658 THE RISK OF ANTICOAGULATION IN ELDERLY FALLERS WITH ATRIAL FIBRILLATION: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction

Anticoagulation of elderly patients with Atrial Fibrillation (AF) and falls remains a domain of contention amongst clinicians. There is limited evidence to guide long-term anticoagulation decision in such patients. We performed a systematic-review and meta-analysis to guide anticoagulation decision.

Methods

We conducted a prospectively registered systematic-review and meta-analysis (PROSPERO: CRD42021228661). Studies investigating patients >65 years of age anticoagulated for AF at risk of falls were included. Outcomes included were stroke/systemic embolism (SSE), CNS bleeds, major non-CNS bleeds, and mortality. CENTRAL, MEDLINE, PsycINFO, CINAHL, DARE, Web of science and Scopus were searched. Two authors performed paper inclusion/exclusion, data extraction, risk of bias and GRADE assessment. Data was pooled quantitatively using random-effects models and expressed as Odds Ratio (OR) and 95% Confidence Intervals (95%CI).

Results

Nine studies were included and five were combined quantitatively. Studies had low to moderate risk of bias. Anticoagulated fallers were at higher risk of SSE (OR = 1.73, 95%CI:1.21–2.47, p = 0.003), CNS bleeds (OR = 1.67, 95%CI:1.25–2.23, p < 0.001), major bleeds (OR = 1.87, 95%CI:1.66–2.11, p < 0.001) and mortality (OR = 1.96, 95%CI:1.71–2.25, p < 0.001) compared to anticoagulated non-fallers. Anticoagulated fallers were at higher risk of major bleeds compared to fallers not on anticoagulation (OR = 1.69, 95%CI:1.03–2.77, p = 0.04). However, there was no statistically significant difference in SSE, CNS bleeds or mortality. In fallers, Direct Oral Anticoagulants (DOACs) have lower risk of CNS bleeds (OR = 0.19, 95%CI:0.09–0.041, p < 0.001) and major bleeds (OR = 0.78, 95%CI:0.60–1.01, p = 0.06) compared to warfarin. There was no statistically significant difference in SSE or mortality between the anticoagulants.

Conclusion: (s)

Falling on anticoagulation is associated with increased risk of complications. However, only risk of major non-CNS bleeds increases when anticoagulating fallers. In fallers, DOACs appear safer than warfarin for bleeding complications. There remains paucity of evidence about anticoagulation in fallers (GRADE certainty = very low—moderate). Further evidence is needed to help clinicians and patients regarding anticoagulation.

Factors associated with the development of acute general surgical pathology in medical in-patients

BACKGROUND

Medical inpatients can develop acute general surgical conditions. However, this is rare. The presence of multiple acute pathologies delays diagnosis and these patients have poorer prognoses.

AIM

To determine the incidence, risk factors and prognosis of medical inpatients developing acute general surgical conditions.

METHODS

A single-centre retrospective case-control study was conducted over one year in the United Kingdom. Medical patients developing acute surgical pathology were identified using the local referral system. For each case, two controls were selected from a pool of medical in-patients receiving no general surgical input during their admission. Patient records were used to collect hospital admission details, demographic and laboratory data. Univariate analysis and multi-variable analysis were performed.

RESULTS

The study included 42 cases and 84 controls. The incidence of general surgical pathology in medical in-patients was 2.3/1000 admissions/year. In multivariate analysis, risk factors associated with developing general surgical pathology were previous abdominal surgery (Odds Ratio [OR] =3.68, 95% Confidence interval [CI]: 1.43 to 9.48, p=0.007) and doubling from baseline creatinine (OR=18.9, 95%CI: 2.57 to 139, p=0.004). Patients with surgical pathology had longer in-patient stays (22.8 vs 9.4 days, p<0.001) and a higher inpatient mortality (23.8% vs 7.1%, p=0.011). Development of surgical pathology was strongly associated with mortality (OR=4.06, 95%CI: 1.36 to 12.1).

CONCLUSION

The development of acute surgical pathology in medical in-patients is rare but associated with longer in-patient stays and higher mortality. We have identified risk-factors associated with the development of surgical pathology which can be used to identify patients at risk of surgical pathology. This article is protected by copyright. All rights reserved.

Timing of electronic reminders did not improve trial participant questionnaire response: a randomized trial and meta-analyses

OBJECTIVES

The objective of this study was to assess whether timing of short messaging service (SMS) reminders improved postal questionnaire return rates from participants in a randomized controlled trial (RCT).

STUDY DESIGN AND SETTING

A Study Within A Trial (SWAT) embedded in a multicenter RCT evaluating three treatments for the frozen shoulder. Participants who provided a mobile telephone number were randomized to either prenotification SMS on the day of the questionnaire mail-out or postnotification SMS 4 days after questionnaire mail-out for the 3-month follow-up. The primary outcome was the proportion of participants who returned a valid questionnaire. A systematic review was undertaken to identify other embedded trials to perform a meta-analysis.

RESULTS

Of the 269 participants, 122/135 (90.4%) returned a valid questionnaire in the prenotification arm and 119/134 (88.8%) in the postnotification arm (difference of -1.6%; 95% CI of difference: -8.9%, 5.7%). There was no difference in time to response (HR = 1.04; 95% CI: 0.80 to 1.34) or need for additional reminders (OR = 0.71; 95% CI: 0.43 to 1.17). Meta-analysis of two RCTs showed no difference in response rates between prenotification and postnotification reminders (OR = 0.78 95% CI: 0.42 to 1.45).

CONCLUSION

Timing of SMS reminders did not improve response rates and time to response or affect the need for additional reminders.

A multicentre Study of Nutrition Risk Assessment in Adult Patients with Inflammatory Bowel Disease Attending Outpatient Clinics

BACKGROUND

Overnutrition and undernutrition can affect patients with inflammatory bowel disease (IBD). Although all IBD outpatients should be screened for nutrition risk, screening is not routinely performed, potentially leading to reduced identification and treatment. This study aimed to estimate the prevalence of nutrition risk in adult IBD outpatients and the proportion of cases who discussed diet and/or nutrition during their routine clinical appointment.

METHODS

Adults with IBD attending outpatient clinics at 4 hospitals in Greece and in UK were recruited. Demographic and anthropometric data were collected using face-to-face patient interviews and clinical records. Patients were classified as high (i.e., body mass index [BMI] < 18.5 or 18.5-20 kg/m2 and weight loss > 5%), moderate (i.e., BMI 20-25 kg/m2 and weight loss > 5%) or low risk of undernutrition and high risk of obesity (i.e., BMI 25-30% and weight gain > 5%). The proportion of patients who discussed diet and/or nutrition during their clinical appointment was calculated.

RESULTS

In total, 390 IBD patients participated. Sixteen (4%) patients were underweight, 113 (29%) were overweight and 71 (18%) were obese. Twenty-one (5%) patients were at high risk of undernutrition; of these 4 (19%) were under dietetic care. Of those at high risk of undernutrition, 11 (52%) had discussed diet and/or nutrition during their routine clinical appointment. Fifty-six (14%) patients had gained more than 5% weight since their last recorded/reported weight and 19 (5%) were at high risk of obesity.

CONCLUSIONS

Few patients were identified to be at high risk of undernutrition and less than a fifth of these were under dietetic care. Overnutrition is a growing problem in IBD with almost half of adult patients being overweight or obese. Diet and/or nutrition were not routinely discussed in this group of IBD outpatients.

Factors associated with spontaneous clearance of chronic hepatitis C virus infection

BACKGROUND & AIMS

Spontaneous clearance of chronic hepatitis C virus (HCV) infection (CHC) is rare. We conducted a retrospective case-control study to identify rates and factors associated with spontaneous clearance of CHC.

METHODS

We defined cases as individuals who spontaneously resolved CHC, and controls as individuals who remained chronically infected. We used data obtained on HCV testing between 1994 and 2013 in the West of Scotland to infer case/control status. Specifically, untreated patients with ⩾2 sequential samples positive for HCV RNA ⩾6months apart followed by ⩾1 negative test, and those with ⩾2 positive samples ⩾6months apart with no subsequent negative samples were identified. Control patients were randomly selected from the second group (4/patient of interest). Case notes were reviewed and patient characteristics obtained.

RESULTS

25,113 samples were positive for HCV RNA, relating to 10,318 patients. 50 cases of late spontaneous clearance were identified, contributing 241 person-years follow-up. 2,518 untreated, chronically infected controls were identified, contributing 13,766 person-years follow-up, from whom 200 controls were randomly selected. The incidence rate of spontaneous clearance was 0.36/100 person-years follow-up, occurring after a median 50months' infection. Spontaneous clearance was positively associated with female gender, younger age at infection, lower HCV RNA load and co-infection with hepatitis B virus. It was negatively associated with current intravenous drug use.

CONCLUSIONS

Spontaneous clearance of CHC occurs infrequently but is associated with identifiable host and viral factors. More frequent HCV RNA monitoring may be appropriate in selected patient groups.

LAY SUMMARY

Clearance of hepatitis C virus infection without treatment occurs rarely once chronic infection has been established. We interrogated a large Scottish patient cohort and found that it was more common in females, patients infected at a younger age or with lower levels of HCV in the blood, and patients co-infected with hepatitis B virus. Patients who injected drugs were less likely to spontaneously clear chronic infection.