Central Register Research Articles

Modulating the organization of medical care and early diagnosis of prostate cancer

Aim. To analyze the existing system of medical care organization and timely diagnostics for prostate cancer (PC).Materials and Methods. The study utilized data from official statistics to analyze the system of medical care organization and the diagnostic methods applied for prostate cancer at different stages.Results. In the country, medical care for patients with prostate cancer is organized into three levels. The first level involves family physicians, urologists, and oncologists in oncology clinics, where access to modern diagnostic facilities is limited. The second level provides advanced diagnostic services through regional oncology centers and major urology departments. The third level offers specialized care at the National Cancer Research Center (NCRC) and select urology clinics. Based on the experience of other countries, it is recommended to improve the system of medical care for prostate cancer by establishing four stages of care. The proposed model takes into account the real situation, emphasizing the need for prevention, timely diagnosis, and effective treatment in accordance with clinical protocols, as well as the coordinated use of human and technological resources from oncology, urology, and morphological services at all stages.Conclusions. The proposed model for organizing medical care, based on evidence-based practices, aims to improve early detection of prostate cancer, enhance the clinical effectiveness of treatment, and optimize the use of resources.

Disparities in SGLT2i utilization among heart failure patients with different ejection fraction in China: findings from chinese cardiovascular association database-heart failure center registry

Abstract Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are recommended for heart failure (HF) patients regardless of left ventricular ejection fraction (LVEF). Although Chinese HF guidelines still recommend traditional renin–angiotensin–aldosterone system inhibitors, beta blockers, mineralocorticoid receptor antagonists, the Chinese Cardiovascular Association (CCA) HF Center Registry has launched a project to promote the guideline-directed medical therapy (GDMT) for HF patients in China. However, data on the utilization of GDMT in Chinese HF patients is scarce, especially SGLT2i. Purpose We aimed to investigate the usage status of SGLT2i in HF patients with different LVEFs and explore associated factors with SGLT2i adoption in hospitalized HF Chinese patients. Methods This is a retrospective real world study using data from the CCA Database-HF Center Registry. The study included HF patients hospitalized in 52 secondary or tertiary hospitals, including 26 accredited heart failure centers (HFC) and 26 non-accredited heart failure centers (NHFC). Centers that meet the 25 quality control standards established by CCA can be accredited as HFC. We evaluated the use rate of SGLT2i overall and by HF type, as well as the change of SGLT2i usage rate at discharge during the study period from 1st July 2022 to 31st March 2023. LASSO and multivariable logistic regression were also used to explore associated factors of SGLT2i adoption at discharge. Result We included 8,843 hospitalized HF patients: 5,326 (60.2%) were male, 2,980 (33.7%) HFrEF, 1,624 (18.4%) HFmrEF, 3,653 (41.3%) HFpEF and 586 (6.6%) lacked EF data. Overall, SGLT2i were adopted in 3,666 (41.5%) HF patients at discharge (58.1% in HFrEF, 45.3% in HFmrEF, 28.8% in HFpEF). Overall, the usage rate of SGLT2i at discharge rose from 35.2% to 50.2%. Specifically, for HFrEF patients, there was a rise from 56.2% to 64.4%. For HFmrEF and HFpEF patients, the usage rate increased from 37.5% to 54.4% and from 22.2% to 35.7%, respectively (Figure 1). The usage rate of SGLT2i was higher in HFC compared with NHFC (47.1% vs. 35.8%, p<0.001). In multivariable logistic regression, older age, new-onset heart failure, hospital location, etc. were associated with a lower usage rate of SGLT2i at discharge. In contrast, HFC, dilated cardiomyopathy, obesity, etc. were associated with a higher utilization rate of SGLT2i (Figure 2). HF classification by LVEF was also an independent influencing factor even after adjusting other factors; when HFrEF was used as a reference, the use rate of SGLT2i was lower in HFmrEF (OR 0.79, 95% CI 0.69 - 0.91) and HFpEF (OR 0.44, 95% CI 0.39 - 0.49). Conclusion In clinical practice in China, the usage rate of SGLT2i for HF treatment is increasing but needs to be further improved. Disparities exist in usage rates among HF patients with different LVEFs. Addressing this disparity necessitates a targeted approach, emphasizing increased utilization in HF patients regardless of LVEF.SGLT2i usage rate in HFFactors affecting SGLT2i adoption in HF

Socioeconomic disparity in utilization of transcatheter aortic valve replacement

Abstract Introduction Transcatheter aortic valve replacement (TAVR) is a major therapeutic option, rapidly replacing surgical aortic valve replacement (SAVR) in patients with aortic stenosis (AS) in recent years. However, the use of TAVR may vary with the socioeconomic status (SES) since new technologies are more likely to have the lower accessibility in some medico-social environments. In South Korean patients with AS, we investigated the difference in the use of TAVR based on SES and whether the difference influences clinical outcomes of patients with AS. Methods Between 2010 and 2020, 30,142 patients newly diagnosed with AS in a tertiary or regional center were investigated through the Korean National Health Insurance System (KNHIS). Patients were received either medical, SAVR or TAVR therapy for AS. The patients were categorized into 3 groups based on the insurance premium level (IPL) of the KNHIS (IPL1, <100 KW; IPL2, 100-249 KW; IPL3, ≥250KW). AS-related death was defined as death by AS, heart failure or ventricular arrhythmia. Cardiovascular (CV) death was defined as AS-related death or death by myocardial infarction or stroke. The study period was divided at year 2015, when the partial coverage for TAVR was implemented by the KNHIS. Results The numbers of patients referred to the tertiary/regional centers have continuously grown for the 11 years but the referring rate has grown even faster since 2015. The proportions of TAVR has increased while that of SAVR has decreased since 2015. TAVR was more frequently chosen by patients with a higher IPL (5.5%, 8.0% and 12.5%, respectively in the IPL1, IPL2 and IPL3, p<0.001), whereas the medical therapy appeared not affected by the IP levels. The patients in the IPL2 (odd ratio [OR] 1.33 [1.20-1.47]) and IPL3 (OR 1.65 [1.45-1.86]) had a higher chance to undergo TAVR than those in the IPL1 whereas the patients in the IPL3 was a lower chance to undergo SAVR than those in the IPL1 (OR 0.86 [0.78-0.94]). In patients with severe AS, the disparities between the IPL1 and IPL3 exaggerated (OR 1.99 [1.70-2.33]) (Figure 1). Higher IPLs were associated with lower risks of CV death and AS-related death. Time-varying Cox proportional hazard models showed that TAVR was associated with a lower risk of CV death than both medical therapy and SAVR in the entire study period and in year 2015 or later, whereas TAVR was associated with a lower risk of AS-related death than the both only in year 2015 or later, after adjustment of relevant covariates including the IPL (Figure 2). The choice of TAVR significantly medicated the associations between IPLs and the risk of CV death (responsible for 3.0% in the IPL2 and 4.1% in the IPL3). Conclusion The SES based on the IPL is independently associated with the choice of TAVR in patients with AS and the association has become stronger since 2015. The disparity in use of TAVR could mediate more frequent CV deaths in patients with the lower IPL.Figure 1Figure 2

Intravascular imaging-guided percutaneous coronary intervention according to lesion complexity

Abstract Background Recent trials have shown intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) has prognostic benefit compared with angiograph-guided PCI in complex coronary artery lesions. However, it is unclear whether this benefit is affected by overall complexity of target lesions in each patient. Objectives To investigate an impact of the number of complex lesion features on the benefit of IVI-guided PCI. Methods A total of 4,611 patients with complex coronary artery lesions from the RENOVATE-COMPLEX-PCI trial (n=1,639) and the institutional registry of a medical center (n=2,972) were classified according to the number of complex lesion features found in each patient. The primary outcome was a target vessel failure (TVF) at 3 years, a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularization. Results The best cut-off number of complex lesion features for the risk of TVF was 3 and patients with ≥3 complex lesion features had higher risk of TVF than those with <3 complex lesion features (11.0% vs. 7.2%; HR 1.59, 95% CI 1.28-1.96, P<0.001). IVI-guided PCI significantly reduced the risk of TVF compared to angiography-guided PCI in both groups (≥3 complex lesion features: 7.4% vs. 14.4%, HR 0.49; 95% CI 0.35-0.69, P<0.001; <3 complex lesion features: 5.7% vs. 8.1%; HR 0.72, 95% CI 0.53-0.98, P=0.039). The benefit of IVI-guided PCI tended to increase as the number of complex lesion features increased (absolute risk reduction for TVF: -0.012 vs. -0.027 vs. -0.055 vs. -0.077, respectively, for the number of complex lesion features 1 vs. 2 vs. 3 vs. ≥4, interaction P=0.048). Conclusion In patients with complex coronary artery lesions, IVI-guided PCI reduced the risk of TVF regardless of overall complexity of the target lesions in each patient. The prognostic benefit of IVI-guided PCI tended to increase as patients had more complex lesion features.Clinical Outcomes

Prescription time trends in patients with high-impact chronic pain: A National Patient Registry Study.

High-impact chronic pain (HICP), defined as chronic pain with a significant impact on daily function, affects approximately 8% of the Western population. In Denmark, HICP still remains to be described at the population level. Some patients with HICP are referred to the Danish pain centres, where they are registered with a procedural code. We conducted a nationwide registry-based study of all Danish patients registered with a visit to a pain centre from January 2005 to March 2022, to explore time trends in the prescription of analgesics and sedatives in this HICP subpopulation. Furthermore, data on socioeconomics and hospital diagnoses are reported. We used data from the Central Person Registry, the Danish National Patient Registry, the Danish National Prescription Registry, combined with data on socioeconomic information from Statistics Denmark. Data was collected on prescriptions 3 months before the first visit to a pain centre. Prescriptions were stratified into five calendar periods: before 2011, 2011-2013, 2014-2016, 2017-2019, and 2020-2022. We identified 66,577 patients referred to a pain centre. Over 15 years, prescriptions before referral declined for opioids (from 53.2% to 31.7%), NSAIDs (from 28.3% to 23.5%), antidepressants (from 20.5% to 16.8%), anxiolytics (from 12.3% to 3.2%), and sleep medication (from 15.8% to 7.6%). In contrast, prescriptions increased for paracetamol (from 31.1% to 48.9%) and gabapentinoids (from 19.2% to 27.7%). In patients with HICP visiting Danish pain centres, prescriptions before referral decreased for opioids over 15 years, with a simultaneously increased prescription of gabapentinoids (gabapentin and pregabalin). This nationwide study of 66,577 Danish patients with high-impact chronic pain reveals a significant decrease in filled opioid prescriptions over the past 15 years, with a simultaneous rise in gabapentinoid use before referral to pain centres. These findings suggest a shift in clinical practice towards alternative pain management strategies. The study underscores the need for continued research into the long-term effects of these changes and their impact on patient outcomes.

5.E. Round table: Crafting Policies for Health Promotion: evidence from local settings

Abstract As communities vary in their needs, challenges, and resources, tailoring health promotion policies to specific contexts becomes imperative for effectiveness. Drawing upon the expertise of seasoned practitioners, policymakers, and researchers, this workshop offers a multifaceted perspective on navigating the complexities inherent in designing, implementing, and evaluating locally tailored health promotion policies, with a specific focus on environmental and social factors. The workshop will make it possible to compare different experiences from various European countries, with high-level speakers who have different backgrounds and roles in their countries and regions, thus providing an interesting and interactive way of comparing and examining real-world examples and best practices. The examples provided delve into: participatory techniques to design healthier environments, to identifying, collecting and elaborating evidence upon which to build policies and actions that are effective in addressing specific health challenges. Through the examples presented, we will seek to make the case for multi-actor and multisectoral collaboration. In addition, we will try to understand How do subnational authorities and partners identify priorities for action. A common question asked to the speakers will therefore: how can a variety of actors (local and regional authorities, university and research centres...) come together to support cross-sectoral action? How can policymakers be supported towards creating environments that prioritize the well-being of all, ensuring a healthier and more prosperous future for everyone? The end goal will be to enable attendees to be equipped with actionable strategies and tools to foster meaningful change within their own communities, by understanding the intricate interplay between community dynamics, stakeholder engagement, evidence-based practices, and policy implementation strategies. The workshop is being organized by the WHO Regions for Health Network (RHN). Key messages • Tailoring health promotion policies to specific contexts is imperative for effectiveness, considering the diverse needs, challenges, and resources of different communities. • Subnational authorities and partners must identify priorities for action and collaborate across sectors to address specific health challenges effectively. Speakers/Panelists Klara Dokova Medical University of Varna, Varna, Bulgaria Camilla Ihlebaek Norwegian University of Life Sciences, Aas, Norway Jo Peden Public Health Wales, Cardiff, UK Odile Mekel NRW Centre for Health, Bochum, Germany Liesbeth van Holten Province of Utrecht, Utrecht, Netherlands

Long-term clinical outcomes and patterns of follow-up after cardiogenic shock: insights from an advanced heart failure referral center registry

Abstract Background Inpatient mortality of patients with cardiogenic (CS) has been reported as high as 50%. Those who present in CS are at high risk of having recurrent admissions to hospital or requiring advanced heart failure (HF) therapies. The Toronto General Hospital (TGH) is a quaternary cardiac center, providing mechanical circulatory support (MCS) and heart transplantation (HT), serving as a regional CS transfer hub for a population of over 8 million people. While inpatient management of CS patients has been studied extensively, there is little data on where or how these patients are followed after their discharge. We aimed to determine the long-term clinical outcomes and nature of follow up after a CS admission. Methods This was a retrospective cohort study of CS patients admitted to TGH between 2014 and 2023. We collected data regarding survival to discharge and the type of follow up patients received after their index CS admission. Survival was compared using Kaplan-Meier methods. Results 1582 patients were admitted during the study. The mean age was 59.9 + 16.1 years, including 474 (30.0%) females and 335 (21.2%) patients with acute myocardial infarction CS. In-hospital mortality was 32.4%, with a further 17 (1.8%) patients transferred to palliative care during their index CS admission. After excluding patients who underwent heart transplantation (HT) or durable MCS implant, 679 patients were discharged alive, with median follow-up of the 307 (range 0 – 3436) days. Overall mortality was 57.0%. Among discharged patients, 396 (56.8%) were followed at the regional hub hospital. A further 54 (8.0%) patients were followed by a cardiology provider at a referring community center. A total of 202 (29.7%) patients did not have outpatient follow up arranged at the time of their discharge and no details of further care were available. Median survival during follow-up was higher among patients with confirmed follow-up at the time of their discharge, but not statistically significant (1798 vs 1775 days, p=0.067). There was a significant survival benefit among CS patients followed at a heart function clinic compared with those who were not, (1821 vs. 1775 days, p= 0.020). In terms of candidacy for advanced therapies, having outpatient follow up was associated with receiving durable MCS or HT (6.3% vs. 0.5%, p=0.003). Conclusion Despite advances in the management of CS, overall mortality remains high at 57.0%. Follow-up after CS admission is of essential importance- both in improvement of long-term outcomes, and access to advanced heart failure therapies. There was a survival benefit among patients who were followed in a specialized heart function clinic. Additionally, having outpatient follow up was significantly associated with receiving advanced therapies. Further research is needed to identify the barriers to accessing post discharge follow-up care.

The effects of angiotensin receptor-neprilysin inhibitors on clinical outcomes in heart failure with mildly reduced or preserved ejection fraction: real-world evidence from the CCA Database-HF Center

Abstract Background Recent clinical trials have demonstrated the potential efficacy and safety of angiotensin receptor-neprilysin inhibitors (ARNI) in patients with heart failure (HF) with mildly reduced or preserved ejection fraction. Nevertheless, the generalizability of these findings in real-world clinical settings remains to be determined. We aimed to compare the real-world effectiveness of ARNI versus angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB)on clinical outcomes in HF patients with mildly reduced or preserved ejection fraction. Methods Patient-level data was derived from the China Cardiovascular Association Database-HF Center Registry. We included exclusively a subpopulation of HF patients with left ventricular ejection fraction (LVEF) >40% and comorbid with hypertension. Patients prescripted with ARNI at discharge and sustaining to ARNI therapy during follow-up were categorized as the ARNI group, while those maintaining the usage of ACEI/ARB after discharge were designated as the ACEI/ARB group. In complete cases, the primary endpoint of all-cause mortality at one year was assessed by the 1:1 propensity score matching (PSM) method. Results In all HF patients with LVEF >40% comorbid with hypertension, the usage of ARNI has increased from 0.9% in 2017 to 37.2% in 2021. A total of 3348 patients in the ARNI group and 7688 patients in the ACEI/ARB group were identified for comparative effectiveness. After 1:1 PSM, 5482 patients were included in the primary analysis, with 2741 patients in each treatment arm. The proportion of patients receiving higher dosages of ARNI (200mg/d and 400mg/d) was 20.9%, 26.6%, 29.2%, and 30.3% at discharge, 1-month, 3-month, and 1-year, respectively. Over the 1-year follow-up, ARNI was associated with a 20% relative reduction in all-cause death compared to the ACEI/ARB therapy (10.5% vs. 12.9%, adjusted hazard ratio [HR], 0.80 [95% CI, 0.69-0.94], P=0.005). The absolute risk difference in all-cause death between ARNI and ACEI/ARB arms was 2.88 per 100 patient-years (incidence rate difference, -2.88 [95% CI, -4.86 to -0.9]). Cardiovascular death also tended to decrease in the ARNI group but with missed statistical significance (4.5% vs. 4.9%, adjusted HR, 0.89 [95% CI, 0.70-1.14], P=0.373). Treatment benefits were more significant in those with LVEF between 40-50% (adjusted HR, 0.62 [95% CI, 0.48-0.79]), 50-60% (adjusted HR, 0.85 [95% CI, 0.68-1.06]), but not observed in HF patients with LVEF>60% (adjusted HR, 1.80 [95% CI, 1.08-2.98]; Pinteraction<0.001). Conclusion In real-world clinical settings, treatment with ARNI was associated with a significant relative risk reduction in all-cause mortality compared with ACEI/ARB in HF patients with mildly reduced or preserved LVEF. The cardiovascular benefit was concentrated in patients with LVEF ≤60%.

Patients on the ledge; ablation of incessant tachycardia. A single centre registry

Abstract Background Incessant tachycardia was first described by Cassidy (1). in 1924, it is strongly associated with tachycardia induced cardiomyopathy. There is no data about its true incidence however, it seems to be more common during infancy and childhood. Objectives To present 5-year single centre experience in ablating incessant tachycardia in a cohort of pediatric and adult patients. Methods From 2018 to 2023, We reviewed patients presented to our centre with incessant tachycardia, their clinical data, ECGs, imaging modalities, procedures details & outcomes were examined thoroughly. Results Over 5 years, 900 patients were referred to our centre for ablation, among them 25 patients (2.7%) presented with incessant tachycardia. Of them: 10 patients were pediatrics (40%), the youngest was 40 days old, 3.4 Kg, 6 patients were haemdynamically unstable necessitating ventilation& IV supports, 14 patients had impaired EF, with the lowest EF of 20%.(A) Regarding the diagnosis, 14 patients had AT (4 CS ostium, 3 LAA, 2 parahisian, 2 Crista, 1 LSPV, 1 TA, 1RAA), 4 AVRT (2 concealed parahisian accessory pathways & 2 PJRT), 3 VT (2 scar related VT, 1 anterior papillary muscle), 4 AFL (3 CTI flutter & 1 mitral isthmus flutter). All patients were ablated using 3D mapping system except 4 pediatric patients (2 AT from CS, 2 concealed parahisian accessory pathways) due to accesses limitations or unavailability of 3D mapping, single catheter technique was used in one patient weighing 3.4kg with AT from CS (only one venous access accommodating 5F catheter could be obtained)(B), Rt & Lt jugular accesses were used for ablation of RAA AT in a pediatric patient with bilaterally occluded femoral veins.(C) NCC was used as a safe access for ablating parahsisan AT & accessory pathways in our cohort.(D) All patients had successful ablation with full recovery for those with impaired function except 2 patients of scar related VT as their EF was impaired previously. Regarding the complications, one patient had DVT and another patient had retroperitoneal hematoma, both were managed conservatively. Conclusion Incessant tachycardia ablation is quite challenging but carries good results. Careful planning, experienced team & selection of the appropriate approach are the keys for successful safe procedures.

Long-term follow-up after infective endocarditis: comparison of patients who have undergone cardiac surgery versus a conservative therapy with and without an indication for cardiac surgery

Abstract Background Infective endocarditis (IE) is still a serious disease, with a high mortality despite cardiac surgery and modern conservative therapy. However, data on long-term follow-up are sparse. Methods Retrospective single centre registry on the hospital course and long-term follow-up of patients with IE who have undergone cardiac surgery or a conservative therapy with and without an indication for cardiac surgery. Results Between 1/2013 and 12/2016, 171 IE patients were treated at our hospital. A follow-up with either patient contact, review of hospital charts or physician contact was performed in 2022. Due to lost to follow-up (n=4) or refusal to participate after discharge (n=1), the final evaluation was performed with 166 patients (97.1%). They were followed-up for a median 2385.0 (between 2156 and 2773) days. 139 (81.3%) of the patients were operated (surgery) and 32 (18.7%) were treated conservatively. Amongst the conservatively treated group, 34.4% (11/32) of the patients had an indication for surgery, but it was decided not to perform it (cons-with) and 65.6% (21/32) had no indication for surgery (cons-without). Operated patients were younger compared to cons treated patients (65.1 ± 13.0 vs 72.8 ± 15.7, p = 0.00016). Whereas hospital mortality was not different between both groups (21.6 % vs 21.9 %, p = 0.97112), calculated 5y mortality was higher in der cons treated group (71.0 % vs 49.6 %, p=0.03168). Conclusions These data on long-term follow-up after IE show a high total mortality amongst all patients regardless of type of therapy, but higher mortality rate after 5 years amongst conservative treated patients (71%) compared toa surgical treated (49.6% p= 0.03168). The highest mortality rate after 5 years (100%) was detected in the cons-with compared to 55% in the cons-without group. More than 2/3 of deaths were due to IE. However, operated patients were younger and had less co-morbidities. Furthermore, rehospitalisation rate for recurrent IE was also high.

Low ambient temperature and incident myocardial infarction with or without obstructive coronary arteries: a Chinese nationwide study.

Although non-optimum ambient temperature is a major non-traditional risk factor for acute myocardial infarction, there is no prior knowledge on whether non-optimum ambient temperature could differentially affect myocardial infarction with obstructive coronary artery disease (MI-CAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Using the Chinese Cardiovascular Association database-Chest Pain Center Registry, a nationwide, time-stratified, case-crossover investigation was conducted from 2015 to 2021. Meteorological data were obtained from an established satellite-based model, and daily exposures were assigned according to the onset of myocardial infarction in each patient. A conditional logistic regression model combined with distributed lag non-linear models (10 days) was used to estimate the exposure-response relationships. A total of 83 784 MINOCA patients and 918 730 MI-CAD patients were included. The risk of MINOCA and MI-CAD associated with low temperature occurred at lag 2 day and lasted to 1 week. Extremely low temperature was associated with a substantially greater odds ratio (OR) of MINOCA [OR 1.58, 95% confidence interval (CI) 1.31-1.90] than MI-CAD (unmatched: OR 1.32, 95% CI 1.23-1.43; equally matched by age and sex: OR 1.25, 95% CI 1.04-1.50), compared with the corresponding reference temperatures (30°C, 35°C, and 30°C). Stronger associations were observed for patients who were aged ≥65 years, female, or resided in the south. There was no significant difference for the impacts of high temperature on MINOCA and MI-CAD. This nationwide study highlights the particular susceptibility of MINOCA patients to ambient low temperature compared with that of MI-CAD patients.

Impact of intravascular imaging on mortality in patients undergoing left main coronary artery PCI. Propensity score matching analysis of the high-volume single centre registry

Abstract Background Recent guidelines endorsed use of intravascular imaging in left main coronary artery (LMCA) percutaneous coronary intervention (PCI). However, impact of adjunctive percutaneous imaging tools on mortality is ambiguous. Purpose The purpose was to investigate impact of intravascular imaging (IVI) on all-cause mortality in patients with LMCA disease. Methods Group of 998 individuals undergoing LMCA PCI was selected from medical records of patients hospitalized in years 2008-2022. Data on mortality were obtained from the Ministry of Digital Affairs. Overall observation time was 14 years (mean 4.3 years). Survival analysis was performed using Cox proportional hazard regression in the overall and propensity-score matched (PSM) population. Results The median age was 71 y.o. (IQR 16), 265 (41.0%) of patients presented with acute myocardial infarction and 183 (20.7%) had history of previous coronary artery bypass grafting (CABG). IVI-guided PCI was performed in 353 (35.4%) patients. In the overall unmatched population, IVI reduced one-year and long-term mortality by 70% (HR 0.3, 95% 0.19-0.47, P<0.001) and 57% (HR 0.43, 95% CI 0.34-0.55, P<0.001). In the subgroup analysis stratified on the history of previous CABG, in patients with unprotected LMCA, IVI resulted in 74% and 63% mortality reduction in the one-year and long-term follow-up (HR 0.26, 95% CI 0.16-0.42, P<0.001; HR 0.37, 95% CI 0.28-0.47, P<0.001; respectively). No influence of IVI on patients with previous CABG was observed. After PSM adjustment for baseline and angiographical characteristics, in the overall population IVI was still associated with significant one-year (HR 0.49, 95% CI 0.25-0.99, P=0.045) and long-term mortality reduction (HR 0.65, 95% CI 0.44-0.97, P=0.03). In patients with unprotected LMCA disease, IVI reduced mortality in two-year observation (HR 0.49, 95% CI 0.26-0.91, P=0.02) and long-term follow-up (HR 0.62, 95% CI 0.41-0.93, P=0.02), with no significant effect in one-year observation. No effect of IVI was observed in the PS-matched cohort of patients with previous CABG. Conclusions Intravascular imaging is associated with significantly better survival in patients undergoing LMCA PCI. The greatest benefit may be obtained in patients with no previous history of CABG. Further studies should investigate subgroups that benefit the most from adjunctive percutaneous tools.PS-matching detailsKaplan-Meier curves in subgroups

Strengthening data management skills amongst public health professionals during the war in Ukraine

Abstract Background The current war in Ukraine has led to disturbances in public health surveillance and epidemiological data flow, which impacts timely decision-making at regional and national levels. The five-year USAID project “Public Health System Recovery and Resilience Activity” (PHS R&R) aims to strengthen the Public Health system of Ukraine, including through the training of specialists in data management and disease surveillance. Objectives An innovative mixed-method, multi-module course was piloted in January 2023 to provide epidemiologists and other public health professionals with up-to-date knowledge and practical skills in disease surveillance and data management. The course was designed based on a needs assessment study carried out across the regional Centres for Disease Control (CDCs) in 2022. Modules were delivered both in person and online to reach a wider audience. Results 1,540 public health specialists attended the first module on Excel skills, online. A further 26 completed a second module, covering disease surveillance methods, data management, and data flow across regions, in person. Over 85% of participants in the second module reported that it was highly relevant to their day-to-day work, especially practical sessions on data analysis and reporting. The second module is currently under revision based on participants’ feedback before being scaled up. A more advanced module on data management is being developed and aimed to launch at the end of 2024. Conclusions The course was timely and relevant for Ukrainian public health specialists in need of enhanced surveillance and data management skills to detect and respond to public health threats. Its innovative format allowed it to train a large cohort of specialists across a variety of essential public health functions despite the full-scale war. This experience would be relevant for any country aiming to strengthen its preparedness for potential public health emergencies, especially in fragile settings. Key messages • The comprehensive training course on epidemiological surveillance and data management will equip Ukrainian public health specialists with data-driven decision-making skills in the war context. • The described training approach would be relevant for the countries which seek sustainable workforce development solutions to strengthen public health systems in fragile settings.

Clinical reality and challenges with familial hypercholesterolemia patients management. 2024 results from the Regional Center for Rare Diseases (RCRD) Registry in Poland

Abstract Background HeFH is one of the most prevalent genetic diseases significantly increasing the risk of CVD events and mortality. Despite new achievements with earlier diagnosis and new effective drugs, most of heFH patients do not achieve LDL-C goal and are still on residual CVD risk. Purpose We aimed to present the most recent data from the regional FH registry in Poland to show the challenges and reality of everyday clinical management with FH patients. Methods The registry is conducted at the RCRD in the 2nd largest, supraregional hospital in Poland. The main inclusion criteria were being phenotypically or genetically diagnosed with FH. Nonadherence was investigated based on detailed interview, monitoring the treatment’s effects and purchasing prescribed medications. For this analysis we investigated only adult FH patients from the registry. Due to small number of cases (n=5), patients treated with inclisiran were not included in this analysis. Results We included 142 consecutive heFH patients at mean age 45,8±14,9 years (min/max 18-75 years; 60% women). Mean BMI was 29.6±5.52 kg/m2, mean baseline TC was 282.9±80 mg/dl (the highest observed was 600 mg/dl), LDL-C 204.2±72.5 mg/dL (the highest observed -762 mg/dl), TG - 151.1±123.4 mg/dl, Lp(a) 37.6±41.5 mg/dl and HDL-C - 52.3±14.2 mg/dl. Most patients were diagnosed with LDLR (72%) or APOB (24%) mutations. High intensity statin therapy was used in 74.3% of patents, ezetimibe (mostly as a part of combination LLT) in 47.2%, and PCSK9 inhibitors in all those that met the reimbursement criteria – 25.6% of FH patients. Non-adherence to statin therapy and ezetimibe in the follow up of 2 years was 27%. In patients treated with statin therapy and ezetimibe mean achieved LDL-C was 153.6±82.82 mg/dl and on triple therapy - 64.5±43.73 mg/dl. Mean achieved LDL-C in the investigated population was 87.9±55.5 mg/dl. LDL-C goal was achieved in 39% of patients – in those treated with triple therapy with PCSK9 inhibitors it was 57.14%, and in those on statins and ezetimibe only 27.1%. Combination therapy of statins and ezetimibe did not significantly change baseline Lp(a) level (p=0.109), but when PCSK9 inhibitors were introduced the mean Lp(a) reduction by 34.2% (p=0.049) was observed. Based on the multivariable regression analysis, the following factors played the most important role for FH patients to be on LDL-C target: DLCN total score (OR 1.21, 95%CI: 1.04-1.40; p=0.013), DLCN category (10.39, 1.43-75.29; p=0.021), ezetimibe use (4.78, 1.15-19.92; p=0.031), and PCSK9 inhibitors use (4.56; 1.40-14.86; p=0.012). Conclusions FH patients in Poland are diagnosed definitely too late (45 years) and most of them are still not on LDL-C goal. Double and especially triple therapy significantly, even 5 times, increase the chance of achieving LDL-C goal, therefore PCSK9 inhibitors should be available for all FH patients, without the limitations existing currently e.g., within B101 drug program in Poland.

Infectious disease prevention among internally displaced people: Perspectives from Lviv, Ukraine

Abstract Background The ongoing war in Ukraine has increased the risk of infection spikes, especially among internally displaced people. The healthcare challenges in the war context necessitate teaching the population of preventative measures, which have become the primary vector of the activities of the Ukrainian Regional Centers for Disease Control and Prevention. Objectives The research aimed to highlight the activities of the Lviv Regional Center for Disease Control and Prevention (CDC) in relation to internally displaced people. Methods The research project analyzed the incidence rate of infectious diseases and vaccination coverage data among the population and internally displaced people in the region. The data were collected from monthly reports of CDC’s departments and alert messages sent by primary care institutions to the CDC. Results According to the Single register of internally displaced people (IDP), 13% of internally displaced people were permanently staying in the Lviv region (the second place was Zakarpattia region - 9% of IDP, and the third was Kyiv - 7% of IDP). In the Lviv region, 237,000 people registered as forcibly displaced. Total, over 700, 000 people are in the area, including the unregistered and 68,000 children. In 2022-2023, the morbidity rates among IDPs did not exceed the rates among the general population in the area. Each IDP residence place had its physician; 11 thousand IDPs were vaccinated, and 3,235 of those were children. In general, 46 mobile medical brigades worked on-site in the Lviv region. Only one spike of gastrointestinal infection was registered. CDC employees provided lectures and workshops on hygiene and food storage in 56 IDP residence places. Conclusions The review results show that coordination between CDCs, local physicians, and mobile medical brigades in the IDP residence areas prevents outbreaks of infectious diseases and swiftly responds to emerging threats. Key messages • The tragic events in Ukraine resulted in healthcare access issues. Lviv CDC, fighting at its own forefront, quickly assessed the risks and efficiently managed the potential hazards. • The Lviv region remains one of the biggest hubs in Ukraine for the temporary residence of internally displaced people, with CDC employees ensuring that preventive measures are effectively carried out.

Evolving atrial fibrillation (AF) care in New Zealand (NZ): a nurse specialist-led clinic aiming to improve standardisation, equity, cost-effectiveness, and lifestyle modification in AF management

Abstract Background Management of atrial fibrillation (AF) in NZ is challenging and variable between regions. NZ has a diverse population with Māori and Pacific ethnic groups, in particular, facing significant difficulties with access to care and inequity in treatment. The integration of nurse specialists into the care of patients with AF is increasingly recognised and discussed in AF management, including the European Society of Cardiology (ESC) guidelines. This approach also allows emphasis on managing lifestyle factors, pivotal contributing factors in disease burden Objective This study assesses the efficacy of a nurse specialist-led AF clinic in a large regional centre in New Zealand. We look specifically at the standardisation of care, lifestyle management, the impact on health equity in managing AF, and the cost-effectiveness of these strategies. Methods A retrospective analysis of the first year of the clinic’s establishment was conducted reviewing the outcomes, attendance, and adherence to management guidelines. The clinic is running three days per week to follow up those presenting to the Emergency Department with a primary diagnosis of AF. After discharge, appointments are available within 48-72 hours of presentation. The clinics efficacy and ability to serve wider NZ populations will also be presented alongside a recently-published, similar initiative in Christchurch, NZ. Results Over the first year, 247 appointments were made (Median age 66, interquartile range 58-76, 48% male, 75% NZ European). 168 patients were established on a rhythm control strategy, with 20 directly referred for ablation, 26 receiving cardioversions, and the remainder established on anti-arrhythmic medication strategies. Lifestyle modifications were addressed with majority of these patients. Demographic data also highlighted once more, a need to focus on equity with only 17.4% of appointments attended by Māori and Pacific patients, lower than would be expected given population data and relative disease burden. Conclusions The Nurse Specialist-led AF clinic shows promising outcomes and is a positive step forward in AF management in this region of NZ. Incorporating ESC guidelines with emphasis on lifestyle factors and including rhythm control strategies to good effect. This clinic brings international standards to a local stage and throws a focus on our unique healthcare needs and an emphasis on equitable delivery of care. This clinic is scalable, effective, and an inclusive approach to AF care.

Remote monitoring and prioritisation for patients awaiting transcatheter aortic valve implantation safely mitigates longer waiting times

Abstract Background • The UK National Health Service (NHS) faces an unprecedented backlog of over 400,000 patients awaiting critical cardiac procedures, incurring thousands of excess deaths (1). • Longer waiting times to transcatheter aortic valve implantation (TAVI) can increase rates of unplanned hospitalisation and death (2). • Remote patient monitoring (RPM) can improve cardiovascular clinical outcomes (3), but its effectiveness in detecting and managing TAVI waiting list deterioration is untested. Purpose 1. Measure the systemic increase in waiting time to TAVI 2. Determine if RPM and prioritisation: · Is acceptable to patients · Detects clinical deterioration · Mitigates the expected increase in adverse events associated with longer waiting times · Does not unfairly disadvantage patients who are not prioritised Methods • We performed an observational cohort study including all patients awaiting TAVI at one UK regional centre between 24th April and 15th November 2023. • Patients were supported to complete an online or telephone-based weekly symptom questionnaire. • Responses were monitored by non-specialist nurses staffing a 'hub', with rule-based escalation to the TAVI team, who could prioritise treatment (Figure 1). • A historical control cohort who did not receive RPM was identified, as sequential unselected patients on the TAVI waiting list in reverse order, from 24th April 2023 to 1st January 2023. This cohort was propensity score-matched to adjust for age, sex, ethnicity and comorbidities. • Waiting time was defined as the date difference between a patient being placed on the waiting list and TAVI completion. • We defined patient acceptability as >80% engagement with at least one symptom questionnaire. • Sensitivity was calculated as the percentage of escalations to the TAVI Consultant resulting in prioritisation. • Kaplan-Meier survival analysis was performed for the primary endpoint of adverse events, defined as emergency department presentation, unplanned hospitalisation or death. Results • The median waiting time to TAVI increased by one month (104 days versus 75 days, p<0.001). • There was 99% (200/202) engagement with RPM • Despite the increased waiting time, there was no significant difference in rate of adverse events between the propensity score-matched RPM and historical control groups (12.5% versus 13.7%, p=0.86) (Figure 2) • 87% (27/31) of escalations to the TAVI Consultant resulted in treatment prioritisation • There was a non-significant difference in median waiting time between prioritised and non-prioritised patients during the study period, but with no clinical consequence to the delay (97 versus 120 days, p=0.16). Conclusions • An RPM pathway can detect patient deterioration on TAVI waiting lists with high sensitivity • RPM-based prioritisation for patients awaiting TAVI can mitigate the increased risk of adverse events associated with longer waiting times, without unfairly disadvantaging non-prioritised patients.Figure 1.RPM pathwayFigure 2

Using Animation to Address Disparities in Kidney Transplantation

ABSTRACT This essay reviews an arts-based project based in Buffalo, New York, seeking to educate patients with kidney failure and their social network about the transplantation process. Through a multi-phase arts-based research project, informed by a community-based steering committee and key stakeholders, 33 educational animated videos were developed and tested for efficacy in samples of diverse patients at a regional transplant center. Animation was chosen for its potential to better explain health concepts more sensibly to patients and support knowledge dissemination to their social network, who may donate a kidney or support a recipient or donor. The videos are 2D, short in duration, and designed for easy viewing on small devices using characters, scenes, narration, and movement. Aesthetic choices reinforce learning: characters have confident posture, memorable features (e.g. hair style, clothing color) with minimal detail, and model diverse races, ethnicities, gender, and body types. Scenes feature light backgrounds, illuminate main images, and are as large as possible for small screens. Narration is slow, calm, and uses strategic pauses to introduce concepts. Movement is selective to reinforce the message (signaling). The animation was guided by self-efficacy theory and the cognitive theory of multimedia learning. Findings to date indicate promising results with respect to patient knowledge and the feasibility of using animation to address disparities in kidney transplantation. Figures illustrate the evolution of the project and provide examples of the art used to capture a given aspect of the transplantation process.

Postoperative opioid use in Norway—a population-based observational study on patterns of long-term use

BackgroundThe utilization patterns of opioid analgesics and the proportion of long-term opioid use after surgery in Norway is largely unknown.MethodsThis study aimed to estimate the proportion of one-year long-term prescription opioid use among all Norwegian postoperative opioid users. Complete data from central health registries (NPR, NorPD, Statistics Norway, CoDR) were linked via the personal identification number unique to all citizens. The study period was January 1st 2010 until December 31st 2019. Long-term opioid use was defined as at least two opioid dispensings within two subsequent 90-day periods, with a minimum average use of 10 MME/day for the first 90 days.ResultsThe study population consisted of 693 495 post-operative opioid users (53.6% women), whereof 73.2% had not used opioids the year before surgery (new users). Among the postoperative opioid users, 3.8% were one-year long-term opioid users. The corresponding figures for new and previous opioid users were 0.4% and 13.1%, respectively. The highest proportions of long-term opioid use were found after transluminal endoscopy, eye surgery and assessments related to surgical procedures. In previous opioid users, the proportion of one-year long-term use was higher among women than men in all age groups, a difference that increased with age.ConclusionsThe proportion of postoperative long-term opioid use in Norway is generally low. We detected higher proportions of long-term opioid use after certain types of surgery, but our crude surgery definition warrants further examination. Previous opioid users pose a particular challenge in the management of postoperative pain.Trial registrationThe study used national health registry data from the period 2010–2019. A pre-registered analysis plan is available at Open Science Framework.

The impact of updated national guidelines for managing unintentional paediatric liquid paracetamol exposures: a retrospective poisons centre study

Introduction In 2015, Australia and New Zealand treatment guidelines recommended a 2 h paracetamol serum concentration for risk assessment of unintentional paracetamol liquid exposures. We assess our experience with this approach. Methods Retrospective case review of children <6 years-old with liquid paracetamol overdoses referred to a regional poisons information centre January 2017 to August 2022. We extracted data on the exposure and management from the poisons information centre and hospital medical records. We identified additional cases with two paracetamol concentrations obtained from September 2022 to June 2024. Results Of 437 paediatric poisonings, 271 were eligible for inclusion. The median age was 24 months, the median time to presentation was 120 min, and paracetamol was the sole ingestant in 92% of cases. Blood testing was recommended in 131 patients (48.3%), occurring at 2 h post-ingestion in 62 patients (47.3%). Testing at a later time was mostly due to delayed presentation, including to hospitals unable to measure paracetamol concentrations. Eighteen patients (16.7%) had repeat blood testing, and five additional cases were identified in the subsequent period. Overall, the concentration decreased in 19 patients (83%), but in three patients it increased, from 73 mg/L to 81 mg/L (0.49–0.54 mmol/L), from 154 mg/L to 179 mg/L (1.03–1.19 mmol/L), and from 56 mg/L to 115 mg/L (0.37–0.77 mmol/L. Symptomatic patients were more likely to receive a second blood test or acetylcysteine while awaiting investigations. Of 19 patients administered acetylcysteine, it was discontinued in five due to low paracetamol serum concentrations. All patients recovered. Discussion Guidelines were followed in >90% of patients and this testing regimen shortened length of stay. Based on these data, Australian treatment guidelines now recommend repeat testing for 2 h paracetamol serum concentrations >100 mg/L (0.67 mmol/L). Conclusion A paracetamol serum concentration between 2 h and 4 h post-ingestion in children <6 years-old with unintentional poisonings of paracetamol liquid can facilitate medical discharge.