Inconclusive decisions and error rates in forensic science

In recent years, there has been discussion and controversy relating to the treatment of inconclusive decisions in forensic feature comparison disciplines when considering the reliability of examination methods and results. In this article, we offer a brief review of the various viewpoints and suggestions that have been recently put forth, followed by a solution that we believe addresses the treatment of inconclusive decisions. We consider the issues in the context of method conformance and method performance as two distinct concepts, both of which are necessary for the determination of reliability. Method conformance relates to an assessment of whether the outcome of a method is the result of the analyst's adherence to the procedures that define the method. Method performance reflects the capacity of a method to discriminate between different propositions of interest (e.g., mated and non-mated comparisons). We then discuss implications of these issues for the forensic science community.

A recycling quality improvement project to engage the multidisciplinary team with sustainability efforts

BACKGROUND

The provision of healthcare itself contributes to the global health crisis of the climate emergency. As critical care is a carbon hotspot within hospital medicine, healthcare professionals must take collaborative action to mitigate the environmental impact of the sector.

AIMS

The purpose of the project was to engage the critical care multidisciplinary team with sustainability efforts, through involvement in a recycling Quality Improvement Project (QIP). The central QIP aimed to increase the recycling rates of single-use plastic enteral feed bottles in the intensive care unit (ICU) over a 31-day period.

STUDY DESIGN

A recycling 'challenge month' was launched, and staff opinion was surveyed before and after this intervention.

RESULTS

The QIP demonstrated an increase in feed bottle recycling by 53.2%, representing a carbon-saving effect of up to 6.02 kg CO2e for the intervention month. Following the central QIP, all survey respondents felt encouraged to consider their ICU's environmental impact.

CONCLUSIONS

Simple successful QIPs can act as a springboard to engage the staff body with sustainability initiatives and ignite wider conversation and consideration of the climate emergency in daily practice.

RELEVANCE FOR CLINICAL PRACTICE

Effective recycling constitutes only one element of responsible environmental stewardship, but authors discuss that it is an effective focus for QIPs. To maximize impact and success within critical care, nursing involvement in leading and participation is essential.

Implementing a Bundle to Improve Surgical Site Infection Rates for Patients Undergoing Nonvaginal-Approach Hysterectomy at a Midwestern Teaching Hospital

Accrediting organizations, third-party payers, and patients review the surgical site infection (SSI) rates of health care organizations. Infection preventionists collaborate with perioperative personnel to decrease SSI rates; they also monitor and report SSI information to national organizations. The standard infection ratio is a comparison of the observed number of SSIs to the predicted number of SSIs based on national benchmark data. Leaders of a midwestern teaching hospital convened an interdisciplinary team (eg, surgeons, perioperative leaders, infection preventionists) to address a standard infection ratio after hysterectomies that was greater than 1.0. The team reviewed national guidelines and published articles on decreasing SSIs (including recommendations for vaginal preparation) before developing and implementing a hysterectomy-specific bundle for SSI prevention. The rate of SSIs decreased 68% after the implementation of the bundle. Perioperative personnel at this facility continue to use the bundle and infection preventionists monitor and report compliance with the bundle's elements.

1192 FALLS PREVENTION: COMMUNITY EXERCISE PROGRAMME; REDUCING RISK OF FALLS, DECONDITIONING AND LONELINESS IN FRAIL ELDERLY PATIENTS

Introduction

Covid has had a devastating effect on the Elderly, resulting in deconditioning, increased falls and loneliness. Tailored exercises can reduce falls in people aged over 65 by 54% and participation in physical activity reduces the risk of hip fractures by 50%, currently costing the NHS £1.7 billion per year in England. This 8-week intervention delivered by trained volunteers in patient’s homes, aims to reduce deconditioning, loneliness and the risk, incidence and fear of falling (FOF) amongst frail patients post-discharge from hospital.

Method

A gap in service was identified in Frail patients discharged from hospital, at risk of falling and awaiting community physiotherapy. A steering group was set up including acute and community therapists, volunteers and carers to design a collaborative intervention to bridge the gap. At risk patients were identified and referred by ward therapists supported by the hospital volunteering team. Volunteers were trained to deliver an 8 weeks programme of progressive exercises in patients’ homes with additional signposting to appropriate statutory and voluntary services. Qualitative and quantitative outcome measures were taken at week 1 and week 8 of the intervention

Results

91.5% total health outcomes improved or maintained by average:

- FOF reduced by 22.5%

- 180 degree turn improved by 43%

- 60 sec Sit to Stand improved by 14.75%

- Timed Up And Go improved by 15.5%

- Confidence to cope at home improved by 15%

- Pain / discomfort (self-reported) improved by 18.75%

- Overall health (self-reported) improved by 8.5%

Conclusion(s)

Targeted exercise at home with skilled volunteers can improve functional fitness and health outcomes in a frail elderly population at risk of falls when discharged home from hospital. The programme increases patients’ connectivity to local voluntary and community sector services. Volunteers’ mental health improves by engaging in meaningful service.

Intensive care nurse practitioners in Australia: A description of a service model in an adult tertiary intensive care unit

BACKGROUND

Although well-established internationally, nurse practitioners (NPs) in Australian adult intensive care units (ICUs) are rare. Australian literature clearly highlights the importance of creating ICU NP roles to meet emerging demands. An ICU NP model of care at a metropolitan hospital in Sydney provides care in four core practice areas: complex case management, vascular access, tracheostomy management, and intrahospital transport of critically ill patients. The ICU NPs also provide training and assessment for ICU nurses and medical officers in these same core practice areas and can efficiently meet service gaps in crisis such as the most recent COVID-19 pandemic.

RESULTS

The ICU NP program described is an innovative model of care that has demonstrated potential benefits to patients and their families. Potential benefits to the healthcare system including supporting advanced practice nursing development in regional and rural Australia and in addressing future ICU workforce issues are also identified. This model of care provides a clear role and structure for the integration of NPs in the adult ICU. Research to evaluate the impact of the role is required and is underway.

CONCLUSIONS

This model is being used to develop a national adult ICU NP fellowship training program for ICU transitional NPs preparing for endorsement or endorsed NPs who require additional ICU-specific training. This immersive clinical training program combined with didactic learning modules offers a framework to support the implementation of the adult ICU NP role as well as a framework for NP fellowship programs in other specialties.

Exploring the link between cancer policies and cancer survival: a comparison of seven countries

Background

Disparity in cancer survival across countries has been linked to variation in cancer policy delivery but there is lack of empirical evidence for this association. We traced the evolution of cancer policies in 20 jurisdictions in Australia, Canada, Denmark, Ireland, Norway, New Zealand and the UK since 1995 and present the findings of an exploratory analysis linking cancer policy consistency to cancer survival.

Methods

We systematically searched and analysed national/regional cancer plans and strategies, mapping timelines of cancer policy evolution. For 10 jurisdictions, evidence was synthesised into five categories: oversight function; cancer plan; implementation plan; budget for plan implementation; and evaluation. We assigned scores evaluating whether a category was present or absent, and weighted scores for consistency. Summed scores were correlated with trends in survival from seven cancers between 1995-2014.

Results

All ten jurisdictions had implemented a high-level structure overseeing, steering or delivering cancer control policies (1995 - 2014); all had also published at least one major cancer plan. There was great variation in oversight mechanisms, ranging from institutionalising cancer control (New South Wales, Ontario) to cancer steering groups or taskforces (Denmark, Northern Ireland, Wales). Frequency and consistency of cancer plans also varied, from a succession of plans that build on each other (Denmark, New South Wales, Ontario) to the publication of isolated plans (New Zealand, Northern Ireland). We found a positive, albeit weak, correlation of cancer policy consistency and improvements in survival over time for six of the seven cancers.

Conclusions

Jurisdictions that have implemented consistent cancer control policies over time tended to be more successful in improving survival for a wide range of cancers. Our findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.

Key messages

• Sustained and consistent strategic cancer planning and investment are crucial for ensuring better patient outcomes, and this requires strong and sustained commitment at all levels.

• The findings can help guide policymakers seeking approaches and frameworks to improve cancer services and, ultimately, cancer outcomes.

Targeted discovery proteomics to identify clinical phenotypes in heart failure with preserved ejection fraction: a proteomics substudy of VITALITY-HFpEF

Background

Heart failure with preserved ejection fraction (HFpEF) is a heterogenous syndrome that may emerge from overlapping systemic processes associated with several medical co-morbidities, often within an inflammatory milieu. Identification of unique proteins associated with distinct phenotypes may yield insight into novel therapeutics.

Purpose

Determine if unique clusters of circulating proteins are associated with specific clinical characteristics in patients with HFpEF.

Methods

A targeted discovery proteomics approach with 358 unique proteins associated with cardiovascular disease and inflammation (Olink) was used at baseline in VITALITY-HFpEF among 789 participants with documented left ventricular EF ≥45% and recent decompensation (<6 mos). Proteins were clustered applying the weighted correlation network analysis (WCNA). The associations of the clinical characteristics and frailty and clusters were estimated with linear regression adjusted for age and eGFR. Frailty was characterized as normal, pre-frail, and frail using the Fried criteria. KCCQ was the primary and 6-minute walk distance (6MWD) the secondary endpoint of VITALITY-HFpEF.

Results

Four unique clusters were identified containing 24, 66, 197, and 81 proteins, respectively. Figure 1 shows the adjusted association of the 4 protein clusters, shown with their hub proteins, with the clinical characteristics. The color (red: positive, green: negative relationship) and intensity indicate the magnitude of the standardized difference (relative to the variation [i.e., T-value]); p-value shown in boxes. Cluster 3, with tumor necrosis factor receptor 1 as a hub protein that mediates apoptosis and inflammation, was associated with greater frailty and physical limitation along with shorter 6MWD. In contrast, cluster 4, with protein C as a hub protein that regulates anticoagulation and exerts a protective function on endothelial cells, is associated with less frailty and younger age, and more frequently male sex. Cluster 2 was associated with only younger age and cluster 1 with no clinical characteristics.

Conclusions

Proteomics appear to identify specific clinical phenotypes associated with HFpEF. Further exploration of this approach may provide insight into the diverse pathophysiology characterizing this disorder and a more targeted approach to therapy.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): VITALITY-HFpEF was funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and Bayer AG, Wuppertal, Germany.

Association of heart rate with heart failure outcomes and the effects of empagliflozin in patients with preserved ejection fraction – EMPEROR-Preserved trial

Background and objective

High resting heart rate (HR) associates with cardiovascular death (CVD) and heart failure hospitalisation (HFH) in patients with reduced ejection fraction (HFrEF), but data are sparse in patients with preserved (HFpEF) or mildly reduced (HFmrEF) ejection fraction. Empagliflozin reduced the risk of CVD and HFH in HFpEF in the EMPEROR-Preserved trial. This study analyses the influence of HR on outcomes in patients with left ventricular ejection fraction (LVEF) >40% in EMPEROR-Preserved and evaluates the effects of empagliflozin across HR categories.

Methods

Patients (n=5988) with HFpEF (LVEF >40%) were categorised to HR <70 beats per minute (bpm), 70–75 bpm and >75 bpm. The composite of CVD or HFH (primary outcome), first HFH, CVD, recurrent HFH and all-cause mortality were studied in the HR groups and in patients separated by sinus rhythm (SR) or atrial fibrillation (AF) and true HFpEF (EF ≥50%) or HFmrEF (EF 40–49%).

Results

Empagliflozin did not influence HR over time. At HR >75 bpm, the primary outcome (hazard ratio: 1.31, 1.13–1.52, p=0.0003), time to first HFH (hazard ratio: 1.25, 1.04–1.49, p=0.02), recurrent HFH (hazard ratio: 1.29, 1.05–1.60, p=0.02), CVD (hazard ratio: 1.49, 1.21–1.84, p=0.0001) and all-cause mortality (hazard ratio: 1.49, 1.28–1.73, p<0.0001) were increased compared to HR of <70 bpm with HR 70–75 bpm showing intermediate results. The influence of HR on the primary outcome was only observed in SR (p trend=0.005), but not in AF (p trend=0.55). Patients with true HFpEF (≥50%) or HFmrEF (40–49%) showed similar effects. The treatment effects of empagliflozin to reduce the primary outcome, time to first HFH and recurrent HFH were not modified by HR.

Conclusions

HR in SR, but not in AF, predicts heart failure outcomes in HFpEF and HFmrEF, but the effects of empagliflozin were not modified by HR.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance

Efficacy of empagliflozin in patients with heart failure according to baseline KDIGO risk categories – findings from the EMPEROR-Pooled

Background and objective

Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with an incrementally higher risk for mortality and morbidity. EMPEROR-Pooled studied 9,718 HF patients across two trials and showed that empagliflozin reduces the risk for HF hospitalization or cardiovascular (CV) death, slows the progression of estimated glomerular filtration rate (eGFR) decline, and improves health status in patients with HF and reduced ejection fraction (HFrEF) as well as preserved ejection fraction (HFpEF).

Purpose

We explored the effect of empagliflozin on CV and kidney endpoints in patients across KDIGO (Kidney Disease Improving Global Outcomes) risk categories in EMPEROR-Pooled.

Methods

3,730 participants with left ventricular EF ≤40% (EMPEROR-Reduced) and 5,988 with left ventricular EF >40% (EMPEROR-Preserved) were categorized using baseline eGFR and UACR values into 4 categories according to KDIGO classification. The key outcomes were (1) a composite of CV death or hospitalization for HF, (2) first hospitalization for HF, (3) CV death and (4) eGFR slope change/year.

Results

The proportion of participants in low-, moderate-, high-, and very high-risk KDIGO categories was 31.4%, 29.6%, 22.0%, 16.9% for empagliflozin and 32.5%, 28.4%, 21.8%, 17.2% for placebo, respectively. Patients on placebo in higher baseline KDIGO risk categories had a higher risk of CV death or hospitalization for HF (6.78, 11.30, 15.15, and 20.70 events per 100 patient-years for low-, moderate-, high-, and very high-risk patients, respectively) (Figure 1). Similar trends were seen for first HF hospitalization (4.46, 7.68, 11.14, and 15.98 per 100 patients-years at risk) and CV death (2.98, 5.31, 5.69, and 7.60 per 100 patients-years at risk). eGFR slope decreased less in higher baseline KDIGO risk categories (−3.13 in low-, −2.81 in moderate-, −2.17 in high- and −1.61 ml/min/1.73 m2 per year in very high-risk category) (Figure 2).

Empagliflozin reduced the risk of CV death or hospitalizations for HF similarly across KDIGO risk categories (hazard ratio [HR] 0.81; 95% confidence interval [CI] 0.66, 1.01 for low-, HR 0.63; 95% CI 0.52, 0.76 for moderate-, HR 0.82; 95% CI 0.68, 0.98 for high- and HR 0.84; 95% CI 0.71, 1.01 for very high-risk group; P trend=0.299). Similarly, empagliflozin reduced the risk of first HF hospitalization (P trend=0.186), CV death (P trend=0.663) or eGFR slope change (P trend=0.069) across the four groups.

Conclusions

Treatment with empagliflozin reduced the risk for CV death or HF hospitalization and slowed the rate of kidney function decline similarly in all KDIGO CKD risk categories.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance

Effects of empagliflozin in patients with heart failure and preserved ejection fraction according to baseline diuretic use: results from the EMPEROR-Preserved trial

Background

In the EMPEROR-Preserved trial, empagliflozin reduced the risk of hospitalizations for heart failure (HHF) or cardiovascular (CV) death in patients with heart failure and preserved ejection fraction (HFpEF). Almost one in five patients in the trial were not on baseline diuretic therapy.

Purpose

To evaluate the efficacy and safety of empagliflozin according to baseline diuretic treatment, as well as change in diuretic therapy after initiation of empagliflozin.

Methods

Patients were categorized into subgroups as no diuretic and furosemide-equivalent diuretic dose of <40, 40 and >40mg and were compared for first HHF or CV death, HHF, CV death, total HHF, change in eGFR slope, and change in Kansas City Cardiomyopathy Questionnaire – Clinical Summary Scores (KCCQ-CSS) between patients on empagliflozin vs. placebo. Changes in diuretic therapy in the two treatment groups were also compared.

Results

Amongst 5815 patients with data on diuretic dose, 1179 (20%) were on no diuretic, 2039 (35%) were on <40mg, 1700 (29%) were on 40mg, and 897 (15%) were on >40mg at baseline. Patients on higher diuretic doses at baseline were more likely to be diabetic, had a higher body weight and NT-proBNP, and lower estimated glomerular filtration rate (eGFR) on average. Patients on higher diuretic doses also had worse health status based on NYHA class and KCCQ-CSS estimates. The reduction of the risk of CVD or HHF, total HHF, preservation of eGFR, and KCCQ-CSS improvement with empagliflozin were consistent across all doses of diuretics (Table 1). The findings for all outcomes were consistent in patients on diuretics (any dose) vs. not on diuretics. Treatment with empagliflozin was associated with decreased rates of initiation (HR: 0.73 [0.59,0.90; p=0.004) or intensification (HR: 0.74; [0.65, 0.84]; p<0.001) of diuretics, while there were increased rates in permanent discontinuation of diuretics (HR: 1.46 [1.17, 1.82]; p<0.001) or diuretic dose reduction (HR: 1.22 [1.06, 1.42]; p=0.007). The incidence of adverse events were similar between treatment arms, irrespective of baseline use of diuretics. Volume depletion events were more common with empagliflozin amongst patients treated with diuretics (7.4 vs 5.7 events per 100 patient-years for empagliflozin vs placebo).

Conclusion

Empagliflozin improved clinical outcomes and health status in patients with HFpEF irrespective of baseline use of diuretics. Additionally, empagliflozin was associated with increased de-escalation or discontinuation of diuretics and decreased chances of initiation or intensification.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance

The clinically extremely vulnerable to COVID: Identification and changes in healthcare while self-isolating (shielding) during the coronavirus pandemic

ObjectiveIn March 2020, Scottish government identified people clinically extremely vulnerable to COVID due to pre-existing health conditions. These people were advised to strictly self-isolate (shield) at home. We examined who was identified as clinically extremely vulnerable, how their healthcare changed during isolation, and whether this process exacerbated healthcare inequalities. ApproachWe linked all individuals on the shielding register in NHS Grampian to their in-patient and out-patient healthcare records from 2015 through 2020. We analysed the method of patients’ identification as clinically extremely vulnerable (via an algorithmic NHS record scan or designated ad hoc by their care-providers). We measured out-patient, in-patient, and emergency healthcare attendances, and compared use rates between two 3-month periods before and during the first strict isolation period. We evaluated changes in care use between those shielding and the general non-shielding population, and differences between shielding sub-populations (by clinical reason for shielding, age, sex, and socio-economic deprivation). ResultsThe shielding register included 16,092 people (3% of the population). 42% of people on the register were not identified by national healthcare record screening, including the majority of cancer and immunocompromised patients. People added to the register by their care-providers were more likely to be young and less economically-deprived. Shielders’ healthcare use decreased during isolation (rate compared to pre-isolation: 0.65 out-patient, 0.54 scheduled in-patient; 0.75 emergency in-patient; 0.71 A&E). However, people shielding had better maintained care than the non-shielding population (e.g. RR 2.9 for scheduled in-patient care). There were inequalities in whose scheduled care was maintained while shielding: younger people and those with cancer had significantly higher visit rates. However, there were no differences in care-preservation between men and women or between socioeconomic deprivation levels. ConclusionsThe reliance on emergency care while shielding indicates that, overall, continuity of care for existing conditions was not optimal. However, there was notable success in maintaining care for cancer. We suggest that integrating demographic and primary care data would improve identification of the clinically vulnerable and help equitably prioritise care.

Inequalities in children’s mental health prescribing and referrals for specialist mental health services

Objective1 in 8 young people in the United Kingdom are estimated to have a diagnosable mental health condition. Prevalence is increasing over time, many are untreated, and need is not evenly distributed across the population. We aimed to investigate trends in children’s mental health prescribing and referrals to specialist outpatient services. ApproachWe linked individual-level healthcare administrative records on community prescribing and referrals to outpatient Child and Adolescent Mental Health Services (CAMHS). The study cohort included all children aged 2 through 17 in the NHS Grampian Health Board region from 2015 to 2021 (average annual population circa 100,000) with a mental health prescription or CAMHS referral. We measured prevalence of mental health prescribing and referrals to CAMHS over time. We investigated demographic and socioeconomic differences, including comparison of rates by age, sex, and residential area deprivation. We also investigated socioeconomic and demographic differences in referral acceptance and rejection. ResultsPrescriptions for mental health drugs have risen 40%: from 5,000 per month in 2015 to 7,000 in 2021. 75% of prescriptions to primary schoolers are to boys, mostly for attention deficit hyperactivity disorder medications. Prescriptions to girls rise during secondary school, mostly for anti-depressants. Prescribing rates are 2.6-fold higher in the most versus least deprived areas. Referrals to CAMHS have risen 20% over the study period, and the proportion of referrals rejected has increased from 18% to 31% – leaving the number of children accepted to specialist care stable. Boys are referred twice as often at younger ages, while girls’ referrals spike during puberty. Since 2015, boys have been referred less and rejected more, with girls now making up 61% of those treated. Referral rates are two-fold higher in the most versus least deprived areas. ConclusionsBoth mental health prescribing and referrals to CAMHS have increased in this population, but the CAMHS service size remained fixed. Presentation and treatment patterns vary dramatically by age and sex, and socioeconomic inequalities are clear and persistent.

997 Audit Examining the Treatment of Patients Who Developed Post Operative Complications Following Appendicectomy

Aim

To identify trends in management of patients with post operative complications following appendicectomy in a district general hospital.

Method

The coding department identified patients who were admitted with appendicitis in the previous year and those who developed post operative complications. Data was gathered retrospectively from these patients using their online records.

Results

Coding identified 270 patients that were admitted between 22/10/20–29/10/21 with appendicitis. 19 patients had post operative complications. 9 had intra-abdominal collections, 5 had wound infections/collections, 3 had an ileus.

15/19 patients with complications underwent imaging, 8 had CT scans and 7 had US scans. Patients waited a mean of 0.4 days between presentation and imaging. Patients waited a mean of 2.2 and median of 0 days between imaging and appendicectomy.

12 patients had complicated appendicitis, 6 had simple appendicitis and 1 had a normal appendix. 16 patients had antibiotics pre and post operatively, 3 did not. The mean length of stay was 5.6 days for patients with complications, compared to a mean length of stay of 3.9 days for all patients with appendicitis.

Conclusions

Early identification and management of appendicitis reduces morbidity, and our centre appears to have lower than average complication rates. The patients who did develop complications, were generally imaged and operated on efficiently

An area of improvement is ensuring all patients undergoing appendicectomies are given at least one preoperative dose of antibiotics and up to 3–5 days post operatively if complicated as per WSES guidelines. We aim to re-audit this after an education drive within our department.

Rare case of cystic anterior mediastinal tuberculosis in an immunocompetent patient

We report a case of a 28-year-old immunocompetent woman found to have a mediastinal lesion on chest x-ray performed as part of a visa renewal process. Computed tomographic imaging revealed a cystic superior anterior mediastinal mass. Although initially asymptomatic, the woman subsequently developed progressive chest discomfort. She underwent surgical resection of the mass. Histological assessment demonstrated necrotizing granulomatous inflammation, while Gene Xpert™ testing was positive for Mycobacterium tuberculosis complex and she was subsequently commenced on anti-tuberculous therapy.

Pragmatic Diagnostic and Therapeutic Algorithms to Optimize New Potassium Binder use in Cardiorenal Disease

BACKGROUND

Pivotal randomized trials demonstrating efficacy, safety and good tolerance, of two new potassium binders (patiromer and sodium zirconium cyclosilicate) led to their recent approval. A major hurdle to the implementation of these potassium-binders is understanding how to integrate them safely and effectively into the long-term management of cardiovascular and kidney disease patients using renin angiotensin aldosterone system inhibitors (RAASi), the latter being prone to induce hyperkalaemia.

METHODS

a multidisciplinary academic panel including nephrologists and cardiologists was convened to develop consensus therapeutic algorithm(s) aimed at optimizing the use of the two novel potassium binders (patiromer and sodium zirconium cyclosilicate) in stable adults who require treatment with RAASi and experience(d) hyperkalaemia in a non-emergent setting.

RESULTS

Two dedicated pragmatic algorithms are proposed. The lowest intervention threshold (i.e. 5.1mmol/L or greater) was the one used in the patiromer and sodium zirconium cyclosilicate) pivotal trials, both drugs being indicated to treat hyperkalaemia in a non -emergent setting. Acknowledging the heterogeneity across specialty guidelines in hyperkalaemia definition and thresholds to intervene when facing hyperkalaemia, we have been mindful to use soft language i.e. "it is to consider", not necessarily "to do".

CONCLUSIONS

Providing the clinical community with pragmatic algorithms may help optimize the management of high-risk patients by avoiding the risks of both hyper and hypokalaemia and of suboptimal RAASi therapy.

Simultaneous measurements of myocardial glucose metabolism and extracellular volumes with hybrid PET/MRI using concurrent injections of Gd-DTPA and [18F]FDG

BACKGROUND

The aims of this study were to investigate the application of a constant infusion (CI) to mitigate the issue of constantly changing Gd-DTPA contrast levels in a bolus injection for extracellular volume (ECV) measurements by (a) comparing a CI alone to a bolus alone and a bolus followed by CI in healthy myocardium, (b) evaluating the impact of glucose suppression using heparin on ECV.

METHODS

Five healthy canine subjects were imaged to compare three different protocols for injecting Gd-DTPA and FDG: bolus alone, CI alone, bolus followed by CI. Suppression of myocardial glucose uptake was induced using a continuous infusion of 20% lipid at a rate of 0.25 mL·min-1·kg-1 as well as 2000 units of intravenous heparin injected 20 minutes prior to FDG/Gd-DTPA injection.

RESULTS

There was no significant effect on ECV measurement when heparin was used for glucose suppression at equilibrium irrespective of infusion protocol). Measurements of ECV in myocardium, regardless of infusion protocol showed no significant difference at all time points (P = 0.21) prior to washout.

CONCLUSIONS

The suppression of myocardial uptake of [18F]FDG with heparin did not alter the determination of myocardial ECV though a larger sample size may show differences. Further, the infusion protocol (bolus or constant infusion) had no effect on the calculated ECV.

Tracking the progress of inflammation with PET/MRI in a canine model of myocardial infarction

BACKGROUND

Following myocardial infarction, tissue undergoes pathophysiological changes involving inflammation and scar tissue formation. However, little is known about the pathophysiology and prognostic significance of any corresponding changes in remote myocardium. The aim of this study was to investigate the potential application of a combined constant infusion of 18F-FDG and Gd-DTPA to quantitate inflammation and extracellular volume (ECV) from 3 to 40 days after myocardial infarction.

METHODS

Eight canine subjects were imaged at multiple time points following induction of an MI with a 60-minute concurrent constant infusion of Gd-DTPA and 18F-FDG using a hybrid PET/MRI scanner.

RESULTS

There was a significant increase in ECV in remote myocardium on day 14 post-MI (P = .034) and day 21 (P = .021) compared to the baseline. ECV was significantly elevated in the infarcted myocardium compared to remote myocardium at all time points post-MI (days 3, 7, 14, 21, and 40) (P < .001) while glucose uptake was also increased within the infarct on days 3, 7, 14, and 21 but not 40.

CONCLUSIONS

The significant increase in ECV in remote tissue may be due to an ongoing inflammatory process in the early weeks post-infarct.

Measurement of the Nucleon F_{2}^{n}/F_{2}^{p} Structure Function Ratio by the Jefferson Lab MARATHON Tritium/Helium-3 Deep Inelastic Scattering Experiment

The ratio of the nucleon F_{2} structure functions, F_{2}^{n}/F_{2}^{p}, is determined by the MARATHON experiment from measurements of deep inelastic scattering of electrons from ^{3}H and ^{3}He nuclei. The experiment was performed in the Hall A Facility of Jefferson Lab using two high-resolution spectrometers for electron detection, and a cryogenic target system which included a low-activity tritium cell. The data analysis used a novel technique exploiting the mirror symmetry of the two nuclei, which essentially eliminates many theoretical uncertainties in the extraction of the ratio. The results, which cover the Bjorken scaling variable range 0.19<x<0.83, represent a significant improvement compared to previous SLAC and Jefferson Lab measurements for the ratio. They are compared to recent theoretical calculations and empirical determinations of the F_{2}^{n}/F_{2}^{p} ratio.

Efficacy of intravenous ferric carboxymaltose in patients with acute heart failure and iron deficiency with and without anaemia: a subgroup analysis of AFFIRM-AHF

Background

Iron deficiency is associated with increased morbidity and mortality in patients with acute heart failure (HF), even in the absence of anaemia.

Purpose

This prespecified subanalysis of the AFFIRM-AHF trial investigated the effects of ferric carboxymaltose (FCM) on recurrent HF hospitalisations and cardiovascular (CV) mortality in patients with and without anaemia defined as baseline haemoglobin (Hb) &lt;12 g/dL, ≥12 g/dL.

Methods

In total, 1108 patients (558 FCM, 550 placebo) were included in the modified intention-to-treat AFFIRM-AHF analysis. The primary outcome was a composite of total HF hospitalisations and CV death, evaluated up to 52 weeks post-randomisation.

Results

Of the 1108 patients, 228 and 329 in the FCM group and 236 and 314 in the placebo group had Hb &lt;12 g/dL and ≥12 g/dL at baseline, respectively. For patients with a baseline Hb ≥12 g/dL, the total number of HF hospitalisations and CV death was 156 and 201 in the FCM and placebo groups, respectively, with a rate ratio (95% confidence interval) of 0.67 (0.48–0.93; p=0.016). For patients with Hb &lt;12 g/dL, this was 136 and 171 in the FCM and placebo groups, respectively (0.97 [0.66–1.41; p=0.862]). This treatment effect was consistent for all secondary outcomes in patients in the FCM group vs placebo, for both Hb subgroups (Figure).

Conclusion

Iron deficiency treatment with FCM following acute HF reduced the risk of HF hospitalisations and CV death, irrespective of Hb level at baseline.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Vifor Pharma Ltd. Figure 1

Efficacy and safety of vericiguat in patients with HFrEF treated with sacubitril/valsartan: results from the VICTORIA trial

Background

In the VICTORIA trial (n=5050) the reduction in the primary composite endpoint of cardiovascular death (CVD) or heart failure hospitalization (HFH) was similar whether or not patients received sacubitril/valsartan. The distribution of those patients who received sacubitril/valsartan after randomization (drop-ins) and the relationship to the efficacy and safety of vericiguat is unknown.

Purpose

We assessed the efficacy and safety of vericiguat in patients who were or were not treated with sacubitril/valsartan at baseline in the VICTORIA trial and the implications of post- randomization use of sacubitril/valsartan.

Methods

A total of 5040 patients were analyzed according sacubitril/valsartan use at randomization or initiated after randomization. The efficacy of vericiguat on the primary composite endpoint and its components, time to first HF hospitalization or all-cause mortality, were assessed according to sacubitril/valsartan use. Safety outcomes included symptomatic hypotension, syncope, worsening renal function, and hyperkalemia.

Results

Overall, 731 patients (360 on vericiguat and 371 on placebo) received sacubitril/valsartan at randomization. Patients treated with sacubitril/valsartan were twice as likely to be from Western Europe or North America, to have a lower ejection fraction and systolic and diastolic blood pressures, were more often on triple therapy (65.9 vs 58.6%), and more likely to have received biventricular pacing (17.9 vs 14.1%) or ICDs (42.3 vs 25.3%). For patients on sacubitril/valsartan at baseline, the adjusted hazard ratios for vericiguat's treatment effect on the primary composite outcome, CVD, and HFH was 0.94 (95% CI 0.74–1.20), 0.81 (95% CI 0.55–1.20) and 0.99 (95% CI 0.76–1.30), respectively. For those patients not on sacubitril/valsartan (2161 vericiguat; 2148 on placebo), the corresponding adjusted hazard ratios for vericiguat's treatment effect on the primary composite outcome, CVD, and HFH were 0.89 (0.80–0.98), 0.95 (0.82–1.11), and 0,87 (0.78–0.98), respectively. There was no significant interaction on the treatment effect of vericiguat based on the use of sacubitril/valsartan. More placebo patients (n=238) received drop-in use of sacubitril/valsartan than vericiguat group (n=187; p=0.007) post-randomization during follow-up (Figure). Overall, adverse events in the 992 patients receiving sacubitril/valsartan (at either baseline or drop-in for at least 3 months) were not significantly different according to those on placebo vs vericiguat for symptomatic hypotension (21.0% vs 23.1), renal dysfunction (8.0 vs 9.0%), and hyperkalemia (10.3 vs 7.9%).

Conclusions

Sacubitril/valsartan use was initiated more frequently after randomization in patients on placebo than on vericiguat. Concomitant use of sacubitril/valsartan did not alter the efficacy of vericiguat and was similarly tolerated in both study arms.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck & Co., Inc. and Bayer

Hemoglobin, anemia, and clinical outcomes in vericiguat global study in subjects with heart failure with reduced ejection fraction (VICTORIA)

Background

In the VICTORIA trial of patients with HFrEF after a worsening HF event, anemia occurred more often in patients treated with vericiguat (7.6%) compared with placebo (5.7%). We explored the association between vericiguat, baseline hemoglobin, and anemia and also whether hemoglobin was related to the benefit of vericiguat in HF.

Methods

Anemia was defined as a hemoglobin &lt;13.0 g/dL in men and &lt;12.0 g/dL in women (WHO anemia). Adverse events reported as new anemia were also evaluated (AE anemia). We evaluated the risk-adjusted relationship between baseline hemoglobin (as both quartiles and continuous variable), hematocrit, and hematinic indices with the primary outcome (composite of cardiovascular death or heart failure hospitalization). Time-updated hemoglobin relationship was also examined.

Results

Of 4812 patients with baseline hemoglobin data available, 1719 (35.7%) were WHO anemic; median hemoglobin was 13.4 g/dL (IQR 12.1 to 14.7 g/dL). In total, 1643 patients had WHO anemia at 16 weeks (of which 284 were new from baseline for vericiguat and 219 for placebo) and this occurred more often in the vericiguat group than the placebo group (P&lt;.001). Subsequently, there was no further decline in hemoglobin over the 96 weeks of follow-up (Figure A). The ratio of hemoglobin/hematocrit remained constant and none of the hematinic indices including red cell density width, mean corpuscular volume, white blood cell or platelet counts changed over time. Overall, AE anemia occurred in 342 patients (7.1%) and was more frequent in those with a lower baseline hemoglobin (hemoglobin Q1: 184 [14.5%], Q2: 94 [7.9%], Q3: 40 [3.4%], Q4: 24 [2.1%]; p&lt;.001). Whereas outcomes were associated, quartiles of baseline hemoglobin were not related to the treatment benefit of vericiguat (compared with placebo) for the primary outcome (Figure B). Additionally, analysis of the time-updated hemoglobin values revealed no association with the treatment effect of vericiguat (compared with placebo) on the primary outcome.

Conclusions

Anemia was present at baseline in over one-third of patients in the VICTORIA trial and was generally mild. Lower hemoglobin was associated with greater frequency of clinical events. Although vericiguat modestly lowered hemoglobin by 16 weeks, this effect did not further progress nor influence the association of benefit of vericiguat.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck & Co., Inc. and Bayer

Vericiguat and health status outcomes in heart failure with reduced ejection fraction: insights from the VICTORIA trial

Background

In the VICTORIA trial, vericiguat compared with placebo reduced the risk of the primary endpoint of cardiovascular death (CVD) or hospitalization for heart failure (HFH) among 5050 patients with worsening HF with reduced ejection fraction (HFrEF).

Purpose

We evaluated whether the efficacy of vericiguat on clinical outcomes varied according to participants' baseline health status, as assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ)-23, and how vericiguat affected health status post-randomization.

Methods

KCCQ-23 was completed at randomization and at 4, 16, and 32 weeks. Patients were grouped based on tertiles of baseline KCCQ total symptom score (TSS; &lt;55.2, 55.2–79.2, and &gt;79.2), clinical summary score (CSS; &lt;52.1, 52.1–76.0, and &gt;76.2) and overall summary score (OSS; &lt;48.5, 48.5–70.8, and &gt;70.8) across tertiles 1–3, respectively. Cox proportional hazard models were performed for the tertiles to evaluate the effects of vericiguat on the primary outcomes.

Results

Overall 4741, 4664, and 4470 participants had KCCQ-TSS (median 68.8 [interquartile range 47.9, 85.4]), KCCQ-CSS (65.6 [45.8, 81.8]) and KCCQ-OSS (59.9 [42.0, 77.1]) available at baseline. Vericiguat reduced CVD or HFH risk across baseline KCCQ-TSS (P=0.21), KCCQ-CSS (P=0.13) and KCCQ-OSS (P=0.65) tertiles (Table). The effect of vericiguat on HFH alone was also not modified by baseline KCCQ-TSS, CSS and OSS (all P&gt;0.05) scores. At 4 weeks after randomization, improvement in both vericiguat and placebo arms was seen in KCCQ-TSS (vericiguat 6.3 vs. placebo 6.3; P=0.85), KCCQ-CSS (vericiguat: 5.7 vs. placebo 5.7, P=0.54), and KCCQ-OSS (vericiguat 6.3 vs. placebo 5.7, P=0.36). Similar results were seen at weeks 16 and 32.

Conclusion

Vericiguat reduced the risk of the composite outcome of CVD or HFH as well as HFH alone across the range of baseline health status. Addition of vericiguat to best standard of care did not significantly improve health status compared with standard of care alone in HF patients with a recent worsening event. The early improvement in KCCQ seen in both randomized groups underscore the need to assess trajectory of health status changes in the spectrum of patients with HFrEF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Merck & Co., Inc. and Bayer

1046 Anterior Lumbar Interbody Fusion Approaches: A Systematic Review

Aim

Anterior lumbar interbody fusion (ALIF) is a well-established alternative to posterior-based interbody fusion techniques, with approach variations, such as retroperitoneal; transperitoneal; open; and laparoscopic well described. Variable rates of complications for each approach have been enumerated in the literature. We aim to elucidate the comparative rates of complications across approach type.

Method

A systematic review of the search databases Pubmed; google scholar; and OVID Medline was made in November 2020 to identify studies related to complications associated with anterior lumbar interbody fusion. PRISMA guidelines were utilised for this review. Studies eligible for inclusion were agreed by two independent reviewers. Meta-analysis was used to compare intra- and postoperative complications with ALIF for each approach.

Results

4575 studies were identified, with 5728 patients across 31 studies included for review following application of inclusion and exclusion criteria. Meta-analysis demonstrated the transperitoneal approach resulted in higher rates of Retrograde Ejaculation (RE) (p &lt; 0.001; CI = 0.05-0.21) and overall rates of complications (p = 0.05; CI = 0.00-0.23). Rates of RE were higher at the L5/S1 intervertebral level. Rates of vessel injury were not significantly higher in either approach method (p = 0.89; CI=-0.04-0.07). Laparoscopic approaches resulted in shorter inpatient stays (p = 0.01).

Conclusions

Despite the transperitoneal approach being comparatively underpowered, its use appears to result in a significantly higher rate of intra- and postoperative complications, although confounders including use of BMP and spinal level should be considered. Laparoscopic approaches resulted in shorter hospital stays, however its steep learning curve and longer operative time have deterred surgeons from its widespread adaptation.

519 Outcomes of Management with Ilizarov Frames in Bone Infection: An Observational Study

Aim

The successful treatment and eradication of bone infection requires a multifaceted approach and may recur even after excision if resultant bone void is not managed effectively. This paper aims to review the clinical effectiveness of antibiotic-impregnated bone void filler and current empirical antibiotic guidelines.

Method

We report a retrospective study of 18 patients with chronic osteomyelitis following injury or surgery managed via Ilizarov Ring Fixator (IRF). All patients were managed by IRF stabilisation procedures with debridement, microbiological sampling, and bone void filling with antibiotic-impregnated biocomposite material, in addition to culture-specific systemic antimicrobial therapy.

Results

Patients were followed up for a mean of 15.9 months. Infection was eradicated in 94.1% of patients in a grossly comorbid demographic. Comorbidities associated with increased risk of osteomyelitis were noted in 72.2% of patients. Anaerobic bacteria were identified in culture for four (22.2%) of the 18 patients.

Conclusions

We detected a higher than suspected growth of anaerobes in our samples, suggesting the need for metronidazole in empirical antibiotic treatment. This study would suggest that the use of STIMULAN® may be preferable in this National Health Service from a cost-effect perspective, as our results are comparable to those using other bone void fillers.

965 Complication Rates in Operatively Managed Ankle Fracture/Dislocations - The Effect of Pre-Reduction Imaging and Compliance with BOAST 12 Guidance

Aim

The BOAST-12 guidelines for the management of ankle fractures aims to optimise functional recovery and reduce complications. They advise against having radiographs prior to urgent reduction of clinically deformed ankles as it could cause an unacceptable delay to subsequent management. Our study aimed to assess the effect of time to acceptable reduction on the risk of complications and time to definitive reduction.

Method

This was a retrospective observational study of patients with ankle fracture-dislocations between 2013 to 2017 at the Northern General Hospital’s Emergency Department (ED). Information collected from 2 patient groups (with and without pre-reduction radiographs), included patient demographics, time to accepted reduction, number of manipulations, operations, and subsequent complications.

Results

242 patients were identified. Time from arrival in ED to acceptable reduction was significantly longer in patients with pre-reduction radiographs versus patients without (184.5 vs 82 minutes, p &lt; 0.00), but did not increase the overall risk of complications (p = 0.62). Pre-reduction radiographs were associated with insignificantly higher rates of post-traumatic osteoarthritis (p = 0.17) and slightly longer wait time for definitive intervention (1 vs 2 days, p = 0.72). However, this had no relationship with the number of manipulations (p = 0.53).

Conclusions

The use of pre-reduction radiographs significantly increased time to acceptable reduction of ankle fracture-dislocations. However, this was not associated with increased risk of complications or time to definitive management.

1044 Impact of Obesity on Complications from Anterior Lumbar Interbody Fusion

Aim

Anterior Lumbar Interbody Fusion is a procedure growing in popularity for conditions including degenerative disc disease, and discogenic back pain. Obesity is a significant risk factor in the development of back pain, with patients with raised BMIs at increased of complications using the posterior approach. This review aims to evaluate the risk profile of this patient cohort using the anterior approach for lumbar interbody fusion.

Method

A systematic review of the search databases Pubmed; google scholar; and OVID Medline was carried out between September 2020-November 2020. Studies evaluating the risks associated with obesity during Anterior Lumbar Interbody Fusion (ALIF) were identified and included for review according to PRISMA guidelines. Studies eligible for inclusion were agreed by two independent reviewers. Meta-analysis was used to compare intra- and postoperative complications in patients with increased BMI during ALIF.

Results

Search terms yielded 435 articles for evaluation. 13 studies were included in this review after applying inclusion and exclusion criteria. Meta-analysis of studies demonstrated a significantly increased risk profile for overall complications in the obese patient cohort (CI = 0.04-0.16, p = 0.002) with significant heterogeneity (I2=86%). Patients with increased BMI were not significantly more likely to develop Vascular complications (CI= -.03-0.02, p = 0.62). Simple pooling demonstrated significant association between increased BMI and blood loss.

Conclusions

Obesity was demonstrated to have an impact on overall complication rates in Anterior Lumbar Interbody Fusion procedures, with postoperative complications including wound infections and lower fusion rates more common in patients in increased BMIs.

Altered inflammasome activation in neonatal encephalopathy persists in childhood

Neonatal encephalopathy (NE) is characterized by altered neurological function in term infants and inflammation plays an important pathophysiological role. Inflammatory cytokines interleukin (IL)‐1β, IL‐1ra and IL‐18 are activated by the nucleotide‐binding and oligomerization domain (NOD)‐, leucine‐rich repeat domain (LRR)‐ and NOD‐like receptor protein 3 (NLRP3) inflammasome; furthermore, we aimed to examine the role of the inflammasome multiprotein complex involved in proinflammatory responses from the newborn period to childhood in NE. Cytokine concentrations were measured by multiplex enzyme‐linked immunosorbent assay (ELISA) in neonates and children with NE in the absence or presence of lipopolysaccharide (LPS) endotoxin. We then investigated expression of the NLRP3 inflammasome genes, NLRP3, IL‐1β and ASC by polymerase chain reaction (PCR). Serum samples from 40 NE patients at days 1 and 3 of the first week of life and in 37 patients at age 4–7 years were analysed. An increase in serum IL‐1ra and IL‐18 in neonates with NE on days 1 and 3 was observed compared to neonatal controls. IL‐1ra in NE was decreased to normal levels at school age, whereas serum IL‐18 in NE was even higher at school age compared to school age controls and NE in the first week of life. Percentage of LPS response was higher in newborns compared to school‐age NE. NLRP3 and IL‐1β gene expression were up‐regulated in the presence of LPS in NE neonates and NLRP3 gene expression remained up‐regulated at school age in NE patients compared to controls. Increased inflammasome activation in the first day of life in NE persists in childhood, and may increase the window for therapeutic intervention.

108 A Multidisciplinary Team Initiative to End PJ Paralysis Was Successful in Achieving Cultural Change on An Acute Geriatric Ward

Introduction

Prolonged bedrest amongst the elderly causes deconditioning leading to; increased hospital length of stay, additional social costs and decreased quality of life. An audit on an acute geriatric ward in November 2018, found that over a third of patients medically fit (PMF) to sit out remained in bed all day. Therefore, a service development initiative was undertaken, addressing the misconception that keeping elderly patients in bed is safe, when in fact, unintentional harm results.

Method

In a root cause analysis, four main reasons for bedrest were identified: risk aversion, unknown function, widespread “bed is safe” culture and lack of equipment. The project tasked getting PMF out of bed each day and was audited daily from November 2018 to present, involving all members of the multi-disciplinary team (MDT) and using a “plan, do, study, act” approach.

Results

Initially, the project showed an increase in percentage of PMF sitting out each day, but this subsequently decreased with winter pressures. However, for a whole year (February 2019–February 2020) a sustained and significant improvement was achieved (64.3%–89.7%). The pre-COVID19 period (February–March 2020) saw fluctuations in PMF sitting out. Data collection halted during the COVID19 peak, although observationally most patients remained in bed. Auditing resumed from June 2020 (COVID19 recovery phase) which showed a steady increase in PMF out of bed, with recent figures surpassing pre-COVID19 levels (97.8%).

Conclusion

Cultural change takes time to embed and needs persistent reviewing by a dedicated and engaged MDT. Improvements were made through more accessible doctor’s advice, better MDT education and communication, daily feedback of data and sourcing additional equipment. Disruption to working patterns over the COVID19 period made this unachievable and the project lost impetus. In the COVID19 recovery phase, the specialized MDT reformed and worked successfully to restore the cultural change as evidenced by audited data.

Exploring Staff Implementation of a Self-directed Parenting Intervention for Parents with Mental Health Difficulties

Parents with mental health difficulties face significant barriers in accessing evidence-based parenting interventions. Self-directed approaches may be a destigmatising, accessible alternative. Evidence has suggested that Triple P Positive Parenting Programme's self-directed format is as effective as more time- and cost-intensive delivery methods. The aim of the current study was to establish whether staff were able to use this intervention with parents with mental health difficulties and to explore staff experiences of implementation. Triple P self-help workbooks were provided to practitioners across three teams. Data were collected regarding workbook uptake and use. Interviews with staff exploring their experiences of implementation were analysed using thematic analysis. Overall, 41 participants were recruited, of which 12 (29.27%) also consented to interviews. Overall, six practitioners (14.63%) reported that they utilised the workbook. Uptake and utilisation were varied, but practitioners who used the workbook reported positive outcomes. Interviews revealed themes regarding practitioner concerns, views of the intervention and implementation issues. Self-directed Triple remains a promising intervention but its feasibility is dependent on addressing barriers to implementation and facilitating a family-focused approach to meet the needs of these parents and their children.

Impact of Substance Use Disorder on Quality of Inpatient Mental Health Services for People With Anxiety and Depression

Objective: Substance use disorders are commonly comorbid with anxiety and depressive disorders and are associated with poor treatment outcomes. The mechanisms underlying this association remain unclear-one possibility is that patients with anxiety/depressive disorders and substance use disorders receive poorer treatment. Concerns have been raised about the quality of inpatient care received by patients with substance use disorders. The purspose of this research was to examine the quality of care received by inpatients with an anxiety or depressive disorder, comparing subgroups with or without a comorbid substance use disorder. Methods: This was a retrospective case-note review of 3,795 patients admitted to inpatient psychiatric wards in England. Data were gathered on all acute admissions with anxiety/depressive illness over a 6-month period, for a number of measures of quality of care derived from national standards. Association of coexisting substance use disorders with a variety of quality of care outcomes (relating to assessment, care planning, medication management, psychological therapies, discharge, crisis planning, and follow-up) was investigated using multivariable regression analyses. Results: In all, 543 (14.3%) patients in the study had a secondary diagnosis of a substance use disorder. Patients with substance use disorders were less likely to have had care plans that were developed jointly (i.e., with input from both patient and clinician; odds ratio [OR] = 0.76, 95% confidence interval [CI] [0.55, 0.93], p = .034) and less likely to have had their medication reviewed either during the admission (OR = 0.83, 95% CI [0.69, 0.94], p = .030) or at follow-up after discharge (OR = 0.58, 95% CI [0.39, 0.86], p = .007). Carers of patients with substance use disorders were less likely to have been provided with information about available support services (OR = 0.79, 95% CI [0.57, 0.98], p = .047). Patients with substance use disorders were less likely to have received adequate (at least 24 hours) notice in advance of their discharge (OR = 0.72, 95% CI [0.54, 0.96], p = .033), as were their carers (OR = 0.63, 95% CI [0.41, 0.85], p = .007). They were less likely to have a crisis plan in place at the point of discharge (OR = 0.85, 95% CI [0.74, 0.98], p = .044). There was also strong evidence that patients with substance use disorders were less likely to have been referred for psychological therapy (OR = 0.69, 95% CI [0.55, 0.87], p = .002). Conclusions: We found evidence of poorer quality of care for inpatients with anxiety and depressive disorders with comorbid substance use disorders, highlighting the need for more to be done to support these patients. Discrepancies in care quality may be contributed to the poor treatment outcomes experienced by patients with substance use disorders, and strategies to reduce this inequality are necessary to improve the well-being of this substantial patient group.

Same day comparison of PET/CT and PET/MR in patients with cardiac sarcoidosis

BACKGROUND

Inflammatory cardiac disorders, in particular, sarcoidosis, play an important role in left ventricular dysfunction, conduction abnormalities, and arrhythmias. In this study, we compared the imaging characteristics and diagnostic information obtained when patients were imaged sequentially with PET/CT and then with hybrid PET/MRI on the same day following a single 18F-FDG injection.

METHODS

Ten patients with known or suspected sarcoidosis underwent imaging in sequence of (a) 99mTc-MIBI, (b) 18F-FDG with PET/CT, and (c) 18F-FDG with 3T PET/MRI. Images were compared quantitatively by determination of SUVmax and SUV on a voxel by voxel basis, and qualitatively by two experienced observers.

RESULTS

When both platforms were compared quantitatively, similar data for the evaluation of enhanced 18F-FDG uptake were obtained. Qualitatively, there were (1) several instances of normal perfusion with delayed enhancement and/or focal 18F-FDG uptake, (2) comparable enhanced 18F-FDG uptake on PET/CT vs. PET/MRI, and (3) diversity in disease patterns with delayed enhancement only, increased 18F-FDG uptake only, or both.

CONCLUSION

In this limited patient study, PET/CT and PET/MR provided similar diagnostic data for 18F-FDG uptake, and the concurrent acquisition of MR images provided further insight into the disease process.

Impact of polyvascular disease and renal dysfunction on cardiovascular outcomes in diabetes: post hoc analyses from EMPA-REG OUTCOME

Background

Individuals with polyvascular disease and impaired renal function are at high risk of cardiovascular (CV) events, but this relationship is not well investigated in people with type 2 diabetes (T2D). Furthermore, the impact of polyvascular disease plus renal dysfunction on the risk for hospitalisation for heart failure (HHF) remains unclear.

Purpose

We investigated this in a post hoc analysis of the EMPA-REG OUTCOME trial in which empagliflozin reduced risk of CV death and HHF versus placebo in people with T2D and vascular disease. In addition, we explored the treatment effect of empagliflozin on CV, HF and mortality outcomes across the spectrum of baseline polyvascular disease and impaired renal function.

Methods

Patients with T2D, CV disease and estimated glomerular filtration rate (eGFR) of ≥30 ml/min/1.73 m2 received empagliflozin 10 mg, 25 mg, or placebo. Vascular beds (VBs) were defined as coronary artery disease, peripheral artery disease, and cerebrovascular disease (Fig). By use of Cox regression, we explored the association between baseline eGFR &lt; or ≥60 ml/min/1.73 m2, with or without polyvascular disease (1 vs ≥2 VBs involved), and CV death, HHF, CV death (excl. fatal stroke)/HHF, and all-cause mortality (ACM), as well as the treatment effect of empagliflozin versus placebo on these outcomes.

Results

Patients with ≥2 VBs involved and eGFR &lt;60 ml/min/1.73 m2 [n=463], were slightly older (mean age 68.2 vs. 64.3 or 62.6 years), had T2D duration &gt;10 years more often (73.4% vs. 63.2% or 54.9%), and a higher HF prevalence at baseline (19.4% vs. 11.1% or 9.2%) versus those with ≥2 VBs involved and eGFR ≥60 ml/min/1.73 m2 [n=866], or those with only 1 VB involved regardless of eGFR [n=5630], respectively. However, characteristics were generally balanced between treatment groups. Notably, co-existing polyvascular disease and eGFR &lt;60 ml/min/1.73 m2 was strongly associated with increased risk of all outcomes. The placebo incidence rates per 1000 patient-years for CV death were 14.4 (95% CI 10.9, 18.3) and 19.6 (12.8, 27.8) in those with 1 VB involved and eGFR ≥60 or eGFR &lt;60, respectively, and 32.7 (21.7, 45.8), and 52.4 (32.9, 76.5) in those with 2 VBs and eGFR ≥60 or eGFR &lt;60 ml/min/1.73 m2, respectively. Importantly, empagliflozin reduced the risk for all outcomes regardless of number of VBs affected and kidney function (Fig).

Conclusions

Co-existing polyvascular disease and eGFR &lt;60 ml/min/1.73 m2 confer an extremely high risk of CV and all-cause mortality, and HHF. Empagliflozin lowered this risk consistently compared with placebo, regardless of polyvascular disease and impaired kidney function.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boehringer Ingelheim and Eli Lilly and Company Diabetes Alliance