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Differential diagnosis of wide QRS tachycardia (WQRST) on the electrocardiogram remains a challenging exercise. Correct diagnosis is important for prescribing appropriate therapy and determining prognosis. Differential diagnosis of wide QRS tachycardia revolves around differentiation between supraventricular tachycardia with aberrant conduction and ventricular tachycardia. Observations such as clinical history, findings of physical examination during tachycardia, AV dissociation, QRS morphology in lead V1 and lead V6, precordial concordance, RS complexes in precordial leads, contralateral bundle branch block during wide QRS tachycardia, R wave morphologies in lead aVR, and ventricular initial/terminal velocity of conduction ratio can help arrive at the correct diagnosis with reasonable accuracy. The observations described here can help arrive at the correct diagnosis of WQRST with both reasonable accuracy and confidence., The diagnosis of wide QRS tachycardia can be challenging, but is essential for appropriate therapy. The differentiation is often between supraventricular tachycardia with aberrant conduction and ventricular tachycardia. A review of historical, clinical, electrocardiographic information during wide QRS tachycardia while keeping in mind the pitfalls and exceptions, may help arrive at the correct diagnosis with reasonable accuracy and confidence

The majority of patients diagnosed with cancer are ≥65 years. However, inclusion of older patients with cancer in clinical trials is limited, and so there is less evidence to guide systemic therapeutic decisions in these patients. There is also debate surrounding the definition of “older patients”. Additionally, comorbidities, as well as life expectancy will influence compliance to any treatment, and physicians may favour less intense regimens for these patients or best supportive care alone. In patients with biliary tract cancer (BTC), surgery followed by adjuvant capecitabine (BILCAP phase 3 trial) is the only potentially curative option, but patients often present with advanced disease, and palliative systemic treatment is given. The availability of novel targeted therapies (oral and monotherapy) in selected populations of patients with BTC may increase the therapeutic artillery for these older patients. Trials to date in patients with BTC have not been age-specific and have not always included age subgroup analysis, and so the evidence to support treatment of older patients is derived via extrapolation, primarily, with only 35% being >60 years in the adjuvant BILCAP study, for example. When this evidence is provided, treated patients tend to gain equivalent survival benefit, irrespective of age. A comprehensive clinical geriatric assessment is recommended. Revision of existing BTC treatment guidelines should incorporate some reference to best practice in older patients with BTC. Observational data may also provide valuable insights in this population. Age sub-group analysis should be encouraged in prospective clinical trials including patients with BTC, with age-specific trials favoured.

IntroductionPancreatic exocrine insufficiency (PEI) in patients with pancreatic malignancy is well documented in the literature and is known to negatively impact on overall survival and quality of life. A lack of consensus opinion remains on the optimal diagnostic test that can be adapted for use in a clinical setting for this cohort of patients. This study aims to better understand the prevalence of PEI and the most suitable diagnostic techniques in patients with advanced pancreatic malignancy.Methods and analysisThis prospective observational study will be carried out in patients with pancreatic malignancy (including adenocarcinoma and neuroendocrine neoplasms). Consecutive patients with inoperable pancreatic malignancy referred for consideration of first-line chemotherapy will be considered for eligibility. The study comprises three cohorts: demographic cohort (primary objective to prospectively investigate the prevalence of PEI in patients with inoperable pancreatic malignancy); sample size 50, diagnostic cohort (primary objective to design and evaluate an optimal diagnostic panel to detect PEI in patients with inoperable pancreatic malignancy); sample size 25 and follow-up cohort (primary objective to prospectively evaluate the proposed PEI diagnostic panel in a cohort of patients with inoperable pancreatic malignancy); sample size 50. The following is a summary of the protocol and methodology.Ethics and disseminationFull ethical approval has been granted by the North West Greater Manchester East Research and Ethics Committee, reference: 17/NW/0597. This manuscript reflects the latest protocol V.8 approved 21 April 2020. Findings will be disseminated by presentation at national/international conferences, publication in peer-review journals and distribution via patient advocate groups.Trial registration number194255, NCT0361643.

Breast cancer (BC) is considered the second leading cause of cancer-related death in women. Accurate diagnosis is thus of utmost importance to avoid the burden of BC. Ankyrin 2 (ANK2) encodes the structural membrane adapter protein ankyrin-B, which is ubiquitously expressed in the human body. In this study, bioinformatics tools were used to determine whether ANK2 could be used as a diagnostic and prognostic biomarker in BC. ANK2 expression was analyzed using ONCOMINE, UALCAN, GEPIA2, and GENT2. Data from these servers showed the downregulated expression of ANK2 in BC relative to that in normal tissue. Further, downregulated ANK2 expression was found in such conditions as estrogen receptor-negative, human epidermal growth factor receptor 2-positive, positive nodal status, basal-like tumor, and triple-negative breast cancer, according to the data from the bc-GenExMiner v4.5 server. Analysis of 18 BC studies retrieved from the cBioPortal database revealed 88 missense mutations with 0.46%–5.09% copy number alterations in the ANK2 gene sequence. Additionally, a positive correlation between downregulated ANK2 expression and reduced survival probability of BC patients was revealed by a Kaplan–Meier plotter. Moreover, chordin-like 1, a tumor suppressor, was highly co-expressed with ANK2, as shown by the ONCOMINE, UCSC Xena, and GEPIA2 tools. The signaling pathways and gene ontologies of ANK2 and its co-expressed genes were identified using the Enrichr platform. The present results suggest that the ANK2 may serve as a biomarker for diagnosis, prognosis, and therapeutic purposes in BC.

Background: Molecular profiling is becoming increasingly relevant in the management of patients with advanced cancer, to identify targetable aberrations and prognostic markers to enable a precision medicine strategy. Methods: Eligible patients were those diagnosed with advanced biliary tract cancer (BTC) including intrahepatic (iCCA) and extrahepatic cholangiocarcinoma (eCCA), gallbladder cancer (GBC), and ampullary carcinoma (Amp) who underwent molecular profiling between April 2017 and June 2020 based on analysis of either tumour samples (FoundationOne CDx&reg, /Oncomine&reg, platforms) or ctDNA (FoundationOne Liquid&reg, platform (Foundation Medicine, Cambridge, MA, USA)). Baseline patient characteristics and molecular profiling outcomes were extracted. The primary aim was to describe sample failure rate. Secondary aims included description of reason for sample failure, summary of findings derived from molecular profiling, and assessment of concordance between paired tissue and ctDNA samples. Results: A total of 149 samples from 104 individual patients diagnosed with advanced BTC were identified and eligible for this analysis: 68.2% iCCA, 100% advanced stage, 94.2% received palliative therapy. The rate of sample failure was 26.8% for tissue and 15.4% for ctDNA, p-value 0.220, predominantly due to insufficient (defined as &lt, 20%) tumour content in the sample (the reason for 91.2% of tissue sample failure). Of the 112 samples successfully analysed, pathological molecular findings were identified in the majority of samples (88.4%) and identification of pathological findings using ctDNA, was possible regardless of whether the patient was on active treatment at time of blood acquisition or not (p-value 1.0). The rate of targetable alterations identified was 40.2% across all successfully-analysed samples (39 iCCA, 6 non-iCCA): IDH1 mutations (19.1% of individual patients), FGFR2 alterations (10.1% and 5.6% of individual patients had FGFR2 fusions and mutations, respectively), 10.6% of all patients (12.4% of patients with successfully analysed samples) entered trials with matched targeted therapies as a consequence. Concordance of findings for paired tissue and paired tissue-ctDNA was high (3/3, 100% and 6/6, 100%, respectively). Twelve ctDNA samples were taken prior to palliative treatment initiation, median maximum mutant allele frequency (MAF) was 0.47 (range 0.21&ndash, 19.8), no significant association between reported maximum MAF and progression-free survival (PFS) or overall survival (OS) (all Cox regression p-values &gt, 0.273). A total of 15 patients (16.6%) harboured alterations in DNA damage repair (DDR) genes, when treated with platinum-based chemotherapy, there was a trend towards increased partial response rate (21.4% vs. 15.9%, p-value 0.653), radiological benefit rate (64.3% vs. 36.2%, p-value 0.071), and longer OS (median OS 20.4 months (95% CI 7.9&ndash, 26.7) vs. 13.3 (95 CI 11.0&ndash, 16.4), Cox Regression HR 0.79 (95% CI 0.39&ndash, 1.61), p-value 0.527). Conclusions: Molecular profiling is of use for identification of novel therapeutic strategies for patients with advanced BTC (mainly iCCA). One in four archived tissue samples may have insufficient tumour content for molecular profiling, ctDNA-based approaches may overcome these obstacles.

Advanced hepatocellular cancer (HCC) is the fourth leading cause of cancer-related death globally and is most common in elderly patients with a peak incidence in the UK at ages 85-89 years. In addition to the well-established risk factors of alcohol and viral hepatitis B and C, rising obesity and associated non-alcoholic fatty liver disease is projected to contribute to increased incidence of advanced HCC in elderly patients. The management of advanced HCC is changing rapidly; for over a decade the multi-kinase inhibitor sorafenib has been the only treatment option that offered a proven survival advantage, but in the last 4 years other treatment options have emerged including other kinase inhibitors, and monoclonal antibodies targeting angiogenesis and immune checkpoint inhibitors. Recent clinical trials have recruited older patients with no maximum age exclusion criteria, and age has not been found to be predictive for treatment effect in subgroup analyses. Chronological age is an unreliable measure of fitness for treatment and frailty may be a more apt descriptor, but the lack of a unified assessment tool has limited its use in current practice. Development of unified frailty assessments and prospective large-scale studies of novel systemic therapies where age and frailty are evaluated would be informative.

Previous literature has sought prognostic factors for the survival of anal cancer patients. The present study aimed to determine prognostic factors for local disease recurrence, distant metastasis and survival for patients treated with radical chemoradiotherapy (CRT) at the Rosemere Cancer Centre, Preston, UK.Patients treated with CRT for nonmetastatic squamous cell anal cancer between September 2000 and January 2013 were studied. Kaplan-Meier and Cox regression analysis assessed the prognostic value of age, sex, tumour size, the proportion of the anal canal circumference involved (ACCI), nodal disease, tumour location and pretreatment haemoglobin.One hundred and 48 patients with a mean age of 63 years were studied, of whom 15% suffered local disease recurrence and 10% developed distant metastasis. The 5-year overall and cancer-specific survival rates were 84% and 86%, respectively. Predictors of local recurrence were tumour size5 cm and over two-thirds ACCI (P 0.01). Predictors of distant metastasis and poor survival were tumour size5 cm (P 0.01), node positive disease on imaging (P 0.05), over two-thirds ACCI (P 0.01) and a pretreatment haemoglobin level below 130 g/l (P 0.05). Multivariate analysis found large tumour size to be the most significant factor for local recurrence (P = 0.002) and survival (P = 0.02) whilst over two-thirds ACCI was most predictive of distant metastasis (P 0.001). Age, gender, palpable lymph nodes and tumour location were not of prognostic value for local disease recurrence, distant metastasis or survival.Tumour size, nodal disease, over two-thirds ACCI and low pretreatment haemoglobin confer poorer prognostic and survival outcomes. Use of intensity-modulated radiation therapy may allow greater radiation doses to be given for locally advanced tumours, thus improving local control and survival and reducing morbidity.

Background: A diagnosis of an old Inferior Wall Myocardial Infarction (IMI), on a routinely performed Electrocardiogram (ECG) often leads to further consultations and imaging studies. The aim of this study was to assess the predictive value of Q waves in inferior leads, alone or in combination with repolarization abnormalities, for the diagnosis of inferior wall myocardial infarction confirmed by imaging studies. Methods: Fifty-six patients, in whom computerized interpretation of the electrocardiogram resulted in the diagnosis of inferior wall myocardial infarction, and in whom imaging studies were also available, were included in this study. Electrocardiograms were performed using the GE MACHD 5500. Electrocardiograms were interpreted using the MUSE GE system. Echocardiograms and nuclear medicine cardiac imaging were performed and interpreted using standard equipment and techniques. S AS 9.3 software (SAS Institute, Inc., Cary, North Carolina) was used to calculate 95% exact binomial confidence intervals (CI) for the population PPVs. Results: Computerized interpretation of the ECGs leading to the diagnosis of old inferior wall myocardial infarction when compared with inferior wall myocardial infarction confirmed by imaging studies, had a positive predictive value of 52.78%. Adding the criteria of Q waves wider than 0.04 ms, using manual interpretation of ECG, increased the positive predictive value of the test to 80%. However, the presence of ST changes and/or negative or isoelectric T waves, in the presence of diagnostic Q waves in the inferior leads, increased the positive predictive value to 92%. Conclusion: These results suggest that the computerized interpretation of ECG results in a high rate of false positive readings of old inferior myocardial infarction. This may result in overutilization of imaging modalities. Presence of diagnostic Q waves in inferior leads, if accompanied by repolarization abnormalities, improves the accuracy of the electrocardiogram for the diagnosis of inferior wall myocardial infarction..

BACKGROUND Atrial fibrillation is a relatively common arrhythmia often seen in patients with permanent pacemakers. In this study we aimed to assess the incidence of atrial fibrillation in patients whose pacemakers were programmed to pace in the right ventricle (VVI) and compared it with patients whose pacemakers were programmed in non-VVI mode(i.e. AAI or DDD). MATERIAL AND METHODS Records of the patients with permanent pacemaker or implantable-cardioverter-defibrillator were evaluated and analyzed. These patients had regular periodic follow-up evaluation over the last 10 years. (January 1, 2002 to December 31, 2012). Patient demographic, pacemaker data, pacing mode, review and analysis of arrhythmia log for occurrence of new atrial fibrillation and echocardiographic findings for left atrial size, mitral regurgitation, were analyzed and recorded. Left atrial size was classified as mild, moderate or severe enlargement, depending on the left atrial dimension. RESULTS Average age was 68 years. There was no gender predominance (51% male). Mean follow-up duration was 6 years and 3 months. Hispanic population represented the majority of the patients (65.4%). Majority of the devices (80.0%) were programmed as DDD pacing mode. Fifty-five patients (52.8%) did not develop atrial fibrillation. 85.7% of the patients paced in VVI-mode had atrial fibrillation while atrial fibrillation occurred in 37.4% among patients paced in non-VVI-mode. This difference was statistically significant (P

Patient: Female, 70 Final Diagnosis: SA block induced by pyridostigmine Symptoms: Asymptomatic Medication: Pyridostigmine Clinical Procedure: Pacemaker insertion Specialty: Electrophysiology Objective: Unusual clinical course Background: Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of inosine monophosphate dehydrogenase (IMPDH) and Methylprednisolone is seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case Report: A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusions: In symptomatic or asymptomatic bradycardia with significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of Inosine Monophosphate Dehydrogenase (IMPDH) and Methylprednisolone are seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case presentation:A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusion: In symptomatic bradycardia or asymptomatic, however, significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Aim: Recent literature has sought prognostic factors for survival outcomes in anal cancer patients. Similarly, our study aims to determine prognostic factors for local disease recurrence, distant metastases and survival from patients treated with standardized radical chemo-radiotherapy at the Rosemere Cancer Centre, Lancashire, UK. Methods: Patients treated with radical concurrent chemoradiation for non-metastatic squamous cell anal cancer from September 2000 to January 2013 were retrospectively studied. Kaplan-Meier and Cox Regression proportional hazards methods were used to assess prognostic value of age, sex, tumour size, anal canal circumference involved (ACCI), nodal disease, tumour location and pre-treatment haemoglobin. Results: A total of 148 patients (95 females, 53 males) with a mean age of 63 were studied. From the sample population 15% of patients suffered local disease recurrence and 10% developed distant metastases. The estimated five-year overall survival and cancer specific survival was 84% and 86% respectively. Predictors of local recurrence were tumour size greater than 5cm and over two-thirds ACCI (p Conclusions: Tumour size, nodal disease, over two thirds ACCI and low pre-treatment haemoglobin confer poorer prognostic and survival outcomes. Future use of intensity modulated radiation therapy (IMRT) can decrease patient morbidity, which may allow increase of radiation doses for locally advanced anal cancers and thus improve local control and survival outcomes. Disclosure: All authors have declared no conflicts of interest.

Ventricular rhythms originate from sites distal to the penetrating bundle of His. In the majority of cases, the resulting QRS complexes are abnormally wide, exhibit axis deviation, and have a range of bizarre morphologies. In some cases, however, ventricular ectopic impulses arise in the distal conduction structures themselves and therefore exhibit narrow QRS complexes. Three basic mechanisms are thought to account for the majority of ventricular rhythms: enhanced automaticity, reentry, and early and late afterdepolarizations. In the case of enhanced automaticity, single or multiple excitable foci spontaneously discharge impulses. In the case of reentry, the sinus impulse traverses a circuit within the distal conduction system or ventricular myocardium, forming a single ectopic ventricular beat if conduction through the circuit is an isolated event, or producing ventricular tachycardia if conduction through the circuit is repetitive. A reentry circuit may consist of anatomically separate pathways with differing conduction properties, or disparate conduction properties (anisotropy) in contiguous myocardium may provide a functional basis for reentry. If the circuit is very small, the mechanism is called micro-reentry. If the circuit consists of larger structures, such as a bundle branch and the contiguous myocardium, the resulting mechanism is called macro-reentry. (The reentry mechanism is described in detail in Chapters 11 and 13.) Early after-depolarization, an early depolarization that occurs before repolarization is complete, is now widely believed to be the physiologic substrate of polymorphic ventricular tachycardia.

In early fetal life, the atrial and ventricular myocardia are continuous. After approximately the first month of gestation, the formation of the annulus fibrosus begins the anatomical and electrical separation of the atria and ventricles, leaving the atrioventricular node and bundle of His as the only electrical connection between the upper and lower chambers. In approximately 0.3% of the population (3 of every 1000 individuals), however, this process of electrical isolation is incomplete. In these subjects, unobliterated myocardial strands persist, making one, or at times more, direct electrical connections between the atrial and ventricular myocardium. These congenitally anomalous fibers are known as accessory pathways or bypass tracts.

The commonly used term sick sinus syndrome refers to a constellation of disorders of sinus rhythm that includes (1) inappropriate sinus bradycardia, (2) barious forms of sinoatrial block, (3) sinus arrest, (4) tachycardia-bradycardia syndrome, (5) sinoatrial nodal suppression by ectopic beats, and (6) sinoatrial reentry. This group of arrhythmias is very often associated with other manifestations of conduction system disease, such as aytrioventricular, fascicular, and bundle branch block, and suppression of escape rhythms from subsidiary pacemakers.

The supraventricular tachycardias can be divided into those arrhythmias originating within the atria per se and those in which the atrioventricular node or accessory atrioventricular connections play a role. The latter arrhythmias are discussed in Chapter 13. Four important tachyarrhythmias, namely, atrial fibrillation, atrial flutter, atrial tachycardia, and multifocal atrial tachycardia, are considered in this chapter, as are premature atrial complexes and ectopic atrial rhythm.

The intraventricular conduction defects are divided into fascicular and bundle branch blocks. The bundle branch blocks may be further classified as complete or incomplete. The criteria for incomplete bundle branch block were first formulated in the 1950s on the basis of animal studies by Demetrio Sodi-Pollares and his associates in Mexico City. In 1969, Mauricio Rosenbaum and his coworkers in Buenos Aires documented Wenckebach periods in the bundle branches on tracings obtained from humans, thereby establishing the existence of intermediate or incomplete forms of both right and left bundle branch block.

In most cases of atrioventricular block, a single level of conduction delay is sufficient to explain the electrocardiographic findings. Consequently, the AV node and distal conduction structures are represented in laddergrams as a one-tiered structure. However, in the case of rapid atrial arrhythmias, as many as three consecutive levels of conduction delay, each with its own conduction characteristics, may be postulated to explain the observed atrioventricular conduction ratios.

Of 1,599 patients who underwent surgery for direct myocardial revascularization In 1973 at Cleveland Clinic Hospital, 19 patients (1.2 percent) developed primary ventricular fibrillation or ventricular tachycardia during the immediate postoperative period. Occurrence of postoperative ventricular tachyarrhythmias could not be predicted by assessment of preoperative symptoms or by evaluation of the extent of coronary artery disease and left ventricular function. There was no increase in early or late mortality or morbidity (including postoperative myocardial infarction) among patients who developed postoperative primary ventricular tachyarrhythmias.

Various studies on the natural history of coronary artery disease have demonstrated that the prognosis of the disease is directly related to its severity and to the degree of associated left ventricular dysfunction as defined primarily with coronary angiography and ventriculography.l-g Two and three vessel coronary artery disease and stenosis of the left main coronary artery appear to have a poor prognosis, and the 5 to 10 year outlook is even worse when they are associated with factors such as left ventricular dysfunction, abnormal electrocardiogram, hypertension, cardiomegaly and congestive heart failure l-l5 The ‘natural history studies have also shown that patients with single vessel coronary artery disease have a better 5 to 10 year survival rate than patients with double or triple vessel disease.1-2*5-8 However, their prognosis appears to differ according to whether the vessel involved is the left anterior descending, left circumflex or right coronary artery.1*2>5v7-g In view of the surgical implications, we will examine the hypothesis that significant disease isolated to the left anterior descending coronary artery is more lethal than any other single vessel coronary disease. This will be examined with three approaches-myocardial infarction studies, angiographic data and data on surgical versus medical treatment.

The distance from the base of the left coronary sinus to the origin of the left main coronary artery was measured in 54 patients. The length of the left main coronary artery and the pattern of arterial dominance were determined in the last 37 patients. These variables were correlated with height, weight, age, sex, and presence or absence of coronary artery disease. Average distance from the basis of the left coronary sinus to the origin of the left main coronary artery was 19.4 +/- 2.7 mm. Average length of the left main coronary artery was 9.7 +/- 4.3 mm. There was a large inherent variability between distance from the base of left coronary sinus to the origin of the left main coronary artery and height of the subjects. Other variables did not show positive correlation. Similar large variability was noticed between of the left main coronary artery and height of the subjects. Thus, from these observations it was not possible to predict the distance from the base of the left coronary sinus to the origin of the left main coronary artery or the length of the left main coronary artery using height or any other variable. The importance of these findings in relation to coronary angiography is discussed.

To determine the effect of acute myocardial infarction (AMI) on serum and urinary activity of beta-galactosidase and beta-glucuronidase (lysosomal enzymes) 40 patients were studied. Eighteen patients had acute myocardial infarction and 22 were assigned as controls. Three of the 18 patients with acute myocardial infarction died within 5 to 10 days after hospitalization. Although the serum and urinary beta-glucuronidase and serum beta-galactosidase activity was higher in patients with acute myocardial infarction when compared with the control subjects these differences did not achieve statistical significance. However, the mean values of urinary beta-galactosidase in the control and acute MI groups were 158.68 and 333.3 nmol/mg creatinine/hr, respectively (p less than 0.046). These findings indicate that there is a significant increase in the urine beta-galactosidase activity during the early phases of acute myocardial infarction.

SUMMARY The linear distance between the bifurcation of the main right and left pulmonary arteries was measured on a plain postero-anterior chest radiograph in 20 healthy subjects and in 50 patients with mitral stenosis. For normal subjects, the range of trans-pulmonary artery distance was 6.7 to 9.5 cm, with a mean of 8.2 cm, and S.D. of ±0.94. The mean value of this trans-pulmonary artery distance for the group of 50 patients with mitral stenosis was 10.1 cm, the range being 8.2 to 13.0 cm, with a S.D. of ±1.2. TPAD in patients with mitral stenosis was significantly greater than the TPAD for normal subjects. Thirty-four out of the 38 patients, i.e. 89.5% with a trans-pulmonary artery distance of more than 9.5 cm, had mean pulmonary artery pressures of more than 30 mm Hg. Out of 12 patients with a trans-pulmonary artery distance of less than 9.5 cm, only seven patients had a mean pulmonary artery pressure of more than 30 mm Hg. No linear correlation could be demonstrated between the trans-pulmonary artery distance and the mean pulmonary artery pressure in patients with mitral stenosis.

196 Background: PEI in patients with advanced pancreatic cancer is well documented, but there is a lack of consensus regarding optimal screening. Methods: Eligible patients for this observational study (NCT03616431) were those diagnosed with aPC referred for consideration of palliative therapy who consented to evaluation by a research dietitian. In addition to symptom and full dietetic assessment (including Mid-Upper Arm Circumference (MUAC), handgrip and stair climb test), full nutritional blood panel, faecal elastase (FE) and 13C mixed triglyceride breath test (for diagnostic cohort (DiC)) were performed. Primary objectives: prospective assessment of PEI prevalence (dietitian-assessed; demographic cohort (DeC)), and to design (using breath test as gold standard; DiC) and validate (follow-up cohort (FuC)) the most suitable screening tool for PEI in patients with aPC. Logistic and Cox regression were used for statistical analysis (Stat v.12). Results: Between 1st July 2018 and 30th October 2020, 112 eligible patients [50 (DeC), 25 (DiC), 37 (FuC)]. Prevalence of PEI in the DeC was 64.0% (PEI-related symptoms were flatus (84.0%), weight loss (84.0%), abdominal discomfort (50.0%) and steatorrhea (48.0%)); 70.0% of patients required pancreatic enzyme replacement therapy and 74.0% had anorexia (low appetite); 44.0% and 18.0% had low vitamin D and vitamin A levels, respectively. Designed PEI screening panel (DiC; 19 patients with breath test completed) included FE [normal/missing (0 points); low (1 point)] and MUAC [normal/missing ( > percentile 25 for age/gender) (0 points); low (2 points)] and identified patients at high-risk (2-3 total points) of PEI [vs. low-medium risk (0-1 total points)]. When patients from DeC and DiC) were analysed together, those classified as “high-risk of PEI” according to the screening panel had shorter overall survival (multivariable Hazard Ratio (mHR) 1.86 (95% CI 1.03-3.36); p-value 0.040) when adjusted for other prognostic factors, including presence of PEI symptoms (mHR 2.28 (95% CI 1.19-4.35); p-value 0.013). The screening panel was tested in the FuC; 78.38% were classified as patients at “high-risk of PEI”; of these, 89.6% were confirmed to have PEI by the dietitian. The panel was feasible for use in clinical practice, (64.8% of patients completed fully the assessments required) and acceptability was high (87.5% of patients would do it again). The majority of patients (91.3%) recommended that all future patients with aPC should have dietitian input. Conclusions: PEI is present in the majority of patients with aPC, and early dietetic input is important to provide a holistic nutritional overview, including, but not limited to, PEI. This proposed screening panel could be used to prioritise patients at higher risk of PEI requiring urgent dietitian input. Its prognostic role needs further validation. Clinical trial information: NCT03616431.