Digital health to support primary care provision during a global pandemic

The urgency of the COVID-19 pandemic in Australia has seen the implementation of digital health technologies to support continuity of high-quality primary care provision. Digital health innovation has been used to operationalise the nation's pandemic preparedness principles by reducing risk of infection to both healthcare workers and at-risk patients, sustaining care for chronic and acute health conditions, and supporting the mental health of the population. In this perspective piece, we document the Australian Federal government's digital health response to ensure the ongoing delivery of high-quality primary care. This includes the implementation of telehealth, point-of-care testing, electronic records and e-prescriptions, national primary care data collection and analysis, and digital communication. Digital health has been a critical element of the pandemic response and paves the way for future primary care provision during disasters and emergencies. Further research is needed to capture the effectiveness, feasibility and acceptability of these innovations for both patients and primary care practitioners.

Epithelial Abnormalities in the Small Intestine of Zambian Children With Stunting

Background

Environmental enteropathy (EE) contributes to impaired linear growth (stunting), in millions of children worldwide. We have previously reported that confocal laser endomicroscopy (CLE) shows fluorescein leaking from blood to gut lumen in vivo in adults and children with EE. We set out to identify epithelial lesions which might explain this phenomenon in Zambian children with stunting non-responsive to nutritional support.

Methods

We performed confocal laser endomicroscopy (CLE) in 75 children and collected intestinal biopsies for histology in 91 children. CLE videos were evaluated, employing the Watson score to determine severity of leakiness. Morphometry was carried out on well-orientated mucosa and 3 biopsies were examined by electron microscopy.

Results

Confocal laser endomicroscopy demonstrated substantial leakage from circulation to gut lumen in 73 (97%) children. Histology consistently showed characteristic changes of EE: villus blunting, lamina propria and epithelial inflammation, and depletion of secretory cells (Paneth cells and goblet cells). Epithelial abnormalities included marked variability in epithelial height, disorganised and shortened microvilli, dilated intercellular spaces, pseudostratification, formation of synechiae between epithelium on adjacent villi, crypt destruction, and abundant destructive lesions which may correspond to the microerosions identified on CLE.

Conclusion

Epithelial abnormalities were almost universal in Zambian children with non-responsive stunting, including epithelial microerosions, cell-cell adhesion anomalies, and defects in secretory cells which may all contribute to impairment of mucosal barrier function and microbial translocation.

Phenotypical variability of the internal acoustic canal in the middle cranial fossa surgery

Introduction: The wide range of anatomical variability of the structures of the middle cranial fossa and the lack of reliable surgical landmarks contribute to a high level of complications in the surgical treatment of vestibular schwannomas. We hypothesized that the cranial phenotype influences the shape of the middle cranial fossa, the orientation of the pyramid of the temporal bone, and the relative topography of the internal acoustic canal. Materials and Methods: The skull base structures were studied on 54 embalmed cadavers and 60 MR images of the head and neck by photo modeling, dissection, and 3D analysis techniques. By the value of the cranial index, all specimens were subdivided into dolichocephalic, mesocephalic, and brachycephalic groups for comparison of variables. Results: The length of the superior border of the temporal pyramid, the apex to squama distance, and the width of the middle cranial fossa all peaked in the brachycephalic group. The value of the angle between the superior border of the pyramid and the axis of the acoustic canal varied from 33 to 58 º; it peaked in the dolichocephalic group and showed its smaller value in the brachycephalic one. The pyramid to squama angle had reversed distribution and dominated in the brachycephalic group. Conclusions: The cranial phenotype influences the shape of the middle cranial fossa, temporal pyramid, and internal acoustic canal. Presented in this paper data help specialists operating on the vestibular schwannoma to localize the internal acoustic canal based on the individual shape of a skull.

Radium-223 in the Treatment of Metastatic Castrate-Resistant Prostate Cancer

Background Radium 223 (Ra-223) has been successfully utilised for the treatment of men with metastatic castrate resistant prostate cancer (mCRPC). To date, no real world outcomes from its use in the Irish population have been described. Methods All men referred to our institution for Ra-223 from September 2016 to March 2019 were included. Patient demographics, treatments received, toxicities and outcomes were recorded. Overall survival (OS) and progression free survival (PFS) were analysed using the Kaplan-Meier method. Results Complete data was available for 54 men. Median age was 75 years (range 61-86 years). The median number of prior systemic treatments for mCRPC was 2 (range 0-4). Median ECOG performance status was 1 at the start of treatment and 2 at completion. The median number of Ra-223 cycles received was 4 with 37%(n=20) completing all 6 planned cycles. The most common treatment-related toxicity was fatigue seen in 52% of patients ( n=28). Improved pain scores were documented in 76% of men requiring opioid analgesia at the start of treatment. The median OS was 7 months. A good ECOG performance status, fewer than 6 bone metastases, normal alkaline phosphatase level at start of treatment and chemotherapy naivety were associated with improved OS. Conclusions Ra-223 is a moderately well tolerated palliative treatment amongst Irish men with mCRPC.

Reduced Fractional Absorption of Zinc in Children With Environmental Enteropathy in Zambia

OBJECTIVES

We measured fractional absorption of zinc (FAZ) in children with environmental enteropathy (EE) and carried out transcriptomic analysis of biopsies from these children in order to compare FAZ to histology of intestinal biopsies, expression of zinc transporter genes, and biomarkers of enteropathy.

METHODS

Fractional absorption of a standardized aqueous dose of zinc was measured by a dual isotope ratio technique in a cohort of children ages between 9 and 24 months in Lusaka, Zambia, who all had non-responsive stunting. Gene expression analysis was carried out on biopsies through RNA sequencing using an Illumina HiSeq2000 platform.

RESULTS

All 33 children had histological features of environmental enteropathy and plasma zinc concentrations below the lower limit of normal. Measured FAZ ranged from 0.18 to 0.93; all values >0.55 were observed in girls. FAZ was negatively correlated with faecal myeloperoxidase (MPO) (ρ = -0.51, n = 17; P = 0.04) and faecal calprotectin (ρ = -0.50, n = 16; P = 0.05), but not blood biomarkers. Of 41 genes with known roles in zinc metabolism, only three metallothionein genes were significantly correlated with FAZ.

CONCLUSIONS

Zinc homeostasis is impaired in children with environmental enteropathy, and was inversely correlated with mucosal inflammation. Reduced FAZ without specific changes in expression of most zinc transporter genes could be explained by reduced absorptive surface area due to villus/microvillus atrophy.

Evaluation of the association between gastric cancer and plasma selenium in Zambian adults: a case–control study

There is some evidence that Selenium (Se) is protective against gastric carcinogenesis, but these data are inconsistent. With a predicted increase in gastric cancer cases in Africa over the next 20 years, there is an urgent need to identify strategies that could be employed to prevent the surge. The objective of our study was to investigate the association between gastric cancer and plasma Se levels in Zambian adults. Our method used a case–control study with cases having either confirmed gastric cancer or premalignancies and controls having none. In addition, we measured antibodies against Helicobacter pylori and human immunodeficiency virus. Data were analysed with Stata 15 software using standard statistical methods. Using a normal reference range for Se of 0.9–1.9 μmol/L, 140/159 (88%) study participants had Se deficiency. Plasma Se levels were similar in all the three groups; 0.33 (interquartile range (IQR) 0.14–0.64) μmol/L for patients with gastric cancer, 0.38 (IQR 0.21–0.60) μmol/L for premalignant lesions and 0.28 (IQR 0.14–0.64) μmol/L in controls, (p-values = 0.35 and 0.34, respectively). In conclusion, we found no association between plasma Se levels and gastric cancer or premalignant lesions among adult Zambian adults.

Escherichia coli alanyl-tRNA synthetase maintains proofreading activity and translational accuracy under oxidative stress

Aminoacyl-tRNA synthetases (aaRSs) are enzymes that synthesize aminoacyl-tRNAs to facilitate translation of the genetic code. Quality control by aaRS proofreading and other mechanisms maintains translational accuracy, which promotes cellular viability. Systematic disruption of proofreading, as recently demonstrated for alanyl-tRNA synthetase (AlaRS), leads to dysregulation of the proteome and reduced viability. Recent studies showed that environmental challenges such as exposure to reactive oxygen species can also alter aaRS synthetic and proofreading functions, prompting us to investigate if oxidation might positively or negatively affect AlaRS activity. We found that while oxidation leads to modification of several residues in Escherichia coli AlaRS, unlike in other aaRSs, this does not affect proofreading activity against the noncognate substrates serine and glycine and only results in a 1.6-fold decrease in efficiency of cognate Ala-tRNA^Ala formation. Mass spectrometry analysis of oxidized AlaRS revealed that the critical proofreading residue in the editing site, Cys666, and three methionine residues (M217 in the active site, M658 in the editing site, and M785 in the C-Ala domain) were modified to cysteine sulfenic acid and methionine sulfoxide, respectively. Alanine scanning mutagenesis showed that none of the identified residues were solely responsible for the change in cognate tRNA^Ala aminoacylation observed under oxidative stress, suggesting that these residues may act as reactive oxygen species “sinks” to protect catalytically critical sites from oxidative damage. Combined, our results indicate that E. coli AlaRS proofreading is resistant to oxidative damage, providing an important mechanism of stress resistance that helps to maintain proteome integrity and cellular viability.

Waxing and Waning Neuroimaging Abnormalities in Langerhans Cell Histiocytosis

Langerhans cell histiocytosis (LCH) is a rare disease in adults characterized by proliferation of CD1a+/CD207+ and S100 myeloid dendritic cells, forming granulomas.1 An inflammatory exudate is often found with “bean-shaped” nucleated histiocytes. We report a patient with multisystem (liver, lung and brain) LCH in whom neuroimaging abnormalities accumulated and partially regressed prior to definitive treatment.

Population level physical activity before and during the first national COVID-19 lockdown: A nationally representative repeat cross-sectional study of 5 years of Active Lives data in England

BACKGROUND

To limit the spread of COVID-19 in March 2020, the population of England was instructed to stay home, leaving only for essential shopping, health-care, work, or exercise. The impact on population activity behaviours is not clear. We describe changes in duration and types of activity undertaken by adults ≥16 years in England between March and May 2016-19 and 2020, by socio-demographic strata.

METHODS

Using nationally representative data collected between November 2015 and May 2020 by the Sport England Active Lives Surveys (n=726,257) we assessed trends in amount and type of non-occupational moderate-to-vigorous physical activity. Using data from n=74,430 mid-April to mid-May respondents, we then estimated the odds ratios of reporting any activity in the four-week recall period in 2020 compared to 2016-19. Gamma regressions estimated the mean ratios (MR) of duration amongst those reporting any activity in 2020 compared to 2016-19.

FINDINGS

Population activity declined substantially after the restrictions were introduced. Compared to 2016-19 levels, the odds of reporting any activity in 2020 were 30% lower (95% confidence interval (CI) 26-34%). The largest declines were amongst non-white ethnicities, the youngest and oldest age groups, and the unemployed; no socio-demographic subgroup had higher odds. Amongst those undertaking activity, weekly duration was similar in the two periods (MR 0.99, 95%CI (0.96-1.01%)). The odds of participating in walking for leisure and gardening were 11% (6-16%) and 15% (9-21%) higher, respectively, whereas the odds for team and racket sport and walking for travel participation were 76% (73-79%) and 66% (64-68%) lower, respectively.

INTERPRETATION

Restrictions introduced in Spring 2020 likely reduced physical activity levels in England. The magnitude of the declines were not uniform by demographic groups or by activity type, which future policies should consider.

FUNDING

TS, KW, SJS, and SB are supported by UK Medical Research Council [grant numbers MC_UU_00006/4 and MC_UU_12015/3] and SB is supported by the NIHR Biomedical Research Centre in Cambridge (IS-BRC-1215-20014).

Public attitudes to, and perceived impacts of 20mph (32km/h) speed limits in Edinburgh: an exploratory study using the Speed Limits Perceptions Survey (SLiPS)

Between 2016 and 2018 a policy was implemented to increase the proportion of 20mph (32 km/h) streets in Edinburgh, UK from approximately 50% to 80%, providing the opportunity to evaluate how behaviour and public perceptions change over time. This is important as negative public responses have been reported to limit the implementation of transport policies and may reduce the effectiveness of the policy. The Speed Limits Perception Survey (SLiPS) was developed to assess changes in public perceptions from baseline to 6 and 12 months post-implementation. We collected 3,485 individual responses to the survey, 64.6% (n=2,253) of which included complete perceptions data. Using exploratory factor analysis, the following perception factors were identified: i) Detraction and resistance, ii) Support, iii) Rule following, iv) Child safety, and v) Walking safety. Following the 20mph implementation at 6-12 months: Support (ii) and Rule following (iii) had increased; Detraction and resistance (i) had decreased; and Child safety (iv) and Walking safety (v) had not changed significantly. These findings indicate that the public in Edinburgh became more positive towards the policy once it was implemented. However, more extensive policy or ongoing communication of the safety benefits of 20mph limits are needed to increase perceptions of safety that might lead to increased walking and cycling. Future research should aim to understand how those implementing speed limit interventions can positively influence public perceptions and how public perceptions about speed limits influence behaviour.

Evaluating the citywide Edinburgh 20mph speed limit intervention effects on traffic speed and volume: A pre-post observational evaluation

OBJECTIVES

Traffic speed is important to public health as it is a major contributory factor to collision risk and casualty severity. 20mph (32km/h) speed limit interventions are an increasingly common approach to address this transport and health challenge, but a more developed evidence base is needed to understand their effects. This study describes the changes in traffic speed and traffic volume in the City of Edinburgh, pre- and 12 months post-implementation of phased city-wide 20mph speed limits from 2016-2018.

METHODS

The City of Edinburgh Council collected speed and volume data across one full week (24 hours a day) pre- and post-20mph speed limits for 66 streets. The pre- and post-speed limit intervention data were compared using measures of central tendency, dispersion, and basic t-tests. The changes were assessed at different aggregations and evaluated for statistical significance (alpha = 0.05). A mixed effects model was used to model speed reduction, in the presence of key variables such as baseline traffic speed and time of day.

RESULTS

City-wide, a statistically significant reduction in mean speed of 1.34mph (95% CI 0.95 to 1.72) was observed at 12 months post-implementation, representing a 5.7% reduction. Reductions in speed were observed throughout the day and across the week, and larger reductions in speed were observed on roads with higher initial speeds. Mean 7-day volume of traffic was found to be lower by 86 vehicles (95% CI: -112 to 286) representing a reduction of 2.4% across the city of Edinburgh (p = 0.39) but with the direction of effect uncertain.

CONCLUSIONS

The implementation of the city-wide 20mph speed limit intervention was associated with meaningful reductions in traffic speeds but not volume. The reduction observed in road traffic speed may act as a mechanism to lessen the frequency and severity of collisions and casualties, increase road safety, and improve liveability.

The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC): International consensus statement and user guide

Effective physical activity messaging plays an important role in the pathway towards changing physical activity behaviour at a population level. The Physical Activity Messaging Framework (PAMF) and Checklist (PAMC) are outputs from a recent modified Delphi study. This sought consensus from an international expert panel on how to aid the creation and evaluation of physical activity messages. In this paper, we (1) present an overview of the various concepts within the PAMF and PAMC, (2) discuss in detail how the PAMF and PAMC can be used to create physical activity messages, plan evaluation of messages, and aid understanding and categorisation of existing messages, and (3) highlight areas for future development and research. If adopted, we propose that the PAMF and PAMC could improve physical activity messaging practice by encouraging evidence-based and target population-focused messages with clearly stated aims and consideration of potential working pathways. They could also enhance the physical activity messaging research base by harmonising key messaging terminologies, improving quality of reporting, and aiding collation and synthesis of the evidence.

P-P11 A tumour responsive, oxygen-generating nanoparticle to combat hypoxia in pancreatic tumours

Background

Pancreatic cancer remains a significant therapeutic challenge and its poor prognosis has remained relatively unchanged for the past 40 years.    Pancreatic tumours are highly desmoplastic and impenetrable lesions in which both gas and mass transfer is severely compromised.   This leads to the development of hypoxia within the tumour and this compromises therapeutic approaches that rely on cytotoxic reactive oxygen species, e.g. photodynamic therapy, sonodynamic therapy and radiotherapy.     Hypoxia also results in a relatively low pH within the tumour microenvironment.  Here we describe a pH sensitive nanoparticle that can generate oxygen in the tumour and enhance ROS generating therapeutic approaches.

Methods

CaO2 NPs were generated by exposing to low frequency ultrasound and subsequently coated using a polymethacrylate polymer that becomes soluble at pH 6.4.   For some studies, the sonosensitiser, Rose Bengal was attached to the particles.   Oxygen generation in tumours (BxPC3) was demonstrated by inserting a dissolved oxygen probe into tumours following IV administration of particles.  Particles were also employed together with photodynamic therapy (PDT) and sonodynamic therapy (SDT) using human xenograft and syngeneic pancreatic tumour models.  In some cases, tumour tissues were recovered and analysed for tumour infiltrating immune cells using flow cytometry.

Results

Conclusions

Coating CaO2 nanoparticles with a pH sensitive polymer provides in situ oxygen generation in tumours. Transient provision of oxygen enhances therapies that depend on the generation of cytotoxic reactive oxygen species. When used with SDT, and using a bilateral syngeneic pancreatic tumour model, a powerful abscopal effect was observed and this was shown to be immune-mediated. The above data suggest that the particles may be exploited to enhance other therapies that depend on the generation of ROS, e.g. radiotherapy, and further suggest that the approach can be used to treat either local or disseminated forms of pancreatic cancer.

840. Clinical Characteristics of Patients Living with HIV Hospitalized for COVID-19

Background

Limited data exists regarding the impact of coronavirus disease 2019 (COVID-19) on people living with human immunodeficiency virus (PLWH). The purpose of the study was to compare the clinical outcomes of patients hospitalized with COVID-19 and HIV versus those without HIV.

Methods

This was a retrospective, cohort study of adult patients admitted with confirmed COVID-19 from March 1^st to May 30^th 2020 at an urban hospital in New York City. Data collected included demographics, past medical history, HIV status, baseline laboratory values, treatment and outcomes such as length of stay, mechanical ventilation, patient disposition at discharge, and in-hospital mortality. Fisher’s exact test was used to compare categorical values and a t-test was used to compare continuous values.

Results

Out of 983 patients, 6.9% were PLWH and 93.1% were HIV-negative. The average age in both groups was 61 vs. 62 years, respectively. There were more male patients in the PLWH than the non-HIV group (76.8% vs. 58.6%). Majority of PLWH were Black (49.3%). Forty-seven percent of PLWH were mechanically ventilated versus 33.3% of the non-HIV group. The most common comorbidity in both groups was hypertension (82.4% vs. 72.6%). When compared to HIV-negative patients, PLWH had a higher rate of kidney disease (72.1% vs. 53.6%, p=0.0086), chronic obstructive pulmonary disease (41.2% vs. 14.5%, p=0.0001), liver disease (45.6% vs. 11.5%, p=0.0001) and current smoking (14.3% vs. 5.8%, p=0.0103). In PLWH, 70.6% of patients were on an integrase-based regimen. Fifty-three percent of PLWH had a CD4 count of > 200 cells/mm³ and 35.3% had an undetectable viral load (< 20 copies/mL). Unadjusted hospital mortality was 51.4% in PLWH and 36.2% in the non-HIV cohort (p=0.0089). The average length of hospital stay was 9.1 days vs. 8.4 days in PLWH versus the non-HIV group (p=0.4493). More patients were discharged to a nursing home in the non-HIV group vs. PLWH (37.8% vs. 14.3%, p=0.0001).

Conclusion

Hospitalized patients with COVID-19 and HIV had a higher in-hospital mortality compared to those without HIV during the first COVID wave in New York City.

Disclosures

All Authors: No reported disclosures

Feasibility of early waking cardiac arrest patients whilst receiving therapeutic hypothermia: The therapeutic hypothermia and early waking (THAW) trial

AIM

To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM).

METHODS

This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment.

RESULTS

50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU) <48 h after admission with a mean ICU length of stay 1.8 ± 0.4 days. Twenty-eight patients (56%) were discharged from the ICU with a modified Rankin Score of 0-2. The overall intra-hospital mortality was 50% (n = 25).

CONCLUSIONS

It is safe and feasible to wake selected comatose OHCA patients at 12 h, allowing for earlier positive neuro-prognostication and reduced ICU stay.

Gastrointestinal endoscopy capacity in Eastern Africa

Background and study aims  Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity. Patients and methods  In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020. Results  Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services. Conclusions  Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.

Predicting Hospital Resource Use During COVID-19 Surges: A Simple but Flexible Discretely Integrated Condition Event Simulation of Individual Patient-Hospital Trajectories

OBJECTIVES

To assist with planning hospital resources, including critical care (CC) beds, for managing patients with COVID-19.

METHODS

An individual simulation was implemented in Microsoft Excel using a discretely integrated condition event simulation. Expected daily cases presented to the emergency department were modeled in terms of transitions to and from ward and CC and to discharge or death. The duration of stay in each location was selected from trajectory-specific distributions. Daily ward and CC bed occupancy and the number of discharges according to care needs were forecast for the period of interest. Face validity was ascertained by local experts and, for the case study, by comparing forecasts with actual data.

RESULTS

To illustrate the use of the model, a case study was developed for Guy's and St Thomas' Trust. They provided inputs for January 2020 to early April 2020, and local observed case numbers were fit to provide estimates of emergency department arrivals. A peak demand of 467 ward and 135 CC beds was forecast, with diminishing numbers through July. The model tended to predict higher occupancy in Level 1 than what was eventually observed, but the timing of peaks was quite close, especially for CC, where the model predicted at least 120 beds would be occupied from April 9, 2020, to April 17, 2020, compared with April 7, 2020, to April 19, 2020, in reality. The care needs on discharge varied greatly from day to day.

CONCLUSIONS

The DICE simulation of hospital trajectories of patients with COVID-19 provides forecasts of resources needed with only a few local inputs. This should help planners understand their expected resource needs.

Benefits outweigh the risks: a consensus statement on the risks of physical activity for people living with long-term conditions

Introduction

The benefits of physical activity for people living with long-term conditions (LTCs) are well established. However, the risks of physical activity are less well documented. The fear of exacerbating symptoms and causing adverse events is a persuasive barrier to physical activity in this population.

This work aimed to agree clear statements for use by healthcare professionals about medical risks of physical activity for people living with LTCs through expert consensus. These statements addressed the following questions: (1) Is increasing physical activity safe for people living with one or more LTC? (2) Are the symptoms and clinical syndromes associated with common LTCs aggravated in the short or long term by increasing physical activity levels? (3) What specific risks should healthcare professionals consider when advising symptomatic people with one or more LTCs to increase their physical activity levels?

Methods

Statements were developed in a multistage process, guided by the Appraisal of Guidelines for Research and Evaluation tool. A patient and clinician involvement process, a rapid literature review and a steering group workshop informed the development of draft symptom and syndrome-based statements. We then tested and refined the draft statements and supporting evidence using a three-stage modified online Delphi study, incorporating a multidisciplinary expert panel with a broad range of clinical specialties.

Results

Twenty-eight experts completed the Delphi process. All statements achieved consensus with a final agreement between 88.5%–96.5%. Five ‘impact statements’ conclude that (1) for people living with LTCs, the benefits of physical activity far outweigh the risks, (2) despite the risks being very low, perceived risk is high, (3) person-centred conversations are essential for addressing perceived risk, (4) everybody has their own starting point and (5) people should stop and seek medical attention if they experience a dramatic increase in symptoms. In addition, eight symptom/syndrome-based statements discuss specific risks for musculoskeletal pain, fatigue, shortness of breath, cardiac chest pain, palpitations, dysglycaemia, cognitive impairment and falls and frailty.

Conclusion

Clear, consistent messaging on risk across healthcare will improve people living with LTCs confidence to be physically active. Addressing the fear of adverse events on an individual level will help healthcare professionals affect meaningful behavioural change in day-to-day practice. Evidence does not support routine preparticipation medical clearance for people with stable LTCs if they build up gradually from their current level. The need for medical guidance, as opposed to clearance, should be determined by individuals with specific concerns about active symptoms. As part of a system-wide approach, consistent messaging from healthcare professionals around risk will also help reduce cross-sector barriers to engagement for this population.

Age-adjusted risk factors are independently associated with an increased risk of ischaemic stroke, transient ischaemic stroke and systemic embolism in the ETNA-AF-Europe registry

Background

Oral anticoagulation is highly effective in preventing ischaemic stroke in patients with atrial fibrillation, but 1–2% of the patients suffer an ischaemic stroke upon anticoagulation. Outcomes are further influenced by various factors, and recent research has focussed on identifying risk factors that could be helpful in predicting stroke outcomes in anticoagulated patients. This could further assist clinicians in timely identification and management of high-risk patients.

Purpose

The present analysis aims to assess the age-adjusted risk predictors of ischaemic stroke and systemic embolic events (SEE) (including transient ischaemic attack [TIA]) during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and stroke and SEE after adjusting for age, given that age is a well-known, strong predictor of stroke.

Results

A total of 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. The mean weight was 81.0±17.3 kg, estimated glomerular filtration rate was 74.4±30.5 ml/min/1.73m2 and males were 56.6%. The mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively.

Univariate analysis demonstrated that history of TIA at baseline was the strongest age-adjusted predictor of stroke and SEE (Wald Chi-square: 77.69; p&lt;0.0001) (Figure 1), followed by CHA2DS2-VASc score (41.09; p&lt;0.0001) (Figure 2), history of ischaemic stroke (29.47; p&lt;0.0001), history of any stroke (all strokes combined including stroke of unknown/unspecified type) (29.18; p&lt;0.0001), subjective frailty as assessed by physician (20.60; p&lt;0.0001), and HAS-BLED score (17.22; p&lt;0.0001).

Conclusion

History of TIA, CHA2DS2-VASc score, history of stroke, frailty and HAS-BLED score are independently associated with an increased age-adjusted risk of ischaemic stroke, TIA and SEE in anticoagulated patients with AF. These findings highlight the importance of optimising anticoagulation therapy in secondary prevention of TIA and in patients with high CHA2DS2-VASc scores, ensuring the correct use of NOACs - adherence and correct dosing - in this high-risk population. These findings also suggest that additional therapies could be needed to prevent stroke in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. History of TIA as a predictorFigure 2. CHA2DS2-VASc score as a predictor

Age-adjusted risk factors are independently associated with an increased risk of major bleeding during the two-year follow-up of the ETNA-AF-Europe registry

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are a preferred treatment option over warfarin for anticoagulation in patients with atrial fibrillation (AF). Management decisions for thromboprophylaxis in AF need to balance the risk of stroke against the risk of bleeding. Various patient characteristics have been identified as independent risk factors for bleeding. A substantial number of bleeding events might be prevented if independent predictors of bleeding were identified.

Purpose

The present analysis aims at assessing age-adjusted risk predictors of major bleeding during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and major bleeding after adjusting for age, given that age is a well-known, strong predictor of anticoagulation-related bleeding in patients with AF.

Results

Overall, 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. Mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively. 438 (3.3%) patients had a history of bleeding events at baseline, of which 138 (1.0%) had a history of major bleeding event.

Univariate analysis demonstrated that recalculated glomerular filtration rate (Cockcroft-Gault Equation) (GFR-CG) at baseline was the strongest age-adjusted predictor of major bleeding (Wald Chi-Square: 31.84; p&lt;0.0001) (Figures 1 and 2), followed by history of major or clinically relevant non-major (CRNM) bleeding (24.08; p&lt;0.0001), HAS-BLED score (21.10; p&lt;0.0001), history of heart failure (derived) (16.59; p&lt;0.0001), subjective frailty as assessed by physician (17.35; p=0.0002), history of major bleeding (14.14; p=0.0002), chronic obstructive pulmonary disease (COPD) (12.84; p=0.0003), CHA2DS2-VASc (12.14; p=0.0005), history of myocardial infarction (MI) (7.79; p=0.005), and left ventricular ejection fraction (LVEF) categorised by 40% (5.45; p=0.02).

Conclusion

Bleeding events on therapy with edoxaban can be predicted by quantifying kidney disease and capturing information on heart failure, frailty, prior bleeding, chronic obstructive lung disease and history of myocardial infarction. These data highlight the need for optimal management of anticoagulation therapy and close follow-up of patients with such risk profiles.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. GFR-CG as a predictor of major bleedingFigure 2. Predictors of major bleeding