Echocardiographic characteristics of patients admitted with acute heart failure with a previous history of cancer: a single-centre observational study

Funding Acknowledgements

Type of funding sources: None.

Background

Cancer and heart failure frequently co-exist, with cancer and chemotherapy exerting a number of pathological effects on the myocardium. Despite this, our understanding of the clinical impact of previous history of cancer in acute heart failure remains unclear.  We therefore performed a retrospective cohort study to identify the echocardiographic characteristics in patients admitted with acute heart failure with and without a diagnosis of solid organ cancer.

Methods

Consecutive patients with signs and/or symptoms of acute heart failure admitted over a period of 33 weeks (7th January – 28th August 2020) were identified. Discharge summaries, electronic notes and shared care networks were manually searched to determine baseline demographics, admission bloods, comorbidities, cancer diagnoses, imaging and echocardiography. Univariate and multivariate Cox regression analysis was performed to identify clinical and biochemical predictors of mortality.

Results

In total, 478 patients were admitted with acute heart failure over the study period (mean age 80 ± 11 years, 53.6% were male and mean NT pro-BNP was 9106). 386 had echocardiography available for review. Of these, 64 (16.6%) had a past or current history of solid organ cancer.

Patients with a past or current history of solid organ cancer had a significantly higher ejection fraction (48% (±9%) vs 44% (±11%), p = 0.003), higher incidence of heart failure with preserved ejection fraction (57.8% vs 33.5%, p < 0.001) and lower incidence of right ventricular impairment (defined using both visual inspection and TAPSE measurements) (25.0% vs 47.8%, p < 0.001).

There were no significant differences in any valvular pathologies between groups (overall prevalence 71.9% vs 71.7%, p = 0.982) No difference was observed between the rate of prior myocardial infarction (28.1% vs 26.0%, p = 0.727) or lung disease (34.4% vs 37.0%, p = 0.692).

Overall, mortality at six months follow up was significantly higher in the group with a current or previous cancer diagnosis (43.4% vs 32.0%, p = 0.046) compared to the group without.

Conclusion

Patients admitted with acute heart failure and a past or current history of cancer have a significantly higher ejection fraction and lower prevalence of right ventricular impairment. Despite the higher ejection fraction their prognosis is worse. Further work is needed to determine potential mechanisms for this, as well as its clinical implications. Abstract Figure. Six Month Survival Kaplan Meier Graph  Abstract Figure. Echocardiogrpahic Features

837 High Prevalence of Anaemia and Mortality in Older Patients Undergoing Emergency Laparotomy

Aim

Anaemia affects 1in10 elderly (>65) patients with a myriad of causes. Elderly patients undergoing emergency laparotomy often present with anaemia. Little is known however about the prevalence of anaemia in older people who require emergency laparotomy and the influence it may have on their outcomes.

Method

Elderly patients (>65-years old) undergoing an emergency laparotomy between May2016-November2018 in a tertiary trauma centre were prospectively identified. Data included patient demographics, haemoglobin, MCV and ferritin, blood transfusions and iron products administered, readmissions and mortality.

Results

231 patients underwent emergency laparotomy. Prevalence of pre-operative anaemia in this group was 43%. 5% were very-anaemic and 38% mildly-anaemic. Ferritin was checked within 89 patients; insufficient levels were present in 20%. 31% of all patients were given blood in the peri-operative period. 100% of patients discharged, were anaemic. For pre-operative anaemic vs non-anaemic patients, ASA grade was higher (4 vs 3), readmission rate was 19% vs 18%, 30-day mortality was 18% vs 14% and 1-year mortality rate high(34% vs 22%, p < 0.05). Very-anaemic patients (92%) received peri-operative blood compared to (41%) of mildly-anaemic patients. 30-day mortality was 0 vs 21% in very-anaemic vs mildly-anaemic patients. Mortality was 45.8% in patients who received transfusions compared to those who did not 19.9% (P < 0.0001).

Conclusions

The prevalence of anaemia in older patients undergoing emergency laparotomy is high and related to significantly increased mortality(12 months after surgery). We have identified a high-risk group of older patients with mild anaemia on presentation who may be at increased risk of mortality 3months after surgery.

Does venous thromboembolism prophylaxis affect the risk of venous thromboembolism and adverse events following primary hip and knee replacement? A retrospective cohort study

Background

The optimum chemical venous thromboembolism (VTE) prophylactic agents following total hip and knee replacement (THR and TKR) remain unknown. NICE recommends multiple agents, including direct oral anticoagulants (DOACs), low-molecular weight heparin (LMWH), and aspirin. We assessed whether VTE prophylaxis affected the risk of VTE and adverse events following primary THR and TKR.

Materials and methods

We reviewed 982 elective primary THRs (59%) and TKRs (41%) at a large tertiary centre during 2018. The primary outcome was any VTE (DVT and/or PE) within 90-days. Secondary outcomes were adverse events within 90-days (major bleeding and wound complications). The association between VTE prophylaxis and outcomes was assessed.

Results

The overall prevalence of VTE and adverse events were 2.7% (n = 27) and 15.2% (n = 136) respectively. The most common agents used were DOAC ± LMWH (50.7%, n = 498), followed by aspirin ± LMWH (35.5%, n = 349) and LMWH alone (4.7%, n = 46). The risk of VTE (aspirin ± LMWH = 3.7%, DOAC = 2.0%, LMWH = 2.2%) was not significantly different between agents (p = 0.294). The risk of any adverse event was significantly higher (p < 0.001) with aspirin ± LMWH (16.1%; n = 56) and LMWH (28.3%; n = 13) compared with DOACs ± LMWH (7.0%; n = 35) in TKRs only, there was no differences between agents for adverse events in THRs (p = 0.644).

Conclusions

Choice of thromboprophylaxis did not influence the risk of VTE following primary THR and TKR. DOACs (+/- LMWH) were associated with the lowest risk of adverse events. Large multicentre trials are still needed to assess the efficacy and safety of these agents following THR and TKR.

To lead or not to lead? Prospective controlled study of emergency nurses' provision of advanced life support team leadership

BACKGROUND AND OBJECTIVES

In many emergency departments advanced life support (ALS) trained nurses do not assume a lead role in advanced resuscitation. This study investigated whether emergency nurses with previous ALS training provided good team leadership in a simulated cardiac arrest situation.

METHODS

A prospective study was conducted at five emergency departments and one nurses' association meeting. All participants went through the same scenario. Details recorded included baseline blood pressure and pulse rate, time in post, time of ALS training, and subjective stress score (1 = hardly stressed; 10 = extremely stressed). Scoring took into account scenario understanding, rhythm recognition, time to defibrillation, appropriateness of interventions, and theoretical knowledge.

RESULTS

Of 57 participants, 20 were ALS trained nurses, 19 were ALS trained emergency senior house officers (SHOs), and 18 were emergency SHOs without formal ALS training. The overall mean score for doctors without ALS training was 69.5%, compared with 72.3% for ALS trained doctors and 73.7% for ALS trained nurses. Nurses found the experience less stressful (subjective stress score 5.78/10) compared with doctors without ALS training (6.5/10). The mean time taken to defibrillate from the appearance of a shockable rhythm on the monitor by the nurses and those SHOs without ALS training was 42 and 40.8 seconds, respectively.

CONCLUSION

ALS trained nurses performed as well as ALS trained and non ALS trained emergency SHOs in a simulated cardiac arrest situation and had greater awareness of the potentially reversible causes of cardiac arrest. Thus if a senior or middle grade doctor is not available to lead the resuscitation team, it may be appropriate for experienced nursing staff with ALS training to act as ALS team leaders rather than SHOs.

Bupropion overdose: a potential problem with the new 'miracle' anti-smoking drug

Bupropion (Zyban) has recently been launched in the UK as an aid to smoking cessation. As a result of the considerable publicity, there has been unprecedented demand for this new drug in primary care. Within a few weeks of its launch, four patients presented to our A&E department having taken bupropion as an intentional overdose. Three recovered with simple supportive measures; one one was critically ill and required admission to the intensive care unit. There are several case reports on bupropion overdose in the US but none so far in the UK.

Snap without crackle or pop: a rude awakening. A case history of penile fracture

Penile fracture is a rare but worrying condition. The presentation to accident and emergency or primary care should not present difficulty in diagnosis but may cause concern with regard to initial treatment and definitive management. Emergency admission to a urologist is mandatory.

A profile of alcohol and drug clients in New Zealand: results from the 1998 national telephone survey

AIMS

To describe the profile of clients seen across the broad spectrum of dedicated alcohol and drug treatment services in New Zealand.

METHODS

217 randomly selected alcohol and drug treatment workers in New Zealand were interviewed by telephone, yielding a randomly selected sample of 291 clients. Workers were asked to identify the age, gender, ethnicity, main substance use problem and geographical location of clients.

RESULTS

60% of clients were male, 28% were Maori, the mean age was 31 years and the largest group of clients were seen for alcohol related issues (45%), followed by cannabis (27%) and opioids (17%). None of these variables differed significantly across residential/non-residential services. Significant trends to emerge were: that Maori clients were more likely to live rurally and to be in treatment for cannabis use, women were more likely to be in treatment for benzodiazepine use and less likely for cannabis use, opioid users were more likely to be seen at Crown Health Enterprise funded services, and cannabis users were (on average) younger than other clients, while alcohol users were older.

CONCLUSIONS

Alcohol and drug treatment services are dominated by clients seeking assistance with alcohol and cannabis use problems. Women are not under-represented in this population. Maori are over-represented. This contrasts with the absence of Asian clients and an under-representation of Pacific Island clients. There are some significant variations in the types of drugs used by different demographic treatment seeking populations. In contrast, client differences across treatment settings are minimal.

Incidence of laxative abuse in community and bulimic populations: a descriptive review

Estimates of the incidence of laxative abuse in bulimics and in the community-at-large vary widely for various population samples. This review identified 73 studies in which laxative abuse could be assessed in bulimics, nonbulimics, and the community-at-large. Relative risk values for laxative abuse among population subsamples were estimated by moment methods statistical procedure based on mixed model analysis. Results indicated that the lifetime occurrence for laxative abuse behavior in the community-at-large was 4.18%. Bulimic behavior increased the risk for laxative abuse 3.57-fold to 14.94%. Several methodologic and population parameter characteristics are examined for their select impact on laxative abuse. Review of medical nomenclature for classifying laxative substances, iatragenic effects of laxative abuse, and assessment recommendations are also included.