Intrapericardial neuroendocrine tumour in a dog

An 11-year-old neutered male Border Terrier presented for pericardiectomy after a nine-month history of tricavitary effusion, dyspnoea and lethargy. Transthoracic echocardiography revealed a fluid-filled structure at the heart base, starting at the mid-right ventricle and extending to the middle of the right atrium. Almost complete compression of the right atrium and the cranial vena cava was noted. Thoracic computed tomography revealed a heterogeneously enhancing and poorly marginated mass within the cranial aspect of the pericardium. A median sternotomy and subtotal pericardiectomy were performed. A non-distinct fluid-filled structure within the pericardium adhered to the epicardium was visualised. The structure was removed via marsupialisation along with extirpation of enlarged sternal lymph nodes. Histopathological examination of the sternal lymph nodes revealed expansile, well-demarcated, unencapsulated nodules of neoplastic cells consistent with a neuroendocrine tumour suspected to be thyroid in origin. After surgery, intractable pleural effusion resulted in euthanasia. Intrapericardial ectopic thyroid tumours are rarely reported in animals. The location of the mass and unusual presentation may have made it challenging for echocardiography to identify this neoplasia. Thoracic computed tomography at an earlier stage may have identified the neoplasia and potentially allowed for surgical intervention.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Measurements of the Electroweak Diboson Production Cross Sections in Proton-Proton Collisions at sqrt[s]=5.02 TeV Using Leptonic Decays

The first measurements of diboson production cross sections in proton-proton interactions at a center-of-mass energy of 5.02 TeV are reported. They are based on data collected with the CMS detector at the LHC, corresponding to an integrated luminosity of 302  pb^{-1}. Events with two, three, or four charged light leptons (electrons or muons) in the final state are analyzed. The WW, WZ, and ZZ total cross sections are measured as σ_{WW}=37.0_{-5.2}^{+5.5}(stat)_{-2.6}^{+2.7}(syst)  pb, σ_{WZ}=6.4_{-2.1}^{+2.5}(stat)_{-0.3}^{+0.5}(syst)  pb, and σ_{ZZ}=5.3_{-2.1}^{+2.5}(stat)_{-0.4}^{+0.5}(syst)  pb. All measurements are in good agreement with theoretical calculations at combined next-to-next-to-leading order quantum chromodynamics and next-to-leading order electroweak accuracy.

Combined searches for the production of supersymmetric top quark partners in proton-proton collisions at s = 13 Te

A combination of searches for top squark pair production using proton-proton collision data at a center-of-mass energy of 13 Te at the CERN LHC, corresponding to an integrated luminosity of 137 fb - 1 collected by the CMS experiment, is presented. Signatures with at least 2 jets and large missing transverse momentum are categorized into events with 0, 1, or 2 leptons. New results for regions of parameter space where the kinematical properties of top squark pair production and top quark pair production are very similar are presented. Depending on the model, the combined result excludes a top squark mass up to 1325 Ge for a massless neutralino, and a neutralino mass up to 700 Ge for a top squark mass of 1150 Ge . Top squarks with masses from 145 to 295 Ge , for neutralino masses from 0 to 100 Ge , with a mass difference between the top squark and the neutralino in a window of 30 Ge around the mass of the top quark, are excluded for the first time with CMS data. The results of theses searches are also interpreted in an alternative signal model of dark matter production via a spin-0 mediator in association with a top quark pair. Upper limits are set on the cross section for mediator particle masses of up to 420 Ge .

Validation of an obstetric quality of recovery scoring tool (ObsQoR-11) after elective caesarean delivery in a developing country: a prospective observational study

BACKGROUND

The obstetric quality of recovery scoring tool (ObsQoR-11) was developed and validated in the United Kingdom for use after elective and emergency caesarean delivery. Quality of recovery scoring tools validated in one country may not be valid in other countries with significant cultural, socio-economic and linguistic variations. The aim of the current study was to validate a Hindi version of the ObsQoR-11.

METHODS

In this prospective observational study, 100 parturients who underwent elective caesarean delivery in a tertiary care obstetric referral university hospital in North India were asked to complete a Hindi version of the ObsQoR-11 scoring tool 24 h after surgery. The performance of the Hindi version of ObsQoR-11 was assessed using measures of validity, reliability, and feasibility.

RESULTS

The Hindi version of ObsQoR-11 correlated moderately with the global health visual analogue scale (r=0.45, 95% CI 0.27 to 0.59; P <0.0001) and discriminated well between good and poor recovery (mean (SD) score 84.6 (9.4) vs 75.0 (11.2); P <0.0001). The reliability and internal consistency were moderate (Cronbach's alpha=0.66; Spearman-Brown Prophesy Reliability estimate=0.57) with good repeatability (intraclass correlation coefficient 0.85, 95% CI 0.69 to 0.93; P <0.0001) and no floor or ceiling effects. All parturients completed the questionnaire (median (IQR) time of completion of 3 (1.5 - 5.5) min).

CONCLUSION

The Hindi version of the ObsQoR-11 questionnaire is a promising scoring tool to evaluate quality of recovery after elective caesarean delivery. Further research is needed to evaluate the Hindi tool in other institutions in India, as well as in other languages.

Role of oral flecainide in assessement of atrio-ventricular conduction in symptomatic bifascicular block

Background

Intravenous flecainide is used to stress Atrio-ventricular (AV) conduction in patients (pts) with a history of syncope & bifascicular (Bi-Fasc) block. Role of oral flecainide is unclear.

Objective

To assess effect of oral Flecainide on infra-Hisian AV conduction in patients with symptomatic Bi-Fasc block.

Methods

Pts presenting with syncope & Bi-Fasc block without advanced AVCD on ECG, 24 hr holter or treadmill exercise test were taken. Those with history suggestive of reflex syncope & positive tilt test were excluded. Remaining underwent electro-physiological (EP) study. Pts with HV interval &gt;100ms or intra/infra-Hisian block at rest or incremental pacing were subjected to PPI. Remaining received oral Flacanide 5 mg/kg (max 300 mg) & EP study was repeated after ½ hr, 1 hr, 2 hrs and 3 hrs. Primary end-point was HV ≥100ms or infra/intra-Hisian type IIB or III block.

Results

Of 41 pts enrolled for study, 28 patients (mean age 60.0 yrs, mean LVEF 60.7%) were eligible for EP Study. Basal PR interval was 185.8±47.4 ms & mean QRS width was 130.6±18.65 ms. On EP study, 4 (14.3%) with resting HV &gt;100 ms & 6 (21.4%) with HV &gt;100 ms on incremental pacing underwent PPI.

Out of remaining 18 pts who were given flecainide, 11 (66.1%) achieved primary endpoint (HV &gt;100 ms in 6, infra-hisian IIB in 2 and 2:1 block in 3 patients). At mean follow up of 6.5 months, 13 (59.1%) out of 22 with PPI had mean 59.1% VP & none of 6 remaining patients had any symptom.

Conclusion

Oral Flecainide significantly increases the diagnostic yield of EP study in patients with symptomatic bi-fasc block.

Funding Acknowledgement

Type of funding sources: None.

A randomised, controlled trial of meditation and yoga in permanent atrial fibrillation: the MAYA study

Background

The role of yoga in paroxysmal atrial fibrillation (AF) is known. But its role in permanent AF has not been studied.

Purpose

The objectives of our study are to evaluate the effects of yoga on symptoms, heart rate, quality of life, hospitalisations, medication adherence and echocardiographic parameters in permanent AF.

Methods

We conducted a single centre, randomised, participant blinded, parallel group, sham-controlled study between October 2019 and September 2020. We included patients aged 18–65 years with permanent AF due to any cause. Patients in New York Heart Association (NYHA) class≥3, modified European Heart Rhythm Association (mEHRA) class ≥3 and left ventricular ejection fraction (LVEF)&lt;30% were excluded. Total of 84 patients underwent randomisation into two groups of 42 each. None of the participants had prior knowledge or contraindications to yoga. Subjects in yoga arm underwent supervised and self-performed yoga sessions consisting of various asanas, pranayamas and dhyana, while those in the sham arm underwent supervised and self-performed joint exercises, each session lasting for 60 minutes/day for 6 days a week along with guideline directed medical therapy in both arms. The primary endpoints were improvement in NYHA class, mEHRA class, heart rate at rest and after 6 minute walk test, 6 minute walk distance, quality of life, medication adherence, hospitalisations, LVEF and left atrial volume index at 3 months. The secondary endpoints included the same parameters assessed at 1month. Quality of life was assessed by the short form (SF)-36 questionnaire which has eight domains. Scores for each domain range from 0 to 100, with a higher score defining a more favourable health state. All analyses were based on intention to treat principle.

Results

The groups were well-matched at baseline. The mean age of study participants was 50.62±12.97 years, 56% were women and the most common risk factor was rheumatic heart disease found in 47.6% of the cases. Four patients in the yoga group and 3 in the sham group were lost to follow up. There was significant improvement in various parameters in the yoga arm at 1 and 3 months. (Figures 1 and 2). Hospitalisation at 3 months was lower in the yoga arm (0.73±0.81) versus sham arm (1.13±0.93); p=0.044. Out of 38 patients in the yoga arm, 6 patients had improvement in the medication adherence compared to 9 patients (out of 39) in the sham arm at 3 months, p=0.419, OR (95% CI) = 0.62 (0.19–1.96). Higher the compliance to yoga, defined by the number of sessions per week, more was the improvement in various parameters. No harms were noted.

Conclusion

Among patients of permanent AF already on medical therapy, yoga significantly improves symptoms, heart rate, functional capacity, quality of life and hospitalisations when compared to a sham procedure. Larger, multicentre, double blinded studies are required to generalise the results, though participant blinding cannot be 100% assured.

Funding Acknowledgement

Type of funding sources: None.

Effect of thrombocytopenia in patients with infective endocarditis: an insight from the National Inpatient Sample database

Introduction

Infective endocarditis (IE) is one of the feared diseases in septic patients, and incidences are rising due to the intravenous drug abuse epidemic. Sepsis causes an escalation of the platelet destructions leading to thrombocytopenia (1). Few independent hospital-based studies have proposed increase mortality with thrombocytopenia in patients with IE (2–5). We aim to evaluate the significance of thrombocytopenia in IE subjects from the national inpatient sample (NIS) database.

Method

We analyzed the NIS database from Jan-2016 to Dec-2018 using Stata 16.0. NIS is the largest publicly available all-payer inpatient care database in the United States, containing data on more than seven million hospital stays per year. We identified patients with IE with or without thrombocytopenia using ICD-10 codes. The primary outcome of interest was in-hospital mortality comparison. We adjusted potential confounders (age, sex, diabetes, hypertension, etc.) with multivariate logistic regression analysis. Further analysis was done after balancing the population co-morbidity using a Greedy propensity match for accuracy.

Results

A total of 174,495 subjects were included in this study with a diagnosis of IE. Among these individuals, 33,285 patients had a concurrent diagnosis of thrombocytopenia. The mean ages were 53±19.5 years for the thrombocytopenia group and 55±19.8 years for others. Females were equally represented in both cohorts. There were 4,945 (14.86%) vs 2,835 (2.01%) mortalities reported in with and without thrombocytopenia group respectively. After propensity matching, there was a pronounced increase in mortality [Odds ratio (OR): 1.93 (1.72 – 2.15), p-value: &lt;0.001] in the group with thrombocytopenia comparing to others. Complications such as Major bleeding requiring blood transfusion [OR: 1.45 (1.35–1.57)], acute myocardial infarction [OR: 1.56 (1.35–1.70)], complete heart block [OR: 1.44 (1.16–1.53)], cardiac arrest [OR: 1.44 (1.25–1.72)], acute respiratory failure [OR: 1.51 (1.39–1.73)] and pressor support requirement [(OR: 1.73 (1.57–2.01)] were notably higher in the cohort of thrombocytopenia with statistically significant p-value (&lt;0.001). The difference in length of stay between both cohorts after propensity match wasn't statistically significant.

Conclusion

In conclusion, IE patients with thrombocytopenia have higher incidences of in-patient mortality and poor outcomes than cohort without thrombocytopenia. Some of the adverse consequences could be temporally explained by complications related to underlying thrombocytopenia. Further investigations are needed to delineate the outcome in this group of subjects.

Funding Acknowledgement

Type of funding sources: None.

Trends in the use of mechanical and bioprosthetic aortic valve replacement in the era of transcatheter aortic valve replacement

Background

The choice between a mechanical versus a bioprosthetic valve in aortic valve replacement (AVR) is based on life expectancy, bleeding risk and co-morbidities, since bioprosthetic AVR (bAVR) as compared to mechanical AVR (mAVR), are associated with a more rapid structural deterioration. However, refinements in bioprosthetic valves and the introduction of transcatheter aortic valve replacement (TAVR) (potential for valve-in-valve procedures), will most likely influence valve selection in the future. The impact of widespread transcatheter valve replacements, on the decision to use bAVR versus mAVR, in the contemporary era and subsequent outcomes remain to be determined.

Purpose

The goal of our study was to assess trends in utilization of bAVR and mAVR in the United States while, assessing in-hospital mortality over time.

Methods

The National Inpatient database (2009–18) was used to study trends in admissions for bAVR and mAVR and in-hospital mortality over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 700,896 inpatient visits for AVR with 70.1% (95% CI 69.2%-71.1%) and 29.9% (95% CI 28.9%-30.8%) visits for bAVR and mAVR, respectively. Those undergoing bAVR were significantly older, [bAVR (69.8 years) vs mAVR (62.7 years) p&lt;0.001]. Heart failure, cardiac arrhythmias, hypertension, diabetes with complications and renal failure were more common in those undergoing a bAVR. Through the course of the study period, the rates of mAVR decreased across all age groups (p trend &lt;0.001), including patients younger than 50 years (p trend &lt;0.001). Both crude (OR = 1.20 95% CI 1.13–1.27) and adjusted (OR = 1.34 95% CI 1.25–1.44) inpatient mortality was higher amongst mAVR recipients.

Conclusions

In the contemporary TAVR era, the utilization of mAVR has decreased across all age groups, including those younger than 50 years old. Although mAVR recipients were healthier with significantly less co-morbidities, inpatient mortality was higher after mAVR compared to bAVR. In addition to understanding the causes accounting for the higher mortality after mAVR, future research should focus on developing TAVR friendly bAVR; possibly enhancing our ability to perform percutaneous valve-in-valve procedures in the future.

Funding Acknowledgement

Type of funding sources: None.

Lifestyle intervention improves Left atrial strain in type 2 diabetes: results from the DIASTOLIC randomised trial

Introduction

Left atrial (LA) strain has been shown to be an independent predictor of cardiovascular events in many conditions and superior to conventional measures of LA function (LA volumes and emptying fraction). The effects of low-energy diet or exercise on cardiovascular function in younger adults with type 2 diabetes (DIASTOLIC) study has previously demonstrated an improvement in left ventricle peak early diastolic strain rate in response to aerobic exercise in patients with type-2 diabetes (T2D). However, the effect of lifestyle intervention on LA function, assessed by cardiac magnetic resonance (CMR) imaging, is unknown.

Methods

The DIASTOLIC study was a prospective, randomised, open-label, blind endpoint trial, that randomised 90 obese participants with T2D (aged 18–65 years) to a 12-week intervention of: (i) routine care, (ii) aerobic exercise training, or (iii) low energy (≈810kcal/day) meal replacement plan (MRP). CMR was performed at baseline and week-12. Images were analysed using Medis v3.1. LA strain (LAS) was assessed using Feature Tracking (QStrain v2.0), corresponding to LA reservoir (LAS-r), conduit (LAS-cd), and booster pump (LAS-bp) using 4- and 2-chamber standard steady-state free precession cine images, and average values calculated. LA emptying fraction (LAEF) was calculated using biplane area-length method (QMass v8.1) for total, passive and active EF.

Results

73 participants with T2D completed the trial and had analysable LA images (28 routine care, 22 exercise and 23 MRP). There was no significant change in CMR measured standard LA volumetric function (LAV/LAEF) and echocardiogram measured LV filling pressures (E/e') in any groups. The routine care arm showed no significant change in body mass index (BMI) or LAS (see Table). In the MRP group, there were significant reductions in BMI (4.8 kg/m2), mean systolic blood pressure (SBP) (13mmHg), and a significant increase in LAS-r and LAS-bp (29.9±7.0 to 32.3±7.0,p=0.036 and 14.6±5.3 to 17.2±3.7,p=0.034). The exercise arm showed a small reduction in BMI (0.8kg/m2), with no significant change in BP or LAS.

Conclusion

There was significant improvement in LAS post-lifestyle intervention in young adults with T2D, despite no change in volumetric measurements. MRP led to weight loss and improved SBP, with associated improved LA filling and contraction.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute for Health Research (NIHR) a career development fellowship.

Marital status, cardiovascular events, and intensive blood pressure lowering among men and women in the Systolic Blood Pressure Intervention Trial

Background

Married persons may have lower rates of mortality and cardiovascular disease (CV) than unmarried persons although data regarding potential differences between men and women are conflicting. The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced CV morbidity and mortality in high-risk patients. We hypothesized that marital status would influence CV event risk and the impact of intensive BP control, and that these effects would vary according to sex.

Purpose

To assess the risks of CV events and mortality according to marital status in a high-risk population, and to assess if marital status modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled, open-label trial of 9361 individuals at high CV risk, at least 50 years of age, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to either intensive or standard BP control and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. Secondary efficacy endpoints included the individual components of the primary endpoint and all-cause death. Event risk according to marital status, including variation of the effects of intensive BP control, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. The group of subjects who were married or living in a marriage-like relationship served as baseline.

Results

Information on marital status was available for 8762 (93.6%) individuals. A total of 4863 (55.5%) were married or in a marriage-like relationship, 3149 (35.9%) were widowed, divorced, or separated, and 750 (8.6%) were never married. Marital status did not differ between patients randomized to intensive versus standard BP control (P=0.51). The risk of the primary endpoint was not significantly affected by marital status (P&gt;0.05), in neither men nor women (P-interaction&gt;0.05). The same was true for its individual components except the risk of CV death which was higher among never married men (adjusted hazard ratio [aHR], 3.29, 95% confidence interval [CI]: 1.34–8.09; P=0.009; P-sex-interaction=0.99). The risk of all-cause death was higher among widowed, divorced, or separated men (aHR, 1.90, 95% CI: 1.35–2.67; P&lt;0.001) and among never married men (aHR, 2.53, 95% CI: 1.51–4.26; P&lt;0.001), but not women belong to these groups (P&gt;0.05; P-sex-interaction=0.24) (Figure). Associations were not modified by age (P-interaction&gt;0.05). Marital status did not modify the effect of intensive BP control for any of the endpoints (P-interaction&gt;0.05).

Conclusions

In SPRINT, never married men had higher risks of both CV death and all-cause death while widowed, divorced, or separated men had a higher risk of all-cause death. The risks and benefits of intensive BP control were not affected by marital status.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Internal jugular vein ultrasound in patients with chronic congestive heart failure

Background

Bedside assessment of intravascular volume in patients with chronic congestive heart failure (CHF) is often difficult. Under- and over-diuresis are common causes of morbidity and readmissions in these patients.

Purpose

We hypothesized that ultrasound assessment of the internal jugular vein would be easier and more reproducible than clinically assessing jugular venous pressure (JVP). Our goal was to create a bedside test that would be simpler to learn than inferior vena cava (IVC) assessment and easier to perform in obese patients.

Methods

Adults with HF (n=53, 52% men, mean age 65 years, mean BMI 29.6 kg/m2, mean LVEF 44%) scheduled for right heart catheterization (RHC) had an ultrasound of their right internal jugular (RIJ) vein performed immediately prior. Cross-sectional area of RIJ was measured during normal breathing with patients at 90 and 45 degrees recumbency and was indexed by height (RIJI). JVP was also assessed clinically. Results were compared to right atrial pressure (RAP) measured by RHC. Operators were blinded to RHC results and vice versa.

Results

JVP was correctly assessed clinically in only 43%. RIJI at 90 and 45 degrees were significantly larger in patients with elevated RAP compared to euvolemic patients (Table). At 90 degrees, RIJI of &gt;15 predicted a RAP of &gt;10 mmHg with 68% sensitivity and 72% specificity. At 45 degrees, RIJI of &gt;10 predicted a RAP of &gt;10 mmHg with 94% sensitivity and a negative predictive value of 80% (Table). Simply being able to see the RIJ at 90 degrees (n=34) had an 82.4% positive predictive value for elevated RAP. IVC data could not be obtained on 23% of patients due to body habitus or inability to lay flat.

Conclusion

Ultrasonographic RIJI is more accurate than clinical assessment in patients with CHF and can be accurately performed even in obese patients. It requires only a basic linear ultrasound probe and was easily performed by clinicians at various stages of training with reproducible results. With the increased availability of bedside ultrasound in clinical practice, it is a feasible method of evaluating chronic CHF patients.

Funding Acknowledgement

Type of funding sources: None.

Does the availability of transcatheter aortic valve replacement impact inpatient outcomes after surgical aortic valve replacement? Analysis of the national inpatient sample

Background

With the introduction of transcatheter aortic valve replacement (TAVR), the treatment of aortic stenosis (AS) has experienced a paradigm shift, altering patient selection for surgical aortic valve replacement (SAVR) over the past decade. What remains to be determined is the impact of a hospital's ability to offer TAVR, in the contemporary era, on inpatient outcomes following SAVR.

Purpose

The goal of this study was to assess inpatient mortality and the use of mechanical aortic valve replacement (mAVR) in patients undergoing SAVR at TAVR versus non-TAVR centers in the United States.

Methods

The National Inpatient Sample (2011–18), a probability sample of inpatient visits in the United States, was used to study trends in admissions for SAVR at TAVR and non-TAVR centers; in-hospital mortality was trended over time. Survey estimation commands were used to determine weighted national estimates.

Results

There were 559,365 inpatient visits for SAVR with 75.2% (95% CI 74.2%-76.2%) and 24.7% (95% CI 23.8%-25.8%) receiving bioprosthetic SAVR (bAVR) and mAVR, respectively at TAVR centers and 64.5% (95% CI 63.3%-65.6%) and 35.5% (95% CI 34.4%-36.7%) receiving bAVR and mAVR, respectively at non-TAVR centers. SAVR recipients at non-TAVR centers were older when compared to recipients at TAVR centers (68.3±0.09 vs 66.9±0.11 years p&lt;0.001). Heart failure, cardiac arrhythmias, peripheral vascular disorders, complicated hypertension and diabetes, renal failure and liver disease were more common in patients undergoing SAVR at TAVR-centers. During the study period, both crude (OR = 0.78 95% CI 0.73–0.83) and adjusted (OR = 0.79 95% CI 0.73–0.86) inpatient mortality was lower amongst SAVR recipients at TAVR centers. The utilization rates of mAVR at both TAVR and non-TAVR centers decreased over time amongst all age groups (p trend &lt;0.001).

Conclusions

Patients undergoing SAVR at TAVR centers were younger and had more co-morbidities compared to patients undergoing SAVR at non-TAVR centers. Although patients undergoing SAVR at TAVR centers had significantly more co-morbidities, inpatient mortality was lower at TAVR centers compared to non-TAVR centers. Further research is needed to determine whether the impact of a multidisciplinary cardiac approach resulted in significant differences in patient selection for SAVR, due to the availability of TAVR, influencing patient outcomes.

Funding Acknowledgement

Type of funding sources: None.

Greater event rates in high-risk patients with a history of heart disease: from the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in patients at high CV risk. Effects were consistent among patients with and without prevalent CV disease. However, it is unknown whether the benefits and risks of intensive BP control are affected by the specific type of heart disease.

Purpose

To assess the risks of incident CV events and safety events in patients with individual types of heart disease, and to assess if the presence of heart disease modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to intensive or standard BP control. The primary efficacy endpoint was the composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We assessed event risk in patients with self-reported heart disease versus those without and further assessed the safety and efficacy of intensive BP control, including relevant interactions, in these individuals, using multivariable Cox proportional-hazards regression.

Results

Of 9361 participants, 326 (3.5%) reported a history of congestive heart failure, 760 (8.1%) of myocardial infarction, 1206 (12.9%) of angina, and 1830 (19.6%) of atrial fibrillation, atrial flutter, or irregular heartbeat. The prevalence of these conditions did not significantly differ between patients randomized to intensive versus standard BP control (P&gt;0.05 for all). At median 3.2 years (range 0–4.8 years), congestive heart failure (adjusted hazard ratio [aHR], 1.94, 95% confidence interval [CI], 1.45–2.61; P&lt;0.001), myocardial infarction (aHR, 1.73, 95% CI, 1.33–2.25; P&lt;0.001), angina (aHR, 1.41, 95% CI, 1.09–1.84; P=0.01), and atrial fibrillation, atrial flutter, or irregular heartbeat (aHR, 1.36, 95% CI, 1.12–1.64; P=0.002) were all independently associated with the primary endpoint (Figure). All conditions except prior myocardial infarction were also associated with composite serious adverse events (P=0.24 for myocardial infarction, P&lt;0.05 for all others). A history of angina modified the efficacy of intensive versus standard BP control, i.e., patients without angina appeared to benefit from intensive BP control (aHR, 0.66, 95% CI, 0.54–0.80; P&lt;0.001) while those with angina did not (aHR, 1.04, 95% CI, 0.76–1.44; P=0.80) (P=0.02 for interaction). No significant interactions were detected for the primary safety endpoint.

Conclusions

In SPRINT, a history of any type of heart disease was associated with a greater risk for both efficacy and safety events. Patients with angina did not appear to derive benefit from intensive BP control.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Primary health insurance and cardiovascular outcomes in the systolic blood pressure intervention trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in high-risk patients. Although antihypertensive therapies were provided at no cost to trial participants, patients were covered by various entities. Insurance coverage provides a unique dimension of risk assessment and may provide additional prognostic information in this setting.

Purpose

To assess the risks of incident CV events and safety events in a high CV risk population according to type of health insurance, and to assess if insurance type interacted with the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial conducted across 102 US sites of 9,361 high-risk adults ≥50 years, without diabetes, and with a systolic BP 130–180 mmHg at screening. Study participants were randomized to intensive (target systolic BP &lt;120mmHg) or standard BP control (target systolic BP &lt;140mmHg) and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. The primary safety endpoint was the composite of serious adverse events. The risk of efficacy and safety events according to type of health insurance, including the effect of intensive BP control in each subgroup, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. Private/other insurance type served as the reference group.

Results

Of 9361 participants, 3980 (42.5%) were covered by private/other insurance, 1483 (15.8%) by a Veterans Affairs (VA) health plan, 2691 (28.8%) by Medicare, 207 (2.2%) by Medicaid, and 1000 (10.7%) were uninsured. Insurance coverage distribution was well-balanced between the two study arms (P&gt;0.05). Compared with patients who had private/other insurance, the risk of the primary endpoint was significantly higher among Medicaid beneficiaries (adj. hazard ratio [HR], 1.81, 95% confidence interval [CI], 1.09–3.00; P=0.02). The risk of death was similarly highest among Medicaid patients (adj. HR, 2.08, 95% CI, 1.08–4.02; P=0.03) and was also significantly higher among VA patients (adj. HR, 1.49, 95% CI, 1.11–2.99; P=0.008) (Figure). Serious adverse events were more common in the VA population (HR, 1.12, 95% CI, 1.01–1.23; P=0.03). Insurance type did not modify the efficacy and safety of intensive BP control (P&gt;0.05 for all interactions).

Conclusions

In SPRINT, Medicaid beneficiaries were at significantly greater risk for experiencing a primary CV event. Medicaid patients and VA patients both had higher mortality than those covered by private/other insurance. The risks and benefits of intensive BP control were not affected by insurance type.

Funding Acknowledgement

Type of funding sources: None. Risk of death and health insurace type

191 Improving Consent and Legibility in Orthopaedic Surgery Through Introducing Pre-Populated Stickers

Aim

Incomplete informed consent can lead to patient dissatisfaction and litigation.1 Time constraints, legibility, human error, limit completion of consent forms, putting surgeons and trusts at risk of litigation.2 The aim of this project was to assess legibility and completeness of handwritten consent forms, with the objective to improve legibility to 100% and risks listed to 100% of those endorsed by the British Orthopaedic Association (BOA).3

Method

An initial baseline study in multiple hospitals across the UK identified 113 patients who underwent hemiarthroplasties. The consent forms were assessed for legibility and risks included, compared to those listed by the BOA. Pre-populated risks stickers were introduced in 1 district general hospital (DGH) and 2 cycles repeated again (62 patients identified).

Results

Overall, 35% of consent forms 1 were illegible; 100% of the time in the risks section. Mean number of risks missing was 2.34 and most frequently missed risk was ‘death’ (missing on 35.5% of consent forms). In the DGH that introduced stickers, consent forms were 100% legible and 100% compliant to the standards set by the BOA when the stickers were used. However, sticker use remained low; only used 20% of the time in the second cycle, marginally increased from the previous cycle (18%).

Conclusions

A high proportion of consent forms are not completed to BOA standards and are illegible. Pre-populated stickers could aid in achieving 100% legibility and 100% risk inclusion. The stickers will be implemented in other trusts and methods to increase compliance with sticker use will be trialled.

773 The Impact of Introducing an Enhanced Recovery Nurse Practitioner on Colorectal ERP Protocol Compliance and Surgical Outcome: A Single-Unit Experience

Introduction

The enhanced recovery programme (ERP) is a validated perioperative care plan that has consistently shown to reduce morbidity and improve patient outcomes. Our trust introduced ERP for major elective colorectal procedures in 2007. However, it had been noted that compliance to protocol was variable. This audit was conducted to see if introduction of an enhanced recovery nurse (ERN) improved compliance.

Method

This was a single-centre, retrospective, closed-loop audit; each cycle consists of resectional cases over a 1-year period. Perioperative data were collected from preoperative assessment documents, anaesthetic charts, operation notes and post-operative patient records. Compliance to 20elements of the agreed ERP protocol and length of stay (LOS) were assessed. First-cycle results were presented locally, leading to protocol revision and introduction of a dedicated ERN. Two years following ERN introduction, data were re-audited and compliance assessed. Statistical analyses were performed using Chi-squared test or independent t-test as appropriate.

Results

Among 101 procedures analysed in the first-cycle, compliance to ERP elements ranged between 30-95%. Following intervention, among 113 cases, compliance improved to 46-99%. Statistically significant improvements were observed in post-operative ERP elements. Compliance to early cessation of intravenous fluids increased from 44% to 61% (p = 0.02), and early urinary catheter removal increased two-fold, from 30% to 62% (p &lt; 0.01). Patients resumed light diet earlier and mobilised out of bed sooner. LOS improved from median of 7(1-48) to 6(2-50) days (p = 0.03).

Conclusions

This study demonstrates that the introduction of a dedicated ERN is associated with significantly improved protocol compliance and reduced LOS following major colorectal resection.

Measurements of angular distance and momentum ratio distributions in three-jet and Z + two-jet final states in pp collisions

Collinear (small-angle) and large-angle, as well as soft and hard radiations are investigated in three-jet and Z  + two-jet events collected in proton-proton collisions at the LHC. The normalized production cross sections are measured as a function of the ratio of transverse momenta of two jets and their angular separation. The measurements in the three-jet and Z  + two-jet events are based on data collected at a center-of-mass energy of 8 TeV , corresponding to an integrated luminosity of 19.8 fb - 1 . The Z  + two-jet events are reconstructed in the dimuon decay channel of the Z  boson. The three-jet measurement is extended to include s = 13 TeV data corresponding to an integrated luminosity of 2.3 fb - 1 . The results are compared to predictions from event generators that include parton showers, multiple parton interactions, and hadronization. The collinear and soft regions are in general well described by parton showers, whereas the regions of large angular separation are often best described by calculations using higher-order matrix elements.