Purpose of Review COVID-19 is now a global pandemic and the illness affects multiple organ systems, including the cardiovascular system. Long-term cardiovascular consequences of are not yet fully characterized. This review seeks to consolidate available data on long-term cardiovascular complications of COVID-19 infection. Recent Findings Acute cardiovascular complications of COVID-19 infection include myocarditis, pericarditis, acute coronary syndrome, heart failure, pulmonary hypertension, right ventricular dysfunction, and arrhythmia. Long-term follow-up shows increased incidence of arrhythmia, heart failure, acute coronary syndrome, right ventricular dysfunction, myocardial fibrosis, hypertension, and diabetes mellitus. There is increased mortality in COVID-19 patients after hospital discharge, and initial myocardial injury is associated with increased mortality. Summary Emerging data demonstrates increased incidence of cardiovascular illness and structural changes in recovered COVID-19 patients. Future research will be important in understanding the clinical significance of these structural abnormalities, and to determine the effect of vaccines on preventing long-term cardiovascular complications.

The cytotoxic natural product (-)-sclerophytin A was constructed in 13 steps from geranial. Highlights from the synthesis are a stereoselective Oshima-Utimoto reaction, a Shibata-Baba indium-promoted radical cyclization, and a novel stereoconvergent epoxide hydrolysis.The oxygenated cembrane diterpenes are a large class of natural products comprising cladiellins, briarellins, asbestinins, and sarcodictyins. Their intricate chemical structures have captivated many in the synthetic chemistry community, with recent successes in the crafting of polyanthellin A1, asbestinins2, briarellins E and F3, vigulariol4, and astrogorgin5 being highly notable recent achievements.6 In addition to intriguing structures, these compounds also tend to possess potent biological activity. Amongst the cladiellins, sclerophytin A (Scheme 1) is a particularly striking compound; it was isolated from the marine soft coral Sclerophytum capitalis and found to exhibit remarkable potency against mouse leukemia cells (cytotoxic at 1 ng/ml versus L1210 cell line), yet its original structural formulation was incorrect.7 , 8 Total syntheses by the Paquette and Overman groups established the correct formulation of sclerophytin A to be that depicted in Scheme 1.9 As a means to examine the utility of the stereoselective Oshima-Utimoto reaction10 in chemical synthesis, we've been attracted to the target sclerophytin A and its structural relatives.11 Herein, we describe a short enantioselective route to ketone 1 (Scheme 1), a key intermediate in a prior synthesis of vigulariol,4b and show that 1 can be readily converted to sclerophytin A by a three step sequence involving a novel stereoconverging epoxide hydrolysis.In terms of retrosynthetic analysis (Scheme 1), we considered that ketone 1 might arise by ring-closing olefin metathesis of triene 2 and that 2 might be obtained from intermediate 3 by a 6-exo-trig radical cyclization of an appropriately modified derivative. The OshimaUtimoto reaction of the allylic alcohol embedded in 4, if it occurs without interference from the adjacent alkenes, was proposed to convert 4 to cyclic acetal 3, stereoselectively. Notably, appropriately functionalized substrate 4 is readily available in a single step from geranial. morken@bc.edu. Supporting Information Available: Characterization and procedures. This material is available free of charge through the internet at http://pubs.acs.org. To begin the synthesis, allylic alcohol (E)-4 was prepared in 92% yield and 98% enantiomeric excess by Brown methallylation12 of geranial and was then subjected to the Oshima-Utimoto reaction. This sequence delivered 3 as a mixture of epimers in 62% yield (Scheme 2). Subsequent Jones oxidation of the Oshima-Utimoto product 3 to the derived lactone revealed >20:1 anti:syn (C4:C5) stereoselection from the Oshima-Utimoto reaction. 13 After α-iodination to give 5, we examined the tin-free radical reactions pioneered by Shibata and Baba for reductive radical-mediated transformation.14 Thus, treatment of 5 with InCl 3 and NaBH 4 d...

ObjectivesTo explore the patient experience, and the role of ophthalmologists and other health and social care professionals in the certification and registration processes and examine the main barriers to the timely certification of patients.DesignQualitative study.SettingTelephone interviews with health and social care professionals and patients in three areas in England.Participants43 health and social care professionals who are part of the certification or registration process. 46 patients certified as severely sight impaired (blind) or sight impaired (partially sighted) within the previous 12 months.ResultsCertification and registration are life changing for patients and the help they receive can substantially improve their lives. Despite this, ophthalmologists often found it difficult to ascertain when it is appropriate to certify patients, particularly for people with long-term conditions. Ophthalmologists varied in their comprehension of the certification process and many regarded certification as the ‘final stage’ in treatment. Administrative procedures meant the process of certification and registration could vary from a few weeks to many months. The avoidable delays in completing certification can be helped by Eye Clinic Liaison Officers (ECLO).ConclusionsA better understanding of the certification and registration processes can help improve standards of support and service provision for people who are severely sighted impaired or sight impaired. Better education and support are required for ophthalmologists in recognising the importance of timely referral for rehabilitative support through certification and registration. ECLOs can improve the process of certification and registration. Finally, better education is needed for patients on the benefits of certification and registration.

Background Daily attending rounds (AR) are a cornerstone of teaching and patient care in academic health centers. Interruptions in health care are common and can cause increased risk of errors, incomplete work, and decreased decision-making accuracy. Interruptions to AR may diminish a trainee's capacity to learn and retain information. Objective We characterized and quantified interruptions that occur during AR. Methods We used a mixed-methods design combining a prospective observational study with a qualitative study. AR were observed January to March 2020 to characterize interruptions, followed by semi-structured interviews with the observed physicians to elucidate the effect of interruptions on workflow and the educational value of rounds. Results There were 378 observed interruptions over the course of 30 AR sessions, averaging 12.6 (range 1–22, median 13) interruptions per rounding session. Bedside nursing staff was the most common source of interruptions (25%) and consultant recommendations was the most common topic of interruption (21%). Most interruptions occurred during patient presentations (76%), and the most common method of interaction was text message (24%). Most team members described negative effects of interruptions, including loss of focus and missing critical clinical information; some also reported that certain interruptions had positive effects on education and clinical care. Interns were more likely to report negative emotional reactions to interruptions. Conclusions AR are frequently interrupted for non-urgent topics by a variety of methods and sources. Negative effects included loss of focus, missed information, and increased stress. Proactive communication, particularly between physicians and nurses, was suggested to reduce interruptions.

Background and Objectives: High reliability organizations in health care must identify defects and systematically approach causal factors with subsequent process redesign to achieve goals important to patients, families, and staff. Root cause analysis (RCA) is a commonly leveraged strategy for reviewing adverse events and can yield immense benefits toward patient safety when applied alongside complementary change management strategies such as Lean and Six Sigma. We performed an RCA in response to a hospital-acquired venous thromboembolism (VTE) event in a postoperative patient for which pharmacologic VTE prophylaxis was not appropriately resumed following removal of an epidural catheter. Methods: A multidisciplinary stakeholder team was assembled to further understand the details of the event. A current process map was created and non-value-added steps were identified. Causal analysis revealed that frequent staff turnover, variable methods of communication between stakeholders, inconsistent responsibilities with respect to ordering and administering pharmacologic VTE prophylaxis, and lack of an established standard work process were key contributors toward the defect of concern. Several countermeasures were introduced to combat these identified root causes, including shifting responsibility for managing VTE prophylaxis orders periepidural catheter removal from the surgical house staff to our regional anesthesia service, and creation of an epidural catheter heparin restart order set, which in one step places an order to resume prophylaxis following catheter removal at a specific time. Recommendations from this session were disseminated to staff through previously established huddles that are a component of our daily management system. Results: Postintervention, review of our updated process demonstrated a reduction in variability through establishment of standard work that is primarily owned by a constant factor in this care pathway (our regional anesthesia team). On review of the subsequent 10 cases of patients with epidural catheters, all patients receiving pharmacologic VTE prophylaxis had a maximum of 1 dose stopped for epidural catheter removal, therefore minimizing time without VTE prophylaxis. Conclusions: RCA can be utilized in the aftermath of an adverse event to establish causal factors and identify countermeasures to prevent recurrence of such an event. It can be further augmented with additional change management strategies including Lean, Six Sigma, the Model for Improvement, and failure modes and effects analysis. These strategies allowed us to design effective error-reducing strategies to achieve a more reliable process, which yielded reduced VTE prophylaxis administration defects that in turn has prevented recurrence of hospital-acquired VTE in patients with epidural catheters.