Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Electric Field, Ictal Theta Power, and Clinical Outcomes in Electroconvulsive Therapy

BACKGROUND

Electroconvulsive therapy (ECT) is efficacious for treatment-resistant depression. Treatment-induced cognitive impairment can adversely impact functional outcomes. Our pilot study linked the electric field to ictal theta power from a single suprathreshold treatment and linked ictal theta power to changes in phonemic fluency. In this study, we set out to replicate our findings and expand upon the utility of ictal theta power as a potential cognitive biomarker.

METHODS

Twenty-seven participants (18 female and 9 male) received right unilateral ECT for treatment-resistant depression. Pre-ECT magnetic resonance imaging and finite element modeling determined the 90th percentile maximum electric field in the brain. Two-lead electroencephalographs were digitally captured across the ECT course, with the earliest suprathreshold treatment used to determine power spectral density. Clinical and cognitive outcomes were assessed pre-, mid-, and post-ECT. We assessed the relationship between the electric field in the brain, ictal theta power, clinical outcome (Inventory of Depressive Symptomatology), and cognitive outcomes (phonemic and semantic fluency) with linear models.

RESULTS

Ictal theta power in the Fp1 and Fp2 channels was associated with the electric field, antidepressant outcome, and phonemic and semantic fluency. The relationship between ictal theta power and phonemic fluency was strengthened in the longitudinal analysis. The electric field in the brain was directly associated with phonemic and semantic fluency but not with antidepressant outcome.

CONCLUSIONS

Ictal theta power is a potential cognitive biomarker early on in the ECT course to help guide parameter changes. Larger studies are needed to further assess ictal theta power's role in predicting mood outcome and changes with ECT parameters.

The community engagement course and action network: strengthening community and academic research partnerships to advance health equity

Background

Historically Black Colleges and Universities and Minority Serving Institutions are uniquely positioned to implement community-campus research partnerships based on a history of service, the pursuit of community trustworthiness and student demographics often similar to surrounding marginalized communities. The Morehouse School of Medicine Prevention Research Center collaborates with members of Historically Black Colleges and Universities, Minority Serving Institutes, and community organizations on the Community Engaged Course and Action Network. This network is the first of its kind and aims to strengthen members' ability to implement Community-Based Participatory Research (CBPR) principles and partnerships. Projects address public health priorities including mental health among communities of color, zoonotic disease prevention, and urban food deserts.

Materials and methods

To assess the effectiveness of the network, a Participatory Evaluation framework was implemented to conduct process evaluation which included review of partnership structures, operations, project implementation processes, and preliminary outcomes of the research collaborations. A focus group of Community Engagement Course and Action Network members (community and academic) was also conducted to identify benefits and challenges of the network with emphasis on key areas for improvement to further enhance the relationships between partners and to facilitate their subsequent community-campus research.

Results

Network improvements were tied to themes strengthening community-academic partnerships including sharing and fellowship, coalition building and collaboration, and greater connections and awareness of community needs through their current community-academic partnerships. The need to conduct ongoing evaluation during and after implementation, for determining the early adoption of CBPR approaches was also identified.

Conclusion

Evaluation of the network's processes, infrastructure, and operation provides early lessons learned to strengthen the network. Ongoing assessment is also essential for ensuring continuous quality improvement across partnerships such as determining CBPR fidelity, assessing partnership synergy, and dynamics, and for quality improvement of research protocol. The implications and potential for advancing implementation science through this and similar networks are great towards advancing leadership in modeling how foundations in community service can advance to CBPR partnership formation and ultimately, health equity approaches, that are local defined and assessed.

Detailed analysis of in-hospital transmission of SARS-CoV-2 using whole genome sequencing

BACKGROUND

Hospital transmission of SARS-CoV-2 has proved difficult to control, with healthcare-associated infections troublesome throughout.

AIM

To understand factors contributing to hospital transmission of infections, which is necessary for containing spread.

METHODS

An outbreak of 56 staff and patient cases of COVID-19 over a 31-day period in a tertiary referral unit is presented, with at least a further 29 cases identified outside of the unit and the hospital by whole genome sequencing (WGS).

FINDINGS

Transmission is documented from staff to staff, staff to patients, and patients to staff, showing disruption of a tertiary referral service, despite implementation of nationally recommended control measures, superior ventilation, and use of personal protective equipment. There was extensive spread from the index case, despite this patient spending only 10 h bed bound on the ward in strict cubicle isolation and with an initial single target low level (C_T = 32) polymerase chain reaction test.

CONCLUSION

This investigation highlights how effectively and rapidly SARS-CoV-2 can spread in certain circumstances. It raises questions about infection control measures in place at the time and calls into question the premise that transmissibility can be reliably detected by using lower sensitivity rapid antigen lateral flow tests. We also highlight the value of early intervention in reducing impact as well as the value of WGS in understanding outbreaks.

The use of pain scales in small animal veterinary practices in the USA

OBJECTIVES

Pain assessment in veterinary medicine is challenging. Uncertainty in the ability to recognise pain in animals contributes to suboptimal analgesia. Pain scales have been developed to aid in pain recognition. It is unknown if such scales are routinely utilised in veterinary practices.

MATERIALS AND METHODS

A survey using RedCap software was emailed to veterinarians and veterinary technicians working in practices across the USA. This study aimed to investigate whether pain scoring was routinely performed and reasons to use or not use pain scales. One hundred and forty-four participants were required to estimate prevalence (95% confidence level, 5% precision) with hypothesised prevalence of approximately 10%.

RESULTS

One hundred and forty-seven participants completed the survey. Seventy (47.6%) responded that pain scoring was performed in their practices, 24 (16.3%), reported "sometimes" and 53 (36.1%) reported pain scores were not performed. Reasons for not pain scoring included no training (51.9%) and busy caseload (48.1%). Disadvantages of pain scales were unreliability (16/82; 20%), duration required for completion (14/82; 17%) and vocalisation (14/82; 17%).

CLINICAL SIGNIFICANCE

Almost 50% of the small animal practices surveyed reported the use of pain scales as part of their routine workflow. However, many practices still do not consistently utilise pain scales to assess pain in dogs and cats. Perceived unreliability and lack of compliance were reasons for this result. Improvement of training and proper pain scale introduction and implementation in small animal practices in the USA appears to be required.

Links between electroconvulsive therapy responsive and cognitive impairment multimodal brain networks in late-life major depressive disorder

BACKGROUND

Although electroconvulsive therapy (ECT) is an effective treatment for depression, ECT cognitive impairment remains a major concern. The neurobiological underpinnings and mechanisms underlying ECT antidepressant and cognitive impairment effects remain unknown. This investigation aims to identify ECT antidepressant-response and cognitive-impairment multimodal brain networks and assesses whether they are associated with the ECT-induced electric field (E-field) with an optimal pulse amplitude estimation.

METHODS

A single site clinical trial focused on amplitude (600, 700, and 800 mA) included longitudinal multimodal imaging and clinical and cognitive assessments completed before and immediately after the ECT series (n = 54) for late-life depression. Another two independent validation cohorts (n = 84, n = 260) were included. Symptom and cognition were used as references to supervise fMRI and sMRI fusion to identify ECT antidepressant-response and cognitive-impairment multimodal brain networks. Correlations between ECT-induced E-field within these two networks and clinical and cognitive outcomes were calculated. An optimal pulse amplitude was estimated based on E-field within antidepressant-response and cognitive-impairment networks.

RESULTS

Decreased function in the superior orbitofrontal cortex and caudate accompanied with increased volume in medial temporal cortex showed covarying functional and structural alterations in both antidepressant-response and cognitive-impairment networks. Volume increases in the hippocampal complex and thalamus were antidepressant-response specific, and functional decreases in the amygdala and hippocampal complex were cognitive-impairment specific, which were validated in two independent datasets. The E-field within these two networks showed an inverse relationship with HDRS reduction and cognitive impairment. The optimal E-filed range as [92.7-113.9] V/m was estimated to maximize antidepressant outcomes without compromising cognitive safety.

CONCLUSIONS

The large degree of overlap between antidepressant-response and cognitive-impairment networks challenges parameter development focused on precise E-field dosing with new electrode placements. The determination of the optimal individualized ECT amplitude within the antidepressant and cognitive networks may improve the treatment benefit-risk ratio.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02999269.

HEARTBEAT4D: An Open-source Toolbox for Turning 4D Cardiac CT into VR/AR

Four-dimensional data sets are increasingly common in MRI and CT. While clinical visualization often focuses on individual temporal phases capturing the tissue(s) of interest, it may be possible to gain additional insight through exploring animated 3D reconstructions of physiological motion made possible by augmented or virtual reality representations of 4D patient imaging. Cardiac CT acquisitions can provide sufficient spatial resolution and temporal data to support advanced visualization, however, there are no open-source tools readily available to facilitate the transformation from raw medical images to dynamic and interactive augmented or virtual reality representations. To address this gap, we developed a workflow using free and open-source tools to process 4D cardiac CT imaging starting from raw DICOM data and ending with dynamic AR representations viewable on a phone, tablet, or computer. In addition to assembling the workflow using existing platforms (3D Slicer and Unity), we also contribute two new features: 1. custom software which can propagate a segmentation created for one cardiac phase to all others and export to surface files in a fully automated fashion, and 2. a user interface and linked code for the animation and interactive review of the surfaces in augmented reality. Validation of the surface-based areas demonstrated excellent correlation with radiologists' image-based areas (R > 0.99). While our tools were developed specifically for 4D cardiac CT, the open framework will allow it to serve as a blueprint for similar applications applied to 4D imaging of other tissues and using other modalities. We anticipate this and related workflows will be useful both clinically and for educational purposes.

1480 The application of an age adjusted D-dimer threshold to rule out suspected venousthromboembolism (VTE) in an emergency department setting: A retrospective diagnostic cohort study

Aims, Objectives and Background

Venous Thromboembolic disease (VTE) poses a diagnostic challenge for clinicians in acute care. Over reliance on reference standard investigations can lead to over treatment and potential harm.

We sought to evaluate the pragmatic performance and implications of using an age adjusted d-dimer (AADD) strategy to rule out VTE in patients with suspected disease attending an emergency department setting.

We aimed to determine diagnostic test characteristics and assess whether this strategy would result in proportional imaging reduction and potential cost savings.

Method and Design

Design

Single centre retrospective diagnostic cohort study.

All patients >50 years old evaluated for possible VTE who presented to the ED over a consecutive 12-month period between January and December 2016 with a positive D-dimer result.

Clinical assessment records and reference standard imaging results were followed up by multiple independent adjudicators and coded as VTE positive or negative.

Results

During the study period, there were 2132 positive D-dimer results. 1236 patients received reference standard investigations. A total increase of 314/1236 (25.1%) results would have been coded as true negatives as opposed to false positive if the AADD cut off point had been applied, with 314 reference standard tests subsequently avoided.

The AADD cut off had comparable sensitivity to the current cut off despite this increase in specificity; sensitivities for the diagnosis of DVT were 99.28% (95% CI 96.06–99.98%) and 97.72% for PE (95% CI 91.94% to 97.72). There were 3 potential false negative results using the AADD strategy.

Conclusion

In patients with suspected VTE with a low or moderate pre-test probability, the application of AADD appears to increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging. This management strategy is likely to be associated with substantial reduction in anticoagulation treatment, investigations and cost/time savings.

The application of an age adjusted D-dimer threshold to rule out suspected venous thromboembolism (VTE) in an emergency department setting: a retrospective diagnostic cohort study

BACKGROUND

Venous Thromboembolic disease (VTE) poses a diagnostic challenge for clinicians in acute care. Over reliance on reference standard investigations can lead to over treatment and potential harm. We sought to evaluate the pragmatic performance and implications of using an age adjusted D-dimer (AADD) strategy to rule out VTE in patients with suspected disease attending an emergency department (ED) setting. We aimed to determine diagnostic test characteristics and assess whether this strategy would result in proportional imaging reduction and potential cost savings.

METHODS

Design: Single centre retrospective diagnostic cohort study. All patients > 50 years old evaluated for possible VTE who presented to the emergency department over a consecutive 12-month period between January and December 2016 with a positive D-dimer result. Clinical assessment records and reference standard imaging results were followed up by multiple independent adjudicators and coded as VTE positive or negative.

RESULTS

During the study period, there were 2132 positive D-dimer results. One thousand two hundred thirty-six patients received reference standard investigations. A total increase of 314/1236 (25.1%) results would have been coded as true negatives as opposed to false positive if the AADD cut off point had been applied, with 314 reference standard tests subsequently avoided. The AADD cut off had comparable sensitivity to the current cut off despite this increase in specificity; sensitivities for the diagnosis of DVT were 99.28% (95% CI 96.06-99.98%) and 97.72% for PE (95% CI 91.94% to 97.72). There were 3 false negative results using the AADD strategy.

CONCLUSIONS

In patients with suspected VTE with a low or moderate pre-test probability, the application of AADD appears to increase the proportion of patients in which VTE can be excluded without the need for reference standard imaging. This management strategy is likely to be associated with substantial reduction in anticoagulation treatment, investigations and cost/time savings.

Adult outcomes of complex pulmonary atresia, ventricular septal defect and major aortopulmonary collaterals following repair during childhood, a single centre experience

Background

Complex pulmonary atresia with a ventricular septal defect and major aortopulmonary collateral arteries (PA VSD MAPCA) is a rare and complex form of congenital heart disease. Staged surgical palliation is carried out in childhood, and in expert centres, is associated with good medium term survival. Adult outcomes following transition to adult care are not known.

Purpose

To establish adult outcomes of PA VSD MAPCA following repair during childhood in our institution

Methods

Review of clinical records for outcome data including life status, NYHA class, employment status, re-intervention in adult life, arrhythmia, pregnancy, exercise capacity and mode of death, where known. We predefined our population into two groups based on their status at transition to adult care, A) complete repair with RV-PA conduit and VSD closed and B) repaired but VSD left open.

Results

188 patients from our series have transitioned to adult services. As many were tertiary referrals (nationally and internationally) the local follow up population was 53 adults (54.7% male), mean age of those alive under follow up is 27.2±6.5 years, with a mean follow up of 25.3±6.1 years. There were 43 in group A and 10 in group B. Mortality in the total population was 18.9% (10/53), group A (16.3%), group B (30.0%), mean age at death 37.5±10.3 years and 29.9±8.4 years, 6/10 deaths were sudden. 22.6% of the whole group had DiGeorge/22q11 microdeletion, with a learning deficit in 32.7% of the cohort, where this could be assessed. Reinterventions included RV-PA conduit change, coil occlusion, pacemaker implantation, ICD implantation and ablation procedures, overall 39.6% underwent reintervention in adult life. Pregnancy occurred in 33.3% of 24 female patients. 50% of individuals were found to have undertaken some form of paid work and of these 11.5% had DiGeorge.

Conclusions

Complex PA VSD MAPCA is associated with good late survival with late attrition including sudden death and heart failure. 22q11 is associated with learning deficit and consequent lack of employment. Non 22q11 have good educational outcomes and there is less observed deficit regarding employment. Successful pregnancy is possible within this population.

Funding Acknowledgement

Type of funding sources: None.

Long-term cost-effectiveness of Dexcom G6 real-time continuous glucose monitoring system in people with type 1 diabetes in Australia

INTRODUCTION

Real-time continuous glucose monitoring (rt-CGM) allows patients with diabetes to adjust insulin dosing, potentially improving glucose control. This study aimed to compare the long-term cost-effectiveness of the Dexcom G6 rt-CGM device versus self-monitoring of blood glucose (SMBG) and flash glucose monitoring (FGM) in Australia in people with type 1 diabetes (T1D).

METHODS

Long-term costs and clinical outcomes were estimated using the CORE Diabetes Model. Clinical input data for the analysis of rt-CGM versus SMBG and FGM were sourced from the DIAMOND study and a network meta-analysis, respectively. Rt-CGM and FGM were associated with quality of life (QoL) benefits due to reduced fear of hypoglycaemia (FoH) and fingerstick testing. Analyses were performed over a lifetime time horizon from an Australian healthcare payer perspective, including direct costs from published data. Future costs and clinical outcomes were discounted at 5% per annum.

RESULTS

Rt-CGM was associated with an increased quality-adjusted life expectancy of 1.199 quality-adjusted life years (QALYs), increased mean total lifetime costs of AUD 21,596 and an incremental cost-effectiveness ratio (ICER) of AUD 18,020 per QALY gained compared with SMBG. Compared with FGM, rt-CGM was associated with an increased quality-adjusted life expectancy of 0.569 QALYs, increased mean total lifetime costs of AUD 11,064 and an ICER of AUD 19,455 per QALY gained. Key drivers of outcomes included HbA_1c benefits and QoL benefits associated with reduced FoH and fingerstick testing.

CONCLUSIONS

Due to improved clinical outcomes and QoL gains rt-CGM is highly cost-effective compared with SMBG and FGM in people with T1D in Australia.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Cerebral Autoregulation Correlation With Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Delayed cerebral ischemia remains one of the principal therapeutic targets after aneurysmal subarachnoid hemorrhage. While large vessel vasospasm may contribute to ischemia, increasing evidence suggests that physiological impairment through disrupted impaired cerebral autoregulation (CA) and spreading depolarizations (SDs) also contribute to delayed cerebral ischemia and poor neurological outcome. This study seeks to explore the intermeasure correlation of different measures of CA, as well as correlation with SD and neurological outcome.

METHODS

Simultaneous measurement of 7 continuous indices of CA was calculated in 19 subjects entered in a prospective study of SD in aneurysmal subarachnoid hemorrhage undergoing surgical aneurysm clipping. Intermeasure agreement was assessed, and the association of each index with modified Rankin Scale score at 90 days and occurrence of SD was assessed.

RESULTS

There were 4102 hours of total monitoring time across the 19 subjects. In time-resolved assessment, no CA measures demonstrated significant correlation; however, most demonstrate significant correlation averaged over 1 hour. Pressure reactivity (PRx), oxygen reactivity, and oxygen saturation reactivity were significantly correlated with modified Rankin Scale score at 90 days. PRx and oxygen reactivity also were correlated with the occurrence of SD events. Across multiple CA measure reactivity indices, a threshold between 0.3 and 0.5 was most associated with intervals containing SD.

CONCLUSIONS

Different continuous CA indices do not correlate well with each other on a highly time-resolved basis, so should not be viewed as interchangeable. PRx and oxygen reactivity are the most reliable indices in identifying risk of worse outcome in patients with aneurysmal subarachnoid hemorrhage undergoing surgical treatment. SD occurrence is correlated with impaired CA across multiple CA measurement techniques and may represent the pathological mechanism of delayed cerebral ischemia in patients with impaired CA. Optimization of CA in patients with aneurysmal subarachnoid hemorrhage may lead to decreased incidence of SD and improved neurological outcomes. Future studies are needed to evaluate these hypotheses and approaches.

Ictal Theta Power as an Electroconvulsive Therapy Safety Biomarker: A Pilot Study

OBJECTIVE

Electroconvulsive therapy (ECT) remains the benchmark for treatment resistant depression, yet its cognitive adverse effects have a negative impact on treatment. A predictive safety biomarker early in ECT treatment is needed to identify patients at cognitive risk to maximize therapeutic outcomes and minimize adverse effects. We used ictal electroencephalography frequency analysis from suprathreshold treatments to assess the relationships between ECT dose, ictal power across different frequency domains, and cognitive outcomes.

METHODS

Seventeen subjects with treatment resistant depression received right unilateral ECT. Structural magnetic resonance imaging was obtained pre-ECT for electric field modeling to assess ECT dose. Serial assessments with 24-lead electroencephalography captured ictal activity. Clinical and cognitive assessments were performed before and after ECT. The primary cognitive outcome was the change in Delis Kaplan Executive Function Verbal Fluency Letter Fluency.

RESULTS

Ictal theta (4-8 Hz) power in the Fp1/Fp2 channels was associated with both whole-brain electric field strength (t(2,12) = 19.5, P = 0.007)/(t(2,10) = 21.85, P = 0.02) and Delis Kaplan Executive Function Verbal Fluency Letter Fluency scores (t(2,12) = -2.05, P = 0.05)/(t(2,10) = -2.20, P = 0.01). Other frequency bands (beta, alpha, delta, and gamma) did not demonstrate this relationship.

CONCLUSIONS

This pilot data identify ictal theta power as a potential safety biomarker in ECT and is related to the strength of the ECT dose. Ictal theta power could prove to be a convenient and powerful tool for clinicians to identify those patients most susceptible to cognitive impairment early in the treatment series. Additional studies are needed to assess the role of longitudinal changes in ictal theta power throughout the ECT series.

643 How the Straight Leg Raise and Crossed Straight Leg Raise Sign Influence Patient Reported Outcome Measures in Patients with a Lumbar Disc Herniation

Aim

Low back pain (LBP) with associated lumbar radiculopathy is common. Clinical assessment utilises the straight leg raise (SLR) test and the more specific crossed straight leg raise (XSLR) test. Patient reported outcome measure (PROMs) scores can assess the contributary biopsychosocial factors to pain. Evidence shows links between radiculopathy and psychosocial issues, but little has assessed them in relation to clinical examination. The aim of this study was to assess the significance of the SLR and XSLR sign on PROMs in patients with an MRI-confirmed lumbar disc herniation.

Method

Patients with an MRI-confirmed lumbar disc herniation who presented with LBP and lumbar radiculopathy were identified. Collected data included the clinical examination outcome, level and side of disc prolapse, interventions and PROMs scores (VAS, ODI, EQ5D, GAD7, PHQ9). Statistical analysis was performed using SPSS.

Results

216 patients were included in this study (mean age 50.4, 41% female, 59% male), 102 had negative straight leg raise (NSLR), 94 had positive SLR and 20 had both a positive SLR and positive XSLR. Patients with a positive clinical test on examination had ‘worse’ PROMs scores, with a positive XSLR sign associated with the ‘worst’ PROMs scores. For each PROM, t-test analysis reported a significant difference between the NSLR and SLR groups and NSLR and XSLR groups (P &lt; .01).

Conclusions

PROMs scores indicating a lower health-related quality-of-life, increased levels of disability, pain, anxiety and depression and greater expectations are associated with a positive SLR or XSLR test.

635 Expectations and Concerns of Patients Attending a Spinal Outpatient Clinic

Aim

Identifying expectations and concerns of patients is vital during clinical consultation in patient-centred healthcare systems. Most spinal surgery is elective and focussed on improving quality of life. Understanding what patients want from treatment at baseline may improve experience and outcomes.

Method

New patient data from the caseload of a single orthopaedic spinal surgeon (from April 2012-18) was analysed with expectations and concerns reported in the outpatient clinic letter (standard practice for surgeon).

Results

Of 940 patients (498 NHS, 442 private), mean age was 58.3 with 46.0% male and 54.0% female. Nearly 1-in-6 patients underwent previous surgery. The most common expectation was ‘reduce pain’ (41.8%), followed by diagnosis (23.0%), treatment options (13.5%), unsure (10.5%). The most common concern was ‘continuation/worsening of pain’ (27.0%), followed by loss of function (15.9%), work-related (8.3%), permanent disability (7.8%). NHS patients were significantly more unsure of expectations (19.7% vs 4.5%, p&lt;.001) and less frequently raised concerns (39.0% vs 18.8%, p&lt;.001). NHS patients had significantly worse Oswestry Disability Index (ODI) scores (46.8% vs 42.0% p&lt;.001), were more depressed (PHQ-9: 11.5 vs 8.9, p&lt;.001) and anxious (GAD-7: 8.2 vs 5.9, p&lt;.001). Private patients were significantly more likely to report problems sleeping (79.4% vs 51.0%, p&lt;.001). Patients concerned about permanent disability had significantly worse ODI (51.0% vs 42.7%, p&lt;.001), PHQ-9 (12.6 vs 10.2 p=.013) and GAD-7 (9.0 vs 7.1, p=.017) scores.

Conclusions

This study identified patient expectations and concerns in spinal outpatient clinic in both healthcare sectors. Future work should explore these findings in context with clinical outcome.

POS1107 THE EFFICACY, SAFETY AND OUTCOME AFTER 5-8 YEARS OF PARENTERAL ANTI-OSTEOPOROTIC THERAPY EVALUATED AT A DISTRICT GENERAL HOSPITAL IN THE UK

Background:

Parenteral anti-osteoporotic medications are frequently recommended for the management of primary and secondary osteoporosis by NICE (1) and EULAR (2) guidelines.

Objectives:

This audit aimed at evaluating the efficacy, adherence and safety profile of denosumab (D), zoledronate (Z) and teriparatide (T).

Methods:

The data of patients initiating D, Z and T from 2012-2021 were retrospectively reviewed using electronic medical records at Basildon hospital.

Results:

We enrolled 146 patients diagnosed with low bone density and on following treatment (3-6 years D (n: 50), 4-5 years Z (n: 50) and 2 years T (n: 46). More than 92% were Caucasian females; 41.7% were above 80 years.

T group had more pronounced reduction in bone mineral density (BMD) with a mean T-score

(spine:-3.9, hip: -2.6, neck of femur: -2.7; followed by Z group (spine: -2.6, hip:-2, neck of femur: -2.5) and D group (spine: -2.3, hip:-2.2, neck of femur: -2.3).

Primary prevention was in 26% and secondary prevention in 73.9%; with the commonest fractures at the vertebrae at 40%.

Oral bisphosphonate was the first choice in 63.6% of the cases (please see graph1). Intolerance, gastric upset or inefficacies were the commonest reasons to avoid them.

After the 3rd Z or 5th D, DXA scan shows improvements or stability in BMD at both hip and spinal areas in 88% and 82% respectively; compared to 69.6% after completing 2 years of T. The rate of improvement or stability plummeted after the 10th D and 5th Z (Please see Table 1).

Table 1.

Monitoring BMD after courses of D, Z and T.

DXA scan:changes in BMD:Afterthe 5thDAfterthe 10thDAfterthe 3rdZAfterthe 5thZAfter2 years of TPercentage of scanned patients100%90%100%60%71.73%Improved or stable BMD at spine or hip areas82%75.5% 88%85.6%69.6%Improved or stable BMD at the spine but declined at hip area18%19.9%12%13.3%24.2%Declined BMD at both spine and hip areas4.4%6%

The course of T was stopped earlier in 28.2% of the cases due to the difficulty in taking injections or side effects including nausea, gastric upset, myalgia, insomnia, poor renal function, raised PTH, ALP and calcium. Dental issues (not osteonecrosis) were the reason to stop Z and D in 2% of each group and 8% choose to discontinue D after developing other non-related comorbidities. There were no fragility fractures during the treatment courses.

The outcome after reviewing 91.3% of those who completed or stopped the T course shows 39% commenced on D whereas 35.7% and 19% on Z and alendronate respectively leaving 7.1% on drug holiday. After completion of the 10th D, 78.5% of the reviewed patients were continued on further D injections whereas 3.5% were switched to T and 17.8% given drug holiday. For those who were reviewed after the 5th Z, 94% were switched to D and 5.8% given drug holiday.

Conclusion:

D, Z and T were well tolerated and could effectively either maintain or improve the BMD at both spinal and hip sites and prevent fragility fractures and T was associated with the most pronounced soar in BMD. There were few cases of deterioration mainly at the hip area with all groups.

Prior bisphosphonate therapy did not show significant influence on the later effects of D, Z or T on BMD. After completion of the treatment for the 3 groups, only 30.87 % of the reviewed cases were advised for drug holiday and majority were switched to D as Z and T is limited to 5 and 2 years course respectively.

Heterogeneity in decision making exists due to variability in recommending these medications, patient preference and mode of administration. To optimize the adherence and effects of anti-osteoporotic medications, stratified guidelines is required for the long term use of these medications and discontinuation of D.

References:

[1]NICE Pathway: 20 August 2019, http://pathways.nice.org.uk/pathways/osteoporosis

[2]Kanis JA et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2019 Jan;30(1):3-44.

Disclosure of Interests:

None declared.

Racial and Ethnic Differences in BRCA1/2 and Multigene Panel Testing Among Young Breast Cancer Patients

Genetic testing for hereditary breast and ovarian cancer (HBOC) is recommended for breast cancer patients diagnosed at age ≤ 50 years. Our objective was to examine racial/ethnic differences in genetic testing frequency and results among diverse breast cancer patients. A retrospective cohort study among women diagnosed with breast cancer at age ≤ 50 years from January 2007 to December 2017 at Columbia University in New York, NY. Among 1503 diverse young breast cancer patients, nearly half (46.2%) completed HBOC genetic testing. Genetic testing completion was associated with younger age, family history of breast cancer, and earlier stage, but not race/ethnicity or health insurance status. Blacks had the highest frequency of pathogenic/likely pathogenic (P/LP) variants (18.6%), and Hispanics and Asians had the most variants of uncertain significance (VUS), 19.0% and 21.9%, respectively. The percentage of women undergoing genetic testing increased over time from 15.3% in 2007 to a peak of 72.8% in 2015. Over the same time period, there was a significant increase in P/LP and VUS results. Due to uncertainty about the clinical implications of P/LP variants in moderate penetrance genes and VUSs, our findings underscore the need for targeted genetic counseling education, particularly among young minority breast cancer patients.

The characteristics of patients requiring readmission to an Australian forensic psychiatric intensive care unit

Introduction

Psychiatric intensive care units (or PICU’s) emerged to manage high acuity patients outside the justice system. Studies have sought to better understand characteristics of those admitted to forensic or civilian PICU’s. Few, in contrast, have explored the frequency and contributors to readmission. The following study was conducted on Apsley unit, a Forensic PICU based in Melbourne, Australia, and seeks to understand the differences which would allow early identification of patients likely to require readmission and the provision of targeted interventions.

Objectives

Examine rates of and contributors to forensic PICU readmission over a 6-month period.

Methods

A retrospective audit was conducted to collect clinical, problem behaviour (and strategies to manage), forensic history and demographic information for consecutively admitted patients to an 8-bed forensic PICU between March-September 2019.

Results

Data analysis is ongoing. Interim analysis found that 96 patients were admitted during the 6-month study period: 74 (77.1%) had a single admission; 22 (22.9%) required readmission. Almost all were admitted from prison (96.9%), most had a psychosis diagnosis (80.2%) and substance abuse history (96.9%), and many had a personality disorder (24.0%) and history of adolescent antisocial behaviour (46.5%). Patients requiring readmission were significantly more likely to have been previously under compulsory mental health treatment (95.5% vs 75.3%, p=.039) and have a Positive Behaviour Support Plan developed during admission (85.7% vs 54.8%, p=.010).

Conclusions

Interim analysis highlighted the multicomplexity for forensic PICU patients alongside the occurrence of problem behaviour during admission and history of compulsory treatment as indicators of increased risk for re-admission.

46 Promoting Advance Care Planning of Patients with Parkinsonism in the Community

Introduction

NICE guideline recommends that all patients with Parkinson’s disease should be reviewed every 6–12 months and offered opportunities to discuss Advanced Care Planning (ACP) (1, 2). There is evidence demonstrating that Advanced Care Plans results in shorter length of stay in the last year of life and lower hospital costs (2, 3). A local baseline audit showed that Advanced Care Planning was not performed adequately.

Methods

A local baseline audit on community care home patients with Parkinsonism was completed in February 2018. A community-based Parkinson’s clinic was commenced in June 2018. Patients with parkinsonism who were unable to attend hospital clinics due to underlying frailty, neuropsychiatry and physical issues, were reviewed. At each visit, advice was provided on medicines management and there were discussions around Advance Care Planning.

A re-audit was completed in August 2019. Patient’s Electronic Patient Records were scrutinised to evaluate progress and identify those who had died. Data was analysed using Microsoft Excel.

Results

The initiative contributed directly to end of life care in 7/17 patients. Parkinson’s disease medications were rationalised in 11/17 (64.70%). 14/17 (82.35%) had a community-based Do Not Resuscitate order completed.

Conclusions

The community Parkinson’s clinic service promoted Advance Care Planning in patients with Parkinsonism. This service provides specialist input in frail older people with Parkinsonism who were unable to attend hospital clinic, promoting end of life choices around where they wished to die and avoiding unnecessary hospitalisation in the final stages of their life.

EHealth Investment Appraisal in Africa: A Scoping Review

eHealth is an opportunity cost, competing for limited available funds with other health priorities such as clinics, vaccinations, medicines and even salaries. As such, it should be appraised for probable impact prior to allocation of funds. This is especially pertinent as recognition grows for the role of eHealth in attaining Universal Health Coverage. Despite optimism about eHealth’s potential role, in Africa there remain insufficient data and skills for adequate economic appraisals to select optimal investments from numerous competing initiatives. The aim of this review is to identify eHealth investment appraisal approaches and tools that have been used in African countries, describe their characteristics and make recommendations regarding African eHealth investment appraisal in the face of limited data and expertise. Methods: Literature on eHealth investment appraisals conducted in African countries and published between January 1, 2010 and June 30, 2020 was reviewed. Selected papers’ investment appraisal characteristics were assessed using the Joanna Briggs Institute checklist for economic evaluations and a newly developed Five-Case Model for Digital Health (FCM-DH) checklist for investment appraisal. 5 papers met inclusion criteria. Their assessments revealed important appraisal gaps. In particular, none of the papers addressed risk exposure, affordability, adjustment for optimism bias, clear delivery milestones, practical plans for implementation, change management or procurement, and only 1 paper described plans for building partnerships. Discussion: Using this insight, an extended 5-Case Model is proposed as the foundation of an African eHealth investment appraisal framework. This, combined with building local eHealth appraisal capabilities, may promote optimal eHealth investment decisions, strengthen implementations and improve the number and quality of related publications.

PSI-6 Effects of rest period prior to processing on vaccine response and blood metabolites in feedlot heifers

It is common for feedyards to rest cattle after transport and prior to administration of their receiving vaccinations in an attempt to minimize transport stress and optimize vaccine efficacy and subsequent growth and performance. This study aimed to test how time of rest after feedlot heifer arrival impacts vaccine titer and blood metabolites indicating cattle health. Eighty mixed-breed heifers (250 ± 4.2 kg BW) were purchased at live auction in Oklahoma City, OK and transported to the Kansas State University in Manhattan. Heifers were allotted in a completely randomized design to one of four treatments processed at 0, 6, 24, or 48 hours after arrival. At the time of processing (d 0) and again on d 35, serum samples were collected and analyzed for infectious bovine rhinotrachitis (IBR) titer, large animal chemistry panel, and hepatic profile by the Kansas State Veterinary Diagnostic Laboratory. There were time × treatment interactions (P &lt; 0.02) for serum IBR titer, glucose, urea nitrogen, and bicarbonate. Specifically, heifers had greater (P &lt; 0.05) IBR titer on d 35 than d 0, as expected because they were vaccinated upon arrival. Upon arrival, cattle held for 48 hours prior to processing had significantly greater (P &lt; 0.05) glucose than those held for 24 hours (108 vs. 68 mg/dL, respectively), with no differences in processing treatment by d 35. Urea nitrogen levels in cattle held for 6, 24, or 48 hr prior to processing were greater (P &lt; 0.05) than those held for 0 hours on d 0 or for any length of time by d 35. Finally, cattle held for 0 or 48 hr prior to processing had lower (P &lt; 0.05) bicarbonate levels on d 0 than those held for 6 or 24 hours by d 35. These data show that while initial rest may be helpful to normalize blood metabolites, cattle should be placed within 24 hours of arrival. However, most blood metabolite levels normalize within 35 days.

PSI-5 Effects of rest period prior to processing on anthelmintic response during the receiving period in feedlot heifers

A major stressor affecting feedlot cattle performance is transportation. Knowing when to process cattle and how much rest to provide prior to processing may improve cattle health and response to processing, such as anthelmintic administration. The goal of this project was to determine the impact of time of rest prior to initial processing on parasite prevalence during the receiving period. Eighty mixed-breed heifers (250±4.2 kg BW) were purchased at live auction in Oklahoma City, OK and transported to the Kansas State University Beef Cattle Research Center in Manhattan. Heifers were allotted in a completely randomized design to one of four treatments processed at 0, 6, 24, or 48 hours after arrival. At processing (d 0), fecal samples were collected, and cattle were subcutaneously injected with 1.0 ml/50 kg BW moxidectin (Cydectin®, Bayer Animal Health, Shawnee Mission, KS) and orally dosed with 1.0 mL/50 kg BW oxfendazole (Synanthic®, Boehringer Ingelheim, St. Joseph, MO). Fecal samples were collected again on d 14. Fecal samples were analyzed by the Kansas State University Veterinary Diagnostic Laboratory for qualitative and quantitative fecal float. Time of processing did not impact (P &gt; 0.05) any measured response criteria. On d 0, there was a high prevalence of fecal parasites, which was significantly reduced by d 14 (94.5% vs. 23.1% of cattle with detected fecal parasites on d 0 vs. 14, respectively). On d 0, semi-quantitative density showed the highest concentration of strongyle and eimeria parasites, which were significantly reduced (P &lt; 0.05) by d 14 (315 and 155 vs. 2 and 6.5 eggs/g of feces detected for strongyle vs. eimeria, respectively). In summary, time of rest prior to processing had no detected impact on anthelmintic response, but the dual injection/oral protocol used in this experiment was highly effective at reducing parasite levels within 2 weeks of administration.

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57 Effects of rest period prior to processing on growth and performance during the receiving period in feedlot heifers

Cattle feeders work to decrease the severity of transport stress. The objective of this experiment was to determine how the time of rest prior to processing impacts subsequent performance in feedlot heifers during the receiving period. Eighty mixed-breed heifers (250 ± 4.2 kg BW) were purchased at live auction in Oklahoma City, OK and transported to the Kansas State University Manhattan. Heifers were allotted in a completely randomized design to one of four treatments, then processed at 0, 6, 24, or 48 hours after arrival. After all cattle were processed, they were placed in individual pens, where daily DMI, refusals, and health outcomes were evaluated twice daily. Cattle were individually weighed on d 0, 14, and 35. Data were analyzed using the GLIMMIX procedure of SAS (v. 9.4, Cary, NC). Time of processing did not impact (P &gt; 0.10) heifer body weight or ADG. Overall, there was a linear inverse relationship between DMI and time at rest (P = 0.027) from d 0 to 14. The same pattern was observed overall, from d 0 to 35 (P = 0.027). Time of rest prior to processing impacted (P = 0.038) the proportion of heifers that reached a target of 2.5% DMI per BW by 14 days after arrival (25, 60, 53, and 24% of cattle with 0, 6, 24, or 48 hours of rest, respectively). While G:F and morbidity did not differ among treatments (P &gt; 0.10), mortality increased linearly (P = 0.026) with increasing time of rest. This study suggests that allowing feedlot heifers to rest after arrival for more than 24 hours before processing may negatively affect subsequent DMI, but without substantially altering body weight or ADG in calves fed in individual pens; additional research in traditional feedlot group-housed pens and environment is warranted to further evaluate these effects.

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Coronary computed tomography versus stress echocardiography-guided management of stable chest pain patients: a propensity matched analysis

Background

Recent recommendations by national and international societies advocate the use of coronary computed tomography (CCT) as the first-line test for the assessment of low-risk patients with suspected stable angina. However limited real-life data exist regarding its relative clinical value versus stress echocardiography (SE)-guided management.

Purpose

We aimed to assess in a real-life setting the clinical value of stress echocardiography (SE)-guided versus CCT-guided management in patients presenting with stable chest pain and no prior history of coronary artery disease (CAD).

Methods

We compared the relative feasibility, efficacy and the proportion of patients undergoing downstream testing including revascularisation and their impact on outcome (mortality and myocardial infarction) when CCT versus SE were used as the first line test for the assessment of stable chest pain.

Of the patients who underwent CCT (N=2192) or SE (N=2081) between October 2013 and October 2014 only those with suspected stable angina and without previous CAD were selected. The population was propensity-matched (total 1980 patients-990 patients each group) to account for differences in the baseline cardiovascular risk factors.

Results

The mean age of the population was 59±13.2 years and 949 (47.9%) patients were male. Inconclusive tests were 6% versus 3% (p&lt;0.005) in CCT versus SE. Severe (&gt;70%) luminal stenosis on CCT and inducible ischemia on SE detected obstructive CAD by invasive coronary angiography in 63% versus 57% patients (p=0.33). Over the entire follow-up period (median 717 (IQR 93–1069) days) significantly more patients underwent invasive coronary angiography (21.5% versus 7.3%, p&lt;0.005) and revascularisation (33.5% versus 3.5%, p&lt;0.005) respectively in the CCT versus the SE group. Following their initial assessment 336 (33.9%) patients in the CCT and 86 (8.7%) in the SE group underwent further functional testing (SE, stress cardiac MRI, exercise electrocardiography) (p&lt;0.005) (Figure 1A). There was no difference in all-cause mortality (p=0.26) or death and myocardial infarction (p=0.16) between the two groups (Figure 1B).

Conclusions

SE when used for the assessment of patients with stable angina and no prior CAD resulted in more conclusive tests, similar detection of obstructive CAD, less overall invasive coronary angiography and revascularization and less subsequent functional tests compared with CCT.

Figure 1

Funding Acknowledgement

Type of funding source: None

A randomised controlled feasibility trial of E-health application supported care vs usual care after exacerbation of COPD: the RESCUE trial

Exacerbations of COPD are one of the commonest causes of admission and readmission to hospital. The role of digital interventions to support self-management in improving outcomes is uncertain. We conducted an open, randomised controlled trial of a digital health platform application (app) in 41 COPD patients recruited following hospital admission with an acute exacerbation. Subjects were randomised to either receive usual care, including a written self-management plan (n = 21), or the myCOPD app (n = 20) for 90 days. The primary efficacy outcome was recovery rate of symptoms measured by COPD assessment test (CAT) score. Exacerbations, readmission, inhaler technique quality of life and patient activation (PAM) scores were also captured by a blinded team. The app was acceptable in this care setting and was used by 17 of the 20 patients with sustained use over the study period. The treatment effect on the CAT score was 4.49 (95% CI: -8.41, -0.58) points lower in the myCOPD arm. Patients' inhaler technique improved in the digital intervention arm (101 improving to 20 critical errors) compared to usual care (100 to 72 critical errors). Exacerbations tended to be less frequent in the digital arm compared to usual care; 34 vs 18 events. Hospital readmissions risk was numerically lower in the digital intervention arm: OR for readmission 0.383 (95% CI: 0.074, 1.987; n = 35). In this feasibility study of the digital self-management platform myCOPD, the app has proven acceptable to patients to use and use has improved exacerbation recovery rates, with strong signals of lower re-exacerbation and readmission rates over 90 days. myCOPD reduced the number of critical errors in inhaler technique compared to usual care with written self-management. This provides a strong basis for further exploration of the use of app interventions in the context of recently hospitalised patients with COPD and informs the potential design of a large multi-centre trial.

Nocturnal temperature-controlled laminar airflow device for adults with severe allergic asthma: the LASER RCT

BACKGROUND

Severe asthma exacerbations are costly to patients and the NHS, and occur frequently in severely allergic patients.

OBJECTIVE

To ascertain whether or not nocturnal temperature-controlled laminar airflow (TLA) device usage over 12 months can reduce severe exacerbations and improve asthma control and quality of life compared with a placebo device, while being cost-effective and acceptable to adults with severe allergic asthma.

DESIGN

A pragmatic, multicentre, randomised, double-blind, placebo-controlled, parallel-group, superiority trial with qualitative interviews. The trial included an internal pilot with qualitative focus groups.

SETTING

Fourteen hospitals in the UK that manage patients with severe asthma.

PARTICIPANTS

Adults (16-75 years) with severe, poorly controlled, exacerbation-prone asthma despite high-intensity treatment, and who are sensitised to a perennial indoor aeroallergen.

INTERVENTION

Nocturnal, home-based TLA treatment using an Airsonett^® (Airsonett AB, Ängelholm, Sweden) device. The comparator was a placebo device that was identical to the active device except that it did not deliver the laminar airflow. Participants were allocated 1 : 1 to TLA therapy or placebo, minimised by site, origin of case, baseline severe exacerbation frequency, maintenance oral corticosteroid use and pre-bronchodilator forced expiratory volume in 1 second.

MAIN OUTCOME MEASURES

Primary outcome - frequency of severe asthma exacerbations occurring within the 12-month follow-up period, defined as worsening of asthma requiring systemic corticosteroids [≥ 30 mg of prednisolone or equivalent daily (or ≥ 50% increase in dose if on maintenance dose of ≥ 30 mg of prednisolone)] for ≥ 3 days. Secondary outcomes - changes in asthma control, lung function, asthma-specific and global quality of life for participants, adherence to the intervention, device acceptability, health-care resource use and cost-effectiveness.

RESULTS

Between May 2014 and January 2016, 489 patients consented to participate in the trial, of whom 249 failed screening and 240 were randomised (n = 119 in the treatment group and n = 121 in the placebo group); all were analysed. In total, 202 participants (84%) reported use of the device for 9-12 months. Qualitative analyses showed high levels of acceptability. The mean [standard deviation (SD)] rate of severe exacerbations did not differ between groups [active 1.39 (1.57), placebo 1.48 (2.03); risk ratio 0.92, 95% CI 0.66 to 1.27; p = 0.616]. There were no significant differences in secondary outcomes for lung function, except for a reduction in mean daily peak expiratory flow [mean (SD) difference 14.7 l/minute (7.35 l/minute), 95% CI 0.32 to 29.1 l/minute; p = 0.045) for those in the active device group. There were no differences in asthma control or airway inflammation and no serious harms related to the device. No significant difference between the groups in quality-adjusted life-years gained over 1 year was observed. In addition, there was no difference in generic or disease-specific health-related quality of life overall, although statistically significant higher quality of life at month 6 was observed. Increases in quality of life were not sufficient to offset the annual costs associated with use of the TLA device.

LIMITATIONS

Missing outcome data could have resulted in an underestimation of exacerbations and rendered the study inconclusive.

CONCLUSIONS

Within the limits of the data, no consistent benefits of the active device were demonstrated, and the differences observed were not sufficient to make the device cost-effective. The types of patients who may benefit from the TLA device, and the reasons for large reductions in exacerbation frequency in severe asthma trials, which also incorporate other methods of recording exacerbations, need to be explored.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN46346208.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 29. See the NIHR Journals Library website for further project information.

Blood biomarkers for memory: toward early detection of risk for Alzheimer disease, pharmacogenomics, and repurposed drugs

Short-term memory dysfunction is a key early feature of Alzheimer's disease (AD). Psychiatric patients may be at higher risk for memory dysfunction and subsequent AD due to the negative effects of stress and depression on the brain. We carried out longitudinal within-subject studies in male and female psychiatric patients to discover blood gene expression biomarkers that track short term memory as measured by the retention measure in the Hopkins Verbal Learning Test. These biomarkers were subsequently prioritized with a convergent functional genomics approach using previous evidence in the field implicating them in AD. The top candidate biomarkers were then tested in an independent cohort for ability to predict state short-term memory, and trait future positive neuropsychological testing for cognitive impairment. The best overall evidence was for a series of new, as well as some previously known genes, which are now newly shown to have functional evidence in humans as blood biomarkers: RAB7A, NPC2, TGFB1, GAP43, ARSB, PER1, GUSB, and MAPT. Additional top blood biomarkers include GSK3B, PTGS2, APOE, BACE1, PSEN1, and TREM2, well known genes implicated in AD by previous brain and genetic studies, in humans and animal models, which serve as reassuring de facto positive controls for our whole-genome gene expression discovery approach. Biological pathway analyses implicate LXR/RXR activation, neuroinflammation, atherosclerosis signaling, and amyloid processing. Co-directionality of expression data provide new mechanistic insights that are consistent with a compensatory/scarring scenario for brain pathological changes. A majority of top biomarkers also have evidence for involvement in other psychiatric disorders, particularly stress, providing a molecular basis for clinical co-morbidity and for stress as an early precipitant/risk factor. Some of them are modulated by existing drugs, such as antidepressants, lithium and omega-3 fatty acids. Other drug and nutraceutical leads were identified through bioinformatic drug repurposing analyses (such as pioglitazone, levonorgestrel, salsolidine, ginkgolide A, and icariin). Our work contributes to the overall pathophysiological understanding of memory disorders and AD. It also opens new avenues for precision medicine- diagnostics (assement of risk) as well as early treatment (pharmacogenomically informed, personalized, and preventive).

Applicability of the five case model to African eHealth investment decisions

BACKGROUND

eHealth programmes in African countries face fierce competition for scarce resources. Such initiatives should not proceed without adequate appraisal of their probable impacts, thereby acknowledging their opportunity costs and the need for appraisals to promote optimal use of available resources. However, since there is no broadly accepted eHealth impact appraisal framework available to provide guidance, and local expertise is limited, African health ministries have difficulty completing such appraisals. The Five Case Model, used in several countries outside Africa, has the potential to function as a decision-making tool in African eHealth environments and serve as a key component of an eHealth impact model for Africa.

METHODS

This study identifies internationally recognised metrics and readily accessible data sources to assess the applicability of the model's five cases to African countries.

RESULTS

Ten metrics are identified that align with the Five Case Model's five cases, including nine component metrics and one summary metric that aggregates the nine. The metrics cover the eHealth environment, human capital and governance, technology development, and finance and economics. Fifty-four African countries are scored for each metric. Visualisation of the metric scores using spider charts reveals profiles of the countries' relative performance and provides an eHealth Investment Readiness Assessment Tool.

CONCLUSION

The utility of these comparisons to strengthen eHealth investment planning suggests that the five cases are applicable to African countries' eHealth investment decisions. The potential for the Five Case Model to have a role in an eHealth impact appraisal framework for Africa should be validated through field testing.

What can trauma patients' experiences and perspectives tell us about the perceived quality of trauma care? a qualitative study set within the UK National Health Service

The global drive for improvements in the efficiency and quality of healthcare has led to the development of frameworks to assist in defining and measuring 'good quality care'. However, such frameworks lack a systematic or meaningful definition of what 'good quality care' means from the patients' perspective. The present research provides an in-depth analysis of patients' experiences in a hospital setting from a quality of care perspective. Forty-five adults (aged 16-70) hospitalised in one of four UK NHS trusts following an unintentional injury were interviewed about their experiences of care. The findings show variability in perceived quality of care within the same hospital episode which cannot be meaningfully captured by existing frameworks. The context of trauma care (e.g. distressing nature of injury, patient vulnerability, expectations of hospitalisation and participants' interaction with different service providers) defined the care experience and the value of being 'cared for'. Participants identified some aspects of good and care which related to holistic, person-centred and personalised care beyond the medical needs. Participants discussed the value of being understood, staff thinking of their needs beyond hospitalisation, staff trying 'their best' despite constrains of current care, having their emotional needs recognised and addressed and staff competence. Patients reported also poor quality of care and 'not being cared for' by specific staff groups which they expected to fulfil this role, rushed and unsympathetic care, lack of recognition for emotional impact of injury mapped onto existing quality frameworks e.g. safety, equity, accessibility and patient-centeredness as well as quality of interaction with providers, empathetic care which extended beyond medical needs, coordination of care, and the positivity of care delivery as important dimensions of quality care with implications for their recovery. The findings have implications for quality frameworks and theoretical definitions of quality of care; they demonstrate the importance of patient experience in addition to clinical effectiveness and safety as an essential dimension of quality care. In terms of practice, the findings support the need to incorporate knowledge and training of injured adults' psychological needs, and the value of interaction with professionals as a patient defined dimension of the quality of care.

Minimal Compared With Standard Monitoring During Sofosbuvir-Based Hepatitis C Treatment: A Randomized Controlled Trial

Background

Oral direct-acting antiviral agents (DAAs) for hepatitis C virus (HCV) became government subsidized in Australia in March 2016, bringing the interferon era to a close. The ideal monitoring schedule for patients receiving DAAs is unclear.

Methods

This study is a randomized controlled trial comparing standard with minimal monitoring in adults receiving sofosbuvir-based therapy for HCV genotypes 1 or 3. Exclusion criteria were cirrhosis or predicted poor adherence. Standard monitoring included blood tests and face-to-face clinic visits at treatment weeks 4 and 12 and 12 weeks after treatment completion. Minimal monitoring included a phone call at weeks 4 and 12 and one set of blood tests plus a clinic visit 12 weeks after treatment completion. The coprimary outcomes were as follows: (1) proportion of participants with sustained virological response; (2) staff time spent on patient support; and (3) patient satisfaction on a 10-point Likert scale.

Results

Thirty-six patients were randomized to standard monitoring and 38 to minimal monitoring. Sustained virological response at 12 weeks after the end of treatment was documented in 32 of 36 (89%) in the standard versus 37 of 38 (97%) in the minimal monitoring group. Staff time was nonsignificantly longer in the standard group (median 69 [interquartile range {IQR}, 54–80] versus 52 [IQR, 40–75] minutes). Patient satisfaction scores were not different (mean 9.8 of 10 standard versus 9.6 of 10 minimal group). There was no difference in adverse events or unplanned hospital visits; mean per-patient blood test costs were higher in the standard monitoring group ($432 versus $123, P < .001).

Conclusions

On-treatment monitoring with blood tests and clinic visits may not be necessary during sofosbuvir-based HCV treatment in selected patients.

Substrate Supporting Disc Method for Confirmed Detection of Total Coliforms and E. coli in all Foods: Collaborative Study

The Coli Complete® substrate supporting disc (SSD) method for simultaneous confirmed total coliform count and Escherichia coli determination in all foods was compared with AOAC most probable number (MPN) methods, 966.23 and 966.24. Twenty-nine laboratories participated in this collaborative study in which 6 food types were analyzed. Four food types, raw ground beef, pork sausage, raw liquid milk, and nut meats, were naturally contaminated with coliform bacteria. Two foods, dry egg and fresh frozen vegetables, were seeded with coliforms. Three food types, ground beef, raw liquid milk, and pork sausage, were naturally contaminated with E. coli. Although pork sausage was naturally contaminated, the level was very low (&lt;10/50 g); therefore, additional E. coli were inoculated into 1 lot of this food type. Three food types, nut meats, dry egg, and fresh frozen vegetables, were inoculated with E. coli. For naturally contaminated samples, duplicate determinations were made on 3 separate lots for each food type. For inoculated samples, low, medium, and high contamination levels plus uninoculated control samples were examined in duplicate. Data were analyzed separately for total coliform bacteria and for E. coli. Mean log MPN counts were determined by the SSD method and the appropriate AOAC MPN method. Results were then analyzed for repeatability, reproducibility, and mean log MPN statistical equivalence. Results were statistically equivalent for all total coliform levels in all food types except frozen vegetable and raw nut meat uninoculated control samples and 1 lot of pork sausage where the SSD method produced statistically significant greater numbers. For the E. coli determinations, results were statistically equivalent across all samples and all levels for each food type. The SSD method has been adopted first action by AOAC International for confirmed detection of total coliforms and E. coli in all foods.

Electroconvulsive therapy treatment responsive multimodal brain networks

Electroconvulsive therapy is regarded as the most effective antidepressant treatment for severe and treatment‐resistant depressive episodes. Despite the efficacy of electroconvulsive therapy, the neurobiological underpinnings and mechanisms underlying electroconvulsive therapy induced antidepressant effects remain unclear. The objective of this investigation was to identify electroconvulsive therapy treatment responsive multimodal biomarkers with the 17‐item Hamilton Depression Rating Scale guided brain structure–function fusion in 118 patients with depressive episodes and 60 healthy controls. Results show that reduced fractional amplitude of low frequency fluctuations in the prefrontal cortex, insula and hippocampus, linked with increased gray matter volume in anterior cingulate, medial temporal cortex, insula, thalamus, caudate and hippocampus represent electroconvulsive therapy responsive covarying functional and structural brain networks. In addition, relative to nonresponders, responder‐specific electroconvulsive therapy related brain networks occur in frontal‐limbic network and are associated with successful therapeutic outcomes. Finally, electroconvulsive therapy responsive brain networks were unrelated to verbal declarative memory. Using a data‐driven, supervised‐learning method, we demonstrated that electroconvulsive therapy produces a remodeling of brain functional and structural covariance that was unique to antidepressant symptom response, but not linked to memory impairment.

Ovulation rates in a stair-step protocol with Letrozole vs clomiphene citrate in patients with polycystic ovarian syndrome

Purpose

To compare ovulation rates between Letrozole and Clomiphene Citrate (CC) using a stair-step protocol to achieve ovulation induction in women with Polycystic Ovarian Syndrome (PCOS).

Methods

This is a retrospective cohort of predominantly Hispanic PCOS women of reproductive age who completed ovulation induction (OI) comparing women who underwent Letrozole stair-step protocol to those who underwent OI with CC stair-step. All women had a diagnosis of PCOS based on the 2003 Rotterdam criteria. For both protocols, sequentially higher doses of Letrozole or CC were given 7 days after the last dose if no dominant follicles were seen on ultrasonography. The primary outcome was ovulation rate (determined by presence of a dominant follicle) between the two treatment groups. Secondary outcomes included time to ovulation, clinical pregnancy rates and side effects.

Results

49 PCOS patients completed a Letrozole stair-step cycle and 43 completed a CC stair-step cycle for OI. Overall, demographics were comparable between both groups. Ovulation rates with the Letrozole stair-step protocol were equivalent to CC stair-step protocol (96% vs 88%, p = 0.17). Although the mean time (days) to ovulation was shorter in the Letrozole group (19.5 vs 23.1, p = 0.027), the pregnancy rates were similar for both groups.

Conclusions

This is the first study to date that has compared the efficacy of the stair-step protocol in PCOS patients using Letrozole and CC. Both Letrozole and CC can be prescribed in a stair-step fashion. Letrozole stair-step was as efficacious as CC stair-step; patients achieved comparable rates of ovulation and clinical pregnancy. Time to ovulation was shorter in the Letrozole protocol.

BET 2: CT head in investigation of near drowning

A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have a CT head scan as part of their initial assessment. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that anyone with GCS≤4 should have a CT head as an abnormal scan at this stage heralds a very poor prognosis.

BET 1: cervical spine immobilisation in the management of drowning victims

A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have cervical spine immobilisation. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that cervical spine injuries are rare in drowning and near drowning unless there is a history of diving or a fall or signs of trauma. Cervical spine immobilisation should be reserved for cases where there is a reasonable suspicion of a spinal injury.

Preliminary prediction of individual response to electroconvulsive therapy using whole-brain functional magnetic resonance imaging data

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The negative FC networks achieve predictive accuracy of 76.23% for ECT response.

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The consensus FCs represent predominately frontal, temporal and subcortical regions.

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FCs that changed significantly were concentrated in frontal and limbic networks.

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Longitudinal change overlapped with two FCs compared with FC with predictive power.

Electroconvulsive therapy (ECT) works rapidly and has been widely used to treat depressive disorders (DEP). However, identifying biomarkers predictive of response to ECT remains a priority to individually tailor treatment and understand treatment mechanisms. This study used a connectome-based predictive modeling (CPM) approach in 122 patients with DEP to determine if pre-ECT whole-brain functional connectivity (FC) predicts depressive rating changes and remission status after ECT (47 of 122 total subjects or 38.5% of sample), and whether pre-ECT and longitudinal changes (pre/post-ECT) in regional brain network biomarkers are associated with treatment-related changes in depression ratings. Results show the networks with the best predictive performance of ECT response were negative (anti-correlated) FC networks, which predict the post-ECT depression severity (continuous measure) with a 76.23% accuracy for remission prediction. FC networks with the greatest predictive power were concentrated in the prefrontal and temporal cortices and subcortical nuclei, and include the inferior frontal (IFG), superior frontal (SFG), superior temporal (STG), inferior temporal gyri (ITG), basal ganglia (BG), and thalamus (Tha). Several of these brain regions were also identified as nodes in the FC networks that show significant change pre-/post-ECT, but these networks were not related to treatment response. This study design has limitations regarding the longitudinal design and the absence of a control group that limit the causal inference regarding mechanism of post-treatment status. Though predictive biomarkers remained below the threshold of those recommended for potential translation, the analysis methods and results demonstrate the promise and generalizability of biomarkers for advancing personalized treatment strategies.