1208 FEASIBILITY OF A PHARMACIST-LED INTERVENTION FOR ATRIAL FIBRILLATION IN LONG-TERM CARE: THE PIVOTALL STUDY

Introduction

Older people in care homes with atrial fibrillation (AF) have complex health needs and would benefit from taking part in research. This study assessed the feasibility of pharmacist implementation of the Atrial Fibrillation Better Care (ABC: Anticoagulation; Better symptoms; Cardiovascular comorbidity management) pathway, and collection of an AF-specific, resident-centred outcome.

Methods

Older residents (aged ≥65 years) with AF were recruited from care homes within Liverpool and Sefton and randomised to receive the pharmacist intervention, or continue their existing treatment. Resident quality of life was assessed using the Atrial Fibrillation Effect on Quality of Life Questionnaire (AFEQT).

Results

Twenty-two care homes were approached about the study, and seven signed up to take part between 28 September 2020 and 29 April 2021. Time taken to recruit care homes ranged from 0 to 122 days. There were 83 residents identified as potentially eligible to take part, but after screening only 28 residents (34%) were invited. Overall, 21 residents were recruited. Eleven residents received the pharmacist intervention and three had ABC recommendations made to their GPs. Two out of four recommendations were implemented. The pharmacist administered the AFEQT questionnaire to 17 residents with capacity and completion rates were 94% and 93% at baseline and six-months, respectively. Residents found the questionnaire difficult; most were unable to distinguish if symptoms were AF-related (n=3), or did not know they had AF (n=8), and questions related to physical activity were not applicable to any of the residents who were bed bound (n=5) or had severely limited mobility (n=12).

Conclusion

There were procedural (encountered before research starts), system (encountered during research) and resident-specific barriers that impacted this study. Barriers need addressing before wider implementation, and AF-specific quality of life measures need to be developed and validated for care home residents. A detailed commentary has been submitted for publication.

Prevalence and outcomes of atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018

Background

Older care home residents are a high-risk group of people with atrial fibrillation (AF) who are under-represented in clinical trials. Improved understanding of AF epidemiology and management in this population is paramount for health and social care organisations to strategically plan services.

Purpose

To determine the trends in AF prevalence and compare adverse health outcomes in older care home residents aged ≥65 years with AF compared to those without AF.

Methods

Retrospective cohort study of people entering a care home between 2003–2018 using nationwide, population-scale anonymised health and administrative data, provisioned from the Secure Anonymised Information Linkage (1 January 2000–31st December 2018). Direct standardisation was used to calculate AF prevalence by year of care entry (2010–2018). Cox regression analyses were used to estimate the risk of adverse health outcomes.

Results

Between 2003 and 2018, 86,602 people aged ≥65 years became new residents in care homes in Wales. Residents with AF (n=14,493) had a significantly higher risk (adjusted hazard ratio [aHR], 95% confidence interval [CI]) of cardiovascular (aHR 1.27 [1.17 to 1.37], p<0.001) and all-cause mortality (aHR 1.14 [1.11 to 1.17], p<0.001), Figure 1. The risk (sub-distribution hazard ratio [sHR], 95% CI) of ischaemic stroke (adjusted sHR 1.55 [1.36 to 1.76], p<0.001) and cardiovascular hospitalisation (adjusted sHR 1.28 [1.22 to 1.34], p<0.001) was also higher in residents with AF, even when mortality was considered a competing event, Figure 1. There was no significant change in age- and sex-standardised prevalence of AF between 2010 and 2018, 16.79% (95% CI 15.85 to 17.94) and 17.02% (95% CI 16.05 to 17.98), respectively (absolute change 2010–2018: 0.06% [95% CI: −1.38 to 1.50], p=0.93), Figure 2.

Conclusions

This study demonstrates unique data on the epidemiology of AF and associated outcomes in older care home residents. Whilst the prevalence of AF remained stable between 2010–2018, residents with AF had significantly higher risk of adverse health events. Treatment of AF in accordance with guidelines is critical in this population to optimise management and reduce adverse health outcomes.

Funding Acknowledgement

Type of funding sources: None.

Differential glycosylation of the protein (PrP) forming scrapie-associated fibrils

PrP is a glycoprotein found in normal brain. In brain affected by scrapie it forms scrapie-associated fibrils (SAF). PrP from SAF shows considerable heterogeneity of size and charge on two-dimensional gels. It separates into six major regions, the three more acidic regions arising as a result of partial proteolytic degradation. The two more basic higher Mr forms (Mr 34,000 and 29,000) of PrP can be reduced in apparent Mr to a lower Mr form (Mr 25,000) with Peptide-N-glycosidase F. In addition, a series of lectins has been found to bind to PrP. Some bind preferentially to the higher Mr forms whereas others bind more strongly to the lower Mr form. Some of the heterogeneity of PrP is therefore due to differential N-glycosylation. We suggest that one or two N-linked carbohydrate chains are bound to the protein causing some of the differences in Mr. The major cause of heterogeneity of PrP is therefore proteolytic cleavage combined with differential glycosylation at the two potential N-glycosylation sites. The glycolipid moiety attached to PrP may be responsible for some lectin binding to all three bands. Using lectins as a probe to study potential differences in N-glycosylation we have looked at their binding to PrP isolated from SAF, from different strains of scrapie and from different regions of the same brain. No major differences in the N-glycan moieties were found.

Post-mortem immunodiagnosis of scrapie and bovine spongiform encephalopathy

Two polyclonal antisera were raised in rabbits against the scrapie-associated fibril protein (PrP) prepared from sheep and mice which were terminally infected with experimental scrapie. The anti-mouse PrP serum identifies the proteins of scrapie-associated fibrils (SAF) from all the host species studied (mouse, hamster, sheep and goat) and bovine spongiform encephalopathy (BSE) fibrils from cow. The anti-sheep PrP serum displays species restricted immunoreactivity. While it identifies several PrP polypeptides from terminally affected sheep, goat and cow material, only the highest molecular weight band is recognised from hamster and there is no detection of mouse PrP. The use of these antisera in routine laboratory testing at post mortem provides a highly sensitive test for scrapie and BSE and may allow the identification of infected animals prior to the onset of clinical signs.

Structural and biochemical evidence that scrapie-associated fibrils assemble in vivo

Scrapie-associated fibrils (SAF) are a ubiquitous pathological feature of brains affected by scrapie and the other scrapie-like agents. They are composed of PrP, a heterogeneous glycoprotein which is also present in normal brain but not as SAF. The PrP protein associated with SAF is partially resistant to proteinase K, whereas the soluble form is not. It has been proposed that SAF do not exist as such in vivo, but rather self-assemble from subunit structures liberated from membranes by detergent extraction during purification. We have purified SAF by a method that does not employ proteinase K. We show that the PrP protein from infected but not uninfected brain is partially resistant to protease digestion before and after detergent extraction. Likewise, SAF can be sheared by sonication before or after detergent extraction. In addition, SAF from mice infected with different strains of scrapie have different sedimentation properties. Since SAF-dependent properties exist before detergent extraction, then so must SAF. They are therefore not a detergent-induced artefact but most probably assemble in vivo.