Intraventricular baclofen for palliative management of acquired generalized dystonia in pediatric patients: a case series and literature review

Dystonia represents a significant source of disability in children. Generalized dystonia, which involves multiple body regions, leads to impaired mobility and motor function, resulting in substantial challenges in daily activities. Surgical treatments are used when medical treatments fail. Intrathecal baclofen (ITB) or deep brain stimulations (DBS) are the most employed surgical therapies. When these options are not feasible or ineffective, some authors have explored the use of intraventricular baclofen (IVB). In this report, we present four cases of pediatric patients with generalized dystonia who underwent treatment with IVB, resulting in notable improvements. To further explore the potential of this treatment modality, we conducted a comprehensive literature review. The findings from our study provide a comprehensive overview that can guide palliative management in similar cases.

Exploring nurses' experiences of performing basic life support in hospital wards: An inductive thematic analysis

AIM

The aim of this study was to undertake an in-depth exploration of the lived experiences of in-hospital, non-intensive care, ward-based nurses' experiences of real-life CPR events.

BACKGROUND

There is growing evidence suggesting that may nurses not be able to successfully perform in a cardiac arrest situation. Reasons include a lack of clear leadership at the arrest, performance anxiety, role confusion and knowledge and skill degradation over time.

METHODS

In-depth semi-structured interviews were conducted with fifteen ward-based hospital nurses from three hospitals. Interviews were recorded, transcribed verbatim and inductive thematic analysis was completed using NVivo 12 software.

FINDINGS

Four main themes emerged from data. The main themes are: (1) Not Being able to Perform When it Matters, (2) Working Really Well as a Team, (3) Reflecting on the Experience: The Good, the Bad & the Ugly and (4) Learning to get it Right for Next Time CONCLUSION: Performing BLS is a stressful and anxiety-provoking experience for ward-based nurses. Anxiety levels appear to decrease slightly only when nurses have had at least one previous real-life experience with resuscitation. Current BLS education does not prepare nurses for the complexities of resuscitation. Future BLS education should focus on in-depth scenarios, including interdisciplinary team training and with greater frequency than the current yearly mandatory sessions. Listening to the lived experiences of nurses who have performed BLS has given much needed insight into approaches that educators can use to improve BLS education delivery.

Low-density lipoprotein cholesterol in adolescents and young adults with type 1 diabetes: Data from the Australasian Diabetes Data Network registry

AIM

To determine low-density lipoprotein cholesterol (LDL-C) screening frequency and levels, and factors associated with elevated LDL-C, in Australasian youth with type 1 diabetes (T1D).

METHODS

Data were extracted from the Australasian Diabetes Data Network (ADDN), a prospective clinical quality registry, on all T1D healthcare visits attended by young people aged 16-25 years (with T1D duration of >1 year) between January 2011 and December 2020. The primary outcomes were elevated LDL-C > 2.6 mmol/L (100 mg/dL) and threshold for treatment: >3.4 mmol/L (130 mg/dL), according to consensus guidelines. Multivariable Generalised Estimated Equations (GEE) were used to examine factors associated with elevated LDL-C across all visits.

RESULTS

A cohort of 6338 young people (52.6% men) were identified, of whom 1603 (25.3%) had ≥1 LDL-C measurement documented. At last measurement, mean age, age at T1D diagnosis and T1D duration were 18.3 ± 2.4, 8.8 ± 4.5 and 8.9 ± 4.8 years, respectively. LDL-C was elevated in 737 (46.0%) and at the treatment threshold in 250 (15.6%). In multivariable GEE elevated LDL-C continuously was associated with older age (OR = 0.07; 0.01-0.13, p = 0.02), female sex (OR = 0.31; 0.18-0.43; p < 0.001), higher HbA1c (OR = 0.04; 0.01-0.08; p = 0.01) and having an elevated BMI (OR = 0.17, 0.06-0.39, p < 0.001).

CONCLUSIONS

LDL-C screening and levels are suboptimal in this cohort, increasing future cardiovascular complication risk. There is an urgent need to understand how healthcare services can support improved screening and management of dyslipidaemia in this population.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

A service evaluation of joint working across sectors to promote self-administration of subcutaneous systemic anti-cancer therapy in breast cancer patients

Introduction

Trastuzumab(T) is a humanized monoclonal antibody used in the treatment of HER2-positive breast cancer and is available as a subcutaneous(sc) formulation thereby allowing short and convenient administration. A lack of trained nurses to administer T at home and/or train patients at home to self-administer, together with challenges in maintaining cold-chain delivery have impeded uptake of home administration.1,2 In order to support patients’ ability to self-administer T at home, we have implemented an educational programme that includes nurse-led training, education material, support apps and follow-up telephone clinics. Home delivery of pre-filled syringes was enabled in collaboration with commercial providers for aseptics and logistic.

Aim

The aim of this service evaluation was to evaluate the utility of this programme from the patients’ perspective and to assess patient satisfaction and impact on quality of life (QOL).

Methods

A previously validated Self-Injection Assessment Questionnaire (SIAQ)3 was modified to assess patient satisfaction, perceptions and impact of the programme. Patients who had agreed to enrol on the ‘self-administration’ scheme, were asked to complete the questionnaire at baseline, at the third training session and at the second self-administered dose. Approval from a Research Ethics Committee is not required for this service evaluation.

Results

All 14 patients offered the questionnaire responded to all questions. The median age was 58 years old (age range 43-76), 11 patients were Caucasian, 2 were Asian and one was African/Caribbean. The average distance from their home address to hospital was 10.1 miles (range 4-19). Following completion of the one-to-one nurse training there was an improvement in patient confidence to self-administer sc. T. No differences in ‘feeling in control of their treatment’ or ‘satisfaction of attending hospital appointments’ were noted. Of the 11 patients who reached the self-administration stage, 10 reported that they felt ‘very confident’ and 8 reported that it was ‘very easy’ to give themselves the injection. All patients rated themselves ‘very satisfied’ with self-administration and reported that the nurse training programme helped them to be more confident. 10 patients reported that the App and written information was useful as well as the pre- and post- administration telephone clinics. All patients reported that the self-administration programme had a positive impact on their QOL by reducing the number of hospital visits. In the first 4 months of self-administration each patient reduced their hospital attendance by an average of 8 appointments (median=8) equating to 10 hours of time that would have been spent at hospital.

Discussion/Conclusion

The subcutaneous T self-administration programme was well received by patients. The nurse training sessions and supportive materials enabled patients to feel more confident about self-administration with no reported incidents or adverse events. This led to fewer hospital visits and improved QOL. This programme was critically dependent on the services of a commercial compounder and homecare provider, emphasizing the importance of joint working between the NHS and commercial sector. Evaluation of this programme will continue and will include other agents, including Phesgo® (sc trastuzumab and pertuzumab) which have more patients and will improve the reliability of the results.

References

1. Tjalma, W., Huizing, M., Papadimitriou, K. The smooth and bumpy road of trastuzumab administration: from intravenous (IV) in a hospital to subcutaneous (SC) at home. Facts Views Vis Obgyn, 2017;9(1):51-55.

2. Grady, PA, Gough, LL. Self-management: a comprehensive approach to management of chronic conditions. American Journal of Public Health 2014; 104(8):e25-31. doi:10.2105/AJPH.2014.302041

3. Keininger D, Coteur G. Assessment of self-injection experience in patients with rheumatoid arthritis: psychometric validation of the Self-Injection Assessment Questionnaire (SIAQ). Health Qual Life Outcomes. 2011;9:2. doi:10.1186/1477-7525-9-2

Resectability of bilobar liver tumours after simultaneous portal and hepatic vein embolization versus portal vein embolization alone: meta-analysis

BACKGROUND

Many patients with bi-lobar liver tumours are not eligible for liver resection due to an insufficient future liver remnant (FLR). To reduce the risk of posthepatectomy liver failure and the primary cause of death, regenerative procedures intent to increase the FLR before surgery. The aim of this systematic review is to provide an overview of the available literature and outcomes on the effectiveness of simultaneous portal and hepatic vein embolization (PVE/HVE) versus portal vein embolization (PVE) alone.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, and Embase up to September 2022. The primary outcome was resectability and the secondary outcome was the FLR volume increase.

RESULTS

Eight studies comparing PVE/HVE with PVE and six retrospective PVE/HVE case series were included. Pooled resectability within the comparative studies was 75 per cent in the PVE group (n = 252) versus 87 per cent in the PVE/HVE group (n = 166, OR 1.92 (95% c.i., 1.13-3.25)) favouring PVE/HVE (P = 0.015). After PVE, FLR hypertrophy between 12 per cent and 48 per cent (after a median of 21-30 days) was observed, whereas growth between 36 per cent and 67 per cent was reported after PVE/HVE (after a median of 17-31 days). In the comparative studies, 90-day primary cause of death was similar between groups (2.5 per cent after PVE versus 2.2 per cent after PVE/HVE), but a higher 90-day primary cause of death was reported in single-arm PVE/HVE cohort studies (6.9 per cent, 12 of 175 patients).

CONCLUSION

Based on moderate/weak evidence, PVE/HVE seems to increase resectability of bi-lobar liver tumours with a comparable safety profile. Additionally, PVE/HVE resulted in faster and more pronounced hypertrophy compared with PVE alone.

Twitter data from the 2019-20 Australian bushfires reveals participatory and temporal variations in social media use for disaster recovery

Social media platforms have proved to be vital sources of information to support disaster response and recovery. A key issue, though, is that social media conversation about disasters tends to tail off after the immediate disaster response phase, potentially limiting the extent to which social media can be relied on to support recovery. This situation motivates the present study of social media usage patterns, including who contributes to social media around disaster recovery, which recovery activities they contribute to, and how well that participation is sustained over time. Utilising Twitter data from the 2019-20 Australian bushfires, we statistically examined the participation of different groups (citizens, emergency agencies, politicians and others) across categories of disaster recovery activity such as donations & financial support or mental health & emotional support, and observed variations over time. The results showed that user groups differed in how much they contributed on Twitter around different recovery activities, and their levels of participation varied with time. Recovery-related topics also varied significantly with time. These findings are valuable because they increase our understanding of which aspects of disaster recovery currently benefit most from social media and which are relatively neglected, indicating where to focus resources and recovery effort.

Low-density lipoprotein cholesterol reduction with evolocumab and its use in clinical practice: evidence from Swedish national register data

Background/Introduction

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors reduce low density lipoprotein cholesterol (LDL-C) levels by around 50% to 60%, and the risk of cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) in randomized clinical trials. Data on LDL-C reduction with PCSK9 inhibitors and its use in clinical practice is lacking.

Purpose

Assess LDL-C reduction with the PCSK9 inhibitor evolocumab and its use in clinical practice in Sweden.

Methods

Population-based, retrospective, longitudinal, observational study of patients initiating evolocumab treatment between July 2015 and May 2020. Patients undergoing lipoprotein apheresis were excluded. Patient level data was obtained from national diagnosis and pharmaceutical registers (covering 100% of the Swedish population), and electronic health records (covering 60% of the Swedish population). The use of evolocumab was assessed based on persistence with and adherence to treatment. Patients were defined as being persistent if they were still taking evolocumab 12 months after treatment initiation. Medication gaps were allowed until a last gap of ≥56 days. Patients were defined as being adherent if the proportion of days covered (PDC) by the drug was ≥80% during that same period. Mean LDL-C reduction was estimated 3 months after evolocumab treatment initiation, using a Generalized Least Squares regression model.

Results

Overall, 2341 patients were included in the analysis, with a median follow-up of 376 days. Median age was 65 years, 43% were women, 79% had a history of ASCVD and, among them, 94% had had a coronary event and 24% had diabetes. 44% of the patients had LDL-C available. Median LDL-C was 4.1 mmol/L and 64% of the patients were receiving oral lipid-lowering treatment (LLT). After 12 months of treatment, 76% of the patients were persistent with evolocumab. In these patients, median PDC over 12 months was 93%, with 86% of these patients being adherent (PDC ≥80%). In the overall population (n=724), the estimated mean LDL-C reduction with evolocumab at 3 months was 48% (2.1 mmol/L, from 4.4 mmol/L at baseline). In patients who were adherent to evolocumab during the first 6 months (n=567), LDL-C reduction was 53% (2.2 mmol/L, from 4.3 mmol/L at baseline) (see figure). In patients who were adherent to both evolocumab and oral LLT (PDC ≥80% over a period of 3 months before and after evolocumab initiation) (n=186), LDL-C reduction was 59% (2.1 mmol/L, from 3.6 mmol/L at baseline). The estimated mean LDL-C reduction remained stable over a 6-month period.

Conclusions

Persistence with and adherence to evolocumab treatment were high over 12 months. LDL-C reduction with evolocumab in clinical practice was similar to that observed in randomized clinical trials and remained stable over 6 months. At evolocumab treatment initiation, many patients had high LDL-C levels and underused oral LLT, potentially due to statin intolerance.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

Long-term incidence of pacemaker implantations and bradycardia among cross-country skiers

Background

Bradycardia is more common among well-trained athletes. The associations of training with pacemaker implantations are less known. We aim to investigate the association of endurance training with incidence of bradycardia and pacemaker implantations in a cohort of endurance athletes. Furthermore, we aim to establish potential sex differences of such associations.

Methods

Swedish skiers (209,072) that completed 1 or more races in the 30 to 90 km cross-country skiing event Vasaloppet (1989–2011) and a matched sample (n=531,949) of nonskiers were followed until first event of bradycardia or pacemaker implantation. The Swedish National Patient Register of in-patient and specialized outpatient care was used to obtain the date of diagnoses. Cox regression was used to investigate associations of number of completed races and finishing time with incidence of bradycardia and pacemaker implantations.

Results

Male skiers had higher incidence of bradycardia (hazard ratio [HR], 1.14; 95% CI, 0.99–1.30) and pacemaker implantations (HR, 1.14; 95% CI, 1.02–1.28) than male nonskiers. Male skiers completing most races or with the fastest finishing times had the highest incidence. The incidence of bradycardia (HR, 0.96; 95% CI, 0.70–1.30) and pacemaker implantations (HR, 0.97; 95% CI, 0.75–1.25) among female skiers in Vasaloppet was not different to that of female nonskiers. There was a trend that female skiers completing most races or with fastest finishing times had lower incidence.

Conclusions

Male skiers had higher incidence of bradycardia and pacemaker implantations. Female skiers in Vasaloppet had non-different incidence of bradycardia and pacemaker implantations. Men with the highest number of races and fastest finishing times had the highest incidence of pacemaker implantations. This indicates that bradycardia associated with training is not always as benign as previously suggested. The response appears to be different between sexes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Uppsala UniversityCKF Dalarna

Does the quality index of adherence to the evidence-based guidelines predict mortality in patients with myocardial infarction?

Background

The SWEDEHEART quality index of hospitals' adherence to the evidence-based (EB) guidelines for myocardial infarction (MI) patients has been continuously used for several decades in Sweden. The grading protocol is based on the consensus among hospitals. The hospitals are awarded points (0, 0.5, 1) for each of the 11 indicators depending on the proportion of patients who received EB treatment and achieved treatment goals. The 11 indicators at present are reperfusion treatment in STEMI (yes/no), time to-reperfusion treatment in STEMI, time to revascularisation in NSTEMI, P2Y12 antagonists at discharge, ACE-inhibitor/ARB at discharge, the proportion of patients at follow-up, smoking cessation at one-year, participation in a physical exercise program, target LDL-cholesterol and target blood pressure at one year.

Purpose

To evaluate whether the SWEDEHEART quality index predicts mortality in patients with MI.

Methods

We used data for all MI patients reported to the SWEDEHEART registry from 72 hospitals in Sweden between 2015–2021. We calculated the difference in quality index between 2021 and 2015. The hospitals were divided into quintiles based on the difference in the score. Logistic regression with log-time offset was used to adjust for confounders (age, gender, diabetes, hypertension, hyperlipidemia, STEMI/NSTEMI, cardiac arrest before admission, occupation status, history of heart failure, prior MI, prior PCI, prior CABG, cardiogenic shock).

Results

We identified 98,635 patients with MI, 32,608 (33.1%) were women and 34,198 (34.7%) had STEMI. The average age was 70.8±12.2 years. The median follow-up time was 2.7 years (IQR 1.06–4.63). The crude all-cause mortality rate was 5.5% at 30-days and 22.3% after long-term follow-up. Most hospitals (72.1%) improved their quality index on average by 3.4% per year (P<0.001). The increase in the quality index continued during COVID-19 pandemic (2020–2021) with average increase of 8.6%, 95% CI, 0.97–1.02; P<0.001. The median change in SWEDEHEART quality index score among the quintiles were −1.5 (Q1), 0,5 (Q2), 2,5 (Q3), 3 (Q4), and 4 (Q5). We found no difference in mortality between the quintiles at 30-days (OR 0.99; 95% CI 0.97–1.02; p=1.02) and long-term (OR 1.01; 95% CI 0,99–1.02; p=0.850).

Conclusion

The SWEDEHEART quality index provides valuable descriptive information about hospitals' adherence to the guidelines. However, the index, in its current form, does not predict mortality in patients with MI.

Funding Acknowledgement

Type of funding sources: None.

Comparison between ticagrelor and clopidogrel in high bleeding risk patients with acute coronary syndrome

Background

Potent antiplatelet agents such as ticagrelor are associated with a lower risk of ischemic events than clopidogrel in patients with acute coronary syndrome (ACS). However, it is uncertain whether the benefits of more intensive anti-ischemic therapy outweigh the risks of major bleeding in individuals who have a high bleeding risk (HBR). This study aimed to assess treatment outcomes following dual antiplatelet therapy (DAPT) using either ticagrelor or clopidogrel in ACS patients with HBR.

Methods

All HBR patients enrolled in the SWEDEHEART registry who were discharged with DAPT using ticagrelor or clopidogrel following ACS between 2010 and 2017 were included in this study. Bleeding risk was assessed using the 4-item PRECISE-DAPT score, which consists of age, prior bleeding, haemoglobin concentration and creatinine clearance. HBR was defined as a PRECISE-DAPT score ≥25. Inverse-probability of treatment weighting was used to adjust for baseline differences between the treatment groups. The main analysis consisted of a doubly robust estimation of causal effect using Cox proportional hazards models. Data on major bleeding, recurrent myocardial infarction (MI), ischemic stroke and all-cause mortality was obtained from national registries, with 365 days of follow-up. Additional outcomes include major adverse cardiovascular events (MACE), a composite of MI, ischemic stroke and all-cause mortality, and net adverse clinical events (NACE), a composite of MACE and major bleeding.

Results

Of all ACS patients, 36% (n=25,042) had a PRECISE-DAPT score ≥25. Approximately half of the study participants were treated with ticagrelor (n=11,848). Ticagrelor reduced the risk of MI (hazard ratio [HR], 0.82 [95% CI 0.74–0.91]), ischemic stroke (HR, 0.73 [95% CI 0.60–0.88]) and MACE (HR, 0.90 [95% CI 0.84–0.97]), while also increasing the risk of major bleeding compared to clopidogrel (HR, 1.30 [95% CI 1.16–1.47]). We found no significant differences in all-cause mortality (HR 1.02 [95% CI 0.92–1.12]) and NACE (HR 0.98 [95% CI 0.92–1.05]).

Conclusions

Ticagrelor was associated with a lower risk of recurrent ischemic events, but a higher risk of major bleeding compared to clopidogrel. There were no significant differences in all-cause mortality and NACE between the treatment groups. These results suggest that more potent antiplatelet agents might not be superior to clopidogrel in ACS patients with HBR.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Stockholm county council

Reflections on the production and use of interviews as a learning tool in educational podcasts for medical undergraduates

Introduction

The therapeutic interview is one of the cornerstones of psychiatric practice. When practitioners are skilled in the art of interviewing, patients are allowed to share their narratives and explore their emotions, while the clinician can diagnose and treat more effectively. Discussions with colleagues can be used to share knowledge and experience. As part of a student project undertaken in Summer 2021, two students were tasked with producing a series of educational podcasts to be used for psychiatric training. Both students chose to complete several interviews with professionals in psychiatry. In this study, they will reflect on the efficacy of interviews as a learning tool, their experiences of podcast interviewing, and the transferable skills that they learned.

Objectives

To reflect on the use of interviews within podcasts and how this can be transferred to practice.

Methods

Based on the literature review, medical students conducted interviews with specialist clinicians in order to gain information around patient treatment. They then reflected on this experience.

Results

The practice of interviewing allowed for the development of a range of skills. It improved communication with senior professionals, provided a deeper knowledge of different psychiatric fields, and developed the written skills needed for the creation of engaging questions.

Conclusions

Interviews are a useful tool in educational podcasts and producing these helped medical students gain specialist insight and learning into different medical fields not thoroughly covered in the undergraduate curriculum. Producing the podcasts helped to develop the key skill of interviewing and communicating with more senior colleagues.

Disclosure

No significant relationships.

“Dissolving Cartesian dualism”: using a novel student-lead podcast to explore the relationship between neurological and psychiatric illness

Introduction

Psychiatric conditions can be both a symptom and a consequence of physical disease. Although understanding of this is important for health care delivery, coverage of the relationship between physical and psychiatric illness in undergraduate medical education is sparse. This relationship is particularly pertinent in neurological disorders, where psychiatric symptomatology is commonplace. As part of a student project, the author was tasked with developing accessible teaching materials to increase interest and understanding among medical students, using podcasts.

Objectives

The aim was to develop podcasts which explored the relationship between psychiatric and neurological illness, for use in undergraduate psychiatric training.

Methods

Literature reviews were performed on podcasting in medical education to identify the optimal methods of production to maximise educational value, and on topics covered in podcasts to inform the interview questions. Experts in the relevant areas were contacted for recorded interviews, later used to create podcasts.

Results

Four interviews were conducted between the author and consultant neurologists specialising in the specific neurological condition. A podcast was produced for each of the following topics: depression in multiple sclerosis, frontotemporal dementia in motor neurone disease, Lewy body dementia, and dissociative seizures.

Conclusions

Psychiatric and physical illness are often intertwined. As the prevalence of psychiatric illness rises, it is becoming increasingly important that this connection is recognised, in order to improve patient experiences and outcomes. Novel teaching modalities, such as podcasts, can provide additional ways to support medical education on this important topic.

Disclosure

No significant relationships.

Rape myth acceptance of students: The influence of social groups

Objective The purpose of the study was two-fold. The first objective was to determine the level of rape myth acceptance of college students. The second objective was to determine the impact of social group membership on rape myth. Participants: 316 undergraduate students were recruited in spring of 2016. Methods: Surveys distributed to students to gauge rape myth acceptance using McMahon and Farmer's Illinois Rape Myth Acceptance scale along with social group belongingness of sports, Greek life, and other student organizations. Results: Data analysis indicated students do not accept rape myths. Data specified no statistical significance, unlike past research, in social group membership such as Greek life and athletics in predicting rape myth acceptance. Conclusion: There is a need to further explore social group membership in its various forms to explain rape myths and why patterns of agreement still exist in this population.

Points to consider in seeking biosafety approval for research, testing, and environmental release of experimental genetically modified biocontrol products during research and development

Novel genetically modified biological control products (referred to as "GM biocontrol products") are being considered to address a range of complex problems in public health, conservation, and agriculture, including preventing the transmission of vector-borne parasitic and viral diseases as well as the spread of invasive plant and animal species. These interventions involve release of genetically modified organisms (GMOs) into the environment, sometimes with intentional dissemination of the modification within the local population of the targeted species, which presents new challenges and opportunities for regulatory review and decision-making. Practices developed for GMOs, primarily applied to date for GM crops may need to be adapted to accommodate different types of organisms, such as insects, and different technologies, such as gene drive. Developers of new GM biocontrol products would benefit from an early understanding of safety data and information that are likely to be required within the regulatory dossier for regulatory evaluation and decision making. Here a generalizable tool drawing from existing GM crop dossier requirements, forms, and relevant experience is proposed to assist researchers and developers organize and plan their research and trialing. This tool requires considering specifics of each investigational product, their intended use, and country specific requirements at various phases of potential product development, from laboratory research through contained field testing and experimental release into the environment. This may also be helpful to risk assessors and regulators in supporting their systematic and rigorous evaluation of new biocontrol products.

Lonar Impact Crater, India: the Best-Preserved Terrestrial Hypervelocity Impact Crater in a Basaltic Terrain as a Potential Global Geopark

Lonar Impact Crater is a simple meteorite impact crater carved out on the ~ 65 Ma old Deccan tholeiitic flood basalts. The crater, though scoured in a basaltic terrain, is still preserved in its most pristine form, with a central crater lake. The geomorphology, geochemistry, geochronology, hydrology, geophysical parameters, and structural aspects of Lonar Crater have been explored in detail, but still continue to contribute valid scientific insights into the geology of terrestrial impact craters. Lonar serves as a potential analog site for studying impact cratering on planetary surfaces with basaltic terrains such as the Moon and Mars. Besides being a highly recognizable impact crater in India, the Lonar crater and its hinterland stand out with its archeological relevance and spiritual influence among the people. The numerous temples in and around the crater premises uphold the cultural significance of the region. The crater and adjacent areas are rich in flora and fauna representing a diverse ecosystem in the vastness of the arid Deccan Flood Basalts. Hence, the astrobleme and its surrounding is declared a Ramsar site and is also a protected wildlife sanctuary. The Indian Government has also declared the crater a National Geological Monument as well as an archaeological monument. Furthermore, the astrobleme is a unique site with socio-cultural and economic significance. With these plethoras of importance, combined with the geological and socio-cultural aspects in its hinterland, together with the most acclaimed UNESCO world heritage centers Ajantha and Ellora caves in the neighborhood, it stands as the right candidate for a UNESCO Global Geopark. However, the crater and its ecosystem are not preserved well enough, and the uniqueness of the crater is diminishing. But after selection as a Ramsar site, the area shows increased vegetation growth. The SWOT analysis conducted in this study accounts for Lonar Crater and its adjoining areas as a potential global geopark. Thus, through this study, we try to propagate the vivid and myriad importance of the Lonar crater and the necessity of protecting this geological monument from both anthropogenic and natural processes and to appraise the necessity for nominating this area as a UNESCO Global Geopark.

The incidence, time distribution and prognostic value of monomorphic ventricular tachycardia in ST-elevation myocardial infarction: the prespecified analysis of VALIDATE SWEADHEART trial

Background

The assessment of prognostic impact of ventricular arrhythmias in ST-elevation myocardial infarction (STEMI) is currently based mainly on their timing with regard to the symptom onset and does not distinguish between monomorphic ventricular tachycardia (VT) and polymorphic VT/ventricular fibrillation (VF). However, recent data indicate long-term hazard of monomorphic VT occurring early in the course of STEMI.

Purpose

To evaluate the incidence, time distribution and prognostic value of early monomorphic VT compared to polymorphic VT/VF in STEMI patients treated by primary percutaneous coronary interventions (PCI).

Methods

A prespecified analysis of the multicentre prospective registry-based randomised VALIDATE-SWEDEHEART trial included STEMI patients enrolled at 16 sites in Sweden between June 2014 and September 2016. Source data verification regarding the type and timing of arrhythmia from all patients with VT/VF during STEMI was performed. Survival status was obtained from the Swedish national population registry. Endpoint was total mortality at 180 days.

Results

In total, 2886 patients were identified. Among them, 97 (3.4%) had VF or polymorphic VT, 16 (0.5%) monomorphic VT, 6 (0.2%) had other undefined shockable rhythm. Total mortality (10.9% vs 2.8%, p≤0.001) was higher among patients with VT/VF. VT/VF was associated with total mortality (HR 3.18 95% CI 1.74–5.8; p≤0.001) after adjustment on age, gender and myocardial infarction localisation. In patients discharged from hospital, VT/VF did not influence the long-term prognosis.

Patients with monomorphic VT had similar clinical characteristics as compared to those with polymorphic VT/VF. The time distribution of VT/VF differed with regard to the type of arrhythmia: 63% of monomorphic VT/VF episodes occurred after PCI (n=10) compared to 24% (n=23) of all documented polymorphic VT/VF, p=0.003. Total mortality (12.5% vs 10.3%, p=0.678) did not differ between patients with monomorphic VT and polymorphic VT/VF. In Cox model, total mortality was not associated with the type of arrhythmia (Figure).

Conclusion

Early VT/VF is a marker of poor short-term outcome in patients with STEMI, which does not affect long-term prognosis in those who are successfully resuscitated and discharged from hospital.

The incidence of monomorphic VT in STEMI treated by primary PCI is low, and it occurs mainly after PCI. Though no significant difference in mortality was found between patients with monomorphic VT and polymorphic VT/VF, the observed low incidence hampers drawing conclusions with regard to the prognostic hazard impact of monomorphic VT.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Swedish Heart Lung Foundation

A real-world analysis of characteristics and lipid-lowering therapy use in patients initiating treatment with evolocumab in Sweden

Background/Introduction

Proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors reduce low-density lipoprotein cholesterol (LDL-C) levels and the risk of cardiovascular events in patients with atherosclerotic cardiovascular disease (ASCVD) in clinical trials. In January 2019, evolocumab reimbursement recommendation in Sweden was broadened to include patients on maximally tolerated oral lipid-lowering therapy (LLT) and either ASCVD and LDL-C ≥2.5 mmol/L, or familial hypercholesterolemia (FH) with no ASCVD and LDL-C ≥3.0 mmol/L.

Purpose

Describe characteristics and LLT use in patients initiating treatment with evolocumab in the context of the 2019 reimbursement recommendation in Sweden.

Methods

Cross-sectional, population-based, retrospective, observational study of patients initiating treatment with evolocumab between January 2019 and June 2020. Data were obtained from national healthcare registers and electronic medical records, covering more than half of the Swedish population.

Results

Out of 1560 patients included, 41% had LDL-C available ≤3 months prior to treatment initiation with evolocumab. Among those with LDL-C available, 79% had ASCVD and 19% had definite, probable or possible FH with no ASCVD. Mean pre-treatment LDL-C levels were 3.7 and 5.0 mmol/L for patients with ASCVD, and FH with no ASCVD, respectively. Most of the patients, 84.6% and 80.0%, respectively, had been ever treated with both statins and ezetimibe. However, 28.0% and 38.3% of them, respectively, were not on oral LLT at the time of treatment initiation with evolocumab. Patient characteristics and LLT use are presented in Table 1.

Conclusions

Patients initiating treatment with evolocumab in Sweden had pre-treatment LDL-C levels far from treatment targets, despite being at very high risk for cardiovascular events. Most of the patients had been treated with both statins and ezetimibe in the past. However, almost a third of them were not using oral LLT at the time of treatment initiation with evolocumab. The conditions in the 2019 evolocumab reimbursement recommendation in Sweden were generally met.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Amgen

659 Unilateral Infarction of Adrenal Gland During Pregnancy: A Case Report and Important Learning Point

Background

Abdominal pain in pregnancy offers a challenge for the General surgeon. Unilateral adrenal infarction is an extremely rare event.

Case presentation:

We report the case of an obese 23-year-old pregnant female G4 P1 + 2 diagnosed with unilateral adrenal infarction and hemorrhage. She presented at 34 + 5 weeks with severe RUQ and flank pain under the obstetric team. After initially being discharged, she later returned with intractable pain. Examination and initial investigations (USS KUB and abdomen) were inconclusive. She was empirically treated for pylonephritis. During the night she underwent emergency c-section due to uncontrollable pain. Subsequently, a CT abdomen demonstrated a unilateral right adrenal infarct with hemorrhage.

Discussion:

Unilateral adrenal infarction often leads to a delay in diagnosis and should be part of differential diagnosis in patients with severe RUQ pain (1.3%). It is a rare event diagnosed generally by CT or MRI scan showing attenuation or swelling of adrenal glands. Physiologically it is due to the state of venous circulation during pregnancy alongside others coagulation risks factor.

Learning point:

To consider adrenal infarction with severe RUQ pain when first line diagnosis normal.

Key Investigations:

MRI during pregnancy and CT AP after. Discussion in MDT and screen for coagulation disorder.

828 Is Isolation Before Elective Surgery the Way Forward During The COVID-19 Pandemic?

Introduction

The COVID-19 pandemic is here to last, and services must adapt to enable elective surgery to continue. Surgery involves high-risk aerosol generating procedures, potentially harmful to staff and patients. The current NICE guidance is for the patient to self-isolate for 72 hours prior to surgery. A question persists: Is 72-hour isolation the way forward in elective general surgery?

Method

In a DGH centre, using an anonymous questionnaire, we prospectively collected data on isolation for 36 elective general surgery patients during the 72h isolation period. The data was analysed to assess the concordance with isolation as well as patient's satisfaction with the process.

Results

75% of patients were concordant with 72 hours of isolation pre-operatively. This was an increase from 35% when compared to patients questioned during the 14 day isolation period. The main factors contributing to isolation breech were visitors to the house and the mode of transport used to attend hospital.

Conclusions

The protocol is now for a COVID swab 72 hours pre-operatively followed by isolation until the operation. Our results show that still significant breaches in isolation remain and patients welfare is adversely affected during that period. Further research and consideration is needed to optimise the COVID isolation protocol.

Evaluation of urinary chloride dipsticks for the rapid estimation of hydration status in patients receiving artificial nutrition: Feasibility study

BACKGROUND AND AIMS

The home parenteral nutrition (HPN) population face many challenges, especially with respect to fluid balance management. A low urinary sodium concentration of <20 mmol/L is commonly used as an indicator of dehydration that requires clinical assessment in these patients. The Quantab titrator dipstick measures chloride concentration of a solution and correlates with sodium concentration. We assessed whether it would be feasible to use the Quantab dipstick in the HPN population and explored relationships between Quantab dipstick estimated chloride concentration and quality of life (QOL).

METHODS

Patients on HPN were asked to collect urine samples at 5 specific times points (day 0,7,14, 21 and 28) to send to the laboratory for formal electrolyte analysis. The participant and a member of laboratory staff tested these samples with the Quantab dipstick to estimate urinary chloride concentration. Participants were instructed to complete a QOL questionnaire at each of the 5 time-points in addition to a baseline demographic questionnaire and an end-of-study questionnaire. Six participants completed an interview at the end of the study period. The relationship between participant-derived and laboratory-derived data was assessed using rank correlation coefficients. QOL assessment was correlated with urine dipstick measurements.

RESULTS

10 patients on HPN completed the study. Data on chloride concentration as estimated by the dipstick (assessed by participants and by the laboratory) and sodium concentration from the laboratory were available for 47 urine samples. There was a positive relationship between participant dipstick estimated chloride concentration and laboratory sodium (Kendall's τ = 0.45; P < 0.001; Spearman's r_s = 0.58 P < 0.001; 47 pairs). There was a strong correlation between chloride concentrations estimated by dipstick in the laboratory and by participants (Kendall 0.58 p < 0.001, Spearman's 0.69 p < 0.001; 47 pairs). In exploratory analyses, there was no relationship between QOL and dipstick estimated chloride concentration. Participants had no issues collecting urine samples but some difficulties were reported with determining the dipstick reading.

CONCLUSIONS

Patients on HPN are able to collect urine specimens, complete QOL questionnaires, and are capable of using the Quantab dipstick to estimate urinary chloride concentration. The Quantab dipstick correlates with laboratory measured sodium and chloride concentrations. Further work is required to fully establish whether this point-of-care test could be used to guide fluid balance management in the HPN population.

The association of mode of location activity and mobility with acute coronary syndrome: a nationwide ecological study

BACKGROUND

We aimed to study the effect of social containment mandates on ACS presentation during COVID-19 pandemic using location activity and mobility data from mobile phone map services.

METHODS

We conducted a cross-sectional study using data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) including all ACS presentations during the pandemic until 7 May 2020. Using a count regression model, we adjusted for day of the week, daily weather and incidence of COVID-19.

RESULTS

A 10% increase in activity around areas of residence was associated with 38% lower rates of ACS hospitalizations, whereas increased activity relating to retail and recreation, grocery stores and pharmacies, workplaces and mode of mobility was associated with 10-20% higher rates of ACS hospitalizations.

CONCLUSION

Government policy regarding social containment mandates has important public health implications for medical emergencies such as ACS and may explain the decline in ACS presentations observed during COVID-19 pandemic.

Preparations for a European R&D roadmap for an inertial fusion demo reactor

A European consortium of 15 laboratories across nine nations have worked together under the EUROFusion Enabling Research grants for the past decade with three principle objectives. These are: (a) investigating obstacles to ignition on megaJoule-class laser facilities; (b) investigating novel alternative approaches to ignition, including basic studies for fast ignition (both electron and ion-driven), auxiliary heating, shock ignition, etc.; and (c) developing technologies that will be required in the future for a fusion reactor. A brief overview of these activities, presented here, along with new calculations relates the concept of auxiliary heating of inertial fusion targets, and provides possible future directions of research and development for the updated European Roadmap that is due at the end of 2020. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

Whole-beam self-focusing in fusion-relevant plasma

Fast ignition inertial confinement fusion requires the production of a low-density channel in plasma with density scale-lengths of several hundred microns. The channel assists in the propagation of an ultra-intense laser pulse used to generate fast electrons which form a hot spot on the side of pre-compressed fusion fuel. We present a systematic characterization of an expanding laser-produced plasma using optical interferometry, benchmarked against three-dimensional hydrodynamic simulations. Magnetic fields associated with channel formation are probed using proton radiography, and compared to magnetic field structures generated in full-scale particle-in-cell simulations. We present observations of long-lived, straight channels produced by the Habara-Kodama-Tanaka whole-beam self-focusing mechanism, overcoming a critical barrier on the path to realizing fast ignition. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

The Haleem-Botchu classification: a novel CT-based classification for lumbar foraminal stenosis

PURPOSE

No clinical CT-based classification system is currently in use for lumbar foraminal stenosis. MRI scanners are not easily available, are expensive and may be contraindicated in an increasing number of patients. This study aimed to propose and evaluate the reproducibility of a novel CT-based classification for lumbar foraminal stenosis.

MATERIALS AND METHODS

The grading was developed as four grades: normal foramen-Grade 0, anteroposterior (AP)/superoinferior (SI) (single plane) fat compression-Grade 1, both AP/SI compression (two planes) without distortion of nerve root-Grade 2 and Grade 2 with distortion of nerve root-Grade 3. A total of 800 lumbar foramen of a cohort of 100 random patients over the age of 60 who had undergone both CT and MRI scans were reviewed by two radiologists independently to assess agreement of the novel CT classification against the MRI-based grading system of Lee et al. Interobserver(n = 400) and intraobserver agreement(n = 160) was also evaluated. Agreement analysis was performed using the weighted kappa statistic.

RESULTS

A total of 100 patients (M:F = 45:55) with a mean age of 68.5 years (range 60-83 years were included in the study. The duration between CT and MRI scans was 98 days (range 0-540, SD-108). There was good correlation between CT and MRI with kappa scores (k = 0.81) and intraobserver kappa of 0.89 and 0.98 for the two readers.

CONCLUSION

The novel CT-based classification correlates well with the MRI grading system and can safely and accurately replace it where required.

[Prenatal path of care following the diagnosis of a malformation for which a novel prenatal therapy is available]

OBJECTIVES

Fetal therapy is part of the available care offer for several severe malformations. The place of these emergent prenatal interventions in the prenatal path of care is poorly known. The objective of this study is to describe the decision-making process of patients facing the option of an emergent in utero intervention.

METHODS

We have conducted a retrospective monocentric descriptive study in the department of maternal-fetal medicine of Necker Hospital. We collected data regarding eligibility or not for fetal surgery and the pregnancy outcomes of patients referred for myelomeningocele, diaphragmatic hernia, aortic stenosis and low obstructive uropathies.

RESULTS

All indications combined, 70% of patients opted for fetal surgery. This rate was lower in the case of myelomeningocele with 21% consent, than in the other pathologies: 69% for diaphragmatic hernias, 90% for aortic stenoses and 76% for uropathy. When fetal intervention was declined, the vast majority of patients opted for termination of pregnancy: 86%. In 14% of the considering fetal surgery, the patient was referred too far.

CONCLUSION

The acceptance rate for fetal surgeries depends on condition. It offers an additional option and is an alternative for couples for which termination of pregnancy (TOP) is not an option. Timely referral to an expert center allows to discuss the place of a fetal intervention and not to deprive couples of this possibility.

Risk of aortic disease in long-distance cross-country skiers; a study of 209,226 patients

Background/Introduction

Aneurysmal dilatation and dissection of the aorta are two facets of aortic disease that can lead to major disability and death. Some risk factors for aortic disease are also risk factors for atherosclerotic disease, but the overall causes of aortic disease are diverse and largely unknown. Persons with aortic aneurysms are advised to limit their physical activity, but associations of physical activity with subsequent incidence of aortic disease are little known. Earlier studies have shown strong association of performance in Vasaloppet with incidence of hypertension, a major risk factor for aortic disease.

Aim

To investigate associations of high levels of physical activity with incidence of aortic disease.

Methods

We studied 209,226 participants in a 30–90 km cross-country skiing event (Vasaloppet) and 536,038 persons from the general population, matched to the skiers on age, sex and residence. The number of completed races during the study period and the fastest relative finishing time in a race was recorded. The main outcomes were: 1) aortic disease (defined as thoracic and abdominal aortic aneurysm and/or aortic dissection); and 2) aortic dissection.

Results

During a median time at risk of 8.8 years, 1,442 aortic disease events and 265 aortic dissections occurred. Skiers had lower incidence of aortic disease than non-skiers (Cox proportional hazards ratio [HR] 0.42; 95% confidence interval [CI] 0.36–0.50). An association of better finishing time with aortic disease was observed, with a dose-response gradient from the fastest third (HR 0.25; 95% CI 0.18–0.35), via the slowest third (HR 0.64; 95% CI 0.49–0.82) to the non-skiers (reference group). Among skiers the number of completed races was not associated with incidence of aortic disease. Skiers also had lower incidence of acute aortic dissection (HR 0.61; 95% CI 0.44–0.85) than non-skiers. Low event rate among skiers made conclusions in subgroups unreasonable. All results are adjusted for age, sex, education and income. Results were similar in models accounting for use of antihypertensive and cholesterol-lowering medicines and genetic syndromes associated with aortic disease.

Conclusion

Participation in a long-distance skiing event was associated with lower risk of aortic disease and aortic dissection. Faster completion of the race was strongly associated with lower incidence of aortic disease. If causal, this study suggests that high physical activity and exercise may be protective against aortic disease.

Kaplan-Meier Aorta disease

Funding Acknowledgement

Type of funding source: None

The importance of comorbidities for long-term outcome after aortic valve intervention in patients with preserved left ventricular ejection fraction, a nation-wide register study

Background

In Aortic stenosis (AS) cardiovascular comorbidities as well as left ventricular ejection fraction (LVEF) have an impact on postoperative outcome among patients undergoing aortic valve replacement (AVR). The prevalence of heart failure (HF) based on LVEF in patients with severe AS varies. Lately HF with preserved LVEF has gained more attention. The aim is to describe the prevalence and prognostic impact of cardiovascular comorbidities, including HF, in relation to LVEF before AVR in a national cohort of patients with AS.

Methods

Patients &gt;18 years, undergoing AVR due to AS 2008–2014 were identified in the national register for heart diseases, SWEDEHEART. Preoperative LVEF and comorbidities were collected from the register and enriched with data from national patient registries. The outcome events were all cause mortality and hospitalization for HF as the main diagnosis. The cohort was separated by preoperative LVEF status; preserved (&gt;50%) or reduced (≤50%). Outcome events were analysed by Cox regression.

Results

10406 patients, median age 73 (18–96) years whereof 3817 (36.7%) women, were included with a median follow-up of 35 months. In the cohort 15.9%, 73.9% and 10.2% received a mechanical, surgical biological and trans-catheter biological valve prosthesis, respectively. Preserved LVEF was present in 7512 (72.2%). Comorbidities were more frequent in the group with reduced LVEF (p&lt;0.001). Irrespective of LVEF HF influenced outcome negatively (see table).

Conclusion

In patients planned for AVR a history of HF irrespective of LVEF worsen postoperative prognosis and a history of HF seems at least as important as LVEF when predicting long-term outcome. When stratifying patients for AVR with preserved LVEF, comorbidities such as HF and atrial fibrillation should be highlighted, and further research to identify risk factors for a negative postoperative outcome in this group seems important in optimizing the follow-up after AVR.

Funding Acknowledgement

Type of funding source: None

Use of proteomics to identify biomarkers associated with chronic kidney disease and long-term outcomes in patients with myocardial infarction

BACKGROUND

Patients with chronic kidney disease (CKD) have poor outcomes following myocardial infarction (MI). We performed an untargeted examination of 175 biomarkers to identify those with the strongest association with CKD and to examine the association of those biomarkers with long-term outcomes.

METHODS

A total of 175 different biomarkers from MI patients enrolled in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry were analysed either by a multiple reaction monitoring mass spectrometry assay or by a multiplex assay (proximity extension assay). Random forests statistical models were used to assess the predictor importance of biomarkers, CKD and outcomes.

RESULTS

A total of 1098 MI patients with a median estimated glomerular filtration rate of 85 mL min^-1 /1.73 m² were followed for a median of 3.2 years. The random forests analyses, without and with adjustment for differences in demography, comorbidities and severity of disease, identified six biomarkers (adrenomedullin, TNF receptor-1, adipocyte fatty acid-binding protein-4, TNF-related apoptosis-inducing ligand receptor 2, growth differentiation factor-15 and TNF receptor-2) to be strongly associated with CKD. All six biomarkers were also amongst the 15 strongest predictors for death, and four of them were amongst the strongest predictors of subsequent MI and heart failure hospitalization.

CONCLUSION

In patients with MI, a proteomic approach could identify six biomarkers that best predicted CKD. These biomarkers were also amongst the most important predictors of long-term outcomes. Thus, these biomarkers indicate underlying mechanisms that may contribute to the poor prognosis seen in patients with MI and CKD.

Long-term survival in patients with coronary artery disease undergoing percutaneous coronary intervention with or without intracoronary pressure wire guidance: a report from SCAAR

Background

Intracoronary pressure wire measurements of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) provide decision-making guidance during percutaneous coronary intervention (PCI). However, limited data exist on the impact of FFR/iFR on long-term clinical outcomes in patients with stable angina, unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI), or STEMI.

Methods

We used data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) on all patients in Sweden undergoing PCI (with or without FFR/iFR guidance) for stable angina, UA/NSTEMI, or STEMI between January 2005 and March 2018. The primary endpoint was all-cause mortality and the secondary endpoints were stent thrombosis or restenosis and periprocedural complications. The primary model was multilevel Cox proportional-hazards regression using an instrumental variable (IV) to adjust for known and unknown confounders with treating hospital as a treatment-preference instrument. The following variables were entered into Cox proportional-hazards regression in addition to the IV: age, sex, diabetes, indication for PCI, severity of coronary disease, smoking status, hypertension, hyperlipidemia, previous myocardial infarction, previous PCI, previous coronary artery bypass graft, type of stent.

Results

In total, 151,001 patients underwent PCI: 31,514 (20.9%) for stable angina, 74,982 (49.6%) for UA/NSTEMI, and 44,505 (29.5%) for STEMI. Of these, FFR/iFR guidance was used in 11,433 patients (7.6%): 5029 (44.0%) with stable angina, 5989 (52.4%) with UA/NSTEMI, and 415 (3.6%) with STEMI; iFR was used in 1156 (10.1%) of these patients. After a median follow-up of 1784 (range 1–4824) days, the FFR/iFR group had lower adjusted risk estimates for all-cause mortality [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.69–0.91; P=0.001] and stent thrombosis and restenosis (HR 0.13; 95% CI 0.09–0.19; P&lt;0.001). The number of periprocedural complications did not differ significantly between the groups (odds ratio 0.69; 95% CI 0.30–1.55; P=0.368). There was no interaction between FFR/iFR and indication for PCI. We found no difference between FFR and iFR (HR 1.12; 95% CI 0.90–1.59; P=0.216).

Conclusions

In this observational study, the use of FFR/IFR was associated with a lower risk of long-term mortality in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI. Our study supports the current European and American guidelines for the use of FFR/iFR during PCI and shows that intracoronary pressure wire guidance has prognostic benefit in patients with stable angina as well as in patients with the acute coronary syndrome.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Heart and Lung Foundation, ALF Västra Götaland, Swedish Scientific Council

Utilization and outcomes of rotational atherectomy in Sweden

Aim

To evaluate utilization and outcomes of rotational atherectomy (RA) using data from the Swedish Coronary and Angioplasty Registry (SCAAR)

Methods

We included 1476 patients with 2218 lesions who underwent RA from 2005 to 2016. To study temporal changes, the study period was divided into three equal time-periods, period A, B and C.

Results

Although the number of RA procedures increased 3-fold from 2005 to 2016, the rate of RA (of all PCI procedures) remained low (0.5% vs 1.2% in 2005 vs 2016). RA patients consisted a high-risk group, with advanced age and clustering of comorbidities. Over time, included patients were older and had a higher risk profile. Trans-radial access, drug eluting stent (DES) use and use of intravascular imaging significantly increased from period A to C whereas positioning of a temporary pacemaker or intra-aortic balloon pump declined. Unfractionated heparin became the main anticoagulant (52 vs 87%) and use of glycoprotein IIb/IIIa inhibitors declined (31 vs 12%, in period A vs C). Following RA, 11% of lesions were treated without stent (15 vs 15 vs 8%, in period A, B and C) (Rota-only). In lesions treated with a stent, a bare metal stent (BMS) was implanted in 39% vs 12% vs 2% and a new generation DES (N-DES) in 5 vs 75 vs 97% (period A vs B vs C) of lesions.

The 3-year cumulative rate of restenosis was 6.7% (122 events), (11.1 vs 7.1 vs 4.1% in period A vs B vs C). As compared to DES, rota-only (adjusted HR 2.71; 95% CI 1.69- 4.36) and BMS (adjusted HR 3.63; 95% CI 2.27- 5.81) were associated with significantly higher risk for restenosis. First generation DES were associated with numerically higher but not significantly different risk for restenosis as compared to N-DES (adjusted HR 1.31; 95% CI 0.74- 2.31).

The 3 year cumulative rate of major adverse cardiac events (MACE), including death, myocardial infarction (MI) or any restenosis was 30.6% (34.2 vs 31.4 vs 28.2%, in period A vs B vs C) and the corresponding numbers for all-cause mortality were 18.1% (18.9 vs 18.4 vs 17.0%). After adjustment for baseline characteristics and angiographic findings, RA in period A was associated with higher risk for MACE as compared to period C (adjusted HR 1.40; 95% CI 1.09- 1.79), due to higher risk for MI and restenosis. The difference disappeared when procedural characteristics, including DES use, were added to the model.

The rate of major in-hospital complications was 7.0%, including in-hospital death 1.3%, periprocedural MI 2.8%, perforation 1.1%, cardiac tamponade 0.7%, stroke 0.2% and major bleedings 2.1%. We found no significant differences over time.

Conclusion

During the studied period, RA remained a rare procedure, utilised in a highly selected population. Over time a declining rate of restenosis and MI after RA was observed, a finding that appeared to be mainly driven by an increased use of DES. The rate of major in-hospital complication remained low.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific International

P1383Procedural differences during de novo paroxysmal atrial fibrillation ablation with a contact force-sensing ablation catheter between Europe and U.S

Background

Although pulmonary vein isolation (PVI) is considered the standard approach of atrial fibrillation ablation worldwide, procedural practice during the ablation varies by geographical region. Using the same magnetic sensor enabled contact force-sensing ablation catheter for the treatment of de novo paroxysmal atrial fibrillation, a comparison of procedural detail between Europe and U.S operators can provide insights into geographic specific clinical practices. 

Purpose

To characterize and compare procedural differences during paroxysmal atrial fibrillation ablation performed with a magnetic sensor enabled contact force-sensing catheter across European and U.S. centers. 

Methods

Procedural data were prospectively collected in clinical cases performed with a new magnetic sensor enabled, contact force ablation catheter within the first 6 months of use at participating centers in Europe and the U.S. Procedure time, PVI time, PVI confirmation method, fluoroscopy usage and lesion delivery parameters were analyzed based on geographies. 

Results

A total of 131 cases across 35 centers in 11 European countries, and 95 cases across 26 U.S. centers were analyzed. Target geometry was created with the ablation catheter in 94 out of 131 (71.8%) European cases, while only 5 out of 95 U.S. cases (5.3%) reported the use of the ablation catheter for model creation. Although a steerable sheath (64.1% and 67.3%) was commonly used with the ablation catheter in both geographies, difference in the utilization of bidirectional contact force catheter (52.7% and 90.5%) and the automated lesion marking module (76.3% and 81.1%) were observed in European and U.S. cases, respectively. The use of adenosine or isoproterenol to confirm PVI was reported in 25% and 64% of the European and U.S. cases. Average waiting periods were 18.2 minutes and 26.5 minutes from reported European and U.S. cases. Total procedural time, mapping time, and fluoroscopy time were similar between European and U.S. cases. (Table). First pass PVI were 66.4% and 72.6% for European and U.S. cases, respectively.

Conclusion

Total procedural time and RF time were similar between European and U.S. cases during de novo paroxysmal atrial fibrillation ablation using the same ablation catheter. Differences in workflow including the use of a mapping catheter for geometry creation and waiting period were observed between the two geographies.

Summary of procedural details De novo PAF N Procedural time(min) Mapping time (min) PVI time (min) Total RF time (min) Fluoro time( min) Europe 131 144.0 ± 56.9 16.6 ± 17.1 69.8 ± 35.0 33.2 ± 15.6 11.6 ± 10.1 U.S. 95 137.6 ± 64.8 18.1 ± 23.5 58.8 ± 31.5 32.3 ± 22.2 12.0 ± 15.8

P425Single procedure pace and ablate. evaluation of efficacy and safety comparing three different vascular routes

Funding Acknowledgements

No financial support for this study

Introduction

Permanent pacemaker implantation combined with AVN ablation is a well-established treatment for rate control in patients with atrial fibrillation refractory to medical therapy. At the same sitting, this has been achieved in a single procedure via the subclavian vein (SCV) for both pacemaker implantation and AVN ablation, by pacemaker implantation via the SCV with femoral access for AVN ablation or by using the femoral vein (FV) for leadless pacemaker implantation and AVN ablation with a coaxial single-puncture technique.

We evaluated all combined procedures (pacemaker implantation and AVN ablation at the same sitting) performed in a single centre over 9 years comparing clinical outcomes, complications rates and procedure times.

Statistical methods: 

Continuous variables are described as mean ± standard deviation (SD), and statistical differences between groups were evaluated by one-way ANOVA. A X2 test was used for categorical variables, with Fisher’s exact test for any field where the expected frequency was ≤5 with pvalue &lt; 0.05 considered as statistically significant. The statistical analysis was performed using SPSS software package. 

Results

 

141 patients underwent AVN ablation at our institution as part of a ‘pace and ablate’ single procedure strategy between 14/2/11 and 10/6/19. 61 patients had a combined procedure via the SCV, 66 patients had pacemaker implanted via the SCV and AVN ablation via the FV in the same sitting and 14 patients had leadless pacemaker (Micra) implantation and AVN ablation via the FV. Our findings suggest that the fluoroscopy time as well as the total catheter laboratory time were much less in the Micra group compared to the other groups. In the conventional pacemaker groups (group 1 and 2), the fluoroscopy time was not statistically different between the two. There was a trend towards acute procedural failure, switching to another access as well as a higher complication rate in the SCV group, however this has not reached statistical significance. 

Conclusion

 

Our early data suggests that pacemaker implantation and AVN ablation with a coaxial single femoral vein puncture technique is safe and takes less fluoroscopy time as well as total laboratory time.

Procedural outcomes All (n = 141) Group 1: SCV (n = 61) Group 2: FV (n = 66) Group 3: Micra (n = 14) P-value Total cath-lab time (mins) 113.1 ± 40.4 106.2 ± 37.2 125.7 ± 42.5 86.9 ± 23.1 0.001 Total fluoroscopy time (mins) 8.8 ± 7.6 11 ± 7.8 7.7 ± 7.6 4.5 ± 3 0.0001 Acute procedural failure, n (%) 9 (6.4) 7 (11.5) 2 (3) 0 (0) **0.6 Complications, n (%) 7 (4.9) 5 (8.2) 2 (3) 0 (0) **0.62 **Fisher"s exact test applied to analysis of Micra VS Other methods

863Leadless endocardial pacing improves symptoms in patients with failed conventional CRT implant in long term follow up

Funding Acknowledgements

EBR Systems, Inc

OnBehalf

WiSE-CRT and LV-SELECT study and POST-M REGISTRY

Background

The WiSE-CRT (Wireless stimulation endocardial) system has advantages over conventional epicardial CRT. Whenever conventional CRT failed to implant or failed to echocardiographic response, the WiSE-CRT was implanted as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) over the last 8 years. All these studies have reported high rates of clinical and echocardiographic response compared to conventional CRT.

Objectives

The purpose of this analysis was to determine the safety and clinical response in the largest available number of implanted patients (pts) with long term follow up of 2 years and the first, second and third generation of WiSE-CRT devices.

Method

All pts undergoing a WiSE-CRT implantation as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) were analysed (N = 165). Pts were followed-up for 24 months and considered CRT responders if an improvement in NYHA ≥ 1 class from baseline (pre-implant) was achieved.

Results

In total, 165 pts were implanted, demographics include: 68.2 ± 9.6 year’s old, 81.8% male, 49.7% with history of AFib and 54.5% non-ischaemic aetiology. The mean intrinsic QRS duration was 165.0 ± 32.3 msec (28 pts pace-maker dependent). 161 pts had the system successfully implanted with no major complications, 3 (1.8%) pts developed a pericardial effusion and 1 (0.6%) electrode was lost during implantation and recovered surgically. During the 24-month follow-up period, 20 (12.1%) pts died from any cause, 4 (2.4%) pts developed TIA or Stroke and 15 (9.1%) pts had pocket or transmitter infection. There was a significant improvement in NYHA functional class in 63.6% pts and an average improvement of -26.1 (-45.1, -7.1) msec in QRS duration.

Conclusion

Despite a history of failed conventional CRT implantation, pts undergoing CRT upgrades with a WiSE-CRT have a high success rate and a complication rate similar to previously described. In addition endocardial LV pacing led to symptomatic improvements in 64% of patients reaching the 24 month of follow up.

Abstract Figure 1: Forest Plot NYHA Responder Rat

P981Comparison of automark utilization and lesion metric target during paroxysmal atrial fibrillation ablation with a contact force-sensing ablation catheter: European and U.S. multicenter Experiences

Background

Accurate delivery of transmural lesion is associated with improved durability of pulmonary vein isolation and reduced reconduction. Lesion quality depends on multiple parameters such as radiofrequency power, tissue-catheter contact, duration of energy application, and catheter tip temperature. Consequently, energy delivery parameters vary based on individual operators’ preferences and procedural needs.

Purpose

To characterize and compare the utilization of automated lesion marking feature and lesion delivery parameters used during paroxysmal atrial fibrillation ablation performed with a magnetic sensor enabled contact force-sensing catheter across European and U.S. centers.

Methods

Procedural data were prospectively collected in clinical cases performed with a new magnetic sensor enabled, contact force ablation catheter within the first 6 months of use at participating centers in Europe and the U.S. Use of bidirectional CF catheters, steerable sheaths, automated lesion marking software and associated lesion delivery parameters during paroxysmal atrial fibrillation ablation were evaluated.

Results

A total of 149 cases across 37 centers in 11 European countries, and 112 cases across 31 U.S. centers were analyzed. A bidirectional contact force catheter (56.4% and 90.2%), a steerable sheath (65.8% and 69.6%), and the automated lesion marking module (77.9% and 90.2%) were used in most European and U.S. cases, respectively. The most commonly reported energy delivery parameters were: lesion index (LSI), Force-Time Integral (FTI), and time from European cases; LSI, average force, and FTI for U.S. cases (Table). Target LSI values were recorded for 126 cases in Europe and 34 in the U.S, ranging from 3 to 6. In anterior/roof segments, most common LSI target values for anterior/roof and posterior/inferior segments were 6 (42.9%) and 5 (51.2%) in Europe, and 5.5 (44.1%) and 5 (54.5%) in the U.S. PVI was confirmed with an average of 20.3 minutes waiting period (69.1%) for European cases and exit block (57.1%) in U.S. cases. First pass PVI were 67.1% and 74.4% for European and U.S. cases, respectively.

Conclusion

Energy delivery parameters and PVI confirmation method varied considerably by geography during paroxysmal atrial fibrillation ablation using the magnetic sensor enabled, contact force ablation catheter. Further study on efficacy implication on these differences in practice should be examined.

Energy delivery parameters used Paroxysmal AF N LSI FTI Time Imp Drop Avg Force Other N/A Europe 149 44.0 % 13.4 % 7.0 % 6.0 % 2.4 % 1.0 % 26.2 % U.S. 112 31.2% 17.9 % 6.2 % 8.0 % 23.2 % 11.7 % 1.8 % Energy delivery parameters used in paroxysmal AF ablation in Europe and U.S.

Early detection, care and control of hypertension and diabetes in South Africa: A community-based approach

Background

Non-communicable diseases (NCDs) are a major public health concern with raised blood pressure and glucose emerging as leading causes of death and disability.

Aim

This community-based demonstration project using community caregivers (CCGs) trained in screening for hypertension and diabetes aimed at improving early detection and linkage to care and management.

Setting

The project was conducted in KwaZulu-Natal province.

Methods

The CCGs were trained in NCD-related health education, promotion and screening for hypertension and diabetes using an accredited programme. The CCGs screened community members for hypertension and diabetes using three screening methods: door-to-door visits, community campaigns and workplaces.

Results

Twenty-five CCGs received the accredited NCD training. A total of 10 832 community members were screened for hypertension and 6481 had their blood glucose measured. Of those screened, 29.7% and 4.4%, respectively, had raised blood pressure (≥ 140/90 mmHg) and blood glucose (≥ 11.0 mmol/L) who required referral to a primary healthcare facility. More than one in five (21.0%, n = 1448), of those with no previous hypertension diagnosis, were found to have raised blood pressure at screening, representing newly detected cases. Less than a third (28.5%) of patients referred to the facilities for raised blood pressure actually presented themselves for a facility assessment, of which 71.8% had their hypertension diagnosis confirmed and were advised to continue, adjust or initiate treatment. Similarly, 29.1% of patients referred to the facilities for raised blood glucose presented themselves at the facility, of which 71.4% received a confirmatory diabetes diagnosis.

Conclusion

Community caregivers played an important role in early detection of raised blood pressure and raised blood glucose, and in referring patients to primary care.

52 A Community Cure for Frequent Reattenders: Developing An Interface Geriatrics Service

Topic

Setting up an interface geriatrics service in a seaside area with a large elderly population. Many elderly patients are readmitted due to the challenge of managing their chronic health conditions in the community. These patients are frail, with frequently exacerbated chronic conditions causing regular readmissions. We noted that treatment was rarely changed during these admissions and patients were not uniformly managed.

Aims

Aims for this project were to improve care for older people, reduce readmissions and produce clear patient care plans.

Interventions

Our first PDSA cycle involved implementing geriatrician presence at community MDTs (involving social services, GPs, intermediate care teams, and various others). This generated home visits to several patients, with a mix of acute and chronic issues. We offered Advance Care planning where appropriate to these patients. We noted several patients were repeatedly discussed at MDT. This brought into focus frequent attenders who were usually well-known to the community. In the next cycle we introduced ‘frequent attender’ plans for these patients, ensuring a unified approach to their management. Subsequent cycles involved geriatrician presence at the ‘frequent attenders’ steering group, and further links with community teams. Our primary intervention has been Advance care & frequent attender plans offering tailored management for complex patients. These are completed by a geriatrician discussing patients wishes for treatment and future care.

Improvements

Readmission rates show up to 90% reduction in admissions/ED attendances for patients following care plan implementation. Feedback from families and patients is positive – the service is ‘pragmatic and supportive’, delivering ‘empathetic care’.

Discussion

Implementing an interface geriatrics service highlights the importance of caring for frail patients in their preferred place of care, reducing unnecessary/inappropriate hospitalisations. Geriatrician presence at community MDTs has improved care by offering prompt access to medical advice and review of complex patients. It highlights patients presenting frequently to services, allowing us to work with patients and families to improve management. A frequent attender list generated by the hospital helps target patients for whom intervention will give significant benefit. We plan to extend this further by working with nursing homes that have high conveyancing rates. The service is being extended to more areas within our region, and we are working with GPs and care homes to further offer advance care planning to vulnerable and frail patients.

Anterior translation of the tibia in relation to femur in mucoid degeneration of ACL - An observational study

Background

Mucoid degeneration (MD) of the anterior cruciate ligament (ACL) are a well-known pathological entity.We have encountered several patients with MD of the ACL, found to have a anterior translation of tibia a exceeding 5 mm with an intact ACL. We studied this cohort and investigated the likely cause of this.

Methods

A retrospective search of our department's radiology system to identify all patients referred from the knee orthopaedic clinic for MR imaging over a span of 10 years. All patients had MD within the substance of the ACL and an intact ACL. We evaluated the degree of anterior translation of the tibia (ATT) in relation to the femur in mucoid degeneration of ACL.

Results

We identified 464 consecutive cases. The mean age was 52 years. There was a male predominance of 261 to 203 female. The average PTF measurement was 2.4 mm with a range of 0-20mm. Of the 464 cases, 3 397 patients had an insignificant ATT of < 5 mm. (0mm. 67. 67 67 patients had a ATT >5 mm. Of them, 32.8% had a ATT of 6 mm, 53.7% had a ATT range between 7 and 9 mm, with the remaining 13.4% above 9 mm in length.

Conclusion

It is essential to look for other secondary signs of ACL tears and not only focus on ATT as well as correlate this with clinical findings.