Evaluating compliance with the care standard of proactively assessing bone health in patients with diabetes: a pilot audit of practice across Asia by the Asia Pacific Consortium on Osteoporosis (APCO)

This pilot audit explored how bone health is assessed patients with diabetes in diverse centres across Asia. Only 343 of 1092 (31%) audited patients had a bone health assessment, 27% of whom were diagnosed with osteoporosis. Quality improvement strategies are needed to address gaps in patient care in this area.

PURPOSE

The Asia Pacific Consortium on Osteoporosis (APCO) Framework outlines clinical standards for assessing and managing osteoporosis. A pilot audit evaluated adherence to clinical standard 4, which states that bone health should be assessed in patients with conditions associated with bone loss and/or increased fracture risk; this report summarises the audit findings in patients with diabetes. A secondary aim was to assess the practicality and real-world use of the APCO bone health audit tool kit.

METHODS

Eight centres across Asia participated in the pilot audit, selecting diabetes as the target group. Participants reviewed their practice records for at least 20 consecutively treated patients with the target condition. Questions covered routine investigations, bone health assessment, osteoporosis diagnosis, and patient referral pathways. Data were summarised descriptively.

RESULTS

The participants represented public hospitals, university medical centres, and private clinics from India, Malaysia, Pakistan, Singapore, Taiwan, and Vietnam that see an estimated total of 95,000 patients with diabetes per year. Overall, only 343 of 1092 audited patients (31%) had a bone health assessment. Osteoporosis was subsequently diagnosed in 92 of 343 (27%) patients.

CONCLUSION

Bone health was not assessed in most patients with diabetes. The results provide insight into current practices across diverse Asian centres and demonstrate the practical value of the audit tool kit. Participant feedback has been used to improve the tool kit. Results of this pilot audit are being used in the respective centres to inform quality improvement projects needed to overcome the gap in patient care.

1255 IMPROVING COMMUNICATION BETWEEN NEXT OF KIN AND MEDICAL STAFF FOR OUR MOST VULNERABLE PATIENTS: A QUALITY IMPROVEMENT PROJECT

Background

This project was completed by a team of junior doctors working across two general medical wards at Queen Alexandra Hospital.

Introduction

Due to persistently high bed occupancy, patients are increasingly subject to multiple moves, increasing the risk of missed or delayed communication (Toye C et al, Clin interv aging, 2019, 14, 2223-2237). Importantly, families who receive good communication from staff are more likely to feel satisfied with the care of their loved one (Ersek M et al, J pain symptom manage, 2021, 62(2), 213–222). Our aim was to increase the occurrence and comprehensiveness of documented discussions between next of kin (NOK) and the medical team, especially in vulnerable patients who may be unable to advocate for themselves.

Methods

We conducted a retrospective, cross-sectional analysis of patient notes across two PDSA cycles. NICE guidelines NG27, NG97 and NG96 provided an audit standard. Patients were identified as at-risk of poor communication if diagnosed with dementia, cognitive impairment, addiction, learning difficulties or needing an interpreter. Targeted intervention prior to re-audit included education of the medical team and introduction of a written prompt within the patient’s notes.

Results

25/55 patients were identified as at-risk in cycle one, with 39/71 patients at-risk in cycle two. Post-intervention, the number of at-risk patients with a documented NOK discussion increased from 74% to 82%. Patient treatment plan discussions increased from 81% to 97%. Discussions, where applicable, regarding escalation of care, Deprivation of Liberty Safeguards (DoLS), capacity and Mental Health Act (MHA) slightly decreased. Conversations regarding patient consent for data sharing were rarely documented.

Conclusion

Our intervention increased the proportion of documented patient discussions; however, it did highlight the need to improve the frequency of documented conversations surrounding escalation of care, DoLS, capacity and MHA. This has provided impetus for further improvement projects.

The effect of eplerenone on the disease onset and progression of phospholamban cardiomyopathy in presymptomatic mutation carriers: results of the i-PHORECAST trial

Background

A pathogenic variant in the gene encoding phospholamban (PLN; p.Arg14del) may cause cardiomyopathy, the pathophysiologic hallmark of which is cardiac fibrosis that may cause malignant ventricular arrhythmias and severe heart failure. There is no evidence-based therapy to modify disease progression in presymptomatic pathogenic variant carriers. Eplerenone is a selective mineralocorticoid receptor antagonist with established antifibrotic properties, and may be a potentially interesting treatment in PLN p.Arg14del mutation carriers.

Purpose

To investigate if preventive therapy with eplerenone attenuates disease onset and progression in PLN cardiomyopathy.

Methods

84 presymptomatic PLN p.Arg14del mutation carriers (median age 39 [27–50] years, 44% males) were randomized 1:1 to receive eplerenone (50mg once daily) or no treatment, and endpoints were adjudicated in a blinded fashion (PROBE design). Baseline values were acquired including demographics, cardiac magnetic resonance imaging (CMR) parameters (ventricular volumes, systolic function, late gadolinium enhancement (LGE)), and electrocardiographic parameters (QRS voltages and ventricular ectopy per 24 hour). Subjects were re-evaluated every year and CMR was performed at baseline and after three years. The composite endpoint included LVEDV/RVEDV increase (>10%), LVEF/RVEF decrease (5%), newly developed LGE on CMR, increase in ventricular ectopy (>100% PVCs/24h if >1000 PVCs/24h), decrease in QRS voltage (>25%), non-sustained ventricular tachycardia, symptoms or arrhythmias necessitating treatment, and cardiovascular death.

Results

Two out of 84 subjects (2%) were lost to follow up. 49 out of 82 remaining subjects (60%) reached the composite end point, 25 (60%) in the control group, 24 (60%) in the treatment group (p=0.825). There was no significant difference between the groups when considering the individual end points, see Table 1. Baseline and follow up CMR was performed on 76 subjects, 39 in the control group, 37 in the treatment group. In total there were 10 (13%) cases of newly developed LGE, 6 (18%) in the control group, 4 (12%) in the treatment group (p=0.556), see Figure 1.

Conclusions

Eplerenone did not significantly attenuate disease onset and progression in presymptomatic PLN p.Arg14del mutation carriers. There was no significant difference in new incidence of LGE between the treatment and control groups.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was financially supported by the Netherlands Cardiovascular Research Initiative, an initiative supported by the Dutch Heart Foundation (The Hague, Netherlands).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Outcome of Heart Transplant Candidates Based on a High Volume Heart Transplant Center Experience in Iran

Background

The waiting list for heart transplants is a valuable data registry that would offer very useful information on the characteristics of patients who have various outcomes while waiting in the list.

Objective

The purpose of this study was to look at the prognosis of those waiting for heart transplants as well as the factors that increase mortality.

Methods

Advanced heart failure patients' demographic, clinical, hemodynamic, and echocardiographic results, as well as their prognosis, were retrieved from the national registry for heart transplantation between 2011 and 2018. The study population was defined and compared in four groups: 1) Death while awaiting HTX, 2) Death after HTX, 3) Alive without a transplant, 4) Transplanted and alive.

Results

The data of 207 patients [75% male, mean (SD) age of 34(10) years] were analyzed. The most common etiology of heart failure was idiopathic dilated cardiomyopathy. A total of 86 patients (41%) were successfully transplanted, with a median (IQR) time between listing and transplantation of 84 (30¬219) days, 54 patients (26.1%) were dead and 32% were still alive. The multivariate analysis showed right atrial pressure, pulmonary capillary wedge pressure, cardiac index, and systolic blood pressure at the time of listing as independent predictors of death.

Conclusion

The study on HTX waiting list is very useful for both allocation strategies and administrative planning for patients with advanced heart failure by development of accurate models and scoring systems using predictors of death in the waiting list.

Anti-hyperglycemic and anti-hyperlipidemic effects of a methanolic extract of Debregeasia salicifolia in Alloxan-induced diabetic albino mice

Diabetes mellitus (DM), an endocrine syndrome characterized by high blood glucose levels due to abrogated insulin activity. The existing treatments for DM have side effects and varying degrees of efficacy. Therefore, it is paramount that novel approaches be developed to enhance the management of DM. Therapeutic plants have been accredited as having comparatively high efficacy with fewer adverse effects. The current study aims to elucidate the phytochemical profile, anti-hyperlipidemic, and anti-diabetic effects of methanolic extract D. salicifolia (leaves) in Alloxan-induced diabetic mice. Alloxan was injected intraperitoneally (150 mg kg-1, b.w), to induced diabetes in mice. The mice were divided into three groups (n=10). Group 1 (normal control) received normal food and purified water, Group II (diabetic control) received regular feed and clean water and group III (diabetic treated) received a methanolic extract of the plant (300 mg kg-1) for 28 days with a typical diet and clean water throughout the experiment. Blood samples were collected to checked serum glucose and concentration of LDL, TC, TG. The extract demonstrated significant antihyperglycemic activity (P<0.05), whereas improvements in mice's body weight and lipid profiles were observed after treatment with the extract. This study establishes that the extract has high efficacy with comparatively less toxicity that can be used for DM management.

Malignant Melanoma of the Genitourinary System

Introduction/Objective

Malignant melanoma (MM) of mucosal membranes (excluding anus and head and neck) is a rare but aggressive disease with poor outcome. There is little information available on the development mechanism, risk factors, and management of this tumor, mainly due to the low number of cases.

Methods/Case Report

We performed a comprehensive literature review on mucosal MM (between 1970-2020). We identified 52 papers reporting 242 patients with primary genitourinary melanomas (limited to urothelium, vagina and cervix). A comprehensive review of the demographics, stage, treatment and survival was performed.

Results (if a Case Study enter NA)

The demographics are provided in Table 1. In 204 cases, lesions were located in the urothelium (urethra: 202, bladder: 2) followed by 34 in the vagina and 4 in uterine cervix. None of the cases had any other known primary source of MM. Molecular studies in a subset of cases revealed alterations in c-KIT, NRAS, BRAF (non-V600E and V600E), TP53 and NF1 (Table 2). Tumor stage was provided in a few (n=10) cases (stage 1=1, stage 2=1, stage 3=3 & stage 4=5). 3 patients had distant metastasis (brain, retroperitoneal and inguinal lymph nodes). Treatment data was available in 178 cases. 177 patients were managed by surgery. In addition to surgery, 10 received chemotherapy, 7 received immunotherapy and chemotherapy, 2 received chemoradiation, 1 received immunotherapy and 1 received radiotherapy. In 43 patients, the treatment regimen was not provided. The outcome was available in 178 cases (range of follow up between 3-97 months), showing 15 deaths of disease. Median survival based on available information in 28 patients was 82% (5-year survival). Table 1 legend: Demographics of genitourinary malignant melanoma cases.

Table 2 legend: Frequency of molecular alterations in genitourinary malignant melanoma.

Conclusion

Similarities in genetic signatures of mucosal and skin MM suggest similar mechanism of development; however, unlike skin melanoma, there is less BRAF mutation and more of PI3K/AKT/mTOR pathway alterations in mucosal MM. Prolonged administration of chemotherapy (i.e., methotrexate) and immune-modulating agents (i.e., natalizumab) may be a risk factor. In light of absence of a definite adjuvant therapy, tumor stage at the time of diagnosis and proper surgical removal have central role in the prognosis and survival of patients.

Atrial fibrillation in unexplained syncope: observations from the Reveal LINQ registry

Background

Implantable loop recorders (ILRs) have come to play an important role in the workup of patients with recurrent syncope of uncertain origin. In addition to detecting bradyarrhythmias related to syncope, which is the main diagnostic focus in these patients, ILRs are also capable of uncovering subclinical atrial fibrillation (AF).

Purpose

We sought to determine the percentage of patients monitored with an ILR for unexplained syncope who have AF detected and to describe clinical actions taken in these patients.

Methods

Patients enrolled in the Reveal LINQ Registry who received an ILR for unexplained syncope and had at least one follow-up form were included. The device automatically detects AF episodes lasting ≥2 minutes. Patients were considered to have AF based on an AF diagnosis made by the treating physician during follow-up or if device-detected AF was adjudicated as true AF by an external reviewer. AF detection rates were calculated using Kaplan-Meier methods.

Results

In total, 498 patients (aged 61.8±20.0 years, 49.6% female, CHA2DS2VASc score 2.2±1.7) were included and followed for 22±12 months. A history of AF was present in 97 (20%) patients, while 401 patients had no history. By 18 months, the incidence of AF was 70.9% (95% CI, 60.8%, 80.3%) in patients with a history of AF and 21.4% (95% CI, 17.4%, 26.1%) in patients without (Figure). AF detection in those with (30.4%) and without (30.1%) syncope during follow-up was similar. By the end of follow-up, and among patients with newly detected AF, 29/86 (33.7%) were on oral anticoagulation, 7 (8.1%) underwent AF ablation, 6 (7.0%) underwent other type of ablation, and 2 (2.3%) received cardioversion. Other actions among the whole cohort included implant of an IPG, ICD, or CRT in 98/498 (19.7%).

Conclusion

Among patients monitored with ILRs to determine the cause of recurrent syncope episodes, approximately 1 in 5 patients had new AF detected. In addition to improving the management of patients with syncope, ILR data served to support AF-related clinical decisions.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic Inc Incidence of AF according to baseline AF