National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Incidence and periprocedural outcomes of heparin-induced thrombocytopenia in on-pump vs off-pump coronary artery bypass grafting patients – analysis from 2016–2019 national inpatient sample

Background

Heparin administered after Coronary Artery Bypass Grafting (CABG) can cause Heparin induced thrombocytopenia (HIT) leading to bleeding or thromboembolic complications. Despite its low incidence, HIT can lead to increased morbidity and in-hospital mortality.

Purpose

To study the incidence and periprocedural outcomes of HIT in On-pump vs Off-pump CABG patients.

Methods

This is a retrospective observational study involving index hospitalizations for CABG between January 1 2016–December 31 2019 from the National Inpatient Sample, the largest all-payer public database of hospital care data in the United States. Our study population included discharged adult patients (≥18 years) hospitalised for CABG using ICD-10 codes (validated in previous studies). Confounders were adjusted using Multivariable Regression Analysis.

Results

During 2016–2019, there were 100,715 principal hospitalizations for On-pump and 25,956 for Off-pump CABG. Mean age was 74.6±13.2 years. The incidence of HIT in the On-pump cohort was 0.33% (n=333) and 0.33% (n=85) in the Off-pump cohort. The On-pump cohort had 76% (n=76,543) males, 24% (n=24172) females (p<0.0001) and the Off-pump cohort had 74.5% (n=19337) males, 24.5% (n=6359) females (p<0.001). The On-pump cohort had 78.2% Whites, 7.1% Blacks, 7.7% Hispanics, and 7% other races, while the Off-pump cohort had 76.9% Whites, 7.8% blacks, 8.9% Hispanics and 6.4% other races. A total of 42.9% hospitalizations in the On-pump cohort had a Charlson Comorbidity Index (CCI) of three or higher and it was 43.5% hospitalizations in the Off-pump cohort. In-hospital mortality in the On-pump cohort was 1.6% and 2% in the Off-pump cohort.

Compared to the non-HIT cohort, On-pump HIT cohort had more females (31.2% vs 24%, p=0.02), were older (mean age: 67.2 years vs 65.7 years; p=0.006), had higher CCI of three or higher (65.8% vs 42.8%, p<0.001), longer LOS (22.2 days vs 9.2 days, p<0.001) with higher in-hospital mortality (13.5% vs 1.5%, p<0.001). Multivariate regression analysis showed HIT cohort had higher odds of in-hospital mortality than non-HIT cohort (aOR: 8; 95% CI: 5.7, 11.2; p<0.001) after controlling for age, sex, race, hospital region and status, income, insurance status and CCI.

The Off-pump HIT cohort had similar incidence of females (26% vs 27%, p=0.710), were older (mean age: 68 years vs 65.8 years; p=0.045), had higher CCI of three or higher (65.9% vs 43.5%, p<0.001), had longer LOS (22.9 days vs 9.4 days, p<0.001) with higher in-hospital mortality (10.6% vs 2%, p<0.001) compared to the non-HIT cohort. Multivariate regression analysis showed HIT cohort had higher odds of in-hospital mortality than non-HIT cohort (aOR: 4.7; 95% CI: 2.3, 9.5; p<0.001) after controlling for age, sex, race, hospital region and status, income, insurance status and CCI.

Conclusion

Our study observed that in-hospital mortality in patients with HIT was significantly high compared to patients without HIT after undergoing On-pump or Off-pump CABG.

Funding Acknowledgement

Type of funding sources: None.

Association and outcomes of vf according to involved coronary artery in STEMI – a nationwide analysis

Background

Ventricular fibrillation (VF) is common in acute ST segment elevation myocardial infarction (STEMI) and is associated with increased in-hospital mortality rate.

Purpose

We sought to investigate the association between VF and artery involved in STEMI

Methods

This is a retrospective observational study of hospitalizations between January 1, 2016 and December 31, 2019, using the National Inpatient Sample (NIS), the largest all-payer public database of hospital care in the United States.

Results

A total of 138,201 patients were primarily hospitalized for STEMI from 2016 to 2019. Among them 12,318 had right coronary artery (RCA) lesions, 427 had left main (LM) lesions, 2381 had left circumflex (LCx) lesions and 12,765 had left anterior descending (LAD) lesions. Mean age of patients with VF and STEMI was 62 years and that with RCA (63 years), LM (65 years), LCx (62 years), LAD (60 years), p<0.001. Females were 30.5% (n=42,231) among all STEMI group and 29.8% (n=3672) RCA, 29% (n=124) LM, 27.4%(n=653) LCx and 28.6%(n=3645) LAD, p<0.001. In-hospital mortality for all patients with STEMI was 7.9%. The in-hospital mortality associated with STEMI there was 5%, 23.4%, 6.6%, 7.1%, (p<0.001) for RCA, LM, LCx and LAD respectively. The incidence of VF among all patients with STEMI was 8.3% (n=11425) and for LM, LAD, LCX, and RCA was 12.9%, 10.7%, 9.2% and 7.9% (p<0.001). Mean hospital length of stay for VF with RCA (6.2 days), LM (5.5 days), LCx (6.9 days) and LAD (7.4 days). After adjusting for age, gender, race, income, comorbidities, hospital teaching status, region and year, patients with STEMI who had VF had higher odds of mortality (aOR 6.4, 95% CI, 6.1 to 6.8; P<0.001). The highest likelihood of mortality observed in patients with VF who had and LCx STEMI (aOR 7.9, CI 95%, 5 to 12.4; p<0.001) followed by RCA STEMI (aOR 7.4, 95% CI 6 to 9.1; p<0.001), and LM STEMI (aOR 6.1, 95% 3.1 to 12; p<0.001).

Conclusion

Highest in-hospital mortality was observed in patients with STEMI who had VF in LCx, followed by RCA and LM. There was higher occurrence of VF in STEMI involving LM.

Funding Acknowledgement

Type of funding sources: None.

Patients and healthcare professionals views on injectables for cardiovascular disease

Introduction

Injectable medicines are increasingly used to manage risk factors for cardiovascular (CV) events, such as PCSK-9 inhibitors in dyslipidaemia and GLP-1 agonists in diabetes. However, there is a paucity of data around the administrative and clinical practicalities when using these injectables, and limited information on patient and healthcare professionals' perceptions.

Purpose

To identify the facilitators and barriers on the use of injectable therapies with CV benefits by undertaking interviews with patients, caregivers and healthcare professionals (HCPs).

Methods

Interviews were conducted via telephone and using MS Teams due to Covid-19 restrictions in the United Kingdom (London and Leeds) and Italy (Rome and Milan) in 2021. Coding was undertaken using NVivo and thematic analysis performed.

Results

A total of 56 patients were interviewed: 30 in the U.K. (mean age 66 yrs, 60% male) and 26 patients in Italy (mean age 63 yrs, 80% male) and 11 caregivers (mean age 59 yrs, 73% female). A total of 38 HCPs were interviewed, 19 in each country and composed of physicians (n=18), pharmacists (n=10), nurses (n=9) and pharmacy technician (n=1). Three distinct themes were identified: (i) Organisational and governance issues - relating to prescribing restrictions and availability of the drugs locally (PCSK9i are initiated and supplied from hospitals) and lack of communication between hospital and primary care setting; (ii) Clinical issues around HCPs' skills and experience - including: lack of experience with these injectables, lack of time to provide education to patients and caregivers, therapeutic inertia (HCPs not adopting a change in practice despite the evidence or due to bureaucratic restrictions) as well as lack of knowledge on long-term effects, and finally (iii) Patient-related issues - relating to behaviours and beliefs such as reluctance about using injectable therapies, and lack of education about these injectables in terms of indications/clinical benefits for use. Despite some differences in the prescribing of these injectables in the two countries, the analysis captured similar facilitators and barriers. Facilitators included prior use of injectables (e.g. insulin), and the ability to reach a clinical target of lower cholesterol by having just a “one shot”. HCPs stated that access to rapid pathology tests would aid uptake of injectables with CV benefit as well as having educational tools on these injectables in practice.

Conclusion

This qualitative study identified barriers to initiation, continuation, and adherence with injectable therapies with CV benefits but also highlighted areas where changes can be made especially around education and support for patients and HCPs.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ACNAP education grant. Sponsored by Amgem and Novo Nordisk

Management of statin intolerance in a pharmacy led cardiology innovative medicines optimisation lipid clinic

Background

Statins are cornerstone in the management of atherosclerotic cardiovascular disease. If a patient has experienced clinically significant adverse drug reactions (ADRs), representing an unacceptable risk or may result in adherence issues, we would consider them intolerant. The prevalence is lower in randomised trials than cohort observational studies, 5% vs. 17%.

Purpose

To assess how many people we reviewed in clinic were able to be re-challenged and successfully continued on a statin, free from side effects.

Methods

Over 6 months we reviewed all patients referred to our innovative clinic for lipid optimisation labelled as “statin intolerant”. Initially, as per our protocol, we adopted a person-centred approach and explored this label (actual vs. potential concerns, any previous issues, symptoms experienced and timings, statins tried (if any), and patient's feelings on re-challenge). A statin re-challenge was offered if not contraindicated. If agreed, based on shared-decision making, we offered patients a once weekly statin (usually rosuvastatin 5mg) with a clear self-management plan to up/down-titrate frequency and dose, until they identify a tolerated regimen. We measured LDL-C at baseline and every 3 months thereafter until satisfactory.

Results

Of 207 patients referred 152 (73%) were labelled as “statin intolerant”. Average age was 62 (±11), 51% females. 78% for secondary prevention and 37% had familial hypercholesterolaemia. The average baseline LDL-C was 4.4mmol/L. 108 (71%) qualified for PCSK9 inhibitors therapy (PCSK9i) as per UK NICE guidance.

The top 3 reported ADRs were musculoskeletal side effects (48%), GI upsets (13%) and deranged LFTs (7%).

25 (58%) of those “intolerant” who did not qualify for PCSK9i attempted a re-challenge with statins vs. 44 (41%) among those who qualified.

Of the 69 patients, who accepted a re-challenge, 43 (62%) were successfully restarted on a statin. At an average of 14 months post re-challenge, LDL-C (available for >80% of the sample) was reduced by an average of 31% in those not on PCSK9i, compared to a 62% reduction (sustained over an average of 40 months) in those on combination therapy with PCSK9i.

The top 3 rosuvastatin regimens established were 5mg OD (29%), 5mg weekly (24%) and 10mg OD (15%). Approximately 80% of patients were on rosuvastatin, and the rest accepted atorvastatin, pravastatin or simvastatin.

There was no attempt to re-challenge in 77 (51%) patients, mostly due to choice (45%) or statins re-challenged prior to referral (44%). We stopped statins in 6 cases due to intolerable ADRs.

Conclusion(s)

By using a person-centred approach, and a variety of strategies to tackle “statin intolerance” we have successfully re-established over 60% of patients with very high CVD risk on statins. While patients who qualified for PCSK9i therapy were less likely to consider re-challenge with statins (41% v 58%), combination lipid-lowering therapies produced better reduction in LDL-C.

Funding Acknowledgement

Type of funding sources: None.

A case of bilateral sclerouveitis with secondary glaucoma right eye

Infectious scleritis is rare and most commonly herpetic in origin. We report an unusual bilateral subacute presentation of scleritis with uveitis and glaucoma which responded to treatment with acyclovir. A 47-year-old male coast guard personnel presented with 2 months history of bilateral red eye. He was initially managed elsewhere as conjunctivitis, and on examination had bilateral diffuse redness of the eyes persisting with phenylephrine, with scleral edema and mild globe tenderness. Investigations for underlying autoimmune systemic illness were normal. He showed inadequate response to topical steroids and cycloplegics and developed uveitis and glaucoma while on steroids. He was then given tablet acyclovir with antiglaucoma topical medications with which he showed rapid response and complete resolution. The case is being reported for highlighting this unusual bilateral presentation of scleritis with uveitis and glaucoma with possible viral etiology.

A study on the determinants of learner satisfaction in moocs

Objective – This paper aims to study how different variables influence learner satisfaction regarding online learning through Massive Open Online Courses (MOOCs). Course Structure, Course Quality, Interaction, and Learning Implementation are the independent variables considered in this study to determine Learner Satisfaction. Design methodology – Data was gathered from 274 respondents in India using a structured questionnaire with a response rate of 92.36%. Multiple linear regression techniques with a standard p-value ≤ of 0.5 were used to analyze the data. An online survey was conducted to understand the satisfaction level consumer have with MOOCs among selected variables. Findings – Course Structure, Course Content, Course Quality, and Learning Implementation influence Learner Satisfaction, whereas interaction does not. Originality/value – The primary purpose behind institutions implementing E-Learning is to meet various student needs. The technology used to conduct E-Learning is of internet, learning environment also becomes complicated. The results reveal how institutions and business related to E-Learning enriches learner satisfaction through MOOCs and further strengthen their implementation.

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.

The management of chyle leak post-oesophagectomy for oesophageal carcinoma: a systematic review

INTRODUCTION

Chyle leak is an uncommon yet potentially fatal complication of oesophagectomy for oesophageal cancer. The management of chyle leak is a debated, controversial topic and to date there is no standardised approach or validated algorithm for its management. This review aims to summarise current treatment algorithms for chyle leak post-oesophagectomy and their outcomes.

METHODS

A systematic search of Embase, MEDLINE, UpToDate and Cochrane was conducted to identify studies reporting on the management of chyle leak following oesophagectomy for oesophageal cancer. Data on interventional success rate and mortality are reported.

FINDINGS

Twenty-one studies met the inclusion criteria including over 23,254 oesophagectomies and identifying 838 chyle leaks (incidence <3.6%). The majority of cases were initially managed conservatively (95.3%), with a failure rate of 50.4%. Immediate surgical or radiological management resolved chylothorax in the majority of cases (97.3%), however the numbers were small. Death occurred in 54 cases (6.6%), all of whom underwent conservative management initially.

CONCLUSIONS

Owing to the heterogeneity of treatment algorithms, timings and indications for interventions, the optimal strategy for managing chyle leak remains unclear. This review has identified an unmet need for prospective multicentre studies assessing the efficacy of predefined algorithms.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Prevalence of cognitive impairment and its association with clinical variables among Patients with Mood Disorders

Introduction

Mood disorders are common psychiatric illnesses with major disability and mortality and it is estimated that 8% to 20% of the population experience a depressive episode at some point in their lives.

Objectives

To find out the prevalence of cognitive impairment among patients with Mood Disorders i.e, Major Depressive Disorder (MDD) and Bipolar Mood Disorder (BMD), etc. and to find out the status of cognitive impairment with clinical variables of Mood Disorders.

Methods

This was a descriptive cross-sectional study conducted among the patients attending both the inpatient and outpatient departments of the National Institute of Mental Health, Dhaka. The duration of the study was fourteen months starting from July 2011 to September 2012. A total of one hundred and thirty-three (n=133) patients who fulfilled the inclusion-exclusion criteria were selected.

Results

The mean age of onset of mood disorder was 30.1± 10.7years.60.2% were male and 39.8% were female respondents. Cognitive impairment was found among 43.6% of the respondents. A substantial proportion of the study population was found to have cognitive impairment. In this study, the cognitive status of the respondents was not associated with the duration of illness (p>0.5).

Conclusions

So assessment of cognitive status should be an essential part of the management of this group of people.

Disclosure

No significant relationships.

A cross sectional observational study on the effect of music on the anxiety state of patients admitted for COVID 19 in a tertiary care hospital in New Delhi

Introduction

COVID 19 has led to dramatic changes in the lives of people leading to an increase in stress and anxiety. Music intervention is a non-medicated method for relieving anxiety. This current study aims to understand whether music can be effectively used to alleviate anxiety in admitted COVID-19 patients.

Objectives

To study the effect of music on anxiety in patients admitted for COVID-19 in a tertiary care hospital in New Delhi

Methods

34 patients (17 females &17 males) were randomly divided into two groups, a control (N=17) and a music group (N=17). Vitals of all the patients were noted. Patients of the music group were asked to listen to relaxing instrumental for 30 minutes, while patients of the control group were asked to relax for 30 minutes. Vitals of all the patients were noted again. Patients were asked to fill State Trait Anxiety Inventory (STAI) before and after intervention.

Results

The post-intervention mean scores of STAI after the music session were lower in the music group than the control group [95.06 (SD 8.5)) versus 102.37 (SD 10.3)]. The differences in mean values of pre- to post-intervention changes between both groups after music session were statistically significant.

Conclusions

Our findings suggest that listening to music lowers anxiety. As music is non- invasive and free of side-effects we recommend that music intervention service should be used to improve health care quality.

Disclosure

No significant relationships.

Strategies for repeat ablation for atrial fibrillation: a multicentre comparison of non-pulmonary vein versus pulmonary vein target ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Approximately 18% of patients with atrial fibrillation (AF) undergo a repeat ablation within 12 months after their index ablation. Despite the high prevalence, comparative studies on non-pulmonary vein (PV) target strategies in repeat AF ablation are scarce.

Purpose: This study aims to describe 12 months efficacy of non-PV and PV target ablations as a repeat ablation strategy.

Methods

A multicentre retrospective, descriptive study was conducted with data of 280 patients who underwent repeat AF ablation. Ablation strategy for repeat ablation was at the operators’ discretion. Non-PV target ablation (n=140) included posterior wall isolation, mitral line, roofline and/or complex fractionated atrial electrogram ablation. PV target ablation (n=140), included re-isolation and/or wide atrium circumferential ablation. Patients’ demographics and rhythm outcomes during 12-months follow-up were analysed.

Results: Overall, the mean age was 63 ± 9 years, 64% were male, and body mass index was 27.1 ± 4.2. Patients undergoing non-PV target ablation had more frequently persistent AF (47.9% vs 14.3%, p &lt; 0.001), and had a higher CHA2DS2 VASc (2.0 vs 1.3, p &lt; 0.001). At 12 months, more atrial tachyarrhythmias were observed in the non-PV target group (48.6%) compared to the PV target group (29.3%, p=0.001). Similarly, a significantly higher AF and atrial tachycardia (AT) recurrence rate was observed after non-PV target ablation compared to PV target ablation (36.4% versus 22.1% and 22.9% versus 10.7%). After adjusting for several associated covariates, a significantly higher AT recurrence risk remained in the non-PV target group (adjusted OR 2.19 95% CI 1.18 – 4.42, p = 0.023) (Figure 1C). Sensitivity analysis was performed with inverse propensity weighting to assess the robustness of the multivariate model and demonstrated comparable outcomes. Both groups significantly de-escalated anti-arrhythmic drug use, de-escalation was more profound after PV target ablation. Patients with isolated PVs during non-PV target ablation had a significantly higher risk for AF recurrence than those with reconnected PVs (Figure 1B).

Conclusion: Compared to PV target ablation, non-PV target repeat ablation did not improve outcomes after 12 months and was independently associated with a higher risk for AT recurrences.