IMscin001 Part 2: a randomised phase III, open-label, multicentre study examining the pharmacokinetics, efficacy, immunogenicity, and safety of atezolizumab subcutaneous versus intravenous administration in previously treated locally advanced or metastatic non-small-cell lung cancer and pharmacokinetics comparison with other approved indications

BACKGROUND

Atezolizumab intravenous (IV) is approved for the treatment of various solid tumours. To improve treatment convenience and health care efficiencies, a coformulation of atezolizumab and recombinant human hyaluronidase PH20 was developed for subcutaneous (SC) use. Part 2 of IMscin001 (NCT03735121) was a randomised phase III, open-label, multicentre, noninferiority study comparing the drug exposure of atezolizumab SC with atezolizumab IV.

PATIENTS AND METHODS

Eligible patients with locally advanced/metastatic non-small-cell lung cancer were randomised 2 : 1 to receive atezolizumab SC (1875 mg; n = 247) or IV (1200 mg; n = 124) every 3 weeks. The co-primary endpoints were cycle 1 observed trough serum concentration (Ctrough) and model-predicted area under the curve from days 0 to 21 (AUC0-21 d). The secondary endpoints were steady-state exposure, efficacy, safety, and immunogenicity. Exposure following atezolizumab SC was then compared with historical atezolizumab IV values across approved indications.

RESULTS

The study met both of its co-primary endpoints: cycle 1 observed Ctrough {SC: 89 μg/ml [coefficient of variation (CV): 43%] versus IV: 85 μg/ml (CV: 33%); geometric mean ratio (GMR), 1.05 [90% confidence interval (CI) 0.88-1.24]} and model-predicted AUC0-21 d [SC: 2907 μg d/ml (CV: 32%) versus IV: 3328 μg d/ml (CV: 20%); GMR, 0.87 (90% CI 0.83-0.92)]. Progression-free survival [hazard ratio 1.08 (95% CI 0.82-1.41)], objective response rate (SC: 12% versus IV: 10%), and incidence of anti-atezolizumab antibodies (SC: 19.5% versus IV: 13.9%) were similar between arms. No new safety concerns were identified. Ctrough and AUC0-21 d for atezolizumab SC were consistent with the other approved atezolizumab IV indications.

CONCLUSIONS

Compared with IV, atezolizumab SC demonstrated noninferior drug exposure at cycle 1. Efficacy, safety, and immunogenicity were similar between arms and consistent with the known profile for atezolizumab IV. Similar drug exposure and clinical outcomes following SC and IV administration support the use of atezolizumab SC as an alternative to atezolizumab IV.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Background

Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods

This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results

Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion

The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

P–383 Cytogenetic analysis of products of conception from miscarriages following natural conception and IVF pregnancy: a comparative study

Study question

Do cytogenetic results from products of conception from miscarriages differ from patients conceiving by natural conception versus IVF? Summary answer: Cytogenetic results were similar, with no statistical difference from miscarriages following natural conception and assisted conception.

What is known already

Cytogenetic sampling of products of conception (POC) following recurrent miscarriages (RM) are recommended to rule out parental chromosomal rearrangements. The RCOG recommends cytogenetic testing in cases of recurrent miscarriages (3 consecutive miscarriages). However some units routinely request cytogenetic analysis following a single miscarriage following an IVF pregnancy. There is no evidence to support the routine sampling of POCs following assisted conception. Study design, size, duration: Retrospective cohort study of 117 cytogenetic samples, followed up by the outcome of parental karyotyping if applicable. Patients were categorised based on mode of conception into natural conception (NC) with recurrent miscarriages (≥3) or one miscarriage following IVF. Data collected between 2018–2020. Primary Outcome measure: Presence and type of cytogenetic abnormality; individual parental targeted G-band karyotyping result. Participants/materials, setting, methods: A total of 117 cytogenetic results were reviewed, of which 35 were unsuitable for analysis due to contamination (Total n = 79: NC = 60, IVF = 19). Main results and the role of chance: Cytogenetic analysis showed abnormal results in 59% of miscarriages following natural conception and 53% of miscarriages from IVF pregnancy (p = 0.46).

Abnormal cytogenetic results were mainly sporadic. Trisomy 16 was the commonest abnormality in both groups. Others included Trisomy 15, 22, 21, 8, 13, 5, 9, 10, 14, 18, single X (Turner’s), all occurring in the same frequency in both groups. As expected 35 out of 45 abnormal cytogenetic results occurred with a maternal age greater than 35 years.

One couple from the NC group were referred to a geneticist for a Trisomy 9 imbalance. All other parental karyotyping results were normal.

Limitations, reasons for caution

This study contains a small sample size, and would benefit from further data collection to account for a percentage of samples being inadequate for analysis. Wider implications of the findings: Cytogenetic results were similar from miscarriages following natural conception and assisted conception. IVF does not increase the risk of miscarriage from abnormal embryonic karyotype. Routine cytogenetic testing following one miscarriage in patients undergoing IVF is not cost effective.

Trial registration number

Not applicable

Molecular response of a sub-antarctic population of the blue mussel (Mytilus edulis platensis) to a moderate thermal stress

The Kerguelen Islands (49°26'S, 69°50'E) represent a unique environment due to their geographical isolation, which protects them from anthropogenic pollution. The ability of the endemic mussel, part of the Mytilus complex, to cope with moderate heat stress was explored using omic tools. Transcripts involved in six major metabolic functions were selected and the qRT-PCR data indicated mainly changes in aerobic and anaerobic energy metabolism and stress response. Proteomic comparisons revealed a typical stress response pattern with cytoskeleton modifications and elements suggesting increased energy metabolism. Results also suggest conservation of protein homeostasis by the long-lasting presence of HSP while a general decrease in transcription is observed. The overall findings are consistent with an adaptive response to moderate stresses in mussels in good physiological condition, i.e. living in a low-impact site, and with the literature concerning this model species. Therefore, local blue mussels could be advantageously integrated into biomonitoring strategies, especially in the context of Global Change.

A Systematic Review Of Primary Ankle Arthrodesis In The Treatment Of Pilon Fractures

BACKGROUND

Pilon fractures are severe, intra-articular and comminuted fractures to the distal tibia. They are uncommon injuries and are often associated with fibular fractures. The optimal management of these fractures is widely debated. Open reduction and internal fixation (ORIF) and external fixation have been used to treat these fractures. Ankle arthrodesis is often used in the latter stages of management for end-stage ankle arthritis. The aim of this systematic review was to identify the outcomes associated with using primary ankle arthrodesis in pilon fractures.

METHODS

Ovid Medline and PubMed were searched from the inception of their databases until October 2018. Eligible literature for use in our review included patient cohorts that had been operated in the form of primary ankle arthrodesis. All relevant data was included that met the inclusion criteria. The demographic of the patients with pilon fractures and this operative management were identified. The outcomes of interest were fusion rate, infection rate, length of follow-up and patient reported outcomes. 8 papers were deemed eligible for review.

RESULTS

Of the 8 papers that were eligible, 6 were retrospective studies, 1 was a case report and 1 was an abstract. There were a total of 109 patients included. Fusion rate was 100% in 5 of the studies. 6 of the 7 studies that reported on infection rate had no post-operative infections. Outcome assessment scores were used in 5 of the studies. The SF-36 score, the FOAS and the AOFAS were used.

CONCLUSIONS

This review shows that primary ankle arthrodesis yields reasonable results in the management of pilon fractures. However, the quantity and quality of current literature is not sufficient and further studies with larger cohorts and longer follow-up times are warranted.

Clinical and laboratory impact of concomitant syphilis infection during acute HIV

INTRODUCTION

Cognitive impairment has been reported in people living with HIV-1 (PLWH) with prior syphilis, while PLWH who present with incident syphilis have reduced blood CD4 T-lymphocyte and elevated HIV-1 RNA levels. However, the clinical, virological and neurocognitive effects of syphilis during acute HIV-1 (AHI) remain unknown.

METHODS

Pre-antiretroviral therapy laboratory outcomes and neurocognitive performance in a four-test battery in the SEARCH10/RV254 AHI cohort were compared according to syphilis status, determined by serum Treponema pallidum haemagglutination (TPHA), Venereal Disease Research Laboratory (VDRL) and syphilis treatment history. Impaired cognitive performance was defined as having z-scores ≤ -1 in at least two tests or ≤ -2 in at least one test.

RESULTS

Out of 595 AHI participants (97% male, median age of 26 years and estimated duration of HIV-1 infection of 19 days), 119 (20%) had history of syphilis (TPHA-positive), of whom 51 (9%) had untreated syphilis (TPHA-positive/VDRL-positive/without prior treatment). Compared with those without syphilis (TPHA-negative), individuals with untreated syphilis had higher CD8 T-lymphocyte levels but not higher plasma HIV-1 RNA or lower CD4 T-lymphocyte levels. Taking into account estimated duration of HIV-1 infection (P < 0.001), and later Fiebig stages (III-V) (P < 0.001), those with untreated syphilis had higher CD8 T-lymphocyte levels (P = 0.049). Individuals with any syphilis (TPHA-positive), but not untreated syphilis, had higher odds of impaired cognitive performance than those without (P = 0.002).

CONCLUSIONS

During AHI, individuals with any history of syphilis (TPHA-positive) had poorer cognitive performance than those without syphilis. However, syphilis was not associated with worsened HIV disease measures as described in chronic infection.

Apolipoprotein E Polymorphism and Frailty: Apolipoprotein ε4 Allele Is Associated with Fatigue but Not Frailty Syndrome in a Community-Dwelling Older Population Cohort

OBJECTIVE

Frailty is known to be influenced by genetics, however, little evidence on the association of Apolipoprotein E (ApoE) genotype and frailty exists which we aim to investigate.

DESIGN

This study is a cross-sectional analysis from a prospective longitudinal study cohort.

SETTING AND PARTICIPANTS

Community-dwelling individuals aged 55 years and older from Beijing region in China.

MEASUREMENTS

A total of 3,569 older adults with a mean age of 75.06(±6.79) years were included. We investigated the association between ApoE polymorphism and frailty syndrome using the frailty index (FI) and frailty phenotype (including association with individual components of the frailty phenotype). Logistic regressions were performed to investigate the relation between ApoE variants and frailty.

RESULTS

There was no significant association between ApoE variants and frailty as assessed by the FI. In the age and sex-adjusted model, compared to the ApoE e3/e3 carriers ApoE e4 carriers had almost 1.5 times higher odds of being frail as assessed by the frailty phenotype. However, the significance was lost on the model with adjustment for cognitive impairment. Compared to the ApoE e3/e3 carriers ApoE e4 carriers had almost two times higher odds of fatigue. ApoE e4 heterozygotes had higher odds of fatigue compared to ApoE e4 non-carriers. No significant association was found between ApoE variants and other components of frailty phenotype.

CONCLUSIONS

Our findings do not support an association between ApoE genotype and frailty irrespective of the frailty assessment tools. Fatigue in older adults is the only component of frailty phenotype influenced by ApoE genotype.

Intrinsic Capacity as a Determinant of Physical Resilience in Older Adults

The traditional disease-oriented model of healthcare is inadequate to address the needs of the older population. Greater attention should be given to strategies that promote healthy aging. Recently proposed constructs of intrinsic capacity (IC) and physical resilience (PR) hold great potential to reshape geriatric medicine and aging research. These constructs accentuate the positive health attributes of older people in contrast to the popular frailty construct that is centered on functional deficits. IC was introduced by the World Health Organization (WHO) as a composite of all the physical and mental capacities. WHO has emphasized enhancement of IC throughout the life course so as to maintain functional ability in old age. PR, recently highlighted by the National Institute on Aging, is the ability to successfully cope with stressors. High levels of resilience can result in desirable clinical and functional outcomes after stressors. Therefore, it is important to understand the underlying physiology of PR and the risk factors contributing to diminished PR. The main goal of this article is to explore the potential relationship between IC and PR. Based on a classical theory of aging, we postulate that IC is a determinant of PR and is also a high-level integrative measure of physiologic reserve which is the fundamental factor underlying one's ability to withstand stressors. A major implication of our postulates is that even though IC is only one of the many determinants of PR, it could serve as an important intervenable target for enhancing resilience in older adults.

Frailty in China: From Research to Practice

Although geriatric research in general has increased in recent years, there is no effective treatment for frailty. Among older adults, those with frailty have an increased risk of falls, disability, and death. The population of older adults has increased rapidly in China, and resulting in an increased demand for medical care services for older adults, including those with frailty. However, much of the research on frailty has been conducted in Europe and the United States, and European and American standards for frailty are not always applicable to Chinese individuals. Clinicians and researchers in China have shown increasing interest in frailty in recent years. Here, we reviewed the current state of frailty research in China.

Association of acute resuscitation and post-resuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest

Background

Although survival for in-hospital cardiac arrest (IHCA) varies markedly across sites, it remains unknown whether high survival at top-performing hospitals is due to high rates of acute resuscitation survival (i.e., achievement of return of spontaneous circulation [ROSC]), post-resuscitation survival (i.e., survival to discharge among patients who achieved ROSC), or both.

Methods

Using 2015–2018 Get With The Guidelines (GWTG)-Resuscitation data, we identified 290 hospitals (86,426 patients) with IHCA. For each hospital, we calculated overall risk-standardized survival (RSSR) to discharge for IHCA using a previously validated hierarchical regression model and categorized hospitals into quartiles based on that metric. Risk-adjusted rates of acute resuscitation survival (defined as return of spontaneous circulation for &gt;20 minutes [ROSC]) and post-resuscitation survival (defined as the proportion of patients achieving ROSC who survived to hospital discharge) were also computed for each hospital. We examined the correlation between a hospital's overall RSSR with its risk-adjusted rate of acute resuscitation and post-resuscitation survival.

Results

Among study hospitals, the median RSSR was 25.1% (inter-quartile range [IQR]: 21.9%–27.7%). The median risk-adjusted rate of acute resuscitation survival was 72.4% (IQR: 67.9%–76.9%) and post-resuscitation survival was 34.0% (IQR: 31.5%–37.7%). Hospital rates of RSSR were less strongly correlated with risk-adjusted rates of acute resuscitation survival (rho=0.50, P&lt;0.001) than post-resuscitation survival (rho=0.90, P&lt;0.001). Compared with hospitals in the lowest quartile of RSSR, hospitals in the highest quartile had substantially higher rates of acute resuscitation survival (Q4: 75.4% vs. Q1: 66.8%; P&lt;0.001) and post-resuscitation survival (Q4: 40.3% vs. Q1: 28.7%; P&lt;0.001). Notably, there was no correlation between hospital risk-adjusted rates of acute resuscitation survival and post-resuscitation survival (rho=0.09, P=0.11).

Conclusion

Hospital that excel in overall IHCA survival in general excel in either acute resuscitation or post-resuscitation care. As most hospital-based quality improvement initiatives largely focus on acute resuscitation survival, our findings suggest that efforts to strengthen post-resuscitation care may offer additional opportunities to improve IHCA survival.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): NHLBI

Elevated GDF-15 levels may indicate malnutrition in chronic compensated heart failure with or without diabetes mellitus

Background/Introduction

Malnutrition is common in chronic heart failure (HF) and is associated with adverse outcomes. Elevated NT-proBNP may indicate increased cardiac stress, whereas growth differentiation factor 15 (GDF-15) is increased in response to tissue injury, inflammation and in diabetes mellitus (DM). GDF-15 also negatively regulates appetite, body weight and skeletal muscle homeostasis.

Purpose

We aim to assess the nutritional status of HF patients with or without DM, and determine if GDF-15 is associated with malnutrition.

Methods

We did a cross-sectional analysis on chronic HF patients in a prospective cohort study, forecAsting Heart Failure decompensation (AHF). Chronic compensated HF was defined as a state following hospital discharge for &gt;30 days, or where there had not been hospitalisation for 30 days preceding phenotyping. Patients with a history of HF decompensation were included. Geriatric Nutritional Risk Index (GNRI), including body mass index (BMI) and serum albumin, was used to assess and categorise nutritional status. Patients were classified as being “malnourished” or “well-nourished” based on GNRI scores of &lt;92 and ≥92, respectively. NT-proBNP and GDF-15 levels were measured and echocardiography was done. The study was approved by institutional review board and complied with Declaration of Helsinki.

Results

Among 73 patients (mean age 66 y, 58.9% male), 32.7% exhibited malnutrition as determined by GNRI. There was no difference in age, sex ratio and NYHA functional class between the malnourished and the well-nourished. BMI (22.1 vs 25.6, P&lt;0.001) and levels of GDF-15 (7216.0 vs 2469.0, P&lt;0.001) and NT-proBNP (7158.0 vs 1321.0, P=0.01) were different between the malnourished and well-nourished. Both GDF-15 and NT-proBNP were inversely correlated with GNRI (GDF-15, r=−0.39, P&lt;0.001; NT-proBNP, r=−0.46, P&lt;0.0001). As expected, DM HF patients had significantly higher levels of GDF-15 than non-DM HF patients. In subgroup analysis of DM HF patients, GDF-15 and NT-proBNP levels were higher in the malnourished than well-nourished (median log-[GDF-15], 9.15 vs 8.10, P&lt;0.01; median log-[NT-proBNP], 9.44 vs 7.00, P&lt;0.01). Whereas in non-DM HF, NT-proBNP levels were not different between the malnourished and well-nourished. Age- and sex-adjusted logistic regression model determined that per log increment in GDF-15 level there was a 5.8-fold increased risk of malnutrition (OR 5.81 [2.43–17.62], P&lt;0.001), and for every log increment in NT-proBNP level there was a 1.8-fold increase in the risk of malnutrition (OR 1.82 [1.23–2.88], P&lt;0.01).

Conclusion(s)

Malnutrition is common in chronic compensated HF patients with a history of hospitalisation, and is associated with elevated NT-proBNP and GDF-15 levels. Elevated GDF-15 levels independently predicted poor nutritional status, and with NT-proBNP may indicate a particularly high-risk HF subgroup

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): 1) Health and Medical Research Fund, Food and Health Bureau, 2) Direct Grant, Faculty of Medicine, CUHK

Report from the First Clinical Trials on Alzheimer's Disease (CTAD) Asia-China 2018 : Bringing together Global Leaders

Population of older adults in Asia, and particularly in China is increasing rapidly. Older population are at increased risk of Alzheimer's disease (AD) and other dementias. Soon, the Chinese population with AD will represent almost half of the world's AD population. There is a desperate need of disease modifying therapies to delay or slow the progression of AD, to tackle this emerging healthcare emergency. In this context, the first CTAD Asia-China conference was held in China to bring together Western and Asian leaders in AD. This meeting focused largely on how to develop successful trials in China, utilizing past experiences from the West.

The Prevalence and Clinical Characteristics of Essential Tremor in Elderly Chineses: A Population-Based Study

OBJECTIVES

To investigate the prevalence and the clinical feature of essential tremor (ET) in a community cohort in Beijing.

METHODS

Using a door-to-door, two-phase approach, we investigated 2,835 residents aged ≥55 years old from rural, urban, and mountain areas.

RESULTS

The prevalence rate of ET was 4.29%, 2.85%, and 2.29% in rural, urban, and mountain areas, respectively. The overall age- and sex-adjusted prevalence was 3.29%. Among those aged ≥75 years, the prevalence rate in the urban area was higher than those in the rural and mountain areas. The prevalence rate increased with age, and the prevalence was higher among men (6.0%) than among women (3.6%). There was a correlation of ET prevalence with age, sex, and habitation area, but not with alcohol, tea drinking, and occupation. Women (25%) with ET were more likely to have head tremor than men (16.9%).

CONCLUSIONS

The ET prevalence in the elderly of Beijing was 3.29% which is higher in the urban area and in men.