Salvage of Chronic Therapy-Resistant Bilateral Charcot Foot Osteoarthropathy with Signs of Osteomyelitis

Charcot arthropathy is an insidious condition affecting the lower limbs of diabetic patients. It is a complication of diabetic neuropathy resulting from subsequent Wallerian degeneration of the nerves. This complication may eventually lead to limb amputation and a poor patient prognosis if not diagnosed and treated successfully. Herein, we report the case of a 73‐year‐old female who presented with rapidly progressive bilateral Charcot foot over a 5‐week period, necessitating an exostectomy on the mid foot, specifically on the cuboid bone and the navicular cuneiform joint. Her presentation with rapidly progressing foot ulcers on the plantar aspect prompted initial treatment based on osteomyelitis. The report will therefore serve as a useful guide on how to properly treat Charcot foot, which may present in an atypical manner.

Impact of COVID-19 pandemic on community medication dispensing: a national cohort analysis in Wales, UK

Background

Population-level information on dispensed medication provides insight on the distribution of treated morbidities, particularly if linked to other population-scale data at an individual-level.

Objective

To evaluate the impact of COVID-19 on dispensing patterns of medications.

Methods

Retrospective observational study using population-scale, individual-level dispensing records in Wales, UK. Total dispensed drug items for the population between 1 st January 2016 and 31 st December 2019 (3-years, pre-COVID-19) were compared to 2020 with follow up until 27 th July 2021 (COVID-19 period). We compared trends across all years and British National Formulary (BNF) chapters and highlighted the trends in three major chapters for 2019-21: 1-Cardiovascular system (CVD); 2-Central Nervous System (CNS); 3-Immunological & Vaccine. We developed an interactive dashboard to enable monitoring of changes as the pandemic evolves.

Result

Amongst all BNF chapters, 73,410,543 items were dispensed in 2020 compared to 74,121,180 items in 2019 demonstrating -0.96% relative decrease in 2020. Comparison of monthly patterns showed average difference (D) of -59,220 and average Relative Change (RC) of -0.74% between the number of dispensed items in 2020 and 2019. Maximum RC was observed in March 2020 (D = +1,224,909 and RC = +20.62), followed by second peak in June 2020 (D = +257,920, RC = +4.50%). A third peak was observed in September 2020 (D = +264,138, RC = +4.35%). Large increases in March 2020 were observed for CVD and CNS medications across all age groups. The Immunological and Vaccine products dropped to very low levels across all age groups and all months (including the March dispensing peak).

Conclusions

Reconfiguration of routine clinical services during COVID-19 led to substantial changes in community pharmacy drug dispensing. This change may contribute to a long-term burden of COVID-19, raising the importance of a comprehensive and timely monitoring of changes for evaluation of the potential impact on clinical care and outcomes.

Risk factors for complicated grief among family members bereaved in intensive care unit settings: A systematic review

Background

Families of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents.

Materials and methods

MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken.

Results

Seven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye.

Conclusion

This systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503)

Long-term prevention of hereditary angioedema attacks with lanadelumab: The HELP OLE Study

Background

The aim was to evaluate long‐term effectiveness and safety of lanadelumab in patients ≥12 y old with hereditary angioedema (HAE) 1/2 (NCT02741596).

Methods

Rollover patients completing the HELP Study and continuing into HELP OLE received one lanadelumab 300 mg dose until first attack (dose‐and‐wait period), then 300 mg q2wks (regular dosing stage). Nonrollovers (newly enrolled) received lanadelumab 300 mg q2wks from day 0. Baseline attack rate for rollovers: ≥1 attack/4 weeks (based on run‐in period attack rate during HELP Study); for nonrollovers: historical attack rate ≥1 attack/12 weeks. The planned treatment period was 33 months.

Results

212 patients participated (109 rollovers, 103 nonrollovers); 81.6% completed ≥30 months on study (mean [SD], 29.6 [8.2] months). Lanadelumab markedly reduced mean HAE attack rate (reduction vs baseline: 87.4% overall). Patients were attack free for a mean of 97.7% of days during treatment; 81.8% and 68.9% of patients were attack free for ≥6 and ≥12 months, respectively. Angioedema Quality‐of‐Life total and domain scores improved from day 0 to end of study. Treatment‐emergent adverse events (TEAEs) (excluding HAE attacks) were reported by 97.2% of patients; most commonly injection site pain (47.2%) and viral upper respiratory tract infection (42.0%). Treatment‐related TEAEs were reported by 54.7% of patients. Most injection site reactions resolved within 1 hour (70.2%) or 1 day (92.6%). Six (2.8%) patients discontinued due to TEAEs. No treatment‐related serious TEAEs or deaths were reported. Eleven treatment‐related TEAEs of special interest were reported by seven (3.3%) patients.

Conclusion

Lanadelumab demonstrated sustained efficacy and acceptable tolerability with long‐term use in HAE patients.

Optimal timing of surveillance ultrasounds in small aortic aneurysms

OBJECTIVE

Small abdominal aortic aneurysms (AAA) surveillance intervals remain controversial and difficult to standardize. Current Society for Vascular Surgery guidelines lack quality evidence. The objective of this study is to examine patients followed in a high volume non-invasive vascular laboratory, determine if the current guidelines are fitting in clinical practice, and attempt to further identify risk factors for accelerated aneurysm growth.

METHODS

A retrospective analysis of patients who underwent at least two ultrasounds for AAA in the vascular laboratory during 2008-2018 with baseline diameter less than 5.0 cm was conducted. Patient demographics were collected. Groups were then created for comparison using the size criteria according to SVS guidelines. In addition, we compared overall growth rates specifically evaluating rapid growth (rate of at least 1.0 cm/year and size change of at least 0.5 cm from previous imaging), expected growth (any growth below 1.0 cm/year and of at least 0.5 cm from baseline) and no growth.

RESULTS

A total of 1581 patients (1232 male and 349 female) were identified with a total of 5945 ultrasound studies. The median age was 73 years and mean follow-up was 27.8 months. Baseline AAA size was 3.0-3.9 cm in 986 patients and 4.0-4.9 cm in 595 patients. The average maximum growth rate was 0.18 cm/year for AAAs 3.0-3.9 cm and 0.36 cm/year for AAAs 4.0-4.9 cm (p<0.001). Patients with AAA 4.0-4.9 cm at baseline were more likely to be white, male, hypertensive and have chronic kidney disease (p <0.05). 1078 patients (68.2%) demonstrated no growth over the observed time period with 342 patients (21.6%) demonstrating expected growth and 161 (10.2%) rapid growth. Male gender and baseline AAA size of 4.0-4.9 cm were more likely to demonstrate rapid growth (p=0.002) and eventual repair (p<0.001). Metformin use was more common in the AAA group with no growth (p <0.05). Freedom from rapid growth and repair indication at two years was significantly lower in those patients with baseline aneurysms 3.0-3.9 cm (p<0.001).

CONCLUSIONS

The overall low rate of events in small AAAs supports continued surveillance every 3 years for AAAs between 3.0 and 3.9 cm and yearly for male patients with AAAs 4.0-4.9 cm as recommended by the SVS Guidelines. Female gender may have less rapid growth than previously reported but likely merit more rigorous surveillance particularly as the AAAs approach 5.0 cm. Metformin use continues to demonstrate it may abrogate aneurysmal growth. Lastly, there is a subset of patients that exhibit more rapid growth of their small AAAs, and further study will be required to further classify these patients.

Sexual dysfunction damages: A legal database review

INTRODUCTION

Procedural specialties are at higher risk for malpractice claims than non-procedural specialties. Previous studies have examined common damages and malpractice lawsuits resulting from specific procedures. Our goal was to analyze urological interventions that led to sexual dysfunction claims.

METHODS

The Casetext legal research platform was queried using search terms for medical malpractice and common men's health procedures between 1993 and 2020. In total, 236 cases were found and 21 cases met the inclusion criteria: malpractice cases against a urologist or urology group, clearly stated legal outcome, and allegation of sexual dysfunction from an intervention that directly caused damages.

RESULTS

A total of 42 damages were cited in 21 lawsuits. The top three damages claimed were erectile dysfunction (14/42, 33.3%), genital pain syndrome (7/42, 16.7%), and urinary incontinence (5/42, 11.9%). The most commonly cited treatments were urinary catheter placement or removal (3/21, 14.3%), robotic-assisted laparoscopic radical prostatectomy (RALP) (3/21, 14.3%), circumcision (3/21, 14.3%), and penile implant (3/21, 14.3%). In 19 of 21 suits (90.4%), the outcome favored the defendant. Two cases favored the plaintiff: penile implant (failure to prove the patient was permanently, organically impotent prior to the procedure; $300 000) and vasectomy (damage to vasculature resulting in loss of testicle, $300 000).

CONCLUSIONS

Most suspected malpractice cases resulting in sexual dysfunction favored the defendant urologist. Interestingly, urinary catheter placement is as likely to result in litigation as other operative interventions, such as RALP, inflatable penile prosthesis, and circumcision. It is possible that thorough preoperative counselling and increased responsiveness to patients' postoperative concerns may have avoided litigation in several cases.

Electronic Medical Record Search Engine (EMERSE): An Information Retrieval Tool for Supporting Cancer Research

PURPOSE

The Electronic Medical Record Search Engine (EMERSE) is a software tool built to aid research spanning cohort discovery, population health, and data abstraction for clinical trials. EMERSE is now live at three academic medical centers, with additional sites currently working on implementation. In this report, we describe how EMERSE has been used to support cancer research based on a variety of metrics.

METHODS

We identified peer-reviewed publications that used EMERSE through online searches as well as through direct e-mails to users based on audit logs. These logs were also used to summarize use at each of the three sites. Search terms for two of the sites were characterized using the natural language processing tool MetaMap to determine to which semantic types the terms could be mapped.

RESULTS

We identified a total of 326 peer-reviewed publications that used EMERSE through August 2019, although this is likely an underestimation of the true total based on the use log analysis. Oncology-related research comprised nearly one third (n = 105; 32.2%) of all research output. The use logs showed that EMERSE had been used by multiple people at each site (nearly 3,500 across all three) who had collectively logged into the system > 100,000 times. Many user-entered search queries could not be mapped to a semantic type, but the most common semantic type for terms that did match was “disease or syndrome,” followed by “pharmacologic substance.”

CONCLUSION

EMERSE has been shown to be a valuable tool for supporting cancer research. It has been successfully deployed at other sites, despite some implementation challenges unique to each deployment environment.

Putative intranuclear coccidium in Mauremys leprosa (Schweigger) from Morocco

Although intranuclear coccidiosis was first identified in chelonians less than 30 years ago, it is now considered an important emerging disease. Symptoms include anorexia, weakness and weight loss, potentially leading to death of the infected animal. The use of molecular tools has led to improved diagnosis and has also led to an increase in known host species. Here we report a putative intranuclear coccidium in Mauremys leprosa (Schweigger), from Morocco, based on 18S rDNA sequence analysis. This is, to the best of our knowledge, the first report of this parasite from a freshwater terrapin species.

Service evaluation of the bereavement care delivered in a UK intensive care unit

BACKGROUND

Losing a loved one in the intensive care unit (ICU) can be a traumatic experience. The literature highlights that relatives of those who have died in ICU can experience symptoms of stress, anxiety, depression, post-traumatic stress disorder (PTSD) and prolonged grief.

AIM

To evaluate the service delivery of the bereavement care that is provided on a 20-bed general ICU.

METHODS AND ANALYSIS

A literature review informing and supporting the service evaluation and development of the questionnaire. Thematic analysis was undertaken using the six-phase framework.

FINDINGS

Five main themes were found: timing; care, dignity and respect; support; information; and memory making. Bereavement care is described as after-death care. However, the participants stipulated that bereavement care should be discussed prior to the death. Participants described using a range of interventions, such as memorial services, condolence letters, follow-up meetings and diaries.

CONCLUSION

Bereavement care was regarded as an important aspect of the care delivered in ICU. It was evident that participants strived to deliver an holistic approach, yet some found this difficult to achieve.

On the diversity and distribution of a data deficient habitat in a poorly mapped region: The case of Sabellaria alveolata L. in Ireland

Data that can be used to monitor biodiversity through time are essential for conservation and management. The reef-forming worm, Sabellaria alveolata (L. 1767) is currently classed as 'Data Deficient' due to an imbalance in the spread of data on its distribution. Little is known about the distribution of this species around Ireland. Using data archaeology, we collated past and present distribution records and discovered that S. alveolata has a discontinuous distribution with large gaps between populations. Many regions lack data and should be targeted for sampling. Biodiversity surveys revealed that S. alveolata supported diverse epibiotic algal communities. Retrograding (declining) reefs supported greater infaunal diversity than prograding (growing) reefs or sand, suggesting that S. alveolata is a dynamic ecosystem engineer that has a lasting legacy effect. Similar research should be carried out for other Data Deficient species, habitats and regions. Such data are invaluable resources for management and conservation.

Epilepsy, antiepileptic drugs, and the risk of major cardiovascular events

OBJECTIVE

This study was undertaken to determine whether epilepsy and antiepileptic drugs (including enzyme-inducing and non-enzyme-inducing drugs) are associated with major cardiovascular events using population-level, routinely collected data.

METHODS

Using anonymized, routinely collected, health care data in Wales, UK, we performed a retrospective matched cohort study (2003-2017) of adults with epilepsy prescribed an antiepileptic drug. Controls were matched with replacement on age, gender, deprivation quintile, and year of entry into the study. Participants were followed to the end of the study for the occurrence of a major cardiovascular event, and survival models were constructed to compare the time to a major cardiovascular event (cardiac arrest, myocardial infarction, stroke, ischemic heart disease, clinically significant arrhythmia, thromboembolism, onset of heart failure, or a cardiovascular death) for individuals in the case group versus the control group.

RESULTS

There were 10 241 cases (mean age = 49.6 years, 52.2% male, mean follow-up = 6.1 years) matched to 35 145 controls. A total of 3180 (31.1%) cases received enzyme-inducing antiepileptic drugs, and 7061 (68.9%) received non-enzyme-inducing antiepileptic drugs. Cases had an increased risk of experiencing a major cardiovascular event compared to controls (adjusted hazard ratio = 1.58, 95% confidence interval [CI] = 1.51-1.63, p < .001). There was no notable difference in major cardiovascular events between those treated with enzyme-inducing antiepileptic drugs and those treated with non-enzyme-inducing antiepileptic drugs (adjusted hazard ratio = .95, 95% CI = .86-1.05, p = .300).

SIGNIFICANCE

Individuals with epilepsy prescribed antiepileptic drugs are at an increased risk of major cardiovascular events compared with population controls. Being prescribed an enzyme-inducing antiepileptic drug is not associated with a greater risk of a major cardiovascular event compared to treatment with other antiepileptic drugs. Our data emphasize the importance of cardiovascular risk management in the clinical care of people with epilepsy.

Eligibility for dapagliflozin in unselected patients hospitalised with decompensated heart failure

Patients with heart failure with reduced ejection fraction (HFrEF) who received the sodium-glucose co-transport 2 inhibitor, dapagliflozin, in the DAPA-HF (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure) study have a significant reduction in worsening heart failure (HF) and cardiovascular death. It is uncertain what proportion of patients admitted to a large regional cardiac centre with decompensated heart failure would be eligible for dapagliflozin post-discharge based on their characteristics at discharge. The DAPA-HF study criteria were retrospectively applied to a cohort of 521 consecutive patients referred to the inpatient HF service in a tertiary cardiac centre in South West Wales between April 2017 and April 2018. Inclusion criteria: left ventricular ejection fraction (LVEF) < 40%, New York Heart Association (NYHA) class II-IV symptoms and an elevated N-terminal pro-B-type naturietic peptide (NT-proBNP). Exclusion criteria: systolic blood pressure (SBP) < 95 mmHg, estimated glomerular filtration rate (eGFR) < 30 ml/min/1.73 m2 or type 1 diabetes mellitus. We did not have complete NTproBNP data for the cohort, as it was not routinely measured at the time in our institute. There were 478 patients, mean age 78 ± 13 years, 57% male and 91% NYHA class II-IV symptoms, were included in the analysis. Of these, 247 patients had HFrEF, 219 (46%) patients met the inclusion criteria, 231 (48%) were excluded as LVEF was > 40%, and 48 (10%) were excluded with NYHA class I symptoms. Of the 219 patients who met the inclusion criteria, 13 (5.9%) had a SBP < 95 mmHg, 48 (22%) had eGFR < 30 ml/min/1.73 m2, leaving 136 (28.5% of total and 55% of those with HFrEF) who met DAPA-HF study criteria. In our study, 28.5% of all heart failure admissions and 55% of patients with HFrEF would be eligible for dapagliflozin post-discharge according to the DAPA-HF study entry criteria.

P90 PERCEIVE: PrEdiction of Risk and Communication of outcome following major lower limb amputation - a collaboratIVE study

Introduction

Major Lower Limb Amputation (MLLA) is a life changing event with significant morbidity and mortality. Inaccurate risk prediction can lead to poor decision making, resulting in delay to definitive surgery, or undertaking amputation when not in the patient’s best interest. We aim to answer: In adult patients undergoing MLLA for chronic limb threatening ischaemia or diabetes, how accurately do health care professionals prospectively predict outcomes after MLLA, and how does this compare to existing prediction tools?

Methods

A multicentre prospective observational cohort study is being delivered through the Vascular and Endovascular Research Network. Dissemination was via an existing network of contacts and social media.

Consecutive data will be collected for seven months from site launch date, including demographic data and pre-operative outcome predictions from surgeons, anaesthetists, and allied healthcare professionals. Follow-up data will comprise 30-day (mortality, morbidity, MLLA revision, surgical site infection, and blood transfusion) and 1-year (mortality, MLLA revision and ambulation). The accuracy of surgeons’ predictions will be evaluated and compared to pre-existing risk prediction scoring tools.

Results

PERCEIVE launched on 01/10/2020 with 23 centres (16 UK, 7 international) registered to collect data. 50 other centres (27 UK, 23 international) have expressed interest/are pursuing local audit/ethical approval. We aim to collect data on clinicians estimate of outcomes for over 500 patients.

Discussion

This study will utilise a trainee research network to provide data on the accuracy of healthcare professionals’ predictions of outcomes following MLLA and compare this to the utility of existing prediction tools in this patient cohort.

Long-term cancer surveillance: results from the Forteo Patient Registry Surveillance Study

The Forteo Patient Registry estimated the incidence of osteosarcoma in US patients treated with teriparatide and enrolled in the study between 2009 and 2019. No incident cases of osteosarcoma were identified among patients registered, and the crude incidence rate was 0 (95% confidence interval [CI], 0-10.2) cases per million person-years.

PURPOSE

The prospective, voluntary Forteo Patient Registry was established to estimate the incidence of osteosarcoma in patients who have received treatment with teriparatide (Forteo).

METHODS

Information on US adults prescribed teriparatide and enrolled in the Forteo Patient Registry 2009-2019 was linked with data from participating state cancer registries annually (2010-2019) to identify incident osteosarcoma cases using a standardized linkage algorithm. Teriparatide exposure was ascertained from self-reported data that included teriparatide initiation and demographics necessary to complete linkage. Osteosarcoma cases diagnosed on or after January 1, 2009, were identified by participating state cancer registries. The crude incidence rate (IR) and standardized incidence ratio (SIR) of observed cases to the expected number of cases adjusted to the background rate (3 per million person-years) and corresponding 95% CIs for the occurrence of osteosarcoma were calculated whereby the cumulative amount of person-time observed was adjusted for mortality.

RESULTS

Data for 75,247 enrolled patients (representing 361,763 cumulative person-years) were linked to each of 42 participating state cancer registries (covering 93% of the US population), which included information on 6180 cases of osteosarcoma. No matches with incident cases of osteosarcoma following registry enrollment were found. The crude IR was 0 (95% CI, 0-10.2) cases per million person-years and the SIR was 0 (95% CI, 0-3.0).

CONCLUSIONS

The ability to draw conclusions about the incidence of osteosarcoma among patients participating in the registry was limited due to the smaller than expected amount of patient follow-up time and the fact that no cases were identified.

Impact of lanadelumab on health-related quality of life in patients with hereditary angioedema in the HELP study

Background

An objective of the phase 3 HELP Study was to investigate the effect of lanadelumab on health‐related quality of life (HRQoL) in patients with hereditary angioedema (HAE).

Methods

Patients with HAE‐1/2 received either lanadelumab 150 mg every 4 weeks (q4wks; n = 28), 300 mg q4wks (n = 29), 300 mg every 2 weeks (q2wks; n = 27), or placebo (n = 41) for 26 weeks (days 0–182). The Angioedema Quality of Life Questionnaire (AE‐QoL) was administered monthly, consisting of four domain (functioning, fatigue/mood, fears/shame, nutrition) and total scores. The generic EQ‐5D‐5L questionnaire was administered on days 0, 98, and 182. Comparisons were made between placebo and (a) all lanadelumab‐treated patients and (b) individual lanadelumab groups for changes in scores (day 0–182) and proportions achieving the minimal clinically important difference (MCID, −6) in AE‐QoL total score.

Results

Compared with the placebo group, the lanadelumab total group demonstrated significantly greater improvements in AE‐QoL total and domain scores (mean change, −13.0 to −29.3; p < 0.05 for all); the largest improvement was in functioning. A significantly greater proportion of the lanadelumab total group achieved the MCID (70% vs 37%; p = 0.001). The lanadelumab 300 mg q2wks group had the highest proportion (81%; p = 0.001) and was 7.2 times more likely to achieve the MCID than the placebo group. Mean EQ‐5D‐5L scores at day 0 were high in all groups, indicating low impairment, with no significant changes at day 182.

Conclusion

Patients with HAE‐1/2 experienced significant and clinically meaningful improvements in HRQoL measured by AE‐QoL following lanadelumab treatment in the HELP Study.

Acute traumatic coagulopathy and the relationship to prehospital care and on-scene red blood cell transfusion

OBJECTIVE

To identify the incidence of acute traumatic coagulopathy (ATC) in trauma patients presenting to the Royal Adelaide Hospital, analyse prehospital contributors, including red blood cell transfusion and assess the clinical significance of ATC.

METHODS

A retrospective database review was undertaken using conventional coagulation assays and viscoelastic testing (ROTEM) for diagnosis of ATC.

RESULTS

Baseline ATC incidence is 10% in trauma patients, increasing to over 80% among those where the prehospital team has attended and given a transfusion of red cells. ATC was significantly associated with higher severity of trauma (odds ratio [OR] 1.11, P < 0.0001), prehospital (OR 11.8, P < 0.0001) and in-hospital blood transfusions (OR 17.9, P < 0.0001), and massive transfusions (P < 0.001).

CONCLUSIONS

Prehospital blood transfusions are given to the most severely injured trauma patients and the incidence of ATC in this group is more than 80%. There is an association with prehospital blood transfusion and increased ATC in part related to patient selection and severity of trauma, with the contribution of red cell transfusions to ATC unclear. This association should allow earlier identification of patients at increased risk of ATC to ensure rapid correction of coagulopathy to decrease the morbidity and mortality of trauma.