The underwater soundscape of the North Sea

As awareness on the impact of anthropogenic underwater noise on marine life grows, underwater noise measurement programs are needed to determine the current status of marine areas and monitor long-term trends. The Joint Monitoring Programme for Ambient Noise in the North Sea (JOMOPANS) collaborative project was funded by the EU Interreg to collect a unique dataset of underwater noise levels at 19 sites across the North Sea, spanning many different countries and covering the period from 2019 to 2020. The ambient noise from this dataset has been characterised and compared - setting a benchmark for future measurements in the North Sea area. By identifying clusters with similar sound characteristics in three broadband frequency bands (25-160 Hz, 0.2-1.6 kHz, and 2-10 kHz), geographical areas that are similarly affected by sound have been identified. The measured underwater sound levels show a persistent and spatially uniform correlation with wind speed at high frequencies (above 1 kHz) and a correlation with the distance from ships at mid and high frequencies (between 40 Hz and 4 kHz). Correlation with ocean current velocity at low frequencies (up to 200 Hz), which are susceptible to nonacoustic contamination by flow noise, was also evaluated. These correlations were evaluated and simplified linear scaling laws for wind and current speeds were derived. The presented dataset provides a baseline for underwater noise measurements in the North Sea and shows that spatial variability of the dominant sound sources must be considered to predict the impact of noise reduction measures.

Contrast echocardiography: a practical guideline from the British Society of Echocardiography

Ultrasound contrast agents (UCAs) have a well-established role in clinical cardiology. Contrast echocardiography has evolved into a routine technique through the establishment of contrast protocols, an excellent safety profile, and clinical guidelines which highlight the incremental prognostic utility of contrast enhanced echocardiography. This document aims to provide practical guidance on the safe and effective use of contrast; reviews the role of individual staff groups; and training requirements to facilitate its routine use in the echocardiography laboratory.

The athlete's heart: insights from echocardiography

The manifestations of the athlete's heart can create diagnostic challenges during an echocardiographic assessment. The classifications of the morphological and functional changes induced by sport participation are often beyond 'normal limits' making it imperative to identify any overlap between pathology and normal physiology. The phenotype of the athlete's heart is not exclusive to one chamber or function. Therefore, in this narrative review, we consider the effects of sporting discipline and training volume on the holistic athlete's heart, as well as demographic factors including ethnicity, body size, sex, and age.

British Society of Echocardiography guideline for the transthoracic echocardiographic assessment of cardiac amyloidosis

These guidelines form an update of the BSE guideline protocol for the assessment of restrictive cardiomyopathy (Knight et al. in Echo Res Prac, 2013). Since the original recommendations were conceived in 2013, there has been an exponential rise in the diagnosis of cardiac amyloidosis fuelled by increased clinician awareness, improvements in cardiovascular imaging as well as the availability of new and effective disease modifying therapies. The initial diagnosis of cardiac amyloidosis can be challenging and is often not clear-cut on the basis of echocardiography, which for most patients presenting with heart failure symptoms remains the first-line imaging test. The role of a specialist echocardiographer will be to raise the suspicion of cardiac amyloidosis when appropriate, but the formal diagnosis of amyloid sub-type invariably requires further downstream testing. This document seeks to provide a focused review of the literature on echocardiography in cardiac amyloidosis highlighting its important role in the diagnosis, prognosis and screening of at risk individuals, before concluding with a suggested minimum data set, for use as an aide memoire when reporting.

Real world hospital costs following stress echocardiography in the UK: a costing study from the EVAREST/BSE-NSTEP multi-entre study

BACKGROUND

Stress echocardiography is widely used to detect coronary artery disease, but little evidence on downstream hospital costs in real-world practice is available. We examined how stress echocardiography accuracy and downstream hospital costs vary across NHS hospitals and identified key factors that affect costs to help inform future clinical planning and guidelines.

METHODS

Data on 7636 patients recruited from 31 NHS hospitals within the UK between 2014 and 2020 as part of EVAREST/BSE-NSTEP clinical study, were used. Data included all diagnostic tests, procedures, and hospital admissions for 12 months after a stress echocardiogram and were costed using the NHS national unit costs. A decision tree was built to illustrate the clinical pathway and estimate average downstream hospital costs. Multi-level regression analysis was performed to identify variation in accuracy and costs at both patient, procedural, and hospital level. Linear regression and extrapolation were used to estimate annual hospital cost-savings associated with increasing predictive accuracy at hospital and national level.

RESULTS

Stress echocardiography accuracy varied with patient, hospital and operator characteristics. Hypertension, presence of wall motion abnormalities and higher number of hospital cardiology outpatient attendances annually reduced accuracy, adjusted odds ratio of 0.78 (95% CI 0.65 to 0.93), 0.27 (95% CI 0.15 to 0.48), 0.99 (95% CI 0.98 to 0.99) respectively, whereas a prior myocardial infarction, angiotensin receptor blocker medication, and greater operator experience increased accuracy, adjusted odds ratio of 1.77 (95% CI 1.34 to 2.33), 1.64 (95% CI 1.22 to 2.22), and 1.06 (95% CI 1.02 to 1.09) respectively. Average downstream costs were £646 per patient (SD 1796) with significant variation across hospitals. The average downstream costs between the 31 hospitals varied from £384-1730 per patient. False positive and false negative tests were associated with average downstream costs of £1446 (SD £601) and £4192 (SD 3332) respectively, driven by increased non-elective hospital admissions, adjusted odds ratio 2.48 (95% CI 1.08 to 5.66), 21.06 (95% CI 10.41 to 42.59) respectively. We estimated that an increase in accuracy by 1 percentage point could save the NHS in the UK £3.2 million annually.

CONCLUSION

This study provides real-world evidence of downstream costs associated with stress echocardiography practice in the UK and estimates how improvements in accuracy could impact healthcare expenditure in the NHS. A real-world downstream costing approach could be adopted more widely in evaluation of imaging tests and interventions to reflect actual value for money and support realistic planning.

Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society

Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.

Health workforce perceptions on telehealth augmentation opportunities

BACKGROUND

The availability and use of telehealth to support health care access from a distance has expanded in response to the COVID-19 pandemic. Telehealth services have supported regional and remote health care access for many years and could be augmented to improve health care accessibility, acceptability and overall experiences for both consumers and clinicians. This study aimed to explore health workforce representatives' needs and expectations to move beyond existing telehealth models and plan for the future of virtual care.

METHODS

To inform recommendations for augmentation, semi-structured focus group discussions were held (November-December 2021). Health workforce representatives with experience in health care delivery via telehealth across country Western Australia were approached and invited to join a discussion.

RESULTS

Focus group participants included 53 health workforce representatives, with between two and eight participants per discussion. In total, 12 focus groups were conducted: seven were specific to regions, three with staff in centralised roles, and two with a mixture of participants from regional and central roles. Findings identified four key areas for telehealth augmentation: improvements required to existing service practice and processes; equity and access considerations; health workforce-focussed opportunities; and consumer-focussed opportunities.

CONCLUSIONS

Following the onset of the COVID-19 pandemic and the rapid increase in health services delivered via telehealth modalities, it is timely to explore opportunities to augment pre-existing models of care. Workforce representatives consulted in this study suggested modifications to existing process and practice that would improve the current models of care, and recommendations on ways to improve clinician and consumer experiences with telehealth. Improving experiences with virtual delivery of health care is likely to support continued use and acceptance of this modality in health care delivery.

Liver Disease Among Patients with Psoriasis: The Malaysian Psoriasis Registry

BACKGROUND

Therapeutic options for psoriasis may be limited for patients with concomitant liver disease.

OBJECTIVE

We aim to report the frequency of liver disease among psoriasis patients, describe the clinical features, treatment modalities and quality of life.

METHODS

This was a multi-center cross-sectional study of psoriasis patients notified to the Malaysian Psoriasis Registry (MPR) from January 2007 to December 2018.

RESULTS

Of 21,735 psoriasis patients, 174 (0.8%) had liver disease. The three most common liver diseases were viral hepatitis (62.1%), fatty liver (14.4%) and liver cirrhosis (10.9%). The male-to-female ratio was 3.8:1. Mean age of onset of psoriasis was higher in those with liver disease compared to those without (37.25 ± 13.47 years vs 33.26 ± 16.96 years, p < 0.001). Psoriasis patients with liver disease had a higher rate of dyslipidemia (27.5%vs16.4%, p < 0.001), hypertension (33.9%vs23.7%, p = 0.002), diabetes mellitus (22.4%vs15.9%, p = 0.021) and HIV infection (5.3%vs0.4%, p < 0.001) compared to those without liver disease.They were also more likely to have severe disease (BSA > 10% and/or DLQI > 10) (59.3%vs49.9%, p = 0.027), psoriatic arthropathy (21.1%vs13.0%, p = 0.002), and nail involvement (78.2%vs56.1%, p < 0.001) compared to those without liver disease. The use of phototherapy (8.4%vs2.6%, p < 0.001), acitretin (7.3%vs2.8%, p < 0.001) and cyclosporin (3.0%vs0.7%, p < 0.001) were significantly higher in the group with liver disease. The mean Dermatology Life Quality Index were similar in both groups (9.69 ± 7.20vs9.62 ± 6.75, p = 0.88).

CONCLUSIONS

The frequency of psoriasis patients with liver disease in MPR was 0.8%. Psoriasis patients with liver disease were more likely to be male, had a higher rate of co-morbidities, severe disease, nail and joint involvement than those without liver disease.

332 THE PATIENT EXPERIENCE OF THE OLDER PERSONS REHAB AT HOME (OPRAH) SERVICE

Background

The Older Persons Rehab at Home (OPRAH) team is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. This provides rehabilitation in the patients’ own home and accelerates discharge from the acute care sector. In this study patient and carer experiences of the service were explored.

Methods

Patients were sent a postal questionnaire after discharge from the service to collect information on the patient experience of the OPRAH service. The following measures were collected: satisfaction with the service, experience of interacting with therapy staff, involvement in shared goal setting and achievement of rehabilitation goals. Data from participants who responded to feedback questionnaires from the first 12 months of the service were analysed using descriptive statistics.

Results

Ninety-five participants were sent feedback questionnaires with 31 responses received (33%). 96% of participants reported that they were satisfied with the service, with the same proportion expressing that they both felt they were treated with respect and dignity and that they had confidence and trust in the staff. All respondents felt that they could understand the answers to any questions they had while receiving rehabilitation and 92% of participants understood their rehabilitation goals, with 88% of participants feeling they achieved their rehabilitation goals. 88% of participants felt they were adequately involved in their care planning with 83% of participants feeling their family members had ample opportunity to ask questions during their rehabilitation experience. Results did not different by age group of patient or by time with the service.

Conclusion

In this structured evaluation of the OPRAH team participants highly rated the service. Our results highlight that this integrated approach to care allowed patients to be involved in shared goal setting with the majority of patients satisfied that they achieved their goals.

311 FROM ONE FRONT DOOR TO ANOTHER: OUTCOMES OF PATIENTS DIRECTLY DISCHARGED FROM THE FRAILTY AT THE FRONT DOOR SERVICE

Background

The Frailty at the Front Door service is a novel service that provides comprehensive geriatric assessment in the emergency department for older adults who have an unplanned emergency presentation to hospital. It is important to monitor outcomes of patients discharged by the service to ensure appropriate patient selection.

Methods

Patients over the age of 75 with a Manchester Triage Score of between three and five and a possible frailty syndrome are eligible for review by the service. After initial review patients are either discharged directly or recommended for admission. We reviewed the outcomes of patients who were discharged directly after Emergency Department (ED) assessment by the service.

Results

Discharge disposition was available for review in 413 (95%) of patients since initiation of the service in October 2021. 30% (n= 122) of patients were discharged directly after initial ED review. Elevated 4AT score (p = 0.002) but not frailty (p = 0.80) was associated with decreased chances of direct discharge. Of patients discharged directly from ED 13% were reviewed post discharge by the community integrated care team (GICOP), with 43% of these reviews taking place within 30 days. Overall, 16% of patients discharged directly represented to ED within 30 days. There was a trend towards lower rates of representation to ED among patients who were seen by GICOP after discharge from ED (p = 0.12).

Conclusion

There was a high rate of direct discharge after review by the service, with low rates of representation to hospital. While limited by low numbers there was a trend towards lower representation rates in patients reviewed post-discharge by the integrated care team. Future quality improvement initiatives will aim to improve the integration between the services and highlighting patients who would benefit from more timely reviews.

225 OLDER PERSONS REHAB AT HOME (OPRAH) INDICATES AN EFFECTIVE ALTERNATIVE PATHWAY TO INPATIENT REHABILITATION

Background

Older adults have longer hospital stays, higher incidence of nosocomial complications and higher readmissions rates. Older persons rehabilitation at home (OPRaH) is a novel service developed to provide patients with intensive domiciliary based therapy to regain function, mobility and social care goals. OPRaH offers a comprehensive geriatric and interdisciplinary approach. The model enables a safe and accelerated discharge from acute care to home.

Methods

Patients are identified and screened by a team coordinator. On Discharge to OPRaH the following measures were collected; basic demographics, referral source, clinical frailty score and Functional Independence Measures (FIM). Outcomes evaluated are the FIM change, readmission rates, length of inpatient stay savings and time on the service. Data from the first year of operation was analysed using descriptive statistics.

Results

109 patients have undergone rehabilitation with the service with a median age of 82 years (63-103 range). Over two thirds (68%) were classified as frail, with 44% living alone. An injurious fall was the most common reason for index hospitalisation (50%). Referral source was inpatient acute medical team in 50% of cases, with 21% from acute geriatrics , 13 % ortho geriatrics, 13% surgical. Average functional independence measure scores improved from 89 to 102 (p = 0.007). There was no difference in the magnitude of improvement by frailty status (13 vs 14, p = 0.85). The average length of stay saving was 7 days per case, with a total of 757 days saved in one year. Readmission rate within 30 days was 9.3 %. Participants highly rated the service through structured evaluation.

Conclusion

This novel service provides a valuable intervention to a wide case-mix of older adults with evidence of improvements in formal markers of functional impairment after intervention. Referral was based on definable rehabilitation goals and not just on frailty status, age, or gender.

342 THE DISCRIMINATORY VALUE OF ANP-LED CGA ON PATIENT REPORTED SYMPTOMS AND IMPACT ON CARERS: A CROSS-SECTIONAL STUDY

Background

Comprehensive Geriatric Assessment (CGA) is a cornerstone in geriatric care. Objective findings from CGA may differ to patient and carer reported symptoms. This study compared patient reported symptoms with objective metrics collected during CGA and explored the relationship with carer burnout.

Methods

Cross-sectional study of patients attending an Advanced Nurse Practitioner (ANP)-led integrated care clinic. Patient-reported geriatric syndromes included low mood, memory concerns, incontinence, falls or dizziness. CGA metrics collected included Barthel Index, Lawton IADLs, MOCA scores, Geriatric depression scale scores, Rockwood Clinical Frailty Scale (CFS) scores and presence or absence of carer burnout. Descriptive statistics were used to compare the relationship between these variables and logistic regression explored the magnitude of association with carer burnout.

Results

We reviewed 99 CGAs over three months. Median age was 81 (IQR 75–86) with 62% female. Cognitive impairment was present in 96% of patients. Self-reported memory trouble was associated with lower MOCA scores (9 vs 23, p &lt; 0.001) and the presence of dizziness was associated with an increased prevalence of falls (89% vs 24%, &lt; 0.001). The presence of incontinence and functional dependency on IADL were both associated with carer strain and a larger magnitude of association with carer strain was seen with increasing frailty (OR 13.7, 95% CI 3.8-58.8 for moderate to severe frailty) than moderate to severe cognitive impairment (OR 8, 95% CI 3.0–24.1)

Conclusion

Older people reported a wide range of symptoms often subtle, some of which are unmasked during CGA. The resultant frailty syndromes often represent increasing degrees of functional impairment impacting on patient and carer quality of life. Striking the balance between patient reported symptoms and objective measurement is important to allow individualised care pathways to be developed as well as highlighting patients at risk of functional and cognitive decline.

355 PREDICTORS OF HOME SUPPORT SERVICES AND THE CONSEQUENCES OF MISMATCH BETWEEN ALLOCATED AND RECEIVED SERVICES IN COGNITIVELY-IMPAIRED OLDER ADULTS

Background

Home support services aim to support older people to remain at home. Despite substantial investment in home support hours (€600 million), this has not translated into increased carers on the ground for older people. We aimed to report patterns of home support service utilisation in older patients with memory problems, and identify any mis-matches between allocated and received hours, and the impact on patients and caregivers.

Methods

Retrospective analysis of consecutive patients referred to community geriatric clinic from January 2021 to May 2022. 95/104 patients who were identified were suitable for inclusion.

Results

Participants had a median age of 82 (IQR 78-86) of whom 57% were female (n=54). 80% (n=76) were frail (CFS ≥4), with 82% dependent for IADLs (Lawton-Brody IADL Scale ≤6). Median MOCA score was 18, with 44% having moderate to severe cognitive impairment (MOCA ≤17). 40% of patients lived with alone (n=38). 52% (n=49) received formal home supports while 80% (n=76) had an informal carer. 37% (n=18) had a mismatch between hours allocated and hours received. There was a significant difference between median hours of care allocated (7) and median hours of care received (5), p &lt;0.001. Increasing age and frailty, worsening cognitive and functional impairment and living status (living alone) predicted allocation of home supports. Patients who lived with family members were 3 times more likely not to receive allocated hours (OR 3.84 (95% CI 1.2–13.7))

Conclusion

In this vulnerable population with cognitive and functional decline, just over half received formal home support hours. A large proportion experienced significant mismatch between allocated and received hours. Family and informal caregivers often have to fill gaps, adding to existing carer strain. Future models of home support should prioritise early intervention for people with IADL loss to remain independent at home and broaden of the scope of practice of carers to facilitate this.

Drowning in antibiotics

INTRODUCTION

The National Confidential Enquiry into Perioperative Deaths (NCEPOD) report recommended that 'fluid prescribing be given the same value as drug prescribing', yet fluid prescription is commonly delegated to junior doctors despite being a notoriously challenging topic. When antibiotics are given as an infusion they are diluted in 100ml of fluid, which is often unaccounted for when thinking about a patient's fluid requirements. This closed-loop audit aimed to assess first, intravenous (IV) fluid therapy and second, electrolyte prescribing compliance with National Institute for Health and Care Excellence (NICE) guidelines, with and without the additional fluid given with antibiotic administration.

METHODS

Two retrospective audits were performed. Total fluid and electrolyte volume received with and without antibiotic fluids was correlated with recommendations in the NICE guidelines. Between cycles 1 and 2, potassium chloride with sodium chloride and glucose (PSG) was introduced as an alternative to IV maintenance fluid, and bolusing of antibiotics was mandatory.

RESULTS

When analysing total fluid volume input per day, 10.4% and 7.45% of patients met their fluid requirement accurately in the first and second cycles, respectively. Within cycle 1, the mean total additional fluid that was given over 3 days with antibiotics was 1,572.73ml. In cycle 2, this decreased to 469.44ml when antibiotics were given as a bolus.

CONCLUSIONS

In this closed-loop audit we noted that patients receiving IV fluids and IV antibiotics received too much additional fluid when the antibiotic dilution fluid was taken into account. Additional fluid was reduced alongside the proportion of electrolyte complications when bolusing of antibiotics was introduced. We recommend that that all nurses are trained to give antibiotics as a bolus because it can help to reduce fluid-related complications.

Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.

Circulating extracellular vesicles correlate with nocturnal blood pressure and vascular organ damage and may serve as an integrative biomarker of vascular health

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Council on Science and Technology, Mexico (CONACYT).

Background

 Elevated blood pressure (BP) has been associated with increased levels of circulating extracellular vesicles (EVs) which could potentially serve as a novel integrative biomarker for vascular health.

Purpose

  The present study therefore aimed to assess the relationship between increased EV release, blood pressure and macrovascular organ damage.

Methods

A total of 83 patients with BP ranging from normal to high were included in the present analysis. Extracellular vesicles were evaluated by flow cytometry (CD41+/Annexin v+). BP evaluation included unobserved automated office BP (AOBP) and ambulatory BP monitoring (24hr-BP, day-BP and night-BP). Carotid-femoral pulse wave velocity (PWV) was measured by the SphygmoCor XCEL as a marker of macrovascular organ damage.

Results

Hypertensive patients (n = 73, BP 132.9 ± 17.4/79.4 ± 14.0) compared to normotensive patients (n = 10, BP 113.4 ± 10.4/71.3 ± 9.6) had higher levels of EVs (10.6 ± 8.2 vs 6.5 ± 4.5 EV/µL; p = 0.02). Circulating EVs were positively correlated with nocturnal systolic BP (r= 0.3; p = 0.01) and night-time dipping (r= -0.26; p = 0.02) in univariable analysis. In contrast, systolic AOBP, 24hr-BP and day-BP did not show significant associations. No significant correlations were found with diastolic BP. EVs were significantly correlated with PWV (r = 0.26 p = 0.02).While all BP measures were associated with PWV, average systolic night-time BP demonstrated the strongest correlation with PWV (r = 0.55; p &lt; 0.001) compared to systolic AOBP (r = 0.51; p &lt; 0.001), 24hr-BP (r = 0.46; p &lt; 0.001), and average day-BP (r = 0.48; p &lt; 0.001). Multivariable regression models confirmed  robustness of the models.

Conclusion

We demonstrate a close positive relationship between a variety of BP measures and levels of circulating EVs as well as macrovascular damage assessed by PWV. The strongest correlation with EVs was found for average systolic nocturnal BP. Given that average nocturnal BP is the strongest predictor of CV events, EVs may serve as a useful integrative marker of vascular health and useful biomarker for CV risk assessment, a proposition that will need to be tested in prospective clinical trials. Abstract Figure.

90 IMPACT OF AN INTEGRATED CARE MODEL FOR OLDER PERSONS: EVALUATING A PILOT PROGRAMME

Background

In September 2019 Sláintecare helped establish an Integrated Care team for Older People. The aim of this service was to provide a Comprehensive Geriatric Assessment (CGA) to older people within a community network. Service user experience/feedback are critically important for development of a team and a service. To give service users a platform to evaluate the service a patient experience survey was conducted.

Methods

The survey was designed by the multidisciplinary team, consisting of 13 closed/3 open questions. A Likert scale was utilised for closed questions and thematic analysis for open questions. A question on impact of COVID-19 was also included.

150 of the 950 service users who received a CGA from June 2020 to June 2021 were selected randomly and invited to participate in the postal survey. All participants received a covering letter, questionnaire and a stamped address envelope to return their completed surveys.

Results

47% response rate (71/150). 77% were aged ≥75. 52% completed the survey themselves, 48% required assistance. 61% attended more than twice and most would prefer to attend a local spoke clinic. 96% agreed/strongly agreed that they were satisfied with the service. 99% felt they were treated with dignity/respect and had confidence in the service. 93% agreed that they were involved in care decisions. 82% reported their carers had the opportunity to discuss concerns. Themes emerging included importance of care close to home, avoiding acute hospital, difficulty parking at tertiary centres. 42% highlighted isolation and loneliness due to COVID-19 as a major issue.

Conclusion

Service users had an overwhelmingly positive experience especially when care was delivered in clinics close to their homes. Development of the hub and spoke model is acceptable and feasible to older people and their carers’ in this region and will be the focus for expansion of this service.

33 ARE CLINICAL TRIALS RANDOMISING HOUSEHOLDS TO LIFESTYLE INTERVENTIONS FOR THE PREVENTION OF COGNITIVE DECLINE FEASIBLE?

Background

Dementia is increasing in prevalence worldwide. Several lifestyle factors have been identified as targets for dementia prevention, which may be more effective if targeted at households instead of an individual. To date there have been no clinical trials randomising households to lifestyle interventions of sleep, diet and/or physical activity to prevent cognitive decline. To inform future studies, qualitative approaches can give valuable in-depth insights into the values and beliefs of all household members towards behavioural change.

Methods

Semi structured interviews were carried out among eight households affected by cognitive impairment. Interview content was analysed, and important themes identified.

Results

Eighteen participants were interviewed within household pods. Among those, eight had cognitive impairment and the remainder were spouses or first-degree relatives living in the same home. Several themes of interest emerged including household members without dementia were more likely to report poor sleep habits; sleep was perceived the hardest behaviour to change; although most participants had healthy diets, most were interested in making a change and felt there was a strong link with nutrition and cognition; physical activity is challenging to adapt due to lack of motivation and focus when individuals are cognitively impaired and motivation to pursue physical activity in households centred on relaxation and social interaction.

Conclusion

This study identified beliefs and preferences of households towards lifestyle intervention trials. Barriers to study participation including risk of harm, complexity of intervention and deviation from routine emerged during discussions. Findings from this study should be used to inform future clinical trial protocols and future qualitative studies should explore acceptability and feasibility of digital intervention applications.

112 INTEGRATED CARE PROGRAMME FOR OLDER PEOPLE (ICPOP) IN A RURAL SETTING—ROLE OF ADVANCED NURSE PRACTITIONER (ANP)

Background

Sláintecare advocates for right care, in the right place at the right time. ANPs for Older Persons in the community are uniquely placed to deliver care as close as possible to the older person’s home and to lead a holistic, flexible model of care minimising admission to acute care and maximising existing local resources. A pilot programme aimed at providing ANP led comprehensive geriatric assessment (CGA) (with Geriatrician support) to older people in a defined area commenced in June 2019. This pilot was part of a larger Hub and Spoke model funded by Sláintecare which gave additional MDT support.

Methods

A referral template was designed. Criteria for referral included; age &gt; 75 years, Rockwood Frailty Scale 4–6 (focusing on Falls, Cognitive Impairment and Complex Frailty). Older people on the cusp of requiring long term care (LTC) were also prioritised. A prospective database of patients was maintained by the ANP to evaluate the service.

Results

From June 2019 to August 2021, 156 patients received an ANP led CGA, mostly conducted in the home. 247 reviews were conducted at the local spoke clinic and 46 joint ANP/Geriatrician home visits. Majority of referrals were from GP (n = 69), hospital (n = 30), LTC reviews (n = 22) and Community Nursing Units (CNUs) (n = 19). 449 outpatient appointments have been removed from the tertiary referral centre. Independent case load management from the ANP includes further appointments, telephone follow up/advice and she is a point of contact where crises arise before referral to acute services. 99% of patients surveyed reported satisfaction with the service especially the ease of local access and home visits.

Conclusion

Older Persons’ ANP can provide longitudinal care pathways for older adults in the community in conjunction with ICPOP and local CNUs, intervening before crises emerge and providing continuity of care and an alternative to acute care.

102 PROMOTING BRAIN HEALTH IN AN INTEGRATED CARE OUTREACH PROGRAMME

Background

Lifestyle modifications, in older at risk populations, may prevent or slow the rate of cognitive decline. Promotion of brain health has been recommended by the WHO and other governing bodies. Supporting patients in making these lifestyle changes, however, can be complex. Generic guidance may not apply to all in a heterogenous and frail patient cohort, when physical mobility may be limited and weight loss/nutrition a concern. We sought to review current practices and barriers to brain health guidance in a regional integrated care outreach programme (ICOP).

Methods

From March–June’21 the comprehensive geriatric assessment (CGA) of consecutive patients were reviewed. Those presenting with cognitive complaints, for their first assessment, were included. Demographic data and data on screening for hearing impairment and sleep disturbance were collected, in addition to information on physical activity and nutritional risk. Whether information and guidance on aspects of brain health was given was also assessed.

Results

30 patients met the inclusion criteria. The mean age was 80.3 and the mean clinical frailty scale (CFS) was 4.4. Hearing impairment was present in 20% (n = 6), with no information available in 10% (n = 3). All patients were screened for sleep disturbance, with 13% (n = 4) not fully satisfied with their sleep. Mobility aids, assistance or supervision were required in 40% (n = 12), and 23% (n = 7) were at medium or high malnutrition risk. Only 30% (n = 9) cooked their own meals. Generic brain health advice, or advice about sleep was documented in 30 (n = 9), without hearing impairment advice documented in any patient.

Conclusion

There are several barriers to brain health advice in the ICOP setting, with only 30% of patients having brain health advice documented. We are currently developing patient information leaflets on brain health, that will take potential barriers into account. Dedicated and specific information on local hearing services is also in development, as part of an ongoing quality improvement project.

Long-term outcome of patients receiving haematopoietic allogeneic stem cell transplantation as first transplant for high-risk Hodgkin lymphoma: a retrospective analysis from the Lymphoma Working Party-EBMT

We analysed long-term outcome of patients receiving haematopoietic allogeneic stem cell transplantation (allo-HSCT) as a first transplant for high-risk Hodgkin lymphoma (HL). One hundred and ninety patients were included in this study, 63% of them had previously received brentuximab vedotin and/or checkpoint inhibitors. Seventy patients (37%) received an unrelated donor allo-HSCT, 99 (51%) had myeloablative conditioning (MAC) and 60% had in vivo T-cell/depleted grafts (TCD). The 100-day cumulative incidence (CI) of grade II-IV acute graft-versus-host disease (GVHD) was 25% and the 3-year CI of chronic GVHD was 38%. The 3-year CI of non-relapse mortality (NRM) and relapse rate were 21% and 38% respectively. After a median follow-up of 58 months, 3-year overall survival (OS) and progression-free survival (PFS) were 58% and 41% respectively. Multivariate analysis showed that, in comparison to reduced-intensity conditioning regimens with or without TCD, MAC using TCD had similar NRM and a lower risk of relapse leading to significantly better OS and PFS. MAC without TCD was associated with higher NRM and worse survival outcomes. These results suggest that in patients with high-risk HL and candidates of allo-HSCT, a MAC strategy with TCD might be the best option.

Simultaneously measured interarm blood pressure difference is not associated with pulse wave velocity in a clinical dataset of at-risk hypertensive patients

Background/Introduction

Recent analysis of systolic inter-arm differences in blood pressure from the INTERPRESS-IPD Collaboration suggest an association with increased all-cause mortality, cardiovascular mortality and cardiovascular events, previous studies have demonstrated associations with other risk parameters.

Purpose

We aimed to reproduce these associations in a cohort of 199 treated, at-risk, hypertensive patients with pulse wave velocity (PWV) as a surrogate marker of cardiovascular (CV) damage.

Methods

Simultaneously measured Inter-arm blood pressure differences, 24 hour ambulatory BP and PWV were measured in 199 treated patients of a tertiary hospital hypertension outpatient clinic. Associations between systolic inter-arm BP difference and PWV were analyzed with uni- and multivariate regression models.

Results

Out of 199 participants, 90 showed an Inter-arm blood pressure difference of more than 5 mmHg. The Inter-arm difference was not associated with PWV. Furthermore, neither observed single blood pressure measurements nor 24 hour ambulatory blood pressure was associated with Inter-arm blood pressure differences.

Conclusion

In our clinical patient cohort we failed to observe an association between inter-arm BP differences and PWV. Mode of assessment, study design or the sample characteristics of this treated, hypertensive cohort may explain the negative results. The limited sample size of the study poses a challenge to the detection of smaller effects in our study.

Funding Acknowledgement

Type of funding sources: None.

1338 Bariatric Surgery as a Viable Treatment for Idiopathic Intracranial Hypertension: A Case Series

Introduction

Idiopathic Intracranial Hypertension (IIH) is a significant cause of preventable blindness. Patients also suffer from debilitating headaches, pulsatile tinnitus, nausea, vomiting, photophobia, and radicular pain. If IIH continues to rise as predicted, treatment cost will increase to 462.7 million GBP annually by 2030. Weight loss is the only proven disease-modifying therapy for reversal of IIH. Bariatric surgery is an attractive treatment option due to superlative weight loss and reversal of related comorbidities. The case series aims to raise awareness of bariatric surgery as a safe and effective treatment modality for IIH.

Method

The case series consists of a retrospective analysis of four patients with a pre-operative diagnosis of IIH. They were referred to our department for bariatric surgery between January to December 2018. They were followed up for a total of two years.

Results

In our case series, all four patients were females with a mean age of 34 years. Mean BMI reduced from 47.3 kg/m2 before surgery to 30 kg/m2 with an EWL of 76.4% at the end of two years after surgery. They all showed significant improvement or resolution in their symptoms related to IIH, and none of them required further CSF pressure reducing procedures afterwards.

Conclusions

Bariatric surgery is a safe and effective method of treating IIH. It is superior compared to medical management and CSF pressure reducing procedures which have high rates of recurrence.

1329 Can One Size Fit All: Is Laparoscopic Roux-En-Y Gastric Bypass the Best Bariatric Procedure for Treating Type 2 Diabetes Mellitus (T2DM)?

Introduction

Bariatric surgery produces superior weight loss and reversal of comorbidities in morbidly obese individuals compared to medical therapy alone. Laparoscopic Roux-en-Y gastric bypass (LRYGB) was traditionally considered to prolonged remission of T2DM compared to other procedures such as Laparoscopic Sleeve-Gastrectomy (LSG). But recently published studies seek to disprove this by emphasising on duration and severity of T2DM before surgery rather than the type of procedure. We aim to verify if the severity of T2DM and type of operation (LRYGB Vs LSG) influence remission rates.

Method

In this retrospective cohort study, 204 patients were diagnosed with T2DM pre-operatively and had undergone either LRYGB or LSG. We used the Individualised Metabolic Surgery Score (IMSS) tool to divide patients into mild, moderate, and severe categories.

Results

Results showed that of the 204 patients 15% (n = 31) had mild disease, 62%( n = 127) had moderate disease and 23% (n = 46) had severe disease. Remission rates in each category were as follows:

Conclusions

We agree that patients with longstanding and severe T2DM have low remission rates after bariatric surgery, probably due to diminished beta-cell reserve. It is in contrary to recent publications which recommend LSG over LRYGB in patients with severe disease. This evidence necessitates further prospective studies before deciding which is the best procedure for patients with severe and longstanding T2DM.

Psychosocial burden of patients with atopic dermatitis at two tertiary referral centres in Malaysia

BACKGROUND

Atopic dermatitis (AD) is a chronic pruritic skin disorder that affects up to 20% of children and 10% of adults. The disease course is unpredictable with periods of exacerbation and remission, thus having a significant impact on the mental health and quality of life (QOL). We evaluated the prevalence of anxiety and depression and their association with disease severity, QOL and their associated factors in adolescents (≥ 13 years old) and adults with AD.

METHODS

A cross-sectional study was conducted involving patients aged ≥ 13 years with AD who fulfilled the Hanifin and Rajka diagnostic criteria. These patients were recruited from Hospital Queen Elizabeth, Kota Kinabalu and Hospital Kuala Lumpur between January 2020 to March 2021. Assessment instruments used were Scoring for Atopic Dermatitis (SCORAD), Patient-Oriented Eczema Measure (POEM), Dermatology Life Quality Index (DLQI) and Hospital Anxiety and Depression Scale (HADS).

RESULTS

Of the 217 participants, 75 (34.6%) had mild eczema, 116 (53.5%) moderate eczema and 26 (12.0%) severe eczema with a mean SCORAD score of 30.4 (standard deviation [SD] = 4.70). Twenty-six (12.0%) and 17 (7.8%) had anxiety and depression, respectively. Patients with moderate to severe disease reported higher HADS-A (HADS-anxiety component), HADS-D (HADS-depression component), POEM, DLQI, itch, sleep loss and skin pain scores (p < 0.001 for all). Severe sleep loss (adjusted odd ratio [AOR] 12.41, p < 0.001) and hospitalisation in the past year (AOR 6.44, p = 0.004) were significant predictors for anxiety whereas those aged 41 to 60 (AOR 10.83, p = 0.020), having severe skin pain (AOR 6.12, p = 0.028), DLQI ≥ 10 (AOR 5.27, p = 0.002) and history of hospitalisation in the past year (AOR 12.73, p = 0.002) had increased risk for depression.

CONCLUSION

The prevalence of anxiety was 12.0% while depression was 7.8% in our cohort. AD renders a significant burden on mental health and QOL with a higher impact on those with more severe disease. The use of screening tools such as HADS and DLQI for assessment of mental health and QOL should be considered to address the multidimensional burden of AD.

Transthoracic echocardiography of hypertrophic cardiomyopathy in adults: a practical guideline from the British Society of Echocardiography

Hypertrophic cardiomyopathy (HCM) is common, inherited and characterised by unexplained thickening of the myocardium. The British Society of Echocardiography (BSE) has recently published a minimum dataset for transthoracic echocardiography detailing the core views needed for a standard echocardiogram. For patients with confirmed or suspected HCM, additional views and measurements are necessary. This guideline, therefore, supplements the minimum dataset and describes a tailored, stepwise approach to the echocardiographic examination, and echocardiography’s position in the diagnostic pathway, before advising on the imaging of disease complications and invasive treatments.

The significance of urgent ultrasound scan for shoulder dislocation in patients above the age of 40: A prospective British Elbow and Shoulder Society pathway implementation study

BACKGROUND

The highlight of the British Elbow and Shoulder Society pathway for the management of traumatic anterior shoulder instability is early imaging in patients aged over 40 years to assess rotator cuff integrity and early repair, if indicated to optimise function. The senior author set up a protocol in our institute to streamline the diagnostic process for this cohort of patients. This was a retrospective analysis from a prospectively collected database to highlight the importance of early specialist imaging.

METHODS

Our protocol is to perform urgent ultrasound scans for all suitable patients above 40 years after first-time traumatic shoulder dislocation. Demographics, associated injuries, ultrasound scan results, operations and functional outcomes were collated.

RESULTS

One year following the introduction of our protocol, 40 patients with a mean age of 67 (range, 42-89; SD = 13.1) had ultrasound. The incidence of full-thickness rotator cuff tears was 57.5% (n = 23). Eleven patients with confirmed full-thickness rotator cuff tears underwent surgery. The mean age of surgical patients was significantly younger than the non-surgical group (p = 0.004).

DISCUSSION

The use of early diagnostic imaging demonstrated a high incidence of full-thickness rotator cuff tears in this cohort of patients. This allowed early surgical repair to optimise function.

The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in Western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is, therefore, one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic, transoesophageal and exercise stress echocardiography play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease, and for helping to determine the appropriate timing and method of intervention. This guideline from the British Society of Echocardiography (BSE) describes the assessment of mitral regurgitation and mitral stenosis, and replaces previous BSE guidelines that describe the echocardiographic assessment of mitral anatomy prior to mitral valve repair surgery and percutaneous mitral valvuloplasty. It provides a comprehensive description of the imaging techniques (and their limitations) employed in the assessment of mitral valve disease. It describes a step-wise approach to identifying: aetiology and mechanism, disease severity, reparability and secondary effects on chamber geometry, function and pressures. Advanced echocardiographic techniques are described for both transthoracic and transoesophageal modalities, including TOE and exercise testing.

Echocardiographic assessment of aortic stenosis: a practical guideline from the British Society of Echocardiography

The guideline provides a practical step-by-step guide in order to facilitate high-quality echocardiographic studies of patients with aortic stenosis. In addition, it addresses commonly encountered yet challenging clinical scenarios and covers the use of advanced echocardiographic techniques, including TOE and Dobutamine stress echocardiography in the assessment of aortic stenosis.

British Society for Echocardiography and British Cardio-Oncology Society guideline for transthoracic echocardiographic assessment of adult cancer patients receiving anthracyclines and/or trastuzumab

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor (EGF) receptor (HER) 2-positive targeted treatment (e.g. trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

A47 SYNTHETIC HUMAN MILK OLIGOSACCHARIDES PREVENT EXPERIMENTAL NECROTIZING ENTEROCOLITIS VIA DIVERGENT TRANSCRIPTOMIC RESPONSES

Background

Breastmilk reduces the risk of necrotizing enterocolitis (NEC) in preterm infants, but the bioactive components mediating this effect are not well understood. Human milk oligosaccharides (HMOs) reduce NEC both in humans and in relevant animal models. However, it is unclear if there are functional differences between individual oligosaccharides.

Aims

The objective of this study was to compare the intestinal transcriptome responses of individual HMOs using complementary in vitro and in vivo models of NEC.

Methods

RNA sequencing was performed on Caco-2Bbe1 gut epithelial cells after exposure to commercially-purified 2’-fucosyllactose (2’FL), 3-fucosyllactose, 6’-siallyllactose, lacto-N-tetraose (LNT) or lacto-N-neotetraose for 24hr at 37°C for 24 h (n=3). Signaling pathways were analyzed in murine- and human-derived NEC enteroids by qPCR. To validate these findings, five-day-old mouse pups were orally gavaged formula with or without individual HMOs, followed by NEC induction with hypoxia (5% O2, 95% N2) and lipopolysaccharide (4 mg/kg/day). Coded ileal sections (n=6–7/group) were analyzed for mucosal injury by histology, immune fluorescence, immunohistochemistry, and gene expression via qPCR.

Results

The HMO transcriptome clustered into divergent functional categories including metabolic process, protein processing and responses to external stimuli. Each synthetic HMO induced a unique transcriptome and exhibited varying effects on the intestinal epithelial functions and biological pathways. This was confirmed in the murine model of NEC, as both LNT and 2FL mitigated NEC injury with comparable recovery of intestinal cell proliferation (Ki67) and expression of stem cells (Lgr5+). Both qPCR and immunofluorescence staining showed differences between 2FL- and LNT-fed pups in host inflammatory and immune responses.

Conclusions

This study demonstrates that synthetic HMOs ameliorate intestinal injury in experimental NEC. However, the mechanisms by which individual oligosaccharides act on the intestine differ, suggesting that single synthetic HMOs may not fully recapitulate the benefits of pooled HMOs. Future studies will further delineate structure-function relationships of synthetic HMOs on host intestinal innate and adaptive immune responses.

Funding Agencies

CIHRFerring Canada Medical Student Research grant

Impact of COVID-19 on UK stress echocardiography practice: insights from the EVAREST sites

Introduction

Healthcare delivery is being transformed by COVID-19 to reduce transmission risk but continued delivery of routine clinical tests is essential. Stress echocardiography is one of the most widely used cardiac tests in the NHS. We assessed the impact of the first (W1) and second (W2) waves of the pandemic on the ability to deliver stress echocardiography.

Methods

Clinical echocardiography teams in 31 NHS hospitals participating in the EVAREST study were asked to complete a survey on the structure and delivery of stress echocardiography as well as its impact on patients and staff in July and November 2020. Results were compared to stress echocardiography activity in the same centre during January 2020.

Results

24 completed the survey in July, and 19 NHS hospitals completed the survey in November. A 55% reduction in the number of studies performed was reported in W1, recovering to exceed pre-COVID rates in W2. The major change was in the mode of stress delivery. 70% of sites stopped their exercise stress service in W1, compared to 19% in W2. In those still using exercise during W1, 50% were wearing FFP3/N95 masks, falling to 38% in W2. There was also significant variability in patient screening practices with 7 different pre-screening questionnaires used in W1 and 6 in W2.

Conclusion

Stress echocardiography delivery restarted effectively after COVID-19 with adaptations to reduce transmission that means activity has been able to continue, and exceed, pre-COVID-19 levels during the second wave. Further standardization of protocols for patient screening and PPE may help further improve consistency of practice within the United Kingdom.

BSE and BCOS Guideline for Transthoracic Echocardiographic Assessment of Adult Cancer Patients Receiving Anthracyclines and/or Trastuzumab

The subspecialty of cardio-oncology aims to reduce cardiovascular morbidity and mortality in patients with cancer or following cancer treatment. Cancer therapy can lead to a variety of cardiovascular complications, including left ventricular systolic dysfunction, pericardial disease, and valvular heart disease. Echocardiography is a key diagnostic imaging tool in the diagnosis and surveillance for many of these complications. The baseline assessment and subsequent surveillance of patients undergoing treatment with anthracyclines and/or human epidermal growth factor receptor (HER) 2-positive targeted treatment (e.g., trastuzumab and pertuzumab) form a significant proportion of cardio-oncology patients undergoing echocardiography. This guideline from the British Society of Echocardiography and British Cardio-Oncology Society outlines a protocol for baseline and surveillance echocardiography of patients undergoing treatment with anthracyclines and/or trastuzumab. The methodology for acquisition of images and the advantages and disadvantages of techniques are discussed. Echocardiographic definitions for considering cancer therapeutics-related cardiac dysfunction are also presented.

Adapting the role of handheld echocardiography during the COVID-19 pandemic: A practical guide

The COVID-19 pandemic has altered our approach to inpatient echocardiography delivery. There is now a greater focus to address key clinical questions likely to make an immediate impact in management, particularly during the period of widespread infection. Handheld echocardiography (HHE) can be used as a first-line assessment tool, limiting scanning time and exposure to high viral load. This article describes a potential role for HHE during a pandemic. We propose a protocol with a reporting template for a focused core dataset necessary in delivering an acute echocardiography service in the setting of a highly contagious disease, minimising risk to the operator. We cover the scenarios typically encountered in the acute cardiology setting and how an expert trained echocardiography team can identify such pathologies using a limited imaging format and include cardiac presentations encountered in those patients acutely unwell with COVID-19.

Echocardiographic RV-E/e' for predicting right atrial pressure: a review

Right atrial pressure (RAP) is a key cardiac parameter of diagnostic and prognostic significance, yet current two-dimensional echocardiographic methods are inadequate for the accurate estimation of this haemodynamic marker. Right-heart trans-tricuspid Doppler and tissue Doppler echocardiographic techniques can be combined to calculate the right ventricular (RV) E/e′ ratio – a reflection of RV filling pressure which is a surrogate of RAP. A systematic search was undertaken which found seventeen articles that compared invasively measured RAP with RV-E/e′ estimated RAP. Results commonly concerned pulmonary hypertension or advanced heart failure/transplantation populations. Reported receiver operating characteristic analyses showed reasonable diagnostic ability of RV-E/e′ for estimating RAP in patients with coronary artery disease and RV systolic dysfunction. The diagnostic ability of RV-E/e′ was generally poor in studies of paediatrics, heart failure and mitral stenosis, whilst results were equivocal in other diseases. Bland–Altman analyses showed good accuracy but poor precision of RV-E/e′ for estimating RAP, but were limited by only being reported in seven out of seventeen articles. This suggests that RV-E/e′ may be useful at a population level but not at an individual level for clinical decision making. Very little evidence was found about how atrial fibrillation may affect the estimation of RAP from RV-E/e′, nor about the independent prognostic ability of RV-E/e′ . Recommended areas for future research concerning RV-E/e′ include; non-sinus rhythm, valvular heart disease, short and long term prognostic ability, and validation over a wide range of RAP.

Echocardiographic assessment of the tricuspid and pulmonary valves: a practical guideline from the British Society of Echocardiography

Transthoracic echocardiography is the first-line imaging modality in the assessment of right-sided valve disease. The principle objectives of the echocardiographic study are to determine the aetiology, mechanism and severity of valvular dysfunction, as well as consequences on right heart remodelling and estimations of pulmonary artery pressure. Echocardiographic data must be integrated with symptoms, to inform optimal timing and technique of interventions. The most common tricuspid valve abnormality is regurgitation secondary to annular dilatation in the context of atrial fibrillation or left-sided heart disease. Significant pulmonary valve disease is most commonly seen in congenital heart abnormalities. The aetiology and mechanism of tricuspid and pulmonary valve disease can usually be identified by 2D assessment of leaflet morphology and motion. Colour flow and spectral Doppler are required for assessment of severity, which must integrate data from multiple imaging planes and modalities. Transoesophageal echo is used when transthoracic data is incomplete, although the anterior position of the right heart means that transthoracic imaging is often superior. Three-dimensional echocardiography is a pivotal tool for accurate quantification of right ventricular volumes and regurgitant lesion severity, anatomical characterisation of valve morphology and remodelling pattern, and procedural guidance for catheter-based interventions. Exercise echocardiography may be used to elucidate symptom status and demonstrate functional reserve. Cardiac magnetic resonance and CT should be considered for complimentary data including right ventricular volume quantification, and precise cardiac and extracardiac anatomy. This British Society of Echocardiography guideline aims to give practical advice on the standardised acquisition and interpretation of echocardiographic data relating to the pulmonary and tricuspid valves.

A practical guideline for performing a comprehensive transthoracic echocardiogram in adults: the British Society of Echocardiography minimum dataset

Since cardiac ultrasound was introduced into medical practice around the middle twentieth century, transthoracic echocardiography has developed to become a highly sophisticated and widely performed cardiac imaging modality in the diagnosis of heart disease. This evolution from an emerging technique with limited application, into a complex modality capable of detailed cardiac assessment has been driven by technological innovations that have both refined 'standard' 2D and Doppler imaging and led to the development of new diagnostic techniques. Accordingly, the adult transthoracic echocardiogram has evolved to become a comprehensive assessment of complex cardiac anatomy, function and haemodynamics. This guideline protocol from the British Society of Echocardiography aims to outline the minimum dataset required to confirm normal cardiac structure and function when performing a comprehensive standard adult echocardiogram and is structured according to the recommended sequence of acquisition. It is recommended that this structured approach to image acquisition and measurement protocol forms the basis of every standard adult transthoracic echocardiogram. However, when pathology is detected and further analysis becomes necessary, views and measurements in addition to the minimum dataset are required and should be taken with reference to the appropriate British Society of Echocardiography imaging protocol. It is anticipated that the recommendations made within this guideline will help standardise the local, regional and national practice of echocardiography, in addition to minimising the inter and intra-observer variation associated with echocardiographic measurement and interpretation.

Bruton tyrosine kinase inhibitors for the frontline treatment of chronic lymphocytic leukemia

Chronic lymphocytic leukemia (cll) is the most commonly diagnosed adult leukemia in Canada. Biologic heterogeneity of cll between patients results in variable disease trajectories and responses to therapy. Notably, compared with patients lacking high-risk features, those with such features-such as deletions in chromosome 17p, aberrations in the TP53 gene, or unmutated immunoglobulin heavy chain variable region genes-experience inferior outcomes and responses to standard chemoimmunotherapy. Novel agents that target the B cell receptor signalling pathway, such as Bruton tyrosine kinase (btk) inhibitors, have demonstrated clinical efficacy and safety in patients with treatment-naïve cll, particularly those with high-risk features. However, given the current lack of head-to-head trials comparing btk inhibitors, selection of the optimal btk inhibitor for patients with cll is unclear and requires consideration of multiple factors. In the present review, we focus on the efficacy, safety, and pharmacologic features of the btk inhibitors that are approved or under clinical development, and we discuss the practical considerations for the use of those agents in the Canadian treatment landscape.

Individual and contextual predictors of retention in Special Olympics for youth with intellectual disability: who stays involved?

BACKGROUND

Despite the recognised benefits of sport, participation is often reported to be low for youth with intellectual disability (ID). The current study was the first to longitudinally examine sport retention in this population, a critical aspect of ensuring participation.

METHODS

Study participants were parents/caregivers of athletes with ID involved in community Special Olympics (SO), 11-22 years of age (N = 345). Participants completed an online survey in 2012 that included caregiver demographic and athlete intrapersonal, interpersonal and broader contextual variables. Retention rates for 2019 were determined using the SO provincial registration lists.

RESULTS

Of the 345 survey participants, 81.7% remained active athletes in 2019. Caregiver demographic and athlete intrapersonal factors were largely unrelated to retention. In contrast, retention was associated with the frequency and number of sports athletes participated in, the perceived psychosocial gains of SO involvement and the environmental supports that were available to facilitate participation; frequency of sport participation was the strongest predictor of remaining a registered athlete.

CONCLUSIONS

This study has implications for future initiatives aimed at increasing sport retention in a population that struggles to be engaged in sport. Efforts should focus on the athlete experience and sport-specific factors. Coaches and caregivers can foster positive experiences and play an important role in continued sport participation.