The need to monitor emerging issues in etomidate usage: the misuse or abuse potential

Since 2011, the misuse or abuse of etomidate has gradually increased when propofol was designated a controlled drug under the Narcotics Control Act in Korea. Accordingly, the Ministry of Food and Drug Safety announced that etomidate would be under the 'Regulation on the designation of drugs that may cause concerns of misuse or abuse' rule in June 2020, which is less stringent than the Narcotics Control Act. Therefore, this review investigates potential misuse or abuse cases of etomidate to consider strengthening its management. A literature search was conducted to compare etomidate with other sedatives in their efficacy and side effects, as well as identify the adverse health outcomes, abuse cases, and analytical methods of etomidate. Etomidate has an equal or higher sedative efficacy and lower risk of adverse cardiopulmonary events than propofol. However, major adverse effects of etomidate include adrenocortical suppression and unproven associated deaths, as well as myoclonus requiring pre-treatment. Although the issue of abuse and misuse of etomidate is emerging in recent years, there are few academic reports on these issues and analytical methods in the forensic field. In order to effectively manage the misuse or abuse of etomidate, it is necessary to continuously monitor related cases with great interest and to be more intensively studied on its abuse potential.

Clinical and electrophysiological characteristics of extra-pulmonary vein triggers in patients who underwent catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Extra-pulmonary vein (PV) triggers play significant roles in atrial fibrillation (AF) recurrence after AF catheter ablation (AFCA).

Purpose

We explore the clinical and electrophysiological characteristics of extra-PV triggers in de novo and repeat-AFCA procedure.

Methods

We included 2,151 patients who had de novo AFCA and 319 repeat AFCA (female 28.0%, 59.1 ± 10.8 years old, paroxysmal AF 65.1%) those underwent post-procedural isoproterenol (ISO) provocation tests. We analysed the clinical, electrophysiological, and procedure-related factors associated with extra-PV triggers.

Results

Extra-PV triggers were documented in 11.9% (1.19 ± 0.42 foci) after de novo-AFCA and 27.0% (1.37 ± 0.65 foci) after repeat-AFCA (p = 0.004). LA volume index (OR 1.02 [1.01-1.03], p = 0.004), history of vascular disease (OR 0.55[0.31-0.91], p = 0.028) and Lead I amplitude of electrocardiogram (OR <0.01 [<0.01-0.62], p = 0.032) were independently associated with the existence of extra-PV triggers in de-novo procedure. Women (OR 1.84 [1.03-3.25], p = 0.037) and LA appendage volume (OR 1.04 [1.01-1.07] p = 0.027) were independently associated with extra-PV triggers during the redo-mapping procedure. Septum (28.4%), coronary sinus (24.0%), and superior vena cava (19.6%) were common extra-PV foci, and septal foci were more commonly found in repeat mapping (38.4% vs. 25.0%, p = 0.025). Among 65 patients who showed extra-PV at the repeat procedures, 19 (29.2%) matched with previous focal or empirical extra-PV ablation sites and 9 (13.8%) were multiple or unmappable sites. AF recurrence rates were significantly higher in both patients with extra-PV triggers after de novo procedures (Log-rank P <0.001; HR 1.93 [1.58-2.36], p= <0.001) and repeat procedures (Log-rank P <0.001, HR 1.87 [1.29-2.70], p= <0.001).

Conclusion

ISO provoked extra-PV triggers commonly found in AF patients with significant remodelling and previous empirical or focal extra-PV ablations. Existence of extra-PV triggers were independently associated with poorer rhythm outcome after both de novo and repeat AFCA. Denovo AF ablation outcome OverallExtra-PV triggers (-)Extra-PV triggers (+)p-value(n = 2151)(n = 1895)(n = 256)Age, yrs58.98 ± 10.9558.73 ± 11.0360.76 ± 10.200.006Male, (%)1550 ( 72.1)1389 ( 73.3)161 ( 62.9)0.001Follow up duration, month50.30 (37.71)51.65 (37.95)40.71 (34.58)<0.001Early recurrence (%)579 ( 27.8)455 ( 24.9)124 ( 48.4)<0.001Clinical recurrence (%)699 ( 33.6)584 ( 32.0)115 ( 44.9)<0.001Abstract Figure. AF free survival according to Extra PVT

Computational modeling for antiarrhythmic drugs for atrial fibrillation according to the genotypes

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by a grant [HI19C0114] from the Ministry of Health and Welfare. Additionally, the work was funded by grants [NRF-2019R1C1C100907512], and [NRF-2020R1A2B01001695] from the Basic Science Research Program run by the National Research Foundation of Korea (NRF) under the Ministry of Science, ICT & Future Planning (MSIP).

Background

The efficacy of antiarrhythmic drugs (AAD) can vary in patients with atrial fibrillation (AF) and the PITX2 gene affects the responsiveness of AADs. We explored the virtual AAD (V-AAD) responses between wild-type and PITX2+/- deficient AF conditions by realistic in-silico AF modeling.

Methods

We tested the V-AADs in AF modeling integrated with patients’ 3D-computed tomography and 3D-electroanatomical mapping, acquired in 25 patients (68% male, 59.8 ± 9.8 years old, 32.0% paroxysmal type). The ion currents for the PITX2+/- deficiency and each AAD (amiodarone, sotalol, dronedarone, flecainide, and propafenone) were defined based on previous publications.

Results

We compared the wild-type and PITX2+/- deficiency in terms of the action potential duration (APD90), conduction velocity (CV), maximal slope of restitution (Smax), and wave-dynamic parameters, such as the dominant frequency (DF), phase singularities (PS), and AF termination rates according to the V-AADs. The PITX2+/- deficient model exhibited a shorter APD90 (p < 0.001), a lower Smax (p < 0.001), mean DF (p = 0.012), PS number (p < 0.001), and a longer AF cycle length (AFCL, p = 0.011). Five V-AADs changed the electrophysiology in a dose dependent manner. AAD-induced AFCL lengthening (p < 0.001) and reductions in the CV (p = 0.033), peak DF (p < 0.001) and PS number (p < 0.001) were more significant in PITX2+/- deficient than wild-type AF. PITX2+/- deficient AF was easier to terminate with class IC AADs than the wild-type AF (p = 0.018).

Conclusions

The computational modeling-guided AAD test was feasible for evaluating the efficacy of multiple AADs in patients with AF. AF wave-dynamics and electrophysiological characteristics are different among the PITX2 deficient and the wild-type genotype models. BaselineChanges after AADClass ICClass IIIWild-typePITX2+/-p-valueWild-typePITX2+/-p-valueWild-typePITX2+/-p-valueWild-typePITX2+/-p-valueAPD90, (ms)243.7 ± 33.8184.4 ± 15.5<0.00138.2 ± 37.343.4 ± 56.20.223275.9 ± 43.5219.0 ± 39.2<0.001284.9 ± 32.8233.8 ± 71.4<0.001CV, (m/s)0.78 ± 0.320.70 ± 0.210.347-0.15 ± 0.18-0.20 ± 0.260.0330.63 ± 0.320.53 ± 0.300.0270.60 ± 0.360.43 ± 0.33<0.001Mean Smax0.787 ± 0.280.531 ± 0.18<0.0010.005 ± 0.260.115 ± 0.24<0.0010.828 ± 0.310.694 ± 0.320.0030.768 ± 0.320.608 ± 0.27<0.001Mean AFCL, (ms)146.96 ± 24.61164.78 ± 22.730.01122.62 ± 24.5537.92 ± 32.72<0.001165.44 ± 36.96190.85 ± 35.61<0.001169.05 ± 25.26203.35 ± 34.78<0.001Peak DF, (Hz)10.68 ± 2.9711.82 ± 3.340.211-2.98 ± 4.94-5.46 ± 4.66<0.00110.01 ± 4.397.23 ± 4.20<0.0016.30 ± 4.325.80 ± 4.070.301Mean DF, (Hz)6.80 ± 0.886.22 ± 0.710.012-1.95 ± 2.44-2.20 ± 1.990.2065.75 ± 1.784.53 ± 2.00<0.0014.14 ± 2.393.69 ± 2.000.077PS Number, (N)101086 ± 9608814150 ± 24778<0.001-59322 ± 99288-7409 ± 27856<0.00150579 ± 6523611568 ± 21868<0.00132951 ± 558643524 ± 8302<0.001PS Life Span, (ms)109.36 ± 113.90102.24 ± 226.640.889-24.87 ± 72.06-41.38 ± 126.350.073103.36 ± 180.6868.05 ± 162.790.14871.91 ± 141.8655.99 ± 217.970.454Table. Effects of AADs in the Wild-type and PITX2+/- Deficiency groupAbstract Figure. Wild-type vs. PITX2+/- baseline model

Long-term outcomes of empirical extra-pulmonary vein linear ablation in patients with persistent atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants [HI18C0070] and [HI19C0114] from the Korea Health 21 R&D Project, Ministry of Health and Welfare, and a grant [NRF-2020R1A2B01001695] from the Basic Science Research Program run by the National Research Foundation of Korea (NRF).

Background

Although extra-pulmonary vein (PV) left atrial (LA) linear ablation has been performed during catheter ablation (CA) of persistent atrial fibrillation (PeAF), the long-term efficacy and safety of this procedure have not yet been verified.

Purpose

We investigated whether an anterior line (AL) and posterior box ablation (POBA) in addition to circumferential PV isolation (CPVI) improves the rhythm without worsening the LA function in PeAF patients.

Methods

We retrospectively compared the additional AL + POBA and CPVI alone groups in 604 patients with PeAF who underwent regular rhythm follow-ups (16.9%; males 79.3%, 58.5 ± 10.7 years of age) after propensity score matching. The primary endpoint was AF recurrence after single procedures and secondary endpoints were the cardioversion rate, response to anti arrhythmic drugs, LA changes, and re-conduction rates of the de-novo ablation lesion set.

Results

After a mean follow-up of 45.2 ± 33.6 months, the clinical recurrence rate did not significantly differ between the two groups (log-rank p = 0.554) despite longer procedure times in the AL + POBA group (p < 0.001). Atrial tachycardia recurrences (p = 0.001) and the cardioversion rates after ablation (p < 0.001) were higher in the AL + POBA group than CPVI group. AL + POBA was associated with better rhythm outcomes in patients with large anterior LA volume indices (p for interaction 0.037) and low mean LAA(left atrial appendage) voltages (p for interaction 0.019). In repeat procedures, the LA pulse pressure elevation was significant after the AL + POBA.

Conclusion

In patients with PeAF, an AL + POBA in addition to the CPVI did not improve the rhythm outcomes nor influence the long-term safety, and lead to more extended procedures. Procedure outcomes OverallAL + POBACPVIp-value(n = 604)(n = 302)(n = 302)Procedure time, min190.8 ± 62.6226.9 ± 49.4154.6 ± 52.8<0.001Ablation time, sec5079 ± 19566420 ± 13723738± 1475<0.001Overall complications24 (4.0)13 (4.3)11 (3.6)0.835Early recurrence, n (%)277 (45.9)129 (42.7)148 (49.0)0.142Recurrence type AT, n (% in early recur)77 (27.8)51 (39.5)26 (17.6)<0.001Clinical recurrence within 1-year, n(%)116 (19.2)52 (17.2)65 (21.5)0.256Recurrence type AT, n (% in clinical recur)60 (23.1)46 (30.7)14 (12.7)0.001Cardioversion, n (% in total recur/ % overall)105 (40.4/17.4)74 (49.3/24.5)31 (28.1/10.3)<0.001POBA, posterior box ablation; AL, anterior line; CPVI, circumferential pulmonary vein isolation; AT, atrial tachycardia;Abstract Figure. Long term ablation outcome

P3762The impact of type and burden of atrial fibrillation on stroke occurrence in patients with atrial fibrillation: from a prospective cohort of atrial fibrillation patients (CODE-AF Registry)

Background and purpose

Although several studies reported that stroke risk in patients with paroxysmal atrial fibrillation (AF) is similar to those with persistent or permanent AF, there is still controversy on the relationship of AF type and stroke occurrence. We investigated the effect of AF type on AF burden and stroke risk in patients with non-valvular AF.

Methods

Within the CODE-AF prospective, outpatient registry (COmparison study of Drugs for symptom control and complication prEvention of Atrial Fibrillation), we identified 8,883 patients ≥18 years of age with non-valvular AF and eligible follow-up visits. We compared AF burden and stroke risk among patients with 3 types of AF: paroxysmal (n=5,808) or persistent (n=2,806) or permanent (n=269).

Results

The median age of the overall population was 68.0 (interquartile range, 60.0–75.0); 36.0% were female. Patients with persistent and permanent AF were older and had higher CHA2DS2-VASc scores and anticoagulation rate than those with paroxysmal AF. Compared with permanent AF (5.2±16.4%), the arrhythmic burden of AF on 24hrs Holter monitoring was significantly lower in paroxysmal AF (2.1±7.2%, p<0.001) and persistent AF (2.0±7.5%, p<0.001). During median follow-up period of 1.38 years (interquartile range: 0.96–1.67), total 82 (0.92%) patients experienced ischemic stroke with incidence rates of 0.51, 1.04 and 1.69 events per 100 person-years for paroxysmal, persistent and permanent AF, respectively. Compared with paroxysmal AF, the risk of ischemic stroke was increased in persistent AF with clinical variable adjusted hazard ratio (aHR) of 1.94 (95% confidence intervals [CI], 1.23–3.07; P=0.005) and permanent AF with aHR of 2.64 (95% CI, 1.09–6.41; P=0.03).

AF type and HR of stroke occurrence Paroxysmal (n=5,808) Persistent (n=2,806) Permanent (n=269) Stoke events 39 37 6 Person years (PYs) 7673 3544 356 /100 PYs 0.51 1.04 1.69 HR (95% CI), p-value HR (95% CI), p-value HR (95% CI), p-value Unadjusted HR 1 (Reference) 2.05 (1.27–3.31), 0.003 3.32 (1.15–7.90), 0.02 Clinical variables adjusted HR 1 (Reference) 1.94 (1.23–3.07), 0.005 2.64 (1.09–6.41), 0.03 PYs: Person years; HR: Hazard ratio.

Conclusion

Persistent and permanent AF was associated with the increased risk of stroke than paroxysmal AF, after adjustment of clinical variables including age, sex, comorbidities and anticoagulation rate. These results suggest that AF type and burden might be related with the risk of ischemic stroke and should be considered in the stroke prevention of AF.

Patient age, remission status and HCT-CI in a combined score are prognostic for patients with AML undergoing allogeneic hematopoietic cell transplantation in CR1 and CR2

For AML, older age, advanced disease and increased hematopoietic cell transplant comorbidity index (HCT-CI) are associated with worse prognosis following allogeneic hematopoietic cell transplantation (HCT). This single-center retrospective study investigated the influence of pre-transplant characteristics on outcomes of 387 patients undergoing allogeneic HCT for AML in CR1 and CR2. The multivariable analysis model for overall survival (OS) included age (hazard ratio (HR)=2.24 for ages 31-64 years and HR=3.23 for age ⩾65 years compared with age ⩽30 years, P=0.003), remission status (HR=1.49 for CR2 compared with CR1, P=0.005) and HCT-CI score (HR=1.47 for ⩾3 compared with <3, P=0.005). Transplant year was significantly associated with OS (P=0.001) but this did not influence the model. A weighted score was developed with age ⩽30, CR1 and HCT-CI score <3 receiving 0 points each, and CR2 and HCT-CI score ⩾3 receiving 1 point each. Ages 31-64 received 2 points, age ⩾65 received 3 points. Scores were grouped as follows: scores 0-1 (low risk, n=36), score 2 (intermediate-low risk, n=147), score 3 (intermediate-high risk, n=141) and scores 4-5 (high risk, n=63) with 3-year OS of 71%, 55%, 42% and 29% for scores 0-1, 2, 3 and 4-5, respectively (P<0.0001). The score predicted nonrelapse mortality (P=0.03) but not cumulative incidence of relapse (P=0.18). This model should be validated for the pre-HCT assessment of AML patients in CR1 and CR2.

Outcomes of patients with therapy-related AML/myelodysplastic syndrome (t-AML/MDS) following hematopoietic cell transplantation

We studied outcomes of 65 consecutive patients with therapy-related AML/myelodyplastic syndrome (t-AML/MDS) who underwent allogeneic hematopoietic cell transplantation (HCT). Previously published scores of HCT-CI, CIBMTR, EBMT and Comorbidity-age index were also evaluated. Median follow-up of survivors was 72 months (range 16-204). At 2 years, overall survival (OS) was 34% (95% confidence interval (CI) 23-45). Nineteen patients (29%) had monosomal karyotype (MK). Patients with MK had an OS of 21% (95% CI 7-41) at 2 years. Abnormal adverse cytogenetics, unrelated donor, bone marrow graft and CIBMTR score were significant risk factors for OS on univariate analysis. On multivariate analysis, abnormal adverse cytogenetics (hazard ratio (HR) 2.7; 95% CI 1.02-7.2; P-value=0.02) and unrelated donor (HR 2.7; 95% CI 1.5-5.0; P-value=0.0013) were independent factors for survival. Non-relapse mortality (NRM) at 2 years was 31% (95% CI 15-47). Donor type was the only factor that was significant for NRM with matched related donors having an NRM of 20% (95% CI 0-42) whereas unrelated donors had NRM of 60% (95% CI 40-80; P-value=0.0007). In conclusion, patients with t-AML/MDS have poor OS. Unrelated donor is a significant risk factor for both higher NRM and decreased OS. Cytogenetics are predictive for OS.

Primary chemotherapy, stereotactic radiosurgery, or whole brain radiotherapy in non-small cell lung cancer (NSCLC) patients with asymptomatic brain metastases

e19063

Background: Approximately 25 to 30% of patients with lung cancer develop brain metastases at some stage and 12∼18% at the time of initial presentation. Whole brain radiotherapy (WBRT) has long been a mainstay of treatment of brain metastases. Another treatment approach, Stereotactic radiosurgery (SRS) is a method of delivering high doses of focal irradiation to a tumor while minimizing the irradiation to the adjacent normal tissue. However, the prognosis of NSCLC patients with asymptomatic brain metastases, who are not treated with SRS or WBRT, has not been fully investigated yet. This study aimed to analyze the outcome for various treatment modalities in NSCLC patients with asymptomatic brain metastases. Methods: We reviewed the medical records of 129 patients with a histopathologically proven NSCLC and a synchronous brain metastases between January 2003 and December 2007. The patients were categorized as primary chemotherapy, primary SRS, and primary WBRT group: primary chemotherapy (78 patients), primary SRS (24 patients), and primary WBRT (27 patients). Results: With median follow-up of 30.0 months (7.2 -70.7), the median overall survival (OS) for the entire patients was 15.6 months (0.5–50.7) and the progression free survival (PFS) was 6.1 months (0.3- 53.0). The OS was 22.4m for primary SRS group, 13.9m for primary chemotherapy group, and 17.7m for primary WBRT group; p=0.86). However, patients treated with primary SRS showed trend toward prolonged survival compared to those of primary WBRT p=0.06). Subset analysis of 110 adenocarcinoma patients showed that the median OS for patients treated with primary SRS was longer than those of primary WRBT (29.3m vs 17.7m p=0.01) or primary chemotherapy (29.3m vs 14.6m p=0.04). Conclusions: These results suggest that for NSCLC patients with asymptomatic brain metastases at first diagnosis, SRS rather than primary chemotherapy or WBRT might be considered as initial treatment, especially for patients with adenocarcinoma.

No significant financial relationships to disclose.

NCCTG phase I trial of temsirolimus (CCI-779) and temozolomide (TMZ) in combination with radiation therapy (RT) in newly diagnosed glioblastoma multiforme (GBM) patients

2019

Background: The mammalian target of rapamycin (mTOR) functions within the PI3K/Akt signaling pathway as a critical modulator of cell survival. We previously demonstrated significant synergy of the mTOR inhibitor sirolimus with RT in glioma xenografts. Methods: The standard cohorts of 3 design was applied with dose escalation of weekly IV CCI-779 in combination with standard TMZ/RT. CCI-779 was given during both RT (60 Gy)/TMZ (75 mg/m2 daily) and adjuvant TMZ (200 mg/m2 daily x 5 every 28 days). Results: A total of 17 patients were enrolled. CCI-779 therapy during RT/TMZ was well tolerated at dose level 0 (25 mg CCI-779, n = 3) and dose level 1 (50 mg CCI-779, n = 6) with 1 of 9 patients experiencing a DLT (Gr 3 fatigue). Dose level 2 (75 mg CCI-779) exceeded the maximally tolerated dose with two of six patients with DLT (<75% CCI-779 delivered; Gr 4 dyspnea). Despite reasonable tolerance during RT/TMZ, the overall regimen was associated with a high rate of infection associated with lymphopenia. After a patient died from PCP on cycle 2 of adjuvant TMZ/CCI-779, antibiotic prophylaxis was mandated. Two other patients died of gram-negative sepsis despite prophylaxis: one after their first dose of CCI-779 and one during cycle 4 of adjuvant therapy. In contrast to our 18% grade 5 infection rate, only 4% grade 3 (no grade 4/5) infections were observed in 26 other CTEP-sponsored clinical trials involving 1,006 patients treated with CCI-779. Results from translational studies evaluating the effects of treatment on immune function will be presented. Further infections were avoided on this trial after CCI-779 therapy was limited to RT/TMZ. Conclusions: Although CCI-779 in combination with RT/TMZ was well-tolerated, adjuvant therapy with TMZ/CCI-779 was associated with an increased risk of opportunistic infections.

[Table: see text]

Elevated levels of Mr 92,000 type IV collagenase during tumor growth in vivo

Our previous studies demonstrated that matrix metalloproteinase (MMP-9) levels were significantly higher in human glioblastoma tissue samples than in low-grade brain tumors and normal brain tissue (Rao et al., Cancer Res. 53, 2208-2211, 1993). In the present study, we measured the levels of MMP-2 and MMP-9 during the growth of glial tumors in nude mice by intracerebral injection of glioblastoma cells. Using gelatin zymography, densitometry, and an enzyme-linked immunosorbent assay, we found that the enzyme activity and protein count of MMP-2 and MMP-9 were a respective 3- to 10- and 2- to 30-fold higher in tumors at day 14 and 28 than in normal tissue. Immunohistochemical staining for MMP-9 showed strong immunoreactivity in tumor cells and the staining intensity was much higher at day 28, compared to day 14. These results suggest that upregulation of MMP-9 plays a major role in the glioma tumor growth in vivo.