Background Antimicrobial resistance (AMR) is a growing global concern. AMR surveillance is a crucial component of the international response; however, passive surveillance of laboratory data is limited without corresponding patient-level clinical data. This study sought to examine the burden of AMR amongst medical inpatients in Rwanda, in the context of their clinical presentations and prior antibiotic exposures. Methods This cohort study was conducted over a 9-month period at a tertiary referral hospital in Kigali, Rwanda. We enrolled 122 adult medical inpatients with a history of fever and a positive microbiological culture result. Data were collected regarding the clinical and microbiological aspects of their admission. Results The most common diagnoses were urinary tract infection (n = 36, 30%), followed by pneumonia (n = 30, 25%) and bacteraemia (11 primary [9%] and 10 catheter-related [8%]). The most common pathogens were E. coli (n = 40, 33%) and Klebsiella pneumoniae (n = 36, 30%). The cohort were heavily antibiotic-exposed at the time of culture with 98% of patients (n = 119) having received an antibiotic prior to culture, with a median exposure of 3 days (IQR 2–4 days). Eighty patients (66%) were specifically prescribed ceftriaxone at the time of culture. Gram-negative organisms predominated (82% [100/122]) and exhibited high rates of resistance, with only 27% (21/77) being susceptible to ceftriaxone, 2.4% (2/82) susceptible to co-amoxiclav and 44% (8/18) susceptible to ciprofloxacin. Susceptibility amongst Gram-negatives was relatively preserved to amikacin (91%, 79/87) and imipenem (85%, 70/82). There were no cases of methicillin-resistant Staphylococcus aureus (0/12) or vancomycin-resistant enterococci (0/2). Discordant antibiotic therapy was significantly associated with in-hospital mortality (OR 6.87, 95%CI 1.80–45.1, p = 0.014). Conclusions This cohort highlights high rates of resistance amongst Gram-negative organisms in Rwanda, including the presence of carbapenem resistance. Nonetheless, the detailed prescribing data also highlight the challenges of using routine laboratory data to infer broader AMR prevalence. The significant exposure to empiric broad-spectrum antibiotic therapy prior to culturing introduces a selection bias and risks over-estimating the burden of resistant organisms. Broadening access to microbiological services and active surveillance outside of teaching hospitals are essential to support national and international efforts to curb the growth of AMR in low-resource settings.

Background Recording large-group lectures is commonplace in higher education, allowing students to access content asynchronously and remotely. With the move towards online learning during the COVID-19 pandemic, recording of small-group teaching sessions has also become increasingly common; however, the educational value of this practice is unknown. Methods All medical students rotating through the Acute Medicine Department of a large teaching hospital were invited to enrol in the study. Consenting students were recorded for the second half of an online case-based learning (CBL) session. The recording was available for 6 months; viewing patterns were analysed. Students were sent a questionnaire after the session, asking them to reflect on the recorded and unrecorded halves of the session. Findings Thirty-three students underwent recording in 12 separate groups; 31 students (94%) completed the questionnaire. All 31 respondents (100%) described the session as “useful” or “very useful”. Twenty-four respondents (77%) recommended continuing to record small-group sessions and 17 (55%) reported being “likely” or “very likely” to watch the recording. Six respondents (19%) reported a negative impact of being recorded. During 6 months of follow-up, no students returned to view the recording for more than 1 minute. Conclusion Despite positive feedback for the session and high student demand for ongoing recording, no students viewed the recording for any significant duration. One-fifth of students reported a negative impact of being recorded. The findings from this study do not support routine recording of small-group CBL sessions, even where demand for this may exist.

Background. Emerging evidence suggests ethnic minorities are disproportionately affected by coronavirus disease 2019 (COVID-19). Detailed clinical analyses of multicultural hospitalized patient cohorts remain largely undescribed. Methods. We performed regression, survival, and cumulative competing risk analyses to evaluate factors associated with mortality in patients admitted for COVID-19 in 3 large London hospitals between 25 February and 5 April, censored as of 1 May 2020. Results. Of 614 patients (median age, 69 [interquartile range, 25] years) and 62% male), 381 (62%) were discharged alive, 178 (29%) died, and 55 (9%) remained hospitalized at censoring. Severe hypoxemia (adjusted odds ratio [aOR], 4.25 [95% confidence interval {CI}, 2.36-7.64]), leukocytosis (aOR, 2.35 [95% CI, 1.35-4.11]), thrombocytopenia (aOR [1.01, 95% CI, 1.00-1.01], increase per 109 decrease), severe renal impairment (aOR, 5.14 [95% CI, 2.65-9.97]), and low albumin (aOR, 1.06 [95% CI, 1.021.09], increase per gram decrease) were associated with death. Forty percent (n = 244) were from black, Asian, and other minority ethnic (BAME) groups, 38% (n = 235) were white, and ethnicity was unknown for 22% (n = 135). BAME patients were younger and had fewer comorbidities. Although the unadjusted odds of death did not differ by ethnicity, when adjusting for age, sex, and comorbidities, black patients were at higher odds of death compared to whites (aOR, 1.69 [95% CI, 1.00-2.86]). This association was stronger when further adjusting for admission severity (aOR, 1.85 [95% CI, 1.06-3.24]). Conclusions. BAME patients were overrepresented in our cohort; when accounting for demographic and clinical profile of admission, black patients were at increased odds of death. Further research is needed into biologic drivers of differences in COVID-19 outcomes by ethnicity.

Background COVID-19 was declared a worldwide pandemic on 11 March 2020. Imperial College Healthcare NHS Trust provides 1412 inpatient beds staffed by 1200 junior doctors and faced a large burden of COVID-19 admissions.Local problem A survey of doctors revealed only 20% felt confident that they would know to whom they could raise concerns and that most were getting information from a combination of informal work discussions, trust emails, social media and medical literature.Methods This quality improvement project was undertaken aligning with Standards for Quality Improvement Reporting Excellence 2.0 guidelines. Through an iterative process, a digital network (Imperial Covid cOmmunications Network; ICON) using existing smartphone technologies was developed. Concerns were collated from the junior body and conveyed to the leadership team (vertical—bottom-up using Google Form) and responses were conveyed from leadership to the junior body (vertical—top-down using WhatsApp and Zoom). Quantitative analysis on engagement with the network (members of the group and number of issues raised) and qualitative assessment (thematic analysis on issues) were undertaken.Results Membership of the ICON WhatsApp group peaked at 780 on 17 May 2020. 197 concerns were recorded via the Google Form system between 20 March and 14 June 2020. There were five overarching themes: organisational and logistics; clinical strategy concerns; staff safety and well-being; clinical (COVID-19) and patient care; and facilities. 94.4% of members agreed ICON was helpful in receiving updates and 88.9% agreed ICON improved collaboration.Conclusions This work demonstrates that a coordinated network using existing smartphone technologies and a novel communications structure can improve collaboration between senior leadership and junior doctors. Such a network could play an important role during times of pressure in a healthcare system.

We agree with the Editorial in the July, 2020, issue of The Lancet Gastroenterology & Hepatology, which emphasised the concerning long-term implications of lockdowns implemented to flatten the epidemic curve of COVID-19 on the health behaviour of individuals with alcohol-use disorder.1The Lancet Gastroenterology & HepatologyDrinking alone: COVID-19, lockdown, and alcohol-related harm.Lancet Gastroenterol Hepatol. 2020; 5: 625Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar A complex interplay of heightened financial difficulties, social isolation, uncertainty about the future, and the redistribution of the health workforce and the disruption to clinical services could contribute to increased alcohol intake and relapse under lockdown conditions, and, subsequently, contribute to further liver-associated complications via direct injury or through late presentations to the appropriate services.1The Lancet Gastroenterology & HepatologyDrinking alone: COVID-19, lockdown, and alcohol-related harm.Lancet Gastroenterol Hepatol. 2020; 5: 625Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 2Rehm J Kilian C Ferreira-Borges C et al.Alcohol use in times of the COVID 19: implications for monitoring and policy.Drug Alcohol Rev. 2020; 39: 301-304Crossref PubMed Scopus (326) Google Scholar, 3Clay JM Parker MO Alcohol use and misuse during the COVID-19 pandemic: a potential public health crisis?.Lancet Public Health. 2020; 5: e259Summary Full Text Full Text PDF PubMed Scopus (443) Google Scholar, 4Da BL Im GY Schiano TD COVID-19 hangover: a rising tide of alcohol use disorder and alcohol-associated liver disease.Hepatology. 2020; (published online May 5.)https://doi.org/10.1002/hep.31307Crossref Scopus (168) Google Scholar, 5Finlay I Gilmore I Covid-19 and alcohol—a dangerous cocktail.BMJ. 2020; 369m1987Crossref PubMed Scopus (99) Google Scholar Lockdown is a complex social phenomenon that provokes different behavioural responses: a population survey of 1555 active drinkers in the UK identified that 21% increased alcohol consumption during the lockdown, while 35% reduced their alcohol intake.6Alcohol Change UK Drinking during lockdown: headline findings.https://alcoholchange.org.uk/blog/2020/covid19-drinking-during-lockdown-headline-findingsDate: 2020Google Scholar The true effect of the lockdown on alcohol intake remains unknown because of a paucity of qualitative data. 2 months after lockdown was declared in the UK (March 23, 2020), we did a cross-sectional telephone survey of patients with pre-existing alcohol disorders registered since 2017 in the alcohol clinic of St Mary's Hospital, London. From May 21 to June 10, 2020, 322 (70%) of 462 patients from the database were contacted and 182 (57%) agreed to participate (appendix). The survey was done in English using a standardised questionnaire by two trained clinicians (JUK, AM). Participants were mainly male (133 [73%] men, 49 [27%] women) and of white ethnicity (141 [78%]), with a median age of 57 years (IQR 49–66). 42 (23%) of the 182 participants were hazardous drinkers and 71 (39%) were moderate-severe alcohol users before lockdown, as assessed by AUDIT score. Of the 182 participants, 43 (24%) reported an increase in their alcohol intake, with a mean increase in the AUDIT score of 57·6%, and a mean weekly consumption of 82·5 units (SD 78). 34 (19%) reported a decrease in their alcohol intake. Although some parameters such as age, mood, and some social conditions differed between those who had increased, decreased, or had an unchanged consumption of alcohol during the lockdown (appendix), a multivariate analysis identified only the pre-lockdown AUDIT score and percentage change of AUDIT score from before to during lockdown as factors associated with increased alcohol intake during lockdown. 69 (38%) patients were classified as abstinent before lockdown, with a mean abstinence period of 19·5 months (SD 22). Of this subgroup, 12 (17%) relapsed during lockdown. Mean AUDIT score within the relapse group at the time of our survey was 15·7 (SD 9·6), representing a 226% mean increase from before lockdown, with a mean weekly consumption of 48·8 units (SD 63) during lockdown. Of the 113 individuals who were previously drinking before the lockdown, 14 (12%) became newly abstinent since the beginning of lockdown. Among all participants, 55 (30%) had either a virtual or face-to-face contact with the clinic during lockdown; 19 (44%) of the 43 individuals who had increased alcohol consumption had a clinic appointment, compared with 36 (26%) of the 139 individuals with decreased alcohol consumption or for whom consumption remained the same (p=0·035; odds ratio [OR] 0·586, 95% CI 0·378–0·908). Of the subgroup of patients who had a virtual or face-to-face consultation during the lockdown, 13 (24%) had contact specifically with an alcohol specialist nurse. Univariate analysis revealed that those who had contact with a specialist nurse were more likely to become newly abstinent, compared with those who did not have contact (two [100%] of two vs two [12%] of 17; p=0·035; OR 1·118, 95% CI 0·032–0·432); a positive trend was observed for reduced relapse during lockdown, occurring after alcohol nurse contact (six [18%] of 33 vs three [60%] of five; p=0·075; OR 0·303, 95% CI 0·110–0·839). We emphasise several points. First, lockdown causes different behavioural changes on alcohol intake, with about 20% of individuals increasing or decreasing their normal alcohol consumption. Although psychosocial distress has been well recognised as a risk of relapse and increased alcohol consumption,7Brown SA Vik PW Patterson TL Grant I Schuckit MA Stress, vulnerability and adult alcohol relapse.J Stud Alcohol. 1995; 56: 538-545Crossref PubMed Scopus (305) Google Scholar the reduction might be associated with decreased financial ability and the decreased availability of on-site alcohol areas (eg, pubs or bars).2Rehm J Kilian C Ferreira-Borges C et al.Alcohol use in times of the COVID 19: implications for monitoring and policy.Drug Alcohol Rev. 2020; 39: 301-304Crossref PubMed Scopus (326) Google Scholar Second, we found no distinct protective factors for relapse, suggesting that pre-lockdown abstinence status is not protective against lockdown-related relapse. The mean duration of abstinence before relapse was long, which has been previously identified as a strong predictor of continuous abstinence.8Kirshenbaum AP Olsen DM Bickel WK A quantitative review of the ubiquitous relapse curve.J Subst Abuse Treat. 2009; 36: 8-17Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar Lockdown might overshadow this paradigm. Third, those who relapsed had a clinically significant average level of alcohol consumption of nearly 49 units weekly post-relapse, which is concordant with previous studies of a high risk of harmful drinking after relapse.9Deltenre P Marot A Dubois M Trépo E Moreno C Assessment of the risk of alcohol relapse following liver transplantation for alcoholic hepatitis using a meta-analysis approach.J Hepatol. 2018; 68: 1322-1323Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar Finally, in a subgroup of patients who had clinical contact during lockdown, contact with an alcohol nurse specialist was a positive predictor for reducing relapse and improving new abstinence. Nonetheless, these findings should be interpreted with caution because of the small sample size of this subgroup. Our data represent a cross-sectional perspective of alcohol disorders during COVID-19 lockdown; any further changes that might present if lockdown conditions change remain to be elucidated. In summary, lockdown represents a risk factor for increasing alcohol consumption in people with alcohol use disorders and relapse for those who were previously abstinent. Those who do relapse are at a high risk of harmful drinking and require a tailored approach for follow-up and intervention. Support from alcohol liaison services could prevent relapse during lockdown. We declare no competing interests. Download .pdf (.66 MB) Help with pdf files Supplementary appendix

WHO Collaborating Centre for Infectious Disease Modelling MRC Centre for Global Infectious Disease Analysis Abdul Latif Jameel Institute for Disease and Emergency Analytics (J-IDEA) Division of Digestive Diseases, Department of Metabolism Digestion and Reproduction Department of Infectious Diseases Department of Primary Care and Public Health NIHR Imperial Biomedical Research Centre Imperial College Healthcare NHS Trust Imperial College London

Background & aims Although metabolic risk factors are associated with more severe COVID-19, there is little evidence on outcomes in patients with non-alcoholic fatty liver disease (NAFLD). We here describe the clinical characteristics and outcomes of NAFLD patients in a cohort hospitalised for COVID-19. Methods This study included all consecutive patients admitted for COVID-19 between February and April 2020 at Imperial College Healthcare NHS Trust, with either imaging of the liver available dated within one year from the admission or a known diagnosis of NAFLD. Clinical data and early weaning score (EWS) were recorded. NAFLD diagnosis was based on imaging or past medical history and patients were stratified for Fibrosis-4 (FIB-4) index. Clinical endpoints were admission to intensive care unit (ICU)and in-hospital mortality. Results 561 patients were admitted. Overall, 193 patients were included in the study. Fifty nine patients (30%) died, 9 (5%) were still in hospital, and 125 (65%) were discharged. The NAFLD cohort (n = 61) was significantly younger (60 vs 70.5 years, p = 0.046) at presentation compared to the non-NAFLD (n = 132). NAFLD diagnosis was not associated with adverse outcomes. However, the NAFLD group had higher C reactive protein (CRP) (107 vs 91.2 mg/L, p = 0.05) compared to non-NAFLD(n = 132). Among NAFLD patients, male gender (p = 0.01), ferritin (p = 0.003) and EWS (p = 0.047) were associated with in-hospital mortality, while the presence of intermediate/high risk FIB-4 or liver cirrhosis was not. Conclusion The presence of NAFLDper sewas not associated with worse outcomes in patients hospitalised for COVID-19. Though NAFLD patients were younger on admission, disease stage was not associated with clinical outcomes. Yet, mortality was associated with gender and a pronounced inflammatory response in the NAFLD group.

The COVID-19 pandemic is challenging the way we practise medicine around the world. We are being forced to adapt as we respond to the ever-changing landscape in which we are practising. A careful risk-benefit assessment is needed for everything we do, and in many cases has led to the shut-down of services that would previously have been seen as essential (urgent cancer investigations, as an example). Cardiopulmonary resuscitation (CPR) is recognised as a potential aerosol-generating procedure,1Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings. (Accessed on 28 March 2020, at https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-healthcare/)Google Scholar which may pose a significant risk of transmission of SARS-CoV-2 to healthcare workers and other patients in the vicinity. A case report from 2003 found evidence of transmission of SARS-CoV (the virus that causes severe acute respiratory syndrome (SARS)) during CPR.2Christian M.D. Loutfy M. McDonald L.C. et al.Possible SARS coronavirus transmission during cardiopulmonary resuscitation.Emerg Infect Dis. 2004; 10: 287-293Crossref PubMed Scopus (218) Google Scholar Despite wearing N95 respirators, at least one of the nine healthcare professionals involved in the resuscitation attempt acquired SARS. There is a similar case report of transmission of Middle East Respiratory Syndrome (MERS) during CPR in South Korea in 2015.3Nam H.-S. Yeon M.-Y. Park J.W. Hong J.-Y. Son J.W. Healthcare worker infected with Middle East Respiratory Syndrome during cardiopulmonary resuscitation in Korea, 2015.Epidemiol Health. 2017; (November 12): 39Google Scholar As the global COVID-19 pandemic spreads, the risk of nosocomial transmission is increasingly being recognised and drastic measures are being taken to mitigate this risk. The Resus Council (UK) has published updated guidelines, recognising the importance of protecting staff and the risk of generating "an infectious aerosol" during chest compressions.1Resuscitation Council UK Statement on COVID-19 in relation to CPR and resuscitation in healthcare settings. (Accessed on 28 March 2020, at https://www.resus.org.uk/media/statements/resuscitation-council-uk-statements-on-covid-19-coronavirus-cpr-and-resuscitation/covid-healthcare/)Google Scholar CPR is widely practised around the world and is the default position in many societies for a patient suffering cardiac arrest. In view of the recognised risks of CPR in the context of COVID-19, policy makers should carefully evaluate the risk-benefit of this procedure. In resource-limited settings, without easy access to adrenaline, defibrillators or intensive care facilities, the minimal benefits of CPR are unlikely to justify the risks to healthcare staff. Policy makers should plan ahead and ensure that healthcare professionals are aware of the risks and policies are in place to protect staff as the prevalence of COVID-19 increases. None.