CIED guided HF management : a prospective cohort study

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Liverpool Clinical Commissioning Group

Background

Heart failure (HF) is associated with significant morbidity and mortality. (1) Cardiac Implantable Electronic Devices (CIED) generated Heart Failure Risk Score (HFRS) alerts may guide management in this complex cohort and help direct resources to appropriate patients. (2)

Aim 

To develop and evaluate an integrated, multidisciplinary approach to HF management for patients with CIED by sharing HFRS alerts directly with the HF teams.

Methods

We undertook a prospective, single centre cohort study of patients who generated high risk HFRS alerts. These alerts were shared with community HF teams responsible for routine care of patient, prompting patient contact and appropriate intervention by the team. Impact of the pathway was evaluated by review of outcomes including hospitalisation and clinical intervention within 4- 6 weeks of the alert and mortality during the follow up period. Ongoing education was provided to help teams deal with alerts. A validated user questionnaire was completed by the stake holders to obtain user feedback.

Results

365 "High risk" alerts were noted in 188 patients in a 2 year period (November 2018 - November 2020). The mean number of alerts per patients was 1.9 and 44 (23%) of patients had >3 "high risk" alerts in the follow up period. Having three or more alerts significantly increased the risk of hospitalisation for heart failure (HR 2.5, CI 1.1–5.6 p = 0.03) but not mortality (HR 2.1 CI 0.6-7.2 p = 0.23). Overall 75 (39%) of patients were hospitalised in the 4-6 week period of the alert – 53 (28%) of these were unplanned of which 24(13%) were for decompensated HF. A further 24(13%) had planned admissions for care to improve therapy (AV node ablation, device and lead replacement) and reduce morbidity (LA appendage occlude, IV Iron therapy). 33(18%) of patients died in the follow up period.  15(8%) received therapy from the device. 18(10%) of patient underwent deactivation of ICD therapy.

Contact was established in 176 (94%) of patients, and alerts actioned appropriately. 55 patients reported being asymptomatic, and in 45 the trends were improving so no further clinical action was taken. 76 patients had an onward referral made for further management including; 32 to a Cardiologist, 20 to primary care, 13 referrals to community HF teams and 11 referrals to palliative care. 23 patients had medications changes instituted. The feedback on the pathway was positive. 

Conclusions 

An integrated approach to HF for patients with CIEDs in situ can facilitate timely risk stratification and intervention in this cohort of patients and potentially reduce unplanned health care utilisation. Intervention in these patients is not limited to HF alone and provides the opportunity for holistic management of this complex cohort Abstract Figure.

Calibrating a chief complaint list for low resource settings: a methodologic case study

BACKGROUND

The chief or presenting complaint is the reason for seeking health care, often in the patient's own words. In limited resource settings, a diagnosis-based approach to quantifying burden of disease is not possible, partly due to limited availability of an established lexicon or coding system. Our group worked with colleagues from the African Federation of Emergency Medicine building on the existing literature to create a pilot symptom list representing an attempt to standardize undifferentiated chief complaints in emergency and acute care settings. An ideal list for any setting is one that strikes a balance between ease of use and length, while covering the vast majority of diseases with enough detail to permit epidemiologic surveillance and make informed decisions about resource needs.

METHODS

This study was incorporated as a part of a larger prospective observational study on human immunodeficiency virus testing in Emergency Departments in South Africa. The pilot symptom list was used for chief complaint coding in three Emergency Departments. Data was collected on 3357 patients using paper case report forms. Chief complaint terms were reviewed by two study team members to determine the frequency of concordance between the coded chief complaint term and the selected symptom(s) from the pilot symptom list.

RESULTS

Overall, 3537 patients' chief complaints were reviewed, of which 640 were identified as 'potential mismatches.' When considering the 191 confirmed mismatches (29.8%), the Delphi process identified 6 (3.1%) false mismatches and 185 (96.9%) true mismatches. Significant chief-complaint clustering was identified with 9 sets of complaints frequently selected together for the same patient. "Pain" was used 2076 times for 58.7% of all patients. A combination of user feedback and expert-panel modified Delphi analysis of mismatched complaints and clustered complaints resulted in several substantial changes to the pilot symptom list.

CONCLUSIONS

This study presented a systematic methodology for calibrating a chief complaint list for the local context. Our revised list removed/reworded symptoms that frequently clustered together or were misinterpreted by health professionals. Recommendations for additions, modifications, and/or deletions from the pilot chief complaint list we believe will improve the functionality of the list in low resource environments.

Audit of Computed Tomography (Brain) Referrals from the Accident and Emergency Department in a Tertiary Care Hospital

Introduction: Non-contrast Computerised Tomography (NCCT) Brain is a common referral made from the Accident and Emergency (A&E) department both for traumatic and non traumatic causes. Aim: To evaluate the veracity of the referrals made by the Accident and Emergency Department clinicians for non-contrast computed tomography Head. Materials and Methods: This was the Retrospective evaluation of diagnostic yield of head Computed Tomography (CT) referrals made from A&E Department of a tertiary care hospital located in northern-central India over three year period between January 2015 to December 2017. CT reports were first grouped into two major group’s trauma and non trauma referrals with further subdivision into positive and negative scan on the basis of presence of abnormality. Subsequently, the positive trauma reports were classified into Major findings (three subgroups extra-axial haemorrhage, brain contusions and other miscellaneous findings) and minor findings like undisplaced fractures of the skull or facial bones with or without subgaleal haematoma. Distribution of trauma cases as per National Institute for Health and Care Excellence (NICE) criteria was then tabulated. Non-trauma reports were also further classified in to the two major clinically important findings of haemorrhage and infarct as well as non-specific minor findings. Results: Of the total data of 2185 head CT (980 trauma cases and 1205 in non trauma cases) referrals done by A&E Department during the study period. The 144 (58.5%) out of trauma cases and 328 (27.2%) out of non trauma cases were with major findings. 788 (80.4%) of trauma cases and 965 (80.1%) out of non trauma cases were referred by Medical Officer (MO)/ Resident as revealed from the audit. Positivity percentages for traumatic and non traumatic causes were 25.1% and 27.2%, respectively. Conclusion: Due to non adherence to existing guidelines or due to poor clinical knowledge, there is poor diagnostic yield of CT referrals made from A&E department. Thus clinical Audit is essential at Department of Radiodiagnosis to streamline the referring protocols and improves the overall efficiency of the healthcare system.

Sonographic Measurement of Visceral Fat Thickness as a Correlate of Existing Metabolic Syndrome- A Cross-sectional Study

Introduction: Metabolic syndrome is a well-known disease of multiple risk factors that has at its core, insulin resistance accompanying abnormal adipose deposition and function. Multiple studies demonstrate a potential relationship between Visceral Fat Thickness (VFT) and metabolic syndrome. Ultrasound provides a radiation free low-cost alternative, which is high reproducible in the quantification of visceral fat and can act as an effective screening modality. The simplicity of the method combined with its objectiveness makes it advantageous for accurate measurement of VFT. Aim: To correlate of sonographic measurement of VFT with existing metabolic syndrome. Materials and Methods: This cross-sectional study was conducted on all patients that underwent ultrasound at the study center between August 2016 to August 2019 and were clinically suspected of suffering from metabolic syndrome at the Endocrinology Outpatient Department (OPD). Collation of data into three categories based on VFT (<7 cm, 7 to 10 cm and >10 cm) was done. The patients in each category underwent further testing and metabolic syndrome was either ruled out or diagnosed. Results: The study cohort comprised of 2022 patients. The VFT ranged between 4 and 16 with a mean value of 10.8 and standard deviation of 2.8. The percentage of patients with metabolic syndrome increased in proportion to the increased VFT. VFT >10 cm was found to have specificity and Positive Predictive Value (PPV) 92.52% and 92.53% respectively while VFT <7 cm was found to have a sensitivity and Negative Predictive Value (NPV) of 95.11% and 95.10%, respectively. Conclusion: Ultrasound seems to be the best screening tool for the assessment of intra-abdominal fat deposition as the number of VFT subjects with metabolic syndrome in Category 1 was higher.

Determination of secretory granule maturation times in pancreatic islet β-cells by serial block-face electron microscopy

It is shown how serial block-face electron microscopy (SBEM) of insulin-secreting β-cells in wild-type mouse pancreatic islets of Langerhans can be used to determine maturation times of secretory granules. Although SBEM captures the β-cell structure at a snapshot in time, the observed ultrastructure can be considered representative of a dynamic equilibrium state of the cells since the pancreatic islets are maintained in culture in approximate homeostasis. It was found that 7.2 ± 1.2% (±st. dev.) of the β-cell volume is composed of secretory granule dense-cores exhibiting angular shapes surrounded by wide (typically ≳100 nm) electron-lucent halos. These organelles are identified as mature granules that store insulin for regulated release through the plasma membrane, with a release time of 96 ± 12 h, as previously obtained from pulsed ³⁵S-radiolabeling of cysteine and methionine. Analysis of β-cell 3D volumes reveals a subpopulation of secretory organelles without electron-lucent halos, identified as immature secretory granules. Another subpopulation of secretory granules is found with thin (typically ≲30 nm) electron-lucent halos, which are attributed to immature granules that are transforming from proinsulin to insulin by action of prohormone convertases. From the volume ratio of proinsulin in the immature granules to insulin in the mature granules, we estimate that the newly formed immature granules remain in morphologically-defined immature states for an average time of 135 ± 14 min, and the immature transforming granules for an average time of 130 ± 17 min.

Adapting blood glucose meter biosensors for the measurement of lactose in dairy ingredients

Commonly used lactose assays [enzymatic spectrophotometric absorbance (EZA) and HPLC] for dairy ingredients are relatively expensive and time consuming. A blood glucose meter (BGM)-based method has successfully been documented as a rapid lactose assay in milk. However, the BGM-based method has not been evaluated in dairy ingredients. The objective of this study was to evaluate the BGM-based lactose analysis method in whey-derived (WD) and skim milk-derived (SMD) ingredients. The study was carried out in 4 phases. In phase 1, the effect of pH and lactose concentrations on the BGM reading was investigated using a factorial design with 2 factors: pH (6.02-7.50) and lactose (0.2 or 0.4%). We found that BGM readings were significantly affected by lower pH values at both lactose levels. In phase 2, the effect of total solids and ingredient type was investigated using a factorial design with 2 factors: ingredient type (WD or SMD) and total solids (0-8%). It was observed that the BGM reading was significantly affected by ingredient type and total solids. Phase 3 involved developing a linear relationship between the BGM reading and the EZA reference method to ascertain the accuracy of the proposed BGM method. Different ingredient types (WD or SMD) and non-lactose solids (0.5-27%) model ingredient dilutions prepared over a range of lactose contents (0.08-0.62%) were measured using the BGM and EZA methods. The average absolute percentage bias difference between the BGM method and EZA reference method results for these model dilutions was found to be between 2.2 and 7.3%. In phase 4, 15 samples procured from commercial sources ranging from 0.01 to 81.9% lactose were evaluated using the BGM method and EZA reference method. The average absolute percentage bias difference for lactose results between the 2 methods ranged from 3.6 to 5.0% and 5.3 to 9.7% for well-performing and poorly performing meters, respectively. Overall, the BGM method is a promising tool for rapid and low-cost analysis of lactose in both high-lactose and low-lactose dairy ingredients.

AB0006 HYPOMETHYLATION OF THE PROMOTER REGION OF TLR4 GENE AT A SYSTEMIC LEVEL IN PATIENTS WITH RHEUMATOID ARTHRITIS AND PERIODONTITIS

Background:

Periodontitis (PD) has long been linked with Rheumatoid arthritis (RA) [1]. Epigenetic modifications are being recently explored to explain such associations, DNA methylation being one such important mechanism.

Objectives:

To study the effect chronic generalized periodontitis on systemic methylation of TLR4 genes in comparison to only RA and RA with PD patients.

Methods:

Twenty-three RA patients, among which 11 patients had chronic generalized PD, 20 patients with only PD and 15 healthy individuals recruited. DNA was isolated from PBMCs of the participants blood, then were first bisulphite converted and then methylation specific PCR were performed using primers for methylated and um-methylated promoters of TLR4. The DNA amplifications were checked in horizontal gel electrophoresis. The methylation signatures were verified by DNA sequencing (Sanger) of the amplified products.

Results:

The anti-CCP, DAS-CRP and HAQ DI were higher in patients with both RA and PD (220±40, 5.7±0.2, 1.5±0.1 respectively, p<0.05). Control samples had shown amplification bands for methylated primers of TLR4 but not for un-methylated primers of TLR4. However, only RA, only PD and RA with PD samples, had shown amplification for un-methylated primers and not for methylated primers. These results together with DNA sequencing indicated that 4 CpG sites in the promoter ofTLR4 genes were hypo-methylated in the PBMCs of patients whereas those remain methylated in healthy individuals.

Conclusion:

The observations indicated that though PD is a localised disease of the gingiva there is a systemic involvement of TLR mediated pathways in them which is similar to those in RA. However, further validation in larger cohort and down-stream signalling molecules needs to be studied.

References:

[1]Ceccarelli F, Saccucci M, Di Carlo G, Lucchetti R, Pilloni A, Pranno N, Luzzi V, Valesini G, Polimeni A. Periodontitis and rheumatoid arthritis: the same inflammatory mediators?. Mediators of inflammation. 2019;2019.

Disclosure of Interests:

None declared

Foldscope as a primary diagnostic tool for oral and urinary tract infections and its effectiveness in oral health education

Due to its speed, accuracy and cost-effectiveness, microscopy has become an integral part of clinical examination for disease diagnosis. However, modern microscopes are very costly and require skilled personnel for their operation and maintenance, and specimen processing and analysis is labour-intensive. Further, lack of such expensive diagnostic tools in remote areas is a serious concern. Affordable point-of-care diagnostic tools are the most useful for timely disease diagnosis and management. The Foldscope is an affordable origami-based microscopy device composed of a series of paper clippings, which, upon assembly, can hold a specimen slide for observation, and this specimen can be viewed via a mobile phone camera attached to it. The present study evaluated the use of the Foldscope in the clinical diagnosis of oral and urinary tract infections and evaluated its efficacy as a motivational tool for improving oral health among school children in India. We qualitatively compared the Foldscope to a clinical microscope by examining five different types of clinical samples. Of the different types of clinical samples, the Foldscope was effective in detecting infection in dental plaque samples and urine samples. Thus, we further analysed 31 dental plaque samples of patients aged 3-13 years and 25 urine samples of patients aged 11-62 years. We also evaluated the use of the Foldscope as an educational tool for motivating oral hygiene among 80 school children aged 12 years and found that students in the Foldscope intervention group had better measures of oral hygiene than did students in the nonintervention group. In summary, our study indicated that the Foldscope is useful in detecting urinary tract infections and kidney stones in urine samples and is a useful motivational tool for oral health education among school-aged children. Furthermore, it may also be useful in oral health monitoring in resource poor settings. LAY DESCRIPTION: Poor and remote population often suffers due to lack of capacity to buy products or avail services which are expensive. In such a society people are not able to afford even the basic detection of diseases. Foldscope may come to rescue here! Foldscope is a paper-based, use-and-throw, affordable microscope. This study explores the use of Foldscope in clinics and diseases diagnosis using patient samples. Preliminary detection of disease associated symptoms in dental and urinary infections and digital record keeping via storage in mobile phone memory and hospital OPD records for monitoring patient's health are some of the advantages of Foldscope for clinical use in resource poor settings. It identifies that Foldscope not only can be used by students or teachers for educational purposes but it can also pave a path for promotion of dental hygiene among young children. The study also suggests that further improvement in design or resolution of Foldscope will broaden the scope of its application, in future.