P3769Rapid referral to a one-stop AF clinic following possible AF detection by community pharmacists leads to early diagnosis and appropriate anticoagulant treatment

Background

Atrial fibrillation is the most common cardiac arrhythmia globally, responsible for one third of ischaemic strokes, often resulting in death or incapacity. This condition, frequently asymptomatic is estimated to be up to 50% undiagnosed. Reducing this risk with appropriate detection and management strategies offers substantial economic and patient benefits. Community pharmacists have been shown to be an accessible healthcare professional capable of detecting atrial fibrillation. Concerns raised utilising community pharmacists is the additional workload for primary care physicians, and lack of a clear pathway to ensure patients are adequate followed with assurance of initiation of anticoagulation therapy.

Purpose

To assess the feasibility of screening by community pharmacists with onward referral to an innovative one-stop AF clinic to enable identification of new cases of AF and subsequent initiation of anticoagulation within 2 weeks.

Methods

21 pharmacies were recruited and trained on pathophysiology of AF and demonstration of pulse taking using pulse check and Kardia mobile device. Any person walking into a community pharmacy aged ≥65 years was offered a free pulse check. For any irregularity detected, individualised counselling was offered with a referral made to a one-stop AF clinic for confirmation and initiation of anticoagulation. Written patient consent was obtained.

Results

672 people were recruited with an average age of 69±3.5 years and 58% female (n=389). There was a history of hypertension in 618 (92%) and diabetes in 242 (36%), the most common co-morbidities. 45 people were referred following an irregular pulse or abnormal ECG rhythm strip, of whom 11 (1.6% of total population) had a confirmed AF diagnosis within 30 day follow up. An additional 8 cases with known AF not receiving anticoagulation termed (actionable AF) were also referred. All 19 cases of new or untreated AF were prescribed anticoagulation by the one stop clinic in accordance with guideline recommendations

Conclusions

ESC guidance recommends opportunistic screening for AF by pulse taking or ECG rhythm strip in patients ≥65 years of age. The 1.6% incidence of new AF was in accordance with meta-analyses identifying 1.4% of those aged ≥65 on a single time point check for presence of AF. Our model utilises the un-tapped skills of community pharmacy to deliver pulse checks of ECG rhythm recordings in an accessible primary care location with a clear referral pathway that is effective in early review and ensuring suitable patients receive anticoagulation. The innovative pathway could provide remote triage at scale and help address the missing people with undiagnosed and actionable AF by opening new channels for identification by healthcare professionals managing long term conditions who like pharmacists have not been considered suitable healthcare professionals due to lack of an established pathway for confirming the potential diagnosis of AF.

Acknowledgement/Funding

NHS England Test Bed Programme

No stone unturned: Nodule Net, an intervention to reduce loss to follow-up of lung nodules

OBJECTIVE

Inadequate lung nodule surveillance leads to diagnostic delays. We implemented a retrospective intervention program, Nodule Net, to improve surveillance in our hospital.

METHODS

9,224 Chest computed tomography (CT) scans between January 1, 2015 and December 31, 2016 were manually reviewed for lung nodules. For patients without follow-up, charts were reviewed to assess follow-up. If follow-up appeared indicated, the clinician or patient was contacted, and follow-up was tracked.

RESULTS

Lung nodules were identified on 5,101 (55%) of 9,224 scans. Follow-up was potentially indicated and not completed in 1,385 (27%). 183 (13%) were excluded after imaging review. 1,202 received outreach. Of the 801 (66%) with a provider in our system, 225 (27%) returned for follow-up. Nodules were stable in 199 (88%), new or growing in 23 (11%), resolved in 3 (1%), and stage 1 lung cancer in 2 (1%). 90 (11%) had follow-up outside our system and 431 (51%) had no follow-up due to a clinical contraindication. 55 (7%) have imaging pending and 14 (2%) are awaiting pulmonary evaluation. Of the 302 (25%) patients with providers outside our system, 121 (40%) had followed-up elsewhere. 146 (48%) had no follow-up due to a clinical reason. 35 (12%) providers did not respond to outreach.

CONCLUSIONS

We identified 1,202 patients with lung nodules who needed follow-up over a two-year period. Compliance was more successful with providers within our hospital system. We recommend robust surveillance for patients to ensure follow-up is completed and clinical contraindications are well documented.

Prevalence and risk factors for Enterobacteriaceae in patients hospitalized with community‐acquired pneumonia

BACKGROUND AND OBJECTIVE

Enterobacteriaceae (EB) spp. family is known to include potentially multidrug-resistant (MDR) microorganisms, and remains as an important cause of community-acquired pneumonia (CAP) associated with high mortality. The aim of this study was to determine the prevalence and specific risk factors associated with EB and MDR-EB in a cohort of hospitalized adults with CAP.

METHODS

We performed a multinational, point-prevalence study of adult patients hospitalized with CAP. MDR-EB was defined when ≥3 antimicrobial classes were identified as non-susceptible. Risk factors assessment was also performed for patients with EB and MDR-EB infection.

RESULTS

Of the 3193 patients enrolled with CAP, 197 (6%) had a positive culture with EB. Fifty-one percent (n = 100) of EB were resistant to at least one antibiotic and 19% (n = 38) had MDR-EB. The most commonly EB identified were Klebsiella pneumoniae (n = 111, 56%) and Escherichia coli (n = 56, 28%). The risk factors that were independently associated with EB CAP were male gender, severe CAP, underweight (body mass index (BMI) < 18.5) and prior extended-spectrum beta-lactamase (ESBL) infection. Additionally, prior ESBL infection, being underweight, cardiovascular diseases and hospitalization in the last 12 months were independently associated with MDR-EB CAP.

CONCLUSION

This study of adults hospitalized with CAP found a prevalence of EB of 6% and MDR-EB of 1.2%, respectively. The presence of specific risk factors, such as prior ESBL infection and being underweight, should raise the clinical suspicion for EB and MDR-EB in patients hospitalized with CAP.

Abstract P4-13-03: Elacestrant (RAD1901) demonstrates anti-tumor activity in models resistant to CDK4/6 inhibitors

Background: Approximately 75% of all breast cancers diagnosed are estrogen receptor-positive (ER+) and currently approved endocrine therapies rely heavily on blocking of the ER signaling pathway. In recent years, the combination of an endocrine agent with other targeted agents have been evaluated to address endocrine resistance and improve progression-free survival (PFS). Recently, it was demonstrated that the addition of a cyclin-dependent kinase 4/6 (CDK4/6) inhibitor to an endocrine agent roughly doubles PFS, leading to the approval and use of certain CDK4/6 inhibitors in combination with either aromatase inhibitors in the first-line metastatic setting or in combination with the selective estrogen receptor degrader (SERD), fulvestrant, in the second-line metastatic setting. While combining CDK4/6 inhibitors and endocrine therapy can result in significantly increased PFS, patients eventually progressed on these combinations, and to date, there is no cure for patients with advanced metastatic ER+ breast cancer. Given the increased use of CDK4/6 inhibitors in the ER+ breast cancer treatment paradigm, it will be important to understand how treatment resistance to CDK4/6 inhibitors manifests in order to optimize therapeutic strategies to target this patient population. We have previously described elacestrant (RAD1901), a novel and orally bioavailable SERD, as an inhibitor of ER+ breast cancer growth in in vitro models and in in vivo patient-derived xenograft (PDX) models. Importantly, elacestrant inhibited the growth of PDX models that were derived from heavily pretreated patients, models harboring mutations in ESR1, and models insensitive to standard of care endocrine therapies. Given these results, we hypothesized that elacestrant would have anti-tumor activity in a CDK4/6 inhibitor-resistant setting. Herein, we describe elacestrant activity in multiple in vitro and in vivo models of CDK4/6 inhibitor resistance in both wild-type and mutant ESR1 backgrounds.

Methods: In vitro models of estrogen-independent ER+ breast cancer, harboring either wild-type or mutant ER, were exposed to increasing concentrations of approved CDK4/6 inhibitors: palbociclib, ribociclib, or abemaciclib. ER expression/signaling, changes in cell cycle mediators, and the effects of elacestrant and other SERDs were examined in these representative models.

Results: Despite prolonged exposure to CDK4/6 inhibitors, the resistant cell lines retained ER, ER signaling, and importantly, ER-driven proliferation. Elacestrant induced dose-dependent growth inhibition in CDK4/6 inhibitor-resistant cells, and this effect was independent of the CDK4/6 inhibitor used to generate resistance. Elacestrant also demonstrated in vivo tumor growth inhibition of CDK4/6 inhibitor-resistant ER+ PDX models.

Conclusions: Our preclinical data demonstrate that elacestrant is a SERD that can inhibit tumor growth in a CDK4/6 inhibitor-resistant setting and provides rationale for examining elacestrant in patients that have progressed on a combination of endocrine therapy with a CDK4/6 inhibitor.

Citation Format: Patel H, Tao N, Arlt H, Bihani T. Elacestrant (RAD1901) demonstrates anti-tumor activity in models resistant to CDK4/6 inhibitors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-13-03.

Abstract P6-20-08: Anti-tumor activity of elacestrant (RAD1901) in models harboring ESR1 mutations resistant to standard of care therapies

Background: Estrogen receptor positive (ER+) breast cancers make up approximately 75% of all breast cancers diagnosed and ER, a protein encoded by the ESR1 gene, plays a major role in the initiation, growth and survival of these cancers. Current targeted therapies inhibit the ER pathway by either blocking the synthesis of the natural ligand of ER, estradiol, (aromatase inhibitors (AI)), or by antagonizing and/or degrading the receptor (selective estrogen receptor modulators (SERMs) and selective estrogen receptor degraders (SERDs)). AIs are used in both the adjuvant and metastatic setting and recent clinical reports have shown that 20-50% of patients that had received AI therapy had detectable mutations in the ER ligand binding domain (ER-LBD). Two frequently found point mutations in the ER-LBD, Y537S and D538G, have been shown to result in estradiol-independence and constitutive activation of ER, consistent with their ability to cause resistance to AIs. While the selection of ESR1 mutations post-AI has been demonstrated clinically, the clinical response of ESR1 mutant tumors to fulvestrant, an approved SERD, is not fully understood. Preclinical studies have suggested that ESR1 mutations can cause decreased binding and a corresponding decrease in potency of ER antagonists, including fulvestrant (SERD) and tamoxifen (SERM). Conversely, clinical data from the SoFEA, PALOMA-3, and FERGI trials suggested the presence of ESR1 mutations did not alter fulvestrant activity. The limited clinical data that exists, however, is based on retrospective study designs with relatively small data sets, making it difficult to accurately predict fulvestrant activity against specific mutations and the activity of fulvestrant against tumors that harbor multiple mutations. In fact, recent additional data from the PALOMA-3 trial suggests that the Y537S mutation, specifically, was selected out in clinical samples from patients treated with fulvestrant, more closely matching preclinical results. This suggests there may be certain contexts of ESR1 mutations where fulvestrant may have limited activity. It will be important to further understand the consequence of specific mutations and to utilize therapies that have activity against all ESR1 mutations. We have previously described elacestrant (RAD1901), a novel orally bioavailable SERD, that exhibited activity in multiple ER+ breast cancer models. Interestingly, elacestrant exhibited similar effects to fulvestrant in in vitro ESR1 mutant models, however, in some in vivo PDX models harboring the Y537S mutation elacestrant inhibited growth, while fulvestrant had limited activity. Here, we describe a more complete in vivo dataset describing elacestrant activity versus fulvestrant in multiple patient-derived xenograft (PDX) models harboring ESR1 mutations.

Methods: Multiple PDX models harboring natural mutations in ESR1 or genetically-engineered CRISPR models were used to assess the anti-tumor efficacy and the pharmacokinetic/pharmacodynamic properties of elacestrant and fulvestrant.

Results: Elacestrant significantly inhibited the growth of xenograft models harboring ESR1 mutations, including those harboring Y537S or D538G mutations and models that were insensitive to fulvestrant and tamoxifen.

Citation Format: Patel H, Tao N, Arlt H, Bihani T. Anti-tumor activity of elacestrant (RAD1901) in models harboring ESR1 mutations resistant to standard of care therapies [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-20-08.

A rare presentation of angioedema with isolated retropharyngeal and supraglottic involvement

Angiotensin converting-enzyme (ACE) inhibitors are commonly prescribed drugs with multiple indications including congestive heart failure, hypertension, and diabetic nephropathy. ACE inhibitor induced angioedema is commonly seen across emergency departments and clinics, with transient swelling of lips, tongue, and other facial structures being the common presentation. Isolated airway obstruction as a result of pharyngeal and laryngeal swelling without facial swelling is a rare presentation. We present a case of a patient on lisinopril therapy for one year who experienced severe airway compromise without the classic symptoms of ACE inhibitor induced angioedema. He required emergent cricothyroidotomy to secure his airway, as fiberoptic laryngoscopy showed 90% obstruction and inability to visualize true vocal cords. His ACE inhibitor therapy was discontinued, and he was discharged home within a few days with no residual symptoms.

Mind the gap: 11 years of train-related injuries at the Royal London Hospital Major Trauma Centre

Introduction This study presents an extensive retrospective database of patients with polytrauma following train-related injuries and highlights the key lessons learnt in this rare clinical presentation. Materials and methods We retrospectively collected data from 127 patients who presented to Royal London Hospital after sustaining train related trauma. We analysed demographics, accident report data, aetiologies and clinical management interventions. All data were screened and injuries were mapped to various anatomical regions. The revised trauma score, injury severity score and new injury severity scores were used to quantify injury extent. Results Mean patient age was 41 years (range 16-81 years) with a 73% to 27% male to female ratio. Deliberate injuries occurred in 71% of patients, with accidental injury accounting for 29%. The mean new injury severity score was 26.48 (range 1-75), with the most common injuries sustained to the chest and the extremities. Pneumothorax, haemothorax or tension pneumothorax occurred in 44% of patients, with 11% suffering a flail chest injury. Traumatic amputations occurred in 33% of patients and 56% of patients required admission to intensive care. Total mortality rates were 19%, with 12% of patients dying at day 0 and 18% at day 7, respectively. Conclusions This study demonstrated the significant impact of train-related polytrauma and provided a comprehensive injury patterns. It was observed that deliberate polytrauma is related to psychiatric deliberate harm but there is no significant difference in the patterns of injuries between accidental and deliberately caused injuries. Overall injuries to the thorax and extremities were the most severe, demonstrating the highest mean injury scores.