Assessing safety of inpatient direct oral anticoagulant prescribing utilising an electronic prescribing system

Introduction

Direct oral anticoagulants (DOACs) are favoured over oral vitamin K antagonists (VKA) due to their fixed-dose regimen and reduced thromboembolic and bleeding risk. Despite clear dose adjustments based on patient characteristics, several observational studies have demonstrated 15-20% of patients being overdosed or underdosed when compared to licensing.1,2 Inappropriate dosing can lead to harm e.g., bleeding or thrombosis which would prolong/escalate hospital stay.

Aim

To assess clinical appropriateness of inpatient DOAC prescriptions across multiple sites of a large London based NHS Trust.

Methods

This study was conducted retrospectively over a seven month-period across 4 sites from a large London based NHS Trust from November 2021. Electronic prescribing system was used to generate daily reports that enabled a specialist haematology pharmacist to assess all adult inpatient DOAC prescriptions for appropriateness as per product licensing for indication. The report included patient characteristics (age, gender, body weight), prescribed DOAC (agent, dose, indication), serum creatinine, hospital site. Queries were escalated for review by the pharmacy or medical teams. Type of intervention (dose, agent, or no change) was recorded, and allocated a clinical severity rating using IMPACCTS.3 This scale runs from a score of 1 indicating a good practice intervention to a score of 5 that prevents serious or major harm including death. This study was approved by the University College London (UCL) School of Pharmacy research ethics committee.

Results

A total of 1,761 inpatient DOAC prescriptions were reviewed, of which 10.1% had a clinical query requiring escalation. Results demonstrate that 77.0% (n=137) of all queries were dose-related, 33.2% overdosed and 43.8% underdosed compared to licensing, the most common agent requiring adjustment being apixaban. Renal-related queries were most frequently observed (50.6%), with 12.8% of patients on edoxaban having CrCl >110ml/min. We found that 2.3% of prescription queries raised required review and stopping antiplatelet agents co prescribed with anticoagulation. Most interventions made had a severity rating of 4 (74.2%), followed by 15.2%, and 10.7% had a score of 1 and 3, respectively. Following pharmacist recommendations, changes made were either dose (38.7 %) or agent (14.6%). Alternatively, it was not applicable due to a change in clinical status, i.e., renal function improved (1.1%) or patient re-weighed (6.2%). Changes to prescriptions did not apply to some patients as documentation of clinical reasoning were recorded (19.7%), or due to patients being discharged (13.5%).

Discussion/Conclusion

This study has demonstrated a significant number of DOAC prescriptions are inappropriate at the point of prescribing when compared to product summary of characteristics for the indications listed. The use of a centralised report to assess appropriateness of DOAC prescribing across several sites has facilitated a centralised mechanism led by a haematolgy specialist to improve safer DOAC prescribing. The most frequent interventions being made included dose amendments based on calculated creatinine clearance and amending (or adding) indications entered on the system. Further work is required to demonstrate effective change management strategies that have been implemented to further improve the safety of DOAC prescribing within the Trust.

References

1. Yao X and Noseworthy P. NOAC dosing and monitoring: really as simple as it seems?: BMJ Publishing Group Ltd and British Cardiovascular Society; 2020;321-2.

2. Garcia Rodriguez L.A., Martin-Perez, et al. 2019. Appropriateness of initial dose of non-vitamin K antagonist oral anticoagulants in patients with non-valvular atrial fibrillation in the UK. BMJ open, 9, e031341-e031341.

3. Ali F et al. Content validity IMPACCTS – instrument for rating clinical pharmacy care contributions. United Kingdom Clinical Pharmacy Association Symposium Proceedings; 2021.

Low dose rivaroxaban therapy in aspirin allergic patients undergoing percutaneous coronary intervention

 

Aspirin in combination with a P2Y12 inhibitor is the mainstay of treatment post percutaneous coronary intervention (PCI) for coronary artery disease (CAD). However, patients who are allergic to or intolerant to aspirin pose a therapeutic challenge especially when encountered in the setting of acute coronary syndrome. Aspirin desensitization strategies have been used in clinical practice to build tolerance prior to coronary intervention but clearly are not practical in the setting of ACS or significant symptomatic CAD. Low dose rivaroxaban (2.5 mg twice a day) has been previously shown to be safe in combination with a P2Y12 inhibitor post ACS compared to aspirin. We therefore sought to see if low dose rivaroxaban is a safe and effective alternative to aspirin in patients post PCI who are unable to take aspirin.This study aims to compare the efficacy (Major adverse cardiovascular events (MACE)) and safety (Bleeding events as defined by Bleeding Academic Research Consortium (BARC) criteria) in patients with confirmed aspirin allergy who were treated with low dose rivaroxaban therapy in place of aspirin in combination with P2Y12 inhibitors post PCI.

Methods

This was a single center observational study which looked at 50 cases of patients with aspirin allergy (47 cases) or significant confirmed aspirin intolerance (3 cases) who underwent PCI between December 2017 and February 2022. Patients were advised to take low dose rivaroxaban 2.5 mg twice a day as an alternative to aspirin 75 mg once a day. A comparator group of 50 matched patients without aspirin allergy who underwent PCI during the same time period and treated with standard aspirin therapy (75mg) along with a P2Y12 inhibitor. Outcomes over follow-up were MACE (mortality, myocardial infarction, stroke, and unscheduled revascularisation) and bleeding events defined by–BARC criteria.

Results

The median age of the aspirin allergy cohort was 62 years old with typical comorbidities associated with CAD. The cohort included a case mix of ACS and stable angina.The P2Y12 inhibitor in the majority of cases (76%) was Clopidogrel; Ticagrelor was used in 20% of cases and Prasugrel in 4% cases. No differences existed between the rivaroxaban and matched patient groups. The median follow-up as 626 days (Interquartile range 237–549). The duration of low dose rivaroxaban therapy was for 12 months with a P2Y12 in 72%, 1–3 months for 22% and finally continued long term (with P2Y12 discontinuation at 12 months) in 6%. No difference existed in the incidence of MACE between the low dose rivaroxaban group (12%) compared to the matched cohort (10% p=0.266). No difference in bleeding outcomes (any bleeding event BARC type >0) were seen (14% in rivaroxaban and 16% in control, p=0.329).

Conclusions

This study provides more supporting evidence that low dose rivaroxaban therapy is an alternative to aspirin when used in combination with a P2Y12 inhibitor post PCI.

Funding Acknowledgement

Type of funding sources: None.

Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Background/Introduction

Targets set by Public Health England (PHE) state that 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc>2) anticoagulated was below the target set by PHE. In addition, optimisation of risk factors can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To provide specialist input from a cardiovascular pharmacist to prevent AF-related strokes through improvement of anticoagulation rates and optimisation of cardiovascular risk factors in patients with AF across three London boroughs over one year, as well as minimising bleed risk in patients on dual antithrombotic therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to identify high-risk AF patients (CHA2DS2VASc>2) by working with primary care clinicians. Utilising “proactive care frameworks” created by UCLPartners and Clinical Effectiveness Group Queen Mary University of London, patients were stratified and prioritised for review. Patients not on anticoagulation were deemed to be at highest risk, requiring an urgent review to assess suitability for anticoagulation. A virtual multidisciplinary team (MDT) would review any complex patients and agree an action plan. Patients on dual antithrombotic therapy were also assessed to determine if antiplatelet therapy was indicated to minimise risk of major bleeding. All AF patients were reviewed for suitability of statin initiation to optimise cardiovascular risk prevention.

Results

At baseline, 86% (7581/8582) of AF patients with a CHA2DS2VASc>2 across the three boroughs were anticoagulated. 1001 patients were reviewed by a specialist pharmacist, with 84% (841/1001) of patients having a CHA2DS2VASc between 2–5, and 28% (280/1001) on antiplatelet monotherapy. Analysis at 12 months following intervention reported that 95% (7888/8280) of AF patients with a CHA2DS2VASc>2 were suitably anticoagulated, an improvement of 9%. 6% (61/1001) of patients were switched from antiplatelets and 25% (246/1001) were newly initiated on anticoagulation. 13% (130/1001) of patients required specialist MDT input to determine appropriateness for anticoagulation initiation. There was also a reduction in dual anticoagulation and antiplatelet therapy from 429 to 252 patients (41% reduction). Lastly of those reviewed, 2609 patients received a recommendation to start a statin for either primary (n=1981) or secondary prevention (n=628).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce to significantly improve and optimise cardiovascular risk, and reduce the risk of stroke in this high-risk population for people with AF across all three boroughs. By extrapolating these results nationally, 3600 strokes could be averted over 18 months.

Funding Acknowledgement

Type of funding sources: None.

Pharmacist-led multidisciplinary approach in preventing strokes in people with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

In England, 90% of patients with atrial fibrillation (AF) are expected to receive anticoagulation as part of targets set by Public Health England by 2029. In 2019/2020, across three London boroughs serving a population of 770,000, the percentage of AF patients at high risk of stroke (CHA2DS2VASc>2) anticoagulated was 87%, 83% and 84%. This placed two of the three localities in the bottom 10% compared to others in England. In addition, optimising cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To prevent AF-related strokes by improving anticoagulation rates and optimising cardiovascular risk factors in patients with AF in all general practices across three London boroughs over one year, and to minimise risk of bleeding in patients on concurrent anticoagulation and antiplatelet therapy.

Methods

A specialist cardiovascular pharmacist was commissioned to systemically identify high-risk AF patients (CHA2DS2VASc>2) by working with primary care clinicians, including up-skilling of primary care pharmacists. Through utilisation of ‘proactive care frameworks’ created by the Clinical Effectiveness Group Queen Mary University of London and UCL Partners, patients were able to be stratified and prioritised for review. AF patients not on anticoagulation or on antiplatelet monotherapy were deemed to be at highest risk, and these patients were reviewed to assess suitability for anticoagulation. Subsequently, patients on concurrent anticoagulation and antiplatelets were assessed to determine if dual antithrombotic prescribing was still indicated to minimise risk of major bleeding. Lastly, to optimise cardiovascular risk prevention, all AF patients were reviewed for suitability of statin initiation for primary or secondary prevention. A virtual multidisciplinary team was convened for complex patients, which included a cardiologist, haematologist, general practitioner and pharmacist to review and agree an action plan.

Results

An interim analysis at 9 months reported that 94% (6745/7145) of patients with a CHA2DS2VASc>2 across the three boroughs were suitably anticoagulated, an improvement of 6% on the initial 88% (6585/7391). There was a reduction in concurrent anticoagulation and antiplatelet therapy from 381 to 262 patients (31.2% reduction) following specialist review. Lastly 2285 patients were reviewed with a recommendation to start a statin for either primary (n=1783) or secondary prevention (n=502).

Conclusion(s)

Provision of a specialist cardiovascular pharmacist supported a multidisciplinary workforce with significant improvement in anticoagulation rates across all three boroughs, reducing the risk of stroke in this high-risk population. In addition, we were able to reduce the risk of bleeding in this cohort of patients by stopping inappropriate antiplatelet therapy, and reduced the risk of cardiovascular disease through statin initiation.

Differentiating border-zone tissue from post-infarct scar using ripple mapping during VT ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Areas of post-infarct ventricular scar and border-zone slow conduction are often highlighted on a bipolar voltage map with generalized values 0.5mV–1.5mV. The true voltage that differentiates regions of conducting from non-conducting tissue is unknown. Ripple Mapping (RM)displays allows conducting tissue to be seen as areas supporting Ripple activation, and non-conducting tissue as areas devoid of Ripple activation.

Purpose

We describe application of Ripple Maps to differentiate areas of scar from conducting tissue during ischemic VT ablation.

Methods

Dense bipolar voltage maps were created (Pentaray catheter, pacing 80-100bpm) and presented as a single value (e.g. 0.5mV-0.5mV) to binarize the color display (red and purple). RMs were superimposed on the voltage map and played above a pre-set noise threshold (>0.05mV). The voltage map mV limit was sequentially reduced ("border-zone threshold") until only those areas devoid of Ripple bars appeared red. The surrounding border-zone supporting ripple activation thus appeared purple. We performed off-line analysis of border-zone voltage thresholds from a series of RM guided VT ablations.

Results

10 consecutive patients (LVEF 32.3±7.5%) with remote myocardial infarction underwent VT ablation (median 19days (IQR 8-33) since last VT). Bipolar voltage mapping (5873±2841 points, median shell area 224cm2), revealed voltages<0.5mV covered a median 11% (IQR 7-17%) of the shell. The border-zone voltage threshold was median 0.2mV (range 0.12mV - 0.3mV). Non-conducting tissue below this value covered only median 5% (IQR 3-7%) of the entire shell. VT was mappable in 4 patients, and the isthmus was bordered by tissue below the same border-zone threshold as found in normal rhythm. The border-zone was homogenized with ablation(40-50W, median 29 mins (IQR 22-33), and clinical VT was non-inducible in all, and 9 pts (91%) remain sustained VT-free at median 90-day follow-up (IQR 23-139), 2-weeks blanking period).

Picture 1 presents an infero-lateral LV infarct collected in an RV paced rhythm (7340points) and displayed at conventional bipolar voltage settings 0.5-1.5mV. Tissue with voltages<0.5mV appear red and cover 30% of the total area. In this case, this border-zone voltage threshold was defined as 0.25mV. Non-conducting tissue, seen as areas devoid of ripple bars below this value, now appeared as red, and covered only 11% of the total area. Picture 2 demonstrates the morphologies of 4 poorly tolerated induced VTs during this case. Each had near perfect pacemaps to the exit sites of border-zone tissue defined using this approach, and were targets for ablation resulting in complete non-inducibility and no VT recurrence in early follow-up.

Conclusion

The bipolar voltage that differentiates putative scar from bordering conducting tissue is unique to each patient, and far lower than 0.5mV-1.5mV. RM presents a practical approach to visualize the border-zone activation to guide ablation.

Exploring Black Women's Pathways to Motherhood Within a Reproductive Justice Framework

Amidst the increasing push to address racial disparities in maternal health equity, fewer studies have considered Black women's perspectives on their needs, concerns, and priorities regarding family planning care. Such evidence might help address the lack of support and information that many Black women report in patient-provider encounters, and broaden empirical knowledge on the contextual factors that influence Black women's reproductive decisions. In the present qualitative study, we explored Black women's pathways to motherhood within a reproductive justice framework. We drew on individual, semi-structured interview data from 31 Black mothers (25-50 years, M_age = 35 years) across the United States. Using consensual qualitative research methods, we elaborated on three themes: (1) intentional family planning, (2) unintended pregnancy, and (3) othermothering. The findings challenge deficit-based stereotypes of Black mothers' reproductive choices and illuminate how health practitioners can facilitate humanizing conversations that prioritize Black women's family planning goals and decision-making.

Assessing the impact of a gynaecomastia assessment and treatment infographic in primary care in Greater Manchester

INTRODUCTION

Men with gynaecomastia are routinely referred to breast clinics, yet most do not require breast surgical intervention. The aim of this study was to assess the impact of a novel point-of-care gynaecomastia decision infographic in primary care on the assessment, management and referral practices to tertiary breast surgical services.

METHODS

A study was carried out of male patient referrals from primary care in Greater Manchester to a tertiary breast centre between January and March in 2018-2020. Referral patterns were compared before and after the infographic went live in general practices in Greater Manchester in January 2020. Data were collected for gynaecomastia referrals, including aetiology, investigation and management.

RESULTS

In total, 394 men were referred to a tertiary breast centre from 163 general practices, of which 271 (68.8%) had a diagnosis of gynaecomastia. Use of the decision infographic by primary healthcare providers was associated with a decrease in male breast referrals with gynaecomastia (79.6% to 62.0%). Fewer gynaecomastia patients were referred with a benign physiological or drug-related cause after implementation of the infographic (52.2% vs 41.8%). Only 10 (3.7%) patients with gynaecomastia underwent breast surgery during the study period.

CONCLUSION

Implementation of a gynaecomastia infographic in primary care in Manchester was associated with a reduction in gynaecomastia referrals to secondary care. We hypothesise that implementation of the infographic into primary care nationally may potentially translate to hundreds of patients receiving more specialty-appropriate referrals, improving overall management of gynaecomastia. Further study is warranted to test this hypothesis.

Telerobotic interventions from a distance: an initial experience in 3D phantom mapping

Introduction

The current COVID-19 pandemic has fostered several accelerations in “remote” patient care such as video and telephone clinics, as well as multidisciplinary collaborations using online platforms with experts consulting the local teams from a distance. The next logical step would be to also offer remote-controlled interventions which the expert operator not on site, but in support of the local team. This is especially valuable for complex interventions when either patient or expert operator can not be present at the same place.

Purpose

We aimed to demonstrate that an expert operator located at far distance (Austria) could directly interact with the remote magnetic navigation system in London (UK) whilst mapping a 3D phantom using an electroanatomical mapping system.

Method

Two experienced operators of the magnetic navigation system were tasked with creating fast anatomic maps (FAM) of the atrial and ventricular chambers of a 3D phantom using remote magnetic navigation in combination with 3D electroanatomical mapping. One was located in the control room of the magnetic catheter lab (UK) and the second one was in Tirol, Austria and connected through a secure remote desktop connection (via high speed fibre optic cable). Using a solid tip magnetic catheter connected to a mechanical drive, all interactions with the system were carried out via the Odyssey platform. Acquisitions for right and left atrium, as well as right and left ventricles plus aorta was compared with regards to mapping duration, map completeness (as judged by the average distance of surface points from 3D CT scan reconstruction), total 3D map volume and need for additional radiation exposure during the mapping process.

Results

Mapping time and map completeness when performed by the distant operator was not inferior to the local operator and both did not require any additional radiation exposure during the mapping process. Table 1 demonstrates the mean parameters for each chamber, respectively. Figure 1 depicts the matched data for chamber completeness as compared for the LA (green= local operator, pink= distant operator) using a contrast CT scan as the gold standard.

Conclusion

Telerobotic 3D mapping of a 3D phantom from a distance was equally fast delivered from the control room as compared to an operator located 1200 km away without compromising on map completeness. This demonstrates the feasibility of telerobotic interventions and stress the need for remote collaboration which is especially valuable when travel of patients and/or physician experts is restricted.

Funding Acknowledgement

Type of funding sources: None.  

A model of uniaxial implant seating by impaction

Implants anchored by press-fit are predominantly implanted by impaction. This method allows sufficiently high forces to be generated easily by the surgeon. Suitable impaction should provide adequate implant seating without damaging the patient (tissues), the implant and implantation system, or the surgeon. However, issues have been documented for all of these factors. In this study a model to predict implant seating is developed, given an applied impaction impulse, the mass of the accelerated components and the push-in resistance force. The model was validated against experimental data for a contemporary femoral stem implanted in a polyurethane foam surrogate for bone, with the input parameters varied. The model tended to overestimate seating but represented seating patterns well. The model can be used to estimate implant seating using easily measured parameters and could be useful in the design of implantation systems, and in optimising impaction strategies.

Telerobotic interventions from a distance: an initial experience in 3D phantom mapping

Introduction

The current COVID-19 pandemic has fostered several accelerations in “remote” patient care such as video and telephone clinics, as well as multidisciplinary collaborations using online platforms with experts consulting the local teams from a distance. The next logical step would be to also offer remote-controlled interventions which the expert operator not on site, but in support of the local team. This is especially valuable for complex interventions when either patient or expert operator can not be present at the same place.

Purpose

We aimed to demonstrate that an expert operator located at far distance (Austria) could directly interact with the remote magnetic navigation system in London (UK) whilst mapping a 3D phantom using an electroanatomical mapping system.

Method

Two experienced operators of the magnetic navigation system were tasked with creating fast anatomic maps (FAM) of the atrial and ventricular chambers of a 3D phantom using remote magnetic navigation in combination with 3D electroanatomical mapping. One was located in the control room of the magnetic catheter lab (UK) and the second one was in Tirol, Austria and connected through a secure remote desktop connection (via high speed fibre optic cable). Using a solid tip magnetic catheter connected to a mechanical drive, all interactions with the system were carried out via the Odyssey platform. Acquisitions for right and left atrium, as well as right and left ventricles plus aorta was compared with regards to mapping duration, map completeness (as judged by the average distance of surface points from 3D CT scan reconstruction), total 3D map volume and need for additional radiation exposure during the mapping process.

Results

Mapping time and map completeness when performed by the distant operator was not inferior to the local operator and both did not require any additional radiation exposure during the mapping process. Table 1 demonstrates the mean parameters for each chamber, respectively. Figure 1 depicts the matched data for chamber completeness as compared for the LA (green= local operator, pink= distant operator) using a contrast CT scan as the gold standard.

Conclusion

Telerobotic 3D mapping of a 3D phantom from a distance was equally fast delivered from the control room as compared to an operator located 1200 km away without compromising on map completeness. This demonstrates the feasibility of telerobotic interventions and stress the need for remote collaboration which is especially valuable when travel of patients and/or physician experts is restricted.

Funding Acknowledgement

Type of funding sources: None. Matched data for aorta

Pharmacist-led medicines optimisation clinic for implantable cardiac device patients

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Cardiac implantable electronic devices (CIED) enhance detection of atrial fibrillation (AF), providing a comprehensive measure of AF burden.  Patients with device-detected AF are usually referred for anticoagulation to their local anticoagulation clinic or General Practitioner (GP), which often delays time to initiation, potentially increasing the risk of stroke.  In addition, AF is associated with increased risk of cardiovascular disease and mortality.  Optimising blood pressure, cholesterol and lifestyle choices can significantly reduce the risk of cardiovascular disease and associated mortality in these patients.

Purpose

To develop and evaluate an innovative pathway to allow Specialist Cardiac Pharmacists to promptly assess and initiate anticoagulation in patients with device-detected AF, and additionally address risk factors for prevention of cardiovascular disease.

Methods

As part of a quality improvement initiative, a pathway was developed where patients with AF identified on CIED who require anticoagulation are referred for assessment and management to a pharmacist-led optimisation clinic.  Specialist Cardiac Pharmacists contact patients within 5 days of referral to discuss and initiate or optimise treatment for AF, blood pressure, cholesterol and lifestyle choices.  Patients deemed inappropriate for anticoagulation were referred back to the medical team for further assessment.  All patients received a follow-up telephone consultation at 4-6 weeks to assess tolerability, adherence and response to treatment.

Results

Between September 2020 and February 2021, 22 patients were referred to the optimisation clinic. Mean age was 74.32 +/- 12.34 years and 77% were men.  Mean CHA2DS2VASc was 3.4 +/- 0.8 and mean HASBLED was 1.2 +/- 0.6. The average time from referral to anticoagulation was 3 days compared to 4 weeks prior to implementation of the pathway. All patients were assessed and appropriately anticoagulated, whereas approximately 15% of patients were still not anticoagulated at 3 months prior to implementation of the pathway despite referral to their local clinic. All patients had their blood pressure and cholesterol reviewed, which were optimised in 23% and 41% of patients respectively.  All patients confirmed adherence and suffered no adverse effects on follow-up.

Conclusion(s): We report the safe and successful implementation of a pharmacist-led medicines optimisation clinic.  This has significantly reduced time to anticoagulation without compromising safety, as well as assuring all patients are appropriately anticoagulated.  In addition, over half of patients required blood pressure and/or cholesterol optimisation to reduce the risk of cardiovascular disease, a service not previously provided for this cohort of patients.

Media framing of emergency departments: a call to action for nurses and other health care providers

BACKGROUND

As part of a larger study focused on interventions to enhance the capacity of nurses and other health care workers to provide equity-oriented care in emergency departments (EDs), we conducted an analysis of news media related to three EDs. The purpose of the analysis was to examine how media writers frame issues pertaining to nursing, as well as the health and social inequities that drive emergency department contexts, while considering what implications these portrayals hold for nursing practice.

METHODS

We conducted a search of media articles specific to three EDs in Canada, published between January 1, 2018 and May 1, 2019. Media items (N = 368) were coded by story and theme attributes. A thematic analysis was completed to understand how writers in public media present issues pertaining to nursing practice within the ED context.

RESULTS

Two overarching themes were found. First, in ED-related media that portrays health care needs of people experiencing health and social inequities, messaging frequently perpetuates stigmatizing discourses. Second, media writers portray pressures experienced by nurses working in the ED in a way that evades structural determinants of quality of care. Underlying both themes is an absence of perspectives and authorship from practicing nurses themselves.

CONCLUSIONS

We recommend that frontline nurses be prioritized as experts in public media communications. Nurses must be supported to gain critical media skills to contribute to media, to destigmatize the health care needs of people experiencing inequity who attend their practice, and to shed light on the structural causes of pressures experienced by nurses working within emergency department settings.

Follow-up studies of schizophrenia I: Natural history and non-psychopathological predictors of outcome

Treatment-resistant schizophrenia does not exist as a discrete entity, so separating patients who will fail to respond to traditional antipsychotics from those who will respond is impossible with 100% accuracy. However, several predictors of poor clinical outcome have emerged from recent research and knowledge of the processes that lead to poor outcome has become increasingly important with the advent of atypical antipsychotics that may be used in patients with treatment-resistant illness. Much of the variation in outcome can be understood in terms of differences in sample selection, outcome definition and stringency of the diagnostic criteria used. Failure to appreciate these mechanisms may lead to over- or underestimation of the proportion of patients with poor treatment response in clinical and research settings. The importance of factors that predict poor outcome should be judged in terms of their effect size and the degree to which alternative explanations for the association with outcome have been excluded. Although much current research is being focused on specific biological predictors, baseline demographic and illness-related factors, such as ethnic group, sex, social class, type of onset, age of onset and concurrent misuse of alcohol or drugs, have large effects on outcome. Although duration of untreated psychosis before first contact with services may independently predict poor outcome, confounding by variables that are associated with both pathways to care and clinical outcome has not been excluded.

39 Care Home Liaison Role- Bridging the Gap Between Acute Hospitals and Care Homes

Introduction

There are over 400,000 people over 65 in UK care homes, three times the number than that in acute hospitals. They are amongst the frailest in our community, with average life expectancy of 15months once in the home. Their needs are often complex and challenging, which when unmet, often result in unwanted and unnecessary hospital admissions.

Imperial College Healthcare Trust (ICHT), along with funding from Health Education England (HEE), have introduced a care home liaison nurse. The aim is to bridge the boundaries, making a significant difference to cross organisation communication and support.

Methods

The care home liaison nurse manages a frailty liaison service with the largest local nursing care home. This home has 140 residents with complex needs. The care home liaison nurse provides a point of contact for advice, guidance and support for individual patient pathways, she provides face to face assessment and treatment or verbal advice. In addition, the nurse supports discharge from the acute setting. This direct contact allows rapid access to specialist advice, and aims to build confidence both within the care home team and within the acute team, that the patients’ needs can be met in their own surroundings.

Results

The preliminary data demonstrates a positive impact this role is having both to the acute trust and most importantly patient’s experience. Comparing ICHT data from April-May 2018 to April-May 2019 it showing that the number of avoidable admissions has decreased from 54.3% to 37.5%, length of stay when patients are admitted has decreased from 11.7 days to 6.5 days, and the number of patients with an advanced care plan has risen 14.9%. Feedback from nursing staff at the care centre as well as that from patients and families has been overwhelmingly positive.

Conclusions

The role is still in the pilot phase. Given the already positive impact it is hoped that it will continue and expand into other care homes and extra sheltered accommodations.

24 Improving the Investigation and Treatment of Anaemia in Older Adults Admitted Through the Acute Medical Unit

Background

This project was based within acute medical unit within a tertiary hospital in London and was conducted by junior doctors working both in geriatrics and in acute medicine. The patient group this project was aimed at was adults aged 65 and over who were admitted under acute medicine.

Introduction

Anaemia is common in older adults and associated with poor outcomes. This project aimed to explore attitudes and improve recognition, investigation and management of anaemic older adults in acute medicine through a multi-pronged approach.

Methods

Serial PDSA cycles were conducted over 3 months. Retrospective audit was performed, reviewing electronic records to compare a 2-week period before and after the interventions, identifying which patients admitted under acute medicine and aged over 65 years were anaemic, underwent haematinics and treatment.

Interventions

Firstly, a survey explored doctors’ attitudes and knowledge of anaemia in older adults as well as identifiable barriers to investigating anaemia when working in acute medicine. The data from this was used to design interventions to address the gaps which emerged. Interventions included an algorithm regarding haematinic interpretation disseminated amongst junior doctors, multiple teaching sessions conducted and posters distributed which highlighted the importance of investigating and treating anaemia.

Results

The initial audit included 144 patients, of which 50 were anaemic, and the re-audit included 148 patients of which 56 were anaemic. Following the interventions, more patients had haematinics requested, from 60% to 70%, and more were treated, from 30 to 55% (p<0.05). Doctors were surveyed before and after the intervention. The repeat survey demonstrated that more doctors felt addressing anaemia was important, 83% from 55% (p<0.05). More doctors were also confident in the interpretation of haematinics, 61% from 28% (p<0.05) and in prescribing iron, 66% from 27% (p<0.05).

Conclusions

Anaemia amongst elderly patients in the acute setting is under-estimated, investigated and treated. Targeted educational interventions can improve doctors’ attitudes and knowledge, helping to facilitate the investigation of older adults and enable treatment.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Eptifibatide is associated with significant cost savings and similar clinical outcomes to abciximab when used during primary percutaneous coronary intervention for ST-elevation myocardial infarction: An observational cohort study of 3863 patients

INTRODUCTION

Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction.

METHODS

This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups.

RESULTS

In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73-1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79-1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71-1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000).

CONCLUSION

This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

An observational cohort study of 3 units versus 5 units slow intravenous bolus oxytocin in women undergoing elective caesarean delivery

This study sought to compare postpartum blood loss and maternal outcomes after 3IU and 5IU oxytocin at elective caesarean delivery. In a prospective observational study, 73 women undergoing elective caesarean delivery under spinal anaesthetic received a slow I.V. injection of either 3IU (n = 35) or 5IU (n = 38) oxytocin after delivery. The main outcome was gravimetrically measured 24-hour postpartum blood loss with a non-inferiority margin of 300 mL. Uterine tone, phenylephrine dose, emesis and hypotension after oxytocin administration were secondary outcomes. Gravimetric postpartum blood loss was lower in the 3IU group (-58.8 mL [95% CI: -212.1, 94.3]) after adjusting for BMI, pre-delivery vasopressor dose, parity, and risk of uterine atony, with the upper confidence limit below the 300 mL margin in support of non-inferiority. Patients receiving 3IU had a higher (non-significant) rate of having post-delivery phenylephrine to treat hypotension (RR = 1.59 [95% CI: 0.97, 2.63]), but of those treated, the 3IU group required significantly less (-427 mcg [95% CI: -740, -114]). The 3IU group had a lower prevalence of vomiting compared to those receiving 5IU (6% versus 24%; P = 0.047). Administration of 3IU oxytocin was non-inferior compared to standard 5IU with respect to blood loss in women undergoing elective caesarean delivery.

Unprecedented staining of polar lipids by a luminescent rhenium complex revealed by FTIR microspectroscopy in adipocytes

Fourier transform infrared (FTIR) microspectroscopy and confocal imaging have been used to demonstrate that the neutral rhenium(i) tricarbonyl 1,10-phenanthroline complex bound to 4-cyanophenyltetrazolate as the ancillary ligand is able to localise in regions with high concentrations of polar lipids such as phosphatidylethanolamine (PE), sphingomyelin, sphingosphine and lysophosphatidic acid (LPA) in mammalian adipocytes.

A qualitative metasynthesis exploring the impact of prostate cancer and its management on younger, unpartnered and gay men

Prostate cancer (PCa) can negatively impact on men's sexual, urinary and emotional functioning, affecting quality of life. Most men with PCa are older (≥65 years), married and heterosexual and little is known about the impact on men who are younger, unpartnered or gay. We aimed to synthesise existing qualitative research on these three groups of men. A systematic metasynthesis was undertaken that included data on the unique impacts of PCa on younger (<65 years) (n = 7 papers), unpartnered (n = 17 papers) or gay or bisexual men (n = 11 papers) using a modified meta-ethnographic approach. The three overarching constructs illustrated the magnified disruption to men's biographies, that included: marginalisation, isolation and stigma-relating to men's sense of being "out of sync"; the burden of emotional and embodied vulnerabilities and the assault on identity-illustrating the multiple threats to men's work, sexual and social identities; shifting into different communities of practice-such as the shift from being part of a sexually active community to celibacy. These findings suggest that PCa can have a particular impact on the quality of life of younger, unpartnered and gay men. This has implications for the provision of tailored support and information to these potentially marginalised groups.

Hemopoietic-specific Sf3b1-K700E knock-in mice display the splicing defect seen in human MDS but develop anemia without ring sideroblasts

Heterozygous somatic mutations affecting the spliceosome gene SF3B1 drive age-related clonal hematopoiesis, myelodysplastic syndromes (MDS) and other neoplasms. To study their role in such disorders, we generated knock-in mice with hematopoietic-specific expression of Sf3b1-K700E, the commonest type of SF3B1 mutation in MDS. Sf3b1K700E/+ animals had impaired erythropoiesis and progressive anemia without ringed sideroblasts, as well as reduced hematopoietic stem cell numbers and host-repopulating fitness. To understand the molecular basis of these observations, we analyzed global RNA splicing in Sf3b1K700E/+ hematopoietic cells. Aberrant splicing was associated with the usage of cryptic 3' splice and branchpoint sites, as described for human SF3B1 mutants. However, we found a little overlap between aberrantly spliced mRNAs in mouse versus human, suggesting that anemia may be a consequence of globally disrupted splicing. Furthermore, the murine orthologues of genes associated with ring sideroblasts in human MDS, including Abcb7 and Tmem14c, were not aberrantly spliced in Sf3b1K700E/+ mice. Our findings demonstrate that, despite significant differences in affected transcripts, there is overlap in the phenotypes associated with SF3B1-K700E between human and mouse. Future studies should focus on understanding the basis of these similarities and differences as a means of deciphering the consequences of spliceosome gene mutations in MDS.

Methods for troubleshooting a video before assessing its clinical impact

No techniques have been established for assessing quality or troubleshooting video materials before evaluating their clinical effectiveness - for example in a randomized controlled trial (RCT). This paper reports three studies leading to the development of such techniques. In the first study 20 adults rated successive video clips for informativeness and style giving separate ratings for visual presentation and spoken commentary. Pooling across raters yielded a profile of the high and low points within the video. The profile for the first video was replicated across two participant groups, each of 20 adults. This profiling technique identified potential trouble-spots within an HRT video and potential repairs were assessed in Study 2 where the rating procedure was changed to a pairwise comparison, enabling revisions to be evaluated against original clips by another 24 adults. The outcome of this comparison was validated in Study 3 using the full profiling procedure and substituting the revised clips for the originals. These studies show that the quick and simple rating techniques developed in Studies 1 and 2 offer ways of checking the micro-quality of a video and identifying potential trouble-spots. This enables weaknesses to be removed before the effectiveness of the video is evaluated in a clinical context.

An efficient approach for limited-data chemical species tomography and its error bounds

We present a computationally efficient reconstruction method for the limited-data chemical species tomography problem that incorporates projection of the unknown gas concentration function onto a low-dimensional subspace, and regularization using prior information obtained from a simple flow model. In this context, the contribution of this work is on the analysis of the projection-induced data errors and the calculation of bounds for the overall image error incorporating the impact of projection and regularization errors as well as measurement noise. As an extension to this methodology, we present a variant algorithm that preserves the positivity of the concentration image.

LISTEN WHILE YOU WORK? The Attitude of Healthcare Professionals to Music in the OR

Although the playing of music is commonplace in the operating theatre, there is nothing in the literature examining whether staff feel this is beneficial. Questionnaires were distributed amongst a random selection of staff in practice at a district general hospital: medical staff from a range of surgical specialities, anaesthetists, and all grades of perioperative staff (nurse/operating department practitioners/healthcare assistants) were encouraged to participate. There were 121 health professionals in total working in the operating theatres. The authors compared the responses to each question amongst the respondents, to check for the tendency to correlate. Out of the 52 health professionals who responded, 36 stated that music is played in their theatre either every day, or two to three times a week. Only five respondents felt that this was too often. Fifteen percent of medical staff were of the opinion that the nursing staff controlled the choice of music. Nursing staff were almost evenly split in thinking that nursing staff, surgical staff and the whole theatre team controlled the choice of music. The majority of both nursing and medical staff felt that they enjoyed their work more and performed better when music was played in theatre. The study concluded that the majority of theatre staff found listening to music while they work a positive experience. The potential for music to have a distracting or detrimental effect on a minority of individuals should always be considered.

First confirmation of Pseudogymnoascus destructans in British bats and hibernacula

White-nose syndrome (WNS) is a fatal fungal infection of bats in North America caused by Pseudogymnoascus destructans. P. destructans has been confirmed in Continental Europe but not associated with mass mortality. Its presence in Great Britain was unknown. Opportunistic sampling of bats in GB began during the winter of 2009. Any dead bats or samples from live bats with visible fungal growths were submitted to the Animal Health and Veterinary Laboratories Agency for culture. Active surveillance by targeted environmental sampling of hibernacula was carried out during the winter of 2012/2013. Six hibernacula were selected by their proximity to Continental Europe. Five samples, a combination of surface swabs or sediment samples, were collected. These were sent to the Center for Microbial Genetics and Genomics, Northern Arizona University, for P. destructans PCR. Forty-eight incidents were investigated between March 2009 and July 2013. They consisted of 46 bat carcases and 31 other samples. A suspected P. destructans isolate was cultured from a live Daubenton's bat (Myotis daubentonii) sampled in February 2013. This isolate was confirmed by the Mycology Reference Laboratory, Bristol (Public Health England), as P. destructans. A variety of fungi were isolated from the rest but all were considered to be saprophytic or incidental. P. destructans was also confirmed by the Center for Microbial Genetics and Genomics in five of the six sites surveyed.

Urban and rural differences in out-of-hospital cardiac arrest in Ireland

BACKGROUND

More than a third of Ireland's population lives in a rural area, defined as the population residing in all areas outside clusters of 1500 or more inhabitants. This presents a challenge for the provision of effective pre-hospital resuscitation services. In 2012, Ireland became one of three European countries with nationwide Out-of-Hospital Cardiac Arrest (OHCA) register coverage. An OHCA register provides an ability to monitor quality and equity of access to life-saving services in Irish communities.

AIM

To use the first year of national OHCAR data to assess differences in the occurrence, incidence and outcomes of OHCA where resuscitation is attempted and the incident is attended by statutory Emergency Medical Services between rural and urban settings.

METHODS

The geographical coordinates of incident locations were identified and co-ordinates were then classified as 'urban' or 'rural' according to the Irish Central Statistics Office (CSO) definition.

RESULTS

1798 OHCA incidents were recorded which were attended by statutory Emergency Medical Services (EMS) and where resuscitation was attempted. There was a higher percentage of male patients in rural settings (71% vs. 65%; p = 0.009) but the incidence of male patients did not differ significantly between urban and rural settings (26 vs. 25 males/100,000 population/year p = 0.353). A higher proportion of rural patients received bystander cardiopulmonary resuscitation (B-CPR) 70% vs. 55% (p ≤ 0.001), and had defibrillation attempted before statutory EMS arrival (7% vs. 4% (p = 0.019), respectively). Urban patients were more likely to receive a statutory EMS response in 8 min or less (33% vs. 9%; p ≤ 0.001). Urban patients were also more likely to be discharged alive from hospital (6% vs. 3%; p = 0.006) (incidence 2.5 vs. 1.1/100,000 population/year; p ≤ 0.001). Multivariable analysis of survival showed that the main variable of interest i.e. urban vs. rural setting was also independently associated with discharge from hospital alive (OR 3.23 (95% CI 1.43-7.31)).

CONCLUSION

There are significant disparities in the incidence of resuscitation attempts in urban and rural areas. There are challenges in the provision of services and subsequent outcomes from OHCA that occur outside of urban areas requiring novel and innovative solutions. An integrated community response system is necessary to improve metrics around OHCA response and outcomes in rural areas.

Costs of cancer care for use in economic evaluation: a UK analysis of patient-level routine health system data

BACKGROUND

The rising financial burden of cancer on health-care systems worldwide has led to the increased demand for evidence-based research on which to base reimbursement decisions. Economic evaluations are an integral component of this necessary research. Ascertainment of reliable health-care cost and quality-of-life estimates to inform such studies has historically been challenging, but recent advances in informatics in the United Kingdom provide new opportunities.

METHODS

The costs of hospital care for breast, colorectal and prostate cancer disease-free survivors were calculated over 15 months from initial diagnosis of cancer using routinely collected data within a UK National Health Service (NHS) Hospital Trust. Costs were linked at patient level to patient-reported outcomes and registry-derived sociodemographic factors. Predictors of cost and the relationship between costs and patient-reported utility were examined.

RESULTS

The study population included 223 breast cancer patients, 145 colorectal and 104 prostate cancer patients. The mean 15-month cumulative health-care costs were £12 595 (95% CI £11 517-£13 722), £12 643 (£11 282-£14 102) and £3722 (£3263-£4208), per-patient respectively. The majority of costs occurred within the first 6 months from diagnosis. Clinical stage was the most important predictor of costs for all cancer types. EQ-5D score was predictive of costs in colorectal cancer but not in breast or prostate cancer.

CONCLUSION

It is now possible to evaluate health-care cost using routine NHS data sets. Such methods can be utilised in future retrospective and prospective studies to efficiently collect economic data.