Experiences of healthcare workers displaced by conflict: lessons from past conflicts and implications

Background

Conflicts cause mass displacement, including of healthcare workers (HCWs). Understanding experiences of HCWs over the displacement trajectory, from push factors out of conflict zones, to barriers and facilitators in transit and host countries, is key to developing support mechanisms and informing policy discussions regarding return and reintegration.

Methodology

We systematically reviewed 6 academic databases and grey literature using combined search terms for HCWs, displacement, conflict, and experiences to identify English-language literature documenting personal or professional experiences of HCWs displaced by conflict, published between 1945 to 2020. Open coding and thematic analysis were used to identify emerging themes. Quality appraisal was conducted.

Results

25 publications from academic journals, snowballed references, and grey literature from 10 geographical contexts and various types of HCW met inclusion criteria, many from conflicts in the Middle-East. 5 themes emerged: Conflict drives displacement: HCWs fled due to direct violence and deteriorating working conditions caused by increased workload, depleting resources, workforce attrition and attacks on healthcare. Giving back: Refugee HCWs were determined to continue working but had to do so informally or by working with humanitarian agencies. Personal and professional integration in host countries: refugee HCWs overcame barriers to relicense after which they reported disadvantage in job applications due to professional gaps and discrimination; many ended up working under-qualified jobs. Psychological toll on HCWs was pronounced. Prospects on return: HCWs desired to return to their home countries but feared political instability and violence.

Conclusions

Policies which support HCW retention during conflict, integration into host health systems, and encourage return post-conflict must be implemented. Further research is required to understand the individual and systemic support mechanisms required.

Key messages

Displaced HCWs experience many personal and professional challenges. Policies that support HCWs across the displacement trajectory and support return and post-conflict system rebuilding are required.

Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a case-controlled study

BACKGROUND

COVID-19 is an ongoing threat to society. Patients who develop the most severe forms of the disease have high mortality. The interleukin-6 inhibitor tocilizumab has the potential to improve outcomes in these patients by preventing the development of cytokine release storm.

AIMS

To evaluate the outcomes of patients with severe COVID-19 disease treated with the interleukin-6 inhibitor tocilizumab.

METHODS

We conducted a retrospective, case-control, single-center study in patients with severe to critical COVID-19 disease treated with tocilizumab. Disease severity was defined based on the amount of oxygen supplementation required. The primary endpoint was the overall mortality. Secondary endpoints were mortality in non-intubated patients and mortality in intubated patients.

RESULTS

A total of 193 patients were included in the study. Ninety-six patients received tocilizumab, while 97 served as the control group. The mean age was 60 years. Patients over 65 years represented 43% of the population. More patients in the tocilizumab group reported fever, cough and shortness of breath (83%, 80% and 96% vs. 73%, 69% and 71%, respectively). There was a non-statistically significant lower mortality in the treatment group (52% vs. 62.1%, P = 0.09). When excluding intubated patients, there was statistically significant lower mortality in patients treated with tocilizumab (6% vs. 27%, P = 0.024). Bacteremia was more common in the control group (24% vs. 13%, P = 0.43), while fungemia was similar for both (3% vs. 4%, P = 0.72).

CONCLUSION

Our study showed a non-statistically significant lower mortality in patients with severe to critical COVID-19 disease who received tocilizumab. When intubated patients were excluded, the use of tocilizumab was associated with lower mortality.

P373 Left atrial mechanics and aortic stiffness following high intensity interval training: a randomised controlled study

Background

Physical inactivity is associated with an increased risk of cardiovascular disease. High intensity interval training (HIIT) has been shown to improve important health parameters, including aerobic capacity, arterial blood pressure, cardiac autonomic modulation and left ventricular mechanics. However, adaptations in left atrial (LA) mechanics and aortic stiffness remain unclear. Therefore, the aim of the present study was to assess any left atrial and aortic adaptations to HIIT.

Methods

Forty-one physically inactive males and females (aged 23 ± 2.7 years) volunteered for the study. Participants were randomised to either a 4-week HIIT intervention (n = 21) or 4-week control period (n = 20). The HIIT protocol consisted of 3 x 30-second maximal cycle ergometer sprints with a resistance of 7.5% body weight, interspersed with 2-minutes of active unloaded recovery. Speckle tracking imaging of the left atrium and M-Mode tracing of the aorta was performed pre and post HIIT and control period using commercially available software (EchoPac; GE Medical Systems). Analysis of covariance, with baseline measures as the covariate, was used to explore any differences in left atrial mechanics and aortic stiffness between the intervention and control groups. Stepwise linear regression analysis using LA stiffness as the dependent variable was conducted.

Results

Following 4-weeks of HIIT, there was significant improvement in LA mechanics, including LA reservoir (13.9 ± 13.4%, p = 0.033) and LA stiffness (-0.05 ± 0.04%-1, p = 0.032) compared to the control condition. In addition, improvements were observed in aortic distensibility (2.1 ± 2.7 cm2 × dyn×-1 × 103, p = 0.031) and aortic stiffness index (-2.6 ± 4.6, p = 0.041) compared to the control condition. In stepwise linear regression analysis, aortic distensibility change was significantly associated with LA stiffness change (p = 0.002), with an R2 of 0.613.

Conclusion

A short-term programme of HIIT was associated with a significant improvement in LA mechanics and aortic stiffness. These adaptations may have important health implications and contribute to the improved left ventricular diastolic and systolic mechanics, aerobic capacity and reduced arterial blood pressure previously documented following HIIT.

Transesophageal three-dimensional echocardiographic assessment of left main coronary artery fistula

We describe a patient with a left main coronary artery fistula with an opening at the superior vena cava-right atrial junction in whom three-dimensional transesophageal echocardiography permitted more accurate assessment of the shape and size of the communication site than two-dimensional transesophageal echocardiography.

Two- and three-dimensional TEE differentiation of lymphoma involving the atrial septum from lipomatous hypertrophy

In this case report we present two-dimensional (2-D) and three-dimensional (3-D) transesophageal echocardiographic (TEE) findings of a patient with lipomatous atrial septal hypertrophy and a patient with Hodgkin's lymphoma with atrial septal involvement. The echocardiographic characteristics that differentiate these two lesions are discussed.

Transesophageal echocardiographic diagnosis of traumatic rupture of the noncoronary cusp of the aortic valve

We report a patient with traumatic aortic valve injury in whom a large defect in the noncoronary cusp of the aortic valve was clearly visualized by multiplane TEE and confirmed at surgery.

Transesophageal echocardiographic findings of an intracavitary cardiac metastasis from a neuroendocrine thymic carcinoma

This case report presents the unusual characteristics of a neuroendocrine thymic carcinoma that probably has metastasized to the left side of the interatrial septum from a primary thymic site.

Transpharyngeal echocardiographic detection of a left internal carotid artery stent

This case report describes a patient in whom a left internal carotid (LIC) artery stent was detected using a transpharyngeal approach during a transesophageal echocardiographic (TEE) study. Using pulsed-Doppler interrogation, flow through and beyond the stent was characterized and restenosis was ruled out.

Sensitivity and specificity of transesophageal echocardiography for determination of aortic valve morphology

BACKGROUND

Preoperative recognition of the presence of bicuspid aortic valve can be important in the planning of procedures. Multiplane transesophageal echocardiography may allow more accurate detection of valvular morphology than does biplane transesophageal echocardiography.

METHODS AND RESULTS

The studies of 710 patients who subsequently underwent valvular or aortic surgery were reviewed in a blinded fashion. The inclusion criteria were adequate short-axis view and operative note confirmation of aortic valve morphology. Six hundred eight patients were submitted to further analysis. Four hundred three patients had aortic stenosis as the primary diagnosis. Three hundred sixty patients had biplane examinations and 248 had multiplane examinations. The sensitivity and specificity of the multiplane technique in assessing aortic valve morphology (bicuspid vs tricuspid valve) was 87% and 91%, respectively. The sensitivity and specificity of the biplane technique was 66% and 56%, respectively. Whether valves were calcified or not did not result in major changes in sensitivity and specificity for either technique.

CONCLUSIONS

Multiplane transesophageal echocardiography provides a more accurate assessment of preoperative aortic valve morphology than does the biplane approach in the majority of patients.

Echocardiographic diagnosis of a stenotic double orifice parachute mitral valve with a single papillary muscle

We present the case of a patient with a single papillary muscle that is supporting both orifices of a stenotic double orifice mitral valve. With the use of both transthoracic and transesophageal echocardiography, we were able to prospectively define this entity, which was confirmed at surgery.

Transesophageal echocardiographic identification of a descending aortic aneurysm rupture into the left lung

This case report describes a patient in whom a descending aortic aneurysm ruptured into the left lung, producing hemoptysis. With transesophageal echocardiography, we were able to define the site and extent of the aneurysm, as well as the two sites of rupture into lung tissue.

Transesophageal three-dimensional echocardiographic assessment of anomalous coronary arteries

We describe the usefulness of transesophageal three-dimensional echocardiography in the evaluation of anomalously arising coronary arteries in four adult patients recently studied by us.