Carbon Footprint of Photon Therapy

PURPOSE/OBJECTIVE(S)

Rising carbon dioxide levels have hazardous impact on human health and climate change. This study estimates the energy utilization of radiation therapy and estimates corresponding carbon footprint.

MATERIALS/METHODS

Patients treated between 07/2020 and 06/2021 using a Varian LINAC system were evaluated. Power draw was directly measured in 1 second increments, from the LINAC machine and the radiation department facility. Patients treated were reviewed for number of fractions and beam duration during each fraction. kWh power consumption was calculated per fraction and per treatment course. Patient commute distance was evaluated using Google Maps. EPA calculator was used to calculate CO2 equivalent (CO2e) footprint.

RESULTS

There were 176 patients treated for 191 treatment courses. Total of 4,517 fractions were delivered (avg 23.6, range 1 to 48). Average BeamOn time was 141 seconds per fraction (22 to 310 sec); electron plans (n = 8) 29 sec, 2D/3D (n = 63) 77 sec, and IMRT (n = 120) 182 sec. BeamOn power draw was ∼36.3 kW. Power consumption per fraction was 1.4 kWh (0.2 to 3.0 kWh), and per course 37.5 kWh (0.9 to 109.1 kWh). LINAC was otherwise in standby mode 71% of time (∼7.3 kW) and ON/ready mode 25% (∼12.5 kW). Patient BeamOn time accounted for 2% of total its time and 8% of its power use during the year. Incremental standby/ready energy contribution per treatment course was 410 kWh (78,332/191). The building power draw was 12.5 kW, for incremental contribution of 576 kWh per course. Average patient travel distance was 9.6 miles (0.7 miles to 73.5 miles), resulting in 711-mile round trip per course (6 miles to 5620 miles). Corresponding carbon footprint for BeamOn time was 0.6 kg CO2e per fraction (electrons 0.1 kg, 2D/3D 0.3 kg, and IMRT 1.1 kg per fx). The treatment course footprint was 16.2 kg CO2e (0.4 kg to 47.2 kg). The attributed standby/ready LINAC footprint was 177.8 kg CO2e per course. The attributed facility footprint was further 250.0 kg CO2e per course. The attributed commute footprint was further 286.3 kg CO23 per course (2.4 kg to 2264.0 kg). The entire treatment course was 730.4 kg CO2e. As such, single fraction was 0.1% of the total CO2e course (0.01% to 0.27%), BeamOn was 2.3% (0.1% to 7.1%), LINAC standby/ready was 28.0% (6.5% to 41.3%), building was 39.4% (9.2% to 58%), and commute was 30.3% (0.6% to 82.9%). The entire program generated 139.5 metric tons of CO2e during the year.

CONCLUSION

Linear accelerator BeamOn carbon footprint varied as a function of technique but was only 2% of the overall patient treatment footprint. The LINAC standby electricity contributed 28%, building electricity 39%, and commute 30%, though this varied significantly per patient, as a function of number of fractions and treatment distance. Fixed CO2e contribution from the standby LINAC and the building draw accounted for ∼67% of the footprint. However, radiation oncologists can potentially impact the overall carbon footprint by prescribing fewer fractions to lower total commute, as clinically indicated.

Defining the Role of Intensity Modulation in Electron Conformal Therapy for the Treatment of Head and Neck Cancer

PURPOSE/OBJECTIVE(S)

The use of bolus electron conformal therapy (BECT) in the treatment of cancers of the head and neck is often limited by an inability to reduce dosimetric hot spots resulting from surface or tissue heterogeneity. In this study, we examined the potential benefits of using a recently patented, low-cost form of Intensity Modulation for electron therapy (IM-BECT) to reduce treatment hotspots in patients undergoing electron beam therapy for cancer of the Head and Neck (HN).

MATERIALS/METHODS

The treatment plans from twelve patients with HN cancer previously treated with BECT were identified (treatment energies ranged from 6-18 MeV and field sizes of 36-625 cm2). Each case included the treatment targets and at least one primary OAR that were defined by the original treating radiation oncologist. Additionally, a target + 2 cm rind structure was created for analysis of the dose deposition in areas immediately surrounding the target volume as a measure of conformality. Each patient plan was transferred into a novel IM-BECT planning software and each case was recomputed as per the original prescription, gantry, couch, collimator angles, and original clinically used bolus. Next, each case was replanned with the inclusion of intensity modulation, as well as a new custom conformal bolus that was designed for optimized range compensation. The patient plans were then normalized such that 100% equals the prescription dose value and then transferred to a plan analysis software for comparison of the target coverage/dose and OAR dose.

RESULTS

Comparison of the BECT and IM-BECT treatment plans demonstrated that IM-BECT was able to significantly reduce dosimetric hotspots for this cohort of patients undergoing radiation therapy for HN cancer, bringing the average maximum dose down from 130.6% to only 120.6% (p = 0.044, paired t-test). Moreover, the impact of IM-BECT appeared to be most substantial in the patients with the highest baseline maximum dose. For patients who had a hotspot of 125% or greater, the hotspot was on average reduced by 19%. Further dosimetric analysis demonstrated a small resultant increase in the low dose deposition to the surrounding normal tissues. For BECT, the average primary OAR mean dose and Target+2cm rind mean dose were 27.5% and 60.0%, respectively. For IM-BECT, the average primary OAR mean dose and Target+2cm rind mean dose increased slightly to 30.9% and 64.6%, respectively [Primary OAR mean (P = 0.0008), and Target+2cm rind mean (P = 0.0001), paired t-test].

CONCLUSION

IM-BECT is an effective method of reducing dosimetric hotspots in patients undergoing radiation therapy for cancer of the HN. This improvement came at the expense of a small increase in dose to the underlying tissues. This retrospective planning study represents the first example of IM-BECT being applied to real patient cases and suggests further development of IM-BECT is warranted.

Outcomes of MR-Guided Stereotactic Body Radiotherapy (MRgSBRT) for Adrenal Metastases: A Multi-Institutional Pooled Analysis

PURPOSE/OBJECTIVE(S)

Stereotactic body radiotherapy (SBRT) is an effective treatment for adrenal metastases, but it is technically challenging and there are concerns about toxicity due to the proximity of organs at risk. We hypothesized that MR-guided SBRT (MRgSBRT) using a 0.35 T MR-Linac for adrenal metastases can achieve durable local control (LC) with a low probability of toxicity.

MATERIALS/METHODS

In an ethics-approved study, we analyzed clinical and dosimetric data of patients treated with MRgSBRT at 10 institutions between 2016-2022. LC, local progression-free survival (LPFS), distant progression-free survival (DPFS) and overall survival (OS) were estimated using Kaplan-Meier method and log-rank test. Responses were evaluated using RECIST criteria. Toxicity was graded according to CTCAE (v4.0). OS and DPFS were calculated on a per-patient basis, while LC and LPFS were calculated on a per-lesion basis.

RESULTS

A total of 249 patients (260 adrenal lesions) were included; median age was 65 years (range 28-91), 65.5% were male, 83.9% had ECOG PS 0-1. The most common primary tumor was lung cancer (69.1%). Adrenal metastases were synchronous, metachronous, oligoprogressive or oligopersistent in 20%, 41.5%, 35.8% and 2.7% of patients, respectively. Metastatic pattern was solitary in 26.9%, oligometastatic in 57.3% and polymetastatic in 15.8% of patients. Right-sided metastases comprised 40%, left-sided 51.5% and lesions were bilateral in 8.5%. Chemotherapy and immunotherapy were administered in 67.1% and 60.6% of patients, respectively. Median gross tumor volume was 21.8 cc (range 1.1-383.2) and median planning target volume was 36.9 cc (range 3.6-516.9). Median total dose was 45 Gy (range 16-60), median fraction number was 5 (range 1-8) and median fraction dose used was 10 Gy (range 5-24). Median BED10 was 100 Gy (range 37.5-132); 87.8% of fractions used adapted plans. At a median follow-up was 17.7 months (IQR 5.5-21.7), local responses were scored as complete response (CR), partial response (PR), stable disease (SD) or progressive disease (PD) in 36.9%, 28.2%, 25.7%, and 9.1%, respectively. Median OS was 30.4 months, with 1- and 2- year OS rates of 75.3% and 57.1%, respectively. On multivariate analysis, significantly higher OS rates were seen in patients achieving a CR (p = 0.007, HR 0.50) and with ECOG scores of 0-1 (p = 0.001, HR 0.43). One- and 2- year LPFS rates were 94.5% and 88.8%, respectively. No local recurrences were observed after treatment to a BED10>100 or with single fraction (range 16-24 Gy). Only 2 patients (0.8%) had ≥grade 3 chronic toxicity.

CONCLUSION

This multi-institutional study of MRgSBRT outcomes for adrenal metastases revealed a 2-year LPFS of 89%, with a <1% risk of ≥grade 3 toxicity. Daily adaptation was performed in 90% of plans, indicating a beneficial role for MR guidance.

Estimated number of symptomatic Lyme borreliosis cases in Germany in 2021 after adjusting for under-ascertainment

BACKGROUND

Although nine of 16 federal states in Germany conduct public health surveillance for Lyme borreliosis (LB), the extent of under-ascertainment is unknown.

OBJECTIVE

As a model for European countries that conduct LB surveillance, we sought to estimate the population-based incidence of symptomatic LB after adjusting for under-ascertainment.

METHODS

Estimating seroprevalence-derived under-ascertainment relies on data from seroprevalence studies, public health surveillance, and published literature. The number of symptomatic LB cases in states that conduct LB surveillance was estimated from studies reporting the seroprevalence of antibodies against Borrelia burgdorferi sensu lato, the proportion of LB cases that are asymptomatic, and the duration of antibody detection. The number of estimated incident symptomatic LB cases was compared with the number of surveillance-reported LB cases to derive under-ascertainment multipliers. The multipliers were applied to the number of 2021 surveillance-reported LB cases to estimate the population-based incidence of symptomatic LB in Germany.

RESULTS

Adjusting for seroprevalence-based under-ascertainment multipliers, the estimated number of symptomatic LB cases in states that conducted surveillance was 129,870 (408 per 100,000 population) in 2021. As there were 11,051 surveillance-reported cases in 2021 in these states, these data indicate there were 12 symptomatic LB cases for every surveillance-reported LB case.

CONCLUSIONS

We demonstrate that symptomatic LB is underdetected in Germany and that this seroprevalence-based approach can be applied elsewhere in Europe where requisite data are available. Nationwide expansion of LB surveillance would further elucidate the true LB disease burden in Germany and could support targeted disease prevention efforts to address the high LB disease burden.

25 EVALUATION OF PATIENTS PRESENTING WITH TIA IN THE AMAU AND TIA FAST ASSESSMENT CLINICS - ARE WE MEETING ESO GUIDELINES?

Background

The European Stroke Organisation published guidelines on the management of Transient Ischaemic Attack (TIA) in 2021. Specialist review of suspected TIA is recommended within 24-hours of symptom onset in a TIA clinic. They suggest using CT or MR angiogram for additional confirmation of large artery stenosis of &gt;50%. They advise against the use of prediction tools alone e.g. ABCD2 score when identifying high-risk patients. Dual antiplatelet therapy is recommended short-term in high risk, non cardio-embolic TIA patients. This audit evaluates if these guidelines are being followed in our institution.

Methods

We evaluated all patients attending the TIA clinic and the Acute Medical Assessment Unit (AMAU) with suspected TIA over a three-week period in 2021 in a single tertiary referral centre. Retrospective data was collected based on chart review.

Results

Twenty patients underwent review in the TIA clinic and eight in the AMAU with suspected TIA in the chosen time period. One patient (3.5%) was seen within 24 hours from symptom onset, 2 were seen within 24-36 hours (7.1%), 4 patients (14.2%) were seen within 36-72 hours, 21 patients (75%) were seen &gt;72 hours after symptom onset. In all patients who had a doppler US showing &gt;50% carotid stenosis, a CT angiogram was performed. ABCD2 scores were recorded but used in combination with clinical judgment. All patients with high-risk, non-cardioembolic TIA received early, short-term dual antiplatelet therapy.

Conclusion

The diagnostic methods and treatment strategies in place for patients attending the TIA clinic or AMAU with TIA were in keeping with the recently published ESO guidelines. However, there was a time delay from symptom onset to time of review in many patients. Further studies are indicated to identify the potential mechanisms behind these delays. Interventions to ensure that we are meeting this ‘time-to-review’ target in patients could be implemented, ensuring high quality, evidence-based care.

Metrics are required for diagnostic accuracy in acute medicine

The article by Subbe et al raise important considerations as to what is deemed quality care in medicine. Throughput in acute medicine is highly prized. Prompt decision making, and action, is certainly required for several groups of unwell patients, but there is system-wide pressure to maintain this fast pace for all patients. It does not automatically follow that quicker medicine benefits all patients to some degree. 'Productivity' may come at the cost of too much medicine - characterised by overdiagnosis, overtreatment, and substantial resource utilisation.

Radium-223 in the Treatment of Metastatic Castrate-Resistant Prostate Cancer

Background Radium 223 (Ra-223) has been successfully utilised for the treatment of men with metastatic castrate resistant prostate cancer (mCRPC). To date, no real world outcomes from its use in the Irish population have been described. Methods All men referred to our institution for Ra-223 from September 2016 to March 2019 were included. Patient demographics, treatments received, toxicities and outcomes were recorded. Overall survival (OS) and progression free survival (PFS) were analysed using the Kaplan-Meier method. Results Complete data was available for 54 men. Median age was 75 years (range 61-86 years). The median number of prior systemic treatments for mCRPC was 2 (range 0-4). Median ECOG performance status was 1 at the start of treatment and 2 at completion. The median number of Ra-223 cycles received was 4 with 37%(n=20) completing all 6 planned cycles. The most common treatment-related toxicity was fatigue seen in 52% of patients ( n=28). Improved pain scores were documented in 76% of men requiring opioid analgesia at the start of treatment. The median OS was 7 months. A good ECOG performance status, fewer than 6 bone metastases, normal alkaline phosphatase level at start of treatment and chemotherapy naivety were associated with improved OS. Conclusions Ra-223 is a moderately well tolerated palliative treatment amongst Irish men with mCRPC.

Age-adjusted risk factors are independently associated with an increased risk of ischaemic stroke, transient ischaemic stroke and systemic embolism in the ETNA-AF-Europe registry

Background

Oral anticoagulation is highly effective in preventing ischaemic stroke in patients with atrial fibrillation, but 1–2% of the patients suffer an ischaemic stroke upon anticoagulation. Outcomes are further influenced by various factors, and recent research has focussed on identifying risk factors that could be helpful in predicting stroke outcomes in anticoagulated patients. This could further assist clinicians in timely identification and management of high-risk patients.

Purpose

The present analysis aims to assess the age-adjusted risk predictors of ischaemic stroke and systemic embolic events (SEE) (including transient ischaemic attack [TIA]) during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and stroke and SEE after adjusting for age, given that age is a well-known, strong predictor of stroke.

Results

A total of 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. The mean weight was 81.0±17.3 kg, estimated glomerular filtration rate was 74.4±30.5 ml/min/1.73m2 and males were 56.6%. The mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively.

Univariate analysis demonstrated that history of TIA at baseline was the strongest age-adjusted predictor of stroke and SEE (Wald Chi-square: 77.69; p&lt;0.0001) (Figure 1), followed by CHA2DS2-VASc score (41.09; p&lt;0.0001) (Figure 2), history of ischaemic stroke (29.47; p&lt;0.0001), history of any stroke (all strokes combined including stroke of unknown/unspecified type) (29.18; p&lt;0.0001), subjective frailty as assessed by physician (20.60; p&lt;0.0001), and HAS-BLED score (17.22; p&lt;0.0001).

Conclusion

History of TIA, CHA2DS2-VASc score, history of stroke, frailty and HAS-BLED score are independently associated with an increased age-adjusted risk of ischaemic stroke, TIA and SEE in anticoagulated patients with AF. These findings highlight the importance of optimising anticoagulation therapy in secondary prevention of TIA and in patients with high CHA2DS2-VASc scores, ensuring the correct use of NOACs - adherence and correct dosing - in this high-risk population. These findings also suggest that additional therapies could be needed to prevent stroke in this population.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. History of TIA as a predictorFigure 2. CHA2DS2-VASc score as a predictor

Age-adjusted risk factors are independently associated with an increased risk of major bleeding during the two-year follow-up of the ETNA-AF-Europe registry

Background

Non-vitamin K antagonist oral anticoagulants (NOACs) are a preferred treatment option over warfarin for anticoagulation in patients with atrial fibrillation (AF). Management decisions for thromboprophylaxis in AF need to balance the risk of stroke against the risk of bleeding. Various patient characteristics have been identified as independent risk factors for bleeding. A substantial number of bleeding events might be prevented if independent predictors of bleeding were identified.

Purpose

The present analysis aims at assessing age-adjusted risk predictors of major bleeding during two-year follow-up of unselected European patients with AF in the ETNA-AF-Europe registry.

Methods

ETNA-AF-Europe is a prospective, multi-centre, post-authorisation, observational study conducted in 825 centres enrolling patients treated with edoxaban once daily in 10 European countries. Wald Chi square tested the association between risk predictors and major bleeding after adjusting for age, given that age is a well-known, strong predictor of anticoagulation-related bleeding in patients with AF.

Results

Overall, 13,417 patients with AF (edoxaban 60 mg: n=10,248; edoxaban 30 mg: n=3169) completed the two-year follow-up. The mean age was 73.6±9.5 years, with ∼84% of the patients aged over 65 years. Mean CHA2DS2-VASc and HAS-BLED scores were 3.2 and 2.5, respectively. 438 (3.3%) patients had a history of bleeding events at baseline, of which 138 (1.0%) had a history of major bleeding event.

Univariate analysis demonstrated that recalculated glomerular filtration rate (Cockcroft-Gault Equation) (GFR-CG) at baseline was the strongest age-adjusted predictor of major bleeding (Wald Chi-Square: 31.84; p&lt;0.0001) (Figures 1 and 2), followed by history of major or clinically relevant non-major (CRNM) bleeding (24.08; p&lt;0.0001), HAS-BLED score (21.10; p&lt;0.0001), history of heart failure (derived) (16.59; p&lt;0.0001), subjective frailty as assessed by physician (17.35; p=0.0002), history of major bleeding (14.14; p=0.0002), chronic obstructive pulmonary disease (COPD) (12.84; p=0.0003), CHA2DS2-VASc (12.14; p=0.0005), history of myocardial infarction (MI) (7.79; p=0.005), and left ventricular ejection fraction (LVEF) categorised by 40% (5.45; p=0.02).

Conclusion

Bleeding events on therapy with edoxaban can be predicted by quantifying kidney disease and capturing information on heart failure, frailty, prior bleeding, chronic obstructive lung disease and history of myocardial infarction. These data highlight the need for optimal management of anticoagulation therapy and close follow-up of patients with such risk profiles.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH Figure 1. GFR-CG as a predictor of major bleedingFigure 2. Predictors of major bleeding

Learning to implement Smart Healthy Age-Friendly Environments

To develop trainings on the implementation of smart healthy age-friendly environments for people who aim to support, for example, their parents, their neighbours or local community, there are precautionary measures that have to be taken into account: the role of the facilitator (volunteer or self-employed), the level of skills, the needs of the end-users, training content and methodologies together with the sustainability of the learning. This article examines these aspects, based on desk research and expert interviews in the Smart Healthy Age-Friendly Environments (SHAFE) fields.

Knowledge and Attitudes of two Latino Groups about Alzheimer Disease: a Qualitative Study

Clustering Latinos under a single group in Alzheimer Disease (AD) research, neglects, among other things cultural and environmental differences. To address this, we examine knowledge and attitudes about AD among two Latino groups. We held 5 focus groups and 2 interviews all in Spanish with Mexicans and Puerto Ricans between 40 and 60 years old living in the Grand Rapids area in Michigan. Using content analysis of the discussions, we identified themes related to knowledge, attitudes and concerns about AD and caregiving. A total of 20 Mexicans and 9 Puerto Ricans participated. Improving knowledge and awareness, barriers and home-based family care were important themes in both Latino groups. Puerto Rican groups raised more concerns about the disease, whereas lack of knowledge was a key theme among Mexican participants. The exploratory study is a first step in promoting research that is attentive to the commonalities and differences of Latino groups and in continuing efforts to enhance health literacy among these groups.

Design and characterization of a prototype tertiary device for proton beam stereotactic radiosurgery

Though potentially beneficial, proton beam stereotactic radiosurgery has not been adopted widely secondary to the technical challenge of safely delivering multiple focused beams of proton radiation. In this study, we describe the design and characterization of a proton beam stereotactic radiosurgery system that can be adopted by existing passive scattering systems. This system utilizes a helmet-like device in which patient-specific brass apertures required for final beam collimation are positioned on a scaffold that is separate from the treatment gantry. The proton snout is then fitted with a generic aperture to focus the primary proton beam onto the patient specific apertures that are in the helmet-like device. The patient-specific apertures can all be placed at the start of the treatment, thus treatment with multiple beams can be accomplished without the delay of switching the apertures. In this report we describe a prototype design of this collimation system and dosimetric testing to verify efficacy. Subsequently, we describe a custom 3D printing of a prototype device and report on overall localization accuracy using Winston-Lutz tests. Our results show that it is possible to develop an add-on device for proton beam radiosurgery that is safe and efficient and capable of wide adoption on existing proton delivery systems.

Commercial beef farms excelling in terminal and maternal genetic merit generate more gross profit

Validation of beef total merit breeding indexes for improving performance and profitability has previously been undertaken at the individual animal level; however, no herd-level validation of beef genetic merit and profit has been previously investigated. The objective of the present study was to quantify the relationship between herd profitability and both herd-average terminal and maternal genetic merit across 1,311 commercial Irish beef herds. Herd-level physical and financial performance data were available from a financial benchmarking tool used by Irish farmers and their extension advisors. Animal genetic merit data originated from the Irish Cattle Breeding Federation who undertake the national beef and dairy genetic evaluations. Herd-average genetic merit variables included the terminal index of young animals, the maternal index of dams, and the terminal index of service sires. The herds represented three production systems: 1) cow-calf to beef, 2) cow-calf to weanling/yearling, and 3) weanling/yearling to beef. Associations between herd financial performance metrics and herd average genetic merit variables were quantified using a series of linear mixed models with year, production system, herd size, stocking rate, concentrate input, and the two-way interactions between production system and herd size, stocking rate, and concentrate input included as nuisance factors. Herd nested within the county of Ireland (n = 26) was included as a repeated effect. Herds with young cattle excelling in terminal index enjoyed greater gross and net profit per hectare (ha), per livestock unit (LU), and per kg net live-weight output. The change in gross profit per LU per unit change in the terminal index of young animals was €1.41 (SE = 0.23), while the respective regression coefficient for net profit per LU was €1.37 (SE = 0.30); the standard deviation of the terminal index is €37. Herd-average dam maternal index and sire terminal index were both independently positively associated with gross profit per ha and gross profit per LU. Each one unit increase in dam maternal index (standard deviation of €38) was associated with a €1.40 (SE = 0.48) and €0.76 (SE = 0.29) greater gross profit per ha and per LU, respectively. Results from the present study at the herd-level concur with previous validation studies at the individual animal level thus instilling further confidence among stakeholders as to the expected improvement in herd profitability with improving genetic merit.

Safety and effectiveness of edoxaban in a real-world clinical setting: Two-year follow-up of the ETNA-AF-Europe study

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Europe

OnBehalf

ETNA-AF-Europe investigators

Background

Oral anticoagulation (OAC) for stroke prevention is essential in the management of patients with atrial fibrillation (AF). The assessment of OAC use in routine clinical care and the effects of this therapy on outcomes and safety are important.  Purpose: We analysed two-year outcome data with adjudicated follow-up results in 13,417 patients with AF treated with edoxaban. Methods: ETNA-AF-Europe (Clinicaltrials.gov: NCT02944019) enrolled 13,417 consecutive patients with AF treated with edoxaban in 825 centres in 10 European countries and 2-year prospectively collected, real world data is presented. Results: Edoxaban was prescribed according to licence recommendations in 83.1% (n = 11,146) of patients (Table). Whilst three quarters of patients were prescribed edoxaban 60 mg (n = 10,248, 76.4%), the quarter prescribed edoxaban 30 mg were older (79.5 versus 71.8 years), had a higher stroke risk (CHA2DS2-VASc score: 3.9 versus 3.0) and a higher bleeding risk (HAS-BLED score: 2.9 versus 2.4). Thromboembolic and bleeding events were more common in patients receiving edoxaban 30 mg OD without differences in intracranial haemorrhage (ICH) (Figure). Patients prescribed a non-recommended dose of edoxaban had a numerically higher stroke risk (CHA2DS2-VASc score: 3.6 versus 3.1) with subsequent higher rates of ischemic stroke and mortality, however they also had higher bleeding rates, with the exception of ICH (table) despite a similar initial bleeding risk (HAS-BLED score: 2.7 versus 2.5). Conclusions: In this large, European data set reporting two-year outcomes on edoxaban therapy, no additional safety signals were observed and event rates were in line with those observed in ETNA-AF after 1 year and in ENGAGE AF-TIMI 48, re-affirming the safety and effectiveness of edoxaban licence recommendations in a real world setting of patients with AF. All key events of interest, other than intracranial haemorrhage, were numerically lower in patients prescribed the licenced recommended dose. Outcomes with rec. vs non-rec. dosesn (%/year [95%CI])Recommended dose (n = 11,146; 83.1%)Non-recommended dose (n = 2271; 16.9%)Any stroke/SEE138 (0.68 [0.57;0.80])31 (0.76 [0.51;1.07])Ischaemic stroke99 (0.48 [0.39;0.59])26 (0.63 [0.41; 0.93])Major bleeding189 (0.93 [0.80;1.07])49 (1.20 [0.89;1.59])Intracranial haemorrhage43 (0.21 [0.15;0.28])7 (0.17 [0.07;0.35])All-cause mortality729 (3.55 [3.30;3.82])208 (5.04 [4.38;5.78])CV mortality405 (1.97 [1.79;2.18])113 (2.74 [2.26;3.30])CI, confidence interval; CV, cardiovascular; rec., recommended; SEE, systemic embolic event.Abstract Figure. Annualised event rates at 2-year FU

Dysregulation of the interleukin-17A pathway in endometrial tissue from women with unexplained infertility affects pregnancy outcome following assisted reproductive treatment

STUDY QUESTION

Which transcriptomic alterations in mid-luteal endometrial scratch biopsies, taken prior to the assisted reproductive treatment (ART) treatment cycle are associated with unsuccessful pregnancy?

SUMMARY ANSWER

Dysregulated interleukin-17 (IL-17) pathway components are demonstrated in women who fail to become pregnant after ART.

WHAT IS KNOWN ALREADY

Implantation failure is now recognised as a critical factor in unexplained infertility and may be an important component of failed ART.

STUDY DESIGN, SIZE, DURATION

Using a prospective longitudinal study design, 29 nulliparous women with unexplained infertility undergoing ART were recruited between October 2016 and February 2018. Mid-luteal stage endometrium and matched serum samples were collected, and patients underwent a single embryo transfer in the subsequent cycle. RNA-seq analysis of endometrial biopsies was performed on the discovery cohort (n = 20).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Gene set enrichment analysis of the differentially expressed genes (DEGs) was performed. Endometrium and serum were then prepared for IL-17A analysis by ELISA.

MAIN RESULTS AND THE ROLE OF CHANCE

There were 204 differentially expressed protein-coding genes identified in tissue from women who became pregnant (n = 9) compared with tissue from women who failed to become pregnant (n = 11) (false discovery rate; P < 0.05). Of the 204 DEGs, 166 were decreased while 38 were increased in the pregnant compared to the non-pregnant groups. Gene set enrichment analysis of the DEGs identified an over-representation of IL-17 and Pl3K-Akt signalling pathways. All the DEGs within the IL-17 signalling pathway (MMP3, MMP1, IL1β, LCN2, S100A9 and FOSL1) demonstrated decreased expression in the pregnant group. Serum IL-17 protein levels were increased in the non-pregnant discovery cohort (n = 11) and these findings were confirmed a validation cohort (n = 9).

LIMITATIONS, REASONS FOR CAUTION

Limitations of our study include the cohort size and the lack of aneuploidy data for the embryos; however, all embryos transferred were single good or top-quality blastocysts.

WIDER IMPLICATIONS OF THE FINDINGS

These findings demonstrate dysregulated IL-17 pathway components in women who fail to become pregnant after ART. Elevated serum levels of the pro-inflammatory cytokine IL-17 may predict failure of ART in women with unexplained infertility. Future trials of anti-IL-17 therapies in this cohort warrant further investigation.

STUDY FUNDING/COMPETING INTEREST(S)

Funding from the UCD Wellcome Institutional Strategic Support Fund, which was financed jointly by University College Dublin and the SFI-HRB-Wellcome Biomedical Research Partnership (ref 204844/Z/16/Z), is acknowledged. The authors have no competing interests.

TRIAL REGISTRATION NUMBER

NA.

Defining standards in colorectal optimisation: a Delphi study protocol to achieve international consensus on key standards for colorectal surgery prehabilitation

INTRODUCTION

Prehabilitation in colorectal surgery is evolving and may minimise postoperative morbidity and mortality. With many different healthcare professionals contributing to the prehabilitation literature, there is significant variation in reported primary endpoints that restricts comparison. In addition, there has been limited work on patient-related outcome measures suggesting that patients with colorectal cancer needs and issues are being overlooked. The Defining Standards in Colorectal Optimisation Study aims to achieve international consensus from all stakeholders on key standards to provide a framework for reporting future prehabilitation research.

METHODS AND ANALYSIS

A systematic review will identify key standards reported in trials of prehabilitation in colorectal surgery. Standards that are important to patients will be identified by a patient and public involvement (PPI) event. The longlist of standards generated from the systematic review and PPI event will be used to develop a three-round online Delphi process. This will engage all stakeholders (healthcare professionals and patients) both nationally and internationally. The results of the Delphi will be followed by a face-to-face interactive consensus meeting that will define the final standards for prehabilitation for elective colorectal surgery.

ETHICS AND DISSEMINATION

The University of Glasgow College of Medical, Veterinary and Life Sciences Ethics Committee has approved this protocol, which is registered as a study (200190120) with the Core Outcome Measures in Effectiveness Trials Initiative. Publication of the standards developed by all stakeholders will increase the potential for comparative research that advances understanding of the clinical application of prehabilitation.

PROSPERO REGISTRATION NUMBER

CRD42019120381.

Mycobacterium bovis BCG Danish Strain 1331 isolated from a periarticular lesion in a domestic cat

A 7-year-old male neutered domestic shorthair outdoor cat was referred for chronic left forelimb lameness, which had been treated with intra-articular injections of triamcinolone acetonide. A soft tissue swelling around the elbow joint, extending from the distal humerus to the proximal ulna, was surgically explored and biopsy samples obtained. Mycobacterium bovis was cultured from samples from the soft tissue and bone. The mycobacteria from the media were killed and the DNA extracted and tested on a multiplex real-time PCR for the absence of specific genes and the presence of mycobacterial genus markers. The PCR revealed bacillus Calmette-Guérin Danish Strain 1331; this was also isolated from the prescapular lymph node, muscle and bone, obtained at post mortem examination. Badgers had been vaccinated with the bacillus Calmette-Guérin vaccine SSI (Statens Serum Institute) in the area where the cat lived, in the spring and autumn of the previous year. To the authors' knowledge, this is the first report of infection with M. bovis bacillus Calmette-Guérin Danish Strain 1331 in a domestic cat, potentially associated with annual vaccination of badgers in the proximity of the cat's home.

Systemic Bevacizumab for Treatment of Respiratory Papillomatosis: International Consensus Statement

OBJECTIVES/HYPOTHESIS

The purpose of this study is to develop consensus on key points that would support the use of systemic bevacizumab for the treatment of recurrent respiratory papillomatosis (RRP), and to provide preliminary guidance surrounding the use of this treatment modality.

STUDY DESIGN

Delphi method-based survey series.

METHODS

A multidisciplinary, multi-institutional panel of physicians with experience using systemic bevacizumab for the treatment of RRP was established. The Delphi method was used to identify and obtain consensus on characteristics associated with systemic bevacizumab use across five domains: 1) patient characteristics; 2) disease characteristics; 3) treating center characteristics; 4) prior treatment characteristics; and 5) prior work-up.

RESULTS

The international panel was composed of 70 experts from 12 countries, representing pediatric and adult otolaryngology, hematology/oncology, infectious diseases, pediatric surgery, family medicine, and epidemiology. A total of 189 items were identified, of which consensus was achieved on Patient Characteristics (9), Disease Characteristics (10), Treatment Center Characteristics (22), and Prior Workup Characteristics (18).

CONCLUSION

This consensus statement provides a useful starting point for clinicians and centers hoping to offer systemic bevacizumab for RRP and may serve as a framework to assess the components of practices and centers currently using this therapy. We hope to provide a strategy to offer the treatment and also to provide a springboard for bevacizumab's use in combination with other RRP treatment protocols. Standardized delivery systems may facilitate research efforts and provide dosing regimens to help shape best-practice applications of systemic bevacizumab for patients with early-onset or less-severe disease phenotypes.

LEVEL OF EVIDENCE

5 Laryngoscope, 131:E1941-E1949, 2021.

Lack of association between acute stroke, post-stroke dementia, race, and β-amyloid status

INTRODUCTION

Stroke and Alzheimer disease share risk factors and often co-occur, and both have been reported to have a higher prevalence in African Americans as compared to non-Hispanic whites. However, their interaction has not been established. The objective of this study was to determine if preclinical Alzheimer disease is a risk factor for stroke and post-stroke dementia and whether racial differences moderate this relationship.

METHODS

This case-control study was analyzed in 2019 using retrospective data from 2007 to 2013. Participants were adults age 65 and older with and without acute ischemic stroke. Recruitment included word of mouth and referrals in Saint Louis, MO, with stroke participants recruited from acutely hospitalized patients and non-stroke participants from community living older adults who were research volunteers. Our assessment included radiologic reads of infarcts, microbleeds, and white matter hyperintensitites (WMH); a Pittsburgh Compound B PET measure of cortical β-amyloid binding; quantitative measures of hippocampal and WMH volume; longitudinal Mini Mental State Examination (MMSE) scores; and Clinical Dementia Rating (CDR) 1 year post-stroke.

RESULTS

A total of 243 participants were enrolled, 81 of which had a recent ischemic stroke. Participants had a mean age of 75, 57% were women, and 52% were African American. Cortical amyloid did not differ significantly by race, stroke status, or CDR post-stroke. There were racial differences in MMSE scores at baseline (mean 26.8 for African Americans, 27.9 for non-Hispanic whites, p = 0.03), but not longitudinally. African Americans were more likely to have microbleeds (32.8% vs 22.6%, p = 0.04), and within the acute stroke group, African Americans were more likely to have small infarcts (75.6% vs 56.8%, p = 0.049).

CONCLUSION

Preclinical Alzheimer disease did not show evidence of being a risk factor for stroke nor predictive of post-stroke dementia. We did not observe racial differences in β-amyloid levels. However, even after controlling for several vascular risk factors, African Americans with clinical stroke presentations had greater levels of vascular pathology on MRI.

Older Adults’ Reflections on Ageism and Racism

The older population is becoming more racially and ethnically diverse. By the year 2050, 39% of those 65+ will be from minority groups, up from 21% in 2012 (Ortman et al., 2014). These figures have significant implications for aging policy, including concerns over ageism and racism. Discrimination can take many forms, and can be present in legislation, advertising, attitudes, the workplace, and the health care system (Snaedal, 2015). The present study examines perceptions of racial and age discrimination of older adults living in the community and its impact on their quality of life. Using a cross-sectional design, 134 participants over the age of 60 were surveyed at three senior centers with ethnically diverse populations. The Attitudes to Aging Questionnaire (AAQ-24) was used to assess participants’ perceptions and experiences with aging and perceptions of racism were assessed using an adaptation of the Modern Racism Scale. Findings from the AAQ-24 revealed an average score of 27.1 (SD=6.66) for psychosocial loss, 28.3 (SD=5.34) for physical change, and 30.5 (SD=4.65) for psychological growth, indicating moderately high levels of ageism. For the racism scale, the average total score for all respondents was 34.4 (SD=7.05), also moderate. This study helps shed some light on what older adults feel about the aging, as well as their concerns with racial discrimination. The insights gained from older adults’ experiences and perceptions can help shape policies for future generations.

Proton vs Hyperarc™ radiosurgery: A planning comparison

For many patients, stereotactic radiosurgery (SRS) offers a minimally invasive, curative option when surgical techniques are not possible. To date, the literature supporting the efficacy and safety of SRS treatment techniques uses photon beams. However, with the number of proton therapy facilities exponentially growing and the favorable physical properties of proton beam radiation therapy, there is an opportunity to develop proton therapy techniques for SRS. The goal of this paper is to determine the ability of clinical proton treatment planning systems to model small field dosimetry accurately and to compare various planning metrics used to evaluate photon SRS to determine the optimum beam configurations and settings for proton SRS (PSRS) treatment plans. Once established, these plan settings were used to perform a planning comparison on a variety of different SRS cases and compare SRS metrics between the PSRS plans and HyperArc™ (VMAT) SRS plans.

Baseline characteristics and follow-up outcomes in routine clinical practice patients categorised by renal function in the ETNA-AF-Europe registry

Background

Edoxaban is an oral factor Xa inhibitor anticoagulant with 50% renal clearance, and proven efficacy and safety in patients (pts) with atrial fibrillation (AF). The post-authorisation, observational, ETNA-AF-Europe registry (NCT02944019) assessed the risks and benefits of edoxaban in pts with AF from 10 European countries.

Purpose

Evaluate baseline characteristics and event rates in pts categorised by creatinine clearance (CrCl) at 1-year follow-up of the ETNA-AF-Europe registry.

Methods

In this analysis, pts were divided into three groups according to CrCl: ≤50 ml/min (I), 50–80 mL/min (II) and ≥80 mL/min (III) (calculated using Cockcroft-Gault). Outcomes were descriptively analysed.

Results

Pts with the lowest CrCl (Group I) were mostly females, and had a higher mean age, lower body weight, higher stroke and bleeding risk scores and were considered more frail than those with higher CrCl (Groups II and III) (Table). Group I experienced higher rates of stroke or SEE, major or CRNM bleeding, cardiovascular death, and had a higher total mortality (Figure). Rates of intracranial haemorrhage (ICH) and haemorrhagic stroke (intracerebral and subarachnoid haemorrhage) were low and similar in pts across the range of CrCl.

Conclusions

Those with lower CrCl had more comorbidities and higher event rates than those with higher CrCl, with the exception of ICH and haemorrhagic stroke. A steep rise in the proportion of pts perceived as frail and in overall mortality in the lowest renal function tertile, raises the question whether low renal function is a determinant or a correlate of mortality.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Daiichi Sankyo Europe GmbH, Munich, Germany

The effect of the Montgomery judgment on settled claims against the National Health Service due to failure to inform before giving consent to treatment

BACKGROUND

A landmark legal judgment in March 2015 (Montgomery) changed the test for determining negligence due to failing to inform patients before consent, by moving away from asking what a reasonable doctor should disclose and asking instead what a reasonable patient would expect to know.

AIM

We sought to determine the effect Montgomery has had on settled claims due to failure to inform compared with claims for other reasons and whether legal firms are adding contributory claims of failure to inform to other principal allegations of negligence.

METHODS

A Freedom of Information request to NHS Resolution provided data on the number of settled claims against the NHS (2005-19) for any cause and where failure to inform before consent was the principal or contributory cause. Time-series regression was used to compare trends before and after 31 March 2015.

RESULTS

The trend in claims/year increased 4-fold for failure to inform (an increase of 9.8/year before 2015 vs. 39.5/year after 2015, P < 0.01), 2.7-fold when failure to inform was the principal cause (7.9/year vs. 21.2/year, P = 0.02) and 9.9-fold as a contributory cause (1.9/year vs. 18.3/year, P < 0.01). There was no material difference in claims due to other causes (334/year vs. 318/year, P = 0.84).

CONCLUSIONS

Montgomery has led to a substantial increase in settled claims of failure to inform before consent, with no coincident change in claims for other causes. The increase in contributory compared with principal causes suggests that lawyers are using the judgment to increase the chances of a successful claim against the NHS.

Measuring step count: why it is important not to assume measures are reliable

BACKGROUND

The validity and reliability of pedometer software Apps versus the previously investigated spring lever and piezoelectric pedometers is unknown.

PURPOSE

To evaluate the validity and reliability (in adults aged 18-65) of two pedometer software Apps, the Walk Star and the Accupedo, with spring lever (Digi-Walker CW 700) and piezoelectric (Omron HJ-720ITC and Tanita PD-724) pedometers in the measurement of step count. The criterion for comparison was researcher tallied direct observation of step count using an electronic E3-EHT hand held tally counter.

METHODS

Eighteen participants walked for 5minutes on a treadmill at slow (2miles per hour) moderate (3miles per hour) and fast walking (4miles per hour) speeds and on urban streets and upon grass at a perceived "comfortable" walking speed.

RESULTS

Bland and Altman plots show wide limits of agreement observed for the Yamax CW 700, Accupedo App and Walk Star App, suggesting these pedometers are unsuitable for measuring step counts in individuals due to high random error (indicating low reliability). Narrow limits of agreement were observed for the Omron HJ-720ITC and the Tanita PD-724 pedometers compared against Tally count and were considered suitable for use.

CONCLUSION

The validity and reliability of pedometers cannot be assumed but must be tested and ensured before use in measuring step count.

Demodex: a skin resident in man and his best friend

Demodex mites are microscopic arachnids found in the normal skin of many mammals. In humans, it is well established that Demodex mite density is higher in patients with the skin condition rosacea, and treatment with acaricidal agents is effective in resolving symptoms. However, pathophysiology of rosacea is complex and multifactorial. In dogs, demodicosis is a significant veterinary issue, particularly the generalized form of the disease which can be fatal if untreated. In each species, clinical and molecular studies have shown that the host's immunological interactions with Demodex mites are an important, but not fully understood, aspect of how Demodex can live in the skin either as a harmless commensal organism or as a pathogenic agent. This review outlines the role of Demodex mites in humans and dogs, considering morphology, prevalence, symptoms, diagnosis, histology treatment and pathogenesis.

THE IMPACT OF AN EDUCATION INTERVENTION: IMPROVING COMMUNICATION BETWEEN OLDER ADULTS AND HEALTH CARE PROVIDERS

As people age, ensuing physical and psychological problems can increase, which makes it paramount to be comfortable discussing medical needs with health care professionals, particularly in light of the danger associated with misunderstanding medication use and combining alcohol with prescriptions and/or over the counter medications (National Institute on Aging, 2018). National studies found that about 40 percent of adults ages 65 and older drink alcohol and often do not understand the dangers of combining alcohol with medications (National Institute for Alcohol and Alcohol Abuse, 2008). An educational intervention was developed with a team of expert physicians, nurses, pharmacists and social workers who work in gerontology to focus on improving communication and addressing alcohol and medication use for older adults. A randomized controlled trial was conducted to assess whether the educational intervention improved older adults’ comfort in communicating with their health care providers, as well as their knowledge of the concomitant use of alcohol and prescription and over-the-counter (OTC) medications. Results of a MANCOVA showed that those in the intervention group showed larger increases in scores on communication with their health providers and knowledge about the implications of combining alcohol with prescription drugs than those in the control group (Wilks’ Lamda=.808, F(3,76)=6.039, p=.001<.05). In addition, linear regression models showed that the intervention was significantly associated with participants’ knowledge of the implications of combining alcohol with prescription drugs. The coefficient across models was approximately 1.00, which represented a substantial increase given the average score of 6.5.

P4756Stroke and bleeding in low, intermediate and high risk patients with atrial fibrillation treated with edoxaban: Results of the ETNA-AF Europe registry

Background

Edoxaban, a direct FXa inhibitor, has been proven non-inferior in efficacy and safer compared to warfarin in the ENGAGE AF-TIMI 48 trial. In routine care, the safety of edoxaban has not been formally established. ETNA-AF-Europe is a multinational, multi-centre, post-authorisation, observational study (NCT02944019) conducted in 825 sites in 10 European countries. Here 13,980 edoxaban-treated patients with AF were enrolled between November 2016 and February 2018, and will be followed-up for 4 years.

Methods

7,672 patients (73.4±9.26 years, 57.5% male) enrolled in the ETNA-AF Europe registry completed the one-year follow-up and were stratified into low-, intermediate- and high-risk for stroke and bleeding using the CHA2DS2-VASc and HASBLED score, respectively. We here analysed the occurrence of stroke, bleeding, intracranial haemorrhage and mortality in such categories.

Results

The mean CHA2DS2-VASc score at baseline was 3.1±1.38 and the mean HAS-BLED score was 2.5±1.1. Not surprisingly, patients at higher risk were older, had a lower body weight, more comorbidities, and a lower creatinine clearance. A higher proportion of patients at high risk received the reduced 30 mg edoxaban dose. Overall, the yearly event rates of stroke, intracranial haemorrhage, major bleeding and death were low. However, these rates increased consistently in patients with higher stroke and bleeding risks. Residual stroke risk on anticoagulation was comparable to the risk of major bleeding (Table 1).

Outcomes by stroke and bleeding risk CHA2DS2-VASc: mean 3.1±1.38 HAS-BLED: mean 2.5±1.1 All patients Low risk (0, 1 if female) Intermediate risk (1, 2 if female) High risk (≥2, 3 if female) Low risk (0, 1) Intermediate risk (2, 3) High risk (≥4) Patients, N 233 1,133 6,304 1,224 4,932 1,516 7,672 First occurrence of outcomes, n (%/year)   All-cause mortality 2 (0.92%) 12 (1.11%) 242 (4.09%) 14 (1.21%) 161 (3.47%) 82 (5.78%) 257 (3.56%)   Intracranial haemorrhage 0 (0.00%) 1 (0.09%) 19 (0.32%) 2 (0.17%) 10 (0.22%) 8 (0.56%) 20 (0.28%)   Major bleeding 0 (0.00%) 6 (0.56%) 62 (1.05%) 2 (0.17%) 43 (0.93%) 23 (1.63%) 68 (0.95%)   Stroke/SEE 0 (0.00%) 4 (0.37%) 59 (1.00%) 3 (0.26%) 41 (0.89%) 19 (1.34%) 63 (0.88%) SEE, systemic embolic event.

Conclusions

In this unselected cohort of patients with AF anticoagulated with edoxaban, high CHA2DS2-VASc and HAS-BLED scores were associated with higher risks of stroke, bleeding and death. Indirectly compared with the expected rates in non-anticoagulated patients, our data underpin the value of anticoagulants such as edoxaban in patients at high risk of stroke and bleeding.

Acknowledgement/Funding

The ETNA-AF Registry was funded by Daiichi Sankyo Europe GmbH, Munich, Germany.

P1257ETNA-AF Europe: First 1-year follow-up snapshot analysis of more than 7,500 AF patients treated with edoxaban in routine clinical practice

Introduction

Edoxaban has been approved for stroke prevention in patients with atrial fibrillation based on its comparable efficacy and superior safety compared to warfarin in the pivotal ENGAGE AF-TIMI 48 trial. ETNA-AF Europe (NCT02944019) was initiated in agreement with the EMA to evaluate benefits and risks of edoxaban treatment in unselected patients in routine clinical practice.

Methods

13,980 patients from across 825 hospital and office-based physicians from 10 European countries (Austria, Belgium, Germany, Ireland, Italy, The Netherlands, Portugal, Spain, Switzerland and United Kingdom) were enrolled, and will be followed-up for 4 years. This snapshot analysis includes baseline and first outcome data of 7,672 patients (56.3% of all enrolled patients) that have completed their first 1-year follow-up visit (mean follow-up: 343.5 days).

Results

The average age of patients was 73.4 years, the mean weight was 81.9 kg (Table 1). Frequent comorbidities include hypertension (77.2%), valvular heart disease (17.4%), congestive heart failure (5.8%) and history of myocardial infarction (4.2%). Patients receiving the 30 mg dose (22.9%) were older, had a lower creatinine clearance and had a higher risk for both stroke and bleeding as compared to those on the 60 mg dose (77.1%). Overall, the incidence of clinical events was low: all-cause mortality: 3.56%/y, major bleeding 0.95%/y, intracranial haemorrhage 0.28%/y, any stroke or systemic embolic events 0.88%/y.

Patient characteristics at Year 1 Patient characteristics All patients Edoxaban 60 mg Edoxaban 30 mg [7,672] [5,916 (77.1%)] [1,756 (22.9%)] Age [years] mean (SD) 73.4 (9.26) 71.8 (8.98) 79.1 (7.81) Body weight [kg] mean (SD) 81.9 (17.33) 84.1 (16.80) 74.3 (16.93) CrCl (CG) [mL/min] mean (SD) 75.0 (30.29) 82.5 (29.14) 51.2 (19.75) CHA2DS2-VASc mean (SD) 3.1 (1.38) 2.9 (1.34) 3.8 (1.28) HAS-BLED mean (SD) 2.5 (1.10) 2.4 (1.07) 2.9 (1.08) First occurrence of all-cause mortality (n, %/year) 257 (3.56%) 129 (2.31%) 128 (7.90%) First occurrence of intracranial haemorrhage (n, %/year) 20 (0.28%) 16 (0.29%) 4 (0.25%) First occurrence of major bleeding (n, %/year) 68 (0.95%) 49 (0.88%) 19 (1.18%) First occurrence of stroke/SEE (n, %/year) 63 (0.88%) 45 (0.81%) 18 (1.11%) CG, Cockcroft-Gault; CrCl, creatinine clearance; SD, standard deviation; SEE, systemic embolic events.

Conclusions

We found low bleeding and stroke rates in 7,672 unselected, mainly elderly AF patients treated with edoxaban in routine clinical practice. These findings were consistent across edoxaban doses and reinforce the effectiveness and safety of NOACs such as edoxaban in routine clinical care in Europe.

Acknowledgement/Funding

Daiichi Sankyo Europe GmbH, Munich, Germany

P4766Edoxaban Treatment in routiNe clinical prActice for patients with atrial fibrillation (AF) in Europe (ETNA-AF-Europe): 1-year follow-up according to body mass index

Background

Non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) have substantially improved anticoagulation therapy for prevention of stroke and systemic embolism in patients with atrial fibrillation (AF), and available routine care data have so far broadly confirmed the safety of different NOACs in routine practice. However, such data for edoxaban are scarce, especially in extremely low and high body weight (BW). These extreme BWs may affect the bioavailability, distribution, and half-life of NOACs and, consequently, outcomes of treatment.

Methods

We analysed outcomes in normal-weight (BMI 18.5–25) vs overweight (BMI 25–30) and obese (BMI >30) patients enrolled into the ETNA-AF-Europe observational study (NCT02944019) collecting information on patients treated with edoxaban in 825 sites in 10 European countries. This snapshot analysis set includes data of 7,672 patients (56.3% of all enrolled patients) which have completed their 1-year follow-up visit (mean follow-up: 343.5 days).

Results

Median patient age was 74 years for all patients, 76 years for patients with a BMI 18.5–25 (group 1), 75 years for patients with BMI 25–30 (group 2), and 72 for patients with a BMI >30 (group 3). CrCl was 64 mL/min for patients with a BMI 18.5–25, 68 mL/min for patients with BMI 25–30, and 72 mL/min for patients with a BMI >30. The CHA2DS2-VASc (mean 3.1±1.38) and HAS-BLED (mean 2.5±1.10) score did not differ significantly between groups. As expected, diabetes and hypertension were significantly less prevalent in leaner patients and - accordingly - inversely correlated to age.

There was no correlation between body weight and life-threatening bleeding (group 1: 0.28%; group 2: 0.40%; group 3: 0.14%). Also, stroke rates (group 1: 0.74%; group 2: 0.81%; group 3: 0.76%) did not differ between groups.

Conclusion

BMI, within the range here assessed, does not affect 1-year outcomes in European AF patients treated with edoxaban.

Acknowledgement/Funding

Daiichi Sankyo Europe GmbH, Munich, Germany

DELAYED REFERRAL FOR DIAGNOSTIC ENDOSCOPY IS A CONTRIBUTING FACTOR TO LATE GASTRIC CANCER DIAGNOSIS IN ZAMBIA

There is evidence that 15 % of gastric cancer patients in Zambia survive more than one-year after diagnosis. The major contributing factor to these poor outcomes is late case detection. We set out to investigate the time course of gastric cancer diagnosis in Zambia. The study was conducted at the University Teaching Hospital, in Lusaka. Consenting patients presenting to the endoscopy unit were enrolled and their endoscopic findings recorded. An interviewer-administered questionnaire was used to collect information on basic characteristics, presenting symptoms and duration. We enrolled 388 patients, 92 (24%) of whom had gastric cancer. About two-thirds of the gastric cancers were located in the distal part of the stomach. The median time to endoscopic gastric cancer diagnosis was 12 weeks, IQR 4-32 weeks after the first health care consultation. This was despite gastric cancer patients seeking healthcare attention within a median of 2 weeks, IQR 0-4 weeks of noticing the symptoms. Patients presenting with persistent vomiting or evidence of blood loss had significantly shorter delays than those with abdominal pain (p<0.05 and p<0.001 respectively). Delayed referral for diagnostic endoscopy is a contributing factor to late gastric cancer diagnosis in Zambia. The delay is highest in patients presenting with abdominal pain.

The 2018 rift eruption and summit collapse of Kīlauea Volcano

In 2018, Kīlauea Volcano experienced its largest lower East Rift Zone (LERZ) eruption and caldera collapse in at least 200 years. After collapse of the Pu'u 'Ō'ō vent on 30 April, magma propagated downrift. Eruptive fissures opened in the LERZ on 3 May, eventually extending ~6.8 kilometers. A 4 May earthquake [moment magnitude (M _w) 6.9] produced ~5 meters of fault slip. Lava erupted at rates exceeding 100 cubic meters per second, eventually covering 35.5 square kilometers. The summit magma system partially drained, producing minor explosions and near-daily collapses releasing energy equivalent to M _w 4.7 to 5.4 earthquakes. Activity declined rapidly on 4 August. Summit collapse and lava flow volume estimates are roughly equivalent-about 0.8 cubic kilometers. Careful historical observation and monitoring of Kīlauea enabled successful forecasting of hazardous events.