Barriers to Telehealth Utilization Among Patients of Limited Income with Chronic Conditions and a Gap in Care

Objective: This study assessed barriers and facilitators to telehealth utilization among patients living in New York City public housing with chronic conditions and a gap in clinical care. Methods: Community health workers performed outreach to eligible patients by telephone between January and March 2021. Consenting respondents answered questions about telehealth barriers, including internet and cell phone access, ownership of digital devices, comfort with using digital devices, comfort with telehealth, cost, awareness, and availability of written materials in patients' preferred language. We obtained demographic and medical information from patients' electronic health records. We used multivariable logistic regression to estimate the association of barriers with the odds of self-reported prior telehealth utilization. Results: A total of 304 consenting patients participated in the program. The average patient had 3.1 telehealth barriers; 76% reported at least one barrier. Regression analysis showed sizable reductions in prior telehealth utilization associated with the barriers of unlimited cell phone minutes (odds ratio [OR]: 0.21 [0.05-0.88], p = 0.033), technological comfort (OR: 0.33 [0.13-0.82], p = 0.016), conceptual comfort with telehealth (OR: 0.15 [0.04-0.54], p = 0.004), and materials in the patient's preferred language (OR: 0.23 [0.07-0.79], p = 0.02). Discussion: With a high prevalence of telehealth barriers, patients with limited income, a chronic condition, and a care gap may benefit from greater technological access and supportive programs for awareness, telehealth comfort, and navigation support. Addressing telehealth barriers could increase the quality of medical care and improve health outcomes for this population.

Prediction of mechanistic subtypes of Parkinson's using patient-derived stem cell models

Parkinson's disease is a common, incurable neurodegenerative disorder that is clinically heterogeneous: it is likely that different cellular mechanisms drive the pathology in different individuals. So far it has not been possible to define the cellular mechanism underlying the neurodegenerative disease in life. We generated a machine learning-based model that can simultaneously predict the presence of disease and its primary mechanistic subtype in human neurons. We used stem cell technology to derive control or patient-derived neurons, and generated different disease subtypes through chemical induction or the presence of mutation. Multidimensional fluorescent labelling of organelles was performed in healthy control neurons and in four different disease subtypes, and both the quantitative single-cell fluorescence features and the images were used to independently train a series of classifiers to build deep neural networks. Quantitative cellular profile-based classifiers achieve an accuracy of 82%, whereas image-based deep neural networks predict control and four distinct disease subtypes with an accuracy of 95%. The machine learning-trained classifiers achieve their accuracy across all subtypes, using the organellar features of the mitochondria with the additional contribution of the lysosomes, confirming the biological importance of these pathways in Parkinson's. Altogether, we show that machine learning approaches applied to patient-derived cells are highly accurate at predicting disease subtypes, providing proof of concept that this approach may enable mechanistic stratification and precision medicine approaches in the future.

Long-term Outcomes Following a Comprehensive Quality Assurance and Process Improvement Endeavor to Minimize Opioid Use After Kidney Transplant

Importance

Opioid use following kidney transplant is associated with an increased risk of graft loss and mortality. Opioid minimization strategies and protocols have shown reductions in short-term opioid use after kidney transplant.

Objective

To evaluate the long-term outcomes associated with an opioid minimization protocol following kidney transplant.

Design, Setting, and Participants

This single-center quality improvement study evaluated postoperative and long-term opioid use before and after the implementation of a multidisciplinary, multimodal pain regimen and education process in adult kidney graft recipients from August 1, 2017, through June 30, 2020. Patient data were collected from a retrospective chart review.

Exposures

Preprotocol and postprotocol implementation use of opioids.

Main Outcomes and Measures

Between November 7 and 23, 2022, opioid use before and after protocol implementation was evaluated up to 1 year after transplant using multivariable linear and logistic regression.

Results

A total of 743 patients were included, with 245 patients in the preprotocol group (39.2% female and 60.8% male; mean [SD] age, 52.8 [13.1 years]) vs 498 in the postprotocol group (45.4% female and 54.6% male; mean [SD] age, 52.4 [12.9 years]). The total morphine milligram equivalents (MME) in the 1-year follow-up in the preprotocol group was 1203.7 vs 581.9 in the postprotocol group. In the postprotocol group, 313 patients (62.9%) had 0 MME in the 1-year follow-up vs 7 (2.9%) in the preprotocol group (odds ratio [OR], 57.52; 95% CI, 26.55-124.65). Patients in the postprotocol group had 99% lower odds of filling more than 100 MME in the 1-year follow-up (adjusted OR, 0.01; 95% CI, 0.01-0.02; P < .001). Opioid-naive patients postprotocol were one-half as likely to become long-term opioid users vs preprotocol (OR, 0.44; 95% CI, 0.20-0.98; P = .04).

Conclusions and Relevance

The study's findings show a significant reduction in opioid use in kidney graft recipients associated with the implementation of a multimodal opioid-sparing pain protocol.

A Systematic Review of Opioid Use and Multimodal Strategies in Solid Organ Transplant Recipients and Living Donors

BACKGROUND

The opioid epidemic has impacted analgesia in the post-operative period for solid organ transplant (SOT) donors and recipients. However, optimal pain management and opioid stewardship strategies have not been identified across this unique population.

OBJECTIVE

the purpose of this systematic review is to evaluate the impact of perioperative opioid use and to describe multimodal analgesic strategies to reduce opiate use in SOT recipients and living donors.

METHODS

A systematic review was conducted. Electronic searches were performed in Medline, Embase, Google Scholar, and Web of Science through December 31, 2021. Title and abstracts were screened. Relevant articles underwent full text review. Literature was separated into effects of opioid exposure on post-transplant outcomes, recipient pain management strategies, and living donor pain management strategies.

RESULTS

Search yielded 25,190 records, and 63 were ultimately included. The impact of opioid use on post-transplant outcomes were assessed in 19 publications. The risk of graft loss in pre-transplant opioid users was assessed in six reports and was found to be higher in the majority (66%) of publications. Opioid minimization strategies were reported in 20 studies in transplant recipients. Twenty-four studies evaluated pain management strategies in living donors. Both populations used a combination of multimodal strategies to minimize opioid use throughout the hospitalization and on discharge.

CONCLUSIONS

1.1.1. OPIOIDS ARE ASSOCIATED WITH SELECT NEGATIVE OUTCOMES IN POST-TRANSPLANT RECIPIENTS. TO MINIMIZE THEIR USE WHILE ALSO MAINTAINING APPROPRIATE ANALGESIA, MULTIMODAL PAIN REGIMENS SHOULD BE CONSIDERED IN SOT RECIPIENTS AND DONORS.

Relationship of binding-site occupancy, transthyretin stabilisation and disease modification in patients with tafamidis-treated transthyretin amyloid cardiomyopathy

BACKGROUND

Tafamidis inhibits progression of transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) by binding TTR tetramer and inhibiting dissociation to monomers capable of denaturation and deposition in cardiac tissue. While the phase 3 ATTR-ACT trial demonstrated the efficacy of tafamidis, the degree to which the approved dose captures the full potential of the mechanism has yet to be assessed.

METHODS

We developed a model of dynamic TTR concentrations in plasma to relate TTR occupancy by tafamidis to TTR stabilisation. We then developed population pharmacokinetic-pharmacodynamic models to characterise the relationship between stabilisation and measures of disease progression.

RESULTS

Modelling individual patient data of tafamidis exposure and increased plasma TTR confirmed that single-site binding provides complete tetramer stabilisation in vivo. The approved dose was estimated to reduce unbound TTR tetramer by 92%, and was associated with 53%, 56% and 49% decreases in the rate of change in NT-proBNP, KCCQ-OS, and six-minute walk test disease progression measures, respectively. Simulating complete TTR stabilisation predicted slightly greater reductions of 58%, 61% and 54%, respectively.

CONCLUSIONS

These findings support the value of TTR stabilisation as a clinically beneficial treatment option in ATTR-CM and the ability of tafamidis to realise nearly the full therapeutic benefit of this mechanism.

CLINICALTRIALS.GOV IDENTIFIER

NCT01994889.

Navigation for youth mental health and addictions: protocol for a realist review and synthesis of approaches and practices (The NavMAP standards project)

INTRODUCTION

Mental health and/or addiction (MHA) concerns affect approximately 1.2 million children and youth in Canada, yet less than 20% receive appropriate treatment for these concerns. Youth who do not receive appropriate support may disengage from care and may experience lasting MHA issues. Families of these youth also support them in finding and accessing care. Thus, system supports are needed to help youth and their families find and equitably access appropriate care. Navigation is an innovation in MHA care, providing patient-centred support and care planning that helps individuals and families overcome barriers to care. Despite the increasing availability of navigation services for youth with MHA concerns, practices and models vary, and no single source has synthesised evidence regarding approaches and outcomes for this population into comprehensive standards.

METHODS AND ANALYSIS

The proposed research will bring together evidence in youth MHA navigation, to establish this important system support as a factor that can enhance the integration and continuity of care for these youth. Our team, which includes researchers, administrators, clinical leads, an MHA navigator and youth and caregivers with lived experience, will be involved in all project stages. Realist Review and Synthesis methodology will be used, the stages of which include: defining scope, searching for evidence, appraising studies and extracting data, synthesising evidence and developing conclusions, and disseminating findings.

ETHICS AND DISSEMINATION

Ethics approval is not required, as the study involves review of existing data. Dissemination plans include scientific publications and conferences and online products for stakeholders and the general public.

Relationship of tafamidis binding site occupancy, transthyretin stabilization, and disease modification in tafamidis treated transthyretin amyloid cardiomyopathy patients

Introduction

Tafamidis inhibits progression of transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) by binding TTR tetramer and inhibiting its dissociation to monomers which can denature and result in amyloid fibril formation and deposition in cardiac tissue.

Purpose

While the phase 3 ATTR-ACT clinical data clearly demonstrated efficacy, quantification of TTR stabilization in patients and the degree to which the approved dose captures the full potential of the mechanism has yet to be assessed.

Methods

Isothermal titration calorimetry and subunit fraction exchange were used to determine affinities to the two binding sites on TTR. These values were used to develop a model of tafamidis binding to TTR in plasma that was applied to individual patient data to calculate TTR binding site occupancy and the change in total TTR levels induced by TTR stabilization. Population pharmacodynamic (PD) models were developed for three measures of disease progression, plasma NT-proBNP levels, Kansas City Cardiomyopathy Questionnaire – Overall Score (KCCQ-OS), and six-minute walk test (6MWT) distance, to evaluate patient response with the degree of TTR occupancy.

Results

In vitro binding data of wild-type TTR confirmed tafamidis binds two sites of TTR with negative cooperativity and provided precise estimates of the binding affinity to TTR and albumin. Modeling individual patient data of tafamidis exposure and increased TTR plasma levels using the in vitro derived binding affinity values confirms single site binding is consistent with complete tetramer stabilization. Patients given 80 mg tafamidis meglumine, the clinically approved dose for ATTR-CM, had a 92% reduction in unbound, unstabilized TTR, which correlated with a 53% decrease in NT-proBNP elevation, a 56% decrease in KCCQ-OS worsening and a 49% reduced decline in the 6MWT. For 100% receptor occupancy and stabilization, the expected effects on these measures are 58%, 61%, and 54% for NT-proBNP, KCCQ-OS, and 6MWT, respectively.

Conclusions

These results demonstrate a quantitative relationship between TTR stabilization, the mechanism of action of tafamidis, and accepted laboratory and patient-based outcomes in ATTR-CM. These results also support the value of TTR stabilization as a clinically beneficial treatment option which maintains the protein in its physiologically active form within the body.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was sponsored by Pfizer.

OP0243 OSTEOPOROSIS CASE-FINDING IN PEOPLE UNDERGOING ROUTINE DIAGNOSTIC CT SCANS ALMOST TRIPLED THE RATE OF OSTEOPOROSIS TREATMENT AT 12 MONTHS. A RANDOMISED, MULTI-CENTRE FEASIBILITY STUDY USING WAITING ROOM FRAX, OPPORTUNISTIC CT BONE DENSITY AND VERTEBRAL FRACTURE ASSESSMENT VERSUS USUAL CARE

Background

Up to 40% of all diagnostic computed tomography (CT) scans include views of the spine or hips. Among older people, osteoporosis or vertebral fractures have been found in 30% of such CT scans. Our ‘PHOENIX’ intervention repurposes CT scans taken for other reasons to identify fractures and measure bone density as an ‘added extra’. Early detection and treatment of osteoporosis in CT-attending patients could improve health outcomes.

Objectives

To determine the feasibility and efficacy of PHOENIX versus usual care in a multi-centre, randomised, pragmatic study conducted in Eastern England involving our Cambridge Specialist Hospital ‘hub’ and four regional General Hospital ‘spokes’.

Methods

Women ≥65 and men ≥75 years attending for routine diagnostic CT scans were invited to participate via a novel consent form incorporating FRAX Fracture Risk Assessment questions. After calculating their FRAX 10-year risk score, higher risk patients were block randomised (1:1:1) to Group 1) PHOENIX intervention, 2) Active Control, where the GP was sent the patients’ FRAX answers only, or 3) Usual Care where data were only analysed after 13 months had elapsed. The CT scans of high FRAX risk patients in Group 1 were retrieved by the Cambridge team using NHS Connecting for Health (Burnbank, UK). The team performed vertebral fracture assessment and measured bone density using QCT Pro (Mindways, USA). They added patient-specific treatment and investigation management advice from ‘drop down’ menus before results were reviewed by a physician, authorised and sent to general practitioners (GPs). Baseline CT scans from groups 2 and 3 were assessed in the same way after 13 months to ensure no patient with osteoporosis/fractures was neglected long term. Assuming 25% attrition, the study was powered to find a superior osteoporosis treatment rate in Group 1 (estimated 20%) versus 16% (Active Control) and 5% (Usual Care). Co-primary feasibility endpoints were the ability to a) randomise 375 patients within 10 months and b) retain 75% of survivors able to complete a 1-year bone health outcome questionnaire. Secondary outcomes included osteoporosis/vertebral fracture identification rates and osteoporosis treatment rates. Stakeholder acceptability and economic aspects will be reported separately.

Results

From 1828 invites, 595 participants consented to participate of whom 213 were excluded due to ‘low’ FRAX score. Mortality at 12 months was 20%. Both feasibility objectives were achieved: 1) 382 people were randomised within 10 months; 2) 84.4% of survivors at 1 year (95%CI: 80.5, 88.3) were successfully followed-up. Groups were well matched at baseline. The average age of 375 patients (334 female, 41 male) was 75.2 years (74.6, 75.9). Osteoporosis of the hip/spine was present in 41% of 362 analysable CT scans. From the 264 spines that were suitable for VFA, 20% (n=53) were found to have vertebral fractures, with 8.3% having multiple vertebral fractures (n=22). Osteoporosis treatment was reported in 8.5% of Usual Care group (2.9, 14.2) and 24.2% (15.4, 33.0) of PHOENIX group participants, while in the Active Control group (FRAX only) it was 18.8% (10.9, 26.6 p=0.021). In the PHOENIX group, a recommendation to treat was sent to 50 patients’ GPs at baseline. Only 18 of the 50 patients (36%) were found to be taking osteoporosis treatment 12 months after this advice was sent.

Conclusion

Osteoporosis treatment rates were almost tripled by screening patients attending for routine diagnostic CT scans with waiting room FRAX, CT-bone densitometry and vertebral fracture analysis.

Acknowledgements

This project is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0816-20027) and by the Cambridge NIHR Biomedical Research Centre (BRC-1215-20014). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Funding is in place to 31.03.2022. Three individuals, Mr Jeremy Dearling, Mrs Tessa Plume and Dr Ann Frost joined our trial group as PPI representatives; they were specifically involved in patient documentation design (particularly the PHOENIX pack, informed consent form which facilitated consent without having a researcher present) and contributed to suggestions for increasing patient recruitment and follow up.

Disclosure of Interests

None declared

AB1559-HPR ESTABLISHING A MULTIDISCIPLINARY CLINIC TO IMPROVE THE QUALITY OF CARE FOR PATIENTS WITH INTERSTITIAL LUNG DISEASE

Background

Patients with interstitial lung disease related to rheumatic disease (ILD-RD) often need to see multiple specialties to establish the diagnosis and for management. Suh care is better provided in a multidisciplinary clinic (MDC) and setting up such a MDC involves significant cost, time and buy in from stakeholders. In our center, we approached starting a MDC as a multiple phased project. Phase 1: confirm improved patient outcomes when multiple specialties are involved in providing care to these patients. Phase 2: application for an internal grant for a prospective pilot clinic and phase 3: the establishment of a permeant MDC. We report the results of our phase 1 analysis.

Objectives

The primary aim of this study was to determine if involvement of our pulmonary and cardiology colleagues in the care of patients with ILD-RD seen in the rheumatology clinic results in improvement in the evaluation and treatment of these patients.

Methods

This is a retrospective, single center, hospital-affiliated outpatient study. All patients seen in the rheumatology clinic with a diagnosis of ILD-RD between January 1 2018 and December 31 2019 were eligible for enrollment. A list of patients was generated by the technology service group using relevant international classification of diseases codes. These records were reviewed and those meeting the inclusion and exclusion criteria were enrolled.

A review of the 1574 charts generated confirmed 41 patients with ILD-RD. Demographic data, as well as disease related data including serological testing, disease manifestation and treatment choices was obtained. Continuous variables were analyzed using T-test or Mann-Whitney U test. Categorical variables were analyzed using Chi-square Tests or Fisher’s exact tests. Statistical analysis was performed using SAS9.4, and p value <0.05 was considered statistically significant.

Results

Patients seen by more than one specialty were more likely to have had a more extensive evaluation for ILD and its complications. The cause of the ILD-RD did not have an impact on the tests performed or the number of specialist seen.

There was a significantly more glucocorticoids monotherapy use in scleroderma related ILD, but disease-modifying antirheumatic drugs were more commonly used in non-scleroderma ILD patients.

Table 1.

Demographics

Non-scleroderma ILD (N = 27)Scleroderma ILD (N = 14)p-valueAge at diagnosis72.8 (10.2)70.5 (13.7)0.55Female70.4% (19/27)71.4% (10/24)0.99Race0.69  Caucasian77.8% (21)85.7% (12) African American22.2% (6)14.3% (14)PAH17.4% (4/23)23.1% (3/13)0.69PFT87.5% (21/24)92.9% (13/14)0.99CT Chest100% (24/24)100% (14/14)Right HCC30.4% (7/23)21.4% (3/14)0.71Number of specialists0.31 18.3% (2)14.3% (2) 237.5% (9)57.1% (8) 34.2% (13)28.6% (4)Medication<0.01 None0% (0)14.3% (2) GC7.4% (2)42.9% (6) GC + DMARDs88.9% (24)42.9% (6) DMARDs3.7% (1)0% (0)

Conclusion

Our data suggests that a MDC for RD-ILD results in a more thorough investigation and treatment, and this will likely lead to improvements in patient outcomes. Based on these findings, our rheumatology group is seeking internal funding for a pilot clinic evaluating prospectively the benefits of an ILD MDC.

References

[1]Leeftink AG, Bikker IA, Vliegen IMH, Boucherie RJ. Multi-disciplinary planning in health care: a review. Health Syst (Basingstoke). 2018;9(2):95-118. Published 2018 Feb 27.

[2]Chaudhuri N, Spencer L, Greaves M, Bishop P, Chaturvedi A, Leonard C. A Review of the Multidisciplinary Diagnosis of Interstitial Lung Diseases: A Retrospective Analysis in a Single UK Specialist Centre. J Clin Med. 2016;5(8):66.

[3]Murali Mohan BV, Tousheed SZ, Manjunath PH, Ravichandra MR, Ranganatha R, Annapandian VM, Kumar MH, Sagar C. Multidisciplinary team obviates biopsy in most patients with diffuse parenchymal lung diseases-A retrospective study from India. Clin Respir J. 2021 Jul;15(7):761-769.

Disclosure of Interests

None declared

Examining the effectiveness of Gateway-an out-of-court community-based intervention to reduce recidivism and improve the health and well-being of young adults committing low-level offences: study protocol for a randomised controlled trial

BACKGROUND

Young adult offenders represent a third of the UK prison population and are at risk of poor health outcomes including drug and alcohol misuse, self-harm and suicide. Court diversion interventions aim to reduce the negative consequences of formal criminal justice sanctions and focus resources on addressing the root causes of offending. Although diversions are widely used, evidence of their effectiveness has not yet been established. Hampshire Constabulary, working together with local charities, have developed the Gateway programme, an out-of-court intervention aimed at improving the life chances of young adults. Issued as a conditional caution, participants undertake a health and social care needs assessment, attend workshops encouraging analysis of own behaviour and its consequences and agree not to re-offend during the 16-week caution.

METHODS

This is a pragmatic, multi-site, parallel-group, superiority randomised controlled trial with a target sample size of 334. Participants are aged 18-24, reside in Hampshire and Isle of Wight and are being questioned for an eligible low-level offence. Police investigators offer potential participants a chance to receive the Gateway caution, and those interested are also invited to take part in the study. Police officers obtain Stage 1 consent and carry out an eligibility check, after which participants are randomised on a 1:1 basis either to receive Gateway or follow the usual process, such as court appearance or a different conditional caution. Researchers subsequently obtain Stage 2 consent and collect data at weeks 4 and 16, and 1 year post-randomisation. The primary outcome is the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes include health status, alcohol and drug use, recidivism and resource use. The primary analysis will compare the WEMWBS score between the two groups at 12 months.

DISCUSSION

This pioneering trial aims to address the evidence gap surrounding diversion in 18-24-year-olds. The findings will inform law enforcement agencies, third sector organisations, policymakers and commissioners, as well as researchers working in related fields and with vulnerable target populations.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Register ( ISRCTN 11888938 ).

Teprotumumab in Clinical Practice: Recommendations and Considerations From the OPTIC Trial Investigators

BACKGROUND

Thyroid eye disease (TED) is a vision-threatening and debilitating condition that until very recently had no Food and Drug Administration (FDA)-approved medical therapies. Teprotumumab has recently been approved to treat TED. We aim to provide guidance for its use, based on the input of the US investigators who participated in Phase 2 and Phase 3 clinical trials.

METHODS

An expert panel was convened on October 11th and November 16th of 2019. All panel members had extensive experience as investigators in the Phase 2 and/or Phase 3 clinical trials of teprotumumab. Consensus among those investigators was reached to determine patient characteristics most appropriate for teprotumumab treatment. Safety guidelines were also reviewed and agreed on.

RESULTS

The authors recommend that teprotumumab be considered first-line therapy for patients with clinically significant ophthalmopathy, including those with disease duration exceeding 9 months. The clinical activity score (CAS) may be useful for longitudinal monitoring but should not be used to determine treatment eligibility. Criteria will likely be expanded after more experience with the drug. Using teprotumumab for patients with TED with substantial signs, symptoms, or morbidity without a CAS score of >4 (e.g., progressive proptosis, diplopia, and early compressive optic neuropathy) or more, could be considered. Diabetes mellitus and inflammatory bowel disease comorbidities should not be exclusionary, but stringent monitoring in these patients is recommended. Drug dosing, administration interval, and duration should adhere to the study protocol: 8 infusions, separated by 3 weeks. Patients with more severe disease may benefit from additional doses. Corticosteroids can be used before or during teprotumumab therapy. Clinical and laboratory monitoring should be consistent with good clinical practice for patients receiving teprotumumab.

CONCLUSIONS

Confirming the efficacy of teprotumumab usage outside the narrow parameters of the completed clinical trials will require rigorous scientific validation. As a step in that direction, we believe its on-label usage is appropriately applied to all patients with TED with substantial symptoms or morbidity, as judged by their physician.

Development and Preliminary Evaluation of a Quality-of-Life Questionnaire for Adults with Neurofibromatosis Type 1 (NF1-AdQOL)

BACKGROUND

Neurofibromatosis type 1 (NF1) is a variable and unpredictable multisystem genetic disorder which predisposes to medical complications, cognitive impairment and disfigurement, of all which can impact negatively upon the health related quality of life (HRQOL) of affected adults.

OBJECTIVES

To develop and validate a disease specific HRQOL adult questionnaire to evaluate effects of NF1 from the patient's viewpoint.

METHODS

The NF1 adult HRQOL questionnaire (NF1-AdQOL) was developed based on patient interviews (n=8), survey of clinicians and piloting of the questionnaire. Adults with NF1 (n=114, 18-40 years) were recruited from three Australian genetics clinics and completed the NF1-AdQOL, Skindex-29 and Short Form-36v2 (SF-36v2) questionnaires. An exploratory factor analysis of the NF1-AdQOL was conducted to assess construct validity. Convergent and discriminant validity of the NF1-AdQOL was determined by using the multi-trait multi-method with Skindex-29 and SF-36v2 scores.

RESULTS

Factor analysis indicated that 62.7% of the common variance could be explained by three factors labelled as 'emotions associated with cosmetic appearance' (12 items), 'social functioning and learning' (11 items) and 'physical symptoms' (8 items). NF1-AdQOL had good internal consistency (Cronbach's α = 0.96). Convergent validity was confirmed by moderate associations with similarly named scales of the Skindex-29 and SF-36v2. Results from all HRQOL questionnaires indicated overall healthy HRQOL for young adults with NF1.

CONCLUSIONS

NF1-AdQOL is a relatively valid, feasible and fairly easy to read tool to measure QOL in adults with NF1. Further evaluation is required to determine its test-retest reliability, responsiveness and validity in larger adult NF1 cohorts.

Natriuretic Equation to Predict Loop Diuretic Response in Patients With Heart Failure

BACKGROUND

Most acute decompensated heart failure admissions are driven by congestion. However, residual congestion is common and often driven by the lack of reliable tools to titrate diuretic therapy. The authors previously developed a natriuretic response prediction equation (NRPE), which predicts sodium output using a spot urine sample collected 2 h after loop diuretic administration.

OBJECTIVES

The purpose of this study was to validate the NRPE and describe proof-of-concept that the NRPE can be used to guide diuretic therapy.

METHODS

Two cohorts were assembled: 1) the Diagnosing and Targeting Mechanisms of Diuretic Resistance (MDR) cohort was used to validate the NRPE to predict 6-h sodium output after a loop diuretic, which was defined as poor (<50 mmol), suboptimal (<100 mmol), or excellent (>150 mmol); and 2) the Yale Diuretic Pathway (YDP) cohort, which used the NRPE to guide loop diuretic titration via a nurse-driven automated protocol.

RESULTS

Evaluating 638 loop diuretic administrations, the NRPE showed excellent discrimination with areas under the curve ≥0.90 to predict poor, suboptimal, and excellent natriuretic response, and outperformed clinically obtained net fluid loss (p < 0.05 for all cutpoints). In the YDP cohort (n = 161) using the NRPE to direct therapy mean daily urine output (1.8 ± 0.9 l vs. 3.0 ± 0.8 l), net fluid output (-1.1 ± 0.9 l vs. -2.1 ± 0.9 l), and weight loss (-0.3 ± 0.3 kg vs. -2.5 ± 0.3 kg) improved substantially following initiation of the YDP (p < 0.001 for all pre-post comparisons).

CONCLUSIONS

Natriuretic response can be rapidly and accurately predicted by the NRPE, and this information can be used to guide diuretic therapy during acute decompensated heart failure. Additional study of diuresis guided by the NRPE is warranted.

A Case of Non-Arteritic Anterior Ischemic Optic Neuropathy with COVID-19

Non-arteritic ischemic optic neuropathy (NAION) is thought to be caused by loss of blood flow to the optic nerve which in turn causes an acute, unilateral and painless vision loss that affects older vasculopathic patients. We report a case of a 43-year-old Hispanic male with the classic presentation of NAION in the setting of a coronavirus disease 2019 (COVID-19) infection. It is well documented that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can cause hypoxemia and thrombophilia in patients, both of which may contribute to the development of NAION. It is uncertain whether the association of NAION and COVID-19 was causal or coincidental but the purpose of this case report is to argue that there is biological plausibility and to help shed light on potential ophthalmologic complications of COVID-19.

Mechanisms of Diuretic Resistance Study: design and rationale

INTRODUCTION

Diuretic resistance is a common complication impairing decongestion during hospitalization for acute decompensated heart failure (ADHF). The current understanding of diuretic resistance mechanisms in ADHF is based upon extrapolations from other disease states and healthy volunteers. However, accumulating evidence suggests that the dominant mechanisms in other populations have limited influence on diuretic response in ADHF. Additionally, the ability to rapidly and reliably diagnose diuretic resistance is inadequate using currently available tools.

AIMS

The Mechanisms of Diuretic Resistance (MDR) Study is designed to rigorously investigate the mechanisms of diuretic resistance and develop tools to rapidly predict diuretic response in a prospective cohort hospitalized with ADHF.

METHODS

Study assessments occur serially during the ADHF hospitalization and after discharge. Each assessment includes a supervised 6-hour urine collection with baseline blood and timed spot urine collections following loop diuretic administration. Patient characteristics, medications, physical exam findings, and both in-hospital and post-discharge HF outcomes are collected. Patients with diuretic resistance are eligible for a randomized sub-study comparing an increased loop diuretic dose with combination diuretic therapy of loop diuretic plus chlorothiazide.

CONCLUSIONS

The Mechanisms of Diuretic Resistance Study will establish a prospective patient cohort and biorepository to investigate the mechanisms of diuretic resistance and urine biomarkers to rapidly predict loop diuretic resistance.

Sodium glucose cotransporter 2 inhibitors as diuretic adjuvants in acute decompensated heart failure: a case series

Aims

Diuretic resistance is common in acute decompensated heart failure (ADHF). When loop diuretic monotherapy is ineffective, thiazides are often recommended as adjunctive therapy, but these agents have many side effects and are associated with worsened survival. In contrast, sodium glucose cotransporter 2 inhibitors (SGLT‐2i's), initially developed as glucose‐lowering medications for type 2 diabetes, improve heart failure outcomes. A candidate contributory mechanism for this benefit is their diuretic effects. We sought to describe the safety and efficacy of SGLT‐2i's as loop diuretic adjuvants in ADHF.

Methods and results

We retrospectively analysed patients who received adjuvant SGLT‐2i therapy between August 2016 and June 2018 at Yale‐New Haven Hospital. Thirty‐one patients comprised the cohort, 58% of whom had type 2 diabetes. Compared with the 24 h prior to SGLT‐2i initiation, average weight loss improved (1.0 ± 2.2 kg, P = 0.03 at Day 1; 1.7 ± 4.9 kg, P = 0.08 at Day 2; and 2.1 ± 5.6 kg, P = 0.06 at Day 3), as did urine output (3.7 ± 2.0 L, P = 0.002 at Day 1; 3.4 ± 1.7 L, P = 0.02 at Day 2; and 3.1 ± 1.7 L, P = 0.02 at Day 3) while loop diuretic dosing remaining stable. Creatinine remained unchanged during the 3 days after initiation, as did blood pressure and the incidence of hypokalaemia (P = NS for all).

Conclusions

In this cohort of patients with ADHF, SGLT‐2i's improved weight loss, urine output, and diuretic efficiency without worsening of creatinine, potassium, or blood pressure. Further study of SGLT‐2i's as a loop diuretic adjuvant is warranted.

Dietary Intake of Gaelic Football Players during Game Preparation and Recovery

It is well established that dietary intake can influence performance and modulate recovery in field-based invasion team sports such as soccer and rugby. However, very limited research currently exists examining dietary intake of Gaelic football players. This research aimed to examine the dietary intake of Gaelic football players 2 days prior to competition, on game day, and for 2 days post-competition. A five-day paper-based food diary was completed by 45 players (25 elite and 20 sub-elite). Preliminary inspection of diaries eliminated 11 participants, and analysis of Goldberg cut-offs identified 1 player as an under-reporter, leaving 33 players in the final analysis. Playing level had no effect on energy, carbohydrate, or fat intake. Average intake of energy was 2938 ± 618 kcal.day⁻¹, carbohydrate was 3.7 ± 1.42 g.kgbm⁻¹.day⁻¹, and fat was 1.34 ± 0.61 g.kgbm⁻¹.day⁻¹. However, elite players consumed 24.1% more protein than sub-elite players (2.2 ± 0.67 vs. 1.8 ± 0.62 g.kgbm⁻¹.day⁻¹). Regardless of playing level, players consumed inadequate amounts of carbohydrate to support optimal performance and recovery and consumed protein and fat in line with general sport nutrition guidelines. Given the unique demands placed on Gaelic football players, it may be necessary to develop nutrition guidelines specific to Gaelic football. Additionally, the design and implementation of Gaelic football-specific education-based interventions may be necessary to address the highlighted nutritional inadequacies.

Empagliflozin in Heart Failure: Diuretic and Cardiorenal Effects

BACKGROUND

Sodium-glucose cotransporter-2 inhibitors improve heart failure-related outcomes. The mechanisms underlying these benefits are not well understood, but diuretic properties may contribute. Traditional diuretics such as furosemide induce substantial neurohormonal activation, contributing to the limited improvement in intravascular volume often seen with these agents. However, the proximal tubular site of action of the sodium-glucose cotransporter-2 inhibitors may help circumvent these limitations.

METHODS

Twenty patients with type 2 diabetes mellitus and chronic, stable heart failure completed a randomized, placebo-controlled crossover study of empagliflozin 10 mg daily versus placebo. Patients underwent an intensive 6-hour biospecimen collection and cardiorenal phenotyping at baseline and again after 14 days of study drug. After a 2-week washout, patients crossed over to the alternate therapy with the above protocol repeated.

RESULTS

Oral empagliflozin was rapidly absorbed as evidenced by a 27-fold increase in urinary glucose excretion by 3 hours (P<0.0001). Fractional excretion of sodium increased significantly with empagliflozin monotherapy versus placebo (fractional excretion of sodium, 1.2±0.7% versus 0.7±0.4%; P=0.001), and there was a synergistic effect in combination with bumetanide (fractional excretion of sodium, 5.8±2.5% versus 3.9±1.9%; P=0.001). At 14 days, the natriuretic effect of empagliflozin persisted, resulting in a reduction in blood volume (-208 mL [interquartile range, -536 to 153 mL] versus -14 mL [interquartile range, -282 to 335 mL]; P=0.035) and plasma volume (-138 mL, interquartile range, -379 to 154±453 mL; P=0.04). This natriuresis was not, however, associated with evidence of neurohormonal activation because the change in norepinephrine was superior (P=0.02) and all other neurohormones were similar (P<0.34) during the empagliflozin versus placebo period. Furthermore, there was no evidence of potassium wasting (P=0.20) or renal dysfunction (P>0.11 for all biomarkers), whereas both serum magnesium (P<0.001) and uric acid levels (P=0.008) improved.

CONCLUSIONS

Empagliflozin causes significant natriuresis, particularly when combined with loop diuretics, resulting in an improvement in blood volume. However, off-target electrolyte wasting, renal dysfunction, and neurohormonal activation were not observed. This favorable diuretic profile may offer significant advantage in the management of volume status in patients with heart failure and may represent a mechanism contributing to the superior long-term heart failure outcomes observed with these agents. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03027960.

Effect on Survival of Concurrent Hemoconcentration and Increase in Creatinine During Treatment of Acute Decompensated Heart Failure

Hemoconcentration during the treatment of acute decompensated heart failure is a surrogate for plasma volume reduction and is associated with improved survival, but most definitions only allow for hemoconcentration to be determined retrospectively. An increase in serum creatinine can also be a marker of aggressive decongestion, but in isolation is not specific. Our objective was to determine if combined hemoconcentration and worsening creatinine could better identify patients that were aggressively treated and, as such, may have improved postdischarge outcomes. A total of 4,181 patients hospitalized with acute decompensated heart failure were evaluated. Those who experienced both hemoconcentration and worsening creatinine at any point had a profile consistent with aggressive in-hospital treatment and longer length of stay (p <0.01), higher loop diuretic doses (p <0.001), greater weight (p = 0.001), and net fluid loss (p <0.001) compared with the remainder of the cohort. In isolation, neither worsening creatinine (p = 0.11) nor hemoconcentration (p = 0.36) at any time were associated with improved survival. However, patients who experienced both (21%) had significantly better survival (hazard ratio 0.80, 95% confidence interval 0.69 to 0.94, p_interaction = 0.005). In conclusion, this combination of hemoconcentration and worsening creatinine, which can be determined prospectively during patient care, was associated with in-hospital parameters consistent with aggressive diuresis and improved postdischarge survival.

Protocol-based nurse coordinator management of ambulatory tacrolimus dosing in de novo renal transplant recipients-A single-center experience with a large African American population

INTRODUCTION

Transplant nurse (RN) coordinators review tacrolimus levels frequently and would be capable of making dose adjustments autonomously if not limited by their license. Collaborative practice agreements could be an answer; thus, the aim of this evaluation was to determine if an RN-driven protocol could be used safely and effectively to manage tacrolimus in ambulatory kidney transplant (KTX) recipients.

METHODS

This was a retrospective review of all solitary adult KTX recipients between August 1, 2016, and July 29, 2017. The primary objective was to evaluate protocol adherence and frequency of use, and secondary objectives were to evaluate the utility of the protocol both overall and based on ethnicity.

RESULTS

A total of 173 patients were included in the evaluation (59% African American [AA], 41% non-African American [non-AA). RN coordinators followed the protocol for 75% of tacrolimus adjustments; however, they only responded to 27% of the overall levels. There was no difference in 180-day tacrolimus-associated readmission (15% AA vs 5% non-AA, P = .06), biopsy-proven acute rejection (4% AA vs 7% non-AA, P = .363), or hyperkalemia (34% AA vs 32% non-AA, P = .87) between groups.

CONCLUSIONS

Transplant nurse coordinators are capable of accurately following a protocol for tacrolimus dosage adjustment in a large, racially diverse kidney transplant center.

Abstract TP273: DISTINCTION: Automated Detection, Identification, Selection, and Triage using Artificial Intelligence in Large Vessel Occlusions Requiring Critical and Timely InterventION

Background: Accurate and rapid identification of large vessel occlusions (LVOs) in acute ischemic stroke patients is critical for early notification of specialists and access to reperfusion therapy. Recent advances in artificial intelligence have enabled the development of a fully automated convolutional neural network (Viz LVO) to detect LVOs on CT angiography (CTA) imaging and notify specialists. Early specialist notification of LVOs may benefit patients who initially present at non-interventional centers and must be transferred, as well as patients who present directly to interventional centers.

Methods: A multicenter observational trial compared a prospective cohort of CTA-proven LVO patients (exposed to Viz LVO) to a retrospective cohort of patients (controls). Patients were segmented based on initial presentation at (1) a non-interventional center or (2) an interventional center. Clinical performance was measured through time-based workflow metrics, rates of treatment, and patient outcome endpoints. Further, an economic analysis was performed based on internal financial data.

Results: Preliminary results of 231 retrospective control patients not exposed to Viz LVO and who initially presented directly to interventional centers between 2016 - 2018 had a mean door-in to groin puncture (DTG) time of 95 minutes. In comparison, 21 prospective patients exposed to Viz LVO and presenting directly to interventional centers showed a mean picture to specialist notification time of 6 minutes, and all had DTG times of less than 95 minutes. Further, the mean contribution margin and net revenue for MS-DRG Codes 023-024 were higher than DRG 061-063 or 064-066 in the prospective patients.

Conclusions: This initial cohort of patients demonstrated improved DTG times for LVO patients initially arriving at interventional centers. Although these improvements were not statistically significant, we are continuing additional data collection to provide sufficient power for this study. Preliminary economic analysis demonstrates that Viz LVO can improve net revenue for hospitals through increased volume of a positive contribution margin procedure.