A large outbreak of the Kappa mutation of COVID-19 in Cork, Ireland, April-May 2021

BACKGROUND

In May 2021, the B.1.617 variant of SARS-CoV-2 emerged in Ireland, and both Delta and Kappa sub-lineages were initially deemed variants of concern (VOCs) on a precautionary basis. We describe a large outbreak of SARS-CoV-2 B.1.617.1 (Kappa mutation) linked to a private gathering among third level students in Cork, Ireland.

METHODS

Surveillance data were available from the Health Service Executive COVID Care Tracker. The epidemiological sequence of infection for each new case in this outbreak was tracked and whole genome sequencing was requested on all linked cases. Enhanced public health control measures were implemented by the Department of Public Health HSE-South to contain onward spread of VOCs, including retrospective contact tracing, lengthy isolation and quarantine periods for cases and close contacts. Extensive surveillance efforts were used to describe and control onward transmission.

RESULTS

There were 146 confirmed SARS-CoV-2 cases linked to the outbreak. All sequenced cases (53/146; 36%) confirmed Kappa mutation. The median age was 21 years (range 17-65). The majority (88%) had symptoms of SARS-CoV-2 infection. There were 407 close contacts; the median was 3 per case (range 0-14). There were no known hospitalisations, ICU admissions or deaths. Vaccination data was unavailable, but the outbreak pre-dated routine availability of COVID-19 vaccines among younger adults in Ireland.

CONCLUSION

Enhanced public health control measures for new and emerging variants of SARS-CoV-2 may be burdensome for cases and close contacts. The overall public health benefit of enhanced controls may only become apparent when evidence on disease transmissibility and severity becomes more complete.

Evaluating the effects of minimum unit pricing in Scotland on the prevalence of harmful drinking: a controlled interrupted time series analysis

OBJECTIVES

In May 2018, the Scottish Government introduced a minimum unit price (MUP) for alcohol of £0.50 (1 UK unit = 8 g ethanol) to reduce alcohol consumption, particularly among people drinking at harmful levels. This study aimed to evaluate MUP's impact on the prevalence of harmful drinking among adults in Scotland.

STUDY DESIGN

This was a controlled interrupted monthly time series analysis of repeat cross-sectional data collected via 1-week drinking diaries from adult drinkers in Scotland (N = 38,674) and Northern England (N = 71,687) between January 2009 and February 2020.

METHODS

The primary outcome was the proportion of drinkers consuming at harmful levels (>50 [men] or >35 [women] units in diary week). The secondary outcomes included the proportion of drinkers consuming at hazardous (≥14-50 [men] or ≥14-35 [women] units) and moderate (<14 units) levels and measures of beverage preferences and drinking patterns. Analyses also examined the prevalence of harmful drinking in key subgroups.

RESULTS

There was no significant change in the proportion of drinkers consuming at harmful levels (β = +0.6 percentage points; 95% confidence interval [CI] = -1.1, +2.3) or moderate levels (β = +1.4 percentage points; 95% confidence interval = -1.1, +3.8) after the introduction of MUP. The proportion consuming at hazardous levels fell significantly by 3.5 percentage points (95% CI = -5.4, -1.7). There were no significant changes in other secondary outcomes or in the subgroup analyses after correction for multiple testing.

CONCLUSIONS

Introducing MUP in Scotland was not associated with reductions in the proportion of drinkers consuming at harmful levels but did reduce the prevalence of hazardous drinking. This adds to previous evidence that MUP reduced overall alcohol consumption in Scotland and consumption among those drinking above moderate levels.

161 CLEAR DISCHARGE PRESCRIBING IN STROKE PATIENTS: A RETROSPECTIVE AUDIT OF DUAL ANTIPLATELET DURATION AT FIRST FOLLOW-UP APPOINTMENT

Background

The risk of further ischaemic events post stroke and TIA is high in the following weeks. Short term treatment with Dual Anti-Platelet Therapy (DAPT) in appropriate patients has been shown to decrease the incidence of recurrent ischaemic events. However continuing DAPT longer than six weeks increases the risk of haemorrhagic complications.

Methods

Retrospective analysis of patients admitted to the Acute Stroke Unit over 4 months in a tertiary referral centre, reviewing discharge summaries and follow-up Outpatient Department (OPD) clinic letters on the online hospital computer system.

Results

We analysed data from 205 patients. 57 patients were discharged on DAPT. Of those, 18(31.6%) did not have a recommended duration of DAPT documented in their discharge summary. 40 patients returned to OPD for review, 16 patients had no documented follow-up, 11 were repatriated to a referring hospital for follow-up locally. The average time of OPD review was 4 months post discharge. Of those 40 patients who attended OPD follow up appointment, 33(82.5%) had documented evidence of a medication review in clinic. 9 of those patients (27.3%) were still inappropriately on DAPT, 5 of whom (55.6%) had no DAPT duration instructions documented in the discharge summary.

Conclusion

Treatment with DAPT puts patients at risk of haemorrhagic complications with longer term use. Clear documentation of treatment duration and communication with the patient and the patient’s GP is vital to ensure medication errors and unnecessary complications for the patient are avoided. Intervention: Following these results, we organised an education session for the Stroke Department staff and re-designed the stroke discharge summary template to highlight instructions on DAPT duration. We also emphasised the importance of communication with the patient’s GP and medication counselling with patients.

Associations between DAPT score and long-term mortality post PCI

Introduction

The dual antiplatelet therapy (DAPT) score was developed to identify patients more likely to derive benefit (score ≥2) or harm (score &lt;2) from DAPT beyond 1-year post PCI. There is no study which looked at the DAPT score and long term outcomes post PCI in Australia.

Purpose

We sought to examine long-term mortality after PCI by the DAPT score in patients treated with DAPT per local guidelines.

Methods

We examined data from the MIG PCI database from 2005 to 2018 in whom the DAPT score could be derived and grouped them as score ≥2 or &lt;2. Long-term mortality was assessed from National Death Index linkage. The primary endpoint was long-term mortality examined using survival analysis. Secondary endpoints included 30-day ischaemic outcomes and in-hospital major bleeding.

Results

Out of 27,740 patients in the study, 9,401 (33.9%) had DAPT score ≥2. They were younger and included more females and higher prevalence of renal impairment. DAPT score ≥2 patients had higher in-hospital major bleeding, 30-day mortality, MI and target vessel revascularisation. DAPT score ≥2 patients had lower long-term survival to 12 years (p&lt;0.001 for all).

Conclusion

A third of all-comer PCI patients had DAPT score ≥2 with greater short-term risk of ischaemic and bleeding outcomes, as well as long-term mortality. Theoretically, those with DAPT score ≥2 would benefit from longer duration of DAPT as ischaemic risk outweighs bleeding risk. However, given our finding of increased short-term bleeding risk and long-term mortality, dynamic bleeding risk assessment should be undertaken to guide pharmacotherapy strategies.

Funding Acknowledgement

Type of funding sources: None.

Functional connectivity of the world's protected areas

Global policies call for connecting protected areas (PAs) to conserve the flow of animals and genes across changing landscapes, yet whether global PA networks currently support animal movement-and where connectivity conservation is most critical-remain largely unknown. In this study, we map the functional connectivity of the world's terrestrial PAs and quantify national PA connectivity through the lens of moving mammals. We find that mitigating the human footprint may improve connectivity more than adding new PAs, although both strategies together maximize benefits. The most globally important areas of concentrated mammal movement remain unprotected, with 71% of these overlapping with global biodiversity priority areas and 6% occurring on land with moderate to high human modification. Conservation and restoration of critical connectivity areas could safeguard PA connectivity while supporting other global conservation priorities.

Covid-19 Epidemic Impact on Clinical Training in Irish GP Training

Aim To describe the effect of the Covid pandemic on the general practice workplace based learning of GP training in Ireland. Methods A prospective national survey of GP trainees who were in their GP practice placements on three separate occasions throughout the winter pandemic of 2020/2021 Results The average response rate to the three surveys was 19.4%. As the pandemic worsened, the number of face to face consultations dropped so that 51% (n=41) of trainees were seeing less than 5 patients face to face by the third survey. Conversely, the number of telephone/video consultations rose so that by the third survey 54% (n=44) of trainees were conducting more than 16 consultations per day remotely. Examinations and GP presentations expected to be daily occurrences diminished as the pandemic grew more severe, such that by the third survey 24-25% of trainees had not conducted a respiratory examination or dealt with new/unexpected hypertension in the previous month. Conclusion This study demonstrates abrupt change to the normal course of their training which was experienced by Irish GP trainees as a result of Covid, with examples from clinical practice. Adaptions of the training programme helped mitigate against the effects of the pandemic.

Clinical risk prediction model for 30-day all-cause re-hospitalisation or mortality in patients hospitalised with heart failure

BACKGROUND

This study aimed to develop a risk prediction model (AUS-HF model) for 30-day all-cause re-hospitalisation or death among patients admitted with acute heart failure (HF) to inform follow-up after hospitalisation. The model uses routinely collected measures at point of care.

METHODS

We analyzed pooled individual-level data from two cohort studies on acute HF patients followed for 30-days after discharge in 17 hospitals in Victoria, Australia (2014-2017). A set of 58 candidate predictors, commonly recorded in electronic medical records (EMR) including demographic, medical and social measures were considered. We used backward stepwise selection and LASSO for model development, bootstrap for internal validation, C-statistic for discrimination, and calibration slopes and plots for model calibration.

RESULTS

The analysis included 1380 patients, 42.1% female, median age 78.7 years (interquartile range = 16.2), 60.0% experienced previous hospitalisation for HF and 333 (24.1%) were re-hospitalised or died within 30 days post-discharge. The final risk model included 10 variables (admission: eGFR, and prescription of anticoagulants and thiazide diuretics; discharge: length of stay>3 days, systolic BP, heart rate, sodium level (<135 mmol/L), >10 prescribed medications, prescription of angiotensin converting enzyme inhibitors or angiotensin receptor blockers, and anticoagulants prescription. The discrimination of the model was moderate (C-statistic = 0.684, 95%CI 0.653, 0.716; optimism estimate = 0.062) with good calibration.

CONCLUSIONS

The AUS-HF model incorporating routinely collected point-of-care data from EMRs enables real-time risk estimation and can be easily implemented by clinicians. It can predict with moderate accuracy risk of 30-day hospitalisation or mortality and inform decisions around the intensity of follow-up after hospital discharge.

Outcomes after percutaneous coronary intervention (PCI) in patients with prior coronary artery bypass grafting (cabg)

Background

In patients with prior CABG requiring subsequent PCI there is uncertainty whether bypass grafts or native coronary arteries should be targeted.

Methods

We analysed data from 2,764 patients with prior CABG in the Melbourne Interventional Group registry (2005–2018), divided into two groups: those undergoing PCI to a native vessel (n=1,928) and those with PCI to a graft vessel (n=836).

Results

Patients with a graft vessel PCI were older, had more high-risk clinical characteristics (prior MI, heart failure, ejection fraction &lt;50%, renal impairment, peripheral and cerebrovascular disease), and high-risk procedural features (ACC/AHA types B2/C lesions). However, patients in the native vessel group were more likely to have PCI to a chronic total occlusion. The majority of graft PCI were to saphenous vein grafts (84%), with 10% to radial and 6% to LIMA/RIMA grafts. Distal embolic protection devices were used in 30% of graft PCI. Patients with graft PCI had higher rates of no reflow (6.3% vs. 1.5%; p&lt;0.001), coronary perforation (p=0.016) and inpatient stent thrombosis (p=0.028). However, 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCE) were similar. Unadjusted long-term mortality (median follow up 4.8 years) was higher in patients who had undergone a graft PCI (44% vs. 32%, p&lt;0.001), but following Cox proportional hazards modelling, PCI vessel type was not a predictor of long-term mortality (HR 1.13; 95% CI 0.96–1.33, p=0.14).

Conclusions

Early clinical outcomes and risk-adjusted long-term mortality are similar for patients with prior CABG undergoing PCI to a native vessel or a bypass graft.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Alfred Hospital

Sex differences in pre-hospital analgesia and outcomes in patients presenting with acute coronary syndromes

Background

Opioid analgesia remains the mainstay of pain management in acute coronary syndromes (ACS). Significant sex differences persist in ACS presentation, management and outcomes, but the impact of sex-differences on pre-hospital pain management of ACS with opioids is unknown. There is increasing awareness of the importance of pre-hospital factors in ACS, as well as emerging concerns with opioid use impairing the gastrointestinal absorption of oral P2Y12 inhibitors.

Purpose

This study examined if sex-differences in pre-hospital pain scores, opioid administration and clinical outcomes exist in ACS patients.

Methods

Patients presenting with ACS via ambulance (2014–2018) that underwent percutaneous coronary intervention (PCI) were prospectively collected via the Victorian Cardiac Outcomes Registry (VCOR), the Melbourne Interventional Group (MIG), and linked to the Ambulance Victoria database. The primary outcome was 30-day major adverse cardiac events (MACE). Secondary outcomes were descriptive analyses of pre-hospital pain score, intravenous morphine equivalent analgesic dosing, plus predictors of MACE and Thrombolysis In Myocardial Infarction (TIMI) 0–1 flow pre-PCI using logistic regression.

Results

10,547 patients were included (female: 2,775 [26.3%]). Opioids were administered to 1,585 (57%) females and 5,068 (65%) males (p&lt;0.001). Adjusted 30-day MACE was similar between opioid groups in both sexes (female: OR 1.21, CI 0.82–1.79, p=0.34; male: OR 0.89, 0.68–1.16, p=0.40). Median pain score at presentation was 6 (IQR 4,8) for both sexes. Median opioid dose was 2.5 mg (IQR 0,10) in females and 5 mg (IQR 0,10) in males (p&lt;0.001), with similar pain relief achieved. Adjusted rates of TIMI 0–1 pre-PCI were higher in patients administered opioids (female: OR 2.83, CI 2.14–3.56, p&lt;0.001; male: OR 2.95, CI 2.49–3.49, p&lt;0.001).

Conclusions

Female patients undergoing PCI received less opioid analgesia, but no sex-differences in pre-hospital pain scores were seen. Opioid administration was associated with impaired antegrade flow in the culprit artery in both sexes, but not short-term MACE. Randomised trials evaluating the clinical implications of opioid administration in ACS with sex subgroup analyses are needed to guide clinical practice.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne Interventional GroupVictorian Cardiac Outcomes Registry

Trends in intra-aortic balloon pump use in cardiogenic shock in the post-SHOCK II trial era

Background

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit.

Purpose

This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use.

Methods

Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression.

Results

Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction (&lt;35%; 18% vs. 11%), and pre-procedural inotrope use (81% vs. 73%), all p&lt;0.05. IABP use was associated with higher inpatient bleeding (18% vs. 13%) and 30-day MACCE (58% vs. 51%), both p&lt;0.05. The rate of MI-CS increased over time, but after 2012 there was a decline in IABP use (Figure 1). IABP use was a predictor of 30-day MACCE (OR 1.6, 95% CI 1.18–2.29, p=0.003). However, IABP was not associated with in-hospital, 30-day or long-term mortality (45% vs. 47%, p=0.44; 46% vs. 50%, p=0.25; 60% vs. 62%, p=0.39).

Conclusions

Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

POS0734 EXTRAPOLATION OF LONG-TERM OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS: REPLICATING A HOPKINS LUPUS COHORT ANALYSIS WITH THE SYSTEMIC LUPUS INTERNATIONAL COLLABORATING CLINICS (SLICC) INCEPTION COHORT

Background:

A disease model of systemic lupus erythematosus (SLE) that predicts short-term outcomes (disease activity and prednisone use) and links them to long-term outcomes (accrual of organ damage and mortality) was previously developed in a single center SLE cohort (Johns Hopkins [JH]) to support health economic analyses (Watson 2015), which has not been comprehensively replicated in other cohorts or contexts.

Objectives:

As part of an effort to develop and refine this existing disease model, the aim of this study was to replicate the previously estimated network of risk equations for short- and long-term outcomes in the SLICC Inception Cohort, an international cohort of patients (33 centers,11 countries).

Methods:

The SLICC Inception Cohort enrolled patients fulfilling ACR Classification Criteria for SLE within 15 months of diagnosis from 1999-2011 with annual follow-up through April 2020. The network of risk equations included two linear random effects models to predict (1) change in annual average Systemic Lupus Disease Activity Index (SLEDAI) score based on patient characteristics and the presence of renal, hematological, and immunological involvement in the prior year and (2) average annual prednisone dose based on SLEDAI score in the same year. These equations were then linked to parametric survival models that predicted time to the occurrence of organ damage (system-specific based on the ACR/SLICC Damage Index) and mortality. We compared model performance between the SLICC Cohort and the original analysis from the JH Cohort.

Results:

In comparison to the JH cohort (N=1354), the SLICC cohort (N=1697) had a smaller fraction of patients of African descent (39% vs 17%) and shorter disease duration at entry (4.8 vs 0.5 years). In the first equation predicting change in annual SLEDAI score, predictors were generally aligned with the same direction and significance, with the exception of renal involvement in the prior period, which had a positive association with change in SLEDAI in the SLICC cohort but was negatively associated in the JH cohort (Table 1). The second equation predicting prednisone dose was also consistent with the original analysis showing a significant positive association between higher disease activity and prednisone use. In all of the parametric survival analyses (individual organ damage and mortality models), coefficients were generally in the same direction and magnitude, though some were no longer significant in the SLICC cohort.

Conclusion:

The relationships identified in the original analysis were broadly replicated in the SLICC Inception Cohort. Observed differences may reflect differences in the patient populations, structure of the two cohorts (prevalent vs inception), and frequency of visits (quarterly visits in the JH cohort vs annual visits with the SLICC cohort may more closely capture a decrease in SLEDAI associated with treatment specifically related to renal involvement). Additional analyses relaxing the requirement to completely align with the original structure are underway to further assess the predictive accuracy of these models.

References:

[1]Watson P, et al. Rheumatology (Oxford). 2015;54(4):623-32.

JH Cohort(N=1354)SLICC Cohort(N=1697)Female, %92.988.8African descent, %38.816.7Disease duration at entry, mean (SD), years4.8 (6.3)0.5 (0.3)SLEDAI at first visit, mean (SD)3.7 (4.1)5.4 (5.4)Change in average annual SLEDAICoefficientCoefficientConstant1.491*5.762*Annual average SLEDAI in prior period−0.460*−0.755*Male gender−0.080−0.207Log transformation of age−0.241*−1.134*Renal involvement in prior period−0.301*0.627*African descent0.383*0.126Increased DNA binding in prior period0.276*0.939*Low complement in prior period0.484*0.775*Hematological involvement in prior period0.104−0.025Anemia in prior period0.152**0.144Associated annual average prednisone dose (mg/day)Constant3.475*2.738*SLEDAI in same period0.777*0.648*

*p<0.001; **p<0.05

Acknowledgements:

We acknowledge the support on this abstract of the following investigators of the Systemic Lupus International Collaborating Clinics:

John Hanly - john.hanly@nshealth.ca

Caroline Gordon - p.c.gordon@bham.ac.uk

Sang-Cheol Bae - scbae@hanyang.ac.kr

Juanita Romero-Diaz - juanita.romerodiaz@gmail.com

Jorge Sanchez-Guerrero - jorge.sanchez-guerrero@uhn.ca

Sasha Bernatsky - sasha.bernatsky@mcgill.ca

Ann Clarke - aeclarke@ucalgary.ca

Daniel Wallace - dwallace@ucla.edu/danielwallac@gmail.com

David Isenberg - d.isenberg@ucl.ac.uk

Anisur Rahman - anisur.rahman@ucl.ac.uk

Joan Merril - JTMmail@aol.com

Paul Fortin - paul.fortin@crchudequebec.ulaval.ca

Dafna Gladman - dafna.gladman@utoronto.ca

Murray Urowitz - m.urowitz@utoronto.ca

Ian Bruce - ian.bruce@manchester.ac.uk

Michelle Petri - mpetri@jhmi.edu

Ellen Ginzler - ellen.ginzler@downstate.edu

MA Dooley - Mary_Dooley@med.unc.edu

Rosalind Ramsey-Godman - rgramsey@northwestern.edu

Susan Manzi - susan.manzi@ahn.org; Susanmanzi@gmail.com

Andreas Jonsen - andreas.jonsen@med.lu.se

Graciela Alarcon - galarcon@uab.edu

Ronald van Vollenhoven - r.vanvollenhoven@amsterdamumc.nl

Cynthia Aranow - CAranow@Northwell.edu

Meggan Mackay – mmackay@northwell.edu

Guillermo Ruiz-Irastorza - r.irastorza@outlook.es

Sam Lim - sslim@emory.edu

Murat Inanc - drinanc@istanbul.edu.tr; minanc2008@gmail.com

Kenneth Kalunian - kkalunian@ucsd.edu

Soren Jacobsen - sj@dadlnet.dk

Christine Peschken - christine.peschken@umanitoba.ca

Diane Kamen - kamend@musc.edu

Anca Askanase - ada20@columbia.edu

Disclosure of Interests:

Ann E Clarke Consultant of: BMS, AstraZeneca, GSK, and Exagen Diagnostics., Yvan St-Pierre: None declared, Victoria Paly: None declared, Ian N. Bruce Speakers bureau: GSK, UCB, Consultant of: BMS, Eli Lilly, GSK, Astra Zeneca, Merck Serono; UCB, ILTOO, Aurinia, Grant/research support from: Genzyme/Sanofi, GSK, Roche, UCB, Chiara Malmberg: None declared, Andrew Briggs Speakers bureau: Alexion, AstraZeneca, Bayer, BMS, Daiichi Sankyo, Eisai, Gilead, GSK, Kite, Merck, Novartis, Rhythm, Roche, Sanofi, Takeda, Consultant of: Alexion, AstraZeneca, Bayer, BMS, Daiichi Sankyo, Eisai, Gilead, GSK, Kite, Merck, Novartis, Rhythm, Roche, Sanofi, Takeda, Yuanhui Zhang Shareholder of: Bristol Myers Squibb., Employee of: Bristol Myers Squibb., Jiyoon Choi Shareholder of: JNJ., Employee of: BMS, Alan Brennan Consultant of: Alan Brennan is a paid consultant on advisory boards regarding cost-effectiveness modelling., Grant/research support from: Alan Brennan received research grants.

Extrapolating In Vitro Screening Assay Data for Thyroperoxidase Inhibition to Predict Serum Thyroid Hormones in the Rat

Thyroperoxidase (TPO) is an enzyme essential for thyroid hormone (TH) synthesis and a target site for a number of xenobiotics that disrupt TH homeostasis. An in vitro high-throughput screening assay for TPO inhibition, the Amplex UltraRed-TPO (AUR-TPO), has been used to screen the ToxCast chemical libraries for this action. Output from this assay would be most useful if it could be readily translated into an in vivo response, namely a reduction of TH in serum. To this end, the relationship between TPO inhibition in vitro and serum TH decreases was examined in rats exposed to 2 classic TPO inhibitors, propylthiouracil (PTU) and methimazole (MMI). Serum and gland PTU, MMI, and TH levels were quantified using tandem liquid chromatography mass spectrometry. Thyroperoxidase activity was determined in thyroid gland microsomes treated with PTU or MMI in vitro and ex vivo from thyroid gland microsomes prepared from exposed animals. A quantitative model was constructed by contrasting in vitro and ex vivo AUR-TPO results and the in vivo time-course and dose-response analysis. In vitro:ex vivo correlations of AUR-TPO outputs indicated that less than 30% inhibition of TPO in vitro was sufficient to reduce serum T4 by 20%, a degree of regulatory significance. Although further testing of model estimates using other TPO inhibitors is essential for verification of these initial findings, the results of this study provide a means to translate in vitro screening assay results into predictions of in vivo serum T4 changes to inform risk assessment.

Multiple deprivation and geographic distance to community physical activity events - achieving equitable access to parkrun in England

Objectives

To evaluate geographic access to free weekly outdoor physical activity events (‘parkrun’) in England, with a particular focus on deprived communities, and to identify optimal locations for future events to further maximise access.

Study design

This study is a cross-sectional ecological analysis of the socio-economic disparities in geographic access to parkrun events in England in late 2018.

Methods

We combined geolocation data on all English Lower Layer Super Output Areas and parkrun events to calculate geodesic distances to the nearest event for more than 32,000 communities in England. We use this measure of geographic access to summarise the relationship between access and socio-economic deprivation, measured using the index of multiple deprivation. We then used geographic coordinates of public green spaces in England to conduct a simple location-allocation analysis to identify 200 locations for future event locations that would maximise access.

Results

In England, 69% of the population live within 5 km of one of the 465 parkrun events. There is a small negative correlation between distance and deprivation, indicating that access is slightly better in more socio-economically deprived areas. Setting up an additional 200 events in optimal locations would improve access: the average distance to the nearest parkrun event would improve by 1.22 km, from 4.65 km to 3.43 km, and approximately 82% of the English population would live within 5 km of a parkrun event.

Conclusion

Over two-thirds of the English population live within 5 km of a parkrun event, and contrary to our expectation, we find that geographic access is slightly better for those living in more deprived communities. Creating additional events may improve geographic access, but effective strategies will still be needed to increase engagement in new and existing events by those living in socio-economically deprived areas.

•

Parkrun in a grass-roots movement that organises free weekly 5 km running and walking events.

•

In England, the median distance to the nearest parkrun event was 3.4 km; 69% of the population lived within 5 km of an event.

•

Access showed no negative socio-economic gradient. In fact, people in deprived communities had better geographic access.

•

Sport England provided funding to set up 200 new events. We identified optimal locations, to further maximise public access.

Incidence, causes and predictors of unplanned hospital readmission after percutaneous coronary intervention

Background

Unplanned hospital readmissions post-percutaneous coronary intervention (PCI) result in a significant burden to the healthcare system and adverse patient outcomes. Understanding factors associated with 30-day readmission rates may help to reduce this burden. Data linkage of clinical quality registry data with routinely collected administrative datasets may assist in overcoming resource constraints that limit collection of follow-up data but is currently under-utilised worldwide.

Objective

To determine the incidence of, and factors associated with unplanned hospital readmissions in the first 30 days following PCI.

Methods

We prospectively collected data on 28,488 patients undergoing PCI between January 2013 and December 2018, who were enrolled in a multi-centre PCI registry. Data linkage to government administrative datasets was used to determine whether patients had an unplanned readmission within 30 days of PCI, the number of admissions prior to PCI and primary reason for readmission (as recorded by the International Classification of Diseases, 10th revision, Australian modification (ICD-10-AM) diagnosis codes). Patients were then divided into 3 groups: those who had 1 or more unplanned readmissions for primarily cardiac issues, those who those who had 1 or more unplanned readmissions for primarily non-cardiac issues, and those who were not readmitted, and compared for baseline, procedural and in-hospital care characteristics.

Results

In total, 3,059 patients (10.7%) had an unplanned hospital readmission within 30 days of PCI, of which, 1,848 patients (60.4%) were readmitted for primarily cardiac diagnoses. Independent predictors of both 30-day cardiac and non-cardiac readmissions were female sex, having &gt;1 admission in the 12 months prior to PCI, acute coronary syndrome presentation, having any in-hospital complication and being discharged on an oral anticoagulant (all p&lt;0.05). A stepwise increase in readmission risk was observed with increasing number of admissions from 1 to &gt;4 admissions in the 12 months prior to PCI. Presentation with cardiogenic shock (p=0.04), having an unsuccessful PCI (p=0.02) and left ventricular systolic dysfunction (p=0.02) were independent predictors of cardiac readmissions but not non-cardiac readmissions. Conversely, age &gt;60 years (p&lt;0.001) and history of diabetes mellitus (p=0.02) were found to be independent predictors of non-cardiac readmissions only.

Conclusion

Thirty-day unplanned hospital readmissions after PCI pose a significant burden to the health system. Most readmissions are primarily due to cardiac diagnoses. The most important predictive factor for both cardiac and non-cardiac readmissions appears to be the number of hospital admissions in the 12 months prior to PCI. This is valuable information for health administrators as treatment and discharge policies, and outpatient follow-up timetables may need to be tailored to patients at high risk for readmission following PCI.

Causes of readmission post-PCI

Funding Acknowledgement

Type of funding source: None

Long-term outcomes following percutaneous coronary intervention for patients with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Despite this, data regarding long-term outcomes following percutaneous coronary intervention (PCI) are limited.

Methods

We identified 756 patients with RA from the Melbourne Interventional Group PCI registry (2005–2018) and compared outcomes to the remaining cohort (N=38,579). Cox regression analysis was performed to assess risk of adverse cardiac events including long-term mortality (derived from linkage with the National Death Index [NDI]).

Results

Patients with RA were older (68.9±10.0 vs. 64.6±12.0 years) and more often female (40% vs. 23%), with higher rates of hypertension (70% vs 67%), previous stroke (9% vs 6%), peripheral vascular disease (9% vs 6%), obstructive sleep apnoea (10% vs 5%), chronic lung disease (22% vs 12%), prior myocardial infarction (32% vs 27%), and impaired renal function (eGFR&lt;60 ml/min/1.73m2 in 31% vs 24%), while rates of current smoking were lower (20% vs. 25%), all p&lt;0.05. Lesions were more frequently complex (ACC/AHA type B2/C in 61% vs 57%), required longer stents (&gt;20mm in 39% vs 35%), and rates of no reflow were higher (5% vs 3%), all p&lt;0.05. 30-day mortality was higher (4.4% vs. 3.3%, p=0.04) mainly owing to higher non-cardiac mortality (1.6% vs. 0.8%, p=0.01). National Death Index-linked long-term mortality was 28% vs. 19% (p&lt;0.01) with mean follow-up 4.6 vs. 5.4 years. Risk of 30-day and long-term mortality (including by indication subgroup) are presented in the Table.

Conclusions

Patients with RA undergoing PCI have more comorbidities and longer, more complex coronary lesions. After adjustment, risk of short-term adverse outcomes are similar, while risk of long-term mortality is higher, particularly among patients with acute coronary syndromes.

Funding Acknowledgement

Type of funding source: None

Sex differences in pharmacotherapy and long-term outcomes in patients with ischaemic heart disease and left ventricular dysfunction

Background

Left ventricular dysfunction and ischaemic heart disease are common amongst women, however, women tend to present later and are less likely to receive guideline-directed medical therapy compared to their male counterparts.

Purpose

To investigate if a sex discrepancy exists for optimal medical therapy (OMT) and long-term mortality in a cohort of patients with known ischaemic heart disease (IHD) and left ventricular dysfunction.

Methods

We analysed prospectively collected data from a multicentre registry database collected between 2005–2018 on pharmacotherapy 30-days post percutaneous coronary intervention (PCI) in 13,015 patients with left ventricular ejection fraction (LVEF) &lt;50%. OMT at 30-days was defined as beta-blocker (BB), angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB) ± mineralocorticoid receptor antagonist (MRA). Long-term mortality was determined by linkage with the National Death Index, with median follow up of 4.7 (IQR 2.0–8.6) years.

Results

Mean age was 65±12 years; women represented 20.2% (2,634) of the cohort. Women were on average 5 years older, had higher average BMI, higher rates of hypertension, diabetes, renal dysfunction, prior stroke and rheumatoid arthritis. Men were more likely to have sleep apnoea, be current/ex-smokers and to have had prior myocardial infarction, PCI and bypass surgery. Overall, 72.3% (9,411) of patients were on OMT, which was similar between sexes (72.7% in women vs. 72.2% in men, p=0.58). Rates of BB therapy were similar between sexes (85.2% vs. 84.5%, p=0.38), while women were less likely to be on an ACEi/ARB (80.4% vs. 82.4%, p=0.02) and more likely to be on a MRA (12.1% vs. 10.0%, p=0.003). Amongst those with LVEF ≤35% (n=1,652), BB (88.7% vs. 87.3%, p=0.46), ACEi/ARB (83.3% vs. 82.1%, p=0.59) and MRA use (32.5% vs. 33.3%, p=0.78) was comparable. Aspirin use was similar between sexes (95.3% vs. 95.9%, p=0.12), while women were less likely to be on statin therapy (93.5% vs. 95.3%, p&lt;0.001) and a second antiplatelet agent (94.4% vs. 95.6%, p=0.007). On unadjusted analysis women had significantly higher long-term mortality of 25.4% compared to 19.0% for men (p&lt;0.001). Kaplan-Meier analysis out to 14 years demonstrated that men on OMT have the best long-term survival overall and women on sub-OMT have significantly poorer outcomes compared to men on sub-OMT. However, after adjusting for OMT and other comorbidities there was no difference in long-term mortality between sexes (HR 0.99, 95% CI 0.87–1.14, p=0.94).

Conclusion

From this large multicentre registry, we found similar rates of guideline-directed pharmacotherapy for left ventricular dysfunction between sexes, however women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality amongst women is likely due to differing baseline risk, given that adjusted mortality was similar between sexes.

Kaplan-Meier Survival Analysis

Funding Acknowledgement

Type of funding source: None

Systematic review and meta-analysis of randomized controlled trials of psychological interventions to improve glycaemic control in children and adults with type 1 diabetes

AIM

We conducted a systematic review aggregate and network meta-analysis of psychological interventions for people with type 1 diabetes to assess their effectiveness in improving glycaemic levels.

METHODS

We searched the following databases from 1 January 2003 to 1 July 2018: MEDLINE, CINAHL, PsycINFO, Embase, Cochrane Controlled Trials, Web of Science, clinicaltrials.gov, Dissertation Abstract International. We included randomized controlled trials (RCT) of psychological interventions for children and adults with type 1 diabetes reported in any language. We extracted data on publications, participant characteristics at baseline, intervention and control group, and data for the primary outcome, change in glycaemic control [HbA_1c (mmol/mol/%)]. Study authors were contacted for missing data. The review was registered with international prospective register of systematic reviews registration (PROSPERO) CRD42016033619.

RESULTS

Twenty-four adult RCTs and 23 of children with type 1 diabetes were included in the systematic review. In aggregate meta-analysis there was no overall effect of psychological intervention compared with control on HbA_1c [adults, nine RCTs, n = 1102, pooled mean difference -0.12, 95% confidence intervals (CI) -0.27 to 0.03, I² = 29.0%, P = 0.19; children, 20 RCTs, n = 2567, -0.09, 95% CI -0.22 to 0.04, I² =54.0% P=0.002]. Network meta-analysis suggested that probability and rank-ordering of effectiveness is highest for attention control groups (b = -0.47, 95% CI -0.80 to -0.12) followed by cognitive behavioural therapy (CBT) (-0.26, 95% CI -0.45 to -0.06) compared with usual care for adults.

CONCLUSIONS

Overall psychological interventions for children and adults with type 1 diabetes do not improve glycaemic control. For adults, CBT-based interventions have the potential to be effective.