Shared decision making in athletes with cardiovascular disease: what we can learn from a masters athlete

A 75-year-old male cyclist began suffering from palpitations on exertion. Symptoms terminated spontaneously with cessation of physical activity. The episodes caused significant distress with an impact on physical performance and quality of life. An echocardiogram showed a dilated left atrium, and an exercise ECG demonstrated that episodes of atrial fibrillation developed when his ventricular rate was above 140 beats per minute. Rate control could not be offered due to a history of sinus bradycardia nor rhythm control due to low likelihood of success. Anticoagulant therapy was commenced but discontinued at patient request as he considered risks to outweigh benefits given his desire to continue cycling. Management of athletes with atrial fibrillation is based on guidelines for the general population; however, treatment goals for athletes may differ. Shared decision making is essential to allow patients to make informed decisions about their care, accepting that individuals view treatment risks and benefits differently.

Accessing Investigational Products Outside of a Trial: Considerations for Neuromuscular Providers

Purpose of Review People with fatal neuromuscular diseases such as ALS want to access investigational products. Trials are our preferred pathway for this, but most people with these diseases will not be able to participate due to restrictive inclusion criteria, travel burdens, or design features they will not accept. This leaves FDA Expanded Access Programs (EAPs), the Right To Try (RTT) pathway, and self-purchase of alternative and off-label treatments (AOTs). Recent Findings A recent survey highlighted physician barriers to the above pathways, including lack of knowledge and concerns about time burdens and risks. Emerging resources are highlighted that can mitigate some of these concerns. Summary With the information in this chapter, we hope that neuromuscular clinicians will feel more knowledgeable and confident in supporting patient request for investigational products.

Non-vitamin K antagonist oral anticoagulant discontinuation in non-valvular atrial fibrillation patients (ASPECT-NOAC)

Background and aim Data on NOAC discontinuation patterns in Turkey are lacking. We conducted a subgroup analysis in ASPECT-NOAC study to determine anticoagulant discontinuation pattern in AF patients with recently initiated NOAC therapy. Methods ASPECT-NOAC was a national, multicenter, 12-month observational study conducted in 34 outpatient cardiology clinics of state, university, private, and research hospitals covering all geographic regions of Turkey. Adult AF patients who were under NOAC therapy for less than four months were enrolled. Patients who discontinued using their NOACs were recorded at the end of 12 months. A comparative analysis of patients with discontinuation of medication was conducted. Results This study included 991 non-valvular AF patients. NOAC continuation data were available for 854 patients. During study follow-up, 74 patients (8.7%) discontinued their NOAC medication. Mean age of these patients was 67.1±11.3 years old and 38 patients (51.4%) were female. Most commonly seen comorbidities were hypertension (66.2%) and coronary heart disease (39.2%). 29 patients (39.2%) had permanent (chronic) AF, followed by 26 patients (35.1%) with paroxysmal AF. Major reason for NOAC discontinuation was stated as physician request (n=46, 62%). Following reasons were patient request (n=17, 23%), other (n=9, 12%), and bleeding (n=2, 3%). Patients with NOAC discontinuation had a shorter duration of AF (21.7±41.7 vs 26.2±53.7 months, p=0.017). There was no significant difference of educational levels between medication discontinuation subgroups (p=0.637). Other baseline characteristics and patient disease and treatment awareness levels were similar with the patients who continued their medication. Of 74 patients, two patients died during the study because of cardiac failure. Conclusion NOAC continuity rate over 12 months was found to be high. NOAC discontinuation rate were higher in the patients with shorter duration of AF. Further studies with long-term follow-up detailing discontinuation reasons are warranted. FUNDunding Acknowledgement Type of funding sources: Private company. Main funding source(s): This study was funded by Pfizer.

SP8.1.5 Breast cancer follow up; Is routine mammography indicated?

Aim This paper aims to review the outcome from yearly mammography in detecting breast cancer recurrence and new primary tumours in patients with a history of breast cancer. Methods From 2014, following treatment for breast cancer, patients were enrolled in a program of self-directed aftercare (SDA). They were given open access to the Breast service. Regular planned appointments were not offered. All patients underwent annual mammography for 5 years. Retrospective analysis of the SDA database from 2014 to 2016 was undertaken, time to and mechanism of detection of breast cancer recurrence in this population was determined. Results 352 patient records were analysed (1760 mammograms), 29 recurrences were identified. 12 locoregional, 12 systemic, 5 locoregional and systemic. Median time to diagnosis of recurrence was 30 months. Locoregional recurrence was detected by surveillance mammography (4 patients), clinical examination following patient request (7 patients), non-breast radiological investigation (5), by non-breast cancer care Doctors (1). No contralateral cancers were detected in patients who had mastectomy or WLE. Conclusion Despite limited evidence for regular clinical assessment post breast cancer treatment, the practice remains recommended. In this study regular clinical review was replaced by open access. Annual mammography was retained. Mammographic value out-with detection of malignancy (new/recurrent) was not assessed. The number of tumours detected (4 out of 1760 mammograms) would suggest that non-stratified routine mammography is of limited value for most patients. Further study is required to determine the risk or value and the cost/benefit analysis of mammographic follow up of breast cancer.

Performing a knee arthroscopy among patients with degenerative knee disease: one-third is potentially low value care

Purpose The purpose of this study was to assess in which proportion of patients with degenerative knee disease aged 50+ in whom a knee arthroscopy is performed, no valid surgical indication is reported in medical records, and to explore possible explanatory factors. Methods A retrospective study was conducted using administrative data from January to December 2016 in 13 orthopedic centers in the Netherlands. Medical records were selected from a random sample of 538 patients aged 50+ with degenerative knee disease in whom arthroscopy was performed, and reviewed on reported indications for the performed knee arthroscopy. Valid surgical indications were predefined based on clinical national guidelines and expert opinion (e.g., truly locked knee). A knee arthroscopy without a reported valid indication was considered potentially low value care. Multivariate logistic regression analysis was performed to assess whether age, diagnosis (“Arthrosis” versus “Meniscal lesion”), and type of care trajectory (initial or follow-up) were associated with performing a potentially low value knee arthroscopy. Results Of 26,991 patients with degenerative knee disease, 2556 (9.5%) underwent an arthroscopy in one of the participating orthopedic centers. Of 538 patients in whom an arthroscopy was performed, 65.1% had a valid indication reported in the medical record and 34.9% without a reported valid indication. From the patients without a valid indication, a joint patient–provider decision or patient request was reported as the main reason. Neither age [OR 1.013 (95% CI 0.984–1.043)], diagnosis [OR 0.998 (95% CI 0.886–1.124)] or type of care trajectory [OR 0.989 (95% CI 0.948–1.032)] were significantly associated with performing a potentially low value knee arthroscopy. Conclusions In a random sample of knee arthroscopies performed in 13 orthopedic centers in 2016, 65% had valid indications reported in the medical records but 35% were performed without a reported valid indication and, therefore, potentially low value care. Patient and/or surgeons preference may play a large role in the decision to perform an arthroscopy without a valid indication. Therefore, interventions should be developed to increase adherence to clinical guidelines by surgeons that target invalid indications for a knee arthroscopy to improve care. Level of evidence IV.

An overview of medical diagnostic laboratories in South Africa that meet the international standard of accreditation: ISO 15189

Accreditation is an official recognition that a facility or laboratory is competent to perform specific tasks and has a documented manual on a Quality Management System (QMS) in place. According to the Accreditation Act 19 of 2006, South African National Accreditation Systems (SANAS) is the only internationally recognised accreditation body in South Africa. The International Organization for Standardization (ISO) standard specifically for medical laboratory accreditation is ISO 15189:2012. This review is designed to bring awareness of accredited and unaccredited medical diagnostic laboratories in SA; to look at the number of accredited, unaccredited laboratories and the rate of accreditation growth; to examine the state of accreditation in South Africa with regard to how many are accredited, suspended or withdrawn; and to highlight the advantages of being an accredited laboratory. It also examines the nonconformances commonly raised during assessment and an overview of accreditation around the world. Upon accreditation, the laboratory is given the right to use the SANAS symbol on patient request forms or results as a confirmation of competency. This has motivated more and more laboratories to be accredited. Diagnostic laboratories contribute much toward the final decisions taken by clinicians to diagnose the patients or treatment; this may be from an accredited or non-accredited laboratory. Since patient care is inextricably linked to pathology testing, every laboratory should engage a premium QMS and be evaluated by an accreditation body to ensure that patients receive a trustworthy report. Accreditation is a voluntary process in South Africa but mandatory in some Western countries. Although some laboratories might lose accreditation along the way, the ratio compared to those accredited is still very small. The fact that a majority remain accredited is a good indication of a well-implemented QMS. The challenges faced by the medical technologist-owned laboratories remain, as they are still not accredited.

How do medical doctors respond to the inappropriate patient request?

Medical doctors need the skill to acquire how they are responding to inappropriate patient's requests. The FAVER approach starts with recognizing inner uncomfortable feelings, which signals that the patient's request is inappropriate. Assuming that the patient doesn't know that their demands are "immoral." The medical doctors need to say "NO" in an explicit state and give excuses such as inadequate medical care, illegal, dishonest, or against policy and avoid lengthy explanations.

https://applications.emro.who.int/emhj/v27/02/1020-3397-2021-2702-195-201-eng.pdf

Background: According to the World Health Organization, the ideal caesarean section rate is 10–15% but rates have increased worldwide over the past few decades. Data on caesarean section rates across all Jordanian health sectors over a long period, including recent data that could guide future healthcare policy and interventions, are currently unavailable. Aims: To investigate caesarean sections trends and identify indications (medical and sociodemographic) associated with caesarean sections in Jordanian health sectors. Methods: Medical records of 2.8 million births in Jordan in 1982–2017 were retrieved and analysed. CS trends were compared across health sectors (governmental, university, private, and military hospitals) and with trends in England, Lebanon and Islamic Republic of Iran. CS indications were established from retrospective data, based on 3799 CS births, in 2 hospitals (governmental and private). Results: The CS rate in Jordan increased over the study period from 5.8 (±1.9)% in 1982–1987 to 31.0 (±0.7)% in 2015–2017. The caesarean sections rate in Jordan was initially lower (1983–2006) then became comparable (2007–2014) to that in England, but lower compared to that in Lebanon (2011–2016). In 2015–2017, caesarean sections rates in Jordanian health sectors were: 40.4 (±2.6)% (university), 39.1 (±1.8)% (private), 36.1 (±0.2)% (military) and 27.4 (±0.7)% (governmental). Previous CS (33.6%), abnormal presentation (20.3%), and patient request (16%) were the most common indications. Conclusions: The CS rate in Jordan is on an alarming upward trend. Urgent action is needed to prevent further increase in CS rate, including provision of clear information, advice, and counselling to pregnant women, as well as strict adherence to high-quality medical guidelines.

Safely reducing haemodialysis frequency during the COVID-19 pandemic

Background Patients undergoing haemodialysis (HD) are at higher risk of developing worse outcomes if they contract COVID-19. In our renal service we reduced HD frequency from thrice to twice-weekly in selected patients with the primary aim of reducing COVID 19 exposure and transmission between HD patients. Methods Dialysis unit nephrologists identified 166 suitable patients (38.4% of our HD population) to temporarily convert to twice-weekly haemodialysis immediately prior to the peak of the COVID-19 pandemic in our area. Changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry were recorded weekly throughout the 4-week project. Hyperkalaemic patients (serum potassium > 6.0 mmol/L) were treated with a potassium binder, sodium bicarbonate and received responsive dietary advice. Results There were 12 deaths (5 due to COVID-19) in the HD population, 6 of which were in the twice weekly HD group; no deaths were definitively associated with change of dialysis protocol. A further 19 patients were either hospitalised and/or developed COVID-19 and thus transferred back to thrice weekly dialysis as per protocol. 113 (68.1%) were still receiving twice-weekly HD by the end of the 4-week project. Indications for transfer back to thrice weekly were; fluid overload (19), persistent hyperkalaemia (4), patient request (4) and compliance (1). There were statistically significant increases in SBP and pre-dialysis potassium during the project. Conclusions Short term conversion of a large but selected HD population to twice-weekly dialysis sessions was possible and safe. This approach could help mitigate COVID-19 transmission amongst dialysis patients in centres with similar organisational pressures.

Safely reducing haemodialysis frequency during the COVID-19 pandemic

Background:Patients undergoing haemodialysis (HD) are at higher risk of developing worse outcomes if they contract COVID-19. In our renal service we reduced HD frequency from thrice to twice-weekly in selected patients with the primary aim of reducing COVID 19 exposure and transmission between HD patients.Methods:Dialysis unit nephrologists identified 166 suitable patients (38.4% of our HD population) to temporarily convert to twice-weekly haemodialysis immediately prior to the peak of the COVID-19 pandemic in our area. Changes in pre-dialysis weight, systolic blood pressure (SBP) and biochemistry were recorded weekly throughout the 4-week project. Hyperkalaemic patients (serum potassium > 6.0mmol/L) were treated with a potassium binder, sodium bicarbonate and received responsive dietary advice.Results:There were 12 deaths (5 due to COVID-19) in the HD population, 6 of which were in the twice weekly HD group; no deaths were definitively associated with change of dialysis protocol. A further 19 patients were either hospitalised and/or developed COVID-19 and thus transferred back to thrice weekly dialysis as per protocol. 113 (68.1%) were still receiving twice-weekly HD by the end of the 4-week project. Indications for transfer back to thrice weekly were; fluid overload (19), persistent hyperkalaemia (4), patient request (4) and compliance (1). There were statistically significant increases in SBP and pre-dialysis potassium during the project. Conclusions:Short term conversion of a large but selected HD population to twice-weekly dialysis sessions was possible and safe. This approach could help mitigate COVID-19 transmission amongst dialysis patients in centres with similar organisational pressures.