Cancer Decedents' Hospital End-of-Life Care Documentation: A Retrospective Review of Patient Records

Objective: International standards of end-of-life care (EOLC) intend to guide the delivery of safe and high-quality EOLC. Adequately documented care is conducive to higher quality of care, but the extent to which EOLC standards are documented in hospital medical records is unknown. Assessing which EOLC standards are documented in patients' medical records can help identify areas that are performed well and areas where improvements are needed. This study assessed cancer decedents' EOLC documentation in hospital settings. Methods: Medical records of 240 cancer decedents were retrospectively evaluated. Data were collected across six Australian hospitals between 1/01/2019 and 31/12/2019. EOLC documentation related to Advance Care Planning (ACP), resuscitation planning, care of the dying person, and grief and bereavement care was reviewed. Chi-square tests assessed associations between EOLC documentation and patient characteristics, and hospital settings (specialist palliative care unit, sub-acute/rehabilitation care settings, acute care wards, and intensive care units). Results: Decedents' mean age was 75.3 years (SD 11.8), 52.0% (n = 125) were female, and 73.7% lived with other adults or carers. All patients (n = 240; 100%) had documentation for resuscitation planning, 97.6% (n = 235) for Care for the Dying Person, 40.0% for grief and bereavement care (n = 96), and 30.4% (n = 73) for ACP. Patients living with other adults or carers were less likely to have a documented ACP than those living alone or with dependents (OR 0.48; 95% CI 0.26-0.89). EOLC documentation was significantly greater in specialist palliative care settings than that in other hospital settings (P < .001). Conclusion: The process of dying is well documented among inpatients diagnosed with cancer. ACP and grief and bereavement support are not documented enough. Organizational endorsement of a clear practice framework and increased training could improve documentation of these aspects of EOLC.

Two emerging phenotypes of atypical inclusion body myositis: illustrative cases

OBJECTIVES

Sporadic inclusion body myositis (IBM) is the most common acquired myopathy in those aged above 50. It is classically heralded by weakness in the long finger flexors and quadriceps. The aim of this article is to describe five atypical cases of IBM, outlining two potential emerging clinical subsets of the disease.

METHODS

We reviewed relevant clinical documentation and pertinent investigations for five patients with IBM.

RESULTS

The first phenotype we describe is young-onset IBM in two patients who had symptoms since their early thirties. The literature supports that IBM can rarely present in this age range or younger. We describe a second phenotype in three middle-aged women who developed early bilateral facial weakness at presentation in tandem with dysphagia and bulbar impairment followed by respiratory failure requiring non-invasive ventilation (NIV). Within this group, two patients were noted to have macroglossia, another possible rare feature of IBM.

CONCLUSIONS

Despite the classical phenotype described within the literature IBM can present in a heterogenous fashion. It is important to recognise IBM in younger patients and investigate for specific associations. The described pattern of facial diplegia, severe dysphagia, bulbar dysfunction and respiratory failure in female IBM patients requires further characterisation. Patients with this clinical pattern may require more complex and supportive management. Macroglossia is a potentially under recognised feature of IBM. The presence of macroglossia in IBM warrants further study, as its presence may lead to unnecessary investigations and delay diagnosis.

Health Care Resource Utilization by Patients with Alagille Syndrome

OBJECTIVE

To assess and characterize health care resource utilization (HRU) in children with the rare, genetic, multisystem disorder, Alagille syndrome.

STUDY DESIGN

This retrospective analysis reviewed commercially insured and Medicaid-insured claims from October 1, 2015 to December 31, 2019 to assess HRU in patients with Alagille syndrome. As there is no specific International Classification ofDiseases-10 code for Alagille syndrome, patients were identified using the following algorithm: ≥1 claim with diagnosis code Q44.7 (other congenital malformations of the liver); <18 years of age, with no history of biliary atresia (International Classification ofDiseases-10 code: Q44.2); and ≥6 months of insurance eligibility prior to diagnosis. HRU was summarized per patient per year over all available claims postdiagnosis.

RESULTS

A total of 171 commercially insured and 215 Medicaid-insured patients with Alagille syndrome were available for analysis. Annually, commercially insured and Medicaid-insured patients averaged 31 medical visits (range, 1.5-237) and 48 medical visits (range, 0.7-690), respectively. The most common visits were outpatient with the majority encompassing lab/imaging and primary care visits (commercially insured: 21 [range, 0.0-183]; Medicaid-insured: 26 [range, 0.0-609]). Inpatient visits were the highest driver of costs in both the commercial and Medicaid populations.

CONCLUSIONS

Patients with Alagille syndrome have a substantial HRU burden driven largely by numerous outpatient visits and costly inpatient stays. Given the complexity and variability of Alagille syndrome presentation, patients may benefit from multidisciplinary and subspecialized care.

Association between risk of dementia and very late-onset schizophrenia-like psychosis: a Swedish population-based cohort study

BACKGROUND

Although the incidence of psychotic disorders among older people is substantial, little is known about the association with subsequent dementia. We aimed to examine the rate of dementia diagnosis in individuals with very late-onset schizophrenia-like psychosis (VLOSLP) compared to those without VLOSLP.

METHODS

Using Swedish population register data, we established a cohort of 15 409 participants with VLOSLP matched by age and calendar period to 154 090 individuals without VLOSLP. Participants were born between 1920 and 1949 and followed from their date of first International Classification of Diseases [ICD], Revisions 8-10 (ICD-8/9/10) non-affective psychotic disorder diagnosis after age 60 years old (or the same date for matched participants) until the end of follow-up (30th December 2011), emigration, death, or first recorded ICD-8/9/10 dementia diagnosis.

RESULTS

We found a substantially higher rate of dementia in individuals with VLOSLP [hazard ratio (HR): 4.22, 95% confidence interval (95% CI) 4.05-4.41]. Median time-to-dementia-diagnosis was 75% shorter in those with VLOSLP (time ratio: 0.25, 95% CI 0.24-0.26). This association was strongest in the first year following VLOSLP diagnosis, and attenuated over time, although dementia rates remained higher in participants with VLOSLP for up to 20 years of follow-up. This association remained after accounting for potential misdiagnosis (2-year washout HR: 2.22, 95% CI 2.10-2.36), ascertainment bias (HR: 2.89, 95% CI 2.75-3.04), and differing mortality patterns between groups (subdistribution HR: 2.89, 95% CI 2.77-3.03).

CONCLUSIONS

Our findings demonstrate that individuals with VLOSLP represent a high-risk group for subsequent dementia. This may be due to early prodromal changes for some individuals, highlighting the importance of ongoing symptom monitoring in people with VLOSLP.

Maralixibat Treatment Response in Alagille Syndrome is Associated with Improved Health-Related Quality of Life

OBJECTIVE

The objective of this study was to assess the impact of treatment response to the ileal bile acid transporter inhibitor maralixibat on health-related quality of life (HRQoL) in children with Alagille syndrome.

STUDY DESIGN

This analysis used data from the ICONIC trial, a phase 2 study with a 4-week double-blind, placebo-controlled, randomized drug withdrawal period in children with Alagille syndrome with moderate-to-severe pruritus. Clinically meaningful treatment response to maralixibat was defined a priori as a ≥1-point reduction in the Itch-Reported Outcome (Observer) score, from baseline to week 48. HRQoL was assessed using the Pediatric Quality of Life Inventory Generic Core, Family Impact, and Multidimensional Fatigue scale scores, which were collected via the caregiver. The minimal clinically important difference for HRQoL ranged from 4 to 5 points, depending on the scale.

RESULTS

Twenty of the 27 patients (74%) included in this analysis achieved an Itch-Reported Outcome (Observer) treatment response at week 48. The mean (SD) change in Multidimensional Fatigue score was +25.8 (23.0) for responders vs -3.1 (19.8) for nonresponders (P = .03). Smaller and non-statistically significant mean changes were observed for the Pediatric Quality of Life Inventory Generic Core and Family Impact scores. Controlling for baseline Family Impact score, responders' Family Impact scores increased an average of 16.9 points over 48 weeks compared with non-responders (P = .05). Smaller and non-statistically significant point estimates were observed for the Pediatric Quality of Life Inventory Generic Core and Multidimensional Fatigue scores.

CONCLUSION

The significant improvements in pruritus seen with maralixibat at week 48 of the ICONIC study are clinically meaningful and are associated with improved HRQoL.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02160782.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

How are medical schools supporting student’s mental wellbeing during the COVID-19 pandemic?

Introduction

The COVID-19 pandemic has impacted medical students in many ways. They are not exempt from personal struggles caused by the health crisis, and many have faced similar challenges adapting to a new learning experience. The University of East Anglia (UEA) has initiatives in place to support medical students including the society Headucate UEA and the Wellbeing Champions scheme established by Norwich Medical School (NMS).

Objectives

Headucate aims to improve mental wellbeing by educational online webinars and social events aimed at university students. NMS Wellbeing Champions offer support and signpost students to resources and the wider student support system at the UEA.

Methods

Headucate was established in 2012 by NMS students that began running workshops at local secondary schools. Their work has expanded to include wellbeing workshops, social events for students and mental health first aid training, so members can provide peer support. Wellbeing Champions are medical student representatives responsible for completing mental health first aid training, communication between students and faculty, providing resources and signposting, creating mental health bulletin newsletters, and running socials exclusively for medical students.

Results

100% of Headucate workshop attendees who completed anonymous feedback agreed that they enjoyed it and that it was useful. No feedback has been collected regarding the success of the Wellbeing Champions. This should be carried out to assess and enhance the project further.

Conclusions

More data is needed to establish the success of the initiatives at NMS and their impact on medical student’s wellbeing.

Disclosure

No significant relationships.

The Success of Headucate: The Student-Led Mental Health Society

Introduction

Headucate: University of East Anglia, a university student-led society, was founded almost 10 years ago by medical students to promote mental health education and raise awareness and funds for mental health causes.

Objectives

Headucate aims to spread mental health awareness and reduce stigma by working with schools, universities, other societies and charities internationally.

Methods

Headucate delivers workshops for children aged 4-18 in primary and secondary schools, community and youth groups and university students. These sessions were delivered in-person pre-COVID and online as interactive webinars since 2020, to spark discussion around mental health, and provide information about the variety of supports available for young people.

Results

In the past decade, Headucate UEA has grown to become one of UEA’s largest student-led groups boasting over 175 members in 2020-2021 from all courses. Within the online world, Headucate’s events have reached worldwide. The initiative has received national recognition, won national student awards and has expanded to set up three further Headucate branches nationwide. Outreach has accelerated and the school workshops reached over 1,000 students in the past year.

Conclusions

Headucate has grown from strength to strength and has plans to continue to develop, with passionate student drivers behind the project. Expansion of the project could include a national mental health university directory, bringing together like-minded mental health advocate students around the country and creating new Headucate branches across the country. To further develop, Headucate could expand outreach to the elderly community as discussed by previous committee.

Disclosure

No significant relationships.

Is TikTok increasing the number of self-diagnoses of ADHD in young people?

Introduction

TikTok is a free mobile application, that enables users to create short videos. TikTok has an estimated one billion monthly active users, comprised of a mostly younger audience. There has been a noticed rise in content discussing ADHD – hashtag ADHD on TikTok has 6.3 billion views. The discussions continue on Twitter, where users are reporting watching TikTok content explaining ADHD symptomatology, subsequently relating to the condition and requesting referrals to specialist psychiatry services. This study aims to identify key themes in discussions around TikTok and ADHD, and its ramifications.

Objectives

This study’s objective is to discuss the relationship between viewing ADHD content of TikTok and self-diagnoses of ADHD in young people.

Methods

In our study, Twitter posts were identified with the words ‘ADHD’ and ‘TikTok’ and established key themes relating to self-diagnosis of ADHD.

Results

Numerous tweets were found discussing individual’s experiences of self-diagnosis of ADHD after watching TikTok videos and relating with the symptomology. Furthermore, many users discussed their efforts to seek diagnosis from psychiatrists. These posts highlighted positive discussion of mental health, and the improvement in quality of life since diagnosis.

Conclusions

Many young people are self-diagnosing ADHD after viewing TikTok videos. This may improve mental health stigma, however the expertise of the video creators should be scrutinised. Furthermore, the impact on already stretched waiting lists should be considered, with individuals who’s perceived ADHD traits are not impacting on their quality of life.

Disclosure

No significant relationships.

The impact of COVID-19 on mental health charity fundraising: An account from the perspective of fundraisers

Introduction

The dawn of COVID-19 brought new rules, restrictions, and lockdowns but this led to the unlikely fall of many sectors, including the charitable sector. There has been a significant decline in funding received by mental health charities, especially during the pandemic. This study looks at the subsequent impact on fundraisers and mental health promotion during COVID-19.

Objectives

The main aim was to uncover how the COVID-19 pandemic has affected the way that mental health charities fundraise, raise awareness, and promote mental health. This aimed to look at the impact of the COVID-19 pandemic on fundraisers supporting mental health charities and their opinion on whether fundraising has either helped or hindered mental health promotion.

Methods

Accounts from fundraisers and local representatives for mental health charities during the COVID-19 pandemic were analysed. Common themes looked at the impact, adaptation, and reasons why fundraisers decided to help during a tough period for the charitable sector.

Results

Mental health charities expressed difficulty in sourcing funds to support their users, especially in a vulnerable time. Fundraisers tried innovative ways to promote mental health and raise money for charities.

Conclusions

Altruism and understanding how precious services such as mental health charities are for the population was the main driver for fundraisers. Mental health charities adapted by turning to online communication and reached out to fundraisers to continually highlight the importance of mental health to their users and fundraisers.

Disclosure

No significant relationships.

The impact of Gender Identity Clinic waiting times on the mental health of transitioning individuals

Introduction

Waiting times for gender identity services, even before the Covid-19 pandemic, have been a cause of concern. Despite the waiting time standard for planned elective care in the NHS being a maximum of 18 weeks, the average waiting time for a first appointment with a gender identity clinic is 18 months. This study aims to analyse the effect that these timings have on the transgender community, and whether they impact the risk of developing mental health conditions such as depression or anxiety.

Objectives

This study’s main aim is to analyse the correlation between waiting times and mental health burden in the transgender community.

Methods

A literature review and analysis on a transgender individual’s mental health and waiting times for Gender Identity Clinics; looking at any key themes and conclusions. Research papers were taken from MEDLINE, The International Journal of Transgender Health, Oxford Academic, SpringerLink and Emerald Insight, with studies publishing date ranging from 2014 – 2021.

Results

The transgender population were found to have higher rates of suicidal ideation, depression and self harm compared to the general population. Longer waiting times were found to contribute to feelings of low mood and suicidal ideation, as well as decreasing overall quality of life.

Conclusions

Longer waiting times can decrease a transgender individual’s quality of life and impact their overall mental wellbeing: especially with the impact of COVID-19 and the rise in referrals.

Disclosure

No significant relationships.

Taking Mental Health into Schools: The work of Headucate Student Society

Headucate: University of East Anglia (UEA) is a student-led organisation aiming to raise awareness around Mental Health through their workshops and events. Events in the last year have included a 24-hour live stream TV fundraiser, UEA’s first Psychiatry and Mental Health conference, a mental health themed stand-up show, mental health assistance workshops, a suicide prevention evening and a variety of panels. Headucate has also collaborated with Beat, the UK’s leading eating disorder charity, to run training aimed at Norwich Medical School students, other healthcare students and Professionals. Headucate provides opportunities for their members, including research, education within the medical community, organising group projects, hosting poster competitions and by collaborating with likeminded initiatives. Workshops were designed to include common mental health conditions; wellbeing; advice regarding looking after yourself and others; ways to get for support and the impact of COVID-19 on our mental health. They are arranged and delivered by our members to school children and university students; they have been adapted to an online platform, which allowed us to reach a wider audience. Outcome measures demonstrating the impact of Headucate’s work were analysed via verbal, written and rated feedback, obtained from participants of workshops and events. Headucate workshops can help to improve mental health awareness and education in schools; however, it is only a local initiative. To educate schools outside of Norfolk, Headucate’s repeatable model can be used to create new branches of organisations that can spread nationwide; so mental health education in schools can be promoted across the UK.

In-home dementia caregiving is associated with greater psychological burden and poorer mental health than out-of-home caregiving: a cross-sectional study

INTRODUCTION

Caregivers who live with a person with dementia who receives care, compared with those who live elsewhere, are often considered to experience greater levels of psychological and affective burden. The evidence for this is, however, only limited to studies employing small sample sizes and that failed to examine caregivers' psychological wellbeing. We address these issues in a large cohort of dementia caregivers.

METHODS

We conducted a cross-sectional study comparing caregivers living with a dementia care recipient (n = 240) to caregivers living elsewhere (n = 255) on caregivers' burden, anxiety, and depression.

RESULTS

We found that caregivers living with the care recipient relative to those living elsewhere showed significantly greater burden and depression, but we found no group difference in anxiety.

CONCLUSIONS

Our study adds to the evidence by showing that cohabiting with a care recipient with dementia is associated with greater burden and poorer psychological wellbeing. Strategies aiming to improve caregivers' burden and psychological wellbeing should take account of caregivers' living arrangements.

Antihypertensive Agents and Incident Alzheimer's Disease: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Hypertension is a recognized risk factor for dementia. However, evidence for using antihypertensive agents to reduce the risk of Alzheimer's disease in people with hypertension is inconclusive.

OBJECTIVE

To examine the association between antihypertensive agents and the incidence of Alzheimer's disease in adults with hypertension and normal cognition.

DESIGN

We conducted a systemic review and performed meta-analyses using Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, Web of science and Scopus, from inception to 18th February 2022.

SETTING

Cohort and case-control studies.

PARTICIPANTS

Adults ≥ 40 years with hypertension and normal cognition.

INTERVENTION

Antihypertensive agents.

MEASUREMENTS

We performed two separate meta-analyses, pooling the adjusted relative risk (RR) of non-antihypertensive comparator and antihypertensive comparator study design.

RESULTS

We included nine studies, totalling 1,527,410 individuals. Meta-analysis of non-antihypertensive user comparator studies found that the use of antihypertensive agents is associated with a reduced risk of incident Alzheimer's disease (RR= 0.94, 95% CI 0.90-0.99; p=0.01). Meta-analysis of antihypertensive comparator studies found evidence that angiotensin II receptor blocker users are associated with a reduction in the risk of Alzheimer's disease compared to other antihypertensive agents (RR= 0.78, 95% CI 0.68-0.88; p< 0.001).

CONCLUSION

Our review provides evidence that the use of antihypertensive agents is associated with a lower incidence of Alzheimer's disease. The use of angiotensin II receptor blockers may provide the most benefit among antihypertensive agents. Lowering raised blood pressure may not be the only mechanism for cognitive protection and further investigation of the effects of angiotensin II on cognition is indicated.

Experimental verification of principal losses in a regulatory particulate matter emissions sampling system for aircraft turbine engines

A sampling system for measuring emissions of nonvolatile particulate matter (nvPM) from aircraft gas turbine engines has been developed to replace the use of smoke number and is used for international regulatory purposes. This sampling system can be up to 35 m in length. The sampling system length in addition to the volatile particle remover (VPR) and other sampling system components lead to substantial particle losses, which are a function of the particle size distribution, ranging from 50 to 90% for particle number concentrations and 10-50% for particle mass concentrations. The particle size distribution is dependent on engine technology, operating point, and fuel composition. Any nvPM emissions measurement bias caused by the sampling system will lead to unrepresentative emissions measurements which limit the method as a universal metric. Hence, a method to estimate size dependent sampling system losses using the system parameters and the measured mass and number concentrations was also developed (SAE 2017; SAE 2019). An assessment of the particle losses in two principal components used in ARP6481 (SAE 2019) was conducted during the VAriable Response In Aircraft nvPM Testing (VARIAnT) 2 campaign. Measurements were made on the 25-meter sample line portion of the system using multiple, well characterized particle sizing instruments to obtain the penetration efficiencies. An agreement of ± 15% was obtained between the measured and the ARP6481 method penetrations for the 25-meter sample line portion of the system. Measurements of VPR penetration efficiency were also made to verify its performance for aviation nvPM number. The research also demonstrated the difficulty of making system loss measurements and substantiates the E-31 decision to predict rather than measure system losses.

OP0275-PARE THE UNACCEPTABLE DELAY TO DIAGNOSIS IN AXIAL SPONDYLOARTHRITIS; DEVELOPING A CALL TO ACTION FOR A GLOBAL HEALTHCARE CHALLENGE

Background:

The current delay to diagnosis from symptom onset represents one of the greatest challenges in axial spondyloarthritis (axSpA). Research shows an average global delay of almost 7 years1 – and as long as 15 years in some cases2 – during which time the condition can progress considerably and lead to irreversible damage. Data indicates that women wait longer than men for a diagnosis3, and there has been very limited progress in reducing the time to axSpA diagnosis. The axSpA diagnosis delay has a hugely detrimental impact on an individual’s quality of life. Because the disease frequently has early onset1, individuals are left with untreated or incorrectly-treated symptoms at a formative period in their life course, whilst they await their diagnosis.

Objectives:

The Axial Spondyloarthritis International Federation (ASIF) set out to coordinate a comprehensive evidence-based global review of the factors influencing the current axSpA diagnosis delay and to produce a definitive report that shines a light on these barriers, as well as providing a resource that can ultimately empower a range of international stakeholders to reduce this delay.

Methods:

A full literature review was carried out to identify relevant available global evidence exploring the axSpA diagnosis delay. In autumn 2020 ASIF held two virtual global forum events, involving patients and patient group representatives, researchers, rheumatologists and other healthcare professionals, to methodically explore key diagnosis challenges across different healthcare systems and the opportunities for addressing these. Break-out discussions were held and participants were asked to identify the personal and societal effects of the diagnostic delay; the reasons it occurs; and initiatives to tackle the challenge. Alongside key stakeholder testimonies, best practices from around the world were also identified. 92 stakeholders participated in the events; they represented patients and healthcare professionals from 23 countries across five continents.

Results:

The findings from these activities were incorporated within a new ‘Delay to Diagnosis’ report, which for the first time definitively sets out the lived realities from a global perspective of the axSpA diagnosis delay. The report identified important commonalities across different countries and healthcare systems contributing to the current average global 7-year diagnosis delay, including:

 •Poor awareness of axSpA, particularly in primary care services

 •Complexities in diagnosing the disease

 •Poorly defined referral pathways

 •Insufficient patient access to rheumatologists and appropriate diagnostics

The report also highlights the significant impact this delay has on individuals and wider society, providing a foundation for future advocacy work. A series of recommendations have also been identified, the implementation of which will help to instigate tangible progress in reducing the current delay.

Conclusion:

Despite longstanding challenges, there are now clear opportunities for transforming how axSpA is diagnosed around the world. This message needs to be heard and acted upon urgently by all those involved in the management and delivery of axSpA care. The future programme of work for ASIF’s Delay to Diagnosis project will respond to these findings and be centred around supporting axSpA patient associations globally to take this call to action forward throughout 2021 and beyond.

References:

[1]Zhao et al; Diagnostic delay in axial spondyloarthritis: a systematic review and meta-analysis; Rheumatology, 2021

[2]Garrido-Cumbrera, M., Poddubnyy, D., Gossec, L. et al. The European Map of Axial Spondyloarthritis: Capturing the Patient Perspective—an Analysis of 2846 Patients Across 13 Countries. Curr Rheumatol Rep 21, 19 (2019)

[3]Jovani et al; Understanding How the Diagnostic Delay of Spondyloarthritis Differs Between Women and Men: A Systematic Review and Metaanalysis; The Journal of Rheumatology December 2016

Disclosure of Interests:

Wendy Gerhart Employee of: I was employed by Janssen Canada from 1992 - 2017, Mehmet Tuncay Duruöz: None declared, Jo Lowe Grant/research support from: No financial grants received individually. However, my role as Project Manager at ASIF is currently funded partially by UCB Global and partially by Novartis Global, Dale Webb Speakers bureau: Janssen and Novartis, Grant/research support from: Individually, no. But NASS receives grants from AbbVie, Biogen, Eli Lilly, Janssen, Novartis and UCB, Lillann Wermskog Grant/research support from: Individually, no. But Spafo Norge receives a small amount of funding for ongoing projects from Novartis., Jo Davies Grant/research support from: Individually, no. However, ASIF are currently funded by UCB, Lilly, Boehringer Ingelheim, Janssen and Novartis; this funding partially covers staff salaries as well as a range of projects, the content and outputs of which are not influenced by the funders., Richard Howard Shareholder of: AbbVie, Amgen, Bristol-Myers Squibb, GSK, Johnson & Johnson, Eli Lilly, Merck, Novartis, Pfizer, and Teva. I own <20 shares of any one stock and these stocks represent <4% of personal investments, Consultant of: Yes, GSK, Novartis - but then donated to Spondylitis Association of America, Grant/research support from: I have not personally received financial grants. SAA has received financial support from AbbVie, Amgen, BI, J&J, Lilly, Novartis, Pfizer, UCB., Michael Mallinson Consultant of: No. But, for full disclosure: I have received honoraria in the past, for participating in patient advisory board activities, from Abbvie, Novartis, Pfizer and UCB., Cheryl L Koehn Grant/research support from: OUR ORGANIZATION, ARTHRITIS CONSUMER EXPERTS, HAS. I HAVE NOT AS AN INDIVIDUAL. HERE IS OUR PUBLICLY AVAILABLE DISCLOSURE ON ALL ONLINE AND PRINT MATERIALS, PRESENTATIONS, MEETINGS, GOVERNMENT CONSULTATIONS:

https://jointhealth.org/about-principles.cfm?locale=en-CA

Over the past 12 months, ACE received grants-in-aid from: Arthritis Research Canada, Amgen Canada, Canadian Institutes of Health Research, Canadian Rheumatology Association, Eli Lilly Canada, Hoffman-La Roche Canada Ltd., Knowledge Translation Canada, Merck Canada, Novartis Canada, Pfizer Canada, Sandoz Canada, Sanofi Canada, St. Paul’s Hospital (Vancouver), UCB Canada, and the University of British Columbia.

The emerging spectrum of COVID-19 neurology: clinical, radiological and laboratory findings

Preliminary clinical data indicate that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is associated with neurological and neuropsychiatric illness. Responding to this, a weekly virtual coronavirus disease 19 (COVID-19) neurology multi-disciplinary meeting was established at the National Hospital, Queen Square, in early March 2020 in order to discuss and begin to understand neurological presentations in patients with suspected COVID-19-related neurological disorders. Detailed clinical and paraclinical data were collected from cases where the diagnosis of COVID-19 was confirmed through RNA PCR, or where the diagnosis was probable/possible according to World Health Organization criteria. Of 43 patients, 29 were SARS-CoV-2 PCR positive and definite, eight probable and six possible. Five major categories emerged: (i) encephalopathies (n = 10) with delirium/psychosis and no distinct MRI or CSF abnormalities, and with 9/10 making a full or partial recovery with supportive care only; (ii) inflammatory CNS syndromes (n = 12) including encephalitis (n = 2, para- or post-infectious), acute disseminated encephalomyelitis (n = 9), with haemorrhage in five, necrosis in one, and myelitis in two, and isolated myelitis (n = 1). Of these, 10 were treated with corticosteroids, and three of these patients also received intravenous immunoglobulin; one made a full recovery, 10 of 12 made a partial recovery, and one patient died; (iii) ischaemic strokes (n = 8) associated with a pro-thrombotic state (four with pulmonary thromboembolism), one of whom died; (iv) peripheral neurological disorders (n = 8), seven with Guillain-Barré syndrome, one with brachial plexopathy, six of eight making a partial and ongoing recovery; and (v) five patients with miscellaneous central disorders who did not fit these categories. SARS-CoV-2 infection is associated with a wide spectrum of neurological syndromes affecting the whole neuraxis, including the cerebral vasculature and, in some cases, responding to immunotherapies. The high incidence of acute disseminated encephalomyelitis, particularly with haemorrhagic change, is striking. This complication was not related to the severity of the respiratory COVID-19 disease. Early recognition, investigation and management of COVID-19-related neurological disease is challenging. Further clinical, neuroradiological, biomarker and neuropathological studies are essential to determine the underlying pathobiological mechanisms that will guide treatment. Longitudinal follow-up studies will be necessary to ascertain the long-term neurological and neuropsychological consequences of this pandemic.

SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes

OBJECTIVES

To understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents.

METHODS

An outbreak investigation involving 394 residents and 70 staff, was carried out in 4 nursing homes affected by COVID-19 outbreaks in central London. Two point-prevalence surveys were performed one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing.

RESULTS

Overall, 26% (95% CI 22-31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70-336) compared with previous years. Systematic testing identified 40% (95% CI 35-46) of residents as positive for SARS-CoV-2, and of these 43% (95% CI 34-52) were asymptomatic and 18% (95% CI 11-24) had only atypical symptoms; 4% (95% CI -1 to 9) of asymptomatic staff also tested positive.

CONCLUSIONS

The SARS-CoV-2 outbreak in four UK nursing homes was associated with very high infection and mortality rates. Many residents developed either atypical or had no discernible symptoms. A number of asymptomatic staff members also tested positive, suggesting a role for regular screening of both residents and staff in mitigating future outbreaks.

Admission patterns and survival from status epilepticus in critical care in the UK: an analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database

BACKGROUND AND PURPOSE

Factors influencing the outcome after the critical care unit (CCU) for patients with status epilepticus (SE) are poorly understood. Survival for these patients was examined to establish (i) whether the risk of mortality has changed over time and (ii) whether admission to different unit types affects mortality risk over and above other risk factors.

METHODS

The Intensive Care National Audit and Research Centre database and the Case Mix Programme database (January 2001 to December 2016) were analysed. Units were defined as neuro-CCU (NCCU), general CCU with 24-h neurological support (GCCU-N) or general CCU with limited neurological support (GCCU-L).

RESULTS

There were 35 595 CCU cases of SE with a 3-fold increase over time (4739 in 2001-2004 to 14 166 in 2013-2016). More recent admissions were older and were more often unsedated on admission. Mortality declined for all units although this was more marked for NCCUs (8.1% in 2001-2004 to 4.4% in 2013-2016 compared to 5.1% and 4.1% for GCCU-L). Acute hospital mortality was two to three times higher than CCU mortality although this has also declined with time. GCCU-L appeared to have lower mortality than NCCUs (odds ratio 0.84, 95% confidence interval 0.72, 0.98) but after post hoc adjustment for case mix there were no differences. Older age and markers of seriousness of morbidity were all associated with increased mortality risk.

CONCLUSIONS

The number of patients admitted to a CCU for SE is rising but critical care and acute hospital mortality is decreasing. Patients treated in an NCCU have higher mortality but this is explicable by more severe underlying disease.

Estimated Life Expectancy and Income of Patients With Sickle Cell Disease Compared With Those Without Sickle Cell Disease

IMPORTANCE

Individuals with sickle cell disease (SCD) have reduced life expectancy; however, there are limited data available on lifetime income in patients with SCD.

OBJECTIVE

To estimate life expectancy, quality-adjusted life expectancy, and income differences between a US cohort of patients with SCD and an age-, sex-, and race/ethnicity-matched cohort without SCD.

DESIGN, SETTING, AND PARTICIPANTS

Cohort simulation modeling was used to (1) build a prevalent SCD cohort and a matched non-SCD cohort, (2) identify utility weights for quality-adjusted life expectancy, (3) calculate average expected annual personal income, and (4) model life expectancy, quality-adjusted life expectancy, and lifetime incomes for SCD and matched non-SCD cohorts. Data sources included the Centers for Disease Control and Prevention, National Newborn Screening Information System, and published literature. The target population was individuals with SCD, the time horizon was lifetime, and the perspective was societal. Model data were collected from November 29, 2017, to March 21, 2018, and the analysis was performed from April 28 to December 3, 2018.

MAIN OUTCOMES AND MEASURES

Life expectancy, quality-adjusted life expectancy, and projected lifetime income.

RESULTS

The estimated prevalent population for the SCD cohort was 87 328 (95% uncertainty interval, 79 344-101 398); 998 were male and 952 were female. Projected life expectancy for the SCD cohort was 54 years vs 76 years for the matched non-SCD cohort; quality-adjusted life expectancy was 33 years vs 67 years, respectively. Projected lifetime income was $1 227 000 for an individual with SCD and $1 922 000 for a matched individual without SCD, reflecting a lost income of $695 000 owing to the 22-year difference in life expectancy. One study limitation is that the higher estimates of life expectancy yielded conservative estimates of lost life-years and income. The analysis only considered the value of lost personal income owing to premature mortality and did not consider direct medical costs or other societal costs associated with excess morbidity (eg, lost workdays for disability, time spent in the hospital). The model was most sensitive to changes in income levels and mortality rates.

CONCLUSIONS AND RELEVANCE

In this simulated cohort modeling study, SCD had societal consequences beyond medical costs in terms of reduced life expectancy, quality-adjusted life expectancy, and lifetime earnings. These results underscore the need for disease-modifying therapies to improve the underlying morbidity and mortality associated with SCD.

Risk of Meningitis in Infants Aged 29 to 90 Days with Urinary Tract Infection: A Systematic Review and Meta-Analysis

OBJECTIVE

To determine the risk of bacterial meningitis in infants aged 29-90 days with evidence of urinary tract infection (UTI).

METHODS

PubMed (MEDLINE), Embase, and the Cochrane Library were systematically searched for studies reporting rates of meningitis in infants aged 29-90 days with abnormal urinalysis or urine culture. Observational studies in infants with evidence of UTI who underwent lumbar puncture (LP) reporting age-specific event rates of bacterial meningitis and sterile cerebrospinal fluid pleocytosis were included. Prevalence estimates for bacterial meningitis in infants with UTI were pooled in a random effects meta-analysis.

RESULTS

Three prospective and 17 retrospective cohort studies were included in the meta-analysis. The pooled prevalence of concomitant bacterial meningitis in infants with UTI was 0.25% (95% CI, 0.09%-0.70%). Rates of sterile pleocytosis ranged from 0% to 29%. Variation in study methods precluded calculation of a pooled estimate for sterile pleocytosis. In most studies, the decision to perform a LP was up to the provider, introducing selection bias into the prevalence estimate.

CONCLUSIONS

The risk of bacterial meningitis in infants aged 29-90 days with evidence of UTI is low. A selective approach to LP in infants identified as low risk for meningitis by other clinical criteria may be indicated.

Improving child weight management uptake through enhanced National Child Measurement Programme parental feedback letters: A randomised controlled trial

This single-blind, pragmatic, cluster randomised controlled trial aims to investigate uptake of children's weight management services in response to enhanced National Child Measurement Programme (NCMP) letters providing weight status feedback to parents in three English counties in 2015. Parents of 2642 overweight or very overweight (obese) children aged 10-11 years received an intervention or control letter informing them of their child's weight status. Intervention letters included (i) a visual tool to help weight status recognition, (ii) a social norms statement, and for very overweight children, (iii) a prepopulated booking form for weight management services. The primary outcome was weight management service enrolment. Additional outcome measures included attendance at and contact made with weight management services, and a number of self-report variables. A small effect was observed, with intervention parents being significantly more likely to enrol their children in weight management services (4.33% of Intervention group) than control parents (2.19% of Control group) in both unadjusted (OR = 2.08, p = .008) and adjusted analyses (AOR = 2.48, p = .001). A similar picture emerged for contact with services (4.80% Intervention vs. 2.41% Control; OR = 2.10, p = .003; AOR = 2.46, p < .001) and attendance at services, although group differences in the latter measure were not significant after corrections for multiple comparisons (1.89% Intervention vs. 1.02% Control; AOR = 2.11, p = .047). No effects were found on self-report variables. Theoretically informed weight status feedback letters appear to be an effective strategy to improve enrolment in paediatric weight management services.

TP3-6 Preliminary evaluation of diagnostic home video telemetry (HVT)

Objectives

To assess the clinical usefulness of HVT over the first 2 years.

Design

Cohort observational.

Subjects

60 patients (49 F) with epilepsies or non-epileptic paroxysmal clinical events.

Methods

48–72 hour continuous video EEG at patients’ own environment.

Results

HVT answered the primary clinical question in 45/60 patients (75%), and provided additional clinical information in 5 patients [2 with unsuspected coexistent psychogenic non-epileptic seizures (PNES) and 3 with unsuspected sleep disorders (SD)]. Of the 12 patients with Idiopathic Generalized Epilepsy, absences had been overestimated in 6 and underestimated in 4, while absence status was recorded in 1 of the 2 patients in whom it had been suspected. Valproate was possible to drastically reduce or stop in 3/6 women. Focal seizures were recorded in 19 of 28 patients with focal epilepsies, PNES were the habitual seizures in further 2 patients, while syndrome classification changed in one. In all 4 patients referred for differentiation between SD and epilepsy, HVT confirmed parasomnias in 2, daytime naps in 1 and idiopathic hypersomnia in 1. The diagnosis of PNES was confirmed in 8 of 13 suspected patients. HVT was unhelpful in the 3 patients referred for not witnessed, poorly understood episodes of loss of consciousness. Three patients switched off the video and 2 failed to change battery on day 2.

Conclusions

HVT is a useful diagnostic test provided that diagnostic hypothesis and clinical question are appropriate.

Paradigms for Recording Cognitive Brain Electrical Activity

Human event-related potentials reflect cognitive processing, and are normally elicited by external events, such as acoustic sounds or visual stimuli. As such they provide an opportunity to study normal and abnormal brain function noninvasively, at sub-second resolution. Advances in multimedia technology permit specialists in informatics and neuropsychology to co-operate in the design and implementation of paradigms, which influence ERP components. The paper illustrates the progression from standard paradigms such as the auditory oddball, which can be used to study memory update through to contingent negative variation and three condition, visual paradigms which can be used to study cognitive and emotional responses. Data from a study investigating the comparative processing of target pictures and words illustrate how external stimuli influence the later cognitive potentials.

Abstract DPOC-003: DIFFERENTIAL PROTEIN EXPRESSION ANALYSIS OF SV40–IMMORTALIZED OVARIAN SURFACE, SV40–IMMORTALIZED FALLOPIAN TUBE AND OVARIAN CANCER SUBTYPE CELL LINE SECRETOMES BY ITRAQ®

BACKGROUND: In 2016, an estimated 22,280 new cases of ovarian cancer will be diagnosed with more than 14,000 women succumbing to the malignancy. These figures have not changed in the last decade. During this time new ovarian cancer models have been refined that involve either the fallopian tube or ovarian surface epithelial cells as the origin for tumorigenesis. With refined proteomics methodology, identification of new secreted biomarkers may be revealed that are specific to a primary fallopian tube or ovarian surface epithelium origin and may ultimately aid in the diagnosis, prognosis or therapy of ovarian cancer patients.

EXPERIMENTAL PROCEDURES: The secretomes of eight cell lines, represented by SV40 immortalized fallopian tube (FT-194, FT-190), SV40 immortalized ovarian surface epithelium (1816-575), low-grade serous adenocarcinoma (HEY), high-grade serous adenocarcinoma (TOV-1946), clear cell adenocarcinoma (TOV21G), cisplatin-sensitive high-grade serous adenocarcinoma (A2780-S) and cisplatin-resistant high-grade serous adenocarcinoma (A2780-CP), were submitted for isobaric tagging for relative and absolute quantification (iTRAQ®) differential expression analysis. Briefly, each of the eight secretomes were trypsin-digested and labeled with one of eight iTRAQ® 8-plex reagents and subsequently submitted for either two-dimensional capillary liquid chromatography direct data dependent peptide tandem mass spectrometry on an Orbitrap Velos system or one-dimensional mass spectrometry analysis.

RESULTS: 456 proteins were identified with the one-dimensional analysis with 2 distinct peptides. 2069 distinct differentially expressed proteins were identified in the two dimensional analysis. Initial relative differential expression rate comparisons of control cell lines, FT-194, FT-190 and 1816-575 versus ovarian cancer subtype and therapy-associated cell lines, HEY, TOV1946, TOV21G, A2780S and A2780CP, are promising. Four proteins were increased greater than three-fold across all ovarian cancer cell lines compared to normal fallopian tube and ovarian surface epithelial control cell lines: stromelysin-1, pigment epithelium-derived factor, matrix metalloproteinase-9 and receptor expression-enhancing protein 6. Large scale inferential statistical methodology will be used to differentiate cell lines.

Citation Format: Yaling Zhou PhD, Daniel Brooks, PhD, Sumana Dey PhD, LeeAnn Higgins, PhD, Todd Markowski, BSc, Chad Hamilton MD, Robin Howard, MA, Sorana Raiciulescu MSc, Amy Skubitz PhD, John D. Andersen DO. DIFFERENTIAL PROTEIN EXPRESSION ANALYSIS OF SV40–IMMORTALIZED OVARIAN SURFACE, SV40–IMMORTALIZED FALLOPIAN TUBE AND OVARIAN CANCER SUBTYPE CELL LINE SECRETOMES BY ITRAQ® [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr DPOC-003.