P27: INTRODUCTION OF A PILOT VIRTUAL FRACTURE CLINIC: A TIME AND COST ANALYSIS

Introduction

The British Orthopaedic Association Standards for Trauma and Orthopaedics(BOAST) have produced guidelines advising that all patients be reviewed by an orthopaedic consultant within 72 hours of presentation. However, data from traditional fracture clinics rarely fulfil this criterion. Furthermore, data from the National Health Service(NHS) has determined that traditional fracture clinics have become unfit for purpose with low patient satisfaction rates, excessive waiting times and over 6.9 million missed appointments every year. Our aim is to test the feasibility of a virtual fracture clinic(VFC) with a view to reducing service costs and improving adherence to BOAST guidelines specified timeline for orthopaedic consultant review.

Method

A retrospective analysis of 103 patients referred to our pilot VFC from January 1st to 31st 2019 was carried out. We included shoulder dislocations, clavicle injuries, simple distal radius fractures, radial head fractures, metacarpal and metatarsal injuries, undisplaced fractures of the medial and lateral malleolus of the ankle and soft tissue injuries. The primary outcome measured time from presentation to review by an orthopaedic consultant. A cost analysis was also performed to estimate the overheads and potential savings associated with VFC introduction. Statistical analysis was done via SPSS.

Result

Following VFC establishment, time from ED presentation to review by orthopaedic consultant reduced from a mean of 229 hours to 72 hours(P=0.0001). Cost analysis demonstrated that the VFC created savings of €3170 per week, amounting to projected savings of €38,040.

Conclusion

VFC has the potential to improve clinical performance while delivering substantial financial savings.

Take-home message

Virtual fracture clinic improves patients review times bringing them in line with BOAST guidelines while providing significant reductions in overheads leading to potential savings of over 38,000 euro.

The absence of the caffeine synthase gene is involved in the naturally decaffeinated status of Coffea humblotiana, a wild species from Comoro archipelago

Caffeine is the most consumed alkaloid stimulant in the world. It is synthesized through the activity of three known N-methyltransferase proteins. Here we are reporting on the 422-Mb chromosome-level assembly of the Coffea humblotiana genome, a wild and endangered, naturally caffeine-free, species from the Comoro archipelago. We predicted 32,874 genes and anchored 88.7% of the sequence onto the 11 chromosomes. Comparative analyses with the African Robusta coffee genome (C. canephora) revealed an extensive genome conservation, despite an estimated 11 million years of divergence and a broad diversity of genome sizes within the Coffea genus. In this genome, the absence of caffeine is likely due to the absence of the caffeine synthase gene which converts theobromine into caffeine through an illegitimate recombination mechanism. These findings pave the way for further characterization of caffeine-free species in the Coffea genus and will guide research towards naturally-decaffeinated coffee drinks for consumers.

Systematic review of endovascular stent grafting versus open surgical repair for the elective treatment of arch/descending thoracic aortic aneurysms

OBJECTIVE

To review comparisons of the effectiveness of endovascular stent grafting (ESG) against open surgical repair (OSR) for treatment of chronic arch or descending thoracic aortic aneurysms (TAA).

DESIGN

Systematic review and meta-analysis DATA SOURCES: MEDLINE, EMBASE, CENTRAL, WHO International Clinical Trials Routine data collection, current controlled trials, clinical trials and the NIHR portfolio were searched from January 1994 to March 2020.

ELIGIBILITY CRITERIA FOR SELECTIVE STUDIES

All identified studies that compared ESG and OSR, including randomised controlled trials (RCTs), quasi-randomised and non-RCTs, comparative cohort studies and case-control studies matched on main outcomes were sought. Participants had to receive elective treatments for arch/descending (TAA). Studies were excluded where other thoracic aortic conditions (eg, rupture or dissection) were reported, unless results for patients receiving elective treatment for arch/descending TAA reported separately.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by one reviewer and checked by another. Risk of Bias was assessed using the ROBINS-I tool. Meta-analysis was conducted using random effects. Where meta-analysis not appropriate, results were reported narratively.

RESULTS

Five comparative cohort studies met inclusion criteria, reporting 3955 ESG and 21 197 OSR patients. Meta-analysis of unadjusted short-term (30 day) all-cause mortality favoured ESG (OR 0.75; 95% CI 0.55 to 1.03)). Heterogeneity identified between larger and smaller studies. Sensitivity analysis of four studies including only descending TAA showed no statistical significance (OR 0.73, 95% CI 0.45 to 1.18)), moderate heterogeneity. Meta-analysis of adjusted short-term all-cause mortality favoured ESG (OR 0.71, 95% CI 0.51 to 0.98)), no heterogeneity. Longer-term (beyond 30 days) survival from all-cause mortality favoured OSR in larger studies and ESG in smaller studies. Freedom from reintervention in the longer-term favoured OSR. Studies reporting short-term non-fatal complications suggest fewer events following ESG.

CONCLUSIONS

There is limited and increasingly dated evidence on the comparison of ESG and OSR for treatment of arch/descending TAA.

PROSPERO REGISTRATION NUMBER

CRD42017054565.

Leptomeningeal Relapse of Embryonal Rhabdomyosarcoma after 15 years

Aim Rhabdomyosarcoma (RMS) is the most common malignant soft tissue tumour of childhood. We present the case of a late relapse of RMS to the leptomeninges after 15 years. Methods A 20 year old male presented with a 3 week history of headaches and nausea. He previously had RMS of his right ear diagnosed at age 5 years which was treated with concurrent chemoradiotherapy. An MRI Brain and Spine confirmed extensive leptomeningeal disease and CSF analysis confirmed the presence of recurrent embryonal RMS. Results He completed two cycles of cyclophosphamide and topotecan followed by 45Gy/25Fr of craniospinal radiotherapy. Conclusion Late relapses beyond five years can be seen in up to 9% of patients, however very late recurrences (>10 years) are exceedingly rare. Molecular based methods such as gene expression profiling can aid risk stratification and survivorship clinics may become increasingly useful in following patients with high risk features.

Food restriction induces functional resilience to sleep restriction in rats

STUDY OBJECTIVES

Sleep restriction (SR) leads to performance decrements across cognitive domains but underlying mechanisms remain largely unknown. The impact of SR on performance in rodents is often assessed using tasks in which food is the reward. Investigating how the drives of hunger and sleep interact to modulate performance may provide insights into mechanisms underlying sleep loss-related performance decrements.

METHODS

Three experiments were conducted in male adult Wistar rats to assess: (1) effects of food restriction on performance in the simple response latency task (SRLT) across the diurnal cycle (n = 30); (2) interaction of food restriction and SR (11 h) on SRLT performance, sleep electroencephalogram, and event-related potentials (ERP) (n = 10-13); and (3) effects of food restriction and SR on progressive ratio (PR) task performance to probe the reward value of food reinforcement (n = 19).

RESULTS

Food restriction increased premature responding on the SRLT at the end of the light period of the diurnal cycle. SR led to marked impairments in SRLT performance in the ad libitum-fed group, which were absent in the food-restricted group. After SR, food-restricted rats displayed a higher amplitude of cue-evoked ERP components during the SRLT compared with the ad libitum group. SR did not affect PR performance, while food restriction improved performance.

CONCLUSIONS

Hunger may induce a functional resilience to negative effects of sleep loss during subsequent task performance, possibly by maintaining attention to food-related cues.

Deciphering the role of Rhodnius prolixus CYP4G genes in straight and methyl-branched hydrocarbon formation and in desiccation tolerance

Insect cuticle hydrocarbons are involved primarily in waterproofing the cuticle, but also participate in chemical communication and regulate the penetration of insecticides and microorganisms. The last step in insect hydrocarbon biosynthesis is carried out by an insect-specific cytochrome P450 of the 4G subfamily (CYP4G). Two genes (CYP4G106 and CYP4G107) have been reported in the triatomines Rhodnius prolixus and Triatoma infestans. In this work, their molecular and functional characterization is carried out in R. prolixus, and their relevance to insect survival is assessed. Both genes are expressed almost exclusively in the integument and have an expression pattern dependent on the developmental stage and feeding status. CYP4G106 silencing diminished significantly the straight-chain hydrocarbon production while a significant reduction - mostly of methyl-branched chain hydrocarbons - was observed after CYP4G107 silencing. Molecular docking analyses using different aldehydes as hydrocarbon precursors predicted a better fit of straight-chain aldehydes with CYP4G106 and methyl-branched aldehydes with CYP4G107. Survival bioassays exposing the silenced insects to desiccation stress showed that CYP4G107 is determinant for the waterproofing properties of the R. prolixus cuticle. This is the first report on the in vivo specificity of two CYP4Gs to make mostly straight or methyl-branched hydrocarbons, and also on their differential contribution to insect desiccation.

Non-communicable disease risk factors among a cohort of mine workers in Mongolia

Background

Prevalence of non-communicable diseases (NCD) are growing among working populations globally. The World Health Organization (WHO) estimates NCD are responsible for 80% of all premature deaths (Lancet, 2016). The purpose of this study is to determine baseline level of NCD and risk factors among mine workers and to identify intervention strategies based on results. The collected results will be compared with a NCD study on the general population of Mongolia.

Methods

A cross sectional design was used for this study. 684 employees were randomly recruited to the study. We utilised WHO questionnaire to collect anthropogenic measurements, health behaviours, alcohol consumption, smoking, NCD and work related information.. The study focused on four (4) key risk factors of hypertension, obesity, drinking habits and smoking habits. These factors are key contributors to NCD and decreased life expectancy.

Results

Results of the study showed prevalence's of hypertension 12.9%, obesity 64.1%, alcohol users 22.1% and smokers 38.8%. The general population prevalence's are 27.5%, 56.8%, 15.5% and 24.8% respectively. Differences between gender in the study cohort for smoking rate (men = 43.3%, women = 8.9%), alcohol consumption (men = 29.9%, women = 16.1%) and central obesity (men = 78.3%, women = 35.1%) were statistically significant (p < 0.05).

Conclusions

Prevalence of arterial hypertension for the mine worker cohort was lower than general population, however, obesity, drinking and smoking rates were higher. The study findings allow us to target intervention strategies to mitigate the risk of NCD development in the future.

Key messages

Understand the risk factors and control measures available to mitigate the risk of the development of NCD. Comparison of the mine site cohort with the general population to understand similarities and differences.

The Impact of Prior Season Vaccination on Subsequent Influenza Vaccine Effectiveness to Prevent Influenza-related Hospitalizations Over 4 Influenza Seasons in Canada

BACKGROUND

Recent studies have demonstrated the possibility of negative associations between prior influenza vaccines and subsequent influenza vaccine effectiveness (VE), depending on season and strain. We investigated this association over 4 consecutive influenza seasons (2011-2012 through 2014-2015) in Canada.

METHODS

Using a matched test-negative design, laboratory-confirmed influenza cases and matched test-negative controls admitted to hospitals were enrolled. Patients were stratified into 4 groups according to influenza vaccine history (not vaccinated current and prior season [referent], vaccinated prior season only, vaccinated current season only, and vaccinated both current and prior season). Conditional logistic regression was used to estimate VE; prior vaccine impact was assessed each season for overall effect and effect stratified by age (<65 years, ≥65 years) and type/subtype (A/H1N1, A/H3N2, influenza B).

RESULTS

Overall, mainly nonsignificant associations were observed. Trends of nonsignificant decreased VE among patients repeatedly vaccinated in both prior and current season relative to the current season only were observed in the A/H3N2-dominant seasons of 2012-2013 and 2014-2015. Conversely, in 2011-2012, during which B viruses circulated, and in 2013-2014, when A/H1N1 circulated, being vaccinated in both seasons tended to result in a high VE in the current season against the dominant circulating subtype.

CONCLUSIONS

Prior vaccine impact on subsequent VE among Canadian inpatients was mainly nonsignificant. Even in circumstances where we observed a trend of negative impact, being repeatedly vaccinated was still more effective than not receiving the current season's vaccine. These findings favor continuation of annual influenza vaccination recommendations, particularly in older adults.

CLINICAL TRIALS REGISTRATION

NCT01517191.

Longitudinal changes in EEG power, sleep cycles and behaviour in a tau model of neurodegeneration

Background

Disturbed sleep is associated with cognitive decline in neurodegenerative diseases such as Alzheimer’s disease (AD) and frontotemporal dementia (FTD). The progressive sequence of how neurodegeneration affects aspects of sleep architecture in conjunction with behavioural changes is not well understood.

Methods

We investigated changes in sleep architecture, spectral power and circadian rhythmicity in the tet-off rTg4510 mouse overexpressing human P301L tau within the same subjects over time. Doxycycline-induced transgene-suppressed rTg4510 mice, tTa carriers and wild-type mice were used as comparators. Spectral power and sleep stages were measured from within the home cage environment using EEG electrodes. In addition, locomotor activity and performance during a T-maze task were measured.

Results

Spectral power in the delta and theta bands showed a time-dependent decrease in rTg4510 mice compared to all other groups. After the initial changes in spectral power, wake during the dark period increased whereas NREM and number of REM sleep bouts decreased in rTg4510 compared to wild-type mice. Home cage locomotor activity in the dark phase significantly increased in rTg4510 compared to wild-type mice by 40 weeks of age. Peak-to-peak circadian rhythm amplitude and performance in the T-maze was impaired throughout the experiment independent of time. At 46 weeks, rTG4510 mice had significant degeneration in the hippocampus and cortex whereas doxycycline-treated rTG4510 mice were protected. Pathology significantly correlated with sleep and EEG outcomes, in addition to locomotor and cognitive measures.

Conclusions

We show that reduced EEG spectral power precedes reductions in sleep and home cage locomotor activity in a mouse model of tauopathy. The data shows increasing mutant tau changes sleep architecture, EEG properties, behaviour and cognition, which suggest tau-related effects on sleep architecture in patients with neurodegenerative diseases.

Pharmacological Modulation of Sleep Homeostasis in Rat: Novel Effects of an mGluR2/3 Antagonist

Increasing vigilance without incurring the negative consequences of extended wakefulness such as daytime sleepiness and cognitive impairment is a major challenge in treating many sleep disorders. The present work compares two closely related mGluR2/3 antagonists LY3020371 and LY341495 with two well-known wake-promoting compounds caffeine and d-amphetamine. Sleep homeostasis properties were explored in male Wistar rats by manipulating levels of wakefulness via (1) physiological sleep restriction (SR), (2) pharmacological action, or (3) a combination of these. A two-phase nonlinear mixed-effects model combining a quadratic and exponential function at an empirically estimated join point allowed the quantification of wake-promoting properties and any subsequent sleep rebound. A simple response latency task (SRLT) following SR assessed functional capacity of sleep-restricted animals treated with our test compounds. Caffeine and d-amphetamine increased wakefulness with a subsequent full recovery of non-rapid eye movement (NREM) and rapid eye movement (REM) sleep and were unable to fully reverse SR-induced impairments in SRLT. In contrast, LY3020371 increased wakefulness with no subsequent elevation of NREM sleep, delta power, delta energy, or sleep bout length and count, yet REM sleep recovered above baseline levels. Prior sleep pressure obtained using an SR protocol had no impact on the wake-promoting effect of LY3020371 and NREM sleep rebound remained blocked. Furthermore, LY341495 increased functional capacity across SRLT measures following SR. These results establish the critical role of glutamate in sleep homeostasis and support the existence of independent mechanisms for NREM and REM sleep homeostasis.

87 Effects of Community Falls Prevention Service Closure on ICD-10 Coded Fracture Rates in Older People: An Interrupted Time Series Approach

Introduction

Guidelines on falls prevention recommend case ascertainment based on opportunistic case ascertainment and referral in those who have fallen. In October 2009 we implemented a novel multidisciplinary, multifactorial falls, syncope and dizziness service with enhanced case-ascertainment through proactive, primary care-based screening for associated risk factors. In addition to comprehensive geriatric assessment, 25% of 4032 service participants underwent strength and balance training. The baseline outcomes have been previously reported.1 Funding was withdrawn, and the service closed on 31/01/2014. We examined the effect of service-closure on fractures presenting to secondary care with and without the service running.

Methods

An interrupted time series method was used. ICD-10 coded fracture numbers attending secondary care were determined (Hospital Episode Statistics from 01/02/2012-31/05/2017) for all North Tyneside residents ≥60 years at the time of service closure, including 25-months with, and 40-months without, service provision.

Results

There was a 0.9% (p=0.018) monthly reduction in falls over 25-months of service provision which increased during the winter months of a 9.8% (p=0.015) increase. In the month following the service closure there was an initial increase in fractures of 8.5% (p=0.231), followed by an increase in the monthly time trend of 1% (p=0.018). This resulted in a post-service monthly increase in fractures of 0.1%, an estimated extra 625 fractures over the 40-month post-service cessation period. At an average £8600 per fracture, the estimated cost may have been £5,375,000.

Conclusions

In this naturalistic experiment, following an initial drop in fractures, disinvestment in this service resulted in a rise in elders’ fractures presenting to secondary care. The closure of the service may have had a large unintended cost, averaging £1.5 million annually, versus annual running costs of £220,000. Further research is needed to control for patient-level characteristics and to establish the cost-effectiveness of the service.

74 Effects of Community Falls Prevention Service Closure on Ischaemic Heart Disease Attendances in Secondary Care: An Interrupted Time Series Approach

Background

In 2009 we implemented a novel multidisciplinary, multifactorial falls, syncope and dizziness service model utilising proactive, primary care-based screening (≥60 years). Participants underwent comprehensive geriatric assessment, while 25% of the 4032 service participants had exercise training. All had additional lifestyle advice on exercise, alcohol intake, weight loss and smoking cessation. The preliminary outcomes of this approach have been previously reported, with occult atrial fibrillation, murmurs, ECG-evident ischaemic heart disease (IHD) etc reported to GPs for further action.1 Funding was withdrawn and the service closed on 31/01/2014. We examined IHD secondary care attendances with and without service provision.

Methods

Patients: North Tyneside residents ≥60 years at time of closure of the service in January 2014, who were presented acutely to secondary care with IHD using an interrupted time series method. ICD-10 coded IHD numbers were determined (Hospital Episode Statistics from 01/02/2012[date of a change in coding compared to service commencement in 2009] until 31/05/2017) including 25-months with, and 40-months without, service provision.

Results

The Table summarises the change in IHD +/- service provision; there was a significant reduction in IHD non-elective admissions during both time series’, but the reduction was significantly lower without service provision.

In addition, immediately following the service closure there was an initial increase in IHD complications of 18.4% (p=0.059) followed by an increase in the time trend of 2.7% (p=0.029), resulting in a 0.6% post-service monthly reduction in IHD complications.

Conclusions

Disinvestment in this service resulted in a slowdown in the underlying reduction of IHD diagnoses in secondary care. However, further research is needed to control for patient-level characteristics, the economic impact and to look at the effect of the service on other cardiovascular diseases.

Reference

1. Parry SW. JAGS 2016; 64 (11):2368–2373.

Validation of the Seegene RV15 multiplex PCR for the detection of influenza A subtypes and influenza B lineages during national influenza surveillance in hospitalized adults

Background. The Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN SOS) has been performing active influenza surveillance since 2009 (ClinicalTrials.gov identifier: NCT01517191). Influenza A and B viruses are identified and characterized using real-time reverse-transcriptase polymerase chain reaction (RT-PCR), and multiplex testing has been performed on a subset of patients to identify other respiratory virus aetiologies. Since both methods can identify influenza A and B, a direct comparison was performed.Methods. Validated real-time RT-PCRs from the World Health Organization (WHO) to identify influenza A and B viruses, characterize influenza A viruses into the H1N1 or H3N2 subtypes and describe influenza B viruses belonging to the Yamagata or Victoria lineages. In a subset of patients, the Seeplex RV15 One-Step ACE Detection assay (RV15) kit was also used for the detection of other respiratory viruses.Results. In total, 1111 nasopharyngeal swabs were tested by RV15 and real-time RT-PCRs for influenza A and B identification and characterization. For influenza A, RV15 showed 98.0 % sensitivity, 100 % specificity and 99.7 % accuracy. The performance characteristics of RV15 were similar for influenza A subtypes H1N1 and H3N2. For influenza B, RV15 had 99.2 % sensitivity, 100 % specificity and 99.8 % accuracy, with similar assay performance being shown for both the Yamagata and Victoria lineages.Conclusions. Overall, the detection of circulating subtypes of influenza A and lineages of influenza B by RV15 was similar to detection by real-time RT-PCR. Multiplex testing with RV15 allows for a more comprehensive respiratory virus surveillance in hospitalized adults, without significantly compromising the reliability of influenza A or B virus detection.

Rapid evaluation for health and social care innovations: challenges for "quick wins" using interrupted time series

Background

Rapid evaluation was at the heart of National Health Service England’s evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods.

Methods

A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard.

Results

The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315.

The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168.

Conclusions

Although it is acknowledged that there is often a need for rapid evaluations in order to identify “quick wins” and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources.

Comprehensive biodiversity analysis via ultra-deep patterned flow cell technology: a case study of eDNA metabarcoding seawater

The characterization of biodiversity is a crucial element of ecological investigations as well as environmental assessment and monitoring activities. Increasingly, amplicon-based environmental DNA metabarcoding (alternatively, marker gene metagenomics) is used for such studies given its ability to provide biodiversity data from various groups of organisms simply from analysis of bulk environmental samples such as water, soil or sediments. The Illumina MiSeq is currently the most popular tool for carrying out this work, but we set out to determine whether typical studies were reading enough DNA to detect rare organisms (i.e., those that may be of greatest interest such as endangered or invasive species) present in the environment. We collected sea water samples along two transects in Conception Bay, Newfoundland and analyzed them on the MiSeq with a sequencing depth of 100,000 reads per sample (exceeding the 60,000 per sample that is typical of similar studies). We then analyzed these same samples on Illumina's newest high-capacity platform, the NovaSeq, at a depth of 7 million reads per sample. Not surprisingly, the NovaSeq detected many more taxa than the MiSeq thanks to its much greater sequencing depth. However, contrary to our expectations this pattern was true even in depth-for-depth comparisons. In other words, the NovaSeq can detect more DNA sequence diversity within samples than the MiSeq, even at the exact same sequencing depth. Even when samples were reanalyzed on the MiSeq with a sequencing depth of 1 million reads each, the MiSeq's ability to detect new sequences plateaued while the NovaSeq continued to detect new sequence variants. These results have important biological implications. The NovaSeq found 40% more metazoan families in this environment than the MiSeq, including some of interest such as marine mammals and bony fish so the real-world implications of these findings are significant. These results are most likely associated to the advances incorporated in the NovaSeq, especially a patterned flow cell, which prevents similar sequences that are neighbours on the flow cell (common in metabarcoding studies) from being erroneously merged into single spots by the sequencing instrument. This study sets the stage for incorporating eDNA metabarcoding in comprehensive analysis of oceanic samples in a wide range of ecological and environmental investigations.

Severity dependent distribution of impairments in PSP and CBS: Interactive visualizations

BACKGROUND

Progressive supranuclear palsy (PSP) -Richardson's Syndrome and Corticobasal Syndrome (CBS) are the two classic clinical syndromes associated with underlying four repeat (4R) tau pathology. The PSP Rating Scale is a commonly used assessment in PSP clinical trials; there is an increasing interest in designing combined 4R tauopathy clinical trials involving both CBS and PSP.

OBJECTIVES

To determine contributions of each domain of the PSP Rating Scale to overall severity and characterize the probable sequence of clinical progression of PSP as compared to CBS.

METHODS

Multicenter clinical trial and natural history study data were analyzed from 545 patients with PSP and 49 with CBS. Proportional odds models were applied to model normalized cross-sectional PSP Rating Scale, estimating the probability that a patient would experience impairment in each domain using the PSP Rating Scale total score as the index of overall disease severity.

RESULTS

The earliest symptom domain to demonstrate impairment in PSP patients was most likely to be Ocular Motor, followed jointly by Gait/Midline and Daily Activities, then Limb Motor and Mentation, and finally Bulbar. For CBS, Limb Motor manifested first and ocular showed less probability of impairment throughout the disease spectrum. An online tool to visualize predicted disease progression was developed to predict relative disability on each subscale per overall disease severity.

CONCLUSION

The PSP Rating Scale captures disease severity in both PSP and CBS. Modelling how domains change in relation to one other at varying disease severities may facilitate detection of therapeutic effects in future clinical trials.

Patterns of mortality in modern stroke care

Background Stroke is a leading cause of death. We looked at the causes (direct and indirect) of in-hospital mortality in a modern stroke unit over a two-year period. Methods We reviewed medical charts of stroke deaths in hospital from 2014-2015 inclusive. Data on stroke type, aetiology, age, length of stay, comorbidities, and documented cause of death were recorded. All patients were included. Results 518 patients were admitted acutely to the stroke service. Overall death rate was 7.5% (n=39). Of fatal strokes 29 (74%) were ischaemic. Average age 78.6 years. Mean survival was 26.4 days (range 1-154). 19 (49%) patients had atrial fibrillation. Forty-nine percent of deaths were due to pneumonia, and 33% were due to raised intracranial pressure. Discussion Mortality rate in our stroke service has decreased from 15% in 1997, and now appears dichotomised into early Secondary Stroke Related Cerebral Events (SSRCEs) and later infections.