Nationwide frequency, risk and outcomes of type-2 myocardial infarction in patients with versus without previously revascularized myocardial infarction (type 1)

Funding Acknowledgements

Type of funding sources: None.

Background

Type 2 myocardial infarction (T2MI), due to a mismatch between myocardial oxygen demand and supply, is being increasingly recognized with improved diagnostics. The upsetting concern of developing T2MI in patients with prior revascularized occlusive acute myocardial infarction (AMI) or type 1 MI (T1MI) makes it crucial to define the clinical profile and outcomes of T2MI in revascularized patients of ACS.

Purpose

To determine the risk and prognosis of T2MI in patients who had previously had coronary revascularization (PCI or CABG)

Methods

We used the National Inpatient Sample (2018) dataset from the United States to identify T2MI adult hospitalizations using ICD-10 codes and define our study arm as T2MI excluding secondary T1MI diagnoses but having prior revascularized (with percutaneous coronary intervention or coronary artery bypass grafting) AMI. We then compared demographics and comorbidities in T2MI cohort with vs without personal history of revascularized AMI. We used multivariate analysis to study the odds of T2MI hospitalizations with prior revascularized AMI and in-hospital outcomes (all-cause mortality, cardiogenic shock and resource utilization) adjusting for confounders.

Results

There were 33155 T2MI adult hospitalizations after excluding AMI (median age 71 years, 50.6% male, 67.3% white); 1435 (4.3%) had previously revascularized AMI. T2MI in the study arm had higher chances of hospitalization with prior revascularized AMI when adjusted for socio-demographics (aOR 6.92, 95% CI:6.50-7.36, p<0.001) and socio-demographics with comorbidities (aOR 5.70, 95%CI: 5.48-5.94, p<0.001) (Table 1). Study arm often had elderly (≥65 years old, 78.4% vs 65.8%), male (66.6% vs 49.9%), white (76.7% vs 66.9%), upper socio-economic class (20.2 vs 16.8%), patients who were often admitted to non-electively (99.3 vs 97.1%) and to rural (10.5 vs 9.3%) hospitalizations compared to control arm. The study arm had a significantly higher prevalence of diabetes mellitus, hyperlipidemia, peripheral vascular disease, chronic obstructive pulmonary disease, renal failure, deficiency anemias, prior TIA/stroke, depression and smoking. T2MI cohort with prior revascularized AMI did not show any significant association with in-hospital all-cause mortality (1.7 vs 3.0%, aOR 0.49, 95%CI 0.18-1.34, p=0.164) and cardiogenic shock (1.7% vs 2.1%, p=0.399) however, had lower hospital expenditure (median USD 31273 vs 36567) and fewer transfers to other facilities (19.5 vs 22.1%) than those without prior revascularized AMI (Table 2).

Conclusion

Population-based analysis of this nationally representative sample revealed up to six times higher risk of developing T2MI in patients with prior history of AMI (revascularized) but without any significant impact on all-cause in-hospital mortality or cardiogenic shock. Future studies are warranted to assess the short-term/long-term outcomes of T2MI in high risk patient population with previously revascularized AMI.

Life-saving transfusion in autoimmune hemolytic anemia: a case report and procedure review of the dilution method

A woman with autoimmune hemolytic anemia (AIHA) presented in the emergency department with life-threatening anemia (hemoglobin 3 g/dL). Exaggeration of preexisting chronic anemia to severe anemia after a recent red blood cell (RBC) transfusion led to suspicion of delayed hemolytic transfusion reaction. Given the urgency for transfusion along with a stronger suspicion for coexistence of an alloantibody, the dilution method proposed by Lawrence Petz and George Garratty was used to find an RBC unit for transfusion. An alloantibody with Fy^b specificity was identified, which was masked by the coexistent autoantibody. This method is based on the assumption that the titers of an alloantibody are higher than that of autoantibody. Diluting the autoantibody would reveal the alloantibody and, for this purpose, a serial doubling dilution of serum is performed. This method has an important limitation of missing any alloantibodies with titers less than that of the autoantibody. In spite of this, this method may be of use at a resource-poor setting, where trained personnel and other reagents intended for advanced immunohematology methods are unavailable.

715 REDUCING OVERTREATMENT OF TYPE 2 DIABETES IN OLDER PEOPLE LIVING IN CARE HOMES

Introduction

Older people in care homes living with frailty are less likely to benefit from tight glycaemic control in the management of type 2 diabetes with increased risk of adverse effects for example hypoglycaemia, falls and hospital admission. We wished to ascertain the scale of the problem and reduce overtreatment. We defined overtreatment based on American Diabetes Association guidelines as being on an agent that can cause hypoglycaemia and having an HBA1C of ≤53 mmol/mol or, an HbA1c 53–64 mmol/mol with either three or more co-morbidities.

Methods

In 2016, we audited the management of type 2 diabetes in older people discharged from LTHT to care homes. We discussed our concerns with diabetes and geriatric medicine colleagues across medical, nursing and pharmacy disciplines. We engaged the support of the citywide diabetes network which comprises secondary care colleagues, general practitioners and pharmacists. We presented the findings of our initial audit to colleagues within primary and secondary care through departmental meetings and citywide network meetings. We wrote a new guideline, specifically for frail older people that was disseminated citywide through these networks. We re-audited in 2020.

Results

In total, 113 cases were reviewed in 2016 and 105 cases in 2020. In 2020, only 6% (6 patients) were overtreated compared to 38% (43 patients) in 2016.

Conclusions

There has been a marked reduction in overtreatment which should result in less adverse events. We believe the reasons for success lie in wide engagement of relevant stakeholder groups around an issue that is important, large in scale and meaningful to both patient and clinician. There are potential cost savings from reducing medications and reducing harm.

229 A Systematic Review Protocol Examining the Role of Immobilisation in Hand Infections

Aim

Hand infections are common and varied, leading to long-term complications when managed poorly. Splinting of the hand in a position of safe immobilisation (POSI) is frequently used to avoid complications including pain and stiffness, however it is not a universally accepted technique because the effects of splinting in hand infections remain unestablished.

This systematic review will compare outcomes in adult hand infections between those treated using hand immobilisation and those not immobilised. The primary aim is to compare patient reported outcomes, for example pain, and the secondary aim is to compare functional active range of motion, complications, and resource use.

Method

A systematic review protocol has been developed. The search strategy was developed following background reading, expert opinion, and review by an academic librarian, and will be used to search MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Central Register of Controlled Trials, to identify publications on management of hand infections including use of hand immobilisation. Title, and full-text screening will be carried out by two independent investigators to identify studies for inclusion. Editorials, letters, and literature reviews will be excluded.

Results

This systematic review has been successfully registered on the PROSPERO International prospective register of systematic reviews (CRD42021232880)

Conclusions

This systematic review will summarise the available evidence to establish the effect of hand immobilisation in hand infections, including whether hand immobilisation leads to improved outcomes in hand infections, which could guide health care professionals in their practice and influence future clinical guidelines.

153 The Patient Perspective on Day Case Arthroplasty

Introduction

Day Case Arthroplasty has been validated as a safe strategy for reducing length of stay for patients undergoing elective arthroplasty. With the ongoing recovery of elective activities following the COVID pandemic and long waiting lists; day case arthroplasty offers a solution for both hospitals and patients. Reducing length of stay will reduce the cost of day case arthroplasty which benefits hospitals, whilst the faster discharge reduces unnecessary exposure to an increased risk of COVID for patients. This study aims to establish the patient perspective on day case arthroplasty to inform the set-up of a patient cantered day case arthroplasty service.

Method

Data was collected at routine preoperative assessment clinics via a structured questionnaire which combined both quantitative and qualitative methods. The questionnaire covered patient demographics, issues pertaining to same-day discharge, level of concern related to common problems faced by patients after joint replacement surgery and patient preference for same day discharge versus more traditional rehabilitation methods.

Results

The study included 79 patients with 43% preferring same day discharge. Postoperative pain, surgical complications and wound healing were the most significant concerns elicited. Patients who preferred same day discharge were statistically younger. The majority of patients felt that their rehabilitation could be completed at home.

Conclusions

The results of this study highlight the demand for day case arthroplasty in this cohort of patients with younger patients preferring same day discharge. Identifying significant concerns will be important to formulate effective perioperative protocols to ensure successful implementation of a patient cantered day case arthroplasty service.

A91 CANADIAN FEMALE FELLOW PERSPECTIVES ON TRAINING IN THE BOYS CLUB: ADVANCED THERAPEUTIC ENDOSCOPY

Background

Unequal female representation in the field of advanced therapeutic endoscopy (ATE) has been recently highlighted in the United States. Previous attempts to determine the barriers of entry into the career have found reasons including lack of mentorship, patriarchy, inflexible hours/call and exposure to fluoroscopy. There is no current literature describing the landscape of exposure to ATE for trainees in Canada or determining differences in experience based on gender.

Aims

We sought to determine the barriers to pursuing a career in advanced therapeutic endoscopy, specifically focussing on the perspectives of Canadian female gastroenterology fellows.

Methods

A survey was developed and distributed to the gastroenterology fellows enrolled in Royal College accredited programs across Canada via an online survey platform.

Results

Responses were received from gastroenterology fellows at 12 out of the 14 Canadian universities with Royal College accredited programs. The response rate was 46% (n=42, 16 female respondents, 26 male respondents). An equal proportion of male (42%, n=11) and female (38%, n=6) trainees indicated interest in a career in ATE. 38% (n=6) of female trainees felt that they had inadequate mentorship opportunities/role models within ATE, in comparison to 4% (n=1) of males (p=0.004). Furthermore, 19% (n=3) of females felt that this lack of mentorship/role models was a primary deterrent from pursuing ATE as a career, in comparison to 0% of males (p=0.02). There was equal self-perceived competency surrounding ATE knowledge between both genders.

Conclusions

Female gastroenterology fellows in Canada lack mentorship and role models in ATE, which they also indicated as a primary deterrent from pursuing it as a career when compared to their male counterparts. Recognizing and addressing the lack of female leadership and visibility is necessary to improve parity and encourage women to train in the male-dominated field of ATE.

Funding Agencies

None

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

Efficacy and safety of high versus standard dose ibuprofen for patent ductus arteriosus treatment in preterm infants: A systematic review and meta-analysis

BACKGROUND

Several small randomized controlled trials (RCTs) and observational studies have compared high (15-20/7.5-10/7.5-10 mg/kg/dose) versus standard dose (10/5/5 mg/kg/dose) ibuprofen for patent ductus arteriosus (PDA) closure, with limited evidence on efficacy and safety.

OBJECTIVE

To systematically review and meta-analyze studies of high versus standard dose ibuprofen for the closure of PDA in preterm infants.

METHODS

Databases were searched for RCTs and observational studies assessing high compared to standard dose of ibuprofen for PDA closure for preterm infants until August 2021. The primary outcome was failure of PDA closure after the first course of ibuprofen. The secondary outcomes were the failure of PDA closure after a second course of ibuprofen, rates of PDA ligation, all-cause mortality prior to hospital discharge, bronchopulmonary dysplasia, necrotizing enterocolitis, bleeding disorders, oliguria, and serum creatinine after treatment.

RESULTS

There were 6 studies with 369 patients (3 RCT, N = 190; 3 observational studies, N = 179). Compared to standard dose, high dose ibuprofen did not significantly decrease the failure rate of PDA closure in preterm infants after the first course (Relative risk (RR) 0.74, 95% confidence interval (CI) 0.53 -1.03, 6 studies, N = 369). High dose ibuprofen significantly decreased the rates of PDA ligation compared to standard dose (RR 0.33, 95% CI 0.16 -0.70, 5 studies, N = 309).

INTERPRETATION

Based on low-grade evidence, high dose ibuprofen may more effectively reduce rates of PDA ligation compared to standard dose with no increase in adverse effects, neonatal morbidities and mortality.

A rare case of an iatrogenic superior mesenteric arteriovenous fistula following surgery for a midgut volvulus

Superior mesenteric arteriovenous fistula is an extremely rare vascular malformation with most cases occurring following abdominal trauma or surgery. They are often asymptomatic or present with various abdominal symptoms with or without features of portal hypertension. A 30-year-old man developed fistulising of the superior mesenteric artery into the superior mesenteric vein following bowel resection surgery for an acquired midgut volvulus. Although endovascular management remains the treatment of choice in such cases due to increased morbidity of a repeat abdominal surgery, definite risks remain, such as coil migration, which happened in this case. The open surgical approach remains the only option in such instances.

Factors associated with antibiotic administration delay among preterm infants with late-onset bloodstream infection

Early antibiotic administration is an important modifiable factor in reducing mortality from late-onset bloodstream infections in preterm infants. In a cohort study including 142 infants with non-coagulase negative staphylococcus bloodstream infection at two tertiary neonatal intensive care units, we identified typical practice-related factors that may be targeted to prevent delays in antibiotic administration. Collection of cerebrospinal fluid or urine sample before administering antibiotics, a longer time taken to site a peripheral intravenous catheter among those without pre-existing access, and a longer time taken to administer fluid boluses were associated with a longer than median time to antibiotic administration.

1697 Undergraduate Otolaryngology: Enhancing Interest and Education with Hands-on Simulation

Introduction

With cancelled student placements due to the COVID-19 pandemic, there is a shift towards non-patient-facing methods to deliver medical education. The aim was to design, deliver and evaluate an ENT course for undergraduate medical students.

Method

A three-part simulation course on common and emergency ENT conditions was delivered by ENT trainees to undergraduate medical students (n = 50). It involved theoretical and hands-on experience with otoscopy on head models; nasoendoscopy and epistaxis management with upper airway head models and nasal packing kits; and management of compromised airways using critical airway models, airway adjuncts, intubation and cricothyroidotomy kits. Delegates were given pre- and post-course questionnaires, with another at six-weeks to test knowledge retention. Results were statistically analysed using paired and independent sample t-tests.

Results

A statistically significant improvement in post-test knowledge of 55% (p<0.01) was observed. Delegates also demonstrated a sustained improvement of 51% (p<0.01) six-weeks later compared to baseline knowledge. 76% and 80% reported improved confidence managing epistaxis and performing intubation respectively; 46% reported increased interest in pursuing ENT as a potential career.

Conclusions

This study demonstrated statistically significant and sustained improvements in knowledge about common and emergency ENT concepts. ENT simulation therefore represents an efficacious mechanism for teaching key ENT concepts and improving confidence in undergraduate medical students, whilst improving interest in pursuing ENT as a career. Additionally, simulation is an invaluable educational adjunct that may foster more realistic, impactful, and safer educational experiences for medical students whilst exposure to patients is minimised due to the current pandemic.

Modified vertical osteotomy cut in bilateral sagittal split osteotomy

Bilateral sagittal split osteotomy (BSSO) is the most common orthognathic surgical procedure for the correction of facial deformities. Like any other surgical procedure, it is also associated with a risk of complications. One of these is described in the literature as notching at the lower inferior border of the mandible. Such discontinuity in the contour of the lower border is often a concern for patients. To overcome this complication, we recommend a modified vertical osteotomy cut while performing BSSO.

Functional Outcome and Complications in Management of Proximal Humerus Fractures Operated with Proximal Humerus Locking Plate

Introduction:

Controversies exist in treatment of proximal humerus fractures as treatment options vary greatly from conservative management, closed pinning, stacked intramedullary nails, plating and hemi-arthroplasty. The purpose of this study is to study the fracture patterns of each case and document the functional outcome and complications post-operative in the management of proximal humerus fractures operated with proximal humerus plate.

Material and Methods:

Thirty five patients with closed proximal humerus fractures, above 18 years old, admitted in our tertiary care hospital during the study period were enrolled. Patients underwent open reduction internal fixation with proximal humerus locking plate under general anaesthesia. Post-operative patients were assessed using Constant and DASH scores. Complications were recorded.

Results:

In our study the absolute Constant score of the study population increases at three months and six months and was found to be significant. Mean Constant score for 4-part fractures was 45.6 which were inferior as compared to 2-part and 3-part fractures (43.1 and 44.6, respectively). The mean Constant score at six months was 51.80 +/- 6.71. All three types of proximal humerus fractures showed significant improvement in the mean DASH score over our study period of six months and was found to be significant. Mean DASH score at six months was 27.97+/-12.84. Out of the 35 cases in the study two had complications. One had implant failure (Neer’s type 3, 60-year-old female) and one had varus collapse (Neer’s type 3, 45-year-old male).

Conclusion:

Due to angular stability and effective maintenance of the intraoperative fracture reduction during follow-up period, early post-operative mobilisation is possible which helps the patient to attain better shoulder range of motion and return to activity faster.

Breast Angiosarcoma Surveillance Study: UK national audit of management and outcomes of angiosarcoma of the breast and chest wall

BACKGROUND

Breast angiosarcomas are rare tumours of vascular origin. Secondary angiosarcoma occurs following radiotherapy for breast cancer. Angiosarcomas have high recurrence and poor survival rates. This is concerning owing to the increasing use of adjuvant radiotherapy for the treatment of invasive breast cancer and ductal cancer in situ (DCIS), which could explain the rising incidence of angiosarcoma. Outcome data are limited and provide a poor evidence base for treatment. This paper presents a national, trainee-led, retrospective, multicentre study of a large angiosarcoma cohort.

METHODS

Data for patients with a diagnosis of breast/chest wall angiosarcoma between 2000 and 2015 were collected retrospectively from 15 centres.

RESULTS

The cohort included 183 patients with 34 primary and 149 secondary angiosarcomas. Median latency from breast cancer to secondary angiosarcoma was 6 years. Only 78.9 per cent of patients were discussed at a sarcoma multidisciplinary team meeting. Rates of recurrence were high with 14 of 28 (50 per cent ) recurrences in patients with primary and 80 of 124 (64.5 per cent ) in those with secondary angiosarcoma at 5 years. Many patients had multiple recurrences: total of 94 recurrences in 162 patients (58.0 per cent). Median survival was 5 (range 0-16) years for patients with primary and 5 (0-15) years for those with secondary angiosarcoma. Development of secondary angiosarcoma had a negative impact on predicted breast cancer survival, with a median 10-year PREDICT prognostic rate of 69.6 per cent, compared with 54.0 per cent in the observed cohort.

CONCLUSION

A detrimental impact of secondary angiosarcoma on breast cancer survival has been demonstrated. Although not statistically significant, almost all excess deaths were attributable to angiosarcoma. The increased use of adjuvant radiotherapy to treat low-risk breast cancer and DCIS is a cause for concern and warrants further study.

Absence of Meckel Cave: A Rare Cause of Trigeminal Neuralgia

Trigeminal neuralgia is a debilitating condition with numerous etiologies. In this retrospective case series, we report a cohort of patients with a rarely described entity, absence of Meckel cave, and propose this as a rare cause of trigeminal neuralgia. A search of the electronic medical record was performed between 2000 and 2020 to identify MR imaging reports with terms including "Meckel's cave" and "hypoplasia," "atresia," "collapse," or "asymmetry." Images were reviewed by 2 blinded, board-certified neuroradiologists. Seven cases of the absence of Meckel cave were identified. Seven patients (100%) had ipsilateral trigeminal neuralgia and ipsilateral trigeminal nerve atrophy, suggesting an association between absence of Meckel cave and trigeminal neuralgia. Absence of Meckel cave is a rare entity of unknown etiology, with few existing reports that suggest the possibility of an association with trigeminal neuralgia. Its recognition may have important implications in patient management. Future studies and longitudinal data are needed to assess treatment outcomes and added risks from surgical intervention in these patients.

A proposed "Radiological Evaluation Score for Bone Tumors" (REST): An objective system for assessment of a radiograph in patients with suspected bone tumor

BACKGROUND

Although radiographs have been widely used in the evaluation of patients with suspected bone tumors, the lack of an objective radiological assessment method leads to a challenge in reaching correct diagnosis. The study aimed to propose a Radiological Evaluation Score for Bone Tumors (REST) which includes eight radiological factors [characteristics, content, cortical breach, distinctiveness, distribution, periosteal reaction, fracture, and soft tissue swelling] to form a single score along with its validation by multidisciplinary observers.

METHODS

We reviewed the radiographs of 100 patients with a primary bone tumor which were selected at random from the database between January 2017 and January 2019 of a tertiary cancer center. Four reviewers (two orthopedic oncologists and two surgical oncologists) independently assessed the radiographs, based on the reporting system of REST. We constituted two groups according to the probable diagnosis of bone tumor (suspected benign tumor and suspected malignant tumor).

RESULTS

The mean score in the suspected benign tumor group was 1.1 (range 0-3, 95% CI 0.8-1.3) and in malignant tumor group was 6.1 (range 2-8, 95% CI 5.8-6.4). A receiver operator characteristic (ROC) curve for REST was with a cutoff of 3.5, with the most diagnostic value area under curve (AUC) of 0.99. The sensitivity was 98% and specificity was 100% with a positive predictive value of 100% and a negative predictive value of 98%. The inter-observer correlation coefficient was 0.985 (p value < 0.05), and Fleiss kappa value for the prediction of the benign or malignant lesion was 0.97 (p value < 0.05). The characteristics and content of tumor, cortical erosion, distinctiveness, distribution, periosteal reaction, and soft tissue mass had a significant correlation with the aggressiveness of bone lesion p value < 0.05.

CONCLUSIONS

The Radiological Evaluation Score for Bone Tumors (REST) is a structured reporting and objective method for the assessment of radiographs in patients with suspected bone tumors. This method is a reliable and helpful tool for clinicians in their outdoor patient department to differentiate a radiograph of a suspected benign tumor from a malignant bone tumor.

935 Stridor in Multiple System Atrophy: An Otolaryngologist Perspective

Background

Bilateral vocal cord paralysis is a rare emergency presentation for Parkinson's disease (PD) but an acknowledged complication of an atypical rarer form of PD called Multi system atrophy ( MSA). MSA is a neurodegenerative disorder comprising of autononic failure, cerebellar ataxia and parkinsonism. An early occurence of stridor can indicate a shorten survival and quality of life remains uncertain. Airway definitive management of this patient group can pose a dilemma for the Otolaryngologist who may be asked to provide a specialist opinion.

Case: We present a case of a 73 year old female who developed mild stridor, hours after an emergency right sided hemiarthroplasty. On day 23 of her admission, there was a sudden airway deteoriation. The otolaryngology and anasthetic emergency team stablised her conservatively with an option of non invasive ventilation. Bilateral vocal cord palsy was observed on nasendoscopy On day 27, she was eventually diagnosed with MSA and showed partial response to a trial of madopar. Both options of a tracheostomy and laser cordotomy were avoided. She was safely discharged with follow up.

Conclusions

There remains gaps in the literature towards an unaminous consensus on stridor management in MSA patients. However, raising awareness of this patient groups will strenghten decision making processes.