2207Cardiovascular outcome in THEMIS -like type 2 diabetes patients in Sweden: a nationwide observational study

Background

The THEMIS study (NCT01991795; in analysis phase; n=19,349) compares the effect of dual antiplatelet therapy (DAPT) vs ASA alone for the prevention of major cardiovascular (CV) events in type 2 diabetes (T2D) patients with coronary artery disease (CAD) at high CV risk, but without prior myocardial infarction (MI) or stroke. However, there is a lack of real-life data on CV risk in a THEMIS-like population compared to MI patients, where treatment with DAPT is guideline standard. The aim of this study was to investigate the CV risk in a THEMIS-like population vs an MI population

Methods

Patients invasively managed in Sweden (2006–2014) were identified using the SWEDEHEART registry and the National Patient Registry. Two populations were studied: a THEMIS-like population including patients with CAD and T2D, ≥1 vessel disease or elective percutaneous coronary intervention [PCI], and no prior stroke or MI), and a MI patient population alive at discharge. The cumulative incidence of the primary composite outcome (CV death (CVD)/MI/stroke) was estimated 3 years after index using the Kaplan-Meier method, and with probability plots adjusted for age, sex, atrial fibrillation, and heart failure. A 30 days blanking period for outcome was added to ensure capture of new events (index THEMIS-pop.: after angiography; index MI-pop.: after discharge).

Results

Overall, 6,534 THEMIS-like patients and 96,638 MI patients were included. At index, the THEMIS-like patients (CAD and T2D without previous MI/stroke) were aged 67.1 years (mean), 26.6% women, 9.2% AF, and 4.7% HF, while the MI patients were aged 67.3 years (mean), 30.7% women, 15.5% T2D, 17.9% previous MI, 5.2% stroke, 6.4% AF, and 4.8% HF. Three-year cumulative incidence for the composite outcome CVD/MI/stroke was 0.149 (95% CI 0.140, 0.158) for THEMIS-like patients, and 0.148 (95% CI 0.145, 0,15) for MI patients (p=0.88 log rank test) (Figure). Corresponding adjusted probably plots: 0.135 (95% CI 0.127, 0.143) and 0.131 (95% CI 0.128, 0.133). MI was the main risk driver with greatest cumulative incidence in both populations (0.091 vs 0.087) (Figure).

Figure 1

Conclusions

In this Swedish real-life setting, THEMIS-like patients, followed from 30 days after invasive intervention, had a similar long-term risk for CV events compared with MI patients surviving 30 days after discharge, with MI as the main risk driver, despite having no previous ischemic events. The present data indicate that long-term ischemic risk prevention should be a key strategy in coronary artery disease patients with diabetes requiring elective invasive intervention.

Acknowledgement/Funding

AstraZeneca

2349Selatogrel, a novel P2Y12 inhibitor for emergency use, achieves rapid, consistent and sustained platelet inhibition following single-dose subcutaneous administration in stable CAD patients

Background

In the setting of AMI, rapid platelet inhibition is desirable but the onset of pharmacodynamic (PD) effect of oral platelet P2Y12 inhibitors is delayed, sometimes for hours. Subcutaneous (s.c) administration of a rapidly-acting P2Y12 inhibitor would overcome many of the limitations of available therapies. Patients with stable CAD were investigated initially.

Purpose

To characterise the inhibition of platelet aggregation and pharmacokinetics (PK) of a single dose of selatogrel, a novel s.c P2Y12 inhibitor, in patients with stable CAD.

Methods

Patients with stable CAD receiving oral antiplatelet therapy (aspirin and/or oral P2Y12 inhibitor) were randomized to 1 of 8 groups based on treatment (selatogrel or matching placebo), dose (8 mg or 16 mg) and s.c injection site (thigh or abdomen). Venous blood samples were collected into PPACK anticoagulant tubes. Platelet reactivity was assessed by VerifyNow PRU (P2Y12 reaction units) test before and 15 min, 30 min and 1, 2, 4, 8 and 24 h after injection. Light-transmittance aggregometry (LTA; ADP 20 uM) was also performed. PK samples were collected up to 24 h post-dose. Adverse events occurring within 30 days were recorded. Responders were defined as having PRU <100 at 30 min after injection and lasting ≥3 h.

Results

345 patients (mean age 65 y; 20% female; 31% diabetes) received selatogrel 8 mg (n=114), selatogrel 16 mg (n=115) or placebo (n=116). 97% were on background therapy with aspirin (or its derivative carbasalate) and 35% with oral P2Y12 inhibitor (clopidogrel 23%, prasugrel 4%, ticagrelor 8%). 89% of subjects were responders to selatogrel 8 mg, 90% to selatogrel 16 mg and 16% to placebo (P<0.0001). At 15 min post-dose, PRU values (mean±SD) were 10±25 with selatogrel 8 mg, 5±10 with selatogrel 16 mg and 163±73 with placebo (Figure). PRU levels were maintained at 2 and 4 h for both doses and gradually returned to pre-dose levels by 24 h post-dose (Figure). LTA results were consistent with the VerifyNow results. PD responses were similar for thigh and abdomen injection sites. Selatogrel was well tolerated: mild dyspnoea (or moderate dyspnoea, n=1, with 16 mg) occurred in 5% and 9% with selatogrel 8 mg and 16 mg, respectively, vs 0% with placebo; dizziness occurred in 4% and 4% vs 1%, respectively, without significant haemodynamic or ECG changes. Bleeding events occurred in 9.6% and 4.3% with selatogrel 8 mg and 16 mg, respectively, vs 6.9% with placebo. Pharmacokinetic data will be presented.

Conclusions

Selatogrel has a rapid PD effect following s.c injection in patients with stable CAD, within 15 min in most patients. The consistent and high levels of P2Y12 inhibition with a single 8 mg or 16 mg dose are sustained for over 4 hours, following which platelet reactivity progressively recovers over 24 h. Selatogrel was well tolerated, with mostly mild, transient dyspnoea observed in <10% patients. These data support further studies of selatogrel for emergency treatment of AMI patients.

Acknowledgement/Funding

Fully funded by Idorsia Pharmaceuticals Ltd

Exploring research participants' perceptions of cardiovascular risk information-Room for improvement and empowerment

OBJECTIVE

The objective of this study was to explore research participants' (adults, age 50-65) perceptions of receiving cardiovascular risk information.

METHODS

Five focus group interviews (N = 31) were performed with research participants aged 50-65 who participated in the Swedish CArdioPulmonary BioImage Study (SCAPIS). The interviews were analyzed using qualitative content analysis.

RESULTS

The categories; the complexity of cardiovascular risk; insufficient presentation of test result; emotional responses; and health examinations provides confirmation, emerged. The test results were written in medical terms and lacked recommendations for further action which made it difficult for lay people to understand and use, and for some, also caused unnecessary worry.

CONCLUSION

There was inadequate guidance concerning the implications of the test results, especially for participants without clinical findings. In order to allow research participants to obtain better cognitive and behavioral control, improvements are needed with regard to how personal risk information is communicated in research projects connected to health services.

PRACTICAL IMPLICATIONS

The participants largely relied on physical signs when assessing their own cardiovascular risk. Health examinations are crucial for helping to add nuance to individuals' risk perceptions. For personal health information to have any real value for individuals, it must be designed from a user perspective.

Isolated primary bone tumours of the lesser trochanter: Demographics, diagnosis and management

Primary bone tumours arising from the lesser trochanter (LT) are rare and the literature describing them is sparse. In this paper, we describe the largest series of LT tumours describing the demographics, diagnosis and management.

METHODS

A retrospective search of prospectively maintained radiology and oncology databases was performed to identify bone tumours of the LT diagnosed between 2007 and 2018. Metastatic lesions were excluded. All cases were re-reviewed by a senior Radiologist and all case of isolated tumours of the LT were included.

RESULTS

23 cases of isolated LT tumours were identified. There were 15 males and 8 females. Mean age of our cohort was 32 (14-63) years. Most (n = 19, 82.6%) cases had classic radiological (Radiographic, MR Imaging and CT) features and therefore did not undergo biopsy. 4 patients had equivocal radiological investigations that required biopsy to confirm the diagnosis. MR imaging was the most commonly used imaging modality for diagnosis (n = 17, 73.9%)There was a broad range of tumour subtypes, and osteochondroma (n = 17, 73.9%) the most frequently diagnosed. Surgical excision was performed in 4 patients (all osteochondromas) and 4 patients underwent therapeutic radiological guided hip injections for symptomatic relief. The remaining cases were managed conservatively and where they were identified incidentally, no intervention was required.

CONCLUSION

We report the largest case series of isolated primary bone tumours of the LT. All isolated primary bone tumours of LT are benign. Osteochondroma is the most common. The diagnosis can be made with on radiological investigations in most patients.

Sex-related response to bivalirudin and unfractionated heparin in patients with acute myocardial infarction undergoing percutaneous coronary intervention: A subgroup analysis of the VALIDATE-SWEDEHEART trial

Aims:

Our aim was to study the impact of sex on anticoagulant treatment outcomes during percutaneous coronary intervention in acute myocardial infarction patients.

Methods:

This study was a prespecified analysis of the Bivalirudin versus Heparin in ST-Segment and Non ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART) trial, in which patients with myocardial infarction were randomised to bivalirudin or unfractionated heparin during percutaneous coronary intervention. The primary outcome was the composite of death, myocardial infarction or major bleeding at 180 days.

Results:

There was a lower risk of the primary outcome in women assigned to bivalirudin than to unfractionated heparin (13.6% vs 17.1%, hazard ratio 0.78, 95% confidence interval (0.60–1.00)) with no significant difference in men (11.8% vs 11.2%, hazard ratio 1.06 (0.89–1.26), p for interaction 0.05). The observed difference was primarily due to lower risk of major bleeding (Bleeding Academic Research Consortium definition 2, 3 or 5) associated with bivalirudin in women (8.9% vs 11.8%, hazard ratio 0.74 (0.54–1.01)) but not in men (8.5% vs 7.3%, hazard ratio 1.16 (0.94–1.43) in men, p for interaction 0.02). Conversely, no significant difference in the risk of Bleeding Academic Research Consortium 3 or 5 bleeding, associated with bivalirudin, was found in women 4.5% vs 5.4% (hazard ratio 0.84 (0.54–1.31)) or men 2.9% vs 2.1% (hazard ratio 1.36 (0.93–1.99)). Bleeding Academic Research Consortium 2 bleeding occurred significantly less often in women assigned to bivalirudin than to unfractionated heparin. The risk of death or myocardial infarction did not significantly differ between randomised treatments in men or women.

Conclusion:

In women, bivalirudin was associated with a lower risk of adverse outcomes, compared to unfractionated heparin, primarily due to a significant reduction in Bleeding Academic Research Consortium 2 bleeds.

An Audit for Radiotherapy Planning and Treatment Errors From a Low-Middle-Income Country Centre

AIMS

To report the findings of an audit for radiotherapy errors from a low-middle-income country (LMICs) centre. This would serve as baseline data for radiotherapy error rates, their severity and causes, in such centres where modern error reporting and learning processes still do not exist.

MATERIALS AND METHODS

A planned cross-sectional weekly audit of electronic radiotherapy charts at the radiotherapy planning and delivery step for all patients treated with curative intent was conducted. Detailed analysis was carried out to determine the step of origin of error, time and contributing factors. They were graded as per indigenous institutional (TMC) radiotherapy error grading (TREG) system and the contributing factors identified were prioritised using the product of frequency, severity and ease of detection.

RESULTS

In total, 1005 consecutive radically treated patients' charts were audited, 67 radiotherapy errors affecting 60 patients, including 42 incidents and 25 near-misses were identified. Transcriptional errors (29%) were the most common type. Most errors occurred at the time of treatment planning (59.7%), with "plan information transfer to the radiation oncology information system" being the most frequently affected sub-step of the radiotherapy process (47.8%). More errors were noted at cobalt units (52/67; 77.6%) than at linear accelerators. Trend analysis showed an increased number of radiotherapy incidents on Fridays and near-misses on Mondays. Trend for increased radiotherapy errors noted in the evening over other shifts. On severity grading, most of the errors (54/60; 90%) were clinically insignificant (grade I/II). Inadequacies and non-adherence towards standard operating procedures, poor documentation and lack of continuing education were the three most prominent causes.

CONCLUSION

Preliminary data suggest a vulnerability of LMIC set-up to radiotherapy errors and emphasises the need for the development of longitudinal prospective processes, such as voluntary reporting and a continued education system, to ensure robust and comprehensive safe practises on par with centres in developed countries.

The psychological responses of amateur riders to their horses’ injuries

Equestrian sport is considered a high-risk environment for equine injury. Due to the close bond between horse and rider, it could be theorised that riders may be impacted psychologically by their horses’ injuries, as seen in athletic pairs and with companion animal ownership. The extensive time commitment and responsibility of care within equestrian sport means that horse riders’ day-to-day life is impacted in a way not seen in other sporting or leisure environments, thus providing a unique opportunity to investigate the psychological responses of riders to their horse’s injury. The aims of this study were to investigate the psychological responses that amateur riders experienced when their horses were injured. 308 amateur horse riders (16 male and 292 female, median age 25-30 category) completed the Psychological Response to Sport Injury Inventory (19-item) (PRSII) and questions regarding demographics, investment in equestrian sport, the horse’s injury and the length of rehabilitation. Devastation was significantly affected by the weekly time investment of riders (H(3)=8.255, P=0.041) and the length of ownership prior to the injury (H(2)=7.690, P=0.021). ‘Devastation’, ‘feeling cheated’, ‘restlessness’ and ‘isolation’ were all significantly affected by the length of rehabilitation for the horse (H(7)=70.825, P=0.000, H(7)=37.799, P=0.000, H(7)=37.799, P=0.004, and H(7)=27.486, P=0.000, respectively). These findings suggest that amateur horse riders are at risk of psychological distress when their horse becomes injured. Whilst the industry has developed strategies to support owners following euthanasia which are already in place, psychological support following horse injury may be necessary to buffer psychological ‘devastation’ within amateur horse owners.

Severe macroglossia after posterior fossa and craniofacial surgery in children

Massive swelling of the tongue can occur after posterior fossa and craniofacial surgery. Several hypotheses have been proposed to explain the occurrence of such severe postoperative macroglossia, but this phenomenon is still poorly understood. Severe postoperative macroglossia can be a life-threatening condition due to upper airway obstruction. Three cases of severe postoperative macroglossia that occurred after cervical spine, craniofacial, and posterior fossa surgical procedures are reported here. These cases required specialized maxillofacial management and a prolonged stay in the intensive care unit. Causal factors involved in this condition are reported, in order to highlight appropriate prevention and treatment options adapted to the management of paediatric patients. An overview of the current literature on severe postoperative macroglossia in paediatric populations is also provided.

Assessment of malocclusion severity and orthodontic treatment needs in 12-15-year-old school children of Namakkal District, Tamil Nadu, using Dental Aesthetic Index

OBJECTIVES

The present study was aimed to assess the severity of malocclusion and orthodontic treatment needs among 12-15-year-old schoolchildren in rural area of Namakkal district, Tamil Nadu, India, using the Dental Aesthetic Index (DAI).

MATERIALS AND METHODS

A cross-sectional study was conducted among a sample of 1078 schoolchildren (12-15 years of age) who were selected by two-stage cluster sampling technique. Severity of malocclusion and orthodontic treatment needs were assessed according to the DAI using a specially designed survey pro forma with the aid of the WHO's Oral Health Survey: Basic Methods. Based on the distribution of data, analysis of variance and unpaired student t-test were used.

RESULTS

Out of the total of 1078 children examined, 528 (49%) were males and 550 (57%) were females. The results indicate that 82.74% of the schoolchildren were found with little or no malocclusion requiring no orthodontic treatment. The gender-wise distribution of DAI score among children aged 12 years had significant difference between males (20.43 ± 3.67) and females (21.62 ± 4.335) (P = 0.015) and children aged 15 years also showed highly significant difference among gender (P = 0.000).

CONCLUSION

Malocclusion not only impacts the appearance of the person but also affects the self-esteem and psychological well-being. This is the first step in understanding the treatment need so that further steps can be taken in preventive and interceptive care.

Abstract P3-14-07: Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study

Background:

The need for post mastectomy radiotherapy (PMRT), may preclude reconstructive surgeons from offering patients immediate, autologous reconstruction. This is due to historical evidence suggesting high rates of short- and long-term complications as well as poorer aesthetic outcomes. As the indications for PMRT broaden this practice denies an ever-increasing number of women the benefit of an immediate reconstruction.

Aim:

This pilot study evaluates the safety of offering radiotherapy prior to mastectomy and immediate DIEP flap reconstruction.

Methods:

Women planned for neoadjuvant chemotherapy (NAcT), mastectomy (following unsuccessful breast conservation surgery (BCS) or upfront selection) and PMRT were offered a change in sequencing of RT at two academic breast surgery units in London, UK. Data was prospectively captured on 19 women, including: patient demographics, treatment details, tumour characteristics, oncological and post-operative outcomes. Operative parameters included unplanned return to theatre [RTT] &lt;30 days, mastectomy skin flap necrosis, and evidence of wound infection at 5 days, 4 and 12 weeks post-operatively. All mastectomies, were performed by one of 3 breast surgeons (DH, FAM, DRL) using a circumareolar incisions with one patient undergoing a vertical pattern incision for skin reduction.

Results:

The cohort demonstrated a broad range of age, body mass index (BMI) and mastectomy weight [mean (range): age=46 years (28-72); BMI = 28.4 kg/m2 (23-37.6) and specimen weight=678gm (257-1040)]. The mean time from completion of NAcT to neoadjuvant radiotherapy (NART) was 31.1 days (9-49 days), and time from completion of NART to mastectomy and DIEP was 17.8 days (13-24 days). There was one unplanned RTT at 72 hours for an evacuation of haematoma, 1 revision of micro-vascular anastomosis, 1 clinical fat necrosis requiring formal excision and 1 wound debridement and primary closure for poor wound healing (vertical pattern skin reduction). There were no flap failures and no mastectomy envelope necrosis. With a mean follow-up of 16.2 months, there were no loco-regional recurrences, 5 distant relapses with mean presentation at 13.7 months and 2 breast-cancer related deaths at 13.9 and 22.2months respectively.

Conclusion:

This pilot study suggests that mastectomy and DIEP reconstruction is surgically feasible within 4 weeks of completing NART. In this small cohort of oncologically high-risk women with altered sequencing of RT we did not observe flap failure or post-mastectomy skin flap necrosis. A larger multicentre study with aesthetic assessment, PROMS and translational aspects is planned.

Citation Format: Thiruchelvam P, Hadjiminas D, Cleator S, Wood S, Leff D, Jallali N, James S, MacNeill F. Neoadjuvant radiotherapy in mastectomy and immediate autologous free flap reconstruction. Findings from the primary radiotherapy and DIEP flap (PRADA) pilot study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-07.

A comparison of HFrEF vs HFpEF's clinical workload and cost in the first year following hospitalization and enrollment in a disease management program

BACKGROUND

Admission with heart failure (HF) is a milestone in the progression of the disease, often resulting in higher intensity medical care and ensuing readmissions. Whilst there is evidence supporting enrolling patients in a heart failure disease management program (HF-DMP), not all reported HF-DMPs have systematically enrolled patients with HF with preserved ejection fraction (HFpEF) and there is a scarcity of literature differentiating costs based on HF-phenotype.

METHODS

1292 consenting, consecutive patients admitted with a primary diagnosis of HF were enrolled in a hospital based HF-DMP and categorized as HFpEF (EF≥45%) or HFrEF (EF<45%). Hospitalizations, primary care, medications, and DMP workload with associated costs were evaluated assessing DMP clinic-visits, telephonic contact, medication changes over 1year using a mixture of casemix and micro-costing techniques.

RESULTS

The total average annual cost per patient was marginally higher in patients with HFrEF €13,011 (12,011, 14,078) than HFpEF, €12,206 (11,009, 13,518). However, emergency non-cardiovascular admission rates and average cost per patient were higher in the HFpEF vs HFrEF group (0.46 vs 0.31 per patient/12months) & €655 (318, 1073) vs €584 (396, 812). In the first 3months of the outpatient HF-DMP the HFrEF population cost more on average €791 (764, 819) vs €693 (660, 728).

CONCLUSION

There are greater short-term (3-month) costs of HFrEF versus HFpEF as part of a HF-DMP following an admission. However, long-term (3-12month) costs of HFpEF are greater because of higher non-cardiovascular rehospitalisations. As HFpEF becomes the dominant form of HF, more work is required in HF-DMPs to address prevention of non-cardiovascular rehospitalisations and to integrate hospital based HF-DMPs into primary healthcare structures.

Post-traumatic stress disorder dimensions and asthma morbidity in World Trade Center rescue and recovery workers

OBJECTIVE

Using data from a cohort of World Trade Center (WTC) rescue and recovery workers with asthma, we assessed whether meeting criteria for post-traumatic stress disorder (PTSD), sub-threshold PTSD, and for specific PTSD symptom dimensions are associated with increased asthma morbidity.

METHODS

Participants underwent a Structured Clinical Interview for Diagnostic and Statistical Manual to assess the presence of PTSD following DSM-IV criteria during in-person interviews between December 2013 and April 2015. We defined sub-threshold PTSD as meeting criteria for two of three symptom dimensions: re-experiencing, avoidance, or hyper-arousal. Asthma control, acute asthma-related healthcare utilization, and asthma-related quality of life data were collected using validated scales. Unadjusted and multiple regression analyses were performed to assess the relationship between sub-threshold PTSD and PTSD symptom domains with asthma morbidity measures.

RESULTS

Of the 181 WTC workers with asthma recruited into the study, 28% had PTSD and 25% had sub-threshold PTSD. Patients with PTSD showed worse asthma control, higher rates of inpatient healthcare utilization, and poorer asthma quality of life than those with sub-threshold or no PTSD. After adjusting for potential confounders, among patients not meeting the criteria for full PTSD, those presenting symptoms of re-experiencing exhibited poorer quality of life (p = 0.003). Avoidance was associated with increased acute healthcare use (p = 0.05). Sub-threshold PTSD was not associated with asthma morbidity (p > 0.05 for all comparisons).

CONCLUSIONS

There may be benefit in assessing asthma control in patients with sub-threshold PTSD symptoms as well as those with full PTSD to more effectively identify ongoing asthma symptoms and target management strategies.

Eastbourne Miami-J Protocol: a Pilot Study for the Care of Cervical Injuries in the Community

PURPOSE OF THE STUDY The aim of this pilot study was to develop The Eastbourne Miami-J Protocol for care of cervical injuries within the community. Led by orthopaedic senior practitioners, a multidisciplinary approach was developed to provide education and collar care for patients on a weekly basis. MATERIALS AND METHODS A total of 51 patients (17 male and 33 female), mean age 74 years (21 to 95) with CT confirmed cervical injuries during November 2010 and May 2014 followed the Eastbourne Miami-J Protocol. RESULTS Patients required collar care on average for 7.25 weeks. Thirty-two patients had single level cervical injuries with C2 the commonest. Complications included: 6 patients with psychosocial issues; 10 patients with skin erythema due to ill-fitting collars and 2 patients with skin breakdown requiring dressings. CONCLUSION The Eastbourne Miami-J protocol demonstrates that a multidisciplinary approach, championed by the casting department, can provide care for patients with cervical injuries within the community.

KEY WORDS

cervical spine, C-spine, cervical collar, community, rehabilitation.