P648Screening and treatment of familial hypercholesterolemia in a French sample of ambulatory care: a retrospective longitudinal cohort study

Background

Familial hypercholesterolemia (FH) is largely underdiagnosed as there are typically no clinical symptoms prior to the first cardiovascular (CV) event. We conducted a study which utilised ambulatory care electronic medical record (EMRs) to alert physicians to possible cases of FH. Specifically, physicians were alerted to LDL-C levels >190 mg/dL (suggesting a risk of FH) and invited to complete the Dutch Lipid Clinic Network score (DLCN).

Purpose

Describe characteristics, comorbidities and clinical management of patients diagnosed with definite or probable FH in an ambulatory care setting.

Methods

All patients with a DLCN score of definite/probable FH (score higher or equal than 6; index event) between January 2016 and September 2018 were identified in the THIN® database (The Health Improvement Network; an anonymized EMR powered by GERSDATA, a Cegedim Health Data Division). These fully anonymized data were collected by 2000 General Practitioners (GP), 130 cardiologists and 40 endocrinologists, receiving 5.5 million patients regularly in their office. Sociodemographic, laboratory measurements, comorbidities, lipid-lowering therapies (LLT), visits to specialists, LDL-C and hospitalizations were collected and analysed at baseline, and 1, 2, 3, 6 months, and 1 year thereafter.

Results

From 999 anonymous patients with a DLCN score, 98 (10%) FH patients were identified (38 [39%] definite FH, 60 [61%] probable FH) while remaining fully anonymous, 9 (9%) of whom already had genetic testing. Mean (SD) age was 57.4 (14.3) years; 56 (57%) patients were female, half (51/98 [52%]) were diagnosed with pure hypercholesterolemia (ICD-10 code: E78.0) and 9 (9%) had a personal history of CV event. 93 patients (95%) had a LDL-C measurement prior to DLCN assessment (definite FH, 36/38 [95%]; probable FH, 57/60 [95%]). Among screened FH patients, 61.2% had LDL-C between 190 to 250 mg/dL and 16.3% had LDL-C higher than 250 mg/dL. At the time of DLCN assessment, one third (30/98 [31%]) of patients were not receiving any LLT, one third ([35%] 34/98) were receiving statins alone, 19% (19/98) receiving LLT combination with statin, and 15% (15) other LLTs. Moderate statin intensity was prescribed in 20% (20/98) of patients; high intensity statin, 17%, (17/98); low intensity, 10% (10/98). No improvement on LLT use (including use of high statin intensity) was observed over the 12-month follow-up.

Conclusion

This is the first study in France that use EMR to screen possible FH patients and support GPs in identifying patients that need to be treated. Our data highlight the need to screen, diagnosis and treat potential FH patients in ambulatory care settings. Longer follow-up is needed to evaluate the impact of FH assessment on referral to specialists, LLT and clinical outcomes.

Acknowledgement/Funding

Amgen

The impact of maternal obesity on intrapartum outcomes in otherwise low risk women: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVES

To evaluate the impact of maternal BMI on intrapartum interventions and adverse outcomes that may influence choice of planned birth setting in healthy women without additional risk factors.

DESIGN

Prospective cohort study.

SETTING

Stratified random sample of English obstetric units.

SAMPLE

17,230 women without medical or obstetric risk factors other than obesity.

METHODS

Multivariable log Poisson regression was used to evaluate the effect of BMI on risk of intrapartum interventions and adverse maternal and perinatal outcomes adjusted for maternal characteristics.

MAIN OUTCOME MEASURES

Maternal intervention or adverse outcomes requiring obstetric care (composite of: augmentation, instrumental delivery, intrapartum caesarean section, general anaesthesia, blood transfusion, 3rd/4th degree perineal tear); neonatal unit admission or perinatal death.

RESULTS

In otherwise healthy women, obesity was associated with an increased risk of augmentation, intrapartum caesarean section and some adverse maternal outcomes but when interventions and outcomes requiring obstetric care were considered together, the magnitude of the increased risk was modest (adjusted RR 1.12, 95% CI 1.02-1.23, for BMI > 35 kg/m(2) relative to low risk women of normal weight). Nulliparous low risk women of normal weight had higher absolute risks and were more likely to require obstetric intervention or care than otherwise healthy multiparous women with BMI > 35 kg/m(2) (maternal composite outcome: 53% versus 21%). The perinatal composite outcome exhibited a similar pattern.

CONCLUSIONS

Otherwise healthy multiparous obese women may have lower intrapartum risks than previously appreciated. BMI should be considered in conjunction with parity when assessing the potential risks associated with birth in non-obstetric unit settings.

The implementation and maintenance of the Ketogenic Diet in children

The Ketogenic Diet is an effective treatment for epilepsy in children. At Johns Hopkins Hospital more than 400 children have been placed on the Ketogenic Diet. The implementation and maintenance of this treatment require significant collaboration between the family and Epilepsy Team. During initiation of the diet, in the hospital, parents attend classes on the history and mechanism of the diet, preparation of meals, psychological issues, complications and the management of childhood illnesses on the ketogenic diet. Many factors are considered in calculating a ketogenic formula. Age, weight, height and activity level are the obvious factors. However, secondary medical diagnoses, medications, neurological deficits, feeding issues and psychological issues are additional factors that affect the formulation of an optimal ketogenic prescription. Once this prescription has been formulated and implemented, many patients require fine-tuning of their ketogenic diets to get the best antiepileptic results while promoting growth. We believe that our success in sustaining this treatment is related to our fine-tuning and management practices.