What makes an athlete? A scoping review: Assessing the use of the word athlete with anterior cruciate ligament rehabilitation review studies. Is there a standard?

The term athlete does not currently have an agreed definition or standardized use across the literature. We analyzed the use of the term "athlete" amongst review studies specific to Anterior Cruciate Ligament (ACL) rehabilitation to investigate if the term was justified in its use. A comprehensive review of a database was performed to identify review papers which used the term "athlete" in the title, and which were related to ACL rehabilitation and surveillance. These papers were analyzed and their source papers were extracted for review. Twenty-eight review papers were identified. Source studies were extracted and analyzed. After removal of duplicates 223 source papers were identified. Despite using the term "athlete" in the review study titles only 5/17 (10.7%) sufficiently justified the use of this term. The term athlete was used in 117/223 (52.5%) of the source studies. Of those, 78/117 source studies (66.7%) justified the term athlete. The remaining 39/117 (33.3%) papers where participants were stated to be athletes, gave no justification. The ambiguous use of the term athlete amongst published studies highlights the need for a definition or justification of the term to be used in studies. The lack of a standard definition leads to the potential for studies to dilute high quality data by the potentially differing rehabilitation requirements and access to resources available to those with varying exercise levels. The indiscriminate use of the term athlete could lead to participants with widely ranging physical activity levels being included in the same study, and being used to create clinical advice for all. Advice could potentially vary across those of differing physical activity levels.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

339 SURGICAL INPATIENT DELIRIUM: AN AUDIT OF THE DOCUMENTATION OF THE 4AT SCORE

Background

Postoperative delirium and perioperative neurocognitive disorder are the commonest postoperative complications in patients over 65 years old. This has implications for brain health with an increased risk of length of stay, a higher incidence of morbidity and mortality. Internationally, perioperative teams often fail to routinely screen for delirium. Our aim was to audit the documentation of the 4AT score for surgical inpatients over 65 years old and gain insight into the incidence on surgical wards.

Methods

Using the guideline for Perioperative Care for People Living with Frailty undergoing Elective and Emergency Surgery from the CPOC and BGS as a standard, an audit of surgical inpatients over 65 was carried out on 3 surgical wards over 5 days. Data was collected including 4AT documentation on admission, day 1 and day 3 post operatively, type of surgery & anaesthesia and risk factors for delirium (dementia, polypharmacy, opioids & benzodiazepine use, PD, surgery&gt;2h, stroke, alcohol, &gt;2 medical conditions, multiple ward moves).

Results

36 surgical patients over 65 years of age were included in the audit. The average age was 78 years old (range 65-91). 50% were admitted under the orthopaedic team, 31% under general surgical teams, 11% urology and 8% under other surgical specialties. 33% of patients had a 4AT documented at any stage during their admission and 25% of patients had a baseline 4AT documented preoperatively. The incidence of delirium was 18.7%. Surgical risk factors for delirium were found in 69% of older inpatients.

Conclusion

Delirium screening was underused in our cohort of older surgical patients despite a proportion of patients developing delirium postoperatively. Under recognition of delirium perioperatively is associated with poor outcomes and higher morbidity and mortality. Further interdisciplinary educational sessions are required to increase awareness and screening of delirium in surgical patients &gt;65 years old with the aim to re-audit in 6 months.

37 RE-AUDIT OF VITAMIN D SUPPLEMENTATION IN FRAIL OLDER ADULTS PRESENTING TO AN IRISH LEVEL 5 EMERGENCY DEPARTMENT

Background

The Department of Health published new guidance in November 2020 “Vitamin D advice for people aged 65 and older” which recommended that all adults ≥65 years should be supplemented with 15micrograms of Vitamin D daily. 55.5% of adults ≥65 years have insufficient/deficient vitamin D levels in winter (TILDA 2020). The Frailty Intervention Team (FIT) assess frail adults ≥65 years in the Emergency Department using medication review and Comprehensive Geriatric Assessment to identify vitamin D supplementation. The audit aim was to determine if compliance with the new guideline improved since the initial audit in January 2021.

Methods

All patients who had a medicine reconciliation completed by the FIT Pharmacist in January 2022 were included in a retrospective audit. Patients were identified from the pharmacist’s worklist. Data was collected from a Hospital Clinical System using a Microsoft Excel®. The data recorded included: Age, Sex, Rockwood Clinical Frailty Score (CFS) and vitamin D supplementation.

Results

The FIT Pharmacist completed 66 medicine reconciliations in January 2022. The mean age (+/-SD) was 82.4 (+/-7.6) years.The male to female ratio was 1:1.75The median CFS was 5 (mildly/moderately frail) with an IQR of 1.

68% (n=45) were prescribed vitamin D. Of those 89% (n=40) were prescribed a supplement containing at least 15micrograms of vitamin D. 32% (n=21) were not prescribed any vitamin D supplementation. 8% (n=5) were prescribed doses lower than 15micrograms of vitamin D.

Conclusion

Compliance with the new guideline was 61% (n=40) in comparison to 65% (n=39) in the initial audit. The results are reflective of adherence to the new guideline in the community. The policy update and education provided post the initial audit has possibly influenced the prescribing of vitamin D in the acute setting which unless patients are re-presenting will not have been captured in the outcome of this re-audit.

306 GERIATRICIAN-LED COMPREHENSIVE GERIATRIC ASSESSMENT IN THE EMERGENCY DEPARTMENT: A COST-EFFECTIVE SERVICE APPROVED BY PATIENTS

Background

Many older people are brought to the Emergency Department (ED) who do not require acute hospital admission but there are risks to these patients if this occurs. The Frailty Intervention Team (FIT) are an interdisciplinary team based in the ED including physiotherapy, occupational therapy, speech and language therapy, dietetics, pharmacy, advanced nurse practitioners, and a geriatric registrar and consultant. They assess frail older patients and suggest alternative care pathways to admission. We aimed to investigate the impact of FIT on admission avoidance, bed days saved and to obtain patient feedback on their experience.

Methods

Routinely collected data from May 2021 to April 2022 was reviewed retrospectively. An anonymous patient feedback questionnaire was posted to 40 patients randomised from the FIT worklist between January to May 2022.

Results

2,025 Comprehensive Geriatric Assessments (CGA) were completed between May 2021 and April 2022. 38% percent of patients were discharged home, 45% of this number had follow-up arranged. 104 patients were transferred directly to an offsite bed, mostly rehabilitation. We estimate we avoided 51 admissions to the acute hospital per month, almost half of these were patients admitted to the hospital and, who we discharged to alternative care pathways or home. The average length of stay in April 2022 was 22 days – by avoiding 615 admissions between May 2021 and April 2022 we have saved 13,530 bed days at an estimated cost saving of almost €11 million. 15 completed questionnaires were returned. 73% were very satisfied with their experience. 87% felt the FIT team helped facilitate their discharge from ED. The main themes identified from open ended questions included thorough assessment, patient centred care and satisfaction with early intervention and discharge.

Conclusion

A Frailty Intervention Team is a cost effective and patient centred way of avoiding unnecessary admissions for older people presenting to the ED.

269 PHARMACIST INTERVENTIONS WITHIN A MULTIDISCIPLINARY CARE TEAM FOR FRAIL OLDER ADULTS PRESENTING TO A LEVEL 4 EMERGENCY DEPARTMENT

Background

Inappropriate polypharmacy and ‘Potentially Inappropriate Prescriptions’ (PIP) are associated with increased morbidity and hospitalisation, in particular among frail older persons. A structured medication review, in conjunction with a Comprehensive Geriatric Assessment (CGA), can address PIP. The aim of the study was to review Frail Intervention Team (FIT) pharmacist interventions for frail, older adults presenting to the Emergency Department (ED) and experiencing medication compliance difficulties, polypharmacy and PIP.

Methods

Patients identified for medication review included those experiencing polypharmacy or medication compliance issues, presenting with a fall, delirium and/or frailty syndromes or complex comorbidities. The medication review process involved completion of medicines reconciliation and medication appropriateness review in accordance with the 7-Steps Medication Review Model (Scottish Government Polypharmacy Model of Care Group, 2018). Pharmacist optimisation recommendations were reviewed by a Consultant Geriatrician or Registrar and discussed with the patient prior to implementation.

Results

The FIT Pharmacist completed medication reviews for 765 patients between May 2021 and April 2022. The mean age (+/-SD) was 83.1 (+/-7.0) years with a median Clinical Frailty Score (CFS) of 5 (mildly/moderately frail). Medication Optimisation recommendations were actioned in 63% (n=483) of patients reviewed. The most commonly encountered PIP’s included: excessive anti-hypertensive/diuretic therapy, long-term acid-suppression therapy, anticholinergics and long-term prophylactic antimicrobials. Prescribing opportunities identified included: bone protection, laxatives and pain management.

Conclusion

FIT pharmacist review, in conjunction with the CGA, led to medication optimisation interventions in the frail older adult cohort presenting to the ED. Future studies should examine the impact of medication review on patient outcomes post-discharge.

287 SILVER TRAUMA REVIEW CLINIC – A NOVEL MODEL OF CARE FOR OLDER TRAUMA

Background

Increasing numbers of older patients are presenting to Emergency Departments (ED) following trauma. These patients require multidisciplinary care that the traditional trauma model fails to provide. Therefore, a Silver Trauma Review Clinic (STRC) was developed in conjunction with the geriatric, ED and physiotherapy services. The goal of the clinic is to provide a comprehensive multidisciplinary management for older patients following non operative traumatic injuries.

Methods

A retrospective review of routinely gathered data was performed of the first 100 patients reviewed in the STRC between May 2021 and April 2022.

Results

Median patient age was 81 years old (IQR 73-86) and 69% were female. Median clinical frailty score was 3 (IQR 2-4). Median time from the patient’s initial ED presentation to clinic was 14 days (IQR 10-24) and median time from the initial review to discharge was 21 days (IQR 8-35). Mean number of assessments was 2. 70% of presentations were as a result of falls under 2 metres. Primary injuries were 17% vertebral fractures, 49% limb fracture, 17% thoracic trauma, 11% pelvic trauma with 15% of patients suffering from multiple injuries. 59% were already on bone protection and a further 29% were commenced on treatment. 21% had an abnormality on Mini-cog testing. 21% were newly diagnosed with orthostatic hypotension and 49% had difficulty with balance or walking. Only 5% required surgery.

Conclusion

The STRC is a novel approach of patient focused multidisciplinary trauma care for frail older patients following non operative trauma, ensuring timely care.

External validation of the simple NULL-PLEASE clinical score in predicting outcomes in men and women with out-of-hospital cardiac arrest

Background

The NULL-PLEASE score (Nonshockable rhythm, Unwitnessed arrest, Long no-flow or Long low-flow period, blood pH &lt;7.2, Lactate &gt;7.0 mmol/L, End-stage renal disease on dialysis, Age ≥85 years, Still resuscitation, and Extracardiac cause) was developed to help identify patients with out-of-hospital cardiac arrest (OHCA) who are unlikely to survive. Although survival after OHCA differs between sexes, the performance of the NULL-PLEASE score according to sex has not been tested previously.

Purpose

To validate the NULL-PLEASE score separately in men and women in a nationwide setting.

Methods

Using Danish nationwide registry data from 2001–2019, we retrospectively identified male and female OHCA survivors with return of spontaneous circulation (ROSC) or ongoing cardiopulmonary resuscitation at hospital arrival. The primary outcome was 1-day mortality. Secondary outcomes were defined as 30-day mortality and the combination of 1-year mortality or anoxic brain damage. Logistic regression with a NULL-PLEASE score of 0 as reference was used for outcome risk estimation. The predictive ability of the score was assessed using area under the receiver operating characteristics (AUCROC) curves.

Results

A total of 2,601 men (median age 67 years (interquartile range (IQR) 56–76 years), and 1,280 women (median age 69 years (IQR 58–79 years) were included. One-day mortality was 31% in men and 42% in women; 30-day mortality was 56% and 71% in men and women, respectively; and 63% of men and 78% of women experienced the combined outcome. For patients with a NULL-PLEASE score ≥9, absolute risks were: 1-day mortality: 82.0% (95% confidence interval [CI]: 75.6–88.4%) for men and 79.1% (95% CI: 71.3–86.8%) for women; 30-day mortality: 98.6% (95% CI: 96.6–100.0) for men and 97.1% (95% CI: 94.0–100.0%) for women; and the combined outcome: 99.3% (95% CI: 97.9–100.0%) for men and 97.1% (95% CI: 94.0–100.0%) for women. AUCROC values for 1-day mortality were 0.827 (95% CI: 0.811–0.844) for men and 0.736 (95% CI: 0.710–0.763) for women. Results were similar for 30-day mortality and for the combined outcome. ROC curves for all outcomes are shown in Figure 1 (men) and Figure 2 (women). For a NULL-PLEASE score cut-point ≥3 to predict 1-day mortality, the positive predictive value was 91.8% in men and 91.1% in women, with a sensitivity of detecting patients who die of 47.3% in men and 51.8% in women. The corresponding negative predictive value for surviving more than 1 day was 54.6% in men and 37.7% in women, and the specificity of detecting patients who survive was 93.7% in men and 85.3% in women.

Conclusions

In a nationwide OHCA-cohort, the NULL-PLEASE score consistently appeared to perform better in men than in women for all outcomes. Nevertheless, its predictive ability was high among both sexes. Sex-specific differences should not be overlooked in clinical decision-making in patients surviving OHCA.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart FoundationThe Danish Foundation TrygFonden

Serial high-sensitivity troponin T concentrations and long-term outcomes in patients with suspected acute coronary syndrome

Background

High-sensitivity troponin assays allow for accurate and rapid rule-in or rule-out of myocardial infarction (MI) among patients with acute-onset chest pain. However, prognostic implications of serial high-sensitivity troponin concentrations are unknown.

Purpose

To determine short- and long-term prognostic implications of high-sensitivity troponin T (hsTnT) concentrations and their changes from baseline, in patients with suspected acute coronary syndrome.

Methods

Retrospective cohort study based on Danish national registries. We identified all patients discharged from the hospital with either MI, unstable angina, suspected MI, or chest pain from January 2012 through December 2019 and merged these individuals with all records of two serial hsTnT measurements obtained ≤7 hours apart during the same hospitalization. The primary outcome was death at days 0–30 and 31–365. Prognostic implications of serial hsTnT were examined in accordance with the 2012 ESC algorithm stratifying patients for normal baseline concentrations and relative changes of 20% and 50% from baseline. In case of a normal baseline concentration, 20% and 50% of the upper reference level (14 ng/l) were used as thresholds instead, i.e., 3 ng/l and 7 ng/l, respectively. Absolute risks were calculated through multivariable logistic regression with average treatment effect modeling (G-formula).

Results

Complete data were available in 28,902 individuals (median age [25th-75th percentile] 65.2 [53.4–75.4] years, 11,632 [40.2%] women). Of these, 11,116 (38.5%) had a final diagnosis of MI, 1518 (5.3%) of unstable angina, and 16,268 (56.3%) of either suspected MI or chest pain. Median baseline hsTnT was 18 ng/l (25th-75th percentile, 10–69), second hsTnT 21 ng/l (25th-75th percentile, 10–248), relative hsTnT change 3.6% (25th-75th percentile, 0–66.7), and time between samples 4.0 hours (25th-75th percentile, 3.2–5.4). Most patients had either two normal hsTnT concentrations (9483, 32.8%) or two elevated hsTnT concentrations (18,235, 63.1%). At 30 days, 796 (2.8%) individuals had died, while an additional 1287 (4.6% of 30-day survivors) died between days 31–365. Baseline hsTnT and the relative hsTnT change both displayed a significant, non-linear association with death and interacted with each other (P&lt;0.001). Tables 1 and 2 show the standardized, absolute risks of death (with 95% confidence intervals) from days 0–30 and from days 31–365, respectively. Patients with two normal hsTnT concentrations had very low mortality rates, irrespective of the magnitude of relative change. Conversely, patients with two elevated hsTnT concentrations consistently had high mortality rates.

Conclusions

This is the first study to assess both short- and long-term outcomes as a function of both baseline hsTnT and its change from first to second measurement. In general, patients with two normal hsTnT concentrations have an excellent prognosis while those with two elevated concentrations require scrutiny.

Funding Acknowledgement

Type of funding sources: None.

POS1576-PARE IMPROVING METHOTREXATE PRESCRIBING AND DISPENSING SAFETY THROUGH A SIMPLE ADJUSTMENT TO ELECTRONIC PRESCRIBING

Background

Methotrexate (MTX) is the most commonly prescribed disease-modifying antirheumatic drug (DMARD) in rheumatoid arthritis, as well as being frequently used in other rheumatic conditions. Having been discovered in 1948 1, its use is established and the toxicity profile is well recognised. In the rheumatology setting, it is prescribed as a once weekly dosing regimen. However, despite experience in the use of MTX, there still remains a concern for patient safety with regards to more frequent ingestion than the weekly dose. This can result in severe complications such as acute kidney injury, myelosuppression, mucositis and even death. According to Medicines and Healthcare products Regulatory Agency (MHRA), there were 11 adverse event reports between 2006 and 2020, and as a result, in 2020 the MHRA outlined guidance to reduce the potentially fatal dosing errors associated with the prescription of MTX 2.

Amongst this guidance, prescribers are instructed to discuss, document and include in the prescription, the specific day of the week MTX is to be taken. Dispensers are also advised to document the day of the week on the MTX drug dispensing label. At King’s College Hospital (KCH) there is an existing mandatory field for day of the week when prescribing inpatient non-cancer MTX treatment. However, this does not exist currently for outpatient electronic prescribing.

Objectives

To update practice in the KCH Rheumatology department, in line with MHRA guidance on MTX prescription.

Methods

A retrospective audit of 30 MTX new and renewal prescriptions over 1 month was conducted to assess concordance with MHRA guidance. The safety-nets of documentation of day of the week on most recent clinic letter, drug prescription and drug dispensing label were reviewed. Following this the electronic prescription system was updated to make “day of the week” a mandatory field required to complete MTX prescriptions. A sample of 30 patients post intervention was then re-audited.

Results

The percentage of new prescriptions across the 2 groups were roughly equivalent (30% vs 33%).

Prior to intervention, 44% of new MTX prescriptions had no form of documentation of the day of the week across all 3 safety-nets, and only 33% had at least 2 of the 3 safety-nets completed. Post-intervention this has increased to 100%. Of those newly prescribed MTX, the inclusion of day of the week on clinic letters rose from 22% to 40%. There were similar improvements seen in safety-nets achieved for repeat prescriptions.

Figure 1.Table 1.Percentage completedPre-interventionPost-interventionNewRenewalNewRenewalDay of the week on letter22%43%50%45%Day of the week on prescription33%38%100%100%Day of the week on packaging33%71%90%100%None of the above44%14%0%0%At least 2 of 3 of the above33%52%100%100%All 3 completed22%14%40%45%

Conclusion

A significant improvement in concordance with MHRA guidance on MTX prescribing and dispensing can be easily achieved by making “the day of the week” a mandatory field to be included on all electronic MTX prescriptions. This change also produces a significant improvement in drug dispensing label safety and clinic letter documentation for patients newly initiated on MTX.

References

[1]Farber S, Diamond LK, Mercer RD, et al. Temporary remissions in acute leukaemia in children produced by folic acid antagonist, 4-aminopteroyl-glutamic acid (aminopterin) N Engl J Med. 1948;238:787–93.

[2]MHRA. Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing. Published 23/9/2020.

Disclosure of Interests

None declared

Physical activity recommendations pre and post abdominal wall reconstruction: a scoping review of the evidence

PURPOSE

There are no universally agreed guidelines regarding which types of physical activity are safe and/or recommended in the perioperative period for patients undergoing ventral hernia repair or abdominal wall reconstruction (AWR). This study is intended to identify and summarise the literature on this topic.

METHODS

Database searches of PubMed, CINAHL, Allied & Complementary medicine database, PEDro and Web of Science were performed followed by a snowballing search using two papers identified by the database search and four hand-selected papers of the authors' choosing. Inclusion-cohort studies, randomized controlled trials, prospective or retrospective. Studies concerning complex incisional hernia repairs and AWRs including a "prehabilitation" and/or "rehabilitation" program targeting the abdominal wall muscles in which the interventions were of a physical exercise nature. RoB2 and Robins-I were used to assess risk of bias. Prospero CRD42021236745. No external funding. Data from the included studies were extracted using a table based on the Cochrane Consumers and Communication Review Group's data extraction template.

RESULTS

The database search yielded 5423 records. After screening two titles were selected for inclusion in our study. The snowballing search identified 49 records. After screening one title was selected for inclusion in our study. Three total papers were included-two randomised studies and one cohort study (combined 423 patients). All three studies subjected their patients to varying types of physical activity preoperatively, one study also prescribed these activities postoperatively. The outcomes differed between the studies therefore meta-analysis was impossible-two studies measured hernia recurrence, one measured peak torque. All three studies showed improved outcomes in their study groups compared to controls however significant methodological flaws and confounding factors existed in all three studies. No adverse events were reported.

CONCLUSIONS

The literature supporting the advice given to patients regarding recommended physical activity levels in the perioperative period for AWR patients is sparse. Further research is urgently required on this subject.

60 EVALUATING THE TIME THAT PATIENT’S WITH DEMENTIA/DELIRIUM SPEND IN THE EMERGENCY DEPARTMENT PRIOR TO TRANSFER TO A WARD

Background

Patients with dementia and delirium are often waiting long times in the emergency department (ED) prior to being transferred to a ward bed during an acute hospital admission. This may be associated with increased morbidity and mortality. Best practice is for rapid triage to an appropriate bed via a delirium/dementia pathway.

Our aim was to document the patient experience time (PET) for older patients with a diagnosis of dementia or delirium in ED in an urban tertiary-referral hospital.

Methods

Over a two-week period 07/12/20–21/12/20, we identified all patients admitted under a general medical specialty through ED, aged ≥65 years, with a diagnosis of dementia or delirium on the admission sheet. Patients admitted with a stroke or hip fracture were excluded. ED PET was recorded, as well as final ward destination.

Results

We included 29 patients in the study—median age was 82 years (range 71–92); 19 (66%) were female. Delirium was the presenting complaint in 79.31% (n = 23) of cases.

Sixteen (55%) patients presented between 8 am-5 pm. The average time spent from triage to ED doctor review was 1 hour 48 minutes; from ED doctor review to medical referral −1 hour 27 minutes; from medical referral to decision for medical admission—2 hours 28 minutes; from decision for medical admission to ward admission- 5 hours. Overall, the average ED PET for these patients was 10 hours 42 minutes.

Five patients (17%) were admitted directly to a Specialist Geriatric Ward (SGW). Twenty patients (69%) did not reach a SGW during the study period.

Conclusion

Patients with dementia and delirium may spend prolonged periods of time in the ED putting them at risk for multiple complications. We hope that by introduction of a dementia/delirium combined pathway and care bundle that we can reduce PET for these vulnerable patients.

202 THE SILVER TRAUMA CLINIC—A MULTIDISCIPLINARY CLINIC FOR FRAIL OLDER PATIENTS FOLLOWING TRAUMATIC INJURY

Background

Increasing numbers of older individuals are presenting to Irish emergency departments following trauma. Advances in the care of chronic diseases have increased the number of older people with active lifestyles, predisposing them to injury. ‘Silver trauma’ has been a relatively neglected despite deficits of traditional trauma care for this vulnerable cohort.

The Silver trauma clinic was developed in conjunction with the Frailty Intervention Team, Geriatric services and HSCP service in May 2021. The goal of the clinic is to provide a comprehensive multidisciplinary management for frail older patients following non operative injuries.

Methods

Frail older patients discharged from the ED can be referred for short interval multidisciplinary trauma review.

A trauma tertiary survey is carried out by an emergency physician with specialist interest in geriatric trauma. Rapid access to imaging ensures timely definitive diagnosis. The service integrates virtually with specialist services, such as spinal orthopaedic services and musculoskeletal interventional radiology.

Physiotherapists initiate a tailored early rehabilitation plan. Consultant geriatrician and frailty ANP screen for complications of injury as well as bone health, falls risk and cognitive screening. The clinic integrates with existing outpatient and community services for older persons.

Results

The clinic has seen 30 patients since commencement in May 2021. Median patient age: 85. Injuries: 25% vertebral fractures, 30% limb fracture, 20% thoracic trauma, 30% pelvic trauma. Mean number assessments: 2. Disposition outcomes: Primary care 50%, Geriatric clinic 30%, Integrated Care Team 10%, specialist clinic 10%.

Conclusion

The Silver trauma clinic is a new approach of patient focused multidisciplinary trauma care for frail older patients following non operative trauma in the Irish health system.

Marital status, cardiovascular events, and intensive blood pressure lowering among men and women in the Systolic Blood Pressure Intervention Trial

Background

Married persons may have lower rates of mortality and cardiovascular disease (CV) than unmarried persons although data regarding potential differences between men and women are conflicting. The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced CV morbidity and mortality in high-risk patients. We hypothesized that marital status would influence CV event risk and the impact of intensive BP control, and that these effects would vary according to sex.

Purpose

To assess the risks of CV events and mortality according to marital status in a high-risk population, and to assess if marital status modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled, open-label trial of 9361 individuals at high CV risk, at least 50 years of age, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to either intensive or standard BP control and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. Secondary efficacy endpoints included the individual components of the primary endpoint and all-cause death. Event risk according to marital status, including variation of the effects of intensive BP control, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. The group of subjects who were married or living in a marriage-like relationship served as baseline.

Results

Information on marital status was available for 8762 (93.6%) individuals. A total of 4863 (55.5%) were married or in a marriage-like relationship, 3149 (35.9%) were widowed, divorced, or separated, and 750 (8.6%) were never married. Marital status did not differ between patients randomized to intensive versus standard BP control (P=0.51). The risk of the primary endpoint was not significantly affected by marital status (P&gt;0.05), in neither men nor women (P-interaction&gt;0.05). The same was true for its individual components except the risk of CV death which was higher among never married men (adjusted hazard ratio [aHR], 3.29, 95% confidence interval [CI]: 1.34–8.09; P=0.009; P-sex-interaction=0.99). The risk of all-cause death was higher among widowed, divorced, or separated men (aHR, 1.90, 95% CI: 1.35–2.67; P&lt;0.001) and among never married men (aHR, 2.53, 95% CI: 1.51–4.26; P&lt;0.001), but not women belong to these groups (P&gt;0.05; P-sex-interaction=0.24) (Figure). Associations were not modified by age (P-interaction&gt;0.05). Marital status did not modify the effect of intensive BP control for any of the endpoints (P-interaction&gt;0.05).

Conclusions

In SPRINT, never married men had higher risks of both CV death and all-cause death while widowed, divorced, or separated men had a higher risk of all-cause death. The risks and benefits of intensive BP control were not affected by marital status.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Greater event rates in high-risk patients with a history of heart disease: from the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in patients at high CV risk. Effects were consistent among patients with and without prevalent CV disease. However, it is unknown whether the benefits and risks of intensive BP control are affected by the specific type of heart disease.

Purpose

To assess the risks of incident CV events and safety events in patients with individual types of heart disease, and to assess if the presence of heart disease modified the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk, without diabetes, and with a systolic BP 130–180 mmHg. Participants were randomized to intensive or standard BP control. The primary efficacy endpoint was the composite of myocardial infarction, other acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We assessed event risk in patients with self-reported heart disease versus those without and further assessed the safety and efficacy of intensive BP control, including relevant interactions, in these individuals, using multivariable Cox proportional-hazards regression.

Results

Of 9361 participants, 326 (3.5%) reported a history of congestive heart failure, 760 (8.1%) of myocardial infarction, 1206 (12.9%) of angina, and 1830 (19.6%) of atrial fibrillation, atrial flutter, or irregular heartbeat. The prevalence of these conditions did not significantly differ between patients randomized to intensive versus standard BP control (P&gt;0.05 for all). At median 3.2 years (range 0–4.8 years), congestive heart failure (adjusted hazard ratio [aHR], 1.94, 95% confidence interval [CI], 1.45–2.61; P&lt;0.001), myocardial infarction (aHR, 1.73, 95% CI, 1.33–2.25; P&lt;0.001), angina (aHR, 1.41, 95% CI, 1.09–1.84; P=0.01), and atrial fibrillation, atrial flutter, or irregular heartbeat (aHR, 1.36, 95% CI, 1.12–1.64; P=0.002) were all independently associated with the primary endpoint (Figure). All conditions except prior myocardial infarction were also associated with composite serious adverse events (P=0.24 for myocardial infarction, P&lt;0.05 for all others). A history of angina modified the efficacy of intensive versus standard BP control, i.e., patients without angina appeared to benefit from intensive BP control (aHR, 0.66, 95% CI, 0.54–0.80; P&lt;0.001) while those with angina did not (aHR, 1.04, 95% CI, 0.76–1.44; P=0.80) (P=0.02 for interaction). No significant interactions were detected for the primary safety endpoint.

Conclusions

In SPRINT, a history of any type of heart disease was associated with a greater risk for both efficacy and safety events. Patients with angina did not appear to derive benefit from intensive BP control.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Primary health insurance and cardiovascular outcomes in the systolic blood pressure intervention trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure (BP) control reduced cardiovascular (CV) morbidity and mortality in high-risk patients. Although antihypertensive therapies were provided at no cost to trial participants, patients were covered by various entities. Insurance coverage provides a unique dimension of risk assessment and may provide additional prognostic information in this setting.

Purpose

To assess the risks of incident CV events and safety events in a high CV risk population according to type of health insurance, and to assess if insurance type interacted with the effect of intensive versus standard BP control.

Methods

SPRINT was a randomized, controlled trial conducted across 102 US sites of 9,361 high-risk adults ≥50 years, without diabetes, and with a systolic BP 130–180 mmHg at screening. Study participants were randomized to intensive (target systolic BP &lt;120mmHg) or standard BP control (target systolic BP &lt;140mmHg) and followed for median 3.2 years (range 0–4.8 years). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or CV death. The primary safety endpoint was the composite of serious adverse events. The risk of efficacy and safety events according to type of health insurance, including the effect of intensive BP control in each subgroup, was evaluated using multivariable Cox proportional-hazards regression with interaction analyses. Private/other insurance type served as the reference group.

Results

Of 9361 participants, 3980 (42.5%) were covered by private/other insurance, 1483 (15.8%) by a Veterans Affairs (VA) health plan, 2691 (28.8%) by Medicare, 207 (2.2%) by Medicaid, and 1000 (10.7%) were uninsured. Insurance coverage distribution was well-balanced between the two study arms (P&gt;0.05). Compared with patients who had private/other insurance, the risk of the primary endpoint was significantly higher among Medicaid beneficiaries (adj. hazard ratio [HR], 1.81, 95% confidence interval [CI], 1.09–3.00; P=0.02). The risk of death was similarly highest among Medicaid patients (adj. HR, 2.08, 95% CI, 1.08–4.02; P=0.03) and was also significantly higher among VA patients (adj. HR, 1.49, 95% CI, 1.11–2.99; P=0.008) (Figure). Serious adverse events were more common in the VA population (HR, 1.12, 95% CI, 1.01–1.23; P=0.03). Insurance type did not modify the efficacy and safety of intensive BP control (P&gt;0.05 for all interactions).

Conclusions

In SPRINT, Medicaid beneficiaries were at significantly greater risk for experiencing a primary CV event. Medicaid patients and VA patients both had higher mortality than those covered by private/other insurance. The risks and benefits of intensive BP control were not affected by insurance type.

Funding Acknowledgement

Type of funding sources: None. Risk of death and health insurace type

Intensive versus standard blood pressure control and vascular procedures: insights from the Systolic Blood Pressure Intervention Trial

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive versus standard blood pressure control reduced cardiovascular (CV) morbidity and mortality. Previous studies have shown that control of blood pressure reduces the risk of stroke and is one of the most modifiable risk factors for carotid artery disease. On the other hand, data on effect of blood pressure control on peripheral artery disease are more diverse. In addition, it is unknown whether intensive blood pressure control affects the risk of vascular procedures.

Purpose

To assess the relationship between intensive blood pressure control and incident vascular procedures.

Methods

SPRINT was a randomized, controlled trial comprising 9,361 individuals ≥50 years of age at high CV risk but without diabetes who had a systolic BP (SBP) 130–180 mmHg. Patients were randomized to intensive (target SBP &lt;120mmHg) or standard antihypertensive treatment (target SBP &lt;140mmHg). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events. We examined the risk of composite and individual vascular procedures with intensive versus standard blood pressure control. We further examined subgroup heterogeneity using interaction analyses.

Results

During a median follow-up time of 3.3 years (range 0–5.5 years), a total of 174 (1.9%) composite vascular procedures were recorded. Intensive blood pressure control did not significantly reduce the risk of composite vascular procedures (intensive blood pressure control, 76 (1.6%) versus standard blood pressure control, 98 (2.1%), hazard ratio 0.76, 95% confidence interval, 0.57 to 1.03; P=0.08) (Figure 1). Similarly, the risks of the individual endpoints of carotid angioplasty, carotid endarterectomy, peripheral angioplasty or thrombolysis, lower extremity amputation for ischemia and gangrene, surgical or vascular procedure for abdominal aortic aneurysm, surgical or vascular procedure for thoracic aortic aneurysm, and surgical or vascular procedure for other problems were not significantly affected (P≥0.05 for all). Intensive blood pressure control reduced the risk of peripheral vascular surgery (intensive blood pressure control, 7 (0.2%) versus standard blood pressure control, 21 (0.5%), hazard ratio 0.33, 95% confidence interval, 0.14 to 0.77; P=0.01), though this was based on a small number of events. The safety and efficacy of intensive BP lowering was not modified by chronic kidney disease, age, sex, race, previous cardiovascular disease, or baseline systolic blood pressure tertile (P≥0.05 for all).

Conclusions

In SPRINT, intensive versus standard blood pressure control did not reduce the risk of composite incident vascular procedures.

Figure 1. Vascular procedures

Funding Acknowledgement

Type of funding source: None

Baseline and on-treatment serum bicarbonate, intensive blood pressure lowering, and mortality: the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

Low bicarbonate levels are associated with higher mortality among patients who are hospitalized or have chronic kidney disease. However, the relationship between bicarbonate and mortality among outpatients on antihypertensive treatment is unclear.

Purpose

To assess the relationship between serum bicarbonate levels, treatment response to intensive blood pressure lowering, and mortality.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high cardiovascular (CV) risk, but without diabetes, and a systolic blood pressure (BP) 130–180 mmHg, were randomized to intensive (target systolic BP &lt;120mmHg) or standard antihypertensive treatment (target systolic BP &lt;140mmHg). Patients with an estimated glomerular filtration rate &lt;25 ml/min/1.73 m2 or end-stage renal disease were excluded. Serum chemistry was drawn at baseline, prespecified intervals, and at close out. We defined on-treatment bicarbonate as the last measurement available for each participant. We then examined the prognostic implications (for death from any cause and death from CV causes) of baseline and on-treatment bicarbonate, using restricted cubic splines, unadjusted and adjusted for demographic, clinical, and laboratory variables. Finally, we explored the effects of intensive blood pressure lowering across the spectrum of bicarbonate using interaction analysis.

Results

A total of 9,334 (99.7%) individuals had a bicarbonate measurement available at baseline and 9,232 (98.6%) had at least one measurement after baseline. Mean baseline bicarbonate was similar between the two study groups (26.3 mmol/l in both; P=0.84), as was on-treatment bicarbonate (25.2 mmol/l in both; P=0.51). Median follow-up was 3.3 years (range 0–4.8), with 365 deaths from any cause (3.9%) and 102 deaths from CV causes (1.1%) recorded during the study period. Baseline and on-treatment bicarbonate both displayed a significant, U-shaped association with death from any cause (adjusted overall trend, P&lt;0.05; non-linearity vs. linearity, P&lt;0.05). Although both were significantly associated with death from CV causes in unadjusted analysis, the significance was lost upon multivariable adjustment (P&gt;0.05) (Figure). Low baseline bicarbonate was significantly associated with death from any cause (&lt;23 vs. 23–29 mmol/l, adj. hazard ratio (HR) 1.45, 95% confidence interval (CI), 1.06–2.00; P=0.02), but high baseline bicarbonate was not (&gt;29 vs. 23–29 mmol/l; P=0.84). Conversely, both low (adj. HR 1.50, 95% CI, 1.14–1.97; P=0.004) and high (adj. HR 4.77, 95% CI, 3.49–6.52; P&lt;0.001) on-treatment bicarbonate was significantly associated with death from any cause. Bicarbonate did not modify the efficacy of intensive blood pressure lowering (P&gt;0.05).

Conclusions

Baseline and on-treatment serum bicarbonate levels both displayed a U-shaped association with the risk of death. The association was not affected by intensive vs. standard blood pressure lowering.

Figure 1

Funding Acknowledgement

Type of funding source: None

Baseline and on-treatment serum potassium and mortality in high risk patients: the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

Observational studies in patients with hypertension have indicated a U-shaped association between on-treatment serum potassium levels and short-time mortality. However, the association between long-time mortality and serum potassium, and the potential modification of this association by intensive blood pressure lowering, are yet to be explored.

Purpose

To assess the relationship between serum potassium levels, treatment response to intensive blood pressure lowering, and mortality.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high cardiovascular (CV) risk, but without diabetes, who had an systolic blood pressure (SBP) 130–180 mmHg, were randomized to intensive (target SBP &lt;120mmHg) or standard antihypertensive treatment (target SBP &lt;140mmHg). Patients with an estimated glomerular filtration rate (eGFR) &lt;25 ml/min/1.73 m2 or end-stage renal disease were excluded. Serum chemistry was drawn at baseline, prespecified intervals, and at close out. On-treatment serum potassium was defined as the last measurement for each participant. We examined the prognostic implications (for death from CV causes and death from any cause) of baseline and on-treatment serum potassium, using restricted cubic splines, unadjusted and adjusted for demographic, clinical, and laboratory variables. We further explored the effects of intensive blood pressure lowering across the serum potassium spectrum using interaction analyses.

Results

A total of 9,336 individuals had a serum potassium measurement available at baseline and 9,233 individuals had at least one subsequent measurement. Mean serum potassium was similar between the two study groups (intensive 4.21 mmol/l vs. standard 4.20 mmol/l; P=0.74); however, on-treatment serum potassium was significantly lower in the intensive group (intensive 4.17 mmol/l vs. standard 4.20 mmol/l; P=0.001). Median follow-up was 3.3 years (range 0–4.8), with 365 deaths from any cause (3.9%) and 102 deaths from CV causes (1.1%) recorded during the study period. Baseline serum potassium appeared to be linearly associated with both types of mortality events (test for overall trend, P&lt;0.05; test for non-linearity versus linearity, P&gt;0.05) on unadjusted analysis. On-treatment serum potassium displayed a U-shaped curve with death from any cause (test for overall trend, P=0.004; test for non-linearity versus linearity, P=0.006), but was not significantly associated with death from CV causes (P&gt;0.05) (Figure). Associations were completely lost upon multivariable adjustment (P&gt;0.05). This was particularly due to adjustment for eGFR. The efficacy of intensive blood pressure lowering was not modified by baseline or on-treatment serum potassium (P&gt;0.05).

Conclusions

Neither baseline nor on-treatment serum potassium levels were associated with death after multivariable adjustment, including renal function. The efficacy of intensive blood pressure lowering was not modified by serum potassium.

Serum Potassium and death

Funding Acknowledgement

Type of funding source: None

Serial changes in high-sensitivity troponin I levels indicate poorer prognosis in patients with suspected acute coronary syndrome who fail to reach a level greater than the 99th percentile

Background

According to the fourth universal definition of myocardial infarction (MI) consensus paper, patients with changing troponins who do not reach a concentration greater than the 99th percentile may still be at high risk and should be followed closely.

Purpose

To determine long-term prognostic implications of high-sensitivity troponin I (hs-TnI) levels and their relative change (Δ) from baseline in subjects with suspected acute coronary syndrome (ACS).

Methods

We conducted a retrospective cohort study through individual participant-level linkage between Danish national registries. Subjects with a final discharge diagnosis of acute MI, unstable angina, suspected MI, or chest pain from October 2013 through December 2016 who had a record of at least two serial hs-TnI (Dimension Vista®, Siemens Healthineers, Erlangen, Germany; 99th percentile: 45 ng/l) measurements during hospitalization comprised the study population. Kaplan-Meier analysis and multivariable Cox regression, incorporating the competing risk of death, were used to examine the prognostic implications of serial hs-TnI. Subjects were categorized according to whether their first and second hs-TnI were normal/elevated as well as Δhs-TnI and its direction, the latter using cut-offs for Δhs-TnI rises and/or falls of 20% and 50%, extrapolated from the recommendations for troponin T. The primary outcome was a composite of death from cardiovascular causes, recurrent MI, or repeat revascularization (i.e. not including the index event unless the patient died) at 12 months.

Results

A total of 14,514 individuals (mean age 62.2 years, 46.6% women) were included of whom 3407 (23.5%) had a final diagnosis of MI, 667 (4.6%) of unstable angina, and 10,440 (71.9%) of either suspected MI or chest pain. Median baseline hs-TnI was 15 ng/l (25.3% elevated), second hs-TnI 15 ng/l (29.4% elevated), Δhs-TnI 0%, and time between samples 6.2 hours. At 12 months, 909 (6.3%) first primary events had occurred. Baseline hs-TnI and Δhs-TnI both displayed a significant, non-linear association with the primary outcome (P&lt;0.001). The Figure shows the prognostic implications of serial hs-TnI. Overall, subjects with two consecutively elevated hs-TnI had the highest 12-month event risk (15.7%), followed by those who went from a normal to an elevated hs-TnI (9.9%), those who went from an elevated to a normal hs-TnI (4.2%), and those with two normal hs-TnI (2.7%). Most either had no significant Δhs-TnI (−20% to 20%: 74.9%) or a large positive Δhs-TnI (&gt;50%: 17.5%). Individuals with any Δhs-TnI (&gt;20% in either direction) had a worse prognosis than those without. This was also true for the group of individuals with two normal hs-TnI (event risk 7.8% in those with a Δhs-TnI &gt;20% versus 2.3% in those without, P&lt;0.001).

Conclusions

Δhs-TnI was an important determinant of poorer prognosis in subjects with suspected ACS, even among individuals who did not reach a concentration greater than the 99th percentile.

Figure 1

Funding Acknowledgement

Type of funding source: None

The ESC algorithm for serial high-sensitivity troponin T changes and long-term outcomes in patients with suspected acute coronary syndrome

Background

The fourth universal definition of myocardial infarction (MI) consensus paper suggests that patients with changing troponins not reaching concentrations greater than the 99th percentile may be at high risk and deserve close scrutiny.

Purpose

To determine long-term prognostic implications of high-sensitivity troponin T (hs-TnT) levels and their relative change (Δ) from baseline in subjects with suspected acute coronary syndrome (ACS).

Methods

We conducted a retrospective cohort study through individual participant-level linkage between Danish national registries, including subjects with a final discharge diagnosis of acute MI, unstable angina, suspected MI, or chest pain from March 2013 through December 2016 who had a record of at least two serial hs-TnT measurements during hospitalization. Individuals were followed for 12 months, until the occurrence of an event, or censoring due to emigration. Kaplan-Meier analysis and Cox regression, incorporating the competing risk of death, were used to examine the prognostic implications of serial hs-TnT. Subjects were categorized according to whether their first and second hs-TnT were normal/elevated as well as Δhs-TnT and its direction, the latter employing a modified version of the 0/3-hour diagnostic algorithm proposed by ESC, i.e., using cut-offs for Δhs-TnT of 20% and 50%. The primary outcome was a composite of presumed death from cardiovascular causes, recurrent MI, or repeat revascularization (i.e., not including the index event unless the patient died) within 12 months.

Results

A total of 13,494 individuals (mean age 63.4 years, 39.5% women) were included. Of these, 6129 (45.4%) had a final diagnosis of MI, 941 (7.0%) of unstable angina, and 6414 (47.5%) of either suspected MI or chest pain. Median baseline hs-TnT was 20 ng/l (72.1% elevated), second hs-TnT 27 ng/l (74.6% elevated), Δhs-TnT 4.8%, and time between samples 5.4 hours. At 12 months, 1055 (7.8%) had experienced a primary event. Baseline hs-TnT and Δhs-TnT both displayed a significant association with the primary outcome (P&lt;0.001 for both overall trends and for non-linearity vs. linearity). The Figure shows the prognostic implications of serial hs-TnT. Overall, subjects with two consecutively elevated hs-TnT had the highest 12-month event risk (10.0%), followed by those who went from an elevated to a normal hs-TnT (8.6%), those who went from a normal to an elevated hs-TnT (6.3%), and those with two normal hs-TnT levels (1.6%). The majority either had non-significant Δhs-TnT (−20% to 20%: 56.8%) or a large positive Δhs-TnT (&gt;50%: 30.6%). Individuals with a positive Δhs-TnT (&gt;20%) had a worse prognosis than those without.

Conclusions

An elevated hs-TnT at any time and Δhs-TnT were both determinants of poorer prognosis in subjects with suspected ACS. Individuals with two normal hs-TnT had a good prognosis, irrespective of their Δhs-TnT.

Figure 1

Funding Acknowledgement

Type of funding source: None

Serum concentrations of DDE, PCBs, and other persistent organic pollutants and mammographic breast density in Triana, Alabama, a highly exposed population

INTRODUCTION

Although some persistent organic pollutants (POPs) are considered human carcinogens, results from studies evaluating exposures and breast cancer risk have been inconsistent, potentially related to varying ages at exposure. Additionally, few studies evaluated the association between POPs exposure and mammographic breast density (MBD), an intermediate biomarker of breast cancer risk. We carried out a cross-sectional study to investigate associations between serum POPs concentrations and MBD measured in 1998 in female residents of Triana, Alabama, in a predominately African American population with high POPs exposures, particularly to p,p'-DDT (1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane).

METHODS

We measured lipid-adjusted serum concentrations (ng/g lipid) of p,p'-DDT and its main metabolite p,p'-DDE (1,1-dichloro-2,2-bis(p-chlorophenyl)ethylene), polychlorinated biphenyls (PCBs), β-hexachlorocyclohexane (β-HCCH), heptachlor epoxide, oxychlordane, trans-nonachlor, mirex, and aldrin for each woman in our study (n = 210). We also measured two MBD metrics, percent MBD (%MBD) and area of MBD (aMBD). Using adjusted Spearman correlation coefficients (rs) we evaluated correlations between %MBD and aMBD with individual POPs in the overall population and by age group (19-40, 41-54, and 55-91 years) and also estimated adjusted mean measures of MBD with 95% confidence intervals across tertiles of analytes using generalized linear models (GLM). We calculated p-values for multiplicative interaction by age group using GLM. Additional analyses excluded women with current hormone replacement therapy (HRT) use and evaluated early-life exposure (prior to age 18) during the heaviest contamination period in Triana (1947-90).

RESULTS

Among all women, we found no correlation between p,p'-DDE and %MBD, but after age stratification and exclusion of HRT users, there was a suggestion of a difference by age group, with younger women having a weak positive correlation (rs = 0.12, p = 0.37) and older women having a weak negative correlation (rs = -0.12, p = 0.43); pinteraction = 0.06. In contrast, PCBs were weakly positively correlated with %MBD among all women, with the correlation magnitudes increasing after excluding current HRT users (rs-total PCBs = 0.17, p = 0.03). After age stratification and exclusion of HRT users, correlations for PCBs were higher among younger and middle-age women, with only a handful of these correlations being statistically significant. For β-HCCH, the strongest finding was a negative correlation among older women (rs = -0.26, p = 0.07). Correlations were positive predominantly in the younger age group for heptachlor epoxide (rs = 0.27, p = 0.04), oxychlordane (rs = 0.35, p = 0.006), and trans-nonachlor (rs = 0.37, p = 0.003), and largely null for the middle and older age groups; pinteraction range: 0.03-0.05. Similar patterns were found in GLM analyses using tertiles of exposure and aMBD as the metric for MBD. Women exposed during the heaviest chemical contamination period in Triana prior to age 18 had positive correlations between %MBD and PCBs, heptachlor epoxide, mirex, oxychlordane, and trans-nonachlor.

CONCLUSIONS

In this population, despite high exposures to p,p'-DDT and thus high serum concentrations of its main metabolite, p,p'-DDE, we did not find strong evidence of a positive association with MBD. In fact, there was some evidence of a negative association among older women for p,p'-DDE; a similar pattern was found for β-HCCH. However, younger women with higher serum levels of PCBs, heptachlor epoxide, oxychlordane, and trans-nonachlor, who were likely exposed in early life, had higher MBD. These findings should be replicated in larger studies.

Ileo-anal pouch excision and permanent ileostomy - Indications and outcomes from a tertiary centre

PURPOSE

Pouch excision is a major complication of ileoanal pouch surgery. Current practice is for this type of surgery to be performed in a specialist centre. We present a series of patients undergoing pouch excision surgery in a high volume centre in the UK and assess the outcomes in these patients.

METHODS

All patients undergoing pouch excision at the Royal Liverpool Hospital between 1995 and 2015 under the care of a single surgeon were included. Demographics and outcomes were taken from patients' notes and a dedicated retrospectively compiled database.

RESULTS

35 patients underwent pouch excision surgery during this period. Around half the patients had their original pouch surgery elsewhere and were referred for management of complications. Median time to pouch excision was 13 years from the original operation. Overall complication rate was 31% with 11% requiring re-intervention post-operatively. There was no mortality in this series.

CONCLUSION

Pouch excision is a complex, high-risk procedure that should be carried out in specialist centres. Our series shows that in such settings, good outcomes can be achieved for these patients.

The effect of hypoglycaemia during hospital admission on health-related outcomes for people with diabetes: a systematic review and meta-analysis

AIM

To assess the health-related outcomes of hypoglycaemia for people with diabetes admitted to hospital; specifically, hospital length of stay and mortality.

METHODS

We conducted a systematic review and meta-analysis of studies relating to hypoglycaemia (< 4 mmol/l) for hospitalized adults (≥ 16 years) with diabetes reporting the primary outcomes of interest, hospital length of stay or mortality. Final papers for inclusion were reviewed in duplicate and the adjusted results of each were pooled, using a random effects model then undergoing further prespecified subgroup analysis.

RESULTS

In total, 15 studies were included in the meta-analysis. The pooled mean difference in length of stay for ward-based inpatients exposed to hypoglycaemia was 4.1 days longer [95% confidence interval (CI) 2.36 to 5.79; I² = 99%] compared with those without hypoglycaemia. This association remained robust across the pre-specified subgroup analyses. The pooled relative risk (RR) of in-hospital mortality was greater for those exposed to hypoglycaemia (RR 2.09, 95% CI 1.64 to 2.67; I² = 94%, n = 7 studies) but not in intensive care unit mortality (RR 0.75, 95% CI 0.49 to 1.16; I² =0%, n = 2 studies).

CONCLUSION

There is an association between inpatient hypoglycaemia and longer length of stay and greater in-hospital mortality. Studies examining this association were heterogenous in terms of both clinical populations and effect size, but the overall direction of the association was consistent. Therefore, glucose concentration should be considered a potential tool to aid the identification of inpatients at risk of poor health-related outcomes.

4877Renal function and intensive blood pressure lowering in high-risk adults without diabetes: insights from the Systolic Blood Pressure Intervention Trial (SPRINT)

Background

The Systolic Blood Pressure Intervention Trial (SPRINT) found that intensive blood pressure (BP) lowering reduced the rates of cardiovascular events and mortality but increased the risk of certain adverse events, in patients with and without chronic kidney disease at baseline. However, it is unclear whether intensive BP management is well-tolerated and modifies risk uniformly across the entire spectrum of renal function.

Purpose

To assess the relationship between renal function, treatment response to intensive BP lowering, and cardiovascular (CV) outcomes.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high CV risk but without diabetes who had a systolic BP (SBP) 130–180 mmHg, were randomized to intensive (target SBP <120mmHg) or standard antihypertensive treatment (target SBP <140mmHg). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, acute decompensated heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events (SAE). Renal function was assessed using the estimated glomerular filtration rate (GFR), calculated with the Modification of Diet in Renal Disease equation. We first assessed whether a linear association was present between eGFR and clinical endpoints using restricted cubic splines. We then examined the prognostic implications of eGFR, unadjusted and adjusted for demographic, clinical, and laboratory variables. We further explored the effects of intensive BP lowering across the eGFR spectrum.

Results

Baseline eGFR was available for 9,324 (>99%) individuals. Mean eGFR was similar between the two groups (intensive group 71.8 ml/min/1.73m2 vs. standard group 71.7 ml/min/1.73m2; P=0.92). Median follow-up was 3.3 years (range 0–4.8), with 561 primary efficacy events (6%) and 3,522 SAE (38%) recorded during the study period. Baseline eGFR was non-linearly associated with the risk of the primary efficacy endpoint, death from CV causes, death from any cause, acute decompensated heart failure, SAE, electrolyte abnormality, and acute kidney injury (test for non-linearity, P<0.05; test for overall trend, P<0.001) and remained significantly associated with all tested endpoints upon multivariable adjustment (P<0.05). Baseline eGFR significantly modified the effects of intensive BP lowering on the primary efficacy endpoint (P=0.02), acute decompensated heart failure (P=0.01), SAE (P=0.01), and acute kidney injury (P=0.04). The Figure shows treatment effects (hazard ratios) across the spectrum of eGFR for these four endpoints. P-values are for the interaction between eGFR and treatment effect. Significant interactions were not detected for other endpoints.

Figure 1

Conclusions

In SPRINT, lower eGFR was associated with a greater risk of both CV events and SAE. Patients with higher eGFR appeared to derive more benefit from intensive BP lowering while the relationship with safety events was complex.

P2627Diffuse coronary artery disease and effect of implantable cardioverter-defibrillators in patients with non-ischaemic systolic heart failure

Background

Implantable defibrillators reduce mortality in patients with ischaemic heart failure. The recent Danish Study to Assess the Efficacy of Implantable Cardioverter Defibrillators in Patients With Non-Ischaemic Systolic Heart Failure on Mortality (DANISH) found no overall effect on all-cause mortality with ICD implantation. Coronary artery disease (CAD) as the cause of heart failure had to be ruled out prior to inclusion into DANISH, but patients could have diffuse atherosclerosis, one- or two-vessel disease on the qualifying coronary angiogram if the investigator did not find that the degree of CAD could explain the severely reduced left ventricular ejection fraction. It is unknown if concomitant coronary atherosclerosis is related to outcome in patients with non-ischaemic cardiomyopathy and whether the effect of implanting an ICD is different in patients with non-ischaemic cardiomyopathy and coronary atherosclerosis.

Purpose

The aim of this study was to investigate the association between coronary atherosclerosis and all-cause mortality in patients with non-ischaemic systolic heart failure and the effect of ICD implantation in these patients.

Methods

Of the 1116 patients from the DANISH study, 838 patients with available coronary angiography data were included in this subgroup analysis. Patients were considered to have coronary atherosclerosis if the invasive cardiologist described diffuse atherosclerosis or coronary stenosis. We used cox regression to assess the relationship between coronary atherosclerosis and mortality and between ICD implantation and mortality in patients with and without coronary atherosclerosis. Data are presented as hazard ratios with 95% confidence intervals.

Results

Of the 838 patients, 266 (32%) had coronary atherosclerosis, 216 (81%) of whom were reported as having atherosclerosis without stenoses. Patients with coronary atherosclerosis were significantly older (median age 67 years vs 61 years), more often male (77% vs 70%) and had a higher prevalence of diabetes (30% vs 17%).

In univariable analysis, coronary atherosclerosis was a significant predictor of all-cause mortality (HR, 1.41; 95% CI, 1.04–1.91; P=0.03). However, the association between coronary atherosclerosis and all-cause mortality disappeared when adjusting for age, gender and diabetes (HR 1.02, 0.75–1.41, P=0.88). Adjusted hazard ratios are shown in Figure 1.

There was no association between ICD treatment and all-cause mortality in patients with or without coronary atherosclerosis (HR 0.94; 0.58–1.52; P=0.79 vs HR 0.82; 0.56–1.20; P=0.30), P for interaction=0.67.

Figure 1

Conclusions

In patients with non-ischaemic systolic heart failure, the concomitant presence of coronary atherosclerosis was associated with increased mortality. However, this association was not independent of other risk factors. ICD implantation was not associated with mortality risk in patients either with or without concomitant coronary atherosclerosis.

Acknowledgement/Funding

TrygFonden (Copenhagen, DK), Medtronic (US) and St. Jude Medical (US)

P3357Reproducibility of myocardial flow reserve estimation using Rubidium-82 PET/CT scans in healthy, young volunteers: comparison of three commercially available software packages

Background

The use of myocardial blood flow (MBF) reserve assessed with cardiac positron emission computed tomography (PET/CT) is well established and contain important prognostic information e.g. in patients with ischaemic heart disease. However, perfusion data must be interpreted under consideration of the limitations of the method. It has previously been concluded that software specific age and sex matched normal values for MBF reserve should be used as reference. Furthermore, reproducibility between scans seems to vary more in persons with higher risk of cardiovascular disease than in those with no risk factors. Comparison between scans has previously been conducted using dipyridamole as a stressor. However, no former studies have addressed this using adenosine as stressor for 82Rb-PET/CT in a combined study of scan reproducibility and software comparison.

Purpose

The aim of this study was to investigate reproducibility of rest- and adenosine stress 82Rb-PET/CT estimated MBF reserve in healthy young volunteers between two scans analysed with three commercially available software packages.

Methods

Forty healthy young volunteers completed two 82Rb-PET/CT rest- and adenosine stress scans obtaining myocardial blood flow (MBF) and MBF reserve, syngo MBF, Quantitative Gated SPECT (QGS) and Corridor4DM (4DM) were used for analyses.

Results

Fifty percent were men and mean (±SD) age was 24±4 years. Varying reproducibility of MBF reserve between scans was found for the different software packages. MBF reserve with syngo.MBF (Figure 1A): mean difference (95% CI) 0.26 (−0.03 to 0.54), P=0.07, limits of agreement: −1.43 to 1.95, MBF reserve with QGS (Figure 1B): mean difference (95% CI) 0.19 (−0.08 to 0.46), P=0.15, limits of agreement: −1.38 to 1.76 and MBF reserve with 4DM (Figure 1C): mean difference (95% CI) 0.08 (−0.17 to 0.34), P=0.50, limits of agreement: −1.37 to 1.53. Significantly higher MBF reserve was measured with 4DM (mean±SD: 4.00±0.96) compared to syngo.MBF (mean±SD 3.75±0.91, P<0.001) and QGS (mean±SD 3.75±0.89, P<0.0001), whereas concordance between MBF reserve measured by syngo.MBF and QGS was high (P=0.87).

Figure 1

Conclusions

All software packages identified the participants with flow values in the high end of the normal range, as expected for healthy volunteers. Varying reproducibility of MBF reserve was found between scans for the different software packages and 4DM seemed to have the highest inter-scan reproducibility. Concordance between MBF reserve measures was high between syngo.MBF and QGS whereas higher MBF reserve measures was conducted from 4DM in comparison with the two other software packages. Our results suggest that MBF analysed with syngo.MBF and QGS may be mutually comparable but that 4DM may be preferred for analyses due to possibly higher scan to scan reproducibility.

P57262018 ESC/ESH guideline-recommended age categories and intensive blood pressure management in high-risk adults: insights from SPRINT

Background

The 2018 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines for arterial hypertension propose different intensities of blood pressure (BP) lowering in patients <65 years, 65–79 years, and ≥80 years of age. However, it is unclear whether intensive BP management is well-tolerated and modifies risk uniformly across this age spectrum.

Purpose

To assess the relationship between age, treatment response to intensive BP lowering, and cardiovascular (CV) outcomes.

Methods

SPRINT was a randomized, controlled trial in which 9,361 individuals ≥50 years of age, at high CV risk but without diabetes who had a systolic BP (SBP) 130–180 mmHg, were randomized to intensive (target SBP <120mmHg) or standard antihypertensive treatment (target SBP <140mmHg). The primary efficacy endpoint was the composite of acute coronary syndromes, stroke, heart failure, or death from CV causes. The primary safety endpoint was the composite of serious adverse events (SAE). We examined the prognostic implications of age, using Cox proportional-hazards regression models adjusted for demographic, clinical, and laboratory variables. Whether a linear association was present between age and clinical endpoints was evaluated using restricted cubic splines. We further explored the effects of intensive BP lowering across the age spectrum using interaction analyses.

Results

Age was noted for all individuals, and 3,805 (41%), 4,390 (47%), and 1,166 (12%) were <65 years, 65–79 years, and ≥80 years, respectively. Mean age was similar between the two study groups (intensive group 67.9 years vs. standard group 67.9 years; P=0.94). Median follow-up was 3.3 years (range 0–4.8), with 562 primary efficacy events (6%) and 3,529 primary safety events (38%) recorded during the study period. Age was linearly associated with the risk of stroke (test for overall trend, P<0.001) and non-linearly associated with the risk of primary efficacy events, death from CV causes, death from any cause, heart failure, and SAE (test for non-linearity, P<0.05; test for overall trend, P<0.001). Age remained significantly associated with all tested endpoints after multivariable adjustment (P<0.001). Furthermore, the risk of primary events increased over guideline-recommended age-categories (65–79 years vs. <65 years; adj. HR 1.65, 95% CI 1.34–2.04; P<0.001 and ≥80 years vs. 65–79 years; adj. HR 1.92, 95% CI 1.54–2.40; P<0.001), as did the risk of SAE (P<0.001). The safety and efficacy of intensive BP lowering was not modified by age whether tested continuously or categorically (P>0.05). The Figure shows similar treatment effects (hazard ratios) across the spectrum of age. P-values are for the interaction between age and treatment effect for each endpoint.

Figure 1

Conclusions

In SPRINT, higher age was associated with a greater risk of both CV events and SAE. However, intensive BP lowering appeared to be associated with similar risks and benefits across the age spectrum.

Abstract P3-04-03: S100β as a predictive biomarker and monitoring tool in endocrine resistant breast cancer

In estrogen receptor positive breast cancer, endocrine therapy is the standard line of treatment and even though it results in reduced recurrence and mortality, a significant number of patients will eventually relapse. Early detection of metastatic disease would significantly enhance management of endocrine resistant breast cancer. Here we investigate the potential of the calcium-binding protein S100β as a predictive biomarker and monitoring tool in endocrine treated patients. Furthermore, the efficacy of S100β inhibition as therapy in patients that fail first line endocrine therapy was examined.

Primary tumor tissue expression of S100β protein was assessed in a retrospective cohort of endocrine treated breast cancer patients. Expression of S100β indicated a significant reduction in time to disease recurrence (n=509, Wilcoxon p&lt;0.0001, hazard ratio 2.43, 95% C.I. is 1.607 to 3.69, p&lt;0.0001, Cox proportional hazard model).

S100β protein is also detectable in serum of breast cancer patients and elevated levels of serum S100β prior to removal of primary tumor is associated with poor disease free survival in endocrine treated patients (n=190, Wilcoxon p=0.0367, hazard ratio 2.68, 95% C.I. is 1.12 to 6.41, p=0.026, Cox proportional hazard model). Serum levels of S100β are significantly reduced after primary tumor resection (n=19, p=0.0003). In serial samples taken during the treatment period, elevated levels of S100β significantly associated with disease progression and with the emergence of metastatic disease (p=0.0031).

In an in-vivo model of endocrine resistant breast cancer, raised levels of S100β marked the emergence of disease progression. The oncogene steroid receptor co-activator 1 (SRC1) and its interaction with homeobox protein (HOXC11) regulates S100β production in a src-kinase dependent manner. Here, src-kinase inhibition reduced tumor burden with a concomitant reduction in serum S100β. We also observed a marked reduction in expression of proliferative marker Ki67 and S100β protein following the treatment of endocrine resistant patient tumor explants with src-kinase inhibitor.

Associations between elevated levels of serum S100β and subsequent disease progression in endocrine treated patients, suggests S100β as a monitoring tool for early detection of disease progression. Additionally high level of S100β can be used as a potential companion diagnostic tool for stratifying patients on endocrine therapy suitable for treatment with small molecule src-kinase inhibitor.

Citation Format: Charmsaz S, Hughes É, Byrne C, Bane F, Tibbitts P, McIlroy M, Hill AD, Young LS. S100β as a predictive biomarker and monitoring tool in endocrine resistant breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-04-03.

Behavioural interventions for sleep problems in people with an intellectual disability: a systematic review and meta-analysis of single case and group studies

BACKGROUND

Behavioural interventions are frequently used to address sleep problems in people with intellectual disabilities (ID). The current study aimed to systematically review evidence on the efficacy of behavioural interventions for children and adults with ID and sleep problems.

METHOD

Electronic and hand searches identified seven studies for inclusion (N = 169). Standardised mean difference effect sizes (d) were calculated for group studies (N = 4). Non-overlap effect sizes (Tau-U) were calculated for single case experimental design studies (SCEDs; N = 3).

RESULTS

A large effect size (weighted d = 0.923, confidence interval: 0.705 to 1.151) across group studies indicated large improvements in sleep problems following behavioural intervention. Effect size across SCEDs (weighted Tau-U: 0.528, confidence interval: 0.351 to 0.705) indicated a 53% improvement compared with baseline. Sleep initiation and sleep maintenance problems showed significant improvements post-intervention. Follow-up effects were less consistent across study designs and suggested that some sleep problems maintain gains better than others.

CONCLUSION

Meta-analytic evidence from group and SCEDs can provide complementary information about efficacy. Findings propose that behavioural interventions are a promising evidence-based practice for improving sleep problems in people with ID.