73 Using the Gold Standards Framework to Identify Opportunities for Advance Care Planning

Introduction

Departmental discharge data (January 2017–January 2018) suggested a high number of “Day 1 Deaths” i.e. an individual who was readmitted 24 hours after discharge, and subsequently died during their readmission. We wondered if this was due to a lack of Advance Care Planning (ACP).

Methods

We undertook a retrospective case note audit of 50 cases from the “readmissions who died” (total 176/7421) subgroup, to understand whether or not they were predictably within the last days, weeks or months of life and whether there was ACP in place. We reviewed all Day 1 Deaths (16/50), and a random selection of cases across the Day 2–30 (34/50) data set.

We used the Gold Standards Framework (GSF) as a prognostic tool, by use of the intuitive “surprise question” (“would you be surprised if this person died within the next days, weeks, months?”) and the disease-specific Prognostic Indictors (PI).

Results

Using the GSF we (retrospectively) predicted death in 94% of the Day 1 deaths and 63% of the Day 2–30 deaths.

There was evidence of ACP in 32/50 patients (64%), predominantly in the form of a DNAR CPR (61%). There was very little evidence of other forms of ACP.

Readmissions were justified on the basis of a medical condition in 100% of cases; this was infective in 60% (30/50).

There were few interactions with secondary care in the 12 months prior to death (mode was 2 admissions in the month prior to death, 4 in the 12 months prior to death).

Conclusions

We must consider our discharge processes and medical decision making at the front door.

A Prognostic indicator Tool would be useful to focus medical decision making.

We must recognise infections as end stage disease in advanced ill health, including advanced frailty.

We need to consider how we facilitate meaningful involvement of older people in their medical care towards the end of life.

Seroprevalence and risk factors of Toxoplasma gondii infection in women with recurrent fetal loss from the province of Khyber Pakhtunkhwa, Pakistan

BACKGROUND

In women with a bad obstetric history (BOH), infection is an established cause of recurrent fetal loss. A common infecting agent is the protozoan parasite Toxoplasma gondii (T. gondii). The aim of this study was to measure the prevalence of toxoplasmosis in women with recurrent fetal loss from the Khyber Pakhtunkhwa province of Pakistan.

METHODS

The study included 360 females aged 16-40 years, of which 180 had a bad obstetric history (study group) and the other 180 had no such history (control group). Blood serum samples were tested for toxoplasma IgM antibodies by Enzyme Linked Immunosorbent Assay and for toxoplasma IgG antibodies using an Immunochromatographic technique.

RESULTS

The overall seroprevalence of toxoplasma infection in study group females was 40.6% and in control group females it was 7.2%. Specifically, IgM prevalence was 12.8% in the study group and 1.1% in the control group. IgG prevalence was 23.9% in the study group and 6.1% in the control group. IgM and IgG combined prevalence was 3.9% in the study group cases. There is a statistically significant association between BOH and seropositivity for T. gondii (p < 0.0001, Chi square test). Various risk factors associated with T. gondii seroprevalence in study and control groups were analyzed.

CONCLUSION

The seroprevalence of toxoplasmosis was significantly higher in women with a bad obstetric history compared to those with no such history. Associated risk factors had no significant effects on the results.

The effectiveness of Sufi music for mental health outcomes. A systematic review and meta-analysis of 21 randomised trials

BACKGROUND

There is some evidence that Sufi music therapy might improve physical and mental well-being; however, no systematic review or meta-analysis has pooled and critiqued the evidence. The aim of this systematic review was to evaluate the effects of Sufi music therapy on mental health outcomes.

METHODS

We searched Medline, PsycINFO, the Web of Science, Science Direct, PsycARTICLES, Cochrane Library, SCOPUS, CINAHL Plus, AMED, and ULAKBIM databases, and the reference lists of the studies found. Papers published in academic peer-reviewed journals were included, as well as from other sources such as chapters in edited books, the grey literature, or conference presentations. Articles published up to March 2020 in Turkish and English were included. Our primary outcome of interest was anxiety and secondary outcomes of interest were other mental health outcomes such as depression. To assess the methodological quality of the articles, the Cochrane Risk of Bias Tool was used. The quality of evidence was assessed using the GRADEpro GDT system.

RESULTS

This search yielded 21 clinical trials that were eligible for inclusion. A meta-analysis, using a random effects model, of 18 randomised controlled trials involving 1454 participants showed that Sufi music therapy with makams, compared with treatment as usual (TAU) or a no-music control group, reduced symptoms of anxiety in the short term in patients undergoing an operation or treatments such as chemotherapy or haemodialysis (standardised mean difference SMD= -1.15, 95 % CI, -1.64 to -0.65; very low-quality evidence). The evidence of Sufi music with makam's effect on anxiety is rated as very low. Qualitative synthesis of secondary outcomes revealed significant effects for depression, positive symptoms in schizophrenia, stress, which however were based on fewer studies. Trials were of moderate methodological quality, and there was significant heterogeneity across the studies.

CONCLUSION

Sufi music may reduce anxiety of patients undergoing medical procedures like haemodialysis, coronary artery surgery, angiography, colonoscopy, bone marrow aspiration and biopsy procedures. Evidence from single studies suggests effects on depression and stress as well. However, due to methodological limitations of the studies, further, higher quality studies are required in other cultures.

Trends in complications and mortality following catheter ablation of atrial fibrillation: results from 22,582 ablations in Australia and New Zealand from 2010 to 2015

Background

Recent studies from the United States report rising rates of in-hospital complications and mortality following catheter ablation of atrial fibrillation (AF) but whether such a trend is observed in other populations is uncertain.

Purpose

To examine the trends in complications and mortality following AF ablations up to 30 days after discharge in Australia and New Zealand (ANZ) using nationwide data.

Methods

All patients ≥18y undergoing catheter ablation of AF from 2010–2015 were identified using hospitalisation data from all public and most private hospitals in ANZ. The primary endpoint was one or more procedural complications during the hospital stay or within 30 days of discharge. The secondary endpoints were mortality and other specific complications. Unadjusted trend was evaluated using Cochran-Armitage test while that of complications, adjusting for differences in other characteristics, was evaluated using multivariate logistic regression with the year of ablation modelled as a continuous variable. Results are reported as odd ratios (OR) and 95% confidence intervals (CI).

Results

A total of 22,582 AF ablations were included (mean age 62.2±11.6y, 29.1% female, 94.4% elective procedures). The number of ablations increased by 26.4% during the study period (3,097 in 2010 to 3,915 in 2015). Rates of heart failure (8.98% to 10.09%, p for trend=0.010), diabetes (4.52% to 12.46%, p&lt;0.001), chronic kidney disease (2.36% to 4.29%, p&lt;0.001) significantly increased over time but that of hypertension decreased (15.27% to 12.29%, p&lt;0.001). The incidence of overall complications (6.55% in 2010 to 6.67% in 2015, OR 0.99, 95% CI 0.96–1.03) was unchanged during the study period (Figure 1A). When individual complications were considered, mortality rate was low with no statistically significant change with time (0.19% to 0.15%, OR 1.03, 95% CI 0.84–1.28) (Figure 1A) while the rate of acute kidney injury (0.23% to 0.51%, OR 1.17, 95% CI 1.02–1.34) increased and that of venous thromboembolism (0.16% to 0.0%, OR 0.71, 95% CI 0.54–0.94) decreased (Figure 1B). Though the incidence of any bleeding (4.49% to 3.98%, OR 0.97, 95% CI 0.93–1.01) was unchanged, that of major bleeding requiring blood transfusion (0.97% to 0.64%, OR 0.87, 95% CI 0.79–0.96) declined significantly (Figure 1B). No significant trend was observed in other complications or when in-hospital (5.13% to 5.21%, OR 1.00, 95% CI 0.97–1.04) and post-discharge (1.55% to 1.63%, OR 0.97, 95% CI 0.91–1.03) complications were separately evaluated.

Conclusions

Though more patients with heart failure, diabetes and chronic kidney disease underwent catheter ablation of AF over time in ANZ, the overall complication rate was unchanged with a significant decrease in the incidences of major bleeding and venous thromboembolism. However, rate of acute kidney injury nearly doubled, and this could be a potential target for efforts to further improve procedural safety.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The National Heart Foundation of Australia

Differences between public and private hospitals in complications following catheter ablation of atrial fibrillation: a cohort study in Australia

Background

Comparing outcomes of care between public and private hospitals is critical to inform patients and improve care quality.

Purpose

To compare complication rates following catheter ablation of atrial fibrillation (AF) up to 30-days post discharge between public and private hospitals.

Methods

We included patients ≥18 years who underwent AF ablation in the Australian states of New South Wales, Queensland, Victoria, and Western Australia from 2010–2015. The primary outcome was the occurrence of any complication up to 30-days after discharge. The association between provider type and the risk of complications was examined using logistic regression with inverse probability of treatment weighting (IPTW) propensity scores to account for differences in measured confounders. The minimum strength of association required for an unmeasured confounder to nullify any observed association was estimated using the E value.

Results

We identified 18,074 AF ablations during the study period (mean age 62.3±11.4y, 28.8% female, 78.4% performed in private hospitals). Patients ablated at public hospitals were younger (59.3 vs. 63.1y, p&lt;0.001) but had higher rates of heart failure (10.3% vs. 7.7%, p&lt;0.001), diabetes (10.9% vs. 7.9%, p&lt;0.001), chronic kidney disease (4.9% vs. 2.2%, p&lt;0.001), and chronic lung diseases (4.2% vs. 3.6%, p=0.046) than those at private hospitals. The unadjusted rate of complications was higher in publics hospitals compared with private ones (7.59% vs. 5.26%, p&lt;0.001). After IPTW, there was good covariate balance with a median standardised difference of 0.006 (range 0.0–0.032) and the adjusted difference in procedural complication rates between two sectors remained significant (OR=1.46, 95% CI 1.24–1.73). The difference was mainly driven by an elevated risk of complications requiring cardiac surgery (OR=3.85, 95% CI 1.35–10.98), acute kidney injury (OR=2.95, 95% CI 1.12–7.74), cardiorespiratory failure (OR=2.69, 95% CI 1.19–6.04), postprocedural infection (OR=2.50, 95% CI 1.28–4.86), and bleeding (OR=1.26, 95% CI 1.02–1.56) (Figure 1). The disparity in the complication rates persisted when in-hospital (OR=1.41, 95% CI 1.16–1.70) and post-discharge (OR=1.52, 95% CI 1.12–2.07) complications were analysed separately. The E value was 1.79, suggesting that the disparity might plausibly be explained by unmeasured confounders.

Conclusion

AF ablation at a public hospital was associated with a 46% higher risk of complications compared with ablation at a private hospital, mainly driven by a higher risk of complications requiring cardiac surgery, acute kidney injury, cardiorespiratory failure, infections, and bleeding. The disparity could be due to differences in care quality between two sectors or explained by unmeasured confounders such as higher procedural complexity in public hospitals.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The National Heart Foundation of Australia

Analysis of non-genetic and genetic influences underlying the growth of Kajli lambs

Data on 2931 Kajli lambs, born from 2007 to 2018, were used to quantify environmental and genetic effects on growth performance of Kajli sheep. Traits considered for evaluation were birth weight (BWT), 120-day adjusted weight (120DWT), 180-day adjusted weight (180DWT), 270-day adjusted weight (270DWT), and 365-day adjusted weight (365DWT). Fixed effects of year of birth, season of birth, sex, birth type, and dam age on these traits were evaluated using linear procedures of SAS, 9.1. Similarly, BWT, 120DWT, 180DWT, and 270DWT were used as fixed effects mixed model analyses. Variance components, heritability and breeding values were estimated by restricted maximum likelihood. The genetic trend for each trait was obtained by regression of the estimated breeding values (EBV) on year of birth. Analyses revealed substantial influence of birth year on all traits. Sex and birth type were the significant sources of variation for BWT and 120DWT. Season of birth did not influence birth weight meaningfully, but had a significant role in the expression of 120DWT, 180DWT, and 270DWT. Heritability estimates were generally low (0.003 ± 0.018 to 0.099 ± 0.067) for all traits. With the exception of the genetic correlation of 180DWT and 365DWT, the genetic correlations between trait were strong and positive. Only 365DWT had a positive genetic trend. Although the heritability estimates for almost all weight traits were low, high and positive genetic correlations between BWT and other weight traits suggest that selection based on BWT would result in the improvement of other weight traits as a correlated response.Keywords: bodyweight, breeding value, genetic correlation, sheep

Discontinuous Involvement of Spermatic Cord Soft Tissue in Testicular Germ Cell Tumors: A Multi-Institution Experience

Introduction/Objective

In the 8th Edition AJCC Cancer Staging Manual, discontinuous involvement of spermatic cord soft tissue (DISC) by testicular germ cell tumors (GCT) is regarded as metastatic deposit (pM1), placing the patient in clinical prognostic stage group (CPSG) III. We conducted a multi-institution study to corroborate or refute the current recommendations. Methods: Thirty-eight cases of GCT with spermatic cord involvement were collected from 13 institutions in Europe, Phillipines and America. Clinical and pathologic data was obtained.

Results

Tumors included 28 (73%) non-seminomatous and 10 (26%) seminomatous GCTs. Mean testicular tumor size was 6.6 cm (range 1.3-18). After review by an uropathologist, cases were classified as cord LVI [T2] (n=3), continuous cord involvement (CCI) [T3] (n=13), and DISC (n=22). Mean cord tumor size for DISC was 0.9 cm (range 0.1-4.5).

CPSG was available for 33 and follow-up (FU) for22 patients with a mean length of FU of 38 months (range 2-144). Seven (39%) DISC patients were CPSG II (regional LN metastases), and 11 (61%) CPSG III (distant metastases). On FU, 5 (45%) DISC patients had no evidence of disease (NED); 6 (55%) were alive with disease (AWD). Three (25%)

CCI patients were CPSG I (local disease), 6 (50%) CPSG II, and 3 (25%) CPSG III. On FU, 6 (60%) CCI patients were NED, 4 (40%) AWD. Cord LVI patients were one in each CPSG. One cord LVI patient was NED, the others were lost at FU. All DISC (100%) patients with available CPSG had advanced disease (CPSG II or III), compared to 75% of CCI, and 67% of cord LVI patients.

Conclusion

Although it did not reach statistical significance (p=0.054; Fisher’s exact test), DISC patients were more likely to have CPSG II and III compared to CCI patients. Our findings suggest a worse behavior in patients with DISC, supporting a higher pathologic stage than CCI.

Determination of the best non-linear function to describe the growth of Kajli sheep

The aim of the present study was to determine the best non-linear growth function to describe the growth of Kajli sheep. For this aim, the Brody, von Bertalanffy, Logistic, and Gompertz models were used to describe the sigmoidal relationship between bodyweight and age of the Kajli sheep. The records obtained from the Livestock Experiment Station, Khushab, were collected between 2007 and 2018. The records comprised 9864 age-weight observations (300 for male, 9564 for female, 7392 for single, 2388 for twin, and 84 for triplet lambs), which extended from birth to 12 months old. Candidate non-linear functions were fitted and the curve parameters were estimated by nlsfit (fit non-linear models) function in R statistical package, version 3.6.1. Goodness of fit criteria that were used to evaluate predictive performances of candidate models were adjusted coefficient of determination (R2adj), Akaike’s information criterion (AIC), Bayesian information criterion (BIC) and root means square error (RMSE). The Brody model was the best non-linear function that described the biological growth pattern of all, male, female, single, twin, and triplet lambs. Differences in curve parameter estimates between male and female suggested a definite pattern of sexual dimorphism. Moreover, a higher estimate of rate of maturity in female lambs reflects their early maturity compared with male Kajli lambs. Similarly, the single-born Kajli animals with highest maturity rate were maturing at an earlier age than twins and triplets. This is the first report on the non-linear pattern of visible changes in bodyweight of Kajli sheep from birth to 12 months old.Key words: age, bodyweight, growth curves, regression, sheep