Normative practices of property rating in Ghana: towards improving policy on rating undeveloped urban lands in secondary cities

PurposeThe paper examined how local authorities have attempted to rate undeveloped land as a means of mobilising revenues and the challenges associated with implementing this policy guideline. It focused on current practices in terms of policy and administration, the availability of undeveloped urban land, its revenue potential, and ways to improve policy for local land taxation.Design/methodology/approachDrawing from the mixed-method approach both qualitative and quantitative data were collected. Officials of the Wa Municipal Assembly, Lands Commission, Land Use and Spatial Planning Authority were purposely selected based on their knowledge and the roles they play in property rating practice. They were interviewed to understand their perceptions and views on rating undeveloped lands. Stratified proportionate and simple random sampling methods were used to select respondents. The respondents included land and landed property owners in three selected neighbourhoods.FindingsThe paper found that there was the prevalence of undeveloped lands mainly held by speculators and individuals constrained by financial challenges to develop their parcels. The Wa Municipal Assembly is unable to implement the policy guideline on charging rent on undeveloped lands due to lack of adequate information and generally unwillingness to implement this provision. Besides, the current guideline is too prohibitive and cannot be implemented in its current form. However, there is a window of opportunity for the Assembly to build data on undeveloped lands and moderately begin the implementation of the policy guideline.Practical implicationsUrban growth in Ghana is characterised by leapfrog development with many patches of undeveloped land in and around cities. The property taxation policies largely do not focus on undeveloped land or unimproved site value. In Ghana, property rate policy on the tax base excludes undeveloped land. However, government policy guidelines prescribe the charging of rent on these lands by local authorities. This paper provides a comprehensive discussion on the revenue potential of undeveloped urban land and why local government authorities have not been able to harness this potential. The paper has therefore recommended ways local authorities can use to mobilise revenue from undeveloped urban land.Originality/valueThere is limited research in rating undeveloped urban land especially looking at it from the perspective of policy and implementation as well as current practices. The paper shed light on the prevalence of undeveloped urban land and the guidelines that exist help local governments mobilise revenue from these lands. It contributes to the understanding that local government can harness the revenue potential of undeveloped land if policy design and implemented regarding these lands is enhanced. The paper also provides a good background and framework for further studies.

When to Start and Stop Bone-Protecting Medication for Preventing Glucocorticoid-Induced Osteoporosis

Glucocorticoid-induced osteoporosis (GIOP) leads to fractures in up to 40% of patients with chronic glucocorticoid (GC) therapy when left untreated. GCs rapidly increase fracture risk, and thus many patients with anticipated chronic GC exposures should start anti-osteoporosis pharmacotherapy to prevent fractures. In addition to low awareness of the need for anti-osteoporosis therapy among clinicians treating patients with GCs, a major barrier to prevention of fractures from GIOP is a lack of clear guideline recommendations on when to start and stop anti-osteoporosis treatment in patients with GC use. The aim of this narrative review is to summarize current evidence and provide considerations for the duration of anti-osteoporosis treatment in patients taking GCs based on pre-clinical, clinical, epidemiologic, and pharmacologic evidence. We review the pathophysiology of GIOP, outline current guideline recommendations on initiating and stopping anti-osteoporosis therapy for GIOP, and present considerations for the duration of anti-osteoporosis treatment based on existing evidence. In each section, we illustrate major points through a patient case example. Finally, we conclude with proposed areas for future research and emerging areas of interest related to GIOP clinical management.

Establishment and Validation of a Gene Signature-Based Prognostic Model to Improve Survival Prediction in Adrenocortical Carcinoma Patients

Background. The current guideline for the management of adrenocortical carcinoma (ACC) is insufficient for accurate risk prediction to guide adjuvant therapy. Given frequent and severe therapeutic side effects, a better estimate of survival is warranted for risk-specific assignment to adjuvant treatment. We attempted to construct an integrated model based on a prognostic gene signature and clinicopathological features to improve risk stratification and survival prediction in ACC. Methods. Using a series of bioinformatic and statistical approaches, a gene-expression signature was established and validated in two independent cohorts. By combining the signature with clinicopathological features, a decision tree was generated to improve risk stratification, and a nomogram was constructed to personalize risk prediction. Time-dependent receiver operating characteristic (tROC) and calibration analysis were performed to evaluate the predictive power and accuracy. Results. A three-gene signature could discriminate high-risk patients well in both training and validation cohorts. Multivariate regression analysis demonstrated the signature to be an independent predictor of overall survival. The decision tree could identify risk subgroups powerfully, and the nomogram showed high accuracy of survival prediction. Particularly, expression of a gene hitherto unknown to be dysregulated in ACC, TIGD1, was shown to be prognostically relevant. Conclusion. We propose a novel gene signature to guide decision-making about adjuvant therapy in ACC. The score shows unprecedented survival prediction and hence constitutes a huge step towards personalized management. As a secondary important finding, we report the discovery and validation of a new oncogene, TIGD1, which was consistently overexpressed in ACC. TIGD1 might shed further light on the biology of ACC and might give rise to targeted therapies that not only apply to ACC but potentially also to other malignancies.

Type 1 Diabetes in Pregnancy: A Review of Complications and Management

Background: Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent’s declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes. Objective: This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care. Methods: A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised. Results: One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised. Conclusion: This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.

Outcomes of Combined Peritoneal and Local Treatment for Patients with Peritoneal and Limited Liver Metastases of Colorectal Origin: A Systematic Review and Meta-Analysis

Background Almost half of all colorectal cancer (CRC) patients will experience metastases at some point, and in the majority of cases, multiple organs will be involved. If the peritoneum is involved in addition to the liver, the current guideline-driven treatment options are limited. The reported overall survival ranges from 6 to 13 months for the current standard of care (systemic treatment). This study aimed to evaluate morbidity and clinical long-term outcomes from a combined local treatment of hepatic metastases with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) used to treat peritoneal metastases. Methods A systematic search was performed in PubMed, Embase.com, Web of Science, and Cochrane. Studies evaluating the clinicopathologic data of patients who had both peritoneal and hepatic metastases treated with CRS-HIPEC were included provided sufficient data on the primary outcomes (overall and disease-free survival) were presented. The quality of included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS). Results Patients treated for peritoneal and liver metastases (PMLM group) had a pooled mean survival of 26.4 months (95% confidence interval [CI] 22.4–30.4 months), with a 3-year survival rate of 34% (95% CI 26.7–42.0%) and a 5-year survival rate of 25% (95% CI 17.3–33.8%). Surgical complications occurred more frequently for these patients than for those with peritoneal metastasis only (40% vs 22%; p = 0.0014), but the mortality and reoperation rates did not differ significantly. Conclusion This systematic review showed that CRS and HIPEC combined with local treatment of limited liver metastasis for selected patients is feasible, although with increased morbidity and an association with a long-term survival rate of 25%, which is unlikely to be achievable with systemic treatment only.

The Role of Left Atrial Strain in Detecting Left Ventricular Diastolic Dysfunction: Comparison between the 2009 and 2016 Recommendations

Background: The frequency of left ventricular diastolic dysfunction (DD) is overestimated by earlier recommendations. We compared the 2009 and 2016 guidelines regarding the detection of DD and explored the potential of adding left atrial (LA) strain to the current guideline. Methods: Consecutive patients with heart failure were enrolled. All the patients were examined using 2-dimensional speckle-tracking echocardiography (2D-STE) and tissue Doppler imaging. DD was evaluated in terms of E/eʹ, eʹ velocity, E, A, tricuspid regurgitation velocity, LA volume, and LA strain. Results: This study evaluated 147 patients (101 males, 68.7%) at a mean age of 54.73±14.42 years. LA strain decreased with increasing grades of DD in both guidelines. The rate of reclassification between the 2 guidelines was 41%. The detection rate of normal diastolic function increased after the implementation of the 2016 guideline. LA strain discriminated individuals with normal diastolic function from those with DD more accurately than did LA volume index (area under the curve [AUC] =0.816 vs AUC=0.759, respectively). When LA strain <23% was incorporated into the 2016 guideline, 2 out of 4 patients with indeterminate diastolic function were reclassified as normal and 2 patients as grade I DD. The rate of reclassification was 4.1% after the addition of LA strain to the current guideline (κ=0.939, P<0.001). Conclusion: This study showed that the current guideline detected lower rates of DD than did the earlier recommendations. Furthermore, the incorporation of LA strain into the current guideline resulted in lower rates of indeterminate diastolic function.

Improving risk stratifcation of pulmonary hypertension patients

Background According to the 2016 ESC/ERS Guidelines on Pulmonary Hypertension (PH), the right atrial area (RAA) and the presence ofa pericardial effusion (PE) are the two main echocardiographic prognostic markers in PH patients (pts). Aim To assess the predictive ability of these two parameters. Methods Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). All-cause mortality was analyzed by PE, RAA and other echocardiographic parameters for positive (PPV) and negative predictive value (NPV) to detect if the current guideline recommended cut-offs can precisely stratify risk in this setting. A survival analysis was performed to evaluate risk stratification (RS) provided by several different cut-offs. Results A total of 51 PH pts (mean age 54±46 years, 33.3% male, baseline BNP of 342.4±439.9pg/mL, mean 6MWT distance of 360.3±109.2 meters and baseline pulmonary artery systolic pressure of 78±26mmHg), of which 64.7% had Group I PH (GI) and 35.3% presented chronic thromboembolic pulmonary hypertension. There were no significant differences between these two groups, however pts in GI were significantly younger (p=0.001), achieved a lower 6MWT distance (p=0.038) and had worse values of right ventricular strain (p=0.040). 27 pts (52.9%) died during a mean follow-up of 52 months, with no differences between groups (p=0.756). The presence of a PE had a low NPV and PPV for the primary endpoint (45.0% and 45.5%, respectively), as well as the guideline recommended cut-offs for RAA (18cm2: NPV- 50.0% and PPV– 55.2%; 26cm2: NPV- 51.3% and PPV– 66.7%). A Pulsed Doppler Tei index (TIp) cut-off of 0.40 had a higher NPV (70.8%) and PPV (74.1%). By Kaplan-Meieran alysis, neither the presence of PE (log rank p=0.508) nor the recommended RAA cut-offs provided accurate risk discrimination (log rank p&gt;0.05 for all). Pts below a TIp cut-off of 0.40 presented a significantly lower survival during follow-up (log rank p=0.002) Conclusion The currently recommended echocardiographic prognostic markers cannot precisely discriminate risk in PH pts. Markers of Right Ventricular Dysfunction may improve RS in this population. FUNDunding Acknowledgement Type of funding sources: None.

EP.FRI.362 Improving Prescribing and Minimising Delay in Administration of Potassium Replacement Therapies: Surgical Audit on Management of Hypokalaemia in Emergency Surgical Unit at a District General Hospital in UK

Aims Surgical patients are prone to hypokalaemia due to gastrointestinal losses1. Hypokalaemia prolongs ileus2 and thus prompt management is essential. No current guideline on hypokalaemia focuses on surgical patients. We aimed to identify the prevalence of hypokalaemia in emergency surgical patients as well as measure timeliness and appropriateness of replacement. Methods We retrospectively reviewed adult emergency surgical admissions exceeding 48 hours between 05/05/2020 and 15/07/2020. A sub-group analysis assessed the timing of intravenous replacement and duration taken to normalise potassium (3.5 mmol/L). We used another NHS trust’s guideline3 as standard for appropriate potassium replacement. Results Of 110 surgical admissions, 26 cases were hypokalaemic. Of these, 15 had initially normal potassium level. Three cases were likely iatrogenic secondary to inappropriate fluid prescribing. Mean potassium in the hypokalaemic group was 3.2 mmol/L (80.8% mild vs. 19.2% moderate). Mean length of stay was 11.3 days for hypokalaemia versus 6.54 days in normokalaemic cases. Mean duration of hypokalaemia was 2.13±1.45 days. Potassium replacement was prescribed correctly in only 50% of cases (23% not prescribed; 25% insufficient; 2% incorrect) and of these correct prescriptions, 46% were not actually administered. When intravenous replacement was given, there was a mean 3.55-hour delay between lab result and administration. Conclusion The majority of hypokalaemic cases developed during admission. Only 27% of these patients had correct potassium replacement in terms of both prescription and administration. Consequently, we have created a local guideline for hypokalaemia in surgical patients to standardise both prevention and management.

Substantially elevated thromboembolic and bleeding risks in patients with AMI following acute/subacute stroke events

Introduction AMI infrequently but concomitantly occurs after stroke events. Current guideline recommends primary PCI with DAPT in the setting of AMI. However, this approach is not necessarily applicable in AMI subjects following acute/subacute stroke events due to its bleeding risk. Clinical management and outcomes of these AMI subjects following remains uncertain. Purpose To characterize management and clinical outcomes in patients with AMI following acute/subacute stroke events (=post-stroke AMI). Methods The current study retrospectively analyzed 2041 AMI patients hospitalized at our institute from 2007 to 2018. Post-stroke AMI was defined as its occurrence within 14 days after ischemic/hemorrhagic stroke. The use of reperfusion and anti-thrombotic therapies, and the occurrence of major adverse cardiovascular events (=CV death, non-fatal MI and non-fatal stroke) and major bleeding events (BARC type 3 or 5) were compared in post-stroke and non-post-stroke AMI patients. Results Post-stroke AMI was identified in 1.1% of entire subjects (=23/2041). Of these, 65% of them (=15/23) had AMI within 3 days from the onset of stoke event. Over 60% of them was due to cardioembolic stroke, followed by hemorrhagic (9%), atherothrombotic ones (8%) and other causes (22%). Post-stroke AMI patients were more likely to exhibit Af (p=0.02) and a history of hemodialysis (p=0.009), and have a lower BMI (p=0.04) and hemoglobin level (p=0.02). They were less likely to receive emergent coronary angiography, and primary PCI was conducted in only 65% of post-stroke AMI patients (Table). Furthermore, they more frequently received thrombectomy (p=0.04) alone rather than stent implantation (p=0.002) (Table). With regard to anti-thrombotic therapy, the proportion of DAPT use was significantly lower in post-stroke AMI subjects (52 vs. 89%, p=0.0001), and 17% of them did not receive any anti-thrombotic agents. Of note, only 48% (p=0.04) and 43% (p=0.0001) of post-stroke AMI patients were treated with other established medical therapies including β-blocker and statin, respectively. During the observational period (median = 2.9 years), post-stroke AMI was associated with a greater likelihood experiencing major adverse cardiovascular events (log-rank p&lt;0.001, Figure), CV death (log-rank p&lt;0.0001) and stroke events (log-rank p&lt;0.0001). Furthermore, the frequency of their major bleeding events was substantially elevated (log-rank p&lt;0.001, Figure). Conclusions In our real-world data, the adoption of guideline-recommended reperfusion and anti-thrombotic therapies were considerably low in AMI subjects following acute/subacute stroke events. Given their elevated risk of cardiovascular and bleeding events, it is required to establish better therapeutic management for mitigating their thrombotic/bleeding risks. FUNDunding Acknowledgement Type of funding sources: None. Table 1 Figure 1

Prognostic value of secondary cardiac alterations in patients with moderate aortic valve stenosis

Purpose Echocardiographic characteristics that predict the progression of moderate aortic valve stenosis (mAS) are lacking. The aim of the present study was to evaluate the prognostic value of left ventricular hypertrophy (LVH), diastolic dysfunction (DD) and pulmonary artery hypertension (PAH) in patients with mAS. Methods A total of 137 patients with asymptomatic mAS (age 72±10 years; females: 51 (37%); Blood Pressure: 143±21 / 78±13 mmHg) were included. Echocardiography was performed at baseline and at follow-up every six or/and twelve months. Patients with concomitant valvular defects, hypertrophic cardiomyopathy or chronic obstructive pulmonary disease were excluded. mAS was defined by current guideline criteria. Left ventricular ejection fraction (LVEF), LVH (LV mass index, males: &gt;115g/m2, females: &gt;95 g/m2), DD (E/e' &gt;14) and PAH (maximum regurgitant velocity of tricuspid valve (TRVmax) &gt;2.8m/s) were assessed. mAS patients were divided into 4 subgroups based on the number of secondary cardiac alterations: (0) no; (1) one; (2) two; (3) three cardiac alterations. The primary endpoint was progression to severe AS with indication for treatment (effective aortic orifice area (EOA) by continuity equation &lt;1 cm2/&lt;0.6 cm2/m2) or the onset of symptoms. Results mAS patients showed (0) no secondary cardiac alterations in 20% (n=28), (1) one in 40% (n=55), (2) two in 26% (n=35) and (3) three in 14% (n=19). Among mAS subgroups, no significant differences were observed for age and comorbidities. Echocardiographic parameters are summarised in Tab.1. In general, mAS patients with ≥ two cardiac alterations showed significantly smaller EOA ((0): 1.32±0.19 vs. 1.29±0.19, p&gt;0.05; (1): 1.26±0.21 vs. 1.18±0.21, p&gt;0.05; (2): 1.29±0.20 vs. 1.01±0.20, p&lt;0.01; (3): 1.31±0.16 vs. 1.06±0.25, p&lt;0.01) and higher mean pressure gradients (PGmean) ((0): 19.8±6.64 vs. 21.8±6.32, p&gt;0.05; (1): 20.0±9.26 vs. 22.3±9.94, p&gt;0.05; (2): 22.7±9.32 vs. 30.5±12.61, p&lt;0.01 (3): 25.0±8.87 vs. 29.4±10.67, p&lt;0.01) between baseline and follow-up (mean follow-up 20±9 months). Further, decrease of EOA/days was significantly higher in these patients ((0) −0.003; (1) −0.006; (2) −0.016; (3) −0.028; p&lt;0.01, Fig. 1). As shown in Kaplan-Meier curve, mAS with ≥ two cardiac alterations showed rapid progression of moderate to severe AS (Fig. 2). Conclusions In 40% of patients with mAS ≥ two secondary cardiac alterations (LV hypertrophy, DD and PAH) were observed. The presence of ≥ two of these secondary cardiac alterations is associated with rapid progression of mAS. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2