Long-Term Survival and Quality of Life Following Transcatheter Aortic Valve Replacement in Nonagenarians

Transcatheter aortic valve replacement (TAVR) has emerged as a successful treatment option for severe aortic stenosis. However, the long-term outcomes of TAVR in nonagenarians is lacking. We aimed to examine the long-term mortality and quality of life in nonagenarians after TAVR. This is a multicenter, retrospective analysis on patients with severe aortic stenosis who underwent TAVR. Patients were divided into 2 groups: nonagenarians (age ≥90 years) and age <90 years. The Kansas City cardiomyopathy questionnaire (KCCQ) and New York Heart Association (NYHA) scores were compared before and after TAVR. All-cause mortality was compared between both groups at 30 days, 1 year, and 5 years after TAVR using the Cox proportional hazard model. A total of 6,896 patients were included, of whom 591 were nonagenarians. Nonagenarians had a higher Society of Thoracic Surgeons perioperative risk of mortality (8.1 ± 4.6% vs 5.4 ± 4.2%, p <0.001) before TAVR. Both groups were similar in KCCQ and NYHA scores at baseline. At 1 year after TAVR, there was no significant difference in improvement in the KCCQ overall score between those aged <90 years and nonagenarians (-4.76, 95% confidence interval [CI] -11.4 to 1.9, p = 0.161). Similarly, there was no statistically significant difference in improvement in NYHA class between the 2 groups at 1 year (odds ratio 1.07, 95% CI 0.85 to 1.25), p = 0.526). The unadjusted 30-day (3.2% vs 2.7%, hazard ratio 1.11, 95% CI 0.70 to 1.80, p = 0.667) and 5-year (28.0% vs 26.6%, hazard ratio 1.05, 95% CI 0.89 to 1.24, p = 0.60) all-cause mortality were similar between the 2 groups. In conclusion, this study demonstrates an excellent long-term mortality rate at 5 years after TAVR in nonagenarians, comparable to patients younger than 90 years. There is a significant and enduring improvement in functional status in nonagenarians, observed up to 1 year after TAVR.

The effects of negative social media connotations on subjective wellbeing of an ageing population: A stressor-strain-outcome perspective

In recent years, users' privacy concerns and reluctance to use have posed a challenge for the social media and wellbeing of its users. There is a paucity of research on elderly users' negative connotations of social media and the way these connotations contribute to developing passive behaviour towards social media use, which, in turn, affects subjective wellbeing. To address this research vacuum we employed the stressor-strain-outcome (SSO) approach to describe the evolution of passive social media use behaviour from the perspective of communication overload, complexity, and privacy. We conceptualized subjective wellbeing as a combination of three components-negative feelings, positive feelings, and life satisfaction. Negative and positive feelings were used to derive an overall affect balance score that fluctuates between 'unhappiest possible' and 'happiest possible'. The proposed research framework was empirically validated through 399 valid responses from elderly social media users. Our findings reveal that communication overload and complexity raise privacy concerns among social media users, which leads to passive usage of social media. This passive social media use improved the subjective wellbeing favourably by lowering negative feelings and raising positive feelings and life satisfaction. The findings also revealed that respondents' overall affect balance leans towards positive feelings as a consequence of passive social media use. This study contributes to the field of technostress by illuminating how the SSO perspective aid the comprehension of the way passive social media use influences the subjective wellbeing of its users.

A268 RESOLUTION RATES IN OPEN-LABEL VERSUS RANDOMIZED CONTROLLED TRIALS FOR MICROBIOTA RESTORATION FOR RECURRENT CLOSTRIDIOIDES DIFFICILE INFECTION: AN UPDATED META-ANALYSIS

Background

Microbiota restoration is highly effective to treat recurrent Clostridioides difficile infection (CDI) in observational studies (cure rates >90%) but efficacy in controlled clinical trials appears lower.

Purpose

We performed an updated meta-analysis to assess the efficacy of microbiota restoration for recurrent CDI in open-label registered prospective clinical trials compared to randomized controlled trials (RCTs).

Method

A systematic search of Embase, Web of Science and Scopus was performed up to June 2022 to identify studies of interest. Clinical trials of microbiota restoration for recurrent CDI with clinical resolution with one dose as the primary outcome were included. We calculated both unweighted and weighted pooled resolution rates (UPR and WPR) with 95% confidence intervals (CI).

Result(s)

Eighteen studies (9 RCTs and 9 open-label trials) with 1149 CDI patients were included. Of the patients treated with microbiota restoration, 881 experienced symptom resolution (UPR 77%%; WPR 79%, 95% CI, 72%-85%). There was significant heterogeneity among studies with an I²of 86%. Analysis of trials with a control arm (non-microbiota restoration) revealed CDI resolution in 357 of 496 patients (UPR 72%; WPR 73%, 95% CI 63%-82%) with microbiota restoration. Among the 9 open-label clinical trials, CDI resolution was seen in 524 of 653 patients after initial microbiota restoration (UPR 80%; WPR 84%, 95% CI 74%-92%). Comparison of resolution rates between RCTs and open-label trials revealed a lower cure rate in RCTs compared to open-label trials (WPR 73% vs 84%, p<0.0001).

Analysis of the 10 trials with non-microbiota restoration revealed CDI resolution in 201 of 397 patients with antibiotics (WPR 52%, 95% CI 43%-60%). There was significant heterogeneity among the included studies with an I²of 61%. Comparison of cure rates with microbiota restoration vs antibiotics showed higher cure rate with microbiota restoration (WPR 73%, [95% CI 63%-82%] vs 52% [95% CI, 43%-60%]; p<0.0001). There were no serious adverse events reported.

Conclusion(s)

Microbiota restoration in a randomized controlled setting leads to lower resolution rates compared to open label and observational settings, likely due to stricter definitions and inclusion criteria. Resolution rates in open label studies were similar to observational studies.

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Disclosure of Interest

None Declared

A233 OUTCOMES OF CLOSTRIDIOIDES DIFFICILE INFECTION IN SURGICAL PATIENTS: RESULTS FROM NATIONAL INPATIENT SAMPLE 2016-2019

Background

Clostridioides difficile infection (CDI) is the most common nosocomial infection and is associated with significant morbidity and mortality.

Purpose

We aimed to identify the burden of CDI in patients undergoing common gastrointestinal (GI) surgical procedures in a national inpatient cohort, as GI surgeries have been thought to be a risk factor for CDI.

Method

We used the National Inpatient Sample (NIS) database from Unites States for the years 2016-2019 for this study. We included adult patients (age ≥ 18), who underwent common GI surgeries (identified using ICD-10 procedure codes), and among them identified patients with diagnosis of CDI. Outcomes assessed included risk of CDI among different surgeries, inpatient mortality, length of stay (LOS) and cost of hospitalization using regression analyses

Result(s)

From 2016 to 2019, an estimated total of 4,438,778 patients were hospitalized and underwent any of the studied GI surgeries. CDI was reported in 32,180 admissions (0.72%). Median age for CDI was higher than non-CDI patients (66 vs 56, p<0.001). Incidence of CDI was 2.5 times higher in patients admitted emergently compared to elective admissions (1.00% vs 0.40%, p<0.0001). Among all surgeries, the incidence of CDI was the highest for small bowel resection at 2.1% followed by partial esophagectomy at 1.6% and partial colectomy at 1.4%. Logistic regression analysis showed the patients undergoing esophagectomy had the highest risk with adjusted Odds Ratio (aOR) of 2.48, (95% CI 2.01 – 3.07, p<0.0001), followed by pancreatectomy with aOR 2.03 (95% CI 1.91 – 2.16, p<0.0001). Overall, surgical patients with CDI had a significantly higher in-patient mortality compared to non-CDI patients (8.2% vs 1.4%, p<0.0001). Logistic regression analysis showed an increased risk of inpatient mortality with CDI, with aOR 1.36, 95% CI 1.30 – 1.42, p<0.0001. Median LOS for surgical patients with CDI was higher than non-CDI patients (14 days vs 3 days, p<0.0001). The linear regression analysis for length of stay showed that among patients undergoing surgical procedures, CDI was associated with an increased LOS with beta of 8.39 days ± SE 0.04 (95% CI 8.31 – 8.46, p<0.0001). The mean cost of hospitalization for surgical patients with CDI was higher than non-CDI patients ($90,590 vs $31,702, p<0.0001) after adjusting for inflation over the four-year period. The linear regression analysis showed that CDI was associated with an increased cost of hospitalization with a beta of $25,343 ± SE 166 (95% CI 25,017 – 25,670, p<0.0001).

Conclusion(s)

CDI among GI surgeries leads to increase in inpatient mortality, length of stay and cost of hospitalization. Although the rate of CDI is showing a downwards trend, its impact on these outcome measures makes it an important complication to prevent and promptly treat in these surgical patients.

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Disclosure of Interest

None Declared

POS0537 TRENDS AND PREDICTORS OF INPATIENT MORTALITY IN PATIENTS WITH CLOSTRIDIODES DIFFICILE INFECTION AMONG THOSE WITH AND WITHOUT RHEUMATOID ARTHRITIS: A NATIONWIDE ANALYSIS

Background:

People with rheumatoid arthritis (RA) have a higher risk of serious infections. The most common nosocomial infection in the United States (US) is Clostridioides difficile infection (CDI) and yet, little is known regarding the impact of comorbid RA on outcomes in persons hospitalized with CDI.

Objectives:

To evaluate the trends over time and predictors of inpatient mortality in hospitalized patients with CDI comparing those with and without RA.

Methods:

We used the National Inpatient Sample (NIS) database, the largest available all-payer database of inpatient hospitalizations in the US. Patients aged ≥18 years admitted with CDI from 2006-2018 were included. Patients with RA were identified using the International Classification of Diseases (ICD) 9 and 10 codes. Categorical variables between CDI patients with and without RA were compared using Chi-squared test. Temporal trends of hospitalization charges, length of stay (LOS) and inpatient mortality were assessed using the Cochrane Armitage test. Predictors of inpatient mortality were assessed using multivariable logistic regression adjusting for: age ≥65, sex, race, presence of RA, and Elixhauser comorbidity index.

Results:

There were 4,396,945 hospitalizations with a discharge diagnosis of CDI in the study period, of which 111,336 (2.5%) had a coexisting diagnosis of RA. Over the study period, the proportion of CDI patients with a diagnosis of RA increased from 1.7% in 2006 to 3.3% in 2018 with a statistically significant trend of rise (p trend<0.001). There were significantly more females in the RA group (78.2%) than without RA (57.5%), p <0.001. RA group was significantly younger (68.0 vs 70.7, P<0.001). Races were similar between the groups.

The inflation-adjusted average charge for hospitalization for CDI without RA was significantly higher than for CDI with RA ($95,863 vs $73,025, p<0.001). There was an increasing trend in inflation-adjusted average charge for hospitalization for both CDI without RA ($76,966 in 2006 to $104,552 in 2018, p<0.001) and CDI with RA ($55,689 in 2006 to $77,295 in 2018, p<0.001). Patients with or without RA had the same median length of stay (LOS) of 7 days. But when trended over time, for patients without RA, the median LOS decreased from 8 days in 2006-08 to 6 days in 2016-18 whereas for patients with RA, the median LOS fluctuated between 6 and 7 days over the course of study period.

CDI patients without RA had a significantly higher mortality over the study period than those with RA (7.8% vs 6.1%, p<0.001). Among non-RA CDI patients, mortality decreased from 9.3% in 2006 to 6.3% in 2018 (p trend <0.001). Hospitalizations of people with CDI and comorbid RA showed an overall decreasing trend (p trend <0.001).

The multivariable analyses found age≥65 was associated with increased inpatient mortality (adjusted odds ratio [aOR], 1.77, 95% confidence interval [CI], 1.73-1.80), whereas a diagnosis of RA was associated with a decreased mortality (aOR 0.86, 95% CI, 0.81-0.91) (Table 1).

Table 1.

Predictors of inpatient mortality

aOR95% C.I. for aORP-valueLowerUpperAge ≥ 651.7651.7301.801<0.001Hospitalization years -Years 2006-2011Ref -Years 2011-20140.7070.6930.721<0.001 -Years 2015-20180.5820.5690.594<0.001Elixhauser Comorbidity Index1.0561.0551.056<0.001Rheumatoid Arthritis0.8590.8100.911<0.001Female0.8700.8550.885<0.001Race -WhiteRef -African American1.0711.0441.099<0.001 -Hispanic1.1441.1081.180<0.001 -Asian/Pacific Islander1.2671.2001.337<0.001 -Native American1.0220.9101.1470.716 -Other races1.2631.2011.329<0.001

aOR = Adjusted Odds Ratio; C.I.= confidence interval

Conclusion:

In this nationwide study, among hospitalized patients with CDI, those with comorbid RA had significantly decreased odds of inpatient mortality than those without RA. Further studies are needed to understand this association.

Figure 1.

Disclosure of Interests:

None declared

Faecal microbiota transplantation for eradicating carriage of multidrug-resistant organisms: a systematic review

BACKGROUND

Multidrug-resistant (MDR) microorganism development in the gut is frequently the result of inappropriate antibiotic use. Faecal microbiota transplantation (FMT) restores normal gut microbiota in patients with Clostridium difficile infection. We hypothesized that it may help in decolonizing MDR organisms (MDROs) and in preventing recurrent MDR infections.

OBJECTIVES

To assess FMT efficacy (eradication rate) for decolonizing MDROs and preventing recurrent MDR infections.

DATA SOURCES

Medline, Embase and Web of Science (inception through 11 February 2019).

STUDY ELIGIBILITY CRITERIA

Clinical trials, retrospective studies, case reports and case series.

PARTICIPANTS

Patients with MDR infections or MDRO colonization treated with FMT.

INTERVENTIONS

FMT.

METHODS

Systematic review.

RESULTS

Twenty-one studies (one randomized clinical trial, seven uncontrolled clinical trials, two retrospective cohort studies, two case series, nine case reports) assessing 192 patients were included. Three studies assessed FMT efficacy in preventing MDR infections; 16 assessed its effect on MDRO colonization; two assessed both. Data from 151 patients were included in the final analyses. In studies with low to moderate risk of bias, the eradication rate was 37.5% to 87.5%. Efficacy was similar in studies looking at infection or colonization and did not differ by length of follow-up. No serious adverse events from FMT were reported. Seven patients died of other causes.

CONCLUSIONS

FMT could be used as a treatment for eradicating MDR colonization and possibly preventing recurrent MDR infections, once more supporting efficacy and safety data are available. Larger well-designed randomized controlled trials are needed to further explore this therapy.

Systematic review with meta-analysis: the impact of Clostridium difficile infection on the short- and long-term risks of colectomy in inflammatory bowel disease

BACKGROUND

Clostridium difficile infection (CDI) is associated with increased mortality in inflammatory bowel disease (IBD), but the risk of colectomy is variable and has not been adequately studied.

AIM

To perform a systematic review and meta-analysis to assess the impact of CDI on colectomy risk in IBD.

METHODS

Multiple databases were searched systematically for observational studies reporting colectomy risk in IBD, stratified by the presence of CDI, and the duration of follow-up (short term 3 months, and long term at least 1 year). Weighted summary estimates were calculated using generalised inverse variance with random-effects model. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Twelve observational studies were identified and included 35 057 IBD patients with CDI, and 929 259 without CDI. CDI did not increase the short-term colectomy risk in IBD patients overall (10 studies) (OR: 1.35; 95% CI: 0.68-2.67), or in patients with ulcerative colitis (nine studies) (OR: 1.20; 95% CI: 0.39-3.76). In contrast, CDI was associated with higher long-term colectomy risk in patients with IBD overall (five studies) (OR: 2.23; 95% CI: 1.18-4.21), and in patients with ulcerative colitis (four studies) (OR: 2.96; 95% CI: 1.19-7.34). The results were stable in subgroups stratified by recruitment period, hospitalisation status and geographical location. All studies were at least of moderate quality. The results were limited in the ability to compare IBD severity and the type of anti-microbial therapy.

CONCLUSION

Based on 12 observational studies with at least moderate quality, Clostridium difficile infection appears to increase colectomy risk in IBD in the long- but not short- term.

Inadvertent intrathecal injections and best practice management

The intrathecal space has become an important anatomic site for medical intervention not only in anesthesia practice, but also in many other medical specialties. Undesired/inadvertent intrathecal injections (UII) are generally rare. There is tremendous variation in reported inadvertent administrations via an intrathecal route in the literature, mainly as individual cases and very small case-series reports. This review aims to identify potential sources of UII, its clinical presentations, and appropriate management. The inadvertent injectants are classified as anesthetic agents and pain medicines, chemotherapeutics, radiological contrast agents, antibiotics and corticosteroids, and miscellaneous chemical agents such as tranexamic acid. The clinical effects of UII are dependent upon inadvertent injectant(s) and dose being administered intrathecally, and can range from no adverse effect to profound neurological consequences and/or death. Prompt cerebrospinal fluid (CSF) lavage and cardiopulmonary support seem to be the mainstay of treatment. If serious consequences are anticipated, CSF lavage could be lifesaving. This review additionally provides some options for comprehensive management and preventing strategies.

Comparative analysis of the human and zebrafish kinomes: focus on the development of kinase inhibitors

Targeting kinases with semi-selective kinase inhibitors is one of the most successful drug development strategies of the 21^st century. Zebrafish have become an increasingly useful model for pharmaceutical development. Water-soluble compounds can be screened for zebrafish phenotypes in a high throughput format against a living vertebrate, and cell-signaling events can be imaged in transparent living fish. Despite zebrafish being a more relevant model than more distantly related systems such as the well-annotated kinome of yeast and drosophila, there is no comparative analysis of the human and zebrafish kinome. Furthermore most approved kinase inhibitors, often called 'DFG in' ATP competitive inhibitors, act on conserved active site residues in the kinase. Since the active site residues can be identified by examining the primary sequence, primary sequence identity can be a rough guide as to whether a particular inhibitor will have activity against another kinase. There is a need to evaluate the utility of zebrafish as a drug development model for active site inhibitors of kinases. Here we offer a systematic comparison of the catalytic domains of classical human kinases with the catalytic domains of all annotated zebrafish kinases. We found a high degree of identity between the catalytic domains of most human kinases and their zebrafish homologs, and we ranked 504 human kinase catalytic domains by order of similarity. We found only 23 human kinases with no easily recognizable homologous zebrafish catalytic domain. On the other hand we found 78 zebrafish kinase catalytic domains with no close human counterpart. These 'additional kinase active sites' could represent potential mediators of zebrafish toxicity that may not be relevant to human kinase inhibitors. We used two clinically approved human kinase inhibitors, one targeting a highly homologous target and one targeting a lesser homologous target, and we compared the known human kinase target structures with modeled zebrafish target structures. As expected, the homologous target had high structural identity, but even the less homologous target had high structural identity in residues contacted by the inhibitor. Overall this analysis should help guide researchers interested in studying human kinases and their inhibitors in more tractable systems.

Comparison between surgery and physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A randomised controlled study of 103 patients with one-year follow-up

In order to compare the outcome from surgical repair and physiotherapy, 103 patients with symptomatic small and medium-sized tears of the rotator cuff were randomly allocated to one of the two approaches. The primary outcome measure was the Constant score, and secondary outcome measures included the self-report section of the American Shoulder and Elbow Surgeons score, the Short Form 36 Health Survey and subscores for shoulder movement, pain, strength and patient satisfaction. Scores were taken at baseline and after six and 12 months by a blinded assessor. Nine patients (18%) with insufficient benefit from physiotherapy after at least 15 treatment sessions underwent secondary surgical treatment. Analysis of between-group differences showed better results for the surgery group on the Constant scale (difference 13.0 points, p - 0.002), on the American Shoulder and Elbow surgeons scale (difference 16.1 points, p < 0.0005), for pain-free abduction (difference 28.8 degrees , p = 0.003) and for reduction in pain (difference on a visual analogue scale -1.7 cm, p < 0.0005).

Prevalence and characteristics of asymptomatic tears of the rotator cuff

We undertook clinical and ultrasonographic examination of the shoulders of 420 asymptomatic volunteers aged between 50 and 79 years. MRI was performed in selected cases. Full-thickness tears of the rotator cuff were detected in 32 subjects (7.6%). The prevalence increased with age as follows: 50 to 59 years, 2.1%; 60 to 69 years, 5.7%; and 70 to 79 years, 15%. The mean size of the tear was less than 3 cm and tear localisation was limited to the supraspinatus tendon in most cases (78%). The strength of flexion was reduced significantly in the group with tears (p = 0.01).

Asymptomatic tears of the rotator cuff should be regarded as part of the normal ageing process in the elderly but may be less common than hitherto believed.

Head injury in children due to cricket ball scenario in developing countries

OBJECTIVES

The aim of the study was the assessment of head injury caused by cricket ball injury in children. In underdeveloped countries, this is particularly important due to the absence of safety precautions. The study was undertaken to increase the public awareness of the need to reduce the morbidity related to this sport.

METHODS

This was a prospective study in which all the children <18 years who had sustained head injury due to cricket balls were enrolled.

RESULTS

The study included 27 children, 26 males and 1 female. Out of these 21 cases of head injury were due to hard plastic cricket balls and the rest were due to conventional cricket balls. In 25 patients, CT scan was done, which revealed a lesion in 21 of them. Six patients required surgery, 3 for extradural hematoma, 1 for acute subdural hematoma, 1 for contusion and 1 for compound depressed fracture. One death occurred in our series. There was no significant difference in the nature of injury sustained by either plastic or conventional cricket balls.

CONCLUSION

Head injury due to cricket balls can lead to serious consequences even if an innocuous plastic ball is used in place of a conventional cricket ball. Public awareness apart from safety measures is required so that helmets are worn during playing. Change in the nature of the balls may bring a reduction in the severity of head injury.

Multicenter evaluation of a new laser guidance system for computed tomography intervention

PURPOSE

To measure the accuracy of laser-guided punctures and to evaluate the usefulness of the developed laser-guided system.

MATERIAL AND METHODS

The study included 67 patients referred for computed-tomography-guided puncture. The majority of the punctured lesions were located in the chest (28 patients) or abdomen (19 patients). The mean diameter of the lesion was 3.1 cm, and the mean path length was 6.8 cm. The laser guide was movable along a horizontal or vertical rail and not physically connected to the CT unit. The angle of insertion was entered manually into the display of the unit by the interventional radiologist. A prospective multicenter trial was carried out.

RESULTS

A mean of 1.1 needle passes were necessary to reach the target, and in 55 (84.6%) of the patients the target was reached on the first needle pass. The mean deviation of the needle from the preselected angle was 1.8 degrees. The mean targeting time (from the initial localizing scan until the needle was in the target) was 15.6 min. In every case, both the usefulness and the ease of use of the laser guidance system were subjectively evaluated on a 5-point scale; the mean usefulness score was 4.5, while the mean ease of use score was 4.7.

CONCLUSION

Different users at four different centers found the laser guidance system useful and easy to use. A high level of accuracy of the puncture angle was obtained in most cases.