Efficacy and safety of rademikibart (CBP-201), a next-generation mAb targeting IL-4Rα, in adults with moderate to severe atopic dermatitis: A phase 2 randomized trial (CBP-201-WW001)

BACKGROUND

Rademikibart (CBP-201) is a next-generation IL-4 receptor alpha-targeting antibody.

OBJECTIVE

We sought to evaluate rademikibart in adults with moderate to severe atopic dermatitis.

METHODS

A total of 226 patients were randomized, double-blind, to subcutaneous rademikibart (300 mg every 2 weeks [Q2W], 150 mg Q2W, 300 mg every 4 weeks [Q4W]; plus 600-mg loading dose) or placebo. Randomization began in July 2020. The trial was completed in October 2021.

RESULTS

The WW001 phase 2 trial achieved its primary end point: significant percent reduction from baseline in least-squares mean Eczema Area Severity Index (EASI) to week 16 with rademikibart 300 mg Q2W (-63.0%; P = .0007), 150 mg Q2W (-57.6%; P = .0067), 300 mg Q4W (-63.5%; P = .0004) versus placebo (-39.7%). EASI scores decreased significantly with 300 mg Q2W and Q4W at the earliest assessment (week 2), with no evidence of plateauing by week 16. Significant improvements were also observed in secondary end points, including pruritus. Across the primary and secondary end points, efficacy tended to be comparable with 300 mg Q2W and Q4W dosing. Rademikibart and placebo had similar, low incidence of treatment-emergent adverse events (TEAEs) (48% vs 54%), serious TEAEs (1.8% vs 3.6%), TEAEs leading to treatment discontinuation (1.2% vs 1.8%), conjunctivitis of unspecified cause (2.9% vs 0%), herpes (0.6% vs 1.8%), and injection-site reactions (1.8% vs 1.8%). Although no discontinuations were attributed to coronavirus disease 2019, pandemic-related restrictions likely had an impact on trial conduct.

CONCLUSIONS

Rademikibart was efficacious and well tolerated at Q2W and Q4W intervals. Q4W dosing is a more convenient frequency than approved for current therapies.

Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel

OBJECTIVE

To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council's complex interventions framework.

METHODS

A phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, and Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout.

RESULTS

From numerous modifiable prescribing behaviours identified, active 'antibiotic time-out' was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers' capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit.

CONCLUSION

This novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit's feasibility and effectiveness.

PSAT014 Pheochromocytoma in a Pregnant Woman with VHL leading to First Trimester Fetal Demise

Introduction

Pheochromocytomas (PCCs) are rare neuroendocrine tumors that secrete catecholamines. They may be associated with familial syndromes such as Multiple Endocrine Neoplasia type 2 (MEN 2), von Hippel-Lindau disease (VHL), and Neurofibromatosis type 1 (NF 1). PCCs are a common cause of malignant hypertension in pregnancy and can lead to adverse maternal and fetal outcomes if left undiagnosed or untreated.

Case Description

A 39-year-old Latin American primigravid woman at 8 weeks 4 days gestation was referred to the endocrinology clinic for labile blood pressure (160/90 mmHg at recent ER visit) and a lab finding of elevated catecholamines (plasma norepinephrine 4720 pg/ml; normal 0-874 pg/ml). She reported chronic headaches and 2-lb unintentional weight loss during pregnancy. Past medical history was significant for right adrenal PCC diagnosed at age 13 (currently status post adrenalectomy), and a cerebrovascular accident at age 29. Family history was relevant for PCC in the patient's sister and mother. The patient's home medications were nifedipine 30 mg daily and prenatal vitamins. On physical exam, her blood pressure was 126/76 mm Hg, heart rate was 67/min and a scar of previous right adrenalectomy was noted. Doxazosin 1 mg daily was added to her regimen and nifedipine was discontinued. The patient was initially planned for an elective cesarean section at term. However, at 10 weeks 5 days of gestation, she had a missed abortion. Further genetic testing of syndromic PCC revealed a heterozygous mutation in the VHL gene. Abdominal MRI showed a left adrenal mass (3.6×2.6×3.6 cm³) and retroperitoneal lymphadenopathy. The patient underwent left adrenalectomy and is currently hemodynamically stable on maintenance hydrocortisone and fludrocortisone.

Discussion

We report a case of PCC complicating pregnancy in a 39-year-old primigravida who had a family history of PCC. In females of reproductive age with a known PCC diagnosis, we suggest early genetic testing as it can further advise family planning, antepartum monitoring, and management. Medically, these patients can be managed with α-adrenergic blockers and calcium-channel blockers, followed by β-blockers. This can improve maternal and fetal outcomes primarily by minimizing paroxysmal elevations in catecholamines. Definitive treatment of PCC is surgical excision, usually performed during the second trimester or postpartum. Management of patients with VHL requires lifelong clinical, laboratory, and imaging surveillance for other manifestations of the disease.

References

Bancos, Irina et al. Maternal and fetal outcomes in phaeochromocytoma and pregnancy: a multicentre retrospective cohort study and systematic review of literature. Lancet Diabetes Endocrinol 2021; 9: 13–21

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Blood pressure reduction in higher cardiovascular risk patients in the Global SYMPLICITY Registry

Background/Introduction

The Global SYMPLICITY Registry (GSR) was designed to evaluate the safety and efficacy of renal denervation (RDN) in real-world patients. Inclusion and exclusion criteria are limited to allow assessment of the effects of RDN on patients with a wide range of comorbidities. The current analysis examines blood pressure (BP) reduction after RDN in higher cardiovascular risk patients.

Purpose

To evaluate blood pressure reduction after RDN in higher cardiovascular risk patients in GSR.

Methods

GSR is a prospective all-comers registry to evaluate the safety and efficacy of RDN. Patients are enrolled in GSR and receive radiofrequency RDN using the Symplicity Flex or Symplicity Spyral catheter. Office and ambulatory BP are measured at each follow-up (3, 6, 12, 24, and 36 months). In this post-hoc analysis, changes from baseline in office and 24-hour ambulatory systolic blood pressure were assessed in patients at higher cardiovascular risk. Higher risk was defined using baseline office systolic or diastolic BP as well as additional risk factors (Figure 1).

Results

As of March 2021, there were 2621 patients characterized as higher cardiovascular risk in GSR. Baseline characteristics included mean age 60.7±12.1 years, 57.6% male, 37.9% type 2 diabetes, 35.8% hypocholesterolemia, 19.7% eGFR &lt;60 mL/min/1.73 m2, 16.2% left ventricular hypertrophy, 10.2% previous stroke and 9.3% previous myocardial infarction. Baseline office systolic BP (OSBP) was 168.8±22.7 mmHg and baseline ambulatory systolic BP (ASBP) 155.3±18.6 mmHg. Mean OSBP reductions after RDN in this higher risk population ranged from −13.1 mmHg at 3 months to −17.5 mmHg at 24 months and −18.9 mmHg at 36 months, and mean ASBP reductions ranged from −7.8 mmHg at 3 months to −9.8 mmHg at 24 months and −9.3 mmHg at 36 months (Figure).

Conclusions

Higher risk patients in GSR had sustained office and ambulatory systolic BP reductions out to 3 years after catheter-based radiofrequency RDN.

Funding Acknowledgement

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

The impact of ventricular-arterial coupling on aerobic capacity across the heart failure spectrum

Background

Ventricular-arterial coupling (VAC) can be evaluated as the ratio between arterial stiffness (pulse wave velocity, PWV) and myocardial deformation (global longitudinal strain, GLS).

Objectives

To evaluate VAC across the spectrum of heart failure (HF).

Methods

We introduced a Doppler-derived, single-beat technique to estimate aortic arch PWV (aa-PWV) in addition to tonometry-derived carotid-femoral PWV (cf-PWV). We measured PWVs and 3D-GLS in 155 healthy controls, 75 subjects at risk of developing HF (American College of Cardiology/American Heart Association Stage A-B) and 236 patients in HF Stage C with preserved (HFpEF, n=104) or reduced ejection fraction (HFrEF, n=132). We evaluated peak oxygen consumption (VO2) and peripheral extraction (AVO2diff) using combined cardiopulmonary-echocardiography exercise stress.

Results

aa-PWV was obtainable in all subjects and significantly lower than cf-PWV in all subgroups (p&lt;0.01). PWVs were directly related and increased with age (all p&lt;0.0001). cf-PWV/3D-GLS was similarly compromised in HFrEF (1.08±0.36) and HFpEF (1.05±0.22), while aa-PWV/3D-GLS was more impaired in HFpEF (0.69±0.11) than HFrEF (0.60±0.15; p&lt;0.01). Stage A-B had values of cf-PWV/3D-GLS and aa-PWV/3D-GLS (0.66±0.25 and 0.47±0.12) higher than controls (0.47±0.10 and 0.40±0.10) but lower than Stage C (all p&lt;0.01). Peak AVO2diff was inversely related with cf-PWV/3D-GLS and aa-PWV/3D-GLS (all p&lt;0.01). cf-PWV/3D-GLS and aa-PWV/3D-GLS independently predicted peak VO2 in the overall population (adjusted R2=0.32 and 0.35; all p&lt;0.0001) but only aa-PWV/3D-GLS was independently associated with flow reserve during exercise (R2=0.51; p&lt;0.0001).

Conclusion

Abnormal VAC is directly correlated with greater severity of HF and worse functional capacity. HFpEF shows a worse VAC than HFrEF when expressed by aa-PWV/3D-GLS.

Funding Acknowledgement

Type of funding sources: None.

A behavioural intervention to increase lay-people's intentions to initiate CPR in the event of Out-of-Hospital Cardiac Arrest: results from BICeP pilot trial

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council

Background

Cardiopulmonary resuscitation (CPR) is the single most important factor determining survival from out of hospital cardiac arrest (OHCA). Even when trained, most lay-people don’t attempt CPR when they encounter OHCA. Working closely with intended users and CPR experts we developed a theory-based text-messaging intervention designed to increase rates of CPR. This pilot study was conducted to evaluate the acceptability of the messages, explore participant responses to them and to trial measures for a full evaluation.

Design

A before-and-after study plus qualitative interviews

Methods

Twenty lay-people from across Scotland agreed to take part and to receive the intervention (35 text-messages over approx. 6 weeks) At baseline and after participants had received intervention (approx. 6 weeks later) we measured how likely people were to perform CPR (intention) in relation to 4 scenarios and self-assessed competence and confidence about performing CPR (self-efficacy) in general. We conducted qualitative interviews with 10 participants to elicit their views of the intervention

Results

Twenty lay-people (6F, 14M; aged 20-84) participated, all providing full baseline data. 19/20 participants received at least 20 messages. 15/20 provided follow-up data and ten were interviewed. Baseline intentions to initiate CPR in CPR scenarios were high (18.1) but still greater after the intervention (19.5). Increases in theory-based predictors of intention, self-efficacy (pre:74.5 post:81.0) and self-assessed competence (pre:19.5 post:20.5) were also observed following the intervention. Qualitative data suggested the intervention was positively received and viewed as helpful in improving confidence by reinforcing and building on messages from training. Interviewees suggested additional options for delivery format and pace would be helpful.

Conclusions

A behaviour-change text-message intervention delivered after CPR training is acceptable, easily scalable and may help improve rates of lay CPR initiation. Full scale evaluation of effectiveness is planned.

Association between genetic and socioenvironmental risk for schizophrenia during upbringing in a UK longitudinal cohort

BACKGROUND

Associations of socioenvironmental features like urbanicity and neighborhood deprivation with psychosis are well-established. An enduring question, however, is whether these associations are causal. Genetic confounding could occur due to downward mobility of individuals at high genetic risk for psychiatric problems into disadvantaged environments.

METHODS

We examined correlations of five indices of genetic risk [polygenic risk scores (PRS) for schizophrenia and depression, maternal psychotic symptoms, family psychiatric history, and zygosity-based latent genetic risk] with multiple area-, neighborhood-, and family-level risks during upbringing. Data were from the Environmental Risk (E-Risk) Longitudinal Twin Study, a nationally-representative cohort of 2232 British twins born in 1994-1995 and followed to age 18 (93% retention). Socioenvironmental risks included urbanicity, air pollution, neighborhood deprivation, neighborhood crime, neighborhood disorder, social cohesion, residential mobility, family poverty, and a cumulative environmental risk scale. At age 18, participants were privately interviewed about psychotic experiences.

RESULTS

Higher genetic risk on all indices was associated with riskier environments during upbringing. For example, participants with higher schizophrenia PRS (OR = 1.19, 95% CI = 1.06-1.33), depression PRS (OR = 1.20, 95% CI = 1.08-1.34), family history (OR = 1.25, 95% CI = 1.11-1.40), and latent genetic risk (OR = 1.21, 95% CI = 1.07-1.38) had accumulated more socioenvironmental risks for schizophrenia by age 18. However, associations between socioenvironmental risks and psychotic experiences mostly remained significant after covariate adjustment for genetic risk.

CONCLUSION

Genetic risk is correlated with socioenvironmental risk for schizophrenia during upbringing, but the associations between socioenvironmental risk and adolescent psychotic experiences appear, at present, to exist above and beyond this gene-environment correlation.

Ventricular-arterial coupling derived from proximal aortic stiffness: impact on aerobic capacity across the heart failure spectrum

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular-arterial coupling (VAC) can be evaluated as the ratio between arterial stiffness (pulse wave velocity, PWV) and myocardial deformation (global longitudinal strain, GLS).

Objectives

To evaluate VAC across the spectrum of heart failure (HF).

Methods

We introduced a Doppler-derived, single-beat technique to estimate aortic arch PWV (aa-PWV) in addition to tonometry-derived carotid-femoral PWV (cf-PWV). We measured PWVs and GLS in 155 healthy controls, 75 subjects at risk of developing HF (American College of Cardiology/American Heart Association Stage A-B) and 236 patients in HF Stage C with preserved (HFpEF, n=104) or reduced ejection fraction (HFrEF, n=132). We evaluated peak oxygen consumption (VO2) and peripheral extraction (AVO2diff) using combined cardiopulmonary-echocardiography exercise stress.

Results

aa-PWV was obtainable in all subjects and significantly lower than cf-PWV in all subgroups (p&lt;0.01). PWVs were directly related and increased with age (all p&lt;0.0001). cf-PWV/GLS was similarly compromised in HFrEF (1.08±0.36) and HFpEF (1.05±0.22), while aa-PWV/GLS was more impaired in HFpEF (0.69±0.11) than HFrEF (0.60±0.15; p&lt;0.01). Stage A-B had values of cf-PWV/GLS and aa-PWV/GLS (0.66±0.25 and 0.47±0.12) higher than controls (0.47±0.10 and 0.40±0.10) but lower than Stage C (all p&lt;0.01). Peak AVO2diff was inversely related with cf-PWV/GLS and aa-PWV/GLS (all p&lt;0.01). cf-PWV/GLS and aa-PWV/GLS independently predicted peak VO2 in the overall population (adjusted R2=0.32 and 0.35; all p&lt;0.0001) but only aa-PWV/GLS was independently associated with flow reserve during exercise (R2=0.51; p&lt;0.0001).

Conclusion

Abnormal VAC is directly correlated with greater severity of HF and worse functional capacity. HFpEF shows a worse VAC than HFrEF when expressed by aa-PWV/GLS.

Enhancing clinician participation in quality improvement training: implementation and impact of an evidence-based initiative to maximise antenatal clinician participation in training regarding women’s alcohol consumption during pregnancy

Background

There are significant challenges in ensuring sufficient clinician participation in quality improvement training. Clinician capability has been identified as a barrier to the delivery of evidence-based care. Clinician training is an effective strategy to address this barrier, however, there are significant challenges in ensuring adequate clinician participation in training. This study aimed to assess the extent of participation by antenatal clinicians in evidence-based training to address alcohol consumption during pregnancy, and to assess differences in participation by profession.

Methods

A 7-month training initiative based on six evidence-based principles was implemented in a maternity service in New South Wales, Australia. Descriptive statistics described participation in training (% attending: any training; six evidence-based principles of training; all principles). Regression analyses examined differences by profession.

Results

Almost all antenatal clinicians participated in some training (182/186; 98%); 69% participated in ≥1 h of training (μ = 88.2mins, SD:56.56). The proportion of clinicians participating in training that satisfied each of the six principles ranged from 35% (training from peers and experts) to 82% (training was educational and instructional). Only 7% participated in training that satisfied all principles. A significantly higher proportion of midwifery compared to medical clinicians participated in training satisfying five of the six training principles.

Conclusions

A training initiative based on evidence-based principles resulted in almost all clinicians receiving some training and 69% participating in at least 1 h of training. Variability between professions suggests training needs to be tailored to such groups. Further research is required to determine possible associations with care delivery outcomes.

Trial registration

Australian and New Zealand Clinical Trials Registry, No. ACTRN12617000882325 (date registered: 16/06/2017).

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

Inactivation of MS2 bacteriophage on copper film deployed in high touch areas of a public transport system

Although SARS-CoV-2 is primarily an airborne risk, the COVID-19 pandemic also highlighted the need for self-disinfection surfaces that could withstand the demand of high occupant densities characteristic of public transportation systems. The aim of this study was to evaluate the durability and antiviral activity of a copper film deployed for 90 days in two high touch locations within an active metropolitan bus and railcar. The antiviral efficacy of this copper film after being deployed in transit vehicles for 90 days (deployed copper film) was then compared to new (unused) copper film to determine if frequent touches and cleaning protocols could decrease the efficacy of the copper films. Deployed copper film, new copper film, and aluminium foil (positive control) coupons were inoculated with ~1 × 10⁶ MS2 virus particles, allowed a contact time of either 5- or 10-min, and analysed for residual viral infectiousness. On both new and deployed copper films, MS2 was completely inactivated (≥5 log reduction) at both time points. These results suggest that the copper film may provide the durability demanded by high touch public spaces while maintaining the antiviral activity necessary to reduce exposure risk and viral transmission via surfaces in public transportation settings.

Validation of the Kinetik Blood Pressure Monitor-Series 1 for use in adults at home and in clinical settings, according to the 2002 European Society of Hypertension International Protocol on the validation of blood pressure devices

The aim of this study was to assess the blood pressure (BP) measurement accuracy of the Kinetik Blood Pressure Monitor-Series 1 (BPM-1) for use in home or clinical settings according to the 2002 European Society of Hypertension International Protocol (ESH-IP). Forty-two participants were recruited to fulfil the required number of systolic and diastolic BP measurements according to the ESH-IP. Nine sequential same-arm BP readings were measured and analysed for each participant using the test device and observer mercury standard readings according to the 2002 ESH-IP. Forty one participants were used to obtain 33 sets of systolic and diastolic BP readings and were included in the analysis. Mean difference between the device measurements and the observer (mercury standard) measurements was 1.1 ± 7.2/1.1 ± 6.8 mmHg (mean ± standard deviation; systolic/diastolic). The number of systolic BP differences between the test and observer measurements that fell within 5, 10 and 15 mmHg was 65, 86 and 92. For diastolic readings, the number of test-observer measurement differences within 5, 10 and 15 mmHg was 77, 91 and 94. The number of participants with at least two out of three differences within 5 mmHg was 28 for systolic and 40 for diastolic BP readings. Three participants had no differences between the test and observer measurements within 5 mmHg in both the systolic and diastolic measurement categories. The Kinetik BPM-1 device fulfilled the requirements of the ESH-IP validation procedure and can be recommended for clinical use and self-measurement within the home.

Application of win ratio methodology in the Global SYMPLICITY Registry for patients with atrial fibrillation or obstructive sleep apnea

Background/Introduction

The win ratio is a new methodology which utilizes multiple hierarchical endpoints to evaluate clinical outcomes in trials. The win ratio may have added benefit in device therapy trials like renal denervation (RDN) where anti-hypertensive medication burden can influence blood pressure (BP) changes.

Purpose

In this analysis, we applied the win ratio to patients in the Global SYMPLICITY Registry (GSR) to quantify potential differences in RDN efficacy according to different comorbidities, specifically atrial fibrillation and obstructive sleep apnea.

Methods

All patients in GSR had an RDN procedure with the Symplicity Flex or Symplicity Spyral catheter. For the win ratio analysis, ambulatory systolic BP (ASBP) measurements, office systolic BP (OSBP) measurements and the number of prescribed anti-hypertensive medications at 6 months were included as hierarchical endpoints. Patients were divided into 1 of 2 groups: with or without atrial fibrillation (AF) at baseline. Each patient was compared with every other patient in the opposing group first according to ASBP to determine “win”, “lose” or “tie” with a threshold of 5 mmHg. Then, ties from the ASBP comparison underwent the comparison using OSBP with a threshold of 10 mmHg. Any tie for a pair comparing OSBP resulted in comparison of number of anti-hypertensive medications with a threshold of 1. Comparisons of ASBP and OSBP were adjusted for baseline SBPs by using residuals from a linear regression. The analysis was repeated for patients grouped according to history of obstructive sleep apnea (OSA) at baseline.

Results

In March 2020, 336 patients with AF at baseline and 2,394 patients with no AF were compared in GSR, resulting in 336 x 2394 = 804,384 pairwise comparisons for the win ratio analysis. A total of 285,709 “wins”, indicating greater ASBP reduction, OSBP reduction, and/or fewer number of anti-hypertensive medications occurred in the AF group compared to the no AF group. Conversely, 256,511 “losses”, meaning greater BP reduction and/or number of medications occurred in the no AF group. The win ratio was thus calculated as 1.11 (95% CI: 0.98, 1.28, p=0.081) indicating similar BP reduction and medication burden after RDN in patients with or without AF in GSR (Figure). Using these methods, the win ratio for patients with and without OSA was calculated to be 0.98 (95% CI: 0.85, 1.13, p=0.81), also indicating similar RDN efficacy regardless of presence of OSA at baseline (Figure). Previously published results of the win ratio analysis of RDN and sham control patients in the SPRYAL HTN-ON MED trial reported a win ratio in favor of RDN of 2.78 (95% CI: 1.58, 5.48, p&lt;0.001).

Conclusions

Application of the win ratio methodology to patients in GSR demonstrated similar efficacy of RDN to patients regardless of whether they had comorbidities of atrial fibrillation or obstructive sleep apnea.

Funding Acknowledgement

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

The psychological and behavioural factors associated with laypeople initiating CPR for out-of-hospital cardiac arrest: a systematic review

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Chief Scientist Office, Scottish Government

OnBehalf

BICeP Study Group

Background

Prompt, effective CPR greatly increases the chances of survival in out-of-hospital cardiac arrest. However, it is often not provided, even by people who have previously undertaken training. Psychological and behavioural factors are likely to be important in relation to CPR initiation by lay-people but have not yet been systematically identified.

Objective

To identify the psychological and behavioural factors associated with CPR initiation amongst lay-people. 

Methods  

Data sources

Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycInfo and Google Scholar. 

Study eligibility criteria

Primary studies reporting psychological or behavioural factors and data on CPR initiation involving lay-people published (inception to 15th January 2020).

Study appraisal and synthesis methods

Potential studies were screened and quality assessed independently by two reviewers. Study characteristics, psychological and behavioural factors associated with CPR initiation were extracted from included studies, categorised by study type and synthesised narratively. 

Results

Ninety studies (132,429 participants) comprising various designs, populations and of mostly weak quality were identified. The strongest and most ecologically valid studies identified factors associated with CPR initiation: the overwhelming emotion of the situation, perceptions of capability, uncertainty about when CPR is appropriate, feeling unprepared  and fear of doing harm. Current evidence is limited by a preponderance of atheoretical cross-sectional surveys using unvalidated measures with relatively little formal testing of posited ‘predictors’.

Conclusions

We will present the psychological and behavioural factors that are likely useful foci for future interventions aiming to increase CPR initiation. The literature in this area would benefit from more robust study designs which make greater use of theory.

Developing a behavioural intervention to increase lay-people"s intentions to initiate CPR in the event of Out-of-Hospital Cardiac Arrest (OHCA)

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Medical Research Council

OnBehalf

BICeP Study Group

Background

Prompt, effective bystander cardiopulmonary resuscitation (CPR) is the single most important factor determining survival from out of hospital cardiac arrest (OHCA), increasing survival up to 4-fold. However only 35%-45% of people trained in CPR actually attempt it when required. This study uses psychological theory and behaviour change techniques (BCTs) to increase the proportion of bystanders who attempt CPR in a real emergency.

Design

Intervention development study

Methods

Intervention content was informed by two recent systematic reviews, which identified barriers to bystander CPR and BCTs within existing training programmes (PROSPERO CRD42018117438; CRD42019126745) and a qualitative study exploring participants’ views (n = 12) of draft text messages. A lay bystander user-involvement panel (n = 7) and an expert advisory group (comprising representatives from CPR training organisations) worked with the research team to co-produce the final intervention and agree the schedule for text message delivery.  BCT content was assessed by two independent experts. A framework analysis of interviews was undertaken. 

Results

Recognising and addressing fears, and helping people to better prepare for real-life situations were identified to be important to participants. Short, simple texts from a credible source and with a positive tone were strongly preferred, there was a strong aversion to anything "guilt-inducing". Pictures and personalisation were important, rewards less so. Regarding frequency: participants varied but around 1/week was considered adequate by most. A total of n = 35 text-messages with verified BCT content were co-developed with participants.

Conclusions

A text message intervention incorporating BCTs, which is acceptable to intended users and CPR trained individuals has been produced and will be subject to future evaluation.

Specimen oriented intraoperative margin assessment in oral cavity and oropharyngeal squamous cell carcinoma

OBJECTIVE

Evaluate the oncologic outcomes and cost analysis of transitioning to a specimen oriented intraoperative margin assessment protocol from a tumour bed sampling protocol in oral cavity (OCSCC) and oropharyngeal squamous cell carcinoma (OPSCC).

STUDY DESIGN

Retrospective case series and subsequent prospective cohort study SETTING: Tertiary care academic teaching hospital SUBJECTS AND METHODS: Retrospective case series of all institutional T1-T2 OCSCC or OPSCC treated with primary surgery between January 1st 2009 - December 31st 2014. Kaplan-Meier survival estimates with log rank tests were used to compare patients based on final margin status. Cost analysis was performed for escalation of therapy due to positive final margins. Following introduction of a specimen derived margin protocol, successive prospective cohort study of T1-T4 OCSCC or OPSCC treated with primary surgery from January 1st 2017 - December 31st 2018. Analysis and comparison of both protocols included review of intraoperative margins, final pathology and treatment cost.

RESULTS

Analysis of our intra-operative tumour bed frozen section protocol revealed 15 of 116 (12.9%) patients had positive final pathology margins, resulting in post-operative escalation of therapy for 14/15 patients in the form of re-resection (7/14), radiation therapy (6/14) and chemoradiotherapy (1/14). One other patient with positive final margins received escalated therapy for additional negative prognostic factors. Recurrence free survival at 3 years was 88.4 and 50.7% for negative and positive final margins respectively (p = 0.048). Implementation of a specimen oriented frozen section protocol resulted in 1 of 111 patients (0.9%) having positive final pathology margins, a statistically significant decrease (p < 0.001). Utilizing our specimen oriented protocol, there was an absolute risk reduction for having a final positive margin of 12.0% and relative risk reduction of 93.0%. Estimated cost avoidance applying the specimen oriented protocol to our previous cohort was $412,052.812017 CAD.

CONCLUSION

Implementation of a specimen oriented intraoperative margin protocol provides a statistically significant decrease in final positive margins. This change in protocol leads to decreased patient morbidity by avoiding therapy escalation attributable only to positive margins, and avoids the economic costs of these treatments.

AB0289 PATIENT REPORTED PHYSICAL HEALTH COMPARED TO CLINICIAN RECORDED BILAG-2004 MUSCULOSKELETAL SYSTEM SCORES – DISCORDANCE BETWEEN PATIENTS AND CLINICIANS

Background:

The musculoskeletal organ system BILAG-2004 (MSK BILAG) assessment is of critical importance in SLE clinical trials. Severe active polyarthritis, MSK BILAG A, by definition includes significant impairment of basic activities of daily living (ADLs), as opposed to MSK BILAG C, D, or E where ability to perform ADLs is expected to be preserved. In clinical trials, BILAG is scored by clinicians without formal review of patient reported outcomes (PROs). The Physical Health domain of the LupusQoL (LQol PH) (range 0 – 100) can be used to assess the patient’s physical function and ADLs. LQoL PH score thresholds defining impairment severity have not been established; however, a transformed LQoL PH score ≤50 suggests more impaired function, which would not be expected in MSK BILAG C, D, or E. Conversely, a score >50 implies no major issues with ADLs, which would be contradictory to the definition of MSK BILAG A.

Objectives:

To assess correlation of patient reported LQoL PH with MSK BILAG scores recorded by clinicians at various timepoints using data from the phase 3 TULIP studies 1,2 and to investigate the percent of discordance between patients and clinicians.

Methods:

Data from TULIP 1 and 2 studies (anifrolumab 300 mg and placebo arms) were pooled to evaluate the relationship between LQoL PH and MSK BILAG scores at baseline, weeks 24 and 52 using Spearman correlations as post-hoc analysis. Mean LQoL PH scores were assessed for each MSK BILAG category at the three timepoints using one-way ANOVA. Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 was calculated at baseline, week 24 and 52. MSK BILAG B was excluded from the analysis because discordance could not be easily defined for this category compared with the more extreme MSK BILAG categories.

Results:

Total of 690 patients were included in the pooled analysis (Table 1). Significant correlations between LQoL PH and MSK BILAG scores were found at each time point (nominal p<0.0001); this relationship became stronger over time. Mean LQoL PH scores were different in each MSK BILAG category, with the highest in MSK BILAG D/E and the lowest in the MSK BILAG A category, thus confirming the discriminatory ability of the LQoL PH (Table 1).

Table 1.

Correlation coefficients (CC) between LQoL PH and MSK BILAG scores, and mean LQoL PH scores with standard deviations (SD) per each MSK BILAG category at baseline, weeks 24 and 52.

BaselineWeek 24Week 52CCNCCNCCNTotal Population-0.25690-0.36626-0.41552MSK BILAGMean LQoL PH Score (SD)Mean LQoL PH Score (SD)Mean LQoL PH Score (SD)0 (D/E)69.3 (24.7)1774.2 (22.1)18674.5 (21.3)2371 (C)62.3 (25.4)6064.0 (23.9)23360.6 (22.5)1848 (B)56.6 (24.4)39855.1 (24.2)16351.3 (24.3)10512 (A)44.9 (25.8)21543.9 (25.9)4444.2 (26.2)26

At baseline, 40% of patients who were assessed by clinicians as having MSK BILAG A reported minimal impairment in physical function and ADLs (LQoL PH >50) and 24.1% who had MSK BILAG C, D, or E reported difficulties with ADLs (LQoL HP ≤50), suggesting discordance between patients and clinicians. This discordance slightly decreased over time (Figure 1).

Figure 1.

Percent of patients with MSK BILAG A and LQoL PH scores >50 and patients with MSK BILAG C, D, or E and LQoL PH scores ≤50 at baseline, weeks 24 and 52.

Conclusion:

Patient reported LQoL PH scores correlated with MSK BILAG scores and showed discriminant validity for MSK BILAG scores. Greater discordance was seen between LQoL PH and MSK BILAG A compared with C, D, or E. These findings suggest a need for further investigation of a role for PROs in MSK BILAG scoring. Formal review of PROs by clinicians during MSK BILAG assessment could be considered in future SLE clinical trials.

References:

[1]Furie R et al. Lancet 2019

[2]Morand EF et al. N Engl J Med 2020

Acknowledgements:

This study was sponsored by AstraZeneca.

Disclosure of Interests:

Ewa Olech Speakers bureau: Abbvie, Amgen, Merck, Pfizer, and UCB, Grant/research support from: BMS, Donald Stull: None declared, Betsy Williams: None declared, Stephanie Bean: None declared, Gabriel Abreu Employee of: AstraZeneca, Erik Schwetje Employee of: AstraZeneca, Raj Tummala Employee of: AstraZeneca, Sean O’Quinn Shareholder of: AstraZeneca, Employee of: AstraZeneca

Clinical Characteristics and Outcomes Among COVID 19 Hospitalized Patients in a Community Hospital in New York City

Background: COVID-19 has disproportionally affected communities of color in the US. These communities exhibit higher prevalence of chronic preventable disease including type 2 diabetes mellitus (DM2) and obesity. DM2 and obesity have been linked to higher morbidity and mortality in the setting of COVID-19 infection (1).

Methods: We query data collected from 521 patients with laboratory-confirmed Covid-19 infection admitted to an inner-city community hospital in Brooklyn, New York between March 20 2020 and May 15 2020. Demographics, pre-infection medical comorbidities, laboratory data at admission and clinical outcomes including in-hospital mortality were analyzed.

Results: Patients were 61 years on average (+/-17.2), 42.8% were female, 53.9% were Hispanic and 33% were African-American. Most common comorbidities included: hypertension (62%), chronic kidney disease (20.8%), diabetes (45 %). Mean BMI was 29.9 (+/- 8.2). Among patients with no prior diagnosis of diabetes mean A1c was 5.8% (+/-1.2) and 8.7 (+/-2.5) amongst those with a previous diagnosis of diabetes. Patients hospitalized with moderate to severe COVID-19 infection and a previous diagnosis of DM2 had significantly higher prevalence of CKD and HTN. Amongst those with T2DM, 19.1% presented with DKA. After adjustment for age, gender, race, BMI and creatinine obese patients, compared with normal-weight patients had significantly higher mortality rate (BMI &gt; 30 kg/m2 [OR: 2.29, CI: 95%, P-value: &lt;0.002]) however this association was not observed for DM2 ([OR: 1.25, CI: 95%, P-value: &lt;0.002]).

Conclusion: Our cohort represents a particular population affected by the first wave of Covid-19 infection in an urban inner-city community in NYC. The population studied had a larger proportion of African-American, Hispanic and younger patients compared to national averages; these differences are related to the demographics of the communities served by our hospital. Obesity is a negative prognostic factor in the course of Covid-19 infection in comparison to normal-weight patients. Obesity is a proinflammatory condition, associated with high levels of prothrombotic factors including angiotensin-II, also elevated in COVID-19. Understanding that link may yield valuable knowledge on the role obesity plays in numerous disease states beyond COVID-19. References:(1). Sabin ML, et al. Lancet. 2020;395(10232): 1243–44.(2). Hussain A, et al. Obes Res Clin Pract. 2020; 14(4): 295–300.

Case Series: Exacerbation of Insulin Resistance With Active COVID 19 Infection

Background: Severe hyperglycemia due to insulin resistance is associated with increased mortality due to induction of pro-inflammatory cytokines, immunodepression, impairing cellular function and healing. We describe 6 patients admitted with COVID19 pneumonia complicated with DKA requiring high dose insulin infusion.

# 1 19 yo African American (AA) male with history of pre-DM and obesity (BMI 41 kg/m2) presented with polyuria, polydipsia, obtunded and intubated in ER. Labs showed pH 7.35, serum sodium (Na) 138 mmol/L, potassium (K) 6.8 mmol/L, chloride (Cl) 85 mmol/L, bicarbonate (HCO3) 10 mmol/L, glucose 1140 mg/dL, lactate 1.4 mmol/L, anion gap (AG) 43, Beta Hydroxybutyrate (BOH) &gt; 4.50 mmol/L. A1c 13.4%. Placed on insulin drip at 29.5 U/hr or 5.7 U/kg/hr. Discharged on Detemir 60 U TID and Novolog 20 U TID ac.

# 2 55 yo female with T2DM and obesity (BMI 37.42 kg/m2) presented with shortness of breath, intubated for hypoxia in ER. Labs showed pH 7.21, serum Na 138 mmol/L, K 5.6 mmol/L, Cl 101 mmol/L, HCO3 13 mmol/L, glucose 557 mg/dL, lactate 5 mmol/L, AG 24, BOH &gt; 0.27 mmol/L. A1c 7.8%. Placed on insulin drip at 23 U/hr or 5 U/kg/hr. Died from multiorgan failure on day 7.

# 3 75 yo Hispanic female with T2DM, HCV, post liver-kidney transplant on immunosuppressants, HTN presented with weakness. Intubated on day 6 for hypoxemia. Placed on stress dose steroids for transplant failure. BMI 30 kg/m2. Labs on day 6 showed pH 6.98, serum Na 140 mmol/L, K 3.5 mmol/L, Cl 100 mmol/L, HCO3 20 mmol/L, glucose 590 mg/dL, AG 20, BOH 1.40 mmol/L. A1c 6.6% a year ago. Placed on insulin drip at 34 U/hr or 10.9 U/kg/hr. She developed ESRD requiring CRRT dialysis. She was made comfort care. Died on day 7.

# 4 38 yo AA male with obesity (BMI 59.5 kg/m2) presenting with confusion, polyuria, polydipsia. Labs showed pH 7.22. serum Na 133 mmol/L, K 6.8 mmol/L, Cl 81 mmol/L, HCO3 15 mmol/L, glucose 1760 mg/dL, lactate 3.8 mmol/L, AG 37, BOH &gt; 4.50 mmol/L. A1c 12.6%. Placed on insulin drip at 36 U/hr or 6 U/kg/hr. Discharged on Detemir 20 U qhs.

# 5 27 yo AA female with T2DM, HTN and obesity (BMI 51 kg/m2), pituitary adenoma presented with seizures. Labs showed pH 7.15, serum Na 133 mmol/L, K 7.0 mmol/L, Cl 84 mmol/L, HCO3 7 mmol/L, serum glucose 951 mg/dL, lactate 1.6 mmol/L, AG 24, BOH &gt;2.45 mmol/L. A1c &gt;15%. Placed on insulin drip at 24 U/hr or 5 U/kg/hr. Died on day 5 from multiorgan failure.

# 6 74 yo Hispanic female with T2DM, HTN and asthma presented with altered mental status. BMI 28 kg/m2. Labs showed pH 7.25, serum Na 155 mmol/L, K 4.6 mmol/L, Cl 125 mmol/L, HCO3 17 mmol/L, serum glucose 779 mg/dL, lactate 2.6 mmol/L, AG 13, BOH &gt;2.45 mmol/L. A1c &gt; 15%. Placed on insulin drip at 24 U/hr or 3.5 U/kg/hr. Died on day 5.

Conclusion: Patients with DM and obesity admitted with Covid19 infection presented with severe insulin resistance and poor outcomes. Cconsideration should be given to assessing therapeutic interventions to enhance insulin sensitivity and improve outcomes.

A Case of Vocal Cord Paralysis and Severe Hypocalcemia

Background: Tetany is the hallmark of hypocalcemia. Vocal cord paralysis is a rare presenting symptom of hypocalcemia, especially without signs of overt tetany or seizures. Clinical case: 18 year old man with history of iron deficiency anemia and dyslipidemia presented with aphasia, right sided upper and lower extremity weakness and facial tingling for 3 days. Physical exam was notable for aphasia, pallor, positive Chvostek and Trousseau sign. Admission labs showed BUN 127 mg/dL (n 8–26 mg/dL), creatinine 12.74 mg/dL (n 0.8–2.00 mg/dL), calcium 5.2 mg/dL (n 8.5–10.5 mg/dL), magnesium (1.8–2.4 mg/dL), phosphorus 10.3 (2.4–4.8 mg/dL), alkaline phosphatase 126 (8–120 U/L), albumin 3.3 g/dL (n 3.0–5.0 g/dL), 25 OH VitD₃ 9.1 ng/mL (n 30–80 ng/mL), PTH 594 pg/mL (n 15–65 pg.mL), COVID 19 PCR negative. Aphasia resolved with 1 gram calcium gluconate infusion. Patient underwent emergent hemodialysis. He was placed on calcium carbonate 1500 mg oral three times daily, calcitriol 1 mcg oral twice daily, ergocalciferol 50,000 IU weekly, sevelamer carbonate 1600 mg tablet three times daily. Kidney biopsy showed membranoproliferative pattern glomerulonephritis with C3 deposits. He was discharged on hemodialysis and referred to a transplant center. Conclusion: Vocal cord paralysis is rare in adults and mostly seen in patients with pseudohypoparathyroidism caused by hypomagnesaemia.^2,3 Identifying vocal cord paralysis as an atypical presentation of hypocalcemia secondary to acute kidney failure requires prompt recognition and treatment. References: 1.Shoback D, Marcus R, Bikle D. Metabolic bone disease. In: Greenspan FS, Gardner DG, editors. Basic and clinical endocrinology. 3rd ed Los Altos (CA): Lange Medical Publications; 2004. p. 3242.van Veelen, M J et al. “Hypocalcaemic laryngospasm in the emergency department.” BMJ case reports vol. 2011 bcr1120103555. 17 Feb. 2011, doi:10.1136/bcr.11.2010.35553.Guise TA, Mundy GR. Clinical review 69: evaluation of hypocalcemia in children and adults. J Clin Endocrinol Metab 1995;80:1473–8

Obesity and Covid-19: A Major Mortality Risk in Patients Hospitalized With Covid-19

The coronavirus disease 2019 COVID-19 pandemic is a major public health crisis. Obesity has emerged as a significant comorbidity for COVID-19 severity. To study the association of both pandemics, we conducted an observational, retrospective cohort study involving 521 patients admitted with Covid-19 to an inner city, community hospital in Brooklyn, NY in the period March 20 to May 2, 2020. Of the cohort, 57.6% was men, mean age was 61.6±17.2 years, and mean BMI was 29.0 ± 8.2 kg /m2. 11% had BMI > 40 kg/m². 53.9% was Hispanic, 33.3% was African American, 7.1% was White, with a predominance of type 2 diabetes (99%). Diabetes, hypertension, coronary artery disease and chronic kidney disease were found in 45%, 41.5%, 15%, and 20.1% cases, respectively. Mean HbA1c was 5.8%± 1.1 in patients with no history of diabetes, 3% presented with diabetic ketoacidosis, mortality rate was 30.6%. Non-survivors were significantly older (median age 68 vs 56, p < 0.03) and had higher rate of microvascular and macrovascular diseases. In patients with diabetes, mortality rate was 40.1%. HbA1c was similar between survivors and non-survivors. Older age and hyperglycemia on admission were the risk factors for mortality. Only 30% of the cohort had normal weight (BMI<25), 30% was overweight and 40% was obese. In univariate analysis, the characteristics at admission significantly associated with mortality were age, BMI, hyperglycemia, diabetes and DKA in patients with or without diabetes. In age- and sex-adjusted multivariable analysis only BMI 30–39 kg/m² (OR = 1.63; 95% CI, 1.10, 2.43; p = 0.015), BMI >40 kg/m² (OR = 2.05; 95% CI, 1.22, 3.44; p = 0.007) and DKA (OR = 1.77; 95% CI, 1.18, 2.64; p = 0.005) remained positively associated with higher mortality. In summary, BMI, and DKA but not diabetes, were positively and independently associated with mortality in patients hospitalized with Covid-19. Reference: (1) Popkin et al., Obesity Reviews 2020 August;21(11):e13128. (2) Cariou et al., Diabetologia 2020 May;63(8): 1500–1515.

Vitamin D deficiency is associated with tuberculosis disease in British children

BACKGROUND: Basic science, epidemiological and interventional research supports a link between vitamin D and tuberculosis (TB) immunity, infection and disease. We evaluated the association between vitamin D levels and TB infection and disease in UK children recruited to the National Institute for Health Research IGRA Kids Study (NIKS).METHODS: Children presenting between 2011 and 2014 were eligible if they had history of exposure to an adult case with sputum smear/culture-positive TB, or were referred and diagnosed with TB disease. Children were assessed at baseline and at 6-8 weeks for immunological evidence of TB infection (interferon-gamma release assay and/or tuberculin skin test) and evidence of TB disease. Some centres routinely measured total 25-hydroxy vitamin D (25-OHD) levels.RESULTS: A total of 166 children were included. The median 25-OHD levels were higher in non-infected children (45.5 nmol/l) than in those with tuberculous infection (36.2 nmol/l) and TB disease (20.0 nmol/l). The difference between TB infection and disease was statistically significant (P < 0.001). By logistic regression, lower vitamin D levels were associated with TB disease among participants with infection or disease, with no evidence of confounding by age, sex, bacille Calmette-Guérin vaccination status, ethnicity, non-contact referral, season or centre.CONCLUSION: Children with TB disease had lower vitamin D levels than children with infection. Implications for prevention and treatment remain to be established.

[Discharge management in pediatric and adolescent psychiatry : Expectations and realities from the parental perspective]

BACKGROUND

Interface management after inpatient care for mentally ill children and adolescents has been proven to be a breaking point in good transition of care between child and adolescent psychiatry, social welfare services, schools, job centre and the judicial system. Criteria for successful discharge management do not exist in child and adolescent psychiatry. Aim of the study ASpeKT was to survey parents on their perception of interface management and to derive recommendations for discharge management.

METHODS

Data regarding interface management were retrieved from parents (T3, n = 124, T4, n = 81) 6 months (T3) and 12 months (T4) after discharge.

RESULTS

The parents stated that accessible help after discharge from inpatient treatment is essential for stability and requires a good coordination. Parents named that they perceived helpful for successful interface management: a case manager, early round table meetings, support in returning to school, seamless access to outpatient follow-up appointments as well as information on further treatment options and contact data.

CONCLUSION

From the perspective of affected families a proactive early individual and reliable care coordination by a constant contact person is essential for a good discharge management.

Integrated reporting in public sector organisations: A study of Australian local councils

Integrated reporting is a voluntary reporting approach that has the potential to transform corporate reporting. This reporting approach involves integrating financial information with sustainability information and requires a coordinated approach by all organisational departments to address social and environmental issues affecting an organisation, a process referred to as integrated thinking. This paper builds on existing research on public sector organisations and explores the current status and motivations for integrated reporting by Australian local councils and the resulting potential organisational change leading to integrated thinking. The findings reveal that while integrated reporting is emerging in Australian local councils, the external motivations for integrated reporting have led to a limited level of organisational change, leading to a low level of integrated thinking in councils. To enable integrated reporting practices to transform and drive change in organisational practices, this paper considers top level managerial support and a strategic vision for this approach is required.

Concentration, distribution, and influence of aging on the 18 kDa translocator protein in human brain: Implications for brain imaging studies

Positron emission tomography (PET) imaging of the translocator protein (TSPO) is widely used as a biomarker of microglial activation. However, TSPO protein concentration in human brain has not been optimally quantified nor has its regional distribution been compared to TSPO binding. We determined TSPO protein concentration, change with age, and regional distribution by quantitative immunoblotting in autopsied human brain. Brain TSPO protein concentration (>0.1 ng/µg protein) was higher than those reported by in vitro binding assays by at least 2 to 70 fold. TSPO protein distributed widely in both gray and white matter regions, with distribution in major gray matter areas ranked generally similar to that of PET binding in second-generation radiotracer studies. TSPO protein concentration in frontal cortex was high at birth, declined precipitously during the first three months, and increased modestly during adulthood/senescence (10%/decade; vs. 30% for comparison astrocytic marker GFAP). As expected, TSPO protein levels were significantly increased (+114%) in degenerating putamen in multiple system atrophy, providing further circumstantial support for TSPO as a gliosis marker. Overall, findings show some similarities between TSPO protein and PET binding characteristics in the human brain but also suggest that part of the TSPO protein pool might be less available for radioligand binding.

Ground and In-Flight Calibration of the OSIRIS-REx Camera Suite

The OSIRIS-REx Camera Suite (OCAMS) onboard the OSIRIS-REx spacecraft is used to study the shape and surface of the mission's target, asteroid (101955) Bennu, in support of the selection of a sampling site. We present calibration methods and results for the three OCAMS cameras-MapCam, PolyCam, and SamCam-using data from pre-flight and in-flight calibration campaigns. Pre-flight calibrations established a baseline for a variety of camera properties, including bias and dark behavior, flat fields, stray light, and radiometric calibration. In-flight activities updated these calibrations where possible, allowing us to confidently measure Bennu's surface. Accurate calibration is critical not only for establishing a global understanding of Bennu, but also for enabling analyses of potential sampling locations and for providing scientific context for the returned sample.

Ground and In-Flight Calibration of the OSIRIS-REx Camera Suite

The OSIRIS-REx Camera Suite (OCAMS) onboard the OSIRIS-REx spacecraft is used to study the shape and surface of the mission's target, asteroid (101955) Bennu, in support of the selection of a sampling site. We present calibration methods and results for the three OCAMS cameras-MapCam, PolyCam, and SamCam-using data from pre-flight and in-flight calibration campaigns. Pre-flight calibrations established a baseline for a variety of camera properties, including bias and dark behavior, flat fields, stray light, and radiometric calibration. In-flight activities updated these calibrations where possible, allowing us to confidently measure Bennu's surface. Accurate calibration is critical not only for establishing a global understanding of Bennu, but also for enabling analyses of potential sampling locations and for providing scientific context for the returned sample.

1199Reduction in blood pressure following renal denervation for patients with differing baseline cardiovascular risk

Background

Lowering blood pressure (BP) reduces clinical events. Renal denervation (RDN) is under investigation for treatment of uncontrolled hypertension and might represent a particularly attractive option for patients with high cardiovascular (CV) risk. To evaluate this proposal, it is important to determine whether baseline CV risk impacts the efficacy of RDN in lowering BP.

Purpose

We evaluated whether BP changes after RDN were dependent on baseline CV risk.

Methods

AHA/ACC Atherosclerosis CV Disease (ASCVD) risk score was calculated for patients in the Global Symplicity Registry (GSR; NCT01534299), a global registry of RDN in patients with uncontrolled hypertension, using baseline office systolic BP, total/HDL cholesterol measurements, diabetic and smoking status, gender, age, and number of baseline anti-hypertensive medications. Patients were separated into 3 groups based on ASCVD risk scores: <10%, ≥10% and <20% and ≥20%. Baseline demographics and 24-hour systolic BP changes at 6 months and 1, 2 and 3 years were compared between groups, as well as rates of adverse events at 3 years.

Results

Individual ASCVD risk scores were calculated for 1,434 patients in GSR. The median ASCVD risk score was 19.4% and 403 patients had a risk score of <10%, 326 a risk score of ≥10 and <20%, and 705 a risk score ≥20%. Patients with ASCVD risk score ≥20% had a higher baseline office systolic BP, were significantly older, and had higher rates of prior myocardial infarction and/or diabetes (all p<0.0001 compared to patients with lower risk scores). RDN reduced BP similarly across all groups of patients. Changes in 24-hour systolic BP at 6 months and 1, 2 and 3 years are shown in Figure 1. Adverse events at 3 years are shown in Table 1.

Adverse events at 3 years ASCVD risk score <10% ASCVD risk score ≥10% & <20% ASCVD risk score ≥20% p-value (N=265) (N=224) (N=468) Death 3 (1.1) 5 (2.2) 41 (8.8) <0.0001 Cardiovascular death 3 (1.1) 2 (0.9) 23 (4.9) 0.0017 Myocardial infarction 6 (2.3) 6 (2.7) 11 (2.4) 0.9513 Stroke 8 (3.0) 9 (4.0) 24 (5.1) 0.3894 Hospitalization for new onset heart failure 4 (1.5) 7 (3.1) 26 (5.6) 0.0194 Values are proportions reported as n (%).

Conclusions

BP changes after RDN were similar for patients with varying baseline ASCVD risk scores, suggesting uniform BP-lowering efficacy of RDN regardless of patients' baseline CV risk. The impact of baseline risk on clinical event reduction by RDN-induced BP reduction will need to be evaluated in further studies.

Acknowledgement/Funding

The Global SYMPLICITY Registry is funded by Medtronic.

Point-of-care Hepatitis C virus testing and linkage to treatment in an Australian inner-city emergency department

BACKGROUND

In Australia, Hepatitis C Virus (HCV) treatment is declining, despite broad access to direct-acting antiviral medication. People who inject drugs are proportionally over-represented in emergency department presentations. Emergency department assessment of people who have injected drugs for HCV presents an opportunity to engage this marginalised population with treatment. We describe the outcomes of risk-based screening and point-of-care anti-HCV testing for emergency department patients, and linkage to outpatient antiviral treatment.

METHODS

During the three-month study period, consecutive adult patients who presented to the emergency department during the study times were screened for risk factors and offered the OraQuick oral HCV antibody test. Those with reactive results were offered venepuncture in the emergency department for confirmatory testing and direct-acting antiviral treatment in clinic. The main outcome measures were the number and proportion of viremic participants that were linked to the hepatitis clinic, commenced treatment and achieved a sustained viral response. Secondary outcome measures were the proportion (%) of presentations screened that were oral antibody reactive, and the prevalence and type of HCV risk factors.

RESULTS

During the study period, 2408 of the 3931 (61%) presentations to the emergency department were eligible for screening. Of these 2408 patients, 1122 (47%) participated, 307 (13%) declined participation and 977 (41%) could not be approached during their time in the emergency department. Among the 1122 participants, 378 (34%) reported at least one risk factor. Subsequently, 368 (97%) of the 378 participants underwent OraQuick anti-HCV test, and 50 (14%) had a reactive result. A risk factor of ever having injected drugs was present in 44 (88%) of participants who were sero-positive. Of the 45 that had blood tested, 30 (67%) were HCV ribonucleic acid (RNA) positive. Three participants died. Of the 27 remaining participants, 10 (37%) commenced treatment and 7 of these 10 (70%) obtained a cure. There was a high rate of homelessness (24%) among anti-HCV positive participants.

CONCLUSION

Among emergency department participants with a risk factor for HCV, positive serology was common using a rapid point-of-care test. A history of injecting drug use was identified as the risk factor with highest yield for positive HCV serology, and is suitable as a single screening question. However, linkage to care post ED presentation was low in this marginalised population. There is a need for new pathways to improve the care cascade for marginalised individuals living with HCV infection.

Childhood adversity, mental health and suicide (CHASE): a methods protocol for a longitudinal case-control linked data study

Introduction

Suicide is a tragic outcome with devastating consequences. In 2018, Scotland experienced a 15% increase in suicide from 680 to 784 deaths. This was marked among young people, with an increase of 53% in those aged 15-24, the highest since 2007. Early intervention in those most at risk is key, but identification of individuals at risk is complex, and efforts remain largely targeted towards universal suicide prevention strategies with little evidence of effectiveness.

Recent evidence suggests childhood adversity is a predictor of subsequent poor social and health outcomes, including suicide. This protocol reports on methodology for harmonising lifespan hospital contacts for childhood adversity, mental health, and suicidal behaviour. This will inform where to 1) focus interventions, 2) prioritise trauma-informed approaches, and 3) adapt support avenues earlier in life for those most at risk.

Methods

This study will follow a case-control design. Scottish hospital data (physical health SMR01; mental health SMR04; maternity/birth record SMR02; mother’s linked data SMR01, SMR04, death records) from 1981 to as recent as available will be extracted for people who died by suicide aged 10-34, and linked on Community Health Index unique identifier. A randomly selected control population matched on age and geography at death will be extracted in a 1:10 ratio. International Classification of Disease (ICD) codes will be harmonised between ICD9-CM, ICD9, ICD10-CM and ICD10 for childhood adversity, mental health, and suicidal behaviour.

Results

ICD codes for childhood adversity from four key studies are reported in two categories, 1) Maltreatment or violence-related codes, and 2) Codes suggestive of maltreatment. ‘Clinical Classifications Software’ ICD codes to operationalise mental health codes are also reported. Harmonised lifespan ICD categories were achieved semi-automatically, but required labour-intensive supplementary manual coding. Cross-mapped codes are reported.

Conclusion

There is a dearth of evidence about touchpoints prior to suicide. This study reports methods and harmonised ICD codes along the lifespan to understand hospital contact patterns for childhood adversity, which come to the attention of hospital practitioners.

Key words

Childhood Adversity, Adverse Childhood Experiences, Mental Health, Self-harm, Suicide, Suicidality, Violence, Hospital episodes, Routine Data, Data Linkage, Study Protocol

Elevated fibrinogen, von Willebrand factor, and Factor VIII confer resistance to dilutional coagulopathy and activated protein C in normal pregnant women

BACKGROUND

Gestational changes in coagulation factor concentrations include elevations in fibrinogen, Factor VIII, and von Willebrand factor (vWF). We hypothesised that blood samples from term pregnant (TP) subjects are less prone to coagulation disturbances from haemodilution compared with those from non-pregnant (NP) females.

METHODS

Blood samples were collected from 15 NP and 15 TP subjects. In vitro haemodilution with normal saline was assessed by modified Clauss fibrinogen assay, factor activity, flow-chamber assay, and thromboelastometry. The impact of human fibrinogen concentrate (hFC), cryoprecipitate, and vWF/Factor VIII (FVIII) concentrate replacement in diluted TP and NP blood was compared. Thrombin generation and activated protein C sensitivity were assessed.

RESULTS

TP blood contained twice the concentrations of fibrinogen, FVIII, and vWF relative to NP blood (P<0.0001). Platelet thrombus formation (PTF) under flow was reduced by 99.2% and 69.2% in diluted NP and TP blood, respectively. Platelet thrombus formation was partially restored by adding vWF/FVIII, but not hFC or cryoprecipitate. Fibrin clot firmness approached the threshold of 10 mm in diluted NP blood, and clot firmness was effectively restored by hFC, but not by vWF/FVIII. In the presence of thrombomodulin, peak thrombin generation was decreased by 86.7% in NP plasma, but by 31.8% in TP plasma (P<0.0001 vs NP plasma), indicating reduced activated protein C sensitivity in TP plasma. Both elevated FVIII and haemodilution contributed to activated protein C insensitivity.

CONCLUSIONS

Our in vitro model showed relative resistance of TP blood to dilutional coagulation changes with respect to platelet adhesion, fibrin polymerisation, and thrombin generation. Careful therapeutic monitoring for different pro-haemostatic agents in pregnant women is warranted.

Cord injury after spinal anaesthesia in a patient with previously undiagnosed Klippel-Feil syndrome

This report presents an obstetric patient with no significant past medical history who underwent spinal anaesthesia for a category-three caesarean section. On examination, she had asymmetrical scapular alignment and a mild scoliosis of the lumbar spine with no functional limitation. Postoperatively the patient developed neuropathic pain symptoms in the right leg which failed to resolve with conventional analgesia. Cervical and lumbar spine magnetic resonance imaging was performed resulting in a diagnosis of a low-lying tethered spinal cord terminating at the level of L5 and congenital fusion of the C7/T1 vertebrae. A tethered spinal cord is a rare condition, which in this case had been completely asymptomatic. However, we suggest that the patient displayed musculoskeletal signs not previously widely reported, which could have indicated the presence of a potential underlying neural tube defect. Based on the imaging findings and the presence of Sprengel's deformity, the patient was diagnosed with Klippel-Feil syndrome.

Estimating Aspergillus fumigatus exposure from outdoor composting activities in England between 2005 and 14

Bioaerosols, ubiquitous in ambient air, are released in elevated concentrations from composting facilities with open-air processing areas. However, spatial and temporal variability of bioaerosols, particularly in relation to meteorology, is not well understood. Here we model relative concentrations of Aspergillus fumigatus at each postcode-weighted centroid within 4 km of 217 composting facilities in England between 2005 and 2014. Facilities were geocoded with the aid of satellite imagery. Data from existing bioaerosol modelling literature were used to build emission profiles in ADMS. Variation in input parameters between each modelled facility was reduced to a minimum. Meteorological data for each composting facility was derived from the nearest SCAIL-Agriculture validated meteorological station. According to our results, modelled exposure risk was driven primarily by wind speed, direction and time-varying emissions factors incorporating seasonal fluctuations in compostable waste. Modelled A.fumigatus concentrations decreased rapidly from the facility boundary and plateaued beyond 1.5-2.0 km. Where multiple composting facilities were within 4 km of each other, complex exposure risk patterns were evident. More long-term bioaerosol monitoring near facilities is needed to help improve exposure estimation and therefore assessment of any health risks to local populations.

Hepatic steatosis is highly prevalent across the paediatric age spectrum, including in pre-school age children

BACKGROUND

The prevalence of non-alcoholic fatty liver disease (NAFLD) in children is 8% in the general population, and 34% in the context of obesity. There is a paucity of data on the prevalence of hepatic steatosis in healthy children in Ontario.

AIMS

To determine the prevalence of hepatic steatosis using abdominal computed tomography (CT) scans in a cohort of previously healthy children across the paediatric age spectrum in Ontario, Canada, and to determine any association between measures of abdominal adiposity and hepatic steatosis.

METHODS

Retrospective review of the SickKids Trauma Database from 2004-2015. Previously healthy children ages 1-17 years having undergone an abdominal CT scan as a part of routine trauma assessment were included, and those with an intra-abdominal injury excluded. Steatosis was defined as a difference between liver and spleen attenuation ≤-25HU. The percentage of the total area occupied by abdominal subcutaneous adipose and visceral adipose tissue was measured. Anthropometrics and baseline demographics were collected.

RESULTS

A total of 503 (51% male) children with mean (±SD) age 9.5 ± 4.5 years and weight z-score of 0.37 ± 1.05 were studied. Seventy-seven (15%, 95% CI [12%-18%]) had hepatic steatosis; no differences found between sexes or across age quartiles. The abdominal subcutaneous adipose tissue area was greater in those with hepatic steatosis compared to those without (32% [22-42] vs 24% [17-36], P = 0.003). The visceral adipose tissue area was significantly greater in older children ≥9.8 years with hepatic steatosis (7.7% [5.1-10] vs 6.6% (4.9-8.5), P = 0.04).

CONCLUSION

Hepatic steatosis was highly prevalent in previously healthy children in Ontario, including children of pre-school age. We found an association between hepatic steatosis and abdominal subcutaneous adipose tissue, and in older children with visceral adipose tissue.

Who's challenging who training for staff empathy towards adults with challenging behaviour: cluster randomised controlled trial

BACKGROUND

One in five adults with intellectual disabilities (ID) known to services display challenging behaviours (CBs), and these individuals are at risk for restrictive practices and poor care. Staff attitudes may contribute to the development and/or maintenance of CBs. We investigated the effectiveness of co-produced Who's Challenging Who? training delivered by people with ID to staff.

METHOD

This study involved a cluster randomised controlled trial (RCT) of Who's Challenging Who? training with follow-up at six and 20 weeks post-randomisation.

PARTICIPANTS

two staff from each of 118 residential care settings for adults with ID at least one of whom displayed aggressive CB.

PRIMARY OUTCOME

Self-reported Staff Empathy for people with Challenging Behaviour Questionnaire.

ANALYSIS

intention to treat of all randomised settings. ISCRTN registration: ISRCTN53763600.

RESULTS

118 residential settings (including 236 staff) were randomised to either receive training (59 settings) or to receive training after a delay (59 settings). The primary analysis included data from 121 staff in 76 settings (51% of staff, 64% of settings). The adjusted mean difference on the transformed (cubed) Staff Empathy for people with Challenging Behaviour Questionnaire score at the primary end point was 1073.2 (95% CI: -938.1 to 3084.5, P = 0.296) in favour of the intervention group (effect size Cohen's d = .19).

CONCLUSIONS

This is the first large-scale RCT of a co-produced training course delivered by people with ID. Findings indicated a small positive (but statistically non-significant) effect on increased staff empathy at 20 weeks, and small to moderate effects for staff reported secondary outcomes in favour of the intervention group.