, and we expanded quickly to four others. Our clinical team increased with junior doctors seconded from surgical units. Senior clinicians from all medical specialties volunteered and I felt lucky to have such a solid team. Hours were spent sweating in personal protective equipment (PPE) and we finished every day physically and emotionally exhausted. I had never fully understood the importance of leadership in a clinical context but now I saw it unfold before me. The hierarchy was flattened, and I knew I could call any boss at any time. Inconsequential habitual ward-round traditions were abandoned. Paper notes vanished in favour of electronic documentation. Efficiency improved. The crisis pulled everyone together, with care and compassion for each other flowing from the top down. I was still waking with a sense of dread every morning. One morning a message from my father brought this to a harsh reality. In London, my grandmother was in hospital with COVID-19. I messaged my boss to say I would be late, I needed to call my family. He responded immediately telling me to take my time. A frantic search for flights and details on travel restrictions followed; until my mother and aunt called me in conference to put their own version of a travel ban on me. I was not to return home; my presence would not alter the outcome. My grandmother made it out of hospital after nearly 4 weeks. During that time, it was nearly impossible to receive a clinical update and she was unable to answer the phone. I understood this to mean the clinical team were overwhelmed. My response was redoubling my own efforts in communication; checking in obsessively with my residents to divide the daily family calls for each patient. After a long day in full PPE, I changed at work and made my way to the train station as was my routine. The curfew imposed by the state government had slipped my mind and as such there were no trains for another hour. I called my partner on the verge of tears and he began searching the government website to clarify if he was legally allowed to leave home after curfew to collect me. Knowing many other juniors also relied on the train, I messaged the clinical team to remind everyone to double check their travel plans. Within a minute one of the senior clinicians called me to offer to return to the hospital to drive me home. He was not on call, it was 9:30 at night, and he was already at home. The offer worsened my proximity to tears with its kindness. In the end, I sent my partner a photo of my identification badge and he came to collect me, risking the police check. Fortunately, we were not stopped, and in retrospect collecting an essential worker was entirely legal, but it made me very anxious. Slowly, but surely, the situation in the wards and the community improved, taking great sacrifice, the impact of which will be felt for many years. Lockdown has only just been lifted as we see the inverse happening in Europe. I wish that we never had to experience it. My only hope is that it offers a change in medical leadership permanently. The compassion I have experienced working in the pandemic response has indicated to me a new generation of leaders who want to take the profession in a different direction. I have seen more admirable and inspiring professional behaviours in the past 9 months than in the previous 6 years. Perhaps it has been what I needed to re-energise my enthusiasm for clinical medicine. One thing that will stay with me for a long time is waking with a heaviness over me. That cannot lift until I see my family again. I declare no competing interests.

W e read with great interest Professor Esler’s perspective on AT1 blockers in the coronavirus disease 2019 (COVID-19) pandemic [1]. It is interesting to note that many international hypertension and cardiac societies are in the process of gathering evidence on this very subject and we will have a robust scientific answer soon. Globally, the speed at which our colleagues are working is astounding. We did, however take particular notice of Professor Esler’s comment that in four decades of practice as a cardiologist, with particular expertise in hypertension, he has never had a patient die of an infection. This has led him to doubt the significance of hypertension as a risk factor in morbidity or mortality from COVID-19. As middle-grade physician trainees with a combined 13 years’ experience in clinical practice, we find this statistic surprising. Both authors can recall specific

ObjectivesWe report on the key clinical predictors of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and present a clinical decision rule that can risk stratify patients for COVID-19.Design, participants and settingA prospective cohort of patients assessed for COVID-19 at a screening clinic in Melbourne, Australia. The primary outcome was a positive COVID-19 test from nasopharyngeal swab. A backwards stepwise logistic regression was used to derive a model of clinical variables predictive of a positive COVID-19 test. Internal validation of the final model was performed using bootstrapped samples and the model scoring derived from the coefficients, with modelling performed for increasing prevalence.ResultsOf 4226 patients with suspected COVID-19 who were assessed, 2976 patients underwent SARS-CoV-2 testing (n = 108 SARS-CoV-2 positive) and were used to determine factors associated with a positive COVID-19 test. The 7 features associated with a positive COVID-19 test on multivariable analysis were: COVID-19 patient exposure or international travel, Myalgia/malaise, Anosmia or ageusia, Temperature, Coryza/sore throat, Hypoxia-oxygen saturation < 97%, 65 years or older-summarized in the mnemonic COVID-MATCH65. Internal validation showed an AUC of 0.836. A cut-off of >= 1.5 points was associated with a 92.6% sensitivity and 99.5% negative predictive value (NPV) for COVID-19.ConclusionsFrom the largest prospective outpatient cohort of suspected COVID-19 we define the clinical factors predictive of a positive SARS-CoV-2 test. The subsequent clinical decision rule, COVID-MATCH65, has a high sensitivity and NPV for SARS-CoV-2 and can be employed in the pandemic, adjusted for disease prevalence, to aid COVID-19 risk-assessment and vital testing resource allocation.

Due to the ongoing COVID-19 pandemic and increased pressure on testing resources, understanding the clinical and epidemiological features closely associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is vital at point of care to enable risk stratification. We demonstrate that an internally derived and validated clinical decision rule, COVID-MATCH65, has a high sensitivity (92.6%) and NPV (99.5%) for SARS-CoV-2 and could be used to aid COVID-19 risk-assessment and resource allocation for SARS-CoV-2 diagnostics.