Fatigue-Related Changes of Daily Function: Most Promising Measures for the Digital Age

Background

Fatigue is a prominent symptom in many diseases and is strongly associated with impaired daily function. The measurement of daily function is currently almost always done with questionnaires, which are subjective and imprecise. With the recent advances of digital wearable technologies, novel approaches to evaluate daily function quantitatively and objectively in real-life conditions are increasingly possible. This also creates new possibilities to measure fatigue-related changes of daily function using such technologies.

Summary

This review examines which digitally assessable parameters in immune-mediated inflammatory and neurodegenerative diseases may have the greatest potential to reflect fatigue-related changes of daily function.

Key Messages

Results of a standardized analysis of the literature reporting about perception-, capacity-, and performance-evaluating assessment tools indicate that changes of the following parameters: physical activity, independence of daily living, social participation, working life, mental status, cognitive and aerobic capacity, and supervised and unsupervised mobility performance have the highest potential to reflect fatigue-related changes of daily function. These parameters thus hold the greatest potential for quantitatively measuring fatigue in representative diseases in real-life conditions, e.g., with digital wearable technologies. Furthermore, to the best of our knowledge, this is a new approach to analysing evidence for the design of performance-based digital assessment protocols in human research, which may stimulate further systematic research in this area.

Dental referrals for patients with diabetes: survey of barriers and enablers for medical and health professionals

BACKGROUND

Oral health care improves diabetes management; however, medical and other health practitioners do not commonly refer their patients with diabetes for oral health care. This study aimed to understand barriers to and enablers of dental referrals for patients with diabetes.

METHODS

Quantitative data were collected from a cross-sectional survey of health care providers attending a virtual Grand Rounds on the relationship between oral health and diabetes. Attendees were invited to complete and share a Forms survey. Barriers to and enablers of dental referrals were compared for 18 health professionals working in inpatient/ward settings to 23 working in community/primary care settings using the chi-square test.

RESULTS

Across both work settings, only 12% of respondents often or always discussed the importance of oral health and only 8% often or always referred their patients with diabetes for dental care. Time barriers, awareness and knowledge of how/where to send dental referrals were significant barriers, while online referral pathways, more education and availability of brochures for the patient to take home were identified as key enablers for dental referrals.

CONCLUSIONS

Online referral pathways, targeted oral health education and resources for medical and health professionals caring for patients with diabetes may increase the number of patients being referred for dental care as part of their diabetes managements. © 2023 Australian Dental Association.

Identification of Fatigue and Sleepiness in Immune and Neurodegenerative Disorders from Measures of Real-World Gait Variability

Current assessments of fatigue and sleepiness rely on patient reported outcomes (PROs), which are subjective and prone to recall bias. The current study investigated the use of gait variability in the "real world" to identify patient fatigue and daytime sleepiness. Inertial measurement units were worn on the lower backs of 159 participants (117 with six different immune and neurodegenerative disorders and 42 healthy controls) for up to 20 days, whom completed regular PROs. To address walking bouts that were short and sparse, four feature groups were considered: sequence-independent variability (SIV), sequence-dependant variability (SDV), padded SDV (PSDV), and typical gait variability (TGV) measures. These gait variability measures were extracted from step, stride, stance, and swing time, step length, and step velocity. These different approaches were compared using correlations and four machine learning classifiers to separate low/high fatigue and sleepiness.Most balanced accuracies were above 50%, the highest was 57.04% from TGV measures. The strongest correlation was 0.262 from an SDV feature against sleepiness. Overall, TGV measures had lower correlations and classification accuracies.Identifying fatigue or sleepiness from gait variability is extremely complex and requires more investigation with a larger data set, but these measures have shown performances that could contribute to a larger feature set.Clinical relevance- Gait variability has been repeatedly used to assess fatigue in the lab. The current study, however, explores gait variability for fatigue and daytime sleepiness in real-world scenarios with multiple gait-impacted disorders.

Ethnic differences in complement system biomarkers and their association with metabolic health in men of Black African and White European ethnicity

Inflammation plays a fundamental role in the development of several metabolic diseases, including obesity and type 2 diabetes (T2D); the complement system has been implicated in their development. People of Black African (BA) ethnicity are disproportionately affected by T2D and other metabolic diseases but the impact of ethnicity on the complement system has not been explored. We investigated ethnic differences in complement biomarkers and activation status between men of BA and White European (WE) ethnicity and explored their association with parameters of metabolic health. We measured a panel of 15 complement components, regulators, and activation products in fasting plasma from 89 BA and 96 WE men. Ethnic differences were statistically validated. Association of complement biomarkers with metabolic health indices (BMI, waist circumference, insulin resistance, and HbA1c) were assessed in the groups. Plasma levels of the key complement components C3 and C4, the regulators clusterin and properdin and the activation marker iC3b were significantly higher in BA compared to WE men after age adjustment, while FD levels were significantly lower. C3 and C4 levels positively correlated with some or all markers of metabolic dysfunction in both ethnic groups while FD was inversely associated with HbA1c in both groups, and clusterin and properdin were inversely associated with some markers of metabolic dysfunction only in the WE group. Our findings of increased levels of complement components and activation products in BA compared to WE men suggest differences in complement regulation that may impact susceptibility to poor metabolic health.

Assessment of Dietary Intake in Three Cohorts of Advanced Age in Two Countries: Methodology Challenges

OBJECTIVES

Dietary intake information is key to understanding nutrition-related outcomes. Intake changes with age and some older people are at increased risk of malnutrition. Application, difficulties, and advantages of the 24-hour multiple pass recall (24hr-MPR) dietary assessment method in three cohorts of advanced age in the United Kingdom (UK) and New Zealand (NZ) is described.

PARTICIPANTS

The Newcastle 85+ study (UK) recruited a single year birth cohort of people aged 85 years during 2006-7. LiLACS NZ recruited a 10-year birth cohort of Māori (indigenous New Zealanders) aged 80-90 years and a single year birth cohort of non-Māori aged 85 years in 2010.

MEASUREMENTS

Two 24hr-MPR were conducted on non-consecutive days by trained assessors. Pictorial resources and language were adapted for the New Zealand and Māori contexts. Detailed methods are described.

RESULTS

In the Newcastle 85+ study, 805 (93%) participants consented to the 24-MPR, 95% of whom completed two 24hr-MPR; in LiLACS NZ, 218 (82%) consented and 203 (76%) Māori and 353 (90%) non-Māori completed two 24hr-MPR. Mean time to complete each 24hr-MPR was 22 minutes in the Newcastle 85+ study, and 45 minutes for Māori and 39 minutes for non-Māori in LiLACS NZ. Dietary assessment of participants residing in residential care and those requiring proxy respondents were successfully included in both studies. Most participants (83-94%) felt that data captured by the 24hr-MPR reflected their usual dietary intake.

CONCLUSIONS

Dietary assessment using 24hr-MPR was successful in capturing detailed dietary data including information on portion size and time of eating for over 1300 octogenarians in the UK and New Zealand (Māori and non- Māori). The 24hr-MPR is an acceptable method of dietary assessment in this age group.

Technology acceptance of digital devices for home use: Qualitative results of a mixed methods study

Objective

Digital devices have demonstrated benefits to patients with chronic and neurodegenerative diseases. But when patients use medical devices in their homes, the technologies have to fit into their lives. We investigated the technology acceptance of seven digital devices for home use.

Methods

We conducted 60 semi-structured interviews with participants of a larger device study on their views on the acceptability of seven devices. Transcriptions were analysed using qualitative content analysis.

Results

Based on the unified theory of acceptance and use of technology, we evaluated effort, facilitating conditions, performance expectancy and social influence of each device.In the effort category, five themes emerged: (a) the hassle to use the device; (b) its usability; (c) comfort; (d) disturbance to daily life; and (e) problems during usage. Facilitating conditions consisted of five themes: (a) expectations regarding a device; (b) quality of the instructions; (c) insecurities with usage; (d) possibilities of optimization; and (e) possibilities to use the device longer. Regarding performance expectancy, we identified three themes: (a) insecurities with the performance of a device; (b) feedback; and (c) motivation for using a device. In the social influence category, three themes emerged: (a) reactions of peers; (b) concerns with the visibility of a device; and (c) concerns regarding data privacy.

Conclusions

We identify key factors that determine the acceptability of medical devices for home use from the participants' perspective. These include low effort of use, minor disruptions to their daily lives and good support from the study team.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Assessing fatigue and sleep in chronic diseases using physiological signals from wearables: A pilot study

Problems with fatigue and sleep are highly prevalent in patients with chronic diseases and often rated among the most disabling symptoms, impairing their activities of daily living and the health-related quality of life (HRQoL). Currently, they are evaluated primarily via Patient Reported Outcomes (PROs), which can suffer from recall biases and have limited sensitivity to temporal variations. Objective measurements from wearable sensors allow to reliably quantify disease state, changes in the HRQoL, and evaluate therapeutic outcomes. This work investigates the feasibility of capturing continuous physiological signals from an electrocardiography-based wearable device for remote monitoring of fatigue and sleep and quantifies the relationship of objective digital measures to self-reported fatigue and sleep disturbances. 136 individuals were followed for a total of 1,297 recording days in a longitudinal multi-site study conducted in free-living settings and registered with the German Clinical Trial Registry (DRKS00021693). Participants comprised healthy individuals (N = 39) and patients with neurodegenerative disorders (NDD, N = 31) and immune mediated inflammatory diseases (IMID, N = 66). Objective physiological measures correlated with fatigue and sleep PROs, while demonstrating reasonable signal quality. Furthermore, analysis of heart rate recovery estimated during activities of daily living showed significant differences between healthy and patient groups. This work underscores the promise and sensitivity of novel digital measures from multimodal sensor time-series to differentiate chronic patients from healthy individuals and monitor their HRQoL. The presented work provides clinicians with realistic insights of continuous at home patient monitoring and its practical value in quantitative assessment of fatigue and sleep, an area of unmet need.

Advancing our understanding of skeletal muscle across the lifecourse: Protocol for the MASS_Lifecourse study and characteristics of the first 80 participants

INTRODUCTION

Sarcopenia, the age-related loss of skeletal muscle strength and mass, carries a significant burden for affected individuals. There has been little investigation of sarcopenia using experimental medicine techniques to study human muscle tissue in detail. The aim of the Muscle Ageing Sarcopenia Studies Lifecourse (MASS_Lifecourse) study is to recruit up to 160 participants, equally divided between females and males between ages 45 and 85 years for detailed phenotyping of skeletal muscle health. Here we describe the protocol for the study and the characteristics of the first 80 participants.

METHODS

We are recruiting participants from three sources in the north-east of England. Study fieldwork comprises a home visit (or videocall) for consent and assessment of health, cognition, lifestyle, and wellbeing. This is followed by a visit to a clinical research facility for assessment of sarcopenia status and collection of samples including a vastus lateralis muscle biopsy. We produced descriptive statistics for the first 80 participants, including expressing their grip strength relative to normative data in the form of Z-scores.

RESULTS

The first 80 participants (53.8 % female) covered the target ages, ranging from 48 to 84 years. They were regularly physically active, reported good physical function and had a prevalence of sarcopenia (including probable sarcopenia) of 11.3 % based on the revised European consensus. Their grip strength was similar to that in the general population, with a mean Z-score of 0.09 standard deviations (95 % CI: -1.64, 1.83) above that expected.

CONCLUSIONS

The MASS_Lifecourse study combines comprehensive health and lifestyle data with a range of biological samples including skeletal muscle. The findings from planned analyses should contribute to improvements in the diagnosis, treatment, and prevention of sarcopenia.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

AB1209 MECHANISTIC FACTORS CONTRIBUTING TO PAIN AND FATIGUE IN FIBROMYALGIA AND ME/CFS: AUTONOMIC AND INFLAMMATORY INSIGHTS FROM AN EXPERIMENTAL MEDICINE STUDY

Background

Fibromyalgia and ME/CFS are multifaceted conditions with overlapping symptoms(1); the pathoaetiological mechanisms are complex and debated(2), however there is a strong association with features of hereditary disorders of connective tissue (hypermobility) and autonomic and inflammatory abnormalities (1,2).

Objectives

To determine potential autonomic and inflammatory mechanisms of pain and fatigue in fibromyalgia and ME/CFS

Methods

After excluding participants with WCC higher than 10 (suggesting acute infection) baseline markers of inflammation (CRP and ESR) were available for 60 patients with confirmed diagnoses of Fibromyalgia and/ or ME/CFS and 23 matched controls. Participants then underwent full research diagnostic evaluation including a hypermobility assessment(1) and autonomic challenge (60 degree head up tilt, ISRCTN78820481). Subjective pain and fatigue were assessed before and after challenge (VAS). Linear regression models were used to explore predictors, with adjustment for confounders as appropriate. Mediation analyses (looking for mechanistic effects) were conducted according to the method of Hayes (3) and mediation considered significant if bootstrapped confidence intervals of the estimated indirect effect did not cross zero. In these mediation analyses predictor variable was group membership (patient or control), outcome variable was change in 1)pain and 2)fatigue induced by challenge and mediatiors 1)no of connective tissue features in hypermobility diagnostic criteria endorsed by participant; 2)baseline inflammatory markers.

Results

ESR and CRP were significantly higher in patients rather than controls, even after correcting for BMI, age and sex (B=5.15, t=2.05, p=0.044; B=1.77, t=2.15, p=0.044 respectively). Adjusted ESR and CRP correlated with both subjective fatigue (B=0.44, t=2.09, p=0.04; B=1.63, t=2.60, p=0.011) and pain severity (B=0.13, t=2.51, p=0.014; B=0.45, t=3.01, p=0.004) at baseline. Autonomic challenge amplified pain (B=14.20, t=2.87, p=0.005) and fatigue (B=31.48, t=5.95, p=<0.001) in patients to a significantly greater degree than controls, controlling for baseline levels. Baseline ESR and CRP also predicted challenge-induced increase in fatigue (B=0.78, t=370, p=<0.001; B=1.91, t=3.36, p=<0.001) and ESR challenge-induced increases in pain (B=0.46, t=2.35, p=0.021).

Mediation analysis demonstrated that number of connective tissue features expressed in hypermobility criteria mediated the degree to which subjective pain was increased by the autonomic challenge (Bootstraped 95% CI of indirect effect do not cross zero, 0.1572 – 6.8171). ESR mediated the degree to which subjective fatigue was increased by the autonomic challenge (Bootstraped 95% CI of indirect effect do not cross zero,0.7541 – 7.3888).

Conclusion

To our knowledge this is the first study to directly explore autonomic and inflammatory mechanisms of pain and fatigue in a combined population of Fibromyalgia and ME/CFS. This study this adds to the evidence-base of baseline inflammatory abnormalities in fibromyalgia and ME/CFS. It highlights their potential role in predicting symptom severity and their potential mechanistic role in autonomic induced pain and fatigue, suggesting future treatment strategies.

References

[1]Eccles JA, Thompson B, Themelis K, Amato ML, Stocks R, Pound A, et al. Beyond bones: The relevance of variants of connective tissue (hypermobility) to fibromyalgia, ME/CFS and controversies surrounding diagnostic classification: an observational study. Clin Med (Lond). 2021;21(1):53-8.

[2]Eccles JA, Davies KA. The challenges of chronic pain and fatigue. Clin Med (Lond). 2021;21(1):19-27.

[3]Hayes AF. Partial, conditional, and moderated moderated mediation: Quantification, inference, and interpretation. Commun Monogr. 2018;85(1):4-40.

Disclosure of Interests

Jessica Eccles: None declared, Charlotte Thompson: None declared, Beth Thompson: None declared, Marisa Amato: None declared, Kristy Themelis: None declared, Hugo Critchley: None declared, Neil Harrison Grant/research support from: speakers bureau, Kevin Davies: None declared

The assessment of sarcopenia and the frailty phenotype in the outpatient care of older people: implementation and typical values obtained from the Newcastle SarcScreen project

Aim

Is it possible to implement the Newcastle SarcScreen, an assessment of sarcopenia and physical frailty, as part of the outpatient care of older people?

Findings

Grip strength measurement was possible in 98.2% and gait speed in 82.1%, with the latter typically not measured due to mobility impairment. We found a high prevalence of probable sarcopenia and the frailty phenotype across all age groups studied.

Message

We successfully implemented the Newcastle SarcScreen. The proforma is available to download as part of this article.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00641-5.

Purpose

Sarcopenia and the frailty phenotype both indicate older adults at risk of adverse health outcomes and yet are not widely assessed in practice. We developed the Newcastle SarcScreen to enable assessment of these two ageing syndromes during clinical care. In the setting of our Older People’s Medicine Day Unit, our aims were to describe the implementation of the SarcScreen and to examine the typical values obtained.

Methods

The SarcScreen comprised height, weight, questions (three on the Fried frailty phenotype and five on the SARC-F questionnaire), grip strength and gait speed. We analysed data from 552 patients completing the SarcScreen. We expressed grip strength as Z-scores (number of standard deviations above the mean expected for a patient’s age and sex).

Results

It was possible to implement the SarcScreen. In 552 patients (65.9% females) with mean age 80.1 (7.7) years, grip strength was feasible in 98.2% and gait speed in 82.1%. Gait speed was typically not assessed due to mobility impairment. Most patients had weak grip strength (present in 83.8%), slow gait speed (88.8%) and the frailty phenotype (66.2%). We found a high prevalence of probable sarcopenia and the frailty phenotype across all age groups studied. This was reflected by low grip strength Z-scores, especially at younger ages: those aged 60–69 had grip strength 2.7 standard deviations (95% CI 2.5–2.9) below that expected.

Conclusion

It is possible to implement an assessment of sarcopenia and the frailty phenotype as part of the routine outpatient care of older people.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41999-022-00641-5.

Fatigue in inflammatory rheumatic diseases: current knowledge and areas for future research

Fatigue is a complex phenomenon and an important health concern for many people with chronic inflammatory rheumatic diseases, such as rheumatoid arthritis, psoriatic arthritis, primary Sjögren syndrome and systemic lupus erythematosus. Although some clinical trials have shown the benefits of cognitive behavioural therapy in fatigue management, the effect of this approach is relatively modest, and no curative treatment has been identified. The pathogenesis of fatigue remains unclear. Despite many challenges and limitations, a growing body of research points to roles for the immune system, the central and autonomic nervous systems and the neuroendocrine system in the induction and maintenance of fatigue in chronic diseases. New insights indicate that sleep, genetic susceptibility, metabolic disturbances and other biological and physiological mechanisms contribute to fatigue. Furthermore, understanding of the relationships between psychosocial factors and fatigue is increasing. However, the interrelationships between these diverse mechanisms and fatigue remain poorly defined. In this Review, we outline various biological, physiological and psychosocial determinants of fatigue in inflammatory rheumatic diseases, and propose mechanistic and conceptual models of fatigue to summarize current understanding, stimulate debate and develop further research ideas.

Autonomic Nervous System Dysfunction in Primary Sjögren's Syndrome

Primary Sjögren's syndrome (pSS) is an autoimmune disease which primarily affects the exocrine glands, but can also affect other organs, including the nervous system. Many studies have reported evidence of autonomic nervous system (ANS) dysfunction in pSS which may contribute to a wide range of symptoms and functional burden. Symptoms of ANS dysfunction are common and widespread among patients with pSS and are associated with other features of the disease, particularly fatigue. Accumulating data on the inter-relationship between the ANS and the immune system via the vagus nerve have been reported. Vagus nerve stimulation (VNS) has also been associated with improvement in fatigue in patients with pSS. Taken together, these data suggest that the ANS may be a potential treatment target for pSS, in particularly those with fatigue being a predominant symptom. Future research to dissect the link between the ANS, immune dysregulation and clinical manifestations in pSS and to evaluate the potential of VNS as a therapy for pSS is warranted.

Ancient DNA, lipid biomarkers and palaeoecological evidence reveals construction and life on early medieval lake settlements

Direct evidence of ancient human occupation is typically established through archaeological excavation. Excavations are costly and destructive, and practically impossible in some lake and wetland environments. We present here an alternative approach, providing direct evidence from lake sediments using DNA metabarcoding, steroid lipid biomarkers (bile acids) and from traditional environmental analyses. Applied to an early Medieval Celtic settlement in Ireland (a crannog) this approach provides a site chronology and direct evidence of human occupation, crops, animal farming and on-site slaughtering. This is the first independently-dated, continuous molecular archive of human activity from an archeological site, demonstrating a link between animal husbandry, food resources, island use. These sites are under threat but are impossible to preserve in-situ so this approach can be used, with or without excavation, to produce a robust and full site chronology and provide direct evidence of occupation, the use of plants and animals, and activities such as butchery.

The effect of intestinal microbiota dysbiosis on growth and detection of carbapenemase-producing Enterobacterales within an in vitro gut model

BACKGROUND

Carbapenemase-producing Enterobacterales (CPE) can colonize the gut and are of major clinical concern. Identification of CPE colonization is problematic; there is no gold-standard detection method, and the effects of antibiotic exposure and microbiota dysbiosis on detection are unknown.

AIM

Based on a national survey we selected four CPE screening assays in common use. We used a clinically reflective in vitro model of human gut microbiota to investigate the performance of each test to detect three different CPE strains under different, clinically relevant antibiotic exposures.

METHODS

Twelve gut models were seeded with a pooled faecal slurry and exposed to CPE either before, after, concomitant with, or in the absence of piperacillin-tazobactam (358 mg/L, 3 × daily, seven days). Total Enterobacterales and CPE populations were enumerated daily. Regular screening for CPE was performed using Cepheid Xpert® Carba-R molecular test, and with Brilliance™ CRE, Colorex™ mSuperCARBA and CHROMID® CARBA SMART agars.

FINDINGS

Detection of CPE when the microbiota are intact is problematic. Antibiotic exposure disrupts microbiota populations and allows CPE proliferation, increasing detection. The performances of assays varied, particularly with respect to different CPE strains. The Cepheid assay performed better than the three agar methods for detecting a low level of CPE within an intact microbiota, although performance of all screening methods was comparable when CPE populations increased in a disrupted microbiota.

CONCLUSION

CPE strains differed in their dynamics of colonization in an in vitro gut model and in their subsequent response to antibiotic exposure. This affected detection by molecular and screening methods, which has implications for the sensitivity of CPE screening in healthcare settings.

The role of interoception in the mechanism of pain and fatigue in fibromyalgia and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)

Introduction

Pain, fatigue and anxiety are common features of fibromyalgia and ME/CFS and significantly impact quality of life. Aetiology is poorly defined but dysfunctional inflammatory, autonomic and interoceptive (sensing of internal bodily signals) processes are implicated.

Objectives

To investigate how altered interoception relates to baseline expression of pain, fatigue and anxiety symptoms in fibromyalgia and ME/CFS and in response to an inflammatory challenge.

Methods

Sixty-five patients with fibromyalgia and/or ME/CFS diagnosis and 26 matched controls underwent baseline assessment: pressure-pain thresholds and self-report questionnaires assessing pain, fatigue and anxiety severity. Participants received injections of typhoid (inflammatory challenge) or saline (placebo) in a randomised, double-blind, crossover design, before completing heartbeat tracking tasks. Three interoception dimensions were examined: subjective sensibility, objective accuracy and metacognitive awareness. Interoceptive trait prediction error was calculated as discrepancy between accuracy and sensibility.

Results

Patients with fibromyalgia and ME/CFS had significantly higher interoceptive sensibility and trait prediction error, despite no differences in interoceptive accuracy. Interoceptive sensibility and trait prediction error correlated with all self-report pain, fatigue and anxiety measures, and with lower pain thresholds. Anxiety mediated the positive-predictive relationships between pain (Visual Analogue Scale and Widespread Pain Index), fatigue impact and interoceptive sensibility. After inflammatory challenge, metacognitive awareness correlated with baseline self-reported symptom measures and lower pain thresholds.

Conclusions

This is the first study investigating interoceptive dimensions in patients with fibromyalgia and ME/CFS, which were found to be dysregulated and differentially influenced by inflammatory mechanisms. Interoceptive processes may represent a new potential target for diagnostic and therapeutic investigation in these poorly understood conditions.

Disclosure

No significant relationships.

24 Loneliness, Social Isolation and Frailty Among Older Adults in England: Results From the English Longitudinal Study of Ageing

Introduction

Ten percent of over 65 s and between a quarter and half of over 85 s are frail. Loneliness and social isolation are associated with increased falls, rates of hospitalisation and mortality. Lonely and socially isolated older adults may also be at risk of frailty. We examined the relationship between loneliness, social isolation and incident frailty among older adults in England longitudinally over 12 years.

Methods

The study sample are 9,171 older adults aged ≥50 years participating in a population representative longitudinal panel survey, the English Longitudinal Study of Ageing Waves 2–8. To define frailty across the biannual waves, we used the Frailty Index (FI), analysed continuously and into categories (FI ≤0.08 non-frail, 0.08–0.25 pre-frail and ≥ 0.25–1 frail). We used baseline (Wave 2): loneliness measure using the UCLA 3-item loneliness scale; social isolation measure using previously reported method (Banks et al. The Institute for Fiscal Studies. 2006.). Both were categorised into low/medium/high. To examine relationships, we used linear mixed methods modelling (for the continuous FI), and Cox proportional hazard model (for the categorical FI).

Results

Loneliness (β = 0.023; 95% CI = 0.022, 0.025) and social isolation (β = 0.007; 95% CI = 0.003, 0.010) were significantly associated with increased FI, after adjusting for cofounders (gender, age, marital status, smoking status and wealth). There was a 60% greater relative risk of belonging to the frail class with a medium loneliness score compared to low (HR = 1.570; 95% CI 1.492, 1.652) and a 160% greater relative risk with high loneliness score compared to low (HR = 2.621; 95% CI 2.488, 2.761). Although less pronounced, there was a 1% greater relative risk of developing frailty with a medium social isolation score compared to low (HR = 1.010, 95% CI 1.010, 1.197) and a 30% greater relative risk with high social isolation score compared to low (HR = 1.267; 95% CI 1.154, 1.390).

Conclusions

Our research indicates both loneliness and social isolation increase risk of developing frailty, expanding on previous evidence. This provides further support to the importance of understanding approaches to promote social inclusion of older adults.

Detection of SARS-CoV-2 within the healthcare environment: a multi-centre study conducted during the first wave of the COVID-19 outbreak in England

BACKGROUND

Understanding how severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is spread within the hospital setting is essential in order to protect staff, implement effective infection control measures, and prevent nosocomial transmission.

METHODS

The presence of SARS-CoV-2 in the air and on environmental surfaces around hospitalized patients, with and without respiratory symptoms, was investigated. Environmental sampling was undertaken within eight hospitals in England during the first wave of the coronavirus disease 2019 outbreak. Samples were analysed using reverse transcription polymerase chain reaction (PCR) and virus isolation assays.

FINDINGS

SARS-CoV-2 RNA was detected on 30 (8.9%) of 336 environmental surfaces. Cycle threshold values ranged from 28.8 to 39.1, equating to 2.2 x 105 to 59 genomic copies/swab. Concomitant bacterial counts were low, suggesting that the cleaning performed by nursing and domestic staff across all eight hospitals was effective. SARS-CoV-2 RNA was detected in four of 55 air samples taken <1 m from four different patients. In all cases, the concentration of viral RNA was low and ranged from <10 to 460 genomic copies/m3 air. Infectious virus was not recovered from any of the PCR-positive samples analysed.

CONCLUSIONS

Effective cleaning can reduce the risk of fomite (contact) transmission, but some surface types may facilitate the survival, persistence and/or dispersal of SARS-CoV-2. The presence of low or undetectable concentrations of viral RNA in the air supports current guidance on the use of specific personal protective equipment for aerosol-generating and non-aerosol-generating procedures.

Idiopathic systemic capillary leak syndrome (Clarkson's disease) presenting with recurrent hypovolemic shock

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson's Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

Improvement of Severe Fatigue Following Nuclease Therapy in Patients With Primary Sjögren's Syndrome: A Randomized Clinical Trial

OBJECTIVE

To assess the safety and efficacy of RSLV-132, an RNase Fc fusion protein, in a phase II randomized, double-blind, placebo-controlled clinical trial in patients with primary Sjögren's syndrome (SS).

METHODS

Thirty patients with primary SS were randomized to receive treatment with RSLV-132 or placebo intravenously once per week for 2 weeks, and then every 2 weeks for 12 weeks. Eight patients received placebo and 20 patients received RSLV-132 at a dose of 10 mg/kg. Clinical efficacy measures included the European League Against Rheumatism (EULAR) Sjögren's Syndrome Disease Activity Index, EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Profile of Fatigue (ProF), and the Digit Symbol Substitution Test (DSST).

RESULTS

Patients randomized to receive RSLV-132 experienced clinically meaningful improvements in the ESSPRI score (P = 0.27), FACIT-F score (P = 0.05), ProF score (P = 0.07), and DSST (P = 0.02) from baseline to day 99, whereas patients who received placebo showed no changes in any of these clinical efficacy measures. This improvement was significantly correlated with increased expression of selected interferon-inducible genes (Pearson's correlations, each P < 0.05).

CONCLUSION

Administration of RSLV-132 improved severe fatigue, as determined by 4 independent patient-reported measures of fatigue, in patients with primary SS.

AB0949 AUTONOMIC AND INFLAMMATORY MECHANISMS OF PAIN AND FATIGUE IN FIBROMYALGIA AND ME/CFS: AN INTERVENTIONAL STUDY

Background:

Fibromyalgia and ME/CFS are complex disorders with overlapping symptoms; the pathoaetiology and clinical distinction are debated, however inflammatory and autonomic abnormalities are observed.

Objectives:

To investigate the role of inflammatory and autonomic nervous system responses in mechanisms of pain and fatigue in fibromyalgia and ME/CFS

Methods:

63 patient participants with clinical diagnoses of fibromyalgia and/or ME/CFS were recruited into a multi-stage interventional study (ISRCTN78820481) alongside 24 healthy controls. All underwent research diagnostic criteria evaluation. The majority underwent autonomic challenge (60 degree head up tilt) and/or inflammatory challenge (placebo-controlled typhoid vaccination) with baseline characterisation of symptoms, inflammatory markers and pre-post measures of pain and fatigue.

Results:

Of the 63 patients, 32% of patients had received a clinical diagnosis of Fibromyalgia; 38% ME/CFS and 30% dual diagnoses. Following research evaluation 89% met ACR diagnostic criteria for fibromyalgia; 94% Canadian Criteria for ME/CFS; 97% Fukada Criteria for ME/CFS

There was a significantly higher ESR in patients compared to controls (p= 0.036). There was a trend towards higher CRP in patients compared to controls (p= 0.076).

ESR correlated with baseline pain score (r=0.309, p=0.011), fatigue severity (r=0.262, p=0.032), fatigue impact (r=0.382, p=0.014) change in fatigue score induced by tilt (r=0.319, p=0.011) and change in pain score induced by placebo-controlled inflammation (r=-0.279, p=0.043). Similarly CRP level correlated with baseline pain score (r=0.340, p=0.005), fatigue impact (r=0.439, p=0.004), change in fatigue (r=-0.277, p=0.045) and pain score (r=-0.394, p=0.014) induced by placebo-controlled inflammation and change in pressure pain theshold induced by tilt (r=0.286, p=0.027).

Baseline IL6 was higher in patients than controls (p = 0.002), correlating with baseline pain score (r = 0.345, p = 0.002) and change in pain score induced by tilt (r=0.281, p=0.21). Change in IL6 induced by inflammatory challenge correlated with inflammation induced fatigue score (r = 0.378, p = 0.01).

Conclusion:

Inflammatory and autonomic mechanisms contribute to pain and fatigue in this frequently overlooked patient group, highlighting possibilities for targeted treatments. Such data will be enriched going forward by neuroimaging and transcriptomic insights.

References:

n/a

Acknowledgments:

This work was supported by Versus Arthritis, Action for Me, Fibroduck Foundation and NIHR

Disclosure of Interests:

Jessica Eccles: None declared, Marisa Amato: None declared, Charlotte Thompson: None declared, Kristy Themelis: None declared, Hugo Critchley: None declared, Neil Harrison Grant/research support from: Yes, Speakers bureau: Yes, Kevin Davies: None declared

EP21 An observational study of the predictors of osteoporosis in men

Background

Osteoporosis is under-recognised and under-treated in men. Previous studies and stratification tools have been limited in their generalisability and while predictors of poor bone density in men have been characterised, evidence has been contradictory. The purpose of this study is to investigate these predictors in the lumbar spine and femoral neck in men.

Methods

Data were collected from 3,901 men referred for DEXA scanning to the Royal Lancaster Infirmary, between 2004 and 2010. BMD was measured in the lumbar spine and femoral neck. Simple and multiple regression models were fitted to each measurement site, using each of the known predictors for poor bone health. The Variance Inflation Factor was used to quantify the severity of multicollinearity and the Akaike Information Criterion was employed to select co-variates.

Results

The following predictors had a significant effect in both measurement sites: age; height; weight; Body Mass Index (BMI); X-ray evidence of osteopenia; and previous fracture(s). Body fat percentage had a significant effect at the lumbar spine only, and tobacco use had a significant effect at the femoral neck only. The adjusted R squared values for the models ranged from 0.16 for the lumbar spine model, to 0.28 for the femoral neck model.

Conclusion

This study demonstrated that further work is needed in assessing the predictors of OP in men. This would open up an interesting observation in clinical practice and provide an opportunity for risk prediction and primary prevention of OP in men, reducing fracture risk. Future studies should include randomised samples and propensity score matching.

Disclosures

N. Kyrtata None. K. Davies None. A. Nune None. M. Bukhari None.

P4359Re-characterising the left ventricular outflow tract and annulus in bi- and tricuspid aortic valves by 3D echocardiography - Comparative insights and implications for aortic valve area calculations

Background

Aortic stenosis severity is defined by the calculated aortic valve area (AVA) using the Doppler-derived continuity equation (CE; AVACE = 0.785 x (LVOTd)2 x LVOT VTI/AV VTI (LVOTd = left ventricular outflow tract diameter; AV = aortic valve; VTI = velocity-time integral)). The LVOTd is the “Achilles heel” due to limitations of conventional 2D imaging and unstandardized measurement sites (0.5–1cm “apical” in the LVOT (LVOTdApi) vs “annulus” level (LVOTdAnn)) with no consensus even in recent guidelines. Geometrical differences in the LVOT and annulus of bicuspid (BAV) and tricuspid (TAV) aortic valves are further confounders. There remains a paucity of evidence to guide best practice. Erroneous LVOTd values will result in inaccurate AVACE estimations, triggering inappropriate intervention, or inaction.

Purpose

To define the optimal LVOTd by transthoracic echocardiography (TTE; LVOTdApi vs LVOTdAnn by 2D vs 3D) for AVACE calculation, and to identify factors accounting for any observed differences between BAVs and TAVs. AVA measured by 3D TTE planimetry (AVA3D) was the reference standard.

Methods

TTEs with 3D datasets of the AV complex in patients with BAVs and TAVs were included. 2D-LVOTdApi and 2D-LVOTdAnn were measured from 2D parasternal long-axis images. 3D-LVOTd values were calculated from the measured circumference, area, and average of minor/major dimensions at the “apical” (3D-LVOTdApi-Circ; 3D-LVOTdApi-Area; 3D-LVOTdApi-Ave) and “annulus” (3D-LVOTdAnn-Circ; 3D-LVOTdAnn-Area; 3D-LVOTdAnn-Ave) levels using multiplanar reconstruction. LVOTVTI and AVVTI were traced from standard spectral Doppler waveforms. The ratio of minor:major dimensions was used as an eccentricity index (EI) of the “apical” (EIApi) and “annulus” (EIAnn) sites.

Results

53 BAVs and 52 TAVs were included. Mean BAV-AVA3D and TAV-AVA3D were 3.48±0.93cm2 and 3.41±0.69cm2 respectively. In BAVs, estimated AVACE using 3D-LVOTdApi-Circ (3.43±1.05cm2; Intraclass correlation (ICC) 0.971) and 3D-LVOTdAnn-Circ (3.40±1.01cm2; ICC 0.968) correlated best with AVA3D. Conversely in TAVs, 3D-LVOTdApi-Area (3.29±0.69cm2; ICC 0.983) and 3D-LVOTdAnn-Area (3.24±0.70cm2; ICC 0.975) performed optimally. 3D-LVOTdApi-Circ and 3D-LVOTdAnn-Circ overestimated TAV-AVA3D due to the greater ellipticity of the “apical” and “annulus” sites in TAVs (TAV vs BAV: EIApi 0.78 vs 0.83, P=0.04; EIAnn 0.84 vs 0.90, P<0.005). 2D-LVOTd-derived AVACE were predictable underestimations of the AVA3D but the “annulus” level outperformed “apical” in both BAVs and TAVs (BAV-ICC 0.857 vs 0.771; TAV-ICC 0.917 vs 0.889).

Conclusions

The “apical” LVOT and “annulus” are more circular in BAVs where 3D circumference (3D-LVOTdApi-Circ or 3D-LVOTdAnn-Circ) yielded the best AVACE. The more elliptical geometry in TAVs resulted in 3D area (3D-LVOTdApi-Area or 3D-LVOTdAnn-Area) the preferred technique. Resolving the quandary of measurement site, 2D-LVOTdAnn is favored over 2D-LVOTdApi for both BAVs and TAVs.

Symptomatic patients with P369S-R408Q mutations: familial Mediterranean fever or mixed auto-inflammatory syndrome?

A 51-year-old South African female of Ashkenazi Jewish descent was admitted with acute pleuritic chest pain, shortness of breath, fatigue and fever. She experienced vague abdominal and calf pains for 30 years. Her monozygotic twin was investigated independently for recurrent abdominal pain. Despite initially responding to antibiotics, treating suspected pneumonia, she developed recurrent fevers and pleuritic chest pain. After thorough investigation without significant findings, she re-attended days after discharge with similar symptoms. Familial Mediterranean fever (FMF) was suggested as she met diagnostic criteria and responded to colchicine, though FMF normally presents before 20 years old. Genetic testing showed no pathogenic mutations but heterozygous P369S and R408Q mutations. The significance of these mutations remains unclear, as they are found in asymptomatic patients, suggesting incomplete penetrance. She remains well, with full symptom resolution, but mixed auto-inflammatory syndrome may be a more appropriate diagnosis in symptomatic patients with both P369S and R408Q mutations.

Fatigue in primary Sjögren's syndrome (pSS) is associated with lower levels of proinflammatory cytokines: a validation study

Primary Sjögren’s syndrome (pSS) is a chronic autoimmune rheumatic disease with symptoms including dryness, fatigue, and pain. The previous work by our group has suggested that certain proinflammatory cytokines are inversely related to patient-reported levels of fatigue. To date, these findings have not been validated. This study aims to validate this observation. Blood levels of seven cytokines were measured in 120 patients with pSS from the United Kingdom Primary Sjögren’s Syndrome Registry and 30 age-matched healthy non-fatigued controls. Patient-reported scores for fatigue were classified according to severity and compared to cytokine levels using analysis of variance. The differences between cytokines in cases and controls were evaluated using Wilcoxon test. A logistic regression model was used to determine the most important identifiers of fatigue. Five cytokines, interferon-γ-induced protein-10 (IP-10), tumour necrosis factor-α (TNFα), interferon-α (IFNα), interferon-γ (IFN-γ), and lymphotoxin-α (LT-α) were significantly higher in patients with pSS (n = 120) compared to non-fatigued controls (n = 30). Levels of two proinflammatory cytokines, TNF-α (p = 0.021) and LT-α (p = 0.043), were inversely related to patient-reported levels of fatigue. Cytokine levels, disease-specific and clinical parameters as well as pain, anxiety, and depression were used as predictors in our validation model. The model correctly identifies fatigue levels with 85% accuracy. Consistent with the original study, pain, depression, and proinflammatory cytokines appear to be the most powerful predictors of fatigue in pSS. TNF-α and LT-α have an inverse relationship with fatigue severity in pSS challenging the notion that proinflammatory cytokines directly mediate fatigue in chronic immunological conditions.

Pain and depression are associated with both physical and mental fatigue independently of comorbidities and medications in primary Sjögren's syndrome

Objectives

To report on fatigue in patients from the United Kingdom primary Sjögren's syndrome (pSS) registry identifying factors associated with fatigue and robust to assignable causes such as comorbidities and medications associated with drowsiness.

Methods

From our cohort (n = 608), we identified those with comorbidities associated with fatigue, and those taking medications associated with drowsiness. We constructed dummy variables, permitting the contribution of these potentially assignable causes of fatigue to be assessed. Using multiple regression analysis, we modelled the relationship between Profile of Fatigue and Discomfort physical and mental fatigue scores and potentially related variables.

Results

Pain, depression and daytime sleepiness scores were closely associated with both physical and mental fatigue (all p ≤ 0.0001). In addition, dryness was strongly associated with physical fatigue (p ≤ 0.0001). These effects were observed even after adjustment for comorbidities associated with fatigue or medications associated with drowsiness.

Conclusions

These findings support further research and clinical interventions targeting pain, dryness, depression and sleep to improve fatigue in patients with pSS.This finding is robust to both the effect of other comorbidities associated with fatigue and medications associated with drowsiness.

Abstract P6-11-01: Field testing of a point-of-care decision support tool for contralateral prophylactic mastectomy

Background: The majority of women undergoing contralateral prophylactic mastectomy (CPM) overestimate their risk of developing a contralateral breast cancer and incorrectly believe the CPM will substantially improve their overall survival. Using the results of our published micro-simulation decision-analytic model (Davies et al. Breast Cancer Res, 2016), we created and tested a CPM decision support tool to provide patients and breast cancer surgeons with individualized estimates of contralateral breast cancer risk and overall mortality.

Methods: The CPM decision support tool had four entry parameters from the micro-simulation model (age, family history of breast cancer, estrogen receptor status, and stage), and a visual depiction of outcomes using icon arrays for chances of developing a contralateral breast cancer and overall mortality with and without CPM. A user-centered design strategy was used with input and iterative refinement from stakeholders, i.e., breast cancer surgeons, patient advocates and breast cancer survivors. The tool was field-tested at MD Anderson Cancer Center with 5 breast cancer surgeons each using the tool with 5 breast cancer patients considering CPM (25 total). Patients completed a knowledge survey immediately before and after viewing the tool and the Decisional Conflict Scale (DCS) after viewing the tool. Surgeons completed the System Usability Scale (SUS) and ratings of the acceptability of the tool.

Results: The mean age of patients was 58 years. All patients reported the tool was helpful in making a decision about CPM and would recommend it to others. Knowledge of breast cancer and key CPM facts increased from before to after using the tool (64% vs. 75%, respectively, P&lt;0.05). The mean score on the DCS was 10.5 (standard deviation =14.3) indicating patients were overall sure about the CPM choice. The majority (72%) of patients were unsure of their interest in CPM before viewing the tool. After viewing the tool, 13 (52%) of patients indicated they did not want CPM, 4 (16%) indicated they wanted CPM, and 8 (32%) remained unsure. Surgeons rated the tool as having a positive impact on the decision-making process and SUS scores were highly favorable (mean 93 on 0-100 scale, with 100 indicating highest usability).

Conclusion: The CPM decision tool had high overall patient satisfaction and improved knowledge about CPM without affecting decisional conflict. Decision support tools may be used to improve the quality of decision-making about CPM by providing surgeons and their patients with useful individualized information about CPM's impact on relevant clinical outcomes, which may lower the incidence of CPM.

Citation Format: Brewster AM, Cantor S, Davies K, Bedrosian I, Parker P, Garrison S, Volk RJ. Field testing of a point-of-care decision support tool for contralateral prophylactic mastectomy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-11-01.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.