Expectations and outcomes of varying treatment strategies for CML presenting during pregnancy

Diagnosing chronic myeloid leukaemia (CML) during pregnancy is rare. Tyrosine kinase inhibitors (TKIs) have traditionally been contraindicated owing to their teratogenicity. Management decisions should consider the risks to mother and foetus of uncontrolled disease and teratogenic medications. Further cases are required to build upon the paucity of current literature. We report 22 cases of CML diagnosed during pregnancy from 2002 to date. Twenty-one pregnancies resulted in healthy babies and one patient miscarried. Some patients remained untreated throughout pregnancy but the majority received one or both of interferon-α and leucapheresis. One patient was started on imatinib at Week 26, and one on hydroxycarbamide in the third trimester. We report haematological parameters during pregnancy to provide clinicians with realistic expectations of management. There were no fetal abnormalities related to treatment during pregnancy. Seventeen patients achieved at least major molecular response on first-line TKI. A diagnosis of CML during pregnancy can be managed without significant consequences for mother or child. Leucapheresis and interferon-α are generally safe throughout pregnancy. Despite having been avoided previously, there is growing evidence that certain TKIs may be used in particular circumstances during the later stages of pregnancy. Future work should aim to further elucidate this safety profile.

The effect of bariatric surgery type on cardiac reverse remodelling

INTRODUCTION

Bariatric surgery is effective in reversing adverse cardiac remodelling in obesity. However, it is unclear whether the three commonly performed operations; Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Sleeve Gastrectomy (LSG) and Laparoscopic Adjustable Gastric Band (LAGB) are equal in their ability to reverse remodelling.

METHODS

Fifty-eight patients underwent CMR to assess left ventricular mass (LVM), LV mass:volume ratio (LVMVR) and LV eccentricity index (LVei) before and after bariatric surgery (26 RYGB, 22 LSG and 10 LAGB), including 46 with short-term (median 251-273 days) and 43 with longer-term (median 983-1027 days) follow-up. Abdominal visceral adipose tissue (VAT) and epicardial adipose tissue (EAT) were also assessed.

RESULTS

All three procedures resulted in significant decreases in excess body weight (48-70%). Percentage change in VAT and EAT was significantly greater following RYGB and LSG compared to LAGB at both timepoints (VAT:RYGB -47% and -57%, LSG -47% and -54%, LAGB -31% and -25%; EAT:RYGB -13% and -14%, LSG -16% and -19%, LAGB -5% and -5%). Patients undergoing LAGB, whilst having reduced LVM (-1% and -4%), had a smaller decrease at both short (RYGB: -8%, p < 0.005; LSG: -11%, p < 0.0001) and long (RYGB: -12%, p = 0.009; LSG: -13%, p < 0.0001) term timepoints. There was a significant decrease in LVMVR at the long-term timepoint following both RYGB (-7%, p = 0.006) and LSG (-7%, p = 0.021), but not LAGB (-2%, p = 0.912). LVei appeared to decrease at the long-term timepoint in those undergoing RYGB (-3%, p = 0.063) and LSG (-4%, p = 0.015), but not in those undergoing LAGB (1%, p = 0.857). In all patients, the change in LVM correlated with change in VAT (r = 0.338, p = 0.0134), while the change in LVei correlated with change in EAT (r = 0.437, p = 0.001).

CONCLUSIONS

RYGB and LSG appear to result in greater decreases in visceral adiposity, and greater reverse LV remodelling with larger reductions in LVM, concentric remodelling and pericardial restraint than LAGB.

Information acquisition and dissemination among a sample of people who inject drugs in Australia

INTRODUCTION

This paper examines the acquisition and dissemination of harm reduction information among people who inject drugs, as well as preferred sources of information.

METHODS

Data were obtained from 862 people who inject drugs, recruited from Australian capital cities for the 2021 Illicit Drug Reporting System. Multivariable regression analyses were performed to assess potential factors associated with knowledge sharing.

RESULTS

Almost two-fifths (37%) reported that they had received information about how to keep themselves safe when using drugs within the past 6 months. Reporting on their last occasion of receiving information, participants stated that it was commonly about injecting practices (56%), overdose prevention (26%) and injection-related injuries (22%), and was mostly received from an alcohol and other drug worker (54%), followed by other health professional (24%) and social network (18%). Among those who reported receiving information, 50% shared this information with other people, predominantly with their social network: no factors were found to be significantly associated with sharing information. The majority reported that peer workers and/or people with lived experience would be the first person they would talk to for information about a range of topics (e.g., injecting/harm reduction practices, overdose prevention).

DISCUSSION AND CONCLUSIONS

Two in five participants had recently obtained information about how to keep themselves safe while using drugs, with half sharing this information with their social network. Peer workers were the preferred source of information, suggesting that the peer educator workforce should be expanded to embrace the capacities and expertise of people who inject drugs.

The effect of surgical complications on long-term prognosis following oesophagectomy

INTRODUCTION

Complications are frequent after oesophagectomy, and there is evidence these adversely impact long-term prognosis. However, the effect of multiple complications, and the absolute magnitude of effect on survival is unclear. This study aimed to examine these effects in a single high-volume UK unit.

METHODS

Patients undergoing oesophagectomy for cancer and who survived to 90 days post-oesophagectomy were analysed. Complications were graded according to the Clavien-Dindo (CD) classification and the Comprehensive Complication Index (CCI). The effect and magnitude of effect of complications on survival were assessed using multivariable cox regression and the risk-adjusted population attributable fraction.

RESULTS

In total, 380 patients were included. Complications occurred in 251 (66.1%). Suffering ≥3 complications (HR 1.89, 95%CI 1.13-3.16, p = 0.015) or an unplanned escalation in care (HR 2.22, 95%CI 1.43-3.45, p < 0.001) significantly reduced survival whereas pulmonary complications and anastomotic leak did not. Patients with a CCI>30 had worse overall survival (HR 1.91, 95%CI 1.32-2.76, p < 0.001) and CCI>30 due to multiple minor complications gave a worse prognosis compared to CCI>30 due to major complications (HR 2.44, 95%CI 1.14-5.20, p = 0.022). An estimated 9.1% (95%CI 3.4-14.4%) of deaths at 5 years were attributable to a CCI>30.

CONCLUSION

Long-term survival following oesophagectomy for cancer is significantly affected by complications and the cumulative effect of multiple complications. Interestingly, multiple minor complications had a worse effect on survival than major complications. The absolute magnitude of effect is substantial: minimising all types of postoperative complications could have significant benefit to overall outcomes.

Changes in epicardial and visceral adipose tissue depots following bariatric surgery and their effect on cardiac geometry

Introduction

Obesity affects cardiac geometry, causing both eccentric (due to increased cardiac output) and concentric (due to insulin resistance) remodelling. Following bariatric surgery, reversal of both processes should occur. Furthermore, epicardial adipose tissue loss following bariatric surgery may reduce pericardial restraint, allowing further chamber expansion. We investigated these changes in a serial imaging study of adipose depots and cardiac geometry following bariatric surgery.

Methods

62 patients underwent cardiac magnetic resonance (CMR) before and after bariatric surgery, including 36 with short-term (median 212 days), 37 medium-term (median 428 days) and 32 long-term (median 1030 days) follow-up. CMR was used to assess cardiac geometry (left atrial volume (LAV) and left ventricular end-diastolic volume (LVEDV)), LV mass (LVM) and LV eccentricity index (LVei - a marker of pericardial restraint). Abdominal visceral (VAT) and epicardial (EAT) adipose tissue were also measured.

Results

Patients on average had lost 21kg (38.9% excess weight loss, EWL) at 212 days and 36kg (64.7% EWL) at 1030 days following bariatric surgery. Most VAT and EAT loss (43% and 14%, p<0.0001) occurred within the first 212 days, with non-significant reductions thereafter. In the short-term LVM (7.4%), LVEDV (8.6%) and LAV (13%) all decreased (all p<0.0001), with change in cardiac output correlated with LVEDV (r=0.35,p=0.03) and LAV change (r=0.37,p=0.03). Whereas LVM continued to decrease with time (12% decrease relative to baseline at 1030 days, p<0.0001), both LAV and LVEDV had returned to baseline by 1030 days. LV mass:volume ratio (a marker of concentric hypertrophy) reached its nadir at the longest timepoint (p<0.001). At baseline, LVei correlated with baseline EAT (r=0.37,p=0.0040), and decreased significantly from 1.09 at baseline to a low of 1.04 at 428 days (p<0.0001). Furthermore, change in EAT following bariatric surgery correlated with change in LVei (r=0.43,p=0.0007).

Conclusions

Cardiac volumes show a biphasic response to weight loss, initially becoming smaller and then returning to pre-operative sizes by 1030 days. We propose this is due to an initial reversal of eccentric remodelling followed by reversal of concentric remodelling. Furthermore, we provide evidence for a role of EAT contributing to pericardial restraint, with EAT loss improving markers of pericardial restraint.

Lessons learned from automated screening of COVID-19 preprints

Preprints occupied the spotlight early in the pandemic, as scientists, the media and the public sought information on the evolving pandemic. While some in the scientific community embraced this shift, others were concerned about the quality of these papers, which had not yet undergone peer review. Furthermore, the flood of COVID-19 preprints quickly overwhelmed the scientific community's ability to monitor and assess new preprints. Automated screening tools that detect beneficial practices, or common problems, in preprints are one potential solution to this problem. These tools could potentially provide individualized feedback, allowing authors to improve their manuscripts prior to publication in a peer-reviewed journal. We have combined many tools into a single pipeline, called ScreenIT. ScreenIT assess factors such as open data and open code, blinding, randomization, power calculations, limitations sections, and data visualization problems. Since June 2020, we have used ScreenIT to screen and post daily reports on more than 23,000 new COVID-19 preprints deposited on bioRxiv and medRxiv. Results show that practices such as sharing data and code are relatively uncommon. Sample size calculations, blinding and randomization are rarely reported and most papers do not report the sex of participants, animals or samples. This work demonstrates the feasibility of using automated tools to rapidly screen many preprints in real time, and provide authors and readers with rapid feedback. However, this approach has important limitations. Automated screening tools can make mistakes. Tools can't always determine whether an item is relevant to a particular manuscript. Further studies are needed to determine whether feedback from automated tools is effective in encouraging authors to improve reporting.

Changes in adipose tissue depots and cardiac geometry following bariatric surgery

Introduction

Cardiac geometry is affected by body composition, with total body adipose volume being related to left ventricular (LV) dilatation (due to increased intravascular volume and cardiac output), and visceral adipose tissue (VAT) to smaller LV cavity size and concentric remodelling (because of insulin resistance) [1]. As such we hypothesised that changes in VAT and total body weight during weight loss would have a differential impact on cardiac geometry. Alongside this, we hypothesised that, as the pericardium is a fixed volume, changes in epicardial adipose tissue (EAT), may have an additional mechanical effect by reducing pericardial restraint.

Purpose

We sought to investigate long term changes in VAT, total weight and EAT following bariatric surgery and relate them to changes in cardiac geometry.

Methods

Forty patients underwent cardiac magnetic resonance (CMR) imaging before and after bariatric surgery, including 21 who underwent short-term (median 209 days), 28 medium-term (median 428 days) and 12 long-term (median 1030 days) imaging follow up. Cardiac volumes (left atrial (LA), LV end-diastolic volume (LVEDV) and stroke volume (LVSV)) were assessed using cardiac MRI. VAT was assessed at L5 using a T1 weighted, water suppressed sequence. EAT volumes were calculated by manual contouring in end-ventricular systole on short axis slices from the mitral valve to the apex. Percentage changes in volumes were calculated between scans for each individual.

Results

Patients on average lost 32kg within the first 428 days following bariatric surgery (54% excess weight loss, p&lt;0.0001), with no significant change in weight at the longer-term time point (Figure 1A). Most VAT loss occurred in the first 209 days (−42%, p&lt;0.0001) with no subsequent change observed at the final two timepoints (Figure 1B). Similarly, EAT loss occurred in the first 209 days (−13%, mean 10ml, p&lt;0.0001) with non-significant changes thereafter (Figure 1C).

There was a significant decrease in both LA (13%, mean 12ml, p&lt;0.0001) and LVEDV (4%, mean 8ml, p=0.0249) at 209 days post-surgery. Both LA volume and LVEDV had returned to baseline by the longest term time point of 1030 days (Figure 2). LVSV followed a similar pattern being reduced at 209 days (by 10%, mean 9ml, p=0.0019), then returning to levels similar to those pre-weight loss at 1030 days (p=0.44) (Figure 2C).

Conclusions

Cardiac volumes show a biphasic response to weight loss, initially becoming smaller and then returning to baseline by 1030 days. We hypothesise that the early drop in LA and LV cavity size is a response to reduced volume from body mass reduction. In contrast, we propose that the increase in LA and LVEDV that follows results from the longer-term effects of reducing VAT, and increased space within the pericardium resulting from EAT loss allowing expansion to occur.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): We acknowledge support from the British Heart Foundation Oxford Center of Research Excellence

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Examining the cost and impact of dosing fees among clients in opioid agonist treatment: Results from a cross-sectional survey of Australian treatment clients

Introduction

Opioid agonist treatment (OAT) clients frequently bear costs associated with their treatment, including dosing fees. This study aimed to explore the financial and social impact of dosing fees upon clients.

Methods

Cross‐sectional survey of people who use opioids regularly (N = 402) between December 2017 and March 2018, conducted in Australia. Dosing fees were calculated and expressed as percentage of income, by OAT type. Consequences and strategies for difficulties making payments were examined as proportions.

Results

A total of N = 360 participants had ever been in OAT and N = 245 participants currently engaged in OAT reported data on dosing fees, of them 53% (n = 129) reported paying dosing fees. Compared to clients with high levels of dosing supervision, those with moderate or low levels of supervision were more likely to pay dosing fees. The median 28‐day dosing fee was AUD$110 (interquartile range AUD$80); median 28‐day income was AUD$1520 (interquartile range AUD$700). For those who paid dosing fees, the fee comprised <10% of total monthly income for 70% of participants; however, 23% of participants paid fees comprising 10% to <20%, and 7% of participants paid fees comprising 20% or more of monthly income. Among those that had ever been in OAT, 72% experienced difficulties in paying treatment costs; 36% left treatment earlier than intended and 25% had been excluded due to payment difficulties.

Discussion and Conclusions

Negative consequences of treatment costs to clients, particularly dosing fees, are evident. These costs impact treatment access and retention that may negatively impact clients' physical health, mental health and social wellbeing.

Complete Revascularisation is associated with Improved Survival after Out of Hospital Cardiac Arrest

Introduction

Coronary artery disease (CAD) is common in patients with Out of Hospital Cardiac Arrest (OOHCA) but the clinical relevance of burden of CAD and evidence for revascularisation strategies in relation to outcomes and modes of death remains unclear.

Purpose

This study sought to assess the extent of CAD as defined by the SYNTAX score and prognostic value of complete compared with incomplete revascularisation by evaluating the SYNTAX revascularisation index (SRI) in patients with OOHCA.

Methods

619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. 237 were excluded for having a non-cardiac aetiology or prior neurological disability. 398 patients were included into the study and of these 272 (68.3%) had early coronary angiography (CAG) and were included in the final analysis.

The baseline SYNTAX score (bSS) and residual SYNTAX score (rSS) were determined from the coronary angiograms by a cardiologist blinded to the outcome. Patients were subdivided into 4 subgroups according to quartiles of the baseline syntax score (bSS) of 0, Group A: 1–10, Group B: 11–20 and Group C: ≥21. Complete revascularisation (CR) was defined as SRI of 1 and incomplete (IR) as SRI &lt;1 where the SRI=(1-[rSS/bSS]) ×100 (Figure 1).

Results

Patients with a bSS of 0 were younger, had less shockable initial arrest rhythms and worse lactate and pH on arrival.Patients with bSS&gt;0 (i.e., those with coronary artery disease) had similar cardiac arrest circumstances in terms of rates of witnessed, bystander CPR and shockable rhythms. Admission metabolic status reflected by pH and lactate and rates of ST elevation/LBBB were also identical for all three groups. However, LVEF on admission decreased significantly as coronary complexity increased (P&lt;0.0001). While early angiography was more preferentially performed in those with higher coronary complexity, paradoxically, those with bSS 1–4 had highest rates of culprit lesions which was reflected in higher rates of PCI (Figure 1).

124 (45.4%) had CR compared with 54.2% with IR. CR was most likely to be achieved as the coronary complexity reduced (Group A – 71.7%, Group B – 41.1%, Group C - 23.3%). There was no difference in rates of cardiogenic shock between both groups (CR 61.1% vs. IR 69% p=ns), but patients with complete revascularisation were younger (58.8 vs 67.8, p&lt;0.0001), lower rates of hypertension and previous CABG (16.2% vs 3.2%, p≤0.0001)

CR was associated with decreased mortality at 30 days (45.9% vs 34.6%, p=0.046) and 12 months (49.3% vs 35.4%, p=0.022). The lower mortality rate in CR appeared to partly be driven by lower cardiac deaths though this was not statistically significant (22% vs 7%, p=0.1) (Figure 2).

Conclusions

CR in a primary coronary aetiology OOHCA group is associated with reduced early and long-term mortality, which may be driven by a reduction in cardiac deaths. Prospective randomised trials in this population are warranted.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Clinical significance of early echocardiography after out-of-hospital cardiac arrest on arrival to a heart attack centre

Background

Left ventricular systolic dysfunction (LVSD) is common after out of hospital cardiac arrest (OOHCA) and can manifest as global or regional change.

Purpose

We evaluated the extent of global and regional LVSD and its association with coronary artery disease (CAD) and outcome in those undergoing coronary angiography after OOHCA.

Methods

619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. 398 patients were included. Rates of cardiogenic shock and extent of CAD, as classified by the SYNTAX score were measured. The primary endpoint was 12-month mortality. Patients with incomplete data were excluded from the analysis.

Results

Two hundred and sixty-six patients (median age 62 [53–71] 76.3% male) underwent both trans-thoracic echocardiography andcoronary angiography on arrival and were included in the final analysis. 81.6% had ventricular fibrillation, 83.5% were witnessed and 51.9% occurred at residence.

Ninety-six patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF] &lt;40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs) on arrival. Patients were classified into 4 groups (Group A: LVEF &lt;40%/Global, Group B: LVEF &lt;40%/RWMA, Group C: LVEF ≥40%/Global and Group D: LVEF ≥40%/RWMA) with frequencies of 10.9%, 25.2%, 41.4% and 22.6%).

Patients in Group D had the shortest low-flow times and lowest rates of epinephrine administration, with most favourable metabolic status on arrival, based on lactate and creatinine values. In Groups B and D (RWMAs), patients were significantly more likely to have a post-ROSC ECG demonstrating ST elevation/LBBB and absence of epinephrine administration during resuscitation with shorter low flow times. Extent of CAD was similar between the four groups. From patients with LVEF ≥40%, patients in Group C had substantially lower SYNTAX scores than compared with Group D (0.5 vs 13.5, p&lt;0.001). However, both Group B and C (RWMA) groups had highest rates of culprit lesions compared with matched global groups which was reflected in higher PCI rates (Figure 1).

The primary endpoint of 12-month mortality was lowest in Group D and highest in the Group A group. A similar effect was observed for poor neurological outcome and 30-day mortality. Patients with regional LVSD had significantly improved survival at 12 months compared with those with global LVSD (70.5% vs 48.3%, p&lt;0.001) vs 51). Those in Group D had highest survival at 12 months, while this was similar for Groups B and C and lowest in Group A (Figure 2). Cardiac aetiology death was significantly higher in those with LVEF &lt;40% compared to those with LVEF ≥40% (70.5% vs 48.3%, p&lt;0.001).

Conclusions

Patients with significant LVEF &lt;40% have higher rates of cardiogenic shock and mortality which was driven by cardiac aetiology death, while presence of RWMAs are associated with a higher rate of culprit coronary lesions and improved outcome

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Role of inpatient coronary CT angiography on clinical decision making during COVID- 19 pandemic

Funding Acknowledgements

Type of funding sources: None.

Background

The COVID-19 pandemic has had a profound effect on healthcare delivery. Here we describe the effect of repurposing of a research Computed Tomography scanner on clinical care of cardiology patients in an urban academic medical centre which did not have routine access to CCTA prior to the pandemic. 

Patients requiring invasive coronary angiography require transfer to a regional cardiac centre (no ICA available on site).

Purpose

We investigated the effect of CCTA on i) diagnostic certainty ii) avoidance of clinician defined unnecessary invasive angiography in hospitalised patients.

Methods

This was a prospective, longitudinal cohort study involving hospitalized patients admitted to an urban academic medical centre (catchment population 650 000) between March 29 and September 21, 2020. Routinely collected (usual care) data were gathered by clinicians who were members of the usual care medical team and ethics approval or explicit patient consent was not required. High-sensitivity Troponin-I was measured on admission and 3- and 6– hours after if mandated (Abbott Architect TnI assay).

A 320-detector scanner (Aquilon ONE, Canon) was used. Intravenous metoprolol was used where required to control the heart rate (target 60 b.p.m.) and sublingual glyceryl trinitrate will be given to all patients immediately before the scan acquisition.

Results

Forty-three patients underwent inpatient CCTA, mean age: 61 ± 13 years (range 30-88y), 54% female. The presenting complaint was typical chest pain in 28 (65%), atypical chest pain in 10 (23%), and a variety of symptoms in 5 (12%) including palpitations, syncope, breathlessness.

Thirty-six (84%) of patients had a detectable TnI above the 99% centile. Median(IQR) peak TnI was 127 (33-635)ng/L.

CCTA was carried out on average 1 day post request. 

CCTA resulted in an improvement in clinician diagnostic certainty (Initial review: 21% yes, 79% probable, post-CCTA review: 84% yes, 16% probable) in providing a diagnosis.

21 (49%) of invasive coronary angiograms were avoided due to CCTA, whilst an inpatient invasive coronary angiogram (ICA) was performed in 4(9%) due to CCTA demonstrating significant disease, and in 2(%) the ICA was changed from out-patient to in-patient. Three ICA tests were requested as OP due to CCTA findings. CCTA did not overestimate disease severity in this cohort. 

We saved 21 inter hospital transfers for ICA during this time period. 

Using NHS England cost tariffs, a cost saving of &gt;£36,000 was made for using CCTA instead of ICA in these 21 patients who would have required ICA.

Conclusion

Inpatient CCTA resulted in greater clinician diagnostic confidence, avoidance of unnecessary invasive angiograms and a significant cost saving. This also reduced the duration of patient stay, reducing the potential exposure of patients to COVID-19.

TCERG1L allelic variation is associated with cisplatin-induced hearing loss in childhood cancer, a PanCareLIFE study

In children with cancer, the heterogeneity in ototoxicity occurrence after similar treatment suggests a role for genetic susceptibility. Using a genome-wide association study (GWAS) approach, we identified a genetic variant in TCERG1L (rs893507) to be associated with hearing loss in 390 non-cranial irradiated, cisplatin-treated children with cancer. These results were replicated in two independent, similarly treated cohorts (n = 192 and 188, respectively) (combined cohort: P = 5.3 × 10-10, OR 3.11, 95% CI 2.2-4.5). Modulating TCERG1L expression in cultured human cells revealed significantly altered cellular responses to cisplatin-induced cytokine secretion and toxicity. These results contribute to insights into the genetic and pathophysiological basis of cisplatin-induced ototoxicity.

Positive effects of community attachment on internalised stigma and wellbeing among people who inject drugs

BACKGROUND

Internalised stigma experienced by people who inject drugs (PWID) is known to have negative health consequences. Research has explored factors that may protect or buffer individuals from the negative consequences of internalised stigma. Community attachment, or perceived connection to a community of like people, can have numerous health-related benefits. However, this relationship may be complex for PWID; being part of a social network of PWID may provide opportunity for more frequent drug use and equipment sharing. This study investigated the relationships between community attachment, internalised stigma, and wellbeing among PWID, while also addressing potential health risks associated with PWID community attachment.

METHODS

PWID (n=603) were recruited through nine peer-based drug user organisations across Australia with assistance from the peak consumer organisation. Participants completed a survey measuring community attachment, internalised stigma, personal wellbeing, injecting frequency, and equipment sharing.

RESULTS

Greater attachment to a PWID community was associated with lower internalised stigma, but also with sharing of injecting equipment and increased frequency of injecting behaviour. The relationship between community attachment and personal wellbeing was mediated by internalised stigma, however this was only the case for PWID who reported no sharing of injecting equipment.

CONCLUSIONS

This research highlights the significance of community attachment for PWID while also noting the complexity of this relationship and the potential negative consequences. It is important to view networks of PWID communities as sources of positive social capital, where norms about health behaviours and harm reduction can be promoted and which can buffer community members from the harms associated with stigma.

Treatment-related fertility impairment in long-term female childhood, adolescent and young adult cancer survivors: investigating dose-effect relationships in a European case-control study (PanCareLIFE)

STUDY QUESTION

Which chemotherapeutic agents and body site-specific radiation fields are dose-dependently associated with an increased risk of fertility impairment in long-term female childhood, adolescent and young adulthood (CAYA) cancer survivors?

SUMMARY ANSWER

Busulfan, lower abdominal radiotherapy (RT) and total body irradiation (TBI) seem to be associated with fertility impairment at any dose, whereas gonadotoxicity of melphalan and procarbazine is suggested at medium/high (>140 mg/m2) or high dose (>5600 mg/m2) therapy, respectively.

WHAT IS KNOWN ALREADY

Several treatment-related fertility deficits, as assessed by both self-reported outcomes and hormonal markers are known to occur following treatment of CAYA cancer. However, knowledge regarding precise dose-related estimates of these treatment-related risks are scarce.

STUDY DESIGN, SIZE, DURATION

The current case-control study was nested within the PanCareLIFE cohort study. In total, 1332 CAYA survivors from 8 countries, 9 institutions and 11 cohorts, participated in and contributed data to the study.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All participants were female 5-year CAYA cancer survivors. In total, 450 cases (fertility impaired survivors) and 882 matched controls (not fertility impaired survivors) were included. Fertility impairment was defined using both questionnaire data (primary or secondary amenorrhea; use of artificial reproductive techniques; unfulfilled wish to conceive) and hormonal data (FSH and anti-Müllerian hormone (AMH)). Multivariable logistic regression models were used to investigate the effect of (i) alkylating agent exposure, and (ii) dose categories for individual chemotherapeutic agents and for RT-exposed body sites.

MAIN RESULTS AND THE ROLE OF CHANCE

A positive dose-effect relationship between cyclophosphamide equivalent dose (CED) score and fertility impairment was found, with survivors with a CED score > 7121 mg/m2 being at a significantly increased risk of fertility impairment (odds ratio (95% CI) = 2.6 (1.9-3.6) P < 0.001). Moreover, cumulative dose variables of the following treatments were significantly associated with fertility impairment: busulfan, carmustine, cyclophosphamide, melphalan, procarbazine, lower abdominal RT and TBI. Busulfan, lower abdominal RT and TBI seem to be associated with fertility impairment at any dose, whereas gonadotoxicity of melphalan and procarbazine is suggested at medium/high (>140 mg/m2) or high dose (>5600 mg/m2) therapy, respectively.

LIMITATIONS, REASONS FOR CAUTION

Our study may have been subject to selection bias since data from about half of the original base cohorts were available for the current study. This could impact the generalizability of our study results.

WIDER IMPLICATIONS OF THE FINDINGS

We identified survivors at high risk for fertility impairment and, consequently, for a reduced or even absent reproductive life span. Both girls and young women who are about to start anti-cancer treatment, as well as adult female survivors, should be counselled about future parenthood and referred to a reproductive specialist for fertility preservation, if desired.

STUDY FUNDING/COMPETING INTEREST(S)

This study has received funding from the European Union's Seventh Framework Programme for research, technological development and demonstration under grant agreement no. 602030. There are no competing interests.

TRIAL REGISTRATION NUMBER

n/a.

O42: THE ROLE OF TOURNIQUETS IN TRANSTIBIAL AMPUTATION FOR PERIPHERAL VASCULAR DISEASE: A SYSTEMATIC REVIEW & META-ANALYSIS

Introduction

The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease.

Method

This systematic review was conducted according to PRISMA guidelines. A systematic search of Medline, Embase and Cochrane Library was undertaken for articles which compared the use of a tourniquet versus no tourniquet in patients undergoing trans-tibial amputation for peripheral vascular disease. The main outcomes included intra-operative blood loss, post-operative transfusion requirement, need for revision surgery and 30-day mortality.

Result

Four studies met the inclusion criteria for quantitative analysis with a total of 267 patients. A tourniquet was used in 130 patients. Both groups were matched for age, gender, co-morbidities and pre-operative haemoglobin. In patients undergoing trans-tibial amputation, tourniquets were associated with significantly lower intra-operative blood loss (Mean difference= -147.6mls; P=0.03) and lower transfusion requirements (pooled odds ratio (OR), 0.12, p=0.03). The need for stump revision (OR, 0.7; p=0.48), proceeding to transfemoral amputation within 30 days (OR, 0.67; p=0.25) and 30-day mortality (OR, 0.65; p=0.41) all favoured tourniquet use but the differences were not found to be significant.

Conclusion

Tourniquets can reduce intra-operative blood loss and transfusion requirements in patients undergoing trans-tibial amputation without increasing ischaemic complications and need for revision surgery.

Take-home message

Tourniquets are safe to use in trans-tibial amputation for severe peripheral vascular disease and can reduce intra-operative blood loss without increasing ischaemic complications.

Developing and testing a principle-based fidelity index for peer support in mental health services

PURPOSE

Evidence suggests that the distinctive relational qualities of peer support-compared to clinical-patient relationships-can be eroded in regulated healthcare environments. Measurement of fidelity in trials of peer support is lacking. This paper reports the development and testing of a fidelity index for one-to-one peer support in mental health services, designed to assess fidelity to principles that characterise the distinctiveness of peer support.

METHODS

A draft index was developed using expert panels of service user researchers and people doing peer support, informed by an evidence-based, peer support principles framework. Two rounds of testing took place in 24 mental health services providing peer support in a range of settings. Fidelity was assessed through interviews with peer workers, their supervisors and people receiving peer support. Responses were tested for spread and internal consistency, independently double rated for inter-rater reliability, with feedback from interviewees and service user researchers used to refine the index.

RESULTS

A fidelity index for one-to-one peer support in mental health services was produced with good psychometric properties. Fidelity is assessed in four principle-based domains; building trusting relationships based on shared lived experience; reciprocity and mutuality; leadership, choice and control; building strengths and making connections to community.

CONCLUSIONS

The index offers potential to improve the evidence base for peer support in mental health services, enabling future trials to assess fidelity of interventions to peer support principles, and service providers a means of ensuring that peer support retains its distinctive qualities as it is introduced into mental health services.

Transitioning a randomized controlled trial to a digital registry – experience from the TAILOR-PCI digital follow-up study on onboarding, engagement and geofencing consent rate

Background/Introduction

TAILOR-PCI is the largest cardiovascular genotype-based randomized trial (NCT#01742117) investigating whether genotype-guided selection of oral P2Y12 inhibitor therapy improves ischemic outcomes after percutaneous coronary intervention (PCI). The TAILOR-PCI Digital Sub-Study tests the feasibility of extending original follow-up of 1 year to 2 years using state-of-the-art digital solutions. Deep phenotyping acquired during a clinical trial can be leveraged by extending follow-up in an efficient and cost-effective manner using digital technology.

Purpose

Our objective is to describe onboarding and engagement of participants initially recruited in a large, pragmatic, international, multi-center clinical trial to a digital registry.

Methods

TAILOR-PCI participants, within 23 months of their index PCI, were invited by letters containing a URL to the Digital Sub-Study website (http://tailorpci.eurekaplatform.org). These invitations were followed by phone calls, if no response to the letter, to determine reason for non-participation. A NIH-funded direct-to-participant digital research platform (the Eureka Research Platform) was used to onboard, consent and enroll participants for the digital follow-up. Participants were asked to answer health-related surveys at fixed intervals using the Eureka mobile app and desktop platform. To capture hospitalizations, participants could enable geofencing to allow background location tracking, which triggered surveys if a hospitalization was detected.

Result(s)

Letters were mailed to 893 of 929 eligible participants across 22 sites in the United States and Canada leading to 226 homepage visits and 118 registrations. There were 107 consents (12.0% of invited; mean age: 66.4±9.0; 19 females [18%]): 47 (44%) participants consented after the letter, 36 (34%) consented after the 1st call and 24 (22%) consented after a 2nd call. Among those who consented, 100 were eligible (7 did not have a smartphone) 81 downloaded the study mobile app and 73 agreed for geofencing (Figure 1). Among the 722 invited participants who were surveyed, 354 declined participation: due to lack of time (146; 20.2%), lack of smartphone (125; 17.3%), difficulty understanding (41; 5.7%), concern about using smartphone (34; 4.7%), concern of data privacy (14; 1.9%), concerns of location tracking (6; 0.8%) and other reasons (57; 7.9%).

Conclusion

Extended follow-up of a clinical trial using a digital platform is feasible but uptake in this study population was limited largely due to lack of time or a smartphone among participants. Based on data from other digital studies, uptake may also have been limited since digital follow-up consent was not incorporated at the time of consent for the main trial.

Figure 1. Onboarding of the digital substudy

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH), National Heart, Lung, and Blood Institute (NHLBI)

New onset left bundle branch block after transcatheter aortic valve implantation and the effect on long-term survival – a UK wide experience

Introduction

New onset left bundle branch block (LBBB) is the most common conduction disturbance associated with transcatheter aortic valve implantation (TAVI). It has been shown to adversely affect cardiac function and increase re-hospitalisation, although its impact on mortality remains contentious.

Methods

We conducted an observational cohort analysis of all TAVI procedures performed by 13 heart teams in the United Kingdom from inception of their structural programmes until 31st July 2013. The primary outcome was 1-year all-cause mortality. Secondary outcomes included left ventricular ejection fraction (LVEF) at 30 days and need for a post-TAVI permanent pacemaker (PPM).

Results

1785 patients were eligible for inclusion to the study. The primary analysis cohort was composed of 1409 patients with complete electrocardiographic (ECG) data pre- and post-TAVI. Pre-existing LBBB was present in 200 (14.2%) patients. New LBBB occurred in 323 (22.9%) patients post TAVI, which resolved in 99 (7%) patients prior to discharge. A balloon-expandable device was implanted in 968 (69%) patients, whilst 421 (30%) patients received a self-expandable valve. New LBBB was observed in 120 (12.4%) and 192 (45.6%) patients receiving a balloon- or self-expandable prosthesis respectively.

Overall 1-year all-cause mortality post TAVI was 18.7%. New onset LBBB was not associated with an increase in 1-year all-cause mortality (p=0.416). Factors that were associated with mortality included an increasing logistic EuroScore (p=0.05), history of previous balloon aortic valvuloplasty (p=0.001), renal impairment (p=0.003), previous myocardial infarction with pre-existing LBBB (p=0.028) and atrial fibrillation (p=0.039). Lower baseline peak and mean AV gradients were also associated with greater mortality at 1 year (p=0.001), likely reflecting underlying left ventricular dysfunction.

In the majority of patients, LVEF remained unchanged following TAVI. Interestingly, the presence or absence of new onset LBBB did not affect LVEF improvement at 30 days. 10% of patients required a PPM post TAVI. Predictors of PPM included new LBBB (OR 2.6, p&lt;0.001), pre-TAVI left ventricular systolic impairment (OR 1.2, p=0.037), a self-expandable device (p&lt;0.001), and pre-existing RBBB (OR 4.0, p&lt;0.001).

Conclusions

These findings suggest that new onset LBBB post TAVI does not increase mortality at 1 year or adversely affect LVEF at 30 days.

Funding Acknowledgement

Type of funding source: None

Mitral regurgitation in acute heart failure: prevalence and response to treatment

 

Heart failure (HF) affects an estimated 90 000 people within the UK. As a consequence of ventricular remodelling, mitral regurgitation (MR) is common in patients with HF, further contributing to poor prognosis, frequent hospitalisation, and higher rates of mortality. Conventional treatment options include medical therapy, cardiac resynchronisation and conventional mitral valve surgery, with transcatheter mitral valve repair (TMVR) reserved for symptomatic patients with left ventricular dysfunction and multiple comorbidities, considered high surgical risk.

Aim

Our objectives were to determine: (1) the proportion of patients with an acute HF admission, ejection fraction (EF) of &lt;50% and moderate or more MR; (2) the effectiveness of optimal medical therapy (OMT) in reducing the severity of MR and symptoms; (3) the number of patients with moderate or more MR, EF &lt;50% and symptoms despite OMT.

Method

We performed a retrospective analysis of patients who presented with acute HF to two large tertiary centres over a five-year period. Based on a combination of electronic care records, and national registry and mortality data, we determined baseline symptoms, symptom progression, and co-morbidities. Echocardiography data was used to assess the degree of MR and EF. Where patients underwent a subsequent echocardiogram on OMT, the change in the degree of MR, EF and symptoms (NYHA class) was examined.

Results

Over a five-year period (Jan 2012–Dec 2017), 1884 patients presented with acute HF. Of this cohort, 302 (16%) had moderate or more MR and EF of &lt;50%. Mortality amongst patients with moderate or more MR was 29.9% at one year (compared to 26.9% for those with less than moderate MR, p=0.058). Of this cohort, 45% had sufficient clinical and echocardiographic paired follow up data to enable assessment of the effects of OMT (Age 78±20.78; Male n=76 (56.3%). This analysis showed, despite OMT, all 135 patients still had moderate or more MR. When compared with previous echocardiography data, 11 (8%) patients showed a reduction in the severity of MR which meant 92% (124) of patient with MR either saw no improvement or worsening of their MR severity. Of those with severe MR, 23% (7) demonstrated an improvement in the degree of MR following OMT. Clinically 70 (51.4%) patients had an improvement in symptoms. There was significant improvement in the NYHA class pre and post optimisation of medical therapy (p&lt;0.001) across all grades of MR. Despite OMT, 124 (92%) patients with moderate or more MR and EF &lt;50% remained symptomatic.

Conclusions

A large portion of patients who present with acute HF have moderate or more MR. Although medical therapy is effective in providing some relief from symptoms, the large majority of patients continue to have moderate or more MR. We propose a portion of these patients are potential candidates for TMVR, and should be considered for further intervention.

Funding Acknowledgement

Type of funding source: None

A randomised phase II trial of hydroxychloroquine and imatinib versus imatinib alone for patients with chronic myeloid leukaemia in major cytogenetic response with residual disease

In chronic-phase chronic myeloid leukaemia (CP-CML), residual BCR-ABL1+ leukaemia stem cells are responsible for disease persistence despite TKI. Based on in vitro data, CHOICES (CHlorOquine and Imatinib Combination to Eliminate Stem cells) was an international, randomised phase II trial designed to study the safety and efficacy of imatinib (IM) and hydroxychloroquine (HCQ) compared with IM alone in CP-CML patients in major cytogenetic remission with residual disease detectable by qPCR. Sixty-two patients were randomly assigned to either arm. Treatment 'successes' was the primary end point, defined as ≥0.5 log reduction in 12-month qPCR level from trial entry. Selected secondary study end points were 24-month treatment 'successes', molecular response and progression at 12 and 24 months, comparison of IM levels, and achievement of blood HCQ levels >2000 ng/ml. At 12 months, there was no difference in 'success' rate (p = 0.58); MMR was achieved in 80% (IM) vs 92% (IM/HCQ) (p = 0.21). At 24 months, the 'success' rate was 20.8% higher with IM/HCQ (p = 0.059). No patients progressed. Seventeen serious adverse events, including four serious adverse reactions, were reported; diarrhoea occurred more frequently with combination. IM/HCQ is tolerable in CP-CML, with modest improvement in qPCR levels at 12 and 24 months, suggesting autophagy inhibition maybe of clinical value in CP-CML.

The value of non-invasive computed tomography coronary angiography in imaging patients with coronary artery bypass grafts

INTRODUCTION

Invasive coronary angiography (ICA) is associated with higher complication rates in patients following coronary artery bypass surgery (CABG). CT coronary angiography (CTCA) has emerged as an attractive alternative. We assessed the impact of CTCA on subsequent ICA.

METHODS

We identified 213 CABG patients undergoing CTCA between 2015 and 2018. In 151 the indication was suspected recurrence of angina. We then identified patients undergoing ICA within 1 year of CTCA.

RESULTS

CTCA obviated the need for ICA in 115 cases (76%). CTCA was better at identifying targets for percutaneous coronary intervention (PCI) to saphenous vein grafts (SVG's) than to native vessels (89% vs 47%). 7 out of 10 lesions of "probable" significance by CTCA proved flow-limiting, and 4 out of 13 "indeterminate" lesions. CTCA concordance was 97% for left internal mammary (LIMA) grafts.

CONCLUSION

CTCA directed management in a majority of patients without ICA. It identified a cohort of patients likely to be candidates for SVG PCI, but was less effective in identifying PCI targets in the native vessels. CTCA renders invasive LIMA cannulation redundant unless a target lesion is suspected.

Hepatitis C virus testing, liver disease assessment and treatment uptake among people who inject drugs pre- and post-universal access to direct-acting antiviral treatment in Australia: The LiveRLife study

Gaps in hepatitis C virus (HCV) testing, diagnosis, liver disease assessment and treatment uptake among people who inject drugs (PWID) persist. We aimed to describe the cascade of HCV care among PWID in Australia, prior to and following unrestricted access to direct-acting antiviral (DAA) treatment. Participants enrolled in an observational cohort study between 2014 and 2018 provided fingerstick whole-blood samples for dried blood spot, Xpert HCV Viral Load and venepuncture samples. Participants underwent transient elastography and clinical assessment by a nurse or general practitioner. Among 839 participants (mean age 43 years), 66% were male (n = 550), 64% (n = 537) injected drugs in the previous month, and 67% (n = 560) reported currently receiving opioid substitution therapy. Overall, 45% (n = 380) had detectable HCV RNA, of whom 23% (n = 86) received HCV treatment within 12 months of enrolment. HCV treatment uptake increased from 2% in the pre-DAA era to 38% in the DAA era. Significant liver fibrosis (F2-F4) was more common in participants with HCV infection (38%) than those without (19%). Age 50 years or older (aOR, 2.88; 95% CI, 1.18-7.04) and attending a clinical follow-up with nurse (aOR, 3.19; 95% CI, 1.61-6.32) or physician (aOR, 11.83; 95% CI, 4.89-28.59) were associated with HCV treatment uptake. Recent injection drug use and unstable housing were not associated with HCV treatment uptake. HCV treatment uptake among PWID has increased markedly in the DAA era. Evaluation of innovative and simplified models of care is required to further enhance treatment uptake.

The Nab experiment: A precision measurement of unpolarized neutron beta decay

Neutron beta decay is one of the most fundamental processes in nuclear physics and provides sensitive means to uncover the details of the weak interaction. Neutron beta decay can evaluate the ratio of axial-vector to vector coupling constants in the standard model, λ = gA/gV, through multiple decay correlations. The Nab experiment will carry out measurements of the electron-neutrino correlation parameter a with a precision of δa/a = 10−3 and the Fierz interference term b to δb = 3 × 10−3 in unpolarized free neutron beta decay. These results, along with a more precise measurement of the neutron lifetime, aim to deliver an independent determination of the ratio λ with a precision of δλ/λ = 0.03% that will allow an evaluation of Vud and sensitively test CKM unitarity, independent of nuclear models. Nab utilizes a novel, long asymmetric spectrometer that guides the decay electron and proton to two large area silicon detectors in order to precisely determine the electron energy and an estimation of the proton momentum from the proton time of flight. The Nab spectrometer is being commissioned at the Fundamental Neutron Physics Beamline at the Spallation Neutron Source at Oak Ridge National Lab. We present an overview of the Nab experiment and recent updates on the spectrometer, analysis, and systematic effects.

Adherence to Once-daily and Twice-daily Direct-acting Antiviral Therapy for Hepatitis C Infection Among People With Recent Injection Drug Use or Current Opioid Agonist Therapy

Background

This study investigated adherence and associated factors among people with recent injection drug use (IDU) or current opioid agonist therapy (OAT) and compared once-daily to twice-daily hepatitis C virus (HCV) direct-acting antiviral (DAA) therapy.

Methods

SIMPLIFY and D3FEAT are international, multicenter studies that recruited participants with recent IDU (previous 6 months; SIMPLIFY, D3FEAT) or current OAT (D3FEAT) between March 2016 and February 2017 in 8 countries. Participants received sofosbuvir/velpatasvir (once daily; SIMPLIFY) or paritaprevir/ritonavir/ombitasvir, dasabuvir (twice daily) ± ribavirin (D3FEAT) for 12 weeks administered in electronic blister packs. We evaluated overall adherence (proportion of prescribed doses taken) and nonadherence (&lt;90% adherent) between dosing patterns.

Results

Of 190 participants, 184 (97%) completed treatment. Median adherence was 92%, with higher adherence among those receiving once-daily vs twice-daily therapy (94% vs 87%, P = .005). Overall, 40% of participants (n = 76) were nonadherent (&lt;90% adherent). Recent stimulant injecting (odds ratio [OR], 2.48 [95% confidence interval {CI}, 1.28–4.82]), unstable housing (OR, 2.18 [95% CI, 1.01–4.70]), and twice-daily dosing (OR, 2.81 [95% CI, 1.47–5.36]) were associated with nonadherence. Adherence decreased during therapy. Sustained virologic response was high in nonadherent (89%) and adherent populations (95%, P = .174), with no difference in SVR between those who did and did not miss 7 consecutive doses (92% vs 93%, P = .897).

Conclusions

This study demonstrated high adherence to once- and twice-daily DAA therapy among people with recent IDU or currently receiving OAT. Nonadherence described did not impact treatment outcomes, suggesting forgiveness to nonadherence.

3326Infective endocarditis after transcatheter aortic valve implantation: findings from a UK nationwide linkage study

Introduction

Infective endocarditis (IE) is a potentially fatal complication of prosthetic valve replacement and increasing use of transcatheter aortic valve implantation (TAVI) has resulted in a new elderly and frail population at increased risk of IE. The incidence of IE after TAVI and factors that influence the risk and subsequent outcome are relatively unknown.

Purpose

To describe the incidence, predictors, echocardiographic findings, microbiology and clinical outcomes of IE following TAVI in the United Kingdom (UK).

Methods

Patients who underwent TAVI between Jan 1 2007 and Dec 31 2016 were identified from the UK TAVI database held by the National Institute for Cardiovascular Outcomes Research. For this cohort, all hospital admissions with a primary diagnosis of IE were identified by linkage with the NHS Hospital Episode Statistics Admitted Patient Care database, or by contact with regional TAVI centres. Additional information concerning clinical presentation, imaging findings, microbiology, management and patient outcome were obtained where possible from the treating physician.

Results

A total of 16,014 patients underwent TAVI, of whom 157 developed IE over a median follow-up of 23.8 (IQR 7.8–52.4) months - an overall incidence of 0.98% (0.53% at one year post-TAVI). The mean age of patients with IE was 79.2±7.8 years, and 69% were male. The median time to IE following TAVI was 10.0 (IQR 4.0–22.3) months.

On multivariate analysis, IE was significantly more common in men (HR 2.05, 95% CI 1.35–3.11, p=0.001) and in patients receiving mechanically-expandable (HR 2.15, 95% CI 1.16–4.01, p=0.015) or balloon-expandable valves (HR 1.60, 95% CI 1.01–2.52, p=0.045) compared to self-expanding valves. IE was also more common in those with an aortic valve peak gradient following TAVI deployment greater than median (HR 1.81, 95% CI 1.23–2.67, p=0.003).

The most common presenting symptom was fever (present in 67.1%). The most frequent causal organisms were enterococci (25.9%), followed by oral streptococci (16.4%) and Staphylococcus aureus (11.8%). Transoesophageal echocardiography demonstrated vegetations in 72.5% of patients, most commonly on the TAVI valve leaflets (58.8%). Only 8.24% of patients underwent surgical valve intervention.

Survival rates at hospital discharge and one year follow up were 61.4% and 54.4%, respectively. Specific factors associated with one-year mortality were cardiogenic shock (HR 4.6, 95% CI 2.1–10.3, p=0.0002), septic shock (HR 3.4, 95% CI 1.4–8.3, p=0.006) and stroke (HR 4.9, 95% CI 1.46–16.7, p=0.01).

Conclusions

The incidence of IE one year after TAVI was 0.53% and greater risk was associated with male sex, mechanically-expandable and balloon-expandable valves, and elevated post-deployment valve gradient. Enterococci were the most common causative organism. Overall survival at one year was 54.4%, with adverse outcome predicted by cardiogenic shock, septic shock or stroke.

Achieving meaningful participation of people who use drugs and their peer organizations in a strategic research partnership

Background

Peer-led programs with people who use drugs (PWUD) have been a key characteristic of the harm reduction in many countries, including their involvement in research. However, peer involvement in research is often limited to recruitment, consultation, and reporting back, rather than a genuine collaboration in the priority setting, design, and conduct of research. PWUD peer organizations face ongoing challenges to demonstrate the depth of their knowledge of current and emerging issues within drug-using networks and the value of their peer insights for effective research and policy. The identification of benefits, barriers, and enablers for meaningful participation of PWUD in research has often been limited to methodological rather than system level factors.

Methods

This paper draws on the experiences and findings of the What Works and Why (W3) Project, a 5-year collaborative study with peer organizations. The study drew on systems thinking methods to develop a framework to demonstrate the role of peer organizations within their community and policy systems. The study required peer staff and researchers to undertake the simultaneous role of drivers, participants, and analysts in the research. To identify the learnings in relation to meaningful participation of PWUD peer organizations in research, we drew together the insights and experiences of peer staff and researchers across the 5 years of the study

Results

The W3 Project provided insights into the nuances of community-engaged research practice and the ongoing benefits, barriers, and enablers to the meaningful participation of PWUD and their peer organizations. These included system-level barriers and enablers beyond individual research projects or methodology. The capacity of research and peer organizations to maintain meaningful peer participation in research can be restricted or enhanced by the systems in which they are embedded.

Conclusions

Recognizing peer organizations as active participants and drivers within community and policy systems can help clarify their unique and critical role in research. Achieving meaningful collaboration with PWUD peer organizations requires looking beyond good practice methods to the system-level factors with attention to the system-level benefits, barriers, and enablers.

Characterising the policy influence of peer-based drug user organisations in the context of hepatitis C elimination

BACKGROUND

Achieving hepatitis C (HCV) elimination goals will require major policy and health service reorientation to scale up testing and treatment among people who inject drugs (PWID). To achieve this, a close partnership with peer-based drug user organisations is required. However, peer organisations have historical and ongoing difficulties in articulating the validity of their service delivery and policy advice, leading to some policy and health services resisting partnership and advice from peer-based drug user organisations.

METHODS

To develop a deeper understanding of the role of peer-based drug user organisations in the HCV response, we analysed data from the W3 Project which used systems thinking methods to draw together the insights of over 90 peer staff from 10 Australian community and peer organisations in HCV and HIV. The resulting system maps were analysed to identify system dynamics and functions that need to be fulfilled for peer organisations to be influential within their community and policy system.

RESULTS

We identified the interactions at a system level which can enhance or constrain the quality and influence of policy advice from peer-based drug user organisations. We found the strength of Peer-based drug user organisations to support the scale up of HCV testing and treatment was their capacity to mediate between, and navigate within, the complex community and policy/health service systems. While peer-based drug user organisations endeavour to demonstrate their capacity and credibility in terms of engagement, alignment, adaptation and influence, policy and service organisations also need recognise their own system role to value and enable peer-based drug user organisations to achieve their potential.

CONCLUSION

If the HCV prevention and treatment system is to reach PWID living with HCV and achieve HCV elimination goals, then policy and health services need to invest in strengthening peer-based drug user organisations as well as recognise, value and act on quality policy advice from PWID peer leadership.

Hepatitis C elimination among people who inject drugs: Challenges and recommendations for action within a health systems framework

The burden of hepatitis C infection is considerable among people who inject drugs (PWID), with an estimated prevalence of 39%, representing an estimated 6.1 million people who have recently injected drugs living with hepatitis C infection. As such, PWID are a priority population for enhancing prevention, testing, linkage to care, treatment and follow-up care in order to meet World Health Organization (WHO) hepatitis C elimination goals by 2030. There are many barriers to enhancing hepatitis C prevention and care among PWID including poor global coverage of harm reduction services, restrictive drug policies and criminalization of drug use, poor access to health services, low hepatitis C testing, linkage to care and treatment, restrictions for accessing DAA therapy, and the lack of national strategies and government investment to support WHO elimination goals. On 5 September 2017, the International Network of Hepatitis in Substance Users (INHSU) held a roundtable panel of international experts to discuss remaining challenges and future priorities for action from a health systems perspective. The WHO health systems framework comprises six core components: service delivery, health workforce, health information systems, medical procurement, health systems financing, and leadership and governance. Communication has been proposed as a seventh key element which promotes the central role of affected community engagement. This review paper presents recommended strategies for eliminating hepatitis C as a major public health threat among PWID and outlines future priorities for action within a health systems framework.

Prevalence of moderate-to-severe TR suitable for percutaneous intervention in TTE patients

Moderate-to-severe tricuspid regurgitation is associated with higher mortality and morbidity yet remains significantly undertreated. The reasons for this are complex but include a higher operative mortality for patients undergoing isolated tricuspid valve surgery. This study sought to determine the prevalence of patients with moderate-to-severe tricuspid regurgitation and identify those who could be potentially suitable for percutaneous tricuspid valve intervention by screening patients referred for transthoracic echocardiography (ECHO) at a tertiary center. Our results showed that the prevalence of moderate-to-severe tricuspid regurgitation in our total ECHO patient population was 2.8%. Of these, approximately 1 in 8 patients with moderate-to-severe tricuspid regurgitation would be potentially suitable for percutaneous intervention, and suggests a large, unmet clinical need in this population.