Predictors and outcomes of early coronary angiography in patients with prior coronary artery bypass surgery presenting with non-ST elevation myocardial infarction.

INTRODUCTION: The best strategy in patients with prior coronary artery bypass graft surgery (CABG) who present with non-ST elevation myocardial infarction (NSTEMI) remains less well defined. We compare the characteristics, therapeutic interventions and outcomes of patients with prior CABG presenting with NSTEMI. METHODS: All patients who presented to our hospital during 2007-2012 with available electronic records were analysed retrospectively. Outcomes were compared between patients who underwent coronary angiography or percutaneous coronary intervention (PCI) versus those who were treated medically. RESULTS: A total of 117 patients were analysed. Of that, 79 patients were managed medically while 38 underwent early angiography, of which only 11 (9.5%) received PCI. Patients treated medically (did not undergo angiography) were older (74±10 vs70±8; p=0.05). ECG changes were the only independent predictor for early angiography (OR 0.4, 95% CI 0.15 to 0.99; p=0.05) while recurrent chest pain (OR 0.2, 95% CI 0.05 to 0.97; p=0.05) predicted PCI on multivariate analysis. The PCI group had higher Global Registry of Acute Cardiac Events (GRACE) score (176±29 vs 150±31; p=0.01). No significant difference was found in readmission rates, morbidity (unstable angina pectoris, NSTEMI, ST elevation myocardial infarction (STEMI), or combination) or mortality at 12 months between the groups who underwent angiography, PCI, or treated medically on univariate and multivariate analysis. CONCLUSIONS: The opportunity to intervene in prior CABG patients presenting with NSTEMI is often low. Initial medical management may be a reasonable option in carefully selected patients particularly in the absence of ongoing symptoms, ECG changes or very high GRACE scores. Further studies are required to evaluate the safety of non-invasive strategies in managing this population

Endoscopic investigation in non-iron deficiency anemia: a cost to the health system without patient benefit

BACKGROUND AND AIMS: The indication for endoscopy to investigate anemia of causes other than iron deficiency is not clear. Increasing numbers of endoscopic procedures for anemia raises concerns about costs to the health system, waiting times, and patient safety. The primary aim of this study was to determine the diagnostic yield of endoscopy in patients referred to undergo investigation for anemia. Secondary aims were to identify additional factors enabling the risk stratification of those likely to benefit from endoscopic investigation, and to undertake a cost analysis of performing endoscopy in this group of patients. METHODS: We performed a retrospective review of endoscopy referrals for the investigation of anemia over a 12-month period at a single center. The patients were divided into three groups: those who had true iron deficiency anemia (IDA), tissue iron deficiency without anemia (TIDWA), or anemia of other cause (AOC). Outcome measures included finding a lesion responsible for the anemia and a significant change of management as a result of endoscopy. A costing analysis was performed with an activity-based costing method. RESULTS: We identified 283 patients who underwent endoscopy to investigate anemia. A likely cause of anemia was found in 31 of 150 patients with IDA (21 %) and 0 patients in the other categories (P < 0.001). A change of management was observed in 35 patients with IDA (23 %), 1 of 14 patients with TIDWA (7.14 %), and 8 of 119 patients with AOC (6.7 %) (P < 0.001). The cost of a single colonoscopy or gastroscopy was approximated to be $2209. CONCLUSIONS: Endoscopic investigation for non-IDA comes at a significant cost to our institution, equating to a minimum of$ 293 797 per annum in extra costs, and does not result in a change of management in the majority of patients. No additional factors could be established to identify patients who might be more likely to benefit from endoscopic investigation. The endoscopic investigation of non-IDA should be minimized

Development of a severity score for CRPS

The clinical diagnosis of Complex Regional Pain Syndrome (CRPS) is a dichotomous (yes/no) categorization necessary for clinical decision-making. However, such dichotomous diagnostic categories do not convey an individual's subtle and temporal gradations in severity of the condition, and have poor statistical power when used as an outcome measure in research. This study evaluated the validity and potential utility of a continuous type score to index severity of CRPS. Psychometric and medical evaluations were conducted in 114 CRPS patients and 41 non-CRPS neuropathic pain patients. Based on the presence/absence of 17 clinically-assessed signs and symptoms of CRPS, an overall CRPS Severity Score (CSS) was derived. The CSS discriminated well between CRPS and non-CRPS patients (p < .001), and displayed strong associations with dichotomous CRPS diagnoses using both IASP diagnostic criteria (Eta = 0.69) and proposed revised criteria (Eta = 0.77-0.88). Higher CSS was associated with significantly higher clinical pain intensity, distress, and functional impairments, as well as greater bilateral temperature asymmetry and thermal perception abnormalities (p's < .05). In an archival prospective dataset, increases in anxiety and depression from pre-surgical baseline to 4 weeks post-knee arthroplasty were found to predict significantly higher CSS at 6- and 12-month follow-up (p's < .05). Results indicate the CSS corresponds with and complements currently accepted dichotomous diagnostic criteria for CRPS, and support its validity as an index of CRPS severity. Its utility as an outcome measure in research studies is also suggested, with potential statistical advantages over dichotomous diagnostic criteria. (C) 2010 Published by Elsevier B.V. on behalf of International Association for the Study of Pain.Neurological Motor Disorder

P571 Vedolizumab (VDZ) real-world outcomes in ulcerative colitis (UC)

Background: In GEMINI 1, UC response to vedolizumab (VDZ) was 47% at Week 6 and 42% by Week 52. Our aim was to assess real-life outcomes for VDZ in UC. Methods: Data collected at 12 Australian (Aus), 1 UK and 2 Hong Kong (HK) centres, assessed response to VDZ at 3, 6, and 12 months using the Mayo Clinic Score (MCS, Aus/HK) or SCCAI and UCEIS (UK). Results: Two hundred and ninety-three patients (53% male, median age 38 years, 196 Aus, 93 UK, 4 HK) were assessed with similar age, disease location and duration allowing combining of data. Median MCS pre VDZ was 8 (range 2–12, n = 152) and Mayo endoscopy subscore 2 of 3 (Aus, HK). Median SCCAI was 8 (range 0–13, n = 87) and UCEIS 5 of 8 (UK). VDZ was the first biological agent in 170 of 293 (58%), prior anti-TNF use occurred in 123 [reason for switching: primary non-response (PNR) n = 46, loss of response (LOR) n = 62, side-effects (SE) n = 15; two patients with side-effects were in remission and not included for analysis]. At VDZ start, 61% taking steroids and 56% immunomodulation (IM). Response rates at 3 months: 220 of 279 (79%) overall responded, TNF-naïve 134 of 163 (82%), TNF-exposed 86 of 116 (74% p = NS). Remission rates at 3 months: 155 of 279 (55%) in clinical remission, TNF-naïve 110 of 163 (67%), TNF-exposed 45 of 116 (39%, p = 0.01). 60 of 132 (45%) patients in remission were on IM and 49 of 101 (49%) if not (NS). Six months: Overall 144 of 235 (61%) in clinical remission, TNF-naïve 97 of 131 (74%), TNF-exposed 47 of 104 (45%, p = 0.03), and 60 of 124 (48%) in endoscopic remission (MES = 0 or 1). Steroids were ceased in 61 of 136 (45%) if in remission and 23 of 85 (27%) if not (p = 0.08). 39% (49 of 125) patients in remission were on IM and 29% (24 of 82) if not (NS). 12 months: Overall 117 of 196 (60%) were in remission, TNF-naïve 72 of 106 (68%), TNF-exposed 45 of 90 (50%, NS). No significant difference in remission rates seen between PNR, LOR, or anti-TNF naïve patients. Steroids ceased in 55 of 110 (50%) if in remission and 6 of 80 (8%) if not (p ≺ 0.001). Thirty-seven of 104 (36%) patients in remission were on IM and 13 of 78 (17%, p = 0.03) if not. Those in remission at 3 and 6 months, 90% (74 of 82) and 92% (96 of 104), respectively maintained remission. Smoking status did not affect response to VDZ. Colectomy occurred in 33 of 293 (11%). Adverse events occurred in 20 of 293 (7%); 2 were serious (Klebsiella sepsis and hemophagocytic syndrome). Conclusions: VDZ induced remission in 55% at 3 months and 61% at 6 months with &gt;90% maintaining remission at 12 months. VDZ use continued for 12 months in 71% (139 of 196) with 61% in remission. Steroids were withdrawn in 50% patients in remission at 12 months. IMs might increase remission rates at 12 months. VDZ was initially more effective in anti-TNF naïve patients but differences were lost at 12 months suggesting patience may be needed in anti-TNF-exposed patients

P571 Vedolizumab (VDZ) real-world outcomes in ulcerative colitis (UC)

Background: In GEMINI 1, UC response to vedolizumab (VDZ) was 47% at Week 6 and 42% by Week 52. Our aim was to assess real-life outcomes for VDZ in UC. Methods: Data collected at 12 Australian (Aus), 1 UK and 2 Hong Kong (HK) centres, assessed response to VDZ at 3, 6, and 12 months using the Mayo Clinic Score (MCS, Aus/HK) or SCCAI and UCEIS (UK). Results: Two hundred and ninety-three patients (53% male, median age 38 years, 196 Aus, 93 UK, 4 HK) were assessed with similar age, disease location and duration allowing combining of data. Median MCS pre VDZ was 8 (range 2–12, n = 152) and Mayo endoscopy subscore 2 of 3 (Aus, HK). Median SCCAI was 8 (range 0–13, n = 87) and UCEIS 5 of 8 (UK). VDZ was the first biological agent in 170 of 293 (58%), prior anti-TNF use occurred in 123 [reason for switching: primary non-response (PNR) n = 46, loss of response (LOR) n = 62, side-effects (SE) n = 15; two patients with side-effects were in remission and not included for analysis]. At VDZ start, 61% taking steroids and 56% immunomodulation (IM). Response rates at 3 months: 220 of 279 (79%) overall responded, TNF-naïve 134 of 163 (82%), TNF-exposed 86 of 116 (74% p = NS). Remission rates at 3 months: 155 of 279 (55%) in clinical remission, TNF-naïve 110 of 163 (67%), TNF-exposed 45 of 116 (39%, p = 0.01). 60 of 132 (45%) patients in remission were on IM and 49 of 101 (49%) if not (NS). Six months: Overall 144 of 235 (61%) in clinical remission, TNF-naïve 97 of 131 (74%), TNF-exposed 47 of 104 (45%, p = 0.03), and 60 of 124 (48%) in endoscopic remission (MES = 0 or 1). Steroids were ceased in 61 of 136 (45%) if in remission and 23 of 85 (27%) if not (p = 0.08). 39% (49 of 125) patients in remission were on IM and 29% (24 of 82) if not (NS). 12 months: Overall 117 of 196 (60%) were in remission, TNF-naïve 72 of 106 (68%), TNF-exposed 45 of 90 (50%, NS). No significant difference in remission rates seen between PNR, LOR, or anti-TNF naïve patients. Steroids ceased in 55 of 110 (50%) if in remission and 6 of 80 (8%) if not (p ≺ 0.001). Thirty-seven of 104 (36%) patients in remission were on IM and 13 of 78 (17%, p = 0.03) if not. Those in remission at 3 and 6 months, 90% (74 of 82) and 92% (96 of 104), respectively maintained remission. Smoking status did not affect response to VDZ. Colectomy occurred in 33 of 293 (11%). Adverse events occurred in 20 of 293 (7%); 2 were serious (Klebsiella sepsis and hemophagocytic syndrome). Conclusions: VDZ induced remission in 55% at 3 months and 61% at 6 months with &gt;90% maintaining remission at 12 months. VDZ use continued for 12 months in 71% (139 of 196) with 61% in remission. Steroids were withdrawn in 50% patients in remission at 12 months. IMs might increase remission rates at 12 months. VDZ was initially more effective in anti-TNF naïve patients but differences were lost at 12 months suggesting patience may be needed in anti-TNF-exposed patients

P571 Vedolizumab (VDZ) real-world outcomes in ulcerative colitis (UC)

Background: In GEMINI 1, UC response to vedolizumab (VDZ) was 47% at Week 6 and 42% by Week 52. Our aim was to assess real-life outcomes for VDZ in UC. Methods: Data collected at 12 Australian (Aus), 1 UK and 2 Hong Kong (HK) centres, assessed response to VDZ at 3, 6, and 12 months using the Mayo Clinic Score (MCS, Aus/HK) or SCCAI and UCEIS (UK). Results: Two hundred and ninety-three patients (53% male, median age 38 years, 196 Aus, 93 UK, 4 HK) were assessed with similar age, disease location and duration allowing combining of data. Median MCS pre VDZ was 8 (range 2–12, n = 152) and Mayo endoscopy subscore 2 of 3 (Aus, HK). Median SCCAI was 8 (range 0–13, n = 87) and UCEIS 5 of 8 (UK). VDZ was the first biological agent in 170 of 293 (58%), prior anti-TNF use occurred in 123 [reason for switching: primary non-response (PNR) n = 46, loss of response (LOR) n = 62, side-effects (SE) n = 15; two patients with side-effects were in remission and not included for analysis]. At VDZ start, 61% taking steroids and 56% immunomodulation (IM). Response rates at 3 months: 220 of 279 (79%) overall responded, TNF-naïve 134 of 163 (82%), TNF-exposed 86 of 116 (74% p = NS). Remission rates at 3 months: 155 of 279 (55%) in clinical remission, TNF-naïve 110 of 163 (67%), TNF-exposed 45 of 116 (39%, p = 0.01). 60 of 132 (45%) patients in remission were on IM and 49 of 101 (49%) if not (NS). Six months: Overall 144 of 235 (61%) in clinical remission, TNF-naïve 97 of 131 (74%), TNF-exposed 47 of 104 (45%, p = 0.03), and 60 of 124 (48%) in endoscopic remission (MES = 0 or 1). Steroids were ceased in 61 of 136 (45%) if in remission and 23 of 85 (27%) if not (p = 0.08). 39% (49 of 125) patients in remission were on IM and 29% (24 of 82) if not (NS). 12 months: Overall 117 of 196 (60%) were in remission, TNF-naïve 72 of 106 (68%), TNF-exposed 45 of 90 (50%, NS). No significant difference in remission rates seen between PNR, LOR, or anti-TNF naïve patients. Steroids ceased in 55 of 110 (50%) if in remission and 6 of 80 (8%) if not (p ≺ 0.001). Thirty-seven of 104 (36%) patients in remission were on IM and 13 of 78 (17%, p = 0.03) if not. Those in remission at 3 and 6 months, 90% (74 of 82) and 92% (96 of 104), respectively maintained remission. Smoking status did not affect response to VDZ. Colectomy occurred in 33 of 293 (11%). Adverse events occurred in 20 of 293 (7%); 2 were serious (Klebsiella sepsis and hemophagocytic syndrome). Conclusions: VDZ induced remission in 55% at 3 months and 61% at 6 months with >90% maintaining remission at 12 months. VDZ use continued for 12 months in 71% (139 of 196) with 61% in remission. Steroids were withdrawn in 50% patients in remission at 12 months. IMs might increase remission rates at 12 months. VDZ was initially more effective in anti-TNF naïve patients but differences were lost at 12 months suggesting patience may be needed in anti-TNF-exposed patients

Longitudinal follow‐up study: effect of psychological co‐morbidity on the prognosis of inflammatory bowel disease

Background Psychological co-morbidity is more common in patients with inflammatory bowel disease (IBD), compared with the general population, but little is known about the cumulative effect of increasing psychological burden on disease behaviour. Aims To examine the effect of psychological co-morbidity on inflammatory bowel disease in a longitudinal follow-up study. Methods We collected complete demographic, symptom and psychological co-morbidity data (anxiety, depression and somatisation scores) at baseline from adults with IBD in biochemical remission (faecal calprotectin <250 µg/g). Objective markers of disease activity, including glucocorticosteroid prescription or flare of disease activity, escalation of therapy, hospitalisation or intestinal resection, were reviewed ≥2 years of follow-up. We performed multivariate Cox regression, controlling for patient characteristics and follow-up duration, to examine cumulative effect of psychological co-morbidities on subsequent IBD behaviour. Results Among 218 participants, 48 (22.0%) had one, 13 (6.0%) two and nine (4.1%) three psychological co-morbidities at baseline. Following multivariate Cox regression analysis, glucocorticosteroid prescription or flare, and escalation of medical therapy were significantly higher among those with two (hazard ratio [HR] = 3.18; 95% confidence interval [CI] 1.44-7.02, and HR = 2.48; 95% CI 1.03-5.93, respectively) or three (HR = 3.53; 95% CI 1.26-9.92, and HR = 8.19; 95% CI 2.88-23.23, respectively) psychological co-morbidities. Occurrence of at least one endpoint of interest was significantly higher with increasing psychological co-morbidity (HR = 1.74; 95% CI 1.07-2.82 for one, HR = 2.47; 95% CI 1.12-5.46 for two and HR = 4.93; 95% CI 1.84-13.17 for three psychological co-morbidities). Conclusions Individuals with IBD in biochemical remission experienced a worse disease course with increasing psychological co-morbidity at baseline