Differential impact of COVID-19 on mental health and burnout

BACKGROUND

There may be differential impact of the COVID-19 pandemic on mental health and burnout rates of healthcare professionals (HCPs) performing different roles.

AIMS

To examine mental health and burnout rates, and possible drivers for any disparities between professional roles.

METHODS

In this cohort study, online surveys were distributed to HCPs in July-September 2020 (baseline) and re-sent 4 months later (follow-up; December 2020) assessing for probable major depressive disorder (MDD), generalized anxiety disorder (GAD), insomnia, mental well-being and burnout (emotional exhaustion and depersonalization). Separate logistic regression models (at both phases) compared the risk of outcomes between roles: healthcare assistants (HCAs), nurses and midwives (nurses), allied health professionals (AHPs) and doctors (reference group). Separate linear regression models were also developed relating the change in scores to professional role.

RESULTS

At baseline (n = 1537), nurses had a 1.9-fold and 2.5-fold increased risk of MDD and insomnia, respectively. AHPs had a 1.7-fold and 1.4-fold increased risk of MDD and emotional exhaustion, respectively. At follow-up (n = 736), the disproportionate risk between doctors and others worsened: nurses and HCAs were at 3.7-fold and 3.6-fold increased risk of insomnia, respectively. Nurses also had a significantly increased risk of MDD, GAD, poor mental well-being and burnout. Nurses also had significantly worsened anxiety, mental well-being and burnout scores over time, relative to doctors.

CONCLUSIONS

Nurses and AHPs had excess risk of adverse mental health and burnout during the pandemic, and this difference worsened over time (in nurses especially). Our findings support adoption of targeted strategies accounting for different HCP roles.

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.

Direct oral anticoagulants compared to vitamin K antagonists for the treatment of left ventricular thrombi

Background

Left ventricular thrombus (LVT) complicates around one in six cases of acute and chronic left ventricular systolic dysfunction and is associated with an increased risk of stroke, major systemic embolism and death, believed to be ameliorated by anticoagulation. Off-label use of direct oral anticoagulants (DOACs) for LVT has steadily increased, largely based on favourable outcomes in atrial fibrillation and venous thromboembolism, but the safety and efficacy of DOACs versus vitamin K antagonists (VKA) for LVT remains uncertain.

Purpose

The main aim of our study was to compare treatment of LVT with VKA to DOAC, focusing on all-cause mortality, stroke, major systemic emboli and major bleeding.

Methods

We conducted a retrospective observational longitudinal study of patients presenting to two large quaternary centres between 2011 and 2021 with a diagnosis of LVT. Patients were eligible if they had a documented LVT and received anticoagulation with either VKA or DOAC. Baseline data, thrombus characteristics, treatment type and duration, follow up imaging and clinical events were recorded using electronic health care records. Outcome measures included thrombus resolution, stroke and systemic embolism (SSE), major bleeding and mortality.

Results

A total of 955 patients were identified, of whom 901 received treatment with either a VKA (567 pts, 62.9%) or a DOAC (334 pts, 37.1%) and were included in the analysis. Underlying aetiologies included acute myocardial infarction (AMI) (38.3%), chronic ischaemic cardiomyopathy (38.0%) and non-ischaemic cardiomyopathy (23.7%). Rivaroxaban (43.4%) was the most frequently prescribed DOAC followed by apixaban (35.9%), and the remaining on edoxaban (20.7%). AMI related LVT was more commonly treated with DOAC (53.0%) and chronic ischaemic cardiomyopathy with VKA (72.9%).

There was a lower baseline LVEF in the VKA cohort (29.5±13.2 vs 33.1±14.2, p<0.0001). Other demographic features were comparable. Median follow up was 2.5 years (IQR: 1–3.5). There were no differences in follow up duration between the two treatments (p=0.17). Greater rates of thrombus resolution were seen in the DOAC group compared to VKA (1 year: 78.4% vs 51.4%, p<0.0001), with higher rates of persistent thrombus over the follow-up period seen in the VKA group (25.1% vs 12.9%, p<0.0001). Rates of stroke and systemic embolization were similar between the groups (VKA 9.3% vs 9.6% DOAC, p=0.93). Higher rates of bleeding (BARC >3, 8.1% VKA, 3.6% DOAC, p=0.031) (Figure 1A) and mortality (VKA 18.5%, DOAC 10.2%, p=0.001) (Figure 1B) were seen in the VKA group over the follow-up period.

Conclusions

In a large multi-centre registry of LVT of mixed aetiology, anticoagulation with DOAC was associated with earlier and greater rates of thrombus resolution and consequential reduced adverse events (major bleeding and mortality) during follow up. A funding application to support a multi-centre randomised control trial is underway.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): This work was supported by the British Heart Foundation (Fellowship FS/CRTF/21/24190 to HM) and the National Institute for Health Research (Biomedical Research Centre Award to Guy's and St Thomas' NHS FT and King's College London).

167 Efficacy of Minimally Invasive Surgery on Hallux Valgus – a Systematic Review and Meta-Analysis

Aim

The aim of this study is to evaluate the effect of minimally invasive surgery over open surgery for hallux valgus with respect to surgical outcomes and patient reported outcomes.

Method

Medline Complete, PubMed, Cochrane Library, Scopus, SAGE Journals and gray literature were searched. Primary outcomes focused on hallux valgus angle, intermetatarsal angle, distal metatarsal articular angle. Secondary Outcomes included the American Foot & Ankle Society Score (AOFAS), as well as Pain on a Visual Analogue Scale(VAS), patient satisfaction, complications, SF-36 questionnaire and Manchester Oxford Foot Questionnaire (MOXFQ).

Results & Conclusions

8 randomized trials and 7 cohort studies were identified (n=907). Radiological outcomes between similar techniques were found to have no significant difference pre-post operatively at final follow up. Visual analogue scale scores were found to be significantly lower in the MIS groups compared to open techniques (MICA v Scarf) in the short term at Day 1 (P<0.00001) MD= -1.96 95% CI: -2.28, -1.65; I2 = 0%; Week 2 (P=0.001) MD= -1.40; 95% CI: -2.26, -0.54; and Week 6 (P=0.005) MD= -1.50; 95% CI: -2.55, -0.45. There was no statistical difference at 6 months (P=0.46) MD= -0.16; 95% CI: -0.59, 0.27; I2 = 0%; or final follow up (6 m to >24m) (P=0.94) MD= -0.02; 95% CI: -0.44, 0.41; I2 = 0%.). There were no statistically important differences between post-operative AOFAS scores across comparisons, whereas AOFAS mean difference was found to be significantly higher in Open Scarf vs MICA (P = 0.003); MD=-5.54; 95% CI: -9.19, -1.88. I2 = 0%.

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.

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.

P6426The use of direct oral anti-coagulations (DOACs) compared to vitamin k antagonist in patients with left ventricular thrombus after acute myocardial infarction

Aim

Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3–6 months for the treatment of LV thrombus post- acute myocardial infarction (AMI). However based on evidence supporting the non-inferiority and potential superiority of Direct Oral Anti-Coagulation's (DOAC) compared to VKA for other indications such as atrial fibrillation, DOACs are being increasingly used off licence for the treatment of left ventricular (LV) thrombus post AMI. In this study we investigated the effect of DOACs compared to VKA on LV thrombus resolution and their safety profile in patients presenting with AMI.

Methods and results

This was a prospective observational study of 2,328 consecutive patients undergoing Percutaneous Coronary Intervention (PCI) for AMI between 2015- 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was the rate of resolution of LV thrombus with bleeding rates as a secondary outcome.

Left ventricular (LV) thrombus was diagnosed by echocardiography, or cardiac magnetic resonance imaging in 98 (5.1%) patients. Sixty patients (61.2%) were started on VKA and 38 patients (38.8%) on DOAC therapy (Rivaroxaban: 57.9%, Apixaban, 36.8% and Edoxaban: 5.3%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia).

Over the follow up period (median 1.8 years), overall rates of LV thrombus resolution were 86%. There was greater and earlier LV thrombus resolution in the DOAC group compared to patients treated with warfarin (75% vs 53%, p=0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2–2.9). Major bleeding such as intracranial bleed, major GI bleed and bleed requiring hospital admission were lower in DOAC group, compared with VKA group (0% vs 5%, p=0.030) with no difference in rates of systemic thromboembolism (p=0.388).

Conclusion

This data suggests improved thrombus resolution in post ACS LV thrombosis in patient treated with DOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for the DOAC patients' vs VKA treated patients. This supports the need for randomised controlled trials to confirm this observational data.

Acknowledgement/Funding

None

P3769Rapid referral to a one-stop AF clinic following possible AF detection by community pharmacists leads to early diagnosis and appropriate anticoagulant treatment

Background

Atrial fibrillation is the most common cardiac arrhythmia globally, responsible for one third of ischaemic strokes, often resulting in death or incapacity. This condition, frequently asymptomatic is estimated to be up to 50% undiagnosed. Reducing this risk with appropriate detection and management strategies offers substantial economic and patient benefits. Community pharmacists have been shown to be an accessible healthcare professional capable of detecting atrial fibrillation. Concerns raised utilising community pharmacists is the additional workload for primary care physicians, and lack of a clear pathway to ensure patients are adequate followed with assurance of initiation of anticoagulation therapy.

Purpose

To assess the feasibility of screening by community pharmacists with onward referral to an innovative one-stop AF clinic to enable identification of new cases of AF and subsequent initiation of anticoagulation within 2 weeks.

Methods

21 pharmacies were recruited and trained on pathophysiology of AF and demonstration of pulse taking using pulse check and Kardia mobile device. Any person walking into a community pharmacy aged ≥65 years was offered a free pulse check. For any irregularity detected, individualised counselling was offered with a referral made to a one-stop AF clinic for confirmation and initiation of anticoagulation. Written patient consent was obtained.

Results

672 people were recruited with an average age of 69±3.5 years and 58% female (n=389). There was a history of hypertension in 618 (92%) and diabetes in 242 (36%), the most common co-morbidities. 45 people were referred following an irregular pulse or abnormal ECG rhythm strip, of whom 11 (1.6% of total population) had a confirmed AF diagnosis within 30 day follow up. An additional 8 cases with known AF not receiving anticoagulation termed (actionable AF) were also referred. All 19 cases of new or untreated AF were prescribed anticoagulation by the one stop clinic in accordance with guideline recommendations

Conclusions

ESC guidance recommends opportunistic screening for AF by pulse taking or ECG rhythm strip in patients ≥65 years of age. The 1.6% incidence of new AF was in accordance with meta-analyses identifying 1.4% of those aged ≥65 on a single time point check for presence of AF. Our model utilises the un-tapped skills of community pharmacy to deliver pulse checks of ECG rhythm recordings in an accessible primary care location with a clear referral pathway that is effective in early review and ensuring suitable patients receive anticoagulation. The innovative pathway could provide remote triage at scale and help address the missing people with undiagnosed and actionable AF by opening new channels for identification by healthcare professionals managing long term conditions who like pharmacists have not been considered suitable healthcare professionals due to lack of an established pathway for confirming the potential diagnosis of AF.

Acknowledgement/Funding

NHS England Test Bed Programme

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.

Safety and efficacy of paramedic treatment of regular supraventricular tachycardia: a randomised controlled trial

INTRODUCTION

Supraventricular tachycardias (SVTs) are a common cause of acute hospital presentations. Adenosine is an effective treatment. To date, no studies have directly compared paramedic-with hospital-delivered treatment of acute SVT with adenosine.

METHOD

Randomised controlled trial comparing the treatment of SVT and discharge by paramedics with conventional emergency department (ED)-based care. Patients were excluded if they had structural heart disease or contraindication to adenosine. Discharge time, follow-up management, costs and patient satisfaction were compared.

RESULTS

Eighty-six patients were enrolled: 44 were randomised to paramedic-delivered adenosine (PARA) and 42 to conventional care (ED). Of the 37 patients in the PARA group given adenosine, the tachycardia was successfully terminated in 81%. There was a 98% correlation between the paramedics' ECG diagnosis and that of two electrophysiologists. No patients had any documented adverse events in either group. The discharge time was lower in the PARA group than in the ED group (125 min (range 55-9513) vs 222 min (range 72-26 153); p=0.01), and this treatment strategy was more cost-effective (£282 vs £423; p=0.01). The majority of patients preferred this management approach. Being treated and discharged by paramedics did not result in the patients being less likely to receive ongoing management of their arrhythmia and cardiology follow-up.

CONCLUSIONS

Patients with SVT can effectively and safely be treated with adenosine delivered by trained paramedics. Implementation of paramedic-delivered acute SVT care has the potential to reduce healthcare costs without compromising patient care.

TRIAL REGISTRATION NUMBER

NCT02216240.

Routine versus no drain placement after elective laparoscopic cholecystectomy: meta-analysis of randomized controlled trials

Routine drainage of the subhepatic space has been a surgical trend of open cholecystectomy, carried on to the era of laparoscopic surgery without substantial evidence. Avoiding the potentially devastating sequelae of an undetected bile leakage is the main rationale behind this practice. Aim of this meta-analysis was to compare evidence on routine drain placement after laparoscopic cholecystectomy versus no drainage. A meta-analysis of randomized controlled trials was conducted; outcome variables included postoperative pain, subhepatic collection, 30-day morbidity, wound-related complications, and drainage interventions. The fixed- and random effects models were used in order to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) or difference in means with 95% confidence interval (CI). Six randomized trials including 1167 patients were identified. Pain scores were significantly higher in the drainage group both at 6-12h (mean difference 1.12, 95% CI 1.01-1.24, P<0.0001) and at 12-24h after surgery (mean difference 1.12, 95% CI 0.86-1.39, P<0.0001). No difference was found with regard to the incidence of subhepatic collection and drainage procedures. A trend in favor of the no drain approach with regard to 30-day morbidity and wound infection was registered, although this was less pronounced after sensitivity analysis. The possible clinical benefit of routine use of abdominal drainage in uncomplicated laparoscopic cholecystectomies requires larger study populations. The approach is however not encouraged on the basis of the present analysis, as it results in increased postoperative pain and overall morbidity.

The safety and efficacy of intracoronary nitrite infusion during acute myocardial infarction (NITRITE-AMI): study protocol of a randomised controlled trial

INTRODUCTION

Acute myocardial infarction (AMI) is a major cause of death and disability in the UK and worldwide. Presently, timely and effective reperfusion with primary percutaneous coronary intervention (PPCI) remains the most effective treatment strategy for limiting infarct size, preserving left ventricular ejection fraction (LVEF) and improving clinical outcomes. However, the process of reperfusion can itself induce cardiomyocyte death, known as myocardial reperfusion injury, for which there is currently no effective therapy. Extensive preclinical evidence exists to suggest that sodium nitrite (as a source of endogenous nitric oxide) is an effective therapeutic strategy for preventing myocardial reperfusion injury. The purpose of NITRITE-AMI is to test whether sodium nitrite reduces reperfusion injury and subsequent infarct size in patients undergoing PPCI for MI.

METHODS AND DESIGN

NITRITE-AMI is a double-blind, randomised, single-centre, placebo-controlled trial to determine whether intracoronary nitrite injection reduces infarct size in patients with myocardial infarction undergoing primary angioplasty. The study will enrol 80 patients presenting with ST-elevation myocardial infarction. Patients will be randomised to receive either a bolus of intracoronary sodium nitrite or placebo (sodium chloride) at the time of PPCI. The primary outcome is infarct size assessed by creatine kinase area under the curve (AUC) over 48 h. Secondary endpoints include troponin T AUC and infarct size, LV dimensions and myocardial salvage index assessed by cardiac MR (CMR), markers of platelet reactivity and inflammation, the safety and tolerability of intracoronary nitrite, and 1 year major adverse cardiac events.

ETHICS AND DISSEMINATION

The study is approved by the local ethics committee (NRES Committee London West London: 11/LO/1500) and by the Medicines and Healthcare Products Regulatory Agency (MHRA) (EudraCT nr. 2010-022460-12). The results of the trial will be published according to the CONSORT statement and will be presented at conferences and reported in peer-reviewed journals.

TRIAL REGISTRATION

United Kingdom Clinical Research Network (Study ID 12117), http://clinicaltrials.gov (NCT01584453) and Current Controlled Trials (ISRCTN:38736987).

Endovascular stent graft repair of renal artery aneurysms

AIM

To evaluate the published outcomes of endovascular stent graft repair of renal artery aneurysms.

METHODS

The English literature was systematically searched using the MEDLINE electronic database up to April 2010. All reports of endovascular stent graft repair of renal artery aneurysms were considered. The primary outcome measures were technical success and perioperative, 30-day and overall morbidity and mortality.

RESULTS

Data for the final analysis were extracted from 20 papers reporting on endovascular stent graft repair of 22 aneurysms in 21 patients. Elective repair was performed in 20 cases (91%), whereas 2 patients (9%) underwent an endovascular repair of a ruptured aneurysm. The technical success rate was 91% (20/22). Neither perioperative/30-day mortality nor significant perioperative morbidity was noticed in this study cohort. Minor perioperative complications developed 6 patients (27%), and were most commonly associated with occlusion of a side branch vessel resulting in segmental infarction of the kidney. None of the patients developed renal impairment. During a mean follow up of 8 months, no patients developed aneurysm-related complications requiring revision.

CONCLUSION

Endovascular stent graft repair of renal artery aneurysms is reported to be a safe and effective treatment option, with good immediate and short-term results. However, no long-term data exists and larger series are required to draw solid conclusions regarding the outcomes of this method.

The effect of humic acid on the formation and solubility of secondary solid phases (Nd(OH)CO3 and Sm(OH)CO3)

The formation of secondary Ln(III) solid phases ( e.g. Nd(OH)CO3 and Sm(OH)CO3) has been studied as a function of the humic acid (HA) concentration in 0.1 M NaClO4 aqueous solution and their solubility has been investigated in the neutral pH range (6.5–8) under normal atmospheric conditions. Nd(III) and Sm(III) were selected as analogues for trivalent lanthanide and actinide ions. The solid phases under investigation have been prepared by alkaline precipitation and characterized by TGA, ATR-FTIR, XRD, TRLFS, DR-UV-Vis and Raman spectroscopy, and solubility measurements. The spectroscopic data obtained indicate that Nd(OH)CO3 and Sm(OH)CO3 are stable and remain the solubility limiting solid phases even in the presence of increased HA concentration (0.5 g/L) in solution. Upon base addition in the Ln(III)-HA system decomplexation of the previously formed Ln(III)-humate complexes and precipitation of two distinct phases occurs, the inorganic (Ln(OH)CO3) and the organic phase (HA), which is adsorbed on the particle surface of the former. Nevertheless, HA affects the particle size of the solid phases. Increasing HA concentration results in decreasing crystallite size of the Nd(OH)CO3 and increasing crystallite size of the Sm(OH)CO3 solid phase, and affects inversely the solubility of the solid phases. However, this impact on the solid phase properties is expected to be of minor relevance regarding the chemical behavior and migration of trivalent lanthanides and actinides in the geosphere.

Acute intermittent porphyria in pregnancy: a common misdiagnosis

Acute intermittent porphyria (AIP) is inherited in an autosomal dominant fashion. Only 10% to 15% of the gene carriers have the clinical syndrome. The prevalence of AIP in Europe is 1/20,000. Pregnancy represents an essential risk factor in patients suffering from AIP. The clinical syndrome in AIP presents mainly with acute attacks, especially during the first trimester. Misdiagnosis of AIP unfortunately is very common. Pregnancy in women with AIP is associated with higher rates of spontaneous abortion, hypertension, low birth weight infants and considerable mortality (2-42%). Pregnancy, despite the major hormonal alterations it causes, is seldom associated with porphyric symptoms. There are only limited reports supporting the use of hemin during pregnancy, but experience indicates that it can be safely administered in pregnant women. Until clinical improvement is achieved, symptomatic treatment is recommended. Despite the fact that pregnancy in women suffering from AIP is related to higher rates of morbidity and complications, close management throughout the pregnancy could ensure a good outcome.

Use and cost of branded and generic drugs in patients with coronary heart disease--results from a prospective survey of 1008 patients in two London hospitals

BACKGROUND

Combination therapy with three classes of drug, antiplatelet, cholesterol and blood pressure lowering treatment markedly reduce the risk of recurrent cardiovascular events in patients with coronary heart disease (CHD). Within each class, generic and branded (patented) drugs are available which have similar efficacy but differ in cost.

AIMS

(i) To assess the extent to which preventive medical drugs are prescribed in patients with CHD and to examine the reasons for drug omissions and (ii) to assess the relative use of branded and generic drugs and the reasons for drug selection.

METHODS

The medication charts and hospital notes of consecutive patients undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) at a large cardiothoracic centre were reviewed over a 3-month period. Interviews with patients, attending cardiologists and general practitioners were undertaken to establish why drugs were and were not prescribed.

RESULTS

Among 1008 patients (755 who had PCI and 253 who had CABG) the use of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB), beta blockers and calcium channel blockers were, respectively, 97, 98, 81, 76 and 18%. The combination of any 4 classes of drug were used in 65% of patients. Almost all patients who did not receive aspirin or a statin had clinical contraindications and were on alternative drugs. In about 12% of patients without an ACE inhibitor (or ARB) and 7% of patients without a beta blocker, no reason to withhold such treatment was identified. Branded drugs were used in 52% of patients; the most commonly prescribed being atorvastatin in 33%. Clinical reasons for using branded rather than generic drugs were identified in 13% of cases.

CONCLUSION

Our results show a high rate of use of secondary preventive cardiac medications in patients undergoing coronary revascularization procedures, but the use of ACE inhibitors or beta blockers is still overlooked in about 1 in 10 patients. Branded drugs are prescribed in about half of all patients undergoing PCI and CABG, but in almost 90% of cases, a generic equivalent could have been used to achieve similar risk reduction. If our results reflect wider practice, an estimated 11 million pounds a year would be saved by the National Health Service by switching to generic alternative drugs.

Intraperitoneal haemorrhage secondary to perforation of uterine fibroid after cystic degeneration. Unusual CT findings resembling malignant pelvic tumor: case report

Intraperitoneal haemorrhage is a rare complication of myomatous uterus. We present a case of a 37-year-old white nullipara who presented in the emergency room with acute, lower-abdominal pain which reportedly started after riding over a bump on a motorcycle. On examination, the abdomen was diffusely tender, with moderate spasm and rebound tenderness in both iliac fossae. Pregnancy test was negative. Computed tomography revealed a soft-tissue mass with cystic components and inhomogeneous appearance. Free fluid in the peritoneal cavity suggested ascites. The patient underwent an exploratory laparotomy. A ruptured, actively bleeding, subserosal, nonpedunculated, cystic degenerated uterine fibroid was found, as well as approximately two liters of free, bloodstained peritoneal fluid and clots. Subtotal hysterectomy without salpingo-oophorectomy was performed, followed by evacuation of the fluid and clots. The patient's postoperative course was uneventful. In conclusion, definitive, preoperative diagnosis of a perforated, haemorrhaging, uterine fibroid is difficult; exploratory laparotomy is both diagnostic and therapeutic in this rare, life-threatening condition.

Ultrasonographic and computed tomography manifestations of intussusception secondary to primary non-Hodgkin's lymphoma diagnosed in puerperium: report of a case and review of the literature

Non-Hodgkin's lymphoma is infrequently diagnosed during pregnancy and puerperium. A 21-year-old woman, para II, gravida II, on the seventh postpartum day arrived at the Emergency Gynaecologic Clinic complaining of colicky abdominal pain associated with bilious vomiting. A large tender mass of firm consistency was palpated in the midline towards the left hypochondrium. A CT scan of the upper abdomen showed thickened small bowel with halo, specifically at the junction of the jejunum with the ileum, resembling imaging of intussusception. Also, blocks of mesenteric and paraortic lymph nodes and multiple lymph nodes inducing enlargement of the anterior mediastinum were found. These findings rendered a picture of lymphoma in Stage at least III. Subsequent exploratory laparotomy confirmed our preoperative diagnosis. Histopathological examination of the lymph node biopsies established the diagnosis of a primary non-Hodgkin's lymphoma. Judging from the extent of the non-Hodgkin's lymphoma in our patient seven days after delivery the disease probably already existed during the last trimester of pregnancy. This study demonstrates a remarkable delay in diagnosis of non-Hodgkin's lymphoma in pregnancy. The diagnostic dilemmas of non-Hodgkin's lymphoma during pregnancy are emphasized and the literature is reviewed.

The association between occupational stress and the risk of developing acute coronary syndromes: the CARDIO2000 Study

OBJECTIVE

The aim of this study was to investigate the association between occupational stress and the risk of developing acute coronary syndromes, in a population-based sample of patients and controls.

METHODOLOGY

During 2000-01, a case-control study was conducted (CARDIO2000). A random and stratified sample of 848 middle aged patients with a first of an acute coronary syndrome and 1078 cardiovascular disease free participants, matched with the patients by gender, age and region, was selected from all regions of Greece. In addition to the common cardiovascular risk factors, the effect of occupational stress on coronary risk was evaluated, after taking into account income, marital status, educational and occupational level of the participants. The levels of occupational stress were measured by administering to the individuals a self-reported questionnaire.

RESULTS

After controlling for age, gender and region, by design, and the presence of smoking, hypertension, hypercholesterolaemia, diabetes mellitus, physical activity status, educational and financial status and nutritional habits, multivariate analysis showed that the levels of occupational stress are positively associated with the risk of developing acute coronary syndromes in the investigated sample (Odds Ratio = 2.2, p < 0.01). Moreover, the presence of occupational stress seems to affect more significantly males than females, smokers than non-smokers, hypertensives than normotensives and high alcohol consumers compared to low alcohol consumers.

CONCLUSIONS

Although the design of the present study does not provide evidence of causality, a strong positive association between occupational stress and acute coronary syndromes seems to exist. Thus, public health policies should take into account lifestyle conditions related to work in the design of preventive strategies at the primary level.

Primary ruptured ovarian pregnancy in a spontaneous conception cycle: a case report and review of the literature

Ovarian pregnancy is an uncommon presentation of ectopic gestation, where the gestational sac is implanted within the ovary. Usually, it ends with rupture, which occurs before the end of the first trimester. Its presentation often is difficult to distinguish from that of tubal ectopic pregnancy and hemorrhagic ovarian cyst. We describe a case of primary ovarian pregnancy in a 31-year-old patient who presented to the emergency room with symptoms and signs of peritonism and positive urine hCG test. The gestation sac was demonstrated in the right ovary by transvaginal sonography. MSD (mean sac diameter) was 15 mm corresponding to the sixth gestational week. Free fluid was found in the Douglas pouch. Culdocentesis was positive for hemoperitoneum. Henceforth, emergency laparotomy and wedge resection of the ovary was perfomed. Aetiological, clinical and therapeutical aspects of this rare extrauterine pregnancy are described. Also, the problems of its differential diagnosis are discussed.

Endometriosis causing extensive intestinal obstruction simulating carcinoma of the sigmoid colon: a case report and review of the literature

Endometriosis with intestinal serosal involvement is not uncommon in women of childbearing age, however, presentation as colon obstruction is rare. Lack of pathognomonic symptoms makes diagnosis difficult, the main problem being differential diagnosis with neoplasm, even intraoperatively. Reported here is a case of extensive bowel obstruction due to sigmoid colon endometriosis in a 43-year-old woman who presented with signs and symptoms of bowel obstruction. Barium enema showed sigmoid obstruction; subsequent exploratory laparotomy showed the sigmoid colon surrounded by fibrous tissue, leading to its angulation and extensive lumen obstruction. Left oophorectomy and radical resection of descending and sigmoid colon as for bowel carcinoma were successfully employed. Pathological examination revealed endometriosis in the bowel wall with preservation of the mucosa. Aetiology, clinical presentation, differential diagnosis and therapeutic options for intestinal obstruction due to endometriosis are discussed.

Incidence of vein thrombosis in peripheral intravenous nutrition: effect of fat emulsions

The relative risk of thrombophlebitis induced by either Long-chain Triglycerides (LCTs) or Medium-chain Triglycerides (MCTs) during peripheral i.v. nutrition (PIN) was evaluated. A total of 76 patients were randomly assigned into group A (n=40) and group B (n=36). The nutritional requirements in both groups were covered by a standardized regime of osmolality 1130 mOsm and pH 5.2, which provided 14 kg/day(-1) nitrogen, 600 kcal/day(-1) of carbohydrates and 1000 kcal/day(-1) of lipids. Group A received the lipids as pure LCTs while group B received a mixture of LCTs/MCTs at a ratio 1:1. The infused nutritional volume was 2000 ml and was delivered via a suitable vein in a proximal forearm, using a fine bore polyurethane 22G catheter. The two standardized regimes were evaluated over a 10 day period regarding the incidence of thrombophlebitis. The cumulative risk of thrombophlebitis was documented to be significantly lower in group A compared to group B (17.5% versus 44.4%, P < 0.05). LCTs appear to prolong peripheral vein feeding by lessening the reaction of venous endothelium to the irritating nutritional infusate.