Impact of "early intervention" parent workshops on outcomes for caregivers of children with neurodisabilities: a mixed-methods study

PURPOSE

This study explored the feasibility, impact and parent experiences of ENVISAGE (ENabling VISions And Growing Expectations)-Families, a parent-researcher co-designed and co-led program for parents/caregivers raising children with early-onset neurodisabilities.

METHODS

Parents/caregivers of a child with a neurodisability aged ≤6 years, recruited in Australia and Canada, participated in five weekly online workshops with other parents. Self-report measures were collected at baseline, immediately after, and 3 months post-ENVISAGE-Families; interviews were done following program completion. Quantitative data were analyzed with generalized estimating equations and qualitative data using interpretive description methodology.

RESULTS

Sixty-five parents (86% mothers) were recruited and 60 (92%) completed the program. Strong evidence was found of effects on family empowerment and parent confidence (all p ≤ 0.05 after the program and maintained at 3-month follow-up). The ENVISAGE-Families program was relevant to parents' needs for: information, connection, support, wellbeing, and preparing for the future. Participants experienced opportunities to reflect on and/or validate their perspectives of disability and development, and how these perspectives related to themselves, their children and family, and their service providers.

CONCLUSIONS

ENVISAGE was feasible and acceptable for parent/caregivers. The program inspired parents to think, feel and do things differently with their child, family and the people who work with them.Implications for rehabilitationENVISAGE (ENabling VISions And Growing Expectations)-Families is a co-designed, validated parent/researcher "early intervention and orientation" program for caregivers raising a child with neurodevelopmental disabilities (NDDs).ENVISAGE-Families empowered parents' strengths-based approaches to their child, family, disability, and parenting.ENVISAGE-Families increased caregivers' confidence in parenting children with NDD's and provided them tools to support connection, collaboration, and wellbeing.Raising children with NDD can have a profound impact on caregivers, who can benefit from strengths-based, future focused supports early in their parenting experience.

Biomarkers of endothelial activation and inflammation in dogs with organ dysfunction secondary to sepsis

Introduction

Alteration in endothelial function during sepsis is thought to play a key role in the progression of organ failure. We herein compared plasma concentrations of endothelial activation biomarkers vascular endothelial growth factor (VEGF), hyaluronan (HA), plasminogen activator inhibitor-1 (PAI-1) and von Willebrand factor (vWF), as well as inflammatory mediator concentrations (IL-6, IL-8, IL-10, C-reactive protein and monocyte chemoattractant protein-1) in dogs with sepsis to healthy dogs.

Methods

This study was a multicenter observational clinical trial conducted at two university teaching hospitals from February 2016 until July 2017. The study included 18 client-owned dogs hospitalized with sepsis and at least one distant organ dysfunction, as well as 20 healthy dogs. Plasma biomarker concentrations were measured using ELISA. Severity of illness in dogs with sepsis was calculated using the 5-variable acute physiologic and laboratory evaluation (APPLEFAST) score. Biomarker concentrations were compared between septic and healthy dogs using linear models.

Results

Septic peritonitis was the most frequent source of sepsis (11/18; 61%), followed by pneumonia (4/18; 22%). Ten dogs (56%) had only 1 organ dysfunction, whereas 3 dogs (17%) had 2, 3 (17%) had 3, 1 (6%) had 4 and 1 (6%) had 5 organ dysfunctions. The median APPLEFAST score in the septic dogs was 28.5 (Q1-Q3, 24-31). Mean plasma concentrations of all endothelial and inflammatory biomarkers, except vWF, were higher in the sepsis cohort than in controls. The mean endothelial biomarker concentrations in the septic cohort ranged from ~2.7-fold higher for HA (difference in means; 118.2 ng/mL, 95% credible limit; 44.5-221.7) to ~150-fold for VEGF (difference in means; 76.6 pg./mL, 95% credible limit; 33.0-143.4), compared to the healthy cohort. Fifteen dogs with sepsis (83%) died; 7 (46%) were euthanized and 8 (53%) died during hospitalization.

Conclusion

Dogs with naturally occurring sepsis and organ dysfunction had higher mean concentrations of biomarkers of endothelial activation and inflammation compared to healthy dogs, broadening our understanding of the pathophysiology of sepsis secondary to endothelial dysfunction.

Emergency versus semi-elective management of mandible fractures: a Maxillofacial Trainee Research Collaborative (MTReC) study

INTRODUCTION

Recent evidence suggests that acute emergency management of mandible fractures does not improve surgical outcomes yet is associated with increased financial burden. Current NHS policy advocating for increased adoption of day-case and semi-elective surgical procedures to reduce bed strain must be balanced with providing timely, effective treatment. Our research aims to determine patient groups currently managed via semi-elective admission and whether this can be extended to other groups to provide safe and effective management of mandible fractures.

METHODS

A multi-national trainee-led audit of mandibular fractures across 49 units was completed by the Maxillofacial Trainee Research Collaborative (MTReC). Each unit prospectively collected data on fractures on admission and at follow-up. Data collected included patient demographics, behaviour, health, injury, timing to intervention and surgical complications.

RESULTS

Data were collected on 947 mandibular fractures. Of the surgically managed patients, 649 (90%) were managed via acute emergency admission at the time of presentation, while 68 (10%) were managed semi-electively. Patient demographics, injury pattern and mechanism appeared to significantly affect timing of management, whereas patient behaviour, health status, timing of injury and presentation did not. Semi-elective management was associated with a significantly shorter inpatient duration (0.9 versus 1.9 days, p=0.000) with no differences in readmission, antibiotic usage or surgical complications (p=1.000, RR 1.030).

CONCLUSION

Our study demonstrates the efficacy of planned admissions and semi-elective management of mandibular fractures. Simple mandibular fractures in compliant patients are suitable for semi-elective treatment. Holistic patient assessment and tailored surgical planning is crucial in determining admission modality to effectively manage mandibular trauma.

Patient centered guidelines for the laboratory diagnosis of Gaucher disease type 1

Gaucher disease (GD) is an autosomal recessive lysosomal storage disorder due to the deficient activity of the acid beta-glucosidase (GCase) enzyme, resulting in the progressive lysosomal accumulation of glucosylceramide (GlcCer) and its deacylated derivate, glucosylsphingosine (GlcSph). GCase is encoded by the GBA1 gene, located on chromosome 1q21 16 kb upstream from a highly homologous pseudogene. To date, more than 400 GBA1 pathogenic variants have been reported, many of them derived from recombination events between the gene and the pseudogene. In the last years, the increased access to new technologies has led to an exponential growth in the number of diagnostic laboratories offering GD testing. However, both biochemical and genetic diagnosis of GD are challenging and to date no specific evidence-based guidelines for the laboratory diagnosis of GD have been published. The objective of the guidelines presented here is to provide evidence-based recommendations for the technical implementation and interpretation of biochemical and genetic testing for the diagnosis of GD to ensure a timely and accurate diagnosis for patients with GD worldwide. The guidelines have been developed by members of the Diagnostic Working group of the International Working Group of Gaucher Disease (IWGGD), a non-profit network established to promote clinical and basic research into GD for the ultimate purpose of improving the lives of patients with this disease. One of the goals of the IWGGD is to support equitable access to diagnosis of GD and to standardize procedures to ensure an accurate diagnosis. Therefore, a guideline development group consisting of biochemists and geneticists working in the field of GD diagnosis was established and a list of topics to be discussed was selected. In these guidelines, twenty recommendations are provided based on information gathered through a systematic review of the literature and two different diagnostic algorithms are presented, considering the geographical differences in the access to diagnostic services. Besides, several gaps in the current diagnostic workflow were identified and actions to fulfill them were taken within the IWGGD. We believe that the implementation of recommendations provided in these guidelines will promote an equitable, timely and accurate diagnosis for patients with GD worldwide.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Heterogeneity of management practices surrounding operable gallbladder cancer - results of the OMEGA-S international HPB surgical survey

BACKGROUND

Gallbladder cancer (GBC) is an aggressive, uncommon malignancy, with variation in operative approaches adopted across centres and few large-scale studies to guide practice. We aimed to identify the extent of heterogeneity in GBC internationally to better inform the need for future multicentre studies.

METHODS

A 34-question online survey was disseminated to members of the European-African Hepatopancreatobiliary Association (EAHPBA), American Hepatopancreatobiliary Association (AHPBA) and Asia-Pacific Hepatopancreatobiliary Association (A-PHPBA) regarding practices around diagnostic workup, operative approach, utilization of neoadjuvant and adjuvant therapies and surveillance strategies.

RESULTS

Two hundred and three surgeons responded from 51 countries. High liver resection volume units (>50 resections/year) organised HPB multidisciplinary team discussion of GBCs more commonly than those with low volumes (p < 0.0001). Management practices exhibited areas of heterogeneity, particularly around operative extent. Contrary to consensus guidelines, anatomical liver resections were favoured over non-anatomical resections for T3 tumours and above, lymphadenectomy extent was lower than recommended, and a minority of respondents still routinely excised the common bile duct or port sites.

CONCLUSION

Our findings suggest some similarities in the management of GBC internationally, but also specific areas of practice which differed from published guidelines. Transcontinental collaborative studies on GBC are necessary to establish evidence-based practice to minimise variation and optimise outcomes.

Evaluation of a prescribing pharmacist-led heart failure (HF) up-titration clinic

Background/Introduction

Pharmacotherapy is considered the cornerstone of treatment for patients with heart failure with reduced ejection fraction (HFrEF). Modulation of the renin-angiotensin-aldosterone (RAAS) and sympathetic nervous system have been shown to improve survival, reduce the risk of heart failure (HF) hospitalisations and improve quality of life. Unless contraindicated or not tolerated, these patients should be prescribed angiotensin-converting enzyme inhibitor (ACEi)/angiotensin-receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 (SGLT2) inhibitor and up-titrated to guideline directed dosages.1 Despite the availability of effective treatments, patients are often sub-optimally dosed and experience a prolonged optimisation process. Pharmacist-led clinics can complement existing services and increase uptake of guideline directed medical therapies (GDMT).

Purpose

To evaluate the effectiveness of pharmacist-led heart failure clinics in the Princess of Wales Hospital, supported by the Heart Failure team, in optimisation of patients with HFrEF.

Methods

Patients who attended HF pharmacist led clinic between November 2020 and November 2021 were included in the analysis. Baseline demographics, left ventricular ejection fraction (LVEF), biomarkers, vital signs and medications were documented at baseline and after optimisation of GDMT. Number of clinics appointments and rate of hospitalisation and mortality were captured during the study period.

Results

76 patients were reviewed over a total of 318 consultations (34% virtual), averaging 4 consultations per patient. The mean age was 71 years, 36% of patients were female, mean LVEF was 32% and NT-proBNP 3078ng/L with 15% of patients on “quadruple therapy” at baseline. 93% of patients were referred by cardiologists and the average time from referral to first appointment was 42 days. Post-optimisation, 67% of patients were receiving “quadruple therapy”, with increased uptake of ACEi/ARB/ARNI, beta-blocker, MRA and SGLT2i from baseline (100%, 77%, 93% and 90% respectively). Mean LVEF increased to 42% and mean NT-proBNP reduced to 1695ng/L. No significant changes in creatinine clearance, blood pressure, heart rate or serum potassium (sK+) were recorded. The hospitalisation rate was 11% for heart failure, 6% for other cardiovascular causes and the mortality rate was 7%.

Conclusions

The pharmacist-led HF clinic demonstrated a high uptake of optimally dosed GDMT and improvements in NT-proBNP and LVEF. Pharmacist-led clinics can enhance the provision of existing heart failure services to improve patient outcomes and heart failure care.

Funding Acknowledgement

Type of funding sources: None.

Impact of weight loss on cardiac function: improvement in left ventricular global longitudinal strain following metabolic surgery

Introduction

Obesity leads to an increased risk of cardiovascular disease (CVD) morbidity and mortality and is associated with the metabolic risk factors such as hypertension, diabetes mellitus, hyperlipidemia [1]. Metabolic surgery has been proven to be the most effective long term weight management tool and has known benefits in CVD prevention [2]. Global longitudinal strain (GLS) is an effective quantitative measurement of left ventricular (LV) function that is also a powerful predictor of future CVD events and mortality [3]. The impact of metabolic surgery on LV structure and function is unknown.

Purpose

This study investigated the changes in cardiac structure and function after metabolic surgery, including GLS. To our knowledge there has not been a study investigating this relationship previously reported.

Methods

Consecutive patients undergoing metabolic surgery at our center between March 2005 and February 2019 were recruited. Patients with transthoracic echocardiographic imaging (TTE) pre and post metabolic surgery (May 2005 to January 2019) were included. Electronic medical records were searched to obtain demographic, surgical and clinical data. GLS was calculated with Velocity Vector Imaging (VVI, Siemens, v2.0, Pennsylvania, USA). Averaged GLS values were derived from 4 chamber, 2 chamber and 3 chamber calculations.

Results

398 patients with pre- and post-operative cardiac imaging were included. Please see Table 1 for the baseline demographics of our study population. The mean age was 60.0 years with 70% being female. There were significant rates of CVD risk factors such as: hypertension (76.4%), diabetes mellitus (58.8%) and hyperlipidemia (76.4%).

The clinical and echocardiographic changes noted post metabolic surgery are detailed in Table 2. Along with decreases in weight post operatively, there were significant improvements in the markers of CVD risk factors such as mean blood pressure (134/75 to 129/72 mmHg, p value &lt;0.001), mean gylcated hemoglobin levels (7.0 to 6.1%, p value &lt;0.001) and mean low density lipoprotein (LDL) levels (97.7 to 88.2 mg/dl, p value &lt;0.001).

There were a number of statistically significant positive changes in the left ventricular structure and function. The mean LV ejection fraction increased from 56.3% to 57.4% (p=0.008); left ventricular mass decreased from 238.2 g to 179.3 g (p value &lt;0.001), and both septal and posterior wall thicknesses decreased significantly (p value &lt;0.001). The LV mass indexed to body surface area (BSA) also decreased from 93.5 g/m2 to 83.1 g/m2.

The average global LV GLS was −15.7% pre-operatively, improving significantly to −17.9% post-operatively (p&lt;0.001).

Conclusion

Our study has shown for the first time the impact of metabolic surgery on ventricular structure and function, with reduction in LV mass and improvement in LV GLS. These novel findings lends further support to the cardiovascular benefits of metabolic surgery.

Funding Acknowledgement

Type of funding sources: None.

Exploring current undergraduate student perspectives on the introduction of the degree apprenticeship scheme in diagnostic radiography - a single institution study

INTRODUCTION

The first degree apprenticeship programme in diagnostic radiography was launched in March 2020. This route into radiography runs in parallel with 'conventional' pre-registration programmes where students apply to a higher education institution (HEI) and undertake discrete clinical placements. The aim of this study was to explore the perspectives of pre-registration students on the diagnostic radiographer degree apprenticeship route.

METHODS

A qualitative approach (online questionnaire) gathered attitudes and opinions of pre-registration students from a single HEI, regarding the degree apprenticeship programme. Participants were pre-registration medical imaging students from all stages of the programme (n = 204). Braun and Clarks's thematic analysis was employed for data analysis.

RESULTS

A response rate of 21% (n = 44) was recorded. Four themes emerged from data analysis: (1) misunderstandings surrounding the degree apprenticeship, (2) financial implications and (3) practical experience associated with both degree courses and (4) the experience the pre-registration degree has to offer.

CONCLUSION

There was an apparent lack of understanding regarding the degree apprenticeship leading students to misinterpret aspects of the course. Additionally, students highlighted the earning aspect of the apprenticeship to be an advantage in comparison to student debts associated with the traditional pre-registration programmes. Furthermore, students emphasised the advantage of the clinical focus practice associated with the degree apprenticeship. Nevertheless, students who have selected the HEI route still value what the traditional pre-registration degree offers.

IMPLICATIONS FOR PRACTICE

As degree apprenticeship programmes become widely available, a greater awareness should, therefore, follow. In the interim, there is scope for HEIs to seek to raise awareness of degree apprenticeship provision. HEIs should seek to allay any concerns and highlight the benefits of having this alternative route into the profession.

The impact of COVID-19 on the clinical experience and training of undergraduate Student radiographers internationally: The clinical tutors' perspective

Introduction

The impact on the clinical training and education of healthcare students by COVID-19 has been documented. However, the thoughts and experiences of clinical tutors (CTs) about radiography students attending for clinical training and education during this now elongated period beyond first recognition of the virus has not been explored. This paper will discuss data collected from CTs in the UK Devolved Nations (UKDN) and the United Arab Emirates (UAE) who were compared because of their similarities in delivery based on individual ‘rules of engagement’ devised by their various health departments.

Aim

The purpose of this study was to examine the clinical tutors' thoughts and experiences of supervising radiography students attending clinical placement during the COVID-19 pandemic.

Methods

The UK Devolved Nations (UKDN) and the United Arab Emirates (UAE) were selected for comparison on an international level as they are geographically distinct with a comparable population and education accredited/acknowledged by the Society and College of Radiographers (SCoR). Data was collected data from CTs across the UKDN and the UAE. The study used an online questionnaire (Google Forms) with closed questions in four themes including: students' experiences, impact on students' clinical placement, attitude of the clinical staff and the potential effects of COVID-19 on future graduates’ skills and competencies. Further data was gathered on the experience of CTs mentoring students during the COVID-19 pandemic.

Results

Data were collected from 59 CTs (81%, n = 48) from UKDN and (19%, n = 11) UAE. Twenty-seven (46%) respondents reported that COVID-19 had a negative impact on clinical practical experience. However, 32 (54%) identified that COVID-19 had no impact on student supervision/feedback or on clinical achievements. Eleven (19%) respondents thought that students should not have been on clinical placement during the pandemic but a further 51% (n = 30) were happy with the students on placement and expressed willingness to delegate work to students. Interestingly, 58% (n = 34) of CTs suggested that future graduates may need a longer preceptorship after they graduate due to receiving decreased clinical experience during the pandemic. Overall, 78% (n = 46) of respondents thought that students improved their clinical confidence by working directly with COVID-19 positive patients.

Conclusion

The current study has identified conflicting opinions across CTs in different clinical departments. Whilst some felt that students should not be in the hospital during the pandemic, others reported that working directly with COVID-19 patients had a positive impact on students as it improved their clinical confidence. Despite the challenges presented by COVID-19, CTs were able to provide direct clinical supervision and feedback to students on clinical placement throughout the pandemic. Nevertheless, future graduates may need a longer preceptorship period due to decreased clinical experience during the pandemic.

Implications for practice

Clinical placements should continue during subsequent COVID-19 waves of infection or future pandemics to ensure development of skills in resilience and adaptability. Underdeveloped skills due to a decreased range of examinations can be rectified when any wave of the infection subsides by providing tailored training based on individual student's needs.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

256 Implementing and Reinforcing Positive Change to Regional Hand Trauma Service with Introduction of the Golden Patient Initiative

Introduction

Significant theatre delays were identified in hand trauma lists at our regional adult hand surgery unity. We aimed to improve theatre delays by implementing a golden patient initiative.

Method

Literature review identified the golden patient initiative, which ensures first patient on the list is identified, communicated to multidisciplinary team, and is optimized for theatre.

Multi-stage intervention according to change management models (ADKAR and McKinsey 7s) was used. This included (1) a new protocol, (2) educational intervention, 3) poster and (4) a variety of information dissemination methods. To ensure multidisciplinary staff engagement and reinforce positive change, we used multiple verbal, visual and written prompts: trauma co-ordinator-led daily reminders, senior involvement, new column in handover list, verbal reminders at departmental meetings, posters in key areas and widely-accessible reference booklet.

Prospective analysis of theatre utilisation pre- and post-intervention to measure impact of intervention.

Results

Analysis of emergency general list (EG) and local anaesthetic list (LA) start times identified an average 40 and 20-minute-long delays respectively. Following introduction of golden patient there was a reduction in delays by 9 minutes in LA and 5 minutes in EG. The latest start time improvement by 8 minutes in LA and 50 minutes in EG. There was also a reduction in operation delays by 2.8% in LA and 14.3% in EG. The estimated annual cost saved in EG is approximately £45,200.

Conclusions

We believe that implementing sustainable change is a complex and challenging process. Implementing the golden patient initiative resulted in a positive impact on hand trauma services.

P43 In vitro activity of cefiderocol and comparators against Gram-negative pathogens: ARTEMIS study in the UK

Objectives

Cefiderocol (CFDC) is a novel siderophore cephalosporin approved in Europe for the treatment of infections caused by aerobic Gram-negative (GN) bacteria in adults with limited treatment options. The aim of the ARTEMIS study was to evaluate the in vitro activity of CFDC and comparators against recent clinical isolates collected across five countries in Europe. Here we report susceptibility data from isolates collected in the UK.

Methods

From January to December 2020, GN clinical isolates were collected from hospitalized patients from all infection sites (excluding the urinary tract). Duplicate isolates of the same species from a single patient were excluded. As a prespecified target, each laboratory collected 75 isolates, with: 20 Klebsiella spp., 20 other Enterobacterales, 20 Pseudomonas aeruginosa and 15 Acinetobacter baumannii isolates expected to be included. CFDC susceptibility testing was conducted using disc diffusion (with 30 μg discs) on Mueller–Hinton agar and Sensititre^™ broth microdilution (BMD) panels [EUMDROXF; centrally tested at International Health Management Associates (IHMA)]. Susceptibility by disc diffusion was reported using zone diameter breakpoints (BPs) of ≥22 mm (or ≥17 mm for A. baumannii isolates, corresponding to MIC values below the pharmacokinetic/pharmacodynamic BPs of ≤2 mg/L). Comparator susceptibility was determined using custom research use only Sensititre^™ BMD panels (CMP2SHIH) according to the EUCAST method for BMD. Antimicrobial susceptibility was interpreted according to EUCAST clinical BPs (v.11 2021).

Results

In total, 517 isolates were collected from nine UK hospitals, of which: 308 (59.6%) were Enterobacterales [including 147 (28.4%) Klebsiella spp.], 148 (28.6%) were P. aeruginosa and 33 (6.4%) were A. baumannii. The most common sites of infection were bloodstream (n = 245; 47.4%), respiratory tract (n = 158; 30.6%) and skin (n = 59; 11.4%). A high percentage of Enterobacterales (90.2%), P. aeruginosa (96.6%) and A. baumannii (96.9%) isolates were susceptible to CFDC by disc diffusion. By central laboratory testing (MIC), 99.0% of Enterobacterales, 99.3% of P. aeruginosa and 93.9% of A. baumannii isolates were susceptible to CFDC. High susceptibility rates (>85%) were also observed for all comparator agents (Table 1). A total of 32/517 (6.2%) isolates were carbapenem resistant, the majority of which (22/32, 68.8%) were susceptible to CFDC by disc diffusion.

Conclusions

Among clinical GN isolates collected from UK hospitals in 2020, a high percentage (98.6%), including carbapenem-resistant isolates, were susceptible to CFDC by BMD. These data support the use of CFDC in patients with GN infections and limited treatment options. The differences identified between EUCAST disc diffusion and BMD using Sensititre^™ panels for CFDC highlight that disc diffusion underestimates Enterobacterales susceptibility to CFDC, which is mainly a result of the area of technical uncertainty (where isolates with MIC of 2 mg/L have a zone diameter of <22 mm and are characterized as resistant). This requires further investigation to explore whether the EUCAST zone diameter BP is optimal for CFDC disc testing.

POS1131 THE INCIDENCE AND PREVALENCE OF CARDIOVASCULAR DISEASES IN GOUT: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

Gout is an inflammatory crystal arthropathy characterised by hyperuricaemia and sodium urate crystal deposition. Both gout and subclinical hyperuricaemia are associated with adverse cardiovascular outcomes. Several studies have found gout to cause an increased risk of cardiovascular disease, but the evidence is not unanimous. The conflicting evidence has made it difficult to establish the extent of the cardiovascular risk to patients with gout.

Objectives:

To describe the incidence and prevalence of cardiovascular disease in gout, compare these results with non-gout controls.

Methods:

PubMed, Scopus and Web of Science were systematically searched in January 2021 for studies reporting prevalence of any cardiovascular disease in a gout population. Studies with non-representative sampling, where a cohort had been used in another study, small sample size (< 100) and where gout could not be distinguished from other rheumatic conditions were excluded. Sample size, prevalence of the investigated cardiovascular disease, definition of gout and cardiovascular disease, demographic data, data source and any comparisons with non-gout controls were extracted from each study. Where prevalence data was reported in ≥3 cohorts meta-analysis was performed using random-effect models.

Results:

Of the 6164 titles identified, 105 full texts were assessed for eligibility with 30 included in the review, producing a gout population of 1,125,988. Pooled prevalence estimates were calculated for six cardiovascular diseases: heart failure (8.73%; 95% confidence interval (CI), 2.85 – 23.76), cerebrovascular accident (4.27%; 95% CI, 1.83 – 9.67), myocardial infarction (2.82%; 95% CI, 1.58 – 5.01), venous thromboembolism (2.05%; 95% CI, 1.22 – 3.43), hypertension (63.94%; 95% CI, 24.51 – 90.64) and cardiovascular mortality (4.75%; 95% CI, 3.56 – 6.31). Twenty studies reported comparisons with non-gout controls, illustrating an increased risk in the gout group across all cardiovascular diseases, particularly for myocardial infarction.

Conclusion:

Cardiovascular diseases are more prevalent in patients with gout and should prompt vigilance from clinicians to the need to assess and stratify cardiovascular risk. These results are in line with other studies which have shown an increased cardiovascular risk for sufferers of hyperuricaemia, highlighting the need for future research to explain this finding. There are limited studies in the literature investigating less common cardiovascular conditions, illustrating the need for future work if a more thorough picture of prevalence is to be established.

Figure 1.

Forest plots of pooled prevalence of: (A) 8.73% for heart failure, (B) 4.27% for cerebrovascular accident, (C) 2.82% for myocardial infarction, (D) 2.05% for venous thromboembolism, (E) 63.94% for hypertension and (F) 4.75% for cardiovascular mortality.

Disclosure of Interests:

None declared.

The Effects of Resuscitative Fluid Therapy on the Endothelial Surface Layer

The goal of resuscitative fluid therapy is to rapidly expand circulating blood volume in order to restore tissue perfusion. Although this therapy often serves to improve macrohemodynamic parameters, it can be associated with adverse effects on the microcirculation and endothelium. The endothelial surface layer (ESL) provides a protective barrier over the endothelium and is important for regulating transvascular fluid movement, vasomotor tone, coagulation, and inflammation. Shedding or thinning of the ESL can promote interstitial edema and inflammation and may cause microcirculatory dysfunction. The pathophysiologic perturbations of critical illness and rapid, large-volume fluid therapy both cause shedding or thinning of the ESL. Research suggests that restricting the volume of crystalloid, or “clear” fluid, may preserve some ESL integrity and improve outcome based on animal experimental models and preliminary clinical trials in people. This narrative review critically evaluates the evidence for the detrimental effects of resuscitative fluid therapy on the ESL and provides suggestions for future research directions in this field.

699 Pre-Operative Screening and Investigation of Patients with Suspected Non-Alcoholic Fatty Liver Disease Among Bariatric Surgery Patients

Introduction

Non-alcoholic fatty liver disease (NAFLD) is becoming more prevalent. The investigations used to diagnose NAFLD include FIB-4 score, NAFLD score and AST/ALT ratio (AAR). Gold-standard for diagnosis is liver biopsy. Bariatric surgery reduces steatosis and fibrosis in NAFLD patients. However, in undiagnosed NAFLD, it can lead to worsening fibrosis and decompensation of cirrhosis, causing complications.

The aim is to identify how well bariatric patients are being screened for NAFLD pre-operatively.

Method

Database analysis was conducted in the bariatric clinics at Royal Derby Hospital and analysed using SPSS.

Results

392 patients’ data (Overall group) were analysed and compared with those who had an AAR&gt;1 (Abnormal group). Abnormal group had a higher mean AAR, NAFLD and FIB-4 scores. Surprisingly, ALT and AST levels were higher in Overall group compared to Abnormal. Generally, patients were not pre-operatively checked sufficiently (81.9% LFTs, 62.2% ASTs).

Conclusions

A large number of patients could have undiagnosed NAFLD due to the lack of LFT/AST checks as ALT scores alone would miss fibrosis. Using AAR&gt;1 and FIB-4 would allow clinicians to detect fibrosis earlier to carry out non-invasive diagnostic measures, avoiding unnecessary biopsies. Early diagnosis means patients undergoing bariatric surgery with possible cirrhosis will not experience decompensation and associated complications.

ICD implantation and device therapy: Fabry vs hypertrophic cardiomyopathy

Background

Cardiac involvement of Fabry disease (FD) includes left ventricular hypertrophy (LVH), inflammation, arrhythmia and sudden death. There are limited data regarding potential risk predictors and no definitive criteria exist to guide implantation of cardiac devices for primary prevention. Despite phenotypic similarities between FD and hypertrophic cardiomyopathy (HCM), FD is specifically excluded from the ESC sudden cardiac death risk prediction tool used for HCM.

Purpose

To evaluate differences in device implantation and arrhythmic burden between advanced Fabry cardiomyopathy and HCM.

Methods

This multi-centre, retrospective study including genetically confirmed FD and age/gender-matched HCM patients all of whom had an implantable cardioverter defibrillator (ICD). Data was collected prior to device implantation on disease characteristics, biomarkers and CMR imaging. Arrhythmia burden and changes in therapy were captured following implantation.

Results

Of the UK FD population under follow-up, 50/880 had an ICD implanted (80% males, 51% non-classical mutation, mean age at device implantation 57±12 years). A comparator group included 64 age- and gender-matched HCM patients (67% males, mean age at implant 46±39 years). Baseline LV mass was greater in FD (291±97g/m2 vs 218±78g/m2, p=0.012). FD patients had higher troponin (95 vs 19ng/l, p&lt;0.001) but similar NT-pro-BNP (1687 vs 888ng/l, p=0.086) levels.

Indications for ICD insertion in FD included: presumed HCM dual pathology 14%, symptomatic NSVT 18%, asymptomatic NSVT 24%, co-existing long QT 2%, CRT-D 14%, no clear indication (primary prevention in the presence of multiple potential arrhythmic risk factors) 28%. All HCM patients were risk stratified and underwent device implantation based on an estimated 5-year SCD risk &gt;4%. All FD patients had a SCD risk &gt;4% using this risk calculator. Arrhythmia were more common in FD over shorter follow-up (37/50, 74% over 4.3±3.0 years vs 28/64 in HCM, 44% over 6.5±2.9 years, p=0.001). Notably, VT requiring anti-tachycardia pacing (ATP) +/− defibrillation therapy from the ICD was more frequent (FD: 14/50, 28% vs HCM: 8/64, 12%, p=0.055), as was immediate shock therapy for sustained VT (p=0.009, figure panel B). FD patients with arrhythmia were often older, had greater LV mass, a larger left atrium and a broader QRS duration. These clinical features tended to occur more frequently in FD than in the HCM group.

Conclusion

This study has shown that delivery of device therapy in Fabry cardiomyopathy is higher than in HCM. Despite similar rates of asymptomatic NSVT, a higher rate of ventricular arrhythmia requiring ATP/defibrillation therapy occurred in FD. Although both FD and HCM had similar risk percentages according to the ESC calculator, active troponitis in FD was double that of HCM.

Funding Acknowledgement

Type of funding source: None

The myocardial phenotype of Fabry disease pre-hypertrophy and pre-detectable storage

Background

Cardiac involvement in Fabry Disease (FD) occurs prior to left ventricular hypertrophy (LVH) and is characterized by low myocardial native T1 with storage reflected by cardiovascular magnetic resonance (CMR) and ECG changes.

Objectives

We hypothesize that a pre-storage myocardial phenotype might occur even earlier, prior to T1 lowering.

Methods

FD patients and age, sex and heart rate matched healthy controls underwent same-day ECG with advanced analysis and multiparametric CMR (cines, global longitudinal strain [GLS], T1 and T2 mapping, stress perfusion [myocardial blood flow, MBF] and late gadolinium enhancement [LGE]).

Results

114 Fabry patients (46±13 years, 61% female) and 76 controls (49±15 years, 50% female) were included. In pre-LVH FD (n=72, 63%), a low T1 (n=32/72, 44%) was associated with a constellation of ECG and functional abnormalities compared to normal T1 FD patients and controls. However, pre-LVH FD with normal T1 (n=40/72, 56%) also had abnormalities compared to controls: reduced GLS (−18±2 vs −20±2%, P&lt;0.001), microvascular changes (lower MBF 2.5±0.7 vs 3.0±0.8mL/g/min, P=0.028), subtle T2 elevation (50±4 vs 48±2ms, p=0.027) and limited LGE (%LGE 0.3±1.1 vs 0%, P=0.004). ECG abnormalities included shorter P wave duration (88±12 vs 94±15ms, P=0.010) and T wave peak time (Tonset–Tpeak; 104±28 vs 115±20ms, P=0.015), resulting in a more symmetric T wave with lower T wave time ratio (Tonset–Tpeak)/(Tpeak–Tend) (1.5±0.4 vs 1.8±0.4, P&lt;0.001) compared to controls.

Conclusions

FD has a measurable myocardial phenotype pre-LVH and pre-detectable myocyte storage with microvascular dysfunction, subtly impaired GLS and altered atrial depolarization and ventricular repolarization intervals.

Proposed stages of cardiac involvement

Funding Acknowledgement

Type of funding source: None

MRI-visible perivascular spaces as an imaging biomarker in Fabry disease

Introduction

Fabry disease (FD) is an X-linked lysosomal storage disorder resulting in vascular glycosphingolipid accumulation and increased stroke risk. MRI findings associated with FD include white matter hyperintensities (WMH) and cerebral microbleeds (CMBs), suggesting the presence of cerebral small vessel disease. MRI-visible perivascular spaces (PVS) are another promising marker of small vessel disease associated with impaired interstitial fluid drainage. We investigated the association of PVS severity and anatomical distribution with FD.

Patients and methods

We compared patients with genetically proven FD to healthy controls. PVS, WMH, lacunes and CMBs were rated on standardised sequences using validated criteria and scales, blinded to diagnosis. A trained observer (using a validated rating scale), quantified the total severity of PVS. We used logistic regression to investigate the association of severe PVS with FD.

Results

We included 33 FD patients (median age 44, 44.1% male) and 20 healthy controls (median age 33.5, 50% male). Adjusting for age and sex, FD was associated with more severe basal ganglia PVS (odds ratio (OR) 5.80, 95% CI 1.03–32.7) and higher total PVS score (OR 4.03, 95% CI 1.36–11.89). Compared with controls, participants with FD had: higher WMH volume (median 495.03 mm³ vs 0, p = 0.0008), more CMBs (21.21% vs none, p = 0.04), and a higher prevalence of lacunes (21.21% vs. 5%, p = 0.23).

Conclusions

PVS scores are more severe in FD than control subjects. Our findings have potential relevance for FD diagnosis and suggest that impaired interstitial fluid drainage might be a mechanism of white matter injury in FD.

Coagulation factor activity patterns of venom-induced consumption coagulopathy in naturally occurring tiger snake (Notechis scutatus) envenomed dogs treated with antivenom

BACKGROUND

Venom-induced consumption coagulopathy (VICC) from tiger snake (Notechis scutatus) envenomation results in a dose-dependent coagulopathy that is detectable on coagulometry. However, individual coagulation factor activities in dogs with tiger snake envenomation have not been determined. This study aimed to characterise VICC and the time course of recovery in tiger snake envenomed dogs and to investigate an association between tiger snake venom (TSV) concentrations and factor activity.

METHODS

This was a prospective, observational, cohort study. The study cohort was 11 dogs of any age, breed, sex, body weight >10 kg, confirmed serum TSV on ELISA and treated with antivenom. Blood was collected at enrolment before antivenom administration, then at 3, 12 and 24 h after antivenom administration. Tiger snake venom concentrations were detected with a sandwich ELISA. Fibrinogen was measured using a modified Clauss method, and coagulation factors (F) II, V, VII, VIII and X were measured with factor-deficient human plasma using a modified prothrombin (PT) and activated partial thromboplastin (aPTT) method. Linear mixed models, with multiple imputations of censored observations, were used to determine the effect of time and TSV concentration on the coagulation times and factor activity. This cohort was compared to 20 healthy controls.

RESULTS

At enrolment, there were severe deficiencies in fibrinogen, FV and FVIII, with predicted recovery by 10.86, 11.75 and 13.14 h after antivenom, respectively. There were modest deficiencies in FX and FII, with predicted recovery by 20.57 and 32.49 h after antivenom, respectively. No changes were detected in FVII. Prothrombin time and aPTT were markedly prolonged with predicted recovery of aPTT by 12.58 h. Higher serum TSV concentrations were associated with greater deficiencies in FII, FV and FVIII, and greater prolongations in coagulation times. The median (range) serum TSV concentration was 57 (6-2295) ng/mL.

CONCLUSIONS

In tiger snake envenomed dogs, we detected a profound, TSV-concentration-related consumption of select coagulation factors, that rapidly recovered toward normal. These findings allowed further insight into tiger snake VICC in dogs.

In vitro effects of lactated Ringer's solution, hypertonic saline, hydroxyethyl starch, hypertonic saline/hydroxyethyl starch, and mannitol on thromboelastographic variables of canine whole blood

OBJECTIVE

To assess the in vitro effects of crystalloid and colloid IV fluids on the thromboelastographic (TEG) variables of canine whole blood.

DESIGN

In vitro experimental study.

SETTING

Veterinary teaching hospital.

ANIMALS

Twenty-two healthy dogs.

INTERVENTION

Citrated whole blood samples collected from healthy dogs were diluted with 3.4% hypertonic saline (HTS 3.4), 7% hypertonic saline (HTS 7), and 20% mannitol at 8% and 16% dilutions; hydroxyethyl starch 130/0.4 (HES 130/0.4) at 16% dilution; lactated Ringer's solution (LRS) at 16%, 33%, and 66% dilutions; and HTS 7-HES 130/0.4 at 25% and 50% dilutions. Kaolin-activated TEG analysis was concurrently performed on diluted and control (undiluted) samples.

MEASUREMENTS AND MAIN RESULTS

Dilution of canine whole blood with LRS compared to control reduced α angle and MA at both 33% (P = 0.009 and P = 0.011, respectively) and 66% dilution (P < 0.001 and P < 0.001, respectively), and prolonged K time at 66% dilution (P = 0.003). At 16% dilution, HTS 3.4, prolonged R time (P = 0.007), while mannitol, a fluid iso osmolar to HTS 3.4, prolonged K time (P = 0.006), reduced α angle (P < 0.001), MA (P = 0.046), and LY60 (P = 0.015). At 8% dilution, HTS 7, a fluid of high osmolarity and tonicity, prolonged R time (P = 0.009) and reduced MA (P = 0.015), while all measured TEG variables were altered at the 16% dilution (P < 0.01 for all variables). HES 130/0.4 reduced α angle (P = 0.031) and MA (P = 0.001) and increased LY60 (P < 0.001) at 16% dilution. Comparing different fluid types, HES 130/0.4 and HTS 3.4 had no to minor, mannitol intermediate, and HTS 7 profound effects on TEG variables (P < 0.05) when compared to LRS at the same dilution.

CONCLUSIONS

In vitro dilution of canine whole blood with commonly used IV fluids leads to thromboelastographic changes consistent with hypocoagulability in a dose dependent manner for all fluid types tested. Viscoelastic changes are also influenced by fluid characteristics, specifically tonicity and osmolarity.

The endothelial glycocalyx: Structure and function in health and critical illness

OBJECTIVE

To conduct a narrative review of the current literature in reference to the structure and function of the endothelial glycocalyx (EG) and its contribution to the pathophysiology of conditions relevant to the veterinary emergency and critical care clinician. Novel therapies for restoring or preserving the EG will also be discussed.

DATA SOURCES

Online databases (PubMed, CAB abstracts, Scopus) were searched between January 1st 2017 and May 1st 2017 for English language articles without publication date restriction. Keywords included EG, endothelial surface layer, degradation, syndecan-1, heparan sulfate, critical illness, sepsis, trauma, and therapeutics.

DATA SYNTHESIS

The EG is a complex and important structure located on the luminal surface of all blood vessels throughout the body. It plays an important role in normal vascular homeostasis including control of fluid exchange across the vascular barrier. Loss or degradation of the EG has an impact on inflammation, coagulation, and vascular permeability and tone. These changes are essential components in the pathophysiology of many conditions including sepsis and trauma. A substantial body of experimental animal and human clinical research over the last decade has demonstrated increased circulating concentrations of EG degradation products in these conditions. However, veterinary-specific research into the EG and critical illness is currently lacking. The utility of EG degradation products as diagnostic and prognostic tools continues to be investigated and new therapies to preserve or improve EG structure and function are under development.

CONCLUSIONS

The recognition of the presence of the EG has changed our understanding of transvascular fluid flux and the pathophysiology of many conditions of critical illness. The EG is an exciting target for novel therapeutics to improve morbidity and mortality in conditions such as sepsis and trauma.

P340Inflammatory cardiomyopathy in Fabry disease

Background

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations in α-galactosidase A. Cardiovascular magnetic resonance (CMR) has helped unveil the pathogenesis of Fabry cardiomyopathy: sphingolipid storage (low T1 mapping values), left ventricular hypertrophy (LVH) and myocardial fibrosis with late gadolinium enhancement (LGE) characteristically present in the basal inferolateral (BIFL) wall. Recent evidence has suggested that the LGE may be inflammation and oedema as part of this pathogenic process.

Purpose

To assess the presence of inflammation in patients with FD using T2 mapping (for oedema/inflammation) supported by blood troponin levels (showing myocyte death and by inference inflammation).

Methods

A multi-centre international study in gene positive FD patients using CMR and blood biomarkers. All participants underwent CMR at 1.5 T. Native T1 and T2 mapping were performed. The T1 mapping sequence was MOLLI with sampling scheme in seconds. LGE used a phase sensitive inversion recovery sequence. Global longitudinal 2D strain (GLS) values were obtained using feature tracking analysis. Blood high-sensitivity troponin T (hsTnT) was measured on the same day.

Results

100 FD patients (age 43.8±1.3 years, 42% male) were included. 45% had LVH, 35% LGE. Low T1 mapping (normal <943ms) was found in 49% and 33% had high hsTnT values (normal <15ng/L). Mean T2 mapping values were 52.6±0.6ms in the BIFL wall and 49.5±0.3ms in the remote myocardium/septum (p<0.001, normal <53ms). T2 values in the BIFL wall were significantly higher among patients with LGE (58.2±6.1ms vs 49.2±3.1ms, p<0.001, Figure 1). In a per-segment analysis of 1600 segments, higher T2 values correlated positively with percentage of LGE per segment (r=0,262, p<0.001), T1 values (r=0,205, p<0.001), maximum wall thickness (r=0,253, p<0.001) and GLS values (r=0,212, p<0.001). HsTnT values were higher among patients with LGE (median of 31 vs 3ng/L in patients without LGE, p<0.001). There was a strong positive correlation between T2 values in the BIFL wall and ln(hsTnT) (r=0.776, p<0.001, Figure 2). The strongest predictor of increased hsTnT in multivariate analysis (age, sex, LVH, septum T1, T2 in the BIFL, GLS, LGE) was T2 in the BIFL wall (β=0.4, p=0.001).

Conclusions

Cardiac involvement in FD goes beyond storage (low T1 values). When LGE is present, this is almost always associated with a high T2 and troponin elevation supporting FD as a chronic inflammatory cardiomyopathy. Initial reports of LGE being fibrosis are too simplistic – LGE in FD appears to have a significant chronic inflammation/oedema component.

Neurological effects of glucocerebrosidase gene mutations

The association between Gaucher disease (GD) and Parkinson disease (PD) has been described for almost two decades. In the biallelic state (homozygous or compound heterozygous) mutations in the glucocerebrosidase gene (GBA) may cause GD, in which glucosylceramide, the sphingolipid substrate of the glucocerebrosidase enzyme (GCase), accumulates in visceral organs leading to a number of clinical phenotypes. In the biallelic or heterozygous state, GBA mutations increase the risk for PD. Mutations of the GBA allele are the most significant genetic risk factor for idiopathic PD, found in 5%–20% of idiopathic PD cases depending on ethnicity. The neurological consequences of GBA mutations are reviewed and the proposition that GBA mutations result in a disparate but connected range of clinically and pathologically related neurological features is discussed. The literature relating to the clinical, biochemical and genetic basis of GBA PD, type 1 GD and neuronopathic GD is considered highlighting commonalities and distinctions between them. The evidence for a unifying disease mechanism is considered.

Potentiators and Correctors in Paediatric Cystic Fibrosis Patients: A Narrative Review

Cystic fibrosis is the most common inherited condition in the Caucasian population and is associated with significantly reduced life expectancy. Recent advances in treatment have focussed on addressing the underlying cause of the condition, the defective production, expression and function of the cystic fibrosis transmembrane conductance regulator (CFTR) protein. Several drugs with different modes of action have produced promising results in clinical trials, and some have been incorporated into routine clinical care for specific patients in many countries worldwide. Further trials continue to explore the safety and efficacy of these drugs in the youngest age groups and to search for more effective therapies to treat the most common disease-causing gene mutations in an ever-expanding drug pipeline. As evidence mounts for the early onset of disease in young patients, the prospect of introducing disease-modifying therapy in early life becomes more pertinent, although the cost implications of these expensive drugs are significant. In this review, we summarise these new therapy advances and review those currently being explored in clinical trials.