FDA Approval Summary: Ivosidenib in Combination with Azacitidine for Treatment of Patients with Newly Diagnosed Acute Myeloid Leukemia with an IDH1 Mutation

On May 25, 2022, FDA approved a supplemental application for ivosidenib (Tibsovo; Servier) extending the indication in patients with newly diagnosed IDH1-mutated acute myeloid leukemia (AML) in older adults or those with comorbidities to include the combination with azacitidine. The efficacy of ivosidenib in combination with azacitidine was evaluated in Study AG120-C-009, a phase 3, multicenter, double-blind, randomized (1:1), controlled study of ivosidenib or matched placebo in combination with azacitidine in adults with previously untreated AML with an IDH1 mutation who were 75 years or older or had comorbidities that precluded use of intensive induction chemotherapy. Efficacy was established on the basis of improved event-free survival and overall survival on the ivosidenib + azacitidine arm [HR, 0.35; 95% confidence interval (CI), 0.17-0.72; P = 0.0038, and HR, 0.44; 95% CI, 0.27-0.73; P = 0.0010], respectively. Furthermore, the rate and duration of complete remission (CR) were improved with ivosidenib versus placebo [CR 47% versus 15%, two-sided P < 0.0001; median duration of CR not estimable (NE; 95% CI, 13.0-NE) months versus 11.2 (95% CI, 3.2-NE) months. The safety profile of ivosidenib in combination with azacitidine was consistent with that of ivosidenib monotherapy, with important adverse reactions including differentiation syndrome (15%) and QT interval prolongation (20%).

SPiRIT study protocol (Shoulder Pain: Randomised trial of Injectable Treatments): a randomised feasibility and pilot study of autologous protein solution (APS) vs corticosteroids for treating subacromial shoulder pain

BACKGROUND

The management of subacromial shoulder pain represents a significant challenge and is typically managed through either physiotherapy, joint injection or surgical intervention. Recent surgical trials have questioned the efficacy and there is a need to improve the evidence base for the non-surgical management of this condition. The study aims to provide evidence of the feasibility of conducting a randomised controlled trial to compare the efficacy of autologous protein solution (APS) against the current standard of care, corticosteroid injection (CSI) for subacromial shoulder pain. Autologous protein solution (APS) is a blood-derived biological injection which has been shown to have anti-inflammatory effects.

METHODS

A parallel-group two-arm randomised control trial will be conducted, comparing APS and CSI for shoulder pain. Fifty patients will be recruited. Feasibility will be assessed by examination of the conversion rate of eligible participants to the total number of participants recruited, whether it is possible to collect the appropriate outcome measures and the levels of retention/data compliance at follow-up dates.

DISCUSSION

CSI is the mainstay of conservative management of subacromial shoulder pain. Trials and systematic reviews have reported differing conclusions, but the consensus view is that any benefits seen from CSI use are most likely to be short-term and there remains a significant number of patients who go on to have surgical intervention despite CSI. Biological injections, such as APS are being increasingly used, in the anticipation they may offer improved longer lasting outcomes for shoulder pain. However, the evidence to demonstrate the comparative efficacy of CSI versus APS does not currently exist. If feasible, a fully powered study will offer clarity to the treatment pathway of thousands of patients each year with subacromial pain.

TRIAL REGISTRATION

The study is funded by the National Institute for Health Research-Research for Patient Benefit, NIHR 201473, Trial Registration Number (ISRCTN12536844: SPiRIT. Shoulder pain: randomised trial of injectable treatments-date of Registration 15/9/2021). Protocol Version V1.0_30Jul2021. IRAS Project ID: 294,982.

A neotropical perspective on the uniqueness of the Holocene among interglacials

Understanding how tropical systems have responded to large-scale climate change, such as glacial-interglacial oscillations, and how human impacts have altered those responses is key to current and future ecology. A sedimentary record recovered from Lake Junín, in the Peruvian Andes (4085 m elevation) spans the last 670,000 years and represents the longest continuous and empirically-dated record of tropical vegetation change to date. Spanning seven glacial-interglacial oscillations, fossil pollen and charcoal recovered from the core showed the general dominance of grasslands, although during the warmest times some Andean forest trees grew above their modern limits near the lake. Fire was very rare until the last 12,000 years, when humans were in the landscape. Here we show that, due to human activity, our present interglacial, the Holocene, has a distinctive vegetation composition and ecological trajectory compared with six previous interglacials. Our data reinforce the view that modern vegetation assemblages of high Andean grasslands and the presence of a defined tree line are aspects of a human-modified landscape.

FDA analysis of ineligibility for acute myeloid leukemia clinical trials by race and ethnicity

BACKGROUND

Patients of certain racial and ethnic groups have been underrepresented in clinical trials for treatment of malignancy. One potential barrier to participation is entry requirements that lead to patients in various racial and ethnic groups not meeting eligibility criteria for studies (ie, "screen failure"). The objective of this study was to analyze the rates and reasons for trial ineligibility by race and ethnicity in trials of acute myeloid leukemia (AML) submitted to the U.S. Food and Drug Administration (FDA) between 2016 and 2019.

MATERIALS AND METHODS

Multicenter, global clinical trials submitted to the FDA to support AML drugs and biologics. We examined the rate of ineligibility among participants screened for studies of AML therapies submitted to the FDA from 2016 to 2019. Data were extracted from 13 trials used in approval evaluations, including race, screen status, and reason for ineligibility.

RESULTS

Overall, patients in historically underrepresented racial and ethnic groups were less likely to meet entry criteria for studies compared to White patients, with 26.7% of White patients, 29.4% of Black patients, and 35.9% of Asian patients not meeting entry criteria. Lack of relevant disease mutation was the reason for ineligibility more frequently among Black and Asian patients. The findings were limited by the small number of underrepresented patients screened for participation.

CONCLUSION

Our results suggest that entry requirements for studies may put underrepresented patients at a disadvantage, leading to less eligible patients and thus lower participation in clinical trials.

Resistant fabric warming is a viable alternative to forced-air warming to prevent inadvertent perioperative hypothermia during hemiarthroplasty in the elderly

BACKGROUND

Surgical site infection (SSI) is associated with inadvertent perioperative hypothermia (IPH). This can be prevented by active patient warming. However, results from comparisons of warming techniques are conflicting. They are based mostly on elective surgery, are from small numbers of patients, and are dominated by the market leader, forced-air warming (FAW). Furthermore, the definition of hypothermia is debatable and systematic reviews of warming systems conclude that a stricter control of temperature is required to study the benefits of warming.

AIM

To analyse core temperatures in detail in a large subset of elderly patients who took part in a randomized trial of patient warming following hemiarthroplasty who had received constant zero-flux thermometry to record their temperature.

METHODS

Regression models with a fixed effect for warming group and covariates related to temperature were compared for 257 participants randomized to FAW or resistant fabric warming (RFW) from a prior clinical trial.

FINDINGS

Those in the RFW group were -0.08°C cooler and had a cumulative hypothermia score -1.87 lower than those in the FAW group. There was no difference in the proportion of hypothermic patients at either <36.5°C or <36.0°C.

CONCLUSIONS

This is the first study to provide accurate temperature measurements in patients undergoing a procedure predominantly under regional rather than general anaesthetic. It shows that RFW is a viable alternative to FAW for preventing IPH during hemiarthroplasty. Further studies are needed to measure the benefits of patient warming in terms of clinically important outcomes.

PM-Scl and Th/To in systemic sclerosis: a comparison of different autoantibody assays

OBJECTIVE

To compare test characteristics of the Euroimmun line blot assay with other assays for two uncommon autoantibody specificities in systemic sclerosis (SSc).

METHODS

Patients from the Johns Hopkins Scleroderma Center were assayed routinely using the Euroimmun platform. Patients positive for anti-Th/To (N = 73) and anti-PM-Scl (PM75 and/or PM100; N = 290) by Euroimmun were compared with SSc patients negative for these autoantibodies. For Th/To antibodies, the comparison assay was immunoprecipitation (IP), performed using 4 Th/To complex components: POP1, RPP40, RPP30, and RPP25. For anti-PM-Scl, IPs were performed with PM100 and PM75. Different Euroimmun cut-offs for assigning antibody positive status (≥ 15/+, ≥ 36/++, ≥ 71/+++) were examined. Kappa statistics were calculated to determine agreement between assays.

RESULTS

The best performing thresholds for defining anti-PM-Scl positivity were both PM75 and PM100 ≥ 15/+ on Euroimmun, corresponding to a kappa statistic of 0.79, sensitivity 72% and specificity 100%. For anti-Th/To, kappa values were lower for all comparisons (κ < 0.5). Given the high sensitivity of defining anti-Th/To by ≥ 15/+ (91-95%), a potential approach is to use Euroimmun screening (15/+ cut-off), followed by confirmatory IP.

CONCLUSION

Given the increasing utilization of Euroimmun and the importance of comparing data across cohorts, continued use of this platform is warranted, acknowledging discordance with IP for some specificities. For these, using a two-step approach (Euroimmun to maximize sensitivity, confirmatory assay to increase specificity) is suggested.

KEY POINTS

• For less common SSc autoantibody specificities, some discordances exist between IP and Euroimmun LIA. • The best performing thresholds for defining anti-PM-Scl positivity were both PM75 and PM100 ≥ 15/+ on Euroimmun. • For Th/To, a two-step approach (Euroimmun to maximize sensitivity, confirmatory assay to increase specificity) is suggested.

HSP90 Inhibition Enhances Cancer Immunotherapy by Modulating the Surface Expression of Multiple Immune Checkpoint Proteins

Cancer immunotherapies, including immune checkpoint blockade, have the potential to significantly impact treatments for diverse tumor types. At present, response failures and immune-related adverse events remain significant issues, which could be addressed using optimized combination therapies. Through a cell-based chemical screen of ∼200,000 compounds, we identified that HSP90 inhibitors robustly decrease PD-L1 surface expression, through a mechanism that appears to involve the regulation of master transcriptional regulators (i.e., STAT-3 and c-Myc). Interestingly, HSP90 inhibitors were found to also modulate the surface expression of additional checkpoint proteins (i.e., PD-L2). In the MC-38 syngeneic mouse tumor model, HSP90 inhibition was found to dramatically reduce PD-L1 surface expression on isolated live tumor cells and, consistent with recent findings, was found to increase the number of activated CD8+ T cells within the tumor microenvironment. These findings provide further rationale to explore HSP90 inhibitors as part of combination immunotherapies for the treatment of cancer.

Neuroprotective Activities of Long-Acting Granulocyte-Macrophage Colony-Stimulating Factor (mPDM608) in 1-Methyl-4-Phenyl-1,2,3,6-Tetrahydropyridine-Intoxicated Mice

Loss of dopaminergic neurons along the nigrostriatal axis, neuroinflammation, and peripheral immune dysfunction are the pathobiological hallmarks of Parkinson's disease (PD). Granulocyte-macrophage colony-stimulating factor (GM-CSF) has been successfully tested for PD treatment. GM-CSF is a known immune modulator that induces regulatory T cells (Tregs) and serves as a neuronal protectant in a broad range of neurodegenerative diseases. Due to its short half-life, limited biodistribution, and potential adverse effects, alternative long-acting treatment schemes are of immediate need. A long-acting mouse GM-CSF (mPDM608) was developed through Calibr, a Division of Scripps Research. Following mPDM608 treatment, complete hematologic and chemistry profiles and T-cell phenotypes and functions were determined. Neuroprotective and anti-inflammatory capacities of mPDM608 were assessed in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-intoxicated mice that included transcriptomic immune profiles. Treatment with a single dose of mPDM608 resulted in dose-dependent spleen and white blood cell increases with parallel enhancements in Treg numbers and immunosuppressive function. A shift in CD4+ T-cell gene expression towards an anti-inflammatory phenotype corresponded with decreased microgliosis and increased dopaminergic neuronal cell survival. mPDM608 elicited a neuroprotective peripheral immune transformation. The observed phenotypic shift and neuroprotective response was greater than observed with recombinant GM-CSF (rGM-CSF) suggesting human PDM608 as a candidate for PD treatment.

P1672Late right heart failure predictors after left ventricular assist device implantation

Background

Right heart failure (RHF) after left ventricular assist device (LVAD) implantation is a significant cause of morbidity and mortality. While multiple predictors of early RHF have been described, information on late RHF is scarce. The aim of this study was to identify predictors of late RHF in LVAD patients.

Methods

A retrospective analysis of all adult patients who underwent HeartWare-VAD implantation for ischemic heart disease or non-ischemic dilated cardiomyopathy in a single centre was performed. Late RHF was defined as RHF requiring hospitalization and medical treatment after 30 days of LVAD implantation.

Results

A total of 16 (10.3%) patients from 156 implantations developed late RHF. Patients developing late RHF were older at time of surgery, 56.7±6.9 vs 49.5±12.5 years; p<0.01. A significantly higher rate of moderate or severe tricuspid regurgitation before implantation was found in patients presenting with late RHF, 81.2% vs 33.5%; p<0.001. Several echocardiographic parameters at discharge post-implant, such as mitral regurgitation, demonstrated a strong association with late RHF. A multivariate Cox proportional-hazards regression analysis (table 1) revealed that significant pre-operative tricuspid regurgitation (moderate or severe) was the strongest predictor of late RHF development after LVAD surgery (HR 5.50, 95% CI [1.34–22.58]; p=0.02). Significant mitral regurgitation post-implantation and older age also predicted late RHF development.

Multivariate Cox proportional-hazards analysis for late right heart failure Variable Hazard ratio 95% confidence interval P-value Tricuspid regurgitation- moderate or severe 5.50 1.34–22.58 0.02 Mitral regurgitation (discharge)- moderate or severe 3.54 1.14–11.02 0.03 Age 1.07 1.01–1.14 0.03 Right ventricular basal diameter 1.14 0.43–3.03 0.79 Right ventricular fractional area change 0.98 0.87–1.10 0.79 Multivariate analysis showing predictors of late right heart failure according to a multivariate model.

Late RHF according to TR severity

Conclusions

Pre-operative significant tricuspid regurgitation and mitral regurgitation after implantation predict the occurrence of late RHF. Prospective studies are needed to determine whether tricuspid valve interventions may reduce late RHF.

P5418Anticoagulation management of heartware left ventricular assist device thrombosis: comparison of heparin and bivalirudin

Introduction and purpose

Pump thrombosis (PT) is a serious left ventricular assist device (LVAD) complication, though there are no guidelines regarding its treatment. We have adopted a strategy of intravenous anticoagulation as the initial treatment strategy in these patients.

Methods

All consecutive patients who received a HeartWare LVAD from July-2009 to January-2018 were retrospectively analyzed. Patients developing a PT were selected, and treatment, outcomes and complications were recorded.

Results

197 patients underwent HVAD, and 49 developed PT. All the patients were initially treated medically, though during the first PT 26.5% of the patients needed surgery [VAD exchange (n=6), transplant (n=6), or decommissioning (n=1)]. The overall survival at 1 year was 63.3%. Patients were treated predominantly with either intravenous heparin or bivalirudin. There were no significant differences neither in complications nor in survival between the 2 treatments (Figure 1); however, patients treated with bivalirudin during the first PT episode had less subsequent re-thrombosis episodes (18.2% vs 57.7%, p<0.05), and percentage time in therapeutic range was greater for bivalirudin compared with heparin (59.7±4.2 vs 36.3±7.1, p<0.01). Nevertheless, time to normalisation of LDH levels with bivalirudin was longer than with heparin (17.2±2.6 vs 10.2±4.5 days, p<0.01) (Table 1).

Table 1. Comparison of baseline characteristics and outcomes between Heparin and Bivalirudin Heparin (n=26) Bivalirudin (n=11) p-value Male, gender n (%) 20 (76.9) 9 (81.8) 1.00 Age when implant (years) 48±11.8 49.8±11.4 0.67 AF n (%) 9 (34.6) 6 (54.5) 0.50 Diagnosis:   Dilated cardiomyopathy n (%) 13 (50) 7 (63.6)   Ischemic heart disease n (%) 12 (46.2) 3 (27.3)   Congenital heart disease n (%) 1 (3.8) 1 (9) 0.50 Thrombolysis (+ alteplase) n (%) 19 (73.1) 4 (36.4) 0.08 Treatment duration (days) 11.5±7.2 15.3±6.5 0.15 % Time in range 36.3±7.1 59.7±4.2 0.009 Hospitalisation (days) 19.1±16.4 31.9±18.2 0.06 Complications:   Ischemic Stroke n (%) 2 (7.7) 4 (36.4) 0.09   Intracraneal bleeding n (%) 2 (7.7) 0 (0) 0.88   Gastrointestinal bleeding n (%) 1 (3.8) 0 (0) 1.00   Serious bleeding n (%) 5 (19.2) 0 (0) 0.29   Any bleeding n (%) 7 (26.9) 2 (18.2) 0.88 LDH   Baseline 271.7±79.3 221.6±41.3 0.10   Admision 727.8±448.2 517.5±171.3 0.21   Maximum 827.1±424.7 1217.6±1004 0.03   Discharge 334.9±135.9 308.6±111.8 0.70   Time to normalisation (days) 10.2±4.5 17.2±2.6 0.004 Outcomes:   Transplant (total) n (%) 7 (26.9) 2 (18.2) 0.88   VAD Exchange (total) n (%) 8 (30.8) 4 (36.4) 1.00   Mortality at 2 years n (%) 15 (57.7) 5 (45.4) 0.831 Rethrombosis:   Rethrombosis n (%) 15 (57.7) 2 (18.2) 0.03   Number of episodes of rethrombosis 0.15     +1 n=6 n=1     +2 n=4 n=1     +3 n=4 n=0     +4 n=1 n=0

Figure 1

Conclusion

VAD thrombosis is a serious life threatening complication, though an initial strategy with enhanced intravenous anticoagulation is an acceptable strategy with either intravenous heparin or bivalirudin.

Acknowledgement/Funding

N. Bouzas-Cruz would like to thank the Spanish Society of Cardiology (Sociedad Española de Cardiología), for her research grant and fellowship.

P1677Elevation of right-sided pressures and right ventricular echocardiographic parameters: predictors of Exercise Limitation in Patients with Implanted Continuous Flow Left Ventricular Assist Devices

Introduction

Left Ventricular Assist Devices (LVAD) improve survival and functional capacity in patients with advanced heart failure (HF). However, there are potential complications.

Purpose

We sought to determine parameters of exercise intolerance in a group of patients with the HeartWare LVAD (HVAD) compared to a group of HF patients.

Methods

This was a single-centre parallel prospective group-study. Briefly, echocardiograms, right heart catheterisation (RHC) and cardiopulmonary exercise tests were performed in forty-two patients admitted for a heart transplant assessment between August2017 and October2018.Of them 20 belonged to the HVAD group and 22 to the HF group.

Results

In our study, HVAD patients had a better exercise capacity than HF patients, although no significant differences were noted (14.0±5.0 ml/kg/min vs 11.3±3.9 ml/kg/min, p=0.06). To determine exercise tolerance, both HVAD and HF groups were subdivided into 2 groups based on the median peak exercise oxygen consumption (peakVO2) for that group. The table shows the comparison between preserved and non-preserved exercise tolerance in HF and HVADpatients. First of all, in the HVADgroup, all resting RHC pressures were significantly lower in the preserved exercise capacity group. However, in HFpatients there were no statistically significant differences between both subgroups in right-sided pressures, but Thermodilution exercise-induced change in cardiac output (ΔCO) and cardiac index (ΔCI) was significantly higher in the patients with preserved exercise tolerance. Secondly, in the HVADgroup the right ventricle was significantly larger in the reduced exercise tolerance subgroup. Moreover, patients with lower peak VO2 had more significant tricuspid regurgitation. Nevertheless, in HFpatients none of the echocardiographic parameters were related to the exercise capacity.

HF HVAD > Median Peak V02 < Median Peak V02 p > Median Peak V02 < Median Peak V02 p Thermodilution CO, l/min: • Rest 4.3±1.0 4.4±1.8 0.82 4.8±0.8 4.2±1.2 0.21 • Exercise 5.6±1.7 4.8±1.8 0.36 7.1±3.2 4.8±0.8 0.05 • ΔCO 1.26±1.0 0.26±0.7 0.02 2.2±2.5 0.4±0.7 0.05 Right Atrium pressure, mmHg 7.0±4.5 6.8±4.10 0.92 4.3±3.2 10.6±6.40 0.02 Mean Pulmonary Artery pressure, mmHg 26.4±12.6 26.5±10.9 0.97 16.8±5.4 30.5±12.5 0.01 Tricuspid Regurgitation, n (%): • None 1 (9) 1 (9) 1 (12) 0 (0) • Mild 7 (64) 8 (73) 7 (88) 4 (44) • Moderate 2 (18) 0 (0) 0 (0) 4 (44) • Severe 1 (9) 2 (18) 0.36 0 (0) 1 (12) 0.03 Right Ventricle Basal Diastolic Diameter, cm 4.0±1.0 4.1±1.0 0.83 3.7±0.5 4.4±0.5 0.02

Conclusion

Right-sided parameters in the echocardiogram and RHC pressures discriminate between preserved and non-preserved exercise capacity in HVADpatients, but not in HFpatients. In these last patients only ΔCO and ΔCI were statistically correlated with peak exercise oxygen consumption

Acknowledgement/Funding

N. Bouzas-Cruz would like to thank the Spanish Society of Cardiology (Sociedad Española de Cardiología), for her research grant and fellowship

C-19 An fMRI Study of Age-Associated Changes in Basic Visual Discrimination

Objective

The study was conducted to determine age-associated changes in functional brain response, measured with fMRI, during visual discrimination with regard to three elementary components of visual perception: shape, location, and velocity. A secondary aim was to validate the method used to isolate the hypothesized brain regions associated with these perceptual functions.

Method

Items from the Visual Assessment Battery (VAB), a simultaneous match-to-sample task, assessed visual discrimination in 40 healthy adults during fMRI. Participants were aged 51-91 and recruited from a larger community sample for a study on normal aging. The tasks were designed to isolate neural recruitment during discrimination of either location, shape, or velocity by using tasks that were identical aside from the perceptual skill required to complete them.

Results

The Location task uniquely activated the dorsal visual processing stream, the Shape task the ventral stream, and the Velocity task V5/MT. Greater age was associated with greater neural recruitment, particularly in frontal areas (uncorrected voxel-level p < .001, family-wise error cluster-level p□.05).

Conclusions

Results validated the specialization of brain regions for spatial, perceptual, and movement discriminations and the use of the VAB to assess functioning localized to these regions. Anterior neural recruitment during visual discrimination increases with age.

Gliosarcoma: distinct molecular pathways and genomic alterations identified by DNA copy number/SNP microarray analysis

PURPOSE

Gliosarcoma is a histologic variant of glioblastoma (GBM), and like GBM carries a poor prognosis. Median survival is less than one (1) year with less than 5% of patients alive after 5 years. Although there is no cure, standard treatment includes surgery, radiation and chemotherapy. While very similar to GBM, gliosarcoma exhibits several distinct differences, morphologically and molecularly. Therefore, we report a comprehensive analysis of DNA copy number changes in gliosarcoma using a cytogenomic DNA copy number (CN) microarray (OncoScan®).

METHODS

Cytogenomic DNA copy number microarray (OncoScan®) was performed on 18 cases of gliosarcoma. MetaCore™ enrichment was applied to the array results to detect associated molecular pathways.

RESULTS

The most frequent alteration was copy number loss, comprising 57% of total copy number changes. The number of losses far exceeded the number of amplifications (***, < 0.001) and loss of heterozygosity events (***, < 0.001). Amplifications were infrequent (4.6%), particularly for EGFR. Chromosomes 9 and 10 had the highest number of losses; a large portion of which correlated to CDKN2A/B loss. Copy number gains were the second most common alteration (26.2%), with the majority occurring on chromosome 7. MetaCore™ enrichment detected notable pathways for copy number gains including: HOXA, Rho family of GTPases, and EGFR; copy number loss including: WNT, NF-kß, and CDKN2A; and copy number loss of heterozygosity including: WNT and p53.

CONCLUSIONS

The pathways and copy number alterations detected in this study may represent key drivers in gliosarcoma oncogenesis and may provide a starting point toward targeted oncologic analysis with therapeutic potential.

The epidemiology and trends in the surgical management of calcaneal fractures in England between 2000 and 2017

Aims

This paper documents the epidemiology of adults (aged more than 18 years) with a calcaneal fracture who have been admitted to hospital in England since 2000. Secondary aims were to document whether publication of the United Kingdom Heel Fracture Trial (UK HeFT) influenced the proportion of patients admitted to hospital with a calcaneal fracture who underwent surgical treatment, and to determine whether there has been any recent change in the surgical technique used for these injuries.

Patients and Methods

In England, the Hospital Episode Statistics (HES) data are recorded annually. Between 2000/01 and 2016/17, the number of adults admitted to an English NHS hospital with a calcaneal fracture and whether they underwent surgical treatment was determined.

Results

During this 17-year period, 62 858 patients were admitted to hospital with a calcaneal fracture. The male-to-female ratio was 2.66:1. The mean annual incidence was 10.5/100 000 for men and 3.8/100 000 for women. The results of the UK HeFT were published in July 2014. The percentage of patients admitted with a calcaneal fracture undergoing internal fixation was 7.31% (3792/51 859) before and 7.38% (534/7229) after its publication. This difference was not statistically significant (p = 0.94). Since 2015, there has been a significant increase in the percentage of calcaneal fractures treated by closed reduction and internal fixation, as opposed to open reduction and internal fixation, from 7.7% (292/3792) to 13.29% (71/534) (p < 0.001).

Conclusion

This study documents the epidemiology and trends in surgical treatment of calcaneal fractures in England. We established that surgeons did not change their practice in terms of offering surgery to these patients in response to the results of the UK HeFT. There has been a significant (p < 0.001) increase in the number of calcaneal fractures being treated surgically using less invasive procedures.

An intravenous insulin protocol designed for pregnancy reduces neonatal hypoglycaemia following betamethasone administration in women with gestational diabetes

AIMS

Marked hyperglycaemia is common following betamethasone administration in women with gestational diabetes (GDM), and may contribute to neonatal hypoglycaemia. Validated protocols to deliver glycaemic stability following betamethasone are lacking. We hypothesized that an intravenous insulin (IVI) protocol for pregnancy-specific glycaemic targets (Pregnancy-IVI) would achieve greater at-target glycaemic control than a generic adult intravenous insulin protocol (Adult-IVI), and may reduce neonatal hypoglycaemia.

METHODS

A retrospective cohort study of the performance Adult-IVI and Pregnancy-IVI following betamethasone in GDM, sequentially implemented at a tertiary hospital, without change in indication for IVI. Cases were identified by electronic record search. Primary outcome was percentage of on-IVI time with at-target glycaemia [blood glucose level (BGL) 3.8-7 mmol/l]. Secondary outcomes were time with critical hyperglycaemia (BGL > 10 mmol/l), occurrence of maternal hypoglycaemia (BGL < 3.8 mmol/l), and incidence of neonatal hypoglycaemia (BGL ≤ 2.5 mmol/l) if betamethasone was administered within 48 h of birth.

RESULTS

The cohorts comprised 151 women (Adult-IVI n = 86; Pregnancy-IVI n = 65). The primary outcome was 68% time-at-target [95% confidence interval (CI) 64-71%) for Pregnancy-IVI compared with 55% (95% CI 50-60%) for Adult-IVI (P = 0.0002). Critical maternal hyperglycaemia (0% vs. 2%, P = 0.02) and hypoglycaemia (2% vs. 12%, P = 0.02) were both lower with Pregnancy-IVI than Adult-IVI. Neonatal hypoglycaemia was less common after Pregnancy-IVI (29%) than after Adult-IVI (54%, P = 0.03). A multiple logistic regression model adjusting for potential confounders gave an odds ratio for neonatal hypoglycaemia with Pregnancy-IVI of 0.27 (95% CI 0.10-0.76, P = 0.01).

CONCLUSIONS

An IVI protocol designed for pregnancy effectively controlled maternal hyperglycaemia following betamethasone administration in GDM. This is the first intervention to show a reduction in betamethasone-associated neonatal hypoglycaemia, linked with optimum maternal glycaemic control.

‘Bridging the Continuum' - Reporting Population-Level Trends Across the Continuum of Care: The Australian National Cancer Control Indicator (NCCI) Web Site

Background: High-quality data can assist the development of policy and cancer strategies, stimulate lines of research, and inform the provision of care leading to better cancer outcomes. In November 2017 Cancer Australia launched the National Cancer Control Indicators (NCCI) Web site ( https://ncci.canceraustralia.gov.au ), Australia's first interactive Web site of cancer-specific, national population-based data across the continuum of care. The NCCI Web site presents a set of indicators for monitoring national cancer trends and benchmarking internationally across seven key aspects of cancer control; prevention, screening, diagnosis, treatment, psychosocial care, research and outcomes. Aim: By presenting a set of indicators using seven domains from the cancer care continuum, the NCCI Web site presents the most current Australian national data for a range of cancer control indicators in an accessible and interactive format. The primary aim of the NCCI Web site (hosted as part of the Cancer Australia Web site) is to monitor and report the most recent population-level trends to drive improvements across the cancer control continuum in Australia, and to facilitate international benchmarking of Australia's cancer control efforts. Methods: National data level on 33 individual measures across the seven cancer continuum domains was accessed from both government and nongovernment data custodians. Where applicable and available for measures, data were disaggregated and presented by age, sex, indigenous status, remoteness area of residence and socioeconomic status. Review of the data analysis was undertaken by 46 external reviewers including data custodians and subject matter experts. Results: Example summary data from several indicators across the NCCI Web site, including demographic disaggregation by age, sex, remoteness area of residence and socioeconomic status (where available) will be provided. e.g., • Smoking prevalence has decreased substantially over the past 30 years, and smoking rates among both adolescents and adults in Australia are among the lowest in the world. • Cancer mortality rates have been falling steadily since 1995, across most cancer types. Australia has lower mortality rates from cancer when compared with most other similar developed countries, about 6% lower than the estimated global average in 2012. National population-level data showing incidence by stage at diagnosis for the top five most common cancers has also been reported on the Web site - making Australia one of the few countries in the world where these data are available. Conclusion: The NCCI Web site is a flagship data Web site providing, for the first time, an evolving high-level national data resource to monitor Australian population-level trends in cancer control across the continuum. As one of the very few cross-continuum cancer reporting resources in the world, this is a valuable resource for use by those within the international cancer control community.

Collection and Reporting of National Cancer Stage at Diagnosis Data in Australia (STaR Project)

Background: Stage at diagnosis is an important prognostic factor for cancer, providing contextual information for interpreting population health indicators such as mortality from cancer and cancer survival. Australian population-based cancer registries (PBCRs) routinely collect information on cancer incidence and mortality. The need for high quality, comprehensive national data on stage at diagnosis to supplement these data are widely recognized in Australia. The collection and dissemination of quality national stage data will enhance the: • ability to better monitor cancer outcomes, inform cancer control policy; • understand variations across different populations; and • identify where further research and targeted strategies may be required to improve cancer outcomes. Linking data on cancer stage at diagnosis with other administrative cancer data will also allow for a better understanding of the relationship between stage at diagnosis, treatments received, patterns of cancer recurrence, and survival outcomes. Aim: To strengthen national data capacity by collecting and reporting cancer stage at diagnosis for Cancer Australia's Stage, Treatment and Recurrence (STaR) project. Methods: Working with state and territory population-based cancer registries (PBCRs) and the Australian Pediatric Cancer Registry, Cancer Australia supported the development and testing of Business Rules for the collection of national cancer stage at diagnosis for: • The top 5 incident cancers based on the Tumor, Node, and Metastasis (TNM) staging system. These rules were endorsed by the Australasian Association of Cancer Registries (AACR) as a national standard in May 2016; and • Childhood cancers, with a separate set of Business Rules for 16 childhood cancer types based on the Toronto Pediatric Cancer Stage Guidelines. These rules were supported by the AACR as a national standard. Results: Using the AACR-endorsed Business Rules, comprehensive national cancer stage at diagnosis data for the top 5 incident cancers (for 2011) have been collected in Australia for the first time. Over 90% of incidence cases were able to be assigned a value for registry-derived (RD) stage at diagnosis for melanoma (97%), prostate (97%), and female breast (94%) cancers. Lower staging completeness was found for colorectal cancers (88%), and for lung cancers (72%). Business Rules for the collection of stage at diagnosis data for pediatric cancers have also been developed; 93% of sample cases diagnosed in the period 2006-2010 were able to be staged, ranging from 84% for nonrhabdomyosarcoma to 100% for hepatoblastoma. Conclusion: The Business Rules enabled the uniform collection of cancer stage at diagnosis data for the first time in Australia. The collection of these data will allow for the linkage of stage at diagnosis to other sources of information, including patterns of treatments applied, and enable reporting of survival and recurrence outcomes by stage.

Collection and Reporting of System-Wide Cancer Treatment Activity Data As Part of the Stage, Treatment and Recurrence (STaR) Project

Background: The need for high quality, comprehensive national data on the treatments applied to cancers is widely recognized within the Australian cancer control community. The analysis and reporting of cancer treatment data will greatly enhance our ability to better understand cancer care activity and outcomes - and in particular the treatments being applied across population groups. Aim: To collect and report national data on cancer treatments, as part of Cancer Australia's Stage, Treatment and Recurrence (STaR) project. The linking of this data with national data on stage at diagnosis, survival and recurrence, will help inform policy and practice and ultimately improve cancer outcomes. Methods: Cancer Australia developed a dataset of selected surgical procedures for the treatment of the top five incidence cancers (prostate, breast, colorectal, lung, and melanoma). A dataset of key selected radiotherapy, and systemic therapies for the treatment of all cancer types was also developed.

Data for reporting system-wide treatment activity were extracted from existing national health administrative datasets, including: the Pharmaceutical Benefits Scheme (PBS), the Medicare Benefits Schedule (MBS) and the National Hospital Morbidity Database (NHMD). The scope of the analysis was selected surgical procedures, radiotherapy procedures, or pharmaceutical agents administered with the general intent to change the outcome of the cancer and/or provide symptom relief/ palliative care. Results: The data reported provide a high-level national system-wide overview of cancer treatments applied, including: • More than 1 million radiotherapy services were provided for all cancers combined in Australia (as indicated by MBS reimbursement claims data) for the years 2013 to 2015 inclusive; • The number of people receiving systemic anticancer therapies in Australia for all cancers combined (as indicated by PBS reimbursement claims data) increased from 198,756 in 2012 to 247,939 in 2016; and • The number of hospital separations recorded in the NHMD (i.e., episodes of admitted patient care) for patients with a principal diagnosis of cancer undergoing surgery for the treatment of the top five high incidence cancers in Australia increased from 53,516 in 2010 to 57,651 in 2015. Conclusion: National cancer treatment data were successfully collected and reported. Australia is one of very few countries in the world to collect and report national system-wide treatment data with a specific focus on cancer. These data will be linked to cancer incidence, stage at diagnosis, survival and recurrence data to help inform for population-level reporting of cancer outcomes.

Randomised crossover trial of telemonitoring in chronic respiratory patients (TeleCRAFT trial)

Objective

To assess the impact of home telemonitoring on health service use and quality of life in patients with severe chronic lung disease.

Design

Randomised crossover trial with 6 months of standard best practice clinical care (control group) and 6 months with the addition of telemonitoring.

Participants

68 patients with chronic lung disease (38 with COPD; 30 with chronic respiratory failure due to other causes), who had a hospital admission for an exacerbation within 6 months of randomisation and either used long-term oxygen therapy or had an arterial oxygen saturation (SpO₂) of <90% on air during the previous admission. Individuals received telemonitoring (second-generation system) via broadband link to a hospital-based care team.

Outcome measures

Primary outcome measure was time to first hospital admission for an acute exacerbation. Secondary outcome measures were hospital admissions, general practitioner (GP) consultations and home visits by nurses, quality of life measured by EuroQol-5D and hospital anxiety and depression (HAD) scale, and self-efficacy score (Stanford).

Results

Median (IQR) number of days to first admission showed no difference between the two groups—77 (114) telemonitoring, 77.5 (61) control (p=0.189). Hospital admission rate at 6 months increased (0.63 telemonitoring vs 0.32 control p=0.026). Home visits increased during telemonitoring; GP consultations were unchanged. Self-efficacy fell, while HAD depression score improved marginally during telemonitoring.

Conclusions

Telemonitoring added to standard care did not alter time to next acute hospital admission, increased hospital admissions and home visits overall, and did not improve quality of life in chronic respiratory patients.

Trial registration number

NCT02180919 (ClinicalTrials.gov).

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project

OBJECTIVE

The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project.

DESIGN

We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach.

SETTING

21-bed medical surgical ICU in a tertiary care, university-affiliated hospital.

RESULTS

33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection.

CONCLUSIONS

For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings.

AMPK antagonizes hepatic glucagon-stimulated cyclic AMP signalling via phosphorylation-induced activation of cyclic nucleotide phosphodiesterase 4B

Biguanides such as metformin have previously been shown to antagonize hepatic glucagon-stimulated cyclic AMP (cAMP) signalling independently of AMP-activated protein kinase (AMPK) via direct inhibition of adenylate cyclase by AMP. Here we show that incubation of hepatocytes with the small-molecule AMPK activator 991 decreases glucagon-stimulated cAMP accumulation, cAMP-dependent protein kinase (PKA) activity and downstream PKA target phosphorylation. Moreover, incubation of hepatocytes with 991 increases the V_max of cyclic nucleotide phosphodiesterase 4B (PDE4B) without affecting intracellular adenine nucleotide concentrations. The effects of 991 to decrease glucagon-stimulated cAMP concentrations and activate PDE4B are lost in hepatocytes deleted for both catalytic subunits of AMPK. PDE4B is phosphorylated by AMPK at three sites, and by site-directed mutagenesis, Ser304 phosphorylation is important for activation. In conclusion, we provide a new mechanism by which AMPK antagonizes hepatic glucagon signalling via phosphorylation-induced PDE4B activation.

The diabetes drug Metformin decreases hepatic glucose production and activates AMP-activated protein kinase (AMPK). Here the authors provide evidence that AMPK activation antagonizes glucagon signalling by activating PDE4B, lowering cAMP levels and decreasing PKA activation.