Clinical Impact of Bleeding Time and Concordance with Platelet Function Analysis at a Single Academic Institution

Introduction/Objective

Bleeding time (BT) was historically used as a screening test to evaluate in vivo primary hemostasis. However, various disadvantages of BT and development of tests such as the platelet function analysis (PFA) contributed towards a discontinuation of its use at many hospitals. As our institution continues to offer BT, we sought to determine the concordance rate of BT with other coagulation tests and its clinical effectiveness.

Methods/Case Report

BT tests from 2014 to 2020 at our institution were evaluated. Results from BT were compared with those from concurrently ordered PFA. A chart review was performed to analyze the effect of BT on patient outcomes, defined as determiningsurgical/medical management or changing the patient’s diagnosis.

Results (if a Case Study enter NA)

From 2014-2020, there were 71 BT orders. There were 22 concurrently ordered PFAs. BT and PFA results were concordant in 14 of 22 instances with 4 of 14 being abnormal while 10 of 14 were normal. In terms of clinical outcomes, after removing five cases from analysis for lack of data, BT had a significant clinical impact in 25 of 66 cases, 20 of 25 determining surgical/medicalmanagement and 5 of 25 changing the patient’s diagnosis. After the release of ASCP’s Choosing Wisely guidance on BT in 2014, the number of BT ordered dropped from 35 in 2014 to 13 in 2015.

Conclusion

At our institution, most BT orders were ordered to assess bleeding risk prior to procedures or to find a cause for bleeding of unknown origin; however, BT affected clinical outcomes in less than half of cases. BT and PFA generally correlated well. Following guidance published by professional groups, including ASCP’s Choosing Wisely, BT utilization saw a decrease.

Factors Affecting Trends in Societal Indicators of Ageing Well in Hong Kong: Policies, Politics and Pandemics

OBJECTIVES

To document the trend in a quality of life indicator for the older Hong Kong population as an assessment of the impact of age friendly city policies, political conflicts and the covid-19 pandemic.

DESIGN

Random telephone survey and collection of government data over four years (2017-2020).

SETTING

Community living older people.

PARTICIPANTS

People aged 50 years and over.

MEASUREMENTS

The Hong Kong Quality of Life Index covering four domains of in income security, health status, capability and enabling environment.

RESULTS

From 2017-9, improvements were seen in various domains in parallel with the adoption of the World Health Organization's Age Friendly City concept by government policy together with a territory wide initiative supported by a major philanthropic organization. However scores of all domains dropped markedly as a result of political conflicts as well as the onset of the pandemic.

CONCLUSION

The documentation of the trend in HKEQOL shows that while it may be used as a macro indicator that is able to reflect policies affecting the well-being of older people, it is also able to reflect the impact of societal unrest and pandemics, and that the latter may override the effect of existing ageing policies. It also follows that during social unrest and pandemics, specific policies targeting older people may be needed to maintain well-being.

Validation of the Construct of Intrinsic Capacity in a Longitudinal Chinese Cohort

OBJECTIVES

We examined the structure and predictive ability of intrinsic capacity in a cohort of Chinese older adults.

METHODS

We used data from the MrOS and MsOS (Hong Kong) study, which was designed to examine the determinants of osteoporotic fractures and health in older Chinese adults. We analysed baseline and the 7-year follow-up data using exploratory factor analysis, confirmatory factor analysis (CFA), and mediation analysis.

RESULTS

The study consisted of 3736 participants at baseline (mean 72.2 years), with 1475 in the 7-year follow-up. Bi-factor CFA revealed five sub-factors labelled as 'cognitive', 'locomotor', 'vitality', 'sensory', and 'psychological' and one general factor labelled as 'intrinsic capacity'. The model fits the data well, with Root Mean Square Error of Approximation (RMSEA)=0.055 (90% CI=0.053-0.058) for the 5-factor model and RMSEA=0.031 (90% CI=0.028-0.035) for the bi-factor model. Significantly lower intrinsic capacity scores were found in older age groups, women, as well as those who had lower levels of education, lower subjective social status, reported more chronic diseases, or a higher number of IADL limitations (All p<0.0001). Intrinsic capacity had a direct effect in predicting incident IADL limitations at the 7-year follow-up (β=-0.21, p<0.001). The effect was larger than the direct effect of the number of chronic diseases on incident IADL limitations (β=0.05, not significant).

CONCLUSIONS

This study supports the construct and predictive validity of the proposed capacity domains of intrinsic capacity. The findings could inform the development of an intrinsic capacity score that would facilitate implementation of the concept of intrinsic capacity in clinical practice.

Predictive Value of the GLIM Criteria in Chinese Community-Dwelling and Institutionalized Older Adults Aged 70 Years and Over

OBJECTIVES

The Global Leadership Initiative on Malnutrition (GLIM) has recently published criteria for classifying malnutrition. This study investigated the associations between malnutrition and adverse outcomes, and identified which component(s) of the GLIM criteria is/are risk factor(s) of adverse outcomes in Chinese older adults.

DESIGN

A prospective cohort study of Chinese older adults in a healthy ageing study.

SETTING

Participants' place of residence.

PARTICIPANTS

Community-dwelling and institutionalized Chinese older adults aged ≥70 years living in Hong Kong.

MEASUREMENTS

Malnutrition at baseline was classified according to selected GLIM criteria. Adverse outcomes including poor self-rated health, functional limitation (Barthel Index), falls, frailty (FRAIL scale), hospitalization and mortality were assessed after a 3-year follow-up. Associations between malnutrition and components of selected GLIM criteria (weight loss, low body mass index (BMI), low muscle mass and disease burden) and each adverse outcome were examined using adjusted binary logistic regression and Cox proportional hazards model. Odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI) are presented.

RESULTS

Data of 1576 community-dwelling (45.5% female, 78.1±6.5 years) and 427 institutionalized (69.6% female, 85.5±6.4 years) older adults were included at baseline. Among community-dwelling older adults, malnutrition was associated with frailty (n=899, OR: 2.44, 95% CI: 1.05-5.70) and mortality (n=1007, HR: 1.37, 95% CI: 1.12-1.66). No association was found for other outcomes. Among institutionalized older adults, malnutrition was not associated with any outcomes. Low BMI and low muscle mass were risk factors of frailty; while weight loss was a risk factor of mortality in community-dwelling older adults. Weight loss and disease burden were risk factors of mortality among institutionalized older adults.

CONCLUSION

The association between malnutrition and frailty and mortality was observed in community but not in institutional settings. Further studies are required to draw more definitive conclusions on the use of GLIM criteria in institutional settings.

Implementing Advance Care Planning in 'The Age of Deferred Death'- the Hong Kong Experience over 4 Years

OBJECTIVES

To plan, implement and evaluate a series of initiatives to improve patient centred quality of end of life care through raising public awareness, promoting the concept that all health and social care professionals should be engaged in this practice, and carrying out pilot of community care models.

DESIGN

Pilot studies of community models of care, training programs for health and social care professionals, public education programmes.

SETTING

Selected hospitals, residential care homes for the elderly, and community centres in Hong Kong.

PARTICIPANTS

Patients and their families at the end of life stage.

MEASUREMENTS

Combination of quantitative and qualitative studies according to different components of the initiative.

RESULTS

Effective training for professional staff occurred using training videos, role play, rather than lectures, and when concepts are integrated into daily practice and quality assurance programmes. Members of the public welcomed end of life care discussions and the implementation of advance care planning. The pilot community care program was found to reduce anxiety, depression, physical symptoms, improve communication within the family as well as promoting a feeling of peace among recipients of the service. It also reduced care giver strain and anxiety, as well as hospital visits and duration of stay. Similar findings were also observed among recipients of care in the residential care setting.

CONCLUSION

A sustainable model would require uptake by policy makers and chief executives of Social Welfare and Health Bureaus, supported by amendments of relevant legal ordinances, which is in progress after public consultation.

International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines

The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.

Neighborhood Social Cohesion Associates with Loneliness Differently among Older People According to Subjective Social Status

OBJECTIVES

To examine whether neighborhood social cohesion can alleviate the negative impact of low subjective social status on feelings of loneliness.

DESIGN

Cross-sectional study.

SETTING

Community, Hong Kong.

PARTICIPANTS

Older people who participated in a cohort study on osteoporosis and general health in Hong Kong (MrOs study).

METHODS

Data were sourced from the 14-year follow-up data of the MrOs study. Loneliness was measured using the 6-item De Jong Gierveld Loneliness Scale. Neighborhood social cohesion was measured by the Hong Kong version of Neighborhood Cohesion Instrument. Linear regression models were used to examine the associations between neighborhood social cohesion and loneliness, controlled for age, sex, marital status, educational level, lifestyle, number of diseases, and maximum lifetime income. The analyses were stratified by subjective social status as measured by a 10-rung self-anchoring scale.

RESULTS

1,037 participants with a mean age of 83 years were included in the study, of whom 72%, 83%, and 64% were classified as at risk of overall loneliness, emotional loneliness, and social loneliness, respectively. Those who were classified as at risk of overall loneliness reported lower subjective social status and had lower levels of neighborhood social cohesion. Linear regression models showed that higher levels of neighborhood social cohesion were associated with lower levels of overall and social loneliness. Stratified analyses showed that the associations between neighborhood social cohesion and loneliness vary across subjective social status groups. Among those with low/middle social status ranking, higher levels of neighborhood social cohesion were associated with lower overall (low-ranking B=-0.111, p=0.001; middle-ranking B=-0.057, p=0.026) and social (low-ranking B=-0.093, p<0.001; middle-ranking B=-0.073, p<0.001) loneliness scores. Among those with high ranking, higher levels of neighborhood social cohesion were associated with lower overall (B=-0.099, p=0.041) and emotional (B=-0.056, p=0.017) loneliness scores, but the associations became insignificant when controlling for maximum lifetime income.

CONCLUSIONS AND IMPLICATIONS

Neighborhood social cohesion may operate differently in different social ranking groups. Interventions to alleviate feelings of loneliness should be subjective social status specific.

Prospective Analysis of Fruit and Vegetable Variety on Health Outcomes in Community-Dwelling Chinese Older Adults

OBJECTIVES

Evidence on the topic regarding fruit and vegetable (FV) variety and health outcomes among older adults is limited. This study explored the prospective association of fruit variety, vegetable variety and combined FV variety with the risk of sarcopenia, frailty, all-cause and cause-specific mortality in community-dwelling Chinese older adults.

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

Community-dwelling Chinese older adults aged ≥65 years in Hong Kong.

MEASUREMENTS

Fruit variety, vegetable variety and combined FV variety at baseline were assessed using a validated food frequency questionnaire and the variety scores were stratified into tertiles. Sarcopenia (Asian Working Group for Sarcopenia 2019), frailty (Cardiovascular Health Study) and all-cause and cause-specific mortality (retrieved from an official database) were assessed at 14-year follow-up. Adjusted binary logistic regression or Cox proportional hazards model were performed to examine the association of fruit variety, vegetable variety and combined FV variety with each health outcome. Data are presented as hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Baseline dietary data of 3992 participants (median age: 72 years (interquartile range: 68-76), 49.9% women) was available. There were 436 and 371 participants who were newly identified as having sarcopenia and frailty respectively, and 1654 all-cause mortality, 367 cardiovascular diseases (CVD) mortality and 534 cancer mortality over 14-year. Tertiles of fruit variety, vegetable variety and combined FV variety were not associated with sarcopenia, frailty, CVD mortality and cancer mortality. Participants in the highest tertile of fruit variety (HR 0.81, 95% CI 0.70-0.95, p-trend 0.010), vegetable variety (HR 0.77, 95% CI 0.67-0.89, p-trend <0.001) and combined FV variety (HR 0.77, 95% CI 0.67-0.89. p-trend <0.001) showed lower risk of all-cause mortality compared with participants in the lowest tertile.

CONCLUSION

Among community-dwelling Chinese older adults, FV variety was not associated with sarcopenia, frailty, CVD mortality and cancer mortality over 14-year. Higher fruit variety, vegetable variety and combined FV variety were associated with a lower risk of all-cause mortality. Promoting a wide FV variety might be recommended to benefit the health and longevity of this population.

Efficacy of HLA-compatible Platelet Transfusion for Patients with Acute Myeloid Leukemia Refractory to Platelet Transfusion

Introduction/Objective

Acute myeloid leukemia (AML) patients often require transfusion support during induction chemotherapy. Platelet transfusion refractoriness (PTR) may develop due to HLA alloimmunization. Management of immune-refractory patients with HLA-compatible platelet transfusions is labor intensive and associated with increased costs. The purpose of this study is to evaluate the efficacy of HLA-compatible platelet units in AML patients.

Methods

Newly diagnosed AML patients undergoing induction chemotherapy in our institute between 2015 and 2018 were identified. Platelet counts and platelet transfusion data from initiation of chemotherapy until platelet recovery (&gt; 20K/µL and increased consistently) were extracted. A 24-hour posttransfusion corrected count increment (CCI) was calculated to evaluate the efficacy of each platelet transfusion. PTR was declared if a patient had a 24-hour CCI &lt; 4K following two consecutive transfusions. Student’s t-test was used for statistical analysis. Results were presented as mean ± SE, * if p &lt; 0.05.

Results

We identified 39 patients with newly diagnosed AML. PTR developed in 22/39 (56%) patients during induction chemotherapy. The average CCI was higher among those without PTR compared to those with PTR (8,408 ± 585 vs. 2,923 ± 360*), and overall platelet transfusion burden (in number of units) was lower (7.29 ± 1.0 vs. 18.55 ± 1.71*). HLA antibodies were identified in 3/22 (14%) PTR patients, as 6/22 (27%) were tested. The average CCI during HLA matched transfusions for these 3 patients was higher than that with random units (2,059 ± 149 vs. -126 ± 306*). Compared to HLA-negative PTR patients receiving random units, the average CCI for HLA-compatible transfusions was still lower, though not significantly (2,059 ± 149 vs. 3,099 ± 390, p = 0.33), while the number of HLA- compatible units transfused was significantly higher (31.0 ± 3.0 vs. 16.6 ± 1.45*).

Conclusion

In a cohort of newly diagnosed AML patients undergoing induction chemotherapy whose PTR was associated with detectable HLA antibodies, transfusion support with HLA-matched products did not lead to reduced overall platelet transfusion rates and CCI remains in the refractory range. This suggests that use of HLA matched platelets among newly diagnosed AML patients with PTR, even in the setting of detectable HLA antibodies, does not appear to result in reduced overall product utilization.

Urine Extracellular Vesicle GATA2 mRNA Discriminates Biopsy Result in Men with Suspicion of Prostate Cancer

PURPOSE

Prostate specific antigen has limited performance in detecting prostate cancer. The transcription factor GATA2 is expressed in aggressive prostate cancer. We analyzed the predictive value of urine extracellular vesicle GATA2 mRNA alone and in combination with a multigene panel to improve detection of prostate cancer and high risk disease.

MATERIALS AND METHODS

GATA2 mRNA was analyzed in matched extracellular vesicles isolated from urines before and after prostatectomy (16) and paired urine and tissue prostatectomy samples (19). Extracellular vesicle GATA2 mRNA performance to distinguish prostate cancer and high grade disease was tested in training (52) and validation (165) cohorts. The predictive value of a multigene score including GATA2, PCA3 and TMPRSS2-ERG (GAPT-E) was tested in both cohorts.

RESULTS

Confirming its prostate origin, urine extracellular vesicle GATA2 mRNA levels decreased significantly after prostatectomy and correlated with prostate cancer tissue GATA2 mRNA levels. In the training and validation cohort GATA2 discriminated prostate cancer (AUC 0.74 and 0.66) and high grade disease (AUC 0.78 and 0.65), respectively. Notably, the GAPT-E score improved discrimination of prostate cancer (AUC 0.84 and 0.72) and high grade cancer (AUC 0.85 and 0.71) in both cohorts when compared with each biomarker alone and PT-E (PCA3 and TMPRSS2-ERG). A GAPT-E score for high grade prostate cancer would avoid 92.1% of unnecessary prostate biopsies, compared to 61.9% when a PT-E score is used.

CONCLUSIONS

Urine extracellular vesicle GATA2 mRNA analysis improves the detection of high risk prostate cancer and may reduce the number of unnecessary biopsies.

Neighborhood disorder predicts lower serum vitamin D levels in pregnant African American women: A pilot study

Pregnant African American women are more likely to live in neighborhoods with more disorder (e.g., vacant housing, littler, crime) and to have vitamin D deficiency due to their darker skin pigmentation and poor production of vitamin D [25(OH)D] from ultraviolet rays. However, no study has examined the potential link between neighborhood disorder and 25(OH)D status in African American pregnant women. Forty-one pregnant African American women completed validated questionnaires about perceived neighborhood disorder (6 items; 3-point scale; range 6-18) and with concurrent serum levels of 25-hydroxyvitamin D [25(OH)D] assessed during pregnancy at 18-24 weeks gestation. Higher levels of perceived neighborhood disorder were associated with lower levels of serum 25(OH)D. Pregnant African American women who report higher disorder in their neighborhood may spend less time outside. Health care providers should include assessment of perceived neighborhood disorder. Future research needs to evaluate the relationships among neighborhood disorder and 25(OH)D levels among pregnant African American women.

Cardiac Manifestations of Sarcopenia

OBJECTIVES

Screening questions for sarcopenia used in the community (SARC-F) may be regarded as indicators of exercise tolerance.

DESIGN

Observational study.

SETTING

We tested the hypothesis that community-living older people who are screened positive for sarcopenia using the SARC-F tool but without a history of heart failure (HF) have a higher prevalence of cardiac abnormalities compared with those who are SARC-F negative.

PARTICIPANTS

Participants were recruited from a territory-wide primary care needs assessment for older people based in community centres, and from non-acute hospitals in the same region as the study centre.

MEASUREMENTS

Participants with a total score of >=4 and who did not have any history of HF were invited to attend for further cardiac assessment. Grip strength, walking speed, and the 6-minute walk test and echocardiography were carried out. Patients with frailty and at least Grade II diastolic dysfunction were considered to have heart failure with preserved ejection fraction (HFpEF) if they also had concomitant elevated N-terminal prohormone of B-type natriuretic peptide (NT-proBNP) of at least 300 pg/ml.

RESULTS

Diastolic dysfunction (DD) was significantly associated with SARC-F score >=4 and higher circulating NT-proBNP levels. ROC curves evaluating the predictive values of SARC-F, HGS and gait speed for DD showed that a combination of SARC-F and HGS or gait speed provided significant incremental value in predicting DD.

CONCLUSIONS

Community living older people with sarcopenia detected using a simple questionnaire have a higher prevalence of DD accompanied by elevated NT proBNP. Addition of hand grip strength or walking speed improve the magnitude of the association. SARC-F may be used as a tool to detect early cardiac dysfunction in the community.

P39 Cross-sectional analysis of 6-minute walk distance and diastolic function in a Hong Kong cohort of community-living older adults

Funding Acknowledgements

CUHK Direct Grant, CUHK Lui Che Woo Institute of Innovative Medicine, Food and Health Bureau of HKSAR (EF); Hong Kong Jockey Club Charities Trust (JW)

Background/Introduction

6-min walk distance (6MWD) can indicate frailty extent, cardiac dysfunction, and heart failure (HF) trajectory. Association of 6MWD with diastolic dysfunction (DD) or cardiac biomarker in community-living elderly without a history of HF remains underexplored.

Purpose

This study aims to determine the association between 6MWD, serum N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and DD in a community-living elderly population without known HF.

Methods

Between Nov 2017 and Aug 2018, 302 Hong Kong Chinese aged ≥60 y and without known HF were recruited into the Undiagnosed heart Failure in Older individuals (UFO) study consisting of robust, pre-frail and frail older adults stratified by FRAIL scale in a ratio of 1:1:1. 6MWD was divided into tertiles. Transthoracic echocardiography and serum NT-proBNP were used to assess cardiac dysfunction. Diastolic function was classified according to international guidelines and NT-proBNP &gt;300 pg/ml was considered elevated.

Results

The ages of participants in the bottom, middle and top tertiles were 80.3 ± 7.4, 73.9 ± 6.3 and 70.0 ± 5.7 years (P &lt; 0.01), respectively, corresponding to a female preponderance of 85.0%, 75.2%, 46.5% (P &lt; 0.01). The highest prevalence rates of hypertension (HT, 76.0% vs 68.3% vs 51.5%, P &lt; 0.01), diabetes mellitus (DM, 41.0% vs 30.7% vs 12.9%, P &lt; 0.01), and ischaemic heart disease (IHD, 14.0% vs 4.0% vs 2.0%, P &lt; 0.01) were observed in the bottom tertile of 6MWD. However, the prevalence of atrial fibrillation (AF) was distributed equally across tertiles (2.0% vs 2.0% vs 2.0%). Frail (63.0% vs 25.7% vs 3.0%, P &lt; 0.01) and pre-frail (36.5% vs 44.6% vs 24.8%, P &lt; 0.01) individuals were most frequently seen in the bottom and middle tertiles of 6MWD.

Using multiple linear regression analysis, S’ velocity, E:E’ ratio and E’ velocity were associated with 6MWD independent of age and sex. Associations between 6MWD and S’, left atrial volume index, E’ and E:E’ remained statistically significant even after adjusting for HT, DM, IHD, AF, stroke, chronic pulmonary disease and arthritis. No correlation was observed between 6MWD and left ventricular ejection fraction. 

Compared with the top tertile of 6MWD, the bottom tertile was associated with increased risks for grade II–IV DD (odds ratio (OR) 3.47, 95% confidence interval (CI) 1.52–7.96, P &lt; 0.01) and NT-proBNP &gt;300pg/ml (OR 10.20, CI 3.74–27.85, P &lt; 0.01, respectively, after adjusting for co-morbidities. The association between reduced 6MWD and elevated NT-proBNP, but not between 6MWD and DD, remained significant (OR 6.00, CI 2.06–17.46) after adjusting for age and sex. The middle tertile was not significantly associated with an increased risk for grade II–IV DD or elevated NT-proBNP.

Conclusion(s)

In this cohort of community-living Hong Kong Chinese elderly recruited equally by frailty status, performance of 6MWD in the bottom and top tertiles was inversely associated with NT-proBNP levels but not with DD.