Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Synergy between callous-unemotional traits and aggression in preschool children: Cross-informant and cross-cultural replication in the UK Wirral Child Health and Development Study, and the Colombian La Sabana Parent-Child Study

Incremental prediction of aggression from callous-unemotional (CU) traits is well established, but cross-cultural replication and studies of young children are needed. Little is understood about the contribution of CU traits in children who are already aggressive. We addressed these issues in prospective studies in the United Kingdom and Colombia. In a UK epidemiological cohort, CU traits and aggression were assessed at age 3.5 years, and aggression at 5.0 years by mothers (N = 687) and partners (N = 397). In a Colombian general population sample, CU traits were assessed at age 3.5 years and aggression at 3.5 and 5.0 years by mother report (N = 220). Analyses consistently showed prediction of age-5.0 aggression by age-3.5 CU traits controlling for age-3.5 aggression. Associations between age-3.5 CU traits and age-5.0 aggression were moderated by aggression at 3.5 years, with UK interaction terms, same informant, β = .07 p = .014 cross-informant, β = .14 p = .002, and in Colombia, β = .09 p = .128. The interactions arose from stronger associations between CU traits and later aggression in those already aggressive. Our findings with preschoolers replicated across culturally diverse settings imply a major role for CU traits in the maintenance and amplification of already established aggression, and cast doubt on their contribution to its origins.

Defining core patient descriptors for perforated peptic ulcer research: international Delphi

BACKGROUND

Perforated peptic ulcer (PPU) remains a common condition globally with significant morbidity and mortality. Previous work has demonstrated variation in reporting of patient characteristics in PPU studies, making comparison of studies and outcomes difficult. The aim of this study was to standardize the reporting of patient characteristics, by creating a core descriptor set (CDS) of important descriptors that should be consistently reported in PPU research.

METHODS

Candidate descriptors were identified through systematic review and stakeholder proposals. An international Delphi exercise involving three survey rounds was undertaken to obtain consensus on key patient characteristics for future research. Participants rated items on a scale of 1-9 with respect to their importance. Items meeting a predetermined threshold (rated 7-9 by over 70 per cent of stakeholders) were included in the final set and ratified at a consensus meeting. Feedback was provided between rounds to allow refinement of ratings.

RESULTS

Some 116 clinicians were recruited from 29 countries. A total of 63 descriptors were longlisted from the literature, and 27 were proposed by stakeholders. After three survey rounds and a consensus meeting, 27 descriptors were included in the CDS. These covered demographic variables and co-morbidities, risk factors for PPU, presentation and pathway factors, need for organ support, biochemical parameters, prognostic tools, perforation details, and surgical history.

CONCLUSION

This study defines the core descriptive items for PPU research, which will allow more robust synthesis of studies.

Effectiveness of quality improvement collaboratives in improving clinical processes and patient outcomes in stroke care

Stroke remains one of the leading causes of death worldwide. In order to tackle the negative impacts of stroke, a high standard of clinical practice and a commitment to continuous quality improvement is needed across the stroke care pathway. One approach to quality improvement is the formation and implementation of quality improvement collaboratives (QIC's). However, there are several barriers to the implementation of a QIC for stroke care which may impact on their success. This article critically appraises a systematic review which assessed the effectiveness of QIC's for driving improvements in stroke care and explored the barriers to implementing a QIC's to improve care.

Exposure to community violence and Callous-Unemotional traits in young children: the role of positive parenting

Introduction

Studies regarding environmental contributions on callous-unemotional (CU) traits in children have informed about the protective role of positive parenting. However, it has not been explored whether findings from these studies -mostly conducted in High-Income Countries- can be generalised to Low-Middle-Income Countries (LMICs). Exposure to community violence is common in LMICs and is associated with emotional and behavioural problems in children. Therefore, it may represent an environmental risk factor for CU traits.

Objectives

This prospective study explores whether positive parenting has a protective role in relation to CU traits in young Colombian children whose families have been exposed to community violence.

Methods

We assessed 235 families with children at age 3.5 years, from three contrasting regions of Colombia, using observations of mother-child interactions and maternal reports of community violence at ages 3.5 and 5.0 years.

Results

Hierarchical multiple linear regression models indicated that maternal positivity at 3.5 years was associated with lower CU traits at age 5.0 years only in children of families exposed to community violence (interaction term p= .001). In the exposed group maternal positivity explained 10% of the variance (β= -.34, p= .001) with low positivity associated with elevated CU traits and high positivity with low CU traits. Maternal praise was not associated with CU traits. However, maternal negativity during play was associated with elevated CU traits as a main effect.

Conclusions

Based on these findings, whether or not exposure to community violence is associated with elevated CU traits depends on maternal positivity, with low positivity creating vulnerability, and high positivity, resilience.

Disclosure

No significant relationships.

Diverse clinical and social circumstances: developing patient-centred care for DR-TB patients in South Africa

OBJECTIVE

To describe the medical, socio-economic and geographical profiles of patients with rifampicin-resistant TB (RR-TB) and the implications for the provision of patient-centred care.

SETTING

Thirteen districts across three South African provinces.

DESIGN

This descriptive study examined laboratory and healthcare facility records of 194 patients diagnosed with RR-TB in the third quarter of 2016.

RESULTS

The median age was 35 years; 120/194 (62%) of patients were male. Previous TB treatment was documented in 122/194 (63%) patients and 56/194 (29%) had a record of fluoroquinolone and/or second-line injectable resistance. Of 134 (69%) HIV-positive patients, viral loads were available for 68/134 (51%) (36/68 [53%] had viral loads of >1000 copies/ml) and CD4 counts were available for 92/134 (69%) (20/92 [22%] had CD4 <50 cells/mm3). Patients presented with varying other comorbidities, including hypertension (13/194, 7%) and mental health conditions (11/194, 6%). Of 194 patients, 44 (23%) were reported to be employed. Other socio-economic challenges included substance abuse (17/194, 9%) and ill family members (17/194, 9%). Respectively 13% and 42% of patients were estimated to travel more than 20 km to reach their diagnosing and treatment-initiating healthcare facility.

CONCLUSIONS

RR-TB patients had diverse medical and social challenges highlighting the need for integrated, differentiated and patient-centred healthcare to better address specific needs and underlying vulnerabilities of individual patients.

Patrolling the boundaries of social domains: Neural activations to violations of expectations for romantic and work relationships

According to the social domains hypothesis, we reduce the information-processing demands of complex social cues by classifying them into a limited number of domains, each with distinct sets of expectations. This requires rapid identification of violations of the boundaries between social domains. We hypothesized that these violations are likely to be associated with neural activation of the salience system. Using fMRI we compared responses of 20 adults to expected and unexpected everyday social scenarios in personal and work interactions. The vignettes exemplified different kinds of scenarios presented in the work setting, i.e., task-focused scenarios which are expected at work and scenarios with a personal focus, which are unexpected at work. The key contrast between task and personal focussed scenarios presented in the work setting was associated with fronto-insular activation. Perceived inappropriateness of the unexpected scenarios, and shorter response time to judgment of inappropriateness were also associated with fronto-insular activation, after controlling for unpleasantness. This study indicates specific neural responses to violations of expectations in different social situations. Our findings suggest that the fronto-insular region is implicated in rapid detection of behaviors that cross the boundaries of social domains, which are hypothesized to be necessary for efficient social information processing.

AB0548 EFFECTIVENESS OF IXEKIZUMAB IN PATIENTS WITH PSORIATIC ARTHRITIS: RESULTS FROM A REAL-WORLD EUROPEAN SURVEY

Background:

Limited real world (RW) data are available for IL-17A blocker ixekizumab (Ixe), approved for psoriatic arthritis (PsA) in EU Feb 2018.

Objectives:

Describe RW outcomes for PsA patients (pts) receiving Ixe.

Methods:

Cross-sectional, observational study of PsA pts treated with Ixe in the 2020 Adelphi PsA Plus Program (FR, DE, ES & UK). Rheumatologists recruited the first 6 consecutive consulting Ixe pts and provided demographics, PsA manifestations, clinical measures (66 swollen joint count (SJC), 68 tender joint count (TJC), psoriasis area and severity index [PASI], body surface area [BSA] affected by psoriasis [PsO]), rheumatologist-recorded pt measures (skin/joint pain & fatigue [0-10 numeric rating scales (NRS)], health assessment questionnaire [HAQ-DI]) & prescribed dose. All outcomes recorded for pts with scores available at Ixe initiation (II) & at last assessment (LA).

Results:

124 rheumatologists provided data for 698 Ixe pts, mean age 49 years (19-79), 48% female, mean BMI 27 (18-44), 56% dermatologist co-managed and mean time diagnosed 6 years (0-35). At Ixe initiation, 78% of pts with known BSA had concomitant mod-sev-PsO defined as BSA≥10% (mean 19.8, n=428) and mean PASI 26.3 (n=164). The predominant PsA phenotype was polyarthritic in 49% (n=345), mono/oligoarthritic in 30% (n=208), axial in 12% (n=81) and enthesitic in 8% (n=55). Previous treatment before Ixe included ≥1 conventional synthetic DMARD (csDMARD) for 71% of pts. Of bio-experienced pts (57%), 40% had received ≥2 biologics. Mean Ixe treatment duration (n=698) 39.4 weeks (wks, 0-170), of which 575 (82%) had received >12 wks of Ixe. 71% of pts received label recommended dose (80mg every 4wks). 52% pts received csDMARD in combination with Ixe. In the RW, Ixe improved TJC, SJC, joint pain, BSA, fatigue and HAQ-DI, Table 1.

Table 1.

Outcomes for pts receiving Ixe >12weeks (n=575)

OverallBSA ≥10% at Ixe initiationMod-sev-PsO physician judgementPredominant mono/oligo arthritisPredominant polyarthritisWith csDMARDWithout csDMARDBSA, n35627025498184188168mean [SD]Ixe initiation (II)19.8 [14.8]24.7 [13.5]23.1 [13.6]17.4 [15.0]20.9 [15.0]21.8 [15.0]17.4 [14.2]Last Assessment (LA)6.6 [7.5]9.3 [8.7]7.9 [7.9]5.0 [6.0]7.6 [8.4]7.3 [7.9]5.9 [7.1]Mean weeks on Ixe43414150414146TJC*, n125728639725669mean [SD, %<5]II12.2 [10.6, 29]14.4 [11.3, 18]12.9 [11.1, 21]6.4 [8.2, 59]15.4 [10.8, 12]13.0 [9.9, 25]11.5 [11.1, 32]LA4.1 [6.4, 77]5.2 [7.7, 71]3.6 [6.3, 80]1.1 [1.4, 97]6.2 [7.7, 64]3.4 [3.9, 73]4.6 [7.8, 80]SJC*, n1458210244846085mean [SD, %<5]II14.8 [13.5, 33]18.8 [14.4, 22]16.3 [13.8, 26]7.2 [8.5, 68]18.2 [13.6, 12]14.5 [12.0, 37]15.1 [14.8, 31]LA4.8 [8.7, 79]7.0 [10.7, 66]5.1 [9.3, 75]0.9 [1.9, 95]6.6 [9.0, 68]3.1 [7.8, 90]5.9 [9.1, 71]Joint pain (NRS 0-10), n575270349166291294281mean [SD]II6.6 [1.7]6.7 [1.7]6.7 [1.7]6.2 [1.8]7.0 [1.5]6.6 [1.7]6.6 [1.6]LA2.7 [1.9]3.0 [2.1]2.8 [2.0]2.1 [1.6]3.0 [2.1]2.8 [1.9]2.5 [1.9]Fatigue (NRS 0-10), n575270349166291294281mean [SD]II5.4 [2.5]5.8 [2.4]5.7 [2.5]4.7 [2.5]5.7 [2.4]5.7 [2.4]5.1 [2.5]LA2.6 [2.1]2.7 [2.1]2.7 [2.2]2.0 [1.9]2.9 [2.2]2.7 [2.1]2.6 [2.1]HAQ DI, n59414210283128mean [SD, %<0.5]II1.8 [0.7, 5]1.9 [0.6, 0]1.8 [0.7, 2]1.9 [0.7, 10]1.8 [0.8, 7]1.9 [0.6, 3]1.7 [0.8, 7]LA0.8 [0.6, 41]0.8 [0.6, 32]0.8 [0.7, 45]0.7 [0.7, 60]0.7 [0.6, 36]0.7 [0.5, 32]0.7 [0.8, 50]

*Additional analysis for pts whose fatigue/joint pain rating improved (from ≥4 at Ixe initiation to ≤3 at LA), their mean TJC was 2.7 & SJC 4.3 at LA for fatigue, TJC 1.7 & SJC 2.7 at LA for joint pain.

When BSA was not recorded, physician judgement of PsO severity was used. No imputation of missing data.

Conclusion:

We report RW outcome data amongst pts treated with Ixe including mono/oligo arthritis and a limited sample of enthesitis and dactylitis pts. Our results are consistent with clinical trial populations across disease domains, including an improvement in joint pain.

Disclosure of Interests:

William Tillett Speakers bureau: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, Pfizer Inc. and UCB, Consultant of: AbbVie, Amgen, Celgene, Lilly, Janssen, Novartis, MSD, Pfizer Inc. and UCB, Grant/research support from: AbbVie, Celgene, Eli Lilly & company, Janssen and UCB, Victoria Navarro-Compán Speakers bureau: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Consultant of: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Grant/research support from: AbbVie, BMS, Janssen, Eli Lilly & Co, MSD, Novartis, Pfizer, Roche and UCB, Nicola Booth: None declared., Thorsten Holzkaemper Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Julie Hill Shareholder of: Eli Lilly & Company, Employee of: Eli Lilly & Company, Ennio Lubrano Speakers bureau: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Consultant of: Alfa-Sigma, Abbvie, Galapagos, Janssen Cilag, Lilly., Tamas Truer Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company.

Drug-resistant tuberculosis patient care journeys in South Africa: a pilot study using routine laboratory data

SETTING: Thirteen districts in Eastern Cape (EC), KwaZulu-Natal (KZN) and Western Cape (WC) Provinces, South Africa.OBJECTIVE: To pilot a methodology for describing and visualising healthcare journeys among drug-resistant tuberculosis (DR-TB) patients using routine laboratory records.DESIGN: Laboratory records were obtained for 195 patients with laboratory-detected rifampicin-resistant TB (RR-TB) during July-September 2016. Health facility visits identified from these data were plotted to visualise patient healthcare journeys. Data were verified by facility visits.RESULTS: In the 9 months after the index RR-TB sample was collected, patients visited a mean of 2.3 health facilities (95% CI 2.1-2.6), with 9% visiting ≥4 facilities. The median distance travelled by patients from rural areas (116 km, interquartile range [IQR] 50-290) was greater than for urban patients (51 km, IQR 9-140). A median of 21% of patient's time was spent under the care of primary healthcare facilities: this was respectively 6%, 37% and 39% in KZN, EC and WC. Journey patterns were generally similar within districts. Some reflected a semi-centralised model of care where patients were referred to regional hospitals; other journeys showed greater involvement of primary care.CONCLUSION: Routine laboratory data can be used to explore DR-TB patient healthcare journeys and show how the use of healthcare services for DR-TB varies in different settings.

Emergency Medicine Journal Editorial Boards: Analysis of Gender, H-Index, Publications, Academic Rank, and Leadership Roles

INTRODUCTION

Our goal in this study was to determine female representation on editorial boards of high-ranking emergency medicine (EM) journals. In addition, we examined factors associated with gender disparity, including board members' academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years.

METHODS

In this retrospective study, we examined EM editorial boards with an impact factor of 1 or greater according to the Clarivate Journal Citations Report for a total of 16 journals. All board members with a doctor of medicine or doctor of osteopathic medicine degree, or international equivalent were included, resulting in 781 included board members. We analyzed board members' gender, academic rank, departmental leadership position, h-index, total publications, total citations, and total publishing years.

RESULTS

Gender disparity was clearly notable, with men holding 87.3% (682/781) of physician editorial board positions and women holding 12.7% (99/781) of positions. Only 6.6% (1/15) of included editorial board chiefs were women. Male editorial board members possessed higher h-indices, total citations, and more publishing years than their female counterparts. Male board members held a greater number of departmental leadership positions, as well as higher academic ranks.

CONCLUSION

Significant gender disparity exists on EM editorial boards. Substantial inequalities between men and women board members exist in both the academic and departmental realms. Addressing these inequalities will likely be an integral part of achieving gender parity on editorial boards.

Upgrade of the gated laser entrance hole imager G-LEH-2 on the National Ignition Facility

A major upgrade has been implemented for the ns-gated laser entrance hole imager on the National Ignition Facility (NIF) to obtain high-quality data for Hohlraum physics study. In this upgrade, the single "Furi" hCMOS sensor (1024 × 448 pixel arrays with two-frame capability) is replaced with dual "Icarus" sensors (1024 × 512 pixel arrays with four-frame capability). Both types of sensors were developed by Sandia National Laboratories for high energy density physics experiments. With the new Icarus sensors, the new diagnostic provides twice the detection area with improved uniformity, wider temporal coverage, flexible timing setup, and greater sensitivity to soft x rays (<2 keV). These features, together with the fact that the diagnostic is radiation hardened and can be operated on the NIF for high neutron yield deuterium-triterium experiments, enable significantly greater return of data per experiment.

Risk Factors for Relapsing Remitting Multiple Sclerosis

Relapsing remitting is the most common type of multiple sclerosis, affecting approximately 85% of all patients. Previous evidence has suggested that the risk factors for developing relapsing remitting multiple sclerosis is multifactorial. Similarly, it has been suggested that these factors also influence the risk of relapse. This article critically appraises and evaluates a systematic review that examined multiple factors associated with the risk of relapse for relapsing remitting multiple sclerosis.