830 Audit of Readmissions Within 30 Days of Total Knee Replacement (TKR)

Background

Total knee replacement (TKR) is a very successful operation but like all surgery carries risks. Patients can be readmitted, but not all necessarily linked to post-operative complications. National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man: 17th annual report, 2020, Prosthetic infection after total knee replacement is (TKR) of average 0.92%.

Aim

To identify causes of readmission after TKR & their frequency, within 30 days of surgery.

Method

Data spanning 2 years (Apr 2018- Apr 2020) were analysed. Patients’ details were retrieved for those with at least one readmission within 30 days of TKR and details include:

Results

Conclusion

86 Adherence to Best Practice Tariffs (BPT) for Neck of Femur (NOF) Fracture Admissions During the COVID-19 Pandemic

Introduction

For patients with fragility hip fractures, care needs to be promptly organised to undertake a holistic assessment and preparation for surgery. The aim of the Best Practice Tariffs (BPT) is to promote hip fracture programmes that provide best practice in the care and secondary prevention of fragility fractures.

Method

Results

Conclusions

Antiplatelet therapy prescription patterns for acute coronary syndrome: a decade analysed

Background/Introduction

Guidelines recommend dual antiplatelet therapy (DAPT) with acetylsalicylic acid (ASA) and ticagrelor following acute coronary syndrome (ACS) regardless of management strategy. Despite this, prescription practices lag and appropriate DAPT is not utilized.

Purpose

We aimed to trend differences in P2Y12 inhibitor prescriptions between ACS patients managed with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). As well, we wanted to analyze the impact practice-changing trial publications, national guideline updates, and publicly funded drug coverage plans may have on prescription patterns.

Methods

From national databases, we obtained data for ACS patients in the province of Ontario, Canada between 2008 and 2018. Using an interrupted-time series with data aggregated monthly, we evaluated types of P2Y12 inhibitor prescribed at hospital discharge and changes to antiplatelet prescription patterns following publication of Ticagrelor versus Clopidogrel in Patients with Acute Coronary Syndrome (PLATO), Canadian Cardiovascular Society (CCS) antiplatelet therapy guidelines, and ticagrelor coverage by a publicly funded medication plan.

Results

We included 114,142 ACS patients; 49% underwent PCI and 8% required CABG. Between October 2008 and March 2018, the proportion of patients discharged on P2Y12 inhibitors increased from 73.4% to 87% (p<0.0001) for PCI patients and 11.4% to 31.4% (p<0.0001) for CABG patients. PLATO publication was associated with a 1.3% (p=0.002) monthly decline in clopidogrel prescriptions amongst PCI patients. The 2010 CCS antiplatelet therapy guidelines were associated with a 0.7% (p<0.0001) monthly decline in clopidogrel prescriptions amongst PCI patients. The approval of ticagrelor by publicly funded medication plan was associated with an increase in ticagrelor prescriptions within the first month (24.5%; p<0.0001) and a continued monthly increase (0.4%; p<0.0001) in PCI patients. The approval was also associated with an increase in monthly ticagrelor prescriptions (0.2%; p<0.0001) amongst CABG patients. The 2012 CCS antiplatelet therapy guidelines were associated with a decline in clopidogrel prescriptions within the first month (6.1%; p=0.003) and a monthly increase in ticagrelor prescriptions (0.3%; p=0.05) amongst PCI patients.

Conclusion

Drug coverage by a publicly funded medication plan and guideline updates had significant impact on P2Y12 inhibitor prescription practices. Despite improvements, P2Y12 inhibitor prescriptions for CABG patients are far behind PCI patients. Further research is necessary to address barriers to appropriate antiplatelet therapy in the ACS population.

Antiplatelet Prescription Patterns

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): New Investigator Fund - Hamilton Health Sciences Foundation, Hamilton, Canada

Sex disparities in completeness of revascularisation and outcomes in patients with ST-elevation myocardial infarction and multivessel coronary artery disease

Background

In patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD), complete revascularisation is associated with reduced mortality compared to culprit only revascularisation. However, there are limited data regarding the relationship between sex and revascularisation strategy in STEMI with multivessel CAD and outcomes.

Purpose

Our aim is to evaluate sex related differences in treatment strategies and outcomes in patients with STEMI and multi-vessel CAD.

Methods

We included all consecutive patients from a provincial registry presenting with STEMI and multivessel CAD treated with percutaneous coronary intervention (PCI) from 2008–2015. The study population consisted of 856 females and 3152 males who were treated with culprit vessel only PCI or complete revascularisation using staged-PCI. The outcomes were death, admission for acute coronary syndrome (ACS), and admission for heart failure (HF). Multivariate Cox proportional hazard models were used to examine the association between treatment strategy and outcomes. Backward stepwise logistic regression was used to identify predictors of patients undergoing staged-PCI versus culprit vessel only PCI.

Results

At 3 years, the incidence of death was higher in females than males (15.9% vs. 8.2%, p<0.001), as were HF admissions (10.3% vs. 5.0%, p<0.001). Females underwent less staged-PCI than males (10.4% vs. 14.8%; adjusted odds ratio 0.75; 95% CI 0.57–0.97). Younger age and increasing Duke jeopardy score were also associated with performing staged-PCI.

After adjusting for baseline characteristics, females had a higher risk of death (HR 1.35; 95% CI 1.07–1.71), ACS admission (HR 1.27; 95% CI 1.00–1.60), and HF admission (HR 1.38; 95% CI 1.03–1.85). Following additional adjustment for revascularisation strategy, only death and HF admission remained significant. Females undergoing staged-PCI had similar survival to males (figure), with no significant interaction between revascularisation strategy and sex (p for interaction = 0.19)

Conclusion

Females with STEMI and multivessel CAD were less likely to be treated with complete revascularisation by staged-PCI and had worse outcomes when compared to males. Survival in both males and females treated with staged-PCI was similar. Our study suggests that addressing the lack of complete revascularisation in females presenting with STEMI may improve outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: None

Organo-functionalized metal–oxide clusters: synthesis and characterization of the reduced cationic species [NaVIV6O6{(OCH2CH2)2NH}6]+

A new diethanolamine functionalized oxovanadium cationic cluster was synthesized and characterized; electrochemical and UV-vis absorption properties are consistent with two distinct MLCT processes.

Kidney dimensions at sonography are correlated with glomerular filtration rate in renal transplant recipients and in kidney donors

The gold standard to assess renal function is the measurement of glomerular filtration rate (GFR). For practical reasons, renal function is often evaluated from serum creatinine (S Cr) or cystatin C (S Cys), and GFR is predicted from SCr. Ultrasound scanning of the kidneys is used only to evaluate renal morphology. The aim of this study was to evaluate the relationship between sonographic renal dimensions and GFR in renal transplant recipients and in kidney donors. GFR (urinary clearance of (99m)Tc-DTPA), S Cr, and S Cys were measured in 33 donors (28 females [F], 5 males [M]; SCr, 0.81-1.90 mg/dL) and 30 recipients (8 F, 22 M; SCr, 0.96-2.42 mg/dL). GFR was also predicted using the Cockcroft and Gault (CG) formula and with the simplified Modification of Diet in Renal Disease (MDRD) formula. Length, width, and depth of kidneys and renal sinus were measured using renal sonography. Among sonographic measurements, kidney length showed the best correlation with GFR. A closer correlation with GFR was found in donors (r = 0.639; P < .00007) than in recipients (r = 0.511; P < .005). In either case, the correlation of kidney length with GFR was greater than that of S Cr or S Cys, and similar to that of CG or MDRD GFR. Accuracy of kidney length as an indicator of GFR impairment was not statistically different from laboratory tests. Only in donors did CG show better accuracy. In conclusion, renal dimensions at sonography closely correlated with GFR. Thus, renal sonography can give information also on the function of the renal graft and of the remaining kidney of living donors.

Nucleotide correlation between HAV isolates from human patients and environmental samples

Hepatitis A disease is endemic in Albania even though records from the Medical Authority show outbreaks involving only limited numbers of people. In the city of Lac, 200 people became ill following an outbreak of hepatitis A started on November 2002. The age distribution of the cases shows a peak in the age group 5-9 (43.5%) followed by the age group 10-14 (28%) and the age group 1-4 (18%). No cases were recorded in the age group 0-1. Drinking water and sewage samples were collected, using electropositive cartridges, during the outbreak. Rotavirus was identified by RT-PCR in two out of five drinking water samples; however, all the samples tested negative for HAV and astrovirus. Rotavirus was also identified in three out of five sewage samples from which four were HAV positive. HAV-RNA was identified in 28 (62.2%) out of 45 IgM anti-HAV positive sera collected during the outbreak. Genotype IA was expressed from all the amplified samples. Sequence analysis of the overlapping VP1-2A region shows 97-99% homology with three Italian strains IT-SCH-00, IT-ZAM-01, and IT-CAP-00 and one Spanish strain (Sa 30/06/95), whereas the phylogenetic tree built from the 168 bp sequence of the VP1-2A shows four clusters, one including 24 out of 28 RT-PCR positive sera. Considering the deduced amino acid sequence, only one substitution was identified and reported previously for genotype IB.

Symmetrical bis(heteroarylmethoxyphenyl)alkylcarboxylic acids as inhibitors of leukotriene biosynthesis

Symmetrical bis(quinolylmethoxyphenyl)alkylcarboxylic acids were investigated as inhibitors of leukotriene biosynthesis and 4, 4-bis(4-(2-quinolylmethoxy)phenyl)pentanoic acid sodium salt (47.Na) met our design parameters for a drug candidate (ABT-080). This compound was readily synthesized in three steps from commercially available diphenolic acid. Against intact human neutrophils, 47.Na inhibited ionophore-stimulated LTB(4) formation with an IC(50) = 20 nM. In zymosan-stimulated mouse peritoneal macrophages producing both LTC(4) and PGE(2), 47.Na showed 9000-fold selectivity for inhibition of LTC(4) (IC(50) = 0.16 nM) over PGE(2) (IC(50) = 1500 nM). Preliminary pharmacokinetic evaluation in rat and cynomolgus monkey demonstrated good oral bioavailability and elimination half-lives of 9 and 5 h, respectively. Pharmacological evaluation of leukotriene inhibition with oral dosing was demonstrated in a rat pleural inflammation model (ED(50) = 3 mg/kg) and a rat peritoneal passive anaphylaxis model (LTB(4), ED(50) = 2.5 mg/kg; LTE(4), ED(50) = 1.0 mg/kg). In a model of airway constriction induced by antigen challenge in actively sensitized guinea pigs, 47.Na dosed orally blocked bronchoconstriction with an ED(50) = 0.4 mg/kg, the most potent activity we have observed for any leukotriene inhibitor in this model. The mode of inhibitory action of 47.Na occurs at the stage of 5-lipoxygenase biosynthesis as it blocks both leukotriene pathways leading to LTB(4) and LTC(4) but not PGH(2) biosynthesis. However, 47.Na does not inhibit 5-lipoxygenase catalysis in a broken cell enzyme assay; therefore it is likely that 47.Na acts as a FLAP inhibitor.

3,5-Bis(trifluoromethyl)pyrazoles: a novel class of NFAT transcription factor regulator

A series of bis(trifluoromethyl)pyrazoles (BTPs) has been found to be a novel inhibitor of cytokine production. Identified initially as inhibitors of IL-2 synthesis, the BTPs have been optimized in this regard and even inhibit IL-2 production with a 10-fold enhancement over cyclosporine in an ex vivo assay. Additionally, the BTPs show inhibition of IL-4, IL-5, IL-8, and eotaxin production. Unlike the IL-2 inhibitors, cyclosporine and FK506, the BTPs do not directly inhibit the dephosphorylation of NFAT by calcineurin.

5-Lipoxygenase inhibitors: synthesis and structure-activity relationships of a series of 1-aryl-2H,4H-tetrahydro-1,2,4-triazin-3-ones

Synthetic routes were developed to access a variety of novel 1-aryl-2H,4H-tetrahydro-1,2,4-triazin-3-one analogs which were evaluated as 5-lipoxygenase (5-LO) inhibitors. The parent structure, 1-phenylperhydro-1,2,4-triazin-3-one (4), was found to be a selective inhibitor of 5-LO in broken cell, intact cell, and human blood assays with IC50 values of 5-21 microM. In a rat anaphylaxis model, 4 blocked leukotriene formation with an ED50 = 7 mg/kg when administered orally. Compound 4 exhibited selectivity for inhibition of 5-LO with little activity against related enzymes: 12-LO from human platelets, 15-LO from soybean, and cyclooxygenase (COX) from sheep seminal vesicle. In pilot subacute toxicity testing, 4 did not produce methemoglobinemia in rats (400 mg/kg po daily for 9 days) or in dogs (200 mg/kg po daily for 28 days). These results indicated that the triazinone structure provided a 5-LO inhibitor template devoid of the toxicity problems observed in the related phenidone (1) and pyridazinone (3) classes of 5-LO inhibitors. The parent compound 4 is a selective, orally bioavailable 5-LO inhibitor which can serve as a useful reference standard for in vivo pharmacological studies involving leukotriene-mediated phenonmena.

(R)-(+)-N-[3-[5-[(4-fluorophenyl)methyl]-2-thienyl]-1-methyl- 2-propynyl]-N-hydroxyurea (ABT-761), a second-generation 5-lipoxygenase inhibitor

Structure-activity optimization of inhibitory potency and duration of action of N-hydroxyurea containing 5-lipoxygenase inhibitors was conducted. The lipophilic heteroaryl template and the link group connecting the template to the N-hydroxyurea pharmacophore were modified. Inhibition of 5-lipoxygenase was evaluated in vitro in a human whole blood assay. An in vitro assay using liver microsomes from monkey was used to evaluate congeners for comparative rates of glucuronidation. (3-Heteroaryl-1-methyl-2-propynyl)-N-hydroxyureas were found to be more resistant to in vitro glucuronidation. The promising inhibitor N-[3-[5-(4-fluorophenoxy)-2-furyl]-1-methyl-2-propynyl]-N- hydroxyurea (6) was found to have stereoselective glucuronidation in monkey and man. The R enantiomer 7 provided longer duration of inhibition as evaluated by an ex vivo whole blood assay. Further optimization of the lipophilic template led to the discovery of (R)-(+)-N-[3-[5-[(4-fluorophenyl)methyl]-2- thienyl]-1-methyl-2-propynyl]-N-hydroxyurea (11) with more effective and prolonged inhibition of leukotriene biosynthesis than zileuton (1) and 7 in monkey and man. The optimized 5-lipoxygenase inhibitor 11 was selected for development as an investigational drug for leukotriene-mediated disorders.

Intraspinal tumour presenting as hydrocephalus in childhood

A case of cervical intramedullary spinal cord tumour presenting with hydrocephalus is reported for its rarity. Possible aetiopathologies and the relevant literature are reviewed.

Poor diagnostic value of adenosine deaminase in pleural, peritoneal & cerebrospinal fluids in tuberculosis

Adenosine deaminase (ADA) was estimated in 84 pleural, 140 peritoneal and 136 cerebrospinal fluids to study its diagnostic usefulness as a routine test for tuberculosis. The sensitivity, specificity, positive and negative predictive values for diagnosing tuberculosis in pleural fluids (ADA > 30 U/l) was 67, 92, 78 and 87 per cent respectively, in peritoneal fluids (ADA > 15 U/1) it was 89, 81, 25 and 99 per cent respectively and in cerebrospinal fluids (ADA > 10 U/l) it was 50, 90 21 and 97 per cent respectively. The differences in mean ADA levels between tuberculous (28.0 and 19.5 U/1) and non-tuberculous (9.7 and 4.8 U/1) peritoneal and cerebrospinal fluids although statistically significant (P < 0.001), were of no practical clinical value. A wide scatter in ADA values was seen in both tuberculous and non-tuberculous fluids. ADA estimation in plasma, lymphocytes and cell fractions of fluids was also not diagnostically useful nor did it throw light on the source of elevated ADA in fluids.

N-acetyl-beta-D-glucosaminidase in the localisation of urinary tract infection in patients with spinal cord injury

This study evaluates the pattern of urinary N-acetyl-beta-D-glucosaminidase (NAG) isoenzyme excretion in patients with spinal cord injury (SCI) and its use as a diagnostic tool in localising the site of urinary tract infection (UTI). NAG-B excretion in 27 control SCI patients (mean 207.78 units) was significantly higher than in 10 normal controls (mean 12.6 units) p less than 0.001). The relative isoenzyme distribution as represented by NAG-B/Total NAG percentage is however similar in both groups, 24.27 and 20.38% respectively. NAG-B excretion in 6 SCI patients with upper UTI was not significantly higher than in 12 SCI patients with lower UTI. NAG-B/Total NAG percentage was significantly different between these two groups (35.3% and 24.98% respectively, p less than 0.05). There was no significant difference in NAG-B excretion or NAG-B/Total NAG percentage between control SCI patients and those with lower UTI. The results indicate that there is a non-selective increase in urinary NAG excretion in control SCI patients and those with lower UTI. In SCI patients with upper urinary UTI there is a selective increase in NAG-B excretion. The overlap in enzyme values between the different groups suggests that the test may not be clinically useful in localising the site of UTI.

Efficacy of enalapril in essential hypertension and its comparison with atenolol

The effect of enalapril was evaluated in 67 patients with essential hypertension, and its therapeutic efficacy was compared with atenolol in a placebo run-in, single-blind, cross-over trial. Enalapril significantly reduced blood pressure in all grades of essential hypertension. As monotherapy it 'normalized' blood pressure in 88%, 50% and 25% of patients with mild, moderate and severe hypertension respectively. Optimal dose for most of the patients was 20 to 40 mg/day. Comparison with atenolol revealed almost parallel efficacy of the two drugs, although enalapril produced a significantly greater reduction in systolic blood pressure in patients with mild and moderate hypertension (P less than 0.01 in each group). No serious side effects were encountered with either drug. Enalapril, therefore, has a potent and slightly superior antihypertensive effect to that of atenolol, and may be used as a 'first-step' drug in the treatment of hypertensive patients.

Blood-brain-barrier and intrathecal immunoglobulin changes in tuberculous meningitis and demyelinating disorders: a preliminary report from a south Indian hospital

Sixty-three paired serum and CSF samples (15 controls and 48 patients) were studied for CSF albumin quotient, IgG index and synthesis rate. Control values for albumin quotient and IgG index were less than 10.0 and less than 0.6 respectively. IgG synthesis rate/day was calculated according to the Tourtellotte formula and a value of greater than 3.0 mg/day is considered high. Our findings in patients with central demyelinations, subacute sclerosing panencephalitis, Guillain Barré Syndrome and cerebrovascular accidents are comparable to earlier studies. Fifteen tuberculous meningitis patients were studied and could be separated into 2 groups, 9 with elevated albumin quotients and 6 with normal albumin quotients. Three patients with elevated albumin quotients and 4 with normal albumin quotients showed increased intrathecal IgG synthesis.