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Objectives This study compared combination diuretic strategies in acute heart failure (AHF) complicated by diuretic resistance (DR). Background Combination diuretic regimens to overcome loop DR are commonly used but with limited evidence. Methods This study was a randomized, double-blinded trial in 60 patients hospitalized with AHF and intravenous (IV) loop DR. Patients were randomized to oral metolazone, IV chlorothiazide, or tolvaptan therapy. All patients received concomitant high-dose IV infusions of furosemide. The primary outcome was 48-h weight loss. Results The cohort exhibited DR prior to enrollment, producing 1,188 ± 476 ml of urine in 12 h during high-dose loop diuretic therapy (IV furosemide: 612 ± 439 mg/day). All 3 interventions significantly improved diuretic efficacy (p Conclusions In this moderately sized DR trial, weight loss was excellent with the addition of metolazone, IV chlorothiazide, or tolvaptan to loop diuretics, without a detectable between-group difference. (Comparison of Oral or Intravenous Thiazides vs. tolvaptan in Diuretic Resistant Decompensated Heart Failure [3T]; NCT02606253)

WHAT IS KNOWN ON THE SUBJECT?: Although the seminal work of McCormack et al. (International Practice Development Journal, 2015, 5, 1) and Nolan, Davies, Brown, Keady, and Nolan () provides useful conceptual frameworks in person-centred care, research is needed to understand how theoretical concepts can be applied into practice to support dementia care. Also, evidence is needed to demonstrate the impacts of implementing person-centred care and staff experiences. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper adds to the emerging work that is providing a greater understanding of how team education in practice can make a difference in building capacity to improve dementia care. We offer timely evidence and useful insights into how an education programme, Gentle Persuasive Approaches (GPA), was implemented ("what worked" and "how") in a large Canadian hospital to improve knowledge and skills among staff in dementia care. The GPA education helped hospital staff enact person-centred care by cultivating shared values and a learning environment to change attitudes, practices and conditions for continuous practice development. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses in advance practice are well positioned to lead dementia education and advocate for person-centred care in hospitals. Hospital leaders are responsible for providing resources to cultivate a supportive environment for continuous learning to ensure the workforce gains the capacity to meet the changing demands and needs of the ageing population. System support is essential for creating conditions to enable person-centred care. ABSTRACT: Introduction Hospital staff lacks knowledge and skills in dementia care. There is a need to understand how person-centred care theory can be operationalized in staff's practices to improve dementia care. Aims To describe the staff's experiences of learning and applying the Gentle Persuasive Approaches (GPA) to enact person-centred care in a hospital. Methods Mixed methods, including posteducation survey and focus groups, were used. Thematic analysis was conducted to identify themes that describe participants' experiences. Results Three hundred and ten staff and leaders in a hospital participated in the GPA education and completed a posteducation survey (n = 297). After 1 year, two follow-up focus groups were conducted with interdisciplinary staff (n = 24) across medicine and mental health programmes. Our analysis identified three themes to enable person-centred care: (a) changing attitudes, (b) changing practices and (c) changing conditions. Discussion This study contributes to the literature by providing evidence of how an education programme was implemented in a large Canadian hospital to build capacity for dementia care. Joint education for interprofessional staff offers value in enabling person-centred care. Implication Mental health nurses are in position to lead dementia education and advocate for person-centred care in hospitals. Staff need structural support to engage in team learning for practice improvement.

This study compared combination diuretic strategies in acute heart failure (AHF) complicated by diuretic resistance (DR).Combination diuretic regimens to overcome loop DR are commonly used but with limited evidence.This study was a randomized, double-blinded trial in 60 patients hospitalized with AHF and intravenous (IV) loop DR. Patients were randomized to oral metolazone, IV chlorothiazide, or tolvaptan therapy. All patients received concomitant high-dose IV infusions of furosemide. The primary outcome was 48-h weight loss.The cohort exhibited DR prior to enrollment, producing 1,188 ± 476 ml of urine in 12 h during high-dose loop diuretic therapy (IV furosemide: 612 ± 439 mg/day). All 3 interventions significantly improved diuretic efficacy (p 0.001). Compared to metolazone (4.6 ± 2.7 kg), neither IV chlorothiazide (5.8 ± 2.7 kg; 1.2 kg [95% confidence interval (CI)]: -2.9 to 0.6; p = 0.292) nor tolvaptan (4.1 ± 3.3 kg; 0.5 kg [95% CI: -1.5 to 2.4; p = 0.456) resulted in more weight loss at 48 h. Median (interquartile range [IQR]) cumulative urine output increased significantly and did not differ among those receiving metolazone (7.78 [IQR: 6.59 to 10.10] l) and chlorothiazide (8.77 [IQR: 7.37 to 10.86] l; p = 0.245) or tolvaptan (9.70 [IQR: 6.36 to 13.81] l; p = 0.160). Serum sodium decreased less with tolvaptan than with metolazone (+4 ± 5 vs. -1 ± 3 mEq/l; p = 0.001), but 48-h spot urine sodium was lower with tolvaptan (58 ± 25 mmol/l) than with metolazone (104 ± 16 mmol/l; p = 0.002) and with chlorothiazide (117 ± 14 mmol/l; p 0.001).In this moderately sized DR trial, weight loss was excellent with the addition of metolazone, IV chlorothiazide, or tolvaptan to loop diuretics, without a detectable between-group difference. (Comparison of Oral or Intravenous Thiazides vs. tolvaptan in Diuretic Resistant Decompensated Heart Failure [3T]; NCT02606253).

Because dementia care is often considered challenging, the importance of offering dementia-specific education has been emphasized. The Gentle Persuasive Approaches (GPA) programme was designed to enhance staff members’ competency and knowledge in dementia care through person-centered strategy training. The GPA was implemented in Vancouver General Hospital, a large urban hospital in British Columbia, Canada since 2014. A total of 310 staff in multiple disciplines were trained. The post-training survey (N= 297) showed highly positive results. Almost all of the staff (99 %) reported finding the training useful and applicable. Two focus groups with 20 staff (physicians, nurses, allied health professionals, care staff) were conducted to explore the impact of their learning experience, and what affected them to apply new knowledge in practice. Our analysis revealed three themes: (1) the program enables staff to change practices by focusing on the values of person-centered care, (2) the program promotes teamwork with interdisciplinary healthcare professionals, patients and families, and (3) barriers to applying the new practice are management and organizational support. The staff reported that the programme allows them to consider patients’ preferences and respect their boundaries, empathize with patients’ experiences, become proactive in making changes in dementia care and work collaboratively with the team. However, these positive outcomes are hindered by workload, staffing, lack of managerial support and the complexity of care. In this presentation, we will discuss the implications of the GPA programme on staff practice and offer practical strategies to sustaining the programme’s effectiveness in acute care.

Cardiac amyloidosis is an infiltrative cardiomyopathy with well described classic findings. Without sufficient clinical suspicion, atypical cases confounded by a background of prior cardiovascular disease will elude detection and treatment. An 84 year-old man presented with dyspnea. Prior history

AL amyloidosis arises from the extracellular deposition of misfolded light chain produced by a plasma cell dyscrasia. Prognosis hinges strongly on cardiac involvement. Cardiac biomarkers, in addition to serum free light chain, form the basis of the Mayo staging system for amyloidosis, with cardiac

Background: Light chain amyloidosis (AL) is characterized by tissue deposition of misfolded proteins that cause multisystem organ dysfunction. Current treatments, including chemotherapy and autologous hematopoietic cell transplantation (AHCT), target plasma cells producing pathogenic amyloid proteins. The development of amyloid protein targeted monoclonal antibody therapy has led to an increased need for objective measurements of clinical response. The 6-minute walk test (6MWT) has been used for years as the primary outcome measure to monitor disease severity in clinical trials of heart failure (HF). For example, HF trials with cardiac devices MIRACLE (Abraham, 2002) and MUSTIC (Cazeau, 2001) demonstrated important therapeutic effects based on an improved 6MWT distance of 39 meters and a change of 23%, respectively. These findings, in conjunction with improvement in other markers of disease activity, lead to approval of cardiac resynchronization for the management of HF. Our primary objective was to determine the impact of chemotherapy on changes in 6MWT in patients with AL cardiac amyloid and correlate these changes with cardiac biomarkers. Patients and Methods: We retrospectively analyzed outcomes of 22 AL amyloid patients with cardiac involvement. Subjects performed 6MWT at diagnosis and at the end of planned initial chemotherapy. All patients received bortezomib (B)-based chemotherapy. About half received chemotherapy alone (45%) and the others received B-based induction chemotherapy followed by AHCT (55%). To identify factors associated with changes in 6MWT, we analyzed cardiac response and changes in New York Heart Association (NYHA) class, troponin I, brain natriuretic peptide (BNP) and left ventricular ejection fraction (LV EF). Cardiac response was defined as BNP decrease of 30% or NYHA class decrease ≥ 2 in subjects with baseline NYHA class 3 or 4 (adapted from Comenzo, 2012). Results: At baseline, 59% (n=13) of patients were modified AL amyloid cardiac stage I/II and 41% (n=9) stage III. The median percent change in 6MWT was an increase in 26.5% with a median change of 90 meters (range, -120 to 365), p < 0.001. Overall, 81% (n=18) had improvement in 6MWT distance, 9% (n=2) declined and 9% (n=2) were unchanged. Patients had reassessment of 6MWT a median of 13.5 months from diagnosis. Hematological responses (HR) included CR (36%), VGPR (36%), PR (23%) and SD (5%). HR was not associated with change in 6MWT. Fifty percent (n=11) experienced a cardiac response. By Wilcoxon rank sum test, variables that were associated with improvement in 6MWT included improved BNP, LV EF, troponin I, NYHA class and cardiac response (all p By multivariate analysis, patients with a cardiac response had significantly better improvement in 6MWT disease compared with patients without cardiac response (p=0.02). A cardiac response was associated with a median increase of 170 meters of distance traveled by 6MWT when compared with patients having no cardiac response. All other variables tested were not statistically significant. Conclusion: In AL amyloid patients with cardiac involvement, the 6MWT can be used as an objective marker of functional improvement complementing biochemical and imaging parameters of response. Furthermore, treatment of cardiac amyloidosis with contemporary standard regimens has a major impact on the disease process by a number of objective parameters. Patients experiencing a cardiac response had substantial improvements in 6MWT. The 6MWT should be incorporated in trials of patients with cardiac amyloid. Disclosures Cornell: Prothena: Research Funding.

e19539 Background: Light chain amyloidosis (AL) is characterized by the accumulation of misfolded proteins that deposit in tissue causing multisystem organ dysfunction. Current treatments target pl...