Platelet transfusions in adult thrombocytopenic ICU patients: Protocol for a sub-study of the PLOT-ICU cohort

INTRODUCTION

Platelet transfusions are frequently used in intensive care unit (ICU) patients, but contemporary epidemiological data are sparse. We aim to present contemporary international data on the use of platelet transfusions in adult ICU patients with thrombocytopenia.

METHODS

This is a protocol and statistical analysis plan for a post hoc sub-study of 504 thrombocytopenic patients from the 'Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU)'. The primary outcome will be the number of patients receiving platelet transfusion in the ICU reported according to the type of product received (apheresis-derived versus pooled whole-blood-derived transfusions). Secondary platelet transfusion outcomes will include platelet transfusion volumes; timing of platelet transfusion; approach to platelet transfusion dosing (fixed dosing versus weight-based dosing) and platelet count increments for prophylactic transfusions. Secondary clinical outcomes will include the number of patients receiving red blood cell- and plasma transfusions during ICU stay; the number of patients who bled in the ICU, the number of patients who had a new thrombosis in the ICU, and the number of patients who died. The duration of follow-up was 90 days. Baseline characteristics and secondary clinical outcomes will be stratified according to platelet transfusion status in the ICU and severity of thrombocytopenia. Data will be presented descriptively.

CONCLUSIONS

The outlined study will provide detailed epidemiological data on the use of platelet transfusions in adult ICU patients with thrombocytopenia using data from the large international PLOT-ICU cohort study. The findings will inform the design of future randomised trials evaluating platelet transfusions in ICU patients.

Development and Usability of an Inexpensive and Reusable Phantom for Ultrasound-Guided Needle Cannulation

Introduction Ultrasound-guided peripheral venous catheter placement (UG-PVCP) is a key skill for establishing intravenous access, especially in patients with anatomical challenges. Ultrasound is highly operator-dependent, and it is essential to ensure a sufficient level of competence when educating healthcare professionals. Competence can be acquired through simulation-based training (SBT) using phantoms or simulators. We developed a phantom for SBT, and in this study, we explore the phantom's usability and technical fidelity. Methods Novices with no experience in UG-PVCP and experts who routinely performed the procedure were asked to perform three ultrasound-guided catheter placement attempts on the phantom. Afterward, they were asked to complete a usability questionnaire consisting of 14 questions exploring the usability and fidelity of the phantom. Results Fifty-seven participants were included in the study: 29 novices and 28 experts. When assessing positive questions about the frequency of use, ease of use, integration of functionality, quickness to learn, and confidence level, the study showed a median score of 4 to 5 out of 5 in the two groups. The median was 1 to 2 out of 5 for negative questions assessing cumbersomeness, unnecessary complexity, and model inconsistency. In an additional comment textbox, one participant mentioned that the cannulation did not feel realistic but that it was good for cannulation practice. Conclusions We believe the phantom is suitable for an educational curriculum since it shows a high level of usability, scoring high on positive questions while scoring low on negative questions, and having high functional fidelity.

Red Blood Cell Transfusion in the Intensive Care Unit

Importance

Red blood cell (RBC) transfusion is common among patients admitted to the intensive care unit (ICU). Despite multiple randomized clinical trials of hemoglobin (Hb) thresholds for transfusion, little is known about how these thresholds are incorporated into current practice.

Objective

To evaluate and describe ICU RBC transfusion practices worldwide.

Design, Setting, and Participants

International, prospective, cohort study that involved 3643 adult patients from 233 ICUs in 30 countries on 6 continents from March 2019 to October 2022 with data collection in prespecified weeks.

Exposure

ICU stay.

Main Outcomes and Measures

The primary outcome was the occurrence of RBC transfusion during ICU stay. Additional outcomes included the indication(s) for RBC transfusion (consisting of clinical reasons and physiological triggers), the stated Hb threshold and actual measured Hb values before and after an RBC transfusion, and the number of units transfused.

Results

Among 3908 potentially eligible patients, 3643 were included across 233 ICUs (median of 11 patients per ICU [IQR, 5-20]) in 30 countries on 6 continents. Among the participants, the mean (SD) age was 61 (16) years, 62% were male (2267/3643), and the median Sequential Organ Failure Assessment score was 3.2 (IQR, 1.5-6.0). A total of 894 patients (25%) received 1 or more RBC transfusions during their ICU stay, with a median total of 2 units per patient (IQR, 1-4). The proportion of patients who received a transfusion ranged from 0% to 100% across centers, from 0% to 80% across countries, and from 19% to 45% across continents. Among the patients who received a transfusion, a total of 1727 RBC transfusions were administered, wherein the most common clinical indications were low Hb value (n = 1412 [81.8%]; mean [SD] lowest Hb before transfusion, 7.4 [1.2] g/dL), active bleeding (n = 479; 27.7%), and hemodynamic instability (n = 406 [23.5%]). Among the events with a stated physiological trigger, the most frequently stated triggers were hypotension (n = 728 [42.2%]), tachycardia (n = 474 [27.4%]), and increased lactate levels (n = 308 [17.8%]). The median lowest Hb level on days with an RBC transfusion ranged from 5.2 g/dL to 13.1 g/dL across centers, from 5.3 g/dL to 9.1 g/dL across countries, and from 7.2 g/dL to 8.7 g/dL across continents. Approximately 84% of ICUs administered transfusions to patients at a median Hb level greater than 7 g/dL.

Conclusions and Relevance

RBC transfusion was common in patients admitted to ICUs worldwide between 2019 and 2022, with high variability across centers in transfusion practices.

Thrombocytopenia and platelet transfusions in ICU patients: an international inception cohort study (PLOT-ICU)

PURPOSE

Thrombocytopenia (platelet count < 150 × 109/L) is common in intensive care unit (ICU) patients and is likely associated with worse outcomes. In this study we present international contemporary data on thrombocytopenia in ICU patients.

METHODS

We conducted a prospective cohort study in adult ICU patients in 52 ICUs across 10 countries. We assessed frequencies of thrombocytopenia, use of platelet transfusions and clinical outcomes including mortality. We evaluated pre-selected potential risk factors for the development of thrombocytopenia during ICU stay and associations between thrombocytopenia at ICU admission and 90-day mortality using pre-specified logistic regression analyses.

RESULTS

We analysed 1166 ICU patients; the median age was 63 years and 39.5% were female. Overall, 43.2% (95% confidence interval (CI) 40.4-46.1) had thrombocytopenia; 23.4% (20-26) had thrombocytopenia at ICU admission, and 19.8% (17.6-22.2) developed thrombocytopenia during their ICU stay. Absence of acquired immune deficiency syndrome (AIDS), non-cancer-related immune deficiency, liver failure, male sex, septic shock, and bleeding at ICU admission were associated with the development of thrombocytopenia during ICU stay. Among patients with thrombocytopenia, 22.6% received platelet transfusion(s), and 64.3% of in-ICU transfusions were prophylactic. Patients with thrombocytopenia had higher occurrences of bleeding and death, fewer days alive without the use of life-support, and fewer days alive and out of hospital. Thrombocytopenia at ICU admission was associated with 90-day mortality (adjusted odds ratio 1.7; 95% CI 1.19-2.42).

CONCLUSION

Thrombocytopenia occurred in 43% of critically ill patients and was associated with worse outcomes including increased mortality. Platelet transfusions were given to 23% of patients with thrombocytopenia and most were prophylactic.

Sexual dimorphism in Louisiana pine snakes (Pituophis ruthveni)

The Louisiana pine snake, Pituophis ruthveni, is a cryptic, federally threatened snake species with several fragmented populations in Louisiana and Texas, USA. There are currently four captive breeding populations in zoos in the USA; however, little scientific data exists on their life history and anatomy. Accurate sex determination and identification of normal reproductive anatomy are an essential part of a veterinary exam and conservation programs. The authors had encountered various cases of sex misidentification in this species that were attributed to lack of lubrication of the sexing probes and enlarged musk glands. Anecdotal observation led to a hypothesis of sexual dimorphism based on body and tail shape. To test this hypothesis, we measured body length, tail length and width, and body to tail taper angle in 15 P. ruthveni (9 males and 6 females). We also obtained tail radiographs of all animals to document the presence of mineralized hemipenes. Significant dimorphism was identified in relative tail length, width, and taper angle; females consistently exhibited a more acute taper angle. Contrary to previous studies in other Pituophis species, a male-biased sexual size dimorphism was not identified. Mineralized hemipenes were confirmed in all males (a newly described trait in this species), and we found that the lateral view was consistently more reliable for identification of hemipenes compared to the ventrodorsal view. This information contributes to the scientific community's understanding of this species and is of use to biologists and veterinarians working toward conservation of this threatened species.

Long-term effects of restriction of intravenous fluid in adult ICU patients with septic shock

PURPOSE

To assess long-term outcomes of restrictive versus standard intravenous (IV) fluid therapy in adult intensive care unit (ICU) patients with septic shock included in the European Conservative versus Liberal Approach to Fluid Therapy in Septic Shock in Intensive Care (CLASSIC) trial.

METHODS

We conducted the pre-planned analyses of mortality, health-related quality of life (HRQoL) using EuroQol (EQ)-5D-5L index values and EQ visual analogue scale (VAS), and cognitive function using Mini Montreal Cognitive Assessment (Mini MoCA) test at 1 year. Deceased patients were assigned numerical zero for HRQoL as a state equal to death and zero for cognitive function outcomes as worst possible score, and we used multiple imputation for missing data on HRQoL and cognitive function.

RESULTS

Among 1554 randomized patients, we obtained 1-year data on mortality in 97.9% of patients, HRQoL in 91.3%, and cognitive function in 86.3%. One-year mortality was 385/746 (51.3%) in the restrictive-fluid group versus 383/767 (49.9%) in the standard-fluid group, absolute risk difference 1.5%-points [99% confidence interval (CI) - 4.8 to 7.8]. Mean differences were 0.00 (99% CI - 0.06 to 0.05) for EQ-5D-5L index values, - 0.65 for EQ VAS (- 5.40 to 4.08), and - 0.14 for Mini MoCA (- 1.59 to 1.14) for the restrictive-fluid group versus the standard-fluid group. The results for survivors only were similar in both groups.

CONCLUSIONS

Among adult ICU patients with septic shock, restrictive versus standard IV fluid therapy resulted in similar survival, HRQoL, and cognitive function at 1 year, but clinically important differences could not be ruled out.

Research priorities for therapeutic plasma exchange in critically ill patients

Therapeutic plasma exchange (TPE) is a therapeutic intervention that separates plasma from blood cells to remove pathological factors or to replenish deficient factors. The use of TPE is increasing over the last decades. However, despite a good theoretical rationale and biological plausibility for TPE as a therapy for numerous diseases or syndromes associated with critical illness, TPE in the intensive care unit (ICU) setting has not been studied extensively. A group of eighteen experts around the globe from different clinical backgrounds used a modified Delphi method to phrase key research questions related to "TPE in the critically ill patient". These questions focused on: (1) the pathophysiological role of the removal and replacement process, (2) optimal timing of treatment, (3) dosing and treatment regimes, (4) risk-benefit assumptions and (5) novel indications in need of exploration. For all five topics, the current understanding as well as gaps in knowledge and future directions were assessed. The content should stimulate future research in the field and novel clinical applications.

Cancer Decedents' Hospital End-of-Life Care Documentation: A Retrospective Review of Patient Records

Objective: International standards of end-of-life care (EOLC) intend to guide the delivery of safe and high-quality EOLC. Adequately documented care is conducive to higher quality of care, but the extent to which EOLC standards are documented in hospital medical records is unknown. Assessing which EOLC standards are documented in patients' medical records can help identify areas that are performed well and areas where improvements are needed. This study assessed cancer decedents' EOLC documentation in hospital settings. Methods: Medical records of 240 cancer decedents were retrospectively evaluated. Data were collected across six Australian hospitals between 1/01/2019 and 31/12/2019. EOLC documentation related to Advance Care Planning (ACP), resuscitation planning, care of the dying person, and grief and bereavement care was reviewed. Chi-square tests assessed associations between EOLC documentation and patient characteristics, and hospital settings (specialist palliative care unit, sub-acute/rehabilitation care settings, acute care wards, and intensive care units). Results: Decedents' mean age was 75.3 years (SD 11.8), 52.0% (n = 125) were female, and 73.7% lived with other adults or carers. All patients (n = 240; 100%) had documentation for resuscitation planning, 97.6% (n = 235) for Care for the Dying Person, 40.0% for grief and bereavement care (n = 96), and 30.4% (n = 73) for ACP. Patients living with other adults or carers were less likely to have a documented ACP than those living alone or with dependents (OR 0.48; 95% CI 0.26-0.89). EOLC documentation was significantly greater in specialist palliative care settings than that in other hospital settings (P < .001). Conclusion: The process of dying is well documented among inpatients diagnosed with cancer. ACP and grief and bereavement support are not documented enough. Organizational endorsement of a clear practice framework and increased training could improve documentation of these aspects of EOLC.

A13 THE RATE OF ADVERSE EVENTS AFTER COVID-19 VACCINATION IS SIMILAR IN PATIENTS WITH CELIAC DISEASE AND NON-CELIAC POPULATION: RESULTS OF A LARGE INTERNATIONAL CROSS-SECTIONAL STUDY

Background

Patients with celiac disease (CeD) reported increased COVID-19 vaccine hesitancy due to a fear of adverse events (AEs). However, the risk of AEs post-COVID-19 vaccination in patients with CeD is unknown.

Purpose

To assess whether the rate of common side effects (SEs) and AEs due to COVID vaccines are higher in patients with CeD compared to a non-CeD population.

Method

We conducted a collaborative international cross-sectional study in 16 countries between April 2022 and July 2022. An online survey was distributed to patients with CeD through patients’ local societies, and to non-CeD from the general population in each country through social media posts, word-of-mouth, and through academic institutions. We collected data on participant demographics, medical conditions, CeD diagnosis, GFD adherence, history of COVID-19 vaccinations (type and doses) and self-reported SEs and AEs post-COVID-19 vaccine. SEs included pain/swelling at the site, fatigue, fever, chills, nausea and/or headaches. AEs included thrombosis, myocarditis, anaphylactic reaction, and hospitalization related to the vaccine. Logistic regression models were used to assess predictors such as CeD diagnosis, age, gender, vaccine type and comorbidities on the likelihood of reporting SEs and AEs post-vaccine.

Result(s)

: A total of 17,795 participants completed the survey, 13,638 with CeD (median age of 45[27]) and 4,157 non-CeD controls (median age of 43[20]). There were no significant differences in sex between CeD and controls. Overall, CeD patients had similar odds of SEs compared with non-CeD individuals (aOR=1.02;95% CI=0.92-1.14). SEs were slightly increased only in the second dose of the vaccine in the CeD population compared to non-CeD individuals (aOR= 1.35; 95% CI=1.19-1.53). The most common reported SEs in CeD and controls were pain/swelling at the injection site (29% vs 23 %, p< 0.0001) and fatigue (29% vs 24%, p<0.0001). The odds of SEs were higher with Moderna Spikevax, AstraZeneca/Oxford and Johnson and Johnson vaccines than after the Pfizer vaccine (p< 0.0001). The overall rate of AEs post-vaccine was similar between patients with CeD and non-CeD individuals (aOR= 1.29; 95% CI= 0.89-1.87). Overall, female gender, older age, GFD adherence, respiratory conditions, obesity and receiving immunosuppressive medications increased the odds of SEs, while only age and a history of allergies increased the odds of AEs.

Conclusion(s)

In this large international study, patients with CeD reported similar rates of SEs and AEs post-COVID vaccine compared to non-CeD individuals. This information is highly relevant as it addresses the main concern leading to COVID-19 vaccine hesitancy in CeD patients.

Disclosure of Interest

None Declared

Effects of 12 mg vs. 6 mg dexamethasone on thromboembolism and bleeding in patients with critical COVID-19 - a post hoc analysis of the randomized, blinded COVID STEROID 2 trial

BACKGROUND

Thromboembolism is more common in patients with critical COVID-19 than in other critically ill patients, and inflammation has been proposed as a possible mechanism. The aim of this study was to investigate if 12 mg vs. 6 mg dexamethasone daily reduced the composite outcome of death or thromboembolism in patients with critical COVID-19.

METHODS

Using additional data on thromboembolism and bleeding we did a post hoc analysis of Swedish and Danish intensive care unit patients enrolled in the blinded randomized COVID STEROID 2 trial comparing 12 mg vs. 6 mg dexamethasone daily for up to 10 days. The primary outcome was a composite outcome of death or thromboembolism during intensive care. Secondary outcomes were thromboembolism, major bleeding, and any bleeding during intensive care.

RESULTS

We included 357 patients. Whilst in intensive care, 53 patients (29%) in the 12 mg group and 53 patients (30%) in the 6 mg group met the primary outcome with an unadjusted absolute risk difference of - 0.5% (95% CI - 10 to 9.5%, p = 1.00) and an adjusted OR of 0.93 (CI 95% 0.58 to 1.49, p = 0.77). We found no firm evidence of differences in any of the secondary outcomes.

CONCLUSIONS

Among patients with critical COVID-19, 12 mg vs. 6 mg dexamethasone daily did not result in a statistically significant difference in the composite outcome of death or thromboembolism. However, uncertainty remains due to the limited number of patients.

Learning insertion of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter: Is clinical experience necessary? A prospective trial

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging and potentially life-saving procedure, necessitating qualified operators in an increasing number of centres. The procedure shares technical elements with other vascular access procedures using the Seldinger technique, which is mastered by doctors not only in endovascular specialties but also in trauma surgery, emergency medicine, and anaesthesiology. We hypothesised that doctors mastering the Seldinger technique (experienced anaesthesiologist) would learn the technical aspects of REBOA with limited training and remain technically superior to doctors unfamiliar with the Seldinger technique (novice residents) given similar training.

METHODS

This was a prospective trial of an educational intervention. Three groups of doctors were enroled: novice residents, experienced anaesthesiologists, and endovascular experts. The novices and the anaesthesiologists completed 2.5 h of simulation-based REBOA training. Their skills were tested before and 8-12 weeks after training using a standardised simulated scenario. The endovascular experts, constituting a reference group, were equivalently tested. All performances were video recorded and rated by three blinded experts using a validated assessment tool for REBOA (REBOA-RATE). Performances were compared between groups and with a previously published pass/fail cutoff.

RESULTS

Sixteen novices, 13 board-certified specialists in anaesthesiology, and 13 endovascular experts participated. Before training, the anaesthesiologists outperformed the novices by 30 percentage points of the maximum REBOA-RATE score (56% (SD 14.0) vs 26% (SD 17%), p<0.01). After training, there was no difference in skills between the two groups (78% (SD 11%) vs 78 (SD 14%), p = 0.93). Neither group reached the endovascular experts' skill level (89% (SD 7%), p<0.05).

CONCLUSION

For doctors mastering the Seldinger technique, there was an initial inter-procedural transfer of skills advantage when performing REBOA. However, after identical simulation-based training, novices performed equally well to anaesthesiologists, indicating that vascular access experience is not a prerequisite to learning the technical aspects of REBOA. Both groups would need more training to reach technical proficiency.

A racial bias test with tertiary cancer centre employees: why anti-racist measures are required for First Nations Australians cancer care equity

Objective To examine implicit bias in employees at a cancer centre using an Australian race (Aboriginal-white) Implicit Association Test (IAT), in an attempt to understand a potential factor for inequitable outcomes of First Nations Australians cancer patients. Methods All employees at an Australian cancer centre were invited to take part in a web-based, cross-sectional study using an Australian race IAT. The results were analysed using Welch t-tests, linear regression and ANOVA. Results Overall, 538/2871 participants (19%) completed the IAT between January and June 2020. The mean IAT was 0.147 (s.d. 0.43, P < 0.001, 95% CI 0.11-0.18), and 60% had a preference for white over First Nations Australians. There was no significant mean difference in IAT scores between sub-groups of gender, age or clinical/non-clinical employees. 21% of employees (95% CI 17.65-24.53) had moderate to strong preference for white over First Nations Australians, compared to 7.1% with moderate to strong preference for First Nations over white Australians (95% CI 5.01-9.09). Conclusions Inequitable cancer survival for First Nations patients has been well established and cancer is now the leading cause of mortality. This paper documents the presence of racial bias in employees at one cancer centre. We argue that this cannot be understood outside the history of colonialism and its effects on First Nations Australians, healthcare workers and our society. Further research is required to evaluate measures of racism, its effect on health care, and how to eliminate it.

Thromboembolic and bleeding events in ICU patients with COVID-19: A nationwide, observational study

BACKGROUND

Intensive care unit (ICU) patients with Coronavirus disease 2019 (COVID-19) have an increased risk of thromboembolic complications. We describe the occurrence of thromboembolic and bleeding events in all ICU patients with COVID-19 in Denmark during the first and second waves of the pandemic.

METHODS

This was a sub-study of the Danish Intensive Care Covid database, in which all patients with SARS-CoV-2 admitted to Danish ICUs from 10th March 2020 to 30th June 2021 were included. We registered coagulation variables at admission, and all thromboembolic and bleeding events, and the use of heparins during ICU stay. Variables associated with thrombosis and bleeding and any association with 90-day mortality were estimated using Cox regression analyses.

RESULTS

We included 1369 patients in this sub-study; 158 (12%, 95% confidence interval 10-13) had a thromboembolic event in ICU and 309 (23%, 20-25) had a bleeding event, among whom 81 patients (6%, 4.8-7.3) had major bleeding. We found that mechanical ventilation and increased D-dimer were associated with thrombosis and mechanical ventilation, low platelet count and presence of haematological malignancy were associated with bleeding. Most patients (76%) received increased doses of thromboprophylaxis during their ICU stay. Thromboembolic events were not associated with mortality in adjusted analysis (hazard ratio 1.35 [0.91-2.01, p = .14], whereas bleeding events were 1.55 [1.18-2.05, p = .002]).

CONCLUSIONS

Both thromboembolic and bleeding events frequently occurred in ICU patients with COVID-19. Based on these data, it is not apparent that increased doses of thromboprophylaxis were beneficial.

Platelet transfusions and thrombocytopenia in intensive care units: protocol for an international inception cohort study (PLOT‐ICU)

Introduction

Thrombocytopenia is frequent in intensive care unit (ICU) patients and has been associated with worse outcome. Platelet transfusions are often used in the management of ICU patients with severe thrombocytopenia. However, the reported frequencies of thrombocytopenia and platelet transfusion practices in the ICU vary considerably. Therefore, we aim to provide contemporary epidemiological data on thrombocytopenia and platelet transfusion practices in the ICU.

Methods

We will conduct an international inception cohort, including at least 1000 acutely admitted adult ICU patients. Routinely available data will be collected at baseline (ICU admission), and daily during ICU stay up to a maximum of 90 days. The primary outcome will be the number of patients with thrombocytopenia (a recorded platelet count < 150 × 10⁹/L) at baseline and/or during ICU stay. Secondary outcomes include mortality, days alive and out of hospital, days alive without life‐support, the number of patients with at least one bleeding episode, at least one thromboembolic event and at least one platelet transfusion in the ICU, the number of platelet transfusions and the indications for transfusion. The primary and secondary outcomes will be presented descriptively. In addition, we will assess risk factors for developing thrombocytopenia during ICU stay and the association between thrombocytopenia at baseline and 90‐day mortality using logistic regression analyses.

Conclusion

The outlined international PLOT‐ICU cohort study will provide contemporary epidemiological data on the burden and clinical significance of thrombocytopenia in adult ICU patients and describe the current platelet transfusion practice.

Restriction of Intravenous Fluid in ICU Patients with Septic Shock

BACKGROUND

Intravenous fluids are recommended for the treatment of patients who are in septic shock, but higher fluid volumes have been associated with harm in patients who are in the intensive care unit (ICU).

METHODS

In this international, randomized trial, we assigned patients with septic shock in the ICU who had received at least 1 liter of intravenous fluid to receive restricted intravenous fluid or standard intravenous fluid therapy; patients were included if the onset of shock had been within 12 hours before screening. The primary outcome was death from any cause within 90 days after randomization.

RESULTS

We enrolled 1554 patients; 770 were assigned to the restrictive-fluid group and 784 to the standard-fluid group. Primary outcome data were available for 1545 patients (99.4%). In the ICU, the restrictive-fluid group received a median of 1798 ml of intravenous fluid (interquartile range, 500 to 4366); the standard-fluid group received a median of 3811 ml (interquartile range, 1861 to 6762). At 90 days, death had occurred in 323 of 764 patients (42.3%) in the restrictive-fluid group, as compared with 329 of 781 patients (42.1%) in the standard-fluid group (adjusted absolute difference, 0.1 percentage points; 95% confidence interval [CI], -4.7 to 4.9; P = 0.96). In the ICU, serious adverse events occurred at least once in 221 of 751 patients (29.4%) in the restrictive-fluid group and in 238 of 772 patients (30.8%) in the standard-fluid group (adjusted absolute difference, -1.7 percentage points; 99% CI, -7.7 to 4.3). At 90 days after randomization, the numbers of days alive without life support and days alive and out of the hospital were similar in the two groups.

CONCLUSIONS

Among adult patients with septic shock in the ICU, intravenous fluid restriction did not result in fewer deaths at 90 days than standard intravenous fluid therapy. (Funded by the Novo Nordisk Foundation and others; CLASSIC ClinicalTrials.gov number, NCT03668236.).

AB1465 BLACK PATIENTS ARE LESS SATISFIED WITH THE PROCESS OF CARE FOLLOWING PRIMARY HIP AND KNEE ARTHROPLASTY: A RETROSPECTIVE STUDY

Background

Patients’ post-operative satisfaction with their hospital experience is important to patient care, hospital reimbursement, and comparison between hospitals. The Press Ganey (PG) inpatient survey is commonly administered to assess patient satisfaction with the process of care. However, whether patient PG survey scores following primary unilateral hip and knee arthroplasty are associated with a patient’s race and socioeconomic status (SES) is unknown.

Objectives

We aimed to determine whether patient PG survey overall assessment scores differ by race and SES.

Methods

We linked data for patients in large institutional hip and knee arthroplasty registries consisting of surgeries from July 2010–February 2012 to their PG survey responses. Patients undergoing primary unilateral surgery of Black or White race who resided in New York, New Jersey, or Connecticut at the time of surgery were included in the analysis. The primary outcome variable was the PG overall assessment score, calculated as the mean of a patient’s ratings for the three questions in the “Overall Assessment” section of the PG survey and dichotomized as either completely satisfied (score of 100) or not completely satisfied (score <100). Primary payor was used as a proxy for patient SES. Multivariable logistic regression was performed for the hip and knee cohorts separately to determine if patient race and primary payor were associated with not being completely satisfied, adjusting for age, sex, and American Society of Anesthesiology (ASA) score.

Results

There were 2,516 hip patients and 2,113 knee patients with PG overall assessment scores included in the analyses (Table 1). Black patients were more likely to be not completely satisfied compared to White patients in both cohorts [hip (odds ratio (OR)=1.64; 95% confidence interval (CI): 1.03, 2.61; p=0.04)]; [knee (OR=1.83; 95% CI: 1.16, 2.88; p=0.01). In the hip cohort, patients between 70-79 years old (OR=1.71; 95% CI: 1.09, 2.67; p=0.02) and older than 80 years (OR=2.00; 95% CI: 1.20, 3.32; p<0.01) were more likely to be not completely satisfied. In the knee cohort, patients 50-59 years old (OR=0.56; 95% CI: 0.33, 0.97; p=0.04) and 60-69 years old (OR=0.57; 95% CI: 0.33, 0.96; p=0.03) were less likely to be not completely satisfied compared to patients <50 years old.

Table 1.

Likelihood of not being completely satisfied with the process of care (PG score <100)

VariableReferenceCategoryHip Cohort (n = 2,516)Knee Cohort (n = 2,113)Odds Ratio95% CIp-valueOdds Ratio95% CIp-valueAge Group<5050-591.02(0.69, 1.50)0.9390.56(0.32, 0.97)0.039<5060-691.04(0.70, 1.54)0.8580.57(0.33, 0.96)0.034<5070-791.71(1.09, 2.67)0.0190.63(0.36, 1.11)0.113<5080+2.00(1.20, 3.32)0.0080.97(0.53, 1.77)0.912SexFemaleMale0.84(0.69, 1.02)0.0821.03(0.83, 1.26)0.816RaceWhiteBlack1.64(1.03, 2.61)0.0381.83(1.16, 2.88)0.010ASA status121.04(0.70, 1.55)0.8321.23(0.60, 2.51)0.580131.45(0.91, 2.29)0.1161.36(0.64, 2.87)0.41914<0.01(0.00, ***)0.968<0.01(0.00, ***)0.977Primary PayorMedicareMedicaid1.35(0.26, 7.01)0.718<0.01(0.00, ***)0.983MedicareOther/Unknown1.24(0.94, 1.64)0.1260.87(0.65, 1.17)0.362MedicarePrivate1.13(0.61, 2.10)0.6881.01(0.57, 1.78)0.983

ASA = American Society of Anesthesiologist (ASA) physical status classification. PG = Press Ganey. CI = Confidence Interval. *** indicates >999.99. Bold indicates p < 0.05

Conclusion

Black patients were less likely to be completely satisfied compared to White patients following total hip and knee arthroplasty. More research is needed to investigate other factors such as perceived staff courtesy and baseline pain and function to understand why these disparities exist.

Acknowledgements

This work was supported by the Stavros Niarchos Complex Joint Reconstruction Center at Hospital for Special Surgery. The content is solely the responsibility of the authors and does not necessarily represent the official views of the center.

Disclosure of Interests

J. Alex Gibbons: None declared, Orett Burke Jr: None declared, Huong Do: None declared, Emily Ying Lai: None declared, Bella Mehta Paid instructor for: Novartis, Letitia Bradford: None declared, Michael Parks Consultant of: ZimmerBiomet, Linda Russell: None declared, Anne Bass: None declared, Mark Figgie Shareholder of: HS2, Mekanika, and Wishbone, Consultant of: Lima and Wishbone, Susan Goodman Consultant of: UCB, Grant/research support from: Novartis

Hands-On Time in Simulation-Based Ultrasound Training - A Dose-Related Response Study

Purpose Point of care ultrasound (POCUS) is widely used, but the sensitivity and specificity of the findings are highly user-dependent. There are many different approaches to ultrasound training. The aim of this study was to explore the effects of hands-on practice when learning POCUS. Methods Junior doctors with no or limited ultrasound experience were included in the study and divided into three groups. They all completed a Focused Assessment with Sonography for Trauma (FAST) course with different amounts of hands-on practice: 40 minutes (n=67), 60 minutes (n=12), and 90 minutes of hands-on time (n=27). By the end of the course, they all completed a previously validated test. Results More hands-on time improved the mean test scores and decreased the test time. The scores of the 40-, 60-, and 90-minute groups were 11.6 (SD 2.1), 12.8 (SD 2.5), and 13.7 (SD 2.5), respectively (p<0.001). The 90-minute group completed the test significantly faster than the other two groups (20 versus 26 minutes, p=0.003). A large inter-individual variation was seen. Conclusion The necessary amount of hands-on training is unknown. This study demonstrates that performance increases with prolonged hands-on time but the inter-individual variation among trainees is very large, thereby making it impossible to define the "optimal" time. This supports the use of the concept of mastery learning where each individual trainee can continue training until proficiency is reached.

A255 INCREASED ENERGY EXPENDITURE AND REDUCED EXERCISE CAPACITY IN CELIAC DISEASE PATIENTS ON A GLUTEN-FREE DIET

Background

Celiac disease (CeD) patients often exhibit impaired nutritional status due to nutrient malabsorption and altered metabolism. Accurate clinical assessment of malnutrition, muscle function and energy requirements are thus essential to prevent and treat malnutrition. Indirect calorimetry (IC) is the most accurate method to measure energy needs, but it is underutilized in outpatient settings.

Aims

To assess the use of IC testing in estimating the resting energy expenditure and exercise-related energy utilization in treated CeD patients compared to patients with other gastrointestinal (GI) conditions.

Methods

Adult patients attending the Celiac and Nutrition Clinic at McMaster University that underwent rest and exercise testing as a part of their nutritional assessment were enrolled. CeD diagnosis was based on positive CeD serology and confirmed by biopsy, and all of them were on a GFD for at least 6 months. Patients with inflammatory bowel disease (IBD), functional gastrointestinal disorders (FGID) and undernutrition due to other causes (UN) were included as controls. Resting energy expenditure was assessed using 3

methods

1) predictive formula (25kcal/kg), 2) Harris Benedict and 3) estimation of VO2 by IC. Exercise capacity and energy expenditure (EE) during exercise was estimated at baseline, moderate and maximum exercise. Statistical analysis was performed using SPSS. ANOVA with Bonferroni corrections and Chi2 test were used to assess differences between continuous and categorical variables, respectively.

Results

A total of 66 patients (CeD n=24; IBD n=15; FGID n=17; UN n=10) were included in the analysis. The REE of GI patients measured using the HB equation and the predictive formula were significantly underestimated compared to IC [Mean Difference (MD)=229 kcal/day p=0.03 and MD=365 kcal/day p&lt;0.001, respectively]. The EE during exercise increased with intensity of exercise. CeD patients had the highest EE during moderate and strenuous exercise (Mean EE = 286 kcal/h and 494 kcal/h respectively) compared to patients with other GI conditions (Moderate and Strenuous for IBD= 218kcal/h and 373kcal/h; for FGIDs 296kcal/hand 467kcal/h, for UN, Mean EE = 181kcal/h and 294kcal/h). Exercise capacity was reduced in CeD compared to predicted exercise capacity (Mean = 86% predicted work capacity, range 72.5–107%), but was significantly higher than IBD (86% vs 73%; p=0.65) and UN patients (86% vs 46%; p=0.004).

Conclusions

Increased energy consumption and reduced exercise capacity is suggestive of chronic impaired nutritional status in treated CeD patients. Future studies with larger sample sizes are needed to understand whether incorporating accurate estimations of energy expenditure in nutritional practices can improve CeD outcomes.

Funding Agencies

CAG

A251 USE OF INDIRECT CALORIMETRY TESTING TO DIRECT NUTRITION SUPPORT IN CRITICALLY ILL PATIENTS WITH GASTROINTESTINAL CONDITIONS

Background

Indirect calorimetry (IC), which measures oxygen uptake and carbon dioxide output, determines energy expenditure (EE) more precisely than predictive equations in critically ill patients. It is unknown whether the use of IC affects energy provision in critically ill patients with gastrointestinal (GI) conditions that affect absorption and digestion

Aims

To (1) compare IC and predictive equations for determining energy needs and (2) evaluate whether IC results affect changes in nutrition support in critically ill patients with GI conditions.

Methods

In a prospective, observational study, IC was performed for 25 to 55 mins in critically ill patients admitted to intensive care or clinical wards at 2 tertiary-care hospitals in Hamilton, Ontario between Feb 2018 to Sept 2021. EE measured by IC was compared to EE determined by a predictive equation (25 kcal/kg) or the Harris-Benedict (HB) formula. A change in energy provision was defined as a change of >10% directed by IC. Continuous data are expressed as means and standard deviation (SD), and categorical data as a proportion of patients. The Mann Whitney U Test (SPSSv26) was used to compare GI and non-GI populations.

Results

Of 296 IC tests in 229 patients, 39 of them were in 30 GI patients (11 female; mean age 62 yrs; SD 19). Admission GI diagnoses were pancreatitis (33%), liver disease (20%), Crohn’s disease/ autoimmune enteropathy (20%), post-bowel resection (10%), chronic abdominal pain (10%), and cholangitis (7%). The predictive formula underestimated EE in 67% of GI patients (mean deficit 503 kcal/day) compared to IC, corresponding to a mean deficit of 25% of patients’ energy needs. The HB formula underestimated EE in 73% of patients (mean deficit 652 kcal/day), a mean deficit of 28% of patients’ energy needs compared to IC. Pancreatitis was the majority diagnosis (75% of the predictive equation; 50% HB) among patients with the highest deficit (>30%) in energy needs when compared to IC. There were no significant differences in the rates of underestimation of energy needs based on predictive and HB formulas between the GI and non-GI patients or between luminal GI and non-luminal GI conditions. After IC, 63% of tests led to changes in energy provisions in GI patients; most requiring an increase in energy provisions (53%).

Conclusions

The use of IC to accurately measure EE led to changes in energy provisions in critically ill GI patients. Preventing over- and underfeeding with the implementation of IC to guide nutrition has the potential to improve outcomes in critically ill patients with gastrointestinal conditions.

Funding Agencies

None

A194 THE ADDITION OF DEAMIDATED GLIADIN PEPTIDE TO TISSUE TRANSGLUTAMINASE ANTIBODIES DOES NOT INCREASE THE ODDS OF CELIAC DISEASE DIAGNOSIS IN AN IGA SUFFICIENT POPULATION

Background

Previous studies proposed that the combination of IgA anti-tissue transglutaminase 2 IgA (TTG) and IgG deamidated gliadin peptide IgG (DGP) antibodies increases celiac disease (CeD) detection rates. However, this remains controversial.

Aims

To evaluate the performance of adding DGP to TTG antibodies, for the diagnosis of celiac disease (CeD) in the immunoglobulin A (IgA)-sufficient population.

Methods

We included consecutive patients with suspected CeD who had both TTG and DGP serology performed simultaneously from 2017–2020 in Hamilton, Canada. Chart review was performed by 3 reviewers to extract data on biopsies, diagnosis of CeD and genetic HLA-DQ2/DQ8. CeD was defined as positive serology (either TTG and/or DGP) and villous atrophy in duodenal biopsies (≥Marsh-3a). A case was defined as an instance of TTG and DGP performed at a single timepoint. A single patient could have represented multiple cases if TTG and DGP were measured at multiple time points. Sensitivity, specificity, negative and positive predictive values were calculated, and ROC curves were generated. Diagnostic odds ratios (DOR) assessed the performance of each serological strategy compared to duodenal biopsies.

Results

There were 580 patients constituting 823 cases that met inclusion criteria, of whom 441 had CeD. IgA-deficient patients (n=100) were excluded. Of the 723 cases remaining, 337 (214 adult;123 pediatric) had serology performed at the time of CeD diagnosis. TTG increased the odds of CeD diagnosis compared with DGP, Diagnostic Odds Ratio (DOR)=53.22 (95% CI 22.63–119.80) vs DOR=21.28 (95% CI 10.67–42.46). The addition of DGP to TTG did not increase the odds of CeD diagnosis [DGP+TTG DOR=51.39 (95% CI 19.36–135.61) vs TTG alone DOR=53.22 (95% CI 22.63–119.80)]. There were 37 discordant cases where only one of either TTG or DGP was positive. HLA-DQ2/DQ8 were absent in 2/9 cases with isolated increased DGP. Among the discordant cases, TTG outperformed DGP (DOR TTG= 4.29; 95% CI 1.09–16.83 vs DOR DGP=0.23; 95% CI 0.06–0.92).

Conclusions

In the IgA-sufficient population, the addition of DGP to TTG testing does not increase the diagnostic accuracy of CeD serologic screening. This has implications in health-care costs as false positive results prompt further investigations. Given these findings, larger prospective studies should be completed prior to adding DGP antibodies to routine TTG serology.

Funding Agencies

None

Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia: The COVID STEROID randomised, placebo-controlled trial

Background

In the early phase of the pandemic, some guidelines recommended the use of corticosteroids for critically ill patients with COVID‐19, whereas others recommended against the use despite lack of firm evidence of either benefit or harm. In the COVID STEROID trial, we aimed to assess the effects of low‐dose hydrocortisone on patient‐centred outcomes in adults with COVID‐19 and severe hypoxia.

Methods

In this multicentre, parallel‐group, placebo‐controlled, blinded, centrally randomised, stratified clinical trial, we randomly assigned adults with confirmed COVID‐19 and severe hypoxia (use of mechanical ventilation or supplementary oxygen with a flow of at least 10 L/min) to either hydrocortisone (200 mg/d) vs a matching placebo for 7 days or until hospital discharge. The primary outcome was the number of days alive without life support at day 28 after randomisation.

Results

The trial was terminated early when 30 out of 1000 participants had been enrolled because of external evidence indicating benefit from corticosteroids in severe COVID‐19. At day 28, the median number of days alive without life support in the hydrocortisone vs placebo group were 7 vs 10 (adjusted mean difference: −1.1 days, 95% CI −9.5 to 7.3, P = .79); mortality was 6/16 vs 2/14; and the number of serious adverse reactions 1/16 vs 0/14.

Conclusions

In this trial of adults with COVID‐19 and severe hypoxia, we were unable to provide precise estimates of the benefits and harms of hydrocortisone as compared with placebo as only 3% of the planned sample size were enrolled.

Trial registration: ClinicalTrials.gov: NCT04348305. European Union Drug Regulation Authorities Clinical Trials (EudraCT) Database: 2020‐001395‐15.

Declining Use of Corticosteroids for Crohn's Disease Has Implications for Study Recruitment: Results of a Pilot Randomized Controlled Trial

Background

Corticosteroids (CS) have been used extensively to induce remission in Crohn’s disease (CD); however, they are associated with severe side effects. We hypothesized that the administration of an exclusive enteral nutrition (EEN) formula to CS would lead to increased CD remission rates and to decreased CS-related adverse events. We proposed to undertake a pilot study comparing EEN and CS therapy to CS alone to assess decrease symptoms and inflammatory markers over 6 weeks.

Aim

The overall aim was to assess study feasibility based on recruitment rates and acceptability of treatment in arms involving EEN

Methods

The pilot study intended to recruit 100 adult patients with active CD who had been prescribed CS to induce remission as part of their care. The patients were randomized to one of three arms: (i) standard-dose CS; (ii) standard-dose CS plus EEN (Modulen 1.5 kcal); or (iii) short-course CS plus EEN.

Results

A total of 2009 CD patients attending gastroenterology clinics were screened from October 2018 to November 2019. Prednisone was prescribed to only 6.8% (27/399) of patients with active CD attending outpatient clinics. Of the remaining 372 patients with active CD, 34.8% (139/399) started or escalated immunosuppressant or biologics, 49.6% (198/399) underwent further investigation and 8.8% (35/399) were offered an alternative treatment (e.g., antibiotics, surgery or investigational agents in clinical trials). Only three patients were enrolled in the study (recruitment rate 11%; 3/27), and the study was terminated for poor recruitment.

Conclusion

The apparent decline in use of CS for treatment of CD has implications for CS use as an entry criterion for clinical trials.

Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta

BACKGROUND

Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE.

METHODS

This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard.

RESULTS

Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed.

CONCLUSION

Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts.

LEVEL OF EVIDENCE

Diagnostic test, no or poor gold standard, level V.

Central and peripheral nervous system complications of COVID-19: a prospective tertiary center cohort with 3-month follow-up

OBJECTIVE

To systematically describe central (CNS) and peripheral (PNS) nervous system complications in hospitalized COVID-19 patients.

METHODS

We conducted a prospective, consecutive, observational study of adult patients from a tertiary referral center with confirmed COVID-19. All patients were screened daily for neurological and neuropsychiatric symptoms during admission and discharge. Three-month follow-up data were collected using electronic health records. We classified complications as caused by SARS-CoV-2 neurotropism, immune-mediated or critical illness-related.

RESULTS

From April to September 2020, we enrolled 61 consecutively admitted COVID-19 patients, 35 (57%) of whom required intensive care (ICU) management for respiratory failure. Forty-one CNS/PNS complications were identified in 28 of 61 (45.9%) patients and were more frequent in ICU compared to non-ICU patients. The most common CNS complication was encephalopathy (n = 19, 31.1%), which was severe in 13 patients (GCS ≤ 12), including 8 with akinetic mutism. Length of ICU admission was independently associated with encephalopathy (OR = 1.22). Other CNS complications included ischemic stroke, a biopsy-proven acute necrotizing encephalitis, and transverse myelitis. The most common PNS complication was critical illness polyneuromyopathy (13.1%), with prolonged ICU stay as independent predictor (OR = 1.14). Treatment-related PNS complications included meralgia paresthetica. Of 41 complications in total, 3 were para/post-infectious, 34 were secondary to critical illness or other causes, and 4 remained unresolved. Cerebrospinal fluid was negative for SARS-CoV-2 RNA in all 5 patients investigated.

CONCLUSION

CNS and PNS complications were common in hospitalized COVID-19 patients, particularly in the ICU, and often attributable to critical illness. When COVID-19 was the primary cause for neurological disease, no signs of viral neurotropism were detected, but laboratory changes suggested autoimmune-mediated mechanisms.

Developing a tool to assess competence in resuscitative endovascular balloon occlusion of the aorta: An international Delphi consensus study

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure that is potentially lifesaving in major noncompressible torso hemorrhage. It may also improve outcome in nontraumatic cardiac arrest. However, the procedure can be technically challenging and requires the immediate presence of a qualified operator. Thus, evidence-based training and assessment of operator skills are essential for successful implementation and patient safety. A prerequisite for this is a valid and reliable assessment tool specific for the procedure. The aim of this study was to develop a tool for assessing procedural competence in REBOA based on best-available knowledge from international experts in the field.

METHODS

We invited international REBOA experts from multiple specialties to participate in an anonymous three-round iterative Delphi study to reach consensus on the design and content of an assessment tool. In round 1, participants suggested items to be included. In rounds 2 and 3, the relevance of each suggested item was evaluated by all participants to reach consensus. Interround data processing was done systematically by a steering group.

RESULTS

Forty panelists representing both clinical and educational expertise in REBOA from 16 countries (in Europe, Asia, and North and South America) and seven different specialties participated in the study. After 3 Delphi rounds and 532 initial item suggestions, the panelists reached consensus on a 10-item assessment tool with behaviorally anchored rating scales. It includes assessment of teamwork, procedure time, selection and preparation of equipment, puncture technique, guidewire handling, sheath handling, placement of REBOA catheter, occlusion, and evaluation.

CONCLUSION

We present the REBOA-RATE assessment tool developed systematically by international experts in the field to optimize content validity. Following further studies of its validity and reliability, this tool represents an important next step in evidence-based training programs in REBOA, for example, using mastery learning.

LEVEL OF EVIDENCE

Therapeutic, level V.

Prophylactic platelet transfusions in hospitalised patients with thrombocytopenia-Protocol for a systematic review with meta-analysis

BACKGROUND

Prophylactic platelet transfusions are frequently used to prevent bleeding in hospitalised patients with thrombocytopenia. Recommendations regarding the use of prophylactic platelet transfusions in non-haematological patients are based on extrapolations, observational studies, and expert opinions, and transfusion with platelets has been associated with adverse effects. We aim to assess the overall benefits and harms of prophylactic platelet transfusions in hospitalised patients with thrombocytopenia.

METHODS/DESIGN

We will conduct a systematic review with meta-analyses and trial sequential analyses in compliance with the recommendations by the Cochrane Collaboration and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We will prepare the manuscript in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We will include randomised clinical trials assessing prophylactic platelet transfusion versus no prophylaxis or placebo in hospitalised patients with thrombocytopenia. The primary outcome is mortality at longest follow-up. Secondary outcomes include episodes of clinically important bleeding, nosocomial infections, transfusion-related adverse events, thromboembolic events, length of hospital stay, quality of life, and days alive without the use of life support. We will conduct prespecified subgroup analyses and sensitivity analyses and assess the risk of random errors by trial sequential analyses.

DISCUSSION

The proposed systematic review will provide an overview of the certainty of evidence for the benefits and harms of prophylactic platelet transfusion in hospitalised patients with thrombocytopenia.

POS0285 ARE RACIAL DISPARITIES IN REVISION TKA OUTCOMES ASSOCIATED WITH HOSPITAL OR SURGEON VOLUME?

Background:

Total knee arthroplasty (TKA) outcomes are linked to surgical volume,1 despite the increase in TKA utilization, racial disparities in TKA outcomes persist. Blacks in the US are at a higher risk of aseptic revision of TKA (R-TKA) when compared to Whites, yet the reasons for this are not understood.

Objectives:

The objective of this study is to examine the relationship between hospital and surgeon annual TKA volume and R-TKA outcomes by race.

Methods:

This is an observational cohort study. New York Statewide Planning and Research Cooperative System data for 2004 – 2013 was used to identify patients who underwent primary TKA. Data through 2015 was used to identify R-TKA within 2 years of the index TKA. Hospital characteristics were obtained from the AHA Annual Survey. Surgeon data was collected from New York State Education Department and New York State Physician Profile. Surgeon annual TKA volume was categorized based on cutoffs established by Wilson et al1 as </=12, 13-59, 60-145 or >/= 146, and hospital TKA volume as </=89, 90-235, 236-644 and >/=645. We calculated the odds of R-TKA in Whites and Blacks separately and generated crude odds ratios (OR) comparing Blacks to Whites to examine trends across volume categories. A multivariable logistic regression model adjusted for known R-TKA risk factors was also performed.

Results:

A total of 163,576 patients were included. Mean (SD) age was 66.4 (10.4) years, 107,233 (65.6%) were female, 124,277 (76.6%) were White and 15,990 (9.8%) were Black. 2925 patients underwent aseptic R-TKA. In logistic regression analysis, Blacks had a higher risk of R-TKA (OR 1.42, 95%CI 1.26-1.6) (Table 1). Risk of R-TKA was also higher when surgeon annual volume was </=12 (OR 1.5, 95%CI 1.25-1.8) or 13-59 (OR 1.16, 95%CI 1.04-1.29) TKA compared to the highest volume surgeons (>/=146). Patients who had surgery at a hospital with annual volume of 236-634 TKA were less likely to undergo R-TKA compared to the highest volume hospitals (>/=645) (OR 0.88, 95%CI 0.79-0.98). Other risk factors for R-TKA were younger age and worker’s compensation, while patients with inflammatory arthritis had a lower risk. Figures 1A and 1B show the odds of R-TKA in Whites and Blacks, respectively, by hospital and surgeon volume. Figure 1C shows the crude OR for Blacks to Whites for each category pair. The OR ranged from 0.9 to 2.5, with the largest disparity found in patients who have TKA performed by surgeons with 60-145 annual TKA volume at the highest volume hospitals (>/=645).

Conclusion:

Patients having TKA by a surgeon performing <60 TKA per year have higher risk of R-TKA. Racial disparities in R-TKA risk are highest for TKA by surgeons performing 60-145 TKA per year at hospitals performing >/=645 TKA per year. Future studies should examine factors, such as whether trainees are involved the surgery, that may vary based on social determines of health, such as patient race and payor.

References:

[1]Wilson S. et al Meaningful thresholds for the volume-outcome relationship in total knee arthroplasty. Journal of bone and joint surgery. 2016;98:1683

Table 1.

Logistic regression of risk for R-TKA

Variable (reference)LevelOdds ratio95% CIp-valueAge--0.950.94-0.95<.001Sex (female)Male1.070.99-1.150.108Race (whiteAsian0.650.42-0.960.031Black1.421.26-1.6<.001Unknown0.810.64-1.020.07Other1.050.92-1.210.446Insurance (Medicare)Medicaid0.890.75-1.060.193Other0.890.7-1.130.331Private0.820.74-0.91<.001Work compensation1.561.35-1.8<.001Surgeon volume (>/=146)</=121.51.25-1.8<.00113-591.161.04-1.290.00660-1451.00.91-1.110.957Hospital volume (>/=645)</= 890.980.84-1.150.84890-2350.990.88-1.120.869236-6440.880.79-0.980.018Hospital bed size (>400 beds)6-1991.131.02-1.250.024200-3991.060.96-1.170.262

Other variables in model: diabetes, obesity, renal disease, COPD, osteoarthritis, osteonecrosis, dislocation, inflammatory arthritis, surgical complication, infection, no college, poverty >20%, years since residency, US/Canada medical school, orthopedic board certified, AHA control, teaching, rural hospital

Disclosure of Interests:

Serene Mirza: None declared, Susan Goodman: None declared, Yi Zhang: None declared, Huong Do: None declared, Bella Mehta: None declared, Stephen Lyman: None declared, Lisa A. Mandl: None declared, Mark Figgie: None declared, Michael Parks Consultant of: Zimmer biomet, Grant/research support from: Zimmer biomet, Linda Russell: None declared, Anne Bass: None declared

Training and education of healthcare workers during viral epidemics: a systematic review

BACKGROUND

It is necessary to train a large number of healthcare workers (HCW) within a limited time to ensure adequate human resources during an epidemic. There remains an urgent need for best practices on development and implementation of training programmes.

OBJECTIVE

To explore published literature in relation to training and education for viral epidemics as well as the effect of these interventions to inform training of HCW.

DATA SOURCES

Systematic searches in five databases performed between 1 January 2000 and 24 April 2020 for studies reporting on educational interventions in response to major viral epidemics.

STUDY ELIGIBILITY CRITERIA

All studies on educational interventions developed, implemented and evaluated in response to major global viral outbreaks from 2000 to 2020.

PARTICIPANTS

Healthcare workers.

INTERVENTIONS

Educational or training interventions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Descriptive information were extracted and synthesised according to content, competency category, educational methodology, educational effects and level of educational outcome. Quality appraisal was performed using a criterion-based checklist.

RESULTS

A total of 15 676 records were identified and 46 studies were included. Most studies were motivated by the Ebola virus outbreak with doctors and nurses as primary learners. Traditional didactic methods were commonly used to teach theoretical knowledge. Simulation-based training was used mainly for training of technical skills, such as donning and doffing of personal protective equipment. Evaluation of the interventions consisted mostly of surveys on learner satisfaction and confidence or tests of knowledge and skills. Only three studies investigated transfer to the clinical setting or effect on patient outcomes.

CONCLUSIONS AND IMPLICATIONS OF FINDINGS

The included studies describe important educational experiences from past epidemics with a variety of educational content, design and modes of delivery. High-level educational evidence is limited. Evidence-based and standardised training programmes that are easily adapted locally are recommended in preparation for future outbreaks.

Training non-intensivist doctors to work with COVID-19 patients in intensive care units

Background

Due to an expected surge of COVID‐19 patients in need of mechanical ventilation, the intensive care capacity was doubled at Rigshospitalet, Copenhagen, in March 2020. This resulted in an urgent need for doctors with competence in working with critically ill COVID‐19 patients. A training course and a theoretical test for non‐intensivist doctors were developed. The aims of this study were to gather validity evidence for the theoretical test and explore the effects of the course.

Methods

The 1‐day course was comprised of theoretical sessions and hands‐on training in ventilator use, hemodynamic monitoring, vascular access, and use of personal protective equipment. Validity evidence was gathered for the test by comparing answers from novices and experts in intensive care. Doctors who participated in the course completed the test before (pretest), after (posttest), and again within 8 weeks following the course (retention test).

Results

Fifty‐four non‐intensivist doctors from 15 different specialties with a wide range in clinical experience level completed the course. The test consisted of 23 questions and demonstrated a credible pass–fail standard at 16 points. Mean pretest score was 11.9 (SD 3.0), mean posttest score 20.6 (1.8), and mean retention test score 17.4 (2.2). All doctors passed the posttest.

Conclusion

Non‐intensivist doctors, irrespective of experience level, can acquire relevant knowledge for working in the ICU through a focused 1‐day evidence‐based course. This knowledge was largely retained as shown by a multiple‐choice test supported by validity evidence. The test is available in appendix and online.

Educational needs in the COVID-19 pandemic: a Delphi study among doctors and nurses in Wuhan, China

OBJECTIVE

To identify theoretical and technical aspects regarding treatment, prevention of spread and protection of staff to inform the development of a comprehensive training curriculum on COVID-19 management.

DESIGN

Cross-sectional study.

SETTING

Nine hospitals caring for patients with COVID-19 in Wuhan, China.

PARTICIPANTS

134 Chinese healthcare professionals (74 doctors and 60 nurses) who were deployed to Wuhan, China during the COVID-19 epidemic were included. A two-round Delphi process was initiated between March and May 2020. In the first round, the participants identified knowledge, technical and behavioural (ie, non-technical) skills that are needed to treat patients, prevent spread of the virus and protect healthcare workers. In round 2, the participants rated each item according to its importance to be included in a training curriculum on COVID-19. Consensus for inclusion in the final list was set at 80%.

PRIMARY OUTCOME MEASURES

Knowledge, technical and behavioural (ie, non-technical) skills that could form the basis of a training curriculum for COVID-19 management.

RESULTS

In the first round 1398 items were suggested by the doctors and reduced to 67 items after content analysis (treatment of patients: n=47; infection prevention and control: n=20). The nurses suggested 1193 items that were reduced to 70 items (treatment of patients: n=49; infection prevention and control: n=21). In round 2, the response rates were 82% in doctors and 93% in nurses. Fifty-eight items of knowledge, technical and behavioural skills were agreed on by the doctors to include in the final list. For the nurses, 58 items were agreed on.

CONCLUSIONS

This needs assessment process resulted in a comprehensive list of knowledge, technical and behavioural skills for COVID-19 management. Educators can use these to guide decisions regarding content of training curricula not only for COVID-19 management but also in preparation for future viral pandemic outbreaks.

Pre-procedural platelet transfusion thresholds in hospitalised children - Protocol for a scoping review

BACKGROUND

Thrombocytopenia is a common condition in hospitalised critically ill children and most platelet transfusions are given as prophylaxis to non-bleeding children prior to invasive procedures such as central venous catheterisation and lumbar puncture. Platelet transfusion may reduce bleeding complications but have also been associated with potential adverse effects and variation in clinical practice exist. To direct future research, we aim to assess the current evidence regarding prophylactic platelet transfusion prior to procedures in hospitalised thrombocytopenic children.

METHODS

We will conduct a scoping review of all study designs in accordance with the Preferred Reporting Items for Systematic and Meta-Analyses (PRISMA) statement. We will include studies on hospitalised children undergoing invasive procedures where the prevalence of thrombocytopenia and the predefined outcome measures, including bleeding, transfusion-related adverse events and use of blood products and life support are reported. We will provide descriptive analyses of the included studies/trials and the quality of evidence will be assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

CONCLUSION

The outlined scoping review will provide an overview on the benefits and harms of prophylactic platelet transfusion prior to invasive procedures in thrombocytopenic hospitalised children.

A22 PREVALENCE OF IRON DEFICIENCY AND SUPPLEMENTATION PRACTICES FOR PATIENTS ON HOME PARENTERAL NUTRITION

Background

Iron deficiency (ID) is common in patients receiving parenteral nutrition (PN), likely due to a lack of iron in the PN formula. There is no clear consensus on how often serum iron should be tested or iron supplementation should be given, at which dose or route, in patients on long-term PN. Within the Hamilton Health Sciences (HHS) home PN (HPN) program, the prevalence of ID or iron deficiency anemia (IDA) is unknown. This knowledge will contribute to better iron prescribing practices with ultimate benefit on patient’s health.

Aims

To assess the prevalence of ID and IDA in patients enrolled in the HHS HPN Program. The secondary aim was to assess supplementation practices for patients enrolled in the HPN program according to gastrointestinal(GI) diagnosis and duration on PN.

Methods

We conducted a retrospective study including consecutive adult patients enrolled in the HHS-HPN program from January 2015 to November 2020. We collected data on demographics (age, sex, and GI diagnosis), iron supplementation (dose, duration, and route), and information related to iron-deficiency (hemoglobin, serum iron, ferritin, TIBC, and folate) at pre-set intervals (enrollment, 3, 6, 12, 18, 24, 30, 36, 48, 60 months) and last measured. ID was defined as ferritin ≤45μg/L or serum iron ≤9μmol/L. IDA was defined as hemoglobin &lt;130g/L in men or &lt;120g/L in women in the context of ID. Data were expressed as median (IQR) for continuous variables and n/N(%) for categorical variables. Chi2 was performed to assess differences between groups and logistic regression to assess predictors of ID and IDA. The analysis was conducted using SPSS software(v26).

Results

The analysis included 125 HPN patients (50 males, median age of 55 (40–65) years). Patients received PN for a median of 195 (83–521) days. The most common diagnoses were malignancy (36.8%) and inflammatory bowel disease (23.2%); the most common indications for HPN was short bowel (29.6%) and bowel obstruction (27.2%). Iron profiles were measured in 77% of patients. At enrollment, 42.2% of patients had ID and 38.9% had IDA. Only 13% of patients with ID and 22.8% with IDA had iron supplementation (Figure 1). A total of 38 patients received iron either oral or IV (oral=44.7% vs IV=55.3%; p=0.66). There was no correlation between low levels of serum iron or ferritin with iron supplementation (p=0.23, 0.45 respectively). Age, sex, diagnosis, or reason for PN did not correlate with ID or IDA at any time point.

Conclusions

Iron-deficiency and IDA are common in patients enrolled in the HHS HPN program independently of age, sex, diagnosis and reason for PN. Prospective studies are needed to implement the most effective way to ensure proper monitoring and treatment of iron deficiency in this population.

Funding Agencies

None

A91 ECONOMIC EVALUATION OF A FECAL MICROBIOTA TRANSPLANTATION PROGRAM FOR RECURRENT CLOSTRIDIOIDES DIFFICILE INFECTION IN ALBERTA

Background

Fecal microbiota transplantation (FMT) is the most effective therapy for recurrent C. difficile infection. Although studies using statistical modeling have shown FMT to be cost-effective, real-world data is lacking.

Aims

To assess the impact of FMT program on the healthcare cost of recurrent C. difficile infections using real-world data from Alberta’s public healthcare system.

Methods

C. difficile infection patients were identified through provincial laboratory database with positive C. difficile results in Edmonton, Alberta between 2009–16. If an initial positive test was followed by ≧2 positive tests within 183 days, an individual was categorized as recurrent C. difficile infection (RCDI). Otherwise, non-recurrent C. difficile infection (non-RCDI) was assigned. Since the Edmonton FMT program was established in 2013, patients were further divided into pre-FMT (2009–12) and post-FMT (2013–16) eras. This divided patients into four study groups as outlined in Table 1. Administrative data, including inpatient stays, ambulatory or emergency room visits, outpatient prescriptions, and physician billings, were extracted. A cost of $389 was assigned to each FMT procedure to account for cost of donor screening and sample preparation. A difference in differences (DID) approach, a tool which estimates the effect of a treatment by comparing outcome difference between treatment group and control group over time, was used to analyze the impact of FMT program on the cost of RCDI. Non-RCDI patients were used as control group to account for changes in treatment costs over time. Ordinary least squares regression, with log-transformed healthcare cost as the dependent variable, was used for the analysis.

Results

4717 non-RCDI and 548 RCDI patients were identified and divided into the 4 groups (Table 1). RCDI patients were significantly older than non-RCDI patients (71.13 vs 62.49; P &lt; 0.001). After adjusting for differences in age, sex, and baseline healthcare utilization, cost for RCDI patients were significantly lower relative to costs for non-RCDI patients in the post-FMT era. Cost of non-RCDI increased by $5,300.08 between the pre- and post-FMT eras, while the cost of RCDI decreased by $7,654.92 in the same time frame (Table 2). FMT program was estimated to have saved $12,954 annually for RCDI patients at mean age, sex, and baseline cost of our overall sample.

Conclusions

Our data suggest that the healthcare cost of RCDI has decreased with the introduction of an FMT program.

Funding Agencies

Alberta Health Services, University of Alberta Hospital Foundation

Thrombocytopenia in intensive care unit patients: A scoping review

BACKGROUND

Thrombocytopenia is frequent in intensive care unit (ICU) patients and may be associated with adverse outcomes. We aimed to assess the incidence, risk factors, and outcomes associated with thrombocytopenia in adult ICU patients.

METHODS

We conducted a scoping review in accordance with the Preferred Reporting Items for Systematic Review and Meta-analyses extension for Scoping Reviews (PRISMA-ScR) and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We included study reports on adult ICU patients with thrombocytopenia and assessed patient-important outcomes, including mortality and health-related quality-of-life.

RESULTS

We included a total of 70 studies comprising a total of 215 098 patients; 57 were cohort studies. The incidence of thrombocytopenia varied from 8 to 56 per 100 admissions (very low quality of evidence). We identified several risk factors including age, sepsis, and higher disease severity (low quality of evidence). Thrombocytopenia was associated with bleeding, use of life support, length of stay in the ICU, and increased mortality (low/very low quality of evidence). Data on platelet transfusion before invasive procedures and transfusion thresholds were limited. No studies assessed the benefits and harms of thromboprophylaxis in ICU patients with thrombocytopenia.

CONCLUSIONS

Thrombocytopenia is common and associated with increased morbidity and mortality in adult ICU patients. Several risk factors for thrombocytopenia exists, but the evidence-base on management strategies, including transfusion thresholds and thromboprophylaxis in ICU patients is very limited.

Good practice statements (GPS) for the clinical care of patients with thrombotic thrombocytopenic purpura

BACKGROUND

Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its management.

METHODS

In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to both immune-mediated TTP (iTTP) and hereditary/congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations.

RESULTS

The panel agreed on eleven recommendations based on evidence ranging from very low to moderate certainty. For first episode and relapses of acute iTTP, the panel made a strong recommendation for the addition of corticosteroids to therapeutic plasma exchange (TPE), and a conditional recommendation for addition of rituximab and caplacizumab. For asymptomatic iTTP with low ADAMTS13, the panel made a conditional recommendation for rituximab outside of pregnancy, and for prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, but a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy.

CONCLUSIONS

The panel's recommendations are based on all the available evidence for the treatment effects of various approaches including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing ADAMTS13 antibody production. There was insufficient evidence for further comparison of different treatment approaches, for which future high-quality studies in iTTP (e.g., rituximab, corticosteroids, recombinant ADAMTS13, and caplacizumab) and in cTTP (eg, recombinant ADAMTS13) are needed.

ISTH guidelines for treatment of thrombotic thrombocytopenic purpura

BACKGROUND

Despite advances in treatment options for thrombotic thrombocytopenic purpura (TTP), there are still limited high quality data to inform clinicians regarding its appropriate treatment.

METHODS

In June 2018, the ISTH formed a multidisciplinary guideline panel to issue recommendations about treatment of TTP. The panel discussed 12 treatment questions related to immune-mediated TTP (iTTP) and hereditary or congenital TTP (cTTP). The panel used the Grading of Recommendations Assessment, Development, and Evaluation approach, including evidence-to-decision frameworks, to appraise evidence and formulate recommendations.

RESULTS

The panel agreed on 11 recommendations based on evidence ranging from very low to moderate certainty. For first acute episode and relapses of iTTP, the panel made a strong recommendation for adding corticosteroids to therapeutic plasma exchange (TPE) and a conditional recommendation for adding rituximab and caplacizumab. For asymptomatic iTTP with low plasma ADAMTS13 activity, the panel made a conditional recommendation for the use of rituximab outside of pregnancy, but prophylactic TPE during pregnancy. For asymptomatic cTTP, the panel made a strong recommendation for prophylactic plasma infusion during pregnancy, and a conditional recommendation for plasma infusion or a wait and watch approach outside of pregnancy.

CONCLUSIONS

The panel's recommendations are based on all the available evidence for the effects of an individual component of various treatment approaches, including suppressing inflammation, blocking platelet clumping, replacing the missing and/or inhibited ADAMTS13, and suppressing the formation of ADAMTS13 autoantibody. There was insufficient evidence for further comparing different treatment approaches (eg, TPE, corticosteroids, rituximab, and caplacizumab, etc.), for which high quality studies are needed.

ISTH guidelines for the diagnosis of thrombotic thrombocytopenic purpura

BACKGROUND

Despite an increase in our understandings of pathogenesis of thrombotic thrombocytopenic purpura (TTP), the approaches for initial diagnosis and management of TTP vary significantly.

OBJECTIVE

The evidence-based guidelines of the International Society on Thrombosis and Haemostasis (ISTH) are intended to support patients, clinicians, and other health care professionals in their decisions about the initial diagnosis and management of acute TTP.

METHODS

In June 2018, ISTH formed a multidisciplinary panel that included hematologists, an intensive care physician, nephrologist, clinical pathologist, biostatistician, and patient representatives, as well as a methodology team from McMaster University. The panel composition was designed to minimize the potential conflicts of interests. The panel used the Grading of Recommendations Assessment, Development, and Evaluation approach and the Population, Intervention, Comparison, Outcome framework to develop and grade their recommendations. Public comments were sought and incorporated in the final document.

RESULTS

The panel agreed on three recommendations covering the initial diagnosis with emphasis on the importance of ADAMTS13 testing (eg, activity, anti-ADAMTS13 IgG or inhibitor) and assessment of the pretest probability of TTP by clinical assessment and/or the risk assessment models like the PLASMIC or French score. The panel noted how availability and turnaround time of ADAMTS13 test results might affect early diagnosis and management, in particular the use of caplacizumab.

CONCLUSIONS

There is a lack of high-quality evidence to support strong recommendations for the initial diagnosis and management of a suspected TTP. The panel emphasized the importance of obtaining ADAMTS13 testing in a proper clinical context. Future research should focus on how to monitor and act on ADAMTS13 levels during remission.

Low-dose hydrocortisone in patients with COVID-19 and severe hypoxia (COVID STEROID) trial-Protocol and statistical analysis plan

Introduction

Severe acute respiratory syndrome coronavirus‐2 has caused a pandemic of coronavirus disease (COVID‐19) with many patients developing hypoxic respiratory failure. Corticosteroids reduce the time on mechanical ventilation, length of stay in the intensive care unit and potentially also mortality in similar patient populations. However, corticosteroids have undesirable effects, including longer time to viral clearance. Clinical equipoise on the use of corticosteroids for COVID‐19 exists.

Methods

The COVID STEROID trial is an international, randomised, stratified, blinded clinical trial. We will allocate 1000 adult patients with COVID‐19 receiving ≥10 L/min of oxygen or on mechanical ventilation to intravenous hydrocortisone 200 mg daily vs placebo (0.9% saline) for 7 days. The primary outcome is days alive without life support (ie mechanical ventilation, circulatory support, and renal replacement therapy) at day 28. Secondary outcomes are serious adverse reactions at day 14; days alive without life support at day 90; days alive and out of hospital at day 90; all‐cause mortality at day 28, day 90, and 1 year; and health‐related quality of life at 1 year. We will conduct the statistical analyses according to this protocol, including interim analyses for every 250 patients followed for 28 days. The primary outcome will be compared using the Kryger Jensen and Lange test in the intention to treat population and reported as differences in means and medians with 95% confidence intervals.

Discussion

The COVID STEROID trial will provide important evidence to guide the use of corticosteroids in COVID‐19 and severe hypoxia.

A ‘Musical Pathway’ for Spacially Disoriented Blind Residents of a Skilled Nursing Facility

The Auditory Directional System provides a “musical pathway” for blind persons to follow to get to interior destinations in an institutional setting. The system's components are a compact disc player and a network of speakers, infrared “people” detection equipment, and a computer-controlled speaker-sequencing system. To engage the Auditory Directional System, the blind resident pushes a centrally located button for a particular destination. When the person arrives at the first musical cue, infrared sensors detect the person and activate the next speaker. The person's presence continues to activate each subsequent speaker until he or she reaches the final destination. To trigger the detection process, the resident's clothing is equipped with retro-reflective tape This article describes the equipment—its purpose and how it works—and the results of a field test with three residents at a skilled nursing facility.

FRI0379 VARIATIONS IN THE UTILIZATION OF BILATERAL TOTAL KNEE ARTHROPLASTY IN THE MANAGEMENT OF OSTEOARTHRITIS

Background:

A third of knee osteoarthritis presents with bilateral symptomatic arthritis. In these patients, treatment options include either a staged Unilateral Total knee arthroplasty (UTKA) procedure, or a simultaneous Bilateral TKA (BTKA) procedure. Even though literature regarding outcomes in BTKA procedure has not consistently been favorable, it remains popular in select patients due to use of a single anesthetic, shorter overall surgical time, lower cost and lower overall use of narcotics. African Americans (AAs) have lower utilization and worse outcomes in UTKA literature. It is unclear whether these racial variations extend to BTKA.

Objectives:

We sought to examine BTKA vs UTKA utilization rates and outcomes comparing AA and White patients.

Methods:

National Inpatient Sample (NIS) - Healthcare Cost and Utilization Project (HCUP) database (2007-2016) was used. We identified all patients ≥ 50 years who underwent elective primary TKA using ICD-9-CM code 81.54 for UTKA and BTKA from January 1, 2012 to September 30, 2015, and ICD-10-CM codes 0SRC0x and 0SRD0x thereafter. Patients with inflammatory arthritis, pathologic fractures, metastatic disease and avascular necrosis were excluded. Major in-hospital complications included post-operative myocardial infarction, prosthetic device complication, surgical wound infection, and venous thromboembolism. Differences in temporal trends in utilization and major in-hospital complications of BTKA vs UTKA were compared between AAs and Whites. Multivariable logistic regression models were used to assess differences in both these trends between AAs and Whites after adjusting for individual (age, sex, Elixhauser comorbidity index, and morbid obesity), hospital level (hospital volume, bed size, region and teaching status) and community level (median household income) variables. Discharge weights were used to enable nationwide estimates. Multiple imputation was performed for missing race variable (11.9%).

Results:

From 2007 to 2016, an estimated 276,194 BTKA (unweighted observations 56,675) and 5,528,429 UTKA (unweighted observations 1,131,329) were identified (Table 1). Females had a higher proportion of TKAs performed (62.1% UTKA vs 55.9% BTKA). Patients had fewer comorbidities (measured by the Elixhauser Index) when undergoing BTKA compared to UTKA. The proportion of BTKA amongst all TKAs declined from 5.53% in 2007-08 to 4.03% in 2015-16. AAs continued to have significantly lower proportion of BTKA utilization compared to Whites (4.68% in AAs vs 6.08% in Whites in 2007-08, whereas 3.28% in AAs vs 4.19% in Whites in 2015-16, adjusted p < 0.001) (Figure 1a). In-hospital complication rates for UTKA and BTKA were significantly higher in Whites compared to AAs throughout the study period (0.77% in AAs vs 0.9% in Whites in 2007-08, whereas 0.69% in AAs vs 0.83% in Whites in 2015-16, adjusted p < 0.001) (Figure 1b). The results were similar after imputation of missing race values.

Conclusion:

In this nationwide sample of patients from 2007 to 2016, we found that AAs have lower utilization rate of BKTA compared to Whites, however the in-hospital complication rates were significantly higher in Whites.

References:

N/A

Table 1.

Weighted frequencies and percentages of demographic characteristics among unilateral TKA vs. bilateral TKA (N = 6, 236, 426).

VariableUnilateral TKABilateral TKAPaN = 5,528,429(Unweighted N = 1,131,329)N = 276,194(Unweighted N = 56,675)Patient CharacteristicsAge, mean (SD)67.4 (0.02)65.0 (0.06)<.0001Sex: Female, n(%)3,429,484 (62.1)154,442 (55.9)<.0001Race, n(%): White4,051,648 (50.9)212,468 (76.9)<.0001 African American352,933 (6.4)14,441 (5.2) Other464,407 (8.4)16,443 (6.0) Missing659,439 (11.9)32,842 (11.9)Morbid Obesity, n(%)401,892 (7.3)20,411 (7.4)0.47Elixhauser Indexd, n(%):<.0001 0716,559 (13.0)41,550 (15.0) 1-44,484,941 (81.1)220,638 (80.0) ≥ 5326,928 (5.9)14,007 (5.1)

Disclosure of Interests:

Bella Mehta: None declared, Kaylee Ho: None declared, Jennifer Bido: None declared, Michael Parks Consultant of: Zimmer Biomet, Linda Russell: None declared, Susan Goodman Shareholder of: Reginosine- Investment, Grant/research support from: Novartis, Horizon, Consultant of: Novartis, Celgene, UCB, Said Ibrahim: None declared

FRI0403 CLINICAL FEATURES OF PROSTHETIC JOINT INFECTIONS DIFFER IN PATIENTS WITH INFLAMMATORY ARTHRITIS AND OSTEOARTHRITIS

Background:

Inflammatory arthritis (IA) patients are at increased risk for prosthetic joint infections (PJI). However, because active IA patients without infections can have elevated inflammatory markers that mimic joint infection, PJI diagnosis is challenging in this population.

Objectives:

We used an institutional PJI registry to identify and compare the clinical, microbiologic, and histopathologic features of culture positive (CP) and culture negative (CN) total hip and knee PJI in IA and OA patients. We also evaluated the relationship between culture positivity, IA, and clinical outcomes.

Methods:

A retrospective cohort of THA/TKA PJIs, from 2009 to 2016, were identified by ICD codes, and confirmed by chart review. IA diagnosis was also confirmed by use of IA-specific medications. CN cases were defined as PJIs with no evidence of microbial growth in intraoperative cultures and CP PJI cases were defined by positive microbial growth in intraoperative cultures. Treatment failure was defined as subsequent surgical treatment for infection after the initial infection surgery. H&E slides of OA and IA PJI cases matched by age (+/-5) sex, and culture status were reviewed by a pathologist for evidence of the histopathologic features listed in Table 2. Fisher’s exact test, chi-square test, and Kaplan-Meier estimates were used.

TABLE 1.

Patient characteristics in IA and OA PJIs

IAOAN%/SDN%/SDp-valueTotal36771Age58.511.466.812<.001BMI30.26.7306.70.861Female2877.833243.1<.001CCI2.81.71.72.10.002Smoking411.18611.20.792Glucorticoids1027.8395.1<.001Culture Negative1027.810914.10.024Treatment Success at 2 years1952.8509660.146

IA- inflammatory arthritis; OA – osteoarthritis; PJI -prosthetic joint infection; CCI – Charlson Comorbidity Index

TABLE 2.

Histopathology and clinical presentation in IA and OA PJIs

OA (N=57)IA (N= 31)CP-IA (N=23)CN-IA (N=8)N (%)p-valueN (%)p-valuePathology Review>10 PMN per HPF42 (74)22 (71)0.80620 (87)2 (25)0.003Chronic Inflammation13 (23)23 (74)0.00118 (78)5 (63)0.393Necrosis17 (30)9 (29)18 (35)1 (13)0.38Clinical PresentationMSIS50 (88)26 (84)0.74722 (96)4 (50)0.009Sinus Tract7 (12)7 (23)0.2335 (22)2 (25)1Elevated ESR or CRP41 (72)24 (77)0.62217 (74)7 (88)1Elevated Synovial WBC33 (58)19 (61)0.82313 (57)6 (75)1Elevated Synovial %PMN31 (54)20 (65)0.37714 (61)6 (75)0.333

OA – osteoarthritis; IA – inflammatory arthritis; CP – culture positive; CN – culture negative; MSIS – meets Musculoskeletal Infection Society diagnostic criteria

Results:

807 PJI cases were identified including 36 IA (33 RA and 3 SLE) and 771 OA. A higher proportion of IA PJI were CN (N=10, 27%) vs. OA PJI (N=109, 14%, p=0.02). IA-PJI were younger, female, on glucocorticoids, and with more comorbidities. Type of surgical treatment did not differ significantly between IA and OA groups. Comparing CN-IA vs. CP-IA, no difference was observed in age, smoking, diabetes, surgical treatment, IA-specific meds or Charlson comorbidities. One-year survivorship of CN-IA and CN-OA were 66% and 87% (p>0.05). Across all CP cases, 57% were staphylococcal, with no differences between groups. Treatment failure was more frequent for CP-IA (42%) compared to CP-OA (30%), (p=0.2).

Histopathology of 88 PJIs (31 IA and 57 OA) was reviewed. The IA cohort presented with more chronic inflammation (p=0.001) than the OA cohort. Within the IA cohort, a higher proportion of CP-IA had >10PMN per HPF (p= 0.003) and met MSIS criteria (p=0.009). Comparing CP-OA and CN-OA, there were no significant differences in histopathology findings or number of patients meeting MSIS criteria.

Conclusion:

IA PJIs are more likely to be culture negative than OA PJIs. Although our analysis was limited by our cohort size, our findings including differences in histopathology, and better clinical outcomes suggest the presence of biologic differences between CN and CP PJI that require further study.

Disclosure of Interests:

Milan Kapadia: None declared, Tania Pannellini: None declared, Carine Moezinia: None declared, Andy Miller: None declared, Mark Figgie: None declared, Peter Sculco: None declared, Michael Cross: None declared, Michael Henry: None declared, Linda Russell: None declared, Laura Donlin Consultant of: Consultant – Genentech/Roche, Allina Nocon: None declared, Susan Goodman Shareholder of: Reginosine- Investment, Grant/research support from: Novartis, Horizon, Consultant of: Novartis, Celgene, UCB