Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

In England, 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation as part of targets set by Public Health England by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc>2) anticoagulated was 87%, 83% and 84%. This placed two of the three localities in the bottom 10% compared to others in England. In addition, optimising cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To prevent AF-related strokes by improving anticoagulation rates and optimising cardiovascular risk factors in patients with AF in all general practices across three London boroughs over one year, and to minimise risk of bleeding in patients on concurrent anticoagulation and antiplatelet therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to systemically identify high-risk AF patients (CHA2DS2VASc>2) by working with primary care clinicians, including up-skilling of primary care pharmacists. Through utilisation of ‘proactive care frameworks’ created by the Clinical Effectiveness Group Queen Mary University of London and UCL Partners, patients were able to be stratified and prioritised for review. AF patients not on anticoagulation or on antiplatelet monotherapy were deemed to be at highest risk, and these patients were reviewed to assess suitability for anticoagulation. Subsequently, patients on concurrent anticoagulation and antiplatelets were assessed to determine if dual antithrombotic prescribing was still indicated to minimise risk of major bleeding. Lastly, to optimise cardiovascular risk prevention, all AF patients were reviewed for suitability of statin initiation for primary or secondary prevention. A virtual multidisciplinary team was convened for complex patients, which included a cardiologist, haematologist, general practitioner and pharmacist to review and agree an action plan.

Results

An interim analysis at 9 months reported that 94% (6745/7145) of patients with a CHA2DS2VASc>2 across the three boroughs were suitably anticoagulated, an improvement of 6% on the initial 88% (6585/7391). There was a reduction in concurrent anticoagulation and antiplatelet therapy from 381 to 262 patients (31.2% reduction) following specialist review. Lastly 2285 patients were reviewed with a recommendation to start a statin for either primary (n=1783) or secondary prevention (n=502).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce with significant improvement in anticoagulation rates across all three boroughs, reducing the risk of stroke in this high-risk population. In addition, we were able to reduce the risk of bleeding in this cohort of patients by stopping inappropriate antiplatelet therapy, and reduced the risk of cardiovascular disease through statin initiation.

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.

Early versus late acute graft pyelonephritis: A retrospective analysis of graft and patient outcomes

BACKGROUND

Acute graft pyelonephritis (AGPN) is thought to affect graft and patient survival among renal transplant recipients. The objective was to compare outcomes among early AGPN (<6 months from transplant) versus late AGPN (>6 months from transplant).

METHODS

This retrospective study analysed 150 patients with AGPN dividing them into early and late AGPN from 2008 to 2016. Predictors of graft loss and mortality were compared using logistic regression analysis. Graft survival and patient survival were analysed using Kaplan-Meyer survival plots.

RESULTS

55.3% (n = 83) had early AGPN and 44.7% (n = 67) had late AGPN. In an early AGPN group, 13.3% had CMV disease on the follow-up, compared to only 3% in the late AGPN group (p > 0.05). Furthermore, 38.6% had prolonged DJ stent in-situ (> 2 weeks) following transplant surgery in the early AGPN compared to only 19.4% in the late AGPN group (p < 0.05). Recurrent GPN was more common in the late AGPN group - (35.8% versus 18.1%). The presence of renal abscess was predictive of graft loss in Univariate analysis (HR-6.12, p < 0.004). There was decreased death-censored graft survival in the early AGPN group (p = 0.035), without a significant difference in the patient survival among the two groups.

CONCLUSION

The occurrence of early AGPN had a significant impact on long-term graft survival in renal transplant recipients, with no significant effect on patient survival. This study underlines the paramount importance of the prevention of urinary tract infection (UTI) in renal transplant recipients.

Psycho-social health and quality of life among kidney donors following transplantation

INTRODUCTION

Living kidney donation is a complex psychological experience for donors. The present study examined the psychosocial impact of kidney donation on donors.

METHODS

The retrospective study included 506 donors who donated a kidney between 2010 and 2018 at a transplant centre in India. These donors responded via a donor insight questionnaire about their hospital anxiety, and their possible level of depression. The information included socio-demographic form with multiple information. The health survey was used periodically evaluate the psychosocial impact among donors following donation, including the transplant outcomes.

RESULTS

The majority of donors were females (79.4%). There was a significant improvement in the quality of life among donors (SF-36) following the donation of a kidney, especially among those donors who maintained good graft functions themselves as well as those who were informed about good kidney function in transplanted recipients. These donors showed a lesser degree of depressive and anxiety scores (HAD score 3.5 and BDI II 4.8) than donors who had problems themselves and/or whose donated kidneys did not function well. Most living donors (89.1%) felt that the act of donation had a positive impact on their lives and those donors would encourage others to donate a kidney. Overall, the graft outcomes impacted the donor's state of mind.

CONCLUSION

The study showed a very positive impact of the acknowledgment of the donor by the recipient, especially those donors whose kidney transplants were well functioning. The state of depression, anxiety, and psycho-social outcomes correlated with the graft outcomes. Donors showed positive insight towards donation, with inner conscience still conclusively willing to donate and encourage others.

Study of the doubly charmed tetraquark [Formula: see text]

Quantum chromodynamics, the theory of the strong force, describes interactions of coloured quarks and gluons and the formation of hadronic matter. Conventional hadronic matter consists of baryons and mesons made of three quarks and quark-antiquark pairs, respectively. Particles with an alternative quark content are known as exotic states. Here a study is reported of an exotic narrow state in the D0D0π+ mass spectrum just below the D*+D0 mass threshold produced in proton-proton collisions collected with the LHCb detector at the Large Hadron Collider. The state is consistent with the ground isoscalar [Formula: see text] tetraquark with a quark content of [Formula: see text] and spin-parity quantum numbers JP = 1+. Study of the DD mass spectra disfavours interpretation of the resonance as the isovector state. The decay structure via intermediate off-shell D*+ mesons is consistent with the observed D0π+ mass distribution. To analyse the mass of the resonance and its coupling to the D*D system, a dedicated model is developed under the assumption of an isoscalar axial-vector [Formula: see text] state decaying to the D*D channel. Using this model, resonance parameters including the pole position, scattering length, effective range and compositeness are determined to reveal important information about the nature of the [Formula: see text] state. In addition, an unexpected dependence of the production rate on track multiplicity is observed.

Angular Analysis of D^{0}→π^{+}π^{-}μ^{+}μ^{-} and D^{0}→K^{+}K^{-}μ^{+}μ^{-} Decays and Search for CP Violation

The first full angular analysis and an updated measurement of the decay-rate CP asymmetry of the D^{0}→π^{+}π^{-}μ^{+}μ^{-} and D^{0}→K^{+}K^{-}μ^{+}μ^{-} decays are reported. The analysis uses proton-proton collision data collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV. The dataset corresponds to an integrated luminosity of 9  fb^{-1}. The full set of CP -averaged angular observables and their CP asymmetries are measured as a function of the dimuon invariant mass. The results are consistent with expectations from the standard model and with CP symmetry.

Tests of Lepton Universality Using B^{0}→K_{S}^{0}ℓ^{+}ℓ^{-} and B^{+}→K^{*+}ℓ^{+}ℓ^{-} Decays

Tests of lepton universality in B^{0}→K_{S}^{0}ℓ^{+}ℓ^{-} and B^{+}→K^{*+}ℓ^{+}ℓ^{-} decays where ℓ is either an electron or a muon are presented. The differential branching fractions of B^{0}→K_{S}^{0}e^{+}e^{-} and B^{+}→K^{*+}e^{+}e^{-} decays are measured in intervals of the dilepton invariant mass squared. The measurements are performed using proton-proton collision data recorded by the LHCb experiment, corresponding to an integrated luminosity of 9  fb^{-1} . The results are consistent with the standard model and previous tests of lepton universality in related decay modes. The first observation of B^{0}→K_{S}^{0}e^{+}e^{-} and B^{+}→K^{*+}e^{+}e^{-} decays is reported.

Observation of the Decay Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ}

The first observation of the semileptonic b-baryon decay Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ}, with a significance of 6.1σ, is reported using a data sample corresponding to 3  fb^{-1} of integrated luminosity, collected by the LHCb experiment at center-of-mass energies of 7 and 8 TeV at the LHC. The τ^{-} lepton is reconstructed in the hadronic decay to three charged pions. The ratio K=B(Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ})/B(Λ_{b}^{0}→Λ_{c}^{+}π^{-}π^{+}π^{-}) is measured to be 2.46±0.27±0.40, where the first uncertainty is statistical and the second systematic. The branching fraction B(Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ})=(1.50±0.16±0.25±0.23)% is obtained, where the third uncertainty is from the external branching fraction of the normalization channel Λ_{b}^{0}→Λ_{c}^{+}π^{-}π^{+}π^{-}. The ratio of semileptonic branching fractions R(Λ_{c}^{+})≡B(Λ_{b}^{0}→Λ_{c}^{+}τ^{-}ν[over ¯]_{τ})/B(Λ_{b}^{0}→Λ_{c}^{+}μ^{-}ν[over ¯]_{μ}) is derived to be 0.242±0.026±0.040±0.059, where the external branching fraction uncertainty from the channel Λ_{b}^{0}→Λ_{c}^{+}μ^{-}ν[over ¯]_{μ} contributes to the last term. This result is in agreement with the standard model prediction.

Cardiovascular disease risk factors and outcomes of acute myocardial infarction in young adults in two nationwide cohorts in the united states

Funding Acknowledgements

Type of funding sources: None.

Background

Acute myocardial infarction (AMI) can have considerable morbidity and devastating socioeconomic and psychological consequences in young adults. Previous studies reveal that the decline in mortality in AMI has mainly been in the older population while being comparatively less significant in younger patients. This study compares young adults (18 to 44 years) hospitalized with AMI across two nationwide cohorts, 2007 and 2017, in the United States (US). It examines the burden of AMI hospitalizations, the prevalence of comorbidities, and in-hospital outcomes in young adults a decade apart. It highlights the rise in AMI hospitalizations, lack of decrease in mortality, sex-based and racial disparities, the surge in post-MI complications, and the decline in reperfusion interventions in young AMI patients over a decade.

Purpose

Coronary heart disease prevalence is challenging to ascertain in younger adults because of limited data and frequent silent clinical presentations. AMI and its complications can cause considerable morbidity, psychological trauma, and socioeconomic burden in the young.

Methods

We identified hospitalizations for AMI in young adults in 2007 and 2017 using the weighted data from the National Inpatient Sample (NIS), which covers 20% of stratified data of all non-federal community hospitals in the US. We compared the following data between the two cohorts: admission rates, sociodemographic features, in-hospital morbidity, complications, mortality, rate of coronary interventions, and healthcare utilization between the two cohorts. We used Pearson’s Chi-square test and Mann-Whitney U test to compare categorical and continuous variables, respectively. We also applied multivariable regression analyses to assess and compare the risk of cardiovascular complications and in-hospital mortality while controlling for confounders, including age, sex, race, median household income quartile, primary insurance enrolment, and pre-existing comorbidities.

Results

AMI’s incidence was higher in males in both the cohorts, although with a decline (71.1% vs 66.1%), whereas it rose from 28.9% to 33.9% in females. Hypertension (47.8% vs 60.7%), smoking (49.7% vs 55.8%), obesity (14.8% vs 26.8%), and diabetes mellitus (22.0% vs 25.6%) increased in the 2017 cohort (Table 1). We found no significant difference in all-cause mortality (aOR = 1.01 (0.93-1.10), p=0.749). Post-AMI complications, cardiogenic shock (aOR = 1.16 (1.06-1.27), p=0.001), and fatal arrhythmias increased. Reperfusion interventions decreased in the 2017 cohort (PCI; aOR=0.95 (0.91-0.98), p&lt;0.001; CABG; aOR=0.66 (0.61-0.71), p&lt;0.001) (Table 2).

Conclusion

Our study highlights the rise in AMI hospitalizations, plateauing of mortality, gender disparity, the surge in post-MI complications, and a reassuring decline in the requirement of reperfusion interventions in young AMI patients over a decade.

Observation of Two New Excited Ξ_{b}^{0} States Decaying to Λ_{b}^{0}K^{-}π^{+}

Two narrow resonant states are observed in the Λ_{b}^{0}K^{-}π^{+} mass spectrum using a data sample of proton-proton collisions at a center-of-mass energy of 13 TeV, collected by the LHCb experiment and corresponding to an integrated luminosity of 6  fb^{-1}. The minimal quark content of the Λ_{b}^{0}K^{-}π^{+} system indicates that these are excited Ξ_{b}^{0} baryons. The masses of the Ξ_{b}(6327)^{0} and Ξ_{b}(6333)^{0} states are m[Ξ_{b}(6327)^{0}]=6327.28_{-0.21}^{+0.23}±0.12±0.24 and m[Ξ_{b}(6333)^{0}]=6332.69_{-0.18}^{+0.17}±0.03±0.22  MeV, respectively, with a mass splitting of Δm=5.41_{-0.27}^{+0.26}±0.12  MeV, where the uncertainties are statistical, systematic, and due to the Λ_{b}^{0} mass measurement. The measured natural widths of these states are consistent with zero, with upper limits of Γ[Ξ_{b}(6327)^{0}]<2.20(2.56) and Γ[Ξ_{b}(6333)^{0}]<1.60(1.92)  MeV at a 90% (95%) credibility level. The significance of the two-peak hypothesis is larger than nine (five) Gaussian standard deviations compared to the no-peak (one-peak) hypothesis. The masses, widths, and resonant structure of the new states are in good agreement with the expectations for a doublet of 1D Ξ_{b}^{0} resonances.

First presentation of pyoderma gangrenosum in a patient with partial immunoglobulin A deficiency

We describe the case of a 58-year-old female with an intensely painful and rapidly enlarging necrotic cutaneous ulcer to the right shin on a background of partial immunoglobulin A deficiency (IgAD). She was seen by various healthcare professionals and managed with upscaling antibiotics for cellulitis requiring an inpatient hospital stay. The dermatology team made a clinical diagnosis of ulcerative Pyoderma Gangrenosum (PG) on assessing the patient 13 days post-onset of symptoms. The patient responded dramatically to steroids and oral tetracycline. This case highlights the unusually described association between PG and IgAD as well as the diagnostic challenge seen in patients presenting with PG.

Measurement of the Nuclear Modification Factor and Prompt Charged Particle Production in p-Pb and pp Collisions at sqrt[s_{NN}]=5 TeV

The production of prompt charged particles in proton-lead collisions and in proton-proton collisions at the nucleon-nucleon center-of-mass energy sqrt[s_{NN}]=5  TeV is studied at LHCb as a function of pseudorapidity (η) and transverse momentum (p_{T}) with respect to the proton beam direction. The nuclear modification factor for charged particles is determined as a function of η between -4.8<η<-2.5 (backward region) and 2.0<η<4.8 (forward region), and p_{T} between 0.2<p_{T}<8.0  GeV/c. The results show a suppression of charged particle production in proton-lead collisions relative to proton-proton collisions in the forward region and an enhancement in the backward region for p_{T} larger than 1.5  GeV/c. This measurement constrains nuclear PDFs and saturation models at previously unexplored values of the parton momentum fraction down to 10^{-6}.

670 FACTORS ASSOCIATED WITH MORTALITY IN MULTI-ETHNIC HOSPITALISED COVID PATIENTS

Introduction

Whilst most patients during the COVID pandemic made an uneventful recovery, there was a significant minority in whom the disease was severe and unfortunately fatal. This survey aims to evaluate independent risk factors for those who died of COVID compared to survivors and to identify any markers for improvement in future management.

Methods

Medical records of all COVID patients admitted to two multi-ethnic, inner city acute district general hospitals over a 6-week period in 2020 were examined. Data collected included demographic details, medical comorbidities, and type of ward where they received care. Multivariable analysis using stepwise backward logistic regression was conducted to examine independent risk factors for those who died from COVID compared to survivors.

Results

Of 951 patients admitted with COVID, 284 died[30%]. Compared to survivors(n = 667), univariate analyses revealed COVID deaths were associated with increasing age[mean(CI): 79.3(77.9–80.7)vs64.7(63.4–66.0);P &lt; 0.001], Black African [16.2%vs11.7%;p &lt; 0.001] & South-Asian [12%vs9.1%;p &lt; 0.001] ethnicity, Hypertension [64.4%vs49.5%;p &lt; 0.001], Chronic Heart Disease(CHD)[40.1%vs20.7%;p &lt; 0.001], Chronic Respiratory Disease [17.6%vs12.0%;p = 0.02] Chronic Kidney Disease [18%vs11.1%;p = 0.004], Chronic Neurological Disease 43.3%vs23.7%;p &lt; 0.001]. Gender, Diabetes, asthma, obesity, Chronic Liver Disease and immunosuppression (disease or treatment related) were not associated with increasing mortality. Death rates between those in general wards vs intensive care were comparable[4.7%vs2.5%;p = 0.1]. Multivariable analyses showed age 60–70 [OR 2.3], age &gt; 70 [OR 6.5], Black Caribbean [OR 1.6], and CHD [1.5] were independent risk factors for COVID deaths.

Discussion

This large multi-ethnic study showed that age &gt; 60, Black Caribbean, and chronic heart disease were independent risk factors for COVID deaths. This study provides valuable information on independent prognostic implications for COVID, which can be used in future interventional studies aiming to improve COVID outcomes or in audits of clinical practice.

671 DEMOGRAPHIC VARIABILITY IN MORTALITY FROM COVID DURING THE TWO SURGES

Introduction

COVID-19 resulted in significant mortality over the last several months. This survey aims to evaluate demographic differences between those hospitalised patients who died of COVID during the first surge [until 31/08/2020] and those who died during the second [01/09/2020–15/03/2021].

Methods

Data was obtained for all patients admitted with COVID during the two pandemic surges at two multi-ethnic,inner-city district general hospitals. Univariate and multivariable analyses [stepwise backward logistic regression] were conducted to evaluate mortality as per patient demographics, length of stay, and whether patients had been managed in critical care.

Results

1013 [21.5%] of 4,707 patients died during this period. Mortality was significantly lower during the second wave,compared to first i.e. 18.5% [632/2784]vs29.5% [381/901];39% reduction [P < 0.001]. This reduction was observed across all ages, gender, ethnic subgroups, and both sites. Advancing age was associated with significant mortality at all times with no differences between the two waves. 77% of all deaths occurred in patient>70. There were fewer deaths among those<50 during the second wave compared to first [7vs12]. Reduction in mortality during second wave was noted across all ethnic sub-groups. However,significantly greater reduction was observed in Black African [54.6%],South-Asian [47.3%],Black Caribbean [44.4%],and East-Asian [44.2%] groups, compared to white subgroup [34.2%]. Majority of patients who died were managed on general medical wards during both waves [n = 824,81.3%]. For patients who spent time in critical care, there were no significant differences in mortality [30.6vs33.7%,p = ns]. There were no differences in terms of length of hospital stay between the two waves. Multivariable analyses showed that Black African [OR 0.47,95%CI 0.27–0.82] was independently associated with lesser mortality during second wave.

Discussion

This large survey has described demographic differences in mortality between the two surges. Lower mortality rates during second wave may be due to better treatment modalities, greater awareness of infection prevention and control,and possibly vaccination. This survey indicates greater psychological support may be required for healthcare workers on general medical wards who looked after greater proportion of COVID deaths.

Patient Understanding of Nonapproved Stem Cell Therapies for Retinal Disease

This prospective survey study demonstrates a lack of retina clinic patient knowledge about appropriate stem cell therapy applications for retinal disease.

Representation of Women in Ophthalmology Receiving Private Industry Funding 2015-2018

PURPOSE

To report the representation of female ophthalmologists receiving private industry funding from 2015 through 2018, and to compare to previously observed trends.

DESIGN

Retrospective, comparative trend study METHODS: The study population consisted of US ophthalmologists listed in CMS Open Payments Database. Data were reviewed for payments for research, consulting, honoraria, industry grants, faculty and speakers, royalties, and services other than consulting. The primary outcome measure was percentage of female representation compared to male in each sub-category of payment.

RESULTS

The percentage of female, board-certified ophthalmologists who practiced in the United States ranged from 21.3% to 24.1%. The total number of reported ophthalmologists with industry ties ranged from 1629 to 1873, of whom between 17.2% and 19.4% were women. Women received significantly less industry compensation by than men in 2015 (median average $3273 vs $4825, P = .003), 2016 ($3600 vs $4750, P = .023), 2017 ($2493 vs $3500, P = .013), and 2018 ($2000 vs $3000, P = .011). Women remained underrepresented in receiving payments for research (ranging from 5.4% of total paid for research to 8.0%), consulting (11%-17.4%), honoraria (6%-14.9%), industry grants (4%-41.2%), royalties and licenses (0.1%-10.2%), faculty and speakers (11.6%-16.4%), and services other than consulting (8.4%-28.9%). Compared to 2013-2014, an increasing proportion of women received industry payments for consulting (P = .012), honoraria (P = .007), royalties and licenses (P = .019), faculty and speakers (P = .007), and services other than consulting (P = .007).

CONCLUSIONS

Female ophthalmologists remain underrepresented in terms of the percentage of women who receive private industry funding and dollar value of the funding.

328 Renal Cell Carcinoma (RCC) Metastasis to the Coracoid Process

A 51-year-old man was diagnosed with renal cell carcinoma (RCC) of the left kidney seven years ago. The tumour was staged as T2N0M0 and the patient underwent an uncomplicated open left radical nephrectomy. The RCC was classified as clear cell and he was kept on biannual renal surveillance thereafter.

Six years after the nephrectomy, the patient had reported a 5-month history of worsening pain and globally restricted movement in their right shoulder. A palpable mass on the coracoid process was noted. MRI imaging had shown a 27x30x17mm lesion suggestive of an expansile osseous mass in the coracoid process. An ultrasound guided biopsy was performed for definitive characterisation. Histology had reaffirmed that the lesion was in fact metastatic clear cell carcinoma in keeping with the patient’s renal primary. CT chest/abdomen/pelvis and NM-Bone SPECT CT scanning had shown no other sites of metastasis. A marginal resection of the lesion was performed with a good macroscopic clearance.

The common sites within the skeleton implicated in RCC include the spine, pelvis and femur. Tumours of the coracoid process are exceedingly rare. From the literature, only four cases of metastasis to the process have been noted: two from breast carcinoma, one from hepatocellular carcinoma and the other from basal cell carcinoma. Thus, this case denotes an extraordinary presentation for a metastasis of RCC many years after the nephrectomy. Furthermore, it emphasises the criticalness of regular follow-up and early intervention as delays could lead to systemic metastasis and a poorer prognosis.

Study of Z Bosons Produced in Association with Charm in the Forward Region

Events containing a Z boson and a charm jet are studied for the first time in the forward region of proton-proton collisions. The data sample used corresponds to an integrated luminosity of 6  fb^{-1} collected at a center-of-mass energy of 13 TeV with the LHCb detector. In events with a Z boson and a jet, the fraction of charm jets is determined in intervals of Z-boson rapidity in the range 2.0<y(Z)<4.5. A sizable enhancement is observed in the forwardmost y(Z) interval, which could be indicative of a valencelike intrinsic-charm component in the proton wave function.

Evidence for a New Structure in the J/ψp and J/ψp[over ¯] Systems in B_{s}^{0}→J/ψpp[over ¯] Decays

An amplitude analysis of flavor-untagged B_{s}^{0}→J/ψpp[over ¯] decays is performed using a sample of 797±31 decays reconstructed with the LHCb detector. The data, collected in proton-proton collisions between 2011 and 2018, correspond to an integrated luminosity of 9  fb^{-1}. Evidence for a new structure in the J/ψp and J/ψp[over ¯] systems with a mass of 4337_{-4}^{+7} _{-2}^{+2}  MeV and a width of 29_{-12}^{+26} _{-14}^{+14}  MeV is found, where the first uncertainty is statistical and the second systematic, with a significance in the range of 3.1 to 3.7σ, depending on the assigned J^{P} hypothesis.

Analysis of Neutral B-Meson Decays into Two Muons

Branching fraction and effective lifetime measurements of the rare decay B_{s}^{0}→μ^{+}μ^{-} and searches for the decays B^{0}→μ^{+}μ^{-} and B_{s}^{0}→μ^{+}μ^{-}γ are reported using proton-proton collision data collected with the LHCb detector at center-of-mass energies of 7, 8, and 13 TeV, corresponding to a luminosity of 9  fb^{-1}. The branching fraction B(B_{s}^{0}→μ^{+}μ^{-})=(3.09_{-0.43-0.11}^{+0.46+0.15})×10^{-9} and the effective lifetime τ(B_{s}^{0}→μ^{+}μ^{-})=2.07±0.29±0.03  ps are measured, where the first uncertainty is statistical and the second systematic. No significant signal for B^{0}→μ^{+}μ^{-} and B_{s}^{0}→μ^{+}μ^{-}γ decays is found and upper limits B(B^{0}→μ^{+}μ^{-})<2.6×10^{-10} and B(B_{s}^{0}→μ^{+}μ^{-}γ)<2.0×10^{-9} at the 95% C.L. are determined, where the latter is limited to the range m_{μμ}>4.9  GeV/c^{2}. The results are in agreement with the standard model expectations.

Seven Day Safety Net Service

A seven day safety net telephone service was developed in an acute medical unit at a university hospital in London. The service attempts to provide all patients discharged from acute medicine with patient activated access to a member of the acute medical team. This allows patients to flag deterioration triggering further review in the ambulatory clinic or to ask for advice on symptoms or medication. Here we evaluate the first sixteen months of the service and report on its benefits and limitations.

Probing Gluon Spin-Momentum Correlations in Transversely Polarized Protons through Midrapidity Isolated Direct Photons in p^{↑}+p Collisions at sqrt[s]=200 GeV

Studying spin-momentum correlations in hadronic collisions offers a glimpse into a three-dimensional picture of proton structure. The transverse single-spin asymmetry for midrapidity isolated direct photons in p^{↑}+p collisions at sqrt[s]=200  GeV is measured with the PHENIX detector at the Relativistic Heavy Ion Collider (RHIC). Because direct photons in particular are produced from the hard scattering and do not interact via the strong force, this measurement is a clean probe of initial-state spin-momentum correlations inside the proton and is in particular sensitive to gluon interference effects within the proton. This is the first time direct photons have been used as a probe of spin-momentum correlations at RHIC. The uncertainties on the results are a 50-fold improvement with respect to those of the one prior measurement for the same observable, from the Fermilab E704 experiment. These results constrain gluon spin-momentum correlations in transversely polarized protons.

Transcatheter aortic valve implantation outcomes compared between bicuspid aortic and tricuspid aortic valve stenosis: an updated systematic review and meta-analysis

Background

TAVI has emerged as an attractive treatment modality based on promising recent trial data. Patients with BAV, a commonly encountered clinical condition have largely been excluded from a majority of trials.

Purpose

Elderly patients with BAV and severe AS are increasingly encountered in clinical practice. This meta-analysis compares clinical outcomes between bicuspid and tricuspid AV patients to address the current knowledge-gap and identify optimal management strategies of these patients.

Methods

A comprehensive literature search was performed in PubMed, Embase, and Cochrane to identify the available observational studies comparing outcomes of TAVI in BAV and TAV patients. Summary effects were calculated using a DerSimonian and Laird random-effects model as odds ratio with 95% confidence intervals for all the clinical endpoints.

Results

16 Observational studies met inclusion criteria, comprising 10,053 patients with BAV and 173,307 patients with TAV that underwent TAVI. No significant differences in 30-day and long-term mortality rates were observed. Patients with BAV had an increased risk of stroke (OR 1.23; 95% CI [1.06–1.44], p=0.007), re-intervention (OR 1.90; 95% CI [1.15–3.15], p=0.01), paravalvular leak (OR 1.42; 95% CI [1.25–1.61], p&lt;0.ehab724.22251), conversion to open surgery (OR 1.93; 95% CI [1.21–3.07], p=0.006), and new pacemaker implantation (1.57; 95% CI (1.06 - 2.33, p=0.02). Adverse event rates are lower with the use of newer generation of valves. No significant difference in major vascular complications, major bleeding, or incidence of AKI was noted.

Conclusions

Complication rates for BAV TAVI are higher, but mortality is similar to TAV TAVI indicating TAVI is an appropriate alternative for intermediate-high risk patients with BAV. A better understanding of valve anatomy, physician expertise, the use of newer-generation valves can help reduce these complications.

Funding Acknowledgement

Type of funding sources: None.

Moving shear stress towards the clinic: preclinical comparison of optical coherence tomography-based versus angiography-based time-averaged wall shear stress estimations

Introduction

Identification of coronary atherosclerotic plaques at risk of causing future acute coronary syndromes remains a major unmet clinical challenge. The addition of vessel biomechanics to intracoronary imaging derived evaluation of plaque morphology, improves identification of plaques likely to develop high risk features. We and others have developed a framework for intracoronary imaging (optical coherence tomography [OCT]) based 3D reconstructions of coronary arteries for computational fluid dynamics (CFD) simulations of shear stress, which are considered the current gold standard approach for quantification of coronary arterial haemodynamics. However, these approaches are time consuming and computationally intensive, resulting in a barrier to clinical uptake.

Purpose

Determination of time averaged wall shear stress (TAWSS) based on 3D coronary geometries from non-invasive 3D Quantitative Coronary Angiography (3D-QCA) has recently been developed (Pie Medical Imaging, Netherlands), which enables results of shear stress simulations to be available within 30 minutes. We sought to compare TAWSS determined from 3D-QCA with gold standard OCT-based CFD simulations in both normal and stenotic arteries in minipigs.

Methods

15 normal and 5 stenotic minipig coronary arteries were studied. Anatomically matched 3D arterial geometries were reconstructed from 3D-QCA and OCT using common centrelines. Boundary conditions for simulations included directly measured inlet blood velocities; parabolic inlet flow profiles, zero pressure outlet; no-slip arterial walls; blood density: 1.05 g/ml; blood dynamic viscosity: 0.035 g/cm.s. Blood was modelled as Newtonian. 3D-QCA TAWSS was obtained with a Kratos Multi-Physics CFD solver. OCT-based simulations were performed using Abaqus/CFD v6.14. TAWSS was calculated for 80 axially matched segments for both methods (1200 and 400 paired comparisons for normal and stenotic arteries, respectively). Data were analysed using Bland-Altman and Wilcoxon matched-pairs signed ranked tests.

Results

Computation times for 3D-QCA and OCT-based CFD were approximately 30 minutes and 2 hours respectively. Axial profiles of TAWSS were similar between the two methods and there was agreement in TAWSS magnitudes and narrow 95% limits of agreement (Figure 1 and Figure 2). Using co-registered TAWSS maps generated by each method, we find similar spatial regional distributions of TAWSS in both normal and stenotic arteries.

Conclusions

Our data suggest that 3D-QCA based TAWSS is feasible in both normal and stenotic arteries. Spatial TAWSS distributions between the two methods are similar with agreement in matched TAWSS comparisons, though there are some small systematic differences in the absolute values of TAWSS, due to different resultant arterial geometries. These encouraging data suggest that further clinical evaluation of rapid TAWSS from 3D-QCA is warranted, which may facilitate clinical adoption of TAWSS assessment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Medical Research Council

128 Rapidly Proliferative Pilomatrixoma On the Eyebrow of A 7-Year-Old Boy – A Case Report

Pilomatrixoma or calcifying epithelioma of Malherbe is a benign tumour originating from pluripotent precursors of hair matrix cells. We present a paediatric patient with a rapidly enlarging eyebrow mass with a differential diagnosis of sebaceous cyst, pyogenic granuloma, or malignancy.

A 7-year-old boy presented in primary care with a 0.5cm non-inflammatory nodule on his medial brow present for 2-3 months. History of previous trauma was not elicited and there were no features of bleeding or ulceration. It was then lanced, following diagnosis of an infected sebaceous cyst. Within weeks, the nodule underwent rapid proliferation, enlarging to 2cm in diameter. He was urgently referred to secondary care pending further investigation for possible trauma-induced pyogenic granuloma or malignancy.

Upon presentation in secondary care, we observed a protruding erythematous and ulcerated mass, indurated in texture and adherent to overlying skin. The patient was submitted to excisional biopsy with a vertical elliptical approach to minimise distortion of the brow. Small, calcified deposits were observed in the tumour substance. Histologically, basaloid basophilic cells were predominant and mixed with ghost cells and foci of giant multinucleate cells, verifying diagnosis of a pilomatrixoma.

Pilomatrixoma exhibits tendency towards mimicry of lesions such as epidermoid, sebaceous, dermoid cyst, pyogenic granuloma or even keratoacanthoma with a pre-operative detection rate as low as 11%. With a bimodal age distribution, arising in the first and sixth decades of life, this case highlights a need for a high degree of suspicion in young patients with careful clinical examination in order to aid diagnosis and prompt appropriate treatment.

161 Current Practice of Antibiotic Prescription in Acute Uncomplicated Diverticulitis

Aim

To review the current antibiotic prescribing practice for patients with acute uncomplicated diverticulitis against the NICE guidelines November 2019, to avoid unnecessary/overuse of antibiotics.

Method

A retrospective review of patients presenting with lower abdominal pain between 1/11/2019 -31/1/2020. All patients with suspected diverticulitis were included. Patients who were subsequently diagnosed with complicated diverticulitis/alternate diagnosis were excluded from the analysis.

Results

22/27 (81.5%) of the patients were admitted. 26 out of 27 (96.3%) patients with acute uncomplicated diverticulitis were administered antibiotics. Antibiotics were indicated as per NICE guidelines in 17 patients (62.97%) and not indicated in 9 patients (33.34%). Admission was not indicated in 20 patients (90.91%) according to NICE guidelines.

Conclusions

Our adherence to NICE guidelines is 66.67% in terms of antibiotic administration, however the drug and duration of antibiotic administration needs to be reviewed.

NICE guidelines recommend that acute uncomplicated diverticulitis can be managed as an outpatient. Antibiotics should be administered only if patient is systemically unwell, is immunosupressed or has significant co morbidities

Branching Fraction Measurements of the Rare B_{s}^{0}→ϕμ^{+}μ^{-} and B_{s}^{0}→f_{2}^{'}(1525)μ^{+}μ^{-} Decays

The branching fraction of the rare B_{s}^{0}→ϕμ^{+}μ^{-} decay is measured using data collected by the LHCb experiment at center-of-mass energies of 7, 8, and 13 TeV, corresponding to integrated luminosities of 1, 2, and 6  fb^{-1}, respectively. The branching fraction is reported in intervals of q^{2}, the square of the dimuon invariant mass. In the q^{2} region between 1.1 and 6.0  GeV^{2}/c^{4}, the measurement is found to lie 3.6 standard deviations below a standard model prediction based on a combination of light cone sum rule and lattice QCD calculations. In addition, the first observation of the rare B_{s}^{0}→f_{2}^{'}(1525)μ^{+}μ^{-} decay is reported with a statistical significance of 9 standard deviations and its branching fraction is determined.

Observation of the Mass Difference between Neutral Charm-Meson Eigenstates

A measurement of mixing and CP violation in neutral charm mesons is performed using data reconstructed in proton-proton collisions collected by the LHCb experiment from 2016 to 2018, corresponding to an integrated luminosity of 5.4  fb^{-1}. A total of 30.6 million D^{0}→K_{S}^{0}π^{+}π^{-} decays are analyzed using a method optimized for the measurement of the mass difference between neutral charm-meson eigenstates. Allowing for CP violation in mixing and in the interference between mixing and decay, the mass and decay-width differences are measured to be x_{CP}=[3.97±0.46(stat)±0.29(syst)]×10^{-3} and y_{CP}=[4.59±1.20(stat)±0.85(syst)]×10^{-3}, respectively. The CP-violating parameters are measured as Δx=[-0.27±0.18(stat)±0.01(syst)]×10^{-3} and Δy=[0.20±0.36(stat)±0.13(syst)]×10^{-3}. This is the first observation of a nonzero mass difference in the D^{0} meson system, with a significance exceeding seven standard deviations. The data are consistent with CP symmetry and improve existing constraints on the associated parameters.

Current nutritional status of mothers and children in Al Ain, United Arab Emirates

Forty-six mothers and children from the United Arab Emirates participated in a pilot study to determine possible micronutrient deficiencies in the country. Thirty-five per cent [35%] of the children and 21% of the mothers had low serum ferritin levels, while 30% of the mothers had low serum 25-hydroxyvitamin D with 28% of mothers having a low serum folate status. These deficiencies are widespread in the nationals of the United Arab Emirates. In view of the increasing importance of intrauterine and early infant nutrition, further investigation and a national study seem warranted

Feto-maternal and renal outcomes of nephrotic syndrome in pregnancy

Proteinuria can range from subnephrotic to nephrotic amounts during pregnancy, though nephrotic syndrome (NS) is rare (0.012%-0.025%). Without a renal biopsy, this distinction may be difficult at times. The objective of our study was assessing about renal and feto-maternal outcomes of these patients. This study was done in a tertiary-care hospital in north India from 2010 to 2019. We included all pregnant women with nephrotic-range proteinuria, with no signs or symptoms suggestive of pre-eclampsia. We studied their treatment modalities, renal, maternal, and fetal outcomes. Eighteen eligible pregnant women diagnosed with NS with no features suggestive of pre-eclampsia or associated comorbidities were included. The gestational age of presentation was 23.2 ± 1.36 weeks. The average proteinuria was 4.38 ± 0.76 g/day. The patients were managed conservatively without kidney biopsy. About 16.7% of pregnancies had worsening of hypertension and acute kidney injury which recovered after delivery. Anasarca was troublesome for four patients requiring fresh-frozen plasma infusion. All were managed conservatively; however, five patients were started on empirical immunosuppression, all five with steroids, while two required the addition of calcineurin inhibitors as well. All had live births, but 25.7% each had preterm and intrauterine growth restriction while one required neonatal intensive care unit admission. The degree of proteinuria had an impact on maternal and fetal outcomes, especially on risk to pre-eclampsia. NS during pregnancy needs evaluation and counseling. Majority of them can be managed conservatively yet specific therapies can safely be tried among symptomatic ones. Despite good outcomes, a sizeable risk to maternal and fetal complications can occur.

Observation of New Resonances Decaying to J/ψK^{+} and J/ψϕ

The first observation of exotic states with a new quark content cc[over ¯]us[over ¯] decaying to the J/ψK^{+} final state is reported with high significance from an amplitude analysis of the B^{+}→J/ψϕK^{+} decay. The analysis is carried out using proton-proton collision data corresponding to a total integrated luminosity of 9  fb^{-1} collected by the LHCb experiment at center-of-mass energies of 7, 8, and 13 TeV. The most significant state, Z_{cs}(4000)^{+}, has a mass of 4003±6_{-14}^{+4}  MeV, a width of 131±15±26  MeV, and spin parity J^{P}=1^{+}, where the quoted uncertainties are statistical and systematic, respectively. A new 1^{+}  X(4685) state decaying to the J/ψϕ final state is also observed with high significance. In addition, the four previously reported J/ψϕ states are confirmed and two more exotic states, Z_{cs}(4220)^{+} and X(4630), are observed with significance exceeding 5 standard deviations.

Pharmacist-led medicines optimisation clinic for implantable cardiac device patients

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cardiac implantable electronic devices (CIED) enhance detection of atrial fibrillation (AF), providing a comprehensive measure of AF burden.  Patients with device-detected AF are usually referred for anticoagulation to their local anticoagulation clinic or General Practitioner (GP), which often delays time to initiation, potentially increasing the risk of stroke.  In addition, AF is associated with increased risk of cardiovascular disease and mortality.  Optimising blood pressure, cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To develop and evaluate an innovative pathway to allow Specialist Cardiac Pharmacists to promptly assess and initiate anticoagulation in patients with device-detected AF, and additionally address risk factors for prevention of cardiovascular disease.

Methods

As part of a quality improvement initiative, a pathway was developed where patients with AF identified on CIED who require anticoagulation are referred for assessment and management to a pharmacist-led optimisation clinic.  Specialist Cardiac Pharmacists contact patients within 5 days of referral to discuss and initiate or optimise treatment for AF, blood pressure, cholesterol and lifestyle choices.  Patients deemed inappropriate for anticoagulation were referred back to the medical team for further assessment.  All patients received a follow-up telephone consultation at 4-6 weeks to assess tolerability, adherence and response to treatment.

Results

Between September 2020 and February 2021, 22 patients were referred to the optimisation clinic. Mean age was 74.32 +/- 12.34 years and 77% were men.  Mean CHA2DS2VASc was 3.4 +/- 0.8 and mean HASBLED was 1.2 +/- 0.6. The average time from referral to anticoagulation was 3 days compared to 4 weeks prior to implementation of the pathway. All patients were assessed and appropriately anticoagulated, whereas approximately 15% of patients were still not anticoagulated at 3 months prior to implementation of the pathway despite referral to their local clinic. All patients had their blood pressure and cholesterol reviewed, which were optimised in 23% and 41% of patients respectively.  All patients confirmed adherence and suffered no adverse effects on follow-up.

Conclusion(s): We report the safe and successful implementation of a pharmacist-led medicines optimisation clinic.  This has significantly reduced time to anticoagulation without compromising safety, as well as assuring all patients are appropriately anticoagulated.  In addition, over half of patients required blood pressure and/or cholesterol optimisation to reduce the risk of cardiovascular disease, a service not previously provided for this cohort of patients.