Development of the ehive Digital Health App: Protocol for a Centralized Research Platform

BACKGROUND

The increasing use of smartphones, wearables, and connected devices has enabled the increasing application of digital technologies for research. Remote digital study platforms comprise a patient-interfacing digital application that enables multimodal data collection from a mobile app and connected sources. They offer an opportunity to recruit at scale, acquire data longitudinally at a high frequency, and engage study participants at any time of the day in any place. Few published descriptions of centralized digital research platforms provide a framework for their development.

OBJECTIVE

This study aims to serve as a road map for those seeking to develop a centralized digital research platform. We describe the technical and functional aspects of the ehive app, the centralized digital research platform of the Hasso Plattner Institute for Digital Health at Mount Sinai Hospital, New York, New York. We then provide information about ongoing studies hosted on ehive, including usership statistics and data infrastructure. Finally, we discuss our experience with ehive in the broader context of the current landscape of digital health research platforms.

METHODS

The ehive app is a multifaceted and patient-facing central digital research platform that permits the collection of e-consent for digital health studies. An overview of its development, its e-consent process, and the tools it uses for participant recruitment and retention are provided. Data integration with the platform and the infrastructure supporting its operations are discussed; furthermore, a description of its participant- and researcher-facing dashboard interfaces and the e-consent architecture is provided.

RESULTS

The ehive platform was launched in 2020 and has successfully hosted 8 studies, namely 6 observational studies and 2 clinical trials. Approximately 1484 participants downloaded the app across 36 states in the United States. The use of recruitment methods such as bulk messaging through the EPIC electronic health records and standard email portals enables broad recruitment. Light-touch engagement methods, used in an automated fashion through the platform, maintain high degrees of engagement and retention. The ehive platform demonstrates the successful deployment of a central digital research platform that can be modified across study designs.

CONCLUSIONS

Centralized digital research platforms such as ehive provide a novel tool that allows investigators to expand their research beyond their institution, engage in large-scale longitudinal studies, and combine multimodal data streams. The ehive platform serves as a model for groups seeking to develop similar digital health research programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49204.

The REWRITE Study - REal-WoRld effectIveness of TrifluridinE/tipiracil in Patients with Previously Treated Metastatic Colorectal Cancer

AIMS

In the pivotal RECOURSE trial, trifluridine/tipiracil improved survival outcomes in refractory metastatic colorectal cancer (mCRC), while demonstrating an acceptable toxicity profile. Routine clinical practice evidence is important to support the ongoing value of recently approved medicines. Our objective was to assess the utilisation patterns and real-world effectiveness of trifluridine/tipiracil in previously treated mCRC patients.

MATERIALS AND METHODS

This was a retrospective observational study including consecutive patients who started trifluridine/tipiracil between 1 April 2018 and 30 September 2019 in the medical oncology departments of three major public hospitals in Portugal. The primary outcome measure was overall survival. Associations between overall survival and patient and tumour characteristics were assessed using multivariate Cox regression analyses.

RESULTS

In total, 111 patients were included in the study, with a mean age of 64 years. From these, 45.9% received two prior lines of treatment, 47.8% had three or more previous lines of treatment and 83.6% had Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at baseline. The median duration of trifluridine/tipiracil treatment was 3.7 cycles (95% confidence interval 3.4-4.1). Most patients (80.4%) remained on their planned dose throughout the trifluridine/tipiracil treatment period, fulfilling 100% relative dose intensity. The median overall survival in the total study cohort was 7.9 months (95% confidence interval 6.4-9.8) and the median progression-free survival was 3.4 months (95% confidence interval 3.2-3.9). The median overall survival was significantly higher in patients with a normal serum lactate dehydrogenase (LDH) level (median overall survival 11.2 months for [135, 205] IU/l LDH [95% confidence interval 8.2-NR] and 13.6 months for [205, 251] IU/l LDH [95% confidence interval 8.2-NR]) and in better fitted (ECOG = 0-1) patients (median overall survival 8.0 months; 95% confidence interval 6.7-10.0). The median time to worsening performance status was 6.2 months (95% confidence interval 5.0-8.0). Treatment discontinuation due to adverse events was low (3.1%).

CONCLUSION

Our study confirms the effectiveness of trifluridine/tipiracil in real-life mCRC patients. Overall survival and progression-free survival outcomes are consistent with the efficacy profile reported in the earlier randomised RECOURSE clinical trial. Like other real-world studies, we found no additional safety concerns in the use of trifluridine/tipiracil.

Outcomes of skin cancer excision in frail patients: A retrospective cohort study

BACKGROUND

Non-melanoma skin cancer (NMSC) is the most common cancer type and incidence increases with age. As a consequence, an increasing number of frail patients are being referred for consideration of skin cancer surgery. However, some of these patients may not live long enough to experience benefit from surgery, while being at risk of postoperative complications.

OBJECTIVES

To investigate the treatment burden of surgical excision of skin cancers in frail individuals.

METHODS

We conducted a single-center retrospective cohort study analyzing outcomes of skin cancer excision in frail versus non-frail patients.

RESULTS

Eighty-eight patients were included. The complication rate was higher in frail versus non-frail patients: 12 (27.9%) versus 9 (18.8%), with 5 unplanned postoperative hospital attendances leading to 3 hospital admissions in the frail cohort. Nine patients in the frail group (21%) died within 6 months of their procedure versus no deaths in the non-frail group (p < 0.001 Fisher's Exact test), with no deaths attributed to skin cancer.

CONCLUSION

Treatment-related complications and mortality are common in frail patients after surgical excision of skin lesions clinically suspicious for skin cancer. Careful consideration should be given, and patients should be adequately counseled about treatment risks and alternative management options, including active surveillance, in particular, if the lesions are expected to remain asymptomatic.

A machine learning approach to determine resilience utilizing wearable device data: analysis of an observational cohort

Objective

To assess whether an individual's degree of psychological resilience can be determined from physiological metrics passively collected from a wearable device.

Materials and Methods

Data were analyzed in this secondary analysis of the Warrior Watch Study dataset, a prospective cohort of healthcare workers enrolled across 7 hospitals in New York City. Subjects wore an Apple Watch for the duration of their participation. Surveys were collected measuring resilience, optimism, and emotional support at baseline.

Results

We evaluated data from 329 subjects (mean age 37.4 years, 37.1% male). Across all testing sets, gradient-boosting machines (GBM) and extreme gradient-boosting models performed best for high- versus low-resilience prediction, stratified on a median Connor-Davidson Resilience Scale-2 score of 6 (interquartile range = 5-7), with an AUC of 0.60. When predicting resilience as a continuous variable, multivariate linear models had a correlation of 0.24 (P = .029) and RMSE of 1.37 in the testing data. A positive psychological construct, comprised of resilience, optimism, and emotional support was also evaluated. The oblique random forest method performed best in estimating high- versus low-composite scores stratified on a median of 32.5, with an AUC of 0.65, a sensitivity of 0.60, and a specificity of 0.70.

Discussion

In a post hoc analysis, machine learning models applied to physiological metrics collected from wearable devices had some predictive ability in identifying resilience states and a positive psychological construct.

Conclusions

These findings support the further assessment of psychological characteristics from passively collected wearable data in dedicated studies.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

An evaluation of knowledge of circular economy among Therapeutic Radiographers/Radiation Therapists (TR/RTTs): Results of a European survey to inform curriculum design

INTRODUCTION

Global warming and the increase in greenhouse gases are a current concern worldwide. The healthcare sector constitutes about 4.4% of all emissions. This study aims to evaluate the knowledge, awareness and attitudes of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) regarding environment-related concepts to inform the development of educational curriculum.

METHODS

A validated self-designed survey was distributed to TR/RTTs across Europe by the SAFE EUROPE partners and via social media between October 2021 and February 2022. The survey was divided into six sections: (i) demographics, (ii) knowledge of Circular Economy (CE) and Green Skills (GS), (iii) personal attitudes, (iv) TR/RTTs attitudes, (v) the importance of CE, and (vi) education. Questions consisted of mostly Likert scales complemented with other closed- and open-ended questions.

RESULTS

31%-42% of participants are aware of national and departmental policies in CE and GS concepts. Even though half of the participants considered that they advocate and practice CE, the open questions indicated that participants only focus on waste management, ignoring all the other dimensions of CE in healthcare. Personal attitudes and lifestyles also did not reflect CE. TR/RTTs considered CE practices and GS development essential. However, the suggested academic level at which these skills should be developed was split between High School (44%) and Bachelor's degree (32%).

CONCLUSION

It is essential to raise awareness among TR/RTTs about the various dimensions of CE applied to healthcare: "green transportation", "environment-friendly procurement", "hospital building design", "food process optimisation", "water reduction", "energy efficiency", and "waste management".

IMPLICATIONS FOR PRACTICE

These GS must be developed by TR/RTTs to decrease their impact on the environment. Their training may need to be lifelong, starting during basic high school education and continuing as healthcare professionals after graduation.

Constructing custom-made radiotranscriptomic signatures from CT angiograms: an application in COVID-19 vascular inflammation

Background

Advances in computational methodologies have enabled processing of large datasets originating from imaging studies. However, most imaging biomarkers suffer from a lack of direct links with underlying biology, as they are only observationally correlated with pathophysiology.

Purpose

To develop and validate a novel AI-assisted image analysis platform, by applying quantitative radiotranscriptomics that quantifies cytokine-driven vascular inflammation from routine CT angiograms (CTA) performed as part of clinical care in COVID-19.

Methods

We used this platform to train the radiotranscriptomic signature C19-RS, derived from the perivascular space around the aorta and the internal mammary artery in routine chest CTAs, to best describe cytokine-driven vascular inflammation, defined using transcriptomic profiles from RNA sequencing data from human arterial biopsies (A). This signature was validated externally in 358 clinically indicated CT pulmonary angiograms from patients with or without COVID-19 from 3 different geographical regions.

Results

First, 22 patients who had a CTA before the pandemic underwent repeat CTA <6 months post COVID-19 infection (B). Compared with 22 controls (matched for age, gender, and BMI) C19-RS was increased only in the COVID-19 group (C). Next, C19-RS was calculated in a cohort of 331 patients hospitalised during the pandemic, and was higher in COVID-19 positives (adjusted OR=2.97 [95% CI: 1.43–6.27], p=0.004, D). C19-RS had prognostic value for in-hospital mortality in COVID-19, with HR=3.31 ([95% CI: 1.49–7.33], p=0.003) and 2.58 ([95% CI: 1.10–6.05], p=0.028) in two testing cohorts respectively (E, F), adjusted for clinical factors and biochemical biomarkers of inflammation and myocardial injury. The corrected HR for in-hospital mortality was 8.24 [95% CI: 2.16–31.36], p=0.002 for those who received no treatment with dexamethasone, but only 2.27 [95% CI: 0.69–7.55], p=0.18 in those who received dexamethasone subsequently to the C19-RS based image analysis, suggesting that vascular inflammation may have been a therapeutic target of dexamethasone in COVID-19. Finally, C19-RS was strongly associated (r=0.61, p=0.0003) with a whole blood transcriptional module representing dysregulation of coagulation and platelet aggregation pathways.

Conclusion

We present the first proof of concept study that combines transcriptomics with radiomics to provide a platform for the development of machine learning derived radiotranscriptomics analysis of routine clinical CT scans for the development of non-invasive imaging biomarkers. Application in COVID-19 produced C19-RS, a marker of cytokine-driven inflammation driving systemic activation of coagulation, that predicts in-hospital mortality and identifies people who will have better response to anti-inflammatory treatments, allowing targeted therapy. This AI-assisted image analysis platform may have applications across a wide range of vascular diseases, from infections to autoimmune diseases.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): EPSRC, British Heart Foundation, NIHR

O045 A systematic review of observational management of cutaneous basal cell carcinoma

Background

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of BCC.

Methods

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

Results

From 2529 titles, four full-text articles reporting on 2298 individuals were eligible. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6–12 weeks. Clearance rates ranged from 52–100% for imiquimod and 2–19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

Conclusion

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility adjusted survival following interventional or observational management of BCC.

Take-home message

This systemic review identifies a lack of data reporting outcomes following observational management of BCC, despite possible advantages of this treatment strategy. Future RCTs should compare quality of life outcomes and utility-adjusted survival following interventional or observational management of BCC.

Dissociative and Epileptic seizures: how to distinguish them?

Introduction

Dissociative seizures (DS) are classified as dissociative convulsions within the group of dissociative disorders. Although they share many features with epileptic seizures (ES), they are not a consequence of abnormal brain discharges and may be related to psychogenic causes. DS represent a common diagnostic and are often confounded with ES.

Objectives

The aim of this study is to review the current evidence about the differential diagnosis between DS and ES.

Methods

We conducted a non-sytematic review on the topic, using Pubmed/Medline database.

Results

Studies emphasize a correct diagnosis before treatment of seizures. DS and ES respond differently to anticonvulsant medication and early or incorrect prescription of can even exacerbate DS. Clinical features and a neuropsychiatric history can also help. The presence of a dissociative “stigmata”, such as unexplained sensory loss, may support a non-epileptic diagnosis. EEG videorecording method is the gold standard diagnosis for DS, however often displays rhythmic movement artifacts that may resemble seizure activity and confound the interpretation. The absence of ictal EEG discharges characteristic of epilepsy is a sign of DS. However, this may not be true for some partial ES, particularly those from temporal lobes, whom also tend to report shorter duration of seizures, whereas patients with DPD often describe experiences lasting for hours or longer.

Conclusions

Distinguish DS from ES can be challenging. However, there are features that can help in the differential diagnosis. A correct diagnosis is essential for an adequate therapeutic approach, better prognosis, reduction of medical costs and also a referral to the right medical specialty.

Disclosure

No significant relationships.

How did the Covid-19 Pandemic Impact the Life of Patients with Schizophrenia Spectrum Disorders?

Introduction

Since the first outbreak, the Covid-19 pandemic has had and still has several implications worldwide, particularly in severe mentally ill patients, leading to multiple challenges in their management.

Objectives

We aim to assess the impact and implications of the Covid-19 pandemic on patients with Schizophrenia Spectrum Disorders (SSD) and the treatment recommendations available.

Methods

We conduct an integrative review using PubMed database. Search terms included: “psychosis” AND “COVID-19 pandemic”, “schizophrenia and COVID-19”, “severe mental illness” AND “COVID-19”. The search period was between 1^st January 2020 and 31^th July 2021.

Results

Studies postulated that people with SSD are at a higher risk of COVID-19 infection with a poorer medical and social outcome which is attributed to factors such as higher rates of disadvantageous lifestyle behaviours, medical comorbidities, antipsychotic medication metabolic effects, psychosocial adversities, smaller social networks and poor engagement with general health services. The Covid-19 pandemic also demanded adjustments in treatment guidelines and monitoring, particularly in patients with SSD on Clozapine. Many studies address the importance of psychiatric care and treatment during the pandemic. They emphasize rapid implementation of measures to decrease the risk of COVID-19 transmission and maintain continuity care and research. An individualized and flexible approach is needed to promote safety of SSD patients.

Conclusions

Particular attention is required by clinicians to help SSD patients face the current pandemic situation. Future epidemiological studies are needed in order to better understand the impact of the COVID-19 pandemic in this population and provide proper care.

Disclosure

No significant relationships.

Methylenedioxymethamphetamine-assisted Psychotherapy For Posttraumatic Stress Disorder: A Review

Introduction

Posttraumatic stress disorder (PTSD) is a psychiatric condition which can be developed following traumatic experience. Treatment guidelines have long considered psychotherapy as a first line treatment. Despite that, PTSD remains an illness with high rates of comorbidity. Therefore, exploring novel therapies is of utmost importance.

Objectives

Clarifying methylenedioxymethamphetamine (MDMA)-assisted psychotherapy efficacy in symptom relief in people with PTSD. Explaining clinical MDMA mechanism of action. Assessing safety of MDMA clinical use.

Methods

PubMed database search, with “MDMA for PTSD” keyword expression. 12 Articles published in the last ten years were selected among the 112 best matches. Reference lists of articles were reviewed to identify additional articles.

Results

Mithoefer et al. (2010) carried out the first controlled clinical study with MDMA-assisted psychotherapy in people with PTSD. Twenty patients with treatment-resistant PTSD were selected. They were given either placebo or two or three sessions of MDMA. 83% of the experimental group no longer met the criteria for PTSD (mean remission lasted 45 months without further MDMA doses) compared with 25% of the placebo group. Further studies were also suggestive of improvements in treatment-resistant PTSD patients undergoing MDMA-assisted psychotherapy. MDMA may increase exposure therapy effectiveness, allowing patients to stay emotionally involved while revisiting past traumas without being overwhelmed by anxiety and fear.

Conclusions

To date, MDMA-assisted psychotherapy studies demonstrated consistently positive results. However, they have been carried out with small groups of individuals. Therefore, larger trials should be conducted to assess MDMA’s efficacy and safety for it to become a licensed medicine.

Disclosure

No significant relationships.

A Link Between Gut Microbiota and Schizophrenia

Introduction

Microorganisms distributed in our tissues and fluids make up the human microbiota. During our lifetime, gastrointestinal microbiota acts as an important modulator of brain development and, in turn, adult behavior and health. Immune response may be triggered by gut microbiota, releasing mediators that penetrate the blood-brain barrier (BBB).

Objectives

Understanding if gut microbiota can influence schizophrenia pathogenesis. Clarifying how gut microbiota can influence schizophrenia treatment, and vice-versa.

Methods

PubMed database search, with “gut microbiota and schizophrenia” keyword expression. Eight articles published in the last ten years were selected among the most recent best match results. Reference lists of articles were reviewed to identify additional articles.

Results

There could be an association between the development of gut microbiota starting during pregnancy and schizophrenia pathogenesis, through an immune-mediated process. Schwarz et al. (2018) investigated the differences in faecal microbiota between individuals with first-episode psychosis and controls. They found psychotic patients to have an increased amount of Lactobacillus bacteria. Yuan et al. (2018) studied microbiota changes in patients with schizophrenia, before and after treatment. Individuals diagnosed with schizophrenia had less faecal Bifidobacterium, Escherichia coli and Lactobacillus. After treatment with risperidone, there was a significant increase in the amount of fecal Bifidobacterium and E. Coli.

Conclusions

Microorganisms living inside our gastrointestinal tract are vital for proper central nervous system (CNS) development. Patients with schizophrenia have anomalies in the composition of the microbiota. It remains unclear if microbiota changes after treatment further influence the course of the disease.

Disclosure

No significant relationships.

Therapeutic potential of serotoninergic psychedelic substances in the treatment of Obsessive Compulsive Disorder

Introduction

Obsessive Compulsive Disorder (OCD) is a psychiatric disorder associated with suffering and disability. The serotoninergic system is implicated in the neurobiological processes of OCD and serotonin reuptake inhibitors (SRIs) are the first-line treatment. However, clinical improvement after starting SRIs can take long and patients may not fully recover. Meanwhile, recent data suggests that activation of 5-HT receptors may exert a therapeutic action in obsessional symptoms. Some psychedelics are strong 5-HT2 receptor agonists and there is a growing research interest as they can be a promising therapeutic approach to OCD.

Objectives

We aim to provide an overview on the current evidence on the therapeutic potential of serotoninergic psychoactive substances in the treatment of OCD.

Methods

Non-systematic review. Literature search in the PubMed database using the terms psychedelics and obsessive-compulsive disorder.

Results

Although research is currently limited to a few small studies, the ones conducted so far showed clinically meaningful acute reduction of OCD symptoms after treatment with serotoninergic psychoactive drugs, as well as possible longer-lasting benefits, particularly with psilocybin and lysergic acid diethylamide (LSD). Furthermore, substance-assisted psychotherapy with psychedelics has been showing promising results, being suitable for OCD treatment. It is important to add that, to date, studies have indicated relatively good tolerability to these drugs.

Conclusions

These promising early findings highlight the role of psychedelics in OCD treatment and the need for further research into efficacy, therapeutic mechanisms and safety, in order to determine whether these drugs may be worthy options for OCD treatment in the future.

Disclosure

No significant relationships.

The Role of N-Acetylcysteine in Obsessive-Compulsive (OCD) and Related Disorders

Introduction

N-acetylcysteine is known for its uses in non-psychiatric conditions, such as paracetamol overdose and as a mucolytic. The rationale for its administration in psychiatric conditions is based on its ability reducing synaptic glutamate release, which was found to be increased in the cerebrospinal fluid of OCD patients.

Objectives

Evaluating N-acetylcysteine efficacy in OCD symptoms. Studying mechanisms underlying its action. Identifying the frequency of side effects.

Methods

PubMed database search, with the “N-acetylcysteine obsessive compulsive” keyword expression. The search was restricted to English-only articles, published in the last ten years. Twenty-five results among the best match correspondence were selected. Reference lists of articles were reviewed to identify additional articles.

Results

Oliver et al. found that a daily dose of 2.400 to 3.000 milligrams of N-acetylcysteine reduced the severity of obsessive-compulsive symptoms with minimal side effects; Smith et al. found inconclusive evidence on its efficacy. A clinical trial from Ghazinadeh et al. revealed N-acetylcysteine to be effective as an add-on to citalopram, reducing the score of resistance/control to obsessions after supplementing with N-acetylcysteine. Costa et al. found out it was superior to placebo in anxiety control as a secondary outcome.

Conclusions

The potential efficacy of N-acetylcysteine in the treatment of psychiatric disorders attracted interest. Mixed evidence was found that N-acetylcysteine may have some benefits controlling compulsions, both as an adjunctive as and as monotherapy. Thus, larger and more robust studies are required to further investigate the clinical effectiveness of N-acetylcysteine in this area.

Disclosure

No significant relationships.

Dealing With Clozapine-Induced Sialorrhea

Introduction

Clozapine is the first atypical antipsychotic. It is used in refractory schizophrenia. It has a heavy side effect burden, including weight gain, dizziness, blurred vision, and sialorrhea. Not only is sialorrhea bothersome, but it can also have with serious consequences, such us aspiration pneumonia, neutropenia, agranulocytosis, myocarditis, and may be responsible for low self-esteem, leading to low treatment compliance and discontinuation.

Objectives

Identifying the mechanism behind clozapine-induced sialorrhea. Finding how frequent clozapine-induced sialorrhea is compared to other antipsychotics. Finding effective ways to prevent clozapine-induced sialorrhea.

Methods

PubMed database search, with “clozapine sialorrhea” keyword expression. 12 Articles published in the last ten years were selected among the 112 best matches. Reference lists of articles were reviewed to identify additional articles.

Results

Clozapine is a muscarinic M1-5 receptor antagonist, explaining its anticholinergic effects. Due to its strong anticholinergic action, sialorrhea is a paradoxical side effect. To prevent it, several drugs can be used, such us scopolamine, pirenzepine, sublingual atropine solutions, clonidine, botulinum neurotoxin, and others. Sialorrhea was relatively more frequently reported in clozapine (1.1%) compared with other antipsychotics (0.31%). Mubaslat and Lambert (2020) found that drops of atropine reduce the rate of saliva secretion significantly better than placebo. Uzun, et al. (2019) observed the adjunction of N‐acetylcysteine allowed a significant decrease of the severity of sialorrhea and was well tolerated.

Conclusions

Although effective in refractory schizophrenia, clozapine side effects, namely sialorrhea, can be bothersome and may affect treatment adherence. Fortunately, we have tools at our disposal to help patients better handle it.

Disclosure

No significant relationships.

Couvade Syndrome: Origin, Characterization, and Frequency

Introduction

The word couvade originated from the French verb couver, meaning to hatch, nest, or brood. Custom of Couvade or Couvade Syndrome (CS) is a poorly understood phenomenon observed since ancient times, in which the expectant father experiences somatic and psychological symptoms of pregnancy.

Objectives

Defining what is CS. Identifying possible origin. Hypothesizing causes. Identifying CS frequency.

Methods

PubMed database search, with “Couvade syndrome” keyword expression. Seven articles were selected among the best matches. Reference lists of articles were reviewed to identify additional articles.

Results

Currently, there are several views on this phenomenon, including religious, cultural, medical, psychoanalytic, and psychological. CS is used in Psychiatry to describe somatic symptoms resembling pregnancy and/or childbirth in expecting fathers, such as weight gain, diarrhea or constipation, toothache, and headache. Lipkin and Lamb (1982) studied 300 couples from New York: they diagnosed Couvade Syndrome in 22,5% of fathers. Nevertheless, Brennan et al. (2007) found different incidence rates of CS diagnose in different areas of the world: 20% in Sweden; 25–97% in United States; 61% in Thailand; 68% in China; 35% in Russia.

Conclusions

Whether CS constitutes a disease entity, or it should be considered a ritual or custom remains a matter of debate. Different rates of CS around the globe may indicate that culture plays an important role. It may be a way for fathers-to-be to cope with changes imposed by pregnancy in the mother and in the couple. Overall, it is a fascinating intersection between the physiological and psychological realms.

Disclosure

No significant relationships.

A systematic review of observational management of cutaneous basal cell carcinoma

BACKGROUND

Cutaneous basal cell carcinoma (BCC) is the commonest cancer in the United Kingdom and United States. Surgical excision is the most common treatment. This review summarises all published outcomes of observational/non-interventional management of cutaneous BCC.

METHODS

This PRISMA-compliant systematic review searched MEDLINE, EMBASE and CENTRAL databases from inception-June 2021. All studies reporting outcomes of observational management for BCC were included.

RESULTS

We identified 2529 titles, from which 4 full-text articles were eligible, reporting on 2298 individuals. Two studies were randomised controlled trials (RCTs) comparing histological clearance rates and adverse events following treatment with an inactive strategy (placebo cream) versus topical 5%-imiquimod (at different frequencies) for 6-12 weeks. Clearance rates ranged from 52-100% for imiquimod and 2-19% for placebo, with more adverse events associated with imiquimod. The other two studies used prospective cohort designs. One study assessed the natural history of BCCs managed expectantly in 39 individuals aged ≥80years. During the 15.8-month follow-up, 46.2% of lesions did not increase in size and 10.3% resolved. The remaining study compared treatment patterns of 1360 patients with non-melanoma skin cancer (NMSC) in individuals with or without limited life-expectancy (LLE). The LLE subgroup had a 5-year mortality rate of 43.3%, with no deaths attributed to NMSC. Only 3.3% of individuals with LLE underwent observational treatment. No study examined quality-of-life or cost-effectiveness.

CONCLUSION

There has been limited investigation of observational management of BCC, despite possible advantages of this strategy. Future RCTs should compare quality-of-life outcomes and utility-adjusted survival following interventional or observational management of BCC.

183 A Systematic Review of Sample Size Calculations in High-Profile Surgical Trials That Use Patient-Reported Outcome Measures

Background

Patient reported outcome measures (PROMs) are increasingly recognised as a measure of treatment efficacy in randomised controlled trials (RCTs). It can be difficult to determine meaningful target differences in PROM scores for sample size calculations and this can risk over-recruitment and/or erroneous trial conclusions. The Difference ELicitation in TriAls (DELTA2) statement sets recommendations for sample size calculations in RCTs including target difference determination. We aimed to evaluate sample size calculations from high-profile surgical RCTs that used PROMs as their primary outcome, against DELTA2 standards, with a focus on target differences.

Method

Pubmed was systematically searched for surgical RCTs published in the five highest ranking journals, by Thomson Reuters impact factor, for medicine and surgery. Studies were included if surgery was the intervention and/or comparator arm, and a PROM was the primary outcome. Surgery was defined as using instrumentation to change macro-anatomy with the aim of improving health. Data were extracted with a piloted data collection sheet that included the DELTA2 reporting recommendations.

Results

Most target differences used in sample size calculations were determined with suboptimal techniques and target difference justification was overall poor. In this sample, £28 million of UK public research spending supported trials with poor target difference justification.

Conclusions

In this sample of trials, sample size calculations were generally not reported to DELTA2 standards. There was frequent use of sub-optimal methods to determine the target difference. This risks over-recruitment and/or erroneous trial conclusions. Clinicians should be aware of these potential pitfalls when interpreting published trials.

Anesthesia or seizure-like behavior? The effects of two Amazonian plants, Acmella oleracea and Piper alatabaccum in zebrafish (Danio rerio)

Abstract Currently, available fish anesthetics can produce important side effects, including respiratory arrest and distress. Easy-to-implement alternatives with low toxicity are needed to ensure fish health as well as to help artisanal fisheries and fish sellers in handling and transporting fishes, and native plants seems to be the best alternative. We aimed to implement an anesthetic protocol using crude ethanolic extracts from flowers and leaves of two Amazonian plants, the Acmella oleracea and Piper alatabaccum. We first tested the extracts for anesthesia, using the zebrafish as model. Even though in some treatments the animals apparently entered deep anesthesia, many of them presented aberrant behaviors and even died. Thus, we performed new experiments testing the extracts effects on seizure-like behaviors of the fish. Only the leaf extract of A. oleracea has potential effects for fish anesthesia. Both the flower extract from this plant and the leaf extract from P. alatabaccum induced seizure-like behavior in the animals. In conclusion, besides bringing a possible new anesthetic protocol for fish, our work draws attention for the neurotoxic effects the anesthetic solutions may cause, since several studies defend other Piper species as anesthetic for fish and A. oleracea flowers’ extract was already pointed as fish anesthetic.

Sex disparities in lipid-lowering therapy and dyslipidemia control in a coronary rehabilitation program

Introduction

Lipid control is one of the most important secondary cardiovascular prevention targets. Although cardiovascular disease is the most common cause of death for both genders, several studies have consistently shown that women are less likely to receive guideline-recommended secondary prevention medications after an acute coronary syndrome (ACS).

Purpose

To compare sex disparities in dyslipidemia control in a secondary prevention population with ACS in light of the ESC Dyslipidemia Guidelines.

Methods

We retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an ACS from January 2011 to October 2019. Clinical data was collected at presentation and during 12 months follow-up. Doses of atorvastatin ≥40 mg, rosuvastatin ≥20 mg or a combination of a statin and ezetimibe were considered high-intensity LDL-lowering therapy (HIT).

Results

Of a total of 881 patients enrolled, mean age 55.0±10.0 year-old, 16.1% were female. At baseline there were no differences respecting clinical features between genders. At admission, 51.4% of patients had ST-elevation myocardial infarction and, concerning to cardiovascular risk factors, 63% patients had dyslipidemia, 46% had hypertension, 19% were diabetic, 76% were smokers or previous smokers, 27% had family history of coronary disease and 12% had previous coronary disease (ACS or &gt;50% coronary artery stenosis). At hospital admission, females and males had similar mean LDL-levels [120.7 vs 118.1 mg/dL, t(708)=0.691, p=0.496]. The vast majority of patients from both genders were prescribed with statins on hospital discharge (99.5%) and maintain it during follow-up (99.3%). Female patients received more HIT during follow-up (67.8% vs 53.9% at baseline, p=0.015; 75.6% vs 59.0% after CRP, p=0.003; and 79.8% vs 65.1% at 1-year-follow-up, p=0.007). During follow-up, at the end of the CRP (about 3 months after event), male patients exhibit a better control of LDL [82.0 vs 75.6 mg/dL, t(597)=2.4, p=0.016)] with 12.8% vs 16.4% below 55 mg/dL and 29.8% vs 44.5% below 70 mg/dL (p=0.008). At 1-year follow-up, both genders exhibited similar LDL-control due to a worsening control of the male population (81.9 vs 80.6 mg/dL, t(540)=0.52, p=0.605). Only 13.3% of females had LDL below 55 mg/dL (vs 12.9%, p=0.921) and 32.5% below 70 mg/dL (vs 37.0%, p=0.432).

Conclusion

This real-life study showed that guideline recommended LDL target is not achieved in the majority of patients, even under a structured CRP. Unlike other reports, there were more women receiving potent anti-dyslipidemic therapy. Nevertheless, women showed a poor control of LDL-concentration after three months of ACS and a similar control after 1-year; this highlights the uncertainties concerning the efficacy of lipid-lowering therapy in women, an underrepresented population in clinical trials.

Funding Acknowledgement

Type of funding sources: None.

FFRCT and Invasive Coronary Angiography – assessing concordance in an unselected UK real world population

Background/Introduction

CT coronary angiography (CTCA) Fractional Flow Reserve (FFRCT) is a key investigation in chronic coronary syndrome (CCS) guidelines. FFR calculated from CTCA may help improve CTCA specificity for flow limiting disease, preventing unnecessary invasive coronary angiography (ICA).

Purpose

To (1) assess the treatment planning potential of FFRCT by determining the concordance of FFRCT with an ICA +/− invasive physiological assessment for the detection of flow limiting CAD in a real world NHS setting and (2) concordance sub-analysis of concordance of invasive iFR and FFRCT.

Methods

A single-centre retrospective analysis of a prospectively maintained clinical CTCA database. We identified patients with CCS who had CTCA FFRCT and subsequent ICA from August 2018 to January 2021. Concordance was assessed on a per patient and per vessel basis (major epicardial vessels: left main stem [LMS], left anterior descending artery [LAD], circumflex [LCx], right coronary artery [RCA]). Two non-invasive ischaemia thresholds were examined an FFRCT ≤0.8 and &lt;0.75 (2 cm distal to stenosis). This was compared to a clinical ICA assessment where a flow limiting lesion was defined as a stenosis &gt;70% (or &gt;50% in the LMS) and/or an end vessel iFR ≤0.89 / FFR ≤0.8. All vessels that underwent an iFR, at the interventionists discretion, were then assessed relative to their end-vessel FFRCT.

Results

565 patients had a CTCA with FFRCT and 164 patients had a subsequent ICA and were suitable for analysis. On a per patient basis 69% of those referred to ICA with an FFRCT ≤0.8 of at least one major epicardial vessel had any flow limiting CAD at ICA. With an FFRCT &lt;0.75 this was 73%. Table 1 illustrates the per vessel concordance.

A total of 120 vessels were included in the iFR subsection analysis. The mean FFRCT was 0.71 (±0.13) and mean iFR was 0.89 (±0.1). Accuracy was 54% (95% CI 45–63%) with a sensitivity of 89% (95% CI 76–96%), specificity 32% (95% CI 22–44%), positive predictive value 45% (95% CI 40–50%) and negative predictive value of 83% (95% CI 66–92%). A Pearson's correlation coefficient of 0.23 was found.

Conclusion

This study demonstrated that the negative predictive value of FFRCT was excellent, including importantly for LMS analysis. The specificity on a per vessel basis was good with the exception of the LAD assessment. This may have implications for interventional planning with this imaging modality. FFRCT correlated poorly with invasive iFR in this subsection analysis although selection bias may be contributing. There remains a significant proportion of patients referred for an ICA where no flow limiting CAD is found.

Funding Acknowledgement

Type of funding sources: None. Table 1. Per vessel concordance analysis of potential flow limiting FFRCT relative to clinical ICA findings. Analysed with an ischaemia threshold of FFRCT ≤0.80 and &lt;0.75. PPV = Positive Predictive Value. NPV = Negative Predictive Value.

1237 Optimising Outpatient Care After Paediatric Burns: The Development of a Chatbot To Identify Complications And Provide Clinical Advice

Aim

More than 6000 children require specialist care from one of fourteen regional burns services in England and Wales each year. Families often have to travel long distances and may not have access to specialist care with restricted services due to Covid-19. This quality improvement project aimed to:

Method

We conducted a national service evaluation of children’s burns services in England and Wales. We then conducted a PRISMA compliant systematic review up to September 2020 to identify studies reporting chatbot use to deliver outpatient care. A chatbot was then developed using Dialogflow to identify complications and provide advice to families.

Results

Across England and Wales, 11 children’s burns services reported outpatient practice: six services follow up all children at three months, three have variable follow-up and two discharge all patients. Our systematic review identified 10 studies reporting chatbot use although none were used following burns. A frame-based system-focused chatbot was developed in conjunction with expert burns surgeons and patient representatives.

Conclusions

Chatbots are effective and acceptable alternatives for in-person follow up. We demonstrate national variation in the provision of outpatient paediatric burn care and have developed a chatbot that can address clinical concerns and provide reassurance to patients and family members. Future studies will determine the acceptability and safety of this chatbot.

Electrochemical and photoluminescence response of laser-induced graphene/electrodeposited ZnO composites

The inherent scalability, low production cost and mechanical flexibility of laser-induced graphene (LIG) combined with its high electrical conductivity, hierarchical porosity and large surface area are appealing characteristics for many applications. Still, other materials can be combined with LIG to provide added functionalities and enhanced performance. This work exploits the most adequate electrodeposition parameters to produce LIG/ZnO nanocomposites. Low-temperature pulsed electrodeposition allowed the conformal and controlled deposition of ZnO rods deep inside the LIG pores whilst maintaining its inherent porosity, which constitute fundamental advances regarding other methods for LIG/ZnO composite production. Compared to bare LIG, the composites more than doubled electrode capacitance up to 1.41 mF cm-2 in 1 M KCl, while maintaining long-term cycle stability, low ohmic losses and swift electron transfer. The composites also display a luminescence band peaked at the orange/red spectral region, with the main excitation maxima at ~ 3.33 eV matching the expected for the ZnO bandgap at room temperature. A pronounced sub-bandgap tail of states with an onset absorption near 3.07 eV indicates a high amount of defect states, namely surface-related defects. This work shows that these environmentally sustainable multifunctional nanocomposites are valid alternatives for supercapacitors, electrochemical/optical biosensors and photocatalytic/photoelectrochemical devices.

Anxiety and depression risk in patients with allergic rhinitis: a systematic review and meta-analysis

BACKGROUND

Allergic diseases appear to be associated with mood disorders. However, particularly regarding allergic rhinitis (AR), such association has not been adequately systematically reviewed. Therefore, we conducted a systematic review and meta-analysis to quantify the association between AR and depression and anxiety.

METHODOLOGY

We performed an electronic search of PubMed, Web of Science and Scopus for observational studies assessing the association between AR and depression and anxiety. Such association was quantified by means of random-effects meta-analysis, with estimation of pooled odds ratio (OR). Sources of heterogeneity were explored by subgroup analysis.

RESULTS

We included a total of 24 primary studies, of which 23 assessed depression and 11 assessed anxiety. Of these, 12 studies presented OR from multivariable regression models and were included in our meta-analysis. AR was associated with higher odds of depression and anxiety.

CONCLUSIONS

AR appears to be associated with high risk of depression and anxiety. While our results point to the importance of mental comorbidities among patients with AR, longitudinal studies are needed adopting uniform definitions and presenting results stratified by AR severity.

Does every woman require a post-lumpectomy mammogram and ultrasound before radiotherapy when negative margins?

PURPOSE

Most studies regarding the value of post lumpectomy imaging (PLI) studies rely on mammography alone and are often focused on patients that present with suspicious microcalcifications or in situ disease. This way, its true benefit remains controversial, which explained the heterogeneity between centers. This is the first study to evaluate the role of mammography with breast and axillary ultrasound undertaken before radiotherapy in patients with conservatively managed invasive and/or in situ carcinoma with negative margins.

MATERIALS AND METHODS

In this retrospective study, medical records for patients referred to our External Radiotherapy Unit between January 2018 and December 2019 were reviewed.

RESULTS

A total of 1251 patients (1262 breasts) were analyzed. A total of 3.4% had suspicious findings for local residual breast disease, with 1.0% having a re-excision positive for residual malignancy. Presentation with microcalcifications alone (OR=4.854), extension of microcalcifications>3cm (OR=13.500), histologic subtype pure ductal carcinoma in situ (OR=12.348), presence of invasive carcinoma≤1mm of the pathological margins (OR=4.630), stage pTis (5.630), and absence of invasive component (OR=4.629), were associated with an increased risk for residual malignancy. Only one patient (0.1%) had nodal residual involvement.

CONCLUSION

PLI detected residual local cancer in 1.0% of the patients. PLI plays an important role in the evaluation of patients undergoing breast-conserving therapy with negative margins. The major question that remains is whether it changes survival outcomes.

Detection of enteroparasites in foliar vegetables commercialized in street- and supermarkets in Aparecida de Goiânia, Goiás, Brazil

Foliar vegetables contaminated with fecal residues are an important route of transmission of intestinal parasites to humans. The aim of this study was to evaluate the presence of parasitic forms of protozoa and helminths on lettuces (Lactuca sativa) and collard greens (Brassica oleracea) sold in street- and supermarkets in the city of Aparecida de Goiânia, Goiás, Brazil. A total of 30 samples of each vegetable (15 samples from each supermarkets and street markets) was analyzed. All samples were processed by spontaneous sedimentation method and centrifugal flotation. In 45% of the samples, immature forms of intestinal parasites were identified with 66.7% helminths eggs and 33.3% protozoan cysts or oocysts. Significantly more lettuce samples were contaminated with eggs, cysts or oocyst of at least one parasite than collard green samples (U=216; Z=-3.45; P <0.001). The parasitic forms were identified morphologically up to the family level with eggs of Ancylostomatidae, Strongyloididae, Ascarididae and Taeniidae, or oocysts of Eimeriidae, to the genus with Cystoisospora sp. and Toxocara sp., and to the species level with Cystoisospora canis, Dipylidium caninum and Hymenolepis nana. The presence of these infective agents in lettuce and collard green from both street- and supermarkets highlights the high risk of spreading parasites by eating raw vegetables sold in Aparecida de Goiânia.

POS0162 PREDICTIVE FACTORS OF A NEW FRAGILITY FRACTURE AFTER WRIST FRAGILITY FRACTURE

Background:

Fragility fractures (FF) are fractures that result from mechanical forces that would not ordinarily result in fracture, known as low-level (or ‘low energy’) trauma.1 Studies have shown that history of wrist fracture increases the risk for subsequent FF.2

Objectives:

To assess predictive factors of FF occurring after a wrist fracture.

Methods:

Retrospective monocentric study that included patients with a wrist FF observed at the emergency department (ED) in a tertiary center, between 1st January 2017 and 31st December 2018. Wrist fractures were identified through the 10th International Classification of Diseases and FF were identified after revision of the clinical record. Patients with relevant missing data were excluded. Seven hundred thirty-three wrist FF were identified. After calculating a representative sample (90% confidence interval), 188 patients were included. Their clinical records until 31th December 2020 (2 to 3 years after FF) were reviewed. SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05. In multivariate analysis we included variables with a significant association in univariate analysis and those with clinical relevance (reported in others studies).

Results:

Wrist fractures represented 44.3% of the FF observed at the ED.

Most patients were woman (83.5%) with a mean age of 70.7 (SD=11.2) years-old at the time of their wrist fracture. A previous FF was seen in 22.9% of patients and 13.3% had a new FF during the follow-up period.

We found an association between the occurrence of a new FF and the number of comorbidities (p=0.012), number of visits to the ED due to falls (p<0.001), previous diagnosis of chronic pulmonary disease (p=0.029) and hematologic pathologies (p=0.047), and the need for hospitalization at time of the wrist FF (p=0.018).

No associations were found between the age at the wrist fracture time, number of drugs taken daily nor its type (anxiolytics, antiepileptics, corticoids), previous fractures (and localization), overweight/obesity and other cardiovascular risk factors, endocrinopathies, psychiatric or neurologic disease or other comorbidities.

After adjustment for age, gender, anti-osteoporotic treatment and comorbidities, the main predictors of a new FF were visits to the ED for falls (p=0.005), chronic pulmonary disease (p=0.040), hematologic pathologies (p=0.004) and need for hospitalization (p=0.040) (table 1).

Table 1.

Multivariate analyses: linear multiple regression for predictive factors of new fragility fracture.

DeterminantsUnstandardized CoefficientsBStandardized Coefficients Beta95.0% CIp-valueAge-0.0250.9750.924 – 1.030NSGender2.0657.8890.757 – 82.165NSNumber of comorbidities0.1861.2040.846 – 1.713NSVisits to the emergency service for falls-2.1360.1180.026 – 0.5290.005Chronic pulmonary disease-1.3260.2660.075 – 0.9400.040Hematologic pathologies-4.2960.0140.001 – 0.2550.004Need for hospitalization-2.7640.0630.004 – 0.8870.040Anti-osteoporotic treatment0.1571.1700.227 – 6.017NS

CI: Confidence Interval; NS: non-significant;

Conclusion:

Certain comorbidities seem to be associated with new FF. Patients with visits to the emergency service after falls and those who needed hospitalization due to the wrist fracture were more prone to have a new FF. There might be a substantial missed opportunity for intervention in these patients.

References:

[1]Osteoporosis: assessing the risk of fragility fracture. London: National Institute for Health and Care Excellence (UK); 2017 Feb. PMID: 32186835.

[2]Crandall CJ, Hovey KM, Cauley JA, Andrews CA, Curtis JR, Wactawski-Wende J, Wright NC, Li W, LeBoff MS. Wrist Fracture and Risk of Subsequent Fracture: Findings from the Women’s Health Initiative Study. Journal of bone and mineral research: the official journal of the American Society for Bone and Mineral Research. 2015;30(11):2086–2095. doi: 10.1002/jbmr.2559.

Disclosure of Interests:

None declared

AB0799 DO WE OVERDIAGNOSE SERONEGATIVE RHEUMATOID ARTHRITIS? – THE ROLE OF MUSCULOSKELETAL ULTRASOUND IN CLARIFYING SERONEGATIVE INFLAMMATORY ARTHRITIS

Background:

Several data indicate that seronegative rheumatoid arthritis (RA-) and seropositive RA (RA+) may have different mechanisms and prognosis, being well established that rheumatoid factor (RF) and anti-citrullinated peptide antibodies (ACPA) have diagnostic and prognostic value. Several conditions, like peripheral spondyloarthritis (SpA), psoriatic arthritis or crystal-related arthropathies may mimic the presentation of RA. Mechanisms and treatment of each of these conditions differ significantly. The authors speculate that RA- may be overdiagnosed in the setting of seronegative chronic inflammatory arthritis and that musculoskeletal ultrasound (US) may help us to better classify these patients through the identification of characteristic lesions of the mentioned diseases.

Objectives:

To compare the frequency of US lesions found in joints and entheses between RA- and RA+ patients.

Methods:

Cross-sectional study: systematic US evaluation of ten joints, twelve entheses and both flexor and extensor tendons of four fingers (Table 1) in consecutive RA- patients. RA+ patients matched for sex and age were recruited. RA- patients included met every of the following criteria: history of chronic polyarthritis, RF and ACPA negativity, no extra-articular features of SpA or RA nor family history of SpA, no suspected crystal-related arthritis.

Results:

Twenty-one RA- patients were included and twenty RA+ patients were recruited as controls. No differences between groups were found in sex, age, body mass index, time of disease evolution or use of biological therapy.

RA- patients had a significantly higher number of entheseal structural and/or inflammatory lesions than RA+ patients (median 2.0 vs. 0.5, U 111.5, p=.008**), with triceps enthesitis being significantly more frequent in RA- patients (p=.036*). In total, 18.7% of RA- entheses had enthesitis lesions vs. only 8.3% of RA+ entheses. One RA- patient had ultrasonographic features of dactylitis which was not clinically evident.

As expected, considering the role of RF and ACPA in erosive RA, RA- patients had a significantly lower number of joints with erosions compared to RA+ patients (median 0.0 vs. 3.0, U 64.5, p<.001***), with significant differences in every considered joint. Erosions were found in 6.7% of RA- joints vs. 32.0% RA+ joints.

Additionally, two RA- patients had hyperechogenic foci in knee cartilage or carpal fibrocartilage suggestive of calcium pyrophosphate deposition.

Table 1.

Comparative frequency of ultrasound lesions found in joints and entheses of RA- and RA+ patients.

RA-(n=21)RA+(n=20)p-valueMdn number of ENTHESES with any lesion per patient ± IQR2.0 ± 3.00.5 ± 2.0.008**Triceps – n (%)8 (38.1%)2 (10.0%).036*Quadriceps – n (%)9 (42.9%)6 (30.0%).393Superior patellar – n (%)4 (19.0%)1 (5.0%).169Inferior patellar – n (%)---Achilles – n (%)9 (42.8%)4 (20.0%).116Plantar fascia – n (%)5 (23.8%)1 (5.0%).089DACTYLITIS – 2nd + 5th finger – n (%)1 (4.8%)--Mdn number of joints with EROSIONS per patient ± IQR0.0 ± 1.03.0 ± 3.0<.001***Ulnar styloid process – n (%)5 (23.8%)11 (55.0%).041*Metacarpophalangeal 2 – n (%)3 (14.3%)11 (55.0%).006**Metacarpophalangeal 5 – n (%)1 (4.8%)10 (50.0%).001**Metatarsophalangeal 1 – n (%)-3 (15.0%)-Metatarsophalangeal 5 – n (%)3 (14.3%)11 (55.0%).006**CHONDROCALCINOSIS – triangular fibrocartilage + knee – n (%)2 (9.5%)--DOUBLE CONTOUR – any joint – n (%)---

RA- – seronegative rheumatoid arthritis; RA+ – seropositive rheumatoid arthritis Mdn – median; IQR – interquartile range; n (%) – absolute number (percentage) of patients with the indicated lesion.

Conclusion:

We found that some patients diagnosed with RA- had, in fact, ultrasonographic features of different diseases, namely enthesitis/dactylitis and crystal deposition. These data suggest that RA- may be overdiagnosed in clinical practice. Systematic US evaluation of joints and entheses may provide valuable diagnostic information in patients with chronic inflammatory seronegative arthritis and improve patient care.

Disclosure of Interests:

None declared

Syncope: call for the missed diagnosis

Funding Acknowledgements

Type of funding sources: None.

Background

Syncope is a common reason for emergency department attendance. This entity may be associated with significant morbidity and mortality and its differential diagnosis is not straightforward. Arrhythmic causes include tachycardia and bradycardia; the later may require pacemaker implantation. Many hospitals lack a dedicated syncope unit to approach these patients. So, patients’ triage may fall into medical or surgical (trauma) areas.

Purpose

To describe the population of patients that required permanent pacemaker implantation in the year of 2019, particularly those who had a previous visit to the emergency department with syncope or presyncope.

Methods

Single-center descriptive analysis of patients that implanted a permanent pacemaker in 2019 (inclusion criteria). Additional information was collected in patients with emergency department visits in the 365 days that preceded the device implantation.

Results

In 2019, a total of 398 patients were admitted for pacemaker implantation in 2019, 55% male (n = 218), 45% female (n = 180), with mean age of 79 years. Regarding indications for pacing, 41% (n= 156) had complete atrioventricular (AV) block, 26% (n = 105) had a second degree AV block, 16% (n = 64) had sinus node dysfunction, 13.5% (n = 53) had atrial fibrillation with slow ventricular conduction, and 3.5% (n = 14) had other indications.

Twenty-two percent (n = 88) of patients had a previous visit to the emergency department (other than the ones that triggered the pacemaker implantation) with complaints of syncope (60%) or presyncope (40%). Of these, 73% (n = 64) were referred to a medical area and 27% (n = 24) were referred to a surgical area; 40 patients presented with traumatic lesions (68% cranioencephalic trauma and 32% other traumas). Of the 88 patients, only 67% (n = 59) performed an ECG and only 23% (n = 20) were referred for observation by a cardiologist in the emergency department.

Comparing medical and surgical triage, we observe that patients referred to the surgical area were less likely to perform an ECG and to be observed by a cardiologist (with statistical significance).

Conclusions

Our work describes a common problem in hospitals without dedicated syncope evaluation units. As all the patients ended up implanting a pacemaker, it is interesting to observe that 22%of these had a "warning" visit to the emergency and 33% of the last did not get and ECG. Also, trauma-oriented approaches result in a lower likelihood of performing a complete evaluation of the cause of the syncopal event. This analysis highlights the need for a comprehensive and multidisciplinary approach of patients presenting with syncope and presyncope to promote early identification and treatment of arrhythmic causes, reducing patient morbidity and healthcare costs.

Socioeconomic and environmental status of riverside communities of Tapajós River, Brazil

Introduction

Public health care acknowledges socioeconomic factors as one of the multiple facets to promote or protect individual or collective health. Understanding and being more acquainted with the dynamics carried out in riverside communities is fundamental to investing in policies aimed at fighting diseases and illnesses that are particular to those communities.

Objective

Describing socioeconomic characteristics, healthcare infrastructure, and occupational activities of population from riverside communities along Tapajós river, Brazil.

Methodology

A descriptive study with 96 residents of communities of Tapajós river, Brazil. Participants have answered a semi-structure questionnaire and the analyses were descriptive and the variable categories were expressed as frequencies.

Results

There was a predominance of male participants (77.09%), incomplete elementary school (58.51%), involved in agricultural sector (85.10%), with a family income up to 1 minimum wage (68.81%). However, only 21.50% have declared making their living exclusively out of agriculture. Seedlings and seeds are mainly obtained through an exchange system running inside the community. In relation to infrastructure, the water comes from artesian wells (68.88%) and 51.63% claim not treating water whatsoever. All interviewees mentioned the lack of a sewage system and residues are taken to a rudimentary cesspool (76.59%). Waste produced by the community is burned out (93.61%). The main difficulties pointed out by the interviewees were: transportation (44.94%), health (32.14%), communication (21.42%) and government cooperation (15.47%).

Conclusions

The communities in this project show similar structural dynamic based on subsistence family agriculture and poor infrastructure of basic services. The data collected can be the basis for future public policies aiming at the promotion of food production autonomy, economic autonomy, and improvement of health indicators of these communities.

Key messages

Contextualizing the structural dynamic of vulnerable populations is key to plan actions aimed at tackling and dealing with social determinants involved in the health-illness process. Contextualizing the structural dynamic of vulnerable populations is fundamental to guide strategies aimed at intervening in the social and health determinants.

Quality of life assement of riverside communities of Tapajós and Cupari Rivers in Pará

Introduction

Riverside population lack basic sanitation infrastructure and access to healthcare. In addition, locals encounter difficulties in accessing basic health care due to climate variability and fluvial activity which results in tidal distortion and attenuation. Quality of life is a broad concept and its measurement should be useful to identify determining and conditioning factors in health-illness process which would be key to the guidance of health public policy measures in a specific community. This study aims at assessing the quality of life of Tapajós and Cupari riverside communities in Pará, Brazil.

Methods

A cross-sectional and descriptive study composed of a group of patients aged 18 and over who have sought care during the volunteer health expedition in the Tapajós and Cupari rivers between mid-July and August 2019. The team of students and professors conducting the survey adopted the WHOQOL-bref questionnaire as a measure of quality of life. The questionnaire consists of 25 questions and 5 domains: physical health, psychological, social relationships, environment, and self-assessment of quality of life. Individual scores vary between 4 and 20. Scores ≤ 10 suggest low quality of life whereas &gt;10 suggest higher quality of life. This statistical analysis was carried out in the SPSS program and was described by means of summary measures: minimum, maximum, median, and standard deviation. Outcomes:The five domains scored &gt;10, with the highest being the psychological domain (16,48, dp = 1,71) and the lowest the environment (14,12 dp = 1,99).

Conclusions

In spite of inherent difficulties generally found in riverside communities, participants reported high perception of quality of life in all domains. The lowest overall perception was the environment domain. This result confirms not only the barriers of physical infrastructure but also access to quality services as a negative health and life determinant.

Key messages

Assessing the quality of life is key to determine which factors influence the health-illness process within a community. Assessing the quality of life is fundamental to guide strategies aimed at intervening in social determinants.

FRI0388 ARE WE OVERLOOKING OSTEOARTHRITIS? – A COMPARATIVE STUDY OF PAIN, FUNCTION AND QUALIFY OF LIFE IN PATIENTS WITH HAND OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS

Background:

Osteoarthritis (OA) is frequently regarded by patients and health care providers as a normal consequence of ageing (1). On the other hand, it is well established that rheumatoid arthritis (RA) is a pathological condition requiring prompt and efficacious treatment and in which remarkable progresses have been achieved in the last decades. Pain and physical limitations are hallmarks of both conditions. Some previous studies suggest that OA and RA may have a similar burden (2,3).

Objectives:

To compare levels of pain, physical disability and health-related quality of life in patients with primary hand osteoarthritis (hOA) and with RA: active disease (aRA) or in remission (rRA).

Methods:

Observational cross-sectional study including patients of two clinical centres with hOA and RA, either in remission or with active disease (at least two swollen and/or tender hand joints). Matching for sex and age was performed. Patients were asked to complete a survey consisting of visual analogic scale (VAS) for pain, Health Assessment Questionnaire (HAQ) and Short Form 36 (SF36). Mean values for each domain were compared between the three groups using one-way ANOVA test with significance accepted for p<.05.

Results:

Thirty patients with hOA and 93 with RA (33 with aRA and 60 with rRA) were included. All patients were caucasian females with no significant differences in age between groups. Patients with hOA reported higher levels of pain in comparison with aRA patients (mean VAS 57.3vs49.3mm, respectively, p=.265) and with rRA patients (57.3vs28.6mm, respectively, p<.001) [F(2.120)=25.907, p<.001]. Regarding physical function, patients with hOA reported levels of disability similar to rRA patients, but significantly lower disability than patients with aRA [F(2.120)=6.962, p=.001]. Patients with hOA evaluated their quality of life significantly better than patients with aRA and in similar levels to patients with rRA, as measured by mental health and general health status domains of SF36.

Conclusion:

Our results show that hOA may have similar or even higher burden of pain than RA; this is in line with previous studies, although most of them did not consider the level of inflammatory activity of RA. On the other hand, patients with hOA seem to preserve function and have better health-related quality of life despite the higher levels of pain. These results highlight OA as a cause of severe pain, which should lead us to try an optimal symptom control for these patients. These findings should also encourage rheumatologists to endeavor efforts to perform more studies in the field of OA, to better understand its pathogenesis and to eventually find disease modifying drugs.

References:

[1]Gignac MAM, Davis AM, Hawker G, Wright JG, Mahomed N, Fortin PR, et al. “What do you expect? You’re just getting older”: A comparison of perceived osteoarthritis-related and aging-related health experiences in middle- and older-age adults. Arthritis Rheum. 2006 Dec 15;55(6):905–12.

[2]El-Haddad C, Castrejon I, Gibson KA, Yazici Y, Bergman MJ, Pincus T. MDHAQ/RAPID3 scores in patients with osteoarthritis are similar to or higher than in patients with rheumatoid arthritis: a cross-sectional study from current routine rheumatology care at four sites. RMD Open. 2017 Jul;3(1):e000391.

[3]Slatkowsky-Christensen B, Mowinckel P, Kvien T. Health status and perception of pain: a comparative study between female patients with hand osteoarthritis and rheumatoid arthritis. Scand J Rheumatol. 2009 Jan;38(5):342–8.

Disclosure of Interests:

None declared

AB0192 RHEUMATOID ARTHRITIS: IS IT WORTH IT TO ADD LEFLUNOMIDE TO METHOTREXATE IN REFRACTORY DISEASE?

Background:

In refractory rheumatoid arthritis (RA), adding other classic synthetic disease-modifying antirheumatic drug (csDMARD) such as leflunomide (LFN) to methotrexate (MTX) is one suitable option [1,2]. Yet, there are safety issues to consider which may limit this strategy, but also regarding its true effectiveness in avoiding exposure to biological DMARDs (bDMARD) or target synthetic DMARDs (tsDMARD).

Objectives:

To assess the effectiveness and safety of adding LFN to MTX and to evaluate the predictors of drug retention, toxicity and inefficacy.

Methods:

A retrospective clinical record review of adult RA patients followed on our rheumatology department in whom LFN was added to MTX was done. Sociodemographic information, comorbidities, disease related information, adverse reactions and disease activity according to Disease Activity Score 28 – C reactive protein (DAS28) were recorded at baseline and after 3, 6 and 12 months of combination therapy (3_DAS28; 6_DAS28; 12_DAS28, respectively). Information regarding toxicity (need to dose adjustment/suspension) and inefficacy (add/switch to bDMARD/tsDMARD) were recorded. Follow-up was considered until last medical record available. SPSS was used for statistical analysis. Kaplan Meier and Cox-regression were used for univariate and multivariate analysis, respectively, significant level was 2-sidedp<.05.

Results:

In total, 77 patients were included, 66.20% females, with a mean age of 56±11 years old. There was a significant reduction of DAS28 only after 3 months of therapy (4.01±1.01 to 2.57±1.52,p=.003; ΔDAS28 = 1.58±1.17). However, during a median follow up time of 64 (IQR 39-83) months, 58.44% of patients needed to change treatment strategy, 66.67% due to toxicity (median time to toxicity 13 months, IQR 2-16) and 33.33% due to inefficacy (median time to inefficacy of 10 months, IQR 5.84-17.64). Gastrointestinal intolerance was the main reported toxicity (46.15%). In univariate analysis, anti-citrullinated protein antibodies (ACPA) positivity, alcohol consumption, lack of comorbidities, hepatic toxicity, higher 6_DAS28, swollen joint count and tender joint count on the 6thmonth were associated to lower retention rates.

In multivariate analysis, lack of comorbidities (HR=3.3, CI 95% 1.4-7.8,p=.006) and higher 6_DAS28 (HR=0.32, CI 95% 0.14-0.72,p=.006) were independent predictors of suspension of combination therapy. Moreover, both male gender (HR=2.87, 95%CI 1.2-6.56,p=.016) and positivity to ACPA (HR=0.1, 95%CI 0.01-0.73,p=.024) were independent predictors of toxicity. There was also higher tendency to toxicity, but without statistical significance, in alcohol consumers (p=.08). Regarding inefficacy, smoking habits (HR=0.15, 95%CI 0.04-0.52) and 3_DAS28 (HR=0.15, 95%CI 0.04-0.53) were independent predictors.

Conclusion:

Addition of LFN to MTX showed an early positive response. However, it was frequently associated to toxicity, and less than half of the patients continued with this therapeutic strategy after 5 years of follow up. Male gender, smoking habits and positivity to ACPA were predictors of worse outcome, as already reported in literature [1]. Lack of comorbidities was an independent predictor of suspension. This can be explained by the fact that physicians tend to adopt a more aggressive strategy on patients without comorbidities, switching earlier to bDMARDs/tsDMARDs.

This study also showed that early response to combination therapy is an independent predictor on drug retention, suggesting that decisions on treatment strategy should be made early after the beginning of MTX/LFN.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15. doi:10.1136/annrheumdis-2019-216655

[2]Kremer J, et al. J Rheumatol. 2004 Aug;31(8):1521-31. PMID: 15290730

Disclosure of Interests:

None declared

AB0236 DIFFERENCES AND DETERMINANTS OF PHYSICIAN’S AND PATIENT’S PERCEPTION IN GLOBAL ASSESSMENT OF RHEUMATOID ARTHRITIS

Background:

Patient’s Global Assessment of Disease Activity (PtGA) and Physician’s Global Assessment of Disease Activity (PhGA) are assessed as part of commonly used measures of disease activity in RA.1Both are important measures in treat-to-target strategies in Rheumatoid Arthritis (RA), but often provide discordant results.2,3This can provide an erroneous assessment of disease activity in patients under Biologic treatment and mislead treatment decisions, namely switches.

Objectives:

To assess differences and determinants of PtGA and PhGA in RA patients under biologic treatment.

Methods:

Cross-sectional study, including 46 patients with RA diagnosed according to the ACR/EULAR criteria, under biologic treatment, consecutively evaluated in day-care unit. Participants completed patient-reported outcomes (PROs), including PtGA, and sociodemographic characteristics. Physicians collected comorbidities and parameters of inflammatory activity (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) and completed PhGA and disease activity score 28 with ESR (DAS28). SPSS was used for statistical analysis and significance level was defined as 2-sided p<0.05.

Results:

Clinical and laboratory characteristics of patients are shown in table 1. PtGA and PhGA were significantly different (36.1±27.6 mmvs8.7±14.2 mm, p< 0.001) and a positive discordance (PtGA>PhGA, more than 25mm in visual analogue scale [VAS]) was found in 54.3% of cases.

PtGA had a correlation with PROs (Pain VAS, 36-Item Short Form Health Survey [SF-36], Health Assessment Questionnaire [HAQ], Functional Assessment of Chronic Illness Therapy [FACIT], EuroQol [EQ5D] and Hospital Anxiety and Depression Scale [HADS]), CRP, tender and swollen joint counts and an association with comorbidities like fibromyalgia or osteoarthritis (OA). No association was found between PtGA and age, sex, education level, profession, employment status, extra-articular manifestations, positivity of rheumatoid factor, ESR, years of disease evolution or number of biologic treatments. In multivariable analyse including SF-36, CRP, tender joints count and OA (R2adjusted= 0.672), the main predictors of PtGA were lower SF36, concomitant OA and higher CRP level.

PhGA had a correlation with PtGA, pain VAS, CRP, tender and swollen joints. No association was found between PhGA and patient or physician age, patient or physician sex, extra-articular manifestations, positivity of rheumatoid factor, ESR level, years of disease evolution or number of biologic treatments. In multivariable analysis including ESR, tender and swollen joints count and CRP (R2adjusted= .800), the main predictors of PhGA were swollen joint count and higher CRP level.

Conclusion:

This study showed the variability implied on global assessment of RA activity. Overall PtGA is based on function and also in subjective and emotional experience of pain, whereas the PhGA is based on more objective measures, more related to disease activity.

References:

[1]Kanekoa Y. et al, Determinants of Patient’s Global Assessment of Disease Activity and Physician’s Global Assessment of Disease Activity in patients with rheumatoid arthritis: A post hoc analysis of overall and Japanese results from phase 3 clinical trials.Modern Rheumatology2018; 28(6):960–967

[2]Furu M. et al. Discordance and accordance between patient’s and physician’s assessments in rheumatoid arthritis.Scand J Rheumatol.2014; 43(4):291-5.

Ann Rheum Dis. 2016 Sep;75(9):1661-6. doi: 10.1136/annrheumdis-2015-208251. Epub 2015 Oct 22.

[3]Portier A. et al, Patient-perceived flares in rheumatoid arthritis: A sub-analysis of the STRASS treatment tapering strategy trial.Joint Bone Spine. 2017; 84(5):577-581

Disclosure of Interests:

None declared

FRI0165 RISK OF CKD IN MEMBRANOUS AND PROLIFERATIVE LUPUS NEPHRITIS - ANALYSIS OF A NATIONWIDE MULTICENTRE COHORT

Background:

Lupus nephritis (LN) is one of the most severe manifestations of Systemic Lupus Erythematosus.

Objectives:

1) To compare proliferative (PLN), membranous (MLN) and mixed LN regarding clinical and laboratory presentation. 2) To investigate predictors of progression to chronic kidney disease (CKD).

Methods:

Multicentre observational study, with retrospective analysis of a prospective cohort, using data from the Portuguese registry of rheumatic diseases – Reuma.pt. Patients with biopsy-proven PLN, MLN and mixed LN were included. Groups were compared using Pearson’s Chi-Square for categorical variables and One-Way ANOVA or Kruskal-Wallis for numerical variables. COX regression analysis was used to investigate predictors of CKD (defined as estimated glomerular filtration rate [eGFR] lower than 60 mL/min/1.73m2for at least 3 months) and Kaplan-Meier curves were drawn.

Results:

236 patients were included. Median follow-up was 8 years (IQR 11; maximum 35 years). As seen in table 1, the level of proteinuria did not differ between groups; however, MLN patients presented with significantly lower serum creatinine. Levels of complement C3 and C4 were reduced in PLN but normal in MLN patients, and there were fewer patients with positive anti-dsDNA antibodies in the MLN group (p<0.001). On univariable COX regression, mixed histology was associated with progression to CKD (HR 26 [95% CI 3 - 255], p 0.005) (figure 1), however, it lost significance after adjusting for eGFR. In fact, eGFR≤75 at one year after the renal biopsy (HR 21 [95% CI 7 - 65], p<0.001) was the strongest predictor of CKD, even after adjusting for hypertension or histology.

Table 1.

Comparative description of the Reuma.pt cohort of patients with proliferative, membranous and mixed LN

PLNMLNMixedPTotal, N186428Females, N (%)157 (85)39 (95)4 (50)0.004EthnicityWhite European, N (%)163 (90)31 (78)7 (88)0.115Other, N (%)19 (10)9 (23)1 (13)Age LN diagnosis(y), median (IQR)30 (20)34 (16)42 (25)0.409SLEDAI at LN diagnosis, median (IQR)16 (9)10 (10)21 (17)0.006*uPCR at LN diagnosis, median (IQR)1675 (2598)1698 (2153)2160 (3320)0.629Creatinine at LN diagnosis, median (IQR)0.80 (0.32)0.70 (0.20)1.00 (0.95)0.006*eGFR at LN diagnosis, mean ± SD98 ± 33112 ± 1782 ± 450.019*Albumin at LN diagnosis, mean ± SD34 ± 734 ± 730 ± 60.390C3 at LN diagnosis, mean ± SD0.65 ± 0.260.90 ± 0.350.53 ± 0.30<0.001*Positive anti-dsDNA LN diagnosis, N (%)115 (91)11 (48)6 (86)<0.001*Use of antimalarials, N (%)166 (94)36 (92)8 (100)0.688Use of immunosuppressants, N (%)163 (94)33 (87)8 (100)0.245Use of corticosteroids, N (%)145 (84)33 (85)7 (100)0.511CKD after LN diagnosis, N (%)27 (15)1 (3)3 (38)0.018*ESRD, N (%)7 (4)1 (3)2 (25)0.016Deaths, N (%)14 (8)2 (5)00.610

uPCR: urinary protein-creatinine ratio, mg/g; y: years; Creatinine presented in mg/dL, eGFR in mL/min/1.73m2,albumin in g/L and C3 in g/L

Note: Baseline data (LN diagnosis) in grey; other data refer to the course of disease

*Significant difference between the proliferative and membranous groups

Figure 1.

Kaplan-Meir curves showing cumulative survival free of CKD in patients with PLN, MLN and mixed LN

Conclusion:

Our results support previous findings from single-centre studies suggesting that MLN has a different serological profile than PLN, possibly reflecting different pathogenesis. Renal function at one year predicts long-term outcome in LN.

Disclosure of Interests:

Filipa Farinha: None declared, Sofia C Barreira: None declared, Maura Couto: None declared, Margarida Cunha: None declared, Diogo Fonseca: None declared, Raquel Freitas: None declared, Luís Inês: None declared, Mariana Luis: None declared, Carla Macieira: None declared, Ana Rita Prata: None declared, Joana Rodrigues: None declared, Bernardo Santos: None declared, Rita Pinheiro Torres: None declared, Ruth J. Pepper: None declared, Anisur Rahman: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer

AB1350-HPR SOCIOECONOMIC BURDEN OF NON-ATTENDANCE IN RHEUMATOLOGY CONSULTATION

Background:

Outpatient non-attendance refers to the phenomenon of patients who have a medical appointment but do not show up at the specified date, time, and location without giving previous notice.1In addition to affecting the efficiency and thereby increasing the healthcare total costs, nonattendance might also delay access to care for users on waiting lists.1Nonattendance at health appointments is costly to services, and can risk patient health.2There is very little data on the nonattendance prevalence and impact in Portugal. This knowledge might be fundamental to improve effectiveness of outpatient care in Portugal.

Objectives:

1) describe patient’s non-attendance rate; 2) assess and characterize the sociodemographic and clinical characteristics among non-attending patients; 3) estimate the economic burden of non-attendance.

Methods:

Retrospective, cross-sectional and analytical study. We reviewed a one-month Rheumatology consultation period regarding performed medical consultations and non-attended consultations without previous notification from patients. Direct economic costs of non-attended appointments were calculated based on the “Amending Agreement to the ULSAM, EPE Program Agreement”.

Results:

982 consultations within January 2018 were included. Appointments episodes for therapeutic prescription, medical reports or programmed admissions were excluded. Fifty-seven (5.8%) of scheduled outpatient appointments were non-attended. Subsequent consultations represented 85.2% of attended appointments and 80.7% of non-attended appointments. Female gender was the most prevalent in both groups – 620 (67.0%) among attended consultations and 37 (65.0%) among non-attended consultations. Mean age was 57±15 years in the first group and 54±16 years in the second one. Among attended appointments, mean education level was 8±5 years versus 9±6 years among non-attended appointments. There were no differences between both groups in gender, age, education level, diagnosis, disease duration and activity or appointment type (first or subsequent consultation). A cost of 2,438 euros was estimated regarding non-attended appointments for this period, what could represent a burden of more than 29,000 euros yearly, in direct costs, only.

Conclusion:

Non-attendance at scheduled appointments in public hospitals seems to be influenced by other factors besides gender, age and education level. The burden of non-attended appointments is undeniable. In addition to the costs estimated in this study, further indirect costs such as poorer patients outcomes, impaired access to medical care and hospital penalties should be taken into account. Implementation of awareness strategies aiming the optimization and effectiveness of healthcare system are required.

References:

[1]Blæhr EE, Kristensen T, Væggemose U, Søgaard R. The effect of fines on nonattendance in public hospital outpatient clinics: study protocol for a randomized controlled trial.Trials. 2016;17(1):288. doi:10.1186/s13063-016-1420-3

[2]Akter S. A qualitative study of staff perspectives of patient non-attendance in a regional primary healthcare setting.Australas Med J. 2014;7(5):218-226. doi:10.4066/AMJ.2014.2056

Disclosure of Interests:

None declared

Fatigue Evaluation through Machine Learning and a Global Fatigue Descriptor

Research in physiology and sports science has shown that fatigue, a complex psychophysiological phenomenon, has a relevant impact in performance and in the correct functioning of our motricity system, potentially being a cause of damage to the human organism. Fatigue can be seen as a subjective or objective phenomenon. Subjective fatigue corresponds to a mental and cognitive event, while fatigue referred as objective is a physical phenomenon. Despite the fact that subjective fatigue is often undervalued, only a physically and mentally healthy athlete is able to achieve top performance in a discipline. Therefore, we argue that physical training programs should address the preventive assessment of both subjective and objective fatigue mechanisms in order to minimize the risk of injuries. In this context, our paper presents a machine-learning system capable of extracting individual fatigue descriptors (IFDs) from electromyographic (EMG) and heart rate variability (HRV) measurements. Our novel approach, using two types of biosignals so that a global (mental and physical) fatigue assessment is taken into account, reflects the onset of fatigue by implementing a combination of a dimensionless (0-1) global fatigue descriptor (GFD) and a support vector machine (SVM) classifier. The system, based on 9 main combined features, achieves fatigue regime classification performances of 0.82 ± 0.24, ensuring a successful preventive assessment when dangerous fatigue levels are reached. Training data were acquired in a constant work rate test (executed by 14 subjects using a cycloergometry device), where the variable under study (fatigue) gradually increased until the volunteer reached an objective exhaustion state.

P1466 Pacman heart documented by multimodality echocardiographic techniques

We report a case of a 78-year old female with hypertension, dyslipidemia, atrial fibrillation under warfarin therapy and previously diagnosed HFpEF. She also had a history of recurrent episodes of bilateral inferior limb acute ischemia requiring urgent embolectomy and one previous cardioembolic stroke. She had no history of ischemic heart disease.

She was admitted to our center due to acute decompensated heart failure (NYHA class III). On physical examination there was evidence of pulmonary congestion with bilateral crackles, without heart murmurs. ECG showed AF rhythm, without any other significant changes.

The transthoracic echocardiogram (TTE) showed moderate biventricular hypertrophy with apical predominance and good systolic function. A partial loss of myocardial tissue in the mid segment of the interventricular septum was noticed, with no left-to-right shunt on color Doppler, apparently without interventricular communication (figure A).

For further elucidation of this finding a contrast-enhanced TTE was performed, revealing a serpiginous route through the septum to a small contained cavity within it (figure B). 3D TTE en face views additionally clarified the semilunar shape of this septal defect and its movement during the cardiac cycle, closing during systole and opening during diastole (figure C).

At this point, clinical history and previous diagnostic exams were reviewed. A thoracic CT conducted 3 years before in another clinical context showed that the ventricular septal defect was already present, with similar characteristics (figure D).

As doubts persisted about the existence of interventricular communication, cardiac catheterization with oximetry and ventriculography was performed and interventricular shunt was excluded. There was no evidence of coronary artery disease. Cardiac MRI was not possible due to lack of patient collaboration.

Final diagnosis was a partial ventricular septal defect (PVSD), probably congenital. The patient was discharged under optimized medical therapy.

PVSDs, which are rarely reported in the literature, are thought to be congenital (sporadic or familial) or a consequence of myocardial infarction. They have been described as "Pacman" heart due to the shape changes during the cardiac cycle, becoming slit-like or even absent during systole, like an opening/closing mouth, resembling the Pacman video game. Related complications include conduction disturbances, rupture and disturbed systolic function.

We describe a rare case of a partial ventricular septal defect, documented by multimodality echocardiographic techniques: 2D TTE first showed an incomplete defect of the mid interventricular septum; contrast-enhanced TTE revealed its serpiginous route to a small cavity; 3D TTE en face views further illustrated its semilunar shape and characteristic movement during the cardiac cycle.

Abstract P1466 Figure.

P1718 Multi-modal imaging characterization of contained aortic subannular rupture after transcatheter aortic valve implantation

INTRODUCTION

Aortic annular rupture is a potentially catastrophic complication after transcatheter aortic valve implantation (TAVI), with an estimated incidence of 1%. Rupture occurs in the anatomical device landing zone, that extends from the aortic root to the distal left ventricular outflow tract (LVOT). It usually occurs in the context of highly calcified aortic valve and LVOT, implantation of balloon-expandable valves, valve oversizing and overdilation to treat paravalvular leakage.

CASE REPORT

An 80-year old woman with no past relevant medical history was admitted to our Cardiology Department with decompensated heart failure because of symptomatic severe aortic stenosis, moderate aortic regurgitation and mild left ventricular (LV) dysfunction. She was already in waiting list for TAVI procedure, after being refused for conventional aortic valve replacement due to a "porcelain" aorta. Her pre-operative angiography showed no significant coronary heart disease, and the cardiac computed tomography (cardiac-CT) revealed a severely calcified aortic valve (Agatston score = 4940). An Acurate neo L (27mm) valve was implanted after clinical stabilization with no immediate complications. Because of paravalvular regurgitation, sequential post-dilation was performed with 25mm and 26mm balloons. Post-procedural angiography showed no contrast extravasation (Panel A). In the first hours after the procedure, she was hypotensive with non-specific mild chest discomfort. The EKG showed sinus rhythm with left anterior fascicular block. A transthoracic echocardiogram revealed a moderate pericardial effusion, with no signs of tamponade, and a moderate "paravalvular leak "at the level of the non-coronary cusp to a pulsatile cavity, between the aortic root and the left atrium (Panel B and C). The patient evolved with haemodynamic and electrical stability with no recurrence of chest discomfort. A retrospective cardiac-CT was performed that confirmed the presence of a multilobular cavity below the left coronary artery in continuous with the LVOT, compatible with a contained subannular aortic rupture (Panel E and F), at the level of previous gross calcification in the pre-operative cardiac-CT (Panel D). The case was discussed in Heart Team and a conservative strategy was adopted due to clinical stability and inoperable condition. The patient was discharged at day 28, after CT reavaluation,, that demonstrate similar findings.

CONCLUSION

We report a rare and potentially fatal complication of TAVI with a self-expandable valve. This clinical case illustrates how balloon post-dilation to treat moderate post-procedural paravalvular regurgitation lead to tearing of a highly calcified aortic annulus. A multi-modality imaging approach, with echocardiography and computer tomography, was essential for full anatomical definition of the subannular rupture, clinical decision-making and for follow-up surveillance.

Abstract P1718 Figure. Panel A,B,C,D,E,F.