Time to coronary catheterization in patients with non-ST-segment elevation acute coronary syndrome and high Global Registry of Acute Coronary Events score

AIMS

Current guidelines recommend an early (<24 h) invasive coronary angiography (ICA) strategy in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients with Global Registry of Acute Coronary Events (GRACE) score over 140. Evidence for this recommendation is based on older trials.

METHODS AND RESULTS

Between 1 February 2016 and 31 July 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA underwent ICA during index hospitalization. Six hundred and fifty-five patients underwent early invasive ICA (within 24 h) and 1112 underwent late ICA (between 24 h and 1 week). One hundred and seven patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent myocardial infarction (MI). Median time from admission to ICA was 13.3 h (IQR 6.0-20.6) for the early group and 59.9 h for the late group (IQR 23.5-96.3). There was no difference between the early and late ICA groups in the primary composite outcome [late catheterization >24 h hazard ratio 1.196, 95% confidence interval (CI) 0.969-1.475, P -value 0.096]. A multivariable Cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late catheterization >24 h hazard ratio 1.0735, 95% CI 0.862-1.327, P -value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (hazard ratio 1.291, 95% CI 0.910-1.831, P -value 0.151).

CONCLUSION

An early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.

Pandemic Racism: Lessons on the Nature, Structures, and Trajectories of Racism During COVID-19

The COVID-19 pandemic has been one of the most acute global crises in recent history, which profoundly impacted the world across many dimensions. During this period, racism manifested in ways specifically related to the pandemic, including xenophobic sentiments, racial attacks, discriminatory policies, and disparate outcomes across racial/ethnic groups. This paper examines some of the pressing questions about pandemic racism and inequity. We review what research has revealed about the nature and manifestations of racism, the entrenchment of structural racism, and trajectories of racism during COVID-19.

The association between phosphate level at admission and early mortality in acute pancreatitis

BACKGROUND

Abnormal phosphate levels are associated with adverse outcomes in critical illness. However, there is scarce evidence on phosphate's impact on acute pancreatitis outcomes, and the few studies examining this subject are relatively small and show conflicting data. We sought to determine the association between phosphate level at admission and the clinical course and outcomes of acute pancreatitis.

METHODS

In this retrospective single-center observational study, we included all adult patients admitted with a primary diagnosis of acute pancreatitis between January 2008 and June 2021. Phosphate levels at admission were classified as normal (2.8-4.5 mg/dl), low (below 2.8 mg/dl), or high (above 4.5 mg/dl).

RESULTS

Out of 2308 cases, 1868 patients had documented phosphate levels at admission and were thus included in our final analysis. 1096 (59%) had normal phosphate levels, 686 (37%) had hypophosphatemia, and 86 (4.6%) had hyperphosphatemia on admission. 30-day mortality rates were 3.4%, 3.8%, and 19% in normal, low, and high phosphate levels, respectively. In univariate analysis, hyperphosphatemia was significantly associated with 30-day mortality, with an OR of 6.54 (95% CI 3.39-12.2, p < 0.001; AUC = 0.58). In a multivariate analysis adjusting for age, MAP, GFR, BUN, and pH, hyperphosphatemia remained a statistically significant independent predictor of early mortality (OR-2.93, 95% CI 1.28-6.51, p = 0.009). Hypophosphatemia was not significantly associated with 30-day mortality in univariate analysis, OR of 1.13 (95% CI 0.67-1.87, p = 0.6).

CONCLUSION

Hyperphosphatemia at admission was independently associated with increased 30-day mortality in patients with acute pancreatitis. Hypophosphatemia at admission was not significantly associated with 30-day mortality.

Generalizable and robust deep learning algorithm for atrial fibrillation diagnosis across geography, ages and sexes

To drive health innovation that meets the needs of all and democratize healthcare, there is a need to assess the generalization performance of deep learning (DL) algorithms across various distribution shifts to ensure that these algorithms are robust. This retrospective study is, to the best of our knowledge, an original attempt to develop and assess the generalization performance of a DL model for AF events detection from long term beat-to-beat intervals across geography, ages and sexes. The new recurrent DL model, denoted ArNet2, is developed on a large retrospective dataset of 2,147 patients totaling 51,386 h obtained from continuous electrocardiogram (ECG). The model's generalization is evaluated on manually annotated test sets from four centers (USA, Israel, Japan and China) totaling 402 patients. The model is further validated on a retrospective dataset of 1,825 consecutives Holter recordings from Israel. The model outperforms benchmark state-of-the-art models and generalized well across geography, ages and sexes. For the task of event detection ArNet2 performance was higher for female than male, higher for young adults (less than 61 years old) than other age groups and across geography. Finally, ArNet2 shows better performance for the test sets from the USA and China. The main finding explaining these variations is an impairment in performance in groups with a higher prevalence of atrial flutter (AFL). Our findings on the relative performance of ArNet2 across groups may have clinical implications on the choice of the preferred AF examination method to use relative to the group of interest.

Coronary computed tomography angiography in the evaluation of acute chest pain in patients with elevated high sensitive cardiac troponin I (hs-cTn) level

Aims CCTA is a well-established and safe imaging modality for the diagnosis of CAD and is gate keeping for invasive coronary angiography (ICA). We aimed to examine CCTA performance in patients presenting with ACP and dynamic hs-cTn elevation compatible with MI but not exceeding 7 folds of the URL. We also examined the performance of GRACE and PTP consortium scores in this population of patients.

Adherence to Guidelines in Heart Failure, Is It Valid for Elderly Patients?

BACKGROUND

Current guidelines for the treatment of heart failure with reduced ejection fraction (HFrEF) are based on studies that have excluded or underrepresented older patients.

OBJECTIVES

To assess the value of guideline directed medical therapy (GDMT) in HFrEF patients 80 years of age and older.

METHODS

A single-center retrospective study included patients hospitalized with a first and primary diagnosis of acute decompensated heart failure (ADHF) and ejection fraction (EF) of ≤ 40%. Patients 80 years of age and older were stratified into two groups: GDMT, defined as treatment at hospital discharge with at least two drugs of the following groups: beta-blockers, angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or mineralocorticoid antagonists; and a personalized medicine group, which included patients who were treated with up to one of these drug groups. The primary outcomes were 90-day all-cause mortality, 90-day rehospitalization, and 3-years mortality.

RESULTS

The study included 1152 patients with HFrEF. 254 (22%) patients who were at least 80 years old. Of the group, 123 were GDMT at discharge. When GDMT group was compared to the personalized medicine group, there were no statistically significant differences in terms 90-day mortality (17% vs. 13%, P = 0.169), 90-day readmission (51 % vs. 45.6%, P = 0.27), or 3-year mortality (64.5% vs. 63.3%, P = 0.915).

CONCLUSIONS

Adherence to guidelines in the older adult population may not have the same effect as in younger patients who were studied in the randomized clinical trials. Larger prospective studies are needed to further address this issue.

Elevated thrombin generation levels in the left atrial appendage in patients with atrial fibrillation

Introduction

Atrial Fibrillation (AF) is the most common sustained arrhythmia. Thrombus formation in the left atrial appendage (LAA) increases the risk for stroke and systemic embolism in AF patients. The proposed mechanisms for thrombus formation in the LAA are stasis, endothelial dysfunction and local hypercoagulability. The aim of this study was to compare thrombin generation potential in various heart chambers among AF patients.

Material and methods

A prospective cross-sectional study of 47 patients with AF undergoing pulmonary vein isolation (PVI). Blood samples from the femoral vein (FV), right atrium (RA), left atrium (LA) and LAA were collected during the PVI procedures. The Samples were collected before heparin administration. Thrombin generation was assessed by the calibrated automated thrombogram (CAT).

Results

A total of 47 patients (36.2% female, mean age 58.7±13, 59.6% with CHADS-VASc ≥2) were enrolled into the study. The mean endogenous thrombin potentials (ETP) were 1580±558, 1433±540, 1141±611 and 1487±760 in the FV, RA, LA and LAA, respectively (P&lt;0.05). The mean thrombin peak heights were 244±124, 199±102, 139±94 and 195±129 in the FV, RA, LA and LAA, respectively (P&lt;0.05).

A post-hoc pairwise comparison demonstrated elevated thrombin generation in the LAA compared to the LA (P=0.014). Furthermore, LA thrombin generation levels were significantly lower from the FV and RA (P&lt;0.05).

Conclusion

In patients with AF, the LAA has increased thrombotic potential compared to the LA. These findings might explain why the LAA is more predisposed to thrombus formation than the LA.

Funding Acknowledgement

Type of funding sources: None.

Serological cross-sectional survey of equine infectious anemia in Saudi Arabia

The equine infectious anaemia virus (EIAV) is one of the most serious equine diseases worldwide. There is scarce information on the epizootiology of equine infectious anaemia (EIA) in Saudi Arabia. Given the importance of the equine industry in Saudi Arabia, this cross- -sectional study aims to provide information about the prevalence of EIAV based on serological surveillance of the equine population in the country. A total of 4728 sera samples were collected (4523 horses and 205 donkeys) between December 2017 and November 2019. All samples were tested using commercially available EIAV ELISA. All tested samples showed negative results for EIAV antibodies with a 95% confidence interval. The results provided evidence that Saudi Arabia's equine populations (horses and donkeys) are currently free of EIAV. The results also suggest the need for continuous monitoring of EIAV and strict regulation when importing horses from other countries.

Is it justified to search for cancer in patients with peripheral arterial disease?

BACKGROUND

Cancer is the leading cause of death in European countries, ahead of cardiovascular diseases. Cancer is also the most common co-morbidity among patients hospitalized for the management of cardiovascular diseases. Through an overview, we searched for the frequency and types of cancer associated with peripheral arterial disease (PAD) in order to address the relevance of cancer screening in patients with PAD.

METHODS

We searched in PubMed database from 1996 to 2020 for retrospective and prospective cohort or cross-sectional or randomized studies evaluating the frequency of all types of cancer in patients with PAD excluding patients with aneurysmal disease. The keywords used were: peripheral arterial disease, arterial thrombosis, acute leg ischemia, critical leg ischemia, chronic leg ischemia, intermittent claudication, malignant tumor, cancer.

RESULTS

Based on published studies, the frequency of cancer in patients with PAD varied widely from 3.8 to 30.4% depending on study design, population, method used to screen for cancer and study period. In medical records database and registers,cancer prevalence varied from 3,8% to 22,4% in 4 retrospective studies of patients with acute limb ischemia and from 10.5 to 30.4% in 3 prospective studies of patients with acute limb ischemia, critical ischemia or intermittent claudication. In 3 retrospective analyses from 2 population-based cohorts and health insurance claims data, incidence of cancer in patients with intermittent claudication, acute limb ischemia or peripheral arterial disease varied from 8% to 11.7%. The frequency of cancer in PAD patients appeared higher than in the general population. Tobacco-dependent cancers seemed to be the most common cancers in PAD. Cancers were also more frequent in case of anemia, amputation and iterative bypass thrombosis in few studies.

CONCLUSION

Although there is no recommendation for cancer screening in patients with PAD, the high prevalence of cancer raises the question of screening patients at high risk such as those with acute or critical limb ischemia and especially in case of severe tobacco use, anemia, amputation and iterative bypass thrombosis. These results call for further studies with larger sample size and long term follow-up.

The prognostic value of heart rate at discharge in acute decompensation of heart failure with reduced ejection fraction

AIMS

The effect of elevated heart rate (HR) on morbidity and mortality is evident in chronic stable heart failure; data in this regard in acute decompensated heart failure (ADHF) setting are scarce. In this single-centre study, we sought to address the prognostic value of HR and beta-blocker dosage at discharge on all-cause mortality among patients with heart failure and reduced ejection fraction and ADHF.

METHODS AND RESULTS

In this retrospective observational study, 2945 patients were admitted for the first time with the primary diagnosis of ADHF between January 2008 and February 2018. Patients were divided by resting HR at discharge into three groups (HR < 70 b.p.m., HR 70-90 b.p.m., and HR > 90 b.p.m.). Evidence-based beta-blockers were defined as metoprolol, bisoprolol, and carvedilol. The doses of prescribed beta-blockers were calculated into a percentage target dose of each beta-blocker and divided to four quartiles: 0 < Dose ≤ 25%, 25% < Dose ≤ 50%, 50% < Dose ≤ 75%, and >75% of the target dose. Cox regression was used to calculate the hazard ratio for various HR categories and adjusting for clinical and laboratory variables. At discharge, 1226 patients had an HR < 70 b.p.m., 1347 patients had an HR at range 70-90 b.p.m., and 372 patients with an HR > 90 b.p.m. The 30 day mortality rate was 2.2%, 3.7%, and 12.1% (P < 0.001), respectively. Concordantly, 1 year mortality rate was 14.6%, 16.7%, and 30.4% (P < 0.001) among patients with HR < 70 b.p.m., HR 70-90 b.p.m., and HR > 90 b.p.m., respectively. The adjusted hazard ratio was significantly increased only in HR above 90 b.p.m. category (hazard ratio, 2.318; 95% confidence interval, 1.794-2.996).

CONCLUSIONS

Patients with ADHF and an HR of <90 b.p.m. at discharge had significantly a lower 1 year mortality independent of the dosage of beta-blocker at discharge. It is conceivable to discharge these patients with lower HR.

The composition of the lipid, protein and mineral fractions of quail breast meat obtained from wild and farmed specimens of Common quail (Coturnix coturnix) and farmed Japanese quail (Coturnix japonica domestica)

The present study was intended to answer 2 scientific hypotheses: 1) the quail species has a significant influence in quail breast meat composition; 2) the wild quail's meat presents healthier composition than their farmed counterparts.

An analysis of the pectoral muscles of wild and captive common quails (Coturnix coturnix) and domestic quails (Coturnix japonica domestica) was performed. The content of fatty acids (FA), amino acids, total cholesterol, and vitamin E, some basic macro- and microminerals in the pectoral muscles of the 2 species of the genus Coturnix were analyzed.

Regarding the quail species influence on meat composition, Japanese Quail (JQ) revealed better lipid composition, characterized by lower saturated FA (SFA; less 3.17 g/100 g of total fatty acids), higher polyunsaturated FA contents (PUFA; more 5.5 g/100 g of total fatty acids) and healthier polyunsaturated FA/saturated FA (P/S) and n-6/n-3 ratios and TI value (1.08, 9.54 and 0.60 vs. 0.76, 12.58, and 0.75, correspondingly). The absence of differences observed on amino acids partial sums and ratios reveals equality between species on protein nutritional quality. On the other hand, Common Quail (CQ) proved to be a better source of copper (0.181 mg/100 g of meat), iron (2.757 mg/100 g of meat), manganese (0.020 mg/100 g of meat), and zinc (0.093 mg/100 g of meat) than JQ.

The comparison of farmed and wild specimens within CQ, showed that wild birds presented lower total cholesterol (less 8.32 mg/g of fresh meat) and total PUFA (less 4.26 g/100 g of total fatty acids), and higher n-3 PUFA contents (more 1.53 g/100 g of total fatty acids), which contributed to healthier P/S and n-6/n-3 ratios, but worst PI (1.60, 8.08, and 113.1 vs. 0.76, 12.58, and 100.8, respectively). The wild species revealed higher α-tocopherol content (2.40 vs. 1.49 µg/g of fresh meat. Differences observed on their mineral composition counterbalance each other.

Under intensive production system and similar feeding and management conditions, the CQ develops better nutritional qualities than JQ. The comparison of wild and farmed species within CQ reveals more similarities than differences. Quail´s meat presents good nutritional quality and introduces variability to human's diet, which is much valued by consumers.

Risk of Worsening Renal Function Following Repeated Exposures to Contrast Media During Percutaneous Coronary Interventions

Background

Multiple contrast media exposures are common, but their cumulative effect on renal function is unknown. We aimed to investigate the renal consequences of repeated exposures to contrast media with coronary interventions.

Methods and Results

We studied 2942 patients who underwent between 1 and 9 procedures. The primary end point was a persistent creatinine increase of ≥50% above baseline at ≥90 days after the last procedure. The effect of cumulative contrast media dose was assessed using Cox models, with cumulative exposure as a time‐dependent variable, and propensity score matching. The primary end point occurred in 190 patients (6.5%), with 6.1%, 6.8%, and 6.2% of patients with 1, 2 or 3, and ≥4 procedures, respectively (P=0.75). In the multivariable Cox model, baseline renal function, diabetes, anemia, acute coronary syndrome, and heart failure were independent predictors of the primary end point (all P≤0.01), whereas cumulative contrast dose was not (hazard ratio [HR], 1.29 [95% CI, 0.89–1.88] for the fourth contrast quartile [>509 mL] versus first contrast quartile [<233 mL]). Propensity score matching yielded 384 patient pairs with similar characteristics and either 1 or 2 to 9 contrast exposures (median cumulative dose, 160 and 480 mL, respectively). Despite large differences in the cumulative contrast exposure, there were similar rates of the primary end points (7.3% versus 6.3%, respectively; HR, 0.76 [95% CI, 0.44–1.32]).

Conclusions

In patients with multiple exposures to contrast media, worsening of renal function over time is associated with known risk factors for the progression of kidney disease but not with cumulative contrast volume.

Current-limiting amplifier for high speed measurement of resistive switching data

Resistive switching devices, important for emerging memory and neuromorphic applications, face significant challenges related to the control of delicate filamentary states in the oxide material. As a device switches, its rapid conductivity change is involved in a positive feedback process that would lead to runaway destruction of the cell without current, voltage, or energy limitation. Typically, cells are directly patterned on MOS transistors to limit the current, but this approach is very restrictive as the necessary integration limits the materials available as well as the fabrication cycle time. In this article, we propose an external circuit to cycle resistive memory cells, capturing the full transfer curves while driving the cells in a way that suppresses runaway transitions. Using this circuit, we demonstrate the acquisition of 10⁵ I, V loops per second without using on-wafer current limiting transistors. This setup brings voltage sweeping measurements to a relevant timescale for applications and enables many new experimental possibilities for device evaluation in a statistical context.

Acute and severe ribavirin-associated hyperuricemia and acute kidney injury: An underrecognized adverse effect

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

To report a case of ribavirin-associated severe hyperuricemia in an immunocompromised patient treated for respiratory syncytial virus (RSV) infection.

Summary

A 21-year-old male with a past medical history of B-cell acute lymphoblastic leukemia was in full remission after allogenic bone marrow transplantation complicated with chronic graft-versus-host disease. He was hospitalized due to fever, malaise, and respiratory syndromes. A diagnosis of RSV upper respiratory tract infection complicated by secondary pneumonia was made, and oral ribavirin (600 mg in 3 divided doses daily) and intravenous levofloxacin (750 mg once daily) were initiated. On day 2 of the hospital admission, the patient’s uric acid levels had increased from a baseline of 4 to 6 mg/dL to values of 19.3 and 22.2 mg/dL after the fourth and fifth doses of ribavirin, respectively, and his serum creatinine steadily had increased from a baseline of 0.7 to 0.8 mg/dL to a value of 1.6 mg/dL. Ribavirin was discontinued after the sixth dose, and a single dose of intravenous rasburicase (7.5 mg) was administered. On day 3, the patient’s serum uric and creatinine concentrations had decreased to 4.7 mg/dL and 1.1 mg/dL, respectively. He continued to recover on antibiotics and was discharged with normal uric acid and serum creatinine levels.

Conclusion

We report a case of severe hyperuricemia and acute kidney injury that developed early after initiation of ribavirin for RSV infection and suspected bacterial pneumonia in an immunocompromised patient without hepatitis C, requiring ribavirin discontinuation and rasburicase administration. To our knowledge, this is the first reported case of severe hyperuricemia in a patient treated with ribavirin for RSV infection rather than chronic hepatitis C. Clinicians should be aware of the possibility of acute and severe hyperuricemia following ribavirin administration.

Risk of Acute Kidney Injury after Intravenous Contrast Media Administration in Patients with Suspected Pulmonary Embolism: A Propensity-Matched Study

BACKGROUND

 Although computed tomography pulmonary angiography (CTPA) is the preferred diagnostic procedure in patients with suspected pulmonary embolism (PE), some patients undergo ventilation/perfusion (V/Q) lung scan due to concern of contrast-associated acute kidney injury (AKI).

METHODS

 The study used a cohort of 4,565 patients with suspected PE. Patients who received contrast during CTPA were compared with propensity score-matched unexposed control patients who underwent V/Q lung scanning. AKI was defined as ≥50% increase in serum creatinine during the first 72 hours after either CTPA or V/Q lung scan.

RESULTS

 Classification and regression tree analysis demonstrated that baseline creatinine was the strongest determinant of the decision to use CTPA. Propensity-score matching yielded 969 patient pairs. There were 44 AKI events (4.5%) in patients exposed to contrast media (CM) and 33 events (3.4%) in patients not exposed to CM (risk difference: 1.1%, 95% confidence interval [CI]: -0.6 to 2.9%; odds ratio [OR]: 1.39, 95% CI: 0.86-2.26; p = 0.18). Using different definitions for AKI and extending the time window for AKI diagnosis gave similar results. In a sensitivity analysis with the inverse probability weighting method, the OR for AKI in the CTPA versus V/Q scan was 1.14 (95% CI: 0.72-1.78; p = 0.58).

CONCLUSION

 Intravenous contrast material administration was not associated with an increased risk of AKI in patients with suspected PE. Given the diagnostic superiority of CTPA, these results are reassuring with regard to the use of CTPE in patients with suspected PE perceived to be at risk for AKI.

Pneumococcal and meningococcal vaccines - A significant reduction of pediatric admissions and deaths

Background

Mortality rates associated with paediatric inpatient stays in mainland Portuguese Hospitals have decreased approximately 50%, between 2000 and 2016, despite the majority of deaths occurring in hospitals. During this timeframe meningococcal and pneumococcal vaccines were introduced in the National Vaccination Programme (NVP). In this study, the authors analyzed admission and mortality rates associated with vaccine preventable diseases such as pneumococcal and meningococcal disease.

Methods

A sequential cross-sectional retrospective study was performed, from 2000 and 2016, to assess the hospitalizations for meningitis, sepsis and pneumonia of children and adolescents at the SNS (National Health Service) hospitals in mainland Portugal. An administrative Portuguese database that contains all the public hospital admissions to mainland Portugal hospitals was utilized and diagnoses were coded per ICD9. National Institute Of Statistics (INE) data was accessed as reference. All admissions of individuals 17 years old and younger were analysed.

Results

A 10-fold reduction of admissions and deaths for pneumococcal pneumonia and a 3-fold reduction of meningococcal sepsis were observed after the introduction of the antipneumococcal and antimeningococcal vaccine in the NVP, respectively.

Conclusions

These results highlight the importance of vaccination to prevent illness, hospital admissions and deaths in children and can provide evidence to educate the public towards vaccination.

Key messages

The results highlight the importance of vaccination to prevent illness, hospital admissions and deaths in children. The results show a 10x reduction in pneumococcal pneumonia hospital admission and deaths and a 3x in meningococcal meningitis.

Appetite and ghrelin levels in iron deficiency anemia and the effect of parenteral iron therapy: A longitudinal study

BACKGROUND

Iron deficiency anemia (IDA) is associated with decreased appetite. The ghrelin hormone is one of the major regulators of appetite.

OBJECTIVES

To evaluate appetite and ghrelin levels in patients with IDA, and to investigate the change in appetite and ghrelin following intravenous iron therapy.

METHODS

A total of 56 IDA patients and 51 controls were included in the study. Both appetite and ghrelin were assessed at baseline and following intravenous iron therapy. These were assessed at corresponding time intervals in the control group. Appetite was assessed by the SNAQ score (Simplified Nutritional Appetite Questionnaire) and fasting ghrelin levels were assessed by acylated ghrelin (AG), unacylated ghrelin (UAG) and their respective ratio AG/UAG.

RESULTS

IDA patients had significantly lower SNAQ scores, yet higher AG levels and higher AG/UAG ratios compared to healthy controls; the mean SNAQ scores were 12.56 ± 3.45 and 16.1 ± 2, respectively (P<0.01); the median AG levels were 57.5 pg/ml and 43 pg/ml respectively (P = 0.007); and the median AG/UAG ratios were 0.48 and 0.25 respectively (P = 0.04). On multivariate linear regression analysis, IDA remained independently associated with decreased SNAQ score (β = -0.524, P<0.001) and increased acylated ghrelin (β = 0.289, P = 0.013). After IDA was treated, SNAQ scores increased significantly by a mean of 2 points. AG and AG/UAG ratios decreased significantly by a mean of -18.44 pg/ml and -0.2 respectively. The control group showed no significant change in SNAQ scores or ghrelin at corresponding time intervals.

CONCLUSIONS

IDA patients have a reduced appetite and paradoxically elevated ghrelin hormone activity compared to healthy controls. Treating IDA enhances appetite and lowers ghrelin levels. Future studies are needed to explore the mechanism of this paradoxical ghrelin activity.

SAT0152 EFFICACY OF BARICITINIB IN PATIENTS WITH MODERATE-TO-SEVERE RHEUMATOID ARTHRITIS WITH 3 YEARS OF TREATMENT: RESULTS FROM A LONG-TERM STUDY

Background:

Baricitinib (Bari) is an oral, selective and reversible Janus kinase 1 and 2 inhibitor approved for the treatment of adults with active RA. In addition to long-term safety which has been disclosed previously with data up to 7 years [1], an important clinical consideration is whether treatment efficacy can be maintained over the long term.

Objectives:

To evaluate the long-term efficacy of once-daily Bari 4 mg in patients with active rheumatoid arthritis (RA) who were either naïve to or who had inadequate response (IR) to methotrexate (MTX)

Methods:

Post hoc analyses of data from two phase 3 studies, RA-BEGIN (MTX-naïve) and RA-BEAM (MTX-IR) for 52 weeks, and one long-term extension (LTE) study (RA-BEYOND) for an additional 96 weeks were conducted (148 weeks in total). At week 52, MTX-naïve patients initially treated with MTX monotherapy, Bari 4 mg monotherapy, or Bari 4 mg +MTX in RA-BEGIN were switched to open-label Bari 4 mg monotherapy for treatment in the LTE. Similarly, at week 52, MTX-IR patients initially treated with Bari 4 mg [+ background MTX noted as (+MTX) for RA-BEAM] or adalimumab (ADA) (+MTX) in RA-BEAM were switched to open-label Bari 4 mg (+MTX) for treatment in the LTE. Patients who received placebo (+MTX) were switched to open-label Bari 4 mg (+MTX) at week 24. The analyses of efficacy (SDAI) and physical function (HAQ-DI) were conducted on all patients who were randomized into the RA-BEGIN and RA-BEAM studies and had received ≥1 dose of study drug after randomization (mITT population). The proportion of patients who reached low disease activity (LDA), as measured by SDAI ≤11, was evaluated along with change from baseline in HAQ-DI. The non-responder imputation (NRI) method was used for the categorical analysis.

Results:

By week 24 in RA-BEGIN (N=584), 62% of patients treated with Bari 4 mg monotherapy or Bari 4 mg +MTX achieved SDAI LDA in comparison to 40% of pts in the MTX monotherapy group; response rates seen at week 24 in the Bari treatment groups were maintained through week 148 (Fig 1A). Similarly, by week 24 in RA-BEAM (N=1,305), 52% of patients treated with Bari 4 mg (+MTX) and 50% of patients treated with ADA (+MTX) achieved a SDAI LDA in comparison to 26% of patients from the PBO (+MTX) group. The response rate seen at week 24 with Bari 4 mg and ADA were maintained through week 148, even after patients switched from ADA to Bari 4 mg at week 52 (Fig 1B). Similar improvement and maintenance patterns in physical function measured by HAQ-DI were demonstrated. The overall discontinuation rate across treatment groups from RA-BEGIN (19.5%) and RA-BEAM (14.2%) have been published. In the LTE, the discontinuation rate from Bari treatment was 13.7% for patients originating from RA-BEGIN (1.1% due to lack of efficacy, 6.4% due to safety) and 12.6% for patients originating from RA-BEAM (1.8% due to lack of efficacy, 5.9% due to safety).

Figure 1.

Proportion of patients achieving SDAI ≤11 in the NRI analysis†In RA-BEGIN, rescue to Bari 4 mg + MTX was offered at week 24.‡In RA-BEAM, rescue to Bari 4 mg (+ MTX) was offered at week 16. At week 24, all PBO + MTX patients were switched to Bari 4 mg + MTX.§Upon entering RA-BEYOND at week 52, MTX and ADA patients were switched to Bari 4 mg.

Conclusion:

Long-term treatment with Bari 4 mg demonstrated the maintenance of clinically-relevant outcomes for up to 3 years. Low discontinuation rates during the LTE indicated that Bari 4 mg treatment was well-tolerated.

References:

[1]Genovese et al.Annals of the Rheumatic Diseases. 2019;78:308-309.

Disclosure of Interests: :

Josef S. Smolen Grant/research support from: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Consultant of: AbbVie, AstraZeneca, Celgene, Celltrion, Chugai, Eli Lilly, Gilead, ILTOO, Janssen, Novartis-Sandoz, Pfizer Inc, Samsung, Sanofi, Li Xie Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Bochao Jia Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Peter C. Taylor Grant/research support from: Celgene, Eli Lilly and Company, Galapagos, and Gilead, Consultant of: AbbVie, Biogen, Eli Lilly and Company, Fresenius, Galapagos, Gilead, GlaxoSmithKline, Janssen, Nordic Pharma, Pfizer Roche, and UCB, Gerd Rüdiger Burmester Consultant of: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Speakers bureau: AbbVie Inc, Eli Lilly, Gilead, Janssen, Merck, Roche, Pfizer, and UCB Pharma, Yoshiya Tanaka Grant/research support from: Asahi-kasei, Astellas, Mitsubishi-Tanabe, Chugai, Takeda, Sanofi, Bristol-Myers, UCB, Daiichi-Sankyo, Eisai, Pfizer, and Ono, Consultant of: Abbvie, Astellas, Bristol-Myers Squibb, Eli Lilly, Pfizer, Speakers bureau: Daiichi-Sankyo, Astellas, Chugai, Eli Lilly, Pfizer, AbbVie, YL Biologics, Bristol-Myers, Takeda, Mitsubishi-Tanabe, Novartis, Eisai, Janssen, Sanofi, UCB, and Teijin, Ayesha Elias Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Anabela Cardoso Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Robert Ortmann Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Chad Walls Shareholder of: Eli Lilly and Company, Employee of: Eli Lilly and Company, Maxime Dougados Grant/research support from: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Consultant of: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma, Speakers bureau: AbbVie, Eli Lilly, Merck, Novartis, Pfizer and UCB Pharma

Efficacy and tolerability of trabectedin in elderly patients with sarcoma: subgroup analysis from a phase III, randomized controlled study of trabectedin or dacarbazine in patients with advanced liposarcoma or leiomyosarcoma

Background

Treatment options for soft tissue sarcoma (STS) patients aged ≥65 years (elderly) can be limited by concerns regarding the increased risk of toxicity associated with standard systemic therapies. Trabectedin has demonstrated improved disease control in a phase III trial (ET743-SAR-3007) of patients with advanced liposarcoma or leiomyosarcoma after failure of anthracycline-based chemotherapy. Since previous retrospective analyses have suggested that trabectedin has similar safety and efficacy outcomes regardless of patient age, we carried out a subgroup analysis of the safety and efficacy observed in elderly patients enrolled in this trial.

Patients and methods

Patients were randomized 2 : 1 to trabectedin (n = 384) or dacarbazine (n = 193) administered intravenously every-3-weeks. The primary end point was overall survival (OS); secondary end points were progression-free survival (PFS), time-to-progression, objective response rate (ORR), duration of response, symptom severity, and safety. A post hoc analysis was conducted in the elderly patient subgroup.

Results

Among 131 (trabectedin = 94; dacarbazine = 37) elderly patients, disease characteristics were well-balanced and consistent with those of the total study population. Treatment exposure was longer in patients treated with trabectedin versus dacarbazine (median four versus two cycles, respectively), with a significantly higher proportion receiving prolonged therapy (≥6 cycles) in the trabectedin arm (43% versus 23%, respectively; P = 0.04). Elderly patients treated with trabectedin showed significantly improved PFS [4.9 versus 1.5 months, respectively; hazard ratio (HR)=0.40; P = 0.0002] but no statistically significant improvement in OS (15.1 versus 8.0 months, respectively; HR = 0.72; P = 0.18) or ORR (9% versus 3%, respectively; P = 0.43). The safety profile for elderly trabectedin-treated patients was comparable to that of the overall trabectedin-treated study population.

Conclusions

This subgroup analysis of the elderly population of ET743-SAR-3007 suggests that elderly patients with STS and good performance status can expect clinical benefit from trabectedin similar to that observed in younger patients.

Trial registration

www.clinicaltrials.gov, NCT01343277.

Calibrated Automated Thrombogram During Pregnancy in Unexplained Recurrent Miscarriages: A Pilot Study

BACKGROUND

Recurrent miscarriages are associated with a high prevalence of thrombophilia. Use of a calibrated automated thrombogram (CAT) can serve as a universal test for thrombophilia.

OBJECTIVES

To examine whether thrombin generation measured by CAT is elevated during the first trimester in women with unexplained recurrent miscarriages.

METHODS

This study comprised 25 pregnant women with recurrent pregnancy loss referred for thrombophilia screening and treated with low-molecular-weight heparin (LMWH). Thrombin generation parameters were measured in women who had miscarriages or live births and who were diagnosed as positive or negative for thrombophilia.

RESULTS

Of the pregnancies, 76% resulted in live birth and 24% ended in miscarriages. Among the women, 76% were positive for thrombophilia. Thrombin generation parameters between pregnancies that ended in miscarriage compared to live births were not significantly different, and CAT parameters failed to predict pregnancy outcome. Although the CAT parameters demonstrated a trend toward a hypercoagulable state in women with thrombophilia, there was no statistical significance (P > 0.05).

CONCLUSIONS

Women with unexplained pregnancy loss demonstrated similar thrombin generation in the first trimester, regardless of the pregnancy outcome. CAT parameters failed to predict pregnancy outcome in women with recurrent unexplained pregnancy loss. Our results should be interpreted with caution due to the small number of participants.

Blood urea nitrogen variation upon admission and at discharge in patients with heart failure

AIMS

Heart failure (HF) is one of the leading causes for hospitalization and mortality. After first admission with acute decompensated HF, some patients are in high risk for short-term and long-term mortality. These patients should be identified, closely followed up, and treated. It has been observed that blood urea nitrogen (BUN) on admission is a predictive marker for short-term mortality. Recently, it has been shown that higher BUN levels on discharge are also a bad prognostic predictor. However, the prognostic value of BUN alteration during hospital stay was not investigated; therefore, we aimed to investigate the effect of BUN variation during hospitalization on mortality.

METHODS AND RESULTS

A retrospective study included patients with first hospitalization with the primary diagnosis of HF. The patients were divided into four groups on the basis of the values of BUN on admission and discharge, respectively: normal-normal, elevated-normal, normal-elevated, and elevated-elevated. Four thousand seven hundred sixty-eight patients were included; 2567 were male (53.8%); the mean age was 74.7 ± 12.7 years. The 90 day mortality rate in the normal-normal group was 7% lower than that in the elevated-normal (14.6%) and normal-elevated (19.3%) groups; P value < 0.01. The 90 day mortality in the elevated-elevated group (28.8%) was significantly higher than that in the other groups; P < 0.001. During the 36 month follow-up, these results are maintained. While sub-dividing BUN levels into <30, 30-39, and >40 mg/dL, higher BUN levels correlated with higher 90 day mortality rate regardless of creatinine levels, brain natriuretic peptide, or age. Moreover, BUN on admission and on discharge correlated better with mortality than did creatinine and glomerular filtration rate at the same points.

CONCLUSIONS

The BUN both on admission and on discharge is a prognostic predictor in patients with HF; however, patients with elevated levels both on admission and on discharge have the worst prognosis. Moreover, worsening or lack of improvement in BUN during hospitalization is a worse prognostic predictor. To the best of our knowledge, this is the first trial to discuss the BUN change during hospitalization in HF.

Abstract P5-05-05: Targeting the androgen receptor with seviteronel, a CYP17 lyase and AR inhibitor, in triple negative breast cancer

Background: Androgen receptor (AR) protein is expressed across breast cancer (BC) subtypes, including up to 50% of triple negative breast cancers (TNBC) and it is often maintained in metastases. Our research demonstrated that TNBC cell lines rely on increased AR for anchorage independent survival, mammosphere formation, tumor initiation, and other stem-cell like properties. Further, AR mRNA levels increased in circulating tumor cells in the blood as compared to levels in the primary tumors of mice harboring human patient derived xenografts (PDX). Seviteronel (SEVI), a CYP17 lyase and AR inhibitor that blocks androgen and estrogen biosynthesis and AR activation, is in phase 2 clinical development for men and women with AR+ solid tumors, including advanced BC and has clinical activity in both basal and LAR subtypes (Innocrin data on file).

Hypothesis: We hypothesized that targeting both androgen biosynthesis and AR activation with an agent such as SEVI would decrease tumor growth in preclinical models of AR+ TNBC.

Methods: Genes regulated by AR under anchorage independent conditions with and without 10 nM dihydrotestosterone (DHT) were identified by AR chromatin immunoprecipitation (ChIP)-seq, RNA-seq, and Ingenuity Pathway Analysis. In vitro activity of SEVI was assayed in AR+ TNBC cell lines (MDA-MB-453 and SUM159). The IC50 of SEVI was determined via crystal violet. Soft agar colony formation assays and growth on poly-HEMA coated plates measured anchorage independent growth. In vivo, an AR+ TNBC patient derived xenograft (HCI-009, generated by Dr. Alana Welm) was grown in NSG mice given either DHT vs. vehicle control or, in a separate experiment, SEVI (150 mg/kg/day PO) vs. vehicle control.

Results: ChIP-seq and RNA-seq in MDA-MB-453 demonstrated that AR chromatin binding and gene regulation increased under anchorage independent conditions in a ligand dependent manner and showed an increase in mTOR signaling, aryl hydrocarbon receptor signaling and metabolism. SEVI inhibited proliferation of AR+ TNBC in a dose-dependent manner and growth on soft agar. In vivo, the AR+ TNBC HCI-009 PDX exhibited a significant increase in tumor volume with DHT indicating AR dependence. SEVI treatment also decreased HCI-009 tumor volume (p=0.0054) and rate of growth (p=0.0146). Nuclear AR protein and classical AR-regulated genes such as KLK3 and FKBP5 were increased with DHT in the HCI-009 xenograft tumors and decreased in mice treated with SEVI and were confirmed at the protein level.

Conclusion: These results further demonstrate the activity of SEVI, a CYP17 lyase and AR inhibitor, in preclinical models of AR+ TNBC. Use of AR targeting agents may be a rational treatment approach for a subset of patients with AR+ TNBC since such tumors may respond less well to chemotherapy than other TNBC molecular subtypes. We continue to identify markers of AR dependence/responsiveness to AR-targeted therapy.

Citation Format: Reese JM, Babbs BL, Christenson JL, Spoelstra NS, Elias A, Eisner JR, Baskin-Bey ES, Gertz J, Richer JK. Targeting the androgen receptor with seviteronel, a CYP17 lyase and AR inhibitor, in triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-05-05.

Abstract P1-15-02: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Schwab R, Clark A, Yau C, Wolf D, Chien AJ, Majure M, Ewing C, Wallace A, Roesch E, Helsten T, Forero A, Stringer-Reasor E, Vaklavas C, Nanda R, Jaskowiak N, Boughey J, Haddad T, Han H, Lee C, Albain K, Isaacs C, Elias A, Ellis E, Shah P, Lang J, Lu J, Tripathy D, Kemmer K, Yee D, Haley B, Korde L, Edmiston K, Northfelt D, Viscusi R, Khan Q, I-SPY 2 Consortium, Symmans WF, Perlmutter J, Hylton N, Rugo H, Melisko M, Wilson A, Singhrao R, Asare S, van't Veer L, DeMichele A, Berry D, Esserman L. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-02.

Enhanced thrombin generation in patients with arterial hypertension

BACKGROUND

Arterial hypertension is associated with greater risk of cardiovascular diseases and thrombotic complications, suggesting that hypertension is a prothrombotic state.

OBJECTIVES

To investigate the relationship between arterial hypertension and thrombin generation, and between blood pressure level and thrombin generation in hypertensive patients.

METHODS

A total of 165 hypertensive patients and 47 healthy adults controls were include in the study. Thrombin generation was assessed in both groups by the Calibrated Automated Thrombogram (CAT) method. Ambulatory blood pressure monitoring (ABPM) was also performed for all patients in the hypertensive group.

RESULTS

Hypertensive patients had significantly higher levels of ETP and peak heights compared to healthy controls; means of ETP 1720.6 ± 267 and 1544.7 ± 302, respectively (P < 0.001) and means of peak height were 297.26 ± 48 and, 273 ± 53, respectively (P < 0.001). On multivariate linear regression analysis, hypertension remained independently associated with increased ETP (β = 0.185, P = 0.047). Analysis restricted to the hypertensive group with ABPM measurement showed statistically significant correlations between all measures of diastolic blood pressure (DBP) and ETP, and multivariate analysis showed that awake DBP was significantly associated with ETP (β = 0.194 for each 1-mm Hg increase in awake DBP, P = 0.012). Furthermore, hypertensive patients with cardiovascular complications had statistically elevated levels of peak height compared to hypertensive patients without cardiovascular complications.

CONCLUSIONS

Hypertensive patients possess enhanced thrombin generation compared healthy controls. Diastolic blood pressure level is independently correlated with increased thrombin generation in hypertensive patients. These findings suggest that arterial hypertension is a prothrombotic state.

D-Dimer Test and Diagnosis of Deep Vein Thrombosis: A Comparative Study of 7 Assays

The current D-Dimer ELISA methods provide high sensitivity and negative predictive value for the diagnosis of deep vein thrombosis but these methods are not suitable for emergency or for individual determination. We have evaluated the performance of 3 newly available fast D-Dimer assays (Vidas D-Di, BioMerieux; Instant IA D-Di, Stago; Nycocard D-Dimer, Nycomed) in comparison with 3 classic ELISA methods (Stago, Organon, Behring) and a Latex agglutination technique (Stago). One-hundred-and-seventy-one patients suspected of presenting a first episode of deep vein thrombosis were investigated. A deep vein thrombosis was detected in 75 patients (43.8%) by ultrasonic duplex scanning of the lower limbs; in 11 of them the thrombi were distal and very limited in size (<2 cm). We compared the performance of the tests by calculating their sensitivity, specificity, positive and negative predictive value for different cut-off levels and by calculating the area under ROC curves. The concordance of the different methods was evaluated by calculating the kappa coefficient. The performances of the 3 classic ELISA and of the Vidas D-Di were comparable and kappa coefficients indicated a good concordance between the results provided by these assays. Their sensitivity slightly declined for detection of the very small thrombi. Instant IA D-Di had a non-significantly lower sensitivity and negative predictive value than the 4 previous assays; however its performance was excellent for out-patients. As expected, the Latex assay had too low a sensitivity and negative predictive value to be recommended. In our hands, Nycocard D-Dimer also exhibited low sensitivity and negative predictive value, which were significantly improved when the plasma samples were tested by the manufacturer. Thus significant progress has been made, allowing clinical studies to be planned to compare the safety and cost-effectiveness of D-Dimer strategy to those of the conventional methods for the diagnosis of venous thrombosis.

Predicting Daily Maintenance Dose of Fluindione, an Oral Anticoagulant Drug

Due to large inter-individual variations, the dose of vitamin K antagonist required to target the desired hypocoagulability is hardly predictible for a given patient, and the time needed to reach therapeutic equilibrium may be excessively long. This work reports on a simple method for predicting the daily maintenance dose of fluindione after the third intake. In a first step, 37 patients were delivered 20 mg of fluindione once a day, at 6 p.m. for 3 consecutive days. On the morning of the 4th day an INR was performed. During the following days the dose was adjusted to target an INR between 2 and 3. There was a good correlation (r = 0.83, p<0.001) between the INR performed on the morning of day 4 and the daily maintenance dose determined later by successive approximations. This allowed us to write a decisional algorithm to predict the effective maintenance dose of fluindione from the INR performed on day 4. The usefulness and the safety of this approach was tested in a second prospective study on 46 patients receiving fluindione according to the same initial scheme. The predicted dose was compared to the effective dose soon after having reached the equilibrium, then 30 and 90 days after. To within 5 mg (one quarter of a tablet), the predicted dose was the effective dose in 98%, 86% and 81% of the patients at the 3 times respectively. The mean time needed to reach the therapeutic equilibrium was reduced from 13 days in the first study to 6 days in the second study. No hemorrhagic complication occurred. Thus the strategy formerly developed to predict the daily maintenance dose of warfarin from the prothrombin time ratio or the thrombotest performed 3 days after starting the treatment may also be applied to fluindione and the INR measurement.

Influence of Long Term Oral Anticoagulants upon Prothrombin Fragment 1 + 2, Thrombin-Antithrombin III Complex and D-Dimer Levels in Patients Affected by Proximal Deep Vein Thrombosis

We have investigated the influence of long term oral anticoagulants (OAC) upon the plasma levels of prothrombin fragment 1 + 2 (F1 + 2), of thrombin-antithrombin III complexes (TAT) and of D-Dimer in 20 patients affected by a proximal deep vein thrombosis (DVT) diagnosed by ultrasonic duplex scanning. Patients (63 ± 17 years, mean ± SD) were sampled at the beginning of the OAC treatment (day 1), which was started 1 to 6 days after diagnosis confirmation and full heparinization, and then 8, 35 and 92 days after. The results were compared to those obtained in a blood donor population (39 ± 10 years) and to an age-matched healthy population (63 ± 19 years). The mean INR determined on days 8, 35 and 92 were almost identical (2.8 ± 0.7, 2.9 ± 0.9 and 2.8 ± 0.6 respectively). In contrast, highly significant variations of the three markers were recorded during the observation period. Eight days after the beginning of OAC, increased levels of TAT complexes were associated with subnormal levels of F1 + 2 suggesting persistence of a hypercoagulable state. On the further sampling times, TAT complexes were in the normal range while F1 + 2 were far below the normal range. Between day 1 and day 92, the levels of D-Dimer continuously decreased reflecting a long-term fibrinolytic process.

This study clearly indicates that high INR are not systematically associated with very low F1 + 2 levels, particularly in the acute phase of thrombosis. Whether or not it is possible to reduce the intensity of the anticoagulant treatment 1 month after its initiation on the basis of very low levels of F1 + 2 can only be determined by prospective clinical trials.

Abstract P4-09-09: Correlation of breast cancer index (BCI) predictive (HoxB13/IL17BR) results to nodal status and hormone receptor expression in early stage HR+ breast cancer

Background: The HoxB13/IL17BR (H/I) ratio, the endocrine response component of the Breast Cancer Index (BCI), was initially discovered in patients with LN- breast cancer, and validated as a predictive biomarker of benefit from extended endocrine therapy (EET) in a cohort from MA.17 that included both LN- and LN+ patients. Here, correlative analyses were performed to further characterize BCI Predictive (H/I) results with nodal status and quantitative hormone receptor expression.

Methods: Analyses were performed using data from the BCI Clinical Database for Correlative Studies, an IRB-approved de-identified database that contains &gt;50 clinicopathologic and molecular variables from cases submitted for BCI in clinical practice (N=19,126). Clinicopathologic variables were abstracted from pathology reports, and were available for a subset of these cases. Cases from patients with confirmed nodal status were analyzed. Chi-squared tests and ANOVA were used to compare results between subgroups.

Results: Analyses included 13,114 patients (median age 58.9y; range 23-92y); 9562 were LN- and 3552 LN+. The distribution of individual H/I scores and proportion of patients classified as High H/I were generally similar in LN- and LN+ patients, though a modestly greater proportion of LN+ patients (46.2%) were classified as High H/I compared to LN- patients (42.0%; P&lt;0.01). In both LN- and LN+ patients, median quantitative ER (qER) expression was slightly higher in patients with Low H/I than with High H/I; qPR showed the same trend but with a larger magnitude (P&lt;0.0001 for both). Similar results were observed for percent positive staining by IHC (P&lt;0.0001). In both LN- and LN+ patients, H/I showed a weak negative correlation with qER (LN-, 0.227; LN+, 0.192) and qPR expression (LN-, 0.311; LN+, 0.311).

Conclusion: In this study to evaluate potential biological correlates of BCI, results showed that H/I biomarker activity did not appear to be dependent on nodal status. Secondly, although ER expression is an established biomarker for endocrine sensitivity, High H/I status did not correlate with increased quantitative ER and PR expression. The H/I ratio may be an independent new marker for endocrine sensitivity independent of the strength of ER expression.

Citation Format: Elias A, Israel MA, Zhang Y, Schnabel CA, Mayordomo J. Correlation of breast cancer index (BCI) predictive (HoxB13/IL17BR) results to nodal status and hormone receptor expression in early stage HR+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-09-09.

Abstract P1-07-12: Correlation of breast cancer index (BCI) prognostic and predictive results to clinicopathologic risk groups in early stage HR+ breast cancer

Background: Both clinicopathologic factors and genomic tests have been shown to be prognostic for risk of late distant recurrence (DR); however, few studies have characterized differential patient stratification.Breast Cancer Index (BCI) is a validated gene expression assay for patients with early-stage HR+ breast cancer that provides a prognostic result for high vs low risk of late distant recurrence and a separate predictive result (based on the HoxB13/IL17BR [H/I] ratio) for high vs low likelihood of benefit from extended endocrine therapy. Thus four categories of results are possible based on a patient's tumor biology. To better understand how patient stratification is affected by a combination of clinicopathologic and genomic factors, this study examined BCI assay results within clinicopathologic risk categories based on tumor size and grade.

Methods: This study utilized data from the BCI Clinical Database for Correlative Studies, an IRB-approved de-identified database which contains clinicopathologic and molecular variables from 19,126 clinical cases submitted for BCI testing. Clinicopathologic variables, abstracted from pathology reports, were available for a subset of these cases. This analysis evaluated cases from LN- patients with available clinicopathologic data. Chi-squared tests were used to compare BCI results between tumor size and grade subgroups.

Results: Analyses included 3843 LN- patients (median age 59.1y; range 26-89y; 74% ≥50y), of which 31%, 52%, 17% were Grade 1, 2, and 3, respectively, and 5%, 22.7%, 48.9%, 21.7%, and 1.6% were T1mi/a, T1b, T1c, T2, and T3, respectively. In analysis based on tumor size, there was a wide distribution of individual BCI Prognostic scores in all tumor size subsets; however, the proportion of patients classified as high risk increased with larger tumor size (T1a/b 39.0%, T1c 50.1%, T2 61.0%; p&lt;.0001). In contrast, BCI Predictive (H/I) was not as strongly correlated with size, with a modestly larger proportion of patients classified as High H/I with larger tumor size (T1a/b 37.2%, T1c 40.5%, and T2 45.3%; p=.005). Within each tumor size category, the proportion of patients classified as BCI High Risk and High H/I increased with tumor grade (p&lt;.0001). However, there was a wide distribution of individual risk assessments by BCI Prognostic and stratification by BCI Predictive (H/I) in all size + grade subsets. In patients with the most favorable clinicopathologic risk profile (T1a/b, G1), BCI classified 20% as high risk, 68% of whom also had High H/I.

Conclusion: While BCI results correlated with tumor size and grade, BCI identified substantial proportions of patients with favorable clinicopathologic features as high risk for late DR and apparent high likelihood of benefit from EET; conversely, BCI also identified patients with high risk clinicopathologic features as low risk for late distant recurrence and apparent low likelihood of benefit from EET. These findings help to differentiate between genomic-based and clinicopathologic-based risk/benefit assessment for patients considering EET.

Citation Format: Mayordomo J, Falkson C, Kepes J, Israel MA, Schroeder BE, Schnabel CA, Elias A. Correlation of breast cancer index (BCI) prognostic and predictive results to clinicopathologic risk groups in early stage HR+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-07-12.

Case Report: Histoplasmosis: First Autochthonous Case from Israel

We present an autochthonous Histoplasma infection in Israel. The patient presented with hoarseness and weight loss. Pathology findings and molecular tests confirmed the diagnosis, and the patient responded to antifungal therapy. Because the patient had an atypical presentation of histoplasmosis, it is likely that other more typical cases have gone unreported. To our knowledge, no other cases have been previously reported from Israel or the Middle East region.

Prevalence of and factors associated with burnout among health care professionals in Arab countries: a systematic review

BACKGROUND

Burnout among healthcare professionals is one of the key challenges affecting health care practice and quality of care. This systematic review aims to (1) estimate the prevalence of burnout among health care professionals (HCP) in Arab countries; and (2) explore individual and work-related factors associated with burnout in this population.

METHODS

Multiple electronic databases were searched for studies published in English or Arabic from January 1980 to November 2014 assessing burnout (using the Maslach Burnout Inventory; MBI) amongst health care professionals (HCP) in Arab countries.

RESULTS

Nineteen studies (N = 4108; 49.3% females) conducted on HCP in Bahrain, Egypt, Jordan, Lebanon, Palestine, Saudi Arabia and Yemen were included in this review. There was a wide range of prevalence estimates for the three MBI subscales, high Emotional Exhaustion (20.0-81.0%), high Depersonalization (9.2-80.0%), and low Personal Accomplishment (13.3-85.8%). Gender, nationality, service duration, working hours, and shift patterns were all significantly associated with burnout.

CONCLUSIONS

Within the constraints of the study and the range of quality papers available, our review revealed moderate-to-high estimates of self-reported burnout among HCP in Arab countries that are similar to prevalence estimates in non-Arabic speaking westernized developed countries. In order to develop culturally appropriate interventions, further research using longitudinal designs is needed to confirm the risk factors for burnout in specific HCP settings and specialties in Arab countries.

The prognostic value of brain natriuretic peptide (BNP) in non-cardiac patients with sepsis, ultra-long follow-up

OBJECTIVES

Sepsis is a multifactorial syndrome with increasing incidence of morbidity and mortality. Identification of outcome predictors is therefore essential. Recently, elevated brain natriuretic peptide (BNP) levels have been observed in patients with septic shock. Little information is available concerning BNP levels in patients with critical illness, especially with sepsis. Therefore, this study aims to evaluate the role of BNP as a biomarker for long-term mortality in patients with sepsis.

METHODS

We studied 259 patients with sepsis and absence of heart failure. BNP levels were obtained for all patients. A long-term survival follow-up was done, and survival was evaluated 90days after admission, and during the subsequent 60months of follow-up.

RESULTS

Eighty-two patients died during the 90-day follow-up (31.7%), 53 died in the index hospitalization (20.5%). On multivariate analysis models, elevated values of BNP were a strong predictor of in-hospital mortality, 90-day and 60-month mortality in patients with sepsis. BNP was a better prognostic predictor than the Sepsis-related Organ Failure Assessment (SOFA) score for 90-day mortality, and a better predictor for 60-month mortality in low risk groups.

CONCLUSION

In the population of hospitalized patients with sepsis, BNP is a strong independent predictor of short- and long-term mortality.

Psychometric Properties of the Malay Language Version of Knee Injury and Osteoarthritis Outcome Score (KOOS) Questionnaire among Knee Osteoarthritis Patients: A Confirmatory Factor Analysis

Introduction: This study aimed to cross-culturally adapt a Malay version of Knee Injury and Osteoarthritis Outcome Score (KOOS) and to evaluate its psychometric properties in patients with knee osteoarthritis (OA).

Materials and Methods: The English version KOOS was translated into a Malay version using forward and backward translation process, followed by face validity and content validity. Two hundred and twenty-six knee OA patients attending the Outpatient and Orthopaedic Clinics, Universiti Sains Malaysia Hospital, completed the Malay version KOOS. Construct validity using confirmatory factor analysis and internal reliability assessment were performed.

Results: The results showed that the original five-factor model with 42 items failed to achieve acceptable values of the goodness of fit indices, indicating poor model fit. A new five-factor model of 26 items demonstrated acceptable level of goodness of fit (comparative fit index= 0.929, incremental fit index= 0.930, Tucker Lewis fit index= 0.920, root mean square error of approximation= 0.073 and Chisquared/degree of freedom= 2.183) indices to signify a model fit. The Cronbach’s alpha value for the new model ranged from 0.776 to 0.946. The composite reliability values of each construct ranged between 0.819 and 0.921, indicating satisfactory to high level of convergent validity.

Conclusion: The five-factor model with 26 items in the Malay version of KOOS questionnaire demonstrated a good degree of goodness of fit and was found to be valid, reliable and simple as an assessment tool for symptoms, pain, activity of daily living, sports and recreational activity and quality of life for Malaysian adults suffering from knee osteoarthritis.

The Prevalence of Thrombophilia in Women With Recurrent Fetal Loss and Outcome of Anticoagulation Therapy for the Prevention of Miscarriages

OBJECTIVE

To estimate the prevalence of thrombophilia in women with recurrent miscarriages and to assess the effect of antithrombotic therapy.

DESIGN

A retrospective cohort study between the years 2004 and 2010.

SETTING

A hypercoagulation community clinic in northern Israel.

PATIENTS

Four hundred ninety pregnant women referred for thrombophilia screening.

MAIN OUTCOME MEASURES

Screening results for thrombophilia and antithrombotic treatment with enoxaparin, aspirin, or both and pregnancy outcomes.

RESULTS

The most common thrombophilia in our study group was factor V Leiden mutation with a prevalence of 20.9% followed by protein S deficiency with a prevalence of 19%. Live birth rate was higher in the group of women who received enoxaparin regardless of whether a specific thrombophilia could be found. This finding was more pronounced in women who had ≥4 miscarriages.

CONCLUSION

The prevalence of thrombophilia was higher in our study group than in the general population. Furthermore, treatment with enoxaparin might improve the rate of live births in women with or without evidence of thrombophilia, especially in women with ≥4 miscarriages.