399 A Re-Audit of Secondary Prevention Medications Following Coronary Artery Bypass Grafting: Are We Still Compliant with The Updated Guidelines?

Introduction

In the years following myocardial revascularisation with bypass grafts, patients remain at risk for subsequent ischemia as a result of native coronary artery disease progression or development of graft occlusion. Therefore, secondary measures, primarily medical therapy, play an indispensable role in post-operative care. An audit conducted in 2014 identified reduced compliance to prescription of secondary prevention medications. This audit aims to re- evaluate the level of compliance to updated guidelines.

Method

A retrospective case-note review of 100 patients, who underwent CABG (Coronary Artery Bypass-Grafts), was conducted primarily focusing on prescription of secondary prevention drugs at discharge, indications, and contraindications.

Results

99% patients were discharged on anti-platelet agents. However, 12%, discharged on dual anti-platelet agents, did not have any indications for them. 97 % patients were discharged on beta-blocker. Of the 3 defaulters, one had contraindication to beta blockade. 96% patients were discharged on one or more lipid lowering agents and 74% were discharged on ACEi/ARBs. Of the 26% patients discharged without RAAS (Renin Angiotensin Aldosterone System) inhibitor, 9% had no clear indication for it whereas for 7%, it was contraindicated at discharge.

Conclusions

A generalised improvement in compliance rate is noted for secondary prevention medications prescription according to updated guidelines from the previous audit.

Atherosclerotic plaque regression - the role of statin therapy

Increasing knowledge of the atherosclerotic process, as well as atherosclerotic plaque composition and morphology, has lead to the identification of vulnerable plaques that lead to acute coronary syndromes. There is growing evidence for atherosclerotic plaque regression, which makes an aggressive targeted therapeutic response based on achieving plaques regression necessary in order to reduce the significant mortality and morbidity associated with coronary heart disease. This review will examine the evidence for atherosclerotic plaque regression, the important role of statins and the available imaging techniques used to investigate this condition. We will also discuss future evolving therapies and possible predictors of plaque regression, which may aid the therapeutic process.

Low-impact scenarios may account for two-thirds of blunt traumatic aortic rupture

BACKGROUND

Traditionally, blunt traumatic aortic rupture (BTAR) is thought to be a high-velocity injury. It was hypothesised that BTAR has a higher than suspected incidence in low-speed accidents, with unique kinematic and demographic risk factors.

METHODS

Using the UK Cooperative Crash Injury Study (CCIS) framework, impact profiling was undertaken for accidents involving BTAR. Equivalence Test Speed (ETS) was the parameter used to compare crash severity within comparable impact configurations, as it is a surrogate marker reflecting the net impact forces acting on the vehicle. ETS=40 mph (the threshold used for safety testing within the EURONCAP scheme) was used to delineate low-impact blunt traumatic aortic rupture (LIBTAR) cases, which were subsequently analysed for aetiological risk factors.

RESULTS

119 fully analysed cases of aortic injury were identified from a total of 16,444 cases reported to the UK CCIS between 1998 and 2007. 79 cases (66.4%) qualified as LIBTAR. Risk factors for LIBTAR were age >60 (p<0.0001), lateral impact direction (OR 2.041, RR 1.99, p=0.003), and struck side seat position (OR 1.934, RR 1.885 p=0.101). Low-impact crash scenarios were found to represent more than 95% of UK road traffic accidents.

CONCLUSION

Low-impact collisions account for two thirds of fatal aortic injuries. Age >60, lateral impacts and struck side seat position are predictive of LIBTAR. Low-impact cases were associated with minor (potentially subclinical) intimomedial injuries. Therefore, it is recommended that a higher index of suspicion of aortic injury is used in low-impact scenarios in the risk groups identified.

Outcome of patients of CML in AP and BC with imatinib: A retrospective analysis of patients from India

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Background: Imatinib is a very active agent in advanced phase CML. The present study assesses the impact of Imatinib therapy on the outcome of Indian patients with CML in Accelerated Phase (AP) and Blast Crisis (BC). Methods: Patients of CML in AP or BC who were treated with Imatinib based therapy between 2001 and 2006 were analyzed retrospectively. Results: A total of 65 patients who received Imatinib based treatment for CML in AP or BC were analyzed. Thirty eight (58.46 %) patients diagnosed in chronic phase (CP) were initiated on Imatinib based treatment at time of progression to AP or BC. The remaining 27 (41.53 %) patients had AP or BC of CML at initial diagnosis. At the time of start of Imatinib treatment 36 (55.38 %) patients had AP and 29 (44.61 %) were in BC. Imatinib as a single agent was used in 41 (63.07 %) patients (27 in AP and 14 in BC) and in combination with oral 6-MP and Etoposide was used in 24 (36.92 %) patients (14 in AP and 10 in BC). Hematological response (HR) was seen in 64.61% (42 out of 65) patients, complete HR in 32 (49.23 %) and partial HR in 10 (15.38 %). Cytogenetic response (CR) was noted in 21 (32.31%) patients (Complete -10, Partial -9, and Minor - 2). Twenty eight (43.07%) patients remained progression free (HR+CR in 16 and only HR in 12 patients) till the last date of follow up (median duration of follow-up was 17 months).For the whole group (n=65) the overall survival from the diagnosis of AP or BC after commencing Imatinib treatment was 65.3%, 51.6% and 34.4% at 1, 2 and 3 years respectively. The median survival was 25 months. The median survival and OS at 1 year, as expected, was significantly better for patients in AP (36 months, 77.4 %) as compared to those in BC (11 months, 48.2%)(p=0.004) and both were much longer than previously reported with non-Imatinib therapy. Outcome in patients with AP or BC was not significantly improved by addition of 6-MP and Etoposide. Temporary discontinuation of Imatinb for grade III/IV toxicity was done in 27 (41.53 %) patients for a median duration of 28 days. Conclusions: Imatinib has improved the outcome of patients with advanced phase CML. Our data also documents this in patients from India. However, Imatinib needs to be studied with newer combinations to achieve long term disease control in patients with CML, particularly those in BC.

No significant financial relationships to disclose.

Status of geriatric oncology in India: A national multicentric survey of oncology professionals

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Background: Elderly cancer patients are underrepresented in cancer services utilization and clinical research in India. National data on providers’ knowledge, attitude and practices with regard to elderly cancer patients is sparse and is urgently required to address needs of this vulnerable and growing population. Methods: A self administered questionnaire was mailed to nationally representative sample of practicing oncologists all over India. 112 Oncologists (Medical Oncologists-51%; Radiation Oncologists-25%; Surgical Oncologists-20%; allied fields-4%) responded out of 250 mailed Questionnaires. Results: A designated Geriatric Oncology unit is in existence in very few (<5%) centers. Majority (51%) considered patients with chronological age of >60 years as elderly for India. Although 75% of elderly patients receive some therapy, only 50% of potentially curable patients and a similar percentage of potentially incurable patients receive standard of care. Also, 50% patients require modification in their treatment and only two-third of treated patients complete therapy. The existent barriers to treatment included poor performance status (53%), advanced stage (16%), and co-morbidities (15%). Only 51% Oncologists always discussed and 28% always enrolled elderly patients in clinical trials. Standard of care and evidence based recommendations for elderly patients were felt to be lacking by 49% and 92% of respondents respectively. The need of separate trials for elderly and a separate discipline of Geriatric Oncology was voiced by 93% and 89% of respondents respectively. Major differences in treatment practice between medical oncologists and non medical oncologists are shown in table . Conclusions: Treatment practices and accrual of elderly cancer patients in clinical trials in India is far from optimal. Formation of a National Geriatric Oncology society and creation of designated Geriatric oncology services at key centers may enhance the understanding and clinical care of this population.

[Table: see text]

No significant financial relationships to disclose.

Contamination of environmental surfaces by genital human papillomaviruses

OBJECTIVE

To investigate contamination of environmental surfaces with human papillomaviruses (HPV) DNA in two genitourinary medicine (GUM) clinics and in an on-site staff leisure and fitness centre.

METHODS

Samples were collected from the treatment rooms and patients' toilets of two GUM clinics situated at two hospital sites and from the toilets of the staff leisure and fitness centre on one of the sites. Samples were tested for the presence of HPV DNA by nested polymerase chain reaction (PCR), and HPV amplicons were typed by reverse line hybridisation using HPV type specific oligonucleotide probes complementary to 35 HPV types. All samples were also tested for beta globin DNA by PCR in order to assess their quality.

RESULTS

HPV DNA was found to be present at more than 50% of the sites sampled in one of the GUM clinics, but was absent in the second, and also from the staff leisure and fitness centre. All HPV DNA detected was found to be cell associated. The most commonly found HPV types were 6, 11, and 16, respectively. HPV infected cells were found to be localised mainly to surfaces used predominantly by medical staff.

CONCLUSIONS

This study has identified contamination of the environment of a GUM clinic. Possible sources for the contamination of the clinic toilets were from genital sites via hands to the environment. Within the treatment rooms the most likely route of HPV DNA contamination of the environment was via the doctor's gloved hands.

Accommodation and refractive error in children with Down syndrome: cross-sectional and longitudinal studies

PURPOSE

To examine the relationship between defective accommodation and refractive errors in children with Down syndrome.

METHODS

Children with Down syndrome aged 4 to 85 months were seen at their homes as part of an ongoing study of visual development. Seventy-five children contributed cross-sectional data and 69 children longitudinal data. Accommodation was measured using a modification of Nott dynamic retinoscopy technique, and refractive error measurements were obtained using Mohindra retinoscopy.

RESULTS

Accommodation was poor, regardless of the refractive error present. The total accommodation produced by the children was related to the refractive error at the time of the test, with the degree of accommodation deficit increasing with the amount of positive refractive error. The longitudinal results showed that although children with Down syndrome did not accommodate accurately, the amount of accommodation elicited did not reflect their maximum amplitude of accommodation. Each child showed a consistent degree of underaccommodation for a given stimulus. Spectacles to correct hypermetropia did not improve the accommodative response.

CONCLUSIONS

In children with Down syndrome, underaccommodation is substantial, even when there is no, or a fully corrected, refractive error. The accommodation system of children with Down syndrome may have the physical capacity to respond to a given stimulus, but the neural control of the system has an anomalous set point. Spectacles do not remedy the situation. This has important implications, especially for children in a learning environment, because near vision is consistently out of focus.

The effect of age, size of target, and cognitive factors on accommodative responses of children with Down syndrome

PURPOSE

To investigate possible factors that may be implicated in the poor accommodative responses of individuals with Down syndrome. This article evaluates the effect of age, angular size of target, and cognitive factors on accommodation.

METHODS

Seventy-seven children with Down syndrome who are participating in an ongoing study of visual development were assessed. One hundred thirty-one developmentally normal children took part in a previous study and provided control data. Accommodation was measured using a modified Nott dynamic retinoscopy technique.

RESULTS

Children with Down syndrome showed considerably poorer accommodative responses than normally developing children. No target used in the present study produced an improved response in children with Down syndrome. Age, angular subtense of target, and cognitive factors could not fully account for the poor accommodation in children with Down syndrome.

CONCLUSIONS

Poor accommodation is a common feature of Down syndrome, regardless of the target used. The etiology of the deficit has yet to be established. It is imperative that educators and clinicians are aware that near vision is out of focus for these children.

Refractive errors in young children with Down syndrome

Significant refractive errors are common among older children and adults with Down syndrome. We examined infants and children with Down syndrome to determine the prevalence of these errors at younger ages. Noncycloplegic retinoscopy was used to determine the refractive state of 92 infants and children with Down syndrome, aged 4 months to 12 years. The results for infants show a similar distribution of refractive errors in patients with Down syndrome and an age-matched control group. However, rather than a narrower distribution for the older age groups, as is the case with the controls, the distribution is wider, and the prevalence of refractive errors (including astigmatism) is higher among young children with Down syndrome than among controls. This high prevalence of refractive defects cannot be explained by the presence of strabismus or other pathologies.

Visual acuity and accommodation in infants and young children with Down's syndrome

Accommodation and visual acuity were measured in 53 children with Down's syndrome aged between 12 weeks and 57 months. Results were compared with data for 136 control (typically developing) children aged between 4 weeks and 48 months. Whereas the control children accommodated accurately on near targets, accommodation was defective in 92% of the children with Down's syndrome, and there was no change in accommodative ability with age. On the other hand, visual acuity lay within normal limits for the younger children. Children over the age of 2 years showed a below-normal visual acuity, which is not explained either by refractive error or by the effect of poor accommodation. The data suggest a sudden change in the rate of development of visual acuity which may be associated with physiological changes in the visual cortex. Previously reported defects of accommodation and visual acuity in older children and adults with Down's syndrome are confirmed by our findings in infants and young children.