Baseline characteristics from a retrospective, observational, US-based, multicenter, real-world (RW) study of avelumab first-line maintenance (1LM) in locally advanced/metastatic urothelial carcinoma (la/mUC) (PATRIOT-II)

465

Background: The JAVELIN Bladder 100 clinical trial demonstrated a significant overall survival and progression-free survival benefit with avelumab 1LM + best supportive care (BSC) vs BSC alone for la/mUC not progressing on platinum-based chemotherapy (PBC). PATRIOT-II aims to describe RW data for avelumab 1LM treatment (tx) of patients (pts) with la/mUC. Methods: PATRIOT-II collected data from pts with la/mUC treated in 37 geographically dispersed oncology practices/communities and academic centers in the US. Pts who initiated avelumab 1LM following PBC were retrospectively enrolled and will be followed up via medical record review for 52 weeks post avelumab 1LM initiation. This analysis focused on pt characteristics and tx data from la/mUC diagnosis through the PBC period and at avelumab 1LM initiation. Disease and PBC tx characteristics, as well as response to PBC, were assessed. All analyses were descriptive. Results: A total of 160 pts were enrolled (Table), 118 (74%) were white, non-Hispanic, 16 (10%), were Black, Asian, or Hispanic, and the rest unknown; 102 (64%) were current or former smokers. 77 (48%) were tested for PD-L1 via various assays, with 44 (57%) of those tumor samples reported as positive. 1L PBC was cisplatin-based in 100 (63%) of pts and carboplatin-based in 60 (38%). Pts received a median of 4 PBC cycles (interquartile range [IQR], 3-6) for a median of 13 weeks (IQR, 10-17). 31 (19%) discontinued PBC due to unacceptable side effects/toxicity. Best observed response was complete response in 21 (13%), partial response in 109 (68%), and stable disease in 17 (11%), with the remainder unknown. Median time to first imaging was 10 weeks (IQR, 5-14) after PBC initiation. 23 (14%) were hospitalized while receiving PBC, and 25 (16%) were seen in the emergency department. Pts proceeded to avelumab 1LM at a median of 4 weeks (IQR, 3-6) following PBC completion. Avelumab was administered at 800 mg every 2 weeks in 130 (81%), 10 mg/kg in 15 (9%), <800 mg in 8 (5%), and >800 mg in 7 (4%) pts. Conclusions: This ‘RW’ study offers valuable insights into characteristics and outcomes of pts with la/mUC treated in the US. Baseline factors, tx patterns and response to PBC were consistent with usual therapy paradigms in the 1L induction setting. Ongoing trials are evaluating the optimal number of PBC cycles and predictive biomarkers. Limitations include the retrospective nature, lack of randomization and central review, potential selection and confounding biases. [Table: see text]

The Effect of COVID-19 on 30-Day Mortality Rates Amongst Fragility Hip Fracture Patients

Aim Fragility hip fracture patients have always been vulnerable to high rates of short term mortality, an issue that may have been exacerbated by the ongoing COVID-19 pandemic. To date, published data regarding Irish hip fracture patients in the era of COVID-19 is limited. This study aims to assess the effect of COVID-19 on 30-day mortality rates amongst a group of Irish hip fracture patients. Additionally, patient demographics, length of stay, admission haematological parameters, fracture type and surgical procedure will be assessed. Methods A multicentre, observational, retrospective study of hip fracture patients (n = 1,017) admitted to six Dublin teaching hospitals during the COVID-19 pandemic (4th February to 9th July 2020) was performed. For comparative purposes, equivalent data was retrospectively collected relating to hip fracture patients admitted to the same six teaching hospitals during the same time period in 2019. Results 481 patients were admitted during the specified timeframe in 2020, compared with 536 in 2019. The mean patient age was 77.6 years and 65.9% of patients were female. There was no statistically significant overall difference in 30-day mortality rates between the study and control groups, at 5.4% in 2020 and 4.3% in 2019 (p=0.338). There was an insignificant decrease in mean length of stay (17.85 days in 2020 vs. 18.82 days in 2019; p=0.106). Advancing age (p=0.021), male gender (p=0.019), low admission haemoglobin (p=0.024) and high admission white cell count (p=0.019) were all associated with increased 30-day mortality. Conclusion We found no significant difference in 30-day mortality rates amongst our cohort of hip fracture patients at the height of the COVID-19 pandemic in Ireland. Advancing age, male gender, anaemia at admission and leucocytosis at admission were associated with increased 30-day mortality. The continuation of COVID-19 related safety protocols in the treatment of hip fracture patients is essential in maintaining a safe hip fracture service.

1235 A Multi-Site Review of Second Hip Fractures Across 6 Dublin Teaching Hospitals

Introduction

Hip fractures are a common presentation to Irish hospitals with 3,701 hip fractures recorded by 16 hospitals in the Irish Hip Fracture Database (IHFD) in 2019. Second hip fractures (HF2) make up a significant proportion of hip fractures and represent an opportunity to prevent subsequent fragility fracture.

Method

Hip fracture datasheets from 2019 in six Dublin hospitals were analysed.

Results

1,284 hip fractures in total were recorded in 2019 in these six hospitals. 112 of these were second hip fractures (8.72%). 24.1% of patients had a HF2 in year 1 post their first hip fracture (HF1). 14.3% of patients had a HF2 in Year 2, 8% in Year 3, 8.9% in Year 4 and 6.3% in Year 5. 17.9% of patients had an HF2 at an unknown time in relation to their HF1. 57.6% of all patients with any hip fracture were started on bone protection medications (BPMs) during their admission. 18.9% continued a pre-admission prescription. 7% of all patients were previously assessed and determined not to require BPM. 6.9% of patients were awaiting outpatient department (OPD) assessment for bone protection. 8.6% had no assessment for bone protection conducted. Of all patients with an HF2, 48.2% were started on BPMs on admission with their HF2. 33% continued BPMs started pre-admission.

Discussion

In 2019, approximately 1 in 10 hip fractures were second hip fractures. Evidence suggests that fracture liaison services represent a viable, economic means of preventing second hip fractures to improve patient outcomes and reduce healthcare expenditure.

The Patient's Second Hip Fracture - One in Ten

Introduction The number of fragility hip fractures (>60 years) are estimated to triple/quadruple by 2050. It is estimated that the prevalence of patient's contralateral hip fractures (HF2s) will increase also. Methods Single hospital, Retrospective review, 2013-2017, Radiograph review, n = 822. Results Management of patient's 2nd hip fractures accounted for 10.5% of all hip fracture surgeries. ~50% occurred within 3 years of the 1st hip fracture. There was no statistically significant difference in discharge destination, length-of-stay or mortality between the HF1 and HF2 cohorts. Discussion Patients with HF2s comprised a significant and stable proportion of all hip fractures treated. We advocate for the provision of a Fracture Liaison Service in each of the 16 hip fracture operating hospitals in Ireland to optimise the secondary prevention of hip fractures.

Remote wireless vital signs monitoring on the ward for early detection of deteriorating patients: A case series

INTRODUCTION

Remote wireless monitoring is a new technology that allows the continuous recording of ward patients' vital signs, supporting nurses by measuring vital signs frequently and accurately. A case series is presented to illustrate how these systems might contribute to improved patient surveillance.

METHODS AND RESULTS

Five hospitals in three European countries installed a remote wireless vital signs monitoring system on medical or surgical wards. Heart rate, respiratory rate and temperature were measured by the system every 2 min. Four cases of (paroxysmal) atrial fibrillation are presented, two cases of sepsis and one case each of pyrexia, cardiogenic pulmonary edema and pulmonary embolisms. All cases show that the remote monitoring system revealed the first signs of ventilatory and circulatory deterioration before a change in the trends of the respective values became obvious by manual vital signs measurement.

DISCUSSION

This case series illustrates that a wireless remote vital signs monitoring system on medical and surgical wards has the potential to reduce time to detect deteriorating patients.

Hip Fracture and the Weekend Effect in an Irish Trauma Hospital

Aims We examined the relationship between the 1-year mortality (OYM) rate and (i) those admitted at the weekend, (ii) those who underwent surgery at the weekend and (iii) those admitted during the NCHD changeover months (January & July) for the management of hip fracture in Tallaght University Hospital (TUH). Methods Admissions to TUH (2013 - 2016) with hip fracture (> 60 years old) were retrospectively examined. Data from the Irish Deaths and Events Registry was analysed to identify death events at 1 year. Logistic regression analysis was performed with respect to OYM with the three variables above. Results 646 hip fracture patients were admitted (2013 – 2016). 178 (27.5%) were weekend admissions, 183 (28.4%) underwent weekend surgery and 93 patients (14.4%) were admitted during NCHD changeover months. There was no significant relationship between OYM and (i) weekend admission, (ii) weekend surgery or (iii) changeover admission in TUH. Conclusion This study offers the first examination of the weekend effect on fragility hip fractures and mortality in Irish patients and reports no significant weekend effect regarding 1-year mortality in this hip fracture cohort.

Postoperative ileus following major colorectal surgery

BACKGROUND

Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research.

METHODS

A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias.

RESULTS

Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness.

CONCLUSION

POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Laboratory evidence of disseminated intravascular coagulation is associated with a fatal outcome in children with cerebral malaria despite an absence of clinically evident thrombosis or bleeding

BACKGROUND

A procoagulant state is implicated in cerebral malaria (CM) pathogenesis, but whether disseminated intravascular coagulation (DIC) is present or associated with a fatal outcome is unclear.

OBJECTIVES

To determine the frequency of overt DIC, according to ISTH criteria, in children with fatal and non-fatal CM.

METHODS/PATIENTS

Malawian children were recruited into a prospective cohort study in the following diagnostic groups: retinopathy-positive CM (n = 140), retinopathy-negative CM (n = 36), non-malarial coma (n = 14), uncomplicated malaria (UM), (n = 91), mild non-malarial febrile illness (n = 85), and healthy controls (n = 36). Assays in the ISTH DIC criteria were performed, and three fibrin-related markers, i.e. protein C, antithrombin, and soluble thrombomodulin, were measured.

RESULTS AND CONCLUSIONS

Data enabling assignment of the presence or absence of 'overt DIC' were available for 98 of 140 children with retinopathy-positive CM. Overt DIC was present in 19 (19%), and was associated with a fatal outcome (odds ratio [OR] 3.068; 95% confidence interval [CI] 1.085-8.609; P = 0.035]. The levels of the three fibrin-related markers and soluble thrombomodulin were higher in CM patients than in UM patients (all P < 0.001). The mean fibrin degradation product level was higher in fatal CM patients (71.3 μg mL(-1) [95% CI 49.0-93.6]) than in non-fatal CM patients (48.0 μg mL(-1) [95% CI 37.7-58.2]; P = 0.032), but, in multivariate logistic regression, thrombomodulin was the only coagulation-related marker that was independently associated with a fatal outcome (OR 1.084 for each ng mL(-1) increase [95% CI 1.017-1.156]; P = 0.014). Despite these laboratory derangements, no child in the study had clinically evident bleeding or thrombosis. An overt DIC score and high thrombomodulin levels are associated with a fatal outcome in CM, but infrequently indicate a consumptive coagulopathy.

Pressure activates colon cancer cell adhesion via paxillin phosphorylation, Crk, Cas, and Rac1

Physical forces can activate colon cancer cell adhesion, critical for metastasis. Paxillin is phosphorylated by FAK and required for pressure-stimulated adhesion. However, whether paxillin acts as an inert scaffolding protein or whether paxillin phosphorylation is required is unknown. Transfection with paxillin point-phosphorylation mutants demonstrated that phosphorylation at tyrosines 31 and 118 together is necessary for pressure-stimulated adhesion. We further evaluated potential paxillin partners. Reducing the adaptor protein Crk or the focal adhesion protein p130Cas blocked pressure-stimulated adhesion. Furthermore, Crk and p130Cas both displayed increased co-immunoprecipitation with paxillin in response to increased pressure, except in cells transfected with a Y31Y118 paxillin mutant. Inhibiting the small GTPase Rac1 also abolished pressure-stimulated adhesion, and reducing paxillin by siRNA blocked Rac1 phosphorylation by pressure. Thus, paxillin phosphorylation at tyrosines 31 and 118 together is necessary for pressure-induced adhesion. Paxillin, Crk and Cas form a trimeric complex that activates Rac1 and mediates this effect.

Temporal changes in factors associated with neutrophil elastase and coagulation in intensive care patients with a biphasic waveform and disseminated intravascular coagulation

Summary. The biphasic waveform is an early marker of disseminated intravascular coagulation (DIC). Neutrophil elastase (NE) cleaves coagulation factors; thus, elevated elastase levels or its dysregulation by alpha-1-protease inhibitor (Alpha1PI) may be linked to DIC. Time courses over a period were determined for factors associated with NE and coagulation in 14 Intensive Care Unit patients with a biphasic waveform who developed DIC. The data were analyzed using a random coefficient linear regression model to predict the variables' mean values on day 0 and their mean rates of change over the period in which the biphasic waveform appeared. The biphasic waveform was normal on day 0, maximized on day 1, and approached normal again by day 4. Alpha1PI/NE complex levels were 2.5-fold greater than normal for the entire period. The A1PI activity, antigen, and specific activity levels were normal on day 0 and increased thereafter by 21.0, 10.5, and 8.9% of normal per day, respectively. Factor II, V, VII, IX, and X activity levels were, respectively, 57, 46, 46, 77, and 46% of normal on day 0, whereas factor VIII and fibrinogen levels were normal. All coagulation factor levels trended upward with time but not significantly. The prothrombin time, but not the activated partial thromboplastin time, was prolonged, and the platelet counts and hematocrits were below normal on day 0 and remained so thereafter. We conclude that events associated with neutrophil activation, elastase release, and perturbations of coagulation precede both the appearance of the biphasic waveform and the diagnosis of DIC in these patients.

Epidural cooling for spinal cord protection during thoracoabdominal aortic aneurysm repair (a case study)

Aneurysms result from damage to artery walls as a result of underlying athrosclerotic and/or thromboembolic disorders. A thoracoabdominal aortic aneurysm involves vessel damage and wall weakening in the thoracic and abdominal segments of the aorta. Thoracoabdominal aortic aneurysm repair is considered to be high risk due to the nature of the intervention that requires an extensive incision with clamping of the thoracic aorta above the renal arteries. Clamping of the aorta renders all areas distal to the clamp at high risk for ischemic trauma especially to the spinal cord where the risk of neurological deficits postoperatively is 7-16% (Cambria, et al., 1997; Davison, et al., 1997). Several adjunct interventions have been tried to reduce the risk of spinal cord injury associated with the ischemia of cross clamping. Epidural cooling has been successful as an adjunct in reducing the neurological deficits. A preoperative nursing assessment indicating the appropriate nursing diagnoses and nursing care required for this patient, allowed for individualization of the plan needed to include this new procedure and plan for best patient outcomes and practices.

Early identification and prognostic implications in disseminated intravascular coagulation through transmittance waveform analysis

Efforts to improve the prognosis in disseminated intravascular coagulation (DIC) have been hampered by the lack of an early, useful and rapidly available diagnostic marker. More recently, a characteristic bi-phasic change in the light transmittance waveform profile of the APTT assay has been associated with DIC. In this prospective study, we have assessed the utility of this assay in the routine clinical setting. 1,470 samples were analysed from 747 patients and 41 patients had DIC. The sensitivity and specificity of the bi-phasic waveform pattern for DIC was 97.6% and 98% respectively. The appearance of a bi-phasic waveform preceded the development of abnormalities in the standard laboratory tests for DIC and waveform changes correlated closely with clinical events. In conclusion, transmittance waveform analysis is not only useful as an early diagnostic and single monitoring marker of DIC but the quantifiable and standardisable changes also allow for prognostic applicability in clinical management.

Novel and diagnostically applicable information from optical waveform analysis of blood coagulation in disseminated intravascular coagulation

Transmittance waveform is the term applied to the optical profile generated from the process of clot formation on standard coagulation tests run on the MDA-180, a new-generation automated coagulation analyser. In patients with disseminated intravascular coagulation, a characteristically abnormal 'biphasic change' is seen on both the activated partial thromboplastin time and thrombin time waveforms. Increasing steepness of the initial slope on the waveform correlates with clinical deterioration and fulminant progression. Although the mechanism underlying the biphasic appearance remains to be elucidated, its identification provides the diagnostic laboratory with a simple, rapid and robust assay for disseminated intravascular coagulation that can help the clinician with urgent and appropriate therapeutic interventions.

Increase in levels of serum keratan sulfate following cartilage proteoglycan degradation in the rabbit knee joint

Following injection of chymopapain into a single knee joint in rabbits, serum keratan sulfate levels rose sharply and remained elevated for at least 48 hours before returning to preinjection levels. These changes were accompanied by depletion of proteoglycans from articular cartilage in the injected joint. We conclude that serum keratan sulfate levels rise predictably following acute loss of proteoglycan from a single joint.

Pattern of follicular development during the estrous cycle of aged rats

The pattern of follicular development during the estrous cycles of aged rats was examined and compared with that of mature rats. In both, preovulatory follicles are derived from a select group of small pre-Graafian follicles which begin to develop at estrus and reach the preovulatory size by the morning of proestrus, but the rate of growth, as judged by an increase in the percentage of granulosa cells incorporating 3H-thymidine, is accelerated in the follicles of aged rats. A second mechanism, which accounts for preovulatory follicles in aged rats, involves the rescue from atresia of pre-Graafian and preovulatory follicles. The existence of this mechanism is supported by the observation that at metestrus in aged rats virtually all follicles, regardless of their state of atresia, possess a high percentage of granulosa cells incorporating 3H-thymidine, indicating that the follicles are growing rapidly. However, some of these rapidly growing follicles show signs of atresia such as pyknotic nuclei within their granulosa cell layers. Since follicles in the initial stage of atresia contain defective oocytes (Peluso et al. 1979b), their rescue and development into preovulatory follicles would result in the ovulation of defective oocytes, a fact which accounts in part of the lower fertility in these older animals.