A scoring tool to predict mortality and dependency after cerebral venous thrombosis

BACKGROUND

We developed a prognostic score to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials..

METHODS

We used data from the International CVT Consortium. We excluded patients with pre-existent functional dependency. We used logistic regression to predict poor outcome (modified Rankin Scale 3-6) at 6 months and Cox regression to predict 30-day and 1-year all-cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunken using Ridge regression to adjust for optimism in internal validation.

RESULTS

Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, we derived the SI₂ NCAL₂ C score utilizing the following components: absence of female Sex-specific risk factor, Intracerebral hemorrhage, Infection of the central nervous system, Neurologic focal deficits, Coma, Age, lower Level of hemoglobin (g/L), higher Level of glucose (mmol/L) at admission, and Cancer. C-statistics were 0.80 (95%CI 0.75-0.84), 0.84 (95%CI 0.80-0.88) and 0.84 (95%CI 0.80-0.88) for the poor outcome, 30 days and 1 year mortality model, respectively. Calibration plots indicated good model fit between predicted and observed values. The SI₂ NCAL₂ C score calculator is freely available at www.cerebralvenousthrombosis.com.

CONCLUSIONS

The SI₂ NCAL₂ C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.

Quantum interferometric power and Bures distance entanglement versus normalized steered coherence under random telegraph noise

This study examines the impact of random telegraph noise on non-separability, non-classicality, and steered coherence in a bipartite system initially prepared in a Gisin state and embedded in both Markovian and non-Markovian environments. To quantify non-separability, we employ the Bures distance entanglement measure ([Formula: see text]); for non-classicality detection, we utilize the quantum interferometric power ([Formula: see text]); and to measure steered coherence, we employ the normalized steered coherence ([Formula: see text]). We analyze the dynamics of these three metrics under the effects of the random telegraph noise through various theoretical and numerical techniques. Our findings demonstrate that the amount of quantum correlations in the system is closely tied to the parameters defining the random telegraph noise and the initial system state. Our results also reveal that all three measures exhibit oscillatory behavior in the non-Markovian regime and monotonic changes with time in the Markovian regime. These results provide a deeper understanding of the robustness and stability of non-separability and coherence under noisy conditions and may have implications for the design of noise-resistant quantum systems.

Post-stroke seizures: risk factors and management after ischemic stroke

Stroke is the leading cause of epilepsy in the elderly, ahead of degenerative diseases, tumors and head injuries. It constitutes a significant complication and a considerable comorbidity. The aim of our study was to describe the main factors implicated in the occurrence of post-stroke seizures and to identify the predictors of seizure recurrence. We conducted a descriptive, retrospective, monocentric study from January 2010 to December 2019, including patients who presented seizures following an ischemic stroke. We classified these seizures according to the International League Against Epilepsy (ILAE) into acute symptomatic seizures (ASS) if they occur within seven days of stroke, and unprovoked seizures (US) if they occur after more than one week. Clinical, para-clinical, therapeutic and follow-up data were statistically analyzed and compared. A total of 52 patients were included (39 men, 13 women; median age 55.1 years). 21 cases (40%) had ASS and the remaining 31 cases (60%) presented US. Young age below 65 years (71%), middle cerebral artery infarcts (83%), and cortical localization (87%) were the main factors depicted in our series. Parietal lobe infarction was more associated with US than ASS (p = 0.035). 24 patients (46%) have presented a recurrence of seizures (8/21 of ASS and 16/31 of US). The use of sodium valproate in monotherapy was identified as a recurrence risk factor (p = 0.013). In patients with post-stroke seizures, parietal lobe infarcts are more associated with US. We identified a higher risk of seizure recurrence in patients treated with sodium valproate monotherapy.

Clinical significance of the hemodynamic gain index in patients undergoing exercise stress testing and coronary computed tomography angiography

Background

Many hemodynamic parameters are used during exercise stress testing but provide limited information regarding obstructive coronary artery disease (CAD) when exercise is suboptimal. Hemodynamic gain index (HGI) is a recently developed and sensitive indicator of ischemia which has been associated with increased mortality.

Purpose

This study sought to evaluate the clinical impact of HGI in patients who underwent concomitant exercise testing and coronary computed tomography angiography (CCTA).

Methods

Consecutive patients from the executive health program between 2010 and 2018 were identified. Resting and peak heart rate (HR) and systolic blood pressure (SBP) were recorded. Framingham risk score (FRS), Duke treadmill score (DTS) and HGI [(HRpeak × SBPpeak) − (HRrest × SBPrest)] / (HRrest × SBPrest) were calculated. The latter was divided into quartiles. The presence or absence of any CAD on CCTA was confirmed. Multivariate analysis and artificial neural network were used to determine the independent predictors of obstructive CAD.

Results

There were 284 patients (mean age 53 years, 83% male). Mean HGI was 1.74±0.67, with severely blunted HGI cut-off of ≤1.25 (Quartile 4). Patients with blunted HGI were older, had higher FRS, and worse DTS. Patients with obstructive CAD showed lower HGI when compared to control (1.36±0.53 vs. 1.77±0.67, P-value 0.005) and had more prevalence of severely blunted HGI ≤1.25 (44% vs. 22%, P-value 0.019). In the multivariate analysis, after adjusting for traditional risk factors, HGI remained independent predictor of obstructive CAD while severely blunted HGI ≤1.25 was associated with 3-fold increased odds of obstructive CAD (P-value 0.05). Using artificial intelligence analysis, blunted HGI remained an independent predictor of obstructive CAD an area under the curve of 0.83 and 0.96, and normalized importance of HGI of 100% and 63%, respectively for different models.

Conclusions

Among patients who underwent concomitant exercise testing and CCTA, blunted HGI ≤1.25 was strongly associated with obstructive CAD after adjusting for traditional risk factors. HGI is robust, practical, and allows clinicians to reclassify patients, change management, and thus improve prognosis.

Funding Acknowledgement

Type of funding sources: None.

Safety and effectiveness of near-zero fluoroscopy paroxysmal AF radiofrequency ablation with a temperature-controlled, contact force-sensing catheter: a Q-FFICIENCY study sub-analysis

Background/Introduction

Q-FFICIENCY evaluated 12-month (M) safety and efficacy of temperature-controlled paroxysmal atrial fibrillation ablation with a novel contact force-sensing, radiofrequency catheter with 3 microelectrodes and 6 thermocouples. Patients underwent pulmonary vein isolation with very high-power short-duration (vHPSD; 90 W/ up to 4 s) mode in combination with conventional-power temperature-controlled (CPTC; 25–50 W) mode.

Purpose

To assess procedural efficiency, safety, and 12M outcomes of participants ablated under near-zero fluoroscopy guidance compared to procedures performed with standard fluoroscopy.

Methods

In this US multi-centre (22 sites), non-randomised investigational study, patients underwent pulmonary vein isolation with vHPSD as primary ablation mode; CPTC was used for PV touch-up or non-PV ablation. Primary safety endpoint was incidence of primary adverse events ≤7 days post-procedure. Primary effectiveness was freedom from documented atrial tachyarrhythmia recurrence and additional pre-defined failure modes (acute failure, repeat ablation, new/higher dose anti-arrhythmic drug). Participants were followed-up through 12M post-ablation (3M blanking & 9M evaluation) to assess safety, effectiveness, and healthcare utilisation.

Results

Of 191 participants enrolled (63.5±10.7 years, CHA2DS2-VASc 2.4±1.5, 60.7% men), 166 were ablated with the investigational catheter, and 165 had fluoroscopy data available for inclusion in this analysis. Forty-four participants received ≤1 minute of fluoroscopy. Compared to the >1-minute of fluoroscopy cohort, the ≤1-minute group showed improved efficiencies in all procedural parameters (Table). Primary adverse event rates were similar among groups (≤1-minute, 4.5%; >1-minute, 3.3%). Kaplan-Meier estimated 12M clinical success rates (i.e., freedom from documented symptomatic recurrence) were similar regardless of fluoroscopy exposure (≤1-minute, 85.4%; >1-minute, 86.0%). Freedom from cardiovascular hospitalisation 12M post-ablation was comparable among groups (90.8% vs 88.0%).

Conclusion

Near-zero fluoroscopy paroxysmal atrial fibrillation ablation with the novel temperature-controlled catheter in vHPSD mode, alone or combined with CPTC, led to enhanced procedural efficiencies with good effectiveness and clinical success without comprising safety.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Biosense Webster, Inc.

KS05.6.A Oral DNA vaccination targeting VEGFR2 combined with the anti-PD-L1 antibody avelumab in patients with progressive glioblastoma - final results. NCT03750071

Background

Vascular endothelial growth factor receptor (VEGFR)2 overexpression on glioblastoma endothelia serves as a target for VEGFR2 primed T cells using VXM01 DNA vaccine encoding for VEGFR2. VXM01 is delivered in a bacterial Ty21a carrier suitable for oral administration. A previous phase I/II study in 14 patients with progressive glioblastoma showed a positive correlation of of VEGFR2 specific T cells as well as altered intra-tumoral immunity with prolonged overall survival. One partial response was reported with VXM01 alone. The current trial aimed at intensifying the efficacy signal and testing the co-administration of a checkpoint inhibitor.

Material and Methods

A multicentre, open-label phase I/II study (EudraCT 2017 003076 31) included 28 patients (25 non-resectable, 3 resectable) with progressive glioblastoma after standard chemoradiotherapy. VXM01 was administered on day 1, 3, 5, 7 followed by boostings q4w. Avelumab (800 mg) was given intravenously q2w. Treatment continued up to week 96 followed by a 2-year observation period. Endpoints included safety and tolerability, objective response rate (ORR), clinical response using immune-response assessment in Neurooncology criteria (iRANO), and immunological assays like ELISpot, FACS, and tumor immune biomarkers.

Results

Treatment with VXM01 106 or 107 CFU plus avelumab was completed in all patients. No treatment-related toxicities were observed. Three partial responses (according to iRANO) with tumor reductions of 58, 81 and 95% to baseline, respectively, were reported in the non-resectable patients (Objective response rate (ORR) was 12% (3/25)). Two of these patients were progression-free > 12 months. Best response in 3 additional non-resectable patients was SD including one patient progression-free > 6 months. In one resected patient, tumor shrinkage of 30% each was observed after initial treatment before resection as well as subsequent to incomplete resection, associated with survival > 18 months, and accompanied by an increase of intratumoral CD8+ T-cells.

Conclusion

VXM01 in combination with avelumab was safe and produced detectable peripheral VEGFR-2-specific immune responses. Three non-resected patients had an objective response, three more patients experienced best response stable disease. For future studies a patient enrichment strategy based on immune biomarkers might be envisaged.

AB0908 Treating to target of psoriasis: An evidence-based consensus on clinical practice recommendations

Background

The Tight Control of psoriatic arthritis (TICOPA) trial revealed a treat to target (T2T) strategy has led to improved clinical outcomes in psoriatic arthritis (PsA). The heterogeneity of the disease, the feasibility of therapy and the associated comorbidities made the implementation of such strategy in routine care a real challenge. There is a high need for establish real world recommendations for the T2T approach in PsA tailored to the disease activity status, the Psoriasis manifestations as well as the individual patient’s requirements.

Objectives

to provide up-to-date, evidence-based and consensus-based recommendations for Treat-to-Target management of psoriatic arthritis (PsA) and its associated clinical manifestations.

Methods

14 key clinical questions were identified by scientific committee according to the Patient/ Population, Intervention, Comparison, Outcomes and Timing (PICOT) approach. Literature Review team performed a systematic review to summarize evidence advocating the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. Subsequently, recommendations were formulated. The level of evidence was determined for each section using the Oxford Centre for Evidence-based Medicine (CEBM) system. A 3-round Delphi process was conducted with 19 experts. All rounds were conducted online. A consensus was achieved on the direction and the strength of the recommendations.

Results

An online questionnaire were sent to expert panel who participated in the three rounds (response rate 100%). At the end of round 3, a total of fifty-one recommendation items, categorized into 6 sections to address the main 6 PsA categories, were obtained. Agreement with the recommendations (rank 7-9) ranged from 89.5-100%. Consensus was reached (i.e.≥75%of respondents strongly agreed or agreed) on the wording of all the 51 clinical standards identified by the scientific committee. Algorithms for the management of PsA have been suggested.

Conclusion

These recommendations provide an updated consensus on the pharmacological treatment of PsA and strategies to reach optimal treat to target outcomes in in common clinical scenarios, based on a combination of evidence and expert opinion. Best treatment decisions should be tailored to each individual patient situation.

Disclosure of Interests

None declared

AB0099 KNEE SYNOVIAL FLUID AND SERUM TNF-α IN RHEUMATOID ARTHRITIS: CORRELATION WITH SONOGRAPHIC PARAMETERS

Background

Rheumatoid arthritis (RA) is a chronic, inflammatory joint condition that affects about 5 out of 1000 persons of the general population [1]. Environment, genetics, and autoimmunity may all have a role in the pathogenesis of the disease [2]. Overproduction of pro-inflammatory cytokines like tumor necrosis factor-α (TNF-α) is the end result of these mechanisms [3].However, little is known about its soluble concentrations in synovial fluid and serum and its association with clinical and ultrasonographic joint parameters.

Objectives

The aim of this study was to assess the presence of TNF-α in serum and synovial fluid of the knee in RA patients with knee effusion and to evaluate its correlation with musculoskeletal ultrasound (MSUS) parameters of the affected knee joint.

Methods

This study included 40 patients (20 RA,10 systemic lupus erythematosus (SLE) and 10 osteoarthritis (OA)) who had knee effusion (unilateral or bilateral) upon clinical examination. The sample size was selected as convenient sample; all patients who fulfilled the inclusion criteria were offered to participate in the study, unless they qualify for any of the exclusion criteria or refuse to participate. The inclusion criteria included the following: a) age ≥ 18 years old, b) patients with knee effusion detected by clinical examination and confirmed by MSUS, c) patients with RA diagnosed according to 2010 ACR /EULAR classification criteria [4],SLE according to SLICC criteria [5] or knee OA diagnosed according to EULAR criteria [6].

Demographic, clinical, and therapeutic data were recruited from all participants. Visual analogue scale (VAS) was used to determine the pain intensity in the affected knee. MSUS examination of the affected knee was performed, and a sample of synovial fluid was aspirated. TNF-α was measured in the aspirated synovial fluid and serum of each patient.

Results

There was a total of 40 patients (20 RA, and 20 age and sex matched non_RA (10 SLE, and 10 OA)). The mean age of RA patients was 48.4 years, most of them were females (80%) with median duration of knee pain of 2 months. Serum TNF-α was barely significantly higher in RA vs. non-RA cases (3.66 ± 0.76 vs 3.24 ± 0.58 U/ml, p= 0.052), while in synovial fluid, difference was not statistically significant (3.73 ± 0.72 vs 3.48 ± 0.58 U/ml, p= 0.252). Also, there was a statistically significantly higher serum TNF-α in RA vs. OA (3.66 ± 0.76 vs 3.06 ± 0.32, p= 0.022). Figure 1 shows that serum TNF-α at cut point of >3.24 U/ml can significantly discriminate RA from OA with 65% sensitivity, and 90% specificity (AUC = 0.725, P = 0.018). There was no statistically significant correlation between synovial TNF-α and MSUS parameters of thee knee either in RA or non_RA patients.

Figure 1.

ROC curve for serum TNF as a discriminator of RA from non-RA

Conclusion

Serum TNF-α is higher in RA than non_RA patients. However, synovial fluid TNF-α level do not differ in RA from non_RA patients. No role of synovial TNF-α in knee pathologies in RA patients.

References

[1]Aletaha, D. and J.S.J.J. Smolen, Diagnosis and management of rheumatoid arthritis: a review. 2018. 320(13): p. 1360-1372.

[2]McInnes, I.B. and G.J.N.E.J.o.M. Schett, The pathogenesis of rheumatoid arthritis. 2011. 365(23): p. 2205-2219.

[3]Smolen, J.S., D. Aletaha, and I.B. McInnes, Rheumatoid arthritis. Lancet, 2016. 388(10055): p. 2023-2038.

[4]Kay, J. and K.S.J.R. Upchurch, ACR/EULAR 2010 rheumatoid arthritis classification criteria. 2012. 51(suppl_6): p. vi5-vi9.

[5]Petri, M., et al., Derivation and validation of the Systemic Lupus International Collaborating Clinics classification criteria for systemic lupus erythematosus. 2012. 64(8): p. 2677-2686.

[6]Zhang, W., et al., EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. 2010. 69(3): p. 483-489.

Disclosure of Interests

None declared

POS1168 TREAT TO TARGET OF GOUT: AN EVIDENCE-BASED CONSENSUS ON CLINICAL PRACTICE GUIDELINES

Background

New therapies, management approaches and evidence regarding the management of gout have become available over the past years. This triggered the need for updated recommendations for the management of gout.

Objectives

to develop an up-to-date consensus evidence-based clinical practice guideline for the management of gout including recommendations for management of acute gout flares, optimum usage of urate lowering therapy for chronic gout as well as patient education and lifestyle guidance.

Methods

An extensive systematic literature review was performed, and evidence-based recommendations were extrapolated, based on 16-key questions identified according to population, intervention, comparator, and outcomes (PICO) approach. For each item, the level of evidence was determined using the Oxford Centre for Evidence-based Medicine (CEBM) system. These were evaluated by a panel of 17-experts via online surveys over a 2-round Delphi process.

Results

At the end of round 2, a total of 30-recommendation items, categorized into 10 domains to were obtained. Agreement with the recommendations (rank 7-9) ranged from 90-100%. Consensus was reached (i.e.≥75%of respondents strongly agreed or agreed) on the wording, the grade of recommendation and level of evidence of all the 30 clinical standards identified by the scientific committee. The guideline emphasized that all gouty patients should be screened for comorbidities. Based on this, an algorithm for treat to target management approach tailored to the individual patient’s needs and associated comorbidities has been outlined.

Conclusion

This work provides updated evidence-based recommendations for the prevention and treatment of acute as well as chronic gouty arthritis. It provides an approach for physicians and patients making decisions on the management of gout. It will also facilitate improvement and uniformity of care.

Disclosure of Interests

None declared

P95 PERI–PROCEDURAL COMPLICATIONS AND LONG–TERM OUTCOMES IN ATRIAL FIBRILLATION PATIENTS STRATIFIED FOR CHRONIC KIDNEY DISEASE SEVERITY UNDERGOING LEFT ATRIAL APPENDAGE OCCLUSION: RESULTS FROM AN INTERNATIONAL, MULTICENTER REGISTRY

Background

Atrial fibrillation (AF) and chronic kidney disease (CKD) often coexist and share an increased risk of thromboembolic events. CKD concomitantly contributes to several pathophysiological changes predisposing towards a pro–haemorrhagic state.

Objective

To evaluate the impact of kidney function on peri–procedural complications and clinical outcomes in AF patients undergoing left atrial appendage occlusion (LAAO) with a Watchman device.

Methods

2124 consecutive AF patients undergoing Watchman implantation at 8 different centers were categorized into CKD stage 1 + 2 (n = 1089), CKD stage 3 (n = 796), CKD stage 4 (n = 170), CKD stage 5 (n = 69) based on the estimated glomerular filtration rate at baseline. The primary efficacy endpoint included a composite of cardiovascular (CV) mortality, stroke, transient ischemic attack, peripheral thromboembolism (TE), and major bleeding.

Results

A non–significant higher incidence of major peri–procedural adverse events (1.7% vs. 2.3% vs. 4.1% vs. 4.3%) was observed with worsening baseline kidney function (p = 0.14). The mean follow–up period was 13 ± 7 months [2226 patient–years (PY)]. In comparison to CKD stage 1 + 2 as a reference, the incidence of the primary endpoint was significantly higher in CKD stage 3 (log–rank p–value= 0.04), CKD stage 4 (log–rank p–value= 0.01), and CKD stage 5 (log–rank p–value= 0.001) (Fig. 1A). A non–significant increase in event rates for stroke/TIA and clinically relevant bleeding was observed among the four groups. LAAO led to a TE risk reduction of 72%, 66%, 62%, and 41% in each group (Fig. 1B). The relative risk reduction in the incidence of major bleeding was 58%, 44%, 51%, and 52%, respectively (Fig. 1C).

Conclusion

Patients with moderate–to–severe CKD had a higher incidence of the primary composite endpoint. The relative risk reduction in the incidence of TE and major bleeding was consistent across CKD groups, irrespective of the very different risk profiles at baseline.

332 Paediatric Ultrasound Scan: Are We Providing a Quality Service?

Aim

Ultrasound scan is the preferred imaging modality in children as it carries no risk of radiation exposure. In this audit, the number of inpatient paediatric ultrasound referrals was assessed over a period of one year. The waiting time was also reviewed in addition to the impact of the results on the management plan.

Method

This was a retrospective audit which included patients who were below 16 and had inpatient ultrasound scan. Case notes were included from January 2020 to December 2020 in a busy district hospital in the UK. The time taken to perform the ultrasound scans and the impact on the management plan were only analysed for the scans requested for abdominal pain.

Results

A total of 914 paediatric ultrasounds scans were requested in 2020. A total number of 28 scans were requested for abdominal pain. The waiting time ranged from 3 to 135 hours with a mean of 23 hours. No scans were positive for appendicitis. Only 2 scans were positive for gynaecological pathologies, i.e., ovarian cysts. All the 28 patients were discharged without undergoing any procedure. Out of the 28 patients, 15 patients had a length of hospital stay of more than 24 hours before discharge.

Conclusions

A mean delay of 23 hours could potentially delay the management of paediatric patients with acute abdominal pathology. None of the patients in this audit underwent any procedure following performed scans. This may indicate that such scans did not alter the management of the studied patients in this audit.

One year outcome and analysis of peri-device leak of left atrial appendage occlusion devices

Background

The prevalence of peri-device leak (PDL) of left atrial appendage occlusion (LAAO) devices has been previously reported. However, there have been only few data that compared different existing devices. The aim of this study was to assess the incidence of PDL with both devices WATCHMAN® and AMPLAZER Amulet®, and to evaluate the clinical outcome at 12 months.

Methods

Consecutive patients who underwent LAAO between January 2018 and 2020 were randomly assigned to either WATCHMAN or AMPLATZER Amulet implantation based on a systematic two-week alternation between both devices. LAA measurements were assessed using cardiac computed tomography angiography (CCTA) prior to, and transesophageal echocardiography (TEE) during the procedure. At 8 weeks post-LAAO, patients underwent TEE and/or CCTA to identify the presence of PDL and/or device-related complications. Patients were then followed for 12 months to identify major adverse cardiovascular/embolic events.

Results

The cohort consisted of 51 patients (25 WATCHMAN, 26 AMPLATZER Amulet; mean age 76±7 years; male gender 76%). Both groups were identically matched for demographics, comorbidities and indication for LAAO. There were 19 patients who had PDL (13 WATCHMAN vs 6 AMPLATZER Amulet, P-value=0.033). Of them, 8 (15%) patients had significant PDL (7 WATCHMAN vs. 1 AMPLATZER Amulet, P-value=0.018). On CCTA, the landing zone maximal diameter of the AMPLATZER Amulet device had the strongest correlation with the final deployed device size (Spearman'rho 0.92, P-value<0.0001). In the multivariate analysis, male gender and device type were independent predictors of any PDL (P-values 0.016 and 0.031, respectively). On a mean follow-up of 12 months, the total number of events was more prevalent in the WATCHMAN group (P-value 0.008), but the incidence of cardio-embolic events reached borderline significance (16% vs. 0%, P-value=0.051).

Conclusions

Among patients who underwent LAAO, almost 15% had significant PDL with the majority belonging to the WATCHMAN group. Still, larger studies are warranted to evaluate its effectiveness in stroke prevention.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2

669 Mortality Risk Prediction for Emergency Laparotomy: Are We Utilising the Best Tool?

Aim

Emergency laparotomy is one of the common operations performed in the UK. To aid in more objective decision making, several scoring systems have been formulated. In this project, we aimed to explore the predictive power of both NELA and P-Possum mortality scores against 30 days and 90 days observed mortality for emergency laparotomy patients.

Method

Patient details from two large district general hospitals were extracted from the NELA database over a period of three years. Pre-operative NELA, post-operative NELA, and P-POSSUM predicted mortality were calculated and compared with the observed 30 days and 90 days mortality for the entire cohort. Model discrimination (statistical accuracy) was tested by calculating the area under the receiver operating characteristic curve (AUC), which was used to assess how accurately the model could discriminate.

Results

There were 378 patients eligible for inclusion with a median age of 64. 39 patients (10.3%) died within 30 days and 52 patients (13.8%) died within 90 days. P-POSSUM score, pre-operative NELA, and post-operative NELA scores predicted the 30 days mortality as (2.7%, 3.7%, and 2.4%) and 90 days mortality as (2.9%, 4.8%, and 4%) respectively. The discriminative power for 30 days and 90 days mortality was highest for the pre-operative NELA score (AUC 0.870, CI: 0.824 – 0.916), (AUC 0.826, CI: 0.769 – 0.884) respectively.

Conclusions

Both NELA and P-Possum scores underpredicted actual 30 days and 90 days mortality. It was however noted that the pre-operative NELA mortality score showed more accurate mortality discriminative power than the other 2 tested tools.

668 Inguinal Hernia Repair: Are We Compliant with The Recommended Consent Process?

Aim

Inguinal hernia repairs are one of the most commonly performed operative procedures in the UK. An adequate consent process gives the patient the autonomy in making decisions related to their care and treatment. In this project, we were auditing whether hernia patients have gone through a standardised consent process from time clinic presentation up to the day of surgery.

Method

This was a retrospective audit based on the Royal College of Surgeons’ (Good Surgical Practice) guidelines and trust local policy. We assessed 50 case notes for patients who had inguinal hernia repair between November 2019 and November 2020 in two of the busy district general hospitals in the UK.

Results

We found that our practice was fully compliant with documenting patient demographics, signatures, and the name of the procedure in the consent forms. Documented discussion prior to surgery was found only on79% of clinic letters. Poor compliance was noted in documenting some of the possible risks in the consent form including testicular atrophy (59%), injury to vas, vessels, and nerves (56%), wound complications (49%), chest infection (24%). Zero compliance was noted in documentation missed hernia and mortality as potential risks to the procedure.

Conclusions

A detailed documented discussion with the patient in relation to benefits, risks, and alternatives of surgery should take place on clinic presentation as well as on the day of surgery to ensure compliance with the consent process.

670 Documentation and Communication of National Emergency Laparotomy Audit (NELA) Mortality and Morbidity Scoring with Patients Prior To Consenting: Are We Following the Best Practice?

Aim

Patients presenting as an emergency have a greater risk of dying than those admitted electively. The ability to stratify risk and calculate a percentage chance of death, not only gives the clinical team a common language to be able to formulate a management plan but also enables them to communicate this with patients and their families. This includes a full explanation of potential risks, benefits, a ceiling of care and management alternatives. In this project, we assessed if the NELA score has been properly calculated, documented prior to surgery for every emergency laparotomy patient and whether such patients were aware of NELA risk predictions prior to consenting.

Method

This was a retrospective audit based on the NELA guidelines of pre-operative risk stratification and the fifth report NELA recommendations. We assessed 50 case notes of patients who had laparotomies from January 2019 to April 2020 in a busy district general hospital in the UK.

Results

We noted that NELA risk prediction score was not utilised/documented in most of the patients with compliance of only 26%. We also found that, in the majority of notes, no NELA score discussion with the patient/family was documented, even with patients who had their NELA score calculated preoperatively. Compliance was only 14% in relation to this category.

Conclusions

A formal assessment of the risk of mortality and morbidity should be made explicit to each patient and should be recorded clearly in the consent form and medical record.

672 Emergency Laparotomy Patients: Is the Current Local Consent Process Compliant with Local and National Guidelines?

Aim

Obtaining valid consent is crucial to patient care. It also minimises the chance for claims regarding legal action for battery, breach of human rights and/or successful clinical negligence claims. In this project, we assessed whether a documented discussion took place prior to signing consent forms and whether consent forms were being completed adequately.

Method

This was a retrospective audit based on the Royal College of Surgeons’ (Good Surgical Practice) guidelines and the local trust policy. We assessed 50 case notes of patients who had a laparotomy from January 2019 to April 2020 in a busy district general hospital in the UK.

Results

We noted that our practice was fully compliant with documenting patient demographics, signatures, and the name of the procedure in consent forms. On the other hand, we found that, in the majority of cases there was no documentation of detailed benefits, risks, alternatives of surgery in case notes where compliance was only 21%. In addition, poor compliance was noted in documenting some of the possible risks e.g., hernia (50% compliance), leak (46% compliance) and ileus (26% compliance).

Conclusions

A detailed discussion with the patient and family including benefits, risks and alternatives of surgery should take place and this should be documented clearly in the case notes prior to signing the consent form.

Early pregnancy-associated ischemic stroke during first trimester in a young woman: A case report

Pregnancy-associated ischemic stroke is rare. The degree of the risk is the highest in the third trimester, but clinicians should be also wary from the beginning of the pregnancy as the risk still exists like demonstrated by our case.

721 Imaging for Suspected Bowel Obstruction in Pennine Acute Trust (PAT): A Comparison with the National Audit of Small Bowel Obstruction’s (NASBO) recommendations

Background

NASBO recommends Computed Topography (CT) over plain abdominal X-ray (AXR) for the investigation of bowel obstruction (BO). AXR is routinely used within PAT for investigation of BO which may be exposing patients to unnecessary radiation and adding unnecessary cost to the service.

Method

A retrospective audit collected data on patients with CT confirmed BO between July 2019 and February 2020. This looked at the percentage of patients who had both CT and AXR to investigate BO. The cost of these AXRs and the percentage of these AXRs that were normal were also calculated.

Results

A search identified 141 patients with CT proven BO. 81/141(57.4%) patients had both AXR and CT as a part of their initial investigations. Of those patients 26/81(32.1%) had no AXR features suggestive of BO. Only 12/81(14.8%) of those patients had serial AXRs following initial imaging. The cost for one AXR is £34.15 which means £2766.15 was spent on potentially unnecessary AXRs within this period.

Conclusions

PAT is performing potentially unnecessary AXRs which is exposing patients to unnecessary radiation and costing the trust. Plain AXRs do not rule out BO. We have recommended an investigation flowchart to PAT A&E departments to reduce unnecessary AXRs being performed.

Monocentric study of 28 cases of chronic inflammatory demyelinating polyneuropathy: first Tunisian study

BACKGROUND

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a rare affection of the peripheral nervous system. Its diagnostic criteria have evolved since 1975. The aim of our work is to study the epidemiological, clinical, and paraclinical aspects of CIDP.

METHODS

We conducted a retrospective study of 28 CIDP patients of the neurology department of the military hospital of Tunis between January 2000 and December 2017. All these patients met the European Federation of Neurological Societies/Peripheral Nerve Society(EFNS/PNS)2010 diagnostic criteria for definite CIDP.

RESULTS

The average age was 50 years with a gender ratio of 1.57. We found sensitivomotor symptoms in 66% of patients. Neurological assessment showed a proximal and distal motor weakness in 50% of cases, the involvement of superficial and deep sensory systems in 44% of patients with a generalized areflexia in all patients. Median Inflammatory Neuropthy Cause and Treatment (INCAT) score was 7. Concerning electrophysiology, all our patients met the EFNS/EPS 2010 diagnostic criteria for a definite CIDP. Screening for concurrent pathologies was positive in 11 patients. On the therapeutic side, there was no superiority of intravenous immunoglobin compared with pulsed methylprednisolone. Oral steroids were used as backup in about 50% of patients. There were good outcomes in 72% of patients who improved very well after treatment.

CONCLUSION

CIDP is a rare and polymorphic disorder with a variety of concurrent pathologies. Our study is the first study in Tunisia and in Maghreb countries which included the most big series of patients. Our results were similar to literature. A multicentral study would be better profitable.

Accident vasculaire cérébral inaugural d’une infection COVID-19 : étude de 9 cas

Introduction

Malgré son tropisme respiratoire et cardiovasculaire, une relation non négligeable entre le nouveau coronavirus 2019 (SARS-CoV-2) et le système neurovasculaire a été décrite.

Objectifs

L’objectif de notre travail était d’étudier les caractéristiques cliniques et pronostiques des accidents vasculaires cérébraux (AVC) chez les patients infectés par le SARS-COV-2.

Patients et méthodes

Nous avons mené une étude rétrospective descriptive incluant 9 patients suivis au service de neurologie de l’hôpital militaire principal d’instructions de Tunis pour accident vasculaire cérébral aigu et présentant une infection par le SARS-CoV-2 diagnostiquée à l’aide d’une réaction en chaîne par polymérase transcriptase inverse (RT-PCR) sur des écouvillons nasopharyngés.

Résultats

Nous avons colligé 9 patients (7 hommes et 2 femmes). L’âge moyen était de 64 ans. Les sous-types d’AVC étaient ischémiques (6 cas) hémorragique (1 cas), et une thrombose veineuse cérébrale (1 cas). Tous les patients avaient au moins 2 facteurs de risque vasculaires. Le score NIHSS moyen était de 16 ± 5. Le pronostic était péjoratif chez la plupart des patients (3 patients étaient décédés et 3 autres ont gardé un handicap sévère).

Discussion

Peu de publications ont étudié les AVC faisant suite à la maladie COVID-19. Plusieurs mécanismes physiopathologiques ont été décrits tels que l’inflammation, l’hypoxie tissulaire et les vascularites. Conformément à la littérature, les AVC chez les patients COVID-19 semblent souvent plus graves par rapport aux AVC survenant chez les personnes non infectées par le sars-CoV-2.

Conclusion

Vu l’impact pronostique défavorable posé par les AVC survenant chez des patients COVID-19, des recherches supplémentaires sont nécessaires à fin d’optimiser leurs prises en charge diagnostique et thérapeutique.

Positive clinical benefit on patient care, quality of life and symptoms after radiofrequency ablation with contact force in persistent atrial fibrillation: analyses from PRECEPT

Background

The management of persistent (PsAF) aims to prevent AF recurrence and associated disabilities while reducing side effects from treatment. Contact force (CF)-guided RF catheters have proven efficacious and safe for pulmonary vein isolation (PVI) to treat paroxysmal AF; however, there is limited evidence on clinical benefits with ablation of PsAF.

Purpose

To assess long-term clinical effects on patients care, symptoms and QOL after CF-guided RF ablation in PsAF.

Methods

PRECEPT was a multicenter study evaluating the safety and efficacy of CF RF catheters in the treatment of symptomatic PsAF (NCT02817776). PVI was performed with or without substrate modification. Patients were followed at 6, 9, 12 and 15 mos to collect the following data: Atrial Fibrillation Effect on Quality-of-Life (AFEQT) score, Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) score, Class I/III AAD use, and incidence of cardioversion and cardiovascular hospitalization.

Results

A total of 333 enrolled patients (65.4±8.8 yrs, 71.2% male, CHA2DS2-VASC score 2.3±1.5) underwent PVI. Compared to baseline, 1) improvements in the AFEQT composite and subscores were seen from 6–15 mos, exceeding Clinical Important Difference (±5 points) in majority of subjects (Figure), 2) proportion of CCS-SAF Class 0 patients (asymptomatic with respect to AF) rose from 0.7% to 81.0%, 3) class I/III AAD use was reduced from 97.0% to 24.7%, and 4) incidence of cardioversion decreased from 62.0% to 10.7%. Moreover, the 1-yr Kaplan-Meier estimate of freedom from hospitalization was 84.2% [95% CI: 80.2%, 88.2%].

Conclusion

CF-guided RF ablation in PsAF patients led to a clinically meaningful improvement in QOL, as well as a reduction in AAD use, cardioversion, and hospitalization.

Figure 1. Mean AFEQT composite and subscore

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This study was funded by Biosense Webster, Inc.

Acute-onset chronic inflammatory demyelinating polyneuropathy with cranial nerves and respiratory tract involvement: A case report

Sixteen percent of chronic inflammatory demyelinating polyneuropathy (CIDP) patients may present acutely like acute idiopathic demyelinating polyneuropathy (AIDP) the demyelinating form of GBS, developing in <8 weeks 2. This entity is classified as acute-onset CIDP (A-CIDP) which presents overlapping clinical and electrophysiological findings with GBS during early stages of disease, but followed with a chronic course beyond 2 months. Also, those who have three or more treatment-related fluctuations (TRF) are included under this term. Distinguishing between acute-onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) and acute idiopathic demyelinating polyneuropathy (AIDP) may be difficult during early stages but is crucial in order to guide treatment strategies without delay. These two forms share some overlapping clinical and electrophysiological findings, including some severe clinical features such as cranial nerve and respiratory tract involvement making the diagnosis of A-CIDP more difficult.

Geospatial Distribution and Predictors of Mortality in Hospitalized Patients With COVID-19: A Cohort Study

BACKGROUND

The global coronavirus disease 2019 (COVID-19) pandemic offers the opportunity to assess how hospitals manage the care of hospitalized patients with varying demographics and clinical presentations. The goal of this study was to demonstrate the impact of densely populated residential areas on hospitalization and to identify predictors of length of stay and mortality in hospitalized patients with COVID-19 in one of the hardest hit counties internationally.

METHODS

This was a single-center cohort study of 1325 sequentially hospitalized patients with COVID-19 in New York between March 2, 2020, to May 11, 2020. Geospatial distribution of study patients' residences relative to population density in the region were mapped, and data analysis included hospital length of stay, need and duration of invasive mechanical ventilation (IMV), and mortality. Logistic regression models were constructed to predict discharge dispositions in the remaining active study patients.

RESULTS

The median age of the study cohort (interquartile range [IQR]) was 62 (49-75) years, and more than half were male (57%) with history of hypertension (60%), obesity (41%), and diabetes (42%). Geographic residence of the study patients was disproportionately associated with areas of higher population density (r s = 0.235; P = .004), with noted "hot spots" in the region. Study patients were predominantly hypertensive (MAP > 90 mmHg; 670, 51%) on presentation with lymphopenia (590, 55%), hyponatremia (411, 31%), and kidney dysfunction (estimated glomerular filtration rate < 60 mL/min/1.73 m2; 381, 29%). Of the patients with a disposition (1188/1325), 15% (182/1188) required IMV and 21% (250/1188) developed acute kidney injury. In patients on IMV, the median (IQR) hospital length of stay in survivors (22 [16.5-29.5] days) was significantly longer than that of nonsurvivors (15 [10-23.75] days), but this was not due to prolonged time on the ventilator. The overall mortality in all hospitalized patients was 15%, and in patients receiving IMV it was 48%, which is predicted to minimally rise from 48% to 49% based on logistic regression models constructed to project disposition in the remaining patients on ventilators. Acute kidney injury during hospitalization (odds ratioE, 3.23) was the strongest predictor of mortality in patients requiring IMV.

CONCLUSIONS

This is the first study to collectively utilize the demographics, clinical characteristics, and hospital course of COVID-19 patients to identify predictors of poor outcomes that can be used for resource allocation in future waves of the pandemic.